Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 64595

AbstractMaterial and MethodsResultsDiscussionConclusionReferences
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2008 | Month : December | Volume : 2 | Issue : 6 | Page : 1163 - 1168

Neostigmine In Unavoidable Post Operative Ileus: A Randomized Clinical Trial

FANAEI SA *,KHATAMI SM **,ZIAEE SA***

*Asst.ProfofSurgery,**ProfessorofVascular Surgery,Dept.ofSurgery,Baqiyatallah University of Medical Science,Tehran,(Iran),***Biostaticsandanalyst,Medical Doctor,Erfan Hospital.

Correspondence Address :
Dr Ziaee,Endo.Surgical Office,3rd Floor,Erfan Hospial,Bakshayesh Str., West Sarv Sq., Sadat Abad 1998884349 Tel&Fax:098 21 22357142 Email :Sali_ziaee@yahoo.com

Abstract

Background: This study was aimed to show the effective way to decrease the rate of postoperative ileus.
Design: Prospective clinical randomized trial of neostigmine in 42 patients with ileus after abdominal surgery.
Intervention: Intravenous administration of 2.5 mg of neostigmine in 500 N/S over 30 min, or placebo. Patients who had no response to the initial injection were eligible to receive open-label neostigmine three hours later.
Settings: Abdominal circumference, time to first flatus and defecation, HR and BP after 3 hours of administration, and radiographic colonic measurements were recorded. Patients were followed for recurrence of ileus. All organic causes of ileus excluded from the study.
Results: 20 out of 21 neostigmine patients (95.23%) passed flatus and stools with first administration of Neostigmine administration, whereas none of the placebo-treated patients passed stools (P < 0.001). In pre study abdominal circumference, there was no significant difference, whereas after 3 hours of intervention, it was decreased significantly (100.85 ±14.61 case group, 124.71 ± 16.15, P<0.0001). No acute serious adverse effects occurred in both groups.
Conclusion: In patients with acute colonic pseudo-obstruction who have not had a response to conservative therapy, treatment with neostigmine rapidly decompresses the colon.

Keywords

Neostigmine, Post Operative, Ileus

Introduction
Postoperative ileus (POI), in the absence of any mechanical obstruction, remains a commonly encountered clinical problem; it is often considered an unavoidable consequence of major abdominal surgery and of other types of surgery as well. The idea that POI is “unavoidable”, may be changing. Consistent, effective mitigation, and possibly even prevention of POI, may soon become attainable goals of standard approaches to perioperative care. On the other hand, the important aspect of our study, is the economic burden of POI. One recent attempt to study the prevalence and economic burden of POI, used data from the year 2002 from Premier’s Perspective™ Comparative Database, which includes 5 million discharges annually(1).

Data from controlled trials have shown that many of the methods used to date in an effort to mitigate POI—for example, use of nasogastric intubation, administration of metoclopramide, delay of solid diet—cannot be relied on, to shorten the duration of POI. So, this study was aimed to show the effective way to decrease the rate of postoperative ileus (POI).

Material and Methods

Patients
Patients with acute colonic pseudo-obstruction, who were 18 years of age or older, were recruited for the study between August 2007 and February 2008, from inpatient medical and surgical wards of hospitals affiliated with the University of Baqiyatallah. Acute colonic pseudo-obstruction was defined as marked colonic distention in the absence of mechanical obstruction. To be eligible for the study, patients had to have a caecal diameter of at least 10 cm on plain radiographs(2). Mechanical obstruction was ruled out by the finding of air throughout all colonic segments including the rectosigmoid, on plain abdominal radiographs. When air was not demonstrable in the rectosigmoid colon, mechanical obstruction was ruled out by radiographical contrast enemas. Patients were enrolled in the study if colonic distention, documented by clinical examination and abdominal radiographs, failed to improve after 24 hours of conservative management that included administering nothing by mouth, nasogastric suction, and intravenous fluid and electrolyte replacement. Any drug that could adversely affect colonic motility, specifically narcotics and anticholinergic agents, was discontinued when possible. One patient, who was subsequently randomly assigned to the placebo group, was enrolled after only 18 hours of conservative therapy, when the consulting gastroenterologist determined that urgent decompression was warranted.

Exclusion criteria included a base-line heart rate of less than 60 beats per minute or systolic blood pressure of less than 90 mm Hg; signs of bowel perforation with peritoneal signs on physical examination or free air on radiographs; active bronchospasm requiring medication; treatment with prokinetic drugs such as cisapride or metoclopramide in the 24 hours before evaluation; a history of colon cancer or partial colonic resection; active gastrointestinal bleeding; pregnancy; a positive history of myocardial infarction and intestinal resection or a serum creatinine concentration of more than 3 mg per deciliter (265 µmol per liter).
The Human-Subjects Committee of the University of Baqiyatallah and its affiliated hospitals approved the study protocol. All patients provided written informed consent.

Study Design
Patients were randomly assigned (by flipping a coin) to receive 2.5 mg of neostigmine intravenously in 500 ml of normal saline over a period of thirty minutes or identical-appearing saline placebo. The injections were given by a physician who was unaware of the patient’s treatment assignments. All patients were monitored by electrocardiography; atropine was available at the bedside, and 1.0 mg was given intravenously as needed, for symptomatic bradycardia. Patients were instructed to remain supine for at least 60 minutes after the injection. Vital signs were recorded immediately before the injection, and five minutes and three hours afterwards.

The physician administering the infusion monitored the clinical response for 30 minutes after the injection. The maximal abdominal circumference and the diameter of the caecum, ascending colon, and transverse colon on plain radiographs, were measured before and three hours after the injection by an investigator who was unaware of the patient’s treatment assignments.

Three hours after the infusion, patients who did not have a reduction in colonic distention on both clinical examination and radiographs, were eligible to receive open-label neostigmine (2.5 mg intravenously) administered by a physician who was unaware of the identity of the study drug. The three-hour period was chosen because of the short half-life of neostigmine. Three hours later, abdominal circumference, colonic diameters, and clinical response were again measured. Patients were monitored for adverse effects during the initial treatment and during open-label treatment, and were then followed for the remainder of their hospitalization. The treatment assignments were not revealed to the investigators, treating physicians, or patients until the last patient had been discharged from the hospital.

Statistical Analysis
On the basis of prior reports, we estimated that 22 patients would be required in each group for the study, to have the power at an alpha level of 0.05, with a beta error of 0.2, to detect a significant difference between groups, assuming a response rate of 80 percent in the neostigmine group (CI: 73-100% , 95%, 91% in previous studies) and 30 percent in the placebo group. We used Fisher's exact test to compare the frequency of clinicalresponses and treatment failures in the two groups. We evaluated the changes in abdominal circumference and colonic diameters with the use of students T test and U Mann-Whitney for non parametric variables. All tests were two-tailed.

Assessment of Outcomes
The outcomes assessed, included an immediate clinical response to the study drug, changes in abdominal girth and colonic diameters on abdominal radiographs three hours after treatment, and the need for colonoscopic decompression or surgery during hospitalization. An immediate clinical response was defined as the passage of flatus or stool with a reduction in abdominal distention on physical examination, within 30 minutes after the injection. Treatment was considered to have failed if open-label neostigmine, colonoscopic or surgical intervention, or both were required because of the recurrence or persistence of colonic distention.


Results

Two patients were excluded from the study. Refused consent and a base-line heart rate of less than 60, were the reasons for exclusion. Twenty one patients were randomly assigned to receive neostigmine, and 21 to receive a saline placebo. All patients had acute abdominal distention. The two groups were similar with regard to age, sex, duration and degree of colonic distention, use of narcotics and anticholinergic medications, history of recent surgical procedures, and severity of illness (Table/Fig 1). The underlying surgical diagnoses included laparoscopic cholecystectomy in 8 patients, laparoscopic appendectomy in 10 patients, total knee replacement in 5 patients and total hip replacement in 3 patients, amputation of diabetic foot in 2 patients, prostatectomy in 11 patients, lumbar laminectomy, exploratory laparotomy after a gunshot wound, and open reduction of multiple fractures with internal fixation, in one patient each.

After treatment, there was prompt evacuation of flatus or stool with a reduction in abdominal distention on physical examination in 20 patients in the neostigmine group (95.23 percent), and none in the placebo group (P<0.001) (Table/Fig 2). The median time to response was 6 minutes (range, 3 to 30). There were also significant reductions in abdominal circumference and colonic diameters in the neostigmine group as compared to the placebo group (Table/Fig 2).

Treatment was considered to have failed in one patient who received neostigmine (4.7 percent), and in fifteen who received placebo (71.42 percent, P=0.04). Only the one patient (5%) in the neostigmine group had no immediate clinical response to initial treatment, but did have a response to open-label therapy, with no recurrence of dilation.

None of the patients required colonoscopic decompression for recurrence of colonic distention.

One of the 15 patients who were assigned to the placebo group did not respond to open-label therapy again. At the discretion of their attending physicians, the patient was treated with conservative measures alone, and colonic distention gradually resolved over the next 48 to 72 hours.

Of the sixteen patients who received open-label therapy, one had previously received neostigmine, and fifteen had received placebo. The majority of patients had an immediate clinical response, and none required colonoscopic or surgical decompression. Of the 37 patients who received neostigmine, either initially or during open-label treatment, 36 (97 percent) had an immediate clinical response, and 1 (3 percent) had recurrent colonic dilation (Table/Fig 3).

The most frequent adverse effect of neostigmine treatment was abdominal pain, which occurred in 9 patients; it was described as mild cramping by 5 patients, and as moderate-to-severe cramping by the other 4. In all patients, the abdominal pain was transient and had no sequelae. Eight patients had excessive salivation, and four vomited. Symptomatic bradycardia requiring atropine occurred in one patient, who felt lightheaded within minutes after the infusion. None of the patients in the placebo group had an adverse effect.


Discussion

The definition of POI universally is discussed (3),(4) Notably, POI also can be associated with other abdominal and nonabdominal procedures (5),(6),(7). Causative factors are thought to be related directly to the surgical procedure itself. Neurogenic (sympathetic hyperactivity), inflammatory (cellular and hormonal factors, including endogenous opioid peptides) and hormonal factors, all play some role in the maintenance of POI, prolonging its duration and/or leading to an increase in pain, distention, and other symptoms (8). However, we restrict our data to POI. Based on this fact, various approaches have appeared over the years in an attempt to reduce POI, and to involve all surgical-team members to a greater or lesser degree.

Fast-track strategies should include only methods or pharmacologic agents that have been documented as effective in helping to reduce the duration of POI, or to diminish the risk of its development. Despite widespread belief that metoclopramide reduces POI, there are no data from randomized controlled trials to support this notion(3). However, extensive reviews of trials and clinical experience have found that NG intubation does not improve POI, and indeed, may exacerbate it[ 9]. Removal of NG tubes after anaesthesia is recommended to avoid other adverse effects, which can include pneumonia, as well as fever, atelectasis, and an increase in the number of days to toleration of solid diet[ 5]. Cisapride does in fact improve POI; however, this drug is no longer available in the United States and some countries, because it increases the risk for serious adverse cardiac effects(10). The absolute benefit of laxatives with respect to helping reduce POI remains unproven; studies have shown variable results(3). A study of aggressive postoperative bowel stimulation with magnesium hydroxide showed an early return (3 days) of bowel function following radical hysterectomy(11).

We found that neostigmine decompressed the colon in patients, with acute colonic pseudo-obstruction better than in previous studies(12). The rate of failed attempt was much lesser than in other studies(12),[13,(14),(15).The last study with 2 mg of neostigmine was too small to evaluate the effect of neostigmine treatment on the risk of colonic perforation and mortality(12). The dose of neostigmine (2.5 mg), its efficacy and no difference in complication rates, are benefits of our study in comparison of other studies. However, our results confirm those of uncontrolled studies(13),(14),(15).



Conclusion

We honestly declare that the use of parasympathomimetic agents such as neostigmine is not without risk. Patients with underlying bradyarrhythmias or those receiving β-adrenergic antagonists may be more susceptible to neostigmine-induced bradycardia. Similarly, neostigmine increases airway secretions and bronchial reactivity, which may exacerbate active bronchospasm. Recently, it was discovered that a new class of drugs—peripherally acting mu-opioid receptor antagonists—may help enhance multimodal management of POI.

Although the cost benefit of the new class of drugs is debated it has been suggested that the individual components of multimodal protocols—for example, laparoscopy—may reduce certain post surgical morbidities (including POI), but do not by them prevent POI. Therefore, combinations of strategies with demonstrated effectiveness—early feeding (16), epidural analgesia, laparoscopic surgery, and use of peripherally acting mu-opioid-receptor antagonists—may help transform the reactive approach to POI, into a proactive multimodal paradigm that effectively targets the diverse aetiologic factors leading to this common clinical problem (12).


References

1.
. Saunders WB, Bowers B, Moss B, Bell TJ, Wang PF. Recorded rate and economicburden associated with postoperative ileus. Paper presented at: American Societyof Health-System Pharmacists Midyear Clinical Meeting; 2004; Orlando, Fla. Abstract 30346.
2.
. Robert J. Ponec, Michael D. Sauders D., Michael B. Kimmey Neostigmine for The treatment of Acute Colonic Pseudo-Obstruction 1999; 341/3:137-41
3.
. Holte K, Kehlet H. Postoperative ileus: progress towards effective management. Drugs. 2002; 62:2603-15.
4.
. Kehlet H, Holte K. Review of postoperative ileus. Am J Surg. 2001; 182(5Asuppl):3S-10S.
5.
. Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg.2000; 87:1480-93.
6.
. Schuster TG, Montie JE. Postoperative ileus after abdominal surgery. Urology. 2002; 59:465-71.
7.
. Bederman SS, Betsy M, Winiarsky R, Seldes RM, Sharrock NE, Sculco TP.Postoperative ileus in the lower extremity arthroplasty patient. J Arthroplasty.2001; 16:1066-70.
8.
. Steinbrook R. Postoperative ileus: why we should treat. Contemporary Surgery.2005; 61(suppl):4-7.
9.
. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg.1995; 221:469-476; discussion 476-78.
10.
. Theodore J. Saelarides. Integrating new agent for postoperative ileus into multimodals protocols. Contemprary Surgery. 2006; (suppl): 15-20
11.
. Fanning J, Yu-Brekke S. Prospective trial of aggressive postoperative bowel stimulation following radical hysterectomy. Gynecol Oncol. 1999; 73:412-14.
12.
. Ponec RJ, Michael D Saundres and Michael B. Kimmey . Neostigmine for the treatment of the treatment of acute colonic pseudo-obstructin. N Engl J M 1999; 341:3:137-41.
13.
. Hutchinson R, Griffiths C. Acute colonic pseudo-obstruction: a pharmacologicalapproach. Ann R Coll Surg Engl 1992; 74:364-7.
14.
. Stephenson BM, Morgan AR, Salaman JR, Wheeler MH. Ogilvie’s syndrome:a new approach to an old problem. Dis Colon Rectum 1995; 38:424-7.
15.
. Turegano-Fuentes F, Munoz-Jimenez F, Del Valle-Hernandez E, et al.Early resolution of Ogilvie’s syndrome with intravenous neostigmine: asimple, effective treatment. Dis Colon Rectum 1997; 40:1353-7.
16.
. S.A. Fanaie, S.A. Ziaee Safety of early oral feeding after gastrointestinal anastomosis : A Randomized Clinical Trial .Indian J Surg . 2005 67; 4: 185-88.

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com