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Journal of Indian Association of Pediatric Surgeons
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Year : 2023  |  Volume : 28  |  Issue : 5  |  Page : 392-396

Outcomes of early oral feeding compared to delayed feeding in children after elective distal bowel anastomosis

1 Department of Pediatric Surgery, AIIMS, Jodhpur, Rajasthan, India
2 Department of Pediatric Surgery, University Hospitals of Leicester, NHS, UK

Date of Submission23-Jan-2023
Date of Decision13-Mar-2023
Date of Acceptance21-Mar-2023
Date of Web Publication05-Sep-2023

Correspondence Address:
Kirtikumar J Rathod
Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.jiaps_19_23

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Background: Conventionally, oral feeds after distal bowel anastomosis surgery (ileostomy/colostomy closure) are delayed until after bowel peristalsis is established. The safety of an early feeding regimen is not established in children. This study compared early feeding regimens with delayed feeding in children undergoing elective intestinal anastomosis surgeries.
Materials and Methods: In this retrospective multicentric cohort study, children undergoing elective distal bowel anastomosis surgery were divided into Group A (oral feeds allowed within 6 h) and Group B (delayed feeds). The two groups were compared for the incidence of abdomen distension, vomiting, surgical site infection, duration of analgesia, length of hospital stay, and readmission rate.
Results: During the study, 58 patients were included: Group A (n = 26) and Group B (n = 32). The duration of analgesia (1.9 vs. 4.01 days) and length of hospital stay (3.38 vs. 5.0 days) were significantly less in Group A. Abdominal distension (7.7% vs. 15.6%), vomiting (11.5% vs. 15.6%), surgical site infection rate (3.8% vs. 12.5%), and readmissions (0% vs. 3.1%) were less in Group A, but statistically not significant.
Conclusion: Early feeding after the elective restoration of distal bowel continuity can be safely practiced in the pediatric population. It is associated with a reduced need for analgesia and shorter hospital stay.

Keywords: Early feeding regimen, intestinal anastomosis, restoration of bowel continuity

How to cite this article:
Jayakumar T K, Rathod KJ, Eradi B, Sinha A. Outcomes of early oral feeding compared to delayed feeding in children after elective distal bowel anastomosis. J Indian Assoc Pediatr Surg 2023;28:392-6

How to cite this URL:
Jayakumar T K, Rathod KJ, Eradi B, Sinha A. Outcomes of early oral feeding compared to delayed feeding in children after elective distal bowel anastomosis. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Oct 2];28:392-6. Available from: https://www.jiaps.com/text.asp?2023/28/5/392/385143

   Introduction Top

Elective intestinal anastomosis is one of the most common surgeries done in children. Intestinal stomas in the form of colostomy or ileostomy are done in children with conditions such as anorectal malformations, Hirschsprung disease, necrotizing enterocolitis, intestinal perforation, intestinal obstruction, and trauma. These patients need elective laparotomy to restore bowel continuity once they are stabilized, or definitive surgery has been done.

After stoma closure, traditionally, these patients fast for 3–5 days until the intestinal peristalsis is evident. The presence of bowel sounds or the passage of flatus or stool is considered a marker of the establishment of peristalsis; however, these criteria are not reliable.[1] Although there is little evidence behind this obligatory fasting period, the concerns behind this tradition are abdominal distension, vomiting, aspiration, and anastomotic leak. Anastomotic leak is often the most worrisome complication for a surgeon. Several adult studies showed evidence that early enteral feeding has successfully reduced complications rate and was found to be beneficial to patients undergoing laparotomies and bowel anastomosis. There have been similar trends in adapting early oral feeding in the pediatric population.[2] Although robust evidence of additional advantages from early feeding is absent, clearly, there are no disadvantages.[3] These studies are very limited, and the available evidence indicates that this approach can be replicated in children. The aim of this study was to compare the outcomes of the early feeding regimen with the delayed feeding after elective distal bowel anastomosis surgery.

   Materials and Methods Top

This is a multicenter study, conducted in the two tertiary care centers, Department of Pediatric Surgery in All India Institute of Medical Sciences (Jodhpur, India) and University Hospitals of Leicester (NHS, UK). During the study period between January 2015 and July 2018, a retrospective chart review was done to identify the patients younger than 18 years of age who underwent surgeries for reversal of stoma, i.e., restoration of bowel continuity by intestinal anastomosis, either for colostomy or ileostomy. Common diagnoses included anorectal malformations, Hirschsprung disease, necrotizing enterocolitis, intestinal perforation, trauma, and small bowel atresia. Stomas done for patients with gastroschisis were excluded from the study.

All of these surgeries were done electively. No mechanical bowel preparation was done. Preoperatively, patients fasted for 6 h for solid food and top feeds, 4 h for breast milk, and 2 h for clear liquids. Preoperatively, prophylactic antibiotics were given to all the patients. Under general anesthesia, all these patients underwent laparotomy to mobilize the stoma, revision of intestinal ends, and end-to-end anastomosis in a single layer with number 4–0 or 5–0, polydioxanone or polyglactin sutures. The nasogastric tube was removed in the operation theater. Postoperative medications included intravenous fluids, antibiotics (only two doses), antiemetics as demanded, and paracetamol injections for analgesia.

The postoperative oral feeding policy differed between two groups of operating surgeons. One group of surgeons (the author's) started early feeding; the other group followed traditional delayed feeding. Patients were divided into two cohorts based on the time of initiation of oral feeds. Group A received oral feeds in the postoperative period after the effect of anesthesia has worn off, and the child is fully awake, which is always within 6 h. Feeds were given as demanded by the patient, and the feeding pattern did not differ compared to the preoperative period. Group B patients were kept nil-by-mouth, routinely during the postoperative period. These patients were observed for the establishment of peristalsis (bowel sounds/passage of flatus or stool). Once the bowel peristalsis is evident, feeds were started in these patients. Patients were discharged once the full feeds were established and had no complaints. Follow-up was done in the outpatient department.

Variables compared between these two groups were age, type of stoma, incidences of abdominal distension, vomiting, surgical site infection, length of hospital stay, duration of analgesia requirement, and readmissions.

All the data were entered in a Microsoft Excel sheet and analyzed using a SPSS® statistics editor Version 23.0, IBM® Corporation, Armonk, NY, USA. All continuous data are described as mean (standard deviation [SD]) and compared using the t-test and Fisher's exact test for comparing the proportions. P < 0.05 was considered statistically significant. Ethical clearance has been obtained to use the patient data.

   Results Top

During the study, 58 patients underwent elective distal bowel anastomosis surgery. Group A (early oral feeding) had 26 patients, while there were 32 patients in Group B (delayed feeding).

The mean (SD) age of patients in Group A was 26.4 (±8.2) months, and in Group B was 30.1 (±10.4) months (P = 0.59). The number of patients with ileostomies and colostomies was six and 20, respectively, in Group A; in Group B, there was six and 26, respectively (P = 0.74).

Abdominal distension was seen among two (7.7%) patients in Group A and 5 (15.6%) patients in Group B (P = 0.44). Vomiting was complained by 3 (11.5%) patients in Group A and 5 (15.6%) patients in Group B, (P = 0.71).

Surgical site infection was reported in 1 (3.8%) patient from Group A and 4 (12.5%) patients from Group B (P = 0.36).

The mean (SD) duration of requirement of analgesia was significantly shorter (P = 0.0001) in Group A, which was 1.9 (±0.7) days, compared to group B, which was 4.01 (±1.4) days. The mean (SD) length of hospital stay was significantly less (P = 0.001) in Group A, 3.38 (±1.7) days, compared to Group B, 5.0 (±1.59) days.

One patient in Group B was readmitted for deep surgical site infection (classification by the Centers for Disease Control). [Table 1] shows the comparison of various study parameters in both groups.
Table 1: Comparison of parameters between Group A and Group B

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   Discussion Top

Delayed feeding after laparotomies, especially after intestinal anastomosis surgeries, has been a traditional norm, still being practiced widely, including our institution. Reasons for delaying the feeds are that it helps in giving adequate rest to the bowel to recover from postoperative ileus and protection of anastomosis. This led to apprehension that early feeding in these patients will lead to abdominal distension, nausea, vomiting, or in worse situation, aspiration and pneumonia.[4] However, there is a little evidence to prove that these complications can aggravate due to early feeding, at least in elective cases. One of the earliest studies showed that enteral nutrition can be started as early as 24 h after colorectal surgery, and recovery from ileus occurs within 48 h.[5] Several adult studies reported similar results.[6],[7] The 2017 European Society for Clinical Nutrition and Metabolism guidelines state that postoperative oral nutrition should not be interrupted as a routine.[8] Although initial systematic review and meta-analyses of studies among pediatric population were not clearly able to demonstrate the benefits of early enteral feeding,[3] the recent analyses have started to show these benefits.[9] A comparison of our data with the available literature is summarised [Table 2].
Table 2: Comparison of various studies assessing early enteral feeding after intestinal anastomosis

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There are multiple causative factors of postoperative ileus. Among them are the anesthetic agents, intraoperative bowel manipulation, local inflammation, opioids, nasogastric intubation, and lack of gut stimulation due to fasting.[10] Elective intestinal anastomosis surgeries involve little manipulation of bowel, tissue trauma, and contamination. Even nasogastric intubation is not required postoperatively; in fact, it can be detrimental in surgeries involving distal bowel.[11],[12] Postoperative fasting for 3–5 days often leads to a catabolic state, malnutrition, weight loss, and reduced immunity.[13] It causes severe discomfort to the children as they do not tolerate starvation for long periods like adults and increases parental anxiety.[14] Prolonged intravenous fluid administration in the due time can lead to fluid and electrolyte imbalances.[3] On the contrary, early initiation of enteral feeds leads to faster recovery from ileus, early establishment of full feeds, and reduced septic complications.[13]

In our study, early feeding was started within 6 h after surgery. Infants were allowed to breastfeed once they were fully awake. Unlike other studies where the feeding pattern was protocolized, in our study population, the author allowed feeds as per the patient's appetite.[13],[15] The feeding was similar to that preoperatively, which means that the patients in this group achieved full feeds immediately. Abdominal distension and vomiting observed in early feeding group were not significantly different compared to the delayed feeding group. These symptoms were managed conservatively by temporarily withholding feeds and antiemetics. Once the symptoms resolved, feeding was restarted as demanded by the patients. Patients in both the groups did not require reinsertion of the nasogastric tube. Perhaps early feeding led to early resolution of ileus. Similar findings were observed in other studies as well.[13],[15],[16],[17] In other studies, early feeding was associated with a shorter duration of parenteral nutrition, and considered it a safe practice.[18],[19],[20],[21]

The duration of analgesia requirement was significantly less in early feeding group. Although the exact cause of this effect is not understood, our knowledge from the literature indicates that early oral feeds might have stimulated the gut and resolved the postoperative ileus.[4],[10] Other factors indirectly contributing to this may be the absence of nasogastric tube and decreased anxiety due to early initiation of feeds.

In our study, the length of hospital stay was significantly less in the early feeding group. This finding has been observed in previous studies.[12],[13],[15],[16],[17] In our experience, the additional days of hospital stay might impose financial burden on the patient's family, due to the parents missing their work and daily earnings.

Surgical site infections and anastomotic leakage are other complications, which are dreaded in patients undergoing stoma closure. In our study, the incidence of surgical site infection was not significantly different between the two groups. Since patients in both the groups are electively operated, and contamination is negligible, the incidence has been less. In a similar study, septic complications were reduced in patients who receive early feeding. The incidence of fever (12.9% vs. 42%) and wound infection (6.5% vs. 29%) was significantly less in early feeding group compared to delayed feeding group, while anastomotic leakage was seen in one patient from each group.[13]

Even in fasting state, a large amount of fluids are secreted within the gut.[22] When the anastomosis can tolerate these secretions, addition of some feeds should not affect it. Studies conducted in animal models have shown that early feeding is associated with higher anastomotic strength and beneficial cytokine profile.[23],[24]

Anastomotic leak was not reported in both groups of our study. Although there is no evidence to claim that traditional delayed feeding protects the anastomosis, the belief among surgeons is strong on this due to apprehension. Studies in adults have reported a fewer septic complications and early recovery with early oral feeding, with a fewer anastomotic leaks.[25]

Our study has the limitations of a retrospective study. The population of the study is heterogeneous. The time of initiation of the feeds was observed, but the time to achieve full feeds was not measured.

   Conclusion Top

Early oral feeding after elective intestinal anastomosis surgery is a safe practice. It is associated with significant reduction in need for analgesia and duration of hospital stay. It is safe to recommend that children undergoing elective distal bowel anastomosis for stoma closure can be started on oral feeds as early as within 6 h. Better evidence can be established with protocol-driven randomized controlled studies in future.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Holte K, Kehlet H. Postoperative ileus: A preventable event. Br J Surg 2000;87:1480-93.  Back to cited text no. 1
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.  Back to cited text no. 2
Braungart S, Siminas S. Early enteral nutrition following gastrointestinal surgery in children: A systematic review of the literature. Ann Surg 2020;272:377-83.  Back to cited text no. 3
Kehlet H, Holte K. Review of postoperative ileus. Am J Surg 2001;182:3S-10S.  Back to cited text no. 4
Moss G. Maintenance of gastrointestinal function after bowel surgery and immediate enteral full nutrition. II. Clinical experience, with objective demonstration of intestinal absorption and motility. JPEN J Parenter Enteral Nutr 1981;5:215-20.  Back to cited text no. 5
Herbert G, Perry R, Andersen HK, Atkinson C, Penfold C, Lewis SJ, et al. Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications. Cochrane Database Syst Rev 2019;7:CD004080.  Back to cited text no. 6
Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev 2006;4:CD004080.  Back to cited text no. 7
Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017;36:623-50.  Back to cited text no. 8
Greer D, Karunaratne YG, Karpelowsky J, Adams S. Early enteral feeding after pediatric abdominal surgery: A systematic review of the literature. J Pediatr Surg 2020;55:1180-7.  Back to cited text no. 9
Mattei P, Rombeau JL. Review of the pathophysiology and management of postoperative ileus. World J Surg 2006;30:1382-91.  Back to cited text no. 10
Davila-Perez R, Bracho-Blanchet E, Tovilla-Mercado JM, Hernandez-Plata JA, Reyes-Lopez A, Nieto-Zermeño J. Unnecessary gastric decompression in distal elective bowel anastomoses in children: A randomized study. World J Surg 2010;34:947-53.  Back to cited text no. 11
Zhou T, Wu XT, Zhou YJ, Huang X, Fan W, Li YC. Early removing gastrointestinal decompression and early oral feeding improve patients' rehabilitation after colorectostomy. World J Gastroenterol 2006;12:2459-63.  Back to cited text no. 12
Yadav PS, Choudhury SR, Grover JK, Gupta A, Chadha R, Sigalet DL. Early feeding in pediatric patients following stoma closure in a resource limited environment. J Pediatr Surg 2013;48:977-82.  Back to cited text no. 13
Klemetti S, Suominen T. Fasting in paediatric ambulatory surgery. Int J Nurs Pract 2008;14:47-56.  Back to cited text no. 14
Sangkhathat S, Patrapinyokul S, Tadyathikom K. Early enteral feeding after closure of colostomy in pediatric patients. J Pediatr Surg 2003;38:1516-9.  Back to cited text no. 15
Ekingen G, Ceran C, Guvenc BH, Tuzlaci A, Kahraman H. Early enteral feeding in newborn surgical patients. Nutrition 2005;21:142-6.  Back to cited text no. 16
Mamatha B, Alladi A. Early oral feeding in pediatric intestinal anastomosis. Indian J Surg 2015;77:670-2.  Back to cited text no. 17
Shang Q, Geng Q, Zhang X, Xu H, Guo C. The impact of early enteral nutrition on pediatric patients undergoing gastrointestinal anastomosis a propensity score matching analysis. Medicine (Baltimore) 2018;97:e0045.  Back to cited text no. 18
Amanollahi O, Azizi B. The comparative study of the outcomes of early and late oral feeding in intestinal anastomosis surgeries in children. Afr J Paediatr Surg 2013;10:74-7.  Back to cited text no. 19
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Davila-Perez R, Bracho-Blanchet E, Galindo-Rocha F, Tovilla-Mercado J, Varela-Fascinetto G, Fernandez-Portilla E, et al. Early feeding versus 5-day fasting after distal elective bowel anastomoses in children. A randomized controlled trial. Surg Sci 2013;4:45-8.  Back to cited text no. 20
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Khalili TM, Navarro RA, Middleton Y, Margulies DR. Early postoperative enteral feeding increases anastomotic strength in a peritonitis model. Am J Surg 2001;182:621-4.  Back to cited text no. 23
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Wallace B, Schuepbach F, Gaukel S, Marwan AI, Staerkle RF, Vuille-Dit-Bille RN. Evidence according to cochrane systematic reviews on alterable risk factors for anastomotic leakage in colorectal surgery. Gastroenterol Res Pract 2020;2020:1–15.  Back to cited text no. 25


  [Table 1], [Table 2]


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