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Deutsches Arzteblatt International Jul 2017Ileus is one of the more common suspected diagnoses in everyday clinical practice. The term can refer either to mechanical or to functional ileus. Any physician who... (Review)
Review
BACKGROUND
Ileus is one of the more common suspected diagnoses in everyday clinical practice. The term can refer either to mechanical or to functional ileus. Any physician who takes care of patients can be confronted with these entities; thus, all should be familiar with them and competent in their management.
METHODS
Recommendations are summarized for the diagnostic evaluation and treatment of ileus of various causes on the basis of a selective literature review.
RESULTS
The manifestations of ileus and its degree of severity generally depend on the site of blockage. The rule until recently was that a patient with suspected mechanical ileus should be taken to surgery within 12 hours; today, however, ileus-particularly of the small bowel-can often be successfully treated conservatively. Likewise, functional ileus only rarely requires surgery: supportive measures, depending on the etiology, usually suffice.
CONCLUSION
Proper treatment depends on the timely determination of the pathogenesis (mechanical versus functional) and on close interdisciplinary collaboration. A special challenge is posed by patients with peritoneal involvement with cancer who present with symptoms of ileus, in whom a clear distinction between mechanical and functional causation cannot always be drawn.
Topics: Adult; Humans; Ileus; Intestinal Obstruction; Intestine, Small
PubMed: 28818187
DOI: 10.3238/arztebl.2017.0508 -
Journal of Visceral Surgery Dec 2016Postoperative ileus (POI) is a major focus of concern for surgeons because it increases duration of hospitalization, cost of care, and postoperative morbidity. The... (Review)
Review
Postoperative ileus (POI) is a major focus of concern for surgeons because it increases duration of hospitalization, cost of care, and postoperative morbidity. The definition of POI is relatively consensual albeit with a variable definition of interval to resolution ranging from 2 to 7 days for different authors. This variation, however, leads to non-reproducibility of studies and difficulties in interpreting the results. Certain risk factors for POI, such as male gender, advanced age and major blood loss, have been repeatedly described in the literature. Understanding of the pathophysiology of POI has helped combat and prevent its occurrence. But despite preventive and therapeutic efforts arising from such knowledge, 10 to 30% of patients still develop POI after abdominal surgery. In France, pharmacological prevention is limited by the unavailability of effective drugs. Perioperative nutrition is very important, as well as limitation of preoperative fasting to 6 hours for solid food and 2 hours for liquids, and virtually no fasting in the postoperative period. Coffee and chewing gum also play a preventive role for POI. The advent of laparoscopy has led to a significant improvement in the recovery of gastrointestinal function. Enhanced recovery programs, grouping together all measures for prevention or cure of POI by addressing the mechanisms of POI, has reduced the duration of hospitalization, morbidity and interval to resumption of transit.
Topics: Humans; Ileus; Incidence; Perioperative Care; Postoperative Complications; Risk Factors
PubMed: 27666979
DOI: 10.1016/j.jviscsurg.2016.08.010 -
British Journal of Pharmacology Jul 2022Postoperative ileus (POI) is a frequent complication after abdominal surgery. The consequences of postoperative ileus can be potentially serious such as bronchial... (Review)
Review
Postoperative ileus (POI) is a frequent complication after abdominal surgery. The consequences of postoperative ileus can be potentially serious such as bronchial inhalation or acute functional renal failure. Numerous advances in peri-operative management, particularly early rehabilitation, have made it possible to decrease postoperative ileus. Despite this, the rate of prolonged postoperative ileus remains high and can be as high as 25% of patients in colorectal surgery. From a pathophysiological point of view, postoperative ileus has two phases, an early neurological phase and a later inflammatory phase, to which we could add a 'pharmacological' phase during which analgesic drugs, particularly opiates, play a central role. The aim of this review article is to describe the phases of the pathophysiology of postoperative ileus, to analyse the pharmacological treatments currently available through published clinical trials and finally to discuss the different research areas for potential pharmacological targets.
Topics: Analgesics, Opioid; Humans; Ileus; Postoperative Complications; Risk Factors
PubMed: 35048360
DOI: 10.1111/bph.15800 -
Revista de Gastroenterologia de Mexico 2017Gallstone ileus represents 4% of the causes of bowel obstruction in the general population, but increases to 25% in patients above the age of 65 years. Gallstone ileus... (Review)
Review
INTRODUCTION
Gallstone ileus represents 4% of the causes of bowel obstruction in the general population, but increases to 25% in patients above the age of 65 years. Gallstone ileus does not present with unique symptoms, making diagnosis difficult. Its management is surgical, but there is no consensus as to which of the different surgical techniques is the procedure of choice. At present, there is no recent review of this pathology.
AIM
To conduct an up-to-date review of this disease.
MATERIALS AND METHODS
Articles published within the time frame of 2000 to 2014 were found utilizing the PUBMED, EMBASE, and Cochrane Library search engines with the terms "gallstone ileus" plus "review" and the following filters: "review", "full text", and "humans".
RESULTS
The results of this review showed that gallstone ileus etiology was due to intestinal obstruction from a gallstone that migrated into the intestinal lumen through a bilioenteric fistula. The presence of 2 of the 3 Rigler's triad signs was considered diagnostic. Abdominal tomography was the imaging study of choice for gallstone ileus diagnosis and the surgical procedures for management were enterolithotomy, one-stage surgery, and two-stage surgery. Enterolithotomy had lower morbidity and mortality than the other 2 procedures.
CONCLUSIONS
The aim of gallstone ileus treatment is to release the obstruction, which is done through enterolithotomy. It is the recommended technique for gallstone ileus management because of its lower morbidity and mortality, compared with the other techniques.
Topics: Digestive System Surgical Procedures; Gallstones; Humans; Ileus; Treatment Outcome
PubMed: 28433486
DOI: 10.1016/j.rgmx.2016.07.006 -
JAMA Surgery Jan 2023Despite the adoption of the optimized Enhanced Recovery After Surgery (ERAS) protocol, postoperative ileus (POI) severely impairs recovery after colorectal resection and...
Electroacupuncture vs Sham Electroacupuncture in the Treatment of Postoperative Ileus After Laparoscopic Surgery for Colorectal Cancer: A Multicenter, Randomized Clinical Trial.
IMPORTANCE
Despite the adoption of the optimized Enhanced Recovery After Surgery (ERAS) protocol, postoperative ileus (POI) severely impairs recovery after colorectal resection and increases the burden on the health care system.
OBJECTIVE
To assess the efficacy of electroacupuncture (EA) in reducing the duration of POI with the ERAS protocol.
DESIGN, SETTING, AND PARTICIPANTS
This multicenter, randomized, sham-controlled trial was conducted in China from October 12, 2020, through October 17, 2021. There was a 1:1 allocation using the dynamic block random method, and analyses were by intention to treat. Patients 18 years or older undergoing laparoscopic resection of colorectal cancer for the first time were randomly assigned to treatment group by a central system.
INTERVENTIONS
Patients were randomly assigned to 4 sessions of EA or sham electroacupuncture (SA) after surgery. All patients were treated within the ERAS protocol.
MAIN OUTCOMES AND MEASURES
The primary outcome was the time to first defecation. Secondary outcomes included other patient-reported outcome measures, length of postoperative hospital stay, readmission rate within 30 days, and incidence of postoperative complications and adverse events.
RESULTS
A total of 249 patients were randomly assigned to treatment groups. After the exclusion of 1 patient because of a diagnosis of intestinal tuberculosis, 248 patients (mean [SD] age, 60.2 [11.4] years; 153 men [61.7%]) were included in the analyses. The median (IQR) time to first defecation was 76.4 (67.6-96.8) hours in the EA group and 90.0 (73.6-100.3) hours in the SA group (mean difference, -8.76; 95% CI, -15.80 to -1.73; P = .003). In the EA group compared with the SA group, the time to first flatus (median [IQR], 44.3 [37.0-58.2] hours vs 58.9 [48.2-67.4] hours; P < .001) and the tolerability of semiliquid diet (median [IQR], 105.8 [87.0-120.3] hours vs 116.5 [92.0-137.0] hours; P = .01) and solid food (median [IQR], 181.8 [149.5-211.4] hours vs 190.3 [165.0-228.5] hours; P = .01) were significantly decreased. Prolonged POI occurred in 13 of 125 patients (10%) in the EA group vs 25 of 123 patients (20%) in the SA group (risk ratio [RR], 0.51; 95% CI, 0.27-0.95; P = .03). Other secondary outcomes were not different between groups. There were no severe adverse events.
CONCLUSIONS AND RELEVANCE
Results of this randomized clinical trial demonstrated that in patients undergoing laparoscopic surgery for colorectal cancer with the ERAS protocol, EA shortened the duration of POI and decreased the risk for prolonged POI compared with SA. EA may be considered as an adjunct to the ERAS protocol to promote gastrointestinal function recovery and prevent prolonged POI after surgery.
TRIAL REGISTRATION
Chinese Clinical Trial Registry Identifier: ChiCTR2000038444.
Topics: Male; Humans; Middle Aged; Enhanced Recovery After Surgery; Electroacupuncture; Postoperative Complications; Laparoscopy; Ileus; Colorectal Neoplasms
PubMed: 36322060
DOI: 10.1001/jamasurg.2022.5674 -
The Journal of Neuroscience : the... Jul 2016Acute brain ischemia induces a local neuroinflammatory reaction and alters peripheral immune homeostasis at the same time. Recent evidence has suggested a key role of...
UNLABELLED
Acute brain ischemia induces a local neuroinflammatory reaction and alters peripheral immune homeostasis at the same time. Recent evidence has suggested a key role of the gut microbiota in autoimmune diseases by modulating immune homeostasis. Therefore, we investigated the mechanistic link among acute brain ischemia, microbiota alterations, and the immune response after brain injury. Using two distinct models of acute middle cerebral artery occlusion, we show by next-generation sequencing that large stroke lesions cause gut microbiota dysbiosis, which in turn affects stroke outcome via immune-mediated mechanisms. Reduced species diversity and bacterial overgrowth of bacteroidetes were identified as hallmarks of poststroke dysbiosis, which was associated with intestinal barrier dysfunction and reduced intestinal motility as determined by in vivo intestinal bolus tracking. Recolonizing germ-free mice with dysbiotic poststroke microbiota exacerbates lesion volume and functional deficits after experimental stroke compared with the recolonization with a normal control microbiota. In addition, recolonization of mice with a dysbiotic microbiome induces a proinflammatory T-cell polarization in the intestinal immune compartment and in the ischemic brain. Using in vivo cell-tracking studies, we demonstrate the migration of intestinal lymphocytes to the ischemic brain. Therapeutic transplantation of fecal microbiota normalizes brain lesion-induced dysbiosis and improves stroke outcome. These results support a novel mechanism in which the gut microbiome is a target of stroke-induced systemic alterations and an effector with substantial impact on stroke outcome.
SIGNIFICANCE STATEMENT
We have identified a bidirectional communication along the brain-gut microbiota-immune axis and show that the gut microbiota is a central regulator of immune homeostasis. Acute brain lesions induced dysbiosis of the microbiome and, in turn, changes in the gut microbiota affected neuroinflammatory and functional outcome after brain injury. The microbiota impact on immunity and stroke outcome was transmissible by microbiota transplantation. Our findings support an emerging concept in which the gut microbiota is a key regulator in priming the neuroinflammatory response to brain injury. These findings highlight the key role of microbiota as a potential therapeutic target to protect brain function after injury.
Topics: Animals; Brain Infarction; CD3 Complex; Disease Models, Animal; Dysbiosis; Encephalitis; Feces; Female; Gastrointestinal Diseases; Gastrointestinal Motility; Homeodomain Proteins; Ileus; Infarction, Middle Cerebral Artery; Leukocytes; Male; Mice; Mice, Inbred C57BL; Mice, Transgenic; Microbiota; Stroke; Tertiary Lymphoid Structures
PubMed: 27413153
DOI: 10.1523/JNEUROSCI.1114-16.2016 -
The Cochrane Database of Systematic... Feb 2023The success of elective colorectal surgery is mainly influenced by the surgical procedure and postoperative complications. The most serious complications include... (Review)
Review
BACKGROUND
The success of elective colorectal surgery is mainly influenced by the surgical procedure and postoperative complications. The most serious complications include anastomotic leakages and surgical site infections (SSI)s, which can lead to prolonged recovery with impaired long-term health. Compared with other abdominal procedures, colorectal resections have an increased risk of adverse events due to the physiological bacterial colonisation of the large bowel. Preoperative bowel preparation is used to remove faeces from the bowel lumen and reduce bacterial colonisation. This bowel preparation can be performed mechanically and/or with oral antibiotics. While mechanical bowel preparation alone is not beneficial, the benefits and harms of combined mechanical and oral antibiotic bowel preparation is still unclear.
OBJECTIVES
To assess the evidence for the use of combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery.
SEARCH METHODS
We searched MEDLINE, Embase, CENTRAL and trial registries on 15 December 2021. In addition, we searched reference lists and contacted colorectal surgery organisations.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) of adult participants undergoing elective colorectal surgery comparing combined mechanical and oral antibiotic bowel preparation (MBP+oAB) with either MBP alone, oAB alone, or no bowel preparation (nBP). We excluded studies in which no perioperative intravenous antibiotic prophylaxis was given.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures as recommended by Cochrane. Pooled results were reported as mean difference (MD) or risk ratio (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel method. The certainty of the evidence was assessed with GRADE.
MAIN RESULTS
We included 21 RCTs analysing 5264 participants who underwent elective colorectal surgery. None of the included studies had a high risk of bias, but two-thirds of the included studies raised some concerns. This was mainly due to the lack of a predefined analysis plan or missing information about the randomisation process. Most included studies investigated both colon and rectal resections due to malignant and benign surgical indications. For MBP as well as oAB, the included studies used different regimens in terms of agent(s), dosage and timing. Data for all predefined outcomes could be extracted from the included studies. However, only four studies reported on side effects of bowel preparation, and none recorded the occurrence of adverse effects such as dehydration, electrolyte imbalances or the need to discontinue the intervention due to side effects. Seventeen trials compared MBP+oAB with sole MBP. The incidence of SSI could be reduced through MBP+oAB by 44% (RR 0.56, 95% CI 0.42 to 0.74; 3917 participants from 16 studies; moderate-certainty evidence) and the risk of anastomotic leakage could be reduced by 40% (RR 0.60, 95% CI 0.36 to 0.99; 2356 participants from 10 studies; moderate-certainty evidence). No difference between the two comparison groups was found with regard to mortality (RR 0.87, 95% CI 0.27 to 2.82; 639 participants from 3 studies; moderate-certainty evidence), the incidence of postoperative ileus (RR 0.89, 95% CI 0.59 to 1.32; 2013 participants from 6 studies, low-certainty of evidence) and length of hospital stay (MD -0.19, 95% CI -1.81 to 1.44; 621 participants from 3 studies; moderate-certainty evidence). Three trials compared MBP+oAB with sole oAB. No difference was demonstrated between the two treatment alternatives in terms of SSI (RR 0.87, 95% CI 0.34 to 2.21; 960 participants from 3 studies; very low-certainty evidence), anastomotic leakage (RR 0.84, 95% CI 0.21 to 3.45; 960 participants from 3 studies; low-certainty evidence), mortality (RR 1.02, 95% CI 0.30 to 3.50; 709 participants from 2 studies; low-certainty evidence), incidence of postoperative ileus (RR 1.25, 95% CI 0.68 to 2.33; 709 participants from 2 studies; low-certainty evidence) or length of hospital stay (MD 0.1 respectively 0.2, 95% CI -0.68 to 1.08; data from 2 studies; moderate-certainty evidence). One trial (396 participants) compared MBP+oAB versus nBP. The evidence is uncertain about the effect of MBP+oAB on the incidence of SSI as well as mortality (RR 0.63, 95% CI 0.33 to 1.23 respectively RR 0.20, 95% CI 0.01 to 4.22; low-certainty evidence), while no effect on the risk of anastomotic leakages (RR 0.89, 95% CI 0.33 to 2.42; low-certainty evidence), the incidence of postoperative ileus (RR 1.18, 95% CI 0.77 to 1.81; low-certainty evidence) or the length of hospital stay (MD 0.1, 95% CI -0.8 to 1; low-certainty evidence) could be demonstrated.
AUTHORS' CONCLUSIONS
Based on moderate-certainty evidence, our results suggest that MBP+oAB is probably more effective than MBP alone in preventing postoperative complications. In particular, with respect to our primary outcomes, SSI and anastomotic leakage, a lower incidence was demonstrated using MBP+oAB. Whether oAB alone is actually equivalent to MBP+oAB, or leads to a reduction or increase in the risk of postoperative complications, cannot be clarified in light of the low- to very low-certainty evidence. Similarly, it remains unclear whether omitting preoperative bowel preparation leads to an increase in the risk of postoperative complications due to limited evidence. Additional RCTs, particularly on the comparisons of MBP+oAB versus oAB alone or nBP, are needed to assess the impact of oAB alone or nBP compared with MBP+oAB on postoperative complications and to improve confidence in the estimated effect. In addition, RCTs focusing on subgroups (e.g. in relation to type and location of colon resections) or reporting side effects of the intervention are needed to determine the most effective approach of preoperative bowel preparation.
Topics: Adult; Humans; Anastomotic Leak; Anti-Bacterial Agents; Colorectal Surgery; Ileus; Surgical Wound Infection; Preoperative Care
PubMed: 36748942
DOI: 10.1002/14651858.CD014909.pub2 -
JAMA Network Open Oct 2021Postoperative ileus is common after abdominal surgery, and small clinical studies have reported that intraoperative administration of dexmedetomidine may be associated... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Postoperative ileus is common after abdominal surgery, and small clinical studies have reported that intraoperative administration of dexmedetomidine may be associated with improvements in postoperative gastrointestinal function. However, findings have been inconsistent and study samples have been small. Further examination of the effects of intraoperative dexmedetomidine on postoperative gastrointestinal function is needed.
OBJECTIVE
To evaluate the effects of intraoperative intravenous dexmedetomidine vs placebo on postoperative gastrointestinal function among older patients undergoing abdominal surgery.
DESIGN, SETTING, AND PARTICIPANTS
This multicenter, double-blind, placebo-controlled randomized clinical trial was conducted at the First Affiliated Hospital of Anhui Medical University in Hefei, China (lead site), and 12 other tertiary hospitals in Anhui Province, China. A total of 808 participants aged 60 years or older who were scheduled to receive abdominal surgery with an expected surgical duration of 1 to 6 hours were enrolled. The study was conducted from August 21, 2018, to December 9, 2019.
INTERVENTIONS
Dexmedetomidine infusion (a loading dose of 0.5 μg/kg over 15 minutes followed by a maintenance dose of 0.2 μg/kg per hour) or placebo infusion (normal saline) during surgery.
MAIN OUTCOMES AND MEASURES
The primary outcome was time to first flatus. Secondary outcomes were postoperative gastrointestinal function measured by the I-FEED (intake, feeling nauseated, emesis, physical examination, and duration of symptoms) scoring system, time to first feces, time to first oral feeding, incidence of delirium, pain scores, sleep quality, postoperative nausea and vomiting, hospital costs, and hospital length of stay.
RESULTS
Among 808 patients enrolled, 404 were randomized to receive intraoperative dexmedetomidine, and 404 were randomized to receive placebo. In total, 133 patients (60 in the dexmedetomidine group and 73 in the placebo group) were excluded because of protocol deviations, and 675 patients (344 in the dexmedetomidine group and 331 in the placebo group; mean [SD] age, 70.2 [6.1] years; 445 men [65.9%]) were included in the per-protocol analysis. The dexmedetomidine group had a significantly shorter time to first flatus (median, 65 hours [IQR, 48-78 hours] vs 78 hours [62-93 hours], respectively; P < .001), time to first feces (median, 85 hours [IQR, 68-115 hours] vs 98 hours [IQR, 74-121 hours]; P = .001), and hospital length of stay (median, 13 days [IQR, 10-17 days] vs 15 days [IQR, 11-18 days]; P = .005) than the control group. Postoperative gastrointestinal function (as measured by the I-FEED score) and delirium incidence were similar in the dexmedetomidine and control groups (eg, 248 patients [72.1%] vs 254 patients [76.7%], respectively, had I-FEED scores indicating normal postoperative gastrointestinal function; 18 patients [5.2%] vs 12 patients [3.6%] had delirium on postoperative day 3).
CONCLUSIONS AND RELEVANCE
In this randomized clinical trial, the administration of intraoperative dexmedetomidine reduced the time to first flatus, time to first feces, and length of stay after abdominal surgery. These results suggest that this therapy may be a viable strategy to enhance postoperative recovery of gastrointestinal function among older adults.
TRIAL REGISTRATION
Chinese Clinical Trial Registry Identifier: ChiCTR1800017232.
Topics: Aged; China; Dexmedetomidine; Digestive System Surgical Procedures; Double-Blind Method; Female; Gastrointestinal Tract; Humans; Hypnotics and Sedatives; Ileus; Intraoperative Care; Male; Middle Aged; Postoperative Complications; Time Factors
PubMed: 34648009
DOI: 10.1001/jamanetworkopen.2021.28886 -
Journal of Gastrointestinal Surgery :... Aug 2023Postoperative ileus is common after gastrointestinal surgery. This network meta-analysis aimed to compare the effectiveness of gum chewing and coffee and caffeine intake... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Postoperative ileus is common after gastrointestinal surgery. This network meta-analysis aimed to compare the effectiveness of gum chewing and coffee and caffeine intake on ileus-related outcomes.
METHODS
A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing noninvasive treatments for ileus after gastrointestinal surgery. The main analyses included random effects network meta-analyses using frequentist methods with simultaneous direct and indirect comparisons of time to first flatus, time to first defecation, and length of stay. Bayesian network meta-analysis using Markov chains was also used.
RESULTS
A total of 32 RCTs comparing 4999 patients were included in this network meta-analysis. Time to flatus was reduced by gum chewing (mean difference compared to control (MD): -11 h, 95% confidence interval (95% CI) - 16 to - 5 h, P < 0.001). Time to defecation was reduced by gum chewing and coffee, with MDs of -18 h (95% CI - 23 to - 13 h, P < 0.001) and -13 h (95% CI - 24 to - 1 h, P < 0.001), respectively. Length of stay was reduced by coffee and gum chewing with MDs of - 1.5 days (95% CI: - 2.5 to - 0.6 days, P < 0.001) and - 0.9 days (95% CI: - 1.3 to - 0.4 days, P < 0.001), respectively.
CONCLUSION
Coffee and gum chewing were proven to be effective noninvasive approaches for shortening the postoperative length of hospital stay and time to first defecation, especially in open gastrointestinal surgery; thus these actions should be recommended after gastrointestinal surgery.
Topics: Humans; Defecation; Coffee; Network Meta-Analysis; Mastication; Flatulence; Ileus; Postoperative Complications; Digestive System Surgical Procedures; Chewing Gum; Length of Stay; Gastrointestinal Motility
PubMed: 37277676
DOI: 10.1007/s11605-023-05702-z -
International Journal of Molecular... Jun 2022Feeding intolerance and the development of ileus is a common complication affecting critically ill, surgical, and trauma patients, resulting in prolonged intensive care... (Review)
Review
Feeding intolerance and the development of ileus is a common complication affecting critically ill, surgical, and trauma patients, resulting in prolonged intensive care unit and hospital stays, increased infectious complications, a higher rate of hospital readmission, and higher medical care costs. Medical treatment for ileus is ineffective and many of the available prokinetic drugs have serious side effects that limit their use. Despite the large number of patients affected and the consequences of ileus, little progress has been made in identifying new drug targets for the treatment of ileus. Inflammatory mediators play a critical role in the development of ileus, but surprisingly little is known about the direct effects of inflammatory mediators on cells of the gastrointestinal tract, and many of the studies are conflicting. Understanding the effects of inflammatory cytokines/chemokines on the development of ileus will facilitate the early identification of patients who will develop ileus and the identification of new drug targets to treat ileus. Thus, herein, we review the published literature concerning the effects of inflammatory mediators on gastrointestinal motility.
Topics: Critical Illness; Gastrointestinal Diseases; Gastrointestinal Motility; Humans; Ileus; Infant, Newborn; Inflammation Mediators; Postoperative Complications
PubMed: 35805922
DOI: 10.3390/ijms23136917