Systematic scoping review of enhanced recovery protocol recommendations targeting return of gastrointestinal function after colorectal surgery

ANZ J Surg. 2020 Jan;90(1-2):41-47. doi: 10.1111/ans.15319. Epub 2019 Jul 4.


Background: Post-operative ileus (POI) and delayed return of gastrointestinal (GI) function are common complications after colorectal surgery. There is a lack of uniformity in enhanced recovery protocols (ERPs) with regards to interventions used to target these complications. This systematic review aims to categorize and summarize management recommendations available from published ERPs.

Methods: A systematic search of Ovid MEDLINE, Embase, Cochrane Library and PubMed databases was performed from January 1990 to May 2018. All studies publishing enhanced recovery or fast-track or multimodal pathway protocols for colorectal surgery in their full-text were included. Data on interventions aimed at reducing the duration of POI were extracted, as well as references quoted to support specific interventions.

Results: Of 481 manuscripts screened, 37 published ERPs were identified from 37 studies (18 cohort, seven historical-control, five guidelines, four randomized controlled trials, one randomized controlled trial protocol, one case series and one narrative review). The most commonly recommended interventions were magnesium-based laxatives (18 of 37, 48.6%), chewing gum (13 of 37, 35.1%), Alvimopan (6 of 37, 16.2%), lactulose (4 of 37, 10.8%), neostigmine (2 of 37, 5.4%) and bisacodyl (2 of 37, 5.4%). Geographical trends were noted for the various interventions, but high-quality evidence was only referenced to support the use of Alvimopan.

Conclusion: ERP recommendations specific to interventions targeting POI and return of GI function are varied. While laxatives are the most commonly recommended intervention, there is only weak evidence reported to support this practice.

Keywords: enhanced recovery; gastrointestinal dysfunction; ileus; lower gastrointestinal.

Publication types

  • Systematic Review

MeSH terms

  • Bisacodyl / therapeutic use
  • Chewing Gum
  • Colonic Diseases / surgery*
  • Humans
  • Ileus / drug therapy*
  • Lactulose / therapeutic use
  • Neostigmine / therapeutic use
  • Piperidines / therapeutic use
  • Postoperative Complications / drug therapy*
  • Recovery of Function*
  • Rectal Diseases / surgery*


  • Chewing Gum
  • Piperidines
  • Bisacodyl
  • Neostigmine
  • Lactulose
  • alvimopan