What is the management of postoperative ileus?

Management of Postoperative Ileus

Implement a comprehensive prevention and treatment strategy centered on opioid-sparing analgesia, optimized fluid management, early mobilization, and early feeding, while avoiding routine nasogastric decompression. 1, 2

Prevention Strategies (Most Critical)

Surgical Approach

• Utilize minimally invasive (laparoscopic) techniques whenever feasible to reduce the inflammatory response and mechanical bowel manipulation that trigger postoperative ileus 1, 3, 2

Fluid Management

• Administer isotonic intravenous fluids to maintain euvolemia while strictly avoiding fluid overload, as excess fluid worsens intestinal edema and prolongs ileus 1, 4, 3, 2
• Target weight gain limited to <3 kg by postoperative day 3 as a specific endpoint to prevent intestinal edema 1, 4, 2
• Monitor fluid balance closely, particularly in patients with high-output stomas or ongoing losses 4

Analgesia (Critical Component)

• Implement mid-thoracic epidural analgesia (T6-T10) for 48-72 hours postoperatively as the backbone of pain control for open abdominal surgeries, which provides superior pain relief while reducing opioid requirements and accelerating bowel recovery 1, 3, 2
• Minimize systemic opioid use aggressively through multimodal opioid-sparing strategies including scheduled acetaminophen, NSAIDs (if not contraindicated), and regional blocks such as transversus abdominis plane (TAP) blocks 1, 3
• Consider alvimopan 12 mg orally starting 30 minutes to 5 hours before surgery, then twice daily until hospital discharge (maximum 7 days) for patients undergoing bowel resection who will receive postoperative opioids 5

Nasogastric Tube Management

• Avoid routine nasogastric tube placement as it may prolong ileus duration 1, 3, 2
• Place nasogastric tubes only for severe abdominal distention, persistent vomiting, or aspiration risk, and remove as soon as these indications resolve 1, 4, 3, 2

Early Mobilization

• Begin ambulation on postoperative day 1 to stimulate bowel function and prevent complications of immobility 1, 3, 2
• Remove urinary catheters early to facilitate mobilization 3, 2

Early Feeding

• Offer clear liquids on postoperative day 1 for bowel resection patients (day 3 for radical cystectomy), advancing to solid foods as tolerated 1
• Start with small portions, particularly after right-sided resections and small-bowel anastomoses 1, 2
• Early oral intake maintains intestinal function even in patients with mild ileus or intestinal edema 1

Treatment of Established Ileus

Initial Assessment and Correction

• Correct electrolyte abnormalities immediately, particularly potassium and magnesium, as these directly affect intestinal smooth muscle contractility 1, 4, 3, 2
• Exclude mechanical obstruction, intra-abdominal sepsis, enteritis, or medication effects before attributing symptoms solely to functional ileus 3

Pharmacological Interventions

• Administer oral laxatives once oral intake resumes: bisacodyl 10 mg twice daily and magnesium oxide 1, 4, 3, 2
• Review and minimize all medications that worsen ileus, including anticholinergics and opioids 4, 3
• For persistent ileus despite conservative measures, consider water-soluble contrast agents or neostigmine as rescue therapy 1, 2

Nutritional Support

• Initiate early enteral tube feeding within 24 hours if oral intake will be inadequate (<50% of caloric requirements) for more than 7 days 1, 2
• If enteral feeding is contraindicated (intestinal obstruction, sepsis, intestinal ischemia, high-output fistulae, severe GI hemorrhage), provide early parenteral nutrition to prevent prolonged malnutrition 1, 4, 2
• Transition back to enteral/oral nutrition as gastrointestinal function recovers 1, 4

Supportive Care

• Continue isotonic IV fluids to maintain hydration while avoiding overload 4, 3
• Maintain NPO status only if severe symptoms (persistent vomiting, severe distention) are present 3
• Administer subcutaneous heparin for venous thromboembolism prophylaxis in patients with prolonged immobility 3

Monitoring and Progression

• Assess for return of bowel function by monitoring passage of flatus, bowel movements, and tolerance of oral intake 3, 2
• Gradually advance diet from clear liquids to solid foods as tolerated once bowel sounds return 3
• Monitor for signs of complications including aspiration, metabolic acidosis (particularly in patients with ileostomy/jejunostomy), or lactic acidosis 4

Common Pitfalls to Avoid

• Do not routinely use chewing gum as current evidence does not support its efficacy in ERAS pathways, despite earlier enthusiasm 1
• Avoid fluid overload, which is one of the most common modifiable factors prolonging ileus 1, 4, 3, 2
• Do not delay nutritional support beyond 7 days of inadequate intake, as this significantly increases morbidity 1, 2
• Recognize that alvimopan efficacy is established only for surgeries involving bowel resection, not for total abdominal hysterectomy alone 5