Early Versus Delayed Postoperative Feeding After Major Gynaecological Surgery and its Effects on Clinical Outcomes, Patient Satisfaction, and Length of Stay: A Randomized Controlled Trial

Long-Term Survival Associated with Direct Oral Feeding Following Minimally Invasive Esophagectomy: Results from a Randomized Controlled Trial (NUTRIENT II)

Advancements in perioperative care have improved postoperative morbidity and recovery after esophagectomy. The direct start of oral intake can also enhance short-term outcomes following minimally invasive Ivor Lewis esophagectomy (MIE-IL). Subsequently, short-term outcomes may affect long-term survival. This planned sub-study of the NUTRIENT II trial, a multicenter randomized controlled trial, investigated the long-term survival of direct versus delayed oral feeding following MIE-IL. The outcomes included 3- and 5-year overall survival (OS) and disease-free survival (DFS), and the influence of complications and caloric intake on OS. After excluding cases of 90-day mortality, 145 participants were analyzed. Of these, 63 patients (43.4%) received direct oral feeding. At 3 years, OS was significantly better in the direct oral feeding group (p = 0.027), but not at 5 years (p = 0.115). Moreover, 5-year DFS was significantly better in the direct oral feeding group (p = 0.047) and a trend towards improved DFS was shown at 3 years (p = 0.079). Postoperative complications and caloric intake on day 5 did not impact OS. The results of this study show a tendency of improved 3-year OS and 5-year DFS, suggesting a potential long-term survival benefit in patients receiving direct oral feeding after esophagectomy. However, the findings should be further explored in larger future trials.

Early oral diet may enhance recovery from benign gynecologic surgery: A single center prospective study

BACKGROUND

Early dietary intake enhanced recovery after surgery (ERAS). There remains a gap in the recognition and implementation of early diet after surgery in medical institutions in Taiwan. This study aimed to investigate whether early oral intake after benign gynecologic surgery results in favorable outcomes in Taiwanese patients.

METHODS

This was a prospective controlled nonrandomized cohort study. Patients who underwent benign gynecological surgery were included in the early- and conventional-diet groups. The primary outcome was length of hospital stay, and the secondary outcome was postoperative complications.

RESULTS

Forty and 38 patients were included in the early and conventional-diet groups, respectively. The early-diet group demonstrated significantly reduced length of hospital stay (the early-diet group, 2.58 ± 0.93 days; conventional-diet group, 4.16 ± 1.13 days; p < 0.001). No increase in postoperative complications was observed in the early-diet group. Laparoscopic surgery reduced the length of hospital stay (β, -0.65; 95% confidence interval [CI], -1.22 to -0.08; p = 0.027), while an increased length of hospital stay was associated with higher visual analog scales (VAS, β, 0.21; 95% CI, 0.03-0.39; p = 0.026) and the conventional-diet group (β, 1.13; 95% CI, 0.65-1.61; p < 0.001) as assessed by multivariate regression analysis.

CONCLUSION

Patients who underwent benign gynecologic surgery tolerated an early oral diet well without an increase in complications. Laparoscopic surgery and lower pain scores also enhanced postoperative recovery.

Fast-track- recovery surgery with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively among surgical gynaecological cancer patients: study protocol of an open-labelled, randomised controlled trial

Introduction

There has been growing evidence on the favourable outcomes of fast-track-recovery (FTR) surgery; to expedite recovery, minimise complications, and reduce the length of hospital stay for surgical patients. However, there is lack of evidence on the effectiveness of FTR in surgical gynaecological cancer (GC) patients. Most of the previous studies did not focus on feeding composition in the FTR surgery protocol. This study aims to determine the effectiveness of FTR feeding with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively on post-operative outcomes among surgical GC patients.

Methods/design

This open-labelled, randomised controlled trial (RCT) will randomly allocate patients into intervention and control groups. Ambulated Malaysian aged over 18 years and scheduled for elective surgery for (suspected) GC, will be included in this study. The intervention group will be given whey-protein-infused carbohydrate-loading drinks on the evening before their operation and 3 h before their operation as well as started on early oral feeding 4 h post-operatively. The control group will be fasted overnight pre-operation and only allowed plain water, and return to a normal diet is allowed when bowel sounds return post-operatively. The primary outcomes of study are length of post-operative hospital stay, length of clear-fluid tolerance, solid-food tolerance and bowel function. Additional outcome measures are changes in nutritional status, biochemical profile and functional status. Data will be analysed on an intention-to-treat basis.

Trial registration

ClinicalTrials.gov, ID: NCT03667755. Retrospectively registered on 12 September 2018;

Protocol version: version 3 dated 27 September 2017.

Promotility agents for the treatment of ileus in adult surgical patients: A practice management guideline from the Eastern Association for the Surgery of Trauma

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.

Impact of Enhanced Recovery after Surgery with Preoperative Whey Protein-Infused Carbohydrate Loading and Postoperative Early Oral Feeding among Surgical Gynecologic Cancer Patients: An Open-Labelled Randomized Controlled Trial

Enhanced Recovery after Surgery (ERAS) with sole carbohydrate (CHO) loading and postoperative early oral feeding (POEOF) shortened the length of postoperative (PO) hospital stays (LPOHS) without increasing complications. This study aimed to examine the impact of ERAS with preoperative whey protein-infused CHO loading and POEOF among surgical gynecologic cancer (GC) patients. There were 62 subjects in the intervention group (CHO-P), which received preoperative whey protein-infused CHO loading and POEOF; and 56 subjects formed the control group (CO), which was given usual care. The mean age was 49.5 ± 12.2 years (CHO-P) and 51.2 ± 11.9 years (CO). The trial found significant positive results which included shorter LPOHS (78.13 ± 33.05 vs. 99.49 ± 22.54 h); a lower readmission rate within one month PO (6% vs. 16%); lower weight loss (−0.3 ± 2.3 kg vs. −2.1 ± 2.3 kg); a lower C-reactive protein–albumin ratio (0.3 ± 1.2 vs. 1.1 ± 2.6); preserved muscle mass (0.4 ± 1.7 kg vs. −0.7 ± 2.6 kg); and better handgrip strength (0.6 ± 4.3 kg vs. −1.9 ± 4.7 kg) among CHO-P as compared with CO. However, there was no significant difference in mid-upper arm circumference and serum albumin level upon discharge. ERAS with preoperative whey protein-infused CHO loading and POEOF assured better PO outcomes.

Is routine nasogastric decompression after hepatic surgery necessary? A systematic review and meta-analysis

OBJECTIVES

Currently the nasogastric tube (NGT) is routinely inserted in clinical after abdominal surgery for decompression in China, yet the practice varies between regions, the role of NGT for the patients after hepatic surgery remains unclear. Therefore, this present meta-analysis aimed to assess the efficacy and safety of NGT placement after hepatic surgery.

DESIGN

A systematic review and meta-analysis DATA SOURCES: PUBMED, EMBASE, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure (CNKI) and Wanfang Database (until Mar 30, 2019) were systematically searched.

REVIEW METHODS

Randomized controlled studies (RCTs) comparing the efficacy and safety of NGT and no NGT treatment after hepatic surgery were included. Data were synthesized using a random-effects or fixed effect model according to the heterogeneity. Outcomes were presented as Mantel-Haenszel style odd ratios (ORs) or mean differences (MDs) with 95% confidence intervals (95% CIs).

RESULTS

Seven studies with 1306 patients were eligible for inclusion. Compared with NGT treatment, the no NGT decompression could shorten the time to first defecation (MD -0.59; -0.79, -0.39), reduce the time to start diet (MD -0.46; -0.90, -0.03), and decrease the length of hospital stay (MD 0.48; -0.93, -0.03), but it could also increase the risk of NGT re-intubation (OR 6.8; 1.77, 26.72), no significant differences were detected on the first passage of flatus (MD -0.34; -0.86, 0.18), the incidence of nausea (OR 0.81; 0.40, 1.67), vomiting (OR 1.06; 0.19, 5.93), abdominal distention (OR 0.87; 0.60, 1.25).

CONCLUSION

Given that very limited information for some endpoints in this present meta-analysis, the routinely insertion of NGT after hepatic surgery is not justified, the no NGT decompression seems to be more beneficial to the prognosis of patients after hepatic surgery, more related studies on this issue are needed.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSION

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

Restrictions and limitations after pelvic floor surgery: what's the evidence?

PURPOSE OF REVIEW

A common concern regarding pelvic floor surgery is the relatively high risk of recurrence. In an effort to minimize this risk, many surgeons instruct their patients to avoid certain activities during the healing process so as not to damage the repair before proper healing has occurred. However, many of these restrictions have been historically based on little to no hard evidence. The purpose of this review is to present the latest evidence-based recommendations regarding restrictions and limitations after pelvic floor surgery.

RECENT FINDINGS

The current review covers postoperative activities that could impact proper healing of a vaginal incision and of the strength of the reconstruction itself. It also looks at safety of the patient and those around her as she heals. Topics include pelvic rest, swimming, lifting exercising, working, and driving. Observational research suggests that many unavoidable activities of daily living may have as great, if not an even greater, risk of impacting the healing process than many of the modifiable activity restrictions that are commonly imposed on patients. This may explain why recent clinical trials show no greater problem with healing in patients randomized to less strict postoperative restrictions than the standard.

SUMMARY

Although further research is necessary, it appears that patients are more satisfied with less strict postoperative limitations, and this less restrictive activity may not have any significant negative impact on the healing process.

Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Delphi process with multiple iterative rounds using a nominal group technique.

OBJECTIVE

The aim of this study was to use expert opinion to achieve consensus on various aspects of postoperative care following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Significant variability exists in postoperative care following PSF for AIS, despite a relatively healthy patient population and continuously improving operative techniques. Current practice appears based either on lesser quality studies or the perpetuation of long-standing protocols.

METHODS

An expert panel composed of 26 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting (one electronic and two face-to-face). Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.

RESULTS

Consensus was reached to support 19 best practice guideline (BPG) measures for postoperative care addressing non-ICU admission, perioperative pain control, dietary management, physical therapy, postoperative radiographs, surgical bandage management, and indications for discharge.

CONCLUSION

We present a consensus-based BPG consisting of 19 recommendations for the postoperative management of patients following PSF for AIS. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.

LEVEL OF EVIDENCE

5.

Comparison of multi-modal early oral nutrition for the tolerance of oral nutrition with conventional care after major abdominal surgery: a prospective, randomized, single-blind trial

Background & aims

Early oral nutrition (EON) has been shown to improve recovery of gastrointestinal function, length of stay and mortality after abdominal surgery; however, early oral nutrition often fails during the first week after surgery. Here, a multi-modal early oral nutrition program is introduced to promote recovery of gastrointestinal function and tolerance of oral nutrition.

Methods

Consecutive patients scheduled for abdominal surgery were randomized to the multimodal EON group or a group receiving conventional care. The primary endpoint was the time of first defecation. The secondary endpoints were outcomes and the cost-effectiveness ratio in treating infectious complications. The rate of infectious-free patients was regarded as the index of effectiveness.

Results

One hundred seven patients were randomly assigned to groups. Baseline characteristics were similar for both groups. In intention-to-treat analysis, the success rate of oral nutrition during the first week after surgery in the multimodal EON group was 44 (83.0%) versus 31 (57.4%) in the conventional care group (P = 0.004). Time to first defecation, time to flatus, recovery time of bowel sounds, and prolonged postoperative ileus were all less in the multimodal EON group (P < 0.05). The median postoperative length of stay in the multimodal EON group was 8 days (6, 12) versus 10 days (7, 18) in the conventional care group (P < 0.001). The total cost of treatment and nutritional support were also less in the multi-modal early oral nutrition group (P < 0.001). The effectiveness was 84.9 and 79.9% in the multimodal EON and conventional care group, respectively (P = 0.475). However, the cost-effectiveness ratio was USD 537.6 (506.1, 589.3) and USD 637.8 (593.9, 710.3), respectively (P < 0.001).

Conclusion

The multi-modal early oral nutrition program was an effective way to improve tolerance of oral nutrition during the first week after surgery, decrease the length of stay and improve cost-effectiveness after abdominal surgery.

Trial registration

Registration number: ChiCTR-TRC-14004395. Registered 15 March 2014.