ABSTRACT & COMMENTARIES
There were no significant differences between the two groups with regard to underlying medical conditions, prior abdominal surgery, or diagnosis of malignancy. No difference was found in the number of subjects who required postoperative antiemetics. There was a statistically significant reduction in the length-of-stay for those patients on the early feeding regimen-average, 4.02 days (group 1) vs. 3.12 days (group 2). While there was a significantly higher incidence of emesis in the study group, this was not associated with any untoward outcome. Schilder et al conclude that early postoperative oral intake results in a decreased length of hospitalization and is well tolerated when compared with traditional dietary management in patients undergoing abdominal surgery on a university gynecologic oncology service. (Schilder JM, et al. Gynecol Oncol 1997;67:235-240.)
COMMENT BY DAVID M. GERSHENSON, MD
More than almost any practice within gynecology, the timing of postoperative feeding has been based on tradition rather than on scientific data. All of us learned patterns of practice during our residencies from senior trainees and attending gynecologists. Until the past few years, it was standard practice to place a nasogastric tube intraoperatively during major abdominal gynecologic surgery and to remove it only when the patient demonstrated signs of bowel function, good bowel sounds, flatus, and bowel movement. However, potential advantages of early feeding include improved wound healing related to better nutrition, diminished discomfort, shorter hospital stay, and enhanced patient satisfaction.Potential concerns of such an approach include prolonged ileus, aspiration, anastomotic leaks, and wound disruption. The traditional method has been challenged over the past few years by studies in the general surgery literature showing that early feeding is beneficial and safe. Such studies were most likely at least partially driven by the managed care environment and the pressure toward cost containment through early hospital discharge. Nevertheless, those studies and the present report support the benefits of early postoperative feeding after relatively uncomplicated abdominal surgery. Importantly, however, this study excluded gynecologic patients who had received prior irradiation or who had intestinal resection. Early postoperative feeding needs to be studied prospectively in these cohorts and in patients who undergo extensive retroperitoneal dissection.
COMMENT BY KENNETH NOLLER, MD
I absolutely love this paper. It is simple and straightforward, and the conclusions may well improve the medical care of most women who have had abdominal gynecological surgery. There is no doubt that we could feed most women earlier following such procedures, just as it has previously been documented that we could feed patients who have undergone cesarean section much earlier. Patients are happier when they are fed earlier (not studied in this paper, but documented in others) and leave the hospital on average a day sooner.To the authors' credit, this study was not motivated by cost containment. However, as noted in the discussion section, the fact that most of the women who were fed early left the hospital a day earlier certainly does reduce costs. Indeed, for all that we complain about the changes that are occurring in medicine due to restriction of funding, some changes have actually resulted in improved patient care. For example, while some of the shortened hospital stays have been over-ambitious, overall, patients have benefited from leaving the hospital earlier. I think we have learned that, as long as you treat patients as if they are sick, they will act as if they are sick.
The final comment of Schilder et al was interesting. Their study so
effectively demonstrated that early feeding was beneficial to patients
that, by the end of the study, it was difficult to enroll control patients
because the physicians in their hospital had routinely begun to practice
differently.
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