Multi-institutional outcomes and cost effectiveness of using alvimopan to lower gastrointestinal morbidity after cystectomy and urinary diversion.
BACKGROUND
Radical cystectomy is associated with significant morbidity and cost, with rates of gastrointestinal complications as high as 30%. Alvimopan is a mu opioid receptor antagonist that has been shown in randomized-control trials to accelerate gastrointestinal recovery in patients undergoing bowel resection with primary anastamosis. We report our experience with gastrointestinal recovery for patients undergoing cystectomy with urinary diversion treated with alvimopan and cost benefit associated.


METHODS
Between January 2008 and October 2012, 80 patients underwent radical cystectomy with urinary diversion at two institutions. Forty-two patients in our study did not receive alvimopan preoperatively. Thirty-eight patients received perioperative alvimopan and were without postoperative nasogastric decompression. Return of bowel function, initiation of diet, and gastrointestinal complications and estimated cost of hospitalization were evaluated.


RESULTS
Times to first flatus (3.1 days versus 4.7 days, p < 0.01, 95% CI 0.96-2.24) and bowel movement (3.9 days versus 4.9 days, p < 0.01, 95% CI 0.45-1.55) were significantly shorter in those patients who received alvimopan. Additionally, the initiation of clear liquid diet (4.1 days versus 5.5 days, p < 0.01, 95% CI 0.70-2.10), regular diet (5.2 days versus 6.3 days, p < 0.01, 95% CI 0.39-1.81) and hospital discharge (6.1 days versus 7.7 days, p = 0.04, 95% CI 0.01-3.21) were accelerated in the alvimopan cohort. There were no incidences of prolonged ileus in patients who received perioperative alvimopan (0% versus 26.2%, p < 0.01). With an approximate average cost of alvimopan administration $825 per hospitalization, the average cost benefit of administration over control was $1515 per hospitalization. The cost benefit was mainly a result of a shorter inpatient hospitalization and lack of gastrointestinal morbidity which accumulated a majority of the difference.


CONCLUSIONS
In our experience, the use of alvimopan perioperatively significantly accelerates the rate of gastrointestinal recovery and hospital discharge, eliminates the need for nasogastric tube decompression, and reduces the incidence of post-operative ileus in patients following radical cystectomy and urinary diversion.
Georgetown University Hospital and Washington Hospital Center, Washington, DC USA.
Anup
A
Vora
Daniel
D
Marchalik
Hanaa
H
Nissim
Keith
K
Kowalczyk
Gaurav
G
Bandi
Kevin
K
McGeagh
John
J
Lynch
Krishnan
K
Venkatesan
Reza
R
Ghasemian
Jonathan
J
Hwang
Mohan Verghese
MV
Hwang
D000368:Aged; D003362:Cost-Benefit Analysis; D015653:Cystectomy; D005260:Female; D005765:Gastrointestinal Agents / Q000191:economics / Q000494:pharmacology; D041981:Gastrointestinal Tract / Q000187:drug effects / Q000503:physiopathology* / Q000601:surgery*; D006801:Humans; D045823:Ileus / Q000453:epidemiology; D015994:Incidence; D008297:Male; D059035:Perioperative Period; D010880:Piperidines / Q000191:economics* / Q000494:pharmacology*; D017450:Receptors, Opioid, mu / Q000037:antagonists & inhibitors / Q000187:drug effects; D020127:Recovery of Function / Q000187:drug effects* / Q000502:physiology; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014547:Urinary Diversion
D005765:Gastrointestinal Agents; D010880:Piperidines; D017450:Receptors, Opioid, mu; C419502:alvimopan