Postoperative ileus in an enhanced recovery pathway—a retrospective cohort study

  • Fabian Grass
  • Juliette Slieker
  • Jonas Jurt
  • Anne Kummer
  • Josep Solà
  • Dieter Hahnloser
  • Nicolas Demartines
  • Martin Hübner
Original Article



Enhanced recovery after surgery (ERAS) protocols advocate no nasogastric tubes after colorectal surgery, but postoperative ileus (POI) remains a challenging clinical reality. The aim of this study was to assess incidence and risk factors of POI.


This retrospective analysis included all consecutive colorectal surgical procedures since May 2011 until November 2014. Uni- and multivariate risk factors for POI were identified by multiple logistic regression and functional and surgical outcomes assessed.


The study cohort consisted of 513 consecutive colorectal ERAS patients. One hundred twenty-eight patients (24.7%) needed postoperative reinsertion of nasogastric tube at the 3.9 ± 2.9 postoperative day. Multivariate analysis retained the American Society of Anesthesiologists group 3–4 (odds ratio (OR) 1.3; 95% CI 1–1.8, p = 0.043) and duration of surgery of >3 h (OR 1.3; 95% CI 1–1.7, p = 0.047) as independent risk factors for POI. Minimally invasive surgery (OR 0.6; 95% CI 0.5–0.8, p ≤ 0.001) and overall compliance of >70% to the ERAS protocol (OR 0.7; 95% CI 0.6–1, p = 0.031) represented independent protective factors. POI was associated with respiratory (23 vs. 5%, p ≤ 0.001) and cardiovascular (16 vs. 3%, p ≤ 0.001) complications.


POI was frequent in the present study. Overall compliance to the ERAS protocol and minimally invasive surgery helped to prevent POI, which was significantly correlated with medical complications.


Enhanced recovery Fast track Colorectal Ileus Nasogastric drainage Compliance 



The authors would like to acknowledge the support provided by all members of the enhanced recovery team in Lausanne, and especially the dedicated nurse V. Addor.

Statement of authorship

Fabian Grass: design, analysis and interpretation, drafting

Juliette Slieker: design, analysis and interpretation, critical revision

Jonas Jurt: analysis and interpretation, critical revision

Anne Kummer: interpretation, critical revision

Dieter Hahnloser: analysis and interpretation, critical revision

Nicolas Demartines: conception, interpretation, critical revision

Martin Hübner: conception and design, analysis and interpretation, drafting

All authors approved the final version

Compliance with ethical standards

This study was approved by the Institutional Review Board (Commission cantonale d’éthique de la recherche sur l’être humain (CER-VD)), and informed consent was obtained from every patient.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Su’a BU, Hill AG (2015) Perioperative use of chewing gum affects the inflammatory response and reduces postoperative ileus following major colorectal surgery. Evidence-based medicine 20(5):185–186CrossRefPubMedGoogle Scholar
  2. 2.
    Ahmed Ali U, Dunne T, Gurland B, Vogel JD, Kiran RP (2014) Actual versus estimated length of stay after colorectal surgery: which factors influence a deviation? Am J Surg 208(4):663–669CrossRefPubMedGoogle Scholar
  3. 3.
    Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M et al (2013) Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 37(2):259–284CrossRefPubMedGoogle Scholar
  4. 4.
    Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J (2011) Enhanced recovery after surgery study Group: adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146(5):571–577CrossRefPubMedGoogle Scholar
  5. 5.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38(6):1531–1541CrossRefPubMedGoogle Scholar
  7. 7.
    Roulin D, Donadini A, Gander S, Griesser AC, Blanc C, Hubner M, Schafer M, Demartines N (2013) Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg 100(8):1108–1114CrossRefPubMedGoogle Scholar
  8. 8.
    Roulin D, Blanc C, Muradbegovic M, Hahnloser D, Demartines N, Hubner M (2014) Enhanced recovery pathway for urgent colectomy. World J Surg 38(8):2153–2159CrossRefPubMedGoogle Scholar
  9. 9.
    Vather R, Josephson R, Jaung R, Kahokehr A, Sammour T, Bissett I (2015) Gastrografin in prolonged postoperative ileus: a double-blinded randomized controlled trial. Ann Surg 262(1):23–30CrossRefPubMedGoogle Scholar
  10. 10.
    Moghadamyeghaneh Z, Hwang GS, Hanna MH, Phelan M, Carmichael JC, Mills S, Pigazzi A, Stamos MJ 2015: Risk factors for prolonged ileus following colon surgery. Surgical endoscopy.Google Scholar
  11. 11.
    Iyer S, Saunders WB, Stemkowski S (2009) Economic burden of postoperative ileus associated with colectomy in the United States. Journal of Managed Care Pharmacy : JMCP 15(6):485–494CrossRefPubMedGoogle Scholar
  12. 12.
    Wolthuis AM, Bislenghi G, Fieuws S, de Buck van Overstraeten A, Boeckxstaens G, D’Hoore A (2016) Incidence of prolonged postoperative ileus after colorectal surgery: a systematic review and meta-analysis. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 18(1):O1–O9CrossRefGoogle Scholar
  13. 13.
    Bragg D, El-Sharkawy AM, Psaltis E, Maxwell-Armstrong CA, Lobo DN (2015) Postoperative ileus: recent developments in pathophysiology and management. Clin Nutr 34(3):367–376CrossRefPubMedGoogle Scholar
  14. 14.
    Vlug MS, Bartels SA, Wind J, Ubbink DT, Hollmann MW, Bemelman WA, Collaborative LSG (2012) Which fast track elements predict early recovery after colon cancer surgery? Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland 14(8):1001–1008CrossRefGoogle Scholar
  15. 15.
    Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B, Charlebois P, Feldman LS et al (2014) Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology 121(5):937–947CrossRefPubMedGoogle Scholar
  16. 16.
    Kiran RP, Murray AC, Chiuzan C, Estrada D, Forde K (2015) Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg 262(3):416–425CrossRefPubMedGoogle Scholar
  17. 17.
    Short V, Herbert G, Perry R, Atkinson C, Ness AR, Penfold C, Thomas S, Andersen HK, Lewis SJ (2015) Chewing gum for postoperative recovery of gastrointestinal function. The Cochrane database of systematic reviews 2:CD006506Google Scholar
  18. 18.
    Sun Y, Li T, Wang N, Yun Y, Gan TJ (2012) Perioperative systemic lidocaine for postoperative analgesia and recovery after abdominal surgery: a meta-analysis of randomized controlled trials. Dis Colon rectum 55(11):1183–1194CrossRefPubMedGoogle Scholar
  19. 19.
    Adam MA, Lee LM, Kim J, Shenoi M, Mallipeddi M, Aziz H, Stinnett S, Sun Z, Mantyh CR, Thacker JK (2015) Alvimopan provides additional improvement in outcomes and cost savings in enhanced recovery colorectal surgery. Annals of surgery.Google Scholar
  20. 20.
    Gero D, Gie O, Hubner M, Demartines N, Hahnloser D 2016: Postoperative ileus: in search of an international consensus on definition, diagnosis, and treatment. Langenbeck’s archives of surgery/Deutsche Gesellschaft fur Chirurgie.Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Fabian Grass
    • 1
  • Juliette Slieker
    • 1
  • Jonas Jurt
    • 1
  • Anne Kummer
    • 1
  • Josep Solà
    • 2
  • Dieter Hahnloser
    • 1
  • Nicolas Demartines
    • 1
  • Martin Hübner
    • 1
  1. 1.Department of Visceral SurgeryUniversity Hospital of Lausanne (CHUV)LausanneSwitzerland
  2. 2.Centre Suisse d’Electronique et de Microtechnique (CSEM)NeuchâtelSwitzerland

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