Early versus delay oral feeding for patients after upper gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials

Feasibility and Safety of Early Oral Feeding After Radical Gastrectomy in Patients With Gastric Carcinoma: A Systematic Review

This systematic review examines the feasibility and safety of early oral feeding (EOF) after radical gastrectomy in patients with gastric cancer. A comprehensive literature search identified eight eligible studies, including both clinical trials and cohort studies, conducted between 2011 and 2020. The review analyzed outcomes such as postoperative complications, length of hospital stay, time to first flatus/bowel movement, and changes in nutritional markers. The findings suggest that EOF is generally feasible and well-tolerated, with high adherence rates reported across studies. Most patients successfully initiated oral intake within 72 hours post-surgery without significant protocol deviations. Regarding safety, the studies reported comparable or lower rates of postoperative complications in EOF groups compared to traditional feeding protocols, though some noted non-significant increases in complications with EOF. Several studies observed potential benefits of EOF, including shorter hospital stays, earlier return of gastrointestinal function, and improved nutritional status. However, the results were mixed, with some studies finding no significant differences in these outcomes. While the review suggests EOF is a viable option for postoperative management after radical gastrectomy, it emphasizes the importance of patient-specific factors and close monitoring during implementation. The heterogeneity in study designs, EOF protocols, and outcome measures limits direct comparisons. Future large-scale randomized controlled trials are warranted to establish standardized EOF protocols and provide more robust evidence for this patient population.

The Outcome of Early Oral Feeding Following Elective Gastrointestinal Surgery

Background Early oral feeding (EOF) after gastrointestinal (GI) surgery is an optimistic way to speed up recovery and shorten hospital stays, but its full effects remain unexplored. Aim This study aims to evaluate the outcomes of EOF in patients having elective gastrointestinal surgery. Methods This open-level, prospective randomized controlled trial was conducted in the Department of Surgery at Sir Salimullah Medical College Mitford Hospital, Dhaka, from March 2022 to February 2023. A total of 50 patients were enrolled and divided into two groups: early oral feeding (EOF) and traditional postoperative oral feeding (TOF), both before and after 48 hours of surgery, using a systematic random sampling technique. Informed written consent was taken from the patients. The patients were monitored on days 1, 3, 5, 7, 14, and 28 following surgeries. Postoperative complications, the duration for nasogastric tube (NGT) removal (days), the early recovery of bowel motility, and the length of the hospital stay (days) were noted. Results In this study, both EOF and TOF groups were found indifferent in terms of age distribution, gender ratio, or body mass index (BMI). However, significant differences emerged in postoperative outcomes. The TOF group experienced a significantly longer duration for nasogastric tube (NGT) removal and the initiation of oral feeding compared to the EOF group (P-value < 0.001). Complication rates, including nausea, vomiting, ileus, anastomotic leakage, wound infection, and pneumonia, did not exhibit statistically significant differences between the groups (P-value > 0.05). Moreover, the EOF group demonstrated an early recovery of bowel motility after surgery and shorter hospital stays compared to the TOF group (P-value < 0.05). Conclusion Starting oral feeding earlier does not increase complications. However, it does speed up recovery and shorten hospital stays.

Early nutrition is safe and does not increase complications after upper gastrointestinal bleeding-a systematic review and meta-analysis of randomized controlled trials

Despite a lack of evidence, patients are often not fed for 48-96 h after upper gastrointestinal bleeding (UGIB); however, many trials have demonstrated the benefits of early nutrition (EN). We conducted a meta-analysis of randomized controlled trials (RTCs) to evaluate the outcomes of EN compared to delayed nutrition (DN) after UGIB. The protocol was registered on PROSPERO (CRD42022372306). PubMed, Embase, CENTRAL, Scopus, and Web of Science were searched on the 27th of April 2024 to identify eligible RCTs. The primary outcomes were early (within 7 days) and late (within 30-42 days) mortality and rebleeding. Pooled risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) were calculated using a random-effects model. A total of 10 trials with 1051 patients were included in the analysis. Early mortality was not significantly different between the two groups (RR 1.20, CI 0.85-1.71, I2 = 0%), whereas late mortality was reduced to a clinically relevant extent in the EN group (RR 0.61, CI 0.35-1.06, I2 = 0%). When comparing the two groups, we found no significant difference in terms of early and late rebleeding (RR 1.04, CI 0.66-1.63, I2 = 0% and RR 1.16, CI 0.63-2.13, I2 = 0%, respectively). Our analysis also showed that the length of hospital stay was reduced in the EN group compared to the DN group (MD -1.22 days, CI: -2.43 to -0.01, I2 = 94%). In conclusion, compared with DN, EN (within 24 h) appears to be a safe intervention and could reduce the length of hospital stay without increasing the risk of complications after UGIB.

Postoperative nutrition in the setting of enhanced recovery programmes

Patients undergoing major surgery for gastrointestinal cancer are at high risk of developing or worsening malnutrition and sarcopenia. In malnourished patients, preoperative nutritional support may not be sufficient and so postoperative support is advised. This narrative review addresses several aspects of postoperative nutritional care in the setting of enhanced recovery programmes. Early oral feeding, therapeutic diet, oral nutritional supplements, immunonutrition, and probiotics are discussed. When postoperative intake is insufficient, nutritional support favouring the enteral route is recommended. Whether this approach should use a nasojejunal tube or jejunostomy is still a matter of debate. In the setting of enhanced recovery programmes with early discharge, nutritional follow-up and care should be continued beyond the short time in hospital. In enhanced recovery programmes, the main specific aspects of nutrition are patient education, early oral intake, and post-discharge care. The other aspects do not differ from conventional care.

Epidural versus patient-controlled intravenous analgesia on pain relief and recovery after laparoscopic gastrectomy for gastric cancer: randomized clinical trial

BACKGROUND

Epidural analgesia (EDA) is a main modality for postoperative pain relief in major open abdominal surgery within the Enhanced Recovery After Surgery protocol. However, it remains unclear whether EDA is an imperative modality in laparoscopic gastrectomy (LG). This study examined non-inferiority of patient-controlled intravenous analgesia (PCIA) to EDA in terms of postoperative pain and recovery in patients who underwent LG.

METHODS

In this open-label, non-inferiority, parallel, individually randomized clinical trial, patients who underwent elective LG for gastric cancer were randomized 1:1 to receive either EDA or PCIA after surgery. The primary endpoint was pain score using the Numerical Rating Scale at rest 24 h after surgery, analysed both according to the intention-to-treat (ITT) principle and per protocol. The non-inferiority margin for pain score was set at 1. Secondary outcomes were postoperative parameters related to recovery and adverse events related to analgesia.

RESULTS

Between 3 July 2017 and 29 September 2020, 132 patients were randomized to receive either EDA (n = 66) or PCIA (n = 66). After exclusions, 64 patients were included in the EDA group and 65 patients in the PCIA group for the ITT analysis. Pain score at rest 24 h after surgery was 1.94 (s.d. 2.07) in the EDA group and 2.63 (s.d. 1.76) in the PCIA group (P = 0.043). PCIA was not non-inferior to EDA for the primary endpoint (difference 0.69, one side 95% c.i. 1.25, P = 0.184) in ITT analysis. Postoperative parameters related to recovery were similar between groups. More EDA patients (21 (32.8%) versus 1 (1.5%), P < 0.001) developed postoperative hypotension as an adverse event.

CONCLUSIONS

PCIA was not non-inferior to EDA in terms of early-phase pain relief after LG.Registration number: UMIN000027643 (https://www.umin.ac.jp/ctr/index-j.htm).

Construction and validation of risk prediction model for gastrointestinal bleeding in patients after coronary artery bypass grafting

This study aimed to develop a risk prediction model for gastrointestinal bleeding in patients after coronary artery bypass grafting (CABG) and assessed its accuracy. A retrospective analysis was conducted on 232 patients who underwent CABG under general anesthesia in our hospital between January 2022 and December 2022. The patients were divided into gastrointestinal bleeding (GIB) group (n = 52) and group without gastrointestinal bleeding (non-GIB) (n = 180). The independent risk factors for gastrointestinal bleeding in post-CABG patients were analyzed using χ2 test, t test and logistic multivariate regression analysis. A prediction model was established based on the identified risk factors. To verify the accuracy of the prediction model, a verification group of 161 patients who met the criteria was selected between January to June 2023, and the Bootstrap method was used for internal validation. The discrimination of the prediction model was evaluated using the area under the curve (AUC), where a higher AUC indicates a stronger discrimination effect of the model. The study developed a risk prediction model for gastrointestinal bleeding after CABG surgery. The model identified four independent risk factors: duration of stay in the intensive care unit (ICU) (OR 0.761), cardiopulmonary bypass time (OR 1.019), prolonged aortic occlusion time (OR 0.981) and re-operation for bleeding (OR 0.180). Based on these factors, an individualized risk prediction model was constructed. The C-index values of the modeling group and the verification group were 0.805 [95% CI (0.7303-0.8793)] and 0.785 [95% CI (0.6932-0.8766)], respectively, which indicated a good accuracy and discrimination of this model. The calibration and standard curves showed similar results, which further supported the accuracy of the risk prediction model. In conclusion, ICU time, cardiopulmonary bypass time, aortic occlusion time and re-operation for bleeding are identified as independent risk factors for gastrointestinal bleeding in patients after CABG. The risk prediction model developed in this study demonstrates strong predictive performance and provides valuable insights for clinical medical professionals in evaluating gastrointestinal complications in CABG patients.

Enhanced Patient Comfort and Satisfaction with Early Oral Feeding after Thoracoscopic Lung Cancer Resection

BACKGROUND The study aimed to compare the patient-reported outcomes in patients who underwent early vs conventional feeding after thoracoscopic lung cancer resection. MATERIAL AND METHODS The study enrolled 211 patients who underwent thoracoscopic lung cancer resection at a tertiary hospital between July 2021 and July 2022. Patients were randomly assigned to the conventional group or the early feeding group. There were 106 patients in the early feeding group and 105 patients in the conventional group. The conventional group received water 4 h after extubation and liquid/semi-liquid food 6 h after extubation. In contrast, the early feeding group received water 1 h after extubation and liquid/semi-liquid food 2 h after extubation. The primary outcomes were the degree of hunger, thirst, nausea, and vomiting. The secondary outcomes were postoperative complications, duration of hospital stay, and chest tube drainage. RESULTS No differences were found between the 2 groups in the degrees of postoperative nausea, vomiting, or pain after extubation for 1, 2, 4, and 8 h. Postoperative complications, duration of chest tube drainage, and duration of hospital stay were also similar (P=0.567, P=0.783, P=0.696). However, the hunger and thirst scores after extubation for 2 h and 4 h decreased and were lower in the early feeding group (both P<0.001). No patients developed choking, postoperative aspiration, gastrointestinal obstruction, or other complications. CONCLUSIONS Early oral feeding after thoracoscopic lung cancer resection is safe and can increase patient comfort postoperatively.