| Abstract|| |
Background: A leakage of intestinal anastomosis is typically regarded as a devastating post-operative complication. Traditionally its believed that long fasting after intestinal surgery protect anastomosis site and most surgeons applied this method. Post-operative long fasting has many physical and mental adverse effects, especially in children, but its benefit has not proven yet. This study aimed to compare the outcomes of early and late oral feeding in intestinal resection and anastomosis surgery in children. Patients and Methods: This randomized, double-blind controlled trial evaluated the outcome of early-feeding following in children aged 1 month to 12 years who underwent intestinal resection and anastomosis and compared the results with those who had late-feeding. The results were anlysed for fever, nausea and vomiting, abdominal distension, first passage of gas and stool were also evaluated hospital stay time, major post-operative complications such as anastomosis leakage, wound infection or dehiscence, intra-abdominal abscess between the two groups. Results: The mean time of first oral feeding in the early feeding group (study group) was 2.5 ± 0.7 days but it was 5.3 ± 0.6 days in the late feeding group (control group). There was no mortality in both groups. There was no difference in major complications in both groups (anastomosis leakage). In the study group, first defecation time was shorter than the control group (3.7 days v. 4.4 days) and they had less hospital stay also (5.2 days vs. 8.3 days) and lower cost of hospitalization. Conclusion: Early oral feeding after intestinal resection and anastomosis in children is a safe method, it has many benefits and does not increase the major or minor post-operative complications (anastomosis leakage) long time fasting is not necessary and has not any beneficial effect and early feeding increases satisfaction of the parents and children, and reduce hospital stay and costs.
Keywords: Children, early feeding, intestinal anastomosis, late feeding
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2013 [cited 2019 Jul 15];10:74-7. Available from: http://www.afrjpaedsurg.org/text.asp?2013/10/2/74/115025
| Introduction|| |
One of the most serious complications after abdominal surgery is leakage of intestinal anastomosis that can be lethal and its regarded as a devastating post-operative complication.  Anastomosis leakage causes considerable adverse effects on patients' survival.  Many factors can affect anastomosis site healing or leakage, for example intraoperative contamination, circulation of intestinal ends, anemia, surgical technic, kind of surgery (elective or emergency), tension in suture line, etc.  There is the traditional belief that the early feeding of patients who underwent intestinal resection and anastomosis can be dangerous and induces stress on anastomosis site and makes it prone to leakage, and most surgeons prefer to remaining their patients not permit oral (NPO) for 4-5 days post-operation. but this is not proven yet, even without any feeding, about 2 L of gastrointestinal and pancreatic secretions enter the small bowel daily and transit from anastomosis site, thus feeding has not an important additional adverse effect on anastomosis site resting and even intestinal feeding has many positive effect on wound healing and reduction of sepsis.  Post-operative ileus is an important reason for remaining patients NPO in post-operative period, but post-operative ileus is a temporary and clinically unimportant physiologic response, small bowel movement return 4-8 h after surgery, On the other hand, early removal of nasogastric tube can reduce fluid and electerlytes loss and accelerates the resolution of post-operative ileus. 
Early feeding is more important among children because despite the adults they cannot tolerate more than 2-3 days fasting (nutrition only with intravenous crystalloid solutions) and longer fasting period requires applying total parenteral nutrition (TPN) that has its own problems and complications and additional costs.
Safety and benefits of early oral feeding after intestinal anastomosis is approved in many similar studies in the adults.  Its safety and usefulness confirmed in few studies in children also. 
| Materials and Methods|| |
This double-blind study was carried out in paediatric surgical patients from February 2011 to September 2012. Sixty seven children who underwent intestinal resection-anastomosis for various reasons were randomized consecutively to early feeding group (study group) and late feeding group (control group). Most common reasons for intestinal resection anastomosis were: colostomy closure, invagination with gangren, midgut volvolus, intestinal obstruction due to adhision band with irreversible Ischemia, complicated meckel diverticulum, intestinal duplications, strangulated hernia with damaged intestine, intestinal trauma. All children who underwent small bowel or colon resection and anastomosis as elective or emergency were included in the study.
Most of operations were including resection and anastomosis of small bowel (59 cases) and some were colon resection anastomosis, including colostomy closure and colon trauma (8 cases). The exclusion criteria were included comorbidity, septic shock before or after the operation, anemia, severe abdominal contamination during the surgery, the severe discrepancy between the diameter of two sides of intestine and technical problem and difficulty of anastomosis (that judged by surgeon) and severe long lasting post-operative ileus (severe post-operative abdominal distention and vomiting).
All operations performed by same pediatric surgeon, using a similar technic, single layer separate stiches with absorbable sutures (vicryl 3-0 -and 4-0). Antibiotics were given similarly for both groups after the surgery.
Before the surgery, the patients randomly assigned to one of the two groups:
In the early feeding group (study group), patients were initially started on clear fluid only 24 h after surgery and progressed to milk and liquids and then soft and regular diet in next day (after 48 h) in case of abdominal distension and vomiting the regimen was stopped for 1 day and then restarted. In the late feeding group (control group), the patients were kept fasting completely for 5 days and (TPN) was started from 2 nd day for them. In the post-operative period, the patients were visited each 12 h and clinical signs and symptoms such as, time of first stool, vomiting, abdominal distension, fever, wound infection, were assessed. All patients were under observe and monitored for signs and symptoms of anastomosis leakage (e.g., fever, tachycardia, abdominal tenderness and deterioration of general condition) and if suspected, more investigations were done. All complications were recorded. Statistical analysis was performed with SPSS 10.0. To compare specific variables t-test and Chi-square tests were used. In all statistical analyses, a P value of <0.05 was considered statistically significant. The Permission was obtained from the ethical Committee of university and the informed consent was obtained from patients parents.
| Results|| |
On a total of 67 patients included in the study, 37 patients were in the early feeding group (study group) and 30 patients in the late feeding group (control group). The mean age of the patients in study group was 17.4 ± 2.43 months and 23.7 ± 3.26 months in control group. There were 20 boys and 17 girls in study group and 19 boys and 11 girls in control group, no significant difference founded in the age and sex between both groups [Table 1].
The mean time of post-operation fasting was 2.5 ± 0.7 days in study group and 5.3 ± 0.6 days in control group, that was significantly shorter in study group [Table 1].
There was one case of anastomosises leakage in each group, both cases of anastomosis leakage underwent re-operation and recovered and we had not any mortality in two groups. There was no significant difference between the minor complications in both groups also [Table 2].
|Table 2: The comparison of the results of the interventions in the study groups|
Click here to view
The passage of first stool was significantly sooner in study group, 3.7 ± 1.1 days versus 4.4 ± 1.1 days in control group (P 0.018) [Table 2].
The hospital stay in study group was 5.2 ± 2.1 days but it was 8.3 ± 2.3 days in control group that is significantly longer (P < 0.0001). The hospital costs were significantly more expensive in control group also [Table 2].
| Discussion|| |
It has long been believed that cessation of oral intake for at least 4-5 days postoperation in intestinal resection anastomosis has a protective role on anastomosis site, many studies have shown that this hypothesis has no basis on scientific evidence and benefits of post-operative early oral feeding such as immunologic enhancement, decrease of surgical infection, prohibition of intestinal villous atrophie and many psychologic positive effect, are now widely accepted.  Toleration of long fasting in children who underwent major surgery is very hard and more problematic than its adult counterpart. Fasting more than 2-3 days in children need to use TPN that has its own problems and costs and complications.
Although, some similar studies are conducted in the past, the current study was one of the few studies performed regarding the children similar studies showed that early oral feeding after elective gastro-intestinal anastomosis is well tolerated, helps in early resolution of ileus, decreased wound infection and short hospital stay.  A study conducted in Iran on 110 patients who underwent abdominal surgery revealed that even feeding after 6 h post-operation is well tolerated and it doesn't increase complications.  Another study performed on 64 children below 12 years old who underwent intestinal resection anastomosis showed that the start of the feeding before 72 h and after 5-7 days has not any difference in the complications.  In a Meta-analysis and systematic review on 11 studies including 837 patients, it was found that long fasting of the patients after the elective gastrointestinal surgery is not useful and the start of early feeding is more beneficial.  Another study in Germany on 100 patients who underwent intestine resection anastomosis showed that the start of the feeding 1-3 days after the small bowel and colon resection is well tolerated by most patients and it can be considered as an important strategy after intestinal surgery.  Another similar study was conducted in Mexico city. To determine the safety and efficacy of early enteral feeding after distal (ileum-colon) elective bowel anastomoses in children. 
Another similar study in Zanjan (Iran) showed that in upper gastrointestinal surgery, the early feeding was safe and economical.  Our study is unique because it involves children in wide age range and includes both elective and emergent surgeries on small and large bowel. Although, safety and efficacy of the early feeding method is shown in this study, but the limitations should be considered and it is better that this method considered for patients who are stable and had not sever post-operative abdominal distention and vomiting and when the intestinal anastomosis is satisfactory from the technical view, that it will be judged by the surgeon.
| Conclusion|| |
This study showed that the early feeding after intestinal resection anastomosis in children is a safe method that improves the condition of the patients without increasing the post-operative complications and this increases parents and patients satisfaction. This approach reduces hospital cost and stay also.
| Acknowledgment|| |
We are grateful to our patients and their parents for participation in our study.
| References|| |
|1.||Luján JJ, Németh ZH, Barratt-Stopper PA, Bustami R, Koshenkov VP, Rolandelli RH. Factors influencing the outcome of intestinal anastomosis. Am Surg 2011;77:1169-75. |
|2.||Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA. Anastomotic leaks after intestinal anastomosis: It's later than you think. Ann Surg 2007;245:254-8. |
|3.||Dag A, Colak T, Turkmenoglu O, Gundogdu R, Aydin S. A randomized controlled trial evaluating early versus traditional oral feeding after colorectal surgery. Clinics (Sao Paulo) 2011;66:2001-5. |
|4.||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. |
|5.||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. |
|6.||Ekingen G, Ceran C, Guvenc BH, Tuzlaci A, Kahraman H. Early enteral feeding in newborn surgical patients. Nutrition 2005;21:142-6. |
|7.||Marwah S, Godara MS, Goyal MS, Marwah N. Early enteral nutrition following gastrointestinal anastomosis. Internet J Gastroenterol 2008;7. |
|8.||Fanaie SA, Ziaee SA. Safety of early oral feeding after gastrointestinal anastomosis: a randomized clinical trial. Indian J Surg 2005;67:185-1. |
|9.||Sholadoye TT, Suleiman AF, Mshelbwala PM, Ameh EA. Early oral feeding following intestinal anastomoses in children is safe. Afr J Paediatr Surg 2012;9:113-6. |
|10.||Böhm B, Haase O, Hofmann H, Heine G, Junghans T, Müller JM.Tolerance of early oral feeding after operations of the lower gastrointestinal tract. Chirurg 2000;71:955-62. |
|11.||Hospital Infantil de Mexico Federico Gomez, Early Feeding vs 5-day Fasting After Distal Elective Bowel Anastomoses in Children. A Randomized Controlled Trial. clinicaltrials.gov/ct2/show/NCT01028807. Available from: www.bioportfolio.com/resources/trial/70013. |
|12.||Hosseini SN, Mousavinasab SN, Rahmanpour H, Sotodeh S. Comparing early oral feeding with traditional oral feeding in upper gastrointestinal surgery. Turk J Gastroenterol 2010;21:119-24. |
Department of Paediatric Surgery, Mohammad Kermanshahi Hospital, Kermanshah University of Medical Sciences, PO Box: 6714415333, Kermanshah
Source of Support: Funded by a grant from Kermanshan University
of Medical Sciences and was permitted and approved by Research
Committee of Kermanshah University of Medical Sciences., Conflict of Interest: None
[Table 1], [Table 2]