Postoperative ileus after abdominal surgery: pathophysiology, prevention and contemporary management: a narrative review

Abstract

Postoperative ileus (POI) remains one of the most frequent complications following abdominal surgery, significantly contributing to delayed gastrointestinal recovery, prolonged hospitalization, and increased healthcare costs. Although a transient impairment of bowel motility is expected after surgical intervention, prolonged POI represents a pathologic state driven by complex perioperative mechanisms. To provide a focused narrative synthesis of the current evidence regarding the pathophysiology, epidemiology, risk factors, prevention strategies, and contemporary management of postoperative ileus in adult abdominal surgery. A targeted literature review was conducted using major biomedical databases, including PubMed/MEDLINE, Scopus, and Google Scholar. Emphasis was placed on high-impact studies published between 2000 and 2025, including randomized controlled trials, systematic and narrative reviews, and Enhanced Recovery After Surgery (ERAS) guidelines. Fifteen high-yield references were selected for narrative analysis based on clinical relevance and methodological robustness. POI is a multifactorial entity involving neurogenic inhibition, inflammatory activation, opioid-mediated dysmotility, and perioperative fluid disturbances that collectively impair coordinated gastrointestinal function. Identified risk factors include advanced age, open surgical approaches, prolonged operative time, and high perioperative opioid exposure. Preventive strategies centered on ERAS pathways — including minimally invasive surgery, opioid-sparing analgesia, early enteral nutrition, mobilization, and goal-directed fluid therapy — demonstrate consistent reductions in POI incidence and duration. Pharmacologic agents such as alvimopan provide adjunctive benefit, while non-pharmacologic measures, including sham feeding, further support gastrointestinal recovery. Effective mitigation of postoperative ileus relies on comprehensive, protocol-driven perioperative care rather than isolated therapeutic interventions. Continued refinement of ERAS implementation, alongside emerging predictive and pharmacologic strategies, will be essential to optimize postoperative recovery and surgical outcomes.