Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 33-38

To compare the safety, benefits, and incidence of postoperative complications among patients having early oral feeding versus traditional feeding in postoperative period following elective intestinal anastomosis


1 Department of Urology, IGMC, Shimla, Himachal Pradesh, India
2 Department of Surgery, IGMC, Shimla, Himachal Pradesh, India

Date of Web Publication1-Feb-2016

Correspondence Address:
Manjeet Kumar
Department of Urology, IGMC, Shimla - 171 001, Himachal Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.175208

Rights and Permissions
  Abstract 


Objective: To compare the safety, benefits and incidence of postoperative complications among patients having early oral feeding versus traditional delayed feeding in postoperative period following elective intestinal anastomosis. Methods: This prospective study was conducted in the department of surgery IGMC Shimla. A total of 40 patients undergoing elective routine intestinal anastomosis were included in this studyIn study group patients were fed early within 8 hrs after surgery starting with liquids, semisolids. In control groups patients were started oral feeding after appearance of bowel sounds, passage of flatus and stool. Patients were matched according to age, sex, indication of surgery, nutritional status. Analysis was done using student t-test regarding timing of appearance of bowel sounds, nausea and vomiting, passage of flatus and stool, postoperative complications, duration of stay. Results: Five patients in study and four patients in control group developed postoperative nausea and vomiting (P>0.05). Average time for appearance of bowel sounds was 0.95 ± 0.39 day in study group and 1.85 ± 0.67 days in control group (P<0.05). In study group mean time to pass flatus was 1.3 ± 0.8 days and 2.7 ± 0.92 days in control group (P<0.05). Mean time for passage of stool was 3.5 ± 1.05 days in study group compared to 4.8 ± 1.79 days in control group (P>0.05). In our study mean time for resumption of normal feeds was 6.05 ± 2.31 days in study group and 8.25 ± 2.75 days in control group (P<0.05). In our study 2 (10%) patients had wound infection in study group while it is 3 (15%) in control group. In control group there was 1 case of anastomotic leak. Patient was explored and transverse loop colostomy was done. Average hospital stay in study group was 7.25 ± 3.57 days while it was 10.9 ± 6.88 days in control group (P>0.05). Conclusions: Early oral feeding after elective intestinal anastomosis is well tolerated. It helps in resolution of ileus, decreased wound infection and improved wound and anastomotic healing leading to shorter hospital stay.

Keywords: Early oral feeding, ileus, intestinal anastomosis, shorter hospital stay


How to cite this article:
Kumar M, Malhotra P, Mahajan P, Gupta A. To compare the safety, benefits, and incidence of postoperative complications among patients having early oral feeding versus traditional feeding in postoperative period following elective intestinal anastomosis. Saudi Surg J 2015;3:33-8

How to cite this URL:
Kumar M, Malhotra P, Mahajan P, Gupta A. To compare the safety, benefits, and incidence of postoperative complications among patients having early oral feeding versus traditional feeding in postoperative period following elective intestinal anastomosis. Saudi Surg J [serial online] 2015 [cited 2022 Dec 3];3:33-8. Available from: https://www.saudisurgj.org/text.asp?2015/3/2/33/175208




  Introduction Top


Conventional treatment after bowel resection entails administration of intravenous fluids and starvation, as ileus occurs after every intra-abdominal operation.[1],[2]

The widespread practice of starving patients in the immediate postoperative period after gastrointestinal surgery has been challenged by a systematic review and meta-analysis in which it was found that “nil by mouth” after gastrointestinal surgery is not beneficial. Further, the apparently beneficial effects of early postoperative enteral feeding on infection rates and length of hospital stay in the hospital are compelling arguments in favor of change in clinical practice.[3] Enteral nutrition, when compared with total parenteral nutrition, is safe, convenient, cost-effective, prevents gastrointestinal atrophy, attenuates the injury stress response, maintains immune competence, preserves normal gut flora, and has minimal complications.[1],[2],[4]

This study was conducted to assess the feasibility, benefits, and complications of early enteral feeding so that a protocol can be advised in our institution for its use.


  Materials and Methods Top


This prospective study was conducted in the Department of Surgery, IGMC, Shimla. A total of 40 patients undergoing elective routine intestinal anastomosis were included in this study. Cases involving anastomosis of the small intestine and large intestine were included. A detailed history was taken, and thorough physical examination was done in each case. Routine blood examination, chest X-ray, and other relevant investigations including serum proteins were done. Gut preparation was done with antibiotics and mechanical preparation as done routinely in Surgery Department.

Cases of anastomosis performed in emergency, anastomosis of stomach and hepatobiliary system, extremes of age, that is, <10 years and >80 years were excluded from this study.

During surgery, details of the operation were recorded. Patients were divided into two groups by computer-generated random numbers.

Group 1

It comprised of 20 patients who underwent gastrointestinal anastomosis and were started early oral feeding 30 ml/h

8 h after surgery. Ryle's tube was removed immediately after surgery. The feeds consisted of clear liquids 30 ml/h normal saline. The quantity of feed was increased by 30 ml/6 hourly as per tolerability. Patients were started on semisolids when patient tolerated 1 l of liquids within 24 h. Semisolids that is, porridge, etc., were started 24–36 h after surgery if the patient had tolerated liquid diet. Solids were started that is normal diet after 48–72 h. In case of nausea and vomiting feeds were withheld and antiemetic given. Ryle's tube was inserted if two or more episodes of vomiting of more than 100 ml occurred in the absence of bowel movement. Ryle's tube was removed when nausea and vomiting settled. The oral feeds were started in reduced quantity and gradually increased as per acceptability of the patients. The patients developing distension, nausea, and vomiting were kept in the study group. In case of vomiting, color, contents, and quantity were noted. Patients with normal postoperative course were discharged when they could tolerate a regular diet.

Group 2

It comprised of 20 patients who were kept “nil by mouth” in the postoperative period. The Ryle's tube was removed when a patient passed flatus as done routinely in our wards. These cases were allowed orally on the appearance of bowel sounds and passage of flatus as done routinely.

The time of resumption of normal feeds was recorded in all patients in both groups. Timing of appearance of bowel sounds, the passage of flatus and stool, postoperative complications, and hospital stay were recorded in all cases. At the end of the study, data were compiled and analyzed as per standard statistical methods.


  Results Top


The study assessed the safety, efficacy, and feasibility of early oral feeding as compared to the traditional methods of feeding. The following were the results of the study:

Age of patients ranged from 13 to 72 years in the study group with a mean of 46.95 ± 15.11 years, and 19–75 years in the control group with a mean of 49.5 ± 14.09 years. The male and female ratio was 1.2:1 in study group and 0.82:1 in control group. The indications of intestinal anastomosis in most cases of the study as well as the control groups were stoma closure and malignancies of large intestine and were comparable.

Average blood loss was 260.75 ± 127.78 ml in study group. The average blood loss was 253.25 ± 155.11 ml in control group. Average time taken to complete surgery in study group was 118.90 ± 52.57 min and 114 ± 52.78 min in control group. It was comparable in both groups. The groups were comparable in age, sex, indications for surgery, average blood loss, and duration of surgery. The difference was statistically insignificant (P > 0.05).

The additional procedures in our study along with intestinal anastomosis were cholecystectomy, suprapubic catheterization, and repair of bladder injury. The additional procedure does not cause any effect on early feeding.

Four patients in study group and three patients in control group experienced postoperative distension. The difference was statistically insignificant (P > 0.05).

Fifteen (75%) patients tolerated early feeding, and other two patients tolerated early feeding with conservative management despite mild nausea and vomiting. After excluding one patient developing subacute intestinal obstruction (SAIO), the tolerance was 79.99%.

Five patients in study group and four patients in control group developed postoperative nausea and vomiting. The difference was statistically insignificant (P > 0.05).

The average time for the appearance of bowel sounds was 0.95 ± 0.39 day in study group and 1.85 ± 0.67 days in control group. The difference was significant between the two groups (P < 0.05).

In the study group mean time to pass flatus was 1.3 ± 0.8 days and 2.7 ± 0.92 days in control group. On statistical analysis, the study group passed flatus earlier than control group significantly (P < 0.05).

Mean time for passage of stool was 3.5 ± 1.05 days in study group compared to 4.8 ± 1.79 days in control group. On statistical analysis, study group passed stool earlier than control group significantly (P < 0.05).

In our study, mean time for the resumption of normal feeds was 6.05 ± 2.31 days in study group, and 8.25 ± 2.75 days in control group. After comparing both groups, normal feeding could be resumed earlier in study group compared to control group (P < 0.05).

In our study, 2 (10%) patients had wound infection in study group while it is 3 (15%) in control group. The wound sepsis was more in control group compared to study group. The wound sepsis was more in patients who had malignancy, blood loss >250 ml, and in whom time taken for surgery was more than 2 h.

In our study, there was no anastomotic leak in study group. In control group, there was 1 case of anastomotic leak. The patient was explored, and transverse loop colostomy was done.

Pneumonia, urinary tract infection, intraabdominal abscess, burst abdomen, and SAIO occurred in both groups, and on statistical analysis there was no significant difference in both groups.

Average hospital stay in study group was 7.25 ± 3.57 days while it was 10.9 ± 6.88 days in control group. The difference in postoperative stay was significant (P > 0.05).


  Discussion Top


Indications of intestinal anastomosis

In both groups, main indication of intestinal anastomosis was malignancies of large intestine; other indications were stoma closure and benign cases involving intestinal anastomosis. [Table 1] contains indications of intestinal anastomosis. The distribution of cases reflects that malignancy cases are more frequent than benign diseases of gut in our study. The indications for intestinal anastomosis in our study were comparable with other studies conducted by Bickel et al.[5] and Reissman et al.[6]
Table 1: Indications for anastomosis

Click here to view


Time taken for surgery

The incidences of complications were more in patients having duration of surgery more than 2 h. The duration of surgery had minimal effect on tolerance of early enteral feeding.

Early feeding tolerance

The tolerance was defined as patients receiving regular diet without developing vomiting and distension. [Table 2] contains details of postoperative monitoring of patients. In study group, in which early feeding was started, 4 (20%) patients developed vomiting and abdominal distension. Out of four patients having vomiting and distension; one patient settled on withholding feeding and giving antiemetics. Ryle's tube was inserted in rest of the three patients for abdominal distension and vomiting not responding to conservative management. One patient had mild vomiting postoperatively, and he was managed conservatively. 15 (75%) patients tolerated early feeding, and other two patients tolerated early feeding with conservative management despite mild nausea and vomiting. After excluding one patient developing SAIO, the tolerance was 79.99%. Other studies indicate that tolerance to oral feeding was 73–90% if oral feeding was started as early as 8 h after surgery. The tolerance was low in patients who were fed within 4 h after surgery as revealed in study by Stewart et al.[7] This may be because patients were in residual effect of anesthetic gases, drugs, and were in postoperative ileus. When feeds were given 8 h after surgery, tolerance was 79–90% as shown in our study and various other studies. The tolerance to early oral feed given 8 h after surgery in our study is comparable to the results of previous studies. This indicates that oral feed can be safely started 8 h after surgery with good tolerance because effects of anesthetic gases are over by that time.
Table 2: Postoperative monitoring

Click here to view


Nausea and vomiting

Five (25%) patients developed vomiting in study group and 4 (20%) patients in control group. Ryle's tube insertion was required in 3 (15%) patients in study group, and 2 (10%) in control group having vomiting. The difference in the incidence of nausea and vomiting in patients of both the groups was not significant (P > 0.05).

Stewart et al.[7] (1998) reported the incidence of nausea and vomiting of 35% in study group. The increased incidence of vomiting might be because of much early feeding that started 4 h after surgery.

Lewis et al.[8] noted that incidence of nausea and vomiting after early feeding was 21% in study group and 13% in control group.

Appearance of bowel sounds

The average time for the appearance of bowel sounds was 0.95 ± 0.39 day in study group and 1.85 ± 0.67 days in control group. The difference was significant between two groups in (P < 0.05). Fanaie and Ziaer [2] concluded that appearance of bowel sounds among two groups were similar (0.5 day). Han-Geurts et al.[9] concluded that bowel sounds appeared in 1-day (1–7) in control group and 1-day (1–4) in study group.

Passage of flatus and stool

In study group mean time to pass flatus was 1.3 ± 0.8 days and 2.7 ± 0.92 days in control group. Mean time for passage of stool was 3.5 ± 1.05 days in study group compared to 4.8 ± 1.79 days in control group. On statistical analysis, study group passed flatus and stool significantly earlier than control group (P < 0.05). Stewart et al.[7] conducted a study in which mean time for passing stool was 4 days in study group compared to 5 days in control group.

Resumption of normal feeds

In our study, mean time for the resumption of normal feeds was 6.05 ± 2.31 days in study group and 8.25 ± 2.75 days in control group [Table 3]. After comparing both groups, normal feeding could be resumed earlier in study group compared to control group (P < 0.05, P = 0.009).
Table 3: Starting oral feed postoperatively and resumption of normal feed

Click here to view


Wound infection

In our study, 2 (10%) patients had wound infection in study group while it was 3 (15%) patients in control group [Table 4]. The results of a meta-analysis of 11 studies by Lewis et al.[8] have shown that incidence of wound infection was 3—30% in study groups and 2—47% in control groups although not significant, was less in early fed group.
Table 4: Postoperative complications

Click here to view


The wound sepsis was more in control group compared to study group. The wound sepsis was more in patients with malignancy, having blood loss >250 ml, and in whom time taken for surgery was more than 2 h. Changes in intestinal permeability have been shown in patients undergoing intestinal surgery; increased permeability being associated with sepsis and systemic inflammation. Bacterial translocation has also been shown in patients undergoing laparotomy, and a higher proportion of patients with bacterial translocation developed sepsis than those without. Early postoperative enteral feeding might have a beneficial effect on the function of the intestinal barrier with respect to permeability, bacterial translocation, and subsequent development of septic complications.[9]

Anastomotic leak

In our study, there was no anastomotic leak in study group. In control group, there was one case of anastomotic leak. In this patient anterior resection was done, he developed high-grade fever, loose stools, and abdominal distension on the 6th postoperative day. He was started on nasogastric aspiration and intravenous fluids. Collection was suspected, and ultrasound (USG) was done. On USG, there was pelvic abscess. The patient was explored; there was anastomotic leak with fecal collection in pelvis. Colostomy was done, and patient improved markedly.

By comparing with other studies, the results were variable. Studies by Di Fronzo et al.,[10] Tsunoda et al.[11] show that the leak was more in study group though it was not significant. By Reissman et al.[6] the incidence was more in control group. According to Lewis et al.[8] difference was not significant. Ng and Neill [12] in 2006 reviewed 15 studies comparing 1352 patients and concluded that early feeding was safe. Total complications were 12.5% for 935 early-fed patients, with no increased risk of anastomotic leak, aspiration pneumonia, or bowel obstruction. For all studies, an average of 86% of patients tolerated early feeding.

This study and various other studies show lesser anastomotic leaks in study group as compared to that of control group. Improved nutritional status in study group cases might have caused lesser wound sepsis, lesser anastomotic leak, and better wound healing.

Other complications

Pneumonia, urinary tract infection, intra-abdominal abscess, burst abdomen, and SAIO occurred in both groups and on statistical analysis there was no significant difference in both groups. The chances of postoperative morbidity and anastomotic leak are increased in cases of malignancy owing to preexisting anemia, hypoproteinemia, and malnutrition. Furthermore, patients harboring malignancy have low immune response, and most of the patients are in the old age group.

In relaparotomy cases, there are problems of serosal tears occurring during the division of dense adhesions, preexisting interloop abscess, and more gut handling leading to prolonged postoperative ileus. Moreover, most of these patients are having dehydration, dyselectrolytemia, and malnutrition and skin excoriation due to excess of fluid loss through stoma. All these factors lead to increased chances of postoperative morbidity and increased complications.

Emergency surgeries are also associated with complications such as dehydration, sepsis, anastomotic leak, abdominal abscess, and burst abdomen, so these surgeries are excluded from this study.

By comparing both groups in our study and other studies, the incidence of complications in both groups were similar, and early feeding is safe regarding postoperative complications including anastomotic dehiscence. The incidence of complications was more in patients with malignancy, having blood loss >250 ml, and in whom time taken for surgery was more than 2 h.

Postoperative stay

Average hospital stay in study group was 7.25 ± 3.57 days while it was 10.9 ± 6.88 days in control group. Refer [Table 5] and [Table 6] for details on postoperative stay. The difference in postoperative stay was significant (P < 0.05, P = 0.039).
Table 5: Postoperative hospital stay

Click here to view
Table 6: Duration of hospital stay

Click here to view


Stewart et al.[7] (1998) concluded that postoperative stay in study group was 9 days (5–28), and 11 (6–18) days in control group.

Lewis et al.[8] found postoperative stay ranging from 6.2 to 14 days in early feeding groups, and 6.8–19 days in control groups in a meta-analysis of 13 randomized controlled trials. Combined results showed a significant reduction by 0.84 days.

In our study as well as in various other studies, the postoperative stay was shorter in study group compared to control group. It was due to the fact that early feeding helps in early bowel movements, faster recovery, and less postoperative complications leading to early discharge from the hospital.


  Conclusions Top


Early oral feeding after elective intestinal anastomosis is well–tolerated, helps in resolution of ileus, decreased wound infection, and improved wound and anastomotic healing leading to a shorter hospital stay. Hence, it is concluded that early oral feeding after intestinal anastomosis is safe, effective, and beneficial to patients.[13]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Carr SC, Eddie L, Bouloss P. Randomized trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal anastomosis. Br Med J 1996;312:869-71.  Back to cited text no. 1
    
2.
Fanaie SA, Ziaer SA. Safety of early oral feeding after gastrointestinal anastomosis. Indian J Surg 2005;67:185-8.  Back to cited text no. 2
    
3.
Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg 1992;216:172-83.  Back to cited text no. 3
    
4.
Silk DB, Gow NM. Postoperative starvation after gastrointestinal surgery. Early feeding is beneficial. BMJ 2001;323:761-2.  Back to cited text no. 4
    
5.
Bickel A, Shtamler B, Mizrahi S. Early oral feeding following removal of nasogastric tube in gastrointestinal operations. A randomized prospective study. Arch Surg 1992;127:287-9.  Back to cited text no. 5
    
6.
Reissman P, Tiong AT, Stephan M, Teoh TA, Cohen SH, Weiss EG, et al. Is early feeding safe after elective colorectal surgery? Ann Surg 1995;222:73-7.  Back to cited text no. 6
    
7.
Stewart BT, Woods RJ, Collopy BT, Fink RJ, Mackay JR, Keck JO. Early feeding after elective open colorectal resections: A prospective randomized trial. Aust N Z J Surg 1998;68:125-8.  Back to cited text no. 7
    
8.
Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: Systematic review and meta-analysis of controlled trials. BMJ 2001;323:773-6.  Back to cited text no. 8
    
9.
Han-Geurts IJ, Hop WC, Kack N. Randomized clinical trial of impact of early enteral feeding on postoperative ileus and recovery. Br J Surg 2007;94:555-64.  Back to cited text no. 9
    
10.
Jemison RA, Kay AW, Ledingham IM, Mackay C, editors. Textbook of Surgical Physiology. 3rd ed. New York: Churchill Livingstone; 1978. p. 254-65.  Back to cited text no. 10
    
11.
Di Fronzo LA, Yamin N, Patel K, O'Connell TX. Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection. J Am Coll Surg 2003;197:747-52.  Back to cited text no. 11
    
12.
Tsunoda A, Shibusawa M, Takata M, Hiratsuka K, Shida K, Kusano M. Early oral feeding should be resumed following the resolution of gastric ileus. Hepatogastroenterology 2005;52:775-9.  Back to cited text no. 12
    
13.
Ng WQ, Neill J. Evidence for early oral feeding of patients after elective open colorectal surgery: A literature review. J Clin Nurs 2006;15:696-709.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusions
References
Article Tables

 Article Access Statistics
    Viewed2700    
    Printed99    
    Emailed0    
    PDF Downloaded237    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]