An anesthesiologist plays a critical role not only in the initiation of surgical anesthesia but also in the selection and transition to an effective maintenance of postoperative analgesia. All patients undergoing bowel resection (BR) experience postoperative ileus (POI), a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees [1
]. Clinically, POI is characterized by delayed passage of flatus and stool, bloating, abdominal distension, abdominal pain, nausea, and vomiting and is associated with an increase in postoperative morbidity and length of hospital stay (LOS) [4
Although the etiology of POI is complex (), it is primarily associated with the surgical stress response, an acute inflammatory response associated with manipulation of the bowel, and endogenous opioids secreted within the gastrointestinal (GI) tract in response to surgical trauma [3
]. Opioid-based analgesia is widely used and considered the standard of care for postoperative pain management [8
]. Opioids mediate analgesia by binding to mu-opioid receptors in the central nervous system [13
]; however, they also bind to peripheral mu-opioid receptors in the GI tract resulting in a disruption of the migrating motor complex and propulsive motor activity associated with GI motility, inhibition of intestinal ion and fluid secretion, and an increase in the overall GI transit time, thereby exacerbating POI [9
Figure 1 The multifactorial etiology of postoperative ileus (POI). Development of POI is multifactorial. Surgical incision and manipulation of the intestines activate inflammatory and stress responses and endogenous opioids. Mast cells release vasoactive substances (more ...)
Attempts to reduce the duration of POI have prompted the study of various preoperative, perioperative, and postoperative regimens to facilitate GI recovery. This review focuses on the anesthetic management routines (e.g., opioid-sparing anesthesia and analgesia, epidural anesthesia and analgesia, and use of peripherally acting mu-opioid receptor (PAM-OR) antagonists) that may result in reduced time to gastrointestinal recovery and hospital length of stay. Application of these interventions by anesthesiologists and best practice management routines across the institution may benefit the patient and the healthcare system.