Current strategies for preventing or ameliorating postoperative ileus: a multimodal approach.

ABSTRACT

PURPOSE: Internal and external factors that contribute to postoperative ileus (POI), the efficacy and safety of various nonpharmacologic and pharmacologic interventions that have been evaluated for the prevention or amelioration of POI, and the current multimodal approach used in patients undergoing major abdominal surgery are described. SUMMARY: Catecholamine and cytokine release associated with the stress response to surgery and the use of certain antiemetic medications, opioid analgesics, and inhaled anesthetics are among the factors that contribute to POI. Early ambulation does not affect the duration of POI, although it has other benefits for patients undergoing abdominal surgery. Clinical experience supports the use of laparoscopy instead of laparotomy if possible, removal of nasogastric tubes shortly after surgery, restriction of intravenous fluids, and initiation of clear oral liquids and ambulation on the first postoperative day. The recommended therapeutic approach for patients undergoing major abdominal surgery involves thoracic epidural analgesia using a local anesthetic with or without an epidural opioid analgesic, and systemic nonsteroidal anti-inflammatory drugs for their opioid-sparing effect if systemic opioid analgesics are used. Buprenorphine may be preferred if a systemic opioid analgesic is used, because it has little effect on gastrointestinal smooth muscle. Metoclopramide, erythromycin, beta blockers, laxatives, neostigmine, naloxone, and gum chewing are not useful for treating POI. CONCLUSION: Most pharmacologic interventions that have been tried in an effort to prevent or ameliorate POI are ineffective or cause intolerable adverse effects. Research is needed to identify and develop new drug therapies for POI.