Early Postoperative Feeding Research Articles

Intraluminal fluid infusion in a rat jejunum ischemia/reperfusion model is associated with improved tissue perfusion and less mucosal damage

This study used an experimental model mimicking early postoperative enteral feeding after the transfer of free jejunal flap and tested the hypothesis that jejunal infusion with dextrose or saline is associated with improved tissue perfusion and/or less mucosal damage after ischemia/reperfusion (IR) injury. Thirty-five male Sprague Dawley rats were randomly divided into five groups: sham group (no IR and no intraluminal infusion); IR control group (IR but not intraluminal infusion); IR plus intraluminal 0.9% NaCl infusion or 5% dextrose or 10% dextrose infusion groups. A jejunal segment of each rat was isolated. The animals had jejunal ischemia for 40min, reperfusion, and intestinal infusion on the basis of their allocation. Jejunal tissue perfusion was measured with laser Doppler flowmetry at one hour and two hours after reperfusion, after which the animals were sacrificed and tissue samples were obtained for the scoring of histological damage at superficial and cryptic epithelium, villus structure, and inflammatory cell infiltration and tissue nitric oxide (NO), interleukin (IL)-1, IL-6, and matrix metalloproteinase-1 (MMP) level measurements. At 1h of reperfusion, IR plus 5% dextrose and 10% dextrose groups both had significantly higher perfusion rates than the IR control group (384.8±26.7 and 462.4±44.7 versus 270.3±34.2 PU, respectively, p<0.05 for both). These differences were maintained at 2h of reperfusion (p<0.05 for both). Saline infusion, however, resulted in improved tissue perfusion only at the early phase of reperfusion. Intraluminal infusion with dextrose solution, either 5% or 10%, was associated with higher tissue NO, IL-1, and IL-6 levels than that in the sham group (p<0.05 for all). In addition, intraluminal infusion of any fluid resulted in less severe histological damage (8.1±0.9 versus 5.8±1.0, 5.4±0.9, and 5.2±1.9, for IR plus saline, 5% dextrose and 10% dextrose groups, respectively, p<0.05 for all). Intraluminal infusion of fluids, particularly dextrose solutions, may be protective against IR injury as demonstrated by improved tissue perfusion and less histological damage. In addition, increases in tissue NO, IL-1, and IL-6 levels in association with dextrose infusion may be explained by the activation of pro-inflammatory and anti-inflammatory protective pathways. These support early enteral feeding after free jejunum flap transfers; however, further studies are warranted.

Nutritional support for enhanced recovery programs in orthopedics: Future perspectives for implementing clinical practice

Over the last 15 years, orthopedic departments have begun to consider a multidisciplinary approach in the management of hip/knee arthroplasty and spine surgery. However, much misperception persists on the founding concepts of rapid-recovery approaches, and most of the programs in orthopedics lacks nutritional support. Despite the complexities of nutritional parameters prognostic potentials, associated interventions mainly focused on using dietary supplements. Nevertheless, an effective integrative nutritional support program for enhancing recovery after surgery should comprehensively account for pre-operative nutritional counseling and optimization, shortening fasting time, early postoperative feeding and integration, and follow-up dietary management after discharge. Au cours des 15 dernières années, les départements d’orthopédie ont commencé à envisager une approche multidisciplinaire dans la prise en charge de l’arthroplastie de la hanche/du genou et de la chirurgie de la colonne vertébrale. Cependant, de nombreuses idées fausses persistent sur les concepts fondateurs des approches de récupération rapide et, la plupart des programmes d’orthopédie manquent de soutien nutritionnel. Malgré la complexité des potentiels pronostiques des paramètres nutritionnels, les interventions associées ont principalement porté sur l’utilisation de compléments alimentaires. Néanmoins, un programme efficace de soutien nutritionnel intégratif visant à améliorer la récupération après une chirurgie devrait prendre en compte les conseils et l’optimisation nutritionnels préopératoires, la réduction du temps de jeûne, l’alimentation et l’intégration postopératoires précoces, ainsi que la gestion diététique après la sortie.

Early Versus Late Oral Refeeding After Pancreaticoduodenectomy for Malignancy: a Comparative Belgian-French Study in Two Tertiary Centers

BackgroundIn the era of fast-track surgery, because pancreaticoduodenectomy (PD) carries a significant morbidity, surgeons hesitate to begin early oral feeding and achieve early discharge. We compared the outcome of two different approaches to the postoperative management of PD in two tertiary centers. MethodsOf patients having undergone PD for malignancy from 2008 to 2017, 100 patients who received early postoperative oral feeding (group A) were compared to 100 patients from another center who received early enteral feeding and a delayed oral diet (group B). Surgical indication and approach and type of pancreatic anastomosis were similar between both groups. Postoperative outcomes were retrospectively reviewed. ResultsPatient characteristics were similar between both groups, except significantly more neoadjuvant treatment in group A (A = 20% vs. B = 9%, p < 0.01). Mortality rates were 3% and 4% in groups A and B, respectively (p = 0.71). The rate of severe postoperative morbidity was significantly lower in group A (13% vs. 26%, p = 0.02), resulting in a lower reoperation rate (p < 0.01). Delayed gastric emptying and clinically relevant pancreatic fistula were similar between both groups but chyle leaks were more frequent in group A (10% vs. 3%, p = 0.04). The median hospital stay was shorter in group A (16 vs. 20 days, p < 0.01). ConclusionIn the present study, early postoperative oral feeding after PD was associated with a shorter hospital stay and did not increase severe postoperative morbidity or the rate of pancreatic fistula. However, it resulted in more chyle leaks and did not prevent delayed gastric emptying.

Intestinal surgery in small animals: historical foundations, current thinking, and future horizons.

Intestinal wounds require precise closure after intestinal biopsy, enterotomy, or enterectomy in small animals. Preexisting factors such as intra-abdominal sepsis and hypoalbuminemia as well as poor surgical technique increase the risk of intestinal dehiscence, with considerable negative impact on patient morbidity and mortality. Live dog studies have demonstrated the dangers of mucosal eversion especially in the septic abdomen. Approximating patterns preserve luminal diameter, heal optimally, and have equal bursting strength compared with inverting patterns after 24 hours. Simple interrupted and simple continuous suture patterns and disposable skin staples are established alternatives for manual wound closure. Knotless quilled suture currently used in laparoscopic gastropexy techniques shows bursting strength equal to monofilament sutures in dog cadaveric intestine. Dehiscence rates with hand sewn vs titanium automated stapling anastomosis are similar in uncomplicated cases; however, auto stapling devices may be the preferred method of anastomosis when preexisting abdominal sepsis is present and when patient size allows it. Regardless of the technique, current standard of care involves leak testing and omental wrapping, followed by early postoperative feeding. The past decade has ushered in an exciting new era of laparoscopic assisted techniques that have the potential to reduce postoperative pain and patient morbidity. An understanding of these applications will establish the future of minimally invasive small animal intestinal surgery for veterinary specialists. In summary, surgeons have a variety of methods at their disposal for optimal clinical outcome in small animal intestinal surgery.

Nutritional Interventions to Improve Clinical Outcomes in Ovarian Cancer: A Systematic Review of Randomized Controlled Trials.

Among all gynaecological neoplasms, ovarian cancer has the highest rate of disease-related malnutrition, representing an important risk factor of postoperative mortality and morbidity. Hence, the importance of finding effective nutritional interventions is crucial to improve ovarian cancer patient’s well-being and survival. This systematic review of randomized controlled trials (RCTs) aims at assessing the effects of nutritional interventions on clinical outcomes such as overall survival, progression-free survival, length of hospital stay (LOS), complications following surgery and/or chemotherapy in ovarian cancer patients. Three electronic bibliographic databases (MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials) were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria, until December 2018. A total of 14 studies were identified. Several early postoperative feeding interventions studies (n = 8) were retrieved mainly demonstrating a reduction in LOS and an ameliorated intestinal recovery after surgery. Moreover, innovative nutritional approaches such as chewing gum intervention (n = 1), coffee consumption (n = 1), ketogenic diet intervention (n = 2) or fruit and vegetable juice concentrate supplementation diet (n = 1) and short-term fasting (n = 1) have been shown as valid and well-tolerated nutritional strategies improving clinical outcomes. However, despite an acceptable number of prospective trials, there is still a lack of homogeneous and robust endpoints. In particular, there is an urgent need of RCTs evaluating overall survival and progression-free survival during ovarian oncology treatments. Further high-quality studies are warranted, especially prospective studies and large RCTs, with more homogeneous types of intervention and clinical outcomes, including a more specific sampling of ovarian cancer women, to identify appropriate and effective nutritional strategies for this cancer, which is at high risk of malnutrition.

Application value of enhanced recovery after surgery in minimally invasive radical resection of esophageal cancer

Objective To investigate the application value of enhanced recovery after surgery with no gastrointestinal decompression tube and with early postoperative oral feeding in minimally invasive radical resection of esophageal cancer. Methods The retrospective cohort study was conducted. The clinicopathological data of 126 patients who underwent minimally invasive McKeown surgery in the General Hospital of Southern Theatre Command of PLA between March 2016 and October 2017 were collected. There were 80 males and 46 females, aged from 52 to 82 years, with an average age of 64 years. Of 126 patients, 82 undergoing li′s with no gastrointestinal decompression tube and receiving early postoperative oral feeding were allocated into non-tube no fasting group, and 44 undergoing end-to-side gastroesophageal anastomosis with tubular stapler, conventionally indwelling gastrointestinal decompression tube, and beginning oral feeding at 1 week after surgery were allocated into traditional treatment group. Observation indicators: (1) surgical and postoperative recovery situations; (2) results of pathological examination; (3) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative tumor recurrence and metastasis up to October 2018. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using independent sample t test. Measurement data with skewed distribution were expressed as M (range), and comparison between groups was analyzed by rank sum test. Count data were described as absolute number or percentage, and comparison between groups was analyzed using chi-square test. Ordinal data were analyzed by rank sum test. Results (1) Surgical and postoperative recovery situations: patients in the two groups underwent minimally invasive McKeown surgery successfully. Operation time, volume of intraoperative blood loss, incidence of anastomotic fistula, incidence of pulmonary complications, and duration of postoperative hospital stay were respectively (326±41)minutes, (225±96)ml, 7.3%(6/82), 24.4%(20/82), and 10 days(range, 6-90 days)in the non-tube no fasting group and (317±37)minutes, (214±66)mL, 9.1%(4/44), 20.5%(9/44), and 14 days (range, 10-42 days) in the traditional treatment group; there was a statistically significant difference in duration of postoperative hospital stay between the two groups (Z=-7.129, P 0.05). (2) Results of pathological examination: the number of lymph node dissected, cases in postoperative TNM stage Ⅰ, Ⅱ and Ⅲ were respectively 27±5, 12, 55, 15 in the non-tube no fasting group and 26±5, 9, 28, 7 in the traditional treatment group, with no statistically significant difference between the two groups (t=0.549, Z=-0.747, P>0.05). (3) Follow-up: of 126 patients, 116 were followed up for 12-31 months, with a median time of 20 months, including 76 in the non-tube no fasting group and 40 in the traditional treatment group. During the follow-up, no tumor recurrence or metastasis was found in the 116 patients. Conclusion The enhanced recovery after surgery with no gastrointestinal decompression tube and with early postoperative oral feeding is safe and feasible in the McKeown surgery, which can significantly shorten the postoperative hospitalization time compared with the traditional treatment. Key words: Esophageal neoplasms; Esophageal cancer; No gastrointestinal decompression tube; Early oral feeding; Enhanced recovery after surgery; Minimally invasive; Duration of postoperative hospital stay

Evaluation of intra- and post-operative outcomes to compare robot-assisted surgery and conventional laparoscopy for gynecologic oncology

To compare robot-assisted surgery and conventional laparoscopy for gynecologic oncology regarding intra- and post-operative outcomes. A retrospective study was performed on consecutive patients with gynecologic oncology from February 2014 to October 2017at Gansu Provincial Hospital, China. Multivariable linear and logistic regression models were performed to explore the difference between two surgeries in the surgical outcomes after adjusting for potential confounders. 276 women were included in this study: 153 robot-assisted surgeries and 123 conventional laparoscopies. The multivariable linear regression model showed that robot-assisted surgery was longer operative time [coefficient (coef), 33.76; 95% CI, 12.47, 55.05; P=0.002) ], higher lymph node yield (coef, 10.41; 95% CI, 7.47, 13.35; P<0.001), shorter time to early post-operative feeding (coef, -1.09; 95% CI, -1.33, -0.84; P<0.001) and less post-operative drainage volume (coef, -368.77; 95% CI, -542.46, -195.09; P<0.001) than conventional laparoscopy. However, no difference was observed between the two surgeries regarding the estimated blood loss (P>0.05). The multivariable logistic regression model showed that post-operative complications were similar between robot-assisted surgery and conventional laparoscopy (P>0.05). Robot-assisted surgery was superior to conventional laparoscopy regarding intra- and post-operative outcomes for gynecologic oncology.

Perioperative nutrition for the treatment of bladder cancer by radical cystectomy.

Radical cystectomy (RC) is the primary surgical treatment for muscle-invasive urothelial carcinoma of the bladder. This major operation is typically associated with an extended hospital stay, a prolonged recovery period and potentially major complications. Nutritional interventions are beneficial in some people with other types of cancer and may be of value in this setting too.To assess the effects of perioperative nutrition in people undergoing radical cystectomy for the treatment of bladder cancer.We performed a comprehensive search using multiple databases (Evidence Based Medicine Reviews, MEDLINE, Embase, AMED, CINAHL), trials registries, other sources of grey literature, and conference proceedings published up to 22 February 2019, with no restrictions on the language or status of publication.We included parallel-group randomised controlled trials (RCTs) of adults undergoing RC for bladder cancer. The intervention was any perioperative nutrition support.Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias and the quality of evidence using GRADE. Primary outcomes were postoperative complications at 90 days and length of hospital stay. The secondary outcome was mortality up to 90 days after surgery. When 90-day outcome data were not available, we reported 30-day data.The search identified eight trials including 500 participants. Six trials were conducted in the USA and two in Europe.1. Parenteral nutrition (PN) versus oral nutrition: based on one study with 157 participants, PN may increase postoperative complications within 30 days (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.07 to 1.82; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance and selective reporting bias) and serious imprecision. This corresponds to 198 more complications per 1000 participants (95% CI 35 more to 405 more). Length of hospital stay may be similar (mean difference (MD) 0.5 days higher, CI not reported; low-quality evidence).2. Immuno-enhancing nutrition versus standard nutrition: based on one study including 29 participants, immuno-enhancing nutrition may reduce 90-day postoperative complications (RR 0.31, 95% CI 0.08 to 1.23; low-quality evidence). These findings correspond to 322 fewer complications per 1000 participants (95% CI 429 fewer to 107 more). Length of hospital stay may be similar (MD 0.20 days, 95% CI 1.69 lower to 2.09 higher; low-quality evidence). We downgraded the quality of evidence of both outcomes for very serious imprecision.3. Preoperative oral nutritional support versus normal diet: based on one study including 28 participants, we are very uncertain if preoperative oral supplements reduces postoperative complications. We downgraded quality for serious study limitations (unclear risk of selection, performance, attrition and selective reporting bias) and very serious imprecision. The study did not report on length of hospital stay.4. Early postoperative feeding versus standard postoperative management: based on one study with 102 participants, early postoperative feeding may increase postoperative complications (very low-quality evidence) but we are very uncertain of this finding. We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and very serious imprecision. Length of hospital stay may be similar (MD 0.95 days less, CI not reported; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and serious imprecision.5. Amino acid with dextrose versus dextrose: based on two studies with 104 participants, we are very uncertain whether amino acids reduce postoperative complications (very low-quality evidence). We are also very uncertain whether length of hospital stay is similar (very low-quality evidence). We downgraded the quality of evidence for both outcomes for serious study limitations (unclear and high risk of selection bias; unclear risk of performance, detection and selective reporting bias), serious indirectness related to the patient population and very serious imprecision.6. Branch chain amino acids versus dextrose only: based on one study including 19 participants, we are very uncertain whether complication rates are similar (very low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance, detection, attrition and selective reporting bias), serious indirectness related to the patient population and very serious imprecision. The study did not report on length of hospital stay.7. Perioperative oral nutritional supplements versus oral multivitamin and mineral supplement: based on one study with 61 participants, oral supplements compared to a multivitamin and mineral supplement may slightly decrease postoperative complications (low-quality evidence). These findings correspond to 135 fewer occurrences per 1000 participants (95% CI 256 fewer to 65 more). Length of hospital stay may be similar (low-quality evidence). We downgraded the quality of evidence of both outcomes for study limitations and imprecision.Based on few, small and dated studies, with serious methodological limitations, we found limited evidence for a benefit of perioperative nutrition interventions. We rated the quality of evidence as low or very low, which underscores the urgent need for high-quality research studies to better inform nutritional support interventions for people undergoing surgery for bladder cancer.

Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids

BackgroundPathways of enhanced recovery in liver surgery decrease inpatient opioid use; however, little data exist regarding their effect on discharge prescriptions and post-discharge opioid intake. MethodsFor consecutive patients undergoing liver resection from 2011–2018, clinicopathologic factors were compared between patients exposed to enhanced recovery vs. traditional care pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The enhanced recovery in liver surgery protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation. ResultsOf 244 cases, 147 enhanced recovery patients were compared with 97 traditional pathway patients. Enhanced recovery patients were older (median 57 years vs 52 years, P = .031) and more frequently had minimally invasive operations (37% vs 16%, P < .001), with fewer major complications (2% vs 9%, P = .011). Enhanced recovery patients were less likely to be discharged with a prescription for traditional opioids (26% vs 79%, P < .001) and less likely to require opioids at their first postoperative visit (19% vs 61%, P < .001) despite similarly low patient-reported pain scores (median 2/10 both groups, P = .500). On multivariable analysis, the traditional recovery pathway was independently associated with traditional opioid use at the first follow-up (odds ratio 6.4, 95% confidence interval 3.5–12.1; P < .001). ConclusionThe implementation of an enhanced recovery in liver surgery pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other populations at risk of persistent opioid use, enhanced recovery strategies can eliminate excess availability of opioids.

Psychological support of esophageal cancer patient?

Important questions are still open about psychological aspects in esophageal cancer (EC) and about the related psychological support. How to cope with the cancer diagnosis and poor prognosis: a psychological counselling may be a valid option to personalize the communication to patients with a poor prognosis. How to cope with long chemoradiotherapy: after neoadjuvant therapy, patients know that curative process is not completed, and they perceive the severity of the neoadjuvant side effects, considering themselves "fragile" and far from a healthy condition before the major surgery they are going to undergo. Therefore, this is a particularly crucial point when psychological support may be useful. How to cope with change of nutritional habits: esophagectomy for cancer strongly impairs nutritional function in the early postoperative period and feeding Jejunostomy impairs emotional function. How to cope with sleep disturbances: most cancer patients report disturbed sleep after cancer diagnosis and/or following cancer treatment. Psychological intervention aims to identify underlying concerns worsening sleep quality. How to cope with postoperative complications: the occurrence of such complications reduces patient's satisfaction and has a negative effect on doctor-patient relationship. How to cope with long-term functions impairment: EC patients need a plan for the future.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy.Case presentationIn case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48.In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28.ConclusionsThe causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

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

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

Prospective comparative study of the effectiveness and patient satisfaction with early postoperative oral feeding as part of the enhanced recovery after surgery (ERAS) protocol managed by the clinical pathway for elective colorectal surgery

Prospective comparative study of the effectiveness and patient satisfaction with early postoperative oral feeding as part of the enhanced recovery after surgery (ERAS) protocol managed by the clinical pathway for elective colorectal surgery

Practice Changes in Postoperative Feeding after Elective Colorectal Surgery: From Prospective Randomized Study to Everyday Practice

Early postoperative feeding is the standard of care after colorectal surgery and is associated with improved outcomes. A controlled study performed at our center demonstrated faster bowel function recovery and shorter hospital stay without an increase in postoperative morbidity for a solid versus clear-liquid diet on postoperative day (POD) 1 after colorectal surgery. The present study aims to evaluate the impact of these findings on the practice of diet advancement by board-certified general surgeons (GS) and colorectal surgeons (CRS) at an urban teaching hospital. Patients undergoing elective colorectal surgery were prospectively evaluated. Data were compared with that of a study cohort that underwent elective colorectal surgery reported in 2012. Early postoperative feeding in the more recent cohort statistically increased for all cases on POD 0 and POD 1. Diet advancement over time revealed significant changes in early feeding on POD 0 for patients operated on by CRS (0% vs 83%; P < 0.0001) but not GS (13% vs 13%; P = 1). Patients operated on by either CRS or GS and offered early feeding on POD 1 did not significantly differ between time periods. Despite well-documented evidence of the advantages of early feeding, GS, but not CRS, remain reluctant to administer early diets to patients after colorectal surgery.

Bowel necrosis associated with early postoperative enteral tube feeding: a case report

Bowel necrosis associated with early postoperative enteral tube feeding: a case report

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

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. 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. 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. 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.

Implementation of an Enhanced Recovery After Surgery Program Can Change Nutrition Care Practice: A Multicenter Experience in Elective Colorectal Surgery.

Enhanced recovery after surgery (ERAS) programs are multimodal evidenced-based care pathways for optimal recovery. Central to ERAS is integration of perioperative nutrition care into the overall management of the patient. This study describes changes to perioperative nutrition care after implementation of an ERAS program, and identifies factors that affect compliance to ERAS care elements and short-term postoperative outcomes. Data were prospectively collected from patients undergoing elective colorectal surgery at 6 hospitals in Alberta, Canada, from 2013-2017. Compliance to nutrition care elements (nutrition risk screening, preoperative carbohydrate loading, early postoperative oral feeding, and mobilization) was recorded before ERAS implementation (pre-ERAS group, n=487) and with ERAS implementation (ERAS group, n=3536). Logistic regression identified factors that affect compliance to care elements, length of hospital stay (LOS), and postoperative complications. A total of 4023 patients were included. The rate of nutrition risk screening improved from 9% (pre-ERAS group) to 74% (ERAS group); 12% were at nutrition risk. Compliance increased for preoperative carbohydrate loading (4%-61%), early postoperative oral feeding (P<.001), and mobilization (P<.001). In multivariable logistic regression, nutrition risk independently predicted low overall compliance (<70%) to ERAS care elements (odds ratio [OR] 2.77; 95% CI, 2.11-3.64; P<.001) and a trend for LOS >5days (OR 1.40; 95%CI, 1.00-1.96; P=.052). Low compliance to ERAS (<70%) predicted postoperative complications (OR 2.69; 95% CI, 2.23-3.24; P<.001). ERAS implementation positively impacted the adoption of standardized perioperative nutrition care practices. Nutrition risk screening identified patients less able to comply with postoperative nutrition care elements and who had longer LOS.

Enhanced Recovery after Surgery (ERAS) in Gynecologic Surgery—A Review

The purpose of this review is to summarize the newly published guidelines on enhanced recovery after surgery (ERAS) in gynecologic oncology and discuss recent studies evaluating the outcomes of ERAS implementation in general gynecology and gynecologic oncology. ERAS guidelines for gynecologic surgery include preoperative diet, preoperative education, multimodal analgesia, early postoperative feeding, early mobilization and urinary catheter removal, avoidance of mechanical bowel preparation and drains, maintenance of normothermia, and minimal fluid shifts. The studies evaluated in this update include mostly retrospective observational studies and few randomized controlled trials. The primary outcome of the majority of studies, length of stay, was found to be less after ERAS implementation than prior to implementation. Secondary outcomes such as rates of readmission, mortality, and postoperative complications yielded mixed results; however, most differences were not statistically significant. Hospital costs also decreased after ERAS implementation, but the cost differences were only statistically significant in half of the studies with a single dissenting study. Implementation of ERAS protocols in gynecologic surgery is becoming ubiquitous as more evidence demonstrates improved patient outcomes and decreased healthcare costs. However, the majority of studies evaluating the efficacy of ERAS protocols are retrospective studies. Now that a standardized set of enhanced recovery guidelines in gynecologic oncology have been published, more institutions will hopefully begin to implement ERAS programs. Future research should subsequently include prospective, randomized controlled trials to validate the benefits concluded from studies based on historical data.

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

ABSTRACTBackground: 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.