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Measures to prevent prolonged postoperative ileus

Measures to prevent prolonged postoperative ileus
Authors:
Jörg C Kalff, MD
Sven Wehner, PhD
Babak Litkouhi, MD
Section Editor:
David I Soybel, MD
Deputy Editor:
Wenliang Chen, MD, PhD
Literature review current through: Dec 2022. | This topic last updated: Sep 22, 2022.

INTRODUCTION — Prolonged postoperative ileus can increase patient pain and discomfort, contributes to prolonged hospitalization, and is a significant burden on the health care system.

There are few effective strategies for managing prolonged postoperative ileus once established, and, thus, a more effective overall strategy minimizes factors that may precipitate or exacerbate the condition (table 1).

Measures used to prevent the development of prolonged postoperative ileus are reviewed here. The epidemiology, clinical features, diagnosis, and supportive care of prolonged postoperative ileus are reviewed elsewhere. (See "Postoperative ileus".)

Many preventive measures have been incorporated into enhanced recovery after surgery (ERAS) protocols, which have generally been credited with expediting postoperative recovery and reducing hospital stay. Enhanced recovery protocols for colorectal and gynecologic surgery are described in detail in other topics. (See "Enhanced recovery after colorectal surgery" and "Enhanced recovery after gynecologic surgery: Components and implementation" and "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)

PROLONGED POSTOPERATIVE ILEUS — Following abdominal surgery, a period of "physiologic" ileus is expected to last for 0 to 24 hours in the small intestine, 24 to 48 hours in the stomach, and 48 to 72 hours in the colon. Prolonged postoperative ileus is said to occur when the patient has symptoms or signs of paralytic ileus (obstipation and intolerance of oral intake) that persist for more than three to five days (depending on the nature of the surgery and what is considered "typical"), without evidence for mechanical bowel obstruction or other postoperative complications. (See "Postoperative ileus", section on 'Diagnosis'.)

Prolonged postoperative ileus can increase patient pain and discomfort and decrease patient satisfaction with the surgical outcome [1]. Prolonged delays in oral feeding can compromise postoperative nutrition, which can lead to greater postoperative catabolism, poor wound healing, susceptibility to infection, and the need for nutritional support [2,3]. These problems contribute to prolonged hospitalization and are a significant burden on the health care system [4-7].

Few therapies are truly effective once prolonged postoperative ileus becomes established. A more effective overall strategy is to prevent postoperative ileus by minimizing risk factors that may precipitate and exacerbate the condition. Interventions aimed at preventing prolonged postoperative ileus are discussed below. They are placed into one of three categories of effective, unproven, and harmful based on current available evidence and summarized in this table (table 1). Risk factors for prolonged postoperative ileus are discussed separately. (See "Postoperative ileus", section on 'Risk factors'.)

EFFECTIVE AND POTENTIALLY EFFECTIVE INTERVENTIONS — Several measures are effective for minimizing the duration of postoperative gastrointestinal dysmotility following abdominal surgery:

Epidural or TAP block — Two analgesia techniques are commonly employed before or after abdominal surgery to help with postoperative pain control and minimize postoperative opioid use. Epidural has been used for a long time, while transverse abdominis plane (TAP) block is relatively new.

Intraoperative epidural anesthesia continued into the postoperative period for pain control is an effective means for accelerating the return of gastrointestinal transit [8-10]. The use of neuraxial local anesthetic agents has the advantages of blocking nociceptive spinal sensory afferents and inhibiting sympathetic efferent outflow. To be effective, epidural catheters should be placed at the midthoracic level to block nociceptive afferent signals from the surgical site and should be used for 48 to 72 hours postoperatively. (See "Postoperative ileus", section on 'Postoperative ileus'.)

The effectiveness of this approach is best illustrated in a 2016 Cochrane review that included 128 trials comparing epidural local anesthetics with opioid-based regimens for adults undergoing abdominal surgery [11]. An epidural with a local anesthetic accelerated the return of flatus by approximately 17 hours (high-quality evidence based on 22 studies) and bowel movement by 22 hours (low-quality evidence based on 28 studies). An epidural with a local anesthetic and an opioid improved pain scores for both open and laparoscopic surgeries; adding an opioid to the solution of local anesthetic did not negatively affect gastrointestinal transit. In patients undergoing open, but not laparoscopic, surgery, an epidural containing a local anesthetic reduced the length of hospital stay by one day (very-low-quality evidence based on 34 studies).

Nevertheless, epidural anesthesia can cause urinary retention or interfere with ambulation in some patients. The risk of epidural catheter-associated infection or bleeding is also a consideration when using epidural analgesia for longer than 24 hours (see "Management of acute perioperative pain in adults", section on 'Epidural analgesia with local anesthetics and opioids'). For these reasons, epidural is not included in many of the enhanced recovery after surgery (ERAS) protocols [12], especially those for laparoscopic surgery. Instead, those protocols use TAP block or surgical site infiltration with long-acting local anesthetics such as liposomal bupivacaine, in combination with non-opioid analgesic agents. (See 'Multimodal analgesia' below and "Enhanced recovery after colorectal surgery", section on 'Pain management'.)

In a small trial of minimally invasive colorectal surgery patients, when used as a part of an enhanced recovery pathway, laparoscopically placed bupivacaine TAP block reduced length of stay (3.45 versus 4.3 days), postoperative narcotics (22.9 versus 50.5 morphine equivalents), time to ambulation (0.96 versus 1.5 days), and bowel function (2.4 versus 3.1 days) compared with conventional oral and intravenous pain medications [13].

In a small trial comparing TAP block with epidural in patients undergoing open and laparoscopic colorectal surgery, TAP block was associated with a 0.5 day reduction in hospital stay and a lower risk of urinary retention (15 versus 30 percent) but a higher risk of nausea and vomiting (33 versus 14 percent) [14]. The time to first flatus was comparable between the two groups. In another small trial of patients undergoing similar surgery, liposomal bupivacaine TAP block was associated with higher numeric pain scores on the day of surgery but lower scores later in the postoperative period compared with epidural [15]. Patients receiving a TAP block required fewer opioids (98 versus 207 mg). Return of bowel function, length of stay, and complication rates were not different. The cost of epidural analgesia was considerably higher than that of TAP block.

The choice between epidural and TAP block is made jointly by the surgical and anesthesia provider, with the latter performing the actual procedure. The current sentiment of the surgical authors is that TAP block is increasingly used in lieu of epidural, especially for less extensive and routine surgeries. When everything goes well in those cases, epidural may become a hindrance to early mobilization and patient autonomy. However, epidural is still of benefit in more extensive surgery; its positive effect on bowel function after the first two to three postoperative days remains unparalleled by TAP block.

Specifically, anatomical or patient factors that favor epidural include a long midline open incision (TAP block is most effective in the subumbilical region), complex hernia repair (which disrupts fascial plane and renders TAP blocks less effective), a history of difficult pain control or opiate dependency, and a history of postoperative nausea/vomiting. Obesity may preclude TAP block at some facilities but not others (with bariatric and/or ultrasound guidance expertise). Anticoagulation favors TAP block because epidural is contraindicated. Additionally, when there is a provider or institutional preference, it usually favors epidural because of its familiarity. However, TAP blocks, especially those performed with liposomal bupivacaine, are gaining popularity because of their added durability in pain control. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Pain prophylaxis'.)

Minimally invasive surgery — Minimally invasive surgical approaches are performed through small incisions. It is both intuitive and widely accepted that minimally invasive surgery decreases the incidence of postoperative ileus compared with open surgery.

Experiments in animals have shown that the length of laparotomy incision significantly influences postoperative gastrointestinal motility [16]. This effect may be mediated by postoperative inflammatory response; longer incisions correlate with greater inflammatory response. (See "Postoperative ileus", section on 'Postoperative ileus'.)

Most randomized trials in the gastrointestinal and gynecologic literature have shown that laparoscopy facilitates quicker resolution of postoperative gastrointestinal dysmotility [17-21]. A 2005 Cochrane review compared laparoscopic with open colorectal surgery in terms of postoperative ileus (as a secondary outcome) in 17 trials; laparoscopy accelerated the passage of flatus or bowel movement by 0.9 to 1 days, which contributed to a 1.5 day shorter hospital stay compared with open surgery [22]. Furthermore, patients undergoing laparoscopic surgery with an intracorporeal anastomosis resumed bowel movements earlier than those with an extracorporeal anastomosis in another trial [23].

On the other hand, not all studies have reproduced these results in a clinically meaningful fashion [24,25]. This could be due to confounding factors such as the use of contemporary ERAS strategies in the control (open surgery) group.

Nevertheless, depending on the procedure performed, ileus after minimally invasive surgery should alert the surgeon to consider other potentially more ominous etiologies for bowel dysfunction (eg, internal or trocar site hernia, visceral injury).

Peripheral acting mu-opioid receptor antagonists — Opioids exacerbate postoperative ileus through activation of mu-opioid receptors. Since peripherally acting mu-opioid receptor antagonists do not cross the blood-brain barrier, they can reduce postoperative ileus without compromising the analgesic effect of opioids [26].

Alvimopan and methylnaltrexone are oral peripherally acting mu-opioid receptor antagonists that are approved by the United States (US) Food and Drug Administration (FDA) to treat postoperative ileus and opioid-induced constipation, respectively.

In early studies, alvimopan appeared to hasten postoperative gastrointestinal recovery after bowel surgery and abdominal hysterectomy [27-32]. In four trials conducted between 1990 and 2016, alvimopan improved composite measures of upper and lower gastrointestinal recovery when administered in 6 and 12 mg preparations after abdominal (predominantly colorectal) surgery [33-36]; one other trial only found alvimopan beneficial to a subgroup of patients receiving opioids via a patient-controlled device [37]. A meta-analysis of 9 trials and 35 nonrandomized comparative studies found low-to-moderate evidence that alvimopan improved outcomes after open bowel resection and open radical cystectomy [38]. Benefits for patients undergoing minimally invasive surgery or treated in contemporary enhanced recovery pathway settings remain uncertain.

In a large administrative database study of over 18,000 propensity-score matched adult patients undergoing small or large bowel resection, alvimopan use was associated with a reduction of 0.62 days in hospital stay (4.6 versus 5.2 days) as well as lower rates of postoperative gastrointestinal (12 versus 16.5 percent) and other in-hospital complications [39]. In another database study of over 12,000 patients, alvimopan was associated with reduced hospital stay for both open (4 versus 6 days) and laparoscopic segmental colectomies (3 versus 4 days). Alvimopan was associated with reduced cost for open (-7 percent) but not laparoscopic surgery [40].

There is increasing evidence that although alvimopan improves outcomes for open abdominal surgery and mixed open/minimally invasive surgery (MIS) [41] when used as a component of ERAS protocols, its effect is less certain for MIS [42]. In a retrospective study of 321 patients undergoing laparoscopic colorectal surgery, alvimopan use was associated with increased cost but no reduction in ileus or length of stay [43].

Concerns for an increased risk for cardiovascular or neoplastic complications led the US FDA to limit the indications and dispensing conditions of alvimopan [44]. Rather than general usage for postoperative ileus, the indication is specified as to accelerate the time to upper and lower gastrointestinal recovery following partial large or small bowel resection surgery with primary anastomosis. In addition, alvimopan is restricted to inpatient use in hospitals that meet criteria for staff training and outcome assessment. The cost of alvimopan may also be an issue for its routine use.

Methylnaltrexone is also under investigation for treatment of opioid-induced gut dysfunction and constipation [45-47]. Although an earlier phase II trial demonstrated some efficacy [48], two subsequent phase III trials evaluating methylnaltrexone for postoperative ileus found no improvement in recovery of gastrointestinal function or time to hospital discharge [49].

Multimodal analgesia — Traditionally, acute perioperative pain management has relied solely on opioid medications to target central mechanisms involved in the perception of pain. However, opioids contribute to postoperative gastrointestinal dysmotility by diminishing normal coordinated gastrointestinal movement.

A better approach, which uses several agents each acting at different sites of the pain pathway, is known as multimodal analgesia [50]. This approach reduces the dependence on, and may reduce or eliminate the need for, opioids. Synergy between opioid and nonopioid medications reduces both the overall opioid dose and unwanted opioid-related side effects. (See "Management of acute perioperative pain in adults".)

Components of multimodal analgesia for abdominal surgery may include:

Local anesthetics — Local anesthetic agents directly block pain receptor activity. They can be administered by local infiltration or continuous infusion at the surgical wound, into the peritoneum, through an epidural, or systemically through an intravenous line.

In multiple trials, intravenous lidocaine was superior to placebo in reported measures of gastrointestinal function, but its advantage over epidural anesthesia was less certain [51]. In trials, lidocaine is usually administered as a bolus at induction followed by a continuous infusion of 1 to 3 mg per kg per hour. However, the optimal dose and duration of therapy are poorly defined. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Intravenous lidocaine'.)

The use of local anesthetics infiltrated subcutaneously into the surgical wound may have a similar beneficial effect, although this effect appears to be limited to laparoscopic incision sites. Local infiltration with a long-acting local anesthetic (liposomal bupivacaine) has also been associated with reduced opioid use, a shorter length of stay (mean three versus four days), and lower overall cost [52].

In several trials of elective midline laparotomy for colorectal resection, bupivacaine, levobupivacaine, or ropivacaine was continuously infused via a wound catheter positioned in either the suprafascial, musculofascial, or subfascial layer of the anterior abdominal wall. This reduced postoperative pain at rest and on movement, opioid consumption, time to first bowel movement, and length of hospital stay without causing more serious adverse events compared with saline (placebo) infusion, according to a 2019 Cochrane review [53].

NSAIDs — Anti-inflammatory agents can diminish the local hormonal response to injury, thus indirectly decreasing pain receptor activation. In addition to reducing opioid use, animal studies have suggested that the anti-inflammatory properties of nonsteroidal anti-inflammatory drugs (NSAIDs) appear to target one of the key pathways in the pathogenesis of postoperative ileus, thereby providing an additional therapeutic mechanism for its benefit [54-56]. (See "Postoperative ileus", section on 'Postoperative ileus' and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Nonsteroidal anti-inflammatory drugs'.)

Ketorolac is an NSAID commonly used to treat postoperative pain. In a retrospective study of 877 patients undergoing elective colorectal surgery involving an anastomosis, there was no association between ketorolac exposure and anastomotic leak (ketorolac 3.1 percent versus no ketorolac 3.3 percent), acute kidney injury, return to the operating room, or readmission [57].

Although the NSAIDs that selectively inhibit cyclooxygenase-2 (COX-2) also possess these properties, they are associated with higher rates of anastomotic leak following gastrointestinal surgery, and we recommend against their use solely for preventing prolonged postoperative ileus following abdominal surgery that involves a gastrointestinal anastomosis [58,59]. Selective COX-2 inhibitors include celecoxib and etoricoxib (the latter is not available in the US). (See 'COX-2 inhibition' below.)

Regulators of neurotransmitters — Other agents work by inhibiting or augmenting the activity of neurotransmitters that carry electrical signals across the gap junctions between neurons, such as substance P, calcitonin gene-related peptide, aspartate, glutamate, and gamma-aminobutyric acid (GABA). Example of such agents include ketamine, clonidine, acetaminophen, gabapentin, and pregabalin.

Acetaminophen — Intravenous acetaminophen is another non-narcotic choice for postoperative analgesia that may similarly decrease postoperative opioid use [60]. We have found this to be especially useful in patients for whom prolonged or continuous NSAID use needs to be avoided. If cost is an issue for intravenous formulation of acetaminophen, it can also be given per rectum. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Acetaminophen'.)

Others — Various other agents, including gabapentin (and its successor pregabalin), ketamine, and clonidine, also possess antihyperalgesic and antiallodynic properties and can reduce the use of postoperative opioids. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Ketamine' and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Gabapentinoids' and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Alpha-2 receptor agonists'.)

Preventive analgesia — Preventive analgesia, also called preemptive analgesia, is an analgesic strategy aimed at preventing the establishment of central sensitization, hyperalgesia, and allodynia. Preventive analgesia must be initiated before the onset of surgical injury (incision) and maintained postoperatively to prevent the inflammatory changes associated with postinjury hypersensitivity. Although the efficacy of preventive analgesia is still debated, it is included in some bundled ERAS protocols.

There are many effective preventive analgesic techniques using various pharmacological agents and interventions. They reduce nociceptor (pain receptor) activation by blocking or decreasing receptor activation and inhibiting the production or activity of pain neurotransmitters. The end result is a reduction in postoperative opioid use and opioid-related side effects. Examples include preoperative TAP block, preincisional wound infiltration with local anesthetic, and preoperative administration of acetaminophen, NSAIDs, and gabapentin or pregabalin. (See "Management of acute perioperative pain in adults", section on 'Preventive analgesia'.)

Surgical technique — Intestinal handling during abdominal surgery stimulates postoperative ileus via both the neuropathic and the inflammatory pathways [61]. Gentle handling and minimal manipulation of the intestines are recommended to reduce postoperative gastrointestinal dysmotility [54,62]. An increased volume of estimated blood loss appears to prolong postoperative ileus, and intraoperative techniques that provide expeditious control of bleeding should be used [63].

Prolonged surgical duration and postoperative complications increase the risk for prolonged postoperative ileus [63-65]. Although the prolonged duration of surgery (>3 hours) increases the risk for postoperative ileus, there is not a strict correlation between the duration of the surgery and the duration of the ileus [63,66-68]. (See "Bowel resection techniques" and "Overview of colon resection".)

Restriction of perioperative fluid administration — Perioperative fluid is administered to replace fluid loss during surgery. Excessive perioperative fluid administration could result in edema formation within the gastrointestinal tract and may lead to postoperative ileus.

Patients who have received liberal fluids were found to have extended time to first flatus and delayed discharge [69]. A meta-analysis that included 3861 patients from 23 randomized studies found an association between liberal fluids and increased time to first bowel movement (two days, 95% CI 1.3-2.3) as well as prolonged duration of hospital stay (four days, 95% CI 3.4-4.4) compared with restricted fluids [70]. Thus, restricted or "goal-directed" fluid administration can be suggested for prevention of postoperative ileus. (See "Intraoperative fluid management", section on 'Choosing a fluid management strategy'.)

Bundled ERAS protocols — Many of the aforementioned preventive measures have been "bundled" into ERAS protocols, which have generally been credited with expediting postoperative recovery and reducing hospital stay. Enhanced recovery protocols for colorectal and gynecologic surgery are described in detail in other topics. (See "Enhanced recovery after colorectal surgery" and "Enhanced recovery after gynecologic surgery: Components and implementation" and "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)

INEFFECTIVE OR UNPROVEN INTERVENTIONS — Dietary manipulation and most pharmacologic therapies other than peripheral acting mu-opioid receptor antagonists are ineffective or unproven for preventing prolonged postoperative ileus.

Chewing gum — The effect of chewing gum on postoperative bowel recovery has been studied in randomized trials following appendectomy [71], cesarean section [72,73], colorectal surgery [74-79], bladder surgery [80], and other intestinal and gynecological surgeries [81-84]. Sham feeding with gum given three or four times per day and chewed for an average of 10 to 30 minutes at a time has been shown to expedite the return of bowel function after abdominal surgery in most but not all studies [85].

A 2015 Cochrane review of 81 randomized trials showed chewing gum reduced time to flatus by 12.5 hours (22 studies; 95% CI -17.2 to -7.8 hours), time to bowel movement by 18.1 hours (20 studies; 95% CI -25.3 to -10.9 hours), and length of hospital stay by 1.0 day (18 studies; 95% CI -1.6 to -0.4 days) compared with conventional postoperative care. The effect sizes were largest in colorectal surgery and smallest in cesarean section [86]. A separate 2016 Cochrane review of 17 trials of cesarean section demonstrated a similar benefit of chewing gum [87]. Two trials published after the Cochrane review demonstrated [88] and failed to demonstrate the benefit of chewing gum [89], respectively.

Although many studies have demonstrated that chewing gum can reduce the risk of prolonged postoperative ileus, it remains unclear which patients will respond and which operations will benefit. Furthermore, given that chewing gum is physiologically sham feeding, its potential benefit may be diminished when patients are fed early [86]. Many centers have implemented ERAS protocols that include early enteral feeding. It is up to the individual center to decide whether to include chewing gum in its ERAS program. Considering that chewing gum is an inexpensive and safe intervention, it represents a simple alternative to early enteral feeding that avoids the associated risks of vomiting in patients who cannot tolerate early feeding for anatomical or physiological reasons. (See 'Routine delayed enteral feeding' below.)

Other methods of sham feeding, such as sucking on candies or ice chips and chewing gum containing xylitol or nicotine, have also been tested with mixed results.

Routine delayed enteral feeding — Historically, food and oral fluids were withheld for a period of time postoperatively under the assumption that gastrointestinal motility returned slowly and that feeding soon after surgery could lead to vomiting or exacerbate postoperative ileus. This assumption has been discredited by contemporary studies [2,90]. Although early feeding may not hasten recovery of ileus per se, routine delayed feeding does not prevent it.

The impact of early enteral feeding (<12 hours after surgery, or day of surgery) on gastrointestinal function has been assessed by multiple trials. Some demonstrated that early enteral feeding reduced the length of postoperative ileus and hospital stay [91-96] while others did not [97-100]. Either way, however, early enteral feeding appeared safe and did not increase the duration of postoperative ileus. A 2009 Cochrane review associated early feeding with reduced mortality, though the mechanism remains unclear [101]. A 2019 systematic review and meta-analysis found early enteral nutrition (initiated within 24 to 48 hours after surgery) reduced time to return of normal bowel function (flatus, bowel movement) and shortened hospital stay [102].

Given that a portion of patients will not tolerate early postoperative feeding because of nausea or vomiting, early enteral feeding is increasingly recognized not as an intervention to shorten postoperative ileus but as a means of identifying those with delayed recovery of the gastrointestinal function (ie, an enteral challenge) [61]. Thus, we suggest against routinely delaying enteral feeding after abdominal surgery. Enteral feeding as early as on the day of surgery is an option for patients who undergo elective surgery and do not have any preexisting intestinal ileus, obstruction, perforation, or systemic sepsis. The decision of early versus delayed enteral feeding should ultimately be individualized for each patient by the operating surgeon based on the surgical procedure performed and other pertinent patient factors.

This issue of early postoperative feeding is also discussed in detail elsewhere. (See "Overview of perioperative nutrition support", section on 'Early enteral feeding'.)

Coffee — The effects of coffee consumption on bowel motility are attributed to alterations in colonic motor activity, but whether this is related to caffeine or other components in the coffee is unknown [103-109].

In a trial of 80 patients undergoing laparoscopic or open colectomy, coffee (compared with water) decreased the time to the first bowel movement (60 versus 71 hours) [109]. In another trial of 105 patients undergoing laparoscopic left-sided colectomy, decaffeinated coffee reduced the time to first bowel movement and solid food tolerance compared with regular coffee and water [110]. In a further prospective trial of 115 patients undergoing elective laparoscopic colon or rectal resection, postoperative coffee was favorable over tea consumption as shown by a significant reduction in time to first bowel movement and first flatus, but not in reduction of length of hospital stay [111].

Given the small sample size and uncertain clinically meaningful benefit, we consider the use of coffee for the sole purpose of hastening recovery from postoperative ileus discretionary at this time. Nonetheless, we do not restrict coffee once patients are tolerating a diet.

Other pharmacologic treatments — Most pharmacologic agents for specific prevention of postoperative ileus have been disappointing, with the exception of peripheral acting mu-opioid receptor antagonists (eg, alvimopan) discussed above. (See 'Peripheral acting mu-opioid receptor antagonists' above.)

Multiple trials have not shown a benefit for pharmacologic treatments, including metoclopramide [102,112-114], erythromycin [102,115,116], or neostigmine [117], in accelerating postoperative gastrointestinal recovery [32].

One small trial using propranolol was encouraging [118], but a subsequent study did not demonstrate improvement in clinical or myoelectric determinants of postoperative ileus [119].

Although early-phase studies showed promising results with ghrelin receptor agonists (eg, ulimorelin) [120,121], which are known to increase gastric emptying in diabetic gastroparesis, subsequent larger trials showed no benefit in gastrointestinal recovery [122,123].

The radiological contrast agent diatrizoate meglumine and diatrizoate sodium solution (Gastrografin) has been used to treat adhesive small bowel obstruction by virtue of its hyperosmolar property. Although there is anecdotal evidence of success with preventing or treating prolonged postoperative ileus with Gastrografin, two trials failed to demonstrate any convincing effect of Gastrografin on improving postoperative gastrointestinal recovery [124,125].

Mosapride and prucalopride are 5-hydroxytryptamine 4 (5HT4) receptor agonists that have been proposed to enhance bowel motility through prokinetic and anti-inflammatory actions. Mosapride has been shown to decrease time to flatus and defecation in two trials [126,127]. Prucalopride is a newer agent to the market [128,129].

A variety of other agents targeting the known pathophysiologic pathways are under investigation. (See "Postoperative ileus", section on 'Normal gastrointestinal motility'.)

Early ambulation — The only study evaluating the effect of early postoperative ambulation on the resolution of postoperative dysmotility did not find a benefit [5]. However, early ambulation is widely recommended by enhanced recovery after surgery (ERAS) protocols for its other benefits, most notably reduction in thromboembolic complications. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Very low thrombosis risk: Early ambulation'.)

Visceral learning — Autonomic behavior is subject to direct suggestion. The effect of "visceral learning" has been studied in patients undergoing abdominal surgery [130]. Specific preoperative counseling in the study group included statements that the patient would have a rapid return of normal gastrointestinal motility, that they would not experience excessive pain or discomfort, and that they would become hungry soon after surgery and be able to eat their favorite food. Although this study was limited by small size (40 patients), it did show that the time to first flatus was significantly shorter (2.6 versus 4.1 days) in the counseled group compared with control patients who received only routine preoperative information.

Acupuncture — Acupuncture is widely accepted in traditional Chinese medicine for treating gastrointestinal illnesses. Two trials showed improved gastrointestinal function in postoperative patients receiving electroacupuncture versus placebo [131,132]. Two other trials failed to show an effect [133,134].

POTENTIALLY HARMFUL INTERVENTIONS

Routine nasogastric tube placement — Randomized trials and meta-analyses do not support the routine prophylactic use of nasogastric tubes following gastrointestinal surgery. (See "Inpatient placement and management of nasogastric and nasoenteric tubes in adults", section on 'Indications'.)

A 2005 Cochrane review evaluated the results of 28 randomized trials involving over 4000 patients undergoing open abdominal surgery that compared routine nasogastric tube placement (until the return of bowel function traditionally defined by the passage of flatus) with no or only transient (defined as removal within 24 hours postoperatively) nasogastric tube placement [135]. Those with routine nasogastric tube placement had significantly slower return of bowel function and trends toward increased pulmonary complications, increased discomfort, and longer length of stay.

COX-2 inhibition — Intestinal manipulation appears to increase cyclooxygenase-2 (COX-2) expression and elevate prostaglandin levels, which, in turn, decreases jejunal contractility. COX-2 inhibition may improve gastrointestinal motility. One randomized trial reported that patients treated with a COX-2-specific inhibitor (valdecoxib; now withdrawn from the market) had a significantly shorter recovery time (time to return of bowel sounds, first bowel movement, tolerance of solid diet, and discharge) and less opioid use when compared with patients on a standard postoperative patient-controlled analgesia (PCA) morphine-only regimen after colorectal resection [136]. However, these agents are associated with a variety of adverse effects, particularly disturbances in intestinal healing leading to the potential for anastomotic dehiscence [58,59]. Given the limited number of studies evaluating any benefit, we recommend against the use of COX-2-specific inhibitors for the sole purpose of hastening bowel recovery after surgery. Selective COX-2 inhibitors include celecoxib and etoricoxib (the latter is not available in the United States). (See "Postoperative ileus", section on 'Postoperative ileus' and "NSAIDs: Adverse cardiovascular effects".)

Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) can and should be used perioperatively as a component of multimodal analgesia, as discussed above. (See 'NSAIDs' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Bowel obstruction".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Postoperative ileus (The Basics)")

SUMMARY AND RECOMMENDATIONS

Scope of problem – Prolonged postoperative ileus is said to occur when the patient has symptoms or signs of paralytic ileus (obstipation and intolerance of oral intake) that persist for more than three to five days (depending on the nature of the surgery and what is considered "typical") without evidence for mechanical bowel obstruction or other postoperative complications. (See 'Prolonged postoperative ileus' above.)

Effective measures for preventing prolonged ileus – Few therapies are truly effective once prolonged postoperative ileus becomes established. A more effective overall strategy is to minimize risk factors that may precipitate and exacerbate the condition. Several measures are effective for preventing prolonged postoperative ileus after abdominal surgery based on varying levels of evidence. The following are suggested (see 'Effective and potentially effective interventions' above):

Midthoracic epidural catheter placement or transverse abdominis plane (TAP) block for postoperative pain control. The choice between the two depends on the extent of the surgical procedure, patient factors, and provider preference. (See 'Epidural or TAP block' above.)

Minimally invasive surgery rather than open laparotomy, when appropriate. (See 'Minimally invasive surgery' above.)

Peripheral acting mu-opioid receptor antagonist (eg, alvimopan). (See 'Peripheral acting mu-opioid receptor antagonists' above.)

Using a multimodal analgesic approach rather than relying solely on opioid agents for postoperative pain control. A typical multimodal analgesic regimen includes acetaminophen, a nonselective nonsteroidal anti-inflammatory drug (NSAID), gabapentin or pregabalin, and possibly intravenous lidocaine. Although controversial, some authors prefer to administer some or all of such medications prior to surgical incision (preventive/preemptive analgesia). (See 'Multimodal analgesia' above.)

Limiting the length of open laparotomy incisions, if possible, and gentle handling and minimal manipulation of the intestines. (See 'Surgical technique' above.)

Limiting the volume of fluid administered in the perioperative period by using a restrictive or goal-directed, rather than a liberal, strategy of fluid management. (See 'Restriction of perioperative fluid administration' above.)

Bundled enhanced recovery after surgery (ERAS) programs for perioperative care. (See 'Bundled ERAS protocols' above and "Enhanced recovery after colorectal surgery" and "Enhanced recovery after gynecologic surgery: Components and implementation" and "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)

Unproven measures for preventing prolonged ileus – Therapies that are ineffective or unproven for preventing prolonged postoperative ileus include gum chewing, coffee, most pharmacologic therapies other than peripheral acting mu-opioid receptor antagonists, early ambulation, acupuncture, visceral learning, and routine delayed enteral feeding. Nevertheless, some of these therapies (eg, early ambulation, early enteral feeding, and gum chewing) are widely used in ERAS protocols for their other effects or because they are harmless and may increase patient satisfaction. (See 'Ineffective or unproven interventions' above.)

Harmful interventions – Potentially harmful interventions include routine placement of nasogastric tubes and the use of selective cyclooxygenase-2 (COX-2) inhibitors (celecoxib and etoricoxib; due to increased risk of anastomotic leak). (See 'Potentially harmful interventions' above.)

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Topic 15155 Version 17.0

References