|Year : 2020 | Volume
| Issue : 1 | Page : 16-21
Postoperative ileus after orthopedic and spine surgery: A critical review
Vishal Kumar, Abhishek Vaish, Raju Vaishya
Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India
|Date of Submission||16-Dec-2019|
|Date of Acceptance||17-Jan-2020|
|Date of Web Publication||17-Mar-2020|
Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi - 110 076
Source of Support: None, Conflict of Interest: None
Constipation and abdominal discomfort are the most common complaints after orthopedic surgery. Still, there is still not much development in the knowledge about postoperative ileus (POI). It is evident due to the lack of published literature on Post Operative Ileus (POI) and its sequel. A comprehensive review of the literature was conducted to identify the risk factors, mechanism, and treatment to treat POI. The literature search was performed using search engines such as PubMed, MEDLINE, SCOPUS, and Google Scholar databases on April 1, 2019. After applying the inclusion and exclusion criteria, we selected nine publications for this review. Only six of these studies were related to POI after orthopedic (4) or spine surgery (2). These studies comprised a total of 231,773 patients of POI. The results showed that invariably, all the patients after gastrointestinal surgeries developed POI, but it was not restricted to it. POI was also seen after orthopedic surgery, with its incidence being maximum in patients undergoing spine and arthroplasty surgery. POI is multifactorial and is invariably an unavoidable cause in the postoperative period leading to increased morbidity and hospital stay. In order to deal with this, identifying the risk factors in a patient in the preoperative period, modifying the anesthesia technique, early mobilization, adequate pain management, recognizing the clinical signs and symptoms of ileus, and treating it promptly lead to achieving the optimal outcomes. The multimodal approach of management of POI is advisable.
Keywords: Abdominal surgery, constipation, orthopedic surgery, postoperative ileus, spine surgery, trauma
|How to cite this article:|
Kumar V, Vaish A, Vaishya R. Postoperative ileus after orthopedic and spine surgery: A critical review. Apollo Med 2020;17:16-21
| Introduction|| |
Constipation and abdominal discomfort are frequent complaints after orthopedic surgery. Despite extensive advancement in surgical techniques, there is still not much development in the knowledge about postoperative ileus (POI). Moreover, the literature is scarce on POI and its sequel. In 1990, Livingston and Passaro defined ileus as “the functional inhibition of propulsive bowel activity, irrespective of pathogenetic mechanisms.” They further defined POI as the “uncomplicated ileus occurring following surgery, resolving spontaneously within 2–3 days.”
Although the occurrence of POI is mostly associated with abdominal surgeries, the incidence of POI after lower extremity reconstruction ranges from 0.3% to 2.0%,, with an even higher incidence (5.6%) following revision total hip arthroplasty. POI is a complication of up to 4% of both total hip and total knee arthroplasties. Spine surgery is no exception in developing POI with approximately 3.5% of patients undergoing lumbar spine surgery who develop POI.
Even after providing the best pre- and perioperative care, the occurrence of constipation remains unavoidable. These changes lead to an extended hospital stay and an increase in the cost of the stay. Understanding the causes and mechanism of POI is of par importance while managing the patients. Among the multifactors associated with the development of POI, important ones such as the use of narcotics, the effect of the autonomic nervous system, psychogenic stress, changes in the gut microbiome, local hormones, and changes in gut motility play important roles.
A retrospective study examining ileus in over 200,000 spine surgery patients found an overall incidence of 2.6% when undergoing a posterior lumbar spinal fusion, 7.5% when undergoing an anterior lumbar spinal fusion, and 8.4% when a patient underwent both anterior and posterior approaches. As there are not many studies and literature on POI and constipation associated with orthopedic surgeries, we intend to review the literature on this common problem for further understanding and update the knowledge.
| Materials and Methods|| |
This study aimed to identify the risk factors for POI, mechanism of POI, and treatment for POI. A comprehensive review of the literature was conducted to identify the risk factors, mechanism, and treatment to treat POI. The literature search was performed using search engines such as PUBMED, MEDLINE, SCOPUS, and Google Scholar databases on April 1, 2019. The literature search was specified to only randomized control trials (RCTs), meta-analysis, and comparative studies. The keywords used were POI and bowel obstruction. Boolean commands used were OR and AND. The only full text which was available freely was included in the study. The effects of age, and systemic inflammation on time required for the restoration of intestinal motility, constipation, excessive small intestine manipulation, ileus, opioid analgesic usage, POI, prokinetic agents, sham feed, the role of pharmacological interventions in prevention and treatment of POI were investigated with the type of surgery. Our inclusion criteria included all studies associated with risk factors, mechanism, and reduction strategies for POI. We excluded the studies with inconclusive results, studies done on children, and the studies published in a non-English language.
Based on our inclusion and exclusion criteria, only quality literature was assessed using Coleman criteria. The following features of the the POI were analyzed:
- Mechanism of POI
- Reduction strategies
- Risk factors
- Treatment modalities.
| Results|| |
After applying the inclusion and exclusion criteria, we selected nine publications for this review. Only six of these studies were related to POI after orthopedic (4) or spine surgery (2). These studies [Table 1],,,,,,,, comprised a total of 231,773 patients of POI, which were included for this review article. The studies contained RCTs, meta-analysis, and comparative studies which concentrated on the risk factors, mechanism, and reduction strategies for the development of POI. The results showed that invariably, all the patients after gastrointestinal (GI) surgeries developed POI, but it was not restricted to it. POI was also seen after orthopedic surgery, with its incidence being maximum in patients undergoing spine and arthroplasty surgery.,,,,,
|Table 1: The demographics of the studies included in this review article|
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Bederman et al. identified 0.32% developed POI lasting more than 3 days in patients who underwent total hip or total knee arthroplasty, with more incidence of POI in elderly male patients undergoing bilateral arthroplasty who were at higher risk. Nelson et al., in a study of 1170 patients undergoing total hip and knee arthroplasties, found 18 patients to have an acute colonic pseudo-obstruction in the postoperative period. These patients were identified to have preoperative risk factors.
Fineberg et al. reviewed the data of 200,000 patients (taken from the Nationwide Inpatient Sample database in the United States) undergoing spinal fusion surgery and identified that anterior fusion surgeries are at more risk of developing POI compared to posterior fusion. The study also identified various risk factors for developing POI such as multiple levels of fusion, male gender, and electrolyte imbalance.
Parvizi et al. studied 4567 patients and reported that the risk factors for POI are older age, male sex, hip arthroplasty, and prior history of abdominal surgery. Lee et al. identified age, body mass index, preexisting comorbidities, type of orthopedic surgery, estimated blood loss, and preoperative constipation as risk factors for developing POI in a review of 612 patients. In a retrospective single-center cohort study, Kiely et al. on 2625 patients suggested the use of intraoperative opioids (hydromorphone) and more than 2 l of postoperative fluid as a contributing factor for the development of POI. The average mean time for passage of flatus was 9.3 days.
In a prospective study of 103 patients undergoing abdominal surgery, Ay et al. noted that the use of intraoperative opioid as a significant contributing factor for POI along with other factors such as use of prolonged nasogastric tube and presence of systemic inflammation. Su'a et al. found in a study of 1019 patients that chewing gums reduced time to flatus by 14 h, time to bowel movement by 23 h, and a reduction in length of hospital stay by 1.1 days. In a retrospective study of 88 patients, Artinyan et al. found a strong correlation between the occurrence of POI and estimated blood loss, total surgical time, and total opiate dose.
| Discussion|| |
POI is a temporary condition of GI motility impairment in the postoperative period. It occurs when the peristaltic movements do not return within 24 h after the surgery. It presents with symptoms such as abdominal distension, constipation, nausea, vomiting, and abdominal cramps. Multiple factors are attributed to this condition [Table 2],,,,,, with colonic hypomotility as the most important cause for POI., POI involves the entire gut, but different parts of the gut get affected differently with differential recovery time. The small intestine is the first part of regaining its function within a few hours, whereas it takes 24–48 h for the gastric motility to come back to normal. Since the colonic smooth muscles lack the gap junctions, synergistic peristaltic movements are lacking in the colon and so take more than 24 h but usually within 48 h for the colonic motility to be back. Neurogenic, inflammatory, and hormonal factors are the primary mechanism which affects the normal bowel function in the postoperative period [Table 2]. Anesthetic agents and the surgery alter this mechanism and do not have a direct action on gut motility. The autonomic nervous system controls the gut motility with the sympathetic system and decreases the motility, whereas the parasympathetic system increases it. There is an increase in the sympathetic activity in the postoperative period leading to high levels of catecholamine, which inhibits the GI motility and thus leads to POI., It is also supported by the fact that alpha- and beta-adrenergic-blocking agents have proved to improve bowel motility in animals, although no studies on humans. The role of neural reflexes in the development of POI is also proven by the animal studies that the intestinal motility in animals undergoing abdominal surgeries has benefited from nerve conduction blockade by blocking the splanchnic nerves. The inflammatory process occurring in the perioperative phase also plays a significant role in the development of POI. Various inflammatory mediators such as interleukin-6 and interleukin-1 are elevated in the postoperative period, which plays an essential role. Other mediators such as nitric oxide (NO), vasoactive peptide, and substance-P inhibit the enteric nervous system and thereby prolong the ileus. The degree of inflammation has been seen to be directly proportional to the duration of POI. Electrolyte imbalance in the form of hypokalemia also has a role to play. Potassium plays an essential role in maintaining the resting membrane potential and thus is an essential factor in the neural and motor function of intestines. Endogenous and exogenous opioids play an important role in delaying the intestinal motility, thereby causing POI and constipation. Among all the receptors on which opioids act, mu-receptors are considered to be responsible for POI.
The prevalance of POI is more in geriatric population due to reduction in immunity and gastrointestinal (GI) functions such as absorption and motility. Furthermore, there is an age-related neuronal loss occurring in myenteric and submucosal plexuses of intestines. Delayed colonic transit seen in the elderly population is due to decreased gene expression of NO, which regulates the colonic transit time and physical inactivity. We believe that prolonged immobility after trauma, orthopedic, and spinal surgery is also a crucial contributory factor for POI and needs to be investigated in the future.
Inflammatory mediators play an essential role in the generation of POI [Table 3].,,,, A pro-inflammatory cascade of events occurring within the intestinal tissue causes POI. Thus, the role of anti-inflammatory drugs plays a vital role in the reduction of POI, by decreasing the load of inflammatory mediators and also having an opioid-sparing effect. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the perioperative period may lead to a 30%–40% dose reduction of opioids. NSAIDs may also help in decreasing the incidence of nausea vomiting and decreasing the gut transit time. Metabolic stress response causing activation of the sympathetic system and increase in the release of adrenergic output also contribute to the development of POI. Increase in the cholinergic activity with the use of edrophonium chloride has shown to decrease the incidence of POI, but its therapeutic role is limited due to its inadvertent side effects. Acetylcholine is an endogenous substance which increases the gut motility. It is degraded by acetylcholinesterase, and its effects of neostigmine have also been shown to improve symptoms of POI. Cisapride leads to increases in acetylcholine by increasing its releases from the intrinsic plexus, and its efficacy in increasing the gut motility has been documented by Bedermanet al. However, other studies did not find any significant changes in the gut motility and POI, with the use of cisapride.
The activation of the inhibitory reflexes and the sympathetic output are also responsible for the development of POI. Epidural block leads to inhibition of these inhibitory reflexes by causing a sympathetic blockade.,, Randomized clinical trials (RCTs) examining continuous thoracic epidural blockade with local anesthetics for more than 24 h have reported a decrease in POI compared with systemic opioid administration. A meta-analysis of 5 RCTs on 261 patients concluded that local epidural anesthetics reduced the POI by 37 h compared with systemic opioids and 24 h compared with epidural opioids.
Intraoperative use of opioids [Table 4],,,,,,, has been recognized as a common cause of POI, and therefore, the role of opiate antagonists (such as alvimopan and methylnaltrexone) for reversing the effects of opioids has been under study. These agents have a selective affinity for peripheral receptors and do not readily cross the blood–brain barrier and thus can reverse the adverse effects of opioids on the GI tract without blocking the central opioid receptors and reversing pain relief., Methylnaltrexone is a pure mu-opioid antagonist which acts peripherally and does not antagonize the central actions of opioids. These agents have been used for reversing constipation induced by opioids, although still not approved by the Food and Drug Administration for their use in POI. In a study, the patient group treated with methylnaltrexone in the postoperative period as compared to the placebo patients showed early recovery of bowel function. Alvimopan antagonizes the peripheral actions of opioids by selectively acting on mu-receptors and has a higher affinity for GI receptors. It is currently the most commonly used drug to combat opioid-induced POI. A multicentric RCT comparing alvimopan with a placebo showed accelerated GI recovery by approximately 20 h in the alvimopan 6 mg group and by 28 h in the alvimopan 12 mg group compared with placebo. The chewing serves to act as sham feeding and is believed to stimulate the cephalic-vagal reflex and translates into increased production of GI hormone. It leads to a reduction in time to resolution of POI and hospital discharge. Early enteral feeding in the immediate postoperative period is now gaining favor as there is evidence to suggest that it is well-tolerated in >80% of patients and decreases the incidence of POI.
Preoperative mechanical bowel preparation was earlier thought to help in POI, but the recent studies have proven it to be rather harmful. Studies also have proved that bowel preparation significantly increased the incidence of POI and length of hospital stay.,
We do acknowledge the limitations of this retrospective review of the literature on POI. Since only a few studies have been published on POI after orthopedic surgery, we were constrained with the limited information on this topic. Moreover, heterogeneity in the previous studies regarding the definition of POI, selection of patients, surgical modalities, and treatment given is another limiting factor in this study. Still, since the problem of constipation and POI is ubiquitous in the clinical practice after orthopedic surgery, this critical review of the existing literature would highlight the problems related to POI and their solutions. More prospective and multicentric studies would be needed to reach definite conclusions, and then, the practice guidelines could be made for the clinicians.
POI is multifactorial and is invariably an unavoidable cause in the postoperative period leading to increased morbidity and hospital stay. We have tried to analyze the important risk factors, mechanism, and treatment for POI in this review article. We believe that various risk factors contributing to POI include the perioperative use of opioids, invasive surgical procedures, prolonged immobilization, aging, and preoperative presence of systemic inflammation as the most important factors for developing POI. The multimodal approach of management of POI is advisable such as avoiding prolonged fasting, chewing, adequate perioperative pain management, and the use of opioid antagonists may help in decreasing the incidence of POI.
| Conclusions|| |
Constipation and abdominal discomfort due to POI are transient and self-limiting complications in the postoperative period after orthopedic surgery. These incidences are often unavoidable, leading to discomfort to the patient, delay in the mobilization, increase in the incidence of deep vein thrombosis, prolonged hospital stay, and increase in health-care spending. The optimal outcomes can be achieved by identifying the patient's risk factors, modifying the anaesthesia techniques, early mobilization, adequate pain management, recognizing the POI clinically. and by treating it promptly. However, the best results are seen when the multidisciplinary approach is applied for the management of the same rather than using a single mode of management. Old age, duration of surgery, use of opioid analgesics and nasogastric tube, and preoperative electrolyte imbalance are found to be the important risk factors for POI. The role of chewing gum and pharmacological measures (such as alvimopan) helps in decreasing the incidence of POI.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]