Colorectal surgery patients prefer simple solid foods to clear fluids as the first postoperative meal

Tolerance to and Postoperative Outcomes With Early Oral Feeding Following Elective Bowel Surgery: A Systematic Review

Although practice guidelines recommend resuming oral feeding immediately after gastrointestinal surgery, many practitioners remain reluctant to order early oral feeding (EOF). Therefore, this review aimed to clarify the tolerance to and postoperative outcomes with EOF among patients undergoing bowel surgery. A systematic review of the literature published between January 1990 and July 2022 with the time of oral intake (early or delayed until resolution of ileus) as the exposure variable was conducted using PubMed and Scopus databases. Outcomes of interest included tolerance to EOF and postoperative adverse effects or complications. After screening 1,667 research articles, 18 randomized control trials, six prospective case series, and four cohort studies met our inclusion criteria, collectively representing data from 2,647 patients in eleven countries. These studies indicate that while most patients tolerate EOF, 5-25% may not tolerate EOF until the fourth postoperative day (POD). Moreover, EOF, at best, has no advantage over delayed feeding in terms of vomiting, nausea, nasogastric tube requirement, or other postoperative complications. In addition, early return of bowel function, lower risk of diarrhea, and lower pain score with EOF are inconsistently reported, and shorter hospitalization with EOF may be limited to those who tolerate oral feeding on POD 0 or 1. Nevertheless, shorter hospitalization with EOF could reduce the cost of hospitalization. A substantial number of patients may not be able to tolerate oral feeding after bowel surgery until POD 4, and in patients who tolerate EOF, the only clear benefit is a shorter length of hospitalization.

The Problem of Appetite Loss After Major Abdominal Surgery

Objective:

To systematically review the problem of appetite loss after major abdominal surgery.

Summary of Background Data:

Appetite loss is a common problem after major abdominal surgery. Understanding of etiology and treatment options is limited.

Methods:

We searched Medline, Cochrane Central Register of Controlled Trials, and Web of Science for studies describing postoperative appetite loss. Data were extracted to clarify definition, etiology, measurement, surgical influence, pharmacological, and nonpharmacological treatment. PROSPERO registration ID: CRD42021224489.

Results:

Out of 6144 articles, we included 165 studies, 121 of which were also analyzed quantitatively. A total of 19.8% were randomized, controlled trials (n = 24) and 80.2% were nonrandomized studies (n = 97). The studies included 20,506 patients undergoing the following surgeries: esophageal (n = 33 studies), gastric (n = 48), small bowel (n = 6), colon (n = 27), rectal (n = 20), hepatobiliary (n = 6), and pancreatic (n = 13). Appetite was mostly measured with the Quality of Life Questionnaire of the European Organization for Research and Treatment of Cancer (EORTC QLQ C30, n = 54). In a meta-analysis of 4 randomized controlled trials gum chewing reduced time to first hunger by 21.2 hours among patients who had bowel surgery. Other reported treatment options with positive effects on appetite but lower levels of evidence include, among others, intravenous ghrelin administration, the oral Japanese herbal medicine Rikkunshito, oral mosapride citrate, multidisciplin-ary-counseling, and watching cooking shows. No studies investigated the effect of well-known appetite stimulants such as cannabinoids, steroids, or megestrol acetate on surgical patients.

Conclusions:

Appetite loss after major abdominal surgery is common and associated with increased morbidity and reduced quality of life. Recent studies demonstrate the influence of reduced gastric volume and ghrelin secretion, and increased satiety hormone secretion. There are various treatment options available including level IA evidence for postoperative gum chewing. In the future, surgical trials should include the assessment of appetite loss as a relevant outcome measure.

Postoperative Dietary Intake Achievement: A Secondary Analysis of a Randomized Controlled Trial

Sufficient postoperative dietary intake is crucial for ensuring a better surgical outcome. This study aimed to investigate the postoperative dietary intake achievement and predictors of postoperative dietary intake among gynecologic cancer patients. A total of 118 participants were included in this secondary analysis. Postoperative dietary data was pooled and re-classified into early postoperative dietary intake achievement (EDIA) (daily energy intake (DEI) ≥ 75% from the estimated energy requirement (EER)) and delay dietary intake achievement (DDIA) (DEI < 75% EER) There was a significant difference in postoperative changes in weight (p = 0.002), muscle mass (p = 0.018), and handgrip strength (p = 0.010) between the groups. Postoperative daily energy and protein intake in the EDIA was significantly greater than DDIA from operation day to discharged (p = 0.000 and p = 0.036). Four significant independent postoperative dietary intake predictors were found: preoperative whey protein-infused carbohydrate loading (p = 0.000), postoperative nausea vomiting (p = 0.001), age (p = 0.010), and time to tolerate clear fluid (p = 0.016). The multilinear regression model significantly predicted postoperative dietary intake, F (4, 116) = 68.013, p = 0.000, adj. R² = 0.698. With the four predictors’ recognition, the integration of a more specific and comprehensive dietitian-led supportive care with individualized nutrition intervention ought to be considered to promote functional recovery.

From clinical guidelines to practice: The nutrition elements for enhancing recovery after colorectal surgery

The Enhanced Recovery After Surgery (ERAS) Care System improves patient outcomes. The ERAS Protocol describes multimodal, evidence-based processes that are bundled into >20 care elements, and the ERAS Implementation Program provides strategies to guide the successful adoption of the care elements. Although formal training is essential to implement ERAS correctly, with this article we aim to bridge the gap between the nutritionally relevant care elements of the protocol and their implementation for colorectal surgery. This article also describes how dietitians can support optimal patient outcomes by playing an active role in implementing, monitoring, and evaluating ERAS practices.

Patient-Controlled Nutrition After Abdominal Surgery: Novel Concept Contrary to Surgical Dogma

Purpose

According to surgical dogma, patients who are recovering from general anesthesia after abdominal surgery should begin with a clear liquid diet, progress to a full liquid diet and then to a soft diet before taking regular meals. We propose patient-controlled nutrition (PCN), which is a novel concept in postoperative nutrition after abdominal surgery.

Methods

A retrospective pilot study was conducted to evaluate the feasibility and effects of PCN. This study was carried out with a total of 179 consecutive patients who underwent a laparoscopic appendectomy between August 2014 and July 2016. In the PCN group, diet was advanced depending on the choice of the patients themselves; in the traditional group, diet was progressively advanced to a full liquid or soft diet and then a regular diet as tolerated. The primary endpoints were time to tolerance of regular diet and postoperative hospital stay.

Results

Time to tolerance of a regular diet (P < 0.001) and postoperative hospital stay (P < 0.001) showed statistically significant differences between the groups. Multivariate analysis using linear regression showed that the traditional nutrition pattern was the only factor associated with postoperative hospital stay (P < 0.001). Multivariate analysis using logistic regression showed that traditional nutrition was the only risk factor associated with prolonged postoperative hospital stay (≥3 days).

Conclusion

After abdominal surgery, PCN may be a feasible and effective concept in postoperative nutrition. In our Early Recovery after Surgery program, our PCN concept may reduce the time to tolerance of a regular diet and shorten the postoperative hospital stay.

A systematic review of feeding practices among postoperative patients: is practice in-line with evidenced-based guidelines?

BACKGROUND

Early oral feeding after surgery is best practice among adult, noncritically ill patients. Evidenced-based guidelines (EBG) recommend commencing liquid and solid feeding within 24 h of surgery to improve patient (e.g. reduced morbidity) and hospital (e.g. reduced length of stay) outcomes. Whether these EBG are adhered to in usual clinical practice remains unknown. The present study aimed to identify the time to commencement of first oral feed (liquid or solid) and first solid feed among postoperative, noncritically ill, adult patients.

METHODS

MEDLINE, CINAHL, SCOPUS and Web of Science databases were searched from inception to June 2016 for observational studies reporting liquid and/or solid feeding practices among postoperative patients. Studies reporting a mean/median time to first feed or first solid feed within 24 h of surgery or where ≥75% of patients were feeding by postoperative day one were considered in-line with EBG.

RESULTS

Of 5826 articles retrieved, 29 studies were included. Only 40% and 22% of studies reported time to first feed and time to first solid feed in-line with EBG, respectively. Clear and free liquids were the first diet types commenced in 86% of studies. When solids were commenced, 44% of studies reported using various therapeutic diet types (e.g. light) prior to the commencement of a regular diet. Patients who underwent gastrointestinal procedures appeared more likely to experience delayed postoperative feeding.

CONCLUSIONS

Our findings demonstrate a gap between postoperative feeding evidence and its practical application. This information provides a strong rationale for interventions targeting improved nutritional care following surgery.

Early use of low residue diet is superior to clear liquid diet after elective colorectal surgery: a randomized controlled trial

OBJECTIVE

Compare the feasibility and patient tolerance to either a clear fluid (CF) or low residue diet (LRD) started on postoperative day (POD) 1 after elective colorectal surgery.

BACKGROUND

Diet advancement after surgery traditionally starts gradually with liquids, on the basis of fears that early solid intake may increase nausea, vomiting, and overall complications. A randomized controlled trial comparing LRD and CF on POD 1 was performed.

METHODS

111 elective colorectal surgery patients were randomized to CF (n = 57) or LRD (n = 54). The primary end point was vomiting on POD 2. Secondary endpoints included nausea score, days to flatus, length of hospital stay (LOS), and postoperative morbidity.

RESULTS

Patient characteristics, surgical technique, intraoperative characteristics, and postoperative opioid use were similar between study arms. CF versus LRD results were as follows: POD2 vomiting (28% vs 14%; P = 0.09), and significant increase in mean nausea score (4.7 vs 3.5; P = 0.01), days to flatus (4.8 vs 3.7 days; P = 0.04), and LOS (7.0 vs 5.0 days; P = 0.01). LOS remained significantly shorter even after adjusting for significant covariates (laparoscopic technique, surgical site, postoperative comorbidity, stoma, and nasogastric tube) with LRD patients having an adjusted 1.4-day decrease in LOS (P < 0.01). There was no significant difference in postoperative morbidity between study arms. Multivariate analysis of all secondary endpoints confirmed an overall significant improvement in outcomes for LRD vs CF (P < 0.01).

CONCLUSIONS

LRD, rather than CF, on POD1 after colorectal surgery is associated with less nausea, faster return of bowel function, and a shorter hospital stay without increasing postoperative morbidity.

Changes in taste preference after colorectal surgery: A longitudinal study

BACKGROUND & AIMS

Nutrition is a key component of surgical enhanced recovery programmes. However, alterations in food preferences are often reported as reasons for patients not eating in the early postoperative period. We hypothesised that taste preferences are altered in the early postoperative period and this dysgeusia affects patients' food choices during this critical time.

METHODS

This is a longitudinal study looking at taste preferences of patients recovering from surgery. Patients undergoing colonic resections were recruited. Using visual analogue scales participants completed a questionnaire, taste tests and preference scoring of food images for the 6 groups of taste (bitter, salty, savoury, sour, spicy and sweet) preoperatively and on postoperative days 1-3. Patients were also offered snacks postoperatively, which represented foods from the six groups and consumption was measured. Differences from baseline were assessed using the Friedman's and Wilcoxon tests.

RESULTS

31 patients were studied. In the immediate postoperative period participants reported deterioration in their sense of taste (p ≤ 0.001), increased nausea (p < 0.001) and hunger (p = 0.03). Sweet, savoury and spicy tastes were the most popular during the perioperative period. However, only palatability for salty taste increased (p = 0.001) following surgery. The highest rated images were for savoury food with only the ratings for salty food increasing after surgery (p < 0.05). These findings concurred with the sweet, savoury and salty snacks being the most consumed foods in the postoperative period. Bitter, sour and spicy foods were the least frequently consumed.

DISCUSSION

This is the first study to investigate postsurgical patients' food preferences. A consistent change in all the individual tastes with the exception of salty in the postoperative period was observed. The most desirable tastes were for savoury and sweet, reflecting patients' preoperative preferences. An improved understanding of taste may improve the resumption of eating after colonic surgery.

Perioperative nutritional management in digestive tract surgery

PURPOSE OF REVIEW

This article reviews the recent research on perioperative nutrition in digestive tract surgery in the light of modern perioperative care principles, that is, enhanced recovery after surgery (ERAS). Four major directions of research emerge: detecting malnutrition, perioperative hyperglycemia/insulin resistance, enteral/parenteral nutrition and immunonutrition.

RECENT FINDINGS

For preoperative nutritional screening/assessment, current data cannot single out superiority for SGA questionnaire, nutritional risk score, Reilly's nutritional risk score or nutritional risk index in the ability to predict nutrition-related complications. The use of ERAS elements to reduce surgical stress and preclude postoperative insulin resistance has recently been clearly linked to reductions in adverse outcomes. There are specific situations in which enteral nutrition is contraindicated and criterias for preoperative and postoperative parenteral nutrition in undernourished patients are defined in guidelines recently available. Several controlled randomized studies and systematic reviews indicate that immune nutrition formulas reduce both morbidity and length of stay after major abdominal surgery.

SUMMARY

To reduce surgical stress, insulin resistance, unnecessary protein losses and postoperative complications, the use of an ERAS protocol is important. Current data shows that the use of perioperative immunonutrition diets for major abdominal surgery is beneficial. Further research on nutritional assessment tools to predict who is at risk for postoperative complications is needed.