Postoperative Oral Nutrition Research Articles

Impact of nutritional compliance within ERAS protocols for hepatopancreatobiliary, radical cystectomy, and head and neck procedures: A case-matched analysis adjusted for major complications

Enhanced recovery after surgery (ERAS®) pathways aim to improve patient outcomes by applying multimodal practices before, during, and after operative procedures. Compared with standard care before ERAS, we investigated whether compliance to ERAS guidelines for nutritional care, preoperative oral carbohydrate loading and postoperative oral nutrition, was associated with a decrease in hospital length of stay (LOS) after pancreaticoduodenectomy, distal pancreatectomy, hepatectomy, radical cystectomy, and head and neck tumor resection with reconstruction. Compliance to ERAS nutrition recommendations was evaluated. Post-ERAS cohort was retrospectively analyzed. Pre-ERAS cohort consisted of case matched patients one year before ERAS: age more than or less than 65 years, body mass index (BMI) more than greater than or less than 30kg/m2, diabetes mellitus, sex, and procedure. Each cohort consisted of 297 patients. Binary linear regressions evaluated the incremental effect of postoperative nutrition timing and preoperative carbohydrate loading on LOS. Multivariate regressions adjusted for postoperative complications. Compliance with preoperative carbohydrate loading for the post-ERAS cohort was 81.7%. Mean hospital LOS was significantly shorter for the post-ERAS cohort compared with pre-ERAS cohort (8.3 vs 10.0 days, p<0.001). By procedure, LOS was significantly shorter for patients undergoing pancreaticoduodenectomy (p=0.003), distal pancreatectomy (p=0.014), and head and neck procedures (p=0.024). Early postoperative oral nutrition was associated with a 3.75-day shorter LOS (p<0.001); no nutrition was associated with a 3.29-day longer LOS (p<0.001). Compliance with ERAS protocols for specific nutritional care practices was associated with a statistically significant decrease in LOS without subsequent increases in 30-day readmission rates and positive financial impact. These findings suggest that ERAS guidelines for perioperative nutrition are a strategic pathway to improved patient recovery and value-based care in surgery.

Reducing postoperative fasting times by implementing a food service in the Post Anaesthesia Care Unit (PACU).

Early oral postoperative nutrition is a proven beneficial element of postoperative care, resulting in improvement in quality of life and a shorter hospital stay. Guidelines state that postoperative oral nutrition can safely be started within the first hours after surgery. However, oral nutrition is mainly investigated starting from postoperative day one (POD1). This pragmatic study assessed whether a food service in the Post Anaesthesia Care Unit (PACU) may reduce postoperative fasting times on postoperative day zero (POD0) early after surgery on this high care unit. The primary outcome was postoperative fasting time in the PACU. Secondary outcomes were postoperative patient experiences and nutritional tolerance. This pragmatic prospective before-after study, included adult patients with a planned overnight stay in the PACU, and without anticipated postoperative dietary restrictions. A food service was developed, allowing re-uptake of oral nutrition early after surgery, already at POD0. Postoperative fasting time in the PACU was defined as the duration of time between the moment of arrival at the PACU, until first postoperative intake or until 9 a.m. on POD1, when most patients were discharged to the surgical ward. Secondary outcomes such as postoperative patient experiences and nutritional tolerance were scored on POD0 at 8 p.m. and on POD1 at 8 a.m. A total of 235 patients were included, 119 in the pre-implementation (control) and 116 in the post-implementation (intervention) group. Mean postoperative fasting time was reduced by a mean of 6.0h (95% CI 4.8-7.4, p-value ≤ .001), from 17.5h in controls to 11.5h in the intervention group. In the intervention group, 45% of patients had nutritional intake on POD0 (8 p.m.), increasing to 80% of patients on POD1 (8 a.m.), compared to no intake at both time-points in the control group. In the intervention group, average patient satisfaction increased over time. Flatus frequency was higher in the intervention group on POD1 (45% vs. 22%, p-value ≤ .001), while postoperative nausea and/or vomiting, and usage of anti-emetic medication were not different between groups. In a heterogeneous group of adult post-surgical patients with a planned overnight stay in the PACU, implementation of a food service resulted in a significant and clinically relevant reduction of postoperative fasting time, and increased patient satisfaction without compromising nutritional tolerance. Registered at www.isrctn.org with study ID ISRCTN17976930.

Comparative study between Traditional and Stapled Gastrointestinal Anastomosis

Background: Intestinal anastomosis is a surgical procedure performed to establish communication between two formerly distant portions of the intestine. This procedure restores intestinal continuity after removal of a pathologic condition affecting the bowel. Intestinal anastomosis is one of the most commonly performed surgical procedures, especially in the emergency setting, and is also commonly performed in the elective setting when resections are carried out for benign or malignant lesions of the gastrointestinal (GI) tract. Objective: The aim of this work was to compare single layer, double layers and stapler intestinal anastomosis (Stomach, Stomach to small, small to small, small to large, large to large) in abdominal procedures and to evaluate the effectiveness of these procedures as regards to its integrity and complications including leakage. Patients and Methods: Prospective study on 50 patients presented with symptoms and signs suggestive for gastric operations, intestinal surgeries, resection and anastomosis according to inclusion and exclusion criteria. Cases were selected from Al-AzharUniversityHospitals and PublicHealthHospitals from March 2018 till June 2019. Results: There were high statistically significance between two groups in intra-operative bleeding, time and cost of operation as 23 patients of stapled group suffered minimal to mild bleeding, high operation cost and less time of procedure while 27 patients suffered minimal to moderate intra-operative bleeding, lower operation cost and longer procedure time. The analysis showed high significance between two groups in post-operative oral nutrition and discharge from hospital as patients underwent stapled anastomosis were allowed for oral nutrition 8 to 24 hours postoperatively and were discharged after 1 to 3 days, while patients underwent traditional anastomosis were allowed for nutrition after 5 to 7 days postoperatively and were discharged after 5 to 10 days. Conclusion: Stapled gastrointestinal anastomosis consumes lesser time at operation room, less intraoperative bleeding, early recovery and oral nutrition of patients, but has higher cost. Traditional gastrointestinal anastomosis consumes longer time at operation room, relatively more intraoperative bleeding, late recovery and oral nutrition of patients, but has lower cost. Both types of gastrointestinal anastomosis has the same postoperative co-morbidities.

Tolerability of early oral nutrition and factors predicting early oral nutrition failure after gastrectomy.

Many studies have suggested the feasibility and safety of early oral nutrition after gastrectomy; however, the tolerability of early oral nutrition has rarely been investigated. This study aimed to investigate the tolerability of early oral nutrition and factors affecting early oral nutrition failure after gastrectomy. We retrospectively reviewed 565 patients with gastric cancer who had undergone gastrectomy and who had received oral nutrition on postoperative day 1. Failure of early oral nutrition was defined as cessation of at least one meal for any reason. Preoperative clinical information and operative factors were analyzed concerning an association with early oral nutrition failure. The tolerability of early oral nutrition after gastrectomy was 74.7%. Of 565 patients, 72 (12.7%) failed early oral nutrition due to adverse gastrointestinal symptoms, 52 (9.2%) failed due to gastric stasis or ileus, and 19 (3.4%) patients failed due to other postoperative complications. In the univariate analysis, age (≥70 years), male sex, preoperative tumor obstruction, remnant stomach cancer, open surgery, operating time (≥4h), and an advanced preoperative stage were associated with failed early oral nutrition. Multivariable analysis of these factors revealed that male sex, preoperative tumor obstruction, operating time, and advanced preoperative stage were independent predictive factors for early oral nutrition failure after gastrectomy. The tolerability of early oral nutrition after gastrectomy was comparable to that of other gastrointestinal surgeries. A tailored approach for postoperative oral nutrition is required based on identified risk factors for early oral nutrition failure.

Clinical Features and Advantages of a Novel Percutaneous Endoscopic Gastrostomy Method.

BackgroundTo study the clinical characteristics of novel percutaneous endoscopic gastrostomy.Material/MethodsWe retrospectively analyzed the hospital records of 173 patients undergoing various methods of gastrostomy (a novel PEG, traditional PEG, and surgical gastrostomy). Clinical characteristics were analyzed. For the novel PEG, the operation was as same as the traditional method for initial steps until the annular guide wire was inserted. The following steps were different: water was injected through an injection port to expand the capsule, then the water sac was confirmed to be close to the gastric wall under endoscope, and, finally, the incision was sutured and covered.ResultsPatient ages ranged from 42 to 93 years (60.8±9.2 years, 91 males and 82 females). Among all patients, there were 27 cases of brain trauma, 42 cases of cerebral infarction, 74 cases of esophageal or cardiac carcinoma, 21 cases of laryngocarcinoma, and 9 cases of Alzheimer disease. Clinical features were significantly better for novel PEG compared to traditional PEG: duration of operation (19.75±3.14 min vs. 37.86±5.33 min and 54.12±9.48 min, P<0.001), intraoperative blood loss (27.14±3.63 ml vs. 43.53±6.24 ml and 75.78±12.41 ml, P<0.001), postoperative pain score (1.12±0.19 pts vs. 3.85±0.44 pts and 6.22±1.06 pts; P<0.001), infection rate (1.35% vs. 3.77% and 2.17%, P<0.001), length of hospital stay (3.16±0.42 d vs. 5.68±0.78 d and 8.29±1.31 d, P<0.001), and time to free activity (2.24±0.26h vs. 3.74±0.48 h and 14.85±2.38 d, P<0.001). The incidence of complications such as wound infection (1.35% vs. 3.77% and 4.76%), vomiting (1.35% vs. 5.66% and 6.52%), and nausea (2.70% vs. 1.88% and 6.52%) in the novel PEG group was lower than in the other groups (P<0.0001). Improved outcomes were obtained without increased medical costs in the novel PEG group.ConclusionsFor patients with difficult postoperative oral nutrition, the novel PEG treatment resulted in overall better clinical outcomes than traditional PEG.

Perioperative weight loss and its influencing factors in patients with colorectal cancer

Objective To investigate the perioperative weight loss and its influencing factors in patients with colorectal cancer, and to provide evidence for the development and management of perioperative nutritional support strategies. Methods Ninety-one patients with colorectal cancer were enrolled and divided into observation group (n=61) with the degree of weight loss less than 5% of preoperative weight and control group (n=30) with the degree of weight loss more than 5% of preoperative weight. Change of body composition and factors of weight loss in patients with colorectal cancer were compared between the two groups by single factor and multivariate analysis. Results Ninety-one patients with colorectal cancer had the average weight loss of 2.0 kg. Of perioperative changes in body composition, the degree of body fat, muscle mass and protein group decreased statistically (P<0.05). Univariate analysis showed that the age, intraoperative blood loss and postoperative oral nutrition intake compliance were the risk factors for the degree of weight loss in patients with colorectal cancer after the operation. Multivariate logistic regression analysis showed that the intraoperative blood loss was an independent influencing factor for the degree of postoperative weight loss in patients with colorectal cancer (P<0.05). Conclusion Age, intraoperative blood loss and postoperative oral nutritional intake compliance may affect the degree of weight loss during perioperative period. Intraoperative blood loss is an independent risk factor affecting the degree of weight loss during perioperative period. In future clinical research and practice, minimally invasive and accurate surgical treatment should be strengthened, the amount of intraoperative blood loss and surgical trauma should be reduced, and the postoperative oral nutrition intake of patients should be paid attention, especially for elderly patients. Personalized dietary guidance and management for different groups should be conducted, and perioperative nutritional status of patients should be improved. Key words: Colorectal cancer; Weight loss; Body composition; Enhanced recovery after surgery

Postoperative oral nutritional supplementation after major gastrointestinal surgery: a randomized controlled clinical trial.

This study aimed to evaluate the efficacy of post-operative oral nutrition supplementation after major gastrointestinal surgery. A prospective randomized controlled trial was conducted to evaluate 174 subjects who were discharged within 2 weeks after major gastrointestinal surgery. The subjects in the study group were prescribed 400 ml/day of Encover® from the day of discharge for 8 weeks, but no supplementation was allowed in the control group. The primary endpoint was the weight loss rate at 8 weeks after discharge compared with the pre-operative weight, and the secondary endpoints included changes in body weight, body mass index, Patient-Generated Subjective Global Assessment score/grade, hematological/ biochemical parameters, and adverse events evaluated at 2, 4, and 8 weeks after discharge. The weight loss rate at 8 weeks after discharge did not differ between two groups (4.23±5.49% vs 4.80±4.84%, p=0.481). The total lymphocyte count, the level of total cholesterol, total protein, and albumin were significantly higher in the study group after discharge. Diarrhea was the most frequent adverse event, and the incidence of adverse events with a severity score of >=3 did not differ between groups (2.3% vs 1.2%). The utility of routine oral nutritional support after major gastrointestinal surgery was not proven in terms of weight loss at 8 weeks after discharge. However, it can be beneficial for early recovery of biochemical parameters.

The Trend of Perioperative Care of Gastrectomy in Kanagawa, Japan

Comprehensive surveys on perioperative care in Japan, including that in community or private hospitals, have not been reported, and current trends remain unclear. The present survey was designed to investigate current routines for perioperative care in patients who undergo surgery for gastric cancer in Kanagawa, Japan. A questionnaire was designed specifically to obtain information on perioperative routines in patients with gastric cancer throughout Kanagawa. A total of 55 hospitals in Kanagawa responded. Most hospitals perform antimicrobial prophylaxis every 3 hours intraoperatively, use a postoperative drainage tube, use a urinary catheter for only 2 days after surgery, administer epidural anesthesia, and encourage early mobilization. Liquid intake until 3 hours before surgery is not allowed in most hospitals. Most hospitals do not routinely provide preoperative nutrition support, perform bowel mechanical preparation, administer prophylaxis against thromboembolism, place a postoperative nasogastric tube, attempt to maintain normovolemia, or administer planned nonsteroidal anti-inflammatory drugs. The day of restarting drinking or eating varies considerably. Many elements of perioperative management, especially postoperative oral nutrition, have yet to be standardized for patients with gastric cancer in Japan. There are great gaps between clinical practice and evidence-based practice in fluid management and drain usage.

Immediate Postoperative Oral Nutrition Following Esophagectomy: A Multicenter Clinical Trial

Immediate start of oral intake is beneficial following colorectal surgery. However, following esophagectomy the safety and feasibility of immediate oral intake is unclear, thus these patients are still kept nil by mouth. This study therefore aimed to determine the feasibility and safety of oral nutrition immediately after esophagectomy. A multicenter, prospective trial was conducted in 3 referral centers between August 2013 and May 2014, including 50 patients undergoing a minimally invasive esophagectomy. Oral nutrition was started postoperatively immediately (clear liquids on postoperative day [POD] 0, liquid nutrition on POD 1 to 6, solid food from POD 7). Nonoral enteral nutrition was started when <50% of caloric need was met on postoperative day POD 5 or when oral intake was impossible. A comparison was made with a retrospective cohort (n= 50) with a per-protocol delayed start of oral intake until POD 4 to7. The median caloric intake at POD 5 was 58% of required. In 38% of the patients nonoral nutrition was started, mainly due to complications (36%). The pneumonia rate was 28% following immediate oral intake and 40% following delayed oral intake (p= 0.202). The aspiration pneumonia rate was 4% in both groups. The anastomotic leakage rate was 14% after immediate oral intake versus 24% following delayed oral intake (p= 0.202). The 90-day mortality rate was 2% in both groups. Hospital stay and intensive care unit stay were significantly shorter following immediate oral intake. Immediate start of oral nutrition following esophagectomy seems to be feasible and does not increase complications compared to a retrospective cohort and literature. However, if complications arise an alternative nutritional route is required. This explorative study shows that a randomized controlled trial is needed.

Canadian practice patterns for pancreaticoduodenectomy.

Discordant practice patterns may be a consequence of evidence-practice gaps or deficiencies in knowledge translation. We examined the current strategies used by hepato-pancreatico-biliary (HPB) surgeons in Canada for the perioperative management of pancreaticoduodenectomy (PD). We generated a web-based survey that focused on the perioperative measures surrounding PD. The survey was distributed to all members of the Canadian Hepato-Pancreatico-Biliary Association. The survey was distributed to 74 surgeons and received a response rate of 50%. Many similarities in surgical techniques were reported; for example, most surgeons (86.5%) reconstruct the pancreas with pancreaticojejunostomy rather than pancreaticogastrostomy. In contrast, variable techniques regarding the use of peritoneal drainage tubes, anastomotic stents, octreotide and other intraoperative modalities were reported. Most surgeons (75.7%) reported that their patients frequently required preoperative biliary drainage, yet there was minimal agreement with the designated criteria. There was variability in postoperative care, including the use of epidural analgesia and timing of postoperative oral nutrition. We identified heterogeneity among Canadian HPB surgeons, suggesting a number of evidence-practice gaps within specific domains of pancreatic resections. Focused research in these areas may facilitate technical agreement and improve patient outcomes following PD.

Evaluation of the effects of postoperative oral nutrition support on body weight in gastric cancer patients by using an elemental diet: A randomized study.

110 Background: Postoperative weight loss causes deterioration in the patient’s quality of life and influences long-term prognosis in gastric cancer patients who have undergone gastrectomy. Moreover, recent retrospective studies indicated postoperative weight loss as a risk factor for premature interruption of S-1 adjuvant chemotherapy. We conducted a prospective randomized controlled study to examine whether the early institution of nutritional support comprising an oral elemental diet (ED) prepared for post-gastrectomy patients with depressed digestive/absorptive function would help prevent postoperative weight loss. Methods: After surgery, patients were randomly assigned to the ED or control groups. The groups were divided according to the surgical methods used (total/distal gastrectomy), clinical stage (≤Ia/&gt;Ia), and patients’ body mass index (&lt;18.5/&gt;18.5). In patients assigned to the ED group (Elental, 300 kcal) was provided in addition to the regular diet from the day starting soft rice diet or equivalent diet to 6–8 weeks after surgery. The primary endpoint was the percentage of body weight change from the pre-surgical body weight to that at 6–8 weeks after surgery. The secondary endpoints were ED adherence, nutrition-related blood parameter changes, and adverse effects. Results: The study included 112 patients from eight hospitals. There was a significant difference in the percentage of body weight loss (%BWL) between the ED and control groups (4.88±3.41% and 6.91±5.06%; P=0.015). Sub-group analysis showed a significant difference in the %BWL in patients who underwent total gastrectomy (5.31±3.43% and 9.11±5.57%; P=0.016). Multivariate analysis demonstrated ED treatment and surgery type as independent factors that affect body weight changes. The mean treatment compliance rate in the 58 ED-group patients was 72.9±33.1%, with a favorable median value of 90.8%. No significant differences were observed in any parameter analyzed, including hematological and non-hematological adverse events, between the two groups. Conclusions: The ED product can prevent postoperative weight loss in gastric cancer patients undergoing gastrectomy. Clinical trial information: 000008056.

The safety and feasibility of early postoperative oral nutrition on the first postoperative day after gastrectomy for gastric carcinoma

Unlike the wide acceptance of early enteral nutrition after colorectal surgery, little information is available regarding the feasibility of immediate oral nutrition after gastric cancer surgery. This study evaluated the feasibility and safety of oral nutrition on the first postoperative day after gastrectomy. From September 2010 to March 2011, 74 consecutive gastric cancer patients received an oral diet on the first postoperative day after gastrectomy. Surgical outcomes, including hospital stay, morbidity, and mortality, were compared with a conventional diet group (n = 96, before September 2010), in which an oral diet was started on the third or fourth postoperative day. No significant differences were found in the clinicopathological characteristics or operation types between the two groups. Average diet start times in the early diet (ED) and conventional diet (CD) groups were 1.8 and. 3.2, respectively (p < 0.001). The mean hospital stay was significantly shorter in the ED group (7.4 vs. 8.9 days, p = 0.004). There was no significant difference in postoperative morbidity (p = 0.947) between the two groups. Gastrointestinal-related complications, such as anastomosis leakage or postoperative ileus, were also similar in the two groups. Overall compliance to early oral nutrition in the ED group was 78.5 %, and an old age (≥70 years) was found to affect the compliance to early postoperative oral nutrition. Postoperative oral nutrition is safe and feasible on the first postoperative day after gastrectomy. However, elderly patients require careful monitoring when applying early oral nutrition after gastrectomy.

Fast track open ileo‐colic resections for Crohn's disease

Introduction of multimodal rehabilitation programmes after open colonic surgery for noninflammatory bowel disease has reduced hospital stay to about 2-3 days, but no data are available from open ileo-colic surgery for Crohn's disease with multimodal rehabilitation regimens. Therefore, the aim of study was to assess outcome after ileo-colic resections for Crohn's disease with multimodal rehabilitation. Thirty-two consecutive ileo-colic resections for Crohn's disease in 29 patients received epidural analgesia and enforced postoperative oral nutrition and mobilization with a scheduled stay of 2 days. Median time to defaecation was 2.5 days and postoperative hospital stay was 3 days. During a 30-day postoperative follow-up there was two re-admissions, one for mechanical bowel obstruction (9 days) and one because of fever and vomiting (6 days). Except for one wound abscess, one cystitis and one pneumonia, no other complications occurred. Fast-track multimodal rehabilitation in open ileo-colic resections for Crohn's disease reduces hospital stay and with low morbidity and readmission rate.

Early oral nutrition after elective colorectal surgery: influence of balanced analgesia and enforced mobilization

Early postoperative nutrition reduces morbidity. We investigated whether the introduction of a new postoperative analgesic and ambulation regimen with enforced mobilization from postoperative day 1 would influence postoperative nutrition intake. Nutrition intake was recorded daily by a record method and compared with the intake in a control group that received the same nutrition regimen but a traditional analgesic and ambulation regimen. The mean intakes of energy during postoperative days 1 to 5 were 73 kJ · kg −1 · d −1 in the intervention group and 52 kJ · kg −1 · d −1 in the control group ( P = 0.04). Protein intakes in the same period were 0.95 g · kg −1 · d −1 in the intervention group and 0.57 g · kg −1 · d −1 in the control group ( P < 0.01). We found that a regimen based on epidural analgesia with local anesthetics, enforced mobilization, and the use of immediate postoperative oral nutrition leads to substantial nutrition intake after colonic surgery during the first postoperative days.

Perioperative oral nutrition.

Much attention has been paid to perioperative intravenous nutrition and postoperative enteral nutrition but the literature concerning perioperative oral nutrition is sparse. This review will draw attention to new ideas about preoperative feeding instead of overnight fasting, it will show that immediate postoperative oral nutrition is tolerated in significant amounts, that liquid supplements may be given routinely after elective surgery, and that it is worth giving dietary advice to malnourished patients on discharge from hospital.