|Year : 2014 | Volume
| Issue : 2 | Page : 173-176
Early Enteral feeding within 24 hours of gastrointestinal surgery versus Nil by mouth: A prospective study
Kunal Kishore, Dakshayani S Nirhale, Virendra S Athavale, Gaurav G Goenka, Murtuza A Calcuttawala
Department of General Surgery, Padamashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||4-Feb-2014|
Department of General Surgery, Padamashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune- 411018
Source of Support: None, Conflict of Interest: None
A prospective study on early enteral feeding v/s Nil by mouth was done on 74 patients in two groups. The study mainly focused on incidence of surgical site infection, post-operative complications, such as pulmonary complications, anastomotic leakage, abdominal distension, vomiting, and cost of treatment in both groups. It was observed that maximum patients in our study were in the age group of 31-40 years with male preponderance having an average of 12 gm % hemoglobin levels and average BMI of 23, which were divided in two groups. In our study, early enteral feeding has less incidence of surgical site infection with most infection by Klebsiella pneumonia in both groups, clinically less complications and less cost incurred. The incidence of vomiting was increased in early enteral fed group but did not lead to cessation of feeding. Early mobilization of patient and early establishment of bowel sounds are the other factors noticed in patients of early enteral fed groups in our study. Cost of treatment is emphasized in our study. Myth of patients keeping nil by mouth after surgery is to be discouraged. Early enteral feeding enhances recovery and can be safely given after all major gastrointestinal surgeries.
Keywords: Complication, cost, enteral feeding, nil by mouth, surgical site infection
|How to cite this article:|
Kishore K, Nirhale DS, Athavale VS, Goenka GG, Calcuttawala MA. Early Enteral feeding within 24 hours of gastrointestinal surgery versus Nil by mouth: A prospective study. Med J DY Patil Univ 2014;7:173-6
|How to cite this URL:|
Kishore K, Nirhale DS, Athavale VS, Goenka GG, Calcuttawala MA. Early Enteral feeding within 24 hours of gastrointestinal surgery versus Nil by mouth: A prospective study. Med J DY Patil Univ [serial online] 2014 [cited 2020 Jul 16];7:173-6. Available from: http://www.mjdrdypu.org/text.asp?2014/7/2/173/126332
| Introduction|| |
Malnutrition is common. It occurs in about 30% of surgical patients with gastrointestinal disease and in up to 60% of those in whom hospital stay has been prolonged because of post-operative complications. It is frequently unrecognized and consequently patients often do not receive appropriate support. There is substantial body of evidence to show that patients who suffer starvation or have signs of malnutrition have a higher risk of death in comparison with patients who have adequate nutritional reserves. 
A period of starvation ("nil by mouth") is common practice after gastrointestinal surgery. 
Early enteral nutrition is defined as all oral intakes (i.e., registered oral intake, supplemented oral feeding) and any kind of tube feeding (gastric, duodenal, or jejunal) containing caloric content commenced within 24 h postoperatively. 
Enteral feeding is believed to diminish stress response, improve immunity and wound healing, and significantly reduce septic complications after major upper abdominal procedures and in the setting of multisystem trauma. This most likely occurs by stimulating enterocyte growth, resulting in improved mucosal barrier function and decreased bacterial translocation. Motility studies that document return of small bowel peristalsis within hours after laparotomy provide the theoretical support for early postoperative enteral nutrition. 
Most of the previous studies done were on the post-operative infections, complications, stay of hospital, mortality etc. Very few studies have studied cost of feeding, and those who have studied cost of treatment, have done mainly on the basis of period of hospital stay.
Our study emphasized more on cost of treatment by taking parameters like cost of I.V Fluids, antibiotics etc. These minor factors add on to the treatment cost in Nil by Mouth group and play a significant role in Indian population. As more number of patients visiting the hospital are from lower socioeconomic status in India.
| Materials and Methods|| |
Ethical clearance for this study was obtained from the Research Ethics Committee of our college and hospital. It has its own teaching institute catering to a population coming from all classes of society but predominantly from the middle and lower classes. While additional informed consents were sought and obtained from all subjects. A total of 74 patients who were admitted in the surgical ward and had undergone gastrointestinal (GI) surgeries during the study period were selected consecutively for the study. All the patients included in the study were informed about the purpose of the study. No one refused to participate in the study.
Exclusion criteria were: Basal metabolic index (BMI) <18, pregnancy, immunocompromised patients, associated medical diseases like: Diabetes mellitus, and Chronic renal failure patients.
| Methods|| |
All the patients were assigned to one among the following groups. Group A:- Early enteral feeding (EEF) (within 24 h after surgery). Group B:-Nil by mouth (NBM) (till passing of flatus). On the type of surgery patients were randomized in two groups. Similar surgical condition (as our study includes various gastrointestinal surgeries) patients were alternatively selected and assigned to each group (one patient getting early enteral feeding and other kept nil by mouth) as the patient comes out from operation room and definitive protocol for each group is followed as stated.
Group A: Route for feeding - Oral/Nasogastric/Jejunostomy. Enteral feeding was started within 24 h of surgery. Clear liquid diet started within 24 hrs of surgery, if tolerated well. Liquid diet- given 24-48 h of surgery. Soft diet was started after 48 h of surgery. Regular diet- After 72 h of surgery. Amount of feeds given as- 10 ml/h on Day 1, increased by 25 ml/h on Day 2, another 25 ml/h by Day 3. Standard antibiotics given- Inj Taxim 1 gm BD + Inj Metro 500 mg TDS + Inj Genta 80 mg twice daily (BD). Patients were given 5-6 points intravenous (IV) fluids (including RL, DNS) within 24 h, and supplemented by I V fluids thereafter as per the requirement till the patient was shifted to full diet. I V antibiotics were given up to 3 days (approximately).
In Group B, patients were given I V Fluids till the passage of flatus, then oral feeds were started. For a period of 3 days 5-6 points I V fluids were given (including RL, DNS) and supplemented by I V fluids thereafter as per the requirement till the patient was shifted to full diet. I V antibiotics were given up to 5 days (approx). Patients were monitored for vomiting, distension of abdomen, and peristalsis. Abdomen and chest examinations were done and post-operative complications like distension of abdomen, pulmonary complications (pneumonia, pleural effusion, etc), anastomotic leakage were registered. In Group B, patients were given IV fluids till the passage of flatus, and then oral feeds were started.
Patients were followed up for 30 days post-operatively in both groups for any surgical site infection (SSI) in suspected cases of SSI. Diagnosis of SSI was made on Centre for disease control (CDC) criteria for defining a SSI. Number of patients having SSI is noted down.
Cost of treatment in both the groups was assessed which include: Cost of Total IV Fluids + Total IV antibiotic as standard. (Based on Culture - Antibiotics stepped up) + Total dressings cost. Standard IV antibiotics : Inj Taxim 1gm BD (Indian rupee Rs 58 each) + Inj Gentamycin 80 mg BD (Rs 8 each) + Inj Metronidazole TDS 500 mg (Rs 18) were started and changed according to culture and sensitivity. In EEF group IV fluids + I V antibiotics required was for 3 days (approx), till the patient shifted to full diet. In NBM group IV fluids + I V antibiotics required was for 5 to 6 days (approx), till the patient shifted to full diet. Cost of 1 ringer lactate- Rs 75, cost of 1 DNS- Rs 35., cost of 1 NS- Rs 25, and cost of each dressing- Rs 25.
Statistical analysis was done by using SPSS software version 11. Comparison between groups was performed by Z-value test and Chi-square test. All results were considered to be significant at the 5% critical value (P<0.05).
| Results|| |
In our study maximum patients were in age group of 31-40 years in both groups. The present study showed comparable hemoglobin (Hb) levels mean Hb level in our study was 12.01gm% and 12.11gm% in both the study groups. In our study mean BMI in our study was 23.22 in group A and 22.34 in group B which was comparable in both groups. [Table 1] shows the types of surgeries included in the study: In our study there were 16 patients of primary repair with Graham's patch, 8 in group A and 8 in group B. A total of 43 patients of resection anastomosis, 21 in group A and 22 in group B. Resection with colostomy was done in four patients, two in Group A and two in group B. Feeding jejunostomy in 2 cases, 1 in each group. Submucosal resection in 2 patients, 1 in each group. Cholecystectomy in three patients, two in group A and one in group B. Open liver abscess drainage in two patients, one in each group. Spleenectomy in one patient given early enteral feeding. Hartman's procedure 1 patient kept NBM.
[Table 2] shows incidence of SSI in our study; there were 10 SSI out of 37 cases in EEF group. Whereas there were 22 SSI out of 37 cases in NBM group. P-value derived is < 0.01 which is statistically significant.
[Table 3] shows complications: In our study Group A, there were 4/37 complications- 1 anastomotic leakage, 1 distension, and 2 pulmonary complications. After distension enteral feeding was stopped. Group B there were 7/37 complications- 3 anastomotic leakage, 1 distension, 3 pneumonia. Even the complications rate is comparable or even less in EEF group. P-value of complication is > 0.05 which is not significant but comparable.
[Table 4] shows cost of treatment: In our study mean cost of treatment in group A is Rs 1133 ( including cost of IV fluids + IV antibiotics + dressings cost). In group B mean cost is Rs 1499. P-value for cost is < 0.0001 which is highly significant that in EEF cost of treatment is less.
Other factors: Early mobilitation of patient and early establishment of bowel sounds are the other factors noticed in patients in group A as compared to group B.
| Discussion|| |
In present study patients on early enteral feeding has less incidence of SSI. Similarly, Heslin  et al., found that there were 13/97 wound infection in EEF group and 8/98 in NBM group and Sagar  et al., found that there were 3/15 wound infection in EEF group and 5/15 in NBM group. There is no significant difference in post-operative complications in both the groups in our study. There were increased incidence of vomiting in group A, but it was not the contraindication to stop the feeding completely. Similarly, Heslin  et al., found anastomotic dehiscence is 3/97 in EEF group and 4/98 in NBM group whereas 3/97 had pneumonia in EEF group and 7/98 in NBM group and Beier-Holgersen  found anastomotic dehiscence is 2/30 in EEF group and 4/30 in NBM group, whereas 1/30 had pulmonary complications in EEF group and 2/30 in NBM group.
Early enteral feeding showed to be cost effective in our study. Similarly, studies by Binderow  et al., and Sagar  et al., showed that EEF were economically less. All the compared studies showed reduced cost on the basis of hospital stay. Our study shows factual differences in cost including minor factors, such as IV fluids and antibiotics.
Early mobilitation of patient and early establishment of bowel sounds are the other factors noticed in patients in group A as compared to group B.
The early enteral feeding can begin postoperatively as soon as the patient is hemodynamically stable. Preferably, it should start within 24 h after surgery and no later than 48 h. As long as there is no significant abdominal distension, enteral feeding is not contraindicated, even with markedly diminished bowel sounds. Most patients can be fed enterally without waiting for flatus.  The route of administration also has effects on organ function, particularly in the intestinal tract. Substrates delivered by the enteral route are better utilized by the gut than those administered parenterally. Immediate or early postoperative EEF stimulates the splanchnic and hepatic circulation; it improves intestinal mucosa blood flow, it prevents intramucosal acidosis and permeability disturbances and it eliminates the need for stress ulcer prophylaxis.  Although there is evidence in the literature to prove the benefits of early enteral feeding, there is a lot of resistance to its implementation. Advances in intensive care and pain management, along with rapid development of modern nutritional supplementation via alternative routes, have greatly aided early patient recovery. Consequently, EEF and enhanced recovery programs have gained ground in recent years. It can be objectively said that early EEF after major gastrointestinal surgery is safe with added advantages. 
| References|| |
|1.||MacFie J. Nutrition and fluid therapy. In: Norman SW, Christopher JK, editors. Bailey and Love's Short practice of surgery. 25 th ed, Chapter 17. London: Hodder Arnold; 2008. p. 223-33. |
|2.||Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: Systematic review and meta-analysis of controlled trials. BMJ 2001;323:773-6. |
|3.||Henning Keinke Andersen, Stephen J Lewis, Steve Thomas. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev 2011;(4):CD004080. |
|4.||Melis M, Fichera A, Ferguson MK. Bowel necrosis associated with early jejunal tube feeding: A complication of postoperative enteral nutrition. Arch Surg 2006;141:701-4. |
|5.||Heslin MJ, Latkany L, Leung D, Brooks AD, Hochwald SN, Pisters PW, et al. A prospective, randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy. Ann Surg 1997;226:567-680. |
|6.||Sagar S, Harland P, Shields R. Early postoperative feeding with elemental diet. Br Med J 1979;1:293-5. |
|7.||Beier-Holgersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut 1996;39:833-5. |
|8.||Binderow SR, Cohen SM, Wexner SD, Nogueras JJ. Must early postoperative oral intake be limited to laparoscopy? Dis Colon Rectum 1994;37:584-9. |
|9.||Braga M, Gianotti L, Gentilini O, Di Carlo V. Feeding the gut early after digestive surgery: Results of a nine year experience. Clin Nutr 2002;21:59-65. |
|10.||Lorenzo D, Rovera F, Pericelli A, Imperatori A. The rationale of early enetral nutrition. Acta Bio Medica 2003;74:41-4. |
|11.||Shrikhande SV, Shetty SG, Singh K, Ingle S. Is early feeding after major gastrointestinal surgery a fashion or an advance? evidence-based review of literature. J Can Res Ther 2009;5:232-9. |
[Table 1], [Table 2], [Table 3], [Table 4]