J Gastrointest Surg

DOI 10.1007/s11605-013-2148-y

ORIGINAL ARTICLE

Defining Postoperative Ileus: Results of a Systematic Review

and Global Survey
Ryash Vather & Sid Trivedi & Ian Bissett

Received: 15 November 2012 / Accepted: 16 January 2013

# 2013 The Society for Surgery of the Alimentary Tract

Abstract
Background There is a lack of an internationally accepted standardised clinical definition for postoperative ileus (POI). This
has made it difficult to estimate incidence and identify risk factors and has compromised external validity of clinical trials.
Aim To clarify terminology of POI and propose concise, clinically quantifiable definitions.
Methods A systematic review extracted definitions from randomised trials published between 1996 and 2011 investigating POI
after abdominal surgery. This was followed by a global survey seeking opinions of those who have published in the field.
Results Definitions were extracted from 52 identified trials. Responses were received in the survey from 45 of 118
corresponding authors. Data were amalgamated to synthesise the following definitions: postoperative ileus (POI) “interval
from surgery until passage of flatus/stool AND tolerance of an oral diet”; prolonged POI “two or more of nausea/vomiting,
inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation occurring on or after
day 4 postoperatively without prior resolution of POI”; recurrent POI “two or more of nausea/vomiting, inability to tolerate
oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation, occurring after apparent resolution of
POI”. Concordance of the latter two definitions with survey responses were ≥75 %.
Conclusion We have proposed standardised endpoints for use in future studies to facilitate objective comparison of
competing interventions.

Keywords Postoperative ileus . Definitions . Abdominal
surgery
Introduction
Postoperative ileus (POI) is an abnormal pattern of gastroin-
testinal motility, most frequently occurring after abdominal
surgery. Its principal features include a mix of nausea and
vomiting, inability to tolerate an oral diet, abdominal disten-
sion and delayed passage of flatus and stool. POI has been
shown to slow patient recovery, increase postoperative
R. Vather : S. Trivedi : I. Bissett
Department of Surgery, University of Auckland,
Auckland, New Zealand
I. Bissett (*)
Department of Surgery, Faculty of Medical and Health Sciences,
The University of Auckland, Private Bag 92019,
Auckland Mail Centre 1142, New Zealand
e-mail: i.bissett@auckland.ac.nz
morbidity and prolong hospital stay.1,2 Additionally, it confers
a financial and resource-intensive burden on institutions, with
the cost of its management in the USA alone being estimated
to be in the vicinity of $US1.5 billion annually.3
The debilitating impact of POI on patients and healthcare
systems alike appears to have been acknowledged by the
surgical community, with the recent emergence of a plethora
of clinical trials investigating potentially therapeutic interven-
tions. However, despite this, there remains a lack of an inter-
nationally accepted standardised clinical definition for POI.
Additionally, the terminology used when describing POI is
inconsistent, with little distinction being made between the
‘normal’ obligatory period of gastrointestinal dysmotility fol-
lowing surgery and the more clinically problematic and path-
ologically significant entity of a ‘prolonged’ postoperative
ileus which may last several days.
Ambiguity surrounding the definition of POI has made it
difficult to reliably and consistently estimate incidence (of-
ten quoted as being between 3 and 32 % after abdominal
surgery)4 and identify risk factors. However, perhaps the
most concerning aspect of this imprecision is the effect it

has had on the external validity of clinical trials. Although
many trials have examined interventions for POI, there is
considerable heterogeneity with respect to the outcomes
being measured as surrogate markers of its occurrence and
resolution. This has consequently made it difficult to com-
pare the relative efficacy of competing therapies and raises
questions as to the propriety and ultimate applicability of the
intervention.
The aim of this study is to clarify the terminology of POI
and propose concise, clinically quantifiable definitions
which may be used in future studies. This will be done by
determining the frequency with which various diagnostic
criteria are used in the scientific literature and obtaining
opinions of authors who have published in the field.
Material and Methods
A systematic review was conducted according to the
Preferred Reporting Items for Systematic Reviews and
Meta–analyses (PRISMA) guidelines.5 This was followed
by an online global survey seeking the opinions of authors
who have published in the field. For clarity and expedience,
the term ‘normal’ POI has been used through the following
text to denote the period of gastrointestinal dysfunction
occurring immediately after surgery; prolonged POI refers
to this dysfunction continuing past the expected timeframe;
and recurrent POI refers to a reoccurrence of this dysfunc-
tion after apparent resolution.
Systematic Review
A systematic literature search through the Ovid MEDLINE,
EMBASE, CINAHL, Cochrane Collaboration and National
Guideline databases was performed spanning the timeframe
January 1996–December 2011 (inclusive). Boolean AND/OR
operators were used to combine keyword and MeSH search
terms. For Ovid MEDLINE and EMBASE, the following
search criteria were used: keywords (Postoperative ileus.mp
OR postsurgical ileus.mp), MeSH terms (Ileus/ OR Intestinal
Pseudo-obstruction/; AND Postoperative complication/). For
CINAHL, ‘Ileus’ was searched as a keyword and ‘Intestinal
Pseudo-obstruction’ as a subject heading. For both the
Cochrane and National Guidelines databases, the term ‘Ileus’
was searched with a filter to reviews. Studies were limited to
randomised controlled trials, systematic reviews and meta-
analyses investigating POI in humans. There were no language
limits. Conference abstracts were not included.
Inclusion criteria included all publications looking at POI
as a primary endpoint following abdominal surgery (i.e.
papers referencing POI as one of several outcomes when
examining unrelated interventions were to be excluded).
Additionally, publications were to evaluate POI using
J Gastrointest Surg
clinically appraisable measurements, with specific reference
to at least one of the following: nausea, vomiting, abdominal
pain, abdominal distension, presence of bowel sounds, pas-
sage of flatus, passage of stool, ability to tolerate an oral
diet, need for nasogastric (NG) tube placement or radiologic
features of ileus. Exclusion criteria included all publications
looking at bowel ‘motility’ only (without clearly making a
link to POI), ileus occurring after non-abdominal procedures
and studies without clinical endpoints.
Two reviewers (RV, ST) independently carried out
searches, using titles and abstracts to exclude irrelevant
publications and collate a list of those requiring full-text
evaluation. This list was compared prior to acquisition of
full-texts and then again after reading through them, with
any discrepancies on which to include being resolved by
discussion and consensus or, if required, arbitration by a
third author (IB). A manual search of the reference lists from
systematic reviews and meta-analyses (as well as retrieved
randomised trials) were conducted to identify any other
potentially relevant studies. Articles which were to undergo
extraction were to be the original published trials—defini-
tions from collated data (systematic reviews and meta-
analyses) were not used.
Two reviewers (RV, ST) independently extracted data
from each acquired full-text manuscript. Parameters
recorded included year of publication, whether endpoints
were for ‘normal’, prolonged or recurrent POI (and if either
of the latter, time point in days at which this definition
became applicable), primary and secondary clinical criteria
used to signal onset or resolution of POI, and type of
surgery. Qualitative assessment of included publications
was not performed as the information of interest was the
definition used and not outcome data.
Online Global Survey
An Ovid MEDLINE search was conducted using the keyword
‘postoperative ileus.mp’ for the period spanning January
2001–December 2011. This time frame was chosen as E-
mail addresses were not consistently cited in corresponding
author information prior to 2001. The search was limited to
humans and had no language restrictions. Publications of
interest were those investigating POI as a primary and clini-
cally appraisable endpoint following abdominal surgery, and
in contrast to the above, systematic review included retrospec-
tive studies as well as prospective studies and reviews. The
final list of authors approached was therefore significantly
broader than those identified in the above Systematic
Review. Relevant articles were identified by screening
through titles and abstracts with full-text evaluation being
undertaken if required.
E-mail addresses of corresponding authors were extracted
from included publications, which were in most instances
J Gastrointest Surg
available in the abstract or full text. If not present, a Google
search of the corresponding author’s name was performed to
retrieve this. A database was created with author name, insti-
tution, specialty and primary E-mail address.
A survey was constructed in English to collect informa-
tion spanning five broad areas—participant personal infor-
mation, terminology and definitions used for ‘normal’,
prolonged and recurrent POI and a free-text section for
questions and comments. This survey was then published
online using a validated independent commercial service6
and beta-tested by consultant surgeons within the authors’
home institution prior to dissemination. An E-mail was then
sent out inviting identified corresponding authors to partic-
ipate in the online survey. There were no incentives for
completion. A reminder E-mail was sent out 2 weeks later
to those who did not respond. The online survey was closed
4 weeks after the original invitation was sent out. Survey
responses were collated and downloaded as a Microsoft
Excel database file.
Statistics
Basic descriptive statistics were used to summarise data for
the systematic review and online global survey, each within
their own POI subset. Graphical depictions of information
were used where appropriate to facilitate ease of interpreta-
tion. Given the descriptive nature of this study, no tests of
statistical significance were performed.
Results
Systematic Review
A total of 3,234 publications were identified for screening
using the predefined search strategy, with 3,043 of these
being excluded based on titles and abstracts (Fig. 1).
Duplicates were then excluded from the 190 publications
exported. Systematic reviews and meta-analyses were iden-
tified and their references searched for relevant articles,
before also being excluded. Full texts were acquired for 66
publications, of which 14 were excluded. The reasons for
this were assessment of POI as a secondary outcome (six),
evaluation of POI using a non-clinical approach (three),
lack of a definition for POI (three), inclusion of non-
abdominal procedures (one) and lack of randomisation
(one). Final extraction was performed on the remaining
52 publications.7–58
‘Normal’ POI was defined in 44 publications;7–50 pro-
longed POI in five publications;54–58 and definitions for
both found in three publications.51–53 No publications
referenced recurrent POI. Seven studies used composite
endpoints to define POI with six using the GI-3 (passage
of flatus, passage of stool and toleration of oral diet) and one
using the GI-2 (passage of stool and toleration of an oral
diet).11,17,28,46,49,50,59 These were split into their individual
components before being entered into the data sheet. All
remaining publications outlined specific clinical criteria in
their definitions.
The relative frequency of clinical criteria used to define
resolution of ‘normal’ POI in the 47 publications identified
is outlined in Fig. 2.7–53 The most commonly used criteria
were the passage of flatus (83 %) and stool (79 %), followed
by ability to tolerate an oral diet (28 %) and presence of
bowel sounds (13 %). All remaining criteria were used to
define resolution in less than 10 % of publications. The
majority of studies investigated ‘normal’ POI in colonic
(75 %) or rectal (43 %) procedures. The open technique
(57 %) was employed more frequently than laparoscopic
(15 %) or mixed/unstated (28 %) techniques in the publica-
tions analysed.
Eight publications were identified which contained
definitions for prolonged POI.51–58 Absence of passage
of flatus (50 %) and stool (88 %) were the primary
means of diagnosing prolonged POI, followed by ongo-
ing nausea and vomiting (25 %) and need for NG tube
insertion (25 %). The time point at which the definition
for prolonged POI was applied varied considerably
(range, 1–7 days) with a mean of 3.9 days and median
of 4 days. Again, most publications investigated pro-
longed POI after colonic (63 %) or rectal (38 %) sur-
gery, with an open technique being used for most procedures
(63 %).
Online Global Survey
A total of 118 individual corresponding authors were iden-
tified and invited to participate in the online survey.
Responses were received from 45 authors (38 % response
rate), with 44 completing the survey in its entirety. Of these,
31 belonged to a surgical specialty (69 %), 7 to anaesthesi-
ology (16 %), 4 to a medical specialty (9 %) and the
remaining 3 to emergency medicine, obstetrics and gynae-
cology, and full-time academia. In total, 22 countries were
represented in this survey with respondents being based
mostly in either the United States (13 participants; 29 %)
or UK (4 participants; 9 %).
With regard to ‘normal’ POI, 31 respondents (71 %)
indicated they had a specific term for this, with over
half referring to it as ‘postoperative ileus’ not further
specified (Table 1). Passage of flatus (68 %) and toler-
ance of an oral diet (61 %) were the most commonly
quoted essential criteria to be met when defining its
resolution (Fig. 3).
A total of 77 % of respondents reported having a
specific term for prolonged POI (Table 2). When asked
 J Gastrointest Surg

Fig. 1 PRISMA flow chart

Identification
illustrating the identification,
screening and exclusion Articlesidentified for screening
process Ovid MEDLINE EMBASE CINAHL Cochrane NG
(n=951) (n=2,038) (n=171) (n=10) (n=64)

Articles excluded during

screening
(n=3,043)

Screening
Articles exported from databases
(n =190 )

Duplicates excluded
(n=114)

Systematic reviews and

meta-analyses
(n = 10 )
Eligibility

Full-text articles retrieved

(n=66)

Exclusion based on full-text

(n = 14)
Included

Articles included in final

analysis
(n = 52)

at what point this ileus moved from being ‘normal’ to
prolonged, answers were given which ranged from 1–
7 days, with a mean of 3.9 days and median of 4 days
(Fig. 4). Out of the 44 respondents, three stated this
depended on whether surgery was laparoscopic or open with-
out providing a specific time point. Most commonly cited
essential criteria to be met when defining a prolonged POI
(Fig. 5) were inability to tolerate an oral diet (82 %) and
absence of flatus (71 %)?
The majority of respondents (59 %) indicated they had a
specific term for recurrent POI (Table 3). Essential criteria to
be met in order to define an ileus as recurrent echoed that for
defining a prolonged POI (Fig. 5). In the free-text section of
this question, four out of the 44 respondents stated a diag-
nosis of recurrent POI could only be made after excluding a
surgical complication as an underlying cause.
Recommended Definitions
Data from the systematic review and global survey were
amalgamated to propose terminology and definitions for post-
operative ileus as outlined below. Early postoperative
mechanical small bowel obstruction must be considered and
excluded as a possible aetiology prior to assignment of these
labels.
& Postoperative ileus, interval from surgery until both the
following criteria are met:
a. Passage of flatus OR stool
b. Tolerance of an oral diet
These events should occur before day 4 postoperatively.
& Prolonged postoperative ileus, defined if two or more
of the following five criteria are met on or after day 4
postoperatively without prior resolution of “postopera-
tive ileus” (as described above):
a. Nausea or vomiting
b. Inability to tolerate an oral diet over last 24 h
c. Absence of flatus over last 24 h
d. Abdominal distension
e. Radiologic confirmation
Concordance of this definition with the global survey
was 80 %, with 35 out of 44 participants citing two or
more of these as essential criteria.
J Gastrointest Surg

Fig. 2 Relative frequency of clinical criteria used to define resolution of ‘normal’ POI in the 47 publications identified in the systematic review

& Recurrent postoperative ileus, defined if two or more Discussion

of the following five criteria are met after an apparent
resolution of “postoperative ileus” (as described above): The present study has revealed that a majority of clinical
a. Nausea or vomiting trials published over the last 15 years focused on shortening
b. Inability to tolerate an oral diet over last 24 h the duration of a ‘normal’ POI, with only a few addressing
c. Absence of flatus over last 24 h the problem of a prolonged POI. A perceptible degree of
d. Abdominal distension concordance was noted in the systematic review and global
e. Radiologic confirmation survey with respect to defining the resolution of a ‘normal’
ileus, with passage of flatus, passage of stool and tolerance
Concordance of this definition with the global survey was
of an oral diet being principal elements. The small number
75 %, with 33 out of 44 participants citing two or more of
of trials investigating prolonged POI and the broad distribu-
these as essential criteria.
tion of essential criteria made a systematic review of little
use when attempting to standardise a definition. Conversely,
Table 1 Responses to the question: “If you have a specific term for the
period of gastrointestinal dysfunction seen immediately after intra-
the global survey revealed that, for both prolonged and
abdominal surgery, what do you call it?” recurrent POI, ongoing nausea and vomiting, inability to
tolerate an oral diet, absence of flatus and stool and disten-
Terminology Number of respondents sion were key elements of diagnosis. Both systematic re-
POI [not further specified] 18 (58 %)
view and global survey identified a prolonged POI as one
Adynamic ileus 4 (13 %)
which continues past day 4 postoperatively.
Physiologic POI 4 (13 %)
‘Ileus’ takes its origins from the ancient Greek verb
‘eileos’, whose literal meaning is to ‘twist or squeeze’.60 It
Normal POI 3 (10 %)
is clear that, in the context of postoperative ileus, this is a
Postoperative dysmotility 1 (3 %)
misnomer, as the primary pathological process appears to be
GI tract dysfunction 1 (3 %)
one of hypomotility. Over the last century ‘ileus’ (as a single
Total 31
word) has frequently been used as an alternate term for
 J Gastrointest Surg

Fig. 3 Responses to the question: “After intra-abdominal surgery almost all patients have a period of gastrointestinal dysfunction. Which essential
criteria must be met in order for you to define a resolution of this gut dysfunction? Please check as many boxes as necessary”

bowel obstruction, and it is only recently that the jargon for are applied by clinical trials and academics who have pub-
these distinct clinical entities has differentiated appropriate- lished in the field.
ly. The ambiguity with which this has evolved has perhaps Postoperative ileus is a clinical diagnosis which has tra-
foreshadowed the interchangeable and somewhat confusing ditionally been associated with a variable combination of
terminology currently used to describe POI and is exempli- upper and lower gastrointestinal symptoms.1,2 Radiologic
fied well by noting the heterogeneity with which definitions investigations may be used in conjunction with clinical
diagnosis to confirm POI but are often more importantly
reserved to exclude bowel obstruction or a precipitating
cause.61 Whilst most studies in the systematic review out-
Table 2 Responses to the question: “In some cases, postoperative gas-
trointestinal dysfunction can extend past the expected timeframe; if you lined individual clinical criteria, seven publications used
have a specific term for this, what do you call it?” gastrointestinal functional recovery composite endpoints to
define a resolving POI. Although these composite endpoints
Terminology Number of respondents
lend elegance and expediency to the outlining of a defini-
Prolonged POI 16 (47 %) tion, they make reference to the same criteria as other
POI [not further specified] 7 (21 %) publications and do not add to the standardisation of a
Paralytic POI 5 (15 %) definition.
Pathologic POI 2 (6 %) A clinical consensus update published in 2006 by
Severe POI 1 (3 %) Delaney et al. has endeavoured to provide definitions for
Adynamic ileus 1 (3 %)
POI. It makes a distinction between primary and secondary
Prolonged GI tract dysfunction 1 (3 %)
POI and also classifies it as type I–III depending on the
Prolonged postoperative dysmotility 1 (3 %)
relative prominence of upper or lower gastrointestinal symp-
tom clusters. The clinical consensus describes POI as being
Total 34
the interval between surgery and passage of flatus or stool
J Gastrointest Surg
Fig. 4 Responses to the question: “What is your expected timeframe (in days) for physiologic postoperative GI tract dysfunction? (i.e. at what time point
does this ongoing gut dysfunction stop being physiologic?). If in your opinion this varies with procedure, please list the maximum duration”
and tolerance of an oral diet over 24 h, which is consistent
with our proposed definition. It is suggested that an ileus is
prolonged if it extends past day 5 postoperatively for open
abdominal surgery or day 3 for laparoscopic abdominal
surgery, and recurrent if there is nausea or vomiting, bloat-
ing and absence of flatus or stool after apparent resolution.61
Our proposed definitions for these are two or more of
nausea/vomiting, inability to tolerate oral diet over 24 h,
absence of flatus over 24 h, distension or radiologic confir-
mation, occurring on or after day 4 postoperatively for
prolonged POI and in the case of recurrent POI occurring
after an apparent resolution of POI. Importantly, despite the
proficiency of the Clinical Consensus Committee, it appears
the attempt at standardisation has been unsuccessful with the
present study finding only 6 of the 31 trials published since
2006 conforming to them.11,16,27,49,50,52
Perhaps the biggest drawback of a non-standardised def-
inition is the inability to impartially compare competing
therapeutic interventions. For instance, a Cochrane review
examining systemic prokinetics for the treatment of POI
included 39 randomised trials in its meta-analysis. The
primary outcomes evaluated by the individual trials differed
considerably, revolving mainly around a variable mixture of
time to stool, time to flatus, toleration of an oral diet or a
collation of these expressed as composite endpoints.62 It
is not possible to objectively appraise competing inter-
ventions when subtle differences exist in their outcome
measures, and a degree of homogeneity with respect to end-
points should be employed by future trials to preclude any
potential bias.
It is prudent to note that most literature evaluates inter-
ventions in the context of ‘normal’ POI and use this as a
proxy for anticipated outcomes in prolonged POI. It is the
latter of these two entities which is clinically and financially
significant and deserves the greater part of our attention.
Variability with respect to terminology and definitions has
led to a ‘generic grouping’ phenomenon, and this has sub-
sequently made it difficult to consider incidence, risk fac-
tors, patient outcomes and fiscal burden as they relate to
‘normal’ and prolonged POI individually. This inconsisten-
cy is also likely to diminish the internal and external validity
of any institutional audit practices which may be in place
(this may be further compounded by the fact that coding of
POI in most centres is wholly at the discretion of the
clinician). Indeed, much emphasis is given in the literature
to Goldstein et al.’s estimation of the annual $US1.5 billion
cost of managing POI in the United States. Identification of
cases of POI in this study were based retrospectively on
coded data, and the authors make the clear point that “stud-
ies on POI have been limited, because no standardized
 J Gastrointest Surg

Fig. 5 This figure collates responses to the questions “Which essential essential criteria must be met in order for you to define a reoccurrence
criteria must be met in order for you to define this as ongoing postop- of postoperative GI dysfunction which appeared to have previously
erative GI dysfunction, which has not yet resolved? Please check as resolved? Please check as many boxes as necessary”, displayed as
many boxes as necessary”, displayed as prolonged POI; and “Which recurrent POI

nomenclature or grading system is available to objectively complications associated with the prolonged hospital stay”.3
define the clinical scope and the clinical relevance of this Much scope therefore remains for trials examining interven-
common postoperative problem”. The authors also go on to tions in this group of patients exclusively.
state “patients with prolonged POI are expected to undergo a The present study has considered ileus following abdominal
greater number of interventions and are at greater risk for surgery only. However, POI is a recognised entity after proce-
dures not involving breach of the peritoneum. This most
notably includes orthopaedic spinal procedures, where be-
Table 3 Responses to the question: “A possible scenario is where
tween 5 and 12 % develop prolonged POI.63 Incidence follow-
postoperative GI dysfunction appears to resolve, only for there to be
a reoccurrence of the symptoms and signs indicating GI dysfunction; if ing lower limb arthroplasty is typically lower at <1 %, but one
you have a specific term for this, what is it?” study has importantly found this lasted more than 3 days in
approximately half the affected patients.64 The pathogenesis of
Terminology Number of respondents
POI in this group is poorly elucidated but is presumed to also
Recurrent POI 12 (46 %) relate to narcotic analgesia, electrolyte disturbances, fluid
Paralytic POI 4 (15 %) imbalances and the surgical stress response.1 It may therefore
Pathologic POI 4 (15 %) be plausible to extend the proposed definitions to apply to POI
POI [not further specified] 2 (8 %) following non-abdominal surgery, and indeed standardisation
Adynamic ileus 1 (4 %) with respect to endpoint reporting stands to similarly improve
GI tract dysfunction 1 (4 %) the external validity of trials conducted in this patient cohort.
Small bowel obstruction 1 (4 %)
Definitions extracted from publications identified in the
Primary POI 1 (4 %)
systematic review were applied by respective investigators
Total 26
prior to study execution. Given that there is no standardised
definition for POI, the results of this systematic review are
J Gastrointest Surg
therefore analogous to those from the online global survey
in that they are fundamentally a collation of academic opin-
ion. It is hoped that the broad opinion base upon which the
proposed definitions were founded hold greater generalis-
ability to authors and institutions and serve to stimulate
further discussion on their propriety and applicability.
Conclusion
There is considerable heterogeneity with which terminology
and definitions of postoperative ileus are used. Three classes
can be broadly identified: postoperative ileus, prolonged post-
operative ileus and recurrent postoperative ileus. A prolonged
postoperative ileus is one which continues past day 4 postop-
eratively. We have proposed definitions based on available
literature and author opinion. Standardisation of endpoints in
future studies is required in order to allow objective compar-
isons between competing interventions.
Funding Ryash Vather is a doctoral student funded by the Royal
Australasian College of Surgeons’ Foundation for Surgery Research
Fellowship.
Conflict of Interest None.
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