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•Management of the Surgical Patient With Postoperative Ileus
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Presentation
Postoperative Ileus (POI)
Can we shorten recovery, and improve patient outcomes?<= /span>
H. Randolph Bailey, M.D., F.A.C.S.
Clinical Professor, Department of Surgery
University of Texas Health Science Center
Houston, Texas
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Faculty Disclosure
•Adolor/GSK Speaker’s Bureau
•Merck Speakers Bureau
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Traditional Management of <= /span>Colorectal Surgical Patients
•Mechanical bowel prep
•NG tube and NPO until flatus or BM
•IM (or IV) opioid analgesia
•Slow dietary advancement
•Slow ambulation
<= span style=3D'font-weight:normal'>•Post-operative stays of 8-12 days
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Recovery after GI surgery
•Three prim= ary issues:
–Restoratio= n of fluid and electrolyte homeostasis
–Pain management
–Ileus reso= lution and restoration of oral nutrition
•Pain and i= leus often interrelated
–More pain         more drugs        more ileus
      more pain= ?
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POI: Definition
•Ileus: functional inhibition of propulsive bowel = activity, irrespective of pathogenetic mechanisms<= /span>1&= #13;
•POI: transient cessation of coordinated bowel motility after surgical intervention, which prevents effective tr= ansit of intestinal contents and/or tolerance of oral intake2
–Primary POI: such cessation occurring in the absen= ce of any precipitating complication
–Secondary POI: that occurring in the presence of a precipitating compli= cation
•Prol= onged ileus: form of POI lasting &g= t;5 days after surgery1,3 
1.Livings= ton EH, Passaro EP Jr. Dig Dis Sci. 1990;35:121-132.
2.Behm B, Stollman= N. Clin Gastroen= terol Hepatol. 2003;1:71-80.
3.Baig MK, Wexner = SD. Dis Colon Rec= tum. 2004;47:516-526.
4.
Clinic= ians use a variety of definitions to describe the changes in bowel activity that occ= ur after abdominal surgery, but nomenclature has not been standardized. Ileus has been defined as the functional inhibition of propulsive bowel activit= y, irrespective of pathogenetic mechanisms.1 Postoperative ileus (POI) has been defined as a transient cessation of coordinated bowel moti= lity that occurs after surgical intervention, particularly colonic surgery, wh= ich prevents effective transit of intestinal contents and tolerance of oral intake.2 Primary POI occurs in the absence of any precipitating complication, whereas secondary POI occurs in the presence of a precipitating complication (eg, infection, anastomotic leak= ).
Ady= namic ileus and paralytic ileus are synonyms for POI.2 The term = paralytic ileus is used to describe POI lasting more than 5 days—possibly even weeks—after surgery.1,3 It is more severe and seems= to represent inhibition of small bowel activity.1
POI mo= st commonly occurs after intraperitoneal operations but may also occur after retroperitoneal and extra-abdominal surgery.4 It is the most common cause of prolonged hospitalization and a significant cause of readmission after abdominal surgery.5,6

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Postop ileus-Natural history
•<= /span>Postoperatively, typically lasts
–<= /span>0-24 hours in small intestine
–<= /span>24-48 hours in stomach
–<= /span>48-72 hours in colon
•Duration the same with right co= lon or
left colon surgery
•<= /span>?increased with duration of surgery
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Manifestations and Consequences
of Prolonged POI<= /div>
•Delayed pa= ssage of flatus and stool
•Increased postoperative pain and cramping
•<= /span>Increased nausea and vomiting
•<= /span>Delay in resuming oral intake
–Possible need for parenteral nutrition
•Delay in postoperative mobilization
–DVT/PE =
•Increased risk of other postop complications
–Deconditioning
–Pulmonary complications
•<= /span>Prolonged hospitalization
–Nosocomial infections
•Decreased patient satisfaction
•Increased healthcare costs
•<= /span>Bed availability?
= 3D"man-closeup
•Bungard TJ, Kale-Pradhan = PB. Pharmacotherapy. 1999;19:416-423.
•Kehlet H, Holte K. Am J Surg. 2001;182(Suppl):3S-10S.
•Behm B, Stollman N. <= /span>Clin Gastroenterol Hepatol. 2003;1:71-80.
Manife= stations of postoperative ileus (POI) include delayed passage of flatus and stool, increased postoperative pain and cramping, and nausea and vomiting.1= ,6,7 In addition, patients with POI typically experience abdominal pain and discomfort.1,6,7
Delay = in resuming a regular diet, poor wound healing, and delay in postoperative mobilization= are other potential consequences of POI.1,2 In some patients, dela= y in resuming enteral feeding may necessitate parenteral feeding.
POI al= so increases the risk of other postoperative complications, including deconditioning a= s a result of delayed postoperative mobilization, pulmonary complications, and other nosocomial infections.1,3 Use of nasogastric tubes can d= elay gastrointestinal recovery and increase the risk of fever and pulmonary complications.3
Prolon= ged POI can result in increased hospital length of stay, decreased patient satisfacti= on, and increased healthcare costs.1,4,5
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Incidence of Prolonged POI for Common Abdominal Surgeries
Procedure Description
Procedures, N
POI Cases, %
Abdominal hysterectomy
456,29= 2
4.1
Large bowel resection
257,336
14.9
Small bowel resection
48,824
19.2
Appendectomy
175,96= 4
6.2
Cholecystectomy
81,013=
8.5
Nephroureterectomy
44,808=
8.9
Other procedures
597,49= 2
9.0
  Total
1,661,= 729
8.5
•Source: HCFA data (Medicare, 1999-2000) evaluating 161,000 major = intestinal/color= ectal resections from 150 US hospitals
•Health Care Financing Administration. Medicare, 1999-2000. Federal Register. Available at: http://www.gpoaccess.gov/= fr.
Accord= ing to 1999-2000 data from the Health Care Financing Administration, the overall incidence of postoperative ileus (POI) was 8.5% for common abdominal surgeries in the United States. The incidence varied with the type of procedure, ranging from 4.1% for abdominal hysterectomy to 19.2% for small bowel resection.
These = data only concern POI that was documented and coded in the medical record.  The true incidence of clinically significant POI is probably higher.
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Length of stay
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Ileus is only one element in= recovery
•Shortening= the duration of POI won’t be helpful as an isolated victory if we don’t address a= ll of the other recovery parameters at the same <= /span>time! •Over the past 10 years, the concept of “fast= track” or “critical pathway” has= been used to address all of the recovery parameters simultaneously. •The goal o= f a “critical pathway” is to accelerate the postoperative recovery process, both in the hospital and at home after discharge.
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What is a “critical pathway”?
•A seque= nce of events through which patients= generally pass on their way from surgery (or = some other intervention) to restoration of = desired outcome, usually wellness
–Includes time frame
–Several temporally related steps may be going on simultaneously
–<= span style=3D'font-size:93%'>Pre-op, intra-op and post-op components (as = well as outpatient recovery phase)
–Includes <= u>appropriate management of each phase
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Critical Pathways (“Fa= st T= rack”) in Surgery
•Effort to identify the “optimum course” of a patient during the postoperative period, and manage each phase with “best demonstrated practices”
–(=3D evidence-based perioperative care)
•Identify an individual patient’s deviation from the “optimum course” and intervene early
•Every exper= ienced surgeon has such an “= ;optimum course” in mind, as well as “standard therapy”,but significant variations = exist among surgeons
–Varies with belief systems, “I was always taught…”, “We’ve always done it this way”, etc.
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Enhanced Recovery After Surgery
(ERAS)
•<= /span>Fast track sounds like the patient and family are being pushed ou= t of the hospital
•My concern is not with length of stay, but patients  experiencing the best outcomes= 3;
•Often good patient care and outcomes translates into shorter = LOS, but that is a secondary benefit!
•<= /span>ERAS a more “friendly” term
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ERAS Pre-Op
•Education = of what to expect
•Fitness= 3;
–Smoking an= d EtOH cessation
–Exercise&#= 13;
–Nutrition-= supplement or weight loss (glucose control)
•Bowel prep=
–Discomfort, dehydration, electrolytes
–Most data support no prep
–Enemas if trans-anal stapling planned
•Fasting= 3;
–Diet day p= rior to surgery
–Carbohydra= te rich drink up until 2-3 hours before surgery
•
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Need for Bowel Prep?
•Trauma literature-Primary repair without MBP
•Paakkonen et al, 2000, RCT
–Leak rate 4% with, vs 2% without, PEG prep (NSS)
–<= /span>Wound inf. Rate 6% vs. 5% (NSS)
•6 other RCT’s corroborating the above!
–<= /span>None in U.S. yet
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Pre-op Fasting
(Scandinavian Guidelines)
•Patients (adults as well as children) may drink clear fluids up to 2 h prior to general or regional anaesthesia
•Patient should not take solid food 6 h prior to induction of anaesthesia
•Breast-feeding should be stopped 4 h prior to induction of anaesthesia. The same applies to <= /span>formula milk =
•Adults may drink up to 150 ml of water with pre-operative oral medication up to= 1 h before induction of anaesthesia, and children up to 75 ml.
•Use of chewing gum and any form of tobacco should be discouraged during the last = 2 h prior to induction of anaesthesia
•
•Soreide et al, Acta Anaesthesiol Scand 2005; 49: 1041—1047
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