Management of prolonged post-operative ileus: evidence-based recommendations

Prolonged post-operative ileus (PPOI) occurs in up to 25% of patients following major elective abdominal surgery. It is associated with a higher risk of developing post-operative complications, prolongs hospital stay and confers a significant financial load on health-care institutions. Literature outlining best-practice management strategies for PPOI is nebulous. The aim of this text was to review the literature and provide concise evidence-based recommendations for its management.

A literature search through the Ovid MEDLINE, EMBASE, Google Scholar and Cochrane databases was performed from inception to July 2012 using a combination of keywords and MeSH terms. Review of the literature was followed by synthesis of concise recommendations for management accompanied by Strength of Recommendation Taxonomy (either A, B or C).

Recommendations for management include regular evaluation and correction of electrolytes (B); review of analgesic prescription with weaning of narcotics and substitution with regular paracetamol, regular non-steroidal anti-inflammatory drugs if not contraindicated, and regular or as-required Tramadol (A); nasogastric decompression for those with nausea or vomiting as prominent features (C); isotonic dextrose-saline crystalloid maintenance fluids administered within a restrictive regimen (B); balanced isotonic crystalloid replacement fluids containing supplemental potassium, in equivalent volume to losses (C); regular ambulation (C); parenteral nutrition if unable to tolerate an adequate oral intake for more than 7 days post-operatively (A) and exclusion of precipitating pathology or alternate diagnoses if clinically suspected (C).

Recommendations have a variable and frequently inconsistent evidence base. Further research is required to validate many of the outlined recommendations and to investigate novel interventions that may be used to shorten duration of PPOI.