Ileus After Colectomy in the Modern Era: A Population-Based Analysis.

Abstract

Background: Postoperative ileus after colectomy is common and associated with increased healthcare costs and patient morbidity. While most Michigan hospitals have implemented enhanced recovery pathways, we hypothesized that ileus would still be clinically relevant.

Objective: To understand the current burden of, and risk factors for postoperative ileus.

Design: Retrospective analysis of patients undergoing elective colectomy. Patient, hospital, perioperative care, and surgical risk factors were tested for association. Multivariable logistic regression was performed to identify independent risk factors for ileus. Risk-adjusted hospital rates of ileus were compared.

Setting: Seventy hospitals in Michigan Surgical Quality Collaborative.

Patients: Prospective database between 2018-2023.

Main outcome measure: The primary outcome was postoperative ileus defined as "no oral intake ≥4 postoperative days or the need for nasogastric tube insertion within 30 days after surgery."

Results: Of 9,571 patients who underwent elective colectomy, there were 9,393 partial and 178 total colectomies. Ileus was diagnosed in 6.56% of the cohort, and hospital crude rates ranged from 0.79% to 22.0%. Ileus was associated with other complications (29.62% vs 7.68%, p < 0.0001), mortality (1.75% vs 0.59%, p = 0.0006), reoperation (16.72% vs 4.92%, p < 0.0001), and readmissions (27.39% vs 6.50%, p < 0.0001). Multivariable analysis showed risk factors for ileus were total (27.5%) versus partial (6.2%) colectomy, hospital size >500 beds, male sex, immunosuppressant medications, non-white race, COPD, sleep apnea, and age >65 years. Factors associated with decreased ileus included minimally invasive (5.2%) versus open (10.1%) surgical approach, alvimopan, ambulation within 24 postoperative hours, and diverticular disease. There was significant hospital variation in risk-adjusted ileus rates.

Limitations: Retrospective study design.

Conclusion: The low observed rate of ileus may reflect the modern era of enhanced recovery and minimally invasive colectomy. Total colectomy is associated with high rate of ileus compared to partial colectomy. Increased implementation of minimally invasive surgery, perioperative alvimopan, and early ambulation might further reduce ileus rates. See Video Abstract.