Prolonged postoperative Ileus: what should be done to improve patient outcome?

Postoperative ileus (POI) is a transient inhibition of gastrointestinal (GI) motility that involves the entire GI tract (1). Prolonged POI is characterized by abdominal distention, nausea, vomiting and delayed passage of flatus and stool. It is defined by two or more of the following criteria occurring on or after the fourth postoperative day without prior resolution of POI: nausea or vomiting, inability to tolerate oral diet over 24 hours, absence of flatus over 24 hours, abdominal distension defined as increased abdominal girth with tympany on percussion, or radiologic confirmation of POI (2). While all patients undergoing bowel resection experience delayed GI recovery to some extent, prolonged POI is a major contributor to postoperative length of stay in patients undergoing major abdominal surgery (3). In addition, prolonged POI is a significant cause of postoperative morbidity in these patients, including malnutrition caused by delayed oral intake, thromboembolism caused by decreased ambulation, wound dehiscence and hernia formation secondary to abdominal distention and aspiration pneumonia (4).

Several factors have previously been described to contribute to the severity and duration of POI, including patient related factors, extent of bowel manipulation, operative time, amount of opioids used to treat postoperative pain and surgical approach (1,5-7). A more recent large series reviewing almost 10,000 patients from the American College of Surgeons National Surgical Quality Improvement Program database identified several five risk factors for the development of prolonged POI including smoking, weight loss, preoperative oral antibiotics, mechanical bowel preparation, and surgical approach (8).

Sugawara et al. (9) conducted a retrospective study aimed to devise a model for stratifying the probability of prolonged POI in patients undergoing abdominal surgery. The authors have reviewed the records of 841 patients who underwent major abdominal surgery after excluding patients who underwent less extensive surgery, or on the other hand “ileus associated surgery”. They devised a nomogram by evaluating predictive factors for prolonged POI. In their cohort, 73 patients (8.8%) developed prolonged POI and on multivariate analysis factors that were found to be independent predictors to prolonged POI were smoking history (P value =0.025), colorectal surgery (P value =0.004) and an open surgical approach (P value =0.002). The prediction model the authors have developed is based on a score a patient receives for the presence of each of the three above mentioned risk factors which eventually translates into a probability to develop prolonged POI. The model showed a discrimination concordance index of 0.71 (95% CI, 0.66–0.77), which means a “good” even though not “strong” model (10). In this series, the probability to develop a prolonged POI in a patient with a smoking history who underwent open colorectal surgery was calculated to be 19.6%.

Since a “history of smoking” (as per the study definitions—including past history and not only around the time of surgery) and the type of surgery (as defined by the patient’s disease) are non-modifiable factors, the most important factor of these three is the only modifiable factor which is the surgical approach. Laparoscopic surgery is associated with well-known benefits as a result of the reduced tissue trauma. These advantages include (but are not limited to) an earlier return of bowel function, with most studies showing approximately a 1-day reduction in the duration of POI in favor of the laparoscopic approach compared to open surgery (11,12). Laparoscopic surgery as well as hand-assisted laparoscopic surgery (HALS) have also been shown to involve a lower rate of POI and a lower requirement for nasogastric tube decompression postoperatively than open surgery (13).

Several other possible interventions have been shown to decrease the incidence of prolonged POI. Gum chewing is a non-invasive, low cost and low risk intervention that has been shown in several studies to shorten POI. A recently published meta-analysis which evaluated 18 randomized controlled trials showed that chewing gum resulted in a statistically significant earlier recovery of bowel function and a lower risk of prolonged POI (odds ratio =0.41, P=0.003) (14).

Alvimopan is a competitive inhibitor of the µ-opioid receptor hence it blocks the peripheral effect of opioid drugs on the GI tract. It has been shown in several multicenter randomized phase III trials to decrease the mean time to GI recovery after bowel resection surgery in 11 to 26 hours (7,15,16). Other pharmacological interventions have been studied (or are undergoing clinical trials nowadays) with clinically and statistically significant benefits yet to be proven. Most importantly, it has been shown that development of accelerated care protocols and pathways and adherence to these protocols may decrease postoperative length of stay and enhance GI motility (5,17,18). In the most recent study specifically looking at the relationship between adherence to Enhanced Recovery After Surgery (ERAS) protocol and the incidence of POI in 131 patients undergoing colorectal resections, the authors found that the time interval to passage of flatus, bowel movements and time to tolerate solid diet all decreased as adherence to the ERAS protocol increased (18). They also found that adherence to at least 85% of the items in the ERAS protocol protected patients from prolonged POI of≥4 days.

Different institutions have developed various ERAS protocols which vary in between them but all refer to preoperative, intraoperative and postoperative factors. One example is shown in Table 1.

In conclusion, identifying the factors that predict prolonged POI as Sugawara et al. (9) did is indeed important. Even more important is understanding the pathways in which POI develops and proactively decreasing the incidence and severity of POI with the implementation of as many of the above mentioned means possible.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ales.2018.02.04). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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