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Ijs_july_aug_05.pmd
Safety of early oral feeding aftergastrointestinal anastomosis: a randomizedclinical trial
Department of Surgery, Baqiyatallah University of Medical Sciences, 1Azad-Tehran University of Medical Sciences, Tehran, Iran
For correspondence:SA Fanaie, Department of Endoscopic Surgery, 13th Floor, Milad Hospital, Hemat Highway, Tehran, IR, Iran. E-mail: Sali_ziaee@yahoo.com
Background: Different abdominal surgeries could benefit from early feeding. Aims: To compare earlyfeeding with traditional postoperative dietary management for development of postoperativegastrointestinal (GI) symptoms. Settings and Design: A prospective randomized controlled study. Methodsand Materials: This was a study of 110 patients who were randomly allocated to early feeding beginningwith liquid diet, 8 h postoperatively; whereas those in the traditional feeding group were given aregular diet with normal bowel sounds. Statistical analysis used: Fisher exact test, P value less than0.05 was significant. Results: There were no differences in patients’ demographics, surgical procedure,and anesthesia used. Complete data were available for 110 patients; 55 were allocated to the early
Original Article
feeding group and 55 to the late feeding group. The incidence of postoperative ileus did not differbetween the two groups [early 1 (1%) vs late (1) 1%, P > 0.05 NS]. However, there was no significantdifference in the rate of intraoperative complication such as, leakage of anastomosis, mesentericembolus, wound infection, and wound dehiscence between groups [7.2% (4) vs 16.36% (9), respectively,P value = 0.093 NS]. Also, there were no significant differences in mortality between the two groups. Conclusion: Early feeding in GI anastomosis seems to be safe, well tolerated, and was not associatedwith increased postoperative GI complaints including ileus and postoperative complications such aswound dehiscence, infection, leakage, anastomosis, and mortality.
Key words: Early feeding, Gastrointestinal anastomosis
How to cite this article:Ahamd FS, Ali ZS.Safety of early oral feeding after gastrointestinal anastomosis: a randomized clinical trial. Indian J Surg 2005;67:185-8.
examined its use after gastrointestinal (GI) anastomo-sis. A randomized controlled trail that compared an
Traditionally, after abdominal surgery, the pas-
early regular diet to conventional postoperative die-
sage of flatus, or bowel movement was the clin-
tary management to determine GI complications and
ical evidence for starting an oral diet. The res-
mortality after major GI anastomosis was conducted.
olution of postoperative ileus defined by the
The secondary purpose of this trial was to evaluate
passage of flatus usually occurred within
the incidence of postoperative ileus after major GI anas-
5 days.[1] Studies were undertaken to evalu-
tomosis with early feeding in comparison with con-
ate whether different abdominal surgeries
could benefit from early feeding. Early feed-ing improves the outcome of patients with
trauma and burns,[2] although few studies have
Between August 2003 and November 2004, after the
Paper Received: May 2005. Paper Accepted: July 2005. Source
study was approved by the Human Research Review
of Support: Nil.
Committee, patients at the referral hospital who had
Indian J Surg | August 2005 | Volume 67 | Issue 4
Free full text available from http://www.indianjsurg.com
GI anastomosis were offered participation, and those
starting the diet, was performed after the first postop-
who agreed gave informed consent. Patients with his-
erative day in the early feeding group. Postoperative
tories of acute obstruction, perforation, intra-abdomi-
ileus was managed by IV Hydration, no oral intake
nal infection and who were aged lesser than 16 years
antiemetic, and radiological evaluation of the abdo-
were excluded. All patients underwent general an-
men. If vomiting was unresponsive to antiemetic, a
esthesia. However, epidural catheter was not used for
nasogastric tube was placed and removed after symp-
pain relief postoperatively. Only those patients who
toms resolved. On the day of discharge, they answered
had laparoscopic procedures were not included be-
questions about nausea, vomiting, cramping, disten-
cause they were discharged from the recovery room
tion, desire for oral feeding, and first day of flatus pas-
sage or bowel movement. A power analysis was donebased on an average incidence of postoperative ileus
After completion of surgery, surgeons called a research
reported in the literature of approximately 25%,[8] with
physician who assigned patients to early or late feed-
a doubling of that rate considered clinically signifi-
ing groups using a random number table with pseudo
cant. With 80% power and a = 0.05, 110 patients were
randomization and disguised block length of five with
needed to show a twofold greater incidence of postop-
1 : 1 ratio. Surgeons were not masked to feeding
erative ileus in the early feeding group.
groups after surgery. Patients in the early feeding groupwere offered simply a liquid diet within 6 h of arrival
Fisher exact test was used to analyze discrete varia-
on the ward. If they tolerated 1 liter within 24 h, they
bles such as postoperative ileus. Continuous variables
were started on free liquid on the second day, and reg-
were analyzed using student’s t-test.
ular diet on the third day. In both groups, the nasogas-tric tube was removed immediately after surgery. Pa-
tients with normal postoperative course were dis-charged when they could tolerate a regular diet. In our
Between August 2003 and November 2004, 110 pa-
study, we did not compare the length of hospital stay
tients who had major abdominal surgery for anasto-
to evaluate all postoperative complications equally in
mosis indications agreed to participate. Complete data
both groups. Demographic information collected in-
were available for 110 patients, with 55 (31men and
cluded the age, sex, medical, and surgical histories of
24 women) patients with 66.45 mean years old to ear-
the patients and indications for anastomosis. The sub-
ly feeding, and 55 (38 men, 17 women) with 63.44
jects had different types of major anastomosis and were
mean years old to late feeding. No patient was exclud-
randomly allocated to feeding groups irrespective of
ed. There were no significant demographic differenc-
anastomotic type to eliminate bias [Table 1]. The length
es between groups, including age, medical, and surgi-
of time until bowel movement was first passed was
also noted. Given the common clinical practice ofmorning and evening patient assessment, bowel func-
Indications for anastomosis approximately were simi-
tion variables, including normal bowel sounds and
lar between groups [Table 1], with biliary tract anasto-
passage of flatus and bowel movement, were treated
mosis common in the early feeding group [14.54% (8)
as ordinal not continuous variables and recorded as
vs 12.72% (7), P > 0.05] and small intestine anasto-
occurring on a specific postoperative day. Patients were
mosis was common in traditional feeding [20% (11) vs
not given oral or rectal bowel stimulants after surgery.
16.36% (9), P > 0.05]. General endo tracheal anesthe-
Whether early oral feeding increased the postopera-
sia was used in all cases. Preoperative complications
tive complications or was it safe and well tolerated
did not differ between the groups. Interestingly, post-
was not very clear. In the early feeding group, the rate
operative complications did not differ significantly
of postoperative complications, even ileus did not dif-
between the groups [Table 2]. However, the incidence
fer from the conventional diet. The main outcome was
of postoperative ileus did not differ between the groups
to evaluate postoperative complications that included
(one patient in the early feeding group and one pa-
wound infection, leakage of anastomosis, obstruction,
tient in the traditional group, P value = 0.8 NS).
mesenteric emboli, upper GI bleeding, wound dehis-
Among the 110 participants, the overall incidence of
cence, prolonged ileus, and mortality. Ileus was de-
complication was 9.09% for the early feeding group
fined as hypoactive bowel sounds, abdominal disten-
and 16.36 for the traditional feeding group.
tion, and no passage of flatus or bowel movement withor without nausea or vomiting after the first postoper-
Most patients had active bowel sounds on the day of
surgery or the first postoperative day, flatus by the firstor second postoperative day, and bowel movement by
The patients had to meet all the criteria in both groups
the second or third postoperative day. The
mean ± standard deviation postoperative day whennormal bowel sounds are auscultated (0.5 ± 0.6 vs 0.5
Same as other studies,[4]–[7] evaluating the ileus, after
± 0.5 days, P = 0.65), flatus was passed (1.7±0.7 vs
Indian J Surg | August 2005 | Volume 67 | Issue 4
Early oral feeding gastrointestinal anastomosis: RCT
1.6 ± 0.8 days, P = 0.7), and first bowel movement
showed bowel activity before flatus was passed, which
reported (3.9 ± 0.7 vs 4.46 ± 1.2 days, P = 0.07),
illustrates that patients tolerate fluid secretions of 1–
early vs late feeding groups, respectively. The subjects
2 l from the stomach and pancreas immediately after
received similar amounts of pain medication, includ-
surgery. Studies also have shown tolerance to clear liq-
ing oral ibuprofen (2427 ± 1665 vs 2535 ± 1737 mg,
uids on postoperative day 1 after GI surgeries.[15],[16],[18]
P = 0.77) early vs late feeding group, respectively.
Marik and Zaloga conducted meta-analysis of prospec-
When data were stratified within feeding groups to
tive, randomized studies comparing early vs late en-
compare type of anastomosis, no significant differenc-
teral feeding demonstrating the benefits of early nutri-
es in any of the outcomes were noted including post-
tion.[4] However, the preferred feeding site for enteral
nutrition remains controversial.[5] Despite this fact,Seenu and Goel[6] showed that early oral feeding after
elective colorectal surgery is safe and can be toleratedby most patients. Similarly,[7] Difronzo et al.[12] demon-
The key finding in our study was that postoperative
strated a high tolerability (86.5%) to early postopera-
complications did not differ significantly between the
tive oral feeding after elective open colon resection.
two groups [Table 2]. Similarly, oral feeding was toler-
These studies were not exclusive to colorectal surgery.
ated with low morbidity following small or large bow-
Suehiro et al.[19] showed that early oral feeding after
el resections[9] and not associated with the occurrence
gastrectomy is safe and the incidence of complications
of anastomotic dehiscence.[10] However, patients un-
including anastomosis leak and wound infection oc-
dergoing elective colorectal resection can be managed
curred equally in both groups. Our study documents a
without postoperative NG catheter, starting oral feed-
further advance in postoperative treatment of patients
ing on the first postoperative day.[11] Interestingly, in
who have major abdominal anastomosis. It was found
older patients undergoing elective open-colon resec-
that by offering liquid 6 h after surgery, increased in-
tion, early feeding results in a short hospital stay and
cidence of ileus, rather than following a rigid proto-
low postoperative morbidity. The results are compara-
col. That finding is supported by Resnick et al.’s re-
ble to those reported for laparoscopy-assisted colecto-
view of postoperative ileus and documentation of nor-
my.[12] Some review literatures support safety of early
mal bowel physiology.[20] Also, there were no differ-
ences in postoperative complications, including,wound infection, wound dehiscence, leakage of anas-
The secondary outcome of our study was the incidence
tomosis, mesenteric embolus, obstruction, upper GI
of postoperative ileus in early feeding groups that was
similar to conventional diet. Postoperative ileus doesnot have a standard definition. Livingston and Passa-
Nausea and vomiting, however, occur more common-
ro[3] define ileus as the functional inhibition of pro-
ly after upper GI surgery than after resection of the
pulsive bowel activity, irrespective of the pathologic
small intestine and colon. However, there is no evi-
mechanism. The exact etiology of ileus is unknown,
dence that bowel rest and a period of starvation are
but it is believed to be more common after laparotomy
beneficial for healing of wounds and anastomotic in-
and procedures that enter the peritoneal cavity.[3] Many
factors are believed to contribute to it, including in-traoperative, bowel manipulation, anesthetic agent,
In our clinical experiment, there were no differences
peri operation narcotics, and postoperative sympathet-
ic hyperactivity.[3],[15] Postoperative ileus can result inaccumulation of gas and secretions leading to disten-
It is therefore concluded that early feeding is safe and
tion, emesis, pain, and longer hospital stay. Currently
well tolerated by patients undergoing bowel resection.
available therapies are supportive and include intra-
In addition, it is not associated with increased postop-
venous hydration and nasogastric suctioning.[3] Tradi-
erative GI complications including postoperative com-
tion dictates advancement of postoperative diet based
on physical signs of bowel function and not on post-operative GI physiology. Animal and human radiolog-
ical and physiologic studies do not support the tradi-tional practice of oral feeding based on auscultation of
Nicholas J Petrelli, Charles Cheng, Deborah Driscoll. Early Postoperative Oral Feeding After Colectomy; An Analysis of Factors
normal bowel sound and passage of flatus and bowel
That May Predict Failure. Annals of Surgical Oncology
movement.[3],[15],[16] After surgery, return of bowel func-
tion and motility usually occurs within 6–12 h in the
Cornelia S Carr, Eddie L, Paul Boulos. Randomized trial of
small bowel, 12–24 h in the stomach, and 48–72 h in
safety and efficacy of immediate postoperative enteral feeding
the colon.[17] Physiologic studies have found that myo-
in patients undergoing gastrointestinal resection. BMJ1996;312:869-71.
electric and motor activity in the stomach is not af-
Livingston EH, Passaro EP Jr, Postoperative ileus. Digest Dis
fected after abdominal surgery.[15] Schilder et al.[16]
Indian J Surg | August 2005 | Volume 67 | Issue 4
Marik PE, Zaloga G. Early enteral nutrition in acutely ill
a clinical review. Obstet Gynecol Surv 2000;55:571-3.
patients: a systematic review. Crit care Med 2001;29:2264-70.
14. Bisgaard T, Kehlet H. Early oral feeding after elective abdominal
Toulson DC,Maria I da silva, Rodrigo G. The impact of early
surgery- what are the issues? Nutrition 2002;18: 944-8.
nutrition on metabolic response and postoperative ileus.
15. Bufo AJ, Feldman S, Daniels GA, Lieberman RC. Early
Current Opinion in Clinical Nutrition & Metabolic Care
postoperative feeding. Dis Colon Rectum 1994;37:1260-5.
16. Schilder JM, Hurteau JA, Look KY, Moore DH, Raff G, Stehman
Seenu V, Goel Ak. Early feeding after elective colorectal
FB, et al. A prospective controlled trial of early postoperative
surgery: is it safe. Trop Gastroenterol 1995;16:72-3.
oral intake following major abdominal gynecologic surgery.
Petrelli NJ, Cheng C, Driscoll D, Rodriguez-Bigas MA. Early
postoperative oral feeding after colectomy: an analysis of
17. Finan MA, Barton DP, Fiorica JV, Hoffman MS, Roberts WS,
factors that may predict failure. Ann Surg Oncol 2001; 8:796-
Gleeson N, et al. Ileus following gynecology surgery. South
Burrows WR, Gingo AJ Jr, Rose SM, Zwick SI, Kosty DL, Dierker
18. Reissman P, Teoh TA, Cohen SM, Weiss EG, Nogueras IJ,
LJ, et al. Safety and efficacy of early postoperative solid food
Wexner SD. Is early oral feeding is safe after elective colorectal
consumption after cesarian section. J Reported Med
surgery? A Prospective randomized trial. Ann Surg 1995;
Bohm B, Haase O, Hofmann H, Heine G, Junghans T, Muller
19. Suehiro T, Matasumata T, Shikada Y, Sugimachi K. Accelerated
JM. Tolerance of early oral feeding after operation of the lower
rehabilitation with early postoperative oral feeding following
gastrointestinal tract Chirurg 2000;71:955-62.
10. De Aguilar-Nascimento JE, Goelzer J. Early feeding after
20. Resnick J, Greenwald DA, Brandt LJ. Dealayed gastric emptying
intestinal anastomosis: risks or benefits? Rev Assoc Med Bras
and postoperative ileus after nongastric abdominal surgery:
Part 1. AM J Gastroentrol 1997;92:751-62.
11. Feo CV, Romanini B, Sortini D, Ragazzi R, Zamboni P, Pancini
21. Schroeder D, Gillanders L, Mahr K, Hill GL. Effects of
GC, et al. Early oral feeding after colorectal resection: a
immediate postoperative enteral nutrition on body
randomized controlled trial. ANZ J Surg 2004;74:296-7.
composition, muscle function and wound healing. J Parenter
12. Difronzo LA, Yamin N, Patel K, O’Connel TX. Benefits of early
feeding and early hospital discharge in elderly patients undergoing
22. Haydock DA, Hill GA. Impaired wound healing in patients
open colon resection. J Am Coll Surg 2003;197:747-52.
with varying degree of malnutrition. J Parenter Enteral Nutr
13. Johnson Casto C, Krammer J, Drake J. Postoperative feeding :
Indian J Surg | August 2005 | Volume 67 | Issue 4
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