Risk Factors for Postoperative Ileus Following Spine Surgery: A Systematic Review With Meta-Analysis

Abstract

Study design

Systematic review and meta-analysis

Objectives

Postoperative ileus (POI) can negatively impact patient recovery and surgical outcomes after spine surgery. Emerging studies have focused on the risk factors for POI after spine surgery. This study aimed to review the available literature on risk factors associated with POI following elective spine surgery.

Methods

Electronic databases were searched to identify relevant studies. Meta-analysis was performed using random-effect model. Risk factors for POI were summarized using pooled odds ratio (OR) with 95% confidence intervals (CI).

Results

Twelve studies were included in the present review. Meta-analysis demonstrated males exhibited a higher risk of POI than females odds ratio (OR, 1.76; 95% CI, 1.54-2.01). Patients with anemia had a higher risk of POI than those without anemia (OR, 1.48; 95% CI, 1.04-2.11). Patients with liver disease (OR, 3.3; 95% CI, 1.2-9.08) had a higher risk of POI. The presence of perioperative fluid and electrolyte imbalances was a predictor of POI (OR, 3.24; 95% CI, 2.62-4.02). Spine surgery involving more than 3 levels had a higher risk of POI compared to that with 1-2 levels (OR, 1.82; 95% CI, 1.03-3.23).

Conclusions

Male sex and the presence of anemia and liver disease were significant patient factors associated with POI. Perioperative fluid and electrolyte imbalance and multilevel spine surgery significantly increased the risk of POI. In addition, through this comprehensive review, we identified several perioperative risk factors associated with the development of POI after spine surgery.

Keywords

postoperative ileus spine surgery anemia liver disease risk factor

Introduction

Postoperative ileus (POI) is characterized by the impairment of gastrointestinal (GI) motility after surgery under anesthesia.^1-3 The common symptoms of POI are postoperative nausea and vomiting, inability to tolerate diet, failure to pass gas or stool, and abdominal distension for more than 3 days.² Although abdominal surgery is known to be the most common cause of POI, POI is also observed as an adverse event after other types of surgery, including cardiovascular,⁴ urological,⁵ gynecology,⁶ and orthopedic surgeries.⁷ In addition, perioperative anesthetics and postoperative analgesics can compound the development of POI.^8,9 Development of POI causes discomfort to the patient and increases patient recovery time, length of hospital stay, and financial burden.^1,3 Patients with POI are at an increased risk of developing deep venous thrombosis, myocardial infarction, sepsis, and aspiration pneumonia.¹⁰ GI motility is well controlled by homeostasis between the nervous and hormonal systems.^11,12 Spinal problems are known to elicit some digestive problems preoperatively,¹³ and spine surgeries inevitably manipulate the spinal cord or spinal nerves, which can result in bowel movement disorder postoperatively.¹⁴

With aging, GI function and bowel motility decreases¹⁵ and an increasing number of elderly patients with degenerative spinal diseases require spine surgery.¹⁶ Accordingly, the spine surgeries have increased by a large number in the past 20 years.^17,18 Although POI is not considered a direct surgical complication, POI does negatively affect patient recovery and surgical outcome.^10,19,20 The pathogenesis of POI following spine surgery is multifactorial, encompassing surgical stress, secretion of inflammatory mediators, imbalance of electrolyte or fluid status, perioperative anesthesia and analgesia,^1,21 and direct intraoperative manipulation of the neural structures.^19,20,22,23 Emerging studies have focused on investigating the risk factors for POI in patients undergoing spine surgery.^24-26 A recent published meta-analysis showed several risk factors associated with POI following spinal fusion surgery.²⁷ However, the results were based on univariate analysis, which would be greatly impacted by confounders and there are potential patient and perioperative factors associated with POI not clarified in the literature, such as gastroesophageal reflux disease (GERD) or fluid and electrolyte imbalances. Hence, we sought to perform a comprehensive review to integrate the available literature and update the risk factor profile associated with POI after spine surgery with a more robust statistical method.

Methods

We conducted a systematic review and meta-analysis in accordance with the Cochrane Handbook for Systematic Reviews of Interventions²⁸ and reported the results according to the Meta-analysis Of Observational Studies in Epidemiology reporting guideline (eMethod 1). The study was registered with PROSPERO (CRD42022358218).

Search Strategy and Study Selection

MEDLINE, Embase, and Cochrane Library databases were searched from inception until November 2022 for relevant articles without language restriction. The search strategy is summarized in eMethod 2.

Inclusion Criteria

Articles meeting the following criteria were included: prospective and/or retrospective cohort and case-control studies that reported POI following spine surgery; and articles reporting at least 1 risk factor for POI. Review articles and conference abstracts were excluded from our review.

Data Extraction

Two investigators (Y.C. and C.E.W.) independently extracted the following baseline and outcome data: first author’s name, study period, inclusion and exclusion criteria, sample size, POI definition, and significant risk factors for POI.

Statistical Analysis

Risk factors for POI with multivariate analysis reported in more than 2 studies were included in the meta-analysis. Statistical analyses were performed using functions available in the metafor package in the R software environment²⁹ (eMethod 3). Effect sizes were presented with corresponding 95% confidence interval (CI).³⁰ Heterogeneity was assessed using I² statistics proposed by Higgins and Thompson, with I² < 25%, 25% < I² < 50%, and I² > 50% indicating low, moderate, and high heterogeneity, respectively.³¹

Appraisal of the Included Studies

Two investigators (Y.C. and H.H.H.) independently completed a critical appraisal of the included literature using the National Heart, Lung, and Blood Institute tool for case-control studies.³²

Results

Study Selection

Our search strategy identified 3343 references from the Cochrane Library, Embase, and MEDLINE electronic databases. After screening titles and abstracts, we excluded duplicates (n = 550) and irrelevant references (n = 2768). The remaining 25 studies were retrieved for a full-text review, 12 of which were included in this review^{19,20,22-26,33-37} (Figure 1).

Figure 1.

PRISMA diagram. We initially extracted 3343 potential references. Eventually, 12 studies fulfilled the eligibility criteria, and were included for meta-analysis. (PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

Characteristics of the Included Studies

A total of 295,292 patients were included (POI = 13,088, no POI = 282,204) from studies that took place from 2002 to 2019. Nine studies reported institutional data,^{19,22,24‒26,33,34,36,37} and the remaining 3 reported results from a nationwide database.^20,23,35 3 studies included patients undergoing spine surgery for spinal deformity,^23,24,36 while the others included patients undergoing several types of spine surgery without a specified etiology. The definitions of POI and the significant risk factors for the development of POI are summarized in Table 1.

Table 1.

Characteristics of Included Studies.

Study	Database	Inclusion Period	Inclusion Criteria	Exclusion Criteria	POI Definition	Sample Size	Significant Risk Factor for POI in Multivariate Analysis
Ohba 2020	Single institution	2012-2019	Surgery for adult de novo degenerative spinal deformity	A history of abdominal surgery, a rounded back because of Parkinson’s disease	≥2 symptoms: Anorexia, nausea, vomiting, failure to pass stool or flatus for 3 days, and abdominal distension or radiographic findings of paralytic ileus within 30 days after spinal surgery.	POI: 25	Lateral and posterior combined approach, higher degree of kyphosis
Ohba 2020	Single institution	2012-2019	Surgery for adult de novo degenerative spinal deformity			No POI: 119
Yilmaz 2022	Single institution	2013-2017	Posterior spine surgery	Surgery in a different hospital, minimally invasive technique, age <18 or >85	≥2 symptoms: Nausea and vomiting, inability to tolerate diet or failure to pass gas or stool during a 24-hour period with abdominal distension with radiological evidence	POI: 40	Surgical levels ≥3, lumbar spine surgery
Yilmaz 2022	Single institution	2013-2017	Posterior spine surgery			No POI: 80 (1:2 matched)	Surgical levels ≥3, lumbar spine surgery
Hendrickson 2022	Single institution	2017-2019	Open instrumented posterior fusion of thoracic and/or lumbar spine.	N/A	≥2 symptoms: Abdominal pain, distension or bloating, nausea or vomiting, absence of passing flatus or stool, or an inability to tolerate oral intake at any point after the completion of surgery	POI: 39	Post-op MME
Hendrickson 2022	Single institution	2017-2019		N/A		No POI: 379	Post-op MME
Park 2021	Single institution	2012-2019	Oblique lateral interbody fusion:	(1) History of irritable bowel syndrome (2) spine infection (3) prolonged bed rest (4) incomplete medical record.	≥2 symptoms at 72 hours postoperatively: (1) ongoing nausea or vomiting (2) the absence of flatus over last 24-hour period (3) inability to tolerate an oral diet over last 24-hour period, (4) abdominal distention (5) radiological confirmation	POI: 33	Inadvertent endplate fracture, intraoperative remifentanil, higher suction drainage amount
Park 2021	Single institution	2012-2019	Oblique lateral interbody fusion:			No POI: 427
Deng 2019	Single institution	2017-2018	Posterior thoraco-lumbar fusion surgery	Spinal trauma, infection or malignancy; opioid analgesics or prokinetic drug 2 weeks before the surgery; serious comorbidities, preoperative ileus.	Intolerance of an oral diet and missing bowel movements/passage of flatus or stool until POD 2	POI: 35	Longer surgical duration, PLIF, higher amount of blood loss, postoperative diet restriction
Deng 2019	Single institution	2017-2018	Posterior thoraco-lumbar fusion surgery			No POI: 391
Gifford 2019	Single institution	2013-2017	Thoracic and/or lumbar fusion surgeries	N/A	Over 48-hour absence of flatus/bowel movements, and intolerance of oral intake in conjunction with abdominal radiographic reports postoperatively	POI: 56	Surgical levels ≥3, intraoperative MME, liver disease
Gifford 2019	Single institution	2013-2017	Thoracic and/or lumbar fusion surgeries	N/A		No POI: 278	Surgical levels ≥3, intraoperative MME, liver disease
Bureta 2018	Single institution	2009-2014	Scoliosis surgery	Instrumentation removal or growing rod placement	Impairment of coordinated propulsive intestinal peristalsis occurring after surgery and lasting for more than 3 days.	POI: 15	Neuromuscular scoliosis.
Bureta 2018	Single institution	2009-2014	Scoliosis surgery	Instrumentation removal or growing rod placement		No POI: 95	Neuromuscular scoliosis.
Durand 2018	NIS	2010-2014	Spinal deformity surgery, age≥ 26, ≥4 levels fused; absence of codes of cancer, vertebral fracture, osteomyelitis, and for cervical fusion.	N/A	ICD-9-CM diagnosis code 560.1	POI: 4375	Male sex, anterior approach, ≥9 levels fused, electrolyte disorders, pathologic weight loss
Durand 2018	NIS	2010-2014		N/A	ICD-9-CM diagnosis code 560.1	NO POI: 55035
Horowitz 2018	Pearl-diver database	2005-2014	Age≥ 65, 1-2 level ALIF for lumbar degenerative disease	Spinal trauma, infection, or malignancy, other spinal fusion, revision fusion	ICD-9-CM diagnosis code 560.1	POI: 642	Perioperative fluid and electrolyte imbalance, male sex
Horowitz 2018	Pearl-diver database	2005-2014	Age≥ 65, 1-2 level ALIF for lumbar degenerative disease		ICD-9-CM diagnosis code 560.1	No POI: 12497	Perioperative fluid and electrolyte imbalance, male sex
Kiely 2016	Single institution	2012	Spinal fusion surgery	N/A	Prolonged ileus: Absence of flatus and/or passage of stool before POD 3, with radiographic confirmation	POI: 45	GERD, cumulative fluid support, positive fluid balance, intra-operative hydromorphone
Kiely 2016	Single institution	2012	Spinal fusion surgery	N/A	Recurrent ileus: Absence of flatus and/or passage of stool over 24 hours after the apparent resolution of POI before POD 3, with radiographic confirmation	No POI: 80 (1:2 match)
Fineberg 2014	NIS	2002-2009	ALF, PLF, circumferential lumbar fusion	Age< 18	ICD-9-CM diagnosis code 560.1	POI: 7741	Male, African American, ≥3 fusion levels, BMP use, alcohol abuse, anemia, lung disease, fluid or electrolyte disorder, pulmonary circulation disorder, weight loss
Fineberg 2014	NIS	2002-2009	ALF, PLF, circumferential lumbar fusion	Age< 18	ICD-9-CM diagnosis code 560.1	No POI: 212781
Al Maaieh 2014	Single institution	2006-2011	LLIF	N/A	Prolonged POI: Absence of flatus and/or passage of stool before POD 3	POI: 42	LLIF at L1–L2, Posterior
Al Maaieh 2014	Single institution	2006-2011	LLIF	N/A	Recurrent POI: Absence of flatus and/or passage of stool over 24 hours after the apparent resolution of POI before POD 3	No POI: 42 (1:1 matched)	Instrumentation, GERD

ALF, anterior lumbar fusion; ALIF, anterior lumbar interbody fusion, APLF; BMP, bone morphogenetic proteins; GERD, gastroesophageal reflux disease; ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification; LLIF, lateral lumbar interbody fusion; MME, milligram morphine equivalents; NIS, National inpatient sample; N/A, not applicable; PLF, posterior lumbar fusion; PLIF, posterior lumbar interbody fusion; POD, post-operative day; POI, post-operative ileus.

Patient Risk Factors

By pooling the multivariate analysis results from the 2 studies, we found that age was not a significant predictor for the development of POI (OR, 1.03; 95% CI, 1.00-1.06, I² = 0%, (e)Figure 1). Males exhibited a higher risk of POI than females (OR, 1.76; 95% CI, 1.54-2.01, I² = 55%, (e)Figure 2). Patients with anemia had a higher risk of POI than those without anemia (OR, 1.48; 95% CI, 1.04-2.11, I² = 35%, (e)Figure 3). Patients with liver disease (OR, 3.3; 95% CI, 1.2-9.08, I² = 0%, (e)Figure 4) had a higher risk of POI. Neither GERD (OR, 2.79.45; 95% CI, .76-10.3; I² = 80%, (e)Figure 5) nor chronic lung disease history (OR, 1.03; 95% CI, .65-1.61; I² = 61%, (e)Figure 6) were associated with POI. There was no difference in the risk of POI between patients with and without preoperative weight loss (OR, 1.76; 95% CI, .79-3.9, I² = 85%, (e)Figure 7). Smoking was not a risk factor for POI (OR, 1.57; 95% CI, .4-6.19, I² = 60%, (e)Figure 8).

Perioperative Risk Factors

The presence of perioperative fluid and electrolyte imbalances was a predictor of POI (OR, 3.24; 95% CI, 2.62-4.02, I² = 78%, (e)Figure 9). Spine surgery involving more than 3 levels was associated with a higher risk of POI compared to that with 1-2 levels (OR, 1.82; 95% CI, 1.03-3.23, I² = 61%, (e)Figure 10).

Appraisal of the Included Studies

The quality assessment of the included studies using the National Heart, Lung, and Blood Institute tool for case-control studies is summarized in eResult1. All of the included studies were defined as having a fair study quality due to certain risk of bias without a fatal flaw detected.

Discussion

Our analysis demonstrated that male sex, anemia, and liver disease were significantly associated with POI. In contrast, age, history of lung disease, GERD, preoperative weight loss, and smoking were not predictors of POI. As for perioperative risk factors, the present meta-analysis showed that the presence of fluid and electrolyte imbalance and multilevel spine surgery (≥3 levels) significantly increased the incidence of POI. The results were summarized in Table 2.

Table 2.

Summary of Findings of Meta-Analysis.

Outcome (POI Risk Factor)	No. of Studies	Or (95% CI)	I², %
Age	2	1.03 (1.00-1.06)	0
Gender (male)	4	1.76 (1.54 to 2.01)	55
Anemia	2	1.48 (1.04 to 2.11)	35
Liver diseases	2	3.3 (1.30 to 9.08)	0
GERD	4	2.79 (.76 to 10.3)	80
Chronic lung disease history	2	1.03 (.65 to 1.61)	61
Preoperative weight loss	3	1.76 (.79 to 3.90)	85
Smoking	2	1.57 (.40 to 6.19)	60
Fluid and electrolyte imbalances	3	3.24 (2.62 to 4.02)	78
Surgical level ≥3	3	2.21 (1.21 to 4.03)	68

CI, confidence interval; GERD, gastroesophageal reflux disease; POI, postoperative ileus; OR, odds ratio.

In addition, through literature review, some patient characteristics were identified as potential risk factors for POI, including African American ethnicity, history of alcohol abuse, and pulmonary circulation disorder, but could not be meta-analyzed, because these factors were reported in only 1 study respectively. Similarly, perioperative factors not included in the meta-analysis but associated with a higher risk of POI were lumbar procedure (compared with cervical and thoracic), longer operative time, increased blood loss, use of bone morphogenetic proteins (BMP), perioperative morphine use, lateral lumbar interbody fusion (LLIF) at L1-L2, endplate fracture, increased suction drainage amount during oblique lumbar interbody fusion (OLIF), surgery for neuromuscular scoliosis, surgical level ≥9 level, and anterior approach in deformity surgery.

The occurrence of POI Is multifactorial.^4,8,9 One of the most discussed patient characteristics related to risk of developing POI in the literature is age.³⁸ Although GI function and bowel motility decline with age,¹⁵ our analysis showed that age did not contribute to the development of POI. As spinal procedures are more commonly performed in the elderly because of the higher prevalence of degenerative diseases,³⁹ it is reasonable that the age distribution of patients in the POI and non-POI groups would be similar, leading to no statistical difference. Although, without a clear explanation proposed, our meta-analysis is in line with studies focusing on POI following abdominal surgery^40,41 that males tend to have a higher incidence of POI than in women. Liver disease was another significant risk factor identified in our study; however, it should be noted that only 2 studies^22,35 reported this outcome, with a wide 95% CI. The overall significant results may be false positives due to the lack of statistical power. In addition, Gifford et al²² defined liver disease as a history of hepatitis, fatty liver disease, or cirrhosis, while Horowitz et al used International Classification of Diseases (ICD) codes to identify patients with liver disease. This inconsistency in the definition of liver disease may have compromised the accuracy of our results. We investigated whether GERD was a significant risk factor for POI because GERD is associated with lower ghrelin levels, and ghrelin plays a role in stimulating intestinal activity through cholinergic pathways.¹⁹ Therefore, it is possible that patients with GERD may have a higher risk of POI; however, our meta-analysis demonstrated no significant findings.

Given that manipulation of the bowel as well as its innervating nerves is relevant to POI, the surgical trajectory that demands bowel manipulation affects the occurrence of POI. At the vertebral level of interest, anterior or anterolateral lumbar spine surgeries, such as ALIF⁴² and OLIF,⁴³ go through the retroperitoneal space and dissect and retract the visceral contents from the vertebra. Therefore, both ALIF and OLIF result in less postoperative pain than with standard posterior spine surgery by preventing paravertebral muscle dissection^42,43; however, they exhibit a higher incidence of POI than with posterior surgery due to a higher degree of bowel manipulation.^26,35 Conversely, LLIF and extreme lateral interbody fusion go through the lateral side of the vertebra using a transpsoas approach without bowel manipulation,^44,45 which results in a lower incidence of bowel-associated complications compared to those with ALIF and OLIF.³⁷ In the study by Deng et al the incidence of POI was lower in the LLIF group compared to posterior approach.³³ It is noteworthy that a caveat postulated by Al Maaieh et al is that LLIF at the L1‒L2 level inherits the highest risk of POI compared to that with other levels, since the celiac plexus is located at L1 and carries parasympathetic innervation to the intestine, which is involved in intestinal motility.³⁷

For patients undergoing spine surgery for deformity correction, the stretching of nerve roots caused by maneuvers for severe curves can activate inhibitory spinal reflexes and cause bowel dysfunction.⁴⁶ In particular, procedures with vertebral fusion over 9 levels and using the anterior approach were both independent risk factors for POI²³ and Ohba et al found lateral and posterior combined approach, and higher degree of kyphosis correction increased the risk of POI.²⁴ Moreover, patients with neuromuscular scoliosis tend to have a kyphotic posture. A flexed posture in a lumbar kyphotic model inhibits GI myoelectric activity and is subsequently associated with a higher incidence of POI.³⁶

Several intraoperative factors have been thought to induce abnormal GI motility owing to inflammation. For example, Fineberg et al found BMP use during fusion surgery was associated with a higher risk of POI due to increased local inflammation.²⁰ Inadvertent endplate fracture during OLIF is also an independent risk factor for POI.²⁶ Endplate fractures might induce the release of cytokines and other inflammatory mediators and affect the nerve plexus in the vicinity of the vertebral column, leading to impaired GI motility.⁴⁷ Moreover, endplate fractures can cause increased postoperative pain, thereby promoting POI development.

Prolonged surgical duration in spine surgery leads to longer anesthesia time, increased blood loss, need for blood transfusion and fluid support, and several complications.^48,49 Using cut-off values of surgical duration, Deng et al found that posterior thoracolumbar spinal fusion surgery over 4.375 h increased the risk of POI,³³ which aligns with the fact that patients undergoing spine surgery over 3 levels had a higher risk of POI due to longer operative time and increased intraoperative opioid use.^20,22,33 Al Maaieh et al also reported that patients receiving additional posterior pedicle screw instrumentation after LLIF had a higher risk of POI than those who received a standalone LLIF approach due to longer surgical duration.³⁷ In addition, multilevel spine surgery, a known risk factor of postoperative urinary retention,⁴⁸ is indicative of prolonged operative duration, increased blood loss, and intravenous fluid support. Higher risk of nerve damage during these procedures would account for the higher risk of POI as well.

Regarding perioperative hemodynamics, intraoperative blood loss >750 mL was associated with a higher incidence of POI.³⁴ A decrease in hemoglobin concentration increases sympathetic and endocrinological stress responses, thereby leading to bowel edema and motility inhibition.⁵⁰ This finding was in accordance with our meta-analysis, which showed that patients with anemia had a significantly higher risk of POI. Increased postoperative drainage amount, signifying bleeding around the surgical field, was also an independent risk factor for POI in patients receiving OLIF.²⁶ Park et al postulated that increased retroperitoneal bleeding and hematoma may elicit derangement of the nerve plexuses and the release of cytokines and inflammatory mediators, leading to impaired GI motility.²⁶

Perioperative fluid and electrolyte imbalance is a potentially modifiable risk factor that is as high as 4-times the risk in patients without perioperative fluid and electrolyte imbalance.^20,23,35 Moreover, excessive fluid support also puts patient at increased risk of developing POI.¹⁹ Fluid and electrolyte imbalances may impair bowel movement and inhibit the GI nervous system.⁵⁰ Fluid support during spine surgery is based on the surgical procedures, duration, blood loss, and the patient’s condition.⁵¹ Careful monitoring and management of perioperative fluid status and electrolyte levels are crucial, not only for intraoperative hemodynamics, but also for postoperative patient care.

Opioids are widely used clinically, including in spine surgery, to achieve optimal anesthesia and postoperative analgesia.⁵² A higher amount of opioid use perioperatively increases the risk of POI.^19,22,25,26 Several opioid receptor types, such as kappa, mu, and delta, have been identified in the intestinal tract.⁵³ Studies have demonstrated the dose-dependent effects of opioids on inhibiting intestinal motility.^1,54,55 Park et al reported that remifentanil, a short-acting opioid with a rapid recovery time, was associated with the development of POI even when used on postoperative day 3.²⁶ In addition, a higher dose of opioid consumption is suggestive of more severe postoperative pain, which may impede early ambulation and further slow the recovery of bowel movement.

Postoperative care strategies to promote recovery also affect the likelihood of POI development. For instance, Deng et al reported that postoperative diet restriction may increase the risk of POI.³⁴ Alternatively, early enteral feeding promotes better functional recovery and patient-reported outcomes following surgery.⁵⁶ In line with postoperative care in patients undergoing abdominal surgery, early enteral nutrition in patients undergoing spine surgery lowers the incidence of POI, shortens the length of hospital stays and decreases the risk of postoperative complications.^57,58

Limitations

The results of this systematic review and meta-analysis should be interpreted in the light of several limitations. First, all the included studies were retrospective in design, which was a potential source of bias due to confounding factors. Second, there was variation in the surgical procedure used across the included studies, which may have varying factors affecting the development of POI. Third, in our review, most of the single institutional studies defined POI using the diagnostic criteria from the review article by Vather et al.² However, for studies utilizing nationwide databases, the diagnosis of POI was based on the ICD codes. In addition, there were no reports of the severity of POI and subsequent management; for example, whether nasogastric tube decompression was needed or if prokinetic medications were prescribed.

Fourth, although liver disease and anemia were identified as significant predictors for the development of postoperative ileus, the inconsistency in the definition of these diseases may have hindered the accuracy of the analysis. Moreover, in nationwide databases, using the ICD codes may limit the data available on the disease severity.

Finally, through literature review, although several factors were reported with a higher risk of POI, we could not perform meta-analysis for these factors as they were reported only once among the included studies.

Conclusions

POI following spine surgery is detrimental to postoperative recovery and increases the risk for developing other complications. Our meta-analysis demonstrated that male sex, anemia, and liver disease were significantly associated with POI. Perioperative fluid and electrolyte imbalance and multilevel spine surgery significantly increased the risk of POI. In addition, through a comprehensive review, we identified several perioperative risk factors associated with the development of POI. The knowledge gained from this study could improve perioperative management and patient recovery after spine surgery.

Supplemental Material

Supplemental Material - Risk Factors for Postoperative Ileus Following Spine Surgery: A Systematic Review With Meta-Analysis

Supplemental Material for Risk Factors for Postoperative Ileus Following Spine Surgery: A Systematic Review With Meta-Analysis by Yu Chang, MD, Chia-En Wong, MD, Wei-Cheng Chen, MD, Hao-Hsiang Hsu, MD, Po-Hsuan Lee, MD, Chi-Chen Huang, MD, and Jung-Shun Lee, MD, MSc in Global Spine Journal

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Po-Hsuan Lee

Jung-Shun Lee

Supplemental Material

Supplemental material for this article is available online.

References

Venara

Neunlist

Slim

, et al. Postoperative ileus: Pathophysiology, incidence, and prevention. J Vis Surg. 2016;153(6):439-446.

Vather

Trivedi

Bissett

. Defining postoperative ileus: Results of a systematic review and global survey. J Gastrointest Surg. 2013;17(5):962-972.

Asgeirsson

El-Badawi

Mahmood

Barletta

Luchtefeld

Senagore

. Postoperative ileus: It costs more than you expect. J Am Coll Surg. 2010;210(2):228-231.

Mishra

Hewage

Islam

Harky

. The correlation between bowel complications and cardiac surgery. Scand J Surg. 2021;110(2):187-192.

Kim

Min

Yoo

Chang

Jeon

. Risk factors for postoperative ileus after urologic laparoscopic surgery. J Korean Surg Soc. 2011;80(6):384-389.

Fujita

Nagano

Suzuki

, et al. Incidence of postoperative ileus after paraaortic lymph node dissection in patients with malignant gynecologic tumors. Int J Clin Oncol. 2005;10(3):187-190.

Klasan

Amic

Dworschak

Madzarac

Heyse

Neri

. Risk factors for ileus after hip and knee arthroplasty. Int J Colorectal Dis. 2019;34(2):261-267.

Becker

Blum

. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. Lancet. 2009;373(9670):1198-1206.

Panchal

Müller-Schwefe

Wurzelmann

. Opioid-induced bowel dysfunction: Prevalence, pathophysiology and burden. Int J Clin Pract. 2007;61(7):1181-1187.

10.

Swong

Johans

Molefe

, et al. Unintended Consequences after postoperative ileus in spinal fusion patients. World Neurosurg. 2019;122:e512-e515.

11.

Thomas

Akwari

Kelly

. Hormonal control of gastrointestinal motility. World J Surg. 1979;3(5):545-552.

12.

Bortoff

. Current concepts: Intestinal motility. N Engl J Med. 1969;280(24):1335-1337.

13.

Watanabe

Sekiguchi

Yonemoto

, et al. Bowel/bladder dysfunction and numbness in the sole of the both feet in lumbar spinal stenosis - A multicenter cross-sectional study. J Orthop Sci. 2017;22(4):647-651.

14.

Oshina

Segawa

Manabe

Oshima

Tanaka

Inanami

. Incidence, prognosis, and risk factors for bladder and bowel dysfunction due to incidental dural tears in lumbar microendoscopic surgery. Spine J. 2020;20(5):688-694.

15.

Phillips

Powley

. Innervation of the gastrointestinal tract: Patterns of aging. Auton Neurosci. 2007;136(1-2):1-19.

16.

Kobayashi

Ando

Nishida

Ishiguro

Imagama

. Epidemiological trends in spine surgery over 10 years in a multicenter database. Eur Spine J. 2018;27(8):1698-1703.

17.

Grotle

Småstuen

Fjeld

, et al. Lumbar spine surgery across 15 years: Trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open. 2019;9(8):e028743.

18.

Oglesby

Fineberg

Patel

Pelton

Singh

. Epidemiological trends in cervical spine surgery for degenerative diseases between 2002 and 2009. Spine (Phila Pa 1976). 2013;38(14):1226-1232.

19.

Kiely

Mount

, et al. The incidence and risk factors for post-operative ileus after spinal fusion surgery: A multivariate analysis. Int Orthop. 2016;40(6):1067-1074.

20.

Fineberg

Nandyala

Kurd

, et al. Incidence and risk factors for postoperative ileus following anterior, posterior, and circumferential lumbar fusion. Spine J. 2014;14(8):1680-1685.

21.

Bragg

El-Sharkawy

Psaltis

Maxwell-Armstrong

Lobo

. Postoperative ileus: Recent developments in pathophysiology and management. Clin Nutr. 2015;34(3):367-376.

22.

Gifford

Minnema

Baum

Humeidan

Vazquez

Farhadi

. Development of a postoperative ileus risk assessment scale: Identification of intraoperative opioid exposure as a significant predictor after spinal surgery. J Neurosurg Spine. 2019;31:748-755.

23.

Durand

Ruddell

Eltorai

AEM

DePasse

Daniels

. Ileus following adult spinal deformity surgery. World Neurosurg. 2018;116:e806-e813.

24.

Ohba

Koyama

Oba

Oda

Tanaka

Haro

. Clinical importance, incidence and risk factors for the development of postoperative ileus following adult spinal deformity surgery. Global Spine J. 2022;12(6):1135-1140.

25.

Hendrickson

Zhang

Amoafo

, et al. Risk factors for postoperative ileus in patients undergoing spine surgery. Global Spine J. 2022:219256822210750.

26.

Park

Chang

Mok

Kim

Chang

B-S

Lee

C-K

. Risk factors for postoperative ileus after oblique lateral interbody fusion: a multivariate analysis. Spine J. 2021;21(3):438-445.

27.

Reed

Mihas

Fortin

, et al. Risk factors for postoperative ileus after thoracolumbar and lumbar spinal fusion surgery: Systematic review and meta-analysis. World Neurosurg. 2022;168:e381-e392.

28.

Higgins

JPT TJ CJ

Cumpston

Page

Welch

, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.3. Cochrane; 2022. Available from www.trainingcochraneorg/handbook.2022. (updated February 2022).

29.

Viechtbauer

. Conducting meta-analyses in R with the metafor package. J Stat Software. 2010;36(3):1-48.

30.

Hozo

Djulbegovic

Hozo

. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5:13.

31.

Higgins

Thompson

Deeks

Altman

. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-560.

32.

National Heart

Blood Institute . Quality assessment tool for case-controlled studies. https://www.nhlbi.nih.gov/health

33.

Yilmaz

Benca

Patel

, et al. What are risk factors for an ileus after posterior spine surgery?-A case control study. Global Spine J. 2022;12(7):1407-1411.

34.

Deng

W-W

Lan

Peng

A-F

, et al. The risk factors for postoperative ileus following posterior thoraco-lumbar spinal fusion surgery. Clin Neurol Neurosurg. 2019;184:105411.

35.

Horowitz

Jain

Puvanesarajah

Qureshi

Hassanzadeh

. Risk Factors, additional length of stay, and cost associated with postoperative ileus following anterior lumbar interbody fusion in elderlypatients. World Neurosurg. 2018;115:e185-e189.

36.

Bureta

Tominaga

Yamamoto

, et al. Risk factors for postoperative ileus after scoliosis surgery. Spine Surg Relat Res. 2018;2(3):226-229.

37.

Al Maaieh

Aichmair

, et al. Multivariate analysis on risk factors for postoperative ileus after lateral lumbar interbody fusion. Spine. 2014;39(8):688-694.

38.

Elgar

Smiley

Feingold

Latifi

. Age increases the risk of mortality by four-fold in patients with emergent paralytic ileus: Hospital length of stay, sex, frailty, and time to operation as other risk factors. Int J Environ Res Publ Health. 2022;19(16):9905.

39.

Watanabe

Kanayama

Takahata

, et al. Perioperative complications of spine surgery in patients 80 years of age or older: A multicenter prospective cohort study. J Neurosurg Spine. 2019;17:1-9.

40.

Ceretti

Maroni

Longhi

, et al. Risk factors for prolonged postoperative ileus in adult patients undergoing elective colorectal surgery: An observational cohort study. Rev Recent Clin Trials. 2018;13(4):295-304.

41.

Wolthuis

Bislenghi

Lambrecht

, et al. Preoperative risk factors for prolonged postoperative ileus after colorectal resection. Int J Colorectal Dis. 2017;32(6):883-890.

42.

Siemionow

KB SK

. Anterior lumbar interbodyfusion (ALIF). In: Baaj

Mummaneni

Uribe

Vaccaro

Greenberg

, eds. Handbook of Spine Surgery. New York: Thieme; 2012.

43.

Mehren

Mayer

Zandanell

Siepe

Korge

. The oblique anterolateral approach to the lumbar spine provides access to the lumbar spine with few early complications. Clin Orthop Relat Res. 2016;474(9):2020-2027.

44.

Kwon

Kim

. Lateral lumbar interbody fusion: Indications, outcomes, and complications. J Am Acad Orthop Surg. 2016;24(2):96-105.

45.

Ozgur

Aryan

Pimenta

Taylor

. Extreme lateral interbody fusion (XLIF): A novel surgical technique for anterior lumbar interbody fusion. Spine J. 2006;6(4):435-443.

46.

Kalff

Schraut

Simmons

Bauer

. Surgical manipulation of the gut elicits an intestinal muscularis inflammatory response resulting in postsurgical ileus. Ann Surg. 1998;228(5):652-663.

47.

Mattei

Rombeau

. Review of the pathophysiology and management of postoperative ileus. World J Surg. 2006;30(8):1382-1391.

48.

Chang

Chi

Tai

, et al. Risk factors for postoperative urinary retention following elective spine surgery: A meta-analysis. Spine J. 2021;21(11):1802-1811.

49.

Kim

Smith

Lim

Cybulski

Kim

. Predictors of unplanned readmission in patients undergoing lumbar decompression: Multi-institutional analysis of 7016 patients. J Neurosurg Spine. 2014;20(6):606-616.

50.

Vather

Bissett

. Risk factors for the development of prolonged post-operative ileus following elective colorectal surgery. Int J Colorectal Dis. 2013;28(10):1385-1391.

51.

Ongaigui

Fiorda-Diaz

Dada

Mavarez-Martinez

Echeverria-Villalobos

Bergese

. Intraoperative fluid management in patients undergoing spine surgery: A narrative review. Front Surg. 2020;7:45.

52.

de Boer

Detriche

Forget

. Opioid-related side effects: Postoperative ileus, urinary retention, nausea and vomiting, and shivering. A review of the literature. Best Pract Res Clin Anaesthesiol. 2017;31(4):499-504.

53.

Holzer

. Treatment of opioid-induced gut dysfunction. Expet Opin Invest Drugs. 2007;16(2):181-194.

54.

Gan

Robinson

Oderda

Scranton

Pepin

Ramamoorthy

. Impact of postsurgical opioid use and ileus on economic outcomes in gastrointestinal surgeries. Curr Med Res Opin. 2015;31(4):677-686.

55.

Story

Chamberlain

. A comprehensive review of evidence-based strategies to prevent and treat postoperative ileus. Dig Surg. 2009;26(4):265-275.

56.

Dietz

Sharma

Adams

, et al. Enhanced recovery after surgery (ERAS) for spine surgery: A systematic review. World Neurosurg. 2019;130:415-426.

57.

Herbert

Perry

Andersen

, et al. Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications. Cochrane Database Syst Rev. 2018;10(7):Cd004080.

58.

Boelens

Heesakkers

Luyer

, et al. Reduction of postoperative ileus by early enteral nutrition in patients undergoing major rectal surgery: Prospective, randomized, controlled trial. Ann Surg. 2014;259(4):649-655.

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