Postoperative Ileus: Time for an Evidence-based Consensus

Abstract

Radical cystectomy (RC) remains the gold standard procedure for the surgical management of bladder cancer. Despite advances made in surgical technique, technology, and patient outcomes, RC continues to carry significant morbidity. In fact, one recent series demonstrated that ‘‘any complication’’ occurred in 80% of patients within 90 d of surgery, and major complications occurred in 35% of patients [1]. Infectious and gastrointestinal complications are consistently the most common in large series of RC perioperative outcomes. In one series, postoperative paralytic ileus (POI) was the most common cause of prolonged hospitalization after RC [2]. Trying to minimize gastrointestinal complications and hasten return of normal bowel function after RC would drastically improve outcomes for our patients. In an attempt to define one of the most common complications of RC, Ramirez and colleagues conducted a systematic review of the urologic literature to identify studies describing gastrointestinal complications postoperatively [3]. Specifically, the authors attempted to identify definitions of POI, to assess the occurrence of POI after cystectomy, and to identify interventions that may prevent or reduce the risk of POI. The current review highlights several important facts regarding POI and its management. First, it is clear from the review that a standard definition for POI remains elusive. In fact, it is so elusive, that only a fraction of the studies included in the review even described an explicit definition of POI. Even in the general surgical literature, there is no consensus definition of POI. Why is a true definition of POI important? As we continue to study patient outcomes and assess quality-improvement methods, standardized definitions of clinical entities become necessary to allow for more accurate reporting and comparisons. Second, another apparent fact is that there are multiple identifiable risk factors for the development of POI. These can be useful for patient counseling prior to surgical intervention and, ideally, modified where possible to reduce the risk of POI. These risk factors could further be used to develop a predictive score for the likelihood of POI after cystectomy, much like a similar predictive score developed for laparoscopic colectomy [4]. Third, many advances in the care of the RC patient have been aimed at reducing the occurrence of POI. One simple method has been reducing the use of nasogastric tubes postoperatively. As demonstrated in the current review [3], studies show no improvement in outcomes with the routine use of nasogastric tubes. These findings are supported by similar results in the colorectal surgical literature [5]. One of