What is the treatment for postoperative ileus?

Treatment of Postoperative Ileus

A multifaceted approach including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric tubes should be used to treat postoperative ileus. 1

Definition and Pathophysiology

Postoperative ileus is the impairment of gastrointestinal motility after surgery, affecting all segments of the gastrointestinal tract and lasting from 5-6 days or longer. It is characterized by:

• Abdominal distention and bloating
• Nausea and vomiting
• Pain
• Accumulation of gas and fluids in the bowel
• Delayed passage of flatus and defecation 2

The pathophysiology is multifactorial, involving:

• Inhibitory sympathetic input
• Release of hormones and neurotransmitters
• Inflammatory reaction
• Effects of opioid analgesics 2

Prevention and Treatment Strategies

1. Pain Management

• Implement opioid-sparing analgesia:

  • Use thoracic epidural analgesia for 48-72 hours when possible 1, 3
  • Substitute opioids with regular acetaminophen/paracetamol 3
  • Add NSAIDs if not contraindicated 3
  • Consider alternatives for minimally-invasive procedures: intrathecal analgesia, intravenous lidocaine, locoregional blocks, continuous infusion of local anesthetics 1

• Consider alvimopan (μ-opioid receptor antagonist):

  • Accelerates GI recovery when opioid analgesia is used 3, 2
  • Administered 12 mg orally at least 30 minutes and up to 5 hours prior to surgery
  • Continue twice daily beginning on first postoperative day until hospital discharge or maximum of 7 days 2

2. Fluid Management

• Optimize fluid administration:
  • Avoid fluid overload by limiting weight gain to <3kg by postoperative day 3 1, 3
  • Consider intraoperative fluid optimization using esophageal Doppler monitoring 1
  • Monitor electrolytes, especially magnesium 3

3. Nutritional Interventions

• Promote early oral feeding:

  • Remove nasogastric tubes if present 3
  • Encourage early oral feeding as soon as the patient is lucid 3
  • Consider a progressive diet approach:
    • Clear liquids until first bowel movement
    • Full liquids until second bowel movement
    • Then advance to goal diet 4

• Consider chewing gum:

  • Studies show shorter time to flatus and first bowel movement 1
  • Though some evidence suggests limited benefit in ERAS pathways 1

4. Mobilization

• Implement early and regular mobilization:
  • Begin on the day following surgery 1
  • Helps stimulate bowel function 3
  • Position patient with head of bed elevated 30-45 degrees to reduce aspiration risk 3

5. Pharmacological Interventions

• Consider laxatives:

  • Oral magnesium oxide 3
  • Bisacodyl (10 mg orally twice daily) 3
  • Polyethylene glycol for patients prone to constipation 4

• For persistent ileus:

  • Metoclopramide may stimulate upper GI motility 3
  • Water-soluble contrast agents and neostigmine may help treat established POI 1
  • Rifaximin may be considered for prolonged ileus with bacterial overgrowth 3

6. Monitoring

• Assess for resolution of ileus:
  • Monitor abdominal distention
  • Check bowel sounds
  • Track passage of flatus/stool 3
  • Make patient nil per os (NPO) with any signs of ileus 4

Special Considerations

• Parenteral nutrition:

  • Reserve for cases with significant malnutrition or when enteral nutrition fails 3
  • Consider when oral intake will be inadequate (<50% of caloric requirement) for more than 7 days 1

• Stenting considerations:

  • Stenting of uretero-ileal anastomosis has shown improved bowel recovery in specific surgical populations 1

Common Pitfalls to Avoid

• Avoid routine nasogastric tube placement as it may prolong ileus 3
• Avoid antiperistaltic agents as they can worsen ileus 3
• Avoid prolonged bowel rest as it can result in changes to intestinal flora 3
• Avoid excessive crystalloid administration (≥2 liters) which increases risk of postoperative ileus 3

By implementing these evidence-based strategies, postoperative ileus can be effectively managed, leading to improved patient comfort, earlier return to normal bowel function, and reduced length of hospital stay.