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Canzan F, Longhini J, Caliaro A, Cavada ML, Mezzalira E, Paiella S, Ambrosi E. The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: a systematic review and meta-analysis of randomized clinical trials. Front Nutr 2024; 11:1369141. [PMID: 38818132 PMCID: PMC11137291 DOI: 10.3389/fnut.2024.1369141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/29/2024] [Indexed: 06/01/2024] Open
Abstract
Background and aims Postoperative ileus is a frequent condition, leading to complications and a longer hospital stay. Few studies have demonstrated the benefit of early oral feeding in preventing ileus after gastrointestinal surgery. This study aims to evaluate the efficacy of early versus delayed oral feeding on the recovery of intestinal motility, length of hospital stay, and complications. Methods We conducted a systematic review and meta-analysis of randomized control trials, searching PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and the ClincalTrials.gov until 31 December 2022. We evaluated the first passage of the stool, the first flatus, complications, length of postoperative stay, and vomiting. We assessed the risk of bias using the Cochrane risk of bias tool (version 2) for randomized trials and the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Results We included 34 studies with a median sample size of 102 participants. With a moderate certainty of the evidence, the early oral feeding may reduce the time taken for the first passage of the stool (MD -0.99 days; CI 95% -1.25, -0.72), the first flatus (MD -0.70 days; CI 95% -0.87, -0.53), and the risk of complications (RR 0.69; CI 95% 0.59-0.80), while with a low certainty of evidence, it may reduce the length of stay (MD -1.31 days; CI 95% -1.59, -1.03). However, early feeding likely does not affect the risk of vomiting (RR 0.90; CI 95% 0.68, 1.18). Conclusion This review suggests that early oral feeding after gastrointestinal surgery may lead to a faster intestinal recovery, shorter postoperative stays, and fewer complications. However, careful interpretation is needed due to high heterogeneity and the moderate-to-low quality of evidence. Future studies should focus on the type and starting time of early oral feeding.
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Affiliation(s)
- Federica Canzan
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Jessica Longhini
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Arianna Caliaro
- Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | | | - Elisabetta Mezzalira
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Elisa Ambrosi
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Madan S, Sureshkumar S, Anandhi A, Gurushankari B, Keerthi AR, Palanivel C, Kundra P, Kate V. Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care in Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial. J Gastrointest Surg 2023; 27:2667-2675. [PMID: 37620661 DOI: 10.1007/s11605-023-05803-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/05/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Practices such as prolonged preoperative fasting, bowel preparation, delayed ambulation and resumption of orals result in morbidity in 15-20% of stoma reversal cases which can be improved by Enhanced Recovery After Surgery (ERAS) pathways. AIM To evaluate the safety, feasibility and efficacy of ERAS pathway in patients undergoing elective loop ileostomy or colostomy reversal surgery METHODS: This was an open-labeled, superiority randomized controlled trial in which patients undergoing loop ileostomy or colostomy reversal were randomized to standard or ERAS care. Patients with ASA class ≥3, needing laparotomy for stoma reversal, cardiac, renal and neurological illnesses were excluded. Components of ERAS protocol included pre-operative carbohydrate loading, avoidance of mechanical bowel preparation, goal directed fluid therapy, avoidance of long-acting opioid anesthetics or analgesics, avoidance of drains, urinary catheter or nasogastric tube, early mobilization and early enteral feeding. The primary outcome was length of stay (LOS) while the secondary outcomes were postoperative recovery and morbidity parameters. RESULTS Forty patients each were randomized to standard care and ERAS. Demographic and laboratory parameters between the two groups were comparable. ERAS group patients had significantly reduced LOS (5.3 ± 0.3 vs 7 ± 2.6; mean difference: 1.73 ± 0.98; p=0.0008). Functional recovery was earlier in the ERAS group compared to the standard care group, such as early resolution of ileus (median-2 days; p<0.001), time to first stool (median-3 days; p=0.0002), time to the resumption of liquid diet (median-3 days; p<0.001) and solid diet (median-4 days; p<0.001). Surgical site infections (SSI) were significantly lesser in ERAS group (12.5% vs 32.5%; p=0.03) while postoperative nausea/vomiting (p=0.08), pulmonary complications (p=0.17) and urinary tract infections (p=0.56) were comparable in both groups. CONCLUSION ERAS pathways are feasible, safe and significantly reduces LOS in patients undergoing elective loop ileostomy or colostomy reversal surgery.
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Affiliation(s)
- Shivakumar Madan
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Sathasivam Sureshkumar
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Amaranathan Anandhi
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | | | - Andi Rajendharan Keerthi
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Chinnakali Palanivel
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Pankaj Kundra
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Vikram Kate
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
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Mvoula L, Irizarry E. Tolerance to and Postoperative Outcomes With Early Oral Feeding Following Elective Bowel Surgery: A Systematic Review. Cureus 2023; 15:e42943. [PMID: 37667705 PMCID: PMC10475250 DOI: 10.7759/cureus.42943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/06/2023] Open
Abstract
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.
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Affiliation(s)
- Lord Mvoula
- Surgery, Lincoln Medical and Mental Health Center, Bronx, USA
| | - Evelyn Irizarry
- Colorectal Surgery, Lincoln Medical and Mental Health Center, Bronx, USA
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He LB, Liu MY, He Y, Guo AL. Nutritional status efficacy of early nutritional support in gastrointestinal care: A systematic review and meta-analysis. World J Gastrointest Surg 2023; 15:953-964. [PMID: 37342843 PMCID: PMC10277940 DOI: 10.4240/wjgs.v15.i5.953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/20/2023] [Accepted: 03/31/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Gastrointestinal surgery is a complicated process used to treat many gastrointestinal diseases, and it is associated with a large trauma: Most patients often have different degrees of malnutrition and immune dysfunction before surgery and are prone to various infectious complications during postoperative recovery, thus affecting the efficacy of surgical treatment. Therefore, early postoperative nutritional support can provide essential nutritional supply, restore the intestinal barrier and reduce complication occurrence. However, different studies have shown different conclusions.
AIM To assess whether early postoperative nutritional support can improve the nutritional status of patients based on literature search and meta-analysis.
METHODS Articles comparing the effect of early nutritional support and delayed nutritional support were retrieved from PubMed, EMBASE, Springer Link, Ovid, China National Knowledge Infrastructure, China Biology Medicine databases. Notably, only randomized controlled trial articles were retrieved from the databases (from establishment date to October 2022). The risk of bias of the included articles was determined using Cochrane Risk of Bias V2.0. The outcome indicators, such as albumin, prealbumin, and total protein, after statistical intervention were combined.
RESULTS Fourteen literatures with 2145 adult patients undergoing gastrointestinal surgery (1138 patients (53.1%) receiving early postoperative nutritional support and 1007 patients (46.9%) receiving traditional nutritional support or delayed nutritional support) were included in this study. Seven of the 14 studies assessed early enteral nutrition while the other seven studies assessed early oral feeding. Furthermore, six literatures had "some risk of bias," and eight literatures had "low risk". The overall quality of the included studies was good. Meta-analysis showed that patients receiving early nutritional support had slightly higher serum albumin levels, than patients receiving delayed nutritional support [MD (mean difference) = 3.51, 95%CI: -0.05 to 7.07, Z = 1.93, P = 0.05]. Also, patients receiving early nutritional support had shorter hospital stay (MD = -2.29, 95%CI: -2.89 to -1.69), Z = -7.46, P < 0.0001) shorter first defecation time (MD = -1.00, 95%CI: -1.37 to -0.64), Z = -5.42, P < 0.0001), and fewer complications (Odd ratio = 0.61, 95%CI: 0.50 to 0.76, Z = -4.52, P < 0.0001) than patients receiving delayed nutritional support.
CONCLUSION Early enteral nutritional support can slightly shorten the defecation time and overall hospital stay, reduce complication incidence, and accelerate the rehabilitation process of patients undergoing gastrointestinal surgery.
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Affiliation(s)
- Li-Bin He
- Department of Anesthesia and Surgery, Xiang'an Hospital Affiliated to Xiamen University, Xiamen 361100, Fujian Province, China
| | - Ming-Yuan Liu
- Department of Endocrine, Xiang'an Hospital, Xiamen University, Xiamen 361100, Fujian Province, China
| | - Yue He
- Department of Rheumatology and Immunology, Run Run Shaw Hospital, Medical College of Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Ai-Lin Guo
- Department of Cardiac Surgery, Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361100, Fujian Province, China
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MacVicar E, Cullen F, Kastora SL, Parnaby C, Mackay C, Ramsay G. A systematic review of the impact of post-operative oral fluid intake on ileus following elective colorectal surgery. Int J Surg 2022; 103:106651. [PMID: 35623600 DOI: 10.1016/j.ijsu.2022.106651] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Ileus (delayed return of bowel function after surgery) is one of the highest priority research questions in modern day colorectal practice. Current Enhanced Recovery After Surgery (ERAS) guidance either does not include a specific recommendation for volume of postoperative oral fluids/foodstuffs or suggests ad-lib fluids. It is unclear if the volume of intake affects ileus rates. This systematic review aimed to determine the optimal fluid volume for patients to consume day one after elective colorectal surgery. METHODS The literature was searched across seven databases, 23/09/2020. Randomised controlled trials of adults undergoing elective colorectal surgery, comparing oral intake postoperatively were eligible for inclusion. Two blinded reviewers assessed papers with disagreements resolved by a third independent reviewer. Main outcomes were resolution of postoperative ileus and length of hospital stay. Secondary outcomes included vomiting, mortality and complications. RESULTS Of 2175 screened papers, eight were eligible for inclusion. All studies gave a clear liquid diet postoperatively. The comparison groups followed a traditional nil-by-mouth approach. All studies showed a minor reduction in postoperative ileus and hospital stay in the intervention group, but we are unable to determine the optimal postoperative oral fluid volume. The low number and poor quality of studies was a significant limitation. None of the trials were conducted within an ERAS protocol: only 883 patients were included in total. CONCLUSIONS From the current literature it is unclear how postoperative oral fluid volume intake affects gastrointestinal function and ileus in elective colorectal surgical patients. This remains an important area for further research.
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Affiliation(s)
- Emma MacVicar
- University of Aberdeen Medical School, Aberdeen, UK.
| | - Fraser Cullen
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK.
| | | | - Craig Parnaby
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK.
| | - Craig Mackay
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK.
| | - George Ramsay
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK; Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
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Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Surgery for Perforation Peritonitis-a Randomized Controlled Trial. J Gastrointest Surg 2022; 26:39-49. [PMID: 34755312 DOI: 10.1007/s11605-021-05184-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways have an uncertain role in emergencies. To the best of our knowledge, there are no trials studying ERAS in perforation peritonitis across the GI tract, despite it being a common surgical emergency. AIMS To evaluate the safety, feasibility and efficacy of adapted ERAS protocols in emergency laparotomy for perforation peritonitis. METHODS This was an open-labeled, superiority randomized controlled trial conducted between October 2018 and June 2020 in patients with perforation peritonitis assigned to standard care or adapted ERAS groups using block randomization. Patients with refractory shock, ASA class 4E, localized peritonitis, etc. were excluded. Components of the adapted ERAS protocol included epidural analgesia, goal-directed fluid therapy, avoidance of opioids, early mobilization, early removal of tubes, drains and catheters, and early enteral feeding. The primary outcome, length of hospitalization (LOH), and the secondary outcomes, functional recovery parameters, were analyzed between both the groups. RESULTS A total of 59 patients in standard care group and 61 patients in adapted ERAS group were included and randomized, and were comparable in terms of demographic and clinico-pathological characteristics. LOH in adapted ERAS group was shorter by 3 days (p < 0.001), and patients showed reduction in time (days) to first flatus (2.84 vs 4.22, p < 0.001), first stool (4.38 vs 6.08, p < 0.001) and solid diet (4.67 vs 8.37, p < 0.001). Post-operative nausea, vomiting (p = 0.05) and surgical site infections (p < 0.001) were reduced in adapted ERAS group. Pre-existing malignancy, respiratory complications and high output stoma were reasons for delayed discharge in adapted ERAS group. CONCLUSION Adapted ERAS pathways considerably reduce LOH in patients undergoing emergency surgery for perforation peritonitis, with no adverse events in 30 days after discharge. TRIAL REGISTRATION Registered at http://ctri.nic.in/Clinicaltrials/login.php (CTRI/2019/02/017537).
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Pu H, Heighes PT, Simpson F, Wang Y, Liang Z, Wischmeyer P, Hugh TJ, Doig GS. Early oral protein-containing diets following elective lower gastrointestinal tract surgery in adults: a meta-analysis of randomized clinical trials. Perioper Med (Lond) 2021; 10:10. [PMID: 33752757 PMCID: PMC7986268 DOI: 10.1186/s13741-021-00179-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 02/22/2021] [Indexed: 02/08/2023] Open
Abstract
Background Although current guidelines make consensus recommendations for the early resumption of oral intake after surgery, a recent comprehensive meta-analysis failed to identify any patient-centered benefits. We hypothesized this finding was attributable to pooling studies providing effective protein-containing diets with ineffective non-protein liquid diets. Therefore, the aim of this paper was to investigate the safety and efficacy of early oral protein-containing diets versus later (traditional) feeding after elective lower gastrointestinal tract surgery in adults. Methods PubMed, Embase, and the China National Knowledge Infrastructure databases were searched from inception until 1 August 2019. Reference lists of retrieved studies were hand searched to identify randomized clinical trials reporting mortality. No language restrictions were applied. Study selection, risk of bias appraisal and data abstraction were undertaken independently by two authors. Disagreements were settled by obtaining an opinion of a third author. Majority decisions prevailed. After assessment of underlying assumptions, a fixed-effects method was used for analysis. The primary outcome was mortality. Secondary outcomes included surgical site infections, postoperative nausea and vomiting, serious postoperative complications and other key measures of safety and efficacy. Results Eight randomized clinical trials recruiting 657 patients were included. Compared with later (traditional) feeding, commencing an early oral protein-containing diet resulted in a statistically significant reduction in mortality (odds ratio [OR] 0.31, P = 0.02, I2 = 0%). An early oral protein-containing diet also significantly reduced surgical site infections (OR 0.39, P = 0.002, I2 = 32%), postoperative nausea and vomiting (OR 0.62, P = 0.04, I2 = 37%), serious postoperative complications (OR 0.60, P = 0.01, I2 = 25%), and significantly improved other major outcomes. No harms attributable to an early oral protein-containing diet were identified. Conclusions The results of this systematic review can be used to upgrade current guideline statements to a grade A recommendation supporting an oral protein-containing diet commenced before the end of postoperative day 1 after elective lower gastrointestinal surgery in adults. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-021-00179-3.
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Affiliation(s)
- Hong Pu
- Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia.,Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Philippa T Heighes
- Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia
| | - Fiona Simpson
- Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia.,Nutrition Services, Royal North Shore Hospital, Sydney, Australia
| | - Yaoli Wang
- Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia.,Department of Critical Care Medicine, Daping Hospital, Chongqing, People's Republic of China
| | - Zeping Liang
- Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia.,Department of Critical Care Medicine, Daping Hospital, Chongqing, People's Republic of China
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke University, Durham, NC, USA
| | - Thomas J Hugh
- Upper GI Surgical Department, Royal North Shore Hospital and the University of Sydney, Sydney, Australia
| | - Gordon S Doig
- Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia.
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The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018. Surg Today 2020; 51:1-31. [PMID: 33320283 PMCID: PMC7788056 DOI: 10.1007/s00595-020-02181-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/27/2022]
Abstract
Background The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide. Methods We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies. Results There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese. Conclusions The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients. Electronic supplementary material The online version of this article (10.1007/s00595-020-02181-6) contains supplementary material, which is available to authorized users.
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Saurabh K, Sureshkumar S, Mohsina S, Mahalakshmy T, Kundra P, Kate V. Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Small Bowel Surgery: a Randomized Controlled Trial. J Gastrointest Surg 2020; 24:2077-2087. [PMID: 32632732 DOI: 10.1007/s11605-020-04684-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency laparotomy for small bowel pathologies comprises a significant number of all emergency surgeries. Application of evidence-based adapted enhanced recovery after surgery (ERAS) protocol can potentially improve the perioperative outcome in these procedures. AIMS To determine the feasibility, safety, and efficacy of adapted ERAS pathway in emergency small bowel surgery. METHODOLOGY This was a single-center, prospective, open-labeled, superiority, randomized controlled trial. Patients suspected to have small bowel pathology by the emergency surgical team were randomized preoperatively into standard care and adapted ERAS group. Patients with American Society of Anesthesiologist class ≥ 3, polytrauma patients with associated other intra-abdominal organ injuries, duodenal ulcer perforations, patients presenting with refractory shock, and pregnant patients were excluded. Primary outcome parameter was the length of hospitalization (LOH). Morbidity and other functional recovery parameters were also assessed. RESULTS Thirty-five patients were included in the adapted ERAS and standard care group. The laboratory and demographic variables were comparable. Patients in the ERAS group had significantly earlier recovery (days) in terms of first fluid diet (1.48 ± 0.18, p < 0.001), solid diet (2.11 ± 0.17, p < 0.001), time to first flatus (1.25 ± 0.24, p < 0.001), and first stool (1.8 ± 0.27, p < 0.001). Postoperative nausea, vomiting (RR 0.69, p = 0.19), pulmonary complications (RR 0.38, p = 0.16), superficial (RR 0.79, p = 0.33), and deep surgical site infections (RR 0.65, p = 0.39) were similar. Compared with the standard care group, ERAS group had significantly shorter LOH (8 ± 0.38 vs. 10.83 ± 0.42; Mean difference, 2.83 ± 0.56; p < 0.001). CONCLUSION Adapted ERAS pathways are feasible, safe, and significantly reduces the LOH in select patients undergoing emergency small bowel surgery.
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Affiliation(s)
- Kumar Saurabh
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Sathasivam Sureshkumar
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Subair Mohsina
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Thulasingam Mahalakshmy
- Department of Preventive Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Pankaj Kundra
- Anesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Vikram Kate
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India.
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10
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Navez J, Hubert C, Dokmak S, Frick De La Maza I, Tabchouri N, Benoit O, Hermand H, Zech F, Gigot JF, Sauvanet A. Early Versus Late Oral Refeeding After Pancreaticoduodenectomy for Malignancy: a Comparative Belgian-French Study in Two Tertiary Centers. J Gastrointest Surg 2020; 24:1597-1604. [PMID: 31325133 DOI: 10.1007/s11605-019-04316-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/19/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the era of fast-track surgery, because pancreaticoduodenectomy (PD) carries a significant morbidity, surgeons hesitate to begin early oral feeding and achieve early discharge. We compared the outcome of two different approaches to the postoperative management of PD in two tertiary centers. METHODS Of patients having undergone PD for malignancy from 2008 to 2017, 100 patients who received early postoperative oral feeding (group A) were compared to 100 patients from another center who received early enteral feeding and a delayed oral diet (group B). Surgical indication and approach and type of pancreatic anastomosis were similar between both groups. Postoperative outcomes were retrospectively reviewed. RESULTS Patient characteristics were similar between both groups, except significantly more neoadjuvant treatment in group A (A = 20% vs. B = 9%, p < 0.01). Mortality rates were 3% and 4% in groups A and B, respectively (p = 0.71). The rate of severe postoperative morbidity was significantly lower in group A (13% vs. 26%, p = 0.02), resulting in a lower reoperation rate (p < 0.01). Delayed gastric emptying and clinically relevant pancreatic fistula were similar between both groups but chyle leaks were more frequent in group A (10% vs. 3%, p = 0.04). The median hospital stay was shorter in group A (16 vs. 20 days, p < 0.01). CONCLUSION In the present study, early postoperative oral feeding after PD was associated with a shorter hospital stay and did not increase severe postoperative morbidity or the rate of pancreatic fistula. However, it resulted in more chyle leaks and did not prevent delayed gastric emptying.
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Affiliation(s)
- Julie Navez
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Catherine Hubert
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Safi Dokmak
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Isadora Frick De La Maza
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Nicolas Tabchouri
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Olivier Benoit
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Hélène Hermand
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Francis Zech
- Institute of Experimental and Clinical Research, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Jean-François Gigot
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Alain Sauvanet
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France.
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Promotility agents for the treatment of ileus in adult surgical patients: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2020; 87:922-934. [PMID: 31136527 DOI: 10.1097/ta.0000000000002381] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ileus is a common challenge in adult surgical patients with estimated incidence to be 17% to 80%. The main mechanisms of the postoperative ileus pathophysiology are fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation. Management includes addressing the underlying cause and supportive care. Multiple medical interventions have been proposed, but effectiveness is uncertain. A working group of the Eastern Association for the Surgery of Trauma aimed to evaluate the effectiveness of metoclopramide, erythromycin, and early enteral nutrition (EEN) on ileus in adult surgical patients and to develop recommendations applicable in a daily clinical practice. METHODS Literature search identified 45 articles appropriate for inclusion. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied to evaluate the effect of metoclopramide, erythromycin, and EEN on the resolution of ileus in adult surgical patients based on selected outcomes: return of normal bowel function, attainment of enteral feeding goal, and hospital length of stay. The recommendations were made based on the results of a systematic review, a meta-analysis, and evaluation of levels of evidence. RESULTS The level of evidence for all PICOs was assessed as low. Neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus. Analyses of 32 randomized controlled trials showed that EEN facilitates return of normal bowel function, achieving enteral nutrition goals, and reducing hospital length of stay. CONCLUSION In patients who have undergone abdominal surgery, we strongly recommend EEN to expedite resolution of Ileus, but we cannot recommend for or against the use of either metoclopramide or erythromycin to hasten the resolution of ileus in these patients. LEVEL OF EVIDENCE Type of Study Therapeutic, level II.
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12
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Herbert G, Perry R, Andersen HK, Atkinson C, Penfold C, Lewis SJ, Ness AR, Thomas S. Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications. Cochrane Database Syst Rev 2019; 7:CD004080. [PMID: 31329285 PMCID: PMC6645186 DOI: 10.1002/14651858.cd004080.pub4] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation. OBJECTIVES To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA). MAIN RESULTS We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I2 = 81, %, Chi2 = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I2 = 0%, Chi2 = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I2 = 0%, Chi2 = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence). AUTHORS' CONCLUSIONS This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.
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Affiliation(s)
- Georgia Herbert
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Rachel Perry
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Henning Keinke Andersen
- Bispebjerg Hospital, Building 39NThe Cochrane Colorectal Cancer Group23 Bispebjerg BakkeCopenhagenDenmarkDK 2400 CPH NV
| | - Charlotte Atkinson
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Christopher Penfold
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Stephen J Lewis
- Derriford HospitalDepartment of GastroenterologyDerriford RoadPlymouthDevonUKPL6 8DH
| | - Andrew R Ness
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolAvonUKBS2 8AE
| | - Steven Thomas
- University Hospitals Bristol NHS TrustHead & Neck SurgeryMarlborough StreetBristolUKBS1 3NU
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Effect of early enteral nutrition on laparoscopic common bile duct exploration with enhanced recovery after surgery protocols. Eur J Clin Nutr 2019; 73:1244-1249. [PMID: 30967640 DOI: 10.1038/s41430-019-0425-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES Protocols for enhanced recovery after surgery (ERAS) provide comprehensive and evidence-based guidelines to improve perioperative care. It remains elusive whether early enteral nutrition (EEN) will play an active role in the ERAS protocols. Laparoscopic common bile duct exploration (LCBDE) is a safe and efficient method to treat patients with bile duct stones. This study aims to assess the safety, tolerability, and outcomes of EEN after LCBDE. SUBJECTS /METHODS From January 2014 to April 2017, a total of 100 patients with postoperative LCBDE were chosen and randomly divided into control group and EEN group. Patients in the control group were treated with traditional management with regular diet when tolerated, while patients in the EEN group were fed with EEN 3 h after LCBDE. The patients' characteristics, time to first flatus, complications, hospitalization stay, and hospitalization expenses were assessed and compared between patients in these two groups. RESULTS EEN accelerated the recovery of gastrointestinal function, being indicated by reduced time to first flatus when compared with control group (P = 0.00). In accordance, the quick recovery of gastrointestinal function resulted in shorter hospitalization stay for the EEN group (P = 0.00); however, no significant difference was shown when comparing the hospitalization expenses. On another hand, early oral feeding increased the occurrence of abdominal distension and diarrhea complications (P = 0.00 and P = 0.03). CONCLUSIONS EEN effectively improves gastrointestinal function, but raises complications such as abdominal distension and diarrhea after LCBDE. It is recommended to implement the EEN as early as possible if the patients are reasonably expected to have high compliance.
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14
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Saito M, Shimazaki Y, Nonoyama T, Tadokoro Y. Associations of number of teeth with medical costs and hospitalization duration in an older Japanese population. Geriatr Gerontol Int 2019; 19:335-341. [PMID: 30761710 DOI: 10.1111/ggi.13622] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/20/2018] [Accepted: 01/06/2019] [Indexed: 12/23/2022]
Abstract
AIM Many studies have reported close relationships between oral and systemic health. We explored the association of the number of remaining teeth with medical costs and hospitalization duration in people aged 75 and 80 years. METHODS Oral health examinations were carried out at dental clinics in 2014. Medical cost and hospitalization duration data for fiscal year 2015 were obtained from the Mie Prefecture health insurer. We analyzed the data of 4700 individuals who met our inclusion criteria: 2745 75-year-olds and 1955 80-year-olds. The effects of remaining tooth numbers on medical costs and hospitalization days were analyzed using a generalized linear model with log link adjustment for confounders. RESULTS Total medical costs for all diseases were significantly higher in those with 20-27, 10-19 and 1-9 teeth, and in edentulous older individuals, compared with those with 28 teeth. Outpatient medical costs for diabetes were significantly higher in those with 20-27 and 1-9 teeth. Inpatient medical costs for digestive cancers were significantly higher in those with 10-19 and 1-9 teeth, and in edentulous older individuals. Hospitalization for digestive cancer was significantly longer in those with 20-27, 10-19 and 1-9 teeth, and in edentulous older individuals, than in those with 28 teeth. The number of teeth as a continuous variable was significantly inversely associated with medical costs for cerebrovascular disease and digestive cancer, and hospitalization days for digestive cancer. CONCLUSION Small numbers of teeth were associated with higher medical costs and longer hospital stays for older Japanese. Geriatr Gerontol Int 2019; 19: 335-341.
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Affiliation(s)
- Mizuki Saito
- Department of Preventive Dentistry and Dental Public Health, School of Dentistry, Aichi Gakuin University, Nagoya, Japan
| | - Yoshihiro Shimazaki
- Department of Preventive Dentistry and Dental Public Health, School of Dentistry, Aichi Gakuin University, Nagoya, Japan
| | - Toshiya Nonoyama
- Department of Preventive Dentistry and Dental Public Health, School of Dentistry, Aichi Gakuin University, Nagoya, Japan
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Toledano S, Sackey J, Willcutts K, Parrott JS, Tomesko J, Al-Mazrou AM, Kiran RP, Brody RA. Exploring the Differences Between Early and Traditional Diet Advancement in Postoperative Feeding Outcomes in Patients With an Ileostomy or Colostomy. Nutr Clin Pract 2019; 34:631-638. [PMID: 30690780 DOI: 10.1002/ncp.10245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND We assessed the differences in postoperative feeding outcomes when comparing early and traditional diet advancement in patients who had an ostomy creation. METHODS At a U.S. tertiary care hospital, data from patients who underwent an ileostomy or colostomy creation from June 1, 2013, to April 30, 2017 were extracted from an institutional database. Patients who received early diet advancement (postoperative days 0 and 1) were compared with traditional diet advancement (postoperative day 2 and later) for demographics, preoperative risk factors, and operative features. The postoperative feeding outcomes included time to first flatus and ostomy output. Mann-Whitney U tests determined bivariate differences in postoperative feeding outcomes between groups. Poisson regression was used to adjust for unequal baseline characteristics. RESULTS Data from 255 patients were included; 204 (80.0%) received early diet advancement, and 51 (20.0%) had traditional diet advancement. Time to first flatus and time to first ostomy output were significantly shorter in the early compared with traditional diet advancement group (median difference of 1 day for both flatus and ostomy output, P < 0.001). Adjusting for baseline group differences (American Society for Anesthesiology Physical Status Classification System, surgical approach, resection and ostomy type) maintained the significant findings for both time to first flatus (β = 1.32, P = 0.01) and time to first ostomy output (β = 1.41, P < 0.001). CONCLUSIONS Early diet advancement is associated with earlier return of flatus and first ostomy output compared with traditional diet advancement after the creation of an ileostomy or colostomy.
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Affiliation(s)
- Sabrina Toledano
- Department of Nutritional Sciences, School of Health Professions, Rutgers University, Camden, New Jersey, USA
| | - Joachim Sackey
- Department of Nutritional Sciences, School of Health Professions, Rutgers University, Camden, New Jersey, USA
| | - Kate Willcutts
- University of Virginia Health System, Charlottesville, Virginia, USA
| | - J Scott Parrott
- Department of Interdisciplinary Studies, Rutgers University, Camden, New Jersey, USA
| | - Jennifer Tomesko
- Department of Nutritional Sciences, School of Health Professions, Rutgers University, Camden, New Jersey, USA
| | - Ahmed M Al-Mazrou
- NewYork-Presbyterian Hospital Columbia University Medical Center, New York, New York, USA
| | - Ravi P Kiran
- NewYork-Presbyterian Hospital Columbia University Medical Center, New York, New York, USA
| | - Rebecca A Brody
- Department of Nutritional Sciences, School of Health Professions, Rutgers University, Camden, New Jersey, USA
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Herbert G, Perry R, Andersen HK, Atkinson C, Penfold C, Lewis SJ, Ness AR, Thomas S. Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications. Cochrane Database Syst Rev 2018; 10:CD004080. [PMID: 30353940 PMCID: PMC6517065 DOI: 10.1002/14651858.cd004080.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation. OBJECTIVES To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA). MAIN RESULTS We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I2 = 81, %, Chi2 = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I2 = 0%, Chi2 = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I2 = 0%, Chi2 = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence). AUTHORS' CONCLUSIONS This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.
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Affiliation(s)
- Georgia Herbert
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Rachel Perry
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Henning Keinke Andersen
- Bispebjerg Hospital, Building 39NThe Cochrane Colorectal Cancer Group23 Bispebjerg BakkeCopenhagenDenmarkDK 2400 CPH NV
| | - Charlotte Atkinson
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Christopher Penfold
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Stephen J Lewis
- Derriford HospitalDepartment of GastroenterologyDerriford RoadPlymouthUKPL6 8DH
| | - Andrew R Ness
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreEducation and Research Centre, Upper Maudlin StreetBristolUKBS2 8AE
| | - Steven Thomas
- University Hospitals Bristol NHS TrustHead & Neck SurgeryMarlborough StreetBristolUKBS1 3NU
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Kim JW, Park YG, Kim JH, Jang EC, Ha YC. The Optimal Time of Postoperative Feeding After Total Hip Arthroplasty: A Prospective, Randomized, Controlled Trial. Clin Nurs Res 2018; 29:31-36. [PMID: 30041540 DOI: 10.1177/1054773818791078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Whether early postoperative feeding (EPF) after total hip arthroplasty (THA) interferes with recovery of gastrointestinal motility is unclear. This randomized controlled trial compared the feasibility and patient tolerance to either EPF (at 4 hr postoperatively) or late postoperative feeding (LPF; ⩾8 hr postoperatively). One hundred forty patients were randomized to EPF (70 hips) or LPF (70 hips). Patient characteristics, surgical technique, intraoperative characteristics, and postoperative managements were similar between two groups. No significant differences were evident between the groups for vomiting (p = .231), nausea (p = .711), regain of appetite (p = .711), amount of diet (p = .630), type of food (p = .429), abdominal pain (p = 1.000), time to passage of flatus (p = .231), time to defecations (p = .619), development of postoperative ileus (p = 1.000), and length of hospital stay (p = .643). EPF and LPF show no difference in nausea, return of bowel function, and length of hospital stay without increasing postoperative morbidity. EPF can begin about 4 hr later after elective THA.
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Affiliation(s)
- Jin-Woo Kim
- Eulji University College of Medicine, Seoul, South Korea
| | - Yong-Gum Park
- Department of Surgery, Chung-Ang University, Seoul, South Korea
| | - Jae-Hyung Kim
- Department of Orthopaedic Surgery, Chung-Ang University, Seoul, South Korea
| | - Eui-Chan Jang
- Department of Orthopaedic Surgery, Chung-Ang University, Seoul, South Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University, Seoul, South Korea
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18
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Mohsina S, Shanmugam D, Sureshkumar S, Kundra P, Mahalakshmy T, Kate V. Adapted ERAS Pathway vs. Standard Care in Patients with Perforated Duodenal Ulcer-a Randomized Controlled Trial. J Gastrointest Surg 2018; 22:107-116. [PMID: 28653239 DOI: 10.1007/s11605-017-3474-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/08/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The objective of this study was to evaluate the feasibility and efficacy of ERAS pathways in patients undergoing emergency simple closure of perforated duodenal ulcer (PDU). METHODS This single-center, prospective, open-labeled, superiority, RCT was carried out from August 2014 to July 2016. Patients of PDU undergoing open simple closure were randomized preoperatively in 1:1 ratio into standard care and adapted ERAS group. Patients with refractory shock, ASA class ≥3, and perforation size ≥1 cm were excluded. Primary outcome was the length of hospitalization (LOH). Secondary outcomes were functional recovery parameters and morbidity. RESULTS Forty-nine and 50 patients were included in standard care and ERAS group, respectively. Patients in ERAS group had a significantly early functional recovery (days) for the time to first flatus (1.47 ± 0.18; p < 0.001), first stool (2.25 ± 0.20; p < 0.001), first fluid diet (2.72 ± 0.38; p < 0.001), and solid diet (3.70 ± 0.44; p < 0.001). LOH in ERAS group was significantly shorter (mean difference of 4.41 ± 0.64 days; p < 0.001). There was a significant reduction in postoperative morbidity such as superficial SSI (RR 0.35, p = 0.02), postoperative nausea and vomiting (RR 0.28, p < 0.0001), and pulmonary complications (RR 0.24, p = 0.04) in the ERAS vs. standard care group with similar leak rates (1/50 vs.2/49). CONCLUSION ERAS pathways are safe and feasible in select patients undergoing emergency simple closure of PDU.
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Affiliation(s)
- Subair Mohsina
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Dasarathan Shanmugam
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Sathasivam Sureshkumar
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Pankaj Kundra
- Department of Anaesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - T Mahalakshmy
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Vikram Kate
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
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19
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Smeets BJJ, Peters EG, Horsten ECJ, Weijs TJ, Rutten HJT, Buurman WA, de Jonge WJ, Luyer MDP. Effect of Early vs Late Start of Oral Intake on Anastomotic Leakage Following Elective Lower Intestinal Surgery: A Systematic Review. Nutr Clin Pract 2017. [PMID: 28628353 DOI: 10.1177/0884533617711128] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Experimental and clinical studies have demonstrated a beneficial effect of early enteral nutrition (EN) on anastomotic leakage following colorectal surgery. Early oral intake is a common form of early EN with various clinical benefits, but the effect on anastomotic leakage is unclear. This systematic review investigates the effect of early vs late start of oral intake on anastomotic leakage following lower intestinal surgery. METHODS A systematic literature search was performed using the PubMed, Embase, Medline, and Cochrane databases. Randomized controlled trials were included that compared early (within 24 hours) vs late start of oral intake following elective surgery of the small bowel, colon, or rectum. Meta-analysis was performed for anastomotic leakage, overall complications, length of stay, and mortality. Sensitivity analysis was performed in which studies of inferior methodological quality were excluded. RESULTS Nine studies including 879 patients met eligibility criteria. Early start of oral intake significantly reduced overall complications (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.46-0.93; P = .02), length of stay (mean difference, -0.89; 95% CI, -1.22 to -0.57; P < .001), and anastomotic leakage (OR, 0.40; 95% CI, 0.17-0.95; P = .04) compared with late start of oral intake. However, in the sensitivity analysis only the overall reduction of length of stay remained significant. CONCLUSION The effect of early oral intake on anastomotic leakage is unclear as existing studies are heterogeneous and at risk of bias. High-quality studies are needed to study the potential benefit of EN on anastomotic healing.
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Affiliation(s)
- Boudewijn J J Smeets
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,GROW School of Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Emmeline G Peters
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,Tytgat Institute for Intestinal and Liver Research, Academic Medical Center, Amsterdam, the Netherlands
| | - Eelco C J Horsten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Teus J Weijs
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,GROW School of Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Willem A Buurman
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, Limburg, the Netherlands
| | - Wouter J de Jonge
- Tytgat Institute for Intestinal and Liver Research, Academic Medical Center, Amsterdam, the Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
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20
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Rees J, Bobridge K, Cash C, Lyons-Wall P, Allan R, Coombes J. Delayed postoperative diet is associated with a greater incidence of prolonged postoperative ileus and longer stay in hospital for patients undergoing gastrointestinal surgery. Nutr Diet 2017; 75:24-29. [DOI: 10.1111/1747-0080.12369] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 04/14/2017] [Accepted: 05/31/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Joanna Rees
- Edith Cowan University, School of Medical and Health Sciences Joondalup Campus; Joondalup Western Australia Australia
| | - Kelly Bobridge
- Dietetics; Joondalup Health Campus; Joondalup Western Australia Australia
| | - Catherine Cash
- Dietetics; Joondalup Health Campus; Joondalup Western Australia Australia
| | - Philippa Lyons-Wall
- Edith Cowan University, School of Medical and Health Sciences Joondalup Campus; Joondalup Western Australia Australia
| | - Rebecca Allan
- Dietetics; Joondalup Health Campus; Joondalup Western Australia Australia
| | - Jacqui Coombes
- Edith Cowan University, School of Medical and Health Sciences Joondalup Campus; Joondalup Western Australia Australia
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21
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Rattray M, Roberts S, Marshall A, Desbrow B. A systematic review of feeding practices among postoperative patients: is practice in-line with evidenced-based guidelines? J Hum Nutr Diet 2017; 31:151-167. [PMID: 28589624 DOI: 10.1111/jhn.12486] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- M Rattray
- School of Allied Health Sciences, Griffith University, Southport, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - S Roberts
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,National Centre of Research Excellence in Nursing (NCREN), Griffith University, Southport, QLD, Australia
| | - A Marshall
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,National Centre of Research Excellence in Nursing (NCREN), Griffith University, Southport, QLD, Australia.,School of Nursing and Midwifery, Griffith University, Southport, QLD, Australia
| | - B Desbrow
- School of Allied Health Sciences, Griffith University, Southport, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
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22
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Knight AW, Blackmon SH. The ongoing debate regarding optimal nutritional routes following esophagectomy. J Thorac Dis 2017; 8:3006-3008. [PMID: 28066569 DOI: 10.21037/jtd.2016.11.56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ariel W Knight
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shanda H Blackmon
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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23
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Berkelmans GHK, Wilts BJW, Kouwenhoven EA, Kumagai K, Nilsson M, Weijs TJ, Nieuwenhuijzen GAP, van Det MJ, Luyer MDP. Nutritional route in oesophageal resection trial II (NUTRIENT II): study protocol for a multicentre open-label randomised controlled trial. BMJ Open 2016; 6:e011979. [PMID: 27496239 PMCID: PMC4985839 DOI: 10.1136/bmjopen-2016-011979] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Early start of an oral diet is safe and beneficial in most types of gastrointestinal surgery and is a crucial part of fast track or enhanced recovery protocols. However, the feasibility and safety of oral intake directly following oesophagectomy remain unclear. The aim of this study is to investigate the effects of early versus delayed start of oral intake on postoperative recovery following oesophagectomy. METHODS AND ANALYSIS This is an open-label multicentre randomised controlled trial. Patients undergoing elective minimally invasive or hybrid oesophagectomy for cancer are eligible. Further inclusion criteria are intrathoracic anastomosis, written informed consent and age 18 years or older. Inability for oral intake, inability to place a feeding jejunostomy, inability to provide written consent, swallowing disorder, achalasia, Karnofsky Performance Status <80 and malnutrition are exclusion criteria. Patients will be randomised using online randomisation software. The intervention group (direct oral feeding) will receive a liquid oral diet for 2 weeks with gradually expanding daily maximums. The control group (delayed oral feeding) will receive enteral feeding via a jejunostomy during 5 days and then start the same liquid oral diet. The primary outcome measure is functional recovery. Secondary outcome measures are 30-day surgical complications; nutritional status; need for artificial nutrition; need for additional interventions; health-related quality of life. We aim to recruit 148 patients. Statistical analysis will be performed according to an intention to treat principle. Results are presented as risk ratios with corresponding 95% CIs. A two-tailed p<0.05 is considered statistically significant. ETHICS AND DISSEMINATION Our study protocol has received ethical approval from the Medical research Ethics Committees United (MEC-U). This study is conducted according to the principles of Good Clinical Practice. Verbal and written informed consent is required before randomisation. All data will be collected using an online database with adequate security measures. TRIAL REGISTRATION NUMBERS NCT02378948 and Dutch trial registry: NTR4972; Pre-results.
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Affiliation(s)
| | - Bas J W Wilts
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ewout A Kouwenhoven
- Department of Surgery, Hospital Group Twente, Almelo, Twente, The Netherlands
| | - Koshi Kumagai
- Division of Surgery, CLINTEC, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Magnus Nilsson
- Division of Surgery, CLINTEC, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Teus J Weijs
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Marc J van Det
- Department of Surgery, Hospital Group Twente, Almelo, Twente, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
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24
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Weijs TJ, Berkelmans GHK, Nieuwenhuijzen GAP, Dolmans ACP, Kouwenhoven EA, Rosman C, Ruurda JP, van Workum F, van Det MJ, Silva Corten LC, van Hillegersberg R, Luyer MDP. Immediate Postoperative Oral Nutrition Following Esophagectomy: A Multicenter Clinical Trial. Ann Thorac Surg 2016; 102:1141-8. [PMID: 27324526 DOI: 10.1016/j.athoracsur.2016.04.067] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 03/01/2016] [Accepted: 04/20/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Immediate start of oral intake is beneficial following colorectal surgery. However, following esophagectomy the safety and feasibility of immediate oral intake is unclear, thus these patients are still kept nil by mouth. This study therefore aimed to determine the feasibility and safety of oral nutrition immediately after esophagectomy. METHODS A multicenter, prospective trial was conducted in 3 referral centers between August 2013 and May 2014, including 50 patients undergoing a minimally invasive esophagectomy. Oral nutrition was started postoperatively immediately (clear liquids on postoperative day [POD] 0, liquid nutrition on POD 1 to 6, solid food from POD 7). Nonoral enteral nutrition was started when <50% of caloric need was met on postoperative day POD 5 or when oral intake was impossible. A comparison was made with a retrospective cohort (n = 50) with a per-protocol delayed start of oral intake until POD 4 to 7. RESULTS The median caloric intake at POD 5 was 58% of required. In 38% of the patients nonoral nutrition was started, mainly due to complications (36%). The pneumonia rate was 28% following immediate oral intake and 40% following delayed oral intake (p = 0.202). The aspiration pneumonia rate was 4% in both groups. The anastomotic leakage rate was 14% after immediate oral intake versus 24% following delayed oral intake (p = 0.202). The 90-day mortality rate was 2% in both groups. Hospital stay and intensive care unit stay were significantly shorter following immediate oral intake. CONCLUSIONS Immediate start of oral nutrition following esophagectomy seems to be feasible and does not increase complications compared to a retrospective cohort and literature. However, if complications arise an alternative nutritional route is required. This explorative study shows that a randomized controlled trial is needed.
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Affiliation(s)
- Teus J Weijs
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | | | | | | | - Camiel Rosman
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT Hospital, Almelo, the Netherlands
| | | | | | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
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