1. GI Patient Recovery Case: Postoperative Ileus
Laurence R. Sands, MD, MBA, FACS, FASCRS
Professor of Clinical Surgery
Chief, Division of Colon and Rectal Surgery
University of Miami School of Medicine
Attending Surgeon
Jackson Memorial Hospital
University of Miami Hospitals and Clinics
University of Miami Hospital
Miami, Florida

2. Faculty Disclosure
It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.
Laurence R. Sands, MD, MBA, FACS, FASCRS, has no financial relationships to disclose. 2

3. Educational Learning Objective
Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures

4. The Patient 48-year-old white male Chief complaint
Rectal bleeding x 4 months
Change in bowel habits

5. History of the Present Illness
6 months of alteration of stool caliber
Associated crampy abdominal pain
Rectal bleeding x 4 months
10 pound weight loss over 3 months
Decreased appetite

6. Past Medical/Surgical History
Hypertension
Benign prostatic hypertrophy
Coronary artery disease
No abdominal surgery in the past
Repair of right knee meniscal tear 20 years ago

7. Medications Atenolol for hypertension
Occasional ibuprofen for joint pain

8. Family History Father with history of colon cancer when he was 65
Underwent surgery with segmental colectomy and postoperative chemotherapy
Disease-free more than 5 years after completion of therapy

9. Social History Occasional social drinker Denies tobacco use
Denies drug use
Works in real estate

10. Plan of Care
Patient advised to undergo colonoscopy for history of change in bowel habits, rectal bleeding, abdominal pain, and weight loss
CT scan advised after colonoscopy

11. Colonoscopic Findings
Multiple colonic polyps
25 to 30 in total
Sessile and pedunculated
3 distinct colonic masses
Ascending colon
Hepatic flexure
Transverse colon
Rectum clear of polyps
Biopsies show multiple tubular adenomas and 3 invasive adenocarcinomas

12. Colon Cancer and Polyps

13. CT Scan Imaging
Masses in the colon
No evidence of metastatic disease

14. CT Image of Right-Sided Colon Cancer

15. Preoperative Studies Exercise stress test Cardiac catheterization
Positive
Cardiac catheterization
Triple vessel disease
CEA level
0.5 (normal)

16. Impression and Plan
Attenuated form of familial adenomatous polyposis (FAP)
Positive catheterization
Need for coronary artery bypass surgery followed by laparoscopic colectomy

17. Surgery
1 month after successful CABG, patient scheduled to undergo laparoscopic total abdominal colectomy with ileorectal anastomosis

18. Preoperative Workup and Support
Liquid diet the day prior to surgery
Full mechanical bowel preparation
GoLYTELY® the day prior to surgery
Oral antibiotic bowel preparation
Neomycin 1 gm at 7 PM and 1 gm at 11 PM the night prior to surgery
Metronidazole 1 gm at 7 PM and 1 gm at 11 PM the night prior to surgery
NPO after midnight prior to surgery
Preoperative counseling provided

19. In The Operating Room Intravenous antibiotics DVT prophylaxis
Ertapenem 1 gm given within 30 minutes of incision
DVT prophylaxis
SQ heparin 5000 units given
General anesthesia induction
Positioned in low lying lithotomy with both arms tucked at the side
Foley catheter and orogastric tube placed

20. Operating Room Events
Laparoscopic total abdominal colectomy performed with ileorectal anastomosis
Warmed gas infuser used for insufflation
Operative time: 280 minutes
Blood loss: 50 ml
Urine output: 150 ml
Orogastric tube removed at the conclusion of surgery

21. Postoperative Orders To recovery room and then to regular floor
Clear liquids ordered once patient is awake and alert in recovery room and able to eat by anesthesia recovery room guidelines
PCA morphine ordered for patient use for analgesia

22. Postoperative Recovery
POD 1 – out of bed to chair
Low urine output
Treated with IV fluid bolus and increase IV rate
POD 2 – early ambulation encouraged
POD 3 – patient complains of severe abdominal pain
Mild tachycardia
No fever
Exam reveals tender and distended abdomen

23. Management of POI NPO Increase IVF for low urine output Labs monitored
Electrolytes (Na, K, Cl, HCO3, Ca, Mg, PO4)
CBC to look for WBC count
Abdominal x-rays
Nasogastric tube placement

24. Postoperative Films of POD 3
Flat plate of abdomen shows multiple loops of distended small bowel
consistent with postoperative ileus

25. Postoperative Ileus
Upright film of abdomen confirms multiple loops of distended small bowel
and no air fluid levels suggesting postoperative ileus and not small bowel obstruction

26. POI Management Upon NGT insertion
850 cc bilious material aspirated from stomach
Kept on low continuous suction
Maintained NGT until bowel function returned
Passage of flatus
Passage of stool
NGT remained present for 7 days
Nutritional support given (TPN)

27. Postoperative Course Bowel function returned NGT removed on POD 10
Diet resumed with clear liquids
POD 12
Low fat, low residue diet started and tolerated
POD 13
Discharge home

28. Postoperative Follow-up
Pathology revealed 3 adenocarcinomas and multiple 25 tubular adenomas
Consistent with attenuated FAP (familial adenomatous polyposis)
T3N1 cancer (stage III disease)
Referred for medical oncology for postoperative chemotherapy

29. Prolonged Length of Stay Following Laparoscopic Total Abdominal Colectomy
What factors may have contributed to the prolonged length of stay in this patient case?
What is the impact of postoperative ileus in terms of cost and resource utilization?
What strategies might have made a difference in length of stay for this patient?

30. Question
Increasing operative time for laparoscopic total abdominal colectomies has been associated with increased postoperative complications, days to resumption of diet, and length of stay.
True or False?
True
False

31. Answer
True
A study by Scheer et al reported that laparoscopic total abdominal colectomies lasting longer than 270 minutes were associated with more postoperative complications, longer time to resume normal diet, and longer length of stay compared with surgeries of shorter duration

32. Study Links Length of Surgery to Higher Incidence of Postoperative Ileus
Retrospective study – all laparoscopic cases
231 right colectomies
210 sigmoid colectomies
46 total abdominal colectomies
In total abdominal colectomy group increased operative time linked to
Increased postoperative complications
Longer postoperative ileus (5 vs 3 days to diet)
Longer length of stay (7 vs 5 days)
To read more about this study, click here:
Scheer A, et al. Dis Colon Rectum. 2009;52:

33. Operative Time and Laparoscopic Total Abdominal Colectomy Outcomes# † *
N = 46
*P = 0.02
†P = 0.003
#P = 0.045
Scheer A, et al. Dis Colon Rectum. 2009;52:

34. Clinical Impact of Postoperative Ileus
Increased postoperative pain
Increased nausea and vomiting
Increased risk of aspiration
Prolonged time to regular diet
Delayed wound healing
Increased risk of malnutrition/catabolism
Prolonged time to mobilization
Increased pulmonary complications
Prolonged hospitalization
Increased health care costs
Kehlet H, Holte K. Am J Surg. 2001;182(5A suppl):3S-10S.
Leslie JB. Ann Pharmacother. 2005;39:
Behm B, Stollman N. Clin Gastroenterol Hepatol. 2003;1:71-80.

35. Hospital Discharge Associated With Recovery of GI Function
GI-2 recovery
Hospital discharge 25 20 15
Patients (%) 10 5 1 2 3 4 5 6 7 8 9 10
Postoperative Day
GI-2 = Recovery of bowel movement and toleration of solid food
Delaney CP, et al. Am J Surg. 2006;191: 35 35

36. Increased Resource Utilization in Colectomy Patients With POI
Average cost/admission
Primary POI: $15,914
Non-POI: $8,316
*P < 0.05
For more information on the economic impact of POI, click on the following link:
Asgeirsson T, et al. J Am Coll Surg. 2010;210:

37. Question
Which element of an enhanced recovery pathway (ERP) was not included in this patient case, but might have helped to reduce the prolonged length of stay?
Patient education and preoperative counseling
Opioid-sparing analgesia
Early ambulation
Prophylactic nasogastric decompression

38. Answer Opioid-sparing analgesia
Preoperative counseling was provided to the patient, and early ambulation was encouraged postoperatively. Routine use of abdominal drains and NG tubes postoperatively are not part of enhanced recovery pathways, as their use is associated with the potential for increased complications without benefit for the patient.
While opioids are often the analgesic of choice following abdominal surgery, they decrease gastric motility, inhibit small and large intestinal propulsion, and have other GI effects that contribute to the abdominal discomfort associated with POI. Opioid-sparing analgesia following colorectal surgery can help to minimize these negative effects on GI recovery.

39. Factors Expediting Return of Bowel Function
Retrospective review of open partial colectomy at single institution
Reviewed several factors to determine quicker time to first BM
Earlier time to first BM noted with:
Early oral intake (76 vs. 134 hours)
Preop use of polyethylene glycol (73 vs. 94 hours)
Early ambulation (78 vs. 95 hours)
Use of NGT (delayed time to first BM by 22 hours)
Concluded: routine use of NGT was not beneficial for bowel recovery
Sindell S, et al. Am J Surg. 2012;203:

40. Opioid-Sparing Pain Management
A number of strategies have been utilized to decrease systemic opioid utilization following colorectal surgery
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Epidural analgesia
IV lidocaine
Wound infiltration with local anesthetics
Liposomal long-acting bupivacaine injection
Gabapentin
Many of the studies investigating opioid-sparing strategies have been conducted in patients following open colorectal surgeries. The benefit for laparoscopic colorectal procedures is less clear

41. Opioid-Sparing Pain Management Ketorolac
Prospective, randomized, double-blind study
102 patients undergoing open colorectal resection
Morphine (1 mg/mL) + Ketorolac (1.2 mg/mL ) PCA vs Morphine PCA (1 mg/mL) + normal saline PCA
PCA settings: 2 mL bolus with 10-minute lockout
Total morphine consumption
Ketorolac/Morphine = 66 mg
Morphine = 81 mg (P < 0.05)
Time to first bowel movement
Ketorolac/Morphine = 1.8 days
Morphine = 2.4 days (P < 0.001)
Chen JY, et al. Clin J Pain. 2009;25:

42. Opioid-Sparing Pain Management Ketorolac: Laparoscopic Surgery
Prospective, randomized, double-blind study (ORAL-CS)
44 patients receiving elective laparoscopic segmental colon resection
Ketorolac 30 mg IV every 6 hours x 48 hours vs. placebo
All patients received morphine PCA
Total morphine consumption:
Ketorolac = 33 mg
Placebo = 63 mg (P = 0.011)
Time to full diet:
Ketorolac = 2.5 days
Morphine = 3 days (P = 0.033)
Length of stay:
Ketorolac = 3.6 days
Morphine = 4.5 days (NS)
For more information on this study, click here:
Schlachta CM, et al. Surg Endosc. 2007;21:

43. Epidural Analgesia vs Parenteral Opioid Analgesia After Colorectal Surgery
Systematic review of randomized, controlled trials
16 trials published between 1987 and 2005
14 trials, open surgery; 2 trials, laparoscopic surgery
Pain on day 1 (VAS score)
WMD – 15 (-19 to -11, P < 0.001)
Duration of GI dysfunction
WMD – 1.55 days (-2.27 to -0.84, P < 0.001)
Length of stay
WMD 0.07 days (-0.4 to 0.54, P = 0.76)
Marret E, et al. Br J Surg. 2007;94:
WMD: weighted mean difference

44. Opioid-Sparing Pain Management Intravenous Lidocaine
Meta-analysis; 8 randomized, controlled trials (n = 161 IV lidocaine, n = 159 controls); 6 open surgery trials; 2 laparoscopy
Duration of POI
Significantly reduced with IV lidocaine
WMD hr ( to -3.47) P < 0.001
Length of hospital stay
Significantly shorter with IV lidocaine
WMD days (-1.38 to -0.31) P < 0.002
VAS pain scores at 24 hr
Significantly lower with IV lidocaine
WMD (-9.63 to -2.23) P < 0.002
Marret E, et al. Br J Surgery. 2008;95:

45. Opioid-Sparing Pain Management IV Lidocaine–Laparoscopic Colectomy* * *
*P < 0.001
To read about the use of IV lidocaine in patients following colorectal surgery, click here.
Kaba A, et al. Anesthesiology. 2007;106:11-18.

46. Enhancing GI Recovery with Peripheral Mu-Opioid Receptor Antagonism
Alvimopan (a peripherally acting mu-opioid receptor antagonist) is FDA-approved for accelerating GI recovery following bowel resection with primary anastomosis
In patients undergoing bowel resection, alvimopan
Accelerated return of bowel function
Reduced the time to discharge order written
Reduced postoperative ileus-related morbidity
Did not reverse postoperative analgesia
Benefit of alvimopan uncertain for laparoscopic procedures, with epidural analgesia, or together with NSAIDs
Barletta JF, et al. J Laparoendoscop Adv Surg Tech. 2011;21:
Vaughan-Shaw PG, et al. Dis Colon Rectum. 2012;55: 46

47. Alvimopan in Laparoscopic Surgery
Retrospective case series review at a single community hospital (2007–2010)
Before and after introduction of alvimopan to perioperative care pathway for laparoscopic colectomy
101 alvimopan patients vs 64 pre-alvimopan controls
Mean length of stay for the alvimopan group was days less than control group (2.81 vs 4.36 days, P < )
POI in alvimopan group was 2% vs 20% in control group (P < )
Itawi EA, et al. JSLS. 2011;15:

48. Fast Track Protocols Help
Fast track protocol vs traditional care
Reduces POI by 43%
Decreased LOS by 1.35 days
Ward CW. Medsurg Nurs. 2012;21:

49. Summary
Postoperative ileus is a real entity with prolonged length of stay and increased morbidity
Use of non-narcotics for pain control may reduce postoperative ileus
Use of alvimopan may be helpful to reduce postoperative ileus by allowing narcotic use and not affecting bowel function
In total abdominal colectomy and longer operations, much consideration for reducing postoperative ileus should be employed