Measures to prevent prolonged postoperative ileus
- Jörg C Kalff, MD
Jörg C Kalff, MD
- Professor of Surgery
- University Medical Center, Bonn
- Sven Wehner, PhD
Sven Wehner, PhD
- Professor of Immune Pathophysiology
- University Medical Center, Bonn
- Babak Litkouhi, MD
Babak Litkouhi, MD
- Assistant Professor
- Yale School of Medicine
Prolonged postoperative ileus can increase patient pain and discomfort, contributes to prolonged hospitalization, and is a significant burden on the health care system.
There are few effective strategies for managing prolonged postoperative ileus once established, and, thus, a more effective overall strategy minimizes factors that may precipitate or exacerbate the condition (table 1).
Measures used to prevent the development of prolonged postoperative ileus are reviewed here. The epidemiology, clinical features, diagnosis, and supportive care of postoperative ileus, and prolonged postoperative ileus, are reviewed elsewhere. (See "Postoperative ileus".)
PROLONGED POSTOPERATIVE ILEUS
Prolonged postoperative ileus is said to occur when the patient has symptoms or signs of paralytic ileus (obstipation and intolerance of oral intake) that persist for more than three to five days (depending on the nature of the surgery and what is considered "typical"), without evidence for mechanical bowel obstruction or other postoperative complications. (See "Postoperative ileus", section on 'Physiologic versus pathologic postoperative ileus' and "Postoperative ileus", section on 'Diagnosis'.)
Prolonged postoperative ileus can increase patient pain and discomfort and decreases patient satisfaction with the surgical outcome . Prolonged delays in oral feeding can compromise postoperative nutrition, which can lead to greater postoperative catabolism, poor wound healing, susceptibility to infection, and the need for nutritional support [2,3]. These problems contribute to prolonged hospitalization and are a significant burden on the health care system [4-7].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Kehlet H, Holte K. Review of postoperative ileus. Am J Surg 2001; 182:3S.
- Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ 2001; 323:773.
- Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg 1992; 216:172.
- Livingston EH, Passaro EP Jr. Postoperative ileus. Dig Dis Sci 1990; 35:121.
- Waldhausen JH, Schirmer BD. The effect of ambulation on recovery from postoperative ileus. Ann Surg 1990; 212:671.
- Clevers GJ, Smout AJ, van der Schee EJ, Akkermans LM. Myo-electrical and motor activity of the stomach in the first days after abdominal surgery: evaluation by electrogastrography and impedance gastrography. J Gastroenterol Hepatol 1991; 6:253.
- Prasad M, Matthews JB. Deflating postoperative ileus. Gastroenterology 1999; 117:489.
- Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg 2007; 104:689.
- Marret E, Remy C, Bonnet F, Postoperative Pain Forum Group. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J Surg 2007; 94:665.
- Kuruba R, Fayard N, Snyder D. Epidural analgesia and laparoscopic technique do not reduce incidence of prolonged ileus in elective colon resections. Am J Surg 2012; 204:613.
- Guay J, Nishimori M, Kopp S. Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery. Cochrane Database Syst Rev 2016; 7:CD001893.
- Uemura K, Tatewaki M, Harris MB, et al. Magnitude of abdominal incision affects the duration of postoperative ileus in rats. Surg Endosc 2004; 18:606.
- Böhm B, Milsom JW, Fazio VW. Postoperative intestinal motility following conventional and laparoscopic intestinal surgery. Arch Surg 1995; 130:415.
- Abraham NS, Young JM, Solomon MJ. Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer. Br J Surg 2004; 91:1111.
- Schwenk W, Böhm B, Haase O, et al. Laparoscopic versus conventional colorectal resection: a prospective randomised study of postoperative ileus and early postoperative feeding. Langenbecks Arch Surg 1998; 383:49.
- Lacy AM, García-Valdecasas JC, Piqué JM, et al. Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer. Surg Endosc 1995; 9:1101.
- Cagnacci A, Pirillo D, Malmusi S, et al. Early outcome of myomectomy by laparotomy, minilaparotomy and laparoscopically assisted minilaparotomy. A randomized prospective study. Hum Reprod 2003; 18:2590.
- Basse L, Madsen JL, Billesbølle P, et al. Gastrointestinal transit after laparoscopic versus open colonic resection. Surg Endosc 2003; 17:1919.
- Zhou ZG, Hu M, Li Y, et al. Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer. Surg Endosc 2004; 18:1211.
- Camilleri M. Alvimopan, a selective peripherally acting mu-opioid antagonist. Neurogastroenterol Motil 2005; 17:157.
- Wolff BG, Michelassi F, Gerkin TM, et al. Alvimopan, a novel, peripherally acting mu opioid antagonist: results of a multicenter, randomized, double-blind, placebo-controlled, phase III trial of major abdominal surgery and postoperative ileus. Ann Surg 2004; 240:728.
- Delaney CP, Wolff BG, Viscusi ER, et al. Alvimopan, for postoperative ileus following bowel resection: a pooled analysis of phase III studies. Ann Surg 2007; 245:355.
- Herzog TJ, Coleman RL, Guerrieri JP Jr, et al. A double-blind, randomized, placebo-controlled phase III study of the safety of alvimopan in patients who undergo simple total abdominal hysterectomy. Am J Obstet Gynecol 2006; 195:445.
- Senagore AJ, Bauer JJ, Du W, Techner L. Alvimopan accelerates gastrointestinal recovery after bowel resection regardless of age, gender, race, or concomitant medication use. Surgery 2007; 142:478.
- Delaney CP, Craver C, Gibbons MM, et al. Evaluation of clinical outcomes with alvimopan in clinical practice: a national matched-cohort study in patients undergoing bowel resection. Ann Surg 2012; 255:731.
- Traut U, Brügger L, Kunz R, et al. Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults. Cochrane Database Syst Rev 2008; :CD004930.
- Smith, L. FDA's strongest REMS to date: Entereg approved with controlled-distribution. The Pink Sheet 2008; 70:6.
- Holzer P. Treatment of opioid-induced gut dysfunction. Expert Opin Investig Drugs 2007; 16:181.
- Yuan CS, Wei G, Foss JF, et al. Effects of subcutaneous methylnaltrexone on morphine-induced peripherally mediated side effects: a double-blind randomized placebo-controlled trial. J Pharmacol Exp Ther 2002; 300:118.
- Neyens R, Jackson KC 2nd. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. J Pain Palliat Care Pharmacother 2007; 21:27.
- Yu CS, Chun HK, Stambler N, et al. Safety and efficacy of methylnaltrexone in shortening the duration of postoperative ileus following segmental colectomy: results of two randomized, placebo-controlled phase 3 trials. Dis Colon Rectum 2011; 54:570.
- Kalff JC, Schraut WH, Simmons RL, Bauer AJ. Surgical manipulation of the gut elicits an intestinal muscularis inflammatory response resulting in postsurgical ileus. Ann Surg 1998; 228:652.
- Josephs MD, Cheng G, Ksontini R, et al. Products of cyclooxygenase-2 catalysis regulate postoperative bowel motility. J Surg Res 1999; 86:50.
- Cheng G, Cassissi C, Drexler PG, et al. Salsalate, morphine, and postoperative ileus. Am J Surg 1996; 171:85.
- Sinatra RS, Jahr JS, Reynolds L, et al. Intravenous acetaminophen for pain after major orthopedic surgery: an expanded analysis. Pain Pract 2012; 12:357.
- Rushfeldt CF, Sveinbjørnsson B, Søreide K, Vonen B. Risk of anastomotic leakage with use of NSAIDs after gastrointestinal surgery. Int J Colorectal Dis 2011; 26:1501.
- Klein M, Krarup PM, Burcharth J, et al. Effect of diclofenac on cyclooxygenase-2 levels and early breaking strength of experimental colonic anastomoses and skin incisions. Eur Surg Res 2011; 46:26.
- Hollenbeck BK, Miller DC, Taub D, et al. Identifying risk factors for potentially avoidable complications following radical cystectomy. J Urol 2005; 174:1231.
- Chapuis PH, Bokey L, Keshava A, et al. Risk factors for prolonged ileus after resection of colorectal cancer: an observational study of 2400 consecutive patients. Ann Surg 2013; 257:909.
- Artinyan A, Nunoo-Mensah JW, Balasubramaniam S, et al. Prolonged postoperative ileus-definition, risk factors, and predictors after surgery. World J Surg 2008; 32:1495.
- de Jonge WJ, van den Wijngaard RM, The FO, et al. Postoperative ileus is maintained by intestinal immune infiltrates that activate inhibitory neural pathways in mice. Gastroenterology 2003; 125:1137.
- Wilson JP. Postoperative motility of the large intestine in man. Gut 1975; 16:689.
- Condon RE, Frantzides CT, Cowles VE, et al. Resolution of postoperative ileus in humans. Ann Surg 1986; 203:574.
- Graber JN, Schulte WJ, Condon RE, Cowles VE. Relationship of duration of postoperative ileus to extent and site of operative dissection. Surgery 1982; 92:87.
- Nisanevich V, Felsenstein I, Almogy G, et al. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005; 103:25.
- Corcoran T, Rhodes JE, Clarke S, et al. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg 2012; 114:640.
- Ngowe MN, Eyenga VC, Kengne BH, et al. Chewing gum reduces postoperative ileus after open appendectomy. Acta Chir Belg 2010; 110:195.
- Shang H, Yang Y, Tong X, et al. Gum chewing slightly enhances early recovery from postoperative ileus after cesarean section: results of a prospective, randomized, controlled trial. Am J Perinatol 2010; 27:387.
- Abd-El-Maeboud KH, Ibrahim MI, Shalaby DA, Fikry MF. Gum chewing stimulates early return of bowel motility after caesarean section. BJOG 2009; 116:1334.
- Asao T, Kuwano H, Nakamura J, et al. Gum chewing enhances early recovery from postoperative ileus after laparoscopic colectomy. J Am Coll Surg 2002; 195:30.
- Matros E, Rocha F, Zinner M, et al. Does gum chewing ameliorate postoperative ileus? Results of a prospective, randomized, placebo-controlled trial. J Am Coll Surg 2006; 202:773.
- Quah HM, Samad A, Neathey AJ, et al. Does gum chewing reduce postoperative ileus following open colectomy for left-sided colon and rectal cancer? A prospective randomized controlled trial. Colorectal Dis 2006; 8:64.
- Schuster R, Grewal N, Greaney GC, Waxman K. Gum chewing reduces ileus after elective open sigmoid colectomy. Arch Surg 2006; 141:174.
- Lim P, Morris OJ, Nolan G, et al. Sham feeding with chewing gum after elective colorectal resectional surgery: a randomized clinical trial. Ann Surg 2013; 257:1016.
- Shum NF, Choi HK, Mak JC, et al. Randomized clinical trial of chewing gum after laparoscopic colorectal resection. Br J Surg 2016; 103:1447.
- Choi H, Kang SH, Yoon DK, et al. Chewing gum has a stimulatory effect on bowel motility in patients after open or robotic radical cystectomy for bladder cancer: a prospective randomized comparative study. Urology 2011; 77:884.
- Chan MK, Law WL. Use of chewing gum in reducing postoperative ileus after elective colorectal resection: a systematic review. Dis Colon Rectum 2007; 50:2149.
- Fitzgerald JE, Ahmed I. Systematic review and meta-analysis of chewing-gum therapy in the reduction of postoperative paralytic ileus following gastrointestinal surgery. World J Surg 2009; 33:2557.
- Ertas IE, Gungorduk K, Ozdemir A, et al. Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial. Gynecol Oncol 2013; 131:118.
- Li S, Liu Y, Peng Q, et al. Chewing gum reduces postoperative ileus following abdominal surgery: a meta-analysis of 17 randomized controlled trials. J Gastroenterol Hepatol 2013; 28:1122.
- Noble EJ, Harris R, Hosie KB, et al. Gum chewing reduces postoperative ileus? A systematic review and meta-analysis. Int J Surg 2009; 7:100.
- Basse L, Thorbøl JE, Løssl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004; 47:271.
- Basse L, Madsen JL, Kehlet H. Normal gastrointestinal transit after colonic resection using epidural analgesia, enforced oral nutrition and laxative. Br J Surg 2001; 88:1498.
- Hansen CT, Sørensen M, Møller C, et al. Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double-blind, placebo-controlled randomized study. Am J Obstet Gynecol 2007; 196:311.e1.
- Mangesi L, Hofmeyr GJ. Early compared with delayed oral fluids and food after caesarean section. Cochrane Database Syst Rev 2002; :CD003516.
- Sculati O, Bardi M, et al. A simple method for resolving postoperative ileus in an early stage in obstetric and gynecological surgery. Curr Ther Res 1981; 29:997.
- Sculati O, Giampiccoli G, Gozzi B, et al. Bran diet for an earlier resolution of post-operative ileus. J Int Med Res 1982; 10:194.
- Brown SR, Cann PA, Read NW. Effect of coffee on distal colon function. Gut 1990; 31:450.
- Rao SS, Welcher K, Zimmerman B, Stumbo P. Is coffee a colonic stimulant? Eur J Gastroenterol Hepatol 1998; 10:113.
- Glatzel H, Hackenberg K. [Effects of caffeine containing and decaffeinated coffee on the digestive functions. X-ray studies of the secretion and peristalsis of stomach, intestines and gallbladder]. Med Klin 1967; 62:625.
- Boekema PJ, Samsom M, van Berge Henegouwen GP, Smout AJ. Coffee and gastrointestinal function: facts and fiction. A review. Scand J Gastroenterol Suppl 1999; 230:35.
- Boekema PJ, Lo B, Samsom M, et al. The effect of coffee on gastric emptying and oro-caecal transit time. Eur J Clin Invest 2000; 30:129.
- Sloots CE, Felt-Bersma RJ, West RL, Kuipers EJ. Stimulation of defecation: effects of coffee use and nicotine on rectal tone and visceral sensitivity. Scand J Gastroenterol 2005; 40:808.
- Müller SA, Rahbari NN, Schneider F, et al. Randomized clinical trial on the effect of coffee on postoperative ileus following elective colectomy. Br J Surg 2012; 99:1530.
- Tollesson PO, Cassuto J, Faxén A, et al. Lack of effect of metoclopramide on colonic motility after cholecystectomy. Eur J Surg 1991; 157:355.
- Jepsen S, Klaerke A, Nielsen PH, Simonsen O. Negative effect of Metoclopramide in postoperative adynamic ileus. A prospective, randomized, double blind study. Br J Surg 1986; 73:290.
- Cheape JD, Wexner SD, James K, Jagelman DG. Does metoclopramide reduce the length of ileus after colorectal surgery? A prospective randomized trial. Dis Colon Rectum 1991; 34:437.
- Bonacini M, Quiason S, Reynolds M, et al. Effect of intravenous erythromycin on postoperative ileus. Am J Gastroenterol 1993; 88:208.
- Smith AJ, Nissan A, Lanouette NM, et al. Prokinetic effect of erythromycin after colorectal surgery: randomized, placebo-controlled, double-blind study. Dis Colon Rectum 2000; 43:333.
- Myrhöj T, Olsen O, Wengel B. Neostigmine in postoperative intestinal paralysis. A double-blind, clinical, controlled trial. Dis Colon Rectum 1988; 31:378.
- Hallerbäck B, Carlsen E, Carlsson K, et al. Beta-adrenoceptor blockade in the treatment of postoperative adynamic ileus. Scand J Gastroenterol 1987; 22:149.
- Ferraz AA, Wanderley GJ, Santos MA Jr, et al. Effects of propranolol on human postoperative ileus. Dig Surg 2001; 18:305.
- Disbrow EA, Bennett HL, Owings JT. Effect of preoperative suggestion on postoperative gastrointestinal motility. West J Med 1993; 158:488.
- Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2005; :CD004929.
- Sim R, Cheong DM, Wong KS, et al. Prospective randomized, double-blind, placebo-controlled study of pre- and postoperative administration of a COX-2-specific inhibitor as opioid-sparing analgesia in major colorectal surgery. Colorectal Dis 2007; 9:52.
- PROLONGED POSTOPERATIVE ILEUS
- EFFECTIVE AND POTENTIALLY EFFECTIVE INTERVENTIONS
- Midthoracic epidural
- Minimally invasive surgery
- Peripheral acting mu-opioid receptor antagonists
- Limiting opioid use
- Surgical technique
- Restriction of perioperative fluid administration
- Chewing gum
- Multimodal fast-track programs and laxatives
- INEFFECTIVE OR UNPROVEN INTERVENTIONS
- Early enteral nutrition
- Other dietary manipulations
- - Bran
- - Coffee
- Other pharmacologic treatments
- Early ambulation
- Visceral learning
- POTENTIALLY HARMFUL INTERVENTIONS
- Routine nasogastric tube placement
- COX-2 inhibition
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS