Abstract
Enhanced Recovery After Surgery (ERAS) protocols advocate early postoperative resumption of normal diet to decrease surgical stress and prevent excessive catabolism. The aim of the present study was to identify reasons for delayed tolerance of normal postoperative diet. This was a retrospective analysis including all consecutive colorectal surgical procedures since May 2011 until May 2017. Data was prospectively recorded by an institutional data manager in a dedicated database. Uni- and multivariate risk factors associated with delayed diet (beyond POD 2) were identified by multiple logistic regression among demographic, surgery- and modifiable pre- and intraoperative ERAS-related items. In a second step, univariate analysis was performed to compare surgical outcomes for patients with early vs. delayed oral intake. The study cohort consisted of 1301 consecutive colorectal ERAS patients. Herein, 691 patients (53%) were able to resume normal diet within two days of surgery according to ERAS protocol, while in 610 patients (47%), a delay in tolerance of normal diet was observed. Male gender was independently correlated to early tolerance (Odds Ratio (OR) 0.66; 95% Confidence Interval (CI) 0.46–0.84, p = 0.002), while ASA score ≥ 3 (OR 1.60; 95% CI 1.12–2.28, p = 0.010), abdominal drains (OR 1.80; 95% CI 1.10–2.49, p = 0.020), right colectomy (OR 1.64; 95% CI 1.08–2.49, p = 0.020) and Hartmann reversal (OR 2.61; 95% CI 1.32–5.18, p = 0.006) constituted risk factors for delayed tolerance of normal diet. Patients with delayed resumption of normal diet experienced more overall (Clavien grade I–V) (47% vs. 21%, p < 0.001) and major (Clavien grade IIIb–V) (11% vs. 4%, p < 0.001) complications and had a longer length of stay (9 ± 5 vs. 5 ± 4 days, p < 0.001). Over half of patients could not tolerate early enteral realimentation and were at higher risk for postoperative complications. Prophylactic drain placement was the only independent modifiable risk factor for delayed oral intake.
Highlights
Resumption of normal solid diet is advocated by Enhanced Recovery After Surgery (ERAS)guidelines to keep the patient in a “close to normal” state through the perioperative period aiming to decrease surgical stress response [1,2,3]
The aim of the present study was to assess tolerance of early postoperative oral re-alimentation after colorectal surgery within ERAS care and to identify risk factors associated with delayed return to normal “everyday” diet
The significant association in the subgroup other surgical procedures was due to disease extent in this subgroup of advanced oncological patients undergoing exclusively palliative resections that could not be assigned to one type of intervention
Summary
Resumption of normal solid diet is advocated by Enhanced Recovery After Surgery (ERAS). Guidelines to keep the patient in a “close to normal” state through the perioperative period aiming to decrease surgical stress response [1,2,3]. Together with concomitant measures including minimal preoperative fasting and carbohydrate loading, early oral intake is an important part of the multimodal. While tolerance of early oral feeding was not influenced by postoperative ileus in a randomized controlled trial [6], other studies revealed even accelerated gastrointestinal recovery by early resumption of oral diet [7,8]. The concept of early oral intake gained even more interest. Not all patients return to normal diet as suggested
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