Postoperativer Ileus: Teil II (Klinische Therapie)

Zusammenfassung

Die Behandlung des postoperativen Ileus beinhaltet zunächst Maßnahmen, die dessen Ausbildung reduzieren. Hierzu gehören die Minimierung des operativen Traumas, eine spinale Sympathikolyse mittels Periduralanästhesie oder eine intravenöse Lidocainbehandlung, die wahrscheinlich alle über eine verminderte Aktivierung viszeraler afferenter Nervenfasern wirken. Neue Daten weisen darauf hin, dass eine postoperative Flü ssigkeitsrestriktion die Entstehung einer postoperativen Motilitätsstörung reduziert. Der Einsatz der Periduralanästhesie und die vermehrte Anwendung von nichtsteroidalen Antiphlogistika anstelle von Opioden zur Schmerztherapie führen ebenfalls zu einer schnelleren Normalisierung der gastrointestinalen Motilität. Eine adäquate Aufklärung des Patienten über die Dauer der postoperativen Motilitätsstörung und die zu erwartende Liegezeit ermöglicht einen frühzeitigen postoperativen Kostaufbau und reduziert die Liegezeit. Ein rascher postoperativer Kostaufbau stimuliert die Dünn- und Dickdarmmotilität über interenterische Reflexkreise, vermeidet intravenöse Zugänge und signalisiert dem Patienten, dass die Entlassung möglich ist. Für die Behandlung einer manifesten postoperativen Motilitätsstörung stehen osmotisch wirksame Laxanzien und als Prokinetika Erythromycin und Acetylcholinesterase-Hemmer, wie z. B. Neostigmin, zur Verfügung. Durch den kombinierten Einsatz von Periduralkatheter, der Vermeidung von Opiaten zur Schmerztherapie, ein früher Kostaufbau und ggf. den Einsatz von Laxanzien und Prokinetika kann der postoperative Ileus in der Regel beherrscht werden. Trotzdem besteht nach wie vor die Notwendigkeit, spezifische und möglichst nebenwirkungsfreie Prokinetika zur Therapie des postoperativen Ileus zu entwickeln.

Abstract

To avoid or reduce postoperative ileus, the operative trauma should be minimized and epidural anesthesia for spinal inhibition of the sympathetic nervous system or i. v. lidocaine should be used, all of which probably act by reducing visceral afferent nerve fiber activity. Recent data suggest that perioperative fluid restriction might reduce postoperative ileus. Epidural anesthesia with local anesthetics and replacing opioids by non-steroidal anti-inflammatory drugs (NSAIDs) for postoperative pain treatment improve the recovery of gastrointestinal motility disturbances. Prior to the operation, the patient should be informed regarding postoperative motility disorders, its length and the presumed resumption of oral food intake, which has been shown to shorten hospital stay. Early postoperative food intake stimulates small and large bowel motility via interenteric reflex arches, avoids i. v. lines and renders discharge acceptable for the patient. Treatment of postoperative ileus includes osmotic laxatives and prokinetic drugs like erythromycine and acetylcholinesterase inhibitors. By combining epidural anesthesia and the sparse use of i. v. opioids with early food intake and, if necessary, laxatives or prokinetics, postoperative ileus should be coped adequately. Nevertheless, the development of new specific prokinetic drugs with minimal or no side effects should remain a target for drug companies to further improve treatment of postoperative ileus.

Schlüsselwörter

Übersichtsarbeit - postoperativer Ileus - Pathophysiologie - Therapie

Key words

Postoperative ileus - pathophysiology - treatment - review

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