The relation of d-Pantothenyl alcohol therapy to the resumption of intestinal function postoperatively

The Relation of d-Pantothenyl Alcohol Therapy to the Resumphon of Intestinal Function Postoperatively RALPH G. DEPALMA, M.D., WILLIAM M. REID, M.D. AND HUGH F. FITZPATRICK, M.D., New York, New York

From tbe Surgical

Service,

St. Luke’s

Hospital,

New York

Progress notes including the foIlowing factors were then studied by a separate group of observers: (I) onset of oral feedings; (2) discontinuance of intravenous fluids; (3) onset of audible peristalsis; (4) presence of abdomina1 distention, nausea or vomiting; (3) passage of fIatus; and (6) removal of gastrointestinal tubes.

City, New York.

T

HIS STUDY was designed to evaIuate the routine use of d-PantothenyI aIcohoI to faciIitate the earIy return of intestina1 activity and to prevent paraIytic iIeus in patients who have undergone intra-abdomina1 surgery. Previously reported experimenta data [r,z] and clinica studies [j-5] have seemingIy estabIished a rationa basis for the use of this agent as a safe, effective drug in the prevention of paraIytic iIeus. The sporadic use of this agent in our hospita1 and the diffIcuIty of evaluating its effects in the isoIated cIinica1 situation led us to undertake this study.

RESULTS The return

gery

of intestina1

is sometimes

TABLE OPERATIONS RECEIVIh’G

PERFORMED D-PANTOTHENYL

ON

I EIGHTY-FIVE

PATIEhTS

ALCOHOL

Type of Surgery

MATERIALS AND METHODS

after surto assess. The

function

diffkuIt

OR

$Pantothenyl AIcohoI

PLACEBO

Placebo (no.)

(no.)

Eighty-five patients undergoing intra-abdomina1 operations of varying magnitude were given the drug or a pIacebo, using the double-blind method. The patients were divided into six groups for analysis. (Table I.) Patients used for this study were picked at random from the ward operative scheduIe; however, an attempt was made to keep the number of patients receiving the drug or placebo approximately balanced in each group. UnIabeIed, identical singIe dose ampuIes of drug or placebo were supplied to the ward surgical service. Each patient received his own suppIy of medication in an individua1 container IabeIed d-Pantot.henyI aicohol. The cIinica1 observers were unaware of whether they administered drug or placebo. The drug dosage was standardized at 500 mg. intramuscularly, one and three hours postoperatively and every six hours thereafter until normal intestina1 function was resumed. The most important factor in normaI intcstina1 function was found to be the toIerat.ion of ora feedings; accordingIy, the drug was discontinued when the patient no Ionger required intravenous fluids.

BiIiary ......................... AbdominaI hysterectomy ......... Gastric. ....................... CoIon resections Abdominoperineal............. Right colectomy ............... Miscellaneous major procedures Intestinal obstruction (no bowel resection). ........ Portacaval shunt .............. RadicaI pancreaticoduodenectomy resection .............. MisceIIaneous Iesser procedures Female adnexa (saIpingectomy, oophorectomy).............. Splenectomy.................. Appendectomy. ............... ExpIoratory Iaparotomy and biopsy. .................... Large incisiona hernia ......... Total. .....................

813

22 8

4

I3 8 4 2

2 2

.

.

2

I

1

I

1

4 I I

3

2

I

I

I

5o

35

American Journal of Surgery, Volume 107, June 1964

DePaIma, DAY

ERAGE)

Reid and Fitzpatrick

%

DA)

1

5 0

PLACEBO

0

DRUG

13 CASES 22

CASES

80

I

BOWEL SOUNDS FIRST NOTED

FLATUS PASSED

NAUSEA VOMITING DISTENTION

100 0

PLACEBO

0

DRUG

8 8

CASES

CASES

t

3

2

FLUIDS TOLERATED (ORAL)

%

4

60

I.1 FLUIDS

LVERAGE)

5

100

REQUIRING G.I. INTUBATION PO.

FIG. I. ResuIts of d-PantothenyI aIcoho1 therapy or pIacebo in thirty-five patients undergoing biIiary tract surgery.

! I.V

FLUIDS

BOWEL

FLATUS

NAUSEA

FLUIDS

TOLER-

SOUNDS

PASSED

VOMITING

ATED

FIRST

(ORAL)

NOTED

DISTENTION

REOUIRING G.I. INTUBATION

PO.

FIG. 2. ResuIts of d-PantothenyI aIcoho1 therapy or placebo in sixteen patients undergoing abdominal hysterectomy.

auscuItation of bowe1 sounds cannot aIways be used as a reIiabIe index of intestina1 function. AudibIe peristaIsis may be present very soon after major surgery [6], and effectivesounding peristaIsis may be present in the face of abdomina1 distention, vomiting and x-ray evidence of iIeus. A patient may pass a smaI1 amount of ffatus, but may not be abIe to toIerate ora feedings. Attempts to “progress” such a patient can worsen the situation and may Iead to a fuII-bIown iIeus. The toIeration of ora feedings without nausea, vomiting or abdomina1 distention appears to be the sine qua non of norma intestina1 function. Our resuIts are projected in the form of composite graphs for patients undergoing biIiary tract surgery and hysterectomy in Figures I and 2. In the biIiary surgery group (Fig. I), drugtreated patients received intravenous fIuids for an average of 1.9 days, toIerated ora ffuids at 2. I days and passed ffatus at 2.6 days. PIacebo-treated patients received intravenous tIuids for an average of 1.2 days, toIerated ora ffuids at 1.6 days and passed ffatus at 2.7 days. BoweI sounds were heard in both groups during the frrst postoperative day. The incidence of iIeus in the drug-treated group was 18 per cent, whiIe in the pIacebo-treated group it was 14 per cent. AI1 patients with iIeus were treated with routine nasogastric suction for this condition and a11 responded SatisfactoriIy. In the hysterectomy group, drug-treated patients behaved quite simiIarIy, as can be

noted from Figure 2. In this group, one patient on d-PantothenyI aIcoho1 underwent a radica1 hysterectomy for carcinoma of the cervix and subsequentIy an iIeus deveIoped which Iasted for tweIve days. This case was excIuded from the graphic anaIysis of days averaged. In both groups, resumption of intestina1 function was not hastened by the use of d-PantothenyI aIcoho1. In the gastric surgery group, a11 cases routineIy had nasogastric tubes: contro1 patients toIerated ora feedings at about 3.8 days with one instance of miId iIeus. Drug-treated patients toIerated ora feedings at 4.3 days. No obvious advantage of drug therapy was seen in this group. The patients undergoing abdominoperinea1 resection toIerated ora feedings on the fourth or fifth days, irrespective of drug treatment. CoIostomy function occurred early in both drug and contro1 patients on about the second day. This function occurred whiIe a reIative iIeus existed and the patient was unabIe to tolerate ora feedings. The variabiIity of the patients undergoing misceIIaneous major surgery does not Iend this group to ready comparison. However, the contro1 patient who underwent portacava1 shunt was abIe to toIerate ora feedings on the second postoperative day, whiIe an iIeus deveIoped in the drug-treated patient Iasting five days and required the use of a nasogastric tube for that period of time. The drug-treated 814

Postoperative

Resumption

who underwent radical pancreatopatient tluodenectomv required intravenous fluids for ten d:lys. All those patients undergoing the procedures listed under miscellaneous Iesser procedures \vere able to tolerate oral feedings on their first postoperative day, had passage of flatus on the SCX(Jnd clay, and no ileus developed or regardIess of drug or required intubation, placebo treatment. SUMMARY

AND

CONCLUSIONS

Using the doubie-blind method, d-Pantothenyl alcohol and a placebo were administered to eighty-five surgical patients undergoing intra-abdominal surgery. d-Pantothenyl alcohol did not shorten the time needed for the resumption of normal intestinal activity nor prevent the development of paralytic ileus in this stud\-.

of Intestinal

Function KEI;EKENCES

2. BLY, C. C., IkM;ENESS, F. \v. and ~.4SSl.~I-, L:. s. EKcct of pantothenic acid and inositol :~ldwl to whoIe wheat bread on evacuation time, digestion, and absorption in the upper gastrointestinal tract of dogs. J. Nutriiion, 26: 161, ‘943. 3. K.4KEItA, L. G., DEQUEVEDO, U. G., TICIIL, I’. and KEI~I.I, II. T. Evaluation of ilopan in postoperative abdominal distention. W’est. ./. Surg., 66: 220, 1958. 4. FRAZER, F. W., FLOWE, B. 11. and ANLYOU, 14’. G. d-Pantothenyl alcohol in the management of paralytic iIus. J. A. M. A., 169: ro,+~, 1959. 5. TVROXV, D. D. Treatment and prevention of postoperative paralytic iIcus with d-Pantothenyl alcohol. Clin. Med., 6: 5, 1939. 6. BAKER, L. \$‘. and DUDLEY, H. A. F. Auscultntion of the abdomen in surgical patients. Lancet, 2: $‘,, 1961.