Not all studies have reported similar findings. Several concluded that other, nonmedical reasons, such as insurance requirements, accounted for the shorter hospital stays in many patients receiving early feeding.
TABLE 1
Complication rates associated with early feeding versus traditional management
| COMPLICATION | EARLY FEEDING* (N=92) | TRADITIONAL MANAGEMENT· (N= 103) |
|---|---|---|
| Nausea | 43.5% | 24.3% |
| Nasogastric tube use | 3.3% | 6.7% |
| Febrile morbidity | 54.3% | 55.3% |
| Pneumonia | 0% | 1.9% |
| Wound complications | 21.7% | 21.4% |
| Atelectasis | 8.7% | 10.7% |
| Length of hospital stay (mean±standard deviation) | 4.6±2.1 | 5.8±2.7 |
| *Clear liquid diet on postoperative day 1 | ||
| †Feeding delayed until return of bowel function | ||
| Reprinted from Obstet Gyn; vol 92; Pearl ML, Valea FA, Fischer M, Mahler L, Chalas E. A randomized controlled trial of early postoperative feeding in gynecologic oncology patients undergoing intraabdominal surgery; pages 94-97; copyright 1998; with permission from American College of Obstetricians and Gynecologists. | ||
Nasogastric tubes only when indicated
The use of NG tubes after laparotomy has been studied extensively. A review of the literature suggests that routine placement of the tubes in asymptomatic patients is not justified and may possibly be harmful.10
In their meta-analysis of the issue, Cheatham et al11 showed that although abdominal distension and vomiting are more frequent in patients who forgo NG tubes postoperatively, fever, atelectasis, and pneumonia are less common, and the interval between surgery and oral feeding is reduced (TABLE 2).
The authors concluded that for every NG tube inserted after abdominal surgery, at least 20 patients can be managed without it.
Forgoing an NG tube also lowers the risk of pulmonary complications, which increases 10-fold when a tube is inserted.12
TABLE 2
Complications associated with selective versus routine NG tube placement
| SELECTIVE PLACEMENT (N) | ROUTINE PLACEMENT (N) | P VALUE | RELATIVE RISK | |
|---|---|---|---|---|
| Patients | 1,986 | 1,978 | ||
| Tubes placed/replaced | 103 | 36 | <.001> | 2.9 |
| Complications | 833 | 1,084 | .03 | 0.76 |
| Deaths | 13 | 25 | .22 | 0.36 |
| Pneumonia | 53 | 119 | <.0001> | 0.49 |
| Atelectasis | 44 | 94 | .001 | 0.46 |
| Fever | 108 | 212 | .02 | 0.51 |
| Vomiting | 201 | 168 | .11 | 1.19 |
| Oral feedings (days) | 3.53 | 4.59 | .04 | |
| Length of stay (days) | 9.32 | 10.1 | .22 | |
| NG=nasogastric | ||||
| Reprinted with permission from Cheatham ML, Chapman WC, Key SP, Sawyer JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995:221:469-478. | ||||
Continue the epidural anesthetic
A number of experts believe that postoperative ileus is caused by stimulation of neural reflexes, which appear to be of 2 kinds: afferent stimuli to the spinal cord and efferent stimuli to the intestines through the sympathetic nervous system. The latter inhibits motility of the intestinal tract. Numerous studies demonstrate that this sympathetic reflex can be blocked by the use of epidural anesthesia.10
For example, Holte et al4 found that postoperative administration of thoracic epidural blockade with local anesthesia significantly reduced both ileus and pulmonary complications. They concluded that continuous epidural anesthesia with local anesthesia and minimally invasive surgery are the 2 most critical events in reducing postoperative ileus.
In a Cochrane review, Jorgensen and colleagues12 compared the effects of epidural local anesthesia and opioid-based analgesic regimens on postoperative gastrointestinal paralysis, nausea and vomiting, and pain after abdominal surgery (TABLE 3). Epidural local anesthetics reduced gastrointestinal paralysis, as compared with systemic or epidural opioids, but provided the same postoperative pain relief. They also found that the addition of opioids to local epidural anesthesia provided superior postoperative analgesia—compared with epidural local anesthetics alone—without increasing the likelihood of ileus.
A study10 of patients undergoing colectomy found postoperative ileus was prevented or decreased with a 2-day regimen that included:
- continuous thoracic epidural anesthesia for 48 hours;
- withholding NG tubes;
- having the patient drink a liter of fluid on the day of surgery;
- initiating feeding after 24 hours;
- administering milk of magnesia; and
- mobilization after 8 hours, if possible.
Physicians in this study also used transverse surgical incisions to reduce pain and pulmonary problems.
TABLE 3
Anesthetic effect on GI function, postoperative pain, and nausea and vomiting: A comparison
| ANESTHETIC | GI FUNCTION RETURNS | PAIN RELIEF | NAUSEA AND VOMITING |
|---|---|---|---|
| Epidural plus local | 24 hr | Comparable | No significant difference |
| Epidural plus opioids | 37 hr | Comparable | No significant difference |
| Systemic plus opioids | 37 hr | Comparable | No significant difference |
| GI=gastrointestinal | |||
| Data from Jorgensen H, et al12 | |||
Clinical recommendations
The deregulation of the autonomic nervous system during surgery alters the gastrointestinal tract postoperatively, with neurotransmitters, local factors, and hormones playing a large role. Some forms of anesthesia also contribute to postoperative ileus, as does the use of narcotic analgesia after surgery.
The most efficient ways to activate the bowel postoperatively are:
- Continuing the thoracic epidural from 24 to 48 hours, which increases the splanchnic blood flow and blocks afferent and efferent sympathetic inhibitory nerve impulses. Note, however, that comparative studies of thoracic epidural anesthesia with local anesthesia are needed to quantify its impact.
- Hydrating the patient with a large amount of fluid in the first 24 hours after surgery.
Following these steps routinely can significantly decrease the risk of postoperative ileus and thus its resulting complications.