ORIGINALS

 

Early postoperative oral feeding impacts positively in patients undergoing colonic resection: results of a pilot study

La alimentación oral precoz posoperatoria tiene un impacto positivo en pacientes sometidos a resección colónica: resultados de un estudio piloto

 

 

M. Lobato Dias Consoli, RD, MS¹, L. Maciel Fonseca, MD¹, R. Gomes da Silva, MD, PhD¹ y M.^a I. Toulson Davisson Correia, MD, PhD¹

¹Alfa Institute of Gastroenterology, Medical School, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

Correspondence

 

 

---

ABSTRACT

Background and aims: Early oral feeding after colorectal resections is one of the many factors that contributes to enhance recovery after surgery, mainly impacting on postoperative ileus. The aim of this study was to evaluate the impact of early postoperative oral feeding in patients undergoing elective colorectal resection.
Methods: Patients were randomly assigned to either a conventional postoperative dietary regimen or a free diet on the first postoperative day.
Results: Altogether 29 patients were enrolled. Clinical characteristics were similar in both groups. Good nutritional status was seen in 86% of patient in the traditional care (TRAD) group versus 46% in the early fed (EF) group (p<0.05). There was no difference between groups in terms of procedures. Median hospital stay was 5.0 days in the TRAD group versus 3.0 days in the EF group (p<0.05). Complication rates and acceptance of diet were similar in both groups. Diarrhea occurred more frequently in the TRAD group (OR=1.86; IC95%:1.08-3.20).
Conclusion: Early oral intake is well tolerated, leads to significant shorter hospital stay and does not increase complications.

Palabras clave: Early nutrition. Postoperative ileus. Colorectal resection.

---

RESUMEN

Antecedentes y objetivos: La alimentación oral precoz tras las resecciones colorrectales es uno de los muchos factores que contribuyen a favorecer la recuperación tras la cirugía, teniendo sobre todo una influencia en el íleo posoperatorio. El propósito de este estudio fue evaluar el impacto de la alimentación oral precoz posoperatoria en pacientes sometidos a resección colorrectal programada.
Métodos: Se distribuyó al azar a los pacientes para recibir un régimen alimenticio posoperatorio convencional o una dieta libre en el primer día de posoperatorio.
Resultados: Se reclutó a un total de 29 pacientes. Las características clínicas fueron similares en ambos grupos. Se observó buen estado nutritivo en el 86% de los pacientes con la atención tradicional (TRAD) frente al 46% en el grupo con alimentación precoz (EF) (p < 0,05). No hubo diferencias entre los grupos con respecto a los procedimientos. La estancia media hospitalaria fue de 5,0 días en el grupo TRAD frente a 3,0 días en el grupo EF (p < 0,05). Las tasas de complicación y aceptación de la dieta fueron similares en ambos grupos. La diarrea ocurrió más frecuentemente en el grupo TRAD (OR = 1,86; IC95%: 1,08-3,20).
Conclusión: La alimentación oral precoz se tolera bien, conlleva una estancia hospitalaria más corta y no aumenta las complicaciones.

Key words: Nutrición precoz. Íleo posoperatorio. Resección colorrectal.

---

Abreviaturas

BMI = body mass index
EF = early fed group
TRAD = traditional care group
NS = non significant
PO = postoperatory

 

Introduction

Fasting or diet restriction postoperatively which contributes to exacerbation of catabolism with concomitant weight loss and muscle wasting. On the other hand, oral nutrition and early enteral nutrition can improve the organic response to stress and thus facilitate the recovery of patients^1,2. Some aspects of the perioperative care of patients undergoing colorectal anastomosis are based on dogmas. The timing of the reintroduction of oral diet after surgery is an example. It has been shown that patients remain exposed to unnecessarily prolonged fasting³. In consequence, the nutritional status is affected, which is important in those patients previously malnourished. In addition, the length of hospital stay and risk of complications increases. After colon resection, patients remain in the hospital on average six to 12 days and the complication rates range from 15% to 20%^4-6. Epidural analgesia, minimally invasive surgey, antiemetic medications, early mobilization after surgery and psychological preparation of the patient, all together, are some of the elements associated with the diet which have been shown to improve early postoperative results^7-13. Several authors^9,14 argue that although multimodal treatment is of extreme importance, the single contribution of each variable remains unclear, probably due to the enormous variety of protocols for rapid recovery. Therefore, in the current study we investigated if only early feeding in patients undergoing colon resection contributes to a faster and more uneventful recovery and early return to normal functions at home.

 

Materials and methods

From July 2006 until January 2008, patients older than 18 years admitted for either open or laparoscopic elective colonic resection with a primary anastomosis were eligible for this trial. Exclusion criteria were emergency procedures, patients who underwent Hartmann's colonic resection or with protective colostomy and those who did not agree to participate. The study was approved by the university and hospital ethical committees and all patients provided written informed consent. On admission all patients were nutritionally assessed by subjective global assessment and body mass index (BMI). Data were collected by a single observer. All patients received thromboprophylaxis and perioperative antibiotics. Neither nasogastric tubes nor intra-abdominal drains were used postoperatively. All anesthetic procedures and agents were standardized, but epidural anesthesia was not performed. Patients were randomized to either traditional care (TRAD) or the early fed group (EF). In both groups, there were 12hs of nil by mouth before surgery. Postoperatively, on the 1^st day, patients in the EF group received 500mL of restricted fluid as the first diet intake and if no nausea and vomits were observed they were able to eat a free diet, immediately thereafter. The TRAD group received nil by mouth until flatus or evacuation happened. All fluids in EF group were discontinued on day 1 after surgical procedure unless there was a medical reason to do otherwise. All patients were encouraged to early mobilization starting immediately after surgery in both groups. Patient follow up was performed daily with special attention to nausea, emesis and other signs of diet intolerance. Criteria for insertion of a nasogastric tube were two consecutive episodes of vomiting greater than 400mL. Discharge from the hospital was possible when patients were fully mobile, pain was controlled with only oral analgesics and tolerance of oral food was adequate. All patients were daily contacted by telephone until day seven after surgery. All complications were recorded.

Study population sample size was based on the assumption that the EF group would present at least one day of difference in hospital stay. To achieve an 80% power with a 2-sided P value of less than 0.05 as significant, 30 patients per group were required. An interim analysis was planned after inclusion of a half of the calculated sample size with a premature study end, if any differences in the primary end point were reached. Statistical analysis was based on an intention-to-treat analysis and it was performed with the Statistical Package for Social Science software (version 10.0; SPSS, Chicago, IL). Calculations of diet intake were performed with Diet PRO (version 4.0). The Mann-Whitney U and Wilcoxon tests were used to compare continuous variables, the chi-square test and the Fisher exact test were used to compare discrete variables. The length of hospital stay was assessed by survival analysis, due to censorship in follow-up time and due to better matching of such analysis for this variable.

 

Results

From July 2006 until January 2008 there were 29 patients who fulfilled inclusion criteria and were randomly assigned to the EF and TRAD groups. Characteristics and surgical details are shown in table I. The most common diagnosis was colorectal cancer (males n=12, females n=12). Laparoscopic procedures were performed in 42.9% of patients in TRAD group and 46.7% of EF group, with no statistical difference between groups (p=NS). Nutritional status of patients before surgery according to subjective global assessment is depicted in figure 1 A and B. When BMI was used, overnutrition (BMI>25kg/m²) was present in 62.1% of patients. There was significant reduction in total length of stay between EF group and TRAD group (p<0.01), as presented in figure 2. The median length of hospital stay was 5.0 days in TRAD group versus 3.0 days in EF group.

Time taken to passage of first flatus was statistically different between the two groups (TRAD = 2^nd day versus EF = 1^st day; p<0.05). Diet intake in TRAD and EF group is showed in figures 3 and 4 respectively. Nine patients presented with postoperative complications. Five patients in the TRAD group and four patients in de EF group (p=NS). There was no statistical difference in the occurrence of nausea and vomiting between the groups. Patients in the TRAD group were 1.86 times more likely to have diarrhea than patients in EF group (IC95%: 1.08 - 3.02; p<0.05). The rate of anastomotic leak was not different between groups (p>0.05). One patient died during the follow-up.

 

Discussion

The results of this randomized pilot clinical trial indicate that early oral diet alone can impact positively in postoperative outcome of patients undergoing colorectal resection.

Although the EF group presented with higher number of malnourished individuals (53%) than the TRAD group (14%) it still had better postoperative recovery reflected by shorter hospital stay, lower incidence of diarrhea and similar complication rates. It is known that nutritional status is directly associated with worse organic response to trauma, increased postoperative ileus and slower recovery⁶. However, it is also known that the passage of food at the anastomosis site enhances healing. It reduces the risk of developing fistulas, the occurrence of nausea and vomiting by increasing local blood flow and peristalsis and, thus stimulates intestinal motility and resolution postoperative ileus^2,7,14,15.

Multimodal treatments do impact on surgical outcomes^5,7-10,12,13, however the contribution of each procedure alone remains unclear. Indeed, this could be due to the diversity of the protocols and its many variables^9,14. Each aspect influencing postoperative recovery should be investigated individually, and consensus reached on its place in fast-track protocols.

The current study only assessed the important role of timing of PO diet reintroduction and it has shown that it alone impacted on recovery of the patients with no increased complications.

In our study, the event diarrhea was 1.86 times more likely to occur in patients who received diet only after passage of flatus. This might be explained by the fact that fasting is associated with greater likelihood of intestinal stasis which contributes to increased bacterial growth and imbalance of the intestinal microbiota. Finally, when motility is recovered diarrhea might occur.

In conclusion, our study shows that early postoperative feeding protocol alone in patients undergoing colon resection results in earlier hospital discharge, quicker postoperative recovery and no changes in complication rates. This result reinforces the idea that early nutrition is crucial in the recovery of the patient, even when malnutrition is present (53% of the early fed group).

 

Grant support

Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq.

 

References

1. Brodner G, Van Aken H, Hertle L, Fobker M, Von Eckardstein A, Goeters C, et al. Multimodal perioperative management- combining thoracic epidural analgesia, forced mobilization, and oral nutrition-reduces hormonal and metabolic stress and improves convalescence after major urologic surgery. Anesth Analg 2001 Jun; 92(6): 1594-600.        [ Links ]

2. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002 Jun; 183(6): 630-41.        [ Links ]

3. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005 Jun; 24(3): 466-77.        [ Links ]

4. Basse L, Thorbol JE, Lossl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004 Mar; 47(3): 271-7; discussion 7-8.        [ Links ]

5. Basse L, Jakobsen DH, Bardram L, Billesbolle P, Lund C, Mogensen T, et al. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg 2005 Mar; 241(3): 416-23.        [ Links ]

6. Correia MI, da Silva RG. The impact of early nutrition on metabolic response and postoperative ileus. Curr Opin Clin Nutr Metab Care 2004 Sep; 7(5): 577-83.        [ Links ]

7. Braga M, Gianotti L, Gentilini O, Liotta S, Di Carlo V. Feeding the gut early after digestive surgery: results of a nine-year experience. Clin Nutr 2002 Feb; 21(1): 59-65.        [ Links ]

8. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 2003 Jul; 46(7): 851-9.        [ Links ]

9. Raue W, Haase O, Junghans T, Scharfenberg M, Muller JM, Schwenk W. 'Fast-track' multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation. Surg Endosc 2004 Oct; 18(10): 1463-8.        [ Links ]

10. Jakobsen DH, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery with fast-track vs conventional care. Colorectal Dis 2006 Oct; 8(8): 683-7.        [ Links ]

11. Kehlet H. Future perspectives and research initiatives in fasttrack surgery. Langenbecks Arch Surg 2006 Sep; 391(5): 495-8.        [ Links ]

12. King PM, Blazeby JM, Ewings P, Longman RJ, Kipling RM, Franks PJ, et al. The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis 2006 Jul; 8(6): 506-13.        [ Links ]

13. Han-Geurts IJ, Hop WC, Kok NF, Lim A, Brouwer KJ, Jeekel J. Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery. Br J Surg 2007 May; 94(5): 555-61.        [ Links ]

14. DiFronzo 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 Nov; 197(5): 747-52.        [ Links ]

15. Kehlet H. Labat lecture 2005: surgical stress and postoperative outcome-from here to where? Reg Anesth Pain Med 2006 Jan- Feb; 31(1): 47-52.        [ Links ]

 

 

Correspondence:
Marcella Lobato Dias Consoli
Rua João Alexandre Pires, 748/202.
Milionários, Belo Horizonte - Minas Gerais -
20620-080 Brazil.
Em-ail: maufop@yahoo.com.br

Recibido: 13-IV-2010.
Aceptado: 17-IV-2010.