© Springer International Publishing Switzerland 2015
Molly Blackley Jackson, Somnath Mookherjee and Nason P. Hamlin (eds.)The Perioperative Medicine Consult Handbook10.1007/978-3-319-09366-6_4747. Postoperative Ileus
(1)
Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
Background
It is normal for patients postoperatively to have “physiologic” gastrointestinal (GI) tract dysmotility. Some degree of dysmotility is expected in all patients following intra-abdominal surgery. Without treatment, it is expected to last 3–6 days following major abdominal surgery [1, 2]. GI tract dysmotility may also occur following thoracic, orthopedic, urologic, and gynecologic operations if somatovisceral reflexes are activated intraoperatively [2].
Ileus, on the other hand, is the state of prolonged dysmotility beyond the expected time frame. As one of the most common postsurgical complications, ileus occurs in 3–30 % of patients following various types of abdominal operations [3]. Clinically, this manifests as the absence of flatus or bowel movement; abdominal distension associated with pain, nausea, and emesis; and the inability to tolerate oral intake. This not only increases patient discomfort, dissatisfaction, and immobility but also increases hospital stay duration by 4–6 days thereby increasing direct health-care costs by approximately $9,000 per hospital stay [3, 4]. The economic consequences of postoperative ileus (POI) following abdominal surgery on the US health-care system are estimated to reach close to $1.5 billion annually [3].
It is unknown why physiological postoperative GI tract dysmotility progresses to POI in some patients. It is likely a multifactorial process, and several mechanisms have been suggested, including autonomic nervous system dysfunction, inhibitory autonomic neural reflexes, inflammatory cytokines, gastrointestinal neurohumoral peptides, systemic opioids, and surgical technique [1, 2].
Preoperative Evaluation
It is difficult to predict which patients will develop POI, but the medicine consultant can anticipate that selected patients are at increased risk and should consider initiating preventative strategies. The following risk factors for POI have been identified:
Perioperative Management
Effective Strategies to Prevent POI
Epidural local anesthetic: Mid-thoracic infusion for 2–3 days postoperatively reduces spinal inhibitory neural reflexes to the gut, thereby blunting the surgical stress response and decreasing the need for systemic opiates, and has been shown to accelerate the return of bowel function by 1–2 days [8]. This intervention has mostly been studied with intra-abdominal surgeries including vascular, gynecologic, and urologic procedures.
Alvimopan (peripherally acting mu-opioid receptor antagonist): Multiple trials have shown decreased time to first stool and tolerance of diet, as well as shortened hospital stay durations [9]. However, due to concern for cardiovascular and neoplastic adverse effects, its use is currently limited to short-term use (15 doses), particular hospitals, and only to patients following bowel resection with primary anastomosis.
Postoperative gum chewing: Meta-analyses reveal shortened time to first flatus and stool and decreased length of stay, with no increase in complications [10].
Avoidance/reduction of systemic opioids: Opiate use increases the risk of POI [5]; acetaminophen, NSAIDs, tramadol, and other non-opioid pain medications can minimize the need for opioids. NSAIDs must be used with caution due to potential gastrointestinal and renal toxicity. Preemptive use of medications to prevent central sensitization, such as gabapentin and dexamethasone, appears to be effective in minimizing postoperative pain if initiated before surgery [11, 12].
Multimodal surgical fast-track programs: Programs used in elective colon surgery show that thoracic epidural analgesia combined with laxatives, early feeding, and early mobilization can achieve normal bowel function within 48 h postoperatively [13].
Potentially Effective Strategies to Prevent POI
Minimally invasive and minimally traumatic surgical techniques: Laparoscopic surgery is associated with a shorter time to recovery of bowel function although it is not clear if this is because of the technique itself or because patients need less opiate pain control postoperatively [14].
Laxative use: Data are limited but suggest benefit with no obvious harm. One trial following hysterectomy found the scheduled use of magnesium oxide laxative significantly minimized time to first bowel movement [15].
Restrictive fluid management: One study showed that restrictive fluid management shortened duration of POI [7].
Postoperative coffee consumption: One small study showed earlier time to first flatus and first bowel movement following open colectomy with postoperative coffee consumption [16].
Unproven Strategies to Prevent POI
Early postoperative feeding: Some patients may suffer nausea or vomiting, but overall, early feeding does not appear harmful and may reduce the length of the hospital stay [17].
Early mobilization: Only one study has evaluated early ambulation and it did not find earlier time to bowel recovery [18].
Promotility agents: Metoclopramide, erythromycin, and neostigmine have not shown any benefit [1]. Cisapride, however, did show benefit but has been pulled from the US market because of reports of cardiac arrhythmias [1].
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