Alvimopan Accelerates Gastrointestinal Recovery After Radical Cystectomy: A Multicenter Randomized Placebo-Controlled Trial

Lamb

et al. 2017

European Urology Focus

In-depth critical analysis of complications following robot-assisted radical cystectomy with intracorporeal urinary diversion. European Urology Focus, (doi:10.1016Focus, (doi:10. /j.euf.2016 This is the author's final accepted version.There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.http://eprints.gla.ac.uk/145598/ RESULTS AND LIMITATIONSThe 90-day all complication rate following ileal conduit and continent diversion was 68% and 82.4% while major complications were 21.0% and 20.6% respectively. 90-day mortality was 3% and 2.9% for ileal conduit and continent diversion patients respectively. On multivariate analysis, blood transfusion requirement was independently associated with major (p=0.002) and all 30-day (p=0.002) and 90-day major complications (p=0.012) while male patients were associated with 90-day major complications (p=0.015). Critical analysis identified surgical complications was responsible for 39.4% of all 90-day major complications. PATIENT SUMMARYIn this report, we looked at the surgical outcomes in bladder cancer patients treated with minimal invasive robotic surgery. We found that surgical complications account for most major complications and previous surgical experience may be a confounding factor when interpreting results from different center even in a randomised trial setting.

Section: Discussionmentioning

confidence: 99%

In-depth Critical Analysis of Complications Following Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion

Lamb

et al. 2017

European Urology Focus

“…As seen in a recent RCT, alvimopan was associated with improved bowel recovery, shorter hospital stay, and reduced postoperative 30-day complications after RC and urinary diversion in patients with BC [6]. It counteracts the effects of opioids in the gut thus preventing the development of delayed GI transit.…”

Section: Discussionmentioning

confidence: 79%

“…Lee at al. did not comment on how many screened patients were excluded from the study and why these patients did not qualify for randomization [6]. Our objective was to identify current clinical practice patterns and outcomes of alvimopan use at a high-volume cancer center and determine why patients did not receive the drug in an appropriately indicated surgical setting.…”

Section: Discussionmentioning

confidence: 99%

“…It was initially reported to accelerate the recovery of bowel function in patients undergoing partial colectomy or total abdominal hysterectomy (TAH) [5]. In October 2013, the US Food and Drug Administration (FDA) expanded its indication to patients undergoing RC and urinary diversion based on the results of a multi-institutional randomized clinical trial (RCT) [6]. In this prospective study, alvimopan hastened bowel recovery by a median of 1.2 days and shortened median length of stay (LOS) by 1 day.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Clinical utilization patterns of alvimopan in a contemporary cohort of patients undergoing radical cystectomy

Fisher

Zargar‐Shoshtari

Gilbert

et al. 2015

Bladder

OBJECTIVE:To evaluate the clinical utilization patterns and outcomes of alvimopan, a peripherally-acting µ-opioid receptor antagonist, after radical cystectomy (RC) and urinary diversion at a high-volume cancer center. PATIENTS AND METHODS:We retrospectively identified 130 consecutive patients who underwent RC and urinary diversion for bladder cancer at our institution from October 2013 to September 2014. Demographic, clinical, and postoperative outcomes were compared between patients who did and did not receive alvimopan using the Kruskal-Wallis test for medians and the chi-square test for proportions. Predictors of 30-day complications and prolonged length of stay (LOS) were analyzed using multivariate logistic regression analysis. RESULTS:Perioperative alvimopan was given to 81 patients (62.3%) during the study period although in 17 patients (13.1%) it was indicated but not given. The most common absolute or relative contraindication for alvimopan usage was prior consumption of opioids for more than 7 consecutive days (n = 18; 13.8%). Patients who received alvimopan had a better performance status (P = 0.06), less comorbidities (P = 0.08), and were more likely to have minimally-invasive surgery (P = 0.07) although these differences did not reach statistical significance. Alvimopan usage was independently associated with less postoperative 30-day complications (odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.15-0.82; P = 0.015), less high-grade complications (OR: 0.12, 95% CI: 0.044-0.34; P < 0.01), and less prolonged hospitalization > 10 days (OR: 0.28, 95% CI: 0.11-0.72; P = 0.008). CONCLUSIONS:Despite its clinical benefits, alvimopan was under-utilized in RC patients, especially in those with worse baseline health. We recommend its incorporation into standardized protocols to optimize perioperative care.

“…5 Recently Lee and colleagues published a randomized trial of the mu opioid receptor blocker alvimopam in patients undergoing radical cystectomy, showing decreased postoperative ileus and length of stay. 13 While alvimopam works similar to ketamine-based approaches, it does not block Ketamine-based analgesia in robotic rc and diversion opioid effects on the respiratory or central nervous system. Our limited success with these previously described protocols led us to look for another approach to decrease opioid usage.…”

Section: Discussionmentioning

confidence: 99%

Initial experience with ketamine-based analgesia in patients undergoing robotic radical cystectomy and diversion

Jacobsohn¹,

Davis²,

El-Arabi³

et al. 2015

CUAJ

Introduction: We instituted a ketamine-predominant analgesic regimen in the peri-and postoperative periods to limit the effects of narcotic analgesia on bowel function in patients undergoing radical cystectomy. The primary end points of interest were time to return of bowel function, time to discharge, and efficacy of the analgesic regimen. Methods: We performed a retrospective chart review of patients undergoing robotic-assisted laparoscopic cystectomy (RARC) with urinary diversion by a single surgeon at our institution from January 1, 2011 to June 30, 2012. Patients receiving the opioid-minimizing ketamine protocol were compared to a cohort of patients undergoing RARC with an opioid-predominant analgesic regimen. Results: In total, 15 patients (Group A) were included in the ketamine-predominant regimen and 25 patients (Group B) in the opioid-predominant control group. Three patients (19%) in Group A discontinued the protocol due to ketamine side effects. The mean time to bowel movement and length of stay in Group A versus Group B was 3 versus 6 days (p < 0.001), and 4 versus 8 days, respectively (p < 0.001). Group A patients received an average of 13.0 mg of morphine versus 97.5 mg in Group B (p < 0.001). Conclusions:Patients who received our ketamine pain control regimen had a shorter time to return of bowel function and length of hospitalization after RARC. Our study has its limitations as a retrospective, single surgeon, single institution study and the nonrandomization of patients. Notwithstanding these limitations, this study was not designed to show inferiority of one approach, but instead to show that our protocol is safe and efficacious, warranting further study in a prospective fashion.