Intervention Review

Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults

  1. Ulrike Traut2,
  2. Lukas Brügger3,
  3. Regina Kunz4,
  4. Christiane Pauli-Magnus5,
  5. Klaus Haug6,
  6. Heiner Bucher7,
  7. Michael T. Koller1,*

Editorial Group: Cochrane Colorectal Cancer Group

Published Online: 23 JAN 2008

Assessed as up-to-date: 22 SEP 2007

DOI: 10.1002/14651858.CD004930.pub3


How to Cite

Traut U, Brügger L, Kunz R, Pauli-Magnus C, Haug K, Bucher H, Koller MT. Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004930. DOI: 10.1002/14651858.CD004930.pub3.

Author Information

  1. 1

    University Hospital Basel, Institute for Clinical Epidemiology, Basel, Switzerland

  2. 2

    University Hospital Basel, Institute of Clinical Epidemiology, Basel, BS, Switzerland

  3. 3

    Inselspital, University of Bern, Department of Visceral and Transplantation Surgery, Bern, Switzerland

  4. 4

    Basler Institute for Clinical Epidemiology, Siegburg, Germany

  5. 5

    University Hospital Basel, Switzerland, Clinical Trail Unit, Basel, Switzerland

  6. 6

    Kantonsspital Luzern, Department of Surgery, Zürich, Switzerland

  7. 7

    University Hospital Basel (USB), Basel Institute for Clinical Epidemiology, Basel, Switzerland

*Michael T. Koller, Institute for Clinical Epidemiology, University Hospital Basel, Hebelstrasse 10, 3rd floor, Basel, CH 4031, Switzerland. MKoller@uhbs.ch.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 23 JAN 2008

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Postoperative adynamic bowel atony interferes with recovery following abdominal surgery. Prokinetic pharmacologic drugs are widely used to accelerate postoperative recovery.

Objectives

To evaluate the benefits and harms of systemic acting prokinetic drugs to treat postoperative adynamic ileus in patients undergoing abdominal surgery.

Search methods

Trials were identified by computerised searches of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and the Cochrane Colorectal Cancer Group specialised register. The reference lists of included trials and review articles were tracked and authors contacted.

Selection criteria

Randomised controlled parallel-group trials (RCT) comparing the effect of systemically acting prokinetic drugs against placebo or no intervention.

Data collection and analysis

Four reviewers independently extracted the data and assessed trial quality. Trial authors were contacted for additional information if needed.

Main results

Thirty-nine RCTs met the inclusion criteria contributing a total of 4615 participants. Most trials enrolled a small number of patients and showed moderate to poor (reporting of) methodological quality, in particular regarding allocation concealment and intention-to-treat analysis. Fifteen systemic acting prokinetic drugs were investigated and ten comparisons could be summarized. Six RCTs support the effect of Alvimopan, a novel peripheral mu receptor antagonist. However, the trials do not meet reporting guidelines and the drug is still in an investigational stage. Erythromycin showed homogenous and consistent absence of effect across all included trials and outcomes. The evidence is insufficient to recommend the use of cholecystokinin-like drugs, cisapride, dopamine-antagonists, propranolol or vasopressin. Effects are either inconsistent across outcomes, or trials are too small and often of poor methodological quality. Cisapride has been withdrawn from the market due to adverse cardiac events in many countries. Intravenous lidocaine and neostigmine might show a potential effect, but more evidence on clinically relevant outcomes is needed. Heterogeneity among included trials was seen in 10 comparisons. No major adverse drug effects were evident.

Authors' conclusions

Alvimopan may prove to be beneficial but proper judgement needs adherence to reporting standards. Further trials are needed on intravenous lidocaine and neostigmine. The remaining drugs can not be recommended due to lack of evidence or absence of effect.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Most prokinetic drugs routinely used to support bowel recovery after major abdominal surgery are not supported by current research evidence

Postoperative ileus (POI) refers to the delayed recovery of bowel function following abdominal surgery. POI may cause major patient discomfort and delayed recovery. Several drugs are commonly used to treat POI but it is unclear which drugs are supported by patient-oriented research.
Many of the 39 studies assessed in this review enrolled only a small number of patients and date back to before 1990. The novel drug alvimopan shortened bowel recovery, but many studies failed to report methodology according to current guidelines. Erythromycin, cholecystokinin, cisapride, dopamine-antagonists, propranolol or vasopressin are not supported due to lack of evidence or absence of effect. Intravenous lidocaine and neostigmine might show to be beneficial, but more evidence is needed.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

對於成人進行腹部手術在術後產生無動性腸阻塞(adynamic ileus)使用全身性促進腸胃蠕動藥理治療(Systemic prokinetic pharmacologic treatment)

術後無動性腸道無力會影響患者接受腹腔手術後的復原情況,目前係廣泛使用促進腸胃蠕動藥理的藥物來促進患者的術後恢復

目標

本研究的主要目的在於評估全身性作用的促進腸胃蠕動藥物對於接受腹部手術患者術後無動性腸阻塞的功效及危害

搜尋策略

利用電腦搜尋Cochrane Central Register of Controlled Trials、MEDLINE、EMBASE和Cochrane Colorectal Cancer Group specialised register等資料庫,以確認納入研究的試驗,被納入研究的試驗與瀏覽的文獻其參考文獻清單也會被追蹤,並與試驗作者進行聯繫

選擇標準

比較全身性使用促進腸胃蠕動藥物和安慰劑或不進行介入性治療效果的隨機性對照平行試驗都會被納入本研究中

資料收集與分析

有4位審閱者會分別獨立的將數據取出並且針對試驗品質進行評估,在需要的時候可以向試驗作者聯繫以取得更多的資訊

主要結論

39個RCT試驗符合本研究的納入標準,其中共有4615位受試者參與試驗,大多數的試驗所納入的受試者人數都較少,並且展現中度至低度的方法學品質,特別是在隱藏分組和意圖治療分析的設計上,有15個全身性作用的促進腸胃蠕動藥物受到研究,並且歸納了10個總結性成果,有6個RCT試驗支持使用Alvimopan藥物,Alvimopan藥物是一種新穎的神經末稍mu類鴉片接受器拮抗劑。但是這些試驗並沒有符合試驗報告規範,且這項藥物仍在開發階段,使用紅黴素(Erythromycin)在所有納入的試驗的結果和成果間具有同質性以及出現了一致性的效果,有一些不夠充分的證據會建議使用膽囊收縮素之類的藥物(cholecystokininlike drugs)、腸胃蠕動促進劑cisapride,多巴胺拮抗劑(dopamineantagonists)、β受體阻斷劑propranolol或血管加壓素(vasopressin)。這些交叉的試驗成果有可能是出現不一致性或是試驗規模太小且缺乏方法學品質,腸胃蠕動促進劑cisapride因為在許多國家都引發心臟方面的不良事件,所以在市面上已經停用,使用Intravenous lidocaine和neostigmine則可能引發一些潛在影響,但是需要更多的臨床試驗證據來顯示使用這些藥物與治療成果的相關性,在試驗中有10個比較結果出現異質性,試驗中並沒有說明主要的藥物不良反應。

作者結論

Alvimopan藥物可能可以發揮功效但是需要更適當的評估來符合報告的標準,也需要針對Intravenous lidocaine和neostigmine進行更多的試驗,其他藥物在缺乏證據及效用的狀況下無法建議進行使用

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

在進行主要腹部手術後常態性的使用促進腸胃蠕動劑可以促進腸道復原,但是近期的研究則提出不同見解,術後腸阻塞(POI)係指在腹部手術後腸道功能延遲復原的症狀,POI可能是造成患者不適和延遲復原的主要原因,有許多藥物是經常被用來治療POI症狀的,但是目前仍無法明確瞭解哪一種藥物受到病患照護導向所支持。39個試驗中有許多試驗只有針對少數患者進行試驗,並且試驗時間發生在1990年以前,新穎的藥物alvimopan可以縮短腸道恢復時間,但是根據現行規範,有許多試驗在報告方法學上所有疏漏,紅黴素、膽囊收縮素藥物(cholecystokinin)、腸胃蠕動促進劑cisapride,多巴胺拮抗劑(dopamineantagonists)、β受體阻斷劑propranolol或血管加壓素(vasopressin)因為缺乏證據和效用因此不建議進行使用,使用Intravenous lidocaine和neostigmine則可能具有一些功效,但是還需要更多證據來證明其效用