Abstract:
Aim
Prolonged postoperative ileus (PPOI) is one of the most common and difficult to manage
complications following colorectal surgery. This thesis aims to examine the healthcare cost
of PPOI, to validate the use of a predictive scoring system for PPOI (the “I-Score”), and to
analyze currently available methods to prevent or treat PPOI, including non-steroidal anti-inflammatories (NSAIDs) and gastrografin. Finally, we will assess whether prucalopride
improves postoperative gut dysmotility after elective colorectal surgery.
Methods
A retrospective review was undertaken to assess the economic impact of PPOI using a strict
and modern definition. A large multi-center cohort study was conducted to prospectively
assess the validity of the I-Score, a prediction tool for PPOI development. A systematic
review and meta-analysis of randomized control trials was conducted to assess whether
NSAIDs reduce PPOI and improve postoperative gut function. A pooled analysis of 2
randomized control trials that compared gastrografin to placebo for PPOI treatment was
conducted. Finally, a multicenter double-blind randomized control trial was undertaken using
a novel serotonin-4 receptor agonist, prucalopride. The purpose of the trial was to determine
if prucalopride was able to improve postoperative recovery of gut function and prevent PPOI
after elective major colorectal surgery.
Findings
This thesis found that PPOI leads to a significant economic burden across all areas of the
healthcare system, and nearly doubles the cost of admission. The I-Score did not accurately
predict PPOI development in a large cohort study, but the study found new risk factors for
POI development. A systematic review found that NSAIDs confer a modest benefit in time to
passage of flatus, stool, and time to tolerance of diet after elective colorectal surgery.
Furthermore, gastrografin given at the onset of PPOI may improve time to tolerate an oral
diet postoperatively but did not significantly improve time to PPOI resolution. Prucalopride
significantly improved time to passage of stool for patients undergoing elective colorectal surgery within an ERAS setting. Prucalopride did not improve time to tolerate diet or reduce
rates of PPOI or length of stay in our series. However, in patients who underwent
laparoscopic surgery, prucalopride improved their time to gut recovery by around 24 hours.
Conclusions
PPOI carries a significant economic burden. NSAIDs may reduce postoperative gut
dysmotility, but gastrografin is likely ineffective as a treatment for PPOI. Prucalopride did not
reduce the rate of PPOI in our study, but may improve postoperative gut function in a subset
of patients who undergo laparoscopic surgery. Further studies are required to refine the
prediction of PPOI, and allow better selection of high-risk patients to target with future
interventions.