From the Guidelines
For postoperative ileus that is refractory to fleet enema, senna-colace, and lactulose, I recommend a multimodal approach, prioritizing opioid-sparing analgesia, early mobilization, and optimized fluid management, as suggested by the most recent guidelines 1.
Key Interventions
- Minimize opioid use by switching to non-opioid pain management like NSAIDs, acetaminophen, or regional anesthesia techniques, to reduce opioid-induced bowel dysfunction.
- Early ambulation is crucial - aim for at least three walks daily, to stimulate bowel movement and prevent complications.
- Optimized fluid management is essential, aiming to have weight gain limited to < 3 kg at postoperative day three, to prevent fluid overload and promote bowel recovery 1.
- Consider prokinetic agents such as metoclopramide or erythromycin, to enhance gastrointestinal motility.
- Nasogastric tube decompression may provide symptomatic relief if significant abdominal distension is present.
- Ensure adequate hydration and electrolyte balance, particularly potassium and magnesium levels, as deficiencies can worsen ileus.
Rationale
The pathophysiology of postoperative ileus is multifactorial, and the incidence and duration depend on multiple parameters related to the patient, the procedure, and perioperative care 1. A multifaceted approach to minimizing postoperative ileus is recommended, including 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.
Additional Considerations
- 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.
- Laxative administration may be beneficial in stimulating bowel movement, although the evidence is limited 1.
- Chewing gum has been shown to be safe and beneficial in restoring gut activity after colorectal surgery, and may be considered as an adjunctive therapy 1.
From the FDA Drug Label
The efficacy of alvimopan in the management of postoperative ileus was evaluated in 6 multicenter, randomized, double-blind, parallel-group, placebo-controlled studies The primary endpoint for all studies was time to achieve resolution of postoperative ileus, a clinically defined composite measure of both upper and lower gastrointestinal recovery Although both 2-component (GI2: toleration of solid food and first bowel movement) and 3-component (GI3: toleration of solid food and either first flatus or bowel movement) endpoints were used in all studies, GI2 is presented as it represents the most objective and clinically relevant measure of treatment response in patients undergoing surgeries that include a bowel resection
- Alvimopan may be considered for the treatment of postoperative ileus that is refractory to other treatments such as fleet enema, senna-colace lactylose, as it has been shown to be effective in reducing the time to achieve resolution of postoperative ileus in patients undergoing bowel resection or radical cystectomy 2.
- The decision to use alvimopan should be made on a case-by-case basis, taking into account the individual patient's clinical situation and medical history.
From the Research
Treatment Options for Postoperative Ileus Refractory to Fleet Enema, Senna-Colace Lactylose
- Postoperative ileus is a severe condition that can occur after abdominal surgery, and its treatment is crucial to prevent complications and improve patient outcomes 3.
- The current treatment options for postoperative ileus include non-pharmacological procedures, such as early rehabilitation and ERAS (Enhanced Recovery After Surgery) procedures, as well as pharmacological interventions 3, 4.
- Pharmacological treatment options for postoperative ileus are limited, and only a few substances have shown evident positive impact, including neostigmin for treatment and alvimopan for prevention, although alvimopan is not registered in some countries 3, 5.
- Other medications, such as methylnaltrexone, have also been shown to be beneficial in the treatment of postoperative ileus 4.
- The use of promotility agents, such as metoclopramide and erythromycin, has been evaluated, but their effectiveness is uncertain, and they are not recommended for routine use 6.
- Early enteral nutrition (EEN) has been shown to facilitate the return of normal bowel function, achieve enteral nutrition goals, and reduce hospital length of stay, and is strongly recommended for patients who have undergone abdominal surgery 6.
Pathophysiology of Postoperative Ileus
- Postoperative ileus has two phases: an early neurological phase and a later inflammatory phase, with a 'pharmacological' phase during which analgesic drugs, particularly opiates, play a central role 7.
- The main mechanisms of postoperative ileus pathophysiology include fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation 6.