From the Guidelines
Post-operative ileus treatment should primarily focus on a multifaceted approach to minimize its occurrence, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission or early removal of nasogastric intubation, as recommended by the Enhanced Recovery After Surgery (ERAS) society 1.
Key Components of Treatment
- Minimally invasive surgery to reduce tissue trauma and stress response
- Optimized fluid management to avoid fluid overload and maintain adequate hydration
- Opioid-sparing analgesia to minimize the negative effects of opioids on bowel motility
- Early mobilization to stimulate bowel function and prevent complications
- Early postoperative food intake to maintain intestinal function and reduce the risk of ileus
- Laxative administration to prevent constipation and promote bowel movements
- Omission or early removal of nasogastric intubation to reduce the risk of ileus and promote early oral intake
Additional Considerations
- Pain management should focus on multimodal analgesia with NSAIDs, acetaminophen, and regional anesthesia techniques when possible
- Pharmacologic treatment may include alvimopan, a peripheral μ-opioid receptor antagonist that can accelerate GI recovery without affecting pain control
- Chewing gum may also help stimulate bowel function through cephalic-vagal stimulation
- Once bowel sounds return and flatus is passed, a clear liquid diet can be initiated and advanced as tolerated
- Most cases of post-operative ileus resolve within 2-4 days, but persistent symptoms beyond 5-7 days warrant further investigation for mechanical obstruction or other complications, as supported by the most recent guidelines 1.
From the FDA Drug Label
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 In the 6 studies, 1,058 patients who underwent a surgery that included a bowel resection received placebo (not including 157 for total abdominal hysterectomy) and 1,096 patients received alvimopan 12 mg (not including 143 for total abdominal hysterectomy)
Treatment for postoperative ileus is alvimopan 12 mg, administered orally, twice daily, starting before surgery and continued until hospital discharge or a maximum of 7 days 2.
- The primary endpoint was time to achieve resolution of postoperative ileus, which was a composite measure of both upper and lower gastrointestinal recovery.
- Alvimopan was shown to be effective in reducing the time to achieve resolution of postoperative ileus in patients undergoing bowel resection or radical cystectomy.
From the Research
Treatment Options for Postoperative Ileus
- Early enteral nutrition (EEN) is strongly recommended to expedite the resolution of ileus in patients who have undergone abdominal surgery 3
- The use of metoclopramide and erythromycin is not recommended as they were not found to be effective in expediting the resolution of ileus 3
- Narcotic sparing analgesia and fluid optimization are recommended as preventive measures to decrease the risk of postoperative ileus 4
- Stimulation of ambulation and stop of opioids are recommended as treatment options for postoperative ileus 4
Medications for Postoperative Ileus
- Alvimopan has been shown to accelerate recovery of gastrointestinal function, shorten the length of hospital stay, and reduce postoperative ileus-related morbidity when used in conjunction with an enhanced recovery strategy 5
- The use of alvimopan at a dose of 12 mg was found to be superior to 6 mg in reducing the incidence of some gastrointestinal-related and serious adverse events 5
Management of Postoperative Ileus
- Addressing the underlying cause and providing supportive care are key components of managing postoperative ileus 3, 6, 7
- The use of nasogastric tube placement is not mandatory, but can be removed without previous clamping or gastrointestinal contrast study 4
- Total parenteral nutrition is recommended from the 7th day without sufficient oral intake 4