The review aims to highlight the importance of acute gastrointestinal failure in the postoperative patient, to clarify the clinical circumstances in which acute intestinal failure complicates postoperative management, and to discuss recent advances and controversy in our understanding of the cause and pathogenesis.Acute postoperative intestinal failure ranges from a self-limiting condition of disordered intestinal peristaltic activity, through to a complex critical illness state associated with abdominal sepsis and intestinal fistulation. Recent developments have focused on the mechanisms of paralytic ileus and preventive strategies, usually as part of programmes of 'fast-track' or 'enhanced recovery' care, and on the optimum management of patients with severe abdominal sepsis, including planned versus on-demand relaparotomy, open abdominal management of severe sepsis and negative pressure wound therapy.Many cases of acute intestinal failure are preventable. Improvements in understanding and preventing paralytic ileus through changes in postoperative care may facilitate recovery of gastrointestinal function after abdominal surgery. Further and better-organized studies are needed to define the optimum strategies for treating patients with severe abdominal sepsis, managing the patient with the open abdomen and defining the role of enteral, as opposed to parenteral nutritional support in such patients.