P a t h o g e n e s i s an d

Clinical and Economic

Consequences of
Postoperative Ileus
Michael G. Doorly, MD, MS, Anthony J. Senagore, MD, MS, MBA*

KEYWORDS
 Postoperative ileus  Abdominal surgery
 Early postoperative small bowel obstruction  Ogilvie syndrome
 Alvimopan

Postoperative ileus (POI) is perceived as an unavoidable outcome of major abdominal

surgery, primarily because of poorly understood multifactorial pathophysiology.1
Although ileus is thought to be a disease of the small intestine, the duration of POI
may be primarily dependent on the return of colonic motility.2 Physicians should
understand the risk factors contributing to the development of POI to help prevent,
recognize, and treat this morbid and financial problem. POI is multifactorial in origin
and the causative factors include neuromuscular, inflammatory, and pharmacologic
influences.1 Understanding the various causes of POI helps to guide its prevention,
diagnosis, treatment, and reduction of cost. The enhanced recovery protocol (fast-
track) provides a consistent checklist that benefits all postoperative patients. Not all
postoperative abdominal distention is POI. Recognizing the differences between
POI, early postoperative small bowel obstruction (EPSBO), and acute colonic
pseudo-obstruction can expedite care and improve survival.

FISCAL BURDEN OF POI

Although not life-threatening, POI can prolong postoperative recovery, increase the
length of stay in hospital, and the use and costs of health care resources.3–6 For
example, up to 25% of colectomy patients suffer POI, which doubles the cost of their
care.7 POI may lead to other costly morbidities. The resultant abdominal distention of
POI increases the risk of hernia formation and wound dehiscence, while nausea and
vomiting affect the resumption of enteral nutrition and increase the risk of malnutrition

The authors have nothing to disclose.

Keck School of Medicine of USC, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA
90033-4612, USA
* Corresponding author.
E-mail address: Anthony.Senagore@med.usc.edu

Surg Clin N Am 92 (2012) 259–272

doi:10.1016/j.suc.2012.01.010 surgical.theclinics.com
0039-6109/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
260 Doorly & Senagore

and impaired wound healing. The need for nasogastric decompression and prolonged
venous access inhibit ambulation, which may increase rates of pulmonary complica-
tions and thromboembolism. Prolonged fasting requires parenteral nutrition, which
costs 3.5 times more per day than enteral nutrition,8 without including the cost of
central venous catheter placement or its complications. The morbidities of POI and
the added care place a greater economic burden on the health care system.
The prolonged hospitalization associated with POI is an important issue at hospitals
with a limited number of beds and high demand for inpatient services. Efforts to mini-
mize POI and lengths of stay in hospital without increasing the risk of postdischarge
readmission have the potential to improve the financial bottom line for hospitals,
private and governmental health insurers, and society at large. Approximately
161,000 Medicare recipients undergo major intestinal or rectal resection each year,
which consumes an estimated 1.8 million days in hospital at a cost of $1.75 billion.9,10
Safely shortening this length of stay would produce significant dividends because the
economic impact of POI is estimated at $750 million per year.11–13
Recurrence of primary (delayed) POI is the cessation of flatus or stool, with bloating
and nausea or vomiting after a period of apparent resolution.14 This process usually
occurs 1 or more days after the patient has been discharged home, subsequently
requiring readmission to the hospital. Readmission occurs in approximately 10% of
patients who undergo major abdominal surgery, and about half of these patients are
readmitted for gastrointestinal (GI) failure or some measure of recurrence of their
POI.15 This is a particularly important problem because the economic costs of read-
mission are exaggerated in part from tests such as computed tomography (CT) scans.
The readmission cost of delayed POI is comparable to the readmission cost of more
serious adverse surgical complications.7 These formidable costs obligate the patho-
physiologic understanding of this frequently preventable disease.

PATHOGENESIS OF POI

The multifactorial approach to prevention and treatment of POI is due in part to its
complex pathogenesis. Studies have identified 3 major precipitating mechanisms
for POI: neurogenic, inflammatory, and pharmacologic (Fig. 1). These mechanisms
overlap to cause the disease, but the neuronal mechanism seems to disproportion-
ately affect the early postoperative period.14 Endogenous neuromuscular inhibitors
of the bowel include norepinephrine, corticotropin-releasing hormone (CRH), nitric
oxide, somatostatin, glucagon, gastric inhibitory peptide, and opioids.16 Neurogenic
bowel inhibition relates to pain-induced neural reflexes, which in turn result in sympa-
thetic hyperactivity and inhibition of GI motility.17,18 Another response to tissue trauma
is the release of CRH from the central nervous system. CRH is recognized to
contribute to the induction and duration of ileus.19 Pain-induced reflexes also generate
endogenous opioids that contribute to GI inhibition. Strategies to reduce postopera-
tive pain and POI include the use of laparoscopic surgery and epidural local anes-
thetics.17,20 POI may occur after minimally invasive surgical procedures, despite
obvious reductions in surgical trauma and manipulation of the bowel, possibly
because of the effects of opioid analgesics mediated by the stimulation of GI opioid
receptors by exogenous opioids.21,22
Localized postoperative inflammation inhibits GI smooth muscle, and the duration
of POI seems to correspond to the magnitude of intestinal inflammatory response.22,23
Surgical manipulation of intestine activates quiescent macrophages and mast cells to
induce several inflammatory cascades, primarily via the arachidonic acid pathway. As
with pain response, these inflammatory mediators cause the release of endogenous
 Clinical and Economic Consequences of POI 261

Fig. 1. Triad of dysmotility. CRH, corticotropin-releasing hormone; NE, norepinephrine; NOS,

nitric oxide synthase.

opioid peptides, which further exacerbate the effects of exogenous opioid analgesics
(administered for analgesia) on the inhibition of bowel function.24–26 Bowel wall
edema, from inflammation or intravenous fluid overload, is another mechanism of
impairing GI motility.18 Generalized inflammation (sepsis) causes fluid shifts that can
lead to electrolyte abnormalities. Aberrations in electrolytes correlate with altered GI
neuromuscular function and with prolonged POI.27
The pharmacologic deterrent to GI motility in postoperative patients is primarily the
opioid class of medications. Opioid use for postoperative pain has been shown to
correlate with the time to return of normal bowel function after surgery.18
The negative effect of opioids on GI motility is believed to occur because of the stim-
ulation of m-opioid receptors in the bowel, leading to inertia in the gut.1,17 Opioids
decrease GI secretion and profoundly inhibit peristalsis that leads to prolonged
POI.23 The opioid dose that slows peristalsis is 25% the dose of adequate anal-
gesia.18,28 This unfortunate mechanism is compounded in patients with analgesic
tolerance because the bowel does not seem to develop tolerance.18 Another study
found no correlation between total morphine dose and incision length.21 These results
suggest that postoperative opioid management is a more important determinant of
POI than the use of minimally invasive surgery.

DIAGNOSIS AND TREATMENT OF POI

POI is not life-threatening, but patients with POI typically experience substantial
discomfort.29 The current challenge of diagnosing and treating POI is the lack of an
established uniform characterization of the disease. There is still dispute about the
duration of normal POI. In 149 patients undergoing major abdominal surgery who
were encouraged to ambulate and take oral liquids on the first postoperative day
and eat solid food on the second postoperative day, more than 4 days elapsed before
GI function returned to normal in half of the patients, and 25% of the patients had not
regained normal GI function after more than 6 days.29 Many surgeons have suggested
that normal POI should last 3 days for laparoscopic surgery and 5 days for open
surgery after bowel resection.14 Prolonged POI lasts longer, and the symptoms are
262 Doorly & Senagore

uniformly recognized: abdominal pain and distention, nausea, vomiting, lack of flatus,
and intolerance to diet. POI can be further classified based on the predominance of
upper versus lower of GI symptoms (Table 1).14
The diagnosis of prolonged POI is based on signs, symptoms, and abdominal
imaging. Ileus reveals itself on an abdominal radiograph as a panintestinal dilatation
with a spotty gas pattern throughout. However, the use of abdominal radiography in
the absolute diagnosis of ileus in the immediate postoperative period is questionable.
Studies report only 19% to 43% specificity and that abdominal radiography is not
prognostic for reoperation.30,31 CT is considered the gold standard for diagnosing
POI because it can differentiate POI from EPSBO more than 98% of the time.31,32
POI has been reported after up to 25% of colectomies, and EPSBO has been reported
after up to 10% of colectomies.7,33 Distinguishing POI from EPSBO is important
because although they have similar presentations, EPSBO is associated with
increased morbidity, reoperation, and mortality.
The treatment of prolonged POI should include bowel rest (nil by mouth), ambula-
tion, strict electrolyte management, and minimal opioid usage. Obtaining relief of
POI-related pain is a two-edged sword because the surgeon balances adequate anal-
gesia with additional impairment of GI motility. Placement of a nondiscriminatory
nasogastric tube (NGT) for POI may prolong the duration of POI and is not associated
with the early return of bowel function.16,34 Vomiting related to POI necessitates NGT
placement for GI decompression. Relaparotomy for prolonged POI is rarely needed,
except in situations when the diagnosis is unclear or translocation of gut flora bacteria
causes a septic response (Fig. 2). At present, the incidence of relaparotomy for pro-
longed refractory POI remains unreported. Resolution of POI is signaled with the return
of flatus, decreased abdominal distension, and toleration of diet.

EPSBO

In addition to symptomatic and radiographic evidence of EPSBO, some investigators

include loss of POI tolerance before postoperative day 30 as the definition of
EPSBO.33,35 Although prolonged POI and EPSBO have similar presentations, the
sequelae of EPSBO tend to be more serious. Understanding the incidence, etiology,
and risk factors for EPSBO can expedite the diagnosis. The reported incidence of
EPSBO differs, ranging from 0.7% to 10%.33,35 The incidence of 0.7% is most likely
an underestimation because it excludes conservatively managed patients.36 Most of
the literature reports an EPSBO rate between 5% and 10%. Risk factors for EPSBO
do not seem to include age, body mass index, American Society of Anesthesiologists
score, or blood loss.37 Elective supracolic procedures have lower incidences of
EPSBO, as does simple exploratory laparotomy (1.3%).33,35,38,39 Laparoscopy is
also associated with lower incidence of EPSBO. When compared with open resection,
laparoscopic ileocolic resection for Crohn disease is associated with 69% less early/
late postoperative small bowel obstruction (SBO) (35.4% vs 11.1%).40 A multicenter
French study reports that 88% of postlaparoscopic SBO is early postoperative.41

Table 1
Types of POI

Type Location Symptoms

I Panintestinal Nausea, vomiting, no flatus
II Upper GI Nausea, vomiting, flatus present
III Lower GI Tolerance of diet, no flatus
 Clinical and Economic Consequences of POI 263

Fig. 2. Ileus versus early small bowel obstruction. (From www.netterimages.com. Ó Elsevier
Inc. All rights reserved; with permission.)

Open procedures posing the highest risk of EPSBO are colectomy, omentectomy, and
pelvic dissection.37,42–44
CT accurately distinguishes EPSBO from POI, and should be the gold standard test
in the early postoperative time period because it can also identify other complications.
If CT suggests EPSBO, an NGT should be placed and water-soluble contrast diatrizoic
acid (Gastrografin, Hypaque) upper GI series performed. Gastrografin is safe in the GI
tract or peritoneal space, accurately predicts the need for surgery, and is associated
with shorter hospital stays.45–47 Barium should be avoided because the viscous prop-
erties may exacerbate partial SBO, the prolonged half-life may confuse future imaging,
264 Doorly & Senagore

and barium causes a difficult-to-treat peritonitis if the bowel perforates. The hyperos-
molar property of Gastrografin may have a therapeutic effect by establishing an
osmotic catharsis, thus speeding the resolution of adhesive SBO and decreasing
the need for surgery.46,48,49 Approximately 90% of early postoperative bowel obstruc-
tions treated with NGT resolve by 6 days, whereas 10% need relaparotomy.33 The risk
of bowel strangulation from EPSBO is 2% to 4%, much lower than the 17% for late
adhesive SBO.36,50
The decision to reoperate on a patient with EPSBO can be difficult, especially if the
patient is comfortable without evidence of strangulation. Operative management for
EPSBO should take place between 1 and 2 weeks, although spontaneous resolution
beyond 10 days is unlikely.33,51 Adhesiolysis after 2 weeks increases the technical
difficulty and the risk of inadvertent enterotomy. In cases of carcinomatosis, radiation
enteritis, and frozen abdomen, conservative management of EPSBO can be used
indefinitely.36 A major problem with adhesive SBO is that the recurrence rate is the
same after adhesiolysis in comparison with conservative management (about
60%).52 Meticulous surgical technique can reduce adhesiogenesis, but the high rate
of recurrence has inspired much research. Strategies to interfere with adhesiogenesis
include barriers or the reduction in inflammation, fibrin, and collagen deposition.53
Nonsteroidal anti-inflammatory drugs and corticosteroids decrease inflammation,
but their safety and effectiveness is questionable.54–56 Heparin and streptokinase
decrease fibrin deposition but they cause unacceptable postoperative bleeding.57,58
Halofuginone, a type I collagen synthase inhibitor, decreases adhesiogenesis in
animals but has yet to be studied in humans because of healing and safety
concerns.59,60 The most effective inhibitor of adhesiogenesis to date is a hyaluronan
carboxymethylcellulose barrier (Seprafilm).54 Studies indicate that Seprafilm can
reduce adhesiogenesis by 33% to 50%, but may increase intraperitoneal abscess
and the rate of anastomotic leaks.61,62 The clinical sequelae of using Seprafilm have
recently been shown to decrease EPSBO by more than 60% with a trend toward
decreasing late adhesive SBO.63,64

ACUTE COLONIC PSEUDO-OBSTRUCTION (OGILVIE SYNDROME)

Acute colonic pseudo-obstruction is a massive dilatation of the colon with constipa-

tion in those in whom a mechanical obstruction has been excluded. The disease
commonly affects individuals with senility or neurologic disease, and those who
receive drugs that affect gut motility. Acute colonic pseudo-obstruction is a serious
condition because patients usually have multiple comorbidities, delayed diagnosis,
inappropriate treatment, and high mortality from ischemia (25%–31%) or perforation
(40%–50%).65 Theories about the pathophysiologic cause include autonomic
dysfunction, reduced colonic ganglion cells, and loss of intrinsic nitric oxide activity,
but the cause remains unknown.65 Patients are commonly critically ill, and present
with a nontender distended abdomen and the inability to pass stool or flatus. They
may also have nausea, vomiting, or abdominal pain. Unlike POI or EPSBO, acute
colonic pseudo-obstruction has little to do with an abdominal operation. In fact, the
most common procedures associated with Ogilvie syndrome are coronary artery
bypass grafting, and spine and orthopedic procedures.66
Symptoms lead to an abdominal radiograph revealing isolated colonic dilatation.
Diagnoses must exclude mechanical colonic obstruction by either CT or Gastrografin
enema. The management of Ogilvie syndrome depends on the patient’s condition and
the risk of perforation. Realized or suspected perforation requires surgical intervention
and is associated with higher mortality.67 Perforation usually means total or segmental
 Clinical and Economic Consequences of POI 265

colectomy with ostomy, while intact colons may be proximally diverted.68,69 Conser-
vative management should include a risk assessment using complete blood count and
serial abdominal radiographs every 12 to 24 hours, because a cecal diameter of more
than14 cm is associated with a 2-fold increase in mortality.67,70 Many surgeons agree
that the risk of cecal perforation increases with a cecal diameter greater than 10 cm.
Failure to improve or worsen by 48 to 72 hours indicates the need for colonic decom-
pression, because waiting longer than 6 days has a greater risk of complication.69,71,72
Monitored intravenous neostigmine in patients without a history of myocardial
ischemia, asthma, or renal failure remains a mainstay of treatment.73 Colonoscopic
decompression is also an accepted therapy, but is technically difficult and carries at
least a 2% risk of perforation.74 Endoscopic and CT-guided percutaneous cecostomy
have been described in patients intolerant to surgery, but the studies were small and
with only marginal success.75–77

ENHANCED RECOVERY AFTER SURGERY

A multimodal approach has been developed to improve postoperative morbidity,

including POI, in surgical patients.10,78 In addition, adoption of enhanced recovery
after surgery (ERAS) at teaching hospitals has been shown to decrease length of
stay.79 Preoperative counseling (patient education), intraoperative fluid restriction,
use of a laparoscopic approach, immediate initiation of clear fluids after surgery,
and early discontinuation of the Foley catheter are all independently associated with
shortened length of stay in hospital.79 Patient education is also an important compo-
nent of fast-track protocols. The discussion should include importance of early ambu-
lation, early enteral nutrition, and effective pain control with both narcotic and
nonsteroidal combinations of oral medications. Although early ambulation does not
seem to reduce the duration of POI, it may contribute to decreasing length of stay
by preventing atelectasis, pneumonia, and deep vein thrombosis while preserving
strength and conditioning.23,80,81 Early enteral nutrition after bowel surgery is safe,
well tolerated, and associated with a decreased length of stay, but does not change
the incidence of POI.17,23 The decreased length of stay associated with early enteral
nutrition may result from an earlier recognition of postoperative tolerance translating
to earlier discharge from hospital. Despite the use of a fast-track protocol, POI after
abdominal surgery can still last a long time.29,82
Anesthesiologists are important participants in the attempt to decrease length of
stay in hospital. Medications used during general anesthesia have a profound effect
on the duration of POI. Inhaled anesthetics (particularly nitrous oxide), atropine, and
catecholamines decrease intestinal motility, especially within the large intestine.34
Midthoracic epidural anesthesia improves postoperative bowel function by blocking
afferent autonomic pain signals, efferent catecholamines, and stress response to
localized inflammation, and decreases the need for peripheral opioids.18,83 Intraoper-
ative fluid management affects postoperative morbidity and duration of POI. One
prospective study compared restrictive and liberal intraoperative fluid administration,
which resulted in no difference in duration of POI or length of stay.84 Another prospec-
tive study showed Doppler-optimized intraoperative fluid management to decrease
POI, nausea, vomiting, and wound infection rates.85
Other postoperative regimens to reduce duration of POI and length of stay have been
met with less success. The evidence is clear that traditional prokinetic medications can
neither prevent nor treat POI. Numerous prospective studies show that erythromycin
simply does not have any effect, and there is a lack of evidence that cholecystokinin-
like drugs, cisapride, dopamine antagonists, propranolol, or vasopressin affect the
266 Doorly & Senagore

duration of POI.86 Prospective studies on medications that block opioid receptors, such
as methylnaltrexone, did not effectively show a decreased duration of POI, and use of
these drugs comes at the expense of inadequate pain control.87 The practice of sham
eating (gum chewing) has been trialed, the results of which are promising yet controver-
sial. Meta-analysis of prospective studies on sham eating revealed the practice to be
well tolerated and had 25% less time to flatus, 32% less time to bowel movement,
and 18% earlier discharge, with similar complication rates.88

POTENTIAL ROLE OF ALVIMOPAN

The newly available peripherally selective m-opioid receptor antagonist alvimopan

(Entereg) offers an adjunct to fast-track protocols with the potential to minimize POI
rates.29 A recent pooled analysis of 3 of the prospective randomized and blinded alvi-
mopan trials confirmed that a 12-mg dose provided optimal reduction in GI morbidity
and return of GI function.89 These benefits are clinically relevant and important to clini-
cians when arranging discharge plans.90 An interesting additional benefit of alvimopan
was a significant decrease in the incidence of POI as a serious adverse event coupled
with a reduction in the proportion of patients who had prolonged hospital stay or read-
mission.88 These benefits translated into a 50% reduction in the proportion of patients
defined as having prolonged hospital stay. Alvimopan has been generally well toler-
ated in the available trials, without producing a negative impact on narcotic analgesia
as demonstrated by pain scores. All these trials included a program of early oral nutri-
tion and ambulation, and compared with the placebo group the reduction in time to
writing the discharge order confirmed the additional benefit of alvimopan even in an
enhanced recovery program.

MEDICATIONS UNDER INVESTIGATION FOR POI

Promising medications to prevent and treat POI are currently under investigation.
Ghrelin agonists have been shown to stimulate motilin receptors and have powerful
prokinetic properties. A recent prospective study in patients undergoing major
abdominal surgery reported the first-in-class ghrelin agonist TZP-101 was well toler-
ated and accelerated the recovery of the upper and lower GI tract, with a large propor-
tion of patients recovering within 72 hours compared with those on placebo.91 The
perioperative intravenous administration of lidocaine has recently become an intense
area of research, especially in the anesthesia literature. Although 2 studies show no
difference, the preponderance of evidence suggests that perioperative intravenous
lidocaine is safe, reduces postoperative pain, reduces the duration of POI, and
decreases the length of stay in hospital.92–98 Escin, a natural mixture of triterpene
saponins, has been used to decrease cerebral edema (anti-inflammation) and chronic
venous insufficiency (venotonic) in China. Animal studies have shown that escin may
also have prokinetic properties. Universities in China are currently investigating
whether escin can reduce POI. Preliminary results indicate that escin can shorten
the time to recovery of GI motility in patients with cancer after colorectal surgery.99
Escin requires central venous administration to prevent peripheral phlebitis.

SUMMARY

The clinical and economic consequences of POI are substantial. Understanding the
pathogenesis contributing to POI (triad of dysmotility) will improve patient care and
speed up postoperative recovery. The physician must be able to differentiate POI
from EPSBO and Ogilvie syndrome. Assuming all postoperative abdominal distention
 Clinical and Economic Consequences of POI 267

to be POI is a critical mistake. The use of appropriate and timely abdominal imaging to
diagnose these diseases will save lives. The goal of enhanced recovery fast-track
protocols is to improve the safety of postoperative care, speed up recovery, and
reduce costs. Medications such as alvimopan, ghrelin agonists, and intravenous lido-
caine can help attain this goal, but it is up to physicians to implement and maintain
enhanced recovery protocols. Fast-track protocols must be implemented via a multi-
specialty approach with shared responsibility toward a common goal. Educating the
patient preoperatively about the anticipated care regimen is also essential. The global
economic importance of POI cannot be overstated. By preventing, recognizing, and
treating POI, one can improve the lives of one’s patients and help safeguard the finan-
cial sustainability of the health care system.

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