From the Guidelines
The use of laxatives in post-operative ileus has limited supporting evidence and is not generally recommended as a primary treatment approach. Post-operative ileus, a temporary impairment of gastrointestinal motility after surgery, is better managed through early mobilization, minimally invasive surgical techniques, and multimodal pain management strategies that reduce opioid use. According to the most recent guidelines, minimally invasive surgery, optimized fluid management, and opioid-sparing analgesia are key components in preventing postoperative ileus 1. While some clinicians may consider osmotic laxatives like polyethylene glycol or magnesium citrate as adjunctive therapy in mild cases, these should not be used in complete bowel obstruction or severe ileus. Stimulant laxatives such as bisacodyl or senna are generally avoided due to their potential to cause cramping in an already compromised bowel.
Some studies have shown that certain interventions can help promote postoperative bowel function, such as:
- Oral magnesium oxide, which has been demonstrated to promote postoperative bowel function in some studies 1
- Bisacodyl, which improved postoperative intestinal function in a RCT with 189 patients undergoing colorectal surgery 1
- Alvimopan, a peripheral μ-opioid receptor antagonist, which accelerates gastrointestinal recovery and reduces the length of stay in patients undergoing open colonic resection having postoperative opioid analgesia 1
- Chewing gum, which has a positive effect on postoperative duration of ileus 1
However, the most recent and highest quality study suggests that early mobilization, early postoperative food intake, and omission of postoperative nasogastric tubes are also important measures in minimizing postoperative ileus 1. The pathophysiology of post-operative ileus involves complex neuroinflammatory mechanisms, sympathetic overactivity, and opioid-induced bowel dysfunction that laxatives alone cannot adequately address. More effective approaches include alvimopan in patients undergoing bowel resection, chewing gum to stimulate the cephalic-vagal reflex, and early enteral feeding when possible. Prokinetic agents like metoclopramide may be considered in specific cases, but their efficacy is also limited.
In terms of specific recommendations, fluid optimization is crucial, and efforts should be taken to correct fluid status early, aiming to have weight gain limited to < 3 kg at postoperative day three 1. Additionally, early oral intake should be encouraged to maintain intestinal function, and small portions should be offered initially, especially after right-sided resections and small-bowel anastomosis 1. Overall, a multimodal approach that incorporates these strategies is likely to be more effective in managing post-operative ileus than relying on laxatives alone.