Early Enteral Nutrition Within 24 Hours of Lower Gastrointestinal Surgery Versus Later Commencement for Length of Hospital Stay and Postoperative Complications

What is the effectiveness of early postoperative enteral nutrition (orally or through any type of tube feeding within 24 hours) compared with traditional management (delayed nutrition) on length of hospital stay (LOS), complications, and mortality/adverse events in patients undergoing lower gastrointestinal (GI) surgery?1Herbert G. Perry R. Andersen H.K. et al.Early enteral nutrition with 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications.Cochrane Database Syst Rev. 2019; : CD004080PubMed Google Scholar Traditionally, patients who recovered from lower GI surgery (defined as GI surgery distal to the ligament of Treitz) moved from no feeding by mouth (NPO) to a full enteral diet, as bowel function returned, typically assessed through auscultation and the passing of flatus. However, as more health care facilities embrace guidelines and clinical practice protocols that align with the enhanced recovery after surgery treatment program (https://erassociety.org/), there is increased awareness that providing early postoperative enteral nutrition (defined for this review as oral intake delivered by mouth or through any type of tube feeding, including gastric, duodenal, or jejunal within 24 hours of surgery) may be beneficial for adult patients. This review is an update from a previous Cochrane review (published in 2011) and provides the most recent evidence. This summary is based on a Cochrane review containing 17 randomized controlled trials with 1,437 adult participants (18 years and older and both sexes). This review focused on early enteral nutrition (within the first 24 hours after lower GI surgery) that was provided orally or by tube (hereafter referred to as early feeding groups) compared with the control groups, who were patients who had no oral intake or any type of nutritive tube feeding before bowel function returned. Excluded from this review were studies that focused on the following:•Children (younger than 18 years)•Comparing different types of enteral nutrition•Patients who served as their own controls or crossover trials•Upper GI surgery•Parenteral nutrition. Primary outcomes were LOS and postoperative complications, including wound infections, intra-abdominal abscesses, anastomotic dehiscence, and pneumonia. Secondary outcomes were mortality, adverse events such as nausea and vomiting, and quality of life. Acting independently, two review authors assessed the studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence. LOS was estimated using mean difference. For other outcomes, risk ratio (RR) was estimated, and confidence intervals (CIs) were calculated at 95%. The reviewers used an inverse-variance random-effects model for LOS and Mantel-Haenszel random-effects model for the secondary outcomes. Results indicated are as follows:•LOS was reported in 16 studies with 1,346 participants. The mean LOS ranged from 4 to 16 days in the early feeding groups and from 6.6 to 23.5 days in the control groups. Mean difference in LOS was 1.95 days shorter in the early feeding group (95% CI, −2.99 to −0.91; P < .001); however, the overall quality of evidence was low.•No differences were found in the incidence of postoperative complications: wound infection (12 studies with 1,181 participants: RR, 0.99; 95% CI, 0.64 to 1.52); intra-abdominal abscesses (6 studies with 554 participants: RR, 1.00; 95% CI, 0.26 to 3.80); anastomotic leak/dehiscence (13 studies with 1,232 participants: RR, 0.78; 95% CI, 0.38 to 1.61; number needed to treat for an additional beneficial outcome = 100); and pneumonia (10 studies with 954 participants: RR, 0.88; 95% CI, 0.32 to 2.42; number needed to treat [NNT] for an additional beneficial outcome = 333). This evidence ranged from low to very low quality.•Mortality was reported in 12 studies with 1,179 participants, and no between-group differences were found (RR, 0.56; 95% CI, 0.21 to 1.52; P = .26; I2 = 0%; χ2 = 3.08; P = .96). The most commonly reported cause of death was anastomotic leak, sepsis, and acute myocardial infarction. This evidence was of low quality.•In terms of adverse events, 7 studies with 613 participants reported vomiting (RR, 1.23; 95% CI, 0.96 to 1.58; P = .10; I2 = 0%; χ2 = 4.98; P = .55; number needed to cause harm [NNTH] = 19), and 2 studies with 118 participants reported nausea (RR, 0.95; 95% CI, 0.71 to 1.26). This evidence was of low quality.•Quality of life was assessed in one study with 51 participants, using the European Organization for Research and Treatment of Cancer (EORTC) surveys (EORTC QLQ-C30 and EORTC QIQ-OV28 [survey tool specifically designed for ovarian cancer]). The tools were both administered before surgery and 30 days after discharge. The scores did not differ between groups at 30 days after discharge: EORTC OV28 control group (28.6 [13.7] vs early feeding 26.5 [14.9]; P = .68 and EORTC C30 control group (56.1 [22.2] vs early feeding 64.6 [17.1]; P = .17). This evidence was of very low quality. This review suggests that early enteral feeding, either by mouth or by tube within the first 24 hours of surgery, may lead to a reduced postoperative LOS in adult patients after lower GI surgery. Caution must be used when interpreting these results, however, as the quality of the evidence ranged from low to very low quality, because of risk of bias in all the included studies. With that caveat in mind, a reduction in LOS by nearly 2 days is an important finding for patients and their families on many levels: less exposure to pathogens that can lead to a reduction in hospital-acquired infections, reduced financial burden, and an earlier return to home.