Enhanced Recovery: A Team Approach to Managing Postoperative Ileus - Episode 6

Postoperative Ileus: Use of Alvimopan

Raoul Concepcion, MD: We’ve all talked about the technique, decreased bowel manipulation, the effect of epidurals, long-acting and short-acting anesthetics, and opioids. We know that there are a couple of agents that are out there. One agent is alvimopan, which has been approved for patients that have a bowel anastomosis, right? You have a tremendous amount of experience with this, Traci. Can you comment on this a little bit?

Traci Hedrick, MD, MS, FACS, FACRS: Alvimopan is an opioid antagonist. It is designed to mitigate the effects of opioids on the gastrointestinal tract without interfering with its ability to control pain. It’s been studied in 3 large randomized controlled trials on, primarily, patients undergoing colorectal resection, but also some in gynecologic surgery. All of these were with patients undergoing open surgery. They were also receiving opioids through patient controlled analgesia. But, the data demonstrate reductions in length-of-stay, primarily mediated through reductions in the development of postoperative ileus.

The drug has been FDA approved for quite some time. We use it in our enhanced recovery pathway. We use it in both open and laparoscopic procedures. I think the data are not clear, however, in the modern-day enhanced recovery program where we’re using very little opioids, if it has the same effect as in the original studies. I think that’s something that needs to be studied. But it’s certainly something that we are using, and I think when you look at the national data, on average, in colorectal, about 20% to 30% of surgeons are using it, nationally.

Raoul Concepcion, MD: The trade name is Entereg?

Traci Hedrick, MD, MS, FACS, FACRS: Entereg, yes.

Raoul Concepcion, MD: It’s an oral agent, correct?

Traci Hedrick, MD, MS, FACS, FACRS: That’s right.

Raoul Concepcion, MD: You had mentioned that the early studies were in open surgery, for patients that were concomitantly also getting opioids postoperatively as part of their analgesia?

Traci Hedrick, MD, MS, FACS, FACRS: Right.

Raoul Concepcion, MD: Did the approval change? I thought it was only approved early on for small bowel anastomoses. But it’s across the board now, correct?

Traci Hedrick, MD, MS, FACS, FACRS: It’s primarily used for large bowel anastomoses. I know a lot of urologists use it as well, so it’s been widely approved for gastrointestinal surgery. I know it has been widely adopted.

Raoul Concepcion, MD: Declan, how do you dose it preoperatively, perioperatively at your institution?

Declan Fleming, MD: Clearly, we begin prior to the time of the operation. We give a preoperative dose at around the time that we give the carbohydrate load drink—so, within a couple hours of the initiation of the operation. Then, it’s dosed BID (twice a day). Depending on when in the day we do the operation, if the person is taking clear liquids in the postoperative period during the same day, we’ll even begin to give the first postoperative dose on the day of the operation. But then it’s twice daily after that. Typically, it’s given for around 7 days. Various places are doing it differently. We’ll usually go ahead and stop the medication after a person has resumption of good bowel function. But, there are different places that will actually give the treatment for the full 7 days, regardless of when the person begins to have bowel function. How’s that done at your institution, Traci?

Traci Hedrick, MD, MS, FACS, FACRS: We give it preoperatively, and twice a day until discharge. Then, we stop it at the time of discharge.

Raoul Concepcion, MD: And, again, it’s an oral agent?

Traci Hedrick, MD, MS, FACS, FACRS: Oral agent.

Raoul Concepcion, MD: And now, so many patients come in the day of surgery. They’re basically taking it at the hospital, right? Before they’re doing that, right?

Traci Hedrick, MD, MS, FACS, FACRS: Right.

Raoul Concepcion, MD: So, it’s 1 dose. Is it the same dose that’s given preoperatively as postoperatively?

Traci Hedrick, MD, MS, FACS, FACRS: Yes, 12 mg.

Raoul Concepcion, MD: And, again, you’re basically giving it through a set number of days. I’m sure everybody is a little bit different. Some may stop it after bowel function returns?

Sanjay Patel, MD: Yes, that’s what we do. We wait until return of bowel function, or 7 days—whichever is earlier.

Declan Fleming, MD: The amount of time a patient spends in the hospital after they’ve had resumption of bowel function, especially after colon surgery, is so short. It’s almost concomitant, right?

Raoul Concepcion, MD: Right.

Traci Hedrick, MD, MS, FACS, FACRS: Yes. Our average length-of-stay is 3 days. So, the vast majority are not getting it for the full 7 days.

Transcript edited for clarity.