REVIEW

Facilitating early recovery of bowel motility after colorectal

surgery: a systematic review
Åsa Wallström and Gunilla Hollman Frisman

Aims and objectives. To determine how restored gastrointestinal motility can be accelerated after colorectal surgery. Background.
Regaining normal bowel functions after surgery is described as unexpectedly problematic. Postoperative ileus is expected after all
surgery where the peritoneum is entered, and the length of surgery has little or no impact in terms of the duration of Postoperative
ileus. There is some speculation about the best way to facilitate bowel motility after colorectal surgery. Design. A systematic review.

Method. The computerised databases Medline, Scopus and CINAHL were searched to locate randomised, controlled trials by using the
following keywords: colorectal surgery, postoperative ileus, recovery of function and gastrointestinal motility. The systematic search
was limited to studies published between January 2002–January 2012. Reference lists were also searched manually.

Results. A total of 34 randomised, controlled trials were included in the review. Recovery of gastrointestinal motility was accelerated
when one of the following forms of treatment was administered: probiotics, early feeding in combination with multimodal regimens,
pentoxifylline, flurbiprofen, valdecoxib, ketorolac, clonidine, ropivacaine, lidocaine or spinal analge-sia. Gum chewing, preoperative
carbohydrate loading, bisacodyl and Doppler-guided fluid management have an uncertain effect on bowel motility. The use of
nonpharmacological interventions, intrathecal morphine, restricted fluid therapy and choline citrate yielded no significant acceleration
in bowel motility.
Conclusions. A multimodal treatment, where the use of morphine is restricted, seems to be the best way to accelerate the recovery of
gastrointestinal bowel motility. However, more studies are required to optimise the multimodal protocol. Relevance to clinical practice.
The early return of bowel functions leads to quicker overall postoperative recovery, which may ease patient discomfort and decrease
hospitalisation costs.

Key words: colorectal surgery, enhanced recovery, gastrointestinal motility, multimodal treatment, postoperative care

Accepted for publication: 4 January 2013

The stomach and jejunum normally regain regular motility

Introduction
Postoperative recovery is a dynamic process during which
patients try to regain their independence and return to everyday
life. Their ability to return to normal living involves a conscious
act, whereas regaining control of phys-ical functions is
considered to be beyond the individual’s control (Allvin et al.
2008).
12–24 hours after major surgery, while this takes 48–72 hours in
the colon (Waldhausen et al. 1990, Condon et al. 1995).
Regaining normal bowel functions after surgery is described as
unexpectedly problematic (Allvin et al. 2008). During early
postoperative recovery, patients’ preoccupation with bowel
activity can contribute to a fear of pain and make them worry
about bed soiling (Worster & Holmes 2009).

Authors: Åsa Wallström, RN, MNSc, Clinical Nurse, Department of Correspondence: Åsa Wallström, Clinical Nurse, Department of Surgery,
Surgery, County Council of Östergötland, Linköping; Gunilla Hollman County Council of Östergötland, 581 85 Linköping, Swe-den.
Frisman, RN, Associate Professor, Division of Nursing Science, Telephone: +46 10 1031110. E-mail: asa.wallstrom@lio.se
Department of Medicine and Health, Faculty of Health Science and
Anaesthetics, Operations and Speciality Surgery Cen-tre, County Council
of Östergötland, Linköping, Sweden

© 2013 John Wiley & Sons Ltd

24 Journal of Clinical Nursing, 23, 24–44, doi: 10.1111/jocn.12258
Review
Postoperative ileus (POI) is defined as a ‘transient cessa-tion
of coordinated bowel motility after surgical interven-tion, which
prevents effective transit of intestinal contents or tolerance of
oral intake’ (Delaney et al. 2006). POI is to be expected after
surgery, especially if the peritoneum is entered, and bowel
resections have the highest incidence of POI compared with
other common abdominal-related sur-gery. The incidence of POI
following large bowel resections is 14 9%, based on a total of
257,336 annual projected procedures in the USA (Goldstein et al.
2007).
Symptoms of POI are abdominal distension, nausea, vomiting,
stomach cramps and absence of bowel sounds. One explanation
for the symptoms is that there is a delayed recovery of motility
patterns in combination with bowel contractions. As a
consequence, no flatus or stool is passed per rectum (Morson et
al. 1990, Holte & Kehlet 2000). The aetiology of POI is
multifactorial, but can broadly be divided into factors related to
surgical procedure and fac-tors related to pharmacological
interventions. These include the activation of inhibitory reflexes,
inflammatory media-tors and opioids (Livingston & Passaro
1990, Delaney et al. 2006).
The first few days after colorectal surgery are stressful for the
patients, both physically and psychologically. Physi-cal
symptoms such as nausea and bowel motility dysfunc-tion are
often associated with fear and anxiety about complications
(Allvin et al. 2008, Jonsson et al. 2011). To prevent fear and
anxiety in the postoperative phase, patients need information
about their role in postoperative recovery (Fearon et al. 2005,
Lassen et al. 2009).
Avoiding postoperative nausea and vomiting is essential from
the patient’s perspective (Habib & Gan 2004, Kerger et al.
2007). One way to relieve postoperative nausea is to create a
nursing care situation where the patients are well informed and
assisted in taking control over their own situ-ation. Nurses may
assist patients in taking control by being informative, available
and understanding, thereby making the postoperative recovery
less frightening and more man-ageable (Börjeson et al. 2010).
The duration of POI is defined as ‘the time from surgical
intervention until passage of flatus or stool, and until initia-tion
of adequate oral intake that is tolerated and maintains hydration
during 24 hours’ (Delaney et al. 2006). The length of surgery has
little or no impact in terms of the duration of POI (Wilson 1975,
Livingston & Passaro 1990). However, patients’ discomfort and
the length of their stay in hospital can be decreased using
minimal inva-sive techniques (Mattei & Rombeau 2006).
Moreover, if the surgeon has had specialised surgical training,
this has been shown to shorten the duration of POI after elective
© 2013 John Wiley & Sons Ltd Journal
of Clinical Nursing, 23, 24–44
Facilitating early recovery of bowel motility after colorectal surgery
colectomy. Surgical training should therefore be considered an
important factor in minimising the duration of POI (Gervaz et al.
2006). Where POI lasts longer than six days, it is defined as
abnormally prolonged ileus. Intraoperative blood loss and
postoperative opiate medication have been identified as risk
factors for prolonged POI (Artinyan et al. 2008).
Postoperative ileus leads to pain, increased catabolism,
decreased ambulation and patient discomfort. Surgical patients
with POI also have a higher risk of pulmonary complications
(Kehlet 2000), and the economic side effects of POI are not
insignificant. POI after colectomy leads to extended hospital
stays and 15% increased hospitalisation costs (Iyer et al. 2009).
According to Goldstein et al. (2007), the median length of
hospital stay among colecto-my patients with POI was four days
longer than for colec-tomy patients with a normal postoperative
recovery.
A survey was conducted in the USA and in five European
countries to investigate clinical practice in colonic surgery. The
survey showed that perioperative care did not conform to
published clinical guidelines, as postoperative nasogastric tubes
were left in many patients for several days, and 50% of the
patients did not eat solid food before day 4 or 5 after the
operation (Kehlet et al. 2006). According to Holte and Kehlet
(2002), the duration of POI can be reduced to 1–2 days after
colonic surgery with a multimodality treatment programme.
However, where standardised accelerated post-operative care
programmes are used for bowel surgery patients, the reported
incidence of POI is still relatively high. In a study by Wolff et al.
(2007), POI was reported in 15% of 727 patients who had had
bowel resections fol-lowed by enhanced recovery pathway care.
The findings indicate that improvements are required to
ameliorate post-operative recovery.
Aims
The aim of this systematic review was to determine how restored
gastrointestinal motility can be accelerated after colorectal
surgery.
Methods
A systematic literature search was conducted in the com-
puterised databases Medline, Scopus and CINAHL to locate
randomised controlled trials (RCTs). RCTs produce the highest
levels of evidence and are recognised as the ‘gold standard’ of
systematic reviews (Roe 2007, Cochrane Consumer Network
2010). Randomised controlled trials were eligible for inclusion if
they were (1) published
25
Å Wallström and G Hollman Frisman
between January 2002–January 2012, (2) published in Eng-lish,
(3) based on research from adult humans (men and women >19
years), (4) refereed and (5) focused on ways of accelerating
gastrointestinal motility after colorectal sur-gery.
Gastrointestinal motility was evaluated in the review by using
the following outcome measures: passage of flatus, defecation
and bowel movement. Randomised controlled trials were
excluded if the findings (1) involved the surgical technique or
method or (2) lacked information about when postoperative
gastrointestinal motility was first observed.
The studies were identified using mainly medical subject
headings (MeSH). The following search terms were used:
colorectal surgery, postoperative ileus, recovery of function and
gastrointestinal motility. The search was conducted by the first
author, using combined keywords. Boolean opera-tors (AND,
OR) were used to expand or limit the search. Individual search
strategies were used for each database because of their unique
indexing terms.
The Medline and CINAHL databases were searched for
RCTs, English language, adult and human, as well as by
publication date. Scopus was only searched by publication date
and English language, as it was not possible to search by RCT,
adult or human. Reference lists of cited articles were searched
manually, and three leading researchers in the area of colorectal
surgery were contacted to identify additional studies, in an
attempt to reduce publication bias (Roe 2007). The first author
examined all the abstracts from the electronic database search
and the manual search. All the studies involved were checked in
Ulrichsweb to con-firm that they had been peer-reviewed. A
protocol (Table 1) was used to facilitate quality assessment (Roe
2007), and two reviewers undertook an independent quality
assessment of the studies involved.
Table 1 Questions extracted from the quality assessment protocol
reproduced by Roe (2007)
Is the study relevant to the review?
Is the study a randomised or quasi-randomised trial?
Was there a clear description of inclusion and exclusion criteria? Was
there potential for selection bias at trial entry (quality of random
allocation concealment)?
Were participants ‘blind’ to treatment status?
Were healthcare providers ‘blind’ to treatment status? Were
outcome assessors ‘blind’ to treatment status? Were the
groups treated identically, other than for named interventions?
Was there a description of withdrawals, dropouts and those lost to
follow-up?
Are results reported for everyone who entered the trial? Are
participants analysed in the groups they were originally
allocated to?
26
Any disagreement between the reviewers was resolved
through discussion and by referring to the original protocol
developed by Grant et al. 2006, . All studies were assessed
according to a strict definition of intention to treat, where all
randomised patients had to be analysed (Gunnarsson 2002). Data
were extracted independently by one reviewer for each
individual study and checked by a second reviewer.
Disagreement between the reviewers was resolved through
discussion, until consensus was reached.
Results
A total of 145 studies were identified through electronic
databases (Scopus 90, Medline 53, CINAHL 2), and 16 studies
were found as a result of a manual search (Fig. 1). One of three
of the leading researchers replied after they had been contacted,
but they had no knowledge of any unpublished studies on the
subject. Twenty-five studies were identified as duplicates and
thus removed. The most common reasons for excluding abstracts
were: (1) failure to meet the study design criteria or (2) failure to
deal with methods of accelerating gastrointestinal motility after
colorectal surgery. In total, 42 studies were retained for full-text
analysis, after which eight more studies were excluded as they
failed to meet the inclusion criteria (Table 2). This left 34 studies
for analy-sis. The studies that remained had involved a total of
2243 participants, which provided a mean sample size of 66
partic-ipants. The extracted data are presented (Table 3) through
a synthesis of the results of the studies analysed.
The interventions in this review differed widely. Compar-
isons were made using nutritional treatment, fluid therapy,
laxatives, multimodal treatment, methods to decrease the use of
opioids, other pharmacological treatment and
nonpharmacological interventions, which revealed a num-ber of
influences on how gastrointestinal bowel motility is restored
Nutritional treatment
Nutrition
The effect of nutrition prior to surgery was analysed in two
studies (n = 135) (Noblett et al. 2006b, Liu et al. 2011). One
study (n = 100) (Liu et al. 2011) was double-blinded and
placebo-controlled, while the other study mentioned blinding of
healthcare staff but lacked a description. Time to first defecation
was significantly reduced with probiotics (Liu et al. 2011).
However, there was no evidence of a reduction in length of
hospital stay. Compared with stan-dard treatment, time to first
passage of flatus and length of hospital stay were not reduced
with preoperative
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 24–44
Review Facilitating early recovery of bowel motility after colorectal surgery

Studies identified by searching the Studies identified Additional studies identified

databases by a manual after contact with leading
Medline (53), Scopus (90), CINAHL (2) search researchers
(n = 145) (n = 16) (n = 0)

Identification Studies after duplicates removed

(n = 136)

Abstract screened Studies excluded

Screening

(n = 136) (n = 94)

Full-text studies assessed for Full-text studies excluded (n = 8)

eligibility Not only colorectal surgery (n = 4)
(n = 42) Not randomised (n = 2)
Eligibility

No measures of bowel motility

(n = 1)
Subgroup study based on trial (n = 1)
Included

Studies included in the

systematic review
(n = 34)

Figure 1 Flowchart.

Table 2 Articles excluded after full-text analysis, giving the princi-pal pants in both groups followed a simplified rehabilitation
reason for exclusion programme, the results showed significantly shorter time to first
Delaney et al. (2005) Colorectal surgery not bowel movement and a reduced stay in hospital. The three
analysed separately studies were assessed and shown to be comparative.
Gatt et al. (2005) No outcome measures for
bowel motility
Han-Geurts et al. (2007) Colorectal surgery not
analysed separately Gum chewing
Lloyd et al. (2010) Not randomised Gum chewing as an intervention for accelerating the resto-ration
Nisanevich et al. (2005) Colorectal surgery not of gastrointestinal bowel motility was investigated in six studies
analysed separately (n = 267) (Asao et al. 2002, McCormick et al. 2005, Hirayama et
Serclova et al. (2009) Colorectal surgery not
al. 2006, Matros et al. 2006, Quah et al. 2006, Schuster et al.
analysed separately
Suehiro et al. (2005) Not randomised 2006). Four of these studies (n = 165) (Asao et al. 2002,
Zingg et al. (2009) Subgroup study McCormick et al. 2005, Hirayama et al. 2006, Schuster et al.
based on trial 2006) were very brief and gave poor descriptions of methods and
results. The lack of information made it difficult to evalu-ate
whether the groups had been treated identically other than for
carbohydrate loading, although there was evidence of a trend named interventions (McCormick et al. 2005, Schuster et al.
towards this (Noblett et al. 2006b). 2006). Time to first passage of flatus was significantly reduced
in two of the studies (n = 43) (Asao et al. 2002, Hirayama et al.
Early feeding 2006). Bowel movement occurred earlier in two of the studies (n
Postoperative early feeding versus standard care was investigated = 122) (McCormick et al. 2005, Schuster et al. 2006), while time
in two studies (n = 150) (Feo et al. 2004, da Fonseca et al. 2011). to first defecation was shorter in two other studies (Asao et al.
In one study (n = 100) (Feo et al. 2004), the fasting group had 2002, Hirayama et al. 2006). Two of the studies provided
nasogastric tubes until first passage of flatus. The results did not evidence of reduced length of hospital stay (McCormick et al.
show any significant differences in terms of time to first bowel 2005, Schuster et al. 2006). The two studies (Matros et al. 2006,
movement or length of hospital stay. In the second study (da Quah et al. 2006) with the
Fonseca et al. 2011), where the (McCormick et al. 2005) partici-

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 24–44 27
 Table 3 Randomised studies promoting postoperative gastrointestinal motility
28

Å Wallström and G Hollman Frisman

Author (year) Method Participants Intervention Outcomes Limitations/Notes

Asao et al. 2-arm RCT. Patients (n = 19) with colorectal (1) Gum chewing (n = 10). Time to first flatus and Withdrawals not
(2002) Mentions random cancer undergoing laparoscopic Chewed gum three times time to first defecation mentioned
allocation, but colectomy a day, from POD one were shorter in the
no description Inclusion or exclusion criteria until oral intake intervention group
given not stated (2) Control (n = 9). (p < 0 01). The reduction
No gum chewing in LOS was not significant
Beaussier 2-arm RCT. Adequate Patients (n = 49) undergoing (1) Ropivacaine (n = 21). Time to first defecation Results not reported for
et al. (2007) random allocation elective open resection of A continuous wound and LOS were shorter in everyone who entered the
concealment. colorectal tumours infusion with ropivacaine the intervention group trial. Powered
Double-blinded. Clear description of inclusion and was started when the (p = 0 02). There was no
Placebo-controlled exclusion criteria. Participants wound was closed significant difference
excluded after randomisation (2) Control (n = 21). between the groups in
(n = 7) Received a continuous terms of time to first
0 9% saline flatus
infusion
Beaussier 2-arm RCT. Adequate Patients (n = 59) >70 years (1) Morphine (n = 26). No significant difference Results not reported for
et al. (2006) random allocation old undergoing resection of Received preoperative between the groups in everyone who entered the
concealment. left colon or rectum due to intrathecal morphine, terms of time to first trial. Powered
Double-blinded. cancer injected via the L4–L5 flatus or LOS
Placebo-controlled Clear description of inclusion interspace
and exclusion criteria. (2) Control (n = 26).
Patients excluded after Received preoperative
randomisation (n = 7) placebo saline, injected
in the subcutaneous space
at the L4–L5 level
Chen et al. 2-arm RCT. Adequate Patients (n = 110) undergoing (1) Morphine + ketorolac Time to first bowel Results not reported for
(2009) random allocation elective colorectal resections (n = 52). Received movements (p < 0 001) everyone who entered the
concealment. Clear description of inclusion morphine and ketorolac and time to first flatus trial
Double-blinded and exclusion criteria. Participants postoperatively in a (p = 0 01) were shorter in
excluded after randomisation PCA device the intervention group
(n = 8) (2) Control (n = 50).
Received morphine
24,23,NursingClinicalofJournal 44–

postoperatively in a PCA
device
Sons&WileyJohn2013© d
Lt
 Table 3 (Continued)

Review
Journal
2013©
Author (year) Method Participants Intervention Outcomes Limitations/Notes

Chen et al. 2-arm RCT. Adequate Patients (n = 79) undergoing (1) Ketorolac (n = 39). Time to first bowel Results not reported for
,NursingClinicalof ,23 44–24
Sons&WileyJohn Ltd

(2005) random allocation elective colorectal resections
concealment. Clear description of
Double-blinded inclusion and
exclusion criteria.
Participants excluded after
randomisation (n = 5)
da Fonseca 2-arm RCT. Adequate Patients (n = 54) undergoing
et al. (2011) random allocation colorectal surgery
concealment Clear description of inclusion
and exclusion criteria.
Participants excluded
after randomisation
(n = 4)
Feo et al. 2-arm RCT. Adequate Patients (n = 100)
(2004) random allocation undergoing elective
Received a PCA device movement was shorter everyone who entered the
with morphine and (p < 0 05) in the trial. Unclear whether the
ketorolac ketorolac group. No groups were treated
(2) Morphine (n = 35). significant difference identically
Received a PCA device between the groups in
with morphine terms of LOS or time to
first flatus
(1) Early feeding (n = 24). Time to first flatus Results not reported for
Oral liquid diet on POD 1 (p = 0 019) and LOS everyone who entered the
and a regular diet within (p = 0 000) were shorter trial. Underpowered. MBP
the next 24 hours in the intervention group prior to laparoscopic
(2) Traditional care surgery
(n = 26). Nothing by
mouth until the first
flatus. Oral liquid diet
and a regular diet within
the next 24 hours
(1) Received a nasogastric No significant differences Powered
tube and were not between the groups in

Facilitating early recovery of bowel motility after colorectal surgery

concealment colorectal resection
for cancer
Clear description of
inclusion and
exclusion criteria
Haase et al. 3-arm RCT. Age-stratified. Patients (n = 74) undergoing
(2005) Adequate random allocation elective conventional
concealment. resection of a primary
Blinded colorectal carcinoma
Clear description of inclusion
and exclusion criteria.
Patients excluded after
randomisation (n = 14)
29
allowed to eat or drink terms of LOS or time to
before passage of flatus first bowel movement
(n = 50)
(2) Were allowed to drink
POD 1 and to eat a soft
diet POD 2 (n = 50)
(1) Relaxation (n = 22). No significant differences Results not reported for
Listened to a tape with between the groups in everyone who entered the
instructions, with the aim terms of time to first trial. Underpowered. MBP
of encouraging relaxation flatus and bowel
(2) Guided imagery movement, or in terms of
(n = 20). Listened to a LOS
tape with instructions,
with the aim of calming
and activating inner
resources
(3) Control (n = 18).
Standard care
 Table 3 (Continued)
30

Å Wallström and G Hollman Frisman

Author (year) Method Participants Intervention Outcomes Limitations/Notes

Herroeder 2-arm RCT. Adequate Patients (n = 66) undergoing
et al. (2007) random allocation elective colorectal surgery
concealment. Clear description of
Double-blinded. inclusion and exclusion
Placebo-controlled criteria. Participants
excluded after
randomisation
(n = 6)
Herzog 2-arm RCT. Mentions random Patients (n = 122)
et al. (2011) allocation but no description with Postoperative
given. ileus 48 hours after
Double-blinded. elective open/laparoscopic
Placebo-controlled colorectal resection
Clear inclusion and
exclusion criteria. Patients
excluded after randomisation
(n = 15)
Hirayama 2-arm RCT. Mentions Patients (n = 24) undergoing
et al. (2006) random allocation but elective open surgery
no description given due to colorectal cancer
Unclear description of
inclusion and exclusion
criteria
Holte et al. 2-arm RCT. Adequate Patients (n = 33)
(2007) random allocation undergoing elective
concealment. colonic surgery
Double-blinded Clear description of inclusion
24,23,NursingClinicalofJournal 44–
(1) Lidocaine (n = 31). LOS (p = 0 004), time to Results not reported for
Received lidocaine I.V. as first bowel movement, everyone who entered the
a loading dose before time to first flatus and trial. Significant pre-
anaesthesia. A continuous time to first defecation existing hypertension in
lidocaine infusion started were shorter (p < 0 05) in the lidocaine group.
after intubation and the intervention group Powered
stopped four hours after
skin closure
(2) Control (n = 29).
Received NaCl 0 9%
intravenously
(1) Choline citrate No significant differences Results not reported for
(n = 50). Received choline between the groups in everyone who entered the
citrate injections every terms of LOS, or time to trial. Postoperative
12 hours until defecation first flatus or first randomisation.
or a maximum of defecation Participants not analysed
10 injections in the groups they were
(2) Placebo (n = 57). originally allocated to.
Received sodium chloride MBP prior to left-sided
resections
(1) Gum chewing (n = 10). Time to first flatus Brief description of
Received three pieces of (p = 0 001) and time to methods. Withdrawals not
gum a day. Each piece of first defecation (p = 0 01) mentioned
gum was chewed for were shorter in the
about 30 minutes. each intervention group
mealtime
(2) Control (n = 14). No
gum chewing
(1) Restricted fluid No significant differences Results not reported for
(n = 16). No fluid preload between the groups in everyone who entered the
at placement of epidural. time to first flatus, bowel trial. All patients in the
Restricted fluid during movements or defecation trial >50 years. Powered

and exclusion criteria. surgery. No I.V. fluids

Participants excluded postsurgery
Sons&WileyJohn2013© d

after randomisation (2) Liberal fluid (n = 16).

(n = 1) Fluid preload at
placement of epidural.
Liberal fluid during
surgery. I.V. fluids
postsurgery
Lt
 Table 3 (Continued)
Journal
2013©
Author (year) Method Participants
Ionescu et al. 2-arm RCT. Adequate Patients (n = 96) undergoing
,NursingClinicalof ,23 44–24
Sons&WileyJohn Ltd
(2009) random allocation elective open colorectal
concealment surgery for neoplasm
Clear description of
inclusion and exclusion
criteria
Khoo et al. 2-arm RCT. Adequate Patients (n = 81) with
(2007) random allocation colorectal cancer
concealment undergoing colorectal
surgery
Clear description
of inclusion and exclusion
criteria. Participants
excluded after randomisation
(n = 11)
Levy et al. 3-arm RCT. Adequate Patients (n = 99) with
(2011) random allocation colorectal disease
concealment undergoing laparoscopic
large bowel resection
Clear description of inclusion
and exclusion criteria.
Participants excluded after
randomisation (n = 8)
31
Review
Intervention Outcomes Limitations/Notes
(1) Fast track (n = 48). Time to first restoration of Powered. MBP in the
Followed a fast-track bowel function control group
protocol (p = 0 042) and LOS
(2) Control (n = 48). (p = 0 001) were shorter
Conventional care in the intervention group
programme
(1) Multimodal (n = 35). Time to first defecation Results not reported for
Pre- and intraoperative and LOS were shorter everyone who entered the
I.V. fluid restriction, (p < 0 001) in the trial. Underpowered. MBP
removal of nasogastric multimodal arm
tube on POD 0, thoracic
epidural and postoperative
mobilisation on POD 0.
No diet restriction
(2) Control (n = 35).
Intravenous fluids given
preoperatively. Normal
intraoperative fluid
practice. Removal of
nasogastric tubes POD 1.
Facilitating early recovery of bowel motility after colorectal surgery
No diet allowed until
signs of bowel recovery
Mobilisation on POD 1
(1) Spinal analgesia Bowel functions returned Results not reported for
(n = 31). Received earlier after spinal everyone who entered the
hyperbaric bupivacaine analgesia (p = 0 017) than trial. Powered. MBP prior
and diamorphine following epidural to left-sided resection
(2) Epidural analgesia analgesia. The difference
(n = 30). Received between PCA and
bupivacaine and fentanyl epidural was not
(3) PCA (n = 30). Received significant. LOS was
intraoperative morphine shorter following spinal
and were then attached analgesia (p = 0 002) or
to a PCA device PCA (p < 0 001) than
after epidural analgesia
 Table 3 (Continued)
32

Å Wallström and G Hollman Frisman

Author (year) Method Participants Intervention Outcomes Limitations/Notes

Liu et al. 2-arm RCT. Adequate Patients (n = 114) with
(2011) random allocation colorectal cancer
concealment. undergoing an elective
Double-blinded. radical colorectomy
Placebo-controlled Clear description of
inclusion and exclusion
criteria. Participants
excluded after randomisation
(n = 14)
Lobo et al. 2-arm RCT. Adequate random Patients (n = 21) undergoing
(2002) allocation concealment elective hemicolectomy and
sigmoidectomy for cancer
Clear description of inclusion
and exclusion criteria. Patients
excluded after randomisation
(n = 1)
Lu et al. 2-arm RCT. Adequate Patients (n = 40) undergoing
(2004) random allocation elective colorectal cancer
concealment. surgery
Double-blinded. Clear description
Placebo-controlled of inclusion and exclusion
criteria
MacKay et al. 2-arm RCT. Adequate Patients (n = 80) undergoing
(2006) random allocation elective colorectal resection
concealment. with primary anastomosis
Blinded Clear inclusion and exclusion
criteria. Patients excluded after
randomisation (n = 11)
Matros et al. 3-arm RCT. Adequate Patients (n = 66) undergoing
(2006) random allocation elective partial colectomy due
24,23,NursingClinicalofJournal 44–
(1) Probiotics (n = 50). Time to first defecation Powered. MBP
Pre- and postoperative (<0 05) was shorter in the
probiotic treatment probiotic group. No
(2) Placebo control significant differences
(n = 50). Pre- and between groups in terms
postoperative oral feeding of LOS
with placebo
(1) Standard (n = 10). LOS (p = 0 001), time to Results not reported for
Standard fluid therapy, first flatus (p = 0 001) and everyone who entered the
generally 3L water and time to first defecation trial. Outcome assessors
154 mmol sodium (p = 0 001) were shorter blind to treatment status.
(2) Restricted (n = 10). in the intervention group Powered. MBP except
Usually 2L water and prior to right
77 mmol sodium hemicolectomy
(1) Pentoxifylline (PTX) Time to first flatus was Unclear whether the
(n = 20). Received PTX shorter in the PTX group groups were treated
I.V. 30 minutes. before (p = 0 0002). No identically. Withdrawals
surgery significant difference not mentioned
(2) Control (n = 20). between the groups in
Received the same volume terms of LOS
saline drip
(1) Standard (n = 32). No significant differences Results not reported for
Received 1 l 0∙9% saline between the groups in everyone who entered the
and 2 l 5% dextrose per terms of LOS, or time to trial. Underpowered. MBP
day I.V., until POD 3 first flatus or bowel prior to left-sided surgery
(2) Restricted (n = 37). movement
Received no intravenous
fluids from POD 1
(1) Bracelet (placebo) No significant difference Attempt at blinding
(n = 23). Acupressure between the groups in participants and

concealment. to colorectal cancer or benign bracelet worn on the wrist terms of LOS, or time to healthcare providers.
Placebo-controlled conditions for 45 minutes three times first flatus, bowel Underpowered
Sons&WileyJohn2013© d

Clear description of inclusion a day movement or defecation

and exclusion criteria (2) Gum chewing (n = 22).
Chewed gum for 45
minutes three times a day
(3) Control (n = 21).
Standard of care
Lt
 Review
Journal
2013© Table 3 (Continued)

Author (year) Method Participants Intervention Outcomes Limitations/Notes

,NursingClinicalof ,23 44–24
Sons&WileyJohn Ltd

McCormick 2-arm RCT. Mentions Patients (n = 88) undergoing (1) Gum chewing (n = 53). LOS (p = 0 029) and time Very brief description of
et al. (2005) random allocation but elective colon resection Chewed one stick of gum to first bowel movement methods and results.
no description given Unclear description of for 15 minutes (p = 0 047) were shorter Withdrawals not
inclusion and exclusion criteria (2) Control (n = 35). No in the intervention group mentioned. Unclear
gum chewing for laparoscopic whether the groups were
colectomy patients. No treated identically
significant differences
between the gum chewing
group and the control arm
for patients undergoing
open colectomy
Noblett et al. 3-arm RCT. Adequate Patients (n = 36) undergoing (1) Water (n = 11). No significant difference in Results not reported for
(2006b) random allocation elective colorectal resections Received 800 mls of time to first flatus, everyone who entered the
concealment Clear description of inclusion water the night before although there was a trial. Mentions blinded
and exclusion criteria. Participants surgery and 400 mls trend towards earlier healthcare providers in
excluded after randomisation three hours before return in the carbohydrate the water and
(n = 1) induction of anaesthesia group compared with the carbohydrate groups, but
(2) Carbohydrate (n = 12). fasting group (p = 0 3) no description given
Received Precarb. and water group

Facilitating early recovery of bowel motility after colorectal surgery

dissolved in 800 mls of (p = 0 13). Reduced LOS
water the night before when comparing the
surgery and Vitajoule carbohydrate (p = 0 019)
dissolved in 400 mls of group and the water
water three hours before group. A trend towards
induction of anaesthesia shorter LOS when
(3) Fasting (n = 12). comparing the
Fasting from midnight the carbohydrate (p = 0 06)
night before surgery group and the fasting
group
Noblett et al. 2-arm RCT. States Patients (n = 108) undergoing (1) Intervention (n = 51). LOS was shorter Results not reported for
(2006a) random allocation but elective colorectal resection Colloid boluses based on (p = 0 005) in the everyone who entered the
no description given. Clear description of inclusion the assessment of an intervention group. No trial. Underpowered
Blinded and exclusion criteria. Patients oesophageal Doppler significant differences
excluded after randomisation probe between the groups in
(n = 5) (2) Control (n = 52). terms of time to first
Intraoperative fluid in a flatus or bowel movement
conventional manner
33
34

Å Wallström and G Hollman Frisman

Table 3 (Continued)

Author (year) Method Participants Intervention Outcomes Limitations/Notes

Quah et al. 2-arm RCT. Adequate Patients (n = 38) undergoing (1) Gum chewing (n = 19). No significant differences Three patients in the gum
(2006) random allocation elective resection for left-sided Chewed gum five minutes between the groups in chewing group did not
concealment colorectal cancer three times daily POD 1 terms of LOS, or time to receive the intervention.
Clear description of inclusion and (2) Control (n = 19). first flatus or first Powered. MBP
exclusion criteria Standard postoperative defecation
care
Schlachta et al. 2-arm RCT. Adequate Patients (n = 50) undergoing (1) Ketorolac (n = 22). Time to first flatus Results not reported for
(2007) random allocation elective laparoscopic colon Received ketorolac I.V. (p < 0 001) was shorter in everyone who entered the
concealment. resection every six hours for the ketorolac group. trial. Divergent numbers
Double-blinded. Clear description of inclusion 48 hours There was no significant for withdrawals.
Placebo-controlled and exclusion criteria. (2) Control (n = 20). difference between the Underpowered. MBP
Participants excluded after Received saline placebo groups in terms of LOS
randomisation (n = 8) I.V. on the same schedule
Schuster et al. 2-arm RCT. Adequate Patients (n = 34) undergoing (1) Gum chewing (n = 17). LOS (p = 0 01) and time Withdrawals not
(2006) random allocation sigmoid colon resection due Chewed gum three times to first bowel movement mentioned. Participants
concealment to cancer or recurrent a day, from POD 1 until (p = 0 04) were shorter in not treated identically.
diverticular disease oral intake the intervention group. Brief description of
Unclear description of (2) Control (n = 17). No Time to first flatus was methods
inclusion and exclusion criteria gum chewing also shorter in the
intervention group, but
the difference was not
significant (p = 0 05)
Sim et al. 2-arm RCT. Adequate Patients (n = 79) undergoing (1) Valdecoxib (n = 40). Time to first bowel sound
(2007) random allocation elective colorectal resection Received valdecoxib (p = 0 046), time to first
concealment. Clear description of inclusion orally one hour – <3 h flatus (p = 0 003) and
Double-blinded. and exclusion criteria before surgery. Doses time to first bowel
Placebo-controlled were administered at movement (p = 0 041)
24 hours intervals after were shorter in the
24,23,NursingClinicalofJournal 44–

the initial dose (up to intervention group. LOS

120 hours) (p = 0 009) was also
Sons&WileyJohn2013© d

(2) Control (n = 39). shorter in the intervention

Received placebo at the group
same intervals
Lt
 Table 3 (Continued)
Journal
2013©
Author (year) Method Participants
Swenson et al. 2-arm RCT. Adequate Patients (n = 45) undergoing
,NursingClinicalof ,23 44–24
Sons&WileyJohn Ltd
(2010) random allocation elective colon resection
concealment Clear description of inclusion
and exclusion criteria. Patients
excluded after randomisation
(n = 3)
van Bree et al. 4-arm RCT. Adequate Patients (n = 93) undergoing
(2011) random allocation elective segmental colectomy
concealment for adenocarcinoma or adenoma
without evidence of metastatic
disease
Clear description of inclusion
and exclusion criteria.
Patients excluded after
randomisation (n = 22)
Wakeling et al. 2-arm RCT. Adequate Patients (n = 134) undergoing
(2005) random allocation elective or semi-elective
concealment. colonic surgery
Blinded Clear description of inclusion
and exclusion criteria.
Participants excluded after
randomisation (n = 6)
Wongyingsinn 2-arm RCT. Adequate Patients (n = 62) undergoing
et al. (2011) random allocation elective laparoscopic
concealment colorectal resection
Clear description of inclusion
and exclusion criteria. Patients
excluded after randomisation
(n = 2)
35
Review
Intervention Outcomes Limitations/Notes
(1) Lidocaine (n = 22). No significant differences Results not reported for
Received an I.V. lidocaine between the groups in everyone who entered the
infusion terms of LOS, or time to trial. A higher dose of
(2) Epidural (n = 20). first flatus or bowel lidocaine was given to
Received a thoracic movement half of the participants in
epidural with bupivacaine the lidocaine group.
and hydromorphone Powered
(1) Laparoscopy/fast track LOS (p = 0 017) and time Results not reported for
(n = 18). Followed a fast- to first defecation everyone who entered the
track protocol (p = 0 042) were shorter trial. Received laxatives
(2) Laparoscopy/standard in the fast-track groups POD 1. Unclear whether
(n = 17). Followed a than in the conventional the groups were treated
conventional care care groups identically. Unclear
programme whether the patients were
(3) Open/fast track analysed in the groups
(n = 18). Followed a they were originally
fast-track protocol allocated to. Powered
(4) Open/standard
(n = 18). Followed a
conventional care
Facilitating early recovery of bowel motility after colorectal surgery
programme
(1) Doppler-guided fluid LOS (p = 0 031) and time Results not reported for
therapy (n = 64). to first defecation everyone who entered the
Received 250 ml boluses (p = 0 014) were shorter trial. Powered. MBP
of colloid solution until in the intervention group.
the stroke volume failed No significant difference
to rise by 10% and/or the between the groups in
CVP rose by 3 mmHg or terms of time to first
more flatus
(2) Control (n = 64). Used
CVP to guide I.V. fluid
treatment. CVP was kept
between 12–15 mmHg
(1) Thoracic epidural No significant differences Results not reported for
catheter (TEA) (n = 30). between the groups in everyone who entered the
Received TEA with terms of LOS, or time to trial. Powered. MBP prior
bupivacaine and first flatus or bowel to sigmoid and rectal
morphine movement surgery
(2) Intravenous lidocaine
(IL) (n = 30). Received
IL via a PCA device
36

Å Wallström and G Hollman Frisman

Table 3 (Continued)

Author (year) Method Participants Intervention Outcomes Limitations/Notes

Wu et al. 2-arm RCT. Mentions random Patients (n = 40) undergoing (1) Clonidine (n = 20). Time to first flatus Withdrawals not
(2004) allocation but no description given. elective colorectal surgery Received PCEA with (p < 0 001) was shorter in mentioned
Double-blinded. Unclear description of inclusion morphine and clonidine in the intervention group.
Placebo-controlled and exclusion criteria ropivacaine No significant difference
(2) Control (n = 20). between groups in terms
Received PCEA with of LOS
morphine and ropivacaine
Xu et al. 2-arm RCT. Adequate random Patients (n = 40) undergoing (1) Flurbiprofen axetil Time to first flatus Powered. MBP
(2008) allocation concealment. elective surgery for colorectal (n = 20). Received (p = 0 01) and time to
Double-blinded. cancer flurbiprofen axetil I.V., first bowel movement
Placebo-controlled Clear description of inclusion 30 minutes before and (p = 0 008) were shorter
and exclusion criteria six hours after skin in the intervention group
incision
(2) Control (n = 20)
Received intralipid I.V. as
placebo
Zingg et al. 2-arm RCT. Adequate random Patients (n = 200) undergoing (1) Bisacodyl (n = 83). Time to gastrointestinal Results not reported for
(2008) allocation concealment. open or laparoscopic Received bisacodyl orally recovery (p = 0 007) and everyone who entered the
Double-blinded. colorectal resection twice daily. The first defecation (p = 0 001) trial. Powered. MBP prior
Placebo-controlled Clear description of inclusion intervention period started was shorter in the to laparoscopic surgery
and exclusion criteria. one day before surgery intervention group. No
Participants excluded after and ended on POD 3 significant difference
randomisation (n = 31) (2) Control (n = 86). between the groups in
Received identical placebo time to first flatus
capsules
24,23,NursingClinicalofJournal 44–

MBP, mechanical bowel preparation; LOS, length of stay; PCA, patient-controlled analgesia; PCEA, patient-controlled epidural analgesia; POD, postoperative day; RCT, randomised controlled trial.
Sons&WileyJohn2013© d
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Review
best quality assessment of the six showed no significant
differences between the groups.
Fluid therapy
Restricted fluid therapy
Postoperative fluid therapy was investigated in three studies (n =
121) (Lobo et al. 2002, MacKay et al. 2006, Holte et al. 2007),
where a standard postoperative fluid therapy was compared with
a restricted fluid therapy. In two studies (n = 101) (MacKay et al.
2006, Holte et al. 2007), no sig-nificant differences in
gastrointestinal motility were found between the groups.
However, by reducing both sodium and fluid, Lobo et al. (2002)
found significantly shorter times to first passage of flatus and
first defecation, as well as shorter hospital stays. The three
studies were assessed and shown to be comparative.
Doppler-guided fluid therapy
Two blinded studies (n = 231) (Wakeling et al. 2005, Noblett et
al. 2006a) were identified which compared stan-dard fluid
therapy with the use of an oesophageal Doppler (monitoring of
cardiac output) as a guide in intraoperative fluid therapy.
Random allocation concealment was men-tioned but not
described in one of the studies (n = 128) (Noblett et al. 2006a).
No reduction in time to first passage of flatus was reported in the
intervention groups, although length of hospital stay was
significantly shorter in both studies. First defecation occurred
significantly earlier in the intervention group, but was only
measured in one study (Wakeling et al. 2005).
Laxative
Bisacodyl
One double-blinded, placebo-controlled study (n = 169) (Zingg
et al. 2008) was identified which investigated pre-and
postoperative use of bisacodyl. First defecation occurred
significantly earlier in the intervention group, but there was no
significant reduction in time to first passage of flatus or tolerance
of solid food.
Multimodal treatment
Multimodal protocols
Three studies (n = 237) (Khoo et al. 2007, Ionescu et al. 2009,
van Bree et al. 2011) have compared multimodal/fast-track care
to conventional care. The study protocols differed in a number of
ways. Two of the studies (n = 167) (Ionescu et al. 2009, van Bree
et al. 2011) included preoperative
© 2013 John Wiley & Sons Ltd Journal
of Clinical Nursing, 23, 24–44
Facilitating early recovery of bowel motility after colorectal surgery
information and carbohydrate loading in their protocol. One of
the study protocols (n = 96) (Ionescu et al. 2009) involved
neither bowel cleaning/enema nor perioperative fluid restric-tion.
Postoperative prokinetics were used in two of the stud-ies (Khoo
et al. 2007, Ionescu et al. 2009), while the third study used
laxatives. All three studies were powered, but only one (Ionescu
et al. 2009) reached the estimated level of power. All studies
showed a significantly reduced length of stay in hospital and a
shorter time to restoration of bowel functions, measured in two
of the studies (Khoo et al. 2007, van Bree et al. 2011) as time to
first defecation.
Methods to decrease the use of opioids
Flurbiprofen
One double-blinded, placebo-controlled study (n = 40) focused
on the effect of intravenous flurbiprofen (NSAID) (Xu et al.
2008). All participants received analgesia (morphine, ropivacaine
and sodium chloride) through a thoracic epidural catheter.
Flurbiprofen was administrated pre- and postoperatively and led
to a significantly reduced time to first passage of flatus.
Ketorolac
The effect of intravenous ketorolac (NSAID) was investi-gated
in three double-blinded studies (n = 218) (Chen et al. 2005,
2009, Schlachta et al. 2007). Two of the studies (n = 176) (Chen
et al. 2005, 2009) compared the effect of ketorolac and morphine
administered through a PCA device with the effect of morphine
administered in the same way. It was unclear whether the
participants in the study by Chen et al. (2005) (n = 74) were
treated identically, other than for named interventions. Both
studies showed a signifi-cantly reduced time to bowel
movements in the ketorolac group, but time to first flatus was
only significantly shorter in one study (Chen et al. 2009). Length
of hospital stay was measured in one of the studies (Chen et al.
2005), but the difference was not significant. The third study
(Schlachta et al. 2007) was placebo-controlled except for the
blinding and evaluated the effect of ketorolac administered
intrave-nously after laparoscopic surgery. All participants
received intravenous morphine administrated through a PCA
device. The quality of this study was assessed as low for reasons
listed in Table 3. The study was powered, but was a long way
from the estimated level of power. The overall inci-dence of
anastomotic leaks in this study was 11%, com-pared with 18%
among the participants who received ketorolac. Passage of first
flatus occurred significantly earlier in the intervention group, but
the intervention did not lead to a reduction in length of hospital
stay.
37
Å Wallström and G Hollman Frisman
Valdecoxib
Participants in a blinded and placebo-controlled study (n = 69)
(Sim et al. 2007) received valdecoxib (NSAID) orally. All
participants received intravenous morphine administered through
a PCA device. One dose was given prior to surgery, and several
doses were administered post-operatively. Valdecoxib generated
significantly earlier pas-sage of flatus, defecation and bowel
movement compared with placebo treatment. The length of
hospital stay was also significantly reduced.
Intravenous lidocaine
The use of intravenous lidocaine was examined in three studies
(n = 162) (Herroeder et al. 2007, Swenson et al. 2010,
Wongyingsinn et al. 2011). Two studies (n = 102) (Swenson et
al. 2010, Wongyingsinn et al. 2011) evaluated the effect of
intravenous lidocaine versus thoracic epidural with bupivacaine.
The effect of lidocaine on time to first passage of flatus, first
bowel movements and length of hos-pital stay was not
significant in either study. The third study was double-blinded
and placebo-controlled, and focused on the effect of intravenous
lidocaine compared with placebo. The intervention led to
significantly earlier bowel movement, earlier passage of flatus
and reduced length of hospital stay. The three studies were
assessed and shown to be comparative.
Ropivacaine
The use of local anaesthetics such as ropivacaine was exam-ined
in one study (n = 42) (Beaussier et al. 2007). Ropiva-caine was
administered as a continuous wound infusion as soon as the
surgical wound was closed. The study was double-blinded and
placebo-controlled. Time to first pas-sage of flatus did not differ
significantly between the groups, but the intervention resulted in
significantly reduced time to first defecation and reduced length
of hospital stay.
Intrathecal morphine
The effect of intrathecal morphine on recovery in older patients
was analysed in a double-blinded, placebo-controlled study (n =
52) (Beaussier et al. 2006). No significant reductions were seen
in time to first passage of flatus or length of hospital stay.
Epidural clonidine
A double-blinded, placebo-controlled study (n = 40) (Wu et al.
2004) was identified which evaluated the effect of epidural
Clonidine (adrenergic agonist). The study lacked descriptions of
how blinding of healthcare providers was established, inclusion
and exclusion criteria, and descriptions
38
of random allocation concealment. Time to first passage of flatus
was significantly shorter in the intervention group, but the
intervention did not lead to a reduction in length of hospital stay.
Spinal analgesia
One study (n = 91) (Levy et al. 2011) compared spinal, epi-dural
and intravenous (patient-controlled) analgesia. Spinal analgesia
resulted in significantly earlier restoration of bowel function
compared with epidural and patient-controlled analgesia. Both
spinal and patient-controlled analgesia reduced the length of
hospital stay significantly compared with epidural analgesia.
Other pharmacological treatment
Choline citrate
Choline citrate is a supplement in the vitamin B complex group.
One study (n = 107) (Herzog et al. 2011) investi-gated the effect
of choline citrate on patients with POI 48 hours after surgery.
The study was placebo-controlled, was double-blinded and
stated that randomisation was performed postoperatively,
although no description was given. No significant results were
found regarding time to first passage of flatus, time to first
defecation or length of hospital stay.
Intravenous pentoxifylline
One study (n = 40) (Lu et al. 2004) analysed preoperative
intravenous pentoxifylline (cytokine inhibitors) treatment as an
intervention for improving the recovery of bowel functions. The
study was double-blinded and placebo-controlled. Whether the
groups were treated identically after the operation is unclear. The
intervention resulted in significantly earlier passage of flatus, but
no reduction in length of hospital stay.
Nonpharmacological interventions
Muscle relaxation and guided imagery
Psychological interventions such as muscle relaxation ther-apy
and guided imagery were compared to standard care in a
blinded, age-stratified study (n = 60) (Haase et al. 2005). There
was no reduction in time to first passage of flatus, first bowel
movement or length of hospital stay in the inter-vention group.
Discussion
The review revealed that recovery of gastrointestinal motil-ity
was accelerated with multimodal treatment, probiotics,
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 24–44
Review
pentoxifylline, flurbiprofen, valdecoxib, ketorolac, cloni-dine,
ropivacaine and spinal analgesia. Nutrition through early feeding
did not, in itself, lead to faster gastrointestinal recovery, but
when it was included in a simplified pathway, the difference was
found to be significant compared with standard care. Intravenous
lidocaine was found to acceler-ate the return of gastrointestinal
motility, but the difference was not significant compared with
epidural analgesia. The effect of gum chewing, preoperative
carbohydrate loading, bisacodyl and Doppler-guided fluid
management was uncer-tain. Hence, the use of
nonpharmacological interventions, intrathecal morphine,
restricted fluid therapy and choline citrate did not lead to a
significant acceleration in bowel motility.
Three multimodal approaches were found to accelerate the
return of gastrointestinal motility (Khoo et al. 2007, Ionescu et
al. 2009, van Bree et al. 2011). The content of the optimal
multimodal protocol is constantly evolving as research results
support the introduction of new treatment strategies.
Unfortunately, compliance with evidence-based treatment
strategies is low, as seen in the survey conducted by Kehlet et al.
2006, which may influence patients nega-tively. However, there
is a gap in the literature regarding the current most optimal
composition of treatment proto-cols, and larger specific
multicentre studies are needed to obtain sustainable evidence.
Also, with an ageing popula-tion in mind, treatment protocols
should be properly adjusted for older patients with comorbidity.
This review revealed both beneficial and ineffectual inter-
ventions, suggesting that future studies that focus on the
composition of multimodal protocols will be of great importance.
The latest and most comprehensive review, written by the
Enhanced Recovery After Surgery (ERAS) group, was published
in 2009 and presented a model for optimal perioperative care in
colorectal surgery (Lassen et al. 2009).
Multimodal treatment is often studied from a medical point of
view and lacks a patient perspective, which is remarkable as
multimodal regimes are demanding for patients in a fragile
situation. Patient empowerment plays a key role during
postoperative recovery (Fearon et al. 2005). Norlyk and Harder
(2009) describe how the patient struggles against the body to
overcome the dilemma, whether by listening to the body’s
signals or by following the regimen, which might explain why
protocol compliance is low in the immediate postoperative phase
(Maessen et al. 2007). To be able to mobilise energy to carry out
the regimen, patients need support from professionals, involv-ing
trust and a sense of security (Norlyk & Harder 2009). A common
concern voiced by critics of fast-track care is
© 2013 John Wiley & Sons Ltd Journal
of Clinical Nursing, 23, 24–44
Facilitating early recovery of bowel motility after colorectal surgery
whether it increases rates of complication and readmission,
which would contribute to increased hospitalisation costs and
longer hospital stays. Two studies evaluated the read-mission
rate after fast-track care compared with standard care, but did not
find any significant differences between the treatments (Gouvas
et al. 2009, Teeuwen et al. 2011). However, successful early
discharge within a fast-track programme demands well-
structured postdischarge follow-up, including well-defined ways
for patients to contact their healthcare providers for advice
(Taylor & Burch 2011).
Interventions that resulted in earlier restoration of gastro-
intestinal bowel motility were not always associated with a
reduced stay in hospital (Lu et al. 2004, Wu et al. 2004, Chen et
al. 2005, Schlachta et al. 2007, Liu et al. 2011). Possible reasons
for this may be inadequate pain manage-ment, wound infections
or a negative electrolyte balance. A study by Aarts et al. (2012)
identified five factors associated with a reduced stay in hospital.
The study was based on 18 ERAS components and concluded
that preoperative counsel-ling, a laparoscopic approach,
intraoperative fluid restric-tion, early intake of clear fluids and
early removal of the urinary catheter resulted in a hospital stay of
five days.
Reduced gut motility is a well-known side effect of opi-oids
(Bueno & Fioramonti 1988), which explains the value of
restricted opioid use during the postoperative phase. This review
indicates that nonsteroidal anti-inflammatory drugs (NSAID)
such as flurbiprofen and ketorolac might be helpful in restricting
opioid use (Chen et al. 2005, 2009, Schlachta et al. 2007, Sim et
al. 2007). Although the use of valdecoxib (Sim et al. 2007) led to
earlier resto-ration of gastrointestinal bowel motility,
cardiovascular toxicity meant that the drug was withdrawn from
the market.
Epidural analgesia is considered to be effective in pain
management in colorectal surgery and has a positive impact on
surgical stress response (Lassen et al. 2009). The com-parison by
Levy et al. (2011) between PCA, spinal analge-sia and epidural
analgesia showed spinal analgesia to be preferable in
laparoscopic colonic surgery. More research is needed to
evaluate the effects of spinal analgesia in open colorectal
resections.
Several studies have concluded that postoperative gum
chewing is safe, inexpensive and easy to implement. How-ever,
this review questioned the effect of gum chewing on the early
restoration of gastrointestinal functions, as many of the studies
were of poor quality. On the other hand, a meta-analysis of the
same studies by Parnaby et al. (2009) concluded that
postoperative gum chewing accelerates the restoration of
gastrointestinal functions. Nevertheless, the
39
Å Wallström and G Hollman Frisman
authors argued that the findings were of limited value as the
studies were significantly heterogeneous.
In this review, passage of flatus, defecation and bowel
movement were used as outcome measures to evaluate gas-
trointestinal bowel motility. Passage of flatus and defeca-tion
have been defined as indicators of restored bowel motility after
surgery (Delaney et al. 2006). Bowel move-ment, on the other
hand, may be mistaken for movement in the small bowel. All
three outcome measures were important, although it could be
argued that passage of flatus was the most reliable. The value of
bowel movement as an outcome measure should be questioned,
if used solely. Where they occur soon after colorectal surgery,
they may be due to small bowel activity and therefore do not
necessarily indicate recovery of gastrointestinal motil-ity (Huge
et al. 2000). However, used in a context of other factors, bowel
movement may be helpful as an out-come measure when
evaluating recovery of bowel motility. A consensus on accurate
outcome measures would be useful in improving the validity of
studies that measure gastrointestinal recovery.
A number of studies made use of preoperative mechanical
bowel preparation. According to Jung et al. (2007), mechanical
bowel preparation causes discomfort in patients and prolongs
POI. This implies that, in the studies that were reviewed,
mechanical bowel preparation may have had an impact on the
outcome measures for gastrointestinal recov-ery. The pre- and
postoperative use of bisacodyl led to ear-lier postoperative
defecation, but it is unclear whether the gastrointestinal function
was accelerated, as there was no reduction either in the time
taken to restore passage of flatus or the time taken to restore
tolerance of solid food.
Psychological interventions such as muscle relaxation therapy
and guided imagery did not restore gastrointestinal functions
more quickly, although 79% of participants in the study thought
they had benefited from listening to the tapes and a majority
stated that they would recommend it to others (Haase et al.
2005). This indicates that a psycho-logical effect played an
important role in their postopera-tive recovery, at least
subjectively.
The results of this review indicate that restricted fluid therapy
does not result in faster gastrointestinal recovery, but that
restricted fluid therapy with less sodium does. A meta-analysis
to compare restricted fluid therapy, stan-dard fluid therapy and
guided fluid therapy (oesophageal Doppler) did not show any
significant differences in recov-ery of bowel functions or in the
length of stay in hospital, but concluded that the risk of cardio
and pulmonary com-plication makes restricted fluid therapy
more favourable than standard fluid therapy (Rahbari et al.
2009). Five of
40
the nine studies subjected to the meta-analysis were included in
this review. A recent study evaluating the effects of restricted
perioperative fluid therapy confirmed that the result for length of
stay in hospital was not signifi-cant (Abraham-Nordling et al.
2012).
The studies reviewed in the analysis consisted almost solely of
elective surgeries, although a considerable amount of colorectal
surgery is acute. Future research should evalu-ate whether the
interventions mentioned above have the same effect in acute care
surgery and, if they do not, how they could be modified to aid a
faster recovery.
Some methodological issues require consideration and may
limit the conclusions drawn from this review. The lit-erature
search was narrowed to the last 10 years of research, but the
RCT limit had the biggest impact on the search response. The
RCT limit was used as RCTs pro-duce the highest levels of
evidence (Cochrane Consumer Network 2010). The review only
involved studies written in English and may therefore have
excluded important studies (publication bias) written in other
languages. The studies that formed part of the review were
small, with a mean sample size of 66 participants, ranging from
19–169 participants. Taken alongside the fact that seven studies
were underpowered, the differences between groups have to be
bigger to be considered statistically significant.
A quality assessment of all the studies focused on selec-tion
bias at trial entry, around the time of treatment, during
assessment of outcomes or at the analysis stage. Individual
components were used to show the importance of quality, as
suggested by Juni et al. (2001), rather than a quality scale. This
may have introduced a degree of subjectivity into the author’s
interpretation, and an attempt was made to reduce this potential
bias by asking a second reviewer to conduct an independent
quality assessment of the studies.
The blinding was difficult to assess in some of the studies, as
there was often no description of the procedure, even though the
authors mentioned that blinding had been used. The assessment
of whether the groups had been treated iden-tically, other than
for named interventions, was also prob-lematic, as postoperative
care descriptions were not specific in a number of studies. A
well-described and well-executed blinding procedure, along with
stringent identical treatment of groups, is essential if
performance bias is to be avoided and internal validity is to be
preserved (Juni et al. 2001).
Most of the studies stated that the results were analysed on an
intention-to-treat basis, but only 14 studies applied a strict
definition of intention to treat (Gunnarsson 2002). According to
Roe (2007), there is a risk of overestimating the effects of
treatment if a study does not analyse all the subjects.
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 24–44
Review Facilitating early recovery of bowel motility after colorectal surgery

Conclusion
Multimodal treatment, where the use of morphine is restricted,
seems to be the best way of accelerating the recovery of
gastrointestinal bowel motility. More studies are required to
examine the content of multimodal proto-cols and how patients
experience them. Future research should also focus on how
multimodal protocols can be optimised for both elective and
acute colorectal surgery.
Relevance to clinical practice
Early restoration of bowel functions leads to faster overall
postoperative recovery, which may ease patient discomfort and
decrease hospitalisation costs.
Acknowledgements
The authors would like to express their thanks to the staff at the
Faculty of Health Science Library at Linköping University for
their help and encouragement.
Contributions
Study design: ÅW, GHF; data collection and analysis: ÅW,
GHF and manuscript preparation: ÅW, GHF.
Conflict of interest
There are no conflicts of interest to declare.

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