What is the management of postoperative ileus (adynamic ileus)?

From the Guidelines

Management of ileus should prioritize a multifaceted approach, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission or early removal of nasogastric intubation, as recommended by the most recent guidelines 1.

Key Components of Ileus Management

• Optimized fluid management to avoid fluid overload, aiming for a weight gain limited to < 3 kg at postoperative day three 1
• Opioid-sparing analgesia to reduce the risk of worsening ileus
• Early mobilization to stimulate bowel motility
• Early postoperative food intake, with small portions initially, especially after right-sided resections and small-bowel anastomosis 1
• Laxative administration to promote bowel function
• Omission or early removal of nasogastric intubation to reduce the risk of gastric stasis and aspiration

Additional Considerations

• Correction of electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which can worsen ileus
• Identification and treatment of the underlying cause of ileus, such as infection, inflammation, or medication side effects
• Consideration of prokinetic agents, such as metoclopramide or erythromycin, although evidence for their effectiveness is limited
• Use of alvimopan, a μ-opioid receptor antagonist, to accelerate gastrointestinal recovery and reduce the length of stay in patients undergoing open colonic resection with postoperative opioid analgesia 1

Prioritizing Recent and High-Quality Evidence

The most recent and highest quality study, published in 2023, provides the basis for these recommendations 1. This study emphasizes the importance of a multifaceted approach to minimizing postoperative ileus, including optimized fluid management, opioid-sparing analgesia, and early mobilization. By prioritizing these evidence-based recommendations, healthcare providers can improve outcomes for patients with ileus, reducing morbidity, mortality, and improving quality of life.

From the Research

Management of Ileus

• The management of ileus includes addressing the underlying cause and supportive care 2.
• Multiple medical interventions have been proposed, but their effectiveness is uncertain 2.
• A study by the Eastern Association for the Surgery of Trauma found that early enteral nutrition (EEN) facilitates the return of normal bowel function, achieving enteral nutrition goals, and reducing hospital length of stay in patients who have undergone abdominal surgery 2.
• The use of metoclopramide and erythromycin to hasten the resolution of ileus is not recommended due to low levels of evidence and uncertain effectiveness 2, 3.

Medical Interventions

• Erythromycin and metoclopramide are options for gastroparesis, while neostigmine is commonly used for paralytic ileus 3.
• Cholinesterase inhibitors may be safe and effective in treating constipation, but their use is poorly prescribed 4.
• Enteral opioid antagonists may be a promising strategy for patients treated with high doses of opioids during sedation 4.

Supportive Care

• Intravenous fluid resuscitation, analgesia, and determining the need for operative vs. nonoperative therapy are important aspects of supportive care 5.
• Nasogastric tube placement is useful for patients with significant distension and vomiting by removing contents proximal to the site of obstruction 5.
• Bowel management protocols using osmotic laxatives may be safe, but their effectiveness is uncertain 4.