Gastrointestinal Feedings Post Op: What s the deal on beginning oral feedings?

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1 Gastrointestinal Feedings Post Op: What s the deal on beginning oral feedings? Kate Willcutts, DCN, RD, CNSC University of Virginia Health System Charlottesville, VA kfw3w@virginia.edu

2 Objectives 1. Discuss research that supports early oral feeding after surgery. 2. Explain evidence supporting swifter advancement to regular diet after surgery

3 Financial Disclosures Presentation at CNW 2017 funded by Abbott

4 Introduction Prolonged periods of nil per os (NPO) associated with iatrogenic malnutrition & reduced patient satisfaction Leading reasons for NPO: peri-operative and pre-procedural fasting practices Fasting after surgery intended to reduce the risk of aspiration pneumonia and anastomotic leaks Since the late 70 s early 80 s -early post operative tube feeding is safe. Early oral feeding after all types of surgeries more common

5 Background Postop Bowel Function Postoperative ileus interruption of bowel function after surgery 1 Nasogastric tube (NGT) for decompression Return of bowel function no good marker. Traditionally bowel sounds, flatus, stool 5 Potential Negatives Nausea, vomiting Aspiration pneumonia Anastomotic leak Wound dehiscence Intra-abdominal infection/fistula 1. Vather R, Trivedi S, Bissett I. Defining postoperative ileus: results of a systematic review and global survey. J. Gastrointest. Surg. May 2013;17(5):

6 Definition of terms Lower GI surgery = colorectal Upper GI surgery = esophagus, stomach, duodenum, liver and/or pancreas No universally accepted definition for early when referring to oral feeding Traditional or late timing usually means after the return of bowel function Oral feeding = initiation of diet progression most started with clear liquids. 6

7 Case Lower GI Surgery 60 year old female POD # 0 s/p elective L hemicolectomy & colostomy for colon CA. No intra-op complications. When would should oral diet be started? How would this decision be made?

8 Typical NPO at midnight for surgery the next day. NPO and/or no tube feeding and/or NGT for decompression after surgery until return of bowel function. What is the total time without nutrition? Minimum ~30 hours. What is the effect of this? Clinical outcomes? Patient satisfaction?

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18 Early Versus Traditional Postoperative Feeding in Patients Undergoing Resectional Gastrointestinal Surgery: A Meta-Analysis Osland et al. JPEN 2011 Compared early to traditional (NPO) post op feeding. Mostly lower GI surgery. Some studies were combination of lower and upper GI - but most of the pts were lower GI. 5 tube feeding studies and 10 oral diet studies. Only included RCTs. Did not include immune enhancing tube feeding studies

19 Odds ratio for complications (nausea and vomiting excluded) Osland E et al. JPEN J Parenter Enteral Nutr 2011;35: Copyright by The American Society for Parenteral and Enteral Nutrition

20 Odds ratios for mortality Osland E et al. JPEN J Parenter Enteral Nutr 2011;35: Copyright by The American Society for Parenteral and Enteral Nutrition

21 Odds ratios for anastomotic leak Osland E et al. JPEN J Parenter Enteral Nutr 2011;35: Copyright by The American Society for Parenteral and Enteral Nutrition

22 Days to passing flatus Osland E et al. JPEN J Parenter Enteral Nutr 2011;35: Copyright by The American Society for Parenteral and Enteral Nutrition

23 Days to first bowel movement Osland E et al. JPEN J Parenter Enteral Nutr 2011;35: Copyright by The American Society for Parenteral and Enteral Nutrition

24 Length of stay (days) Osland E et al. JPEN J Parenter Enteral Nutr 2011;35: Copyright by The American Society for Parenteral and Enteral Nutrition

25 Case Upper GI Surgery 60 yr old female POD # 0 s/p gastrectomy. No intra-op complications. When would should oral diet be started? How would this decision be made?

26 Upper GI Surgery Usually for cancer High risk of malnutrition High risk of post op complications Increased chance for prolonged periods NPO Surgeons reluctant to start oral feeding until at least 5 days after upper GI surgery 1 Concern for leakage and possible fistula formation 2 May tube feed more likely if can achieve access distal to anastomosis. 1. Petrelli et al. 2. Wang et al.

27 Early Post Op Oral Feeding for upper GI Systematic review/meta-analysis to evaluate the practice of early oral feeding after upper GI surgery in adults. What is the effect of early oral feeding as compared to traditional (or late) timing of oral feeding on: length of stay? need for NGT reinsertion? anastomotic leaks? pneumonia? need for reoperation? mortality? readmission? Willcutts, Chung, Erenburg. et al. Ann Surg Jul;264(1):54-63.

28 Inclusion & Exclusion Criteria 28

29 Results: Study Population 15 studies met the full-text inclusion criteria 8 RCTs N= non-rcts N = 1132 Type of Surgery RCT n (%) Non-RCT n (%) RCT + non-rct n (%) Gastrectomy 507 (52) 697 (61) 1204 (57) Esophagectomy 109 (11) 316 (39) 425 (20) Hepatobiliary 249 (25) 119 (10) 368 (17) Other 115 (12) (5) Total Willcutts, Chung, Erenburg. et al. Ann Surg Jul;264(1):

30 Results: Start Time of Oral Feeding Intervention (Early) Comparison (Traditional or Late) # of studies (%) Start time 12 (80%) POD 1 or earlier 2 (13%) POD 2 1 (7%) POD 3 (esoph.) # of studies (%) Start time 6 (40%) Return of bowel function 4 (27%) POD 3 2 (13%) POD 4 1 (7%) each POD 5, 6, & 7 Note: POD 3 for one study was the early group. Esophagectomy pts. Late group was POD 5.

31 Hospital Length of Stay P <0.01 P = 0.10 P <0.01 Hospital length of stay for early fed groups a mean difference of days shorter than the late (traditional) fed groups.

32 Need for NGT Reinsertion P = 0.12 P = 0.82 P = 0.18 Reduced need for NGT reinsertion in the early fed group although not 32 statistically significant

33 Pneumonia P < 0.01 P = 0.34 P= 0.01 Less pneumonia in the early fed group 33

34 Anastomotic Leaks P = 0.99 P = 0.31 P = Statistically not significant no increase in leaks in the early fed groups

35 Reoperations & Mortality P = 0.29 P = 0.73 P = 0.28 Statistically insignificant fewer reoperations in early fed group. Mortality only 3 studies did not have 0 in both groups Effect size /456 in study groups; 19/446 in control groups 35 p = 0.75

36 Conclusions from Meta Analysis Early postoperative oral feeding seems to be as safe as the traditional (or late) timing of postoperative oral feeding after upper GI surgeries. Statistically significant shorter LOS in early fed groups. Trend towards reduced anastomotic leaks, reoperations and need for NGT reinsertion in early fed groups. More studies of each type of upper GI surgery are needed. More data on the actual amount of oral intake and overall patient satisfaction with earlier oral feeding could demonstrate patient-centered benefits to a more progressive approach to postoperative feeding. 36

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42 Enhanced Recovery After Surgery (ERAS) Multimodal Protocol 1999 Kehlet & Mogensen 1st multimodal Evidence-based interventions Preop, intraop and postop To reduce surgical stress and postoperative catabolism Quicker return to mobility, oral intake, home.

43 Factors that improve gut motility Reduced use of opioids Regional analgesia Reduced use of IV fluids Early mobilization Early oral intake Ljungqvist, L et al. JAMA Jan 11, 2017

44 Enhanced Recovery After Surgery Ljungqvist, L et al. JAMA Jan 11, 2017

45 ERAS Nutrition Components Preadmission nutrition screening and nutrition support Preop Carbs No NPO Early oral intake of fluids and solids Ljungqvist, L et al. JAMA Jan 11, 2017

46 ERAS Gastrectomy Summary and recommendation: Patients undergoing total gastrectomy should be offered drink and food at will from POD 1. They should be advised to begin cautiously and increase intake according to tolerance. Evidence level: Moderate Recommendation grade: Weak Patients clearly malnourished or those unable to meet 60 per cent of daily requirements by POD 6 should be given individualized nutritional support, as detailed above. Evidence level: Moderate Recommendation grade: Strong Mortensen, K et al. Brit J Surg

47 Take Home Points Early post op diet safe after lower GI surgery Early post op diet safe after upper GI surgery No evidence to support step-wise diet advancement after surgery ERAS protocols incorporate early oral diet.

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49 References Bauer VP. The evidence against prophylactic nasogastric intubation and oral restriction. Clin. Colon Rectal Surg. Sep 2013;26(3): Kawamura YJ et al. Patient's appetite is a good indicator for postoperative feeding: a proposal for individualized postoperative feeding after surgery for colon cancer. Int J Colorectal Dis Ljungqvist, L et al. Enhanced Recovery After Surgery: A Review.JAMA Jan 11, 2017 Osland E et al. Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN. 2011;35: Mortensen K et al. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS ) Society recommendations. Brit J Surg 2014 Petrelli NJ et al. Early postoperative oral feeding after colectomy: an analysis of factors that may predict failure. Ann Surg Oncol 2001; 8: Vather R et al. Defining postoperative ileus: results of a systematic review and global survey. J. Gastrointest. Surg. May 2013;17(5): Wang D et al. Is nasogastric or nasojejunal decompression necessary following gastrectomy for gastric cancer? A systematic review and meta-analysis of randomised controlled trials. J Gastrointest Surg 2015; 19: Warren J et al. Postoperative diet advancement: Surgical dogma vs evidence-based medicine. Nutr Clin Pract. 2011;26(2): Willcutts KF 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 Jul;264(1): Yeung SE, Fenton TR. Colorectal surgery patients prefer simple solid foods to clear fluids as the first postoperative meal. Dis Colon Rectum. 2009

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