The effect of laparoscopy and/or fast track multimodal management on postoperative gastrointestinal motility after
colonic surgery.
SH van Bree1, MS Vlug2, WA Bemelman2, MW Hollmann3, WJ de Jonge1, SA Snoek1, EP van der Zanden1, FO The1, RJ
Bennink4, GE Boeckxstaens1,5. Department of 1Gastroenterology, 2Surgery, 3Anesthesiology, 4Nuclear Medicine, Academic
Medical Center, Amsterdam, the Netherlands. 5Department of Gastroenterology, University Hospital Leuven, Catholic
University of Leuven, Leuven, Belgium.
Postoperative ileus is a major determinant of recovery after colorectal surgery characterized by delayed gastrointestinal (GI)
transit. Both laparoscopic surgery (Lap) and fast track multimodal perioperative care (FT) have been reported to improve
recovery. However, randomized trials comparing the effect on postoperative GI motility are lacking. The aim of this trial is to
determine whether FT and Lap lead to faster recovery of GI transit after colonic surgery, and to evaluate the relationship
between GI transit and clinical recovery.
Patients requiring segmental colectomy for malignant colorectal disease were invited to participate in this randomized controlled
trial. Patients were randomized to FT- or Standard care, and to Lap- or Open colectomy. Primary endpoint was GI transit.
Secondary endpoints were clinical signs/symptoms of GI motility, recorded daily until discharge. 24 h after surgery, patients
underwent a solid gastric emptying test (99m-Tc labelled pancake, 115 Kcal) and ingested 60 ml of indium-111 labelled water to
assess colonic transit on postoperative day 2 and 3. The latter is represented as geometrical center (GC) of activity (segment
0=small intestine, 1=proximal colon, 2=distal colon, 3=toilet).
In total 93 patients were randomized to one of the 4 treatment groups. 22 patients had to be excluded because of
protocol violations or major surgical complications. Patients undergoing Lap FT had a significantly higher colonic
GC (0-3) on postoperative day 3 (median 2.6; IQR (2.0-2.9)) compared to Lap Standard (2.2; (1.6-2.5), p=0.044),
Open FT (2.0; (1.6-2.4), p=0.010) and Open Standard (1.3; (1.0-1.5), p<0.001). Similarly, the Lap FT group
recovered significantly better and had a shorter time to first defecation compared to the other 3 treatment groups.
However, gastric retention 24 h after surgery did not differ between groups (p=0.613). Clinical recovery correlated
significantly with colonic GC at day 3 (r= -0.42, p<0.001;Spearman’s rank correlation).
Conclusions: Colonic transit, but not gastric emptying, recovers significantly faster after Lap FT compared to the
other 3 treatment groups, leading to a more rapid clinical recovery. These data provide objective information that
Lap FT is the surgical procedure of choice with the fastest recovery of GI function after colorectal surgery.
Table 1
Colonic GC day 3
Indium defecated day 3, %
Days until discharge
Lap FT
(n=18)
2.6 (2.0-2.9)
70 (19-94)
3.9 (3.0-4.8)
First defecation, h
27 (18-53)
Gastric retention day 1, %
70 (36-94)
Lap Standard
(n=17)
Open FT Open Standard
(n=18)
(n=18)
P*
2.2 (1.6-2.5) 2.0 (1.6-2.4) 1.3 (1.0-1.5) <0.001
p=0.044
37 (0-58)
p=0.010
26 (0-57)
0 (0-0)
p=0.043
p=0.001
5.0 (3.9-9.5) 5.9 (5.0-7.0)
p=0.027
p=0.001
55 (44-71)
45 (25-74)
p=0.014
81 (34-95)
p<0.001
58 (26-71)
6.0 (5.0-8.5)
0.002
<0.001
p<0.001
90 (52 -107)
0.007
p=0.003
58 (31-100)
0.613
Data are median (IQR). p: significant difference (p<0.05) compared to Lap FT, Mann-Whitney U test. *Kruskal-Wallis test