Primary prevention

Attempts to prevent postoperative ileus should begin in the perioperative setting, including appropriate intra-operative fluid management and avoidance of opioid analgesia. Enhanced recovery after surgery (ERAS) pathways are increasingly utilized in an attempt to expedite recovery of intestinal function and shorten hospital length of stay.[28][29][30] The mainstays of ERAS pathways include minimally invasive surgery, avoiding opioids, multimodal pain control, early ambulation, and early intake of oral fluids and solids.[3][28][31][32]

In patients undergoing surgery and requiring opioid analgesia, decreasing the use of systemically administered opioid analgesics helps to prevent postoperative ileus. Patient-controlled analgesia pumps are beneficial as they reduce the overall amount of opioid given compared with round-the-clock analgesic dosing administered by a nurse.[33] Useful adjuncts for pain management include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ketorolac, other nonopioid analgesics such as acetaminophen, and local anesthetics administered via epidural.[3][28][34][35][36][37][38][39][40][41][42]

Recommendations for primary prevention of prolonged postoperative ileus include:

  • The use of laparoscopy instead of laparotomy, using minimally invasive surgical techniques and with minimal bowel manipulation[3][28][43][44][45]

  • Reduction in the routine use of nasogastric tubes perioperatively, or removal of orogastric or nasogastric tubes immediately at the completion of surgery[28][32]

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

  • Gentle handling of tissues and minimizing intra-operative bleeding[46]

  • Early enteral feeding[28][47][48][49]

  • Ambulation on the first postoperative day

  • Use of NSAIDs and patient-controlled analgesia[22][27][28][42][50][51]

  • Reducing parenteral opioid administration via the use of epidural analgesia.[3][28][49][52][53] Epidural analgesia (thoracic epidural) and regional analgesia (transverse abdominis plane blocks [TAP]) are both effective in reducing incidence of postoperative ileus and providing enhanced postoperative analgesia.[53]

  • Intravenous lidocaine administration during and after general anesthesia, which may reduce opiate requirements postoperatively, though the effect on gastrointestinal (GI) recovery remains uncertain.[28][49][54][55]

Other interventions to prevent or reduce postoperative ileus include peripherally acting mu-opioid receptor antagonists, chewing gum, bisacodyl, magnesium oxide, daikenchuto, and coffee consumption all have some indications in affecting an established ileus, though they are not routinely recommended.[3][28][32][49][56]

  • Alvimopan is a highly selective mu-opioid receptor antagonist that may reduce the incidence of postoperative ileus.[56][57][58] It is indicated for short-term hospital use only (maximum of 15 doses) in adults who have undergone or are undergoing small or large bowel resection.[59] In patients receiving alvimopan, GI function returned 15 to 22 hours earlier and hospital discharge occurred approximately 16 to 20 hours earlier compared with those receiving placebo.[32][57][60][61][62][63][64][65][66][67] Short-term administration was associated with minimal adverse events.

    The majority of published studies have included only open abdominal surgery, and strong data are lacking regarding the benefit of alvimopan in laparoscopic surgery. One nonrandomized trial showed that alvimopan was successful in avoiding postoperative ileus after laparoscopic right colectomy, but larger randomized prospective trials are needed before it can be recommended in laparoscopic surgery.[66]

  • Several randomized controlled trials and meta-analyses have shown decreased duration of postoperative ileus in patients given chewing gum after surgery.[60][68][69][70][71][72][73][74][75][76] The available evidence suggests that gum chewing in the immediate postoperative period after a cesarean section is well tolerated and may enhance early recovery of bowel function, though the quality of the evidence is very low.[28][32][76]

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