Acute Intestinal Failure.11
Acute Intestinal Failure.11
Acute Intestinal Failure.11
Purpose of review
The review aims to highlight the importance of acute gastrointestinal failure in the
postoperative patient, to clarify the clinical circumstances in which acute intestinal
failure complicates postoperative management, and to discuss recent advances and
controversy in our understanding of the cause and pathogenesis.
Recent findings
Acute postoperative intestinal failure ranges from a self-limiting condition of disordered
intestinal peristaltic activity, through to a complex critical illness state associated with
abdominal sepsis and intestinal fistulation. Recent developments have focused on
the mechanisms of paralytic ileus and preventive strategies, usually as part of programmes
of fast-track or enhanced recovery care, and on the optimum management of patients
with severe abdominal sepsis, including planned versus on-demand relaparotomy, open
abdominal management of severe sepsis and negative pressure wound therapy.
Summary
Many cases of acute intestinal failure are preventable. Improvements in understanding
and preventing paralytic ileus through changes in postoperative care may facilitate
recovery of gastrointestinal function after abdominal surgery. Further and betterorganized studies are needed to define the optimum strategies for treating patients with
severe abdominal sepsis, managing the patient with the open abdomen and defining the
role of enteral, as opposed to parenteral nutritional support in such patients.
Keywords
enhanced recovery, fistula, ileus, parenteral nutrition, sepsis
Curr Opin Crit Care 16:347352
2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1070-5295
Introduction
Whereas failure of organ systems has long been recognized
as a key feature of critical illness, the potential for failure of
the gastrointestinal system as both a consequence and a
potential driver of the critical illness state has been of more
recent interest. The current review addresses the cause,
pathogenesis and epidemiology of acute postoperative
intestinal failure, and highlights current advances and
controversies in the management of the postoperative
patient with acute intestinal failure.
Definition of intestinal failure
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patients who continue to show signs of intestinal obstruction after 7 days [5]. In contrast, obstruction developing
after laparoscopic surgery is much more commonly the
result of port-site herniation [7] and early laparotomy
should be considered in order to avoid strangulated
obstruction. It is especially important to distinguish
mechanical obstruction from paralytic ileus in patients
with early postoperative small bowel obstruction and
prompt radiological assessment, preferably by a contrast-enhanced CT scan, seems to be the most appropriate imaging modality [8]. Those patients who require
relaparotomy can be extremely challenging to manage.
The abdominal cavity can be hostile in the early postoperative period and inadvertent intestinal injury, even if
recognized and treated immediately, is associated with a
high incidence of abdominal sepsis, intestinal fistulation
and type II intestinal failure [9] (see below).
Postoperative ileus is also a frequent cause of type I
intestinal failure and indeed, frequently needs to be
distinguished from mechanical intestinal obstruction.
The clinical importance of postoperative ileus is underlined by the fact that it is currently the most common
reason for delayed discharge following abdominal surgery
[10], leading to a mean increase in length of hospital stay
of approximately 5 days and a 10-fold increase in readmission rates. Postoperative ileus occurs as a result of
transient impairment of coordinated intestinal motility
[11]. Whereas it may affect all segments of bowel, the
pattern of recovery differs according to the portion of the
intestinal tract affected, with recovery occurring notably
quicker in the small intestine than in the stomach or
the colon [12]. The return of colonic motility appears to
be the key factor responsible for the clinical resolution
of postoperative ileus [13]. The mechanisms of ileus
are probably complex and multifactorial. Whereas ileus
usually complicates abdominal surgery, it may also complicate critical illness states and nonabdominal surgical
procedures, including hip surgery, retroperitoneal and
spinal procedures, lower limb orthopaedic and neurosurgery [14]. Whereas disordered intestinal electrical
activity may be the immediate cause of the clinical
syndrome of abdominal distension, constipation, nausea
and vomiting [13], the pathogenesis of the abnormal
electrical and contractile activity may relate to release
of inflammatory mediators, including cytokines, prostaglandins and nitric oxide [12,13], as well as inhibitory
sympathetic nervous activity induced by handling of the
intestines. These effects may be augmented by the
effects of gut hormones and neurotransmitters, including
vasoactive intestinal polypeptide, substance P and calcitonin gene-related peptide [15]. In particular, opioids,
both endogenous and exogenously administered, seem to
play a central role in the development of postoperative
ileus, probably via m-receptor mediated reduction of
transit [16].
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Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Conclusion
Acute inability of the gastrointestinal tract to support
nutritional, fluid and electrolyte requirements is a common postoperative problem, but ranges in scope and
severity from the stable postoperative patient with
abdominal distension and vomiting who will settle spontaneously with nasogastric drainage and intravenous fluid
therapy for a few days, through to the critically ill patient
on the intensive care unit with severe sepsis, an open
abdomen and multiple intestinal defects. Recent developments in the field of acute postoperative intestinal
failure range from attempts to gain an understanding
and prevent (or at least minimize) the former and to
provide effective critical care for the latter. In the context
of the most severe cases of type II intestinal failure, the
ultimate aim of treatment, which includes not only
patient survival but also avoidance of permanent intestinal failure, may be difficult to achieve. Centralization
of care for these patients in units with large multidisciplinary teams, composed of physicians, nurses, dieticians, pharmacists, enterostomatherapists and clinical
psychologists, may represent the most appropriate and
cost-effective means by which to achieve this. Future
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This is an excellent review which addresses the cause, pathogenesis, indications
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47 Trevelyan SL, Carlson GL. Is TNP in the open abdomen safe and effective?
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