Abstract
Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC’s. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS—macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.
Highlights
Postoperative gastrointestinal dysfunction (POGD), commonly referred to as postoperative ileus (POI), is a widely known complication characterized by a transient impairment of gastrointestinal (GI) function after abdominal surgery
Further clinical studies on 5HT4 receptor (5HT4R) agonists and vagal nerve stimulation are required to establish their usefulness as novel therapies, and more work needs to be done of short and long term impact of gut surgical manipulation on patient outcomes
Enteric glial cells (EGCs) are abundant in the gut and they may play a role in the pathophysiology of POI and POGD
Summary
Postoperative gastrointestinal dysfunction (POGD), commonly referred to as postoperative ileus (POI), is a widely known complication characterized by a transient impairment of gastrointestinal (GI) function after abdominal surgery. In a randomized control trial, early enteral nutrition in patients undergoing major rectal surgery has been shown to reduce POI by improving recovery of gut motility, a reduction in the time to first defecation and length of hospital stay (Boelens et al, 2014).
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