Cancer incidence increases exponentially with age and often requires surgical intervention. As one ages, there can be decreased salivary flow, decreased absorptive capacity of intestinal cells, decreased acid secretion, as well as decreased gastric motility.

Aging is accompanied by an increase in body fat, a decrease in lean body mass, and a decrease in total body water, which can affect drug distribution, half-life, and elimination. The kidneys’ main function is to eliminate excess body fluid and waste, and though this function may be intact, often the ability to eliminate some medications may decrease by 50% or more, which leads to high blood concentrations.

Careful lab analysis of BUN and creatinine levels can assist in determining postoperative drug dosing. Gastric motility and emptying related to the surgical procedure, especially during abdominal surgery, can be absent for up to 24 hours with the duration of ileus, continuing for days following the procedure.

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Surgical trauma, manipulation of the intestines, loss of blood flow, and electrolyte imbalance during surgery all can negatively affect a patient’s return to normal motility patterns.1-3

There are numerous problems associated with decreased bowel motility. One of the more serious consequences is the risk of aspiration as food and fluids accumulate in the stomach, thus increasing the risk for aspiration. Elderly patients have a decrease in esophageal function and weaker gag reflex, which also can contribute to the risk of aspiration.1

In peritoneal surface malignancies, which include malignant peritoneal mesothelioma, appendicle and colorectal malignances often disseminate throughout the peritoneum. A cornerstone of treatment has been cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy resulting in delayed gastric motility as one of its major complications.

One reason for this is that the omentum, as well as other organs, is sacrificed in an attempt to completely eradicate disease during the CRS procedure. Though it is poorly understood why, patients undergoing this procedure have delayed motility preservation of the right gastric epiploic omental artery (GEA), whose gastric branch supplies blood to both sides of the stomach as well as omental branches.

It was thought that removal of the GEA might have a positive effect on eliminating this complication. Unfortunately a randomized trial did not conclude that preserving this artery had any effect.6

Studies have yet to be conducted investigating the role of intraoperative chemotherapy as a compounding factor. One theory is that the common use of cisplatin that has a well-known side effect of neurotoxicity may negatively impact the nerve stimulation necessary for peritstatilis to take place, but further research is needed to confirm this hypothesis.

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Trends in the management of post-operative delayed gastric emptying include early enteral feeding, mitigating opioid use, limiting the use of routine nasogastric tubes, early ambulation, epidural anesthesia, and laproscopic surgery when possible. A review of the literature suggests that more prospective trials are needed to ameliorate this postoperative complication.4.5

References

  1. Fong ZV, Ferrone CR, Thayer SP, et al. Understanding hospital readmissions after pancreaticoduodenectomy: can we prevent them?: a 10-year contemporary experience with 1,173 patients at the Massachusetts General Hospital. J Gastrointest Surg. 2014;18(1):137-144.
  2. van Berge Henegouwen MI, van Gulik TM, DeWit LT et al. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients. J Am Coll Surg. 1997;185(4):373-379.
  3. Räty S, Sand J, Lantto E, Nordback I. Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy. J Gastrointest Surg. 2006;10(8):1131-1139.
  4. Enestvedt CK, Diggs BS, Cassera MA, et al. Complications nearly double the cost of care after pancreaticoduodenectomy. Am J Surg. 2012;204(3):332-338.
  5. van Bree SH, Vlug MS, Bemelman WA, et al. Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Gastroenterology. 2011;141(3):872-880.e1-4.
  6. Evers DJ, Smeenk RM, Bottenberg PD, et al. Effect of preservation of the right gastro-epiploic artery on delayed gastric emptying after cytoreductive surgery and HIPEC: a randomized clinical trial. Eur J Surg Oncol. 2011;37(2):162-167.

Topics:

Gastrointestinal Cancer General Oncology Side-Effect Management