Primary prevention

Attempts to prevent postoperative ileus should begin in the perioperative setting.

Enhanced recovery after surgery (ERAS) pathways are used in an attempt to expedite recovery of intestinal function and shorten hospital length of stay.[28]​ This multimodal approach reduces morbidity rates, improves recovery, and shortens length of hospital stay after major colorectal surgery.[28] The mainstays of ERAS pathways include minimally invasive surgery, avoiding opioids, multimodal pain control, early ambulation, and early intake of oral fluids and solids.[28][32]​​

Recommendations for primary prevention of prolonged postoperative ileus according to ERAS pathways include:

  • Using minimally invasive surgical techniques (e.g., laparoscopy rather than laparotomy) whenever possible[28]

  • Limiting opioid administration through the use of multimodal anaesthesia and analgesia techniques

    • Reduce parenteral opioid administration via the use of epidural analgesia.[28][33][34]​​[35]​ However, in practice the use of epidural analgesia may be challenging due to its impact on the patients' mobility.

    • Useful adjuncts for pain management include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac, and analgesics and local anaesthetics administered via epidural.[28][36][37][38][39][40]​​​[41]​​[42][43][44][45][46][47]

    • The use of lidocaine infusions is recommended to reduce opioid use after surgery, but it is unclear whether this treatment reduces the risk of postoperative ileus.[28][48]

  • Gentle handling of tissues and minimising intra-operative bleeding[49]

  • Eliminating routine placement of nasogastric tubes[28][35]

  • Restricting intravenous fluids (goal-directed fluid administration)[28]

  • Early ambulation[28]

  • Establishing early enteral feeding (during the first 24-48 hours after the surgery).[28]​[50][51][52]

The ERAS Society guidelines do not recommend other preventative measures such as gum chewing, using peripherally acting mu-opioid receptor antagonists (e.g., alvimopan - licensed in the US), or administering oral agents such as bisacodyl or magnesium oxide, daikenchuto (a traditional Japanese herbal medicine), or coffee due to weak or conflicting evidence to support their routine use.[6][28]​​ However, the ERAS Society guidelines recommend against withholding coffee from postoperative patients who can take oral liquids.[28]

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