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Annals of Surgical Oncology 8:796-800 (2001)
© 2001 Society of Surgical Oncology

ORIGINAL ARTICLES

Early Postoperative Oral Feeding After Colectomy: An Analysis of Factors That May Predict Failure

Nicholas J. Petrelli, MD, Charles Cheng, MD, Deborah Driscoll, BA and Miguel A. Rodriguez-Bigas, MD

From the Division of Surgical Oncology, Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, New York.

Correspondence: Address correspondence and reprints requests to: Nicholas J. Petrelli, MD, Medical Director, Helen F. Graham Cancer Center, 4735 Ogletown-Stanton Road, MAPII, Suite 1201, Newark, DE 19713; Fax: 302-428-5790; E-mail: npetrelli{at}christianacare.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Previous studies have shown that early postoperative oral feeding is feasible. Traditionally patients were fed when flatus or defecation documented the return of bowel function. This study was undertaken to determine factors that may preclude early feeding.

Methods: One hundred four successive patients underwent colorectal surgery from October 1999 to January 2001. Eighty-nine patients started an oral diet either on postoperative day 1 or 2. Their clinical outcomes were recorded prospectively. Fifteen of the 104 patients were excluded for small-bowel resection (5 patients), perioperative complications (5 patients), prior radiation (3 patients), and small-bowel obstruction (2 patients). A failure in postoperative feeding consisted of nausea, vomiting, or readmission.

Results: The mean age of our cohort was 65 years (range, 28–87 years). There were 45 male and 44 female patients. The mean postoperative hospital stay was 6 days (range, 3–13 days). The median American Society of Anesthesiology score was II (range, I–IV). The types of resection performed were right colectomy (27 patients), low anterior resection (26 patients), sigmoid resection (11 patients), abdominoperineal resection (8 patients), formation or closure of colostomy (7 patients), posterior pelvic exenteration (4 patients), total colectomy (3 patients), left colectomy (2 patients), and transverse colectomy (1 patient). Sixty-five patients (73%) tolerated early oral feeding. Of the 24 patients that did not, 16 had nausea or emesis, and 8 required readmission for postoperative complications (small-bowel obstruction [4 patients], wound dehiscence [1 patient], abdominal pain [1 patient], and anastomotic leak [2 patients]). Univariate analysis revealed that the use of volume expanders contributed to intolerance of early feeding. On multivariate analysis, blood loss during the operation was the only factor contributing to failure of early postoperative oral feeding.

Conclusions: Early oral feeding is safe and feasible for postcolectomy patients with a history of colorectal neoplasms.

Key Words: Oral feeding • Colorectal • Colectomy • Postoperative


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Traditionally after abdominal surgery, the passage of flatus or bowel movement was the clinical evidence for starting an oral diet. The resolution of postoperative ileus defined by the passage of flatus was in the order of 5 days. With the advent of laparoscopic colectomy, patients have been fed routinely by postoperative day 2.1,2 Studies were undertaken to evaluate whether open colectomy patients could benefit from early feeding. These studies have demonstrated that early postoperative oral feeding is feasible.3–8

Laparoscopic surgery has been shown to reduce length of stay after surgery, with a resultant reduction in cost.9,10 A potential benefit of early oral feeding in open abdominal surgery would be a reduced hospital stay, leading to a reduction in hospital cost.

DiFronzo et al.,3 in a prospective series of 200 patients, demonstrated a high tolerability (86.5%) to early postoperative oral feeding after elective open colon resection. We initiated our study with the intent of confirming the previous findings. In addition, we attempted to identify variables that may preclude early postoperative oral feeding.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
One hundred four consecutive patients undergoing elective surgery by the colorectal service at Roswell Park Cancer Institute were prospectively evaluated from October 1999 to January 2001. The majority of patients had epidural catheters inserted before the induction of general anesthesia. After the planned surgery, the nasogastric tube was removed in the recovery room. Early postoperative oral feeding was administered by giving a full liquid diet on either postoperative day 1 or 2. No promotility agent was used. The amount of oral intake was recorded. No limit for oral intake was established. The full liquid diet was advanced as tolerated to a regular diet.

The perioperative variables that were evaluated consisted of age, sex, American Society of Anesthesiology score, length of operative time, estimated intraoperative blood loss, amount of intraoperative fluid received, type of surgical procedure, and type of postoperative pain control. Estimated blood loss was categorized for blood loss of <250 ml, 250 to 500 ml, and >500 ml. The subcategories were chosen to correspond to the usual criteria for possible blood replacement for significant blood loss. Similarly, operating time was subcategorized to <4 hours and >4 hours to reflect the increased amount of fluid shift after 4 hours of an open abdominal operation.

The hospital course was documented. Through patient interviews and physical examination, tolerance to early postoperative oral feeding was documented. Intolerance to early postoperative feeding was defined as the patient’s having either nausea or vomiting. In addition, if the patient was readmitted because of a gastrointestinal complaint, early postoperative oral feeding was considered a failure.

The variables were analyzed with the SPSS statistical package.11 The Mann-Whitney U-test12 was used for the continuous data. For the categorical data, {chi}2 tests (with Fischer’s exact test, where appropriate) were used. All P values are unadjusted for multiple comparisons.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
One hundred four patients were evaluated during our study period. Fifteen patients were excluded for the following reasons: small-bowel resection (five patients), early perioperative complications (five patients), prior pelvic radiation (three patients), and small-bowel obstruction (two patients). The early perioperative complications were open abdominal wound for poor bowel preparation (two patients), sepsis (one patient), ischemic heart disease (one patient), and a postoperative pelvic hemorrhage (one patient).

Eighty-nine patients were fed with a full liquid diet. Twenty-one patients were fed on postoperative day 1, and 64 patients were fed on postoperative day 2. Three patients were fed on postoperative day 3, and one patient was fed on postoperative day 4. These four patients who did not have documented early postoperative oral feeding were excluded from analysis. Surgical procedures performed on these patients are listed in Table 1. The most common procedures were right colectomy, low anterior resection, and sigmoid resection.


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  		TABLE 1. Type of surgical procedure
 
There were 45 male patients (50%) and 44 female patients. The mean age was 65 years (range, 28–87 years). The mean hospital stay was 6 days. Sixty-five patients (73%) tolerated early postoperative oral feeding. Their mean hospital stay was 5 days (range, 3–13 day). Twenty-four patients (27%) failed early postoperative oral feeding. The mean hospital stay for patients who failed was 8 days (range, 4–13 days). Sixteen of the 24 patients who failed had nausea or vomiting, requiring that the patient be non-per oral status. Eight of 24 patients required readmission to the hospital for the following reasons: anastomotic bowel leak (two patients), abdominal wound dehiscence (one patient), abdominal pain (one patient), and small-bowel obstruction (four patients).

The perioperative variables evaluated are listed in Table 2 and Table 3. By use of the Mann-Whitney and Fisher’s exact tests, the only variable that had a significant difference for the patients who failed early oral feeding was the amount of volume expander solution received during surgery. The average amount of volume expander used in patients who failed early oral feeding was 170 ml, compared with 38 ml used in patients who tolerated early oral feeding.


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  		TABLE 2. Variables analyzed
 

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  		TABLE 3. Variables analyzed with the Mann-Whitney (mean rank test)a
 
A logistical regression analysis of the variables is listed in Table 4. When entered in a multivariate analysis, the only variable that had significance in successful early oral postoperative feeding was the amount of estimated blood loss.


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  		TABLE 4. Multivariate analysis
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
There has been a trend toward earlier oral feeding in postabdominal surgery patients in the recent decade. Traditionally, surgeons waited for the resolution of postoperative ileus with nasogastric tube decompression. The routine use of nasogastric decompression after colorectal surgery became a myth with studies showing its limited role in postoperative care for abdominal surgery.13,14 The resumption of bowel activity with the return of function in the small bowel and stomach within 48 hours after abdominal surgery has been well documented.15,16 With the advent of the laparoscopy era, several studies demonstrated that early oral feeding was possible for patients who underwent laparoscopic colon resection.5,9,17,18 Clinical pathways were used for those patients who underwent laparoscopic resection, and patients were usually fed by 48 hours after surgery regardless of clinical documentation of bowel activity as manifested by flatus or bowel movement. This provided the rationale for oral feeding 48 hours after laparoscopic resection.

To investigate whether there was a difference in ileus pattern between postlaparoscopy and post-open abdominal surgery patients, Milsom et al.17 performed a randomized trial that demonstrated a significantly shorter time to first flatus for patients who underwent laparoscopic surgery, but no significant difference in time to first bowel movement. In the same study, there was no difference in the length of hospital stay for both groups of patients.

To evaluate whether the feeding pattern administered to laparoscopic surgery patients could be applied to open-abdominal surgery patients, Reissman et al.19 performed a randomized study in which there was no difference in the frequency of vomiting or nasogastric tube reinsertion. In addition, the authors did not find a statistical difference in time to resolution of ileus nor in length of hospital stay.

DiFronzo et al.3 prospectively analyzed 200 patients during a 5-year period and demonstrated that >80% of the patients tolerated early oral feeding with no complications after colon surgery. They defined early postoperative oral feeding as clear liquid diet on postoperative day 2, with advancement of diet as tolerated. In that series, multivariate analysis showed that being male and undergoing a total colectomy were the two factors associated with early postoperative oral feeding intolerance.3 This could have been caused by increased oral intake by male patients or prolonged ileus from the retroperitoneal dissection after abdominal colectomy.

In our study, 73% of the patients tolerated early postoperative oral feeding without sequelae. We have used readmission as a criterion for failure of early postoperative oral feeding. Re-examination of the data for the patients readmitted showed three patients requiring reoperation (one for anastomotic leak, one for lysis of adhesions, and one for closure of an abdominal wound dehiscence), with the rest of the patients presenting with problems that were treated conservatively. If we narrowed the criteria of failing early postoperative oral feeding to patients who had nausea or vomiting after surgery and to patients who underwent reoperation, we would have a tolerability rate of 78%.

To minimize the morbidity of postoperative nausea or vomiting, we tried to identify factors that may contribute to intolerance of early oral feeding. Our univariate analysis of the data showed that patients who failed early oral feeding received more volume expanders than patients who tolerated early feeding. The volume expanders we used during surgery consisted of hepastarch (Hespan, Baxter Pharmaceutical, New Providence, NJ) and albumin solutions. The average amount of volume expander used in patients who failed early oral feeding was 170 ml, compared with 38 ml used in patients who tolerated early oral feeding. One may hypothesize that the volume expanders used contributed to additional bowel wall edema and subsequently prolonged the length of the ileus. However, we are not certain of the clinical significance of this finding.

In the logistical regression model, the effect of the colloid infusion was not significant. The only factor that had a significant difference on multivariate analysis was the estimated amount of blood loss. This may be related to the volume required to replenish the blood loss incurred during the operation, leading to an increase in third-space fluid content. This, as proposed previously, may lead to a prolongation of the ileus.

We had anticipated that the difference in postoperative analgesia may effect the outcome of early postoperative oral feeding. The majority of our patients had an epidural catheter placed before the induction of general anesthesia. The infusion through the catheter was initiated before the termination of the surgery. The typical epidural infusate consisted of morphine or hydromorphone and bupivacaine. The infusion continued at a prescribed rate and was adjusted appropriately for pain level by the pain team. An epidural catheter was not placed in 10 patients for reasons not ascertained. These patients had patient-controlled analgesia infused through an intravenous access line for their postoperative pain control. The agents we often used were morphine or hydromorphone. There was a trend for more successful outcome in early postoperative oral feeding for patients with an epidural catheter, but no statistical significance was reached (P = .33).

Other perioperative factors, such as the amount of oral intake when feeding was resumed, could explain why the number of patients who failed early postoperative oral feeding did not reach statistical significance in our study. Factors such as previous abdominal surgeries or concomitant surgery performed during colon resection also did not affect the outcome of early postoperative oral feeding.

In contrast to the study by DiFronzo et al.,3 we did not find male sex to have an effect on whether patients would tolerate early oral feeding. The type of surgery did have an effect on the outcome of early postoperative oral feeding in their study. Total abdominal colectomy was associated with a significantly higher percentage of intolerance to early feeding compared with other types of resection. This may be caused by the extent of retroperitoneal dissection. In our report, three patients underwent a total colectomy, and one of them developed nausea after early oral feeding on postoperative day 2. In our study, left- or right-sided resection did not affect the outcome (P = .07).

One factor we did not analyze was the length of the abdominal incision. A recent analysis by Cali et al.20 did not find the length of incision to be a significant factor for the return of bowel function.

We believe, on the basis of our current experience and previously published results, that a regimented oral feeding protocol can be followed in postcolorectal surgery cancer patients. We now have a program to prospectively follow patients with oral feeding beginning on the first postoperative day after elective colorectal surgery in cancer patients. We have continued the use of epidural catheter insertion as the primary means of postoperative pain control.

In our experience with early postoperative feeding, we have encountered patients who were reluctant to have early oral intake. On the basis of this, we have begun to advise patients of the likelihood of being fed early on in the postoperative period during their preoperative visit. An established patient-teaching protocol can address this as well as other perioperative concerns that may help to allay unfounded fears of early postoperative feeding.

Patients with small-bowel resections were excluded from our early postoperative oral feeding protocol because of the fear of possible anastomotic bowel leakage. Knowing that small bowel ileus resolves early in the postoperative period, feeding patients after small bowel resection will be an extension of this postoperative feeding protocol.


   Footnotes
 
Presented in part at the 54th Annual Cancer Symposium of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.

Received for publication March 16, 2001. Accepted for publication June 20, 2001.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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