Surgery of the small bowel is a mainstay of practice for the general and acute care surgeon. Any abdominal operation must take into consideration the small bowel, both as a potential site of pathology or iatrogenic injury during the operation itself, and postoperatively, when ileus or adhesive small bowel obstruction may extend hospital length of stay. Despite the widespread importance of small bowel pathology to surgeons, the care of these patients relies on traditional surgical teaching. Evidence-based management in this area remains nascent, with few randomized controlled trials providing data to either support or refute dogma. Surgeons’ reluctance to undertake a study that appears to deviate from standard care may contribute, in part, to the paucity of high-quality data.
Of the extant studies in the area, many focus on streamlining care for patients with postoperative ileus or adhesive small bowel obstruction. Nonpharmocologic methods such as gum chewing,1 as well as newer pharmaceuticals such as Alvimopan,2 have been studied in an attempt to reduce the incidence of postoperative ileus, and Gastrografin has been suggested to facilitate resolution of partial small bowel obstruction.3 Surgical technique has also evolved over the years, with the development of new energy devices for mesenteric ligation and the linear cutting stapler for bowel anastomoses. It has now become common practice to use a variety of staplers for intestinal anastomoses, but controversy remains regarding the equivalency of hand-sewn and stapled anastomoses.
The topics presented in this review highlight recent developments and recommendations regarding the management of surgical issues of the small bowel. This discussion represents a sampling of the few high-quality studies in the area, and demonstrates the need for rigorous clinical trials to further inform surgical practice. Hopefully, further randomized controlled trials will clarify factors to improve outcomes in patients with small bowel disease, and ultimately guide standardization of care.
Randomized clinical study of Gastrografin administration in patients with adhesive small bowel obstruction.
Biondo S, Parés D, Mora L, Martı Ragué J, Kreisler E, Jaurrieta E
Br J Surg. 2003;90(5):542–546.Takeaway Point: The use of oral Gastrografin can help diagnose a complete small bowel obstruction, and hasten resolution of a partial small bowel obstruction.
Commentary: The authors present a randomized study of orally administered Gastrografin to identify patients who will need an operation for a small bowel obstruction, and to speed recovery of bowel function in patients with partial obstructions. They demonstrate an overall shorter hospital stay in patients receiving Gastrografin studies, both those requiring surgery, and those managed nonoperatively. Gastrografin has the potential to expedite identification of patients with complete small bowel obstruction who will require operation, and to hasten the resolution of partial obstructions that can be safely managed conservatively.
Introduction: Controversy continues to exist over the appropriate timing of operative intervention in adhesive small bowel obstruction (SBO). Determining whether the obstruction is complete or partial is an important decision point in the management of these patients. Oral administration of Gastrografin has been used to differentiate partial from complete obstructions, and may have a therapeutic effect in early adhesive SBO.
Objectives: To evaluate the ability of Gastrografin to resolve a partial SBO.
Trial Design: Single-center, prospective, randomized trial.
Inclusion Criteria: Any patient admitted with signs or symptoms of postoperative small bowel obstruction.
Exclusion Criteria: Age < 18 years, pregnancy, allergy to iodine, known nonspecific inflammatory bowel disease, symptoms suggestive of strangulating obstruction (fever, tachycardia, continuous pain with peritoneal irritation, metabolic acidosis), obstruction complicating an infective intraabdominal process such as diverticular disease, known abdominal cancer, prior abdominal radiotherapy, intestinal obstruction within the first 4 weeks after an abdominal operation, or known or suspected intestinal vascular disorder.
Intervention: 100 mL Gastrografin administered via nasogastric tube (NGT) after decompression in the emergency department. The NGT was then clamped for 3 hours, and serial abdominal radiographs were obtained. If the Gastrografin did not reach the colon in 24 hours, laparotomy was performed. If symptoms did not resolve by 4–5 days, laparotomy was performed.
Primary Endpoint: Success of nonoperative management and length of hospital stay.
Secondary Endpoints: Readmission, time between admissions, surgical operation, mortality.
Sample Size: 92 patients at one center in Spain between February 2000 and November 2001, making up 100 visits, were randomized; 10 episodes in 9 patients were later excluded because the final diagnosis was not SBO. Of the included patients, 44 episodes in 42 patients were randomized to Gastrografin and 46 episodes in 41 patients to the control group.
Statistical Analysis: ANOVA, χ2 test, Student’s t-test.
Baseline Data: All groups had similar baseline characteristics. Overall, 85.6% of episodes resolved with conservative management.
Primary: In patients who were treated successfully with nonoperative management, hospital stay was significantly decreased in the Gastrografin group (2.8 days vs. 5.8 days, p < 0.001). All patients who had contrast in the colon at 24 hours were successfully treated nonoperatively.
Secondary: Patients in the Gastrografin group had a decreased total length of stay after surgical intervention.
Conclusion: The use of oral Gastrografin early in the course of an adhesive small bowel obstruction may identify a complete obstruction and better stratify patients to operative intervention, and can shorten the time to resolution of partial obstructions.
Limitations: The diagnosis of bowel obstructions was based on plain radiographs, and in patients with CT scans the decision to go to the operating room may be based on different factors. The difference in total length of stay may represent earlier operation for the Gastrografin group (after 24 hours) rather than the 4–5 days of nonoperative management allowed for the control group.
Alvimopan, a novel, peripherally acting μ opioid antagonist: Results of a multicenter, randomized, double-blind, placebo-controlled, phase III trial of major abdominal surgery and postoperative ileus.
Wolff BG, Michelassi F, Gerkin TM, Techner L, Gabriel K, Du W, Wallin BA, Alvimopan Postoperative Ileus Study Group
Ann Surg. 2004;240(4):728–734.Takeaway Point: In patients undergoing gastrointestinal (GI) surgery, the μ-opioid receptor antagonist alvimopan speeds recovery of GI tract function and reduces in-hospital stay.
Commentary: The authors present a large, multicenter, randomized controlled trial, comparing alvimopan at 6 and 12 mg doses to placebo for patients undergoing laparotomy with either bowel resection or radical hysterectomy. The patients receiving alvimopan had accelerated GI recovery and decreased time to discharge with equivalent opioid usage. The improved effect of the 12 mg dose has raised the question of whether even higher doses should be used. The effectiveness of the drug among patients undergoing laparoscopic surgery or epidural analgesia, techniques associated with both decreased incidence and duration of postoperative ileus, has not been studied, and therefore the effectiveness of alvimopan in such scenarios is uncertain.
Introduction: Multiple factors are thought to contribute to the pathogenesis of postoperative ileus (POI), one of which may be the action of opioid analgesics on μ-opioid receptors in the GI tract. Alvimopam is a peripherally acting antagonist of the μ receptor, and acts in the GI tract to attenuate the antimotility effects of opioid analgesics.
Objectives: The present study was performed to evaluate the efficacy and safety of alvimopan (6 or 12 mg) for the management of POI in patients undergoing partial bowel resection with primary anastomosis or radical hysterectomy.
Trial Design: Multicenter, randomized, placebo-controlled, double-blinded, parallel-group study.
Inclusion Criteria: ≥18 years of age, scheduled to undergo a partial small- or large-bowel resection with primary anastomosis or radical total abdominal hysterectomy (rTAH), scheduled to receive postoperative pain management with intravenous patient-controlled analgesia with opioids, and scheduled to have the nasogastric tube (NGT) removed at the end of surgery.
Exclusion Criteria: Epidural analgesia, NGT insertion after surgery, ileostomy or colostomy, surgical procedure not specified by the protocol, cancellation of surgery.
Intervention: Patients were randomized to receive an oral dose of alvimopan (6 or 12 mg) or identical placebo capsules at least 2 hours before surgery and then twice daily beginning on postoperative day (POD) 1 until hospital discharge, or for a maximum of 7 days of postoperative treatment.
Primary Endpoint: Time to recovery of gastrointestinal function, as defined by the latter of two events: time until patient tolerated solid food, or time until either flatus or bowel movement (BM).
Secondary Endpoints: Time (in hours) from the end of surgery to first flatus, first BM, tolerance of solid food, ready for hospital discharge (based solely on the recovery of GI function as defined by the surgeon), and time to discharge order written.
Sample Size: 510 patients from 34 North American centers were randomized, 165 to placebo, 169 to 6 mg alvimopan, and 176 to 12 mg alvimopan.
Statistical Analysis: Cox proportional-hazards model, Kaplan–Meier cumulative survival curve, modified intention-to-treat (MITT) analysis.
Baseline Data: Baseline characteristics were similar between groups. Fewer patients underwent small bowel resection in the placebo group. Forty-one patients were excluded from analyses, 16 from the placebo group and 25 from the two treatment arms. The remaining 469 patients comprised the MITT population.
Primary: The time to recovery of GI function was significantly accelerated by alvimopan at 6 mg (105 vs. 120 hours, p < 0.05) and 12 mg doses (98 hours, p < 0.001).
Secondary: Time to hospital discharge was decreased in both alvimopan groups, by 13 hours for the 6-g group (p 0.070) and by 20 hours for the 12-mg group (p 0.003) compared with the placebo group. The average opioid consumption was similar between all groups.
Conclusion: In patients undergoing open bowel resection or radical hysterectomy, alvimopan speeds recovery of GI function and time to hospital discharge.
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