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ALVIMOPAN ADDITION TO ENHANCED RECOVERY PROGRAM SPEEDS RECOVERY FOLLOWING COLORECTAL SURGERY
Charles A. James
*1, Ray S. King
1, Ana De Roo
1, Dana Hayden
1, Evie H. Carchman
1,2,3, Charlea Heise
1, Cristina Sanger
1,2, Elise H. Lawson
1, Julia R. Berian
11Surgery, University of Wisconsin-Madison, Madison, WI; 2VA Medical Center Madison, Madison, WI; 3University of Wisconsin-Madison Carbone Cancer Center, Madison, WI
Background: Enhanced Recovery After Surgery (ERAS) protocols in colorectal surgery aim to optimize perioperative care and improve recovery through evidence-based, multidisciplinary strategies. Alvimopan is an FDA-approved peripheral opioid receptor antagonist that has been associated with improved return of bowel function and decreased hospital stay. We aimed to evaluate the addition of Alvimopan to an existing ERAS protocol on length of stay.
Methods: This is a single institutional retrospective case-control study. Alvimopan was added to an existing ERAS protocol in 2022. Patients with recent opioid use, severe hepatic or renal impairment, pregnancy, breastfeeding, or prior cardiovascular events were not eligible. We included patients undergoing elective colon resection with planned primary anastomosis between May 2022 and August 2024. Patients were excluded if admitted prior to operation for any medical reason besides bowel preparation alone. Patients who received Alvimopan were matched to two control cohorts: (1) contemporaries in the 2022-2024 implementation window who did not receive Alvimopan, and (2) historical controls from 2018-2022. Cases were matched to controls by nearest neighbor propensity matching on ASA score, age, and operation. The primary outcome was postoperative length of stay (LOS); secondary outcomes included rates of ileus – defined as the need for postoperative nasogastric tube placement, as well as rates of SSI, reoperation, and readmission. Multivariable regression was performed to adjust for additional covariates, linear for LOS (continuous outcome), and logistic for ileus.
Results: There were no significant differences between groups with regard to age, race, BMI, ASA class, preoperative diagnosis, or procedure performed. LOS was significantly shorter for Alvimopan cases than controls, both contemporary 3.5 vs 5.1 days (p<0.001) and historic 3.4 vs 4.5 days (p<0.0001). Rates of ileus were lower for Alvimopan cases, contemporary 6% vs 16.4% (p = 0.009) and historic 5.9% vs 12.9% (p = 0.017). There were no differences in the rates of reoperation, readmission or surgical site infections. After multivariable regression adjusting for age, sex, BMI, ASA class, diagnosis, operative approach, case length, and post-discharge disposition, Alvimopan remained significant, reducing LOS by 0.75 to 1.0 days (for historic vs contemporary, respectively) and ileus (OR 0.89 and 0.81, with p = 0.038 and p = 0.003, respectively).
Conclusion: The addition of Alvimopan to an existing ERAS protocol in patients undergoing colorectal surgery is associated with significant additional reductions in both LOS and rates of postoperative ileus. Maintaining a high quality of care requires ongoing attention to existing protocols, adaptations where necessary, and continuous outcomes assessment to demonstrate improvement with those adaptations.
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