Can't we just let them eat? Defining and addressing under-use of the oral route in a post-surgical ward

Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Building 12 Missenden Road, Camperdown NSW 2050, Australia. .
Asia Pacific Journal of Clinical Nutrition (Impact Factor: 1.7). 04/2013; 22(2):200-5. DOI: 10.6133/apjcn.2013.22.2.12
Source: PubMed


Early postoperative nutrition improves outcomes. However, postoperative fasting is a tradition that persists in some areas of surgical practice. This retrospective audit was performed to benchmark current nutrition support practices on a mixed specialty surgical ward in a large tertiary-referral teaching hospital. Thirty-eight consecutive patients, who were undergoing gynaecological or urological surgical procedures between November 2010 and May 2011, had data collected including demographics, nutritional status, details of surgery performed, postoperative complications, modes of nutrition support and time taken to progress to solid oral diet. Energy and protein provision and adequacy was estimated for the first week postoperatively. Sixteen patients commenced parenteral nutrition postoperatively without any trial of oral or enteral nutrition. Reasons for using parenteral nutrition included observed or expected gut dysmotility and lack of enteral access for feeding. These patients did demonstrate longer length of stay and higher rates of postoperative complications. Given the proportion of patients initiated immediately on parenteral nutrition and maintained on it alone, it can be argued that these patients are not able to demonstrate tolerance and receive the benefits of early enteral feeding predicted by studies within these patient groups. None of the patients met their energy and protein requirements in the first week postoperatively. Despite support in the literature, it can be challenging to implement early postoperative nutrition support after pelvic surgery. It may be necessary to employ a variety of strategies to change this aspect of practice and promote earlier introduction of an oral diet or the use of enteral nutrition.

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Available from: Suzie Ferrie, Oct 02, 2015
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    ABSTRACT: Gastro-intestinal (G-I) motility is impaired ("paralytic ileus") after abdominal surgery. Premature feeding attempts delay recovery by inducing "feeding intolerance," especially abdominal distention that compromises respiration. Controlled studies (e.g., from Sloan-Kettering Memorial Hospital) have lead to recommendations that patients not be fed soon after major abdominal surgery to avoid this complication. We postulate that when total fluid inflow of feedings, digestive secretions, and swallowed air outstrip peristaltic outflow from the feeding site, fluid accumulates. This localized stagnation triggers G-I vagal reflexes that further slow the already sluggish gut, leading to generalized abdominal distention. Similarly, vagal cardiovascular reflexes in susceptible subjects could account for the 1:1,000 incidence of unexplained bowel necrosis reported with enteral feeding. We re-evaluated our data, which supports this postulated mechanism for the induction of "feeding intolerance." We had focused our efforts on postoperative enteral nutrition, with the largest reported series of immediate feeding of at least 100 kcal/hour after major surgery. We found that this complication can be avoided consistently by monitoring inflow versus peristaltic outflow, immediately removing any potential excess from the feeding site. We fed intraduodenally immediately following "open" surgery for 31 colectomy and 160 consecutive cholecystectomy patients. The duodenum was aspirated simultaneously just proximal to the feeding site, efficiently removing all swallowed air and excess feedings. To salvage digestive secretions, the degassed aspirate was re-introduced manually (and later automatically) via a separate feeding channel. Hourly assays were performed for nitrogen balance, serum amino acids, and for the presence of removed feedings in the aspirate. The colectomy patients had X-ray motility studies initiated 5 – 17 hours after surgery. Clinically normal motility and absorption resumed within two hours. Fed BaSO4 traversed secure anastomoses, to exit in bowel movements within 24–48 hours of colectomy. All patients were in positive protein balance within 2 – 24 hours, with elevated serum amino acids levels and without adverse G-I effects. Limiting inflow to match peristaltic outflow from the feeding site consistently prevented "feeding intolerance." These patients received immediate full enteral nutrition, with the most rapid resolution of postoperative paralytic ileus, to date.
    Annals of Surgical Innovation and Research 05/2009; 3:3. DOI:10.1186/1750-1164-3-3
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    ABSTRACT: Papers p 773The widespread practice of starving patients in the immediate period after gastrointestinal surgery has been challenged by a systematic review and meta-analysis in this issue (p 773), which finds that “nil by mouth” after gastrointestinal surgery may not be beneficial.1 Further, the apparently beneficial effects of early postoperative enteral feeding on infection rates and length of stay in hospital are compelling arguments in favour of a change in clinical practice.The rationale of nil by mouth and gastric decompression is to prevent postoperative nausea and vomiting and protect the anastomosis, allowing it time to heal before being stressed by food. Nausea and vomiting, however, occur more commonly after upper gastrointestinal surgery than after resection of the small intestine and colon. In our clinical experience nasogastric decompression can usually be discontinued 12-24 hours after resection of the small intestine and colon.There is no evidence that bowel rest and a period of starvation are beneficial for healing of wounds and anastomotic integrity. Indeed, the evidence is that luminal nutrition may enhance wound healing and increase anastomotic strength, particularly in malnourished patients. 2 3The findings of the meta-analysis, however, raise some important questions. Should early postoperative feeding be restricted to patients with pre-existing malnutrition; is its efficacy related to the degree of surgical injury; and is the main site of action of luminal nutrition the level of the intestinal barrier?Pre-existing malnutrition has been shown to be a major clinical problem in surgical patients.4 Although several factors—age, coexisting disease, type and extent of surgical procedure, blood loss, duration of procedure, skill of the surgeon, and the disease itself—have been shown to be associated with postoperative complications, nutritional depletion is an independent determinant of serious complications after major gastrointestinal surgery.5 Surgical injury itself increases resting energy expenditure and protein loss, and intake of energy and protein after gastrointestinal surgery fall well below what is required throughout the stay in hospital. 6 7 Understandably, the advocates of early postoperative enteral feeding have therefore often focused on its use in malnourished patients.Pre-existing nutritional depletion, however, may not be the only nutritional factor associated with postoperative complications after gastrointestinal surgery. Two recent studies on postoperative enteral feeding showed that nutritional support was associated with a significant reduction in postoperative complications, a reduction that was independent of preoperative nutritional status. 7 8The benefits of postoperative enteral feeding in normally nourished surgical patients indicate that it is reduced nutritional intake that predisposes patients to developing complications, including deficits in muscle function and surgical fatigue.7 There is thus no evidence that early postoperative enteral feeding should be restricted to malnourished patients undergoing gastrointestinal resection. Indeed, one study has found that supplementing “normal” oral diet in hospital wards with as little as 1250 kJ (300 kcal) and 12 g of protein per day resulted in a reduction of postoperative complications in patients undergoing gastrointestinal surgery.7 Therefore, there may be a threshold of nutritional intake which, if not achieved, may predispose some patients to postoperative complications.9As the authors have pointed out, the randomised trials they identified were heterogeneous as to underlying diagnosis and type of surgery. Ten of 11 studies reported the site of surgery. Importantly, in all but two studies most patients underwent lower gastrointestinal surgery. In the two studies in which patients underwent major upper gastrointestinal surgery, early postoperative enteral nutrition either afforded no advantages over standard care or seemed to have a deleterious effect. 10 11One explanation of these results might be that the surgical injury is less and the metabolic response to it relatively modest in patients undergoing lower gastrointestinal surgery, compared with patients undergoing major upper gastrointestinal surgery. Only in patients undergoing lower gastrointestinal surgery does enteral nutrition in the early postoperative period have an important impact.Recently, changes in intestinal permeability have been shown in patients undergoing gastrointestinal surgery, increased permeability being associated with sepsis and systemic inflammation.12 Bacterial translocation has also been shown in patients undergoing laparotomy, and a higher proportion of patients with bacterial translocation developed sepsis than those without.13 There is, however, no evidence in humans that increased intestinal permeability correlates with bacterial translocation or that early postoperative enteral nutrition influences intestinal permeability or reduces the incidence of bacterial translocation. The appealing hypothesis that early postoperative luminal nutrition might have a beneficial effect on the function of the intestinal barrier in respect of permeability, bacterial translocation, and the subsequent development of septic complications has no supporting evidence at present.What impact could the findings of this systematic review have on daily surgical practice? The review shows that there is no clinical benefit to starving patients in the early postoperative period after gastrointestinal resection. Further, the finding that postoperative infections can be reduced and hospital stay shortened by starting early postoperative enteral nutrition should challenge clinicians to consider this treatment. The findings pave the way for an appropriate multicentred trial to assess early enteral feeding in patients undergoing elective gastrointestinal resection. The patients recruited to such a trial should be stratified by nutritional status and type of surgical procedure. The outcome measures should include not just effects on wound infection, other infectious complications, and dehiscence of the anastomosis but also surgical fatigue, muscle function, quality of life after discharge from hospital, and cost effectiveness.FootnotesDBAS has been reimbursed by NUMICO to attend conferences and a recent symposium.References1.↵Lewis SJ, Egger M, Sylvester PA, Thomas S.Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials.BMJ2001;323:773–776.OpenUrlFREE Full Text2.↵Schroeder D, Gillanders L, Mahr K, Hill GL.Effects of immediate post operative enteral nutrition on body composition, muscle function and wound healing.J Parenter Enteral Nutr1991;15:376–383.OpenUrlFREE Full Text3.↵Haydock DA, Hill GA.Impaired wound healing in patients with varying degrees of malnutrition.J Parenter Enteral Nutr1986;10:550–554.OpenUrlFREE Full Text4.↵Hill GL, Pickford I, Young GA, Schorah CJ, Blackett RC, Burkinshaw L.Malnutrition in surgical patients: an unrecognised problem.Lancet1977;i:689–692.OpenUrl5.↵Payne-James J, Grimple G, Silk DHulsewe KW, Von Meyenfeldt MF, Soeters PB.Nutrition support for the surgical patient. In: Payne-James J, Grimple G, Silk D eds.Artificial nutritonal support in clinical practice.London: Greenwich Medical;605–16.6.↵Payne-James J, Grimple G, Silk DElia M.Metabolic response to starvation, injury, sepsis. In: Payne-James J, Grimple G, Silk D eds.Artificial nutritional support in clinical practice.London: Greenwich Medical;1–24.7.↵Keele AM, Bray MJ, Emery PW, Duncan HD, Silk DB.Two phase randomised controlled clinical trial of postoperative oral dietary supplements in surgical patients.Gut1997;40:393–399.OpenUrlFREE Full Text8.↵Beier-Holgersen R, Boesby S.Influence of post operative enteral nutrition on post surgical infections.Gut1996;39:833–835.OpenUrlFREE Full Text9.↵Silk DBA, Green CJ.Peri-operative nutrition: parenteral versus enteral.Curr Opin Clin Nutr Metab Care1998;i:21–27.OpenUrlCrossRef10.↵Heslin MJ, Latkany L, Leung D, Brooks AD, Hochwalk SN, Pisters PWT, et al.A prospective randomised trial of early enteral feeding after resection of upper GI malignancy.Ann Surg1997;226:567–580.OpenUrlCrossRefMedlineWeb of Science11.↵Watters JM, Kirkpatrick SM, Norris SB, Shamji FM, Wells GA.Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility.Ann Surg1997;226:367–380.OpenUrl12.↵Reynolds JV, Kanwar S, Welsh FKS, Windsor ACJ, Murchan P, Barclay GR, et al.Does the route of feeding modify gut barrier function and clinical outcome in patients after major upper gastrointestinal surgery.J Parent Ent Nutr1997;21:196–201.OpenUrlCrossRef13.↵O'Boyle CJ, MacFie J, Mitchell CJ, Johnson D, Sagar PM, Sedman PC.Microbiology of bacterial translocation in humans.Gut1998;42:29–35.OpenUrlFREE Full Text
    BMJ Clinical Research 11/2001; 323(7316):761-2. DOI:10.1136/bmj.323.7316.761 · 14.09 Impact Factor
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    ABSTRACT: Undernutrition is common in patients admitted for surgery and is often unrecognised, untreated and worsens in hospital. The complex synergistic relationship between nutritional status and the physiological responses to surgery puts patients at high nutritional risk. There are clear prospective associations between inadequate nutritional status and the risk of poorer outcomes for surgical patients, including infection, complications and length of stay. However, practically and ethically evidence that nutritional interventions can significantly reduce these poor outcomes is difficult to obtain. Nevertheless health professionals have a duty of care to ensure our patients are properly fed, by whatever means, to meet their physiological requirements.
    Australian Prescriber 01/2003; 26. · 0.38 Impact Factor
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