Enteral Feeding After Gastric Intestinal Resection
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Optimum nutrition has always been a major target of post: operative care. Ileus is a common phenomenon after abdominal surgery, therefore early oral feeding is avoided and nasogastric decompression is being used. Conventionally, post abdominal surgery, the passage of flatus, or bowel movement was the clinical evidence of starting an oral diet. The end of post operative ileus based to be taken by the passage of flatus usually occurred within 5 days. The many studies have proved that the routine use of a nasogastric tube after abdominal Surgery and colorectal surgery may not be necessary. studies were undertaken to evaluate /whether different abdominal surgeries could benefit from early feeding. Early feeding improves the outcome of the patients with trauma and Burns although few studies have examined its use after gastro intestinal anastomosis. In case of laparoscopic colectomy patients have been fed routinely on day 2 after operation and that is being safely tolerated by the majority of patients.
There are many evidences which indicate that immediate feeding after operation is actually feasible and safe whether post laparoscopic or post laparotomy , including gastro intestinal surgery. It has been proved by many studies that early enteral feeding in surgical patients improves nutrition and immunity and ultimately reducing septic complications and over all morbidity when compared with parenteral nutrition.
A study conducted that compared an early regular diet to conventional post operative dietary management to determine G1 complications and mortality after major G1 anastomosis.
The aim of this study was to assess the safety and tolerability outcomes of early oral feeding after elective gastro intestinal anastomosis.
Patients and Methods
Between July 2006 and December 2009, after the study was approved by ethical review committee, patients were offered participation and informed consent taken. Patients with chronic liver disease or those with metastasis and patients with histories of acute obstruction, perforation and intra abdominal infection were excluded. Patients were subject to a thorough history, physical examination and investigations.
The patients were then randomized into two groups. Randomization done using sealed envelopes.
(Early feeding); 30 patients were offered simply a liquid diet within 6 hours of arrival on the ward. If 1 liter was being tolerated they were free for free liquid on the second day and then regular diet on the third day. (Tolerance is being indicated by an absence of vomiting or abdominal distension).
(Regular feeding) 30 patients were managed conventionally (that is nothing by mouth until the resolution of ileus, then a fluid diet, followed by regular diet.
All patients underwent general anesthesia no nasogastric tube was inserted in any patients during surgery in patients in group 1 and a nasogastric tube was inserted in all patients during surgery and continued till the resolution of ileus in group 2.
The patients were monitored for vomiting, abdominal distension length of ileus, tolerance of regular diet, length of hospitalization and complications.
If there were two episodes of vomiting in the absence of bowel sounds or passage of flatus in the absence of any bowel movement, insertion of nasogastric tube was implemented.Also those who suffered from abdominal distension, emesis and succussion splash of stomach were diagnosed with acute dilatation of stomach, subjected to G I decompression. If there was anastomosis failure, treatment ensued such as antibiotics, nutritional support, ileostomy or colostomy.
Patients with normal post operative course were discharged when they could tolerate a regular diet.
Demographics were age and sex, medical and surgical histories of the patients and indications for anastomosis were noted. Different patients had different types of anastomosis were randomly allocated to group 1 irrespective of anastomotic type to eliminate bias. Table 1.
Indications group 1 group 2
Tuberculous 5 5
Closure of 20 20
Colorectal surgery 5 5
The main outcome was to evaluate post operative complications that included wound infection, leakage of anastomosis, obstruction, mesenteric emboli, upper G1 bleeding, wound dehiscence, prolonged ileus, and mortality. Ileus was defined as hypoactive bowel sounds, abdominal distension and no passage of flatus or bowel movement with or without nausea or vomiting after the first post operative day 3.
Statistical analysis of data done by SPSS version 10. For continuous variables, descriptive statistics were calculated and were reported as mean +SD. Categorical variables were described using frequency distribution. The student T-test for paired samples was used to detect difference in the mean of continuous variables and the chi-square test was used in cases with low expected frequencies (a P value <0.05 was considered to be significant).
Between August 2006 and November 2009 60 patients who had abdominal surgery for anastomosis indications gave consent to involve in to study. 30 patients (22 males and 08 females) with 59 mean years old in group 1 and 30 patients (20 males and 10 females) with 55 mean years old in group 2. Demographically no significance between groups regarding age, medical and surgical history. Indications for anastomosis were similar between groups table 1.
The majority of patients in early feeding group 50% tolerated the early feeding. Vomiting was more common as compared to late feeding group 25% and 20% respectively but did not reach to statistical significant level table 2.
Events group 1 group 2 p value
N/G tube reinsertion
Time to passage of flatus
Post operative event is compared in shown in table 3
Post op complications anastomatic acute dilatation of pulmonary wound infections
leakage stomach infections
12.5% pts failed tolerate early feeding.Failure was reflected by recurrent vomitingwith abdominal distension without bowel sound.They were probably not because of the method of early feeding but because of confounding factors table 4
Factors tolerated failed p value
Intra op blood
Delaying oral feeding until reduction of ileus in abdominal surgery had become a myth. In recent decade trend is toward earlier feeding. The routine nasogastric tube decompression after abdominal and colorectal surgery has already been refuted. A randomized study on general surgeon showed that 72% of them performed routine gastro intestinal decompression after excision and anastomosis of intestine.
The volume of secreted digestive juices is about 5 to 9 litters, and the gas secreted by deglutition and intestine is about 30-300ml and the volume extracted by gastrointestinal decompression every day was less than 10% of digestive juices. After operation on abdominal region, gastro intestinal motor function is reduced and the function of intestinal absorption is not greatly reduced. Clever et al reported that paralysis of intestine could not be alleviated by gastro intestinal decompression.
The gastro intestinal tract motility of patients undergoing abdominal surgery is transiently impaired.
There are multiple factors for this phenomenon including physical manipulation of the bowel, surgical stress, inflammatory mediators, and changes in electrolytes, normal reflux, inhalation anesthetics, and use of opiates. Post operative ileus can result in accumulation of gas and secretion leading to distention, emesis, pain and longer hospital stay. Currently available therapies are supportive and include intra venous hydration and nasogastric suctioning 19.Conventionally post operative diet based on physical signs of bowel function and not on post operative gastro intestinal physiology. Animal and human radiological and physiologic studies do not support the practice of oral feeding based on auscultation of normal bowel sounds and passage of flatus and bowel movement.
It has been shown that paralysis of the small bowel is transient (6-12 hr), the gastric paralysis lasts 12-24 h, and paralysis of colon lasts 48-72 hrs. Physiologic studies have fond that mayo electric and motor activity in the stomach is not affected after abdominal surgery. Childer et al 21 showed bowel activity before flatus was passed which dictates that patients can tolerate fluid secretions of 1-2 litre from the stomach and Pancreas immediately after surgery. Studies also have shown tolerance to clear liquids on 1st post operative day after G1 surgeries.
In our study 80% tolerated early feeding and 20% presented with recurrent vomiting and abdominal distension with intestinal sound. There were also confounding factor which had a significant impact on tolerability of early oral feeding. Age, gender, type of operation and previous abdominal operation had not impact.
In this study, the time to first passage of flatus (P =0.04) and the time to first defecation (P = 0.005) were sooner in the early feeding group. The post operative stays for the early feeding and the groups 2 were 6.2 + 0.2 day (3-11) and 6.9 + 0.5 days (3.12) respectively as also shown by tong et al. Peachier et al 28reported that early feeding did not affect the ileus and did not significantly shorten the length of hospitalization. Early oral feeding within 24 hours after gastro intestinal surgery is safe, well tolerated, may improve gastro intestinal motility and plays an important role in enhanced recovery and outcome. Marik and zaloga conducted Meta analysis of prospective, randomized studies comparing early VS late enteral feeding demonstrating the benefits of early nutrition. However, the preferred feeding site for enteral nutrition remains controversial. Despite this fact Seenu and Goel Showed that early oral feeding after elective coloracted surgery is safe and can be tolerated by most patients. Difronzo Et al also showed a high tolerability 86.5% to early post operative oral feeding after elective open colonic resection. These studies were not exclusive to colorectal surgeries and snchiro et al. Showed that early oral feeding even after gastrectomy is safe. In our study there was no difference in post operative morbidity like wound infections, wound dehiscence, leakage of anastomosis, mesenteric embolus, obstruction, upper G1 bleeding and mortality.
Nausea and vomiting occur frequently after upper G1 surgery than post resection of the small intestine and colon. Nevertheless there is evidence that bowel rest and nil per month are beneficial for healing of wound and anastomotic integrity.
In conclusion G1 decompression following excision and anastomosis of lower digestive tract can not reduce the pressure of G1 tract and has no obvious effect upon preventing of post operative complications contrary to expectation; it may increase the incidence rate of pharyngo laryngitis and other complications. If length of operation and amount of blood loss is kept at optimum, early oral feeding after G1 anastomosis is safe and can be tolerated by majority of patients. It lowered general and local complications and reduces the duration of hospital stay and may become a feature of post operative management.
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