Postoperative feeding: a clinical review

The effect of diets delivered into the gastrointestinal tract on gut motility after colorectal surgery-a systematic review and meta-analysis of randomised controlled trials

BACKGROUND/OBJECTIVES

Despite best practice guidelines, feeding methods after colorectal surgery vary due to the difficulties translating evidence into practice. The aim was to determine the effectiveness of diets delivered into the gastrointestinal tract (GIT) on gut motility following colorectal surgery.

SUBJECTS/METHODS

EMBASE, MEDLINE, CINAHL, Web of Science and PubMed were systematically searched. Randomised controlled trials investigating effectiveness of a diet on gut motility after colorectal surgeries were included. Outcomes included postoperative ileus, length of stay, mortality, nausea and vomiting.

RESULTS

A total of 756 potential studies were identified; of these, 10 trials reporting on 1237 unique patients were included. There is evidence that early feeding reduces time (days) to first flatus (mean difference (MD):-0.64; 95% CI:-0.84 to -0.44) and bowel movements (MD:-0.64; 95% CI:-1.01 to -0.26), when compared to traditional postoperative fasting. Introducing solids versus the progression of fluids to solids had no effect on time (days) to first flatus (MD:0.13; 95% CI:-1.99 to 1.74) or bowel movement (MD:0.20; 95% CI:-0.50 to 0.98). Complete nutrition compared to hypocaloric nutrition had no effect on time to first flatus (MD:-0.60; 95% CI:-1.66 to 0.46) or bowel movement (MD:-0.20; 95% CI:-1.59 to 1.19), whereas coffee and diet compared to water and diet significantly decreased time (days) to first bowel movement (MD:-0.60; 95% CI:-0.97 to -0.19) but had no effect on time to first flatus (MD:-0.20; 95% CI:-0.57 to 0.09).

CONCLUSIONS

Any form of early postoperative diet provided into the GIT early after colorectal surgery is likely to stimulate gut motility, resulting in earlier return of bowel function and shorter length of stay.

Meta-Analysis of the Effect of Gum Chewing After Gynecologic Surgery

OBJECTIVE

To describe the scientific evidence related to gum chewing to reduce ileus after gynecologic surgery.

DATA SOURCES

A literature search was performed using Ovid Medline, Embase, Cochrane Library, CINAHL, Scopus, and Web of Science databases.

STUDY SELECTION

Inclusion criteria included randomized controlled trials (RCTs) on the use of gum chewing after gynecologic surgery in which the main outcomes measured were time to first flatus, time to defecation, and length of hospital stay.

DATA EXTRACTION

Data on authors, country, randomization method, the type of disease, surgical and anesthetic methods, sample characteristics such as age and body mass index, gum chewing program, and study results were extracted from selected articles.

DATA SYNTHESIS

Of 493 publications, eight RCTs conducted between 2013 and 2017 involving 1,077 women were included in our meta-analysis. Weighted mean differences (WMDs) with 95% confidence intervals were calculated for the eight studies with the use of Cochrane Review Manager Version 5.3 (RevMan; 2014). The pooled results showed that gum chewing was superior to no gum chewing, with a reduction in WMD for time to first flatus of -6.20 hours (95% confidence interval [CI] [-9.51, -2.88]), WMD for time to first defecation of -9.03 hours (95% CI [-14.02, -4.04]), and WMD for length of hospital stay of -0.36 days (95% CI [-0.72, -0.01]).

CONCLUSION

Gum chewing significantly reduced the time to first flatus and defecation after gynecologic surgery and should be recommended by health care providers.

Early feeding in pediatric patients following stoma closure in a resource limited environment

BACKGROUND

Establishment of enteral nutrition is necessary after intestinal surgery. In resource-strained environments, it can be critical. This study examined the effect of early feeding in pediatric patients undergoing stoma closure in a country with mid-level socioeconomic indices.

METHODS

With parenteral consent and ethics board approval, patients were prospectively enrolled in early feeding (Group 1), starting feeds 24h post-operation with a protocol driven increase. They were compared with similar patients managed without a specific protocol over the 12 months prior (Group 2).

RESULTS

There were 31 patients in each group with similar mean age and weight. The mean first sustained feed was achieved at 28.5 ± 4.4 h* in Group 1 vs. 153.8 ± 28.6 h in Group 2. Full feeds were achieved within 62.3 ± 19.2 h* vs. 196.0 ± 40.5 h in Group 1 and 2, respectively. Mean hospital stay was 7.2 days* in Group 1 vs. 9.4 days in Group 2. A reduction in postoperative fever and wound infections was observed in Group 1 (*p<0.05).

CONCLUSION

Early enteral feeding after elective bowel anastomosis is well tolerated in children and results in shorter hospital stay and fewer complications.

A randomized controlled trial evaluating early versus traditional oral feeding after colorectal surgery

OBJECTIVE

This prospective randomized clinical study was conducted to evaluate the safety and tolerability of early oral feeding after colorectal operations.

METHODS

A total of 199 patients underwent colorectal surgery and were randomly assigned to early feeding (n = 99) or a regular diet (n = 100). Patients' characteristics, diagnoses, surgical procedures, comorbidity, bowel movements, defecation, nasogastric tube reinsertion, time of tolerance of solid diet, complications, and length of hospitalization were assessed.

RESULTS

The two groups were similar in terms of gender, age, diagnosis, surgical procedures, and comorbidity. In the early feeding group, 85.9% of patients tolerated the early feeding schedule. Bowel movements (1.7±0.89 vs. 3.27±1.3), defecation (3.4±0.77 vs. 4.38±1.18) and time of tolerance of solid diet (2.48±0.85 vs. 4.77±1.81) were significantly earlier in the early feeding group. There was no change between the groups in terms of nasogastric tube reinsertion, overall complication or anastomotic leakage. Hospitalization (5.55±2.35 vs. 9.0±6.5) was shorter in the early feeding group.

CONCLUSIONS

The present study indicated that early oral feeding after elective colorectal surgery was not only well tolerated by patients but also affected the postoperative outcomes positively. Early postoperative feeding is safe and leads to the early recovery of gastrointestinal functions.

The Effects of the Video Education Program on the Residual urine, Gas Passing and State Anxiety of Hysterectomy Patients

PURPOSE

The purpose of this study was to identify the effects of a pre-operation video assisted education program on residual urine, gas passing and state anxiety in women undergoing hysterectomy.

METHODS

Nonequivalent control group non-synchronized design was used for the study. In the research, video assisted education program was applied to the experimental group while a similar conventional education was done to the control group. The pre-operation state anxiety and post-operation residual urine and gas discharge of both the groups were measured. The data were analyzed using SPSS.

RESULTS

The experimental group was significantly higher than control group on gas passing (t=3.04, p=.00). However the residual urine (t=0.34, p=.73) and state anxiety (t=0.81, p=.82) did not make significant differences.

CONCLUSION

This study is very meaningful in that it developed and provided a nursing intervention can positively affect hysterectomy patients. The pre-operation video assisted education program may be an effective nursing intervention that is clinically practical and useful to reduce time of the gas passing of hysterectomy patients after the operation.

Early postoperative feeding in resectional gastrointestinal surgical cancer patients

Malnutrition is present in the majority of patients presenting for surgical management of gastrointestinal malignancies, due to the effects of the tumour and preoperative anti-neoplastic treatments. The traditional practice of fasting patients until the resumption of bowel function threatens to further contribute to the malnutrition experienced by these patients. Furthermore, the rationale behind this traditional practice has been rendered obsolete through developments in anaesthetic agents and changes to postoperative analgesia practices. Conversely, there is a growing body of literature that consistently demonstrates that providing oral or tube feeding proximal to the anastomosis within 24 h postoperatively, is not only safe, but might be associated with significant benefits to the postoperative course. Early post operative feeding should therefore be adopted as a standard of care in oncology patients undergoing gastrointestinal resections.

A randomised controlled trial of early initiation of oral feeding after cesarean section

OBJECTIVE

To evaluate the safety and efficacy of early oral feeding after cesarean delivery.

METHODS

Two hundred women who had cesarean section were randomly assigned to early feeding or routine feeding. Women in the early feeding group were encouraged to take sips of water 8 h post-operatively, followed by oral tea of 100 mL at the time of supervision. Women in the routine feeding group were managed by restricting oral intake for the first 24 h and administration of sips of water 24-48 h post-operatively. The outcome measures include the rate of ileus symptoms, post-operative time interval to presence of bowel sounds, passage of flatus and bowel movement, time interval to return to regular diet, length of hospital stay, post-operative complications, acceptability and benefit of early oral feeding.

RESULTS

The early feeding group had a shorter mean post-operative time interval to bowel sounds 18.90 +/- 4.17 h versus 36.21 +/- 3.52 h (p < 0.001), passage of flatus 44.81 +/- 3.73 h versus 60.58 +/- 4.40 h (p < 0.001) and bowel movement 58.30 +/- 5.91 h versus 72.76 +/- 4.25 h (p < 0.001). There was no significant difference in paralytic ileus symptoms. Early feeding group had a shorter mean hospital stay 4.80 +/- 0.59 days versus 6.69 +/- 0.71 days (p = 0.001). Early feeding group required less intravenous fluid 7.14 +/- 1.34 bottles versus 11.8 +/- 1.32 bottles (p < 0.001).

CONCLUSIONS

Early feeding after cesarean section was well tolerated and safe and can be implemented without an increase in adverse outcome.

Fast track clinical pathway implications in esophagogastrectomy

AIM: To investigate the feasibility of fast track clinical pathway for esophageal tumor resections.

METHODS: One hundred and fourteen patients with esophageal carcinoma who underwent esophagogastrectomy from January 2006 to October 2007 in our department were studied. Fast track clinical pathway included analgesia control, fluid infusion volume control, early ambulation and enteral nutrition. Nasogastric tube was removed 3 d after operation and chest tube was removed 4 d after operation as a routine, and full liquid diet 5 d after operation.

RESULTS: Among 114 patients (84 men and 30 women), 26 patients underwent fast track surgery, including 17 patients over 65 years old and 9 under 65 (P = 0.014); 18 patients who had preoperative complications could not bear fast track surgery (P < 0.001). No significant differences in tolerance of fast track surgery were attributed to differences in gender, differentiated degree or stage of tumor, pathological type of tumor, or operative incision. The median length of hospital stay was 7 d (5-28 d), 4% patients were readmitted to hospital within 30 d of discharge. Three patients died and postoperative mortality was 2.6%. All 3 patients had no determinacy to fast track surgery approach.

CONCLUSION: The majority of patients with esophageal carcinoma can tolerate fast track surgery. Patients younger than 65 or who have no preoperative diseases have the best results. Median length of hospital stay has been reduced to 7 d.

To eat or not to eat: facilitating early oral intake after elective colonic surgery in the Netherlands

BACKGROUND & AIMS

It was shown that patients in the Netherlands remain exposed to unnecessarily prolonged starvation after abdominal surgery. The present study examined whether a structured collaborative effort would help to implement the early start of oral nutrition after colorectal surgery.

METHODS

In 2006, twenty-six Dutch hospitals signed up to a "breakthrough project" concerning the implementation of the enhanced recovery after surgery (ERAS) programme with early oral feeding as one of the key elements. Each hospital determined the usual start of food intake by analyzing 50 patients who underwent a colorectal resection in 2004 (n=1126). Subsequently, over the course of one year 861 colorectal surgery patients were treated according to the ERAS programme. The first day that patients were eating before and after the breakthrough project was compared using Kaplan-Meier analyses and Cox regression models.

RESULTS

Patients treated according to the ERAS programme were eating 3 days earlier than the patients traditionally treated (p<0.000). Two days after surgery 65% of the ERAS patients were eating normal food versus 7% of the pre-ERAS patients.

CONCLUSIONS

The present nationwide collaborative effort was successful in implementing a change towards an early start of oral nutrition after abdominal surgery.

Review of the pathophysiology and management of postoperative ileus

Investigations in the pathophysiology and treatment of postoperative ileus continue to evolve. Bowel rest is no longer a mandatory component of postoperative recovery. Tolerance of enteral nutrition and normalization of the abdominal examination are more accurate indications of the resolution of postoperative ileus than passage of flatus or first bowel movement. A multimodal "fast track" recovery approach incorporated into a clinical pathway provides a more rapid return of intestinal function and shortened hospital stay in patients undergoing major, uncomplicated gastrointestinal surgery.

Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review

AIM

To review research on early oral feeding following elective, open colorectal surgery.

BACKGROUND

Fasting following gastrointestinal surgery is a traditional surgical practice, based on fears of causing postoperative complications if oral intake begins before bowel function returns, but fasting following elective surgery is questionable as a best practice.

METHODS

Searches in Journals@Ovid CINAHL, MEDLINE, PubMed, Web of Science and The Cochrane Library for primary studies, published during 1995-2004, used the keywords: 'surgery', 'postoperative', 'elective, 'colorectal', 'bowel, 'colon', 'oral', 'enteral', 'feeding', 'early', 'traditional'. Studies of adults undergoing elective, open colorectal surgery who were allowed fluids and food before bowel function returned (early feeding) were included. Outcomes of interest were safety, tolerability, duration of gastrointestinal ileus and length of hospital stay. Critical appraisal of randomized and controlled studies was undertaken following inclusion.

RESULTS

Fifteen studies comprising 1352 patients were reviewed. All studies concluded early feeding was safe, based on complications rates. Total complications were 12.5% (range 0-25%) for 935 early feeding patients, with no increased risk of anastomotic leak, aspiration pneumonia, or bowel obstruction. For all studies an average of 86% patients (range 73-100%) tolerated early feeding. Studies demonstrating faster resolution of postoperative ileus or shorter hospitalization were associated with multimodal perioperative care, including early mobilization, epidural analgesia and comprehensive patient education. Appraisal of five randomized trials revealed no blinding and inadequate randomization.

CONCLUSIONS

This review supports early oral feeding after elective, open colorectal surgery and challenges the traditional practice of fasting patients until return of bowel function. Early feeding was safe, well-tolerated and easy to implement. Reduced length of ileus and shorter hospitalization may occur with multimodal protocols.

RELEVANCE TO CLINICAL PRACTICE

Nurses can highlight this new evidence for other health professionals, advocate development of clinical protocols featuring early feeding and participate in multi-disciplinary, multi-method research regarding benefits of early feeding.

The impact of early nutrition on metabolic response and postoperative ileus

PURPOSE OF REVIEW

Early nutrition has been evaluated and used as a possible strategy to decrease the negative impact of the metabolic response to injury and postoperative ileus. The metabolic response to injury, be it surgical or traumatic, is a physiological mechanism that, according to the magnitude and duration of the event, can impact on the patient's morbidity and survival. The adequate initial approach is a determinant factor that might influence its outcome. Simultaneously, gastrointestinal tract motility is transiently impaired, leading to the so-called postoperative ileus. The latter not only causes patient discomfort, but is also related to abdominal complications and worsening of the nutritional status, as well as increased length of hospital stay and costs.

RECENT FINDINGS

Multimodal surgical strategies such as preoperative intake of a carbohydrate drink, together with patient education of the postoperative care plan, efficacious analgesia and early nutrition have been described to significantly decrease the stress response and improve the ileus. Therefore, these strategies accelerate rehabilitation and, as a consequence, decrease complications and length of hospital stay and its related costs.

SUMMARY

Understanding perioperative pathophysiology and implementing care regimes through a multimodal approach in order to reduce the stress of the operation and the related postoperative ileus are major challenges. These factors will certainly impact on patient outcomes.