All patients undergoing bowel resection experience postoperative ileus, a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees. An anesthesiologist plays a critical role, not only in the initiation of surgical anesthesia, but also with the selection and transition to effective postoperative analgesia regimens. Attempts to reduce the duration of postoperative ileus have prompted the study of various preoperative, perioperative, and postoperative regimens to facilitate gastrointestinal recovery. These include modifiable variables such as epidural anesthesia and analgesia, opioid-sparing anesthesia and analgesia, fluid restriction, colloid versus crystalloid combinations, prokinetic drugs, and use of the new peripherally acting mu-opioid receptor (PAM-OR) antagonists. Review and appropriate adaptation of these multiple modifiable interventions by anesthesiologists and their surgical colleagues will facilitate implementation of a best-practice management routine for bowel resection procedures that will benefit the patient and the healthcare system. 1. Introduction An anesthesiologist plays a critical role not only in the initiation of surgical anesthesia but also in the selection and transition to an effective maintenance of postoperative analgesia. All patients undergoing bowel resection (BR) experience postoperative ileus (POI), a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees [1–3]. Clinically, POI is characterized by delayed passage of flatus and stool, bloating, abdominal distension, abdominal pain, nausea, and vomiting and is associated with an increase in postoperative morbidity and length of hospital stay (LOS) [4]. Although the etiology of POI is complex (Figure 1), it is primarily associated with the surgical stress response, an acute inflammatory response associated with manipulation of the bowel, and endogenous opioids secreted within the gastrointestinal (GI) tract in response to surgical trauma [3–7]. Opioid-based analgesia is widely used and considered the standard of care for postoperative pain management [8–12]. Opioids mediate analgesia by binding to mu-opioid receptors in the central nervous system [13]; however, they also bind to peripheral mu-opioid receptors in the GI tract resulting in a disruption of the migrating motor complex and propulsive motor activity associated with GI motility, inhibition of intestinal ion and fluid secretion, and an increase in
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