Postoperative Ileus: A Necessary Evil or a Preventable Nightmare?

Carlos E Costa Almeida
há 2 horas
3 min de leitura

Postoperative ileus is a common complication, occurring in 10–20% of patients undergoing major abdominal surgery. It adversely affects patient recovery by increasing the risk of venous thromboembolism and hospital-acquired infections, as well as prolonging length of stay (LoS). Most surgeons have encountered this complication, which may arise several days after surgery and can be highly distressing for both patients—causing abdominal distension, pain, and vomiting—and clinicians.

According to a paper published in the BJS by Dr. Miriam Khalil et al. from the UK, the pathogenesis of postoperative ileus is not fully understood. The authors describe two phases: an early neurogenic phase and a later inflammatory phase. In the early phase, an inhibitory spinal reflex pathway is activated, whereas in the later phase, there is an increase in nitric oxide- and prostaglandin-releasing leukocytes, triggered by intestinal manipulation. These processes reduce intestinal smooth muscle contractility and contribute to the development of postoperative ileus. As is well known, opioid use exacerbates these mechanisms, which is why opioid analgesia is a recognized risk factor. Other risk factors identified by the authors include male sex and longer procedures involving greater degrees of bowel manipulation.

For many years, postoperative ileus was considered an unavoidable consequence of surgery. However, there are now several strategies that may help reduce its incidence.

The treatment of postoperative ileus can be compared to a rusty engine, from which the rust is removed so that it can start working again.

Enhanced Recovery After Surgery (ERAS) was introduced in 2003 with guidelines aimed at reducing postoperative ileus and other complications. However, over time, the program has often been interpreted primarily as a strategy to shorten hospital length of stay. One reason for its occasional failure is the tendency to standardize its application across all patients. In reality, patient care should be individualized, as each patient has different needs and recovery trajectories. For example, oral intake should not be initiated uniformly across all patients, but rather according to individual clinical tolerance. Although ERAS protocols recommend early oral intake within 24 hours to reduce postoperative ileus, this may not be appropriate in all cases. Patients without evidence of bowel function, or those who have undergone intraoperatively complicated procedures, are less likely to tolerate early feeding.

The authors talk about different strategies to reduce the postoperative ileus. I would like to highlight the following:

Chewing gum may promote bowel motility in the postoperative period. I have used this approach in the past. While some studies have reported positive effects, larger trials have shown no significant impact on length of stay (LOS). Importantly, chewing gum is unlikely to cause harm, so its use may still be considered, I think.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) remains controversial. According to the authors, any benefit in bowel function is probably related to reduced opioid use within a multimodal analgesic strategy, rather than a direct effect on gut motility. However, NSAIDs—particularly non-selective ones—have been associated with an increased risk of anastomotic leakage after colorectal surgery, so they should be used with caution. We also need to keep in mind their potential to increase postoperative bleeding. If the surgery was associated with significant bleeding, or if the patient is at higher bleeding risk, it is probably wiser to avoid them.
Probiotics appear to improve intestinal recovery after surgery. However, despite these promising findings, robust evidence is still lacking.
Vagal nerve stimulation may reduce intestinal inflammation and smooth muscle dysfunction. This emerging, non-invasive technique requires further investigation.

In this context, laparoscopic surgery has been a game-changer, I think. By minimizing bowel handling, it helps lower the risk of postoperative ileus. When combined with opioid-sparing pain management strategies, the effect is even stronger. Other measures, like early oral intake, often become possible only because of these improvements.

In summary, postoperative ileus is a common consequence of abdominal surgery and is often associated with additional complications. Therefore, every effort should be made to minimize its occurrence. It should not be regarded as an inevitable or normal component of the postoperative course, but rather as a preventable complication that requires active management.