Postoperative Darmpassage-Störungen in der Intensivmedizin

Der postoperative Ileus (POI) ist ein häufiges Krankheitsbild, insbesondere nach offenen viszeralchirurgischen Eingriffen. Er ist nicht nur für den individuellen Patienten, sondern das gesamte Gesundheitssystem eine Belastung. Der Beitrag fasst die aktuelle Datenlage zur Therapie des POI zusammen. Die wichtigste, jedoch auch schwierigste Aufgabe besteht darin, einen POI von anderen Komplikationen zu unterscheiden.

Kernaussagen

• Beim postoperativen Ileus (POI) handelt es sich um eine physiologische bis pathologische Störung der Darmmotilität mit subjektiver Belastung des einzelnen Patienten und auch einer objektivierbaren ökonomischen Belastung.

• Das Krankheitsbild ist benigne, multifaktoriell und sollte bereits präoperativ mit einer adäquaten Prophylaxe bedacht werden.

• Präoperativ können hierbei der Wasser- und Elektrolythaushalt sowie ein ausreichender Ernährungsstatus mit nur kurzen Nüchternheitsperioden beeinflusst werden.

• Intraoperativ sollten soweit möglich alternative Analgetika zu Opioiden eingesetzt werden, z. B. Lidocain-Perfusoren oder eine PDK-Anlage.

• Die unmittelbare Anlage einer Magensonde ist nicht notwendig und sollte nicht routinemäßig durchgeführt werden. ERAS-Konzepte unterstützen in der Umsetzung einer frühen Genesung.

• Tritt dennoch ein POI auf, sollten Symptome wie Schluckauf, Erbrechen, Übelkeit, pralles, aufgetriebenes, schmerzhaftes Abdomen, Intoleranz des Kostaufbaus und fehlende Winde oder ausbleibender Stuhlgang ein Hinweis darauf sein.

• Das Krankheitsbild ist klinisch zu diagnostizieren, bildgebende Verfahren können ergänzt werden, insbesondere, wenn ein sekundärer POI wahrscheinlich sein könnte. Dies stellt im klinischen Alltag häufig die größte Herausforderung dar, insbesondere nach viszeralchirurgischen Operationen mit Darmanastomosen.

• Die Gabe von Prokinetika sowie Dexamethason bei POI ist evident für den Abgang von Winden bis zum ersten Stuhl. Die erneute Toleranz von solidem Essen wird am meisten durch Prokinetika und Opioidantagonisten beeinflusst.

• Die am besten untersuchten Prokinetika sind Metoclopramid, Mosaprid und Erythromycin. Als Opioidantagonisten werden am häufigsten Alvimopan und Methylnaltrexon angewendet.

• Andere Therapieansätze umfassen die Gabe von Kaffee und Kaugummi, die Behandlung mit NSAID, Gastrografin, Magnesium (i. v. oder Beutel), Neostigmin, Laxanzien, Erythromycin oder Einläufen.

Schlüsselwörter

postoperativer Ileus - POI - Magen-Darm-Trakt - Darmverschluss - Motilitätsstörungen

Publication History

Article published online:
05 March 2025

• Literatur

• 1 Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie e.V. (DGAV), Deutsche Gesellschaft für Koloproktologie e.V. (DGK). S3-Leitlinie Perioperatives Management bei gastrointestinalen Tumoren (POMGAT), Version 1.0, AWMF-Registernr. 088–01 0OL. 2023 Accessed January 22, 2025 at: https://register.awmf.org/de/leitlinien/detail/088-010OL
• 2 Gero D, Gie O, Hubner M. et al. Postoperative ileus: in search of an international consensus on definition, diagnosis, and treatment. Langenbecks Arch Surg 2017; 402: 149-158
• 3 Delaney CP. Postoperative ileus profiles, risk factors, and definitions – a framework for optimizing surgical outcomes in patients undergoing major abdominal and colorectal surgery. Clin Consens Update Gen Surg. 2006
• 4 Panwar R, Pal S. The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy. Hepatobiliary Pancreat Dis Int 2017; 16: 353-363
• 5 Su’a BU, Pollock TT, Lemanu DP. et al. Chewing gum and postoperative ileus in adults: a systematic literature review and meta-analysis. Int J Surg 2015; 14: 49-55
• 6 Flores-Funes D, Campillo-Soto Á, Pellicer-Franco E. et al. The use of coffee, chewing-gum and gastrograffin in the management of postoperative ileus: A review of current evidence. Cir Esp 2016; 94: 495-501
• 7 Holte K, Kehlet H. Postoperative ileus: progress towards effective management. Drugs 2002; 62: 2603-2615
• 8 Buchanan L, Tuma F. Postoperative Ileus. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Accessed January 21, 2025 at: http://www.ncbi.nlm.nih.gov/books/NBK560780/
• 9 Koscielny A, Engel D, Maurer J. et al. The role of lymphoid tissue in the attenuation of the postoperative ileus. Am J Physiol Gastrointest Liver Physiol 2013; 304: G401-G412
• 10 The FO, Bennink RJ, Ankum WM. et al. Intestinal handling-induced mast cell activation and inflammation in human postoperative ileus. Gut 2008; 57: 33-40
• 11 Hellstrom EA, Ziegler AL, Blikslager AT. Postoperative Ileus: Comparative Pathophysiology and Future Therapies. Front Vet Sci 2021; 8: 714800
• 12 Wells CI, Milne TGE, Seo SHB. et al. Post-operative ileus: definitions, mechanisms and controversies. ANZ J Surg 2022; 92: 62-68
• 13 Namba Y, Hirata Y, Mukai S. et al. Clinical indicators for the incidence of postoperative ileus after elective surgery for colorectal cancer. BMC Surg 2021; 21: 80
• 14 Lee MJ, Vaughan-Shaw P, Vimalachandran D. ACPGBI GI Recovery Group. A systematic review and meta-analysis of baseline risk factors for the development of postoperative ileus in patients undergoing gastrointestinal surgery. Ann R Coll Surg Engl 2020; 102: 194-203
• 15 Sommer NP, Schneider R, Wehner S. et al. State-of-the-art colorectal disease: postoperative ileus. Int J Colorectal Dis 2021; 36: 2017-2025
• 16 Goldstein JL, Matuszewski KA, Delaney CP. et al. Inpatient economic burden of postoperative ileus associated with abdominal surgery in the United States. Pharm Ther 2007; 32: 82-90
• 17 Traeger L, Koullouros M, Bedrikovetski S. et al. Cost of postoperative ileus following colorectal surgery: A cost analysis in the Australian public hospital setting. Colorectal Dis 2022; 24: 1416-1426
• 18 Gustafsson UO, Scott MJ, Hubner M. et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018. World J Surg 2019; 43: 659-695
• 19 Bugada D, Lorini LF, Lavand’homme P. Opioid free anesthesia: evidence for short and long-term outcome. Minerva Anestesiol 2021; 87: 230-237
• 20 Kaufmann M, Orth V, Dorwarth TJ. et al. Two-stage laparoscopic transversus abdominis plane block as an equivalent alternative to thoracic epidural anaesthesia in bowel resection-an explorative cohort study. Int J Colorectal Dis 2024; 39: 18
• 21 Zhang X, Zheng W, Chen C. et al. Goal-directed fluid therapy does not reduce postoperative ileus in gastrointestinal surgery: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97 (45) e13097
• 22 Vlug MS, Wind J, Hollmann MW. LAFA study group. et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 2011; 254: 868-875
• 23 Zhuang CL, Ye XZ, Zhang CJ. et al. Early versus traditional postoperative oral feeding in patients undergoing elective colorectal surgery: a meta-analysis of randomized clinical trials. Dig Surg 2013; 30: 225-232
• 24 Boelens PG, Heesakkers FF, Luyer MD. et al. Reduction of postoperative ileus by early enteral nutrition in patients undergoing major rectal surgery: prospective, randomized, controlled trial. Ann Surg 2014; 259: 649-655
• 25 Nygren J. The metabolic effects of fasting and surgery. Best Pract Res Clin Anaesthesiol 2006; 20: 429-438
• 26 Gianotti L, Biffi R, Sandini M. et al. Preoperative Oral Carbohydrate Load Versus Placebo in Major Elective Abdominal Surgery (PROCY): A Randomized, Placebo-controlled, Multicenter, Phase III Trial. Ann Surg 2018; 267: 623-630
• 27 Roslan F, Kushairi A, Cappuyns L. et al. The Impact of Sham Feeding with Chewing Gum on Postoperative Ileus Following Colorectal Surgery: a Meta-Analysis of Randomised Controlled Trials. J Gastrointest Surg 2020; 24: 2643-2653
• 28 Hsu YC, Szu SY. Effects of Gum Chewing on Recovery From Postoperative Ileus: A Randomized Clinical Trail. J Nurs Res 2022; 30: e233
• 29 Sammut R, Trapani J, Deguara J. et al. The effect of gum chewing on postoperative ileus in open colorectal surgery patients: A review. J Perioper Pract 2021; 31: 132-139
• 30 Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007; (03) CD004929
• 31 Fragkos KC, Sebepos-Rogers G, Rahman F. When is parenteral nutrition indicated in the hospitalized, acutely ill patient?. Curr Opin Gastroenterol 2020; 36: 129-135
• 32 Harada T, Hirosawa T, Morinaga K. et al. Metoclopramide-induced Serotonin Syndrome. Intern Med 2017; 56: 737-739
• 33 Chapman MJ, Jones KL, Almansa C. et al. Blinded, Double-Dummy, Parallel-Group, Phase 2a Randomized Clinical Trial to Evaluate the Efficacy and Safety of a Highly Selective 5-Hydroxytryptamine Type 4 Receptor Agonist in Critically Ill Patients With Enteral Feeding Intolerance. JPEN J Parenter Enteral Nutr 2021; 45: 115-124
• 34 Stakenborg N, Labeeuw E, Gomez-Pinilla PJ. et al. Preoperative administration of the 5-HT4 receptor agonist prucalopride reduces intestinal inflammation and shortens postoperative ileus via cholinergic enteric neurons. Gut 2019; 68: 1406-1416
• 35 Shaw M, Pediconi C, McVey D. et al. Safety and efficacy of ulimorelin administered postoperatively to accelerate recovery of gastrointestinal motility following partial bowel resection: results of two randomized, placebo-controlled phase 3 trials. Dis Colon Rectum 2013; 56: 888-897
• 36 Bugaev N, Bhattacharya B, Chiu WC. et al. Promotility agents for the treatment of ileus in adult surgical patients: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2019; 87: 922-934
• 37 Bragg D, El-Sharkawy AM, Psaltis E. et al. Postoperative ileus: Recent developments in pathophysiology and management. Clin Nutrit 2015; 34: 367-376
• 38 Jang J, Kwok B, Zhong H. et al. Alvimopan for the Prevention of Postoperative Ileus in Inflammatory Bowel Disease Patients. Dig Dis Sci 2020; 65: 1164-1171
• 39 Delaney CP, Wolff BG, Viscusi ER. et al. Alvimopan, for postoperative ileus following bowel resection: a pooled analysis of phase III studies. Ann Surg 2007; 245: 355-363
• 40 Büchler MW, Seiler CM, Monson JR. et al. Clinical trial: alvimopan for the management of post-operative ileus after abdominal surgery: results of an international randomized, double-blind, multicentre, placebo-controlled clinical study. Aliment Pharmacol Ther 2008; 28: 312-325
• 41 Hyde LZ, Kiely JM, Al-Mazrou A. et al. Alvimopan Significantly Reduces Length of Stay and Costs Following Colorectal Resection and Ostomy Reversal Even Within an Enhanced Recovery Protocol. Dis Colon Rectum 2019; 62: 755-761
• 42 Beavers J, Orton L, Atchison L. et al. The Efficacy and Safety of Methylnaltrexone for the Treatment of Postoperative Ileus. Am Surg 2022; 88: 409-413
• 43 Schwenk ES, Grant AE, Torjman MC. et al. The Efficacy of Peripheral Opioid Antagonists in Opioid-Induced Constipation and Postoperative Ileus: A Systematic Review of the Literature. Reg Anesth Pain Med 2017; 42: 767-777
• 44 Buscail E, Deraison C. Postoperative ileus: A pharmacological perspective. Br J Pharmacol 2022; 179: 3283-3305
• 45 Wattchow DA, De Fontgalland D, Bampton PA. et al. Clinical trial: the impact of cyclooxygenase inhibitors on gastrointestinal recovery after major surgery – a randomized double blind controlled trial of celecoxib or diclofenac vs. placebo. Aliment Pharmacol Ther 2009; 30: 987-998
• 46 Rahbari NN, Weitz J, Hohenberger W. et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 2010; 147: 339-351
• 47 Hermanns H, Hollmann MW, Stevens MF. et al. Molecular mechanisms of action of systemic lidocaine in acute and chronic pain: a narrative review. Br J Anaesth 2019; 123: 335-349
• 48 Wang L, Wang M, Li S. et al. Nebulized lidocaine ameliorates allergic airway inflammation via downregulation of TLR2. Mol Immunol 2018; 97: 94-100
• 49 Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI). S3-Leitlinie Behandlung akuter perioperativer und posttraumatischer Schmerzen, Version 4.1, AWMF-Registernr. 001–025. 2022 Accessed January 22, 2025 at: https://register.awmf.org/de/leitlinien/detail/001-025
• 50 Vaghiri S, Prassas D, David SO. et al. Caffeine intake enhances bowel recovery after colorectal surgery: a meta-analysis of randomized and non-randomized studies. Updates Surg 2024; 76: 769-782
• 51 Gkegkes ID, Minis EE, Iavazzo C. Effect of Caffeine Intake on Postoperative Ileus: A Systematic Review and Meta-Analysis. Dig Surg 2020; 37: 22-31
• 52 Yang W, Pu J. Efficacy of ileus tube combined with meglumine diatrizoate in treating postoperative inflammatory bowel obstruction after surgery. World J Gastrointest Surg 2023; 15: 1950-1958
• 53 Alkan S, Cakir M, Sentiurk M. et al. The efficacy and results of medical treatment in postoperative ileus. Niger J Clin Pract 2023; 26: 497-501
• 54 Kubota K, Mase A, Matsushima H. et al. Daikenchuto, a traditional Japanese herbal medicine, promotes colonic transit by inducing a propulsive movement pattern. Neurogastroenterol Motil 2019; 31: e13689
• 55 Endo M, Hori M, Mihara T. et al. Zingiberis Siccatum Rhizoma, the active component of the Kampo formula Daikenchuto, induces anti-inflammatory actions through α7 nicotinic acetylcholine receptor activation. Neurogastroenterol Motil 2017; 29
• 56 Ishizuka M, Shibuya N, Nagata H. et al. Perioperative Administration of Traditional Japanese Herbal Medicine Daikenchuto Relieves Postoperative Ileus in Patients Undergoing Surgery for Gastrointestinal Cancer: A Systematic Review and Meta-analysis. Anticancer Res 2017; 37: 5967-5974
• 57 Kunitomi Y, Nakashima M, Takeuchi M. et al. Efficacy of Daikenchuto in the prevention of bowel obstruction in patients with colorectal cancer undergoing laparoscopic surgery: An observational study using a Japanese administrative claims database. Support Care Cancer 2023; 31: 133
• 58 Dudi-Venkata NN, Kroon HM, Bedrikovetski S. et al. A global survey of surgeons’ preferences and practice with regard to laxative use after elective colorectal surgery. Int J Colorectal Dis 2020; 35: 759-763
• 59 McKechnie T, Elder G, Ichhpuniani S. et al. Perioperative intravenous dexamethasone for patients undergoing colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38: 32
• 60 Bansal T, Singhal S, Taxak S. et al. Dexamethasone in anesthesia practice: A narrative review. J Anaesthesiol Clin Pharmacol 2024; 40: 3-8
• 61 Behera BK, Misra S, Jena SS. et al. The effect of perioperative dexmedetomidine on postoperative bowel function recovery in adult patients receiving general anesthesia. Minerva Anestesiol 2022; 88: 51-61
• 62 Beloeil H, Garot M, Lebuffe G. et al. Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery. Anesthesiology 2021; 134: 541-551
• 63 Wang Y, Yang JW, Yan SY. et al. Electroacupuncture vs Sham Electroacupuncture in the Treatment of Postoperative Ileus After Laparoscopic Surgery for Colorectal Cancer: A Multicenter, Randomized Clinical Trial. JAMA Surg 2023; 158: 20-27
• 64 Iskander O. An outline of the management and prevention of postoperative ileus: A review. Medicine (Baltimore) 2024; 103: e38177
• 65 Yang JW, Shao JK, Wang Y. et al. Effect of acupuncture on postoperative ileus after laparoscopic elective colorectal surgery: a prospective, randomized, controlled trial. EClinicalMedicine 2022; 49: 101472
• 66 Buscail E, Planchamp T, Le Cosquer G. et al. Postoperative ileus after digestive surgery: Network meta-analysis of pharmacological intervention. Br J Clin Pharmacol 2024; 90: 107-126
• 67 Rodríguez-Padilla A, Morales-Martín G, Pérez-Quintero R. et al. Postoperative ileus after stimulation with probiotics before ileostomy closure. Nutrients 2021; 13: 626