Early Feeding and the Incidence of Gastrointestinal Symptoms After Major Gynecologic Surgery
ABSTRACT & COMMENTARY
Macmillan and associates have reported the findings of a study in which they compared early feeding with traditional postoperative dietary management for development of postoperative gastrointestinal symptoms after major gynecologic surgery for benign conditions. Women were randomly allocated to early feeding of low residue diets six hours postoperatively or traditional dietary management of clear liquids with normal bowel sounds, and regular diet with passage of flatus. Demographic data were collected, and women answered questionnaires on their perception of bowel function and pain. Complete data were available for 139 women—67 allocated to the early feeding group and 72 to the late feeding group. The incidence of postoperative ileus for the study population was 4.4% and did not differ between groups (early 3% vs late 5.8%; P = 0.68). There were no differences in patient demographics, surgical procedures, anesthesia used, and intraoperative complications between groups. With the exception of more complaints of nausea in the late feeding group (23% vs 13%; P = 0.04), there were no differences in other postoperative complications, pain medicine, requirements, fluid and caloric intake, median pain scores, and gastrointestinal function. The low incidence of perioperative complications made the power to detect differences between groups low. MacMillan et al concluded that low residue diet six hours after major gynecologic surgery for benign indications was not associated with increased postoperative gastrointestinal complaints, including ileus. (MacMillan SLM, et al. Obstet Gynecol 2000;96:604-608).
Comment by David M. Gershenson, MD
This study confirms other recent studies of patients who undergo major abdominal surgeries: early feeding is consistently not associated with an increased incidence of gastrointestinal problems, including ileus. The findings of these studies shatter time-honored practices of withholding feeding until the patient has active bowel sounds or passes flatus. We must overlook the fact that the impetus for several of these studies was the pressure for early discharge exerted by HMOs (and based on no prospective data). In fact, for many major abdominal procedures, including oncologic surgeries, shorter hospital stays have been proven to be safe and cost-effective. It should be pointed out that, for purposes of this study, patients with histories of malignancy, inflammatory bowel disease or obstruction, or those with current or past surgeries that involved extensive lysis of adhesions of the bowel were excluded. The incidence of ileus was 4.4% in this study, with an incidence of severe ileus of 0.7%. That fits with my experience in gynecologic oncology patients. For patients who do develop postoperative ileus, management should initially include supportive care consisting of no oral intake, intravenous hydration, and antiemetics. Radiologic studies should be used as needed. If the patient has vomiting despite these measures, a nasogastric tube should be placed.
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