Feeding Post-Pyloromyotomy: A Meta-analysis

The Safety and Efficacy of Early Enteral Nutrition After Paediatric Enterostomy Closure - The EPOC Study

INTRODUCTION

Keeping children nil by mouth until return of bowel function after intestinal anastomosis surgery is said to reduce complications. Fasting may extend up to five days, risking malnourishment and usage of parenteral nutrition. This study aims to establish the efficacy and safety of early enteral nutrition in children undergoing intestinal stoma closure.

METHODOLOGY

A retrospective cohort study of children aged three months to 16 years who underwent an intestinal stoma closure between 1/1/2019 and 31/12/2021 at two tertiary paediatric hospitals was undertaken. Children fed clear fluids within 24 h (EEN) were compared to those commencing feeds later (LEN). The primary outcome was length of post-operative stay (LOS) and secondary outcomes included: time to feeds; time to stool; and complications.

RESULTS

Of the 129 children that underwent a stoma closure, 69 met inclusion criteria: 35 (51 %) in the LEN group and 34 (49 %) in the EEN group. Children in the EEN group had a significantly shorter LOS (92.6 h vs 121.7 h, p = 0.0045). Early feeding was also associated with a significantly decreased time to free fluids (p < 0.001) and full enteral intake (p = 0.007). There was no significant intergroup difference in complications.

CONCLUSION

Commencing feeding within 24 h of stoma closure is efficacious and safe, with clear reductions in LOS, time to full feeds and time to stool, and no increase in complications. Further research is required to extrapolate these findings to other populations.

LEVEL OF EVIDENCE

III.

The Impact of Early Enteral Nutrition on Post-operative Hospital Stay and Complications in Infants Undergoing Congenital Cardiac Surgery: A Systematic Review and Meta-analysis

Introduction: The congenital cardiac diseases (CHDs) are the leading cause of death in children. The CHDs detection and management have greatly improved over the past few decades. This review aimed to assess the effectiveness of early enteral nutrition (EEN) on postoperative outcomes in infants undergoing congenital cardiac surgery. Methods: Electronic databases PubMed, Clinical Key, UpToDate, the Cochrane Library, and Google Scholar were searched for studies published in the English language, between 2004 and 2021. This review carried out based on PRISMA statement and studies qualities assessed using "Downs and Black score". Hospital stay, intensive care unit (ICU) stay, mechanical ventilation support, aortic cross clamping and cardiopulmonary bypass were as primary outcomes. Similarly infections, vomiting and mortality were as secondary outcomes of included studies. Results: This review consists of 887 infants from 10 studies. Of these, 470 infants were assigned to the intervention group and 417 to the control group. The post-operative hospital stay shorted in the EEN group than the control group (SMD=-0.63, 95% CI: -1.03 to -0.22, P=0.0, I²=87%). Similarly, EEN group lessen the ICU stay (SMD=-0.15, 95% CI: -0.42, 0.11, P=0.0, I²=71%), mechanical ventilation support (SMD=-0.31, 95% CI: -0.51, -08, P=0.08, I²=47%), aortic cross clamping (SMD=-0.92, 95% CI: -0.31, 2.4, P=0.00, I²=96%), and cardiopulmonary bypass (SMD=-0.0, 95% CI: -0.42 to 43, P=0.00, I²=71%). Secondary postoperative complications such as infections (RR=0.68, 95% CI: 0.43 to 1.08, P=0.40, I²=3%). vomiting (RR=1.47, 95% CI: 0.80 to 2.69, P=0.90, I²=0%) and postoperative mortality (RR=0.42, 95% CI: 0.03 to 5.82, P=0.00: I²=80%) significantly reduced. Conclusion: Postoperative outcomes were improved in the intervention group compared to the control group, including shorter hospital stays, ICU stays, mechanical ventilation, and less postoperative complications.

Systematic review and meta-analysis of safety and efficacy of early enteral nutrition as an isolated component of Enhanced Recovery After Surgery [ERAS] in children after bowel anastomosis surgery

BACKGROUND

Postoperative feeding practices are not uniform in children undergoing bowel anastomosis surgery. Primary aim of this review was to evaluate the safety and efficacy of early enteral nutrition (EEN) as an isolated component of enhanced recovery in children undergoing bowel anastomosis surgery.

METHODS

Medical search engines (PubMed, CENTRAL, Google scholar) were accessed from inception to January 2021. Randomized Controlled Trials (RCT)s, non-randomized controlled trials, observational studies and retrospective studies comparing EEN, initiated within 48 h vs late enteral nutrition (LEN), initiated after 48 h in children ≤ 18 years undergoing bowel anastomosis surgery were included. Primary outcome measure was the incidence of postoperative complications (anastomotic leak, abdominal distension, surgical site infection, wound dehiscence, vomiting and septic complications). Secondary outcome measures were the time to passage of first feces and the length of hospital stay.

RESULTS

Twelve hundred and eighty-six children from 10 studies were included in this review. No difference was seen between the EEN and LEN groups in the incidence of anastomotic leak (1.69% vs 4.13%; p = 0.06), abdominal distention (13.87% vs 12.31%; p = 0.57), wound dehiscence (3.07% vs 2.69%; p = 0.69) or vomiting (8.11% vs 8.67%; p = 0.98). The incidence of surgical site infections (7.51% vs 11.72%; p = 0.04), septic complications (14.02% vs 26.22%; p = 0.02) as well as pooled overall complications (8.11% vs 11.27%; RR 0.71; 95% CI = 0.56 to 0.89; p = 0.003; I² = 33%) were significantly lower in the EEN group. The time to passage of first feces (MD - 17.23 h; 95% CI -23.13 to -11.34; p < 0.00001; I² = 49%) and the length of hospital stay (MD -2.95 days; 95% CI -3.73 to -2.17; p < 0.00001; I² = 93%) were significantly less in the EEN group.

CONCLUSION

EEN is safe and effective in children following bowel anastomosis surgery and is associated with a lower overall incidence of complications as compared to LEN. EEN also promotes early bowel recovery and hospital discharge. However, further well designed RCTs are required to validate these findings.

LEVEL OF EVIDENCE

V.

Safety and benefit of ad libitum feeding following laparoscopic pyloromyotomy: retrospective comparative trial

PURPOSE

In this study, we evaluated the impacts of ad libitum feedings on outcomes following laparoscopic pyloromyotomy in patients with infantile hypertrophic pyloric stenosis.

METHODS

Pediatric patients with infantile hypertrophic pyloric stenosis who underwent laparoscopic pyloromyotomy were included. Patients were stratified into ad libitum and structured feeding groups. Primary outcomes were times from surgery completion to goal feeding and discharge.

RESULTS

A total of 336 patients were included in the study with 63 patients (18.8%) in the ad libitum feeding group. The ad libitum feeding group experienced significantly shorter times from surgery completion to both goal feedings (10.7 h vs 18.7 h; p < 0.001) and hospital discharge (21.6 h vs 23.1 h; p = 0.008) compared to the structured protocol group. Postoperative emesis (47.% vs 30.8%; p = 0.011) was higher in the ab libitum cohort, but the rates of return to an emergency department and/or readmission (4.8% vs 2.2%; p = 0.26) were similar.

CONCLUSION

Ad libitum feeding after pyloromyotomy decreases time to reach goal feeding and hospital discharge. While it may contribute to a higher incidence of emesis, it does not appear to significantly increase hospital readmission. Ad libitum feeding appears to be a safe and beneficial alternative to structured feeding protocols following pyloromyotomy.

LEVEL OF EVIDENCE

III.

Hypertrophic Pyloric Stenosis

Hypertrophic pyloric stenosis is a common condition seen in the first 1 to 3 months after birth. Patients typically present with nonbilious projectile emesis after feeds that may result in hypokalemic, hypochloremic metabolic alkalosis. Although inability to tolerate feeds is frequently seen with self-limited conditions such as reflux, a low threshold to obtain an ultrasonographic image is important to prevent a delay in diagnosis. Although operative intervention is the treatment, it is imperative that patients are hydrated and serum electrolyte concentrations normalized before the induction of anesthesia. Laparoscopic pyloromyotomy is safe and effective. Postoperative emesis is normal, and reassurance to parents is appropriate. There is no significant long-term physiologic impairment from pyloric stenosis after successful surgical intervention.

Early enteral feeding after intestinal anastomosis in children: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Delayed enteral feeding (DEF) contributes to postoperative complications among children undergoing intestinal surgery. Various recent studies indicate the benefits of early enteral nutrition after intestinal surgery in adults. This systematic review and meta-analysis evaluates whether early enteral feeding (EEF) is beneficial in children who underwent intestinal anastomosis.

METHODS

MEDLINE, PubMed, the Cochrane Library, and Web of Science databases were searched for RCTs that addressed the effect of EEF in children (younger than 18 years old) undergoing intestinal anastomosis. EEF was defined as starting enteral feeding before the 3rd postoperative day. Studies were selected based on predetermined inclusion and exclusion criteria. A meta-analysis was performed using RevMan 5.3 to estimate odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs).

RESULTS

Four RCT studies met the inclusion criteria, comprising 97 cases with EEF and 89 cases with DEF. Enteral feeding started significantly earlier in the EEF group compared to the DEF group (MD = - 2.80; 95% CI - 3.11 to - 2.49; p < 0.00001). Postoperative anastomotic leak rate was unchanged between EEF and DEF groups (OR = 0.86; 95% CI 0.17-4.46; p = 0.86). The EEF group had a shorter length of hospital stay (MD = - 3.38; 95% CI - 4.29 to - 2.48; p < 0.00001), earlier time to bowel movement return (MD = - 0.57; 95% CI - 0.79 to - 0.35; p < 0.00001), lower incidence of surgical infection (OR = 0.27; 95% CI 0.08-0.90; p = 0.03), and faster tolerance of full enteral feeding (MD = - 2.00; 95% CI - 3.01 to - 2.79; p < 0.00001). Incidence of fever (OR = 0.37; 95% CI 0.10-1.31; p = 0.12), emesis, and abdominal distention (OR = 0.63; 95% CI 0.13-3.16; p = 0.58) were not different between the two groups.

CONCLUSIONS

Early enteral feeding after intestinal anastomosis in children does not increase the risk of postoperative anastomotic leak, fever, emesis, and abdominal distention. However, early enteral feeding is beneficial as it promotes the return of bowel function, reduces the length of hospital stay and the incidence of surgical infection in comparison to delayed enteral feeding.

Guidelines of the Italian Society of Videosurgery (SIVI) in Infancy for the minimally invasive treatment of Hypertrophic Pyloric Stenosis in neonates and infants

The most appropriate treatment for the infantile Hypertrophic Pyloric Stenosis (HPS) is still debated. The non-surgical conservative treatment with oral or intravenous administration of atropine does not enjoy a widespread appreciation for several factors (...).

Early enteral feeding after pediatric abdominal surgery: A systematic review of the literature

INTRODUCTION

Traditionally enteral nutrition has been delayed following abdominal surgery in children, to prevent complications. However, recent evidence in the adult literature refutes the supposed benefits of fasting and suggests decreased complications with early enteral nutrition (EEN). This review aimed to compile the evidence for EEN in children in this setting.

METHODS

Databases Pubmed, EmBase, Medline and reference lists were searched for articles containing relevant search terms according to PRISMA guidelines. First and second authors reviewed abstracts. Studies containing patients less than 18 years undergoing abdominal surgery, with feeding initiated earlier than standard practice, were included. Studies including pyloromyotomy were excluded. Primary outcome was length of stay (LOS). Secondary outcomes included time to full enteral nutrition, time to stool and postoperative complications.

RESULTS

Fourteen articles met inclusion criteria - five on neonatal abdominal surgery, three on gastrostomy formation and six on intestinal anastomoses. There were three randomized control trials (RCTs), five cohort studies, four historical control trials, one nonrandomized trial and one case series. Nine studies showed a decreased LOS with EEN. Most studies which reported time to full enteral nutrition showed improvement with EEN; however, time to stool was similar in most studies. Postoperative complications were either decreased or not statistically different in EEN groups in all studies.

CONCLUSION

Studies to date in a limited number of procedures suggest EEN appears safe and effective in children undergoing abdominal surgery. Although robust evidence is lacking, there are clear benefits in LOS and time to full feeds, and no increase in complications.

LEVEL OF EVIDENCE

IV.

Idiopathic Hypertrophic Pyloric Stenosis with Complete Ladd's Band: A Rare Association

A male infant aged 45 days presented with projectile nonbilious vomiting for 2 weeks. Ultrasound showed picture of idiopathic hypertrophic pyloric stenosis. Laparoscopic pyloromyotomy was done, but postoperative vomiting that was mainly nonbilious continued without improvement. After 4 days of persistent vomiting, laparoscopic exploration was done and complete pyloromyotomy was confirmed and malrotation with complete Ladd's band was found, then case converted to open laparotomy and Ladd's procedure was done. Postoperatively, vomiting stopped completely and baby began gradual feeding till reaching full feed. Despite that the presentation of concurrent Idiopathic Hypertrophic Pyloric Stenosis with malrotation is extremely rare; a formal laparoscopic abdominal exploration should be done as the first step before proceeding to pyloromyotomy.

Feeding Advancement and Simultaneous Transition to Discharge (FASTDischarge) after laparoscopic gastrostomy

BACKGROUND

Laparoscopic gastrostomy (LG) is a common surgical procedure. However, there is little consensus on a postoperative feeding regimen. With prior nasogastric feed tolerance, there should be no delay in resumption of feeds and subsequent discharge to home. This is a report on a Feeding Advancement and Simultaneous Transition-Discharge (FAST-Discharge) pathway, which to date has not been reported in the literature.

METHODS

A retrospective review of patients who underwent LG was performed from May 2010 to May 2015. All were outpatients who were on prior nasogastric feeds. The postoperative order set initiates feeds in 4 h to advance to goal as tolerated. Time to initial feed and goal nutrition, and overall length of stay (LOS) were evaluated.

RESULTS

122 patients were identified with 55% percent being male and with a median operative age of 15 months (IQR 8-27). 53% were started on bolus feeds. Initial feeds were started at a median of 2.8 h (IQR: 1.8-4.7). The median duration to goal nutrition was 6 h (IQR: 0-14). 97% reached full feeds within 24 h with no complications related to feed advancement. Median LOS was 26 h (IQR: 24-30).

CONCLUSION

An expedited pathway with early feeding and discharge is possible after laparoscopic gastrostomy tube placement with a low risk for adverse events.

LEVEL OF EVIDENCE

Level III.

Pyloric stenosis: an enigma more than a century after the first successful treatment

Despite hypertrophic pyloric stenosis (HPS) being one of the most frequently treated pediatric surgical conditions, its etiology remains incompletely understood. We review the diagnosis and treatment of this condition with an emphasis on the evolution of surgical techniques that led to laparoscopic pyloromyotomy, the most frequently performed technique for HPS today. In addition, we review key developments in the understanding of HPS etiology and treatment, including the postulated etiology of work-induced hypertrophy of the pylorus, its association with prokinetic macrolide antibiotics, and the emerging role of atropine sulfate as a medical treatment for HPS or a rescue treatment for incomplete myotomy.

A randomized trial to assess advancement of enteral feedings following surgery for hypertrophic pyloric stenosis

PURPOSE

The rate of feeding advancement following surgery for hypertrophic pyloric stenosis (HPS) affects length of stay. We hypothesized that: 1) a relaxed feeding regimen following pyloromyotomy would allow infants to achieve feeding goals more quickly without affecting postoperative emesis, and 2) preoperative metabolic derangements would impair the ability to advance feedings following pyloromyotomy.

METHODS

A prospective, randomized trial compared two postoperative feeding methods. The primary outcome was length of time to tolerate two consecutive goal feeds (GFs). Infants were randomized into the Incremental-arm (N=74), in which infants were gradually advanced on enteral formula, or the Relaxed-arm (N=69), in which infants were allowed to consume up to GF immediately. Preoperative variables, time to GF, preoperative laboratory values, and postoperative emesis were recorded. A p-value less than 0.05 was significant.

RESULTS

Patient demographics, pyloric ultrasound measurements, and episodes of postoperative emesis were similar between groups. Infants in the Relaxed-arm reached GF more quickly than those in the Incremental-arm and had a shorter length of stay (p<0.001). Infants with preoperative serum chloride less than 100mmol/L reached GF more slowly than those with normal labs (p<0.03).

CONCLUSION

Following surgery for HPS, surgeons can safely utilize a relaxed, nonstructured feeding regimen, which may allow infants to reach feeding goals more quickly without untoward vomiting.

LEVEL OF EVIDENCE

Level 1-therapeutic.

Laparoscopic versus open pyloromyotomy in infants: a systematic review and meta-analysis

PURPOSE

To determine whether open or laparoscopic pyloromyotomy is superior for the treatment of hypertrophic pyloric stenosis in infants.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL for articles comparing laparoscopic and open procedures. We conducted meta-analyses when possible and described other results narratively.

RESULTS

Our meta-analyses revealed no significant difference in our primary outcome of major complications [risk difference (RD) 0.03, 95% confidence interval (CI) -0.03 to 0.08, P = 0.35, I ² = 55%], or in our secondary outcomes of all perioperative complications (RD -0.01, 95% CI -0.06 to 0.04, P = 0.74, I ² = 0%), operative time [mean difference (MD) 0.68, 95% CI -3.60 to 4.79, P = 0.76, I ² = 86%], and length of stay (MD -2.60, 95% CI -6.05 to 0.86, P = 0.14, I ² = 0%). Laparoscopy was associated with a shorter time to full feeds (standardized mean difference -0.25, 95% CI -0.43 to -0.06, P = 0.009, I ² = 8%) and a slightly higher rate of inadequate pyloromyotomy (RD 0.04, 95% CI 0.00-0.08, P = 0.03, I ² = 0%). Results from one randomized controlled trial indicate a better cosmetic outcome after laparoscopy compared to open procedure.

CONCLUSION

There is no strong evidence to support a recommendation of one procedure over the other; therefore, the choice of laparoscopic or open procedure should be left to the discretion of the surgeon.