Postoperative ileus: impact of pharmacological treatment, laparoscopic surgery and enhanced recovery pathways

Abstract

Almost all patients develop postoperative ileus (POI) after abdominal surgery. POI represents the single largest factor influencing length of stay (LOS) after bowel resection, and has great implications for patients and resource utilization in health care. New methods to treat and decrease the length of POI are therefore of great importance. During the past decade, a substantial amount of research has been performed evaluating POI, and great progress has been made in our understanding and treatment of POI. Laparoscopic procedures, enhanced recovery pathways and pharmacologic treatment have been introduced. Each factor has substantially contributed to decreasing the length of POI and thus LOS after bowel resection. This editorial outlines resource utilization of POI, normal physiology of gut motility and pathogenesis of POI. Pharmacological treatment, fast track protocols and laparoscopic surgery can each have significant impact on pathways causing POI. The optimal integration of these treatment options continues to be assessed in prospective studies.

Figure 1

Normal physiology of gut motility.

Figure 2

Pathogenesis of postoperative ileus. ¹Laparoscopic surgery decreases the surgical stress and inflammatory response; ²Primarily exogenous opioids, e.g. morphine, binding to μ-receptors in the GI tract, which results in disorganized and non propulsive motility and, thus, prolongs ileus. In addition, activation of opioid receptors, which occurs following major abdominal surgery, inhibits acetylcholine release, reduces gastrointestinal motility, and has been demonstrated to play a key role in POI regulatory pathways[10,29,36-38]. Alvimopan inhibits this effect by blocking the pheripheral opioid μ receptor.