Intermountain Healthcare's Enhanced Recovery Protocol for Colon Surgery With and Without Alvimopan Use

Narcotic pain medicines bind mu-opioid receptors in the bowel and delay the return of normal function. Alvimopan is a peripherally acting mu-opioid receptor antagonist that blocks mu-opioid receptors in the gastrointestinal tract but does not compromise central nervous system-mediated opioid-based analgesia. Length of stay is an important surrogate measure of quality after colon surgery and the most common reason for prolonged Length of Stay after abdominal surgery is delayed gastrointestinal recovery (postoperative ileus).

The Food and Drug Administration has approved alvimopan (dosed preoperatively and twice daily postoperatively for up to 15 in-hospital doses) for the acceleration of upper and lower gastrointestinal recovery after partial bowel resection with primary anastomosis. In the 5 phase III alvimopan efficacy trials, a simple standardized accelerated postoperative care pathway was used rather than a comprehensive, multidisciplinary colon surgery care process model that is used by Intermountain Healthcare. In the most recently completed alvimopan phase III trial, the mean postoperative length of stay was 5.2 days whereas the mean length of stay at Intermountain Healthcare is 4.4 days without the addition of alvimopan to the multidisciplinary colon care process model.

This trial will investigate if the addition of alvimopan to the Intermountain Healthcare multidisciplinary care process can decrease length of stay compared with the multidisciplinary care process plus placebo.

Inclusion criteria

• Age > 18
• Patient scheduled to receive opioid-based postoperative pain management ≥ 48 hrs
• Elective colon/rectal resection with anastomosis as primary procedure
• Patient enrolled in multidisciplinary colon care process

Exclusion criteria

• Pregnancy or lactation
• Chronic opioid use or > 3 doses in 7 days prior to surgery
• History of multiple previous abdominal operations, gastrectomy, bariatric surgery, short bowel syndrome
• Complete bowel obstruction
• Patients with end-stage renal disease as defined by the need for dialysis and the commonly accepted threshold for dialysis is a Glomerular Filtration Rate of < 15.
• Patients with severe hepatic impairment (Childs-Pugh class C)
• ASA 4 or 5 (ASA 4 s incapacitating systemic disease that is a constant threat to life)
• Non-English speaking patients