Feasibility and Safety of Early Oral Feeding After Radical Gastrectomy in Patients With Gastric Carcinoma: A Systematic Review.

This systematic review examines the feasibility and safety of early oral feeding (EOF) after radical gastrectomy in patients with gastric cancer. A comprehensive literature search identified eight eligible studies, including both clinical trials and cohort studies, conducted between 2011 and 2020. The review analyzed outcomes such as postoperative complications, length of hospital stay, time to first flatus/bowel movement, and changes in nutritional markers. The findings suggest that EOF is generally feasible and well-tolerated, with high adherence rates reported across studies. Most patients successfully initiated oral intake within 72 hours post-surgery without significant protocol deviations. Regarding safety, the studies reported comparable or lower rates of postoperative complications in EOF groups compared to traditional feeding protocols, though some noted non-significant increases in complications with EOF. Several studies observed potential benefits of EOF, including shorter hospital stays, earlier return of gastrointestinal function, and improved nutritional status. However, the results were mixed, with some studies finding no significant differences in these outcomes. While the review suggests EOF is a viable option for postoperative management after radical gastrectomy, it emphasizes the importance of patient-specific factors and close monitoring during implementation. The heterogeneity in study designs, EOF protocols, and outcome measures limits direct comparisons. Future large-scale randomized controlled trials are warranted to establish standardized EOF protocols and provide more robust evidence for this patient population.

The Outcome of Early Oral Feeding Following Elective Gastrointestinal Surgery.

Background Early oral feeding (EOF) after gastrointestinal (GI) surgery is an optimistic way to speed up recovery and shorten hospital stays, but its full effects remain unexplored. Aim This study aims to evaluate the outcomes of EOF in patients having elective gastrointestinal surgery. Methods This open-level, prospective randomized controlled trial was conducted in the Department of Surgery at Sir Salimullah Medical College Mitford Hospital, Dhaka, from March 2022 to February 2023. A total of 50 patients were enrolled and divided into two groups: early oral feeding (EOF) and traditional postoperative oral feeding (TOF), both before and after 48 hours of surgery, using a systematic random sampling technique. Informed written consent was taken from the patients. The patients were monitored on days 1, 3, 5, 7, 14, and 28 following surgeries. Postoperative complications, the duration for nasogastric tube (NGT) removal (days), the early recovery of bowel motility, and the length of the hospital stay (days) were noted. Results In this study, both EOF and TOF groups were found indifferent in terms of age distribution, gender ratio, or body mass index (BMI). However, significant differences emerged in postoperative outcomes. The TOF group experienced a significantly longer duration for nasogastric tube (NGT) removal and the initiation of oral feeding compared to the EOF group (P-value < 0.001). Complication rates, including nausea, vomiting, ileus, anastomotic leakage, wound infection, and pneumonia, did not exhibit statistically significant differences between the groups (P-value > 0.05). Moreover, the EOF group demonstrated an early recovery of bowel motility after surgery and shorter hospital stays compared to the TOF group (P-value < 0.05). Conclusion Starting oral feeding earlier does not increase complications. However, it does speed up recovery and shorten hospital stays.

Perioperative liberal drinking management promotes postoperative gastrointestinal function recovery after gynecological laparoscopic surgery: A randomized controlled trial.

STUDY OBJECTIVE: This study aims to evaluate the effect of perioperative liberal drinking management, including preoperative carbohydrate loading (PCL) given 2 h before surgery and early oral feeding (EOF) at 6 h postoperatively, in enhancing postoperative gastrointestinal function and improving outcomes in gynecologic patients. The hypotheses are that the perioperative liberal drinking management accelerates the recovery of gastrointestinal function, enhances dietary tolerance throughout hospitalization, and ultimately reduces the length of hospitalization. DESIGN: A prospective randomized controlled trial. SETTING: Operating room and gynecological ward in Wuhan Union Hospital. PATIENTS: We enrolled 210 patients undergoing elective gynecological laparoscopic surgery, and 157 patients were included in the final analysis. INTERVENTIONS: Patients were randomly allocated in a 1:1:1 ratio into three groups, including the control, PCL, and PCL-EOF groups. The anesthetists and follow-up staff were blinded to group assignment. MEASUREMENTS: The primary outcome was the postoperative Intake, Feeling nauseated, Emesis, Examination, and Duration of symptoms (I-FEED) score (range 0 to 14, higher scores worse). Secondary outcomes included the incidence of I-FEED scores >2, and other additional indicators to monitor postoperative gastrointestinal function, including time to first flatus, time to first defecation, time to feces Bristol grade 3-4, and time to tolerate diet. Additionally, we collected other ERAS recovery indicators, including the incidence of PONV, complications, postoperative pain score, satisfaction score, and the quality of postoperative functional recovery at discharge. MAIN RESULTS: The PCL-EOF exhibited significantly enhanced gastrointestinal function recovery compared to control group and PCL group (p < 0.05), with the lower I-FEED score (PCL: 0[0,1] vs. PCL-EOF: 0[0,0] vs. control: 1[0,2]) and the reduced incidence of I-FEED >2 (PCL:8% vs. PCL-EOF: 2% vs. control:21%). Compared to the control, the intervention of PCL-EOF protected patients from the incidence of I-FEED score > 2 [HR:0.09, 95%CI (0.01-0.72), p = 0.023], and was beneficial in promoting the patient's postoperative first flatus [PCL-EOF: HR:3.33, 95%CI (2.14-5.19),p < 0.001], first defecation [PCL-EOF: HR:2.76, 95%CI (1.83-4.16), p < 0.001], Bristol feces grade 3-4 [PCL-EOF: HR:3.65, 95%CI (2.36-5.63), p < 0.001], first fluid diet[PCL-EOF: HR:2.76, 95%CI (1.83-4.16), p < 0.001], and first normal diet[PCL-EOF: HR:6.63, 95%CI (4.18-10.50), p < 0.001]. Also, the length of postoperative hospital stay (PCL-EOF: 5d vs. PCL: 6d and control: 6d, p < 0.001), the total cost (PCL-EOF: 25052 ± 3650y vs. PCL: 27914 ± 4684y and control: 26799 ± 4775y, p = 0.005), and postoperative VAS pain score values [POD0 (PCL-EOF: 2 vs. control: 4 vs. PCL: 4, p < 0.001), POD1 (PCL-EOF: 1 vs. control: 3 vs. PCL: 2, p < 0.001), POD2 (PCL-EOF: 1 vs. control:2 vs. PCL: 1, p < 0.001), POD3 (PCL-EOF: 0 vs. control: 1 vs. PCL: 1, p < 0.001)] were significantly reduced in PCL-EOF group. CONCLUSIONS: Our primary endpoint, I-FEED score demonstrated significant reduction with perioperative liberal drinking, serving as a protective intervention against I-FEED>2. Gastrointestinal recovery metrics, such as time to first flatus and defecation, also showed substantial improvements. Furthermore, the intervention enhanced postoperative dietary tolerance and expedited early recovery. TRIAL REGISTRATION: ChiCTR2300071047(https://www.chictr.org.cn/).

Optimal time to initiate early oral feeding in postoperative patients with upper gastrointestinal malignancy: A network meta-analysis.

BACKGROUND: With the development of enhanced recovery after surgery, early oral feeding is likely to become the preferred mode of nutrition after surgery for upper gastrointestinal tract malignancies. However, the optimal time to initiate early oral feeding remains unknown. OBJECTIVE: We aimed to compare the effects of different introduction times of early oral feeding in patients with upper gastrointestinal malignancies in terms of safety, tolerance, and effectiveness and to identify the optimal time for early oral feeding after surgery. METHODS: A random-effects meta-analysis was performed to identify evidence from relevant randomized controlled trials. Ten electronic databases were searched for randomized controlled trials from their earliest records to May 2023. Data were analyzed using the Stata 16.0 software. RESULTS: A total of 22 randomized controlled trials including 2510 patients and seven time points for oral feeding after surgery were considered. Regarding safety, oral feeding initiated on postoperative day 3 may be the safest (high-quality evidence) compared with other times. Regarding tolerance, oral feeding initiated on postoperative day 5 may be the most well-tolerated (moderate-quality evidence) compared with other times. Regarding effectiveness, oral feeding initiated on postoperative day 3 may be the most effective (moderate-quality evidence) compared with other times. CONCLUSIONS: Early oral feeding is safe, tolerable, and effective in postoperative patients with upper gastrointestinal malignancies. The optimal time to initiate early oral feeding after surgery was most likely postoperative day 3. The results of this meta-analysis provide evidence-based guidelines for clinical decision-making.

Long-Term Survival Associated with Direct Oral Feeding Following Minimally Invasive Esophagectomy: Results from a Randomized Controlled Trial (NUTRIENT II).

Advancements in perioperative care have improved postoperative morbidity and recovery after esophagectomy. The direct start of oral intake can also enhance short-term outcomes following minimally invasive Ivor Lewis esophagectomy (MIE-IL). Subsequently, short-term outcomes may affect long-term survival. This planned sub-study of the NUTRIENT II trial, a multicenter randomized controlled trial, investigated the long-term survival of direct versus delayed oral feeding following MIE-IL. The outcomes included 3- and 5-year overall survival (OS) and disease-free survival (DFS), and the influence of complications and caloric intake on OS. After excluding cases of 90-day mortality, 145 participants were analyzed. Of these, 63 patients (43.4%) received direct oral feeding. At 3 years, OS was significantly better in the direct oral feeding group (p = 0.027), but not at 5 years (p = 0.115). Moreover, 5-year DFS was significantly better in the direct oral feeding group (p = 0.047) and a trend towards improved DFS was shown at 3 years (p = 0.079). Postoperative complications and caloric intake on day 5 did not impact OS. The results of this study show a tendency of improved 3-year OS and 5-year DFS, suggesting a potential long-term survival benefit in patients receiving direct oral feeding after esophagectomy. However, the findings should be further explored in larger future trials.

Early oral feeding following intestinal anastomosis surgery in infants: a multicenter real world study.

Background: To prevent postoperative complications, delayed oral feeding (DOF) remains a common model of care following pediatric intestinal anastomosis surgery; however, early oral feeding (EOF) has been shown to be safe and effective in reducing the incidence of complications and fast recovery after pediatric surgery. Unfortunately, the evidence in support of EOF after intestinal anastomosis (IA) in infants is insufficient. Therefore, this study was primarily designed to evaluate the safety and efficacy of EOF. In addition, the current status of EOF application and associated factors that favor or deter EOF implementation were also assessed. Methods: A total of 898 infants were divided into two groups (EOF group, n = 182; DOF group, n = 716), and the clinical characteristics were collected to identify the factors associated with EOF in infants. Complications and recovery were also compared to define the safety and efficacy after balancing the baseline data by propensity score matching (PSM) (EOF group, n = 179; DOF group, n = 319). Results: The total EOF rate in infants with IA was 20.3%. Multivariate logistic regression revealed significant differences in the EOF rates based on IA site and weight at the time of surgery (OR = 0.652, 95% CI: 0.542-0.784, p < 0.001) and (OR = 1.188, 95% CI: 1.036-1.362, p = 0.013), respectively. The duration of total parenteral nutrition (TPN), parenteral nutrition (PN), and postoperative hospital stay were significantly shorter in the EOF group than the DOF group [2.0 (1.0, 2.0) d vs. 5.0 (3.0, 6.0) d; 6.0 (5.0, 8.0) d vs. 8.0 (6.0, 11.0) d; 10.0 (7.0, 14.0) d vs. 12.0 (9.0, 15.0) d, all p < 0.001]. The rates of abdominal distension and vomiting in the EOF group were significantly higher than the DOF group (17.9% vs. 7.2%, p < 0.001; 7.8% vs. 2.5%, p = 0.006); however, no differences were found in failure to initial OF, diarrhea, hematochezia, and anastomotic leakage between the two groups (p > 0.05). Conclusion: The overall rate of EOF in infants following IA was low, and the sites of anastomosis and weight at surgery were two factors associated with EOF. Nevertheless, performing EOF in infants after IA was safe and effective, reduced PN usage, shortened the hospital stay, and did not increase the rate of severe complications.Clinical Trial Registration: ClinicalTrails.gov, identifier NCT04464057.

The feasibility of a "no tube, no fasting" fast-track recovery protocol after esophagectomy for esophageal cancer patients aged 75 and over.

Objective: For elderly patients aged ≥75 with esophageal cancer, whether surgical treatment is safe and effective and whether it is feasible to use a relatively radical "no tube, no fasting" fast-track recovery protocol remain topics of debate. We conducted a retrospective analysis to shed light on these two questions. Methods: We retrospectively collected the data of patients who underwent McKeown minimally invasive esophagectomy (MIE) combined with early oral feeding (EOF) on postoperative day 1 between April 2015 and December 2017 at Medical Group 1, Ward 1, Department of Thoracic Surgery of our hospital. Preoperative characteristics, postoperative complications, operation time, intraoperative blood loss, duration of anastomotic leakage (day), hospital stay, and survival were evaluated. Results: Twenty-three elderly patients with esophageal cancer underwent surgery with EOF. No significant difference was observed in intraoperative measures. The incidence of postoperative complications was 34.8% (8/23). Two patients (8.7%) were terminated early during the analysis of the feasibility of EOF. For all 23 patients, the mean hospital stay was 11.4 (5-42) days, and the median survival was 51 months. Conclusion: Patients aged ≥75 with resectable esophageal cancer can achieve long-term survival with active surgical treatment. Moreover, the "no tube, no fasting" fast-track recovery protocol is safe and feasible for elderly patients.

Faster recovery and bowel movement after early oral feeding compared to late oral feeding after upper GI tumor resections: a meta-analysis.

Background: There were more than 1 million new cases of stomach cancer concerning oesophageal cancer, there were more than 600,000 new cases of oesophageal cancer in 2020. After a successful resection in these cases, the role of early oral feeding (EOF) was questionable, due to the possibility of fatal anastomosis leakage. It is still debated whether EOF is more advantageous compared to late oral feeding. Our study aimed to compare the effect of early postoperative oral feeding and late oral feeding after upper gastrointestinal resections due to malignancy. Methods: Two authors performed an extensive search and selection of articles independently to identify randomized control trials (RCT) of the question of interest. Statistical analyses were performed including mean difference, odds ratio with 95% confidence intervals, statistical heterogeneity, and statistical publication bias, to identify potential significant differences. The Risk of Bias and the quality of evidence were estimated. Results: We identified 6 relevant RCTs, which included 703 patients. The appearance of the first gas (MD = -1.16; p = 0.009), first defecation (MD = -0.91; p < 0.001), and the length of hospitalization (MD = -1.92; p = 0.008) favored the EOF group. Numerous binary outcomes were defined, but significant difference was not verified in the case of anastomosis insufficiency (p = 0.98), pneumonia (p = 0.88), wound infection (p = 0.48), bleeding (p = 0.52), rehospitalization (p = 0.23), rehospitalization to the intensive care unit (ICU) (p = 0.46), gastrointestinal paresis (p = 0.66), ascites (p = 0.45). Conclusion: Early postoperative oral feeding, compared to late oral feeding has no risk of several possible postoperative morbidities after upper GI surgeries, but has several advantageous effects on a patient's recovery. Systematic Review Registration: identifier, CRD 42022302594.

Study protocol for feasibility and safety of adopting early oral feeding in post total laparoscopic total gastrectomy (overlap esophagojejunostomy): A multicentre randomized controlled trial.

Background: Total laparoscopic total gastrectomy (TLTG) for gastric cancer, especially with overlap esophagojejunostomy, has been verified that it has advantages of minimally invasion, less intraoperative bleeding, and faster recovery. Meanwhile, early oral feeding (EOF) after the operation has been demonstrated to significantly promote early rehabilitation in patients, particularly with distal gastrectomy. However, due to the limited application of TLTG, there is few related research proving whether it is credible or safe to adopt EOF after TLTG (overlap esophagojejunostomy). So, it is urgent to start a prospective, multicenter, randomized clinical trials to supply high level evidence. Methods/design: This study is a prospective, multicenter, randomized controlled trial with 200 patients (100 in each group). These eligible participants are randomly allocated into two different groups, including EOF group and delay oral feeding (DOF) group after TLTG (overlap esophagojejunostomy). Anastomotic leakage will be carefully observed and recorded as the primary endpoints; the period of the first defecation and exhaust, postoperative length of stay and hospitalization expenses will be recorded as secondary endpoints to ascertain the feasibility and safety of adopting EOF after TLTG (overlap esophagojejunostomy). Discussion: Recently, the adoption of TLTG was limited due to its difficult anastomotic procedure, especially in vivo esophagojejunostomy. With the innovation and improvement of operating techniques, overlap esophagojejunostomy with linear staplers simplified the anastomotic steps and reduced operational difficulties after TLTG. Meanwhile, EOF had received increasing attention from surgical clinicians as a nutrition part of enhanced recovery after surgery (ERAS), which had shown better results in patients after distal gastrectomy. Considering the above factors, we implemented EOF protocol to evaluate the feasibility and safety of adopting EOF after TLTG (overlap esophagojejunostomy), which provided additional evidence for the development of clinical nutrition guidelines. Clinical trial registration: [www.chictr.org.cn], identifier [ChiECRCT20200440 and ChiCTR2000040692].

Early versus delay oral feeding for patients after upper gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: To evaluate the efficacy and safety of early oral feeding (EOF) in patients after upper gastrointestinal surgery through meta-analysis of randomized controlled trials (RCTs). METHODS: We analyzed the endpoints of patients including the length of stay (LOS), time of first exhaust, anastomotic leakage and pneumonia from included studies. And we retrieved RCTs from medical literature databases. Weighted mean difference (WMD), risk ratios (RR) and 95% confidence intervals (CI) were calculated to compare the endpoints. RESULTS: In total, we retrieved 12 articles (13 trial comparisons) which contained 1771 patients. 887 patients (50.1%) were randomized to EOF group whereas 884 patients (49.9%) were randomized to delay oral feeding group. The result showed that compared with the delay oral feeding group, EOF after upper gastrointestinal surgery significantly shorten the LOS [WMD = - 1.30, 95% CI - 1.79 to - 0.80, I2 = 0.0%] and time of first exhaust [WMD = - 0.39, 95% CI - 0.58 to - 0.20, I2 = 62.1%]. EOF also reduced the risk of pneumonia (RR: 0.74, 95% CI 0.55 to 0.99, I2 = 0.0%). There is no significant difference in the risk of anastomotic leak, anastomotic bleeding, abdominal abscess, reoperation, readmission and mortality. CONCLUSIONS: Overall, compared with the traditional oral feeding, EOF could shorten the LOS and time of first exhaust without increasing complications after upper gastrointestinal surgery.

Impact of Early Oral Feeding on Nasogastric Tube Reinsertion After Elective Colorectal Surgery: A Systematic Review and Meta-Analysis.

Background: Colorectal cancer is a common malignant tumor appearing in the gastrointestinal tract. Surgical resection is recognized as the best means to improve patient survival. However, it is controversial whether early oral feeding (EOF) after elective colorectal resection demonstrates safety and efficacy in concerned clinical outcomes. Methods: We searched PubMed, Embase, Cochrane Library, and CNKI from inception to September 2021. Two authors independently screened the retrieved records and extracted data. EOF was defined as feeding within 24 h after surgery, while traditional oral feeding (TOF) was defined as feeding that started after the gastrointestinal flatus or ileus was resolved. The primary outcome was nasogastric tube insertion, and the secondary outcomes were the length of hospital stay and total complications. Categorical data were combined using odds ratio (OR), and continuous data were combined using mean difference (MD). Results: We screened 10 studies from 34 records after full-text reading, with 1,199 patients included in the analysis. Nasogastric tube reinsertion (OR 1.69; 95% CI 1.08 to 2.64, p=0.02) was more frequent in the EOF group, and older ages (>60 years) were associated with higher risk of nasogastric tube reinsertion (OR 2.05; 95% CI 1.05 to 3.99, p = 0.04). Reduced length of hospital stay (MD -1.76; 95% CI -2.32 to -1.21; p < 0.01) and the rate of total complications (OR 0.49; 95% CI 0.37 to 0.65, p < 0.01) were observed in EOF compared with TOF. Conclusions: EOF was safe and effective for patients undergoing elective colorectal surgery, but the higher rate of nasogastric tube reinsertion compared with TOF should not be ignored.

Management of oral feeding following total laryngectomy around the world: YO-IFOS international study.

BACKGROUND: To analyze worldwide practices regarding the initiation of oral feeding after total laryngectomy (TL). METHODS: Online survey. RESULTS: Among the 332 responses received, 278 from 59 countries were analyzed. Our results showed that 45.6% of respondents started water and 45.1% started liquid diet between postoperative days 7 and 10. Semi-solid feeds were initiated between days 10 and 14 for 44.9% of respondents and a free diet was allowed after day 15 for 60.8% of respondents. This timing was significantly delayed in cases of laryngo-pharyngectomy and after prior radiotherapy (p < 0.001). A greater proportion of respondents in Africa and Oceania allowed early oral feeding before day 6 as compared with the rest of the world (p < 0.001). CONCLUSION: Despite increasing number of publications, there is still a lack of evidence to support early oral feeding. The majority of respondents preferred to delay its initiation until at least 7 days after surgery.

Nutritional assessment in esophageal fast-track surgery: comparisons of 4 objective malnutrition screening tools.

BACKGROUND: This cohort study aimed to compare the performance of the 2015 diagnostic criteria for malnutrition of the European Society of Clinical Nutrition and Metabolism (ESPEN), the Nutritional Risk Screening 2002 (NRS 2002), Malnutrition Universal Screening Tool (MUST), and Short-Form of Mini-Nutritional Assessment (MNA-SF) in detecting malnutrition risk and predicting postoperative complications and the failure of early oral feeding (EOF) programs in esophageal cancer patients. METHODS: The 4 tools were used to conduct malnutrition assessments before surgery. The patients were divided into the groups of severe malnutrition and mild/moderate malnutrition and the incidences of the endpoints were observed. Multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were conducted. RESULTS: Two hundred and nineteen consecutive esophageal cancer patients were included in the study. The prevalence rates of severe malnutrition as determined by the ESPEN 2015 criteria, MUST, NRS 2002, and MNA-SF were 24.7%, 29.7%, 23.7%, and 16.0%, respectively. The moderate/severe malnutrition risk screened by the MUST had a high sensitivity (100.0%) with malnutrition identified by the ESPEN 2015 criteria. In total, 42 (19.2%) patients experienced major complications, and the incidence rate of EOF failure was 7.3%. The severe malnutrition identified by the ESPEN 2015 criteria, MUST, and NRS 2002 were comparable in predicting the incidence of postoperative pulmonary complications, anastomotic leakage, readmission to intensive care units (ICUs), and EOF failure, but the ESPEN 2015 criteria was better in predicting postoperative overall complications, major complications, and delayed hospital discharge. CONCLUSIONS: The ESPEN 2015 criteria specializes in identifying severe malnutrition and is better in predicting adverse surgical outcomes; however, the MUST and NRS 2002 are better superior in detecting early malnutrition and are also valuable in the perioperative management in esophageal surgery. It is recommended that the MUST be used as the malnutrition screening tool before the ESPEN 2015 criteria is applied.

Early versus delayed oral feeding after gastrectomy for gastric cancer: A systematic review and meta-analysis.

BACKGROUND: Early oral feeding has been shown to be safe and effective for most surgeries, while surgeons and nurses are still hesitant to implement it in gastric cancer patients who undergo gastrectomy. OBJECTIVES: This review aimed to investigate the safety and feasibility of early versus delayed oral feeding in gastric cancer patients after gastrectomy. DESIGN: A systematic review and meta-analysis of randomized controlled trials. DATA SOURCES: The literature search was performed in 7 databases from inception to March 7, 2021. REVIEW METHODS: Randomized controlled trials that compared the effects of early oral feeding and delayed oral feeding in gastric cancer patients who undergo gastrectomy were included. The primary outcome was hospital days, and secondary outcomes included hospital costs, postoperative complication rates, feeding intolerance rates, annal exhaust time, albumin levels and prealbumin levels. According to the presence of heterogeneity, fixed or random effect meta-analysis was applied. RESULTS: Nine trials involving 1087 gastric cancer patients who undergo gastrectomy were pooled in this systemic review and meta-analysis. The results showed that early oral feeding significantly decreased hospital days (mean difference = -1.50, 95% confidence interval = -1.91 to -1.10, P < 0.001) and hospital costs (mean difference = -4.21, 95% confidence interval = -5.00 to -3.42, P < 0.001) compared to delayed oral feeding, while the incidences of postoperative complications (risk ratio = 0.96, 95% confidence interval = 0.72 to 1.26, P = 0.76) and feeding intolerance (risk ratio = 0.95, 95% confidence interval = 0.79 to 1.15, P = 0.62) were comparable between the two groups. In comparison to delayed oral feeding, early oral feeding was associated with shorter annal exhaust time (mean difference = -0.61, 95% confidence interval = -0.81 to -0.40, P < 0.001) and higher levels of albumin (mean difference = 3.77, 95% confidence interval = 2.42 to 5.12, P < 0.001) and prealbumin (mean difference = 18.11, 95% confidence interval = 15.33 to 20.88, P < 0.001). Furthermore, the results of distal gastrectomy subgroup analysis indicated that hospital days were shorter in the early oral feeding group than in the delayed oral feeding group. CONCLUSIONS: For gastric cancer patients who undergo gastrectomy, early oral feeding was associated with shorter hospital days and lower hospital costs, but early oral feeding did not increase the incidences of postoperative complications or feeding intolerance. Moreover, early oral feeding also decreased the annal exhaust time but increased the levels of albumin and prealbumin.

Effects of preoperative oral carbohydrate administration combined with postoperative early oral intake in elderly patients undergoing hepatectomy with acute-phase inflammation and subjective symptom burden: A prospective randomized controlled study.

BACKGROUND: Enhanced recovery after surgery (ERAS) has received increasing attention. Preoperative oral carbohydrate and postoperative early oral feeding (POC-PEOF) as the basic nutrition administration in the ERAS program suffers from low adherence. The role and benefits of administering POC-PEOF in elderly patients with hepatocellular carcinoma (HCC) are unclear. Therefore, the randomized controlled trial evaluated the effects of POC-PEOF in elderly patients with HCC undergoing hepatectomy with inflammation and patient self-reported symptom burden compared with the corresponding outcomes of traditional fasting protocols. METHODS: Elderly patients with HCC (n = 126) were randomly assigned to two groups using the sealed envelope technique. Sixty-three patients were included in the intervention (POC-PEOF) group and received POC-PEOF administration, whereas the 63 patients in the control (FAST) group underwent conventional fasting. Acute-phase inflammation markers, patient self-reported symptom burdens, and postoperative outcomes were compared between the two groups. RESULTS: The average age was 69.60 ± 5.00 years in the POC-PEOF group and 70.44 ± 6.15 years in the FAST group. Compared to prolonged fasting, POC-PEOF achieved significant positive results, including lower overall levels of inflammatory response mediators (CRP, IL-6) on postoperative day (POD) 1, POD 3, and POD 5 (P < 0.05), lower patient self-reported symptom burdens of thirst, hunger, anxiety and nausea (P < 0.05), faster gastrointestinal function return with shortened times to first flatus and first defecation (48.31 ± 13.24 h vs. 96.26 ± 23.12 h and 72.87 ± 21.12 h vs. 144.34 ± 23.31 h, and P = 0.034 and P = 0.013, respectively). Furthermore, the average postoperative hospitalization duration in the POC-PEOF group was shorter than that in the FAST group (6.93 ± 0.98 d vs. 8.12 ± 1.15 d, P = 0.042). There was no significant difference of total complications between the groups (25.39 % vs 36.51 %, RR 0.696, 95 % CI 0.408-0.187, P = 0.177). CONCLUSION: POC-PEOF helps lessen acute-phase inflammation and relieves the subjective symptom burden, which can ensure better positive postoperative outcomes in elderly HCC patients undergoing hepatectomy.

Efficacy and safety of early oral feeding in postoperative patients with upper gastrointestinal tumor: A systematic review and meta-analysis.

BACKGROUND: Early oral feeding (EOF) is an important measure for early recovery of patients with gastrointestinal tumors after surgery, which has emerged as a safe and effective postoperative strategy for improving clinical outcomes. AIM: To determine the safety and efficacy of early oral feeding in postoperative patients with upper gastrointestinal tumor. METHODS: This meta-analysis was analyzed using Review Manager version 5.3 and Stata version 14. All clinical studies that analyzed efficacy and safety of EOF for postoperative patients with upper gastrointestinal tumor were included. RESULTS: Fifteen studies comprising 2100 adult patients met all the inclusion criteria. A significantly lower risk of pneumonia was presented in the EOF compared with TOF group [relative risk (RR) = 0.63, 95% confidence interval (CI): 0.44-0.89, P = 0.01]. Length of hospital stay was significantly shorter in the EOF group than in the TOF group [weighted mean difference (WMD) = -1.91, 95%CI: -2.42 to -1.40; P < 0.01]. Cost of hospitalization was significantly lower (WMD = -4.16, 95%CI: -5.72 to -2.61; P < 0.01), and CD4 cell count and CD4/CD8 cell ratio on postoperative day 7 were significantly higher in the EOF group than in the TOF group: CD4 count (WMD = 7.17, 95%CI: 6.48-7.85; P < 0.01), CD4/CD8 ratio (WMD = 0.29, 95%CI: 0.23-0.35; P < 0.01). There was no significant difference in risk of anastomotic leak and total postoperative complications. CONCLUSION: EOF as compared with TOF was associated with lower risk of pneumonia, shorter hospital length of stay, lower cost of hospitalization, and significantly improved postoperative immune function of patients.

Early Nasojejunal Nutrition Versus Early Oral Feeding in Patients After Pancreaticoduodenectomy: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to test the hypothesis that early oral feeding (EOF) is superior to early nasojejunal nutrition (ENN) after pylorus-preserving pancreaticoduodenectomy (PPPD) in terms of delayed gastric emptying (DGE). BACKGROUND: DGE is a common complication after PPPD. Although EOF after PPPD is recommended by several international guidelines, there is no randomized trial to support this recommendation. METHODS: From September 2016 to December 2017, a total of 120 patients undergoing PPPD were randomized into the ENN, EOF, or saline groups at a 1:1:1 ratio (40 patients in each group). The primary endpoint was the rate of clinically relevant DGE. Secondary endpoints included overall morbidity, postoperative pancreatic fistula, post-pancreatectomy hemorrhage, abdominal infection, length of hospital stay, reoperation rate, and in-hospital mortality. RESULTS: The baseline characteristics and operative parameters were comparable between the groups. The incidence of clinically relevant DGE varied significantly among the three groups (ENN, 17.5%; EOF, 10.0%; saline, 32.5%; p =0.038). The saline group had a higher clinically relevant DGE rate than the EOF group (p = 0.014). The saline group also had greater overall morbidities than the ENN and EOF groups (p = 0.041 and p = 0.006, respectively). There were no significant differences in other surgical complication rates or postoperative hospital stay. No mortality was observed in any of the groups. CONCLUSIONS: Nutritional support methods were not related to DGE after PPPD. EOF was feasible and safe after PPPD, and additional ENN should not be routinely administered to patients after PPPD. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT03150615.

Assessment of an integrated knowledge translation intervention to improve nutrition intakes among patients undergoing elective bowel surgery: a mixed-method process evaluation.

BACKGROUND: A large evidence-practice gap exists regarding provision of nutrition to patients following surgery. The aim of this study was to evaluate the processes supporting the implementation of an intervention designed to improve the timing and adequacy of nutrition following bowel surgery. METHODS: A mixed-method pilot study, using an integrated knowledge translation (iKT) approach, was undertaken at a tertiary teaching hospital in Australia. A tailored, multifaceted intervention including ten strategies targeted at staff or patients were co-developed with knowledge users at the hospital and implemented in practice. Process evaluation outcomes included reach, intervention delivery and staffs' responses to the intervention. Quantitative data, including patient demographics and surgical characteristics, intervention reach, and intervention delivery were collected via chart review and direct observation. Qualitative data (responses to the intervention) were sequentially collected from staff during one-on-one, semi-structured interviews. Quantitative data were summarized using median (IQR), mean (SD) or frequency(%), while qualitative data were analysed using content analysis. RESULTS: The intervention reached 34 patients. Eighty-four percent of nursing staff received an awareness and education session, while 0% of medical staff received a formal orientation or awareness and education session, despite the original intention to deliver these sessions. Several strategies targeted at patients had high fidelity, including delivery of nutrition education (92%); and prescription of oral nutrition supplements (100%) and free fluids immediately post-surgery (79%). Prescription of a high energy high protein diet on postoperative day one (0%) and oral nutrition supplements on postoperative day zero (62%); and delivery of preoperative nutrition handout (74%) and meal ordering education (50%) were not as well implemented. Interview data indicated that staff regard nutrition-related messages as important, however, their acceptance, awareness and perceptions of the intervention were mixed. CONCLUSIONS: Approximately half the patient-related strategies were implemented well, which is likely attributed to the medical and nursing staff involved in intervention design championing these strategies. However, some strategies had low delivery, which was likely due to the varied awareness and acceptance of the intervention among staff on the ward. These findings suggest the importance of having buy-in from all staff when using an iKT approach to design and implement interventions.