Is early oral feeding after gastric cancer surgery feasible? A systematic review and meta-analysis of randomized controlled trials

An updated systematic review and meta-analysis of the efficacy and safety of early oral feeding vs. traditional oral feeding after gastric cancer surgery

Introduction

Early oral feeding (EOF) has been shown to improve postoperative recovery for many surgeries. However, surgeons are still skeptical about EOF after gastric cancer surgery due to possible side effects. This updated systematic review and meta-analysis aimed to investigate the efficacy and safety of EOF in patients after gastric cancer surgery.

Methods

Randomized controlled trials (RCTs) investigating EOF in patients after gastric cancer surgery were searched in the databases of PubMed, Embase, Clinicaltrials.gov, and Cochrane from 2005 to 2023, and an updated meta-analysis was performed using RevMan 5.4 software.

Results

The results of 11 RCTs involving 1,352 patients were included and scrutinized in this analysis. Hospital days [weighted mean difference (WMD), -1.72; 95% confidence interval (CI), -2.14 to -1.30; p<0.00001), the time to first flatus (WMD, -0.72; 95% CI, -0.99 to -0.46; p<0.00001), and hospital costs (WMD, -3.78; 95% CI, -4.50 to -3.05; p<0.00001) were significantly decreased in the EOF group. Oral feeding tolerance [risk ratio (RR), 1.00; 95% CI, 0.95-1.04; p=0.85), readmission rates (RR, 1.28; 95% CI, 0.50-3.28; p=0.61), postoperative complications (RR, 1.02; 95% CI, 0.81-1.29; p=0.84), anastomotic leakage (RR, 0.83; 95% CI, 0.25-2.78; p=0.76), and pulmonary infection (RR, 0.65; 95% CI, 0.31-1.39; p=0.27) were not significantly statistical between two groups.

Conclusion

This meta-analysis reveals that EOF could reduce hospital days, the time to first flatus, and hospital costs, but it was not associated with oral feeding tolerance, readmission rates, or postoperative complications especially anastomotic leakage and pulmonary infection, regardless of whether laparoscopic or open surgery, partial or total gastrectomy, or the timing of EOF initiation.

Early Oral Feeding is Safe and Comfortable in Patients with Gastric Cancer Undergoing Radical Total Gastrectomy

Data supporting the safety and clinical efficacy of early oral feeding (EOF) after total gastrectomy are limited. The aim of this prospective randomized controlled study was to explore the safety and clinical efficacy of two early enteral nutrition approaches for gastric cancer patients after radical total gastrectomy. The EOF group had faster postoperative recovery of intestinal function than the enteral tube feeding (ETF) group. The times to first flatus and first defecation were shorter in the EOF group (p < 0.05). In addition, the EOF protocol effectively avoided abdominal distension (p < 0.05). The hospitalization cost of the EOF group was lower than that of the ETF group (p < 0.05). Moreover, oral nutrition satisfied the physiological need for oral intake. People were more satisfied with EOF (p < 0.01). Furthermore, it is worth noting that compared with ETF, EOF did not increase the risk of anastomotic complications such as leakage and bleeding. Most obviously, EOF not only avoided the risk of complications during tube insertion, but also avoided the discomfort experience of nasal feeding tube. In summary, compared with ETF, EOF promotes early bowel recovery effectively without increasing the risk of postoperative complications. It is safe and comfortable for gastric cancer patients undergoing radical total gastrectomy.

Evaluation of early liquid drinking after radical gastrectomy in gastric cancer: a Chinese multicenter propensity score matching analysis

Background

Enhanced recovery after surgery is used in gastrointestinal surgery. This study aimed to access the effects of early liquid drinking (ELD) on gastrointestinal function recovery in patients with gastric cancer (GC) who underwent radical gastrectomy, as high-quality evidence on the outcomes of ELD after gastrectomy is currently lacking.

Methods

Clinicopathological data of patients with GC from 11 centers were retrospectively analysed. Clinical outcomes were investigated in 555 patients, including 225 who started drinking liquid within 48 h (ELD group) of surgery and 330 who started drinking liquid after flatus resumption (traditional liquid drinking [TLD] group). Propensity score matching (PSM) analysis was performed using a match ratio of 1:1 and 201 patients were selected from each group for the analysis. Primary outcome was time to first passage of flatus. Secondary outcomes included time to first defecation, post-operative hospitalization days, occurrence of short-term post-operative complications, and hospitalization costs.

Results

After PSM, baseline characteristics were not significantly different between the two groups. The time to first flatus (2.72 ± 1.08 vs 3.36 ± 1.39 days), first defecation (4.34 ± 1.85 vs 4.77 ± 1.61 days), and post-operative hospital stay (8.27 ± 4.02 vs 12.94 ± 4.43 days) were shorter in the ELD group than in the TLD group (all P < 0.05). The ELD group had lower hospitalization costs than the TLD group ([7.83 ± 2.44 vs 8.78 ± 3.41] × 10⁴ RMB, P = 0.041). No significant differences were observed in the incidence of post-operative complications.

Conclusions

Compared with TLD, post-operative ELD could promote rapid recovery of gastrointestinal function and reduce hospitalization costs; moreover, ELD does not increase the risk of post-operative complications.

Faster recovery and bowel movement after early oral feeding compared to late oral feeding after upper GI tumor resections: a meta-analysis

Background

There were more than 1 million new cases of stomach cancer concerning oesophageal cancer, there were more than 600,000 new cases of oesophageal cancer in 2020. After a successful resection in these cases, the role of early oral feeding (EOF) was questionable, due to the possibility of fatal anastomosis leakage. It is still debated whether EOF is more advantageous compared to late oral feeding. Our study aimed to compare the effect of early postoperative oral feeding and late oral feeding after upper gastrointestinal resections due to malignancy.

Methods

Two authors performed an extensive search and selection of articles independently to identify randomized control trials (RCT) of the question of interest. Statistical analyses were performed including mean difference, odds ratio with 95% confidence intervals, statistical heterogeneity, and statistical publication bias, to identify potential significant differences. The Risk of Bias and the quality of evidence were estimated.

Results

We identified 6 relevant RCTs, which included 703 patients. The appearance of the first gas (MD = -1.16; p = 0.009), first defecation (MD = -0.91; p < 0.001), and the length of hospitalization (MD = -1.92; p = 0.008) favored the EOF group. Numerous binary outcomes were defined, but significant difference was not verified in the case of anastomosis insufficiency (p = 0.98), pneumonia (p = 0.88), wound infection (p = 0.48), bleeding (p = 0.52), rehospitalization (p = 0.23), rehospitalization to the intensive care unit (ICU) (p = 0.46), gastrointestinal paresis (p = 0.66), ascites (p = 0.45).

Conclusion

Early postoperative oral feeding, compared to late oral feeding has no risk of several possible postoperative morbidities after upper GI surgeries, but has several advantageous effects on a patient's recovery.

Systematic Review Registration

identifier, CRD 42022302594.

Is an Early Resumption of a Regular Diet After Laparoscopic Roux-en-Y Gastric Bypass Safe?

Background

Return to a normal diet is a crucial step after bariatric surgery. Proximal anastomosis is a source of concern for early feeding as the passage of solid food through a recent anastomosis could well increase pressure and the risk of leakage. This study aims to assess the safety of an early normal diet after a laparoscopic Roux-en-Y gastric bypass (LRYGB).

Materials and Methods

All consecutive patients undergoing primary LRYGB between January 2015 and December 2020 were included prospectively. Three postoperative pureed diets were compared at 4 weeks, 2 weeks, and 1 week. All-cause morbidity at 90 days was the main outcome. Overall complications, severe complications (Clavien-Dindo ≥ grade 3a), length of hospital stay, number of emergency, and unplanned consultations during the 3 postoperative months were recorded for each group.

Results

Three hundred and sixty-seven patients with a mean BMI of 42.10 kg/m² (± SD: 4.78) were included. All-cause morbidity at 90 days was 11.7% (43/367) and no significant difference was observed between the 3 groups. Adjustment for patients and operative cofounders did not demonstrate any increased risk of postoperative complications between the 3 groups, with an odds ratio of 1, 1.23(95% CI [0. 55–2.75]), and 1.14 (95% CI [0.49, 2.67]) for groups 1, 2, and 3 respectively. Severe complications (Clavien-Dindo ≥ grade 3a) and emergency or unplanned consultations were also similar in the 3 groups.

Conclusion

Return to a normal diet 1 week after LRYGB did not increase short-term morbidity and unplanned consultations. It may be safe and contribute to patient comfort.

Graphical abstract

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

PURPOSE

To evaluate the efficacy and safety of early oral feeding (EOF) in patients after upper gastrointestinal surgery through meta-analysis of randomized controlled trials (RCTs).

METHODS

We analyzed the endpoints of patients including the length of stay (LOS), time of first exhaust, anastomotic leakage and pneumonia from included studies. And we retrieved RCTs from medical literature databases. Weighted mean difference (WMD), risk ratios (RR) and 95% confidence intervals (CI) were calculated to compare the endpoints.

RESULTS

In total, we retrieved 12 articles (13 trial comparisons) which contained 1771 patients. 887 patients (50.1%) were randomized to EOF group whereas 884 patients (49.9%) were randomized to delay oral feeding group. The result showed that compared with the delay oral feeding group, EOF after upper gastrointestinal surgery significantly shorten the LOS [WMD = - 1.30, 95% CI - 1.79 to - 0.80, I² = 0.0%] and time of first exhaust [WMD = - 0.39, 95% CI - 0.58 to - 0.20, I² = 62.1%]. EOF also reduced the risk of pneumonia (RR: 0.74, 95% CI 0.55 to 0.99, I² = 0.0%). There is no significant difference in the risk of anastomotic leak, anastomotic bleeding, abdominal abscess, reoperation, readmission and mortality.

CONCLUSIONS

Overall, compared with the traditional oral feeding, EOF could shorten the LOS and time of first exhaust without increasing complications after upper gastrointestinal surgery.

Resectable Gastric Adenocarcinoma Cancer and the Role of Early Feeding on Clinical Outcome

Background: Gastric adenocarsinoma is one of the most common gastrointestinal tract cancer, it could be found either in elderly or young patients.  Surgical resection is still the main therapeutic option  and  the gold standard for the resectable cases.  Enhanced recovery protocols has been announced  to improved the clinical outcome in of gastrointestinal cancer surgery. Especially in upper GI cancer, which still challenging in starting the oral feeding after surgical resection. We will reported the clincal outcome of early feeding on resectable gastric adenocarsinoma patients.   Methods: This was a retrospective study, taken from January 2018 - December 2020.  All resectable gastric adenocarsinoma  patients were included.  Tumor locations, type of resection and reconstruction were evaluated.  All patients had early oral feeding from the first post operative day, continued with liquid and semi solid food.  The short term outcome were recorded including the anastomose leakage and surgical site infection.     Results: We reported eight gastric cancer patients during this study, 1 patient was young gastric cancer patiens and the rest were > 50 years old patients.  Gastric anthrum was the most common tumor site with partial gatrectomy and Billroth II  have been done.  3 patients were corpus site and 1 case of fundus cancer,  total gastrectomy and roux en y esófago-jejunostomy reconstruction was done.  We found   no anastomosis leakage.  No SSI and no readmission associated with post operative morbidity.    Conclusion:  Early feeding on resectable gastric adenocarsinoma patients was feasibel, has good clinical outcomes and could tolerated well, no matter what type of gastric resection we did.      

Early versus the traditional start of oral intake following esophagectomy for esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Nil by mouth is considered the standard of care during the first days following esophagectomy. However, with the routine implementation of enhanced recovery after surgery, early oral intake is more likely to be the preferred mode of nutrition following esophagectomy. The present study aims to evaluate the safety and effectiveness of early oral intake following esophagectomy for esophageal cancer.

METHODS

Comprehensive literature searches were conducted using PubMed, Web of Science, Embase, and Cochrane Library. Weighted mean differences (WMD) and odds ratios (OR) with 95% confidence intervals (CI) were calculated as the effect sizes for continuous and dichotomous variables, respectively.

RESULTS

Fourteen studies with a total of 1947 patients were included. Length of hospital stay (WMD =  - 3.94, CI: - 4.98 to - 2.90; P < 0.001), the time to first flatus (WMD =  - 1.13, CI: - 1.25 to - 1.01; P < 0.001) and defecation (WMD =  - 1.26, CI: - 1.82 to - 0.71; P < 0.001) favored the early oral intake group. There was no statistically significant difference in mortality (OR = 1.23, CI: 0.45 to 3.36; P = 0.69). Early oral intake also did not increase the risk of pneumonia and overall postoperative complications.

CONCLUSIONS

Current evidence indicates early oral intake following esophagectomy seems to be safe and effective. It may be the preferred mode of nutrition following esophagectomy. However, more high-quality studies are still needed to further validate this conclusion.

Early postoperative feeding following surgery for upper gastrointestinal cancer: A systematic review

Nutrition post major upper gastrointestinal (UGI) cancer surgery is a significant consideration known to affect postoperative recovery and the ability to tolerate adjuvant treatment. This systematic review assessed the effect of early oral feeding (EOF), compared to traditional timing of oral feeding, following major surgery for UGI cancer on postoperative complications, postoperative length of hospital stay (LOS), nutritional status and quality of life (QOL). The literature was searched up to March 9th 2020 using CINHAL, PubMed, MEDLINE, Embase, Scopus and Web of Science databases. Quality assessment was completed using the Academy of Nutrition and Dietetics quality criteria checklist. Fifteen articles were included, consisting of seven randomised controlled trials, six cohort studies and two non-randomised trials, with a total of 2517 participants. The type and timing of EOF varied considerably across studies with limited reporting of energy and protein intakes from oral or enteral feeding. Fourteen studies assessed postoperative complications of which 13 reported no difference between EOF and standard care. Fourteen studies assessed postoperative LOS and of these, 13 reported a reduced length of stay in the EOF group. Four of 15 studies assessing nutritional status found no difference between groups. Three of 15 studies assessed QOL with inconsistent findings. This review found EOF reduced postoperative LOS and did not increase postoperative complications. However, the optimal timing for the introduction of EOF could not be established. Furthermore, the type of EOF varied considerably making comparison across studies challenging and demonstrates a need for internationally standardised definitions.

Intolerability to postoperative early oral nutrition in older patients (≥70 years) undergoing gastrectomy for gastric cancer: A case-control study

Background

Postoperative early oral nutrition has increasingly been adopted for patients undergoing gastrectomy. However, intolerability to early oral nutrition remains a major concern, especially in older patients. This study aimed to investigate early oral nutrition intolerability in older patients who had undergone gastrectomy.

Methods

We retrospectively reviewed 825 patients who had undergone gastrectomy for gastric carcinoma between 2017 and 2019. All patients received an oral diet on postoperative day 1. Patients were divided into older (≥70 years) and younger (<70 years) adult groups, and short-term outcomes and intolerability to oral nutrition were compared. Intolerability to early oral nutrition was defined as oral diet cessation due to adverse gastrointestinal symptoms.

Results

Among the 825 patients (≥70 years, n = 286; <70 years, n = 539), 151 (18.3%) developed intolerability to early oral nutrition, of whom 100 patients were < 70 years old and 51 were ≥70 years old. The most common symptom causing intolerability was abdominal distension. The mean duration of fasting after developing intolerability was 2.8 ± 2.4 days. The incidence of intolerability in the older and younger adult groups was 17.8% and 18.6%, respectively (p = 0.799). In terms of sex, operative approach, gastric resection, lymph node dissection, reconstruction, and tumor stage subgroups, the older adult group did not exhibit a significant increase in intolerability. Postoperatively, the older adult group showed a higher incidence of systemic complications; however, anastomotic complications did not significantly differ between the two groups.

Conclusions

Postoperative early oral nutrition can safely be adopted for older patients undergoing gastrectomy, with acceptable intolerability and surgical outcomes.

Early vs. Delayed Feeding after Endoscopic Submucosal Dissection for Gastric Cancer: A Systematic Review and Meta-Analysis

Background: Endoscopic submucosal dissection (ESD) for gastric cancer is increasingly performed worldwide due to its efficacy and safety. This study aimed to assess the evidence of the impact of early vs. delayed feeding after ESD on quality of care, which remains to be fully determined. Methods: Electronic databases (PubMed, the Cochrane Central Register of Controlled Trials, EMBASE) and the trial registries (the World Health Organization International Clinical Trials Platform Search Portal and ClinicalTrials.gov) were searched for studies performed prior to September 2020. Study selection, data abstraction, and quality assessment were independently performed using the Grading of Recommendations Assessment, Development, and Evaluation approach. Self-rated satisfaction and hospital stay were chiefly analyzed. Results: Two randomized controlled trials (239 patients) were included. The early and delayed post-ESD feeding groups had similar rates of post-ESD bleeding (risk ratio 1.90, 95% CI 0.42 to 8.63; I² = 0%). Early post-ESD feeding resulted in increased patients’ satisfaction in comparison to delayed post-ESD feeding (standard mean difference (MD) 0.54, 95% CI 0.27 to 0.81; I² = 0%) and reduced the length of hospital stay (MD −0.83, 95% CI −1.01 to −0.65; I² = 0%). Conclusion: Early post-ESD feeding was associated with increased patients’ satisfaction and reduced hospital stay in comparison to delayed feeding, while the rate of complications did not differ to a statistically significant extent. As we must acknowledge the limited number of reviewed studies, various trials regarding the quality of care are further needed to determine the benefits of early feeding after ESD.

Robotic versus laparoscopic gastrectomy for gastric cancer: The largest meta-analysis

BACKGROUND

Minimally invasive surgery (MIS) has been increasingly used in the treatment of gastric cancer (GC). Laparoscopic gastrectomy (LG) has shown several advantages over open surgery in dealing with GC, although it is still considered a demanding procedure. Robotic gastrectomy (RG) is now being employed with increased frequency worldwide and has been reported to overcome some limitations of conventional LG. The aim of this updated meta-analysis is to compare surgical and oncological outcomes of RG versus LG for gastric cancer.

MATERIALS AND METHODS

A systematic review and meta-analysis was conducted using the PubMed, MEDLINE and Cochrane library database of published studies comparing RG and LG up to March 2020. The evaluated end-points were intra-operative, post-operative and oncological outcomes. Dichotomous data were calculated by odds ratio (OR) and continuous data were calculated by mean difference (MD) with 95% confidence intervals (95% CI), and a random-effect model was always applied.

RESULTS

Forty retrospective studies describing 17,712 patients met the inclusion criteria. With respect to surgical outcomes, robotic compared with laparoscopic gastrectomy was associated with higher operating time [MD 44.73, (95%CI 36.01, 53.45) p < 0.00001] and less intraoperative blood loss [MD -18.24, (95%CI -25.21, -11.26) p < 0.00001] and lower rate of surgical complication in terms of Dindo-Clavien ≥ 3 classification [OR 0.66, (95%CI 0.49, 0.88) p = 0.005]. With respect to oncological outcomes, the RG group showed a significantly increased mean number of retrieved lymph nodes [MD 1.84, (95%CI 0.84, 2.84) p = 0.0003], but mean proximal and distal resection margin distance and the recurrence rate were not significantly different between the two approaches.

CONCLUSIONS

With respect to safety, technical feasibility and oncological adequacy, robotic and laparoscopic groups were comparable, although the robotic approach seems to achieve better short-term surgical outcomes. Moreover, a higher rate of retrieved lymph nodes was observed in the RG group.

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.

Effects of a stepwise, local patient-specific early oral feeding schedule after gastric cancer surgery: a single-center retrospective study from China

Nowadays, early oral feeding after gastrectomy has been gradually accepted and applied in the clinical practice, but there is still no specific uniform feeding regimen available which works best for patients in different regions with different races and eating habits. Aiming to establish an early oral feeding schedule suitable for local Chinese patients after gastric surgery, from May 2014 to May 2018, 87 gastric cancer patients undergoing various types of gastric resections were enrolled in an early feeding protocol and their clinical course was reviewed retrospectively. A stepwise, local patient-specific, early oral feeding schedule was proposed, implemented within an early recovery after surgery (ERAS) protocol and accessed in terms of its safety and tolerability. The primary surgical outcomes included: a median (interquartile range; IQR) postoperative hospital stay of 6 (3) days; 67 (77%) patients were well tolerant of this schedule from postoperative day (POD) 1 to POD 4; 20 (23%) patients had mild I/II grade complications (Clavien-Dindo classification); 3 (3%) patients had IIIB complications, zero cases of hospital mortality. Compared to similar studies in the past, our early oral feeding program is also safe and beneficial, and it can shorten the postoperative hospital stay without causing any increase in postoperative complications. In summary, our work herein reported the establishment of a detailed early oral feeding schedule embedded within an ERAS protocol which was found to be suitable for local Chinese patients after gastric surgery. Accordingly, this early oral feeding schedule is worth further research and promotion.

Comparison of Early Oral Feeding With Traditional Oral Feeding After Total Gastrectomy for Gastric Cancer: A Propensity Score Matching Analysis

Background: The present study aimed to compare the feasibility and safety of early oral feeding (EOF) with traditional oral feeding (TOF) after radical total gastrectomy for gastric cancer.

Methods: This retrospective study included consecutive patients who underwent total gastrectomy from April 2016 and November 2018. These patients were divided into two groups, according to their postoperative feeding protocol: EOF group (n = 314) and TOF group (n = 433). Propensity score matching was used to balance the potential confounders, and 276 patients were selected from each group. The EOF group received oral diet on postoperative day one, while the TOF group were started on oral feeding after the passage of flatus.

Results: No significant differences were found in the postoperative complications (P = 0.426) and tolerance to oral feeding (P > 0.056) between the two groups. The changes in perioperative nutritional markers were also similar between the two groups (P > 0.05). The time to first passage of flatus or defecation (47.19 ± 12.00 h vs. 58.19 ± 9.89 h, P < 0.0001) and length of postoperative hospital stay (6.84 ± 2.31 days vs. 7.72 ± 2.86 days, P < 0.0001) were significantly lower in the EOF group compared to the TOF group.

Conclusion: EOF may be safe and feasible after radical total gastrectomy with faster recovery and no increased risk of postoperative complications.

Effects of Early Initiation of Solid Versus Liquid Diet after Endoscopic Submucosal Dissection on Quality of Life and Postoperative Outcomes: A Prospective Pilot Randomized Controlled Trial

BACKGROUND/AIMS

Feeding recommendations after endoscopic submucosal dissection (ESD) for gastric neoplasms are not established and based on clinical experience.

METHODS

This was a prospective pilot randomized controlled trial. Patients undergoing ESD for gastric neoplasms were randomly assigned to solid (n = 50) or liquid diet (n = 50) groups. Beginning the day after hemostasis confirmation until discharge, the solid diet group started on a diet of rice porridge, whereas the liquid diet group started on a liquid diet, with gradual transition to solid food. The primary endpoint was delayed bleeding rate. The secondary endpoints were quality of life (QOL), ulcer-stage, hospital fees, and post-ESD symptoms.

RESULTS

Delayed bleeding occurred in the solid diet group (2%) but not in the liquid diet group. The QOL evaluation using European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-STO22 showed better score in the solid diet group. The patients who felt dietary restriction at discharge was of a larger number in the liquid diet group (p = 0.019). More patients experienced appetite loss (p = 0.038), constipation (p = 0.022), and dietary restriction (p = 0.037) in the liquid diet group during hospitalization. The other endpoints were equivalent between the groups.

CONCLUSION

Early initiation of solid foods after ESD is feasible and associated with higher QOL, potentially rendering conventional liquid diets unnecessary, although additional studies are needed (Trial registration number: UMIN000013297).

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications

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.

Safety of early oral feeding after total laparoscopic radical gastrectomy for gastric cancer (SOFTLY): Study protocol for a randomized controlled trial

BACKGROUND

Gastric cancer is the third most common cause of cancer-related deaths and has the fifth highest incidence worldwide, especially in eastern Asia, central and Eastern Europe, and South America. Currently, surgery is the only curative treatment for gastric cancer; however, there is an increasing trend toward laparoscopic radical gastrectomy. Early oral feeding (EOF) has been shown to benefit clinical outcomes compared with open gastrectomy under conditions of enhanced recovery after surgery. There are a lack of guidelines and evidence for the safety and feasibility of EOF in patients undergoing laparoscopic radical gastrectomy. Thus, a prospective randomized trial is warranted.

METHODS/DESIGN

The EOF after total laparoscopic radical gastrectomy (SOFTLY) study is a single-center, parallel-arm, non-inferiority randomized controlled trial which will enroll 200 patients who are pathologically diagnosed with gastric cancer and undergo laparoscopic radical gastrectomy. The primary endpoint, incidence of anastomotic leakage, is based on 1.9% in the control group in the CLASS-01 study. The patients will be randomized (1:1) into two groups: the EOF group will receive a clear liquid diet on post-operative day 1 (POD1) and the delayed oral feeding (DOF) group will receive a clear liquid diet on post-operative day 4 (POD4). The demographic and pathologic characteristics will be recorded. Total and oral nutritional intake, general data, total serum protein, serum albumin, blood glucose, and temperature will be recorded before surgery and at the time of hospitalization. Adverse events will also be recorded. The occurrence of post-operative fistulas, including anastomotic leakage, will be recorded as the main severe post-operative adverse event and represent the primary endpoint.

DISCUSSION

The safety and feasibility of EOF after gastrectomy has not been established. The SOFTLY trial will be the first randomized controlled trial involving total laparoscopic radical gastrectomy, in which the EOF group (POD1) will be compared with the DOF group (POD4). The results of the SOFTLY trial will provide data on the safety and feasibility of EOF after total laparoscopic radical gastrectomy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IOR-15007660 . Registered on 28 December 2015. The study has full ethical and institutional approval.

Safety of early oral feeding after total laparoscopic radical gastrectomy for gastric cancer (SOFTLY-1): a single-center randomized controlled trial

Objectives: The aim of this study is to explore the safety and feasibility of early oral feeding (EOF) on short-term postoperative outcomes.

Trial design: A prospective randomized non-inferiority trial.

Materials and methods: From August 27, 2015 to March 31, 2017, 100 consecutive patients with gastric cancer in Xijing Hospital were recruited. Patients undergoing total laparoscopic radical gastrectomy (TLRG) received either EOF group or delayed oral feeding (DOF group). The endpoints were anastomotic leakage, the recovery of bowel function, the postoperative complications and costs. The process of randomization used a computer-generated sequence that was kept in a sealed envelope by a nurse that did not participate in the trial. None of the participants, administrators of interventions and those assessing outcomes was blinded.

Results: Ultimately, 51 patients were in EOF group and 49 in DOF group, which both are comparable. The postoperative hospital stay in EOF group was significantly lower than DOF group (5.18±1.47 days vs 6.18±2.46 days, P=0.016). Furthermore, there was a trend for a reduction in the time of first flatus (10.3 hrs) and defecation (12.7 hrs) in EOF group compared to DOF group, but it was not statistically significant. Meanwhile, there were no significant differences in postoperative complications between two groups. One patient in the EOF group developed a fistula in the surgical remnant, which was recorded as other leakages; there was no difference between the two groups (P=0.582).

Conclusion: EOF does not seem to be more harmful than DOF, and might significantly improve the short-term outcomes for patients receiving TLRG.

Early Oral Feeding Following McKeown Minimally Invasive Esophagectomy: An Open-label, Randomized, Controlled, Noninferiority Trial

OBJECTIVE

Our objective was to evaluate the impact of early oral feeding (EOF) on postoperative cardiac, respiratory, and gastrointestinal (CRG) complications after McKeown minimally invasive esophagectomy for esophageal cancer.

SUMMARY BACKGROUND DATA

Nil-by-mouth with enteral tube feeding is routinely practiced after esophagectomy.

METHODS

Patients were randomly allocated to receive oral feeding on the first postoperative day (EOF group) or late oral feeding (LOF group) 7 days after surgery. The primary endpoint was the occurrence of postoperative CRG complications, and the secondary outcomes included bowel function recovery and short-term quality of life (QOL).

RESULTS

Between February 2014 and October 2015, 280 patients were enrolled in this study. There were 140 patients in the EOF group and 140 patients in the LOF group. EOF was noninferior to LOF for CRG complications (30.0% in the EOF group vs. 32.9% in the LOF group; 95% confidence interval of the difference: -13.8% to 8.0%). Compared with the LOF group, the EOF group showed significantly shorter time to first flatus (median of 2 days vs. 3 days, P = 0.001) and bowel movement (median of 3 vs. 4 days, P < 0.001). Two weeks after the operation, patients in the EOF group reported higher global QOL and function scores and lower symptom scores than patients in the LOF group.

CONCLUSIONS

In patients after McKeown minimally invasive esophagectomy is noninferior to the standard of care with regard to postoperative CRG complications. In addition, patients in the EOF group had a quicker recovery of bowel function and improved short-term QOL.

Early postoperative oral feeding shortens first time of bowel evacuation and prevents long term hospital stay in patients undergoing elective small intestine anastomosis

AIM

This study was conducted to compare outcome of early oral feeding (EOF) versus traditional oral feeding (TOF) in patients undergoing elective small intestine anastomosis.

BACKGROUND

Appropriate nutritional support after major surgeries is a real medical concern. As traditional surgical techniques have been replaced by novel methods, postoperative care should be revised as well. Early postoperative oral feeding was studied in trauma and burn. However, there are few trials among patients after major surgeries.

METHODS

This randomized single-blinded controlled trial was performed on 108 patients who had small intestine anastomosis at Imam Hossein Medical Centre in 2012. The patients were randomly assigned to schedule EOF (with starting oral feeding on the first day after surgery and complete return of the Gag reflex) or TOF (with delaying oral feeding till first passage of flatus and bowel movement). We compared overall prevalence of postoperative complication, length of hospital stay and outcome of surgery in two groups.

RESULTS

The time of the first passage of stool was shorter in EOF group than in TOF group (3.2 ± 0.59 days versus 3.6 ± 0.66 days (p= 0.006). The mean length of hospital stay in EOF group was also shorter than in TOF group (3.8 ± 1.06 days versus 6.3 ± 1.0 days, p= 0.001). The length of hospital stay shorter than 4 days was found in 75.9% of patients in EOF group and 11.1% of those patients in TOF group (p < 0.001).

CONCLUSION

The use of EOF in patients undergoing small intestine anastomosis can shorten time of the first passage of stool as well as reduce length of hospital stay.

Safety and efficacy of early oral feeding for enhanced recovery following gastrectomy for gastric cancer: A systematic review

BACKGROUND

Early oral feeding (EOF) is believed to be a crucial item of Enhanced Recovery After Surgery (ERAS) programs. Though this is widely accepted for colorectal surgery, evidence for early oral feeding after gastrectomy is scarce. The aim of this review is to assess the evidence of safety and benefits of early oral feeding after gastrectomy in patients with gastric cancer.

METHODS

A systematic literature search of Pubmed, Embase and Cochrane was performed for eligible studies published till September 2018. Studies were analyzed and selected by predetermined criteria.

RESULTS

After having assessed 23 eligible articles, a total of four randomized controlled trials (RCT) remained who fully met all requirements to be included in this review. All four RCTs compared early oral feeding (n = 320) with conventional care (n = 334) after gastrectomy. In all four studies, EOF was associated with a decreased length of hospital stay ranging from -1.3 to -2.5 days when compared to conventional care. A faster time to first flatus was recorded in all four studies in the EOF group, ranging from -6.5 hours to -1.5 days. Furthermore, EOF does not increase postoperative complication risk when compared to conventional care.

CONCLUSION

Current evidence for early oral feeding after gastrectomy is promising, proving its safety, feasibility and benefits. However, most studies have been conducted amongst an Asian population. Well powered and larger randomized controlled trials performed amongst a Western population is needed.

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications

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.

Early Postoperative Oral Feeding After Total Gastrectomy in Gastric Carcinoma Patients: A Retrospective Before-After Study Using Propensity Score Matching

BACKGROUND

Despite its clinical benefits, early oral nutrition after total gastrectomy is not widely implemented because of concerns about tolerability and safety. We investigated the feasibility and safety of early oral nutrition after total gastrectomy in gastric carcinoma patients.

METHODS

This is a retrospective before-after study. From 2008-2016, 301 patients received conventional oral feeding (COF) before May 2012, and 454 patients, early oral feeding (EOF) after May 2012. The EOF group received oral diet on postoperative day 1, and the COF group was maintained nil-by-mouth until patients demonstrated gas passage. After balancing potential confounders using propensity score matching, 203 patients were selected in each group.

RESULTS

Both matched groups demonstrated well-balanced baseline characteristics. The EOF group demonstrated significantly earlier first flatus time (2.9 vs 3.1 days, P = .013) and hospital discharge (8.9 vs 12.6 days, P < .001) than the COF group. No significant differences were observed for overall morbidity and mortality, but the EOF group demonstrated lower incidence of abdominal infection (3.0% vs 7.4%, P = .044) and anastomosis leakage (1.5% vs 4.9%, P = .048). Subgroup analyses by age, sex, operative approach, lymph node dissection, and tumor stage demonstrated no increased risk of morbidity, anastomosis leakage, and short hospital stay in the EOF group.

CONCLUSION

Early oral nutrition may be feasible and safe after total gastrectomy, with no increase in postoperative complications. Large, randomized, controlled trials are warranted to further investigate the clinical benefits of early oral nutrition after total gastrectomy.

The Optimal Time of Postoperative Feeding After Total Hip Arthroplasty: A Prospective, Randomized, Controlled Trial

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.

Clinical pathway after gastrectomy for gastric cancer: A case series of laparoscopic gastrectomy and early oral intake with "iEat™"

INTRODUCTION

We investigated the validity of the clinical pathway of early oral intake using a special type of food "iEat™" for patients after laparoscopic gastric cancer surgery.

METHODS

Fifty-two patients who underwent laparoscopic surgery for gastric cancer between April 2012 and October 2013 were the participants. We provided postoperative care in accordance with a clinical pathway for laparoscopic gastrectomy that begins oral intake with "iEat™ the day after surgery. We examined complications resulting from oral intake, postoperative complications, and the length of postoperative hospital stay.

RESULTS

Of the 52 patients, 30 underwent distal gastrectomy and 22 underwent total gastrectomy. 50 patients was able to start early oral intake in accordance with our clinical pathway. No anastomotic leak complications were observed, and 9 patients (17.3%) developed complications as results of surgery. There was no complication related to early oral intake with "iEat™". Re-operation were performed in two cases. Overall mean and median postoperative hospital stays were 8.3 days and 6 days, respectively. There was a single case of hospital re-admission. The completion rate of this early oral intake clinical pathway was 86.5%.

CONCLUSION

Clinical pathway of recovery program combined laparoscopic suregry and early oral intake with "iEat™" could be useful for gastric cancer. This study indicates that using non-liquid food like iEat™ can be feasiblel, and water or liquid food don't have to be used in early oral feeding after laparoscopic gastrectomy.

EARLY ORAL FEEDING POST-UPPER GASTROINTESTINAL TRACT RESECTION AND PRIMARY ANASTOMOSIS IN ONCOLOGY

Background:

The practice of starving patients in the immediate period after upper gastrointestinal surgery is widespread. Early oral intake has been shown to be feasible and may result in faster recovery and decrease length of hospital.

Aim:

To evaluate the feasibility and safety of oral nutrition on postoperative early feeding after upper gastrointestinal surgeries.

Methods:

Observational cohort design study with convenience retrospective data in both genders, over 18 years, undergoing to total gastrectomy and/or elective esophagectomy. They have received oral or enteral nutrition in less than 48 h after surgery, and among those who started with enteral nutrition, the oral feeding up to seven days.

Results:

The study was performed in 161 patients, 24 (14.9%) submitted to esophagectomy, 132 (82%) to total gastrectomy and five (3.1%) to esophagogastrectomy. Was observed good dietary acceptance and low percentage (29%) of gastrointestinal intolerances, more pronounced among those with enteral diet. Most of the patients did not present postoperative complications, 11 (6.8%) were reopened, five (3.1%) had fistulas, three (1.9%) wound dehiscence, three (1.9%) fistula more wound dehiscence and six (3.7%) other non-infectious complications.

Conclusion:

Early oral diet is safe and viable for patients undergoing upper gastrointestinal surgery.

Feeding Practices and Nutrition Intakes Among Non-Critically Ill, Postoperative Adult Patients: An Observational Study

BACKGROUND

Evidence-based guidelines (EBG) recommend recommencing oral feeding (liquids and solids) ≤24 hours after surgery. The aims of this study were to determine time to first diet (any) and solid-diet prescriptions, delivery, and intakes among adult, non-critically ill, postoperative patients.

METHODS

This prospective cross-sectional study included 100 postsurgical patients. Demographic and perioperative dietary-related data were collected from patients' medical records or via direct observation. Dietary intakes were observed for the duration patients were enrolled in the study (from end of surgery to discharge). The amount of energy (kcal) and protein (g) consumed per patient per day was analyzed and considered adequate if it met ≥75% of a patient's estimated requirements.

RESULTS

89 and 52 patients consumed their first intake and first solid intake ≤24 hours after surgery, respectively. For their first intake, 53% of patients had clear or free liquids. Median times to first diet prescription (range: 1.3-5.7 hours), delivery (range: 2.1-12.5 hours), and intake (range: 2.2-13.9 hours) were ≤24 hours after surgery for all patient groups. Time to first solid-diet prescription (range: 1.3-77.8 hours), delivery (range: 2.1-78.0 hours) and intake (range: 2.2-78.2 hours) varied considerably. Urologic and gastrointestinal patients experienced the greatest delays to first solid-diet prescription and first solid intake. Only 26 patients met both their energy and protein requirements for ≥1 day during their stay.

CONCLUSION

While practice appears consistent with EBG recommendations for commencing nutrition (any type) after surgery, the reintroduction of adequate diet requires improvement.

Effect of early oral feeding on length of hospital stay following gastrectomy for gastric cancer: a Japanese multicenter, randomized controlled trial

PURPOSE

This multicenter, randomized controlled study evaluates the safety of early oral feeding following gastrectomy, and its effect on the length of postoperative hospital stay.

METHODS

The subjects of this study were patients who underwent distal gastrectomy (DG) or total gastrectomy (TG) for gastric cancer between January 2014 and December 2015. Patients were randomly assigned to the early oral feeding group (intervention group) or the conventional postoperative management group (control group) for each procedure. We evaluated the length of postoperative hospital stay and the incidence of postoperative complications in each group.

RESULTS

No significant differences in length of postoperative stay were found between the intervention and control groups of the patients who underwent DG. The incidence of postoperative complications was significantly greater in the DG intervention group. In contrast, the length of postoperative stay was significantly shorter in the TG intervention group, although the TG group did not attain the established target sample size.

CONCLUSION

Early oral feeding did not shorten the postoperative hospital stay after DG. The higher incidence of postoperative complications precluded the unselected adoption of early oral feeding for DG patients. Further confirmative studies are required to definitively establish the potential benefits of early oral feeding for TG patients.

The Impact of Postoperative Enteral Immunonutrition on Postoperative Complications and Survival in Gastric Cancer Patients - Randomized Clinical Trial

BACKGROUND

Immunomodulating enteral nutrition in the perioperative period may reduce postoperative complications in cancer patients. Little is known if this effect translates to the better survival. The aim of study was to assess the impact of postoperative immunomodulating enteral nutrition on postoperative complications and survival of gastric cancer patients.

METHODS

A group of 98 gastric cancer patients was randomly assigned for postoperative immunomodulating enteral nutrition n = 44 (Reconvan, Fresenius Kabi, Bad Homburg, Germany), or standard enteral nutrition n = 54 (Peptisorb, Nutricia, Schipol, The Netherlands). Postoperative complications, mortality, 6-mo and 1-yr survival were analyzed.

RESULTS

The overall postoperative morbidity did not differ between the groups. The rate of pulmonary complications (excluding pneumonia) was significantly lower in immunomodulation group (0% vs 9.3%, p = 0.044), as well as 60-day mortality (0% vs. 11.1%, p = 0.037). There was no difference in 6-mo and 1-yr survival between the groups.

CONCLUSIONS

Postoperative immunomodulating enteral nutrition may reduce respiratory complications and postoperative mortality in comparison to standard enteral nutrition. Despite this effect, it did not improve 6-mo and 1-yr survival in immunomodulation group. Probably the beneficial effect of immunomodulating enteral nutrition is too weak to be significant in such a number of patients.

Effects of nurse-led clinical pathway in coronary artery bypass graft surgery: A quasi-experimental study

AIMS AND OBJECTIVES

To develop and evaluate the effects of a nurse-led clinical pathway for patients undergoing coronary artery bypass graft surgery.

BACKGROUND

A clinical pathway is a multidisciplinary care plan, based on evidence and guidelines to provide consistent, quality care to patients and improve outcomes.

DESIGN

Prospective, quasi-experimental design.

METHODS

Patients hospitalised for coronary artery bypass graft between April 2014-November 2015 in a hospital in Turkey were studied. First 42 usual care patients were enrolled to determine outcomes and plan for the development of the clinical pathway followed by 40 patients in the newly developed clinical pathway. The primary outcome was length of stay and secondary outcomes related to recovery from surgery (e.g., time to extubation, first feeding).

RESULTS

The mean age for the clinical pathway group was 60 and for usual care was 63 years. Most were male (CP = 78%, UC = 69%). There were significant differences between groups for the primary outcome. Length of stay in the intensive care unit was 38.9 hr for CP and 50.7 hr for usual care patients p < .01. Total hospital time was 144.4 hr for clinical pathway and 162.2 hr for usual care, p < .05. For secondary measures, the following times were less for the clinical pathway group than for the usual care: time to extubation and nasogastric tube removal (5.7 vs. 8.6 hr, p < .01), first oral feeding (4.7 vs. 10.9 hr, p < .001), first mobilisation (8.4 vs. 22.9 hr, p < .001) and first bowel movement (69.8 vs. 85.9 hr, p < .01). There were no statistically significant differences in the 3-month readmission rates and complication rates between the groups, except the renal complication rates were higher in the usual care (n = 16, 38%) than in the clinical pathway (n = 7, 17.5%) (p < .05).

CONCLUSION

The nurse-led clinical pathway was effective in improving length of stay in both the ICU and hospital as well as the secondary outcomes.

RELEVANCE TO CLINICAL PRACTICE

This study contributes to previous studies supporting clinical pathway use can improve the length of stay and quality of care in patients undergoing coronary artery bypass graft surgery.

Enhanced Recovery After Surgery

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgical procedures. Meta-analyses, randomized controlled trials, and large prospective cohort studies were reviewed. Each item of the perioperative treatment pathway in the English language was examined and reviewed. Enhanced recovery after surgery items that were the strongest predictors for a shorter hospital stay and lower morbidity were absence of a nasogastric tube, early mobilization, early oral nutrition, early removal of the epidural, early removal of the urinary catheter, and utilization of nonopioid analgesia. Based on evidence available for each element of the perioperative care pathway, ERAS provides a protocol for perioperative care. This protocol allows for further evidence-based studies that are adequately powered between institutions.

Efficacy of fast track surgery in laparoscopic radical gastrectomy for gastric cancer:a meta-analysis of randomized controlled trials

OBJECTIVE

To conduct a systematic review of efficacy and security of fast track surgery (FTS) in laparoscopic radical gastrectomy for gastric cancer.

METHODS

We searched PubMed, Embase, and Cochrane Library Databases and supplemented by other searches to collect randomized controlled trials (RCTs) on the comparison of fast track surgery combined with laparoscopy versus laparoscopy separately used in radical gastrectomy for gastric cancer before December 2016. After screening for inclusion, data extraction, and quality assessment, meta-analysis was conducted by the Review Manager 5.3 software.

RESULTS

A total of 6 RCTs, involving 464 patients, were included. There were 232 patients in the FTS group and conventional care group separately. Compared with the conventional care group, patients of FTS group had shorter postoperative hospital stay [WMD = -1.85, 95%CI: (-2.60, -1.11), P < .00001], earlier first flatus [WMD = -9.33, 95%CI: (-13.74, -4.91), P < .0001], lower level of C-reactive protein (CRP) at postoperative day 4 [WMD = -13.94, 95%CI: (-22.74, -5.15), P = .002], and less hospitalization fees [SMD = -1.12, 95%CI: (-2.07, -0.18), P = .02]. There were no significant differences in operation time, intraoperative blood loss, and postoperative complications between the two groups.

CONCLUSION

Based on current evidence, the FTS protocol is safe and effective in laparoscopic radical gastrectomy for gastric cancer. Due to the limitations of our study, further larger and multicenter studies are needed to validate our findings.

Assessment of nutritional status in laparoscopic gastrectomy for gastric cancer

Malnutrition is very common in gastric cancer patients and can be detected in up to 85% of patients with gastric cancer. Malnutrition is associated with increased morbidity and mortality, prolonged hospital stay, poor treatment tolerance, and lower survival rate. Malnutrition also has an impact on quality of life. The early detection of nutritional risk with appropriate nutritional care can significantly reduce patient's postoperative morbidity and mortality. Because there is no gold standard tool, appropriate tools should be selected and applied depending on one's institutional conditions. And, it is recommended that nutritional assessment should be achieved for every patient at pre/post-operative period.

Perioperative Management of Elderly Patients with Gastrointestinal Malignancies: The Contribution of Anesthesia

INTRODUCTION

Elderly patients suffering from gastrointestinal malignancies are particularly prone to perioperative complications. Elderly patients often present with reduced physiological reserves, and comorbidities can limit treatment options and promote complications. Surgeons and anesthesiologists must be aware of strategies required to deal with this vulnerable subgroup.

METHODS

We provide a brief review of current and emerging perioperative strategies for the treatment of elderly patients with gastrointestinal malignancies and frequent comorbidities.

RESULTS

Especially in combination with advanced age, the effects of malignancies can be devastating, bringing new health challenges, exacerbating preexisting conditions, and exerting severe psychological strain. An interdisciplinary assessment and process planning provide an ideal setting to identify and prevent potential complications, especially in regards to frailty and cardiovascular risk. In addition, important perioperative considerations are presented, such as malnutrition, fasting, intraoperative neuromonitoring, and hemodynamic control, as well as postoperative early mobilization, pain, and delirium management.

CONCLUSION

The decisions and interventions made in the perioperative stage can positively influence many intra- and postoperative factors, significantly improving the chances of successful treatment of elderly cancer patients. Appropriate management can help prevent or mitigate complications, secure a quick recovery, and improve short- and long-term outcomes.

Does having a gastrectomy delay time to feeding and prolong hospital stay in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?

AIM

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is routinely used to treat selected patients with peritoneal carcinomatosis, but can be associated with prolonged hospital stay, significant morbidity and mortality. Our objective was to assess whether patients undergoing gastrectomy as part of CRS/HIPEC were at increased risk of delayed feeding time and prolonged hospital stay.

METHODS

Two hundred and fourteen consecutive patients with peritoneal carcinomatosis treated with CRS/HIPEC between 2001 and 2016 were stratified by whether CRS included gastrectomy (n = 19, 9%) and compared. Primary outcomes were time to full feeds and rate of serious morbidity (Clavien-Dindo grades III-V). Secondary outcomes were durations of ICU and hospital stays.

RESULTS

Of 214 patients undergoing CRS/HIPEC, those undergoing gastrectomy (19, 8.9%) had increased time to full feeds (8 vs. 5 days, p < 0.01), and duration of ICU (2 vs. 1 days, p < 0.01) and total hospital stays (16 vs. 14 days, p = 0.013). There was no significant increase in serious complications, although increased risk of pneumonia was noted (21% vs. 4.1%, p = 0.011). Undergoing gastrectomy was not independently prognostic in multivariable analysis including high peritoneal tumour load (PCI >12), multiple CRS procedures (number >2) and operation duration (>480 min) in which operative duration remained independently prognostic (p < 0.01).

CONCLUSIONS

After surgery, early oral refeeding may be beneficial in the majority of patients undergoing CRS/HIPEC. However, patients found to have high peritoneal tumour load with extended surgery and those who underwent gastrectomy should be considered for early post-operative TPN due to the significant risk of delayed time to full feeds.

Total gastrectomy-induced reductions in food intake and weight are counteracted by rikkunshito by attenuating glucagon-like peptide-1 elevation in rats

BACKGROUND

Decrease in appetite and weight after total gastrectomy in patients with gastric cancer leads to a decrease in quality of life, increased mortality, and may necessitate discontinuation of adjuvant chemotherapy. The aim of this study is to determine whether rikkunshito, a Japanese herbal medicine, increases food intake and weight after gastrectomy in rats.

METHODS

Male rats underwent gastrectomy followed by roux-en-Y reconstruction or sham operation and were then treated with rikkunshito for 14 days starting on postoperative day 3. Daily food intake, weight, plasma glucagon-like peptide-1 (GLP-1), and ghrelin levels were measured. A pilot study to measure pre- and postoperative plasma GLP-1 levels was conducted in patients who underwent total gastrectomy for gastric cancer.

RESULTS

Administration of rikkunshito after gastrectomy in rats significantly increased food intake and weight, which continued for at least 2 weeks after treatment. Both fasting and postprandial plasma GLP-1 levels were increased markedly after gastrectomy compared with sham-operated animals. Increased GLP-1 levels in rats after gastrectomy were suppressed markedly by rikkunshito. rikkunshito had no significant effect on plasma ghrelin levels after gastrectomy. Treatment with a GLP-1 receptor antagonist significantly improved food intake and weight after gastrectomy. Plasma fasting GLP-1 levels in patients with gastric cancer were increased greatly after gastrectomy on postoperative day 1.

CONCLUSION

Administration of rikkunshito suppresses plasma GLP-1 levels after total gastrectomy, which is associated with recovery from reduced food intake and weight in rats.