Early versus delayed oral feeding after major gynaecologic surgery.
This is an updated and expanded version of the original Cochrane review, first published in 2014. Postoperative oral intake is traditionally withheld after major abdominal gynaecologic surgery until the return of bowel function. The concern is that early oral intake will result in vomiting and severe paralytic ileus, with subsequent aspiration pneumonia, wound dehiscence, and anastomotic leakage. However, clinical studies suggest that there may be benefits from early postoperative oral intake. Currently, gynaecologic surgery can be performed through various routes: open abdominal, vaginal, laparoscopic, robotic, or a combination. In this version, we included women undergoing major gynaecologic surgery through all of these routes, either alone or in combination.
To assess the effects of early versus delayed (traditional) initiation of oral intake of food and fluids after major gynaecologic surgery.
On 13 June 2023, we searched the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, the citation lists of relevant publications, and two trial registries. We also contacted experts in the field for any additional studies.
We included randomised controlled trials (RCTs) that compared the effect of early versus delayed initiation of oral intake of food and fluids after major gynaecologic surgery, performed by abdominal, vaginal, laparoscopic, and robotic approaches. Early feeding was defined as oral intake of fluids or food within 24 hours post-surgery, regardless of the return of bowel function. Delayed feeding was defined as oral intake after 24 hours post-surgery, and only after signs of postoperative ileus resolution. Primary outcomes were: postoperative ileus, nausea, vomiting, cramping, abdominal pain, bloating, abdominal distension, need for postoperative nasogastric tube, time to the presence of bowel sounds, time to the first passage of flatus, time to the first passage of stool, time to the start of a regular diet, and length of postoperative hospital stay. Secondary outcomes were: infectious complications, wound complications, deep venous thrombosis, urinary tract infection, pneumonia, satisfaction, and quality of life.
Two review authors independently selected studies, assessed the risk of bias, and extracted the data. We calculated the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous data. We examined continuous data using the mean difference (MD) and a 95% CI. We tested for heterogeneity between the results of different studies using a forest plot of the meta-analysis, the statistical tests of homogeneity of 2 x 2 tables, and the I² value. We assessed the certainty of the evidence using GRADE methods.
We included seven randomised controlled trials (RCTs), randomising 902 women. We are uncertain whether early feeding compared to delayed feeding has an effect on postoperative ileus (RR 0.49, 95% CI 0.21 to 1.16; I² = 0%; 4 studies, 418 women; low-certainty evidence). We are uncertain whether early feeding affects nausea or vomiting, or both (RR 0.94, 95% CI 0.66 to 1.33; I² = 67%; random-effects model; 6 studies, 742 women; very low-certainty evidence); nausea (RR 1.24, 95% CI 0.51 to 3.03; I² = 74%; 3 studies, 453 women; low-certainty evidence); vomiting (RR 0.83, 95% CI 0.52 to 1.32; I² = 0%; 4 studies, 559 women; low-certainty evidence), abdominal distension (RR 0.99, 95% CI 0.75 to 1.31; I² = 0%; 4 studies, 559 women; low-certainty evidence); need for postoperative nasogastric tube placement (RR 0.46, 95% CI 0.14 to 1.55; 3 studies, 453 women; low-certainty evidence); or time to the presence of bowel sounds (MD -0.20 days, 95% CI -0.46 to 0.06; I² = 71%; random-effects model; 3 studies, 477 women; low-certainty evidence). There is probably no difference between the two feeding protocols for the onset of flatus (MD -0.11 days, 95% CI -0.23 to 0.02; I² = 9%; 5 studies, 702 women; moderate-certainty evidence). Early feeding probably results in a slight reduction in the time to the first passage of stool (MD -0.18 days, 95% CI -0.33 to -0.04; I² = 0%; 4 studies, 507 women; moderate-certainty evidence), and may lead to a slightly sooner resumption of a solid diet (MD -1.10 days, 95% CI -1.79 to -0.41; I² = 97%; random-effects model; 3 studies, 420 women; low-certainty evidence). Hospital stay may be slightly shorter in the early feeding group (MD -0.66 days, 95% CI -1.17 to -0.15; I² = 77%; random-effects model; 5 studies, 603 women; low-certainty evidence). The effect of the two feeding protocols on febrile morbidity is uncertain (RR 0.96, 95% CI 0.75 to 1.22; I² = 47%; 3 studies, 453 women; low-certainty evidence). However, infectious complications are probably less common in women with early feeding (RR 0.20, 95% CI 0.05 to 0.73; I² = 0%; 2 studies, 183 women; moderate-certainty evidence). There may be no difference between the two feeding protocols for wound complications (RR 0.82, 95% CI 0.50 to 1.35; I² = 0%; 4 studies, 474 women; low-certainty evidence), or pneumonia (RR 0.35, 95% CI 0.07 to 1.73; I² = 0%; 3 studies, 434 women; low-certainty evidence). Two studies measured participant satisfaction and quality of life. One study found satisfaction was probably higher in the early feeding group, while the other study found no difference. Neither study found a significant difference between the groups for quality of life (P > 0.05).
Despite some uncertainty, there is no evidence to indicate harmful effects of early feeding following major gynaecologic surgery, measured as postoperative ileus, nausea, vomiting, or abdominal distension. The potential benefits of early feeding include a slightly faster initiation of bowel movements, a slightly sooner resumption of a solid diet, a slightly shorter hospital stay, a lower rate of infectious complications, and a higher level of satisfaction.
Charoenkwan K
，Nantasupha C
，Muangmool T
，Matovinovic E
... -
《Cochrane Database of Systematic Reviews》
Preoperative nutrition therapy in people undergoing gastrointestinal surgery.
Poor preoperative nutritional status has been consistently linked to an increase in postoperative complications and worse surgical outcomes. We updated a review first published in 2012.
To assess the effects of preoperative nutritional therapy compared to usual care in people undergoing gastrointestinal surgery.
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, three other databases and two trial registries on 28 March 2023. We searched reference lists of included studies.
We included randomised controlled trials (RCTs) of people undergoing gastrointestinal surgery and receiving preoperative nutritional therapy, including parenteral nutrition, enteral nutrition or oral nutrition supplements, compared to usual care. We only included nutritional therapy that contained macronutrients (protein, carbohydrate and fat) and micronutrients, and excluded studies that evaluated single nutrients. We included studies regardless of the nutritional status of participants, that is, well-nourished participants, participants at risk of malnutrition, or mixed populations. We excluded studies in people undergoing pancreatic and liver surgery. Our primary outcomes were non-infectious complications, infectious complications and length of hospital stay. Our secondary outcomes were nutritional aspects, quality of life, change in macronutrient intake, biochemical parameters, 30-day perioperative mortality and adverse effects.
We used standard Cochrane methodology. We assessed risk of bias using the RoB 1 tool and applied the GRADE criteria to assess the certainty of evidence.
We included 16 RCTs reporting 19 comparisons (2164 participants). Seven studies were new for this update. Participants' ages ranged from 21 to 79 years, and 62% were men. Three RCTs used parenteral nutrition, two used enteral nutrition, eight used immune-enhancing nutrition and six used standard oral nutrition supplements. All studies included mixed groups of well-nourished and malnourished participants; they used different methods to identify malnutrition and reported this in different ways. Not all the included studies were conducted within an Enhanced Recovery After Surgery (ERAS) programme, which is now current clinical practice in most hospitals undertaking GI surgery. We were concerned about risk of bias in all the studies and 14 studies were at high risk of bias due to lack of blinding. We are uncertain if parenteral nutrition has any effect on the number of participants who had a non-infectious complication (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.36 to 1.02; 3 RCTs, 260 participants; very low-certainty evidence); infectious complication (RR 0.98, 95% CI 0.53 to 1.80; 3 RCTs, 260 participants; very low-certainty evidence) or length of hospital stay (mean difference (MD) 5.49 days, 95% CI 0.02 to 10.96; 2 RCTs, 135 participants; very low-certainty evidence). None of the enteral nutrition studies reported non-infectious complications as an outcome. The evidence is very uncertain about the effect of enteral nutrition on the number of participants with infectious complications after surgery (RR 0.90, 95% CI 0.59 to 1.38; 2 RCTs, 126 participants; very low-certainty evidence) or length of hospital stay (MD 5.10 days, 95% CI -1.03 to 11.23; 2 RCTs, 126 participants; very low-certainty evidence). Immune-enhancing nutrition compared to controls may result in little to no effect on the number of participants experiencing a non-infectious complication (RR 0.79, 95% CI 0.62 to 1.00; 8 RCTs, 1020 participants; low-certainty evidence), infectious complications (RR 0.74, 95% CI 0.53 to 1.04; 7 RCTs, 925 participants; low-certainty evidence) or length of hospital stay (MD -1.22 days, 95% CI -2.80 to 0.35; 6 RCTs, 688 participants; low-certainty evidence). Standard oral nutrition supplements may result in little to no effect on number of participants with a non-infectious complication (RR 0.90, 95% CI 0.67 to 1.20; 5 RCTs, 473 participants; low-certainty evidence) or the length of hospital stay (MD -0.65 days, 95% CI -2.33 to 1.03; 3 RCTs, 299 participants; low-certainty evidence). The evidence is very uncertain about the effect of oral nutrition supplements on the number of participants with an infectious complication (RR 0.88, 95% CI 0.60 to 1.27; 5 RCTs, 473 participants; very low-certainty evidence). Sensitivity analysis based on malnourished and weight-losing participants found oral nutrition supplements may result in a slight reduction in infections (RR 0.58, 95% CI 0.40 to 0.85; 2 RCTs, 184 participants). Studies reported some secondary outcomes, but not consistently. Complications associated with central venous catheters occurred in RCTs involving parenteral nutrition. Adverse events in the enteral nutrition, immune-enhancing nutrition and standard oral nutrition supplements RCTs included nausea, vomiting, diarrhoea and abdominal pain.
We were unable to determine if parenteral nutrition, enteral nutrition, immune-enhancing nutrition or standard oral nutrition supplements have any effect on the clinical outcomes due to very low-certainty evidence. There is some evidence that standard oral nutrition supplements may have no effect on complications. Sensitivity analysis showed standard oral nutrition supplements probably reduced infections in weight-losing or malnourished participants. Further high-quality multicentre research considering the ERAS programme is required and further research in low- and middle-income countries is needed.
Sowerbutts AM
，Burden S
，Sremanakova J
，French C
，Knight SR
，Harrison EM
... -
《Cochrane Database of Systematic Reviews》
ResearchGate
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