Prolonged ileus

I remember it as a problem 10 years ago when some patients had prolonged ileus without we understanding the reason. That is not to say I understand it now but it certainly seems to have grown much less of a problem. My conviction is that better surgery has done away with most of the problem. And I would also credit anaesthesia for a large share in the improvement.

In my opinion adherences and ileus go together, and we see a lot less of adherences as well. I do a lot of reoperative surgery to support my statement, because a statement it is for I cannot prove it. I have been especially impressed with the few adherences we see in reoperative laparoscopic bowel surgery. Just to give an example we did laparoscopic ileorectal anastomosis for chronic obstipation in a patient some time ago. We now took out her entire colon in a second laparoscopic operation and there were no adherences at all. We have had the same experience about adherences in restorative proctectomy after previous colectomy for acute attacks of ulcerative colitis. We used to spend quite some time to sort adherences in many of those patients. In a series of 15 patients with previous colectomy we have now done laparoscopic ileo-rectal anastomosis for reconstruction. In not a single case were adherences a problem. It seems that the colectomy we do today does not produce adherences, and no prolonged ileus. I credit technique for it.

The typical situation when we saw prolonged paralytic ileus was after Kock pouches. Sometimes we had to reoperate which could be ackward, spending hours sorting bowel and in the end it was named mechanical obstruction due to adherent bowel, because there was no other explanation. I have grown reluctant to accept adherent bowel as an indication for surgery. A little patience before operation is good because most of these patients do not have the typical derangement of homeostasis seen in classical mechanical obstruction due to a band or incarcerated hernia.

I have come to view postoperative ileus as a response to the surgical trauma. It is longer in bigger operations. It is also longer in difficult operations.

We see a different problem, but perhaps of similar cause, today. Of our elective bowel surgery (including colitis and colon obstruction) 96% of patients have regained bowel motor function (passing faeces or ostomy content) within 7 days. However, 10% of the patients are still not tolerating regular food at 7 days. About 5% of patients develop what I call the postoperative gut failure syndrome. It happens to patients that have began eating. The typical events are recurring ileus and often hypersecretion seen as womiting, excessive ostomy flow, or diarrhea if an ileorectal or ileoanal anastomosis. The patients loose significant amounts of fluid in their bowel and may become dehydrated and oliguric. They stop drink and eat and feel sick. Some develop fever which can be quite alarming. It seems to be entirely a small bowel problem. I assume that in earlier experience these patients did not regain bowel motor function but instead went directly into the state of prolonged paralytic ileus.

I do not know how to avoid the gut failure but to make the operations more precise. And to be very observant about that the patient stays on normal postoperative course. The gut is the most sensitive organ of all and it fails much quicker and easier than any other organ (except for the brain). There is, in my mind, ample evidence to view the gut as the primary shock organ that responds with various degrees of failure for a variety of reasons after surgery.

We rarely use metochlopramide or cisapride, but occasionally give water soluble contrast medium which seems to trigger the slow gut.

Keep the gut happy, and good luck with your research.

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