PDF | This is a case of a year-old man presenting with caecum perforation and obstruction in the splenic flexure. During surgical exploration. Left-Sided Colonic Obstruction Due to Brid Ileus and Coexisting Right Colon Cancer without Palpable Mass [Turk J Colorectal Dis ]. Am J Surg. Jan;(1); discussion Treatment of acute postoperative ileus with octreotide. Cullen JJ(1), Eagon JC, Dozois EJ, Kelly KA.
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Gossypiboma Causing Mechanical Intestinal Obstruction: A Case Report
The duration of postoperative ileus following abdominal surgery is quite variable, and prolonged postoperative ileis is an iatrogenic phenomenon with important influence on patient morbidity, hospital costs and length of stay in hospital.
Adequate treatment for prolonged postoperative ileus is important to improve patient morbidity and clinical efficiency. Both clinical and pharmacological management strategies have improved rapidly over the last decade, and appropriate and timely management using multimodal techniques should be used for optimal care.
In this review, we define postoperative ileus, describe the pathogenesis and briefly discuss clinical management before detailing potential pharmacologic management options. In systems that try to minimize hospital stay after abdominal surgery, one of the principal limiting factors is the recovery of adequate bowel function, which can delay discharge or lead to readmission. Postoperative briid POI is the term given to the cessation of intestinal function following surgery.
Although all surgical procedures put the patient at risk for POI, gastrointestinal tract surgeries in particular are associated with a temporary cessation of intestinal function. The duration of POI varies, ilus from a few hours to several ieus.
Prolonged postoperative ileus, also known as pathologic postoperative ileus, can be caused by a myriad of pathologic processes that are treated with limited success by clinical and pharmacologic management.
Studies of large administrative databases show that, on average, patients with a diagnosis of POI stay 5 days longer in hospital after abdominal surgery than patients without POI. In this review, we define POI, describe the pathogenesis and briefly discuss clinical management before detailing current pharmacologic management options. Postoperative ileus has been variably defined, but involves a temporary cessation of bowel function with a variable reduction in activity sufficient to prevent effective transit of intestinal contents.
Its ileuus is related to a complex series of inter-relations among inhibitory neural iileus, release of neurotransmitters and inflammatory mediators, and endogenous and exogenous opioids. A unique and important form of POI that becomes an important clinical problem occurs when the symptoms are absent or appear to resolve, but become evident 1 or more days later.
It is also important to be able to identify patients who have POI that lasts long enough to be considered clinically unacceptable or problematic. Three clinical manifestations of POI have been described in ileuus literature, and these are outlined in Table 1. Normal bowel function requires the coordination of gastrointestinal motility, mucosal transport and defecation reflexes, and these actions are influenced by neurogenic, inflammatory and pharmacologic mechanisms.
Limiting the effect of these altered pathways forms the basis of many therapeutic options for decreasing the severity and duration of Ileud, and it is therefore necessary to ilues the pathogenesis before understanding treatment options.
Neurogenic mechanisms appear to play the most important role in early POI. Sympathetic stimulation inhibits gastrointestinal motility, whereas parasympathetic activity primarily stimulates it.
After surgery, the sympathetic system tends to be substantially more active than the parasympathetic system, leading to decreased motility and ileus. Inflammatory mechanisms likely play an important role, but the exact nature and extent of their involvement is poorly understood.
This may be precipitated by direct intestinal manipulation, particularly during open surgery. Pharmacologic mechanisms have also been shown to play an important role in prolonged POI through endogenous and exogenous opioids to decrease gastrointestinal motor activity.
Until recently, the treatment options available for prolonged POI primarily consisted of nasogastric tube insertion, correction of electrolyte abnormalities and administration of intravenous fluids.
Several new studies have called into question the efficacy of routine nasogastric tube placement for prevention of suspected POI, and they suggest that this common practice may actually prolong the duration of POI.
More rigorously designed trials to investigate the true effects are needed to draw stronger conclusions, but at this time both techniques appear to be safe, and although early ambulation does not appear to decrease the duration of POI, starting a clear-liquid diet early after surgery probably does. The prevention of POI may be the most cost-effective, time-effective and patient-centred approach to management; however, no technique is currently available to prevent ileus.
Several strategies may be used to reduce the clinical consequences of ileus, including minimizing intestinal trauma during surgery, using midthoracic epidural anesthesia and minimizing the need for opioids in pain management — strategies that have all been shown to reduce the risk of prolonged POI. The rest of our review will focus on the pharmacologic management of POI, which can be used as part of a full multimodal strategy for its prevention and treatment.
Many of the bris management techniques available to the surgeon are still under active investigation for effectiveness and are based broadly on bid known pathophysiologic influences highlighted previously.
Minimizing sympathetic inhibition of gastrointestinal motility has achieved greatest success through prevention of sympathetic activation with adequate pain management, minimal surgical trauma and appropriate selection of intraoperative anesthesia.
Neostigmine is an acetylcholinsterase inhibitor that causes an increase in cholinergic parasympathetic activity in the gut wall, which is believed to thereby stimulate ileuss motility.
Some studies have shown moderate effectiveness in alleviating acute colonic pseudo-obstruction, but the clinical usefulness of neostigmine in postoperative patients nrid be limited by adverse effects including abdominal cramps, excess salivation, vomiting and bradycardia.
Use of edrophonium chloride and bethanechol chloride, which competitively inhibit acetylcholine on the binding site of acetylcholinesterase, has been ileuw to show improvement of POI. Cisapride is a serotonin 5-HT 4 receptor antagonist that promotes acetylcholine release from postganglionic nerve endings in the myenteric plexus and is thought to indirectly improve gastrointestinal motility.
Metocloprimide is suspected to enhance gastrointestinal motility without stimulating gastric secretion, but its use has not been substantiated for POI. Most clinical trials evaluating the effects of metoclopromide on decreasing POI have shown no difference compared with patients receiving placebo with regard to flatus, bowel sounds and bowel movements.
Decreasing inflammation may be indicated in patients who are about to undergo major intestinal surgery, as this is thought to be an important contributing factor to POI. Nonsteroidal anti-inflammatory NSAIDs agents can be used in conjunction with opioid analgesics for their dual effects on pain control and inflammatory inhibition. Two novel drugs are being investigated for this reason: Opioid therapy for postoperative or chronic pain is frequently associated with adverse effects, the most common being brkd and debilitating bowel dysfunction, so alvimopan and methylnaltrexone may also be useful in the treatment of chronic opioid bowel dysfunction.
In a recent review of 3 phase III multicentre trials Table 2111314 Alvimopan significantly accelerated gastrointestinal recovery after segmental bowel resection, with recovery being accelerated by about 18—22 hours in different trials.
Patients who received alvimopan also had reduced postoperative morbidity, shorter stays in hospital and decreased incidence of readmission compared with those who received placebo.
Alternative medications are less well studied in the treatment of POI. For example, several laxatives are commonly used to treat constipation, but their value in the treatment of POI is unknown. In a randomized trial of bisacodyl administration versus placebo twice daily starting on postoperative day 1, patients who received bisacodyl had significantly earlier bowel movements than those who received placebo 25 h v.
Reducing the duration of POI reduces a patient’s postoperative stay in hospital and thus can have profound effects on patient satisfaction, hospital efficiency and the economic burden of major abdominal surgery on the healthcare system.
Although the duration of POI is variable, we now have a better understanding of the impact of perioperative opioid analgesia, the benefits of thoracic epidural analgesia with local anesthesia and the benefits of avoiding nasogastric tube placement.
Pharmacological management of postoperative ileus
Several multimodal care pathways have been effective in substantially decreasing the length of stay in hospital after major abdominal surgery, and results from these studies show the promising benefit of aggressive postoperative management for prevention and treatment of ileus. All authors designed and wrote the article and approved the final version for publication. None declared for Dr. Delaney is a paid consultant with Adolor Corporation and Wyeth, and has received honoraria from both companies, and travel assistance and speaker fees from Adolor.
Cleveland OH fax gro. National Center for Biotechnology InformationU. Journal List Can J Surg v. Author information Copyright and License information Disclaimer.
This article has been cited by other articles in PMC. Abstract The ileuus of postoperative ileus following abdominal surgery is quite variable, and prolonged postoperative ileus is an iatrogenic phenomenon with important influence on patient morbidity, hospital costs and length of stay in hospital. Open in a separate window.
Inflammatory mechanisms Inflammatory mechanisms likely play an important role, but the exact nature and extent of their involvement is poorly understood. Pharmacologic mechanisms Pharmacologic mechanisms have also been shown to play an important role in prolonged POI through endogenous and exogenous opioids to decrease bgid motor activity.
Minimizing sympathetic inhibition Minimizing sympathetic inhibition of gastrointestinal motility has achieved greatest success through prevention of sympathetic activation bfid adequate pain management, minimal surgical trauma and appropriate selection of intraoperative anesthesia.
Ileuz inflammation Decreasing inflammation may be indicated in patients who are about to undergo major intestinal surgery, as this is thought to be an important contributing factor to POI.
Alternative medications Alternative medications are less well studied in the treatment of POI. Clinical consensus update in general surgery. Pharmatecture, LLC ; Holte K, Kehlet H. Br J Surg ; Prospective randomized controlled trial between a pathway of Controlled Rehabilitation with Early Ambulation and Diet CREAD and traditional postoperative care after laparotomy and intestinal resection.
Dis Colon Rectum ; Mattei P, Romgeau JL. Review of the pathophysiology and management of postoperative ileus. World J Surg ; Clinical perspective on postoperative ileus and the effect ileuz opiates.
Neurogastroenterol Motil ;16 Suppl 2: Fast-track post-operative management protocol for patients with high comorbidity undergoing complex bgid and pelvic colorectal surgery.
Kehlet H, Holte K. Multimodal strategies to improve surgical outcome. Am J Surg ; Mechanisms and treatment of postoperative ileus. Mechanisms of postoperative ileus. Neurogastroenterol Motil ;16 suppl 2: Alvimopan, a novel, peripherally acting mu-opioid antagonist.
Pharmacological management of postoperative ileus
Alvimopan, for postoperative ileus following bowel resection: Phase III trial of alvimopan, a novel, peripherally acting, mu opioid antagonist, for postoperative ileus after major abdominal surgery. Viscusi ER, et al. Alvimopan, a peripherally acting mu-opioid receptor antagonist, compared with placebo in postoperative ileus after major abdominal surgery: Adolor Corporation and GlaxoSmithKline.