American journal of surgery
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Opioid bowel dysfunction (OBD) is a common adverse effect associated with opioid therapy. OBD is commonly described as constipation; however, it is a constellation of adverse gastrointestinal (GI) effects, which also includes abdominal cramping, bloating, and gastroesophageal reflux. The mechanism for these effects is mediated primarily by stimulation of opioid receptors in the GI tract. ⋯ There are 2 peripherally selective opioid receptor antagonists, methylnaltrexone and ADL 8-2698 (Adolor Corporation, Exton, PA, USA), that are currently under investigation for their use in treating OBD. Early studies confirm that they are effective at normalizing bowel function in opioid-treated patients without entering the central nervous system and affecting analgesia. With a better understanding of the prevalence of OBD and its pathophysiology, a more aggressive approach to preventing and treating OBD is possible and will likely improve the quality of life of patients with pain.
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Opioids are widely used analgesics in patients with advanced cancer. However, their effectiveness for pain relief is often limited by the most frequently occurring side effect, opioid bowel dysfunction (OBD). Because conventional laxation measures are often ineffective in treating OBD, alternative approaches need to be investigated. ⋯ Bioavailability of MNTX is low after oral administration, and plasma levels do not correlate with its actions in the gut, suggesting a predominantly local luminal action of MNTX on the gut. In patients receiving long-term opioid therapy, MNTX administered intravenously or orally was effective in reducing the delay in oral-cecal transit and eliciting laxation responses in all subjects without causing withdrawal symptoms. MNTX is a peripherally selective opioid antagonist that may have clinical utility in managing OBD with minimal adverse effects.
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Failure of arterial serum lactate to achieve normal levels has been associated with an increased mortality among medical and trauma patients. At our institution the ability of the patient to normalize arterial serum lactate has been utilized as an end point of resuscitation. In this study, we examine the correlation between length of time to lactate normalization and mortality. ⋯ Prolongation of lactate clearance is associated with increasing mortality. Failure of a patient to normalize lactate is associated with 100% mortality. Measurement of arterial serum lactate is a simple and effective predictor of outcome and end point of therapy.
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Full thickness rectal prolapse in young adults with normal pelvic floor is a disease in which the rectum is exceedingly long and mobile. Surgical treatment should correct both anatomical defects by combined rectopexy and colonic resection, which is expected to be less constipating than rectopexy alone. The aim of this study was to describe an original procedure of rectopexy to the pelvic floor with prosthetic material combined with sigmoid resection, and to evaluate prospectively anatomical and functional results. ⋯ In young adults with rectal prolapse and normal pelvic floor undergoing prosthetic rectopexy and sigmoid resection (a) morbidity was low, (b) anatomical control was obtained in all cases, (c) emptying problems were corrected, and (d) deleterious effects are likely to occur if they had no constipation before operation or if rectal compliance was previously altered.
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The current attractiveness of neoadjuvant chemotherapy lies in its ability to downstage both the primary tumor and the axilla, making many patients good candidates for breast-conserving surgical techniques. This has been an important achievement in a patient group whose tumors are often considered inoperable. Attention has more recently turned to the use of neoadjuvant chemotherapy in patients with operable tumors. ⋯ Axillary irradiation may provide adequate regional control in patients who are clinically node negative. In addition, sentinel lymph node dissection has been shown to provide accurate assessment of the axilla in patients who have received neoadjuvant chemotherapy. An important ramification of the concept of neoadjuvant chemotherapy is that surgery that takes place after the completion of systemic therapy can become minimally invasive, accomplished in an outpatient setting without the need for an operating room suite.