Platinum Priority – Review – Bladder CancerEditorial by Mathew C. Raynor and Raj S. Pruthi on pp. 598–599 of this issueDefinition, Incidence, Risk Factors, and Prevention of Paralytic Ileus Following Radical Cystectomy: A Systematic Review
Introduction
Despite major improvements in perioperative patient care, radical cystectomy (RC) continues to be associated with a high complication rate [1], [2], [3]. One of the most common complications is postoperative paralytic ileus (POI) [2], [3], [4], [5]. Transient cessation of bowel activity is expected following major abdominal surgery with small bowel motility and gastric emptying returning quite quickly (within 24 and 48 h, respectively). Large bowel recovery, however, is typically more protracted, taking up to 3–5 d to resume activity [6], [7]. Despite the expectation of diminished intestinal motility following surgery, the period without signs of bowel function often extends beyond what is acceptable and is then diagnosed as POI.
POI has been mainly studied in patients undergoing general abdominal surgery. It has been shown to prolong the length of stay (LOS) by days to weeks and is associated with increased morbidity and costs [8], [9], [10]. Estimates of incidence vary in the general surgery literature, and clinical trials have been conducted to identify strategies to prevent POI. A meta-analysis of the effect of postoperative gum chewing revealed a decrease in the rate of POI and LOS [11]. A Cochrane review of the effect of prokinetic agents on POI found that certain medications reduce time to flatus and duration of hospital stay [12]. Epidural anesthesia, in contrast to opiate use, was found to reduce POI but not length of hospital stay [13]. Alvimopan, a peripherally acting μ-opioid receptor antagonist, was found to reduce time to flatus as well as accelerate time to hospital discharge [14]. Finally, early commencement of oral fluids has been shown to reduce time to bowel sounds and solid diet intake and has demonstrated improvement toward shorter hospital stays [15].
To improve our understanding of POI as it relates specifically to RC patients, we conducted a systematic review of the evidence base on POI for patients undergoing RC. We sought to capture the reported incidence of POI, interventions to prevent POI, and risk factors for POI among RC populations. We also include standardized care pathways that, although they do not examine a specific intervention, have similarly been used to optimize gastrointestinal (GI) recovery and/or the incidence of POI.
Section snippets
Evidence acquisition
We conducted a systematic review of Medline from 1966 to February 2011 in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines [16] using the following search criteria:
- 1.
Medical Subject Headings (MeSH) terms: cystectomy, preoperative care or intraoperative care or postoperative care or perioperative care or postoperative period or intraoperative complications or postoperative complications
- 2.
Ovid text word terms: preoperative care or intraoperative care or
Overview
Initially, our search yielded 727 potentially relevant publications (Fig. 1). The titles of all 727 results were reviewed, and if the publication could not be eliminated based on title alone, the abstract was subsequently reviewed. The remaining 332 manuscripts were reviewed in full to determine eligibility. A total of 77 articles contained data in accordance with the eligibility criteria.
From these 77 articles, we identified 13 793 patients who underwent RC and who were noted to have
Conclusions
The incidence and definition of POI after RC is highly variable. An improved reporting strategy is needed to identify true incidence and risk factors and, most important, to guide future research for both potential preventive and therapeutic interventions.
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