NIHR Signal Early oral feeding after stomach surgery is safe and reduces time spent in hospital

Published on 24 March 2016

After upper gastrointestinal surgery, returning a patient to oral feeding on the day of the surgery, or the day after, is as safe as waiting for a few days. It also reduces the time the patient spends in hospital by about two days, potentially saving money.

This systematic review and meta-analysis found no difference in adverse outcomes – such as leakage at the surgical site, need for re-insertion of a feeding tube, reoperations, readmissions or mortality – when adults were fed early compared with later after upper gastrointestinal surgery.

Future research is needed on patient satisfaction and to see if patients undergoing surgery at different sites, such as the stomach, oesophagus or liver, respond differently to the return of oral feeding. Nevertheless, the results suggest that early post-surgical oral feeding is generally safe. These results support NICE guidance.

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Why was this study needed?

It’s usual to wait a few days after upper gastrointestinal surgery before returning the patient to oral feeding. This is to allow time for the bowel to start functioning again. Stomach secretions are often drained during this time via a tube running through the nose. If oral feeding is started too soon, there is the risk of leakage around the surgical join and other complications such as nausea, vomiting or difficulties in breathing.

There is growing evidence that early oral feeding after uncomplicated upper gastrointestinal surgery may not only be safe but also increase patient satisfaction and reduce length of stay in hospital. This review aimed to compare early postoperative oral feeding to traditional, later oral feeding after any type of upper gastrointestinal surgery.

What did this study do?

This systematic review and meta-analysis of 15 studies – eight randomised controlled trials and seven cohort studies – included 2012 adult patients. Trials examined the effect of early oral feeding compared to traditional later feeding. Time of feeding was the sole difference between groups. Participants were adults who had undergone surgery on the stomach (57%), oesophagus (20%), liver, pancreas, gallbladder or bile ducts (17%) or other upper gastro-intestinal surgical site (5%).

In 12 of the 15 studies, oral feeding in the early group was started on the day after surgery or earlier. In two studies early feeding started two days after surgery, and in one study it started three days after surgery. In the late feeding group comparator, six of the 15 studies waited for the return of the patient’s bowel function, four started three days after surgery, two started four days after surgery, and one started each of five, six and seven days after surgery.

None of the trials were in the UK. Four were in China, three in Korea, two in Japan and one in each of the Netherlands, Norway, Iran, Poland, India and Nepal. The randomised controlled trials were mostly at low risk of bias – the cohort studies at higher risk. To see if including the cohort studies might influence the results, meta-analyses were carried out twice: once using all studies and once with the randomised controlled trials alone. Unless stated otherwise, results below are from the randomised controlled trials alone.

What did it find?

  • Hospital stay was significantly shorter in the early rather than late-fed group (weighted mean difference -1.72 days, 95% confidence interval [CI] -1.25 to -2.2, meta-analysis of three trials).
  • There was no significant difference between early and late feeding in risk of leakage at the surgical site (anastomotic leak), pneumonia, re-insertion of a stomach tube, reoperation, readmission or mortality.
  • Pooling all studies showed a reduced risk of pneumonia in the early compared to late-fed group (odds ratio [OR] 0.6, 95% CI 0.41 to 0.89). However this result should be treated cautiously – there was no difference when looking at randomised trials alone.

What does current guidance say on this issue?

NICE guidance published in 2006 (and considered up to date when last reviewed in 2014) recommends that healthcare professionals should consider giving post-abdominal surgery patients who can swallow safely, and in whom there are no specific concerns about gut function or integrity, some oral intake within 24 hours of surgery. It also recommends that the patient should be monitored carefully for any signs of nausea or vomiting.

What are the implications?

These findings suggest that early oral feeding after upper gastrointestinal surgery reduces the amount of time patients have to stay in hospital and does not increase the risk of adverse effects. These results confirm NICE guidance and previous research.

There are limitations to the interpretation of this evidence. More studies are needed to assess patients’ requirements after surgery at different sites. This is especially the case with surgery of the oesophagus, due to the difficulty of reoperation in the case of leaks. More research is also required on the diet used, the impact of the patients’ nutritional status before the operation, and how early oral feeding affects overall patient satisfaction.

This research may help clinicians and those designing Enhanced Recovery Programmes and specifying protocols for post-operative care after surgery to the oesophagus and stomach.

Citation and Funding

Willcutts KF, Chung MC, Erenberg CL, et al. Early Oral Feeding as Compared With Traditional Timing of Oral Feeding After Upper Gastrointestinal Surgery: A Systematic Review and Meta-analysis. Ann Surg. 2016. [Epub ahead of print].

No funding information was provided for this study.

Why was this study needed?

It’s usual to wait a few days after upper gastrointestinal surgery before returning the patient to oral feeding. This is to allow time for the bowel to start functioning again. Stomach secretions are often drained during this time via a tube running through the nose. If oral feeding is started too soon, there is the risk of leakage around the surgical join and other complications such as nausea, vomiting or difficulties in breathing.

There is growing evidence that early oral feeding after uncomplicated upper gastrointestinal surgery may not only be safe but also increase patient satisfaction and reduce length of stay in hospital. This review aimed to compare early postoperative oral feeding to traditional, later oral feeding after any type of upper gastrointestinal surgery.

What did this study do?

This systematic review and meta-analysis of 15 studies – eight randomised controlled trials and seven cohort studies – included 2012 adult patients. Trials examined the effect of early oral feeding compared to traditional later feeding. Time of feeding was the sole difference between groups. Participants were adults who had undergone surgery on the stomach (57%), oesophagus (20%), liver, pancreas, gallbladder or bile ducts (17%) or other upper gastro-intestinal surgical site (5%).

In 12 of the 15 studies, oral feeding in the early group was started on the day after surgery or earlier. In two studies early feeding started two days after surgery, and in one study it started three days after surgery. In the late feeding group comparator, six of the 15 studies waited for the return of the patient’s bowel function, four started three days after surgery, two started four days after surgery, and one started each of five, six and seven days after surgery.

None of the trials were in the UK. Four were in China, three in Korea, two in Japan and one in each of the Netherlands, Norway, Iran, Poland, India and Nepal. The randomised controlled trials were mostly at low risk of bias – the cohort studies at higher risk. To see if including the cohort studies might influence the results, meta-analyses were carried out twice: once using all studies and once with the randomised controlled trials alone. Unless stated otherwise, results below are from the randomised controlled trials alone.

What did it find?

  • Hospital stay was significantly shorter in the early rather than late-fed group (weighted mean difference -1.72 days, 95% confidence interval [CI] -1.25 to -2.2, meta-analysis of three trials).
  • There was no significant difference between early and late feeding in risk of leakage at the surgical site (anastomotic leak), pneumonia, re-insertion of a stomach tube, reoperation, readmission or mortality.
  • Pooling all studies showed a reduced risk of pneumonia in the early compared to late-fed group (odds ratio [OR] 0.6, 95% CI 0.41 to 0.89). However this result should be treated cautiously – there was no difference when looking at randomised trials alone.

What does current guidance say on this issue?

NICE guidance published in 2006 (and considered up to date when last reviewed in 2014) recommends that healthcare professionals should consider giving post-abdominal surgery patients who can swallow safely, and in whom there are no specific concerns about gut function or integrity, some oral intake within 24 hours of surgery. It also recommends that the patient should be monitored carefully for any signs of nausea or vomiting.

What are the implications?

These findings suggest that early oral feeding after upper gastrointestinal surgery reduces the amount of time patients have to stay in hospital and does not increase the risk of adverse effects. These results confirm NICE guidance and previous research.

There are limitations to the interpretation of this evidence. More studies are needed to assess patients’ requirements after surgery at different sites. This is especially the case with surgery of the oesophagus, due to the difficulty of reoperation in the case of leaks. More research is also required on the diet used, the impact of the patients’ nutritional status before the operation, and how early oral feeding affects overall patient satisfaction.

This research may help clinicians and those designing Enhanced Recovery Programmes and specifying protocols for post-operative care after surgery to the oesophagus and stomach.

Citation and Funding

Willcutts KF, Chung MC, Erenberg CL, et al. Early Oral Feeding as Compared With Traditional Timing of Oral Feeding After Upper Gastrointestinal Surgery: A Systematic Review and Meta-analysis. Ann Surg. 2016. [Epub ahead of print].

No funding information was provided for this study.

Early Oral Feeding as Compared With Traditional Timing of Oral Feeding After Upper Gastrointestinal Surgery: A Systematic Review and Meta-analysis

Published on 19 January 2016

Willcutts, K. F.,Chung, M. C.,Erenberg, C. L.,Finn, K. L.,Schirmer, B. D.,Byham-Gray, L. D.

Ann Surg , 2016

OBJECTIVE: To compare the effects of early oral feeding to traditional (or late) timing of oral feeding after upper gastrointestinal surgery on clinical outcomes. BACKGROUND: Early postoperative oral feeding is becoming more common, particularly as part of multimodal or fast-track protocols. However, concerns remain about the safety of early oral feeding after upper gastrointestinal surgery. METHODS: Comprehensive literature searches were conducted across 5 databases from January 1980 until June 2015 without language restriction. Risk of bias of included studies was appraised and random-effects model meta-analyses were performed to synthesize outcomes of anastomotic leaks, pneumonia, nasogastric tube reinsertion, reoperation, readmissions, and mortality. RESULTS: Fifteen studies comprising 2112 adult patients met all the inclusion criteria. Mean hospital stay was significantly shorter in the early-fed group than in the late-fed group [weighted mean difference = -1.72 d, 95% confidence interval (CI) -1.25 to -2.20, P < 0.01). Postoperative length of stay was also significantly shorter (weighted mean difference = -1.44 d, 95% CI -0.68 to -2.20, P < 0.01). There was no significant difference in risk of anastomotic leak, pneumonia, nasogastric tube reinsertion, reoperation, readmission, or mortality in the randomized controlled trials (RCTs). The pooled RCT and non-RCT results, however, showed a significantly lower risk of pneumonia in early-fed as compared with late-fed group (odds ratio = 0.6, 95% CI 0.41-0.89, P = 0.01). CONCLUSIONS: Early postoperative oral feeding as compared with traditional (or late) timing is associated with shorter hospital length of stay and is not associated with an increase in clinically relevant complications.

Expert commentary

This meta-analysis examines the impact of early post-operative feeding versus previously conventional practice in heterogeneous groups of patients having upper gastrointestinal surgery. The feeding intervention was also highly variable. Despite this, there was a clear advantage of early feeding in terms of post-operative length of stay with no increase in peri-operative morbidity including, where relevant, anastomotic leakage. Reassuringly the effect appeared stronger and more consistent in the randomised studies. Early feeding is part of Enhanced Recovery Programmes which many centres have now introduced. Early feeding should now be standard of care in patients having major upper gastrointestinal surgery and studies to examine even earlier introduction of feeding may be appropriate.

Professor JN Primrose, Director of Wessex CRN