Postoperative ileus follows any operation. Although worsened if the peritoneum is entered, the length and duration of surgery does not influence the severity of postoperative ileus. Inhibitory alpha 2-adrenergic reflexes with peptidergic afferents contribute to postoperative ileus. Clinically, treatment of ileus centers around symptomatic relief with nasogastric suction. Trials of adrenergic blockade combined with cholinergic stimulation have met with limited success. Prokinetic drugs have not been proved effective in the treatment of this disorder. Two types of ileus exist: postoperative and paralytic. Postoperative ileus resolves spontaneously after two to three days, and probably reflects inhibition of colonic motility. Paralytic ileus is more severe, last more than three days, and seems to represent inhibition of small bowel activity. No discrete structural changes cause postoperative ileus and the role of peptidergic neuronal systems of the enteric nervous system has not been elucidated. Possible central or humoral mechanisms have not been studied extensively. The possible direct inhibition of enteric or spinal nerves by anesthetic agents not cleared from these tissues remains to be studied. Also in need of study is the potential alteration of neurotransmitter receptor activity within the enteric nervous plexus after manipulation of the bowel.

Reliable, valid information on patient presurgical risk factors, process of care during surgery, and 30-day morbidity and mortality rates is available for all major surgical procedures in the 123 VAMCs performing surgery in the VHA. With this information, the VHA has established the first prospective outcome-based program for comparative assessment and enhancement of the quality of surgical care among multiple institutions for several surgical subspecialties. Key features to the success of the NSQIP are the support of the surgeons who practice in the VHA, consistent clinical definitions and data collection by dedicated nurses, a uniform nationwide informatics system, and the support of VHA administration and managerial staff.

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