What is the management of postoperative ileus?

Management of Postoperative Ileus

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

Initial Assessment and Management

• Correct electrolyte abnormalities, particularly potassium and magnesium, which can affect intestinal motility 2
• Place a nasogastric tube for decompression only in patients with severe abdominal distention, vomiting, or risk of aspiration, and remove as early as possible 2, 1
• Administer isotonic intravenous fluids to correct and prevent dehydration while avoiding fluid overload 2
• Aim for weight gain limited to <3 kg by postoperative day three to prevent intestinal edema 1
• Administer subcutaneous heparin to reduce the risk of thromboembolism in patients with prolonged immobility 2

Pharmacological Interventions

• Implement opioid-sparing analgesia strategies, such as mid-thoracic epidural analgesia, to prevent prolongation of postoperative ileus 1, 2
• Consider alvimopan (12 mg orally) administered at least 30 minutes before surgery and twice daily postoperatively until hospital discharge (maximum 7 days) to accelerate gastrointestinal recovery when opioid analgesia is necessary 3
• Administer oral laxatives such as bisacodyl (10-15 mg daily) and magnesium oxide once oral intake is resumed 1, 2
• For persistent ileus, consider water-soluble contrast agents or neostigmine as rescue therapy 1
• Avoid medications that can worsen ileus, such as anticholinergics 2

Nutritional Support

• Maintain nil per os (NPO) status initially until signs of bowel function return 2
• Encourage early oral intake with small portions once bowel sounds return, especially after right-sided resections and small-bowel anastomosis 1
• If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate early tube feeding 1
• If enteral feeding is contraindicated (intestinal obstruction, severe ileus, sepsis, intestinal ischemia), provide early parenteral nutrition 1

Early Mobilization

• Encourage early mobilization as soon as the patient's condition allows to stimulate bowel function 1, 2
• Early removal of urinary catheters can facilitate mobilization 2
• Prolonged bed rest increases pulmonary complications, thromboembolism, insulin resistance, and decreases muscle strength 1

Monitoring and Follow-up

• Monitor for signs of returning bowel function, including passage of flatus, bowel sounds, and bowel movements 2
• Resume oral intake gradually once bowel function returns, starting with clear liquids and advancing as tolerated 2
• Continue to assess for complications such as abdominal distention, nausea, vomiting, and pain 2

Special Considerations

• Alvimopan is contraindicated in patients who have taken therapeutic doses of opioids for more than 7 consecutive days immediately before starting alvimopan 3
• Alvimopan should be discontinued if adverse reactions occur, particularly in patients with severe renal impairment or hepatic impairment 3
• Japanese patients may require closer monitoring when using alvimopan due to approximately 2-fold greater exposure compared to Caucasian subjects 3
• Chewing gum may help stimulate bowel function through cephalic-vagal stimulation, though evidence in elective ERAS pathways does not strongly support its use 1, 2

Prevention Strategies

• Prefer laparoscopic over open surgical approaches when surgery is necessary 2
• Implement enhanced recovery after surgery (ERAS) protocols that include multiple components to reduce the incidence and duration of postoperative ileus 1
• Avoid routine use of nasogastric tubes as they may prolong ileus 1, 2
• Maintain proper fluid balance without overload to prevent intestinal edema 1, 2

Postoperative ileus is a multifactorial condition with both neural and inflammatory phases 4, 5. The early neural phase is triggered by activation of afferent nerves during surgery, while the inflammatory phase starts after 3-6 hours and can last several days 4. Understanding this pathophysiology helps guide appropriate management strategies at different time points after surgery.