From the Guidelines
The management of postoperative 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 consensus guidelines 1. This approach is supported by the latest evidence, which emphasizes the importance of minimizing postoperative ileus through a combination of these strategies 1. Key components of this approach include:
- Minimally invasive surgery, which has been shown to lead to faster return of bowel function and reduced duration of postoperative ileus 1
- Optimized fluid management, which involves balancing adequate resuscitation with avoidance of fluid overload, aiming for a weight gain limited to < 3 kg at postoperative day three 1
- Opioid-sparing analgesia, which can help reduce the risk of postoperative ileus by minimizing the use of opioids, which can worsen ileus 1
- Early mobilization, which stimulates bowel motility and can help reduce the duration of postoperative ileus 1
- Early postoperative food intake, which can help stimulate the gastrocolic reflex and promote bowel function, with small portions offered initially, especially after right-sided resections and small-bowel anastomosis 1
- Laxative administration, which may help promote bowel function, although the evidence for this is limited 1
- Omission or early removal of nasogastric intubation, which can help reduce the duration of postoperative ileus by avoiding unnecessary stimulation of the gut and promoting early oral feeding 1. By prioritizing this multifaceted approach, clinicians can help minimize the risk of postoperative ileus and improve outcomes for patients undergoing surgery 1.
From the FDA Drug Label
Postoperative ileus is the impairment of gastrointestinal motility after intra-abdominal surgery or other, non-abdominal surgeries. The management approach for postoperative ileus includes the use of alvimopan, a selective antagonist of the cloned human µ-opioid receptor, which antagonizes the peripheral effects of opioids on gastrointestinal motility and secretion by competitively binding to gastrointestinal tract µ-opioid receptors.
- Key points:
- Alvimopan is administered orally, 12 mg twice daily, starting at least 30 minutes and up to 5 hours prior to the scheduled start of surgery.
- A standardized accelerated postoperative care pathway is implemented, including early nasogastric tube removal, early ambulation, and early diet advancement.
- The primary endpoint for the management of postoperative ileus is the time to achieve resolution of postoperative ileus, a clinically defined composite measure of both upper and lower gastrointestinal recovery.
- Clinical decision: The use of alvimopan, in combination with a standardized accelerated postoperative care pathway, may help to reduce the duration of postoperative ileus and improve gastrointestinal recovery after surgery 2.
From the Research
Management Approach for Postoperative Ileus
The management of postoperative ileus involves a multi-modal approach to resolve the temporary cessation of bowel motility, a common complication of major surgery 3. The traditional approach includes:
- Opioid minimization
- Early ambulation
- Early feeding
Newer Medications
Newer medications, such as methylnaltrexone and alvimopan, which are peripherally acting mu opioid receptor antagonists, have been found to be beneficial in the management of postoperative ileus 3, 4. Alvimopan has been shown to accelerate gastrointestinal recovery after bowel resection or hysterectomy in phase III trials 4.
Treatment Options
The treatment options for postoperative ileus also include early refeeding, gum chewing, and the use of tube feeds 5. Experimental drugs are also being developed to prevent or shorten the course of ileus.
Enhanced Recovery After Surgery (ERAS) Protocols
ERAS protocols, minimally invasive surgical approaches, and the use of specific pharmaceutical therapies have been introduced to improve the quality of perioperative care and reduce perioperative morbidity and length of stay 6. The ERAS pathway and laparoscopic approach have been found to be effective in reducing patient morbidity and promoting early return of gut function.
Challenges and Limitations
Despite the availability of these treatment options, the use of alvimopan is limited due to its potential complications and cost 7. Therefore, the management of postoperative ileus remains a challenging clinical problem, and further research is needed to develop effective and cost-effective treatment strategies.