Over the past 20 years of medical research, there has been a significant increase in awareness of the importance of early feeding after colorectal surgeries. Surgeons transitioned from the routine historical decompression of the gastrointestinal tract through a nasogastric tube, through the introduction of the oral diet after giving the first flatus, up to the present times, in which reliable medical evidence indicates that early feeding is beneficial for the fast recovery of patients after these operations. Ways, complications associated with colon surgery and the time of introducing the diet after it always aroused controversy in the medical community. In “Advances in Surgery”, researchers from Singapore gathered in their article scientific achievements of recent years, which correspond to the many questions and concerns of surgeons.
There are evidences that the state of nutrition of the patient before surgery have a big impact on serious postoperative complications. The difference in the incidence of morbidity and mortality in well-nourished patients compared to those malnourished is significant (29% to 72% and 4% to 23%). Cachexia is generally caused by a disease or is a side effect of a treatment e.g. chemotherapy. The surgery itself contributes to a significant nutritional deficiency. Surgical stress leads to the catabolic state. There is an increase in demand for energy and protein. As a result, a cascade of metabolic processes leads to impaired immunity, muscle weakness, delayed wound healing, and thus to increase the number of complications. Lack of adequate nutritional support can result in the loss of about 10,000 kcal and 100 g of proteins within a few days.
The traditional approach to the postoperative nutrition assumed that the intestine after the operation is inactive. The task of the surgeon was the decompression of the gastrointestinal tract and the administration of intravenous fluids until the sound of peristalsis, flatus and bowel movements appear. Nutrition was initiated gradually from liquid diet. However, it turned out that the concept of “bowel rest” is wrong. Starvation does not inhibit the function of the intestines. Moreover, prolonged fasting, leads to the reduction of visceral blood flow and, therefore, results in profound adverse structural and functional changes in the gastrointestinal system. Authors disagree with the importance of bowel sounds as a reliable indicator of the return of intestinal peristalsis. It has been proven that the noise may come from a random contractile activity not leading to the formation of propulsive movements. It was further discovered that the activity of small intestine is back immediately after the surgery, bowel sounds are back after 2-3 days, and passing of flatus takes place on the fifth day. Another study showed that the activity of the colon is back after 2-3 days after surgery.
Opponents of early feeding believe that the demand for nutrients can be covered with total parenteral nutrition (TPN). However, it had been revealed that simply providing adequate calories, proteins, carbohydrates, fats, and macro and micronutrients is not enough. The rout of administration of food is also important. In a study of healthy volunteers it has been found that the body of those fed parenterally for 7 days has increased its catabolism in comparison to those fed traditionally. Moreover, in TPN subjects deterioration of the intestinal barrier functioning and the immune system functioning have been detected. These arguments favor the superiority of enteral nutrition (if possible) over the TPN.
Some of the surgeons are concerned that the early feeding can lead to postoperative obstruction and leakage of newly formed anastomosis. Postoperative ileus is a common complication after colorectal surgery (18% of cases). It is caused by the cascade of inflammatory processes and stress associated with surgery, which are caused by the manipulation of the gut and lead to impairment of the splanchnic blood flow. The whole effect is not limited only to the portion of irritated intestine, but to the entire gastrointestinal tract. Impaired mobility of the intestine is also associated with disorganized electrical activity of the muscle. It is proven that early enteral feeding is beneficial for the organization and stimulation of that electrical activity by inducing reflexes and increasing the secretion of gastrointestinal hormones. Consequently this leads to faster onset of normal propulsive bowel movements.
Theoretical induction of anastomotic leakage caused by a volume of food was so far the key argument against early feeding after colorectal surgery. However, supporters of the above theory overlooked the fact that more than 6l of intestinal juice is secreted into the gastrointestinal tract daily, even if there is a complete cessation of the administration of food and liquids enterally. What is more, critical for proper healing of the anastomosis is the blood circulation in the area of anastomosis in order to provide the required amount of substrates. Studies in many facilities have provided evidence that early feeding following intestinal surgery accelerates the healing, strengthens the structure anastomosis and increases the amount of collagen in the healing tissue. Moss et al demonstrated in an animal model that early nutrition doubles the pressure at which it comes to the perforation of the intestinal anastomosis.
A large meta-analysis of 11 prospective randomized studies on 837 patients comparing early enteral nutrition to the practice of limiting the supply of food after the surgery showed superiority of the first method. Patients started on early feeding within 24 hours after the operation had less infection and their hospitalization was shorter. Moreover, in the 2011 meta-analysis of 15 prospective randomized trials on 1,240 patients (the majority of the operations were colorectal) demonstrated a statistically significant reduction in postoperative complications.
Knowing that enteral nutrition on the first day after the operation is favorable, the next step was to investigate whether solid foods are safe as “first line” diet following colorectal surgery. Conclusion was as follows: “There is no physiological reason of which the surgical patient with undisturbed swallowing mechanism should not eat solid food in the first day after the operation.” According to recent studies, such a diet is better tolerated by patients, shortens hospital stay and is not associated with an increased incidence of complications.
In summary, there is no justification for maintaining patients who underwent colorectal surgery without feeding for longer than a day. Early enteral nutrition has beneficial effects on intestinal mucosal barrier integrity and lymphatic tissue of the intestines. Postoperative intestinal activity normalizes itself faster when early feeding applied, which leads to faster flatus and bowel movement. Given the overwhelming evidence of its safety early feeding should certainly be introduced as a standard postoperative care after colorectal surgery.
Written by: Michał Godzisz, Krzysztof Grzechnik, Katarzyna Godzisz
Sources:
1.Cheryl Lau MD, FRCS(Edin), Edward Phillips MD, Does Diet Make a Difference Following Colon Surgery? Advances in Surgery 49 (2015) 95–10.
2. Rohatiner T,Wend J, Rhodes S, et al. A prospective evaluation of current practices of early postoperative feeding after elective intestinal surgery. Am Surg 2012;10:1147–50.
3. Wilmore DW. Metabolic response to severe surgical illness: overview. World J Surg 2000;24:705.
4. Clevers GJ, Smout AJ, van der Schee EJ, et al. Myo-electrical and motor activity of the stomach in the first days after abdominal surgery: evaluation by electrogastrography and impedance gastrography. J Gastroenterol Hepatol 1991;6:253.
5. Delaney CP, Kehlet H, Senagore AJ, et al. Postoperative ileus: profiles, risk factors, and definitions— a framework for optimizing surgical outcomes in patients undergoing major abdominal and colorectal surgery. 2006.
6. Luckey A, Livingston E, Tache Y. Mechanisms and treatment of postoperative ileus. Arch Surg 2003;138(2):206–14.
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