Fast-track Pathway for Minimally Invasive Colorectal Surgery with and without Alvimopan (Entereg) TM : Which is More Cost-effective? SCOTT R. KELLEY, M.D.,* BRUCE G. WOLFF, M.D.,* JENNA K. LOVELY, PHARM.D.,† DAVID W. LARSON, M.D.* From the *Department of Colon and Rectal Surgery and †Hospital Pharmacy Services, Mayo Clinic, Rochester, Minnesota Multimodal fast-track (FT) pathways for both open and laparoscopic colorectal surgery have been shown to improve gastrointestinal recovery, shorten length of stay, and decrease morbidity. The aim of our study was to determine if using alvimopan (Entereg)ä in the setting of a FT minimally invasive colorectal pathway is beneficial and cost-effective. All minimally invasive colorectal surgeries performed by one surgeon using a multimodal FT pathway with and without alvimopan were reviewed. Ninety total patients were identified, 64 patients treated without and 26 with alvimopan. Main outcomes included postoperative day tolerating a soft diet, return of gastroin- testinal function, length of stay, 30-day readmission rate, and patient care, anesthesia, pharmacy, and combined cost. Tolerance of a soft diet, return of gastrointestinal function, and length of stay were all shorter and showed significance in the alvimopan group (mean 2.1 vs 2.8 days, mean 1.5 vs 2.4 days, and mean 3.5 vs 4.5 days, respectively) (P 5 0.0197, P 5 0.0029, and 0.0158, respectively). Patient care and combined hospital costs were both increased in the nonalvimopan group; how- ever, combined hospital costs was not significant (P 5 0.0216 and P 5 0.0875, respectively). The 30-day readmission rate of 6.3 per cent was also not significant in this group (P 5 0.0941). Patients undergoing minimally invasive colorectal surgery treated with a multimodal FT pathway toler- ated a soft diet sooner, had earlier return of bowel function, a shorter length of stay, and lower patient care and combined costs when alvimopan was used. P OSTOPERATIVE ILEUS (POI) after open and laparo- scopic bowel resection is a common adverse event known to prolong recovery, extend length of stay, and increase resource use and costs. 1 Accelerated, en- hanced recovery and fast-track pathways have recently started gaining acceptance showing an improved return of gastrointestinal function, shortened length of stay, and decreased morbidity. 2–4 Alvimopan (Entereg) TM is a peripherally acting m-opioid receptor antagonist that blocks the enteric effects of opioids while preserving the central m-opioid receptor analgesic activity. Ap- proved for decreasing POI, alvimopan has been shown to promote an earlier return of gastrointestinal func- tion and reduce overall costs as well as hospital length of stay by nearly one day. 5, 6 To date no reports have been published specifically evaluating minimally in- vasive colorectal surgery and the cost-effectiveness of using a multimodal fast-track pathway with and without alvimopan. 7 The aim of our study was to determine if using alvimopan in the setting of a fast-track mini- mally invasive colorectal pathway is beneficial and cost-effective. Methods Using a prospectively maintained database, a retro- spective review of all minimally invasive (laparoscopic or hand-assisted) surgeries performed by one co- lorectal surgeon (B.G.W.) using a multimodal fast- track pathway between 2006 and 2011 was conducted. All patients who were older than or equal to 18 years of age and had undergone a minimally invasive colorectal surgery and were treated in a fast-track pathway were candidates for study eligibility. Exclusions included age younger than 18 years, conversion to an open procedure, patients treated outside of the multimodal fast-track recovery protocol, pregnancy, chronic opioid use greater than seven days, and colonic inertia. The multimodal fast-track recovery protocol at our institution was introduced in 2006 and includes: 1) preoperative patient education focusing on recovery expectations; 2) no use of abdominal drains; 3) use of nonopioid analgesia with a cornerstone of scheduled Address correspondence and reprint requests to Scott R. Kelley, M.D., Department of Surgery, TriHealth–Good Samaritan Hospi- tal, 375 Dixmyth Avenue, Cincinnati, OH 45220. E-mail: scott_ kelley@trihealth.com. 630