Early oral protein-containing diets following elective lower gastrointestinal tract surgery in adults: a meta-analysis of randomized clinical trials

doi:10.1186/s13741-021-00179-3

. 2021 Mar 23;10(1):10.

doi: 10.1186/s13741-021-00179-3.

Early oral protein-containing diets following elective lower gastrointestinal tract surgery in adults: a meta-analysis of randomized clinical trials

Hong Pu^{1

2}, Philippa T Heighes¹, Fiona Simpson^{1

3}, Yaoli Wang^{1

4}, Zeping Liang^{1

4}, Paul Wischmeyer⁵, Thomas J Hugh⁶, Gordon S Doig⁷

Affiliations

¹ Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia.
² Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China.
³ Nutrition Services, Royal North Shore Hospital, Sydney, Australia.
⁴ Department of Critical Care Medicine, Daping Hospital, Chongqing, People's Republic of China.
⁵ Department of Anesthesiology and Surgery, Duke University, Durham, NC, USA.
⁶ Upper GI Surgical Department, Royal North Shore Hospital and the University of Sydney, Sydney, Australia.
⁷ Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia. Gordon.Doig@EvidenceBased.net.

PMID: 33752757
PMCID: PMC7986268
DOI: 10.1186/s13741-021-00179-3

Early oral protein-containing diets following elective lower gastrointestinal tract surgery in adults: a meta-analysis of randomized clinical trials

Hong Pu et al. Perioper Med (Lond). 2021.

. 2021 Mar 23;10(1):10.

doi: 10.1186/s13741-021-00179-3.

Authors

Hong Pu^{1

2}, Philippa T Heighes¹, Fiona Simpson^{1

3}, Yaoli Wang^{1

4}, Zeping Liang^{1

4}, Paul Wischmeyer⁵, Thomas J Hugh⁶, Gordon S Doig⁷

Affiliations

¹ Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia.
² Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China.
³ Nutrition Services, Royal North Shore Hospital, Sydney, Australia.
⁴ Department of Critical Care Medicine, Daping Hospital, Chongqing, People's Republic of China.
⁵ Department of Anesthesiology and Surgery, Duke University, Durham, NC, USA.
⁶ Upper GI Surgical Department, Royal North Shore Hospital and the University of Sydney, Sydney, Australia.
⁷ Northern Clinical School Intensive Care Research Unit, Faculty of Medicine and Health, University of Sydney, Kolling Building-RNSH, Pacific Hwy, St Leonards, NSW, 2065, Australia. Gordon.Doig@EvidenceBased.net.

PMID: 33752757
PMCID: PMC7986268
DOI: 10.1186/s13741-021-00179-3

Abstract

Background: Although current guidelines make consensus recommendations for the early resumption of oral intake after surgery, a recent comprehensive meta-analysis failed to identify any patient-centered benefits. We hypothesized this finding was attributable to pooling studies providing effective protein-containing diets with ineffective non-protein liquid diets. Therefore, the aim of this paper was to investigate the safety and efficacy of early oral protein-containing diets versus later (traditional) feeding after elective lower gastrointestinal tract surgery in adults.

Methods: PubMed, Embase, and the China National Knowledge Infrastructure databases were searched from inception until 1 August 2019. Reference lists of retrieved studies were hand searched to identify randomized clinical trials reporting mortality. No language restrictions were applied. Study selection, risk of bias appraisal and data abstraction were undertaken independently by two authors. Disagreements were settled by obtaining an opinion of a third author. Majority decisions prevailed. After assessment of underlying assumptions, a fixed-effects method was used for analysis. The primary outcome was mortality. Secondary outcomes included surgical site infections, postoperative nausea and vomiting, serious postoperative complications and other key measures of safety and efficacy.

Results: Eight randomized clinical trials recruiting 657 patients were included. Compared with later (traditional) feeding, commencing an early oral protein-containing diet resulted in a statistically significant reduction in mortality (odds ratio [OR] 0.31, P = 0.02, I² = 0%). An early oral protein-containing diet also significantly reduced surgical site infections (OR 0.39, P = 0.002, I² = 32%), postoperative nausea and vomiting (OR 0.62, P = 0.04, I² = 37%), serious postoperative complications (OR 0.60, P = 0.01, I² = 25%), and significantly improved other major outcomes. No harms attributable to an early oral protein-containing diet were identified.

Conclusions: The results of this systematic review can be used to upgrade current guideline statements to a grade A recommendation supporting an oral protein-containing diet commenced before the end of postoperative day 1 after elective lower gastrointestinal surgery in adults.

Keywords: Elective surgery; Meta-analysis; Mortality; Postoperative nutrition; Protein.

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Conflict of interest statement

Drs. Pu, Heighes, Simpson, Wang, Hugh, and Ms. Liang reported no funding conflicts. Dr. Doig reported receiving academic research grants related to nutrition in critical illness from the Australian National Health and Medical Research Council, Fresenius Kabi Deutschland GmbH, and Baxter Healthcare Pty Ltd and speakers honoraria from Fresenius Kabi Deutschland GmbH; Baxter Healthcare Australia, Pty Ltd; Nestle Healthcare, Vevy, Switzerland; and Nutricia Pharmaceutical (Wuxi) Co., Ltd. China. Dr. Wischmeyer reported receiving grant funding related to Improving Nutrition Delivery in Acute Illness from the National Institute of Health National Heart, Lung, and Blood Institute R34 HL109369; Canadian Institutes of Health Research; Baxter; Fresenius; Lyric Pharmaceuticals; Isomark, Inc.; and Medtronics. He served as a consultant on Improving Nutrition Care in Intensive Care Unit (ICU) and Perioperative Medicine to Nestle, Abbott, Fresenius, Baxter, Medtronics, Nutricia, and Lyric Pharmaceuticals, and Takeda for research related to this work. He received honoraria or travel expenses for lectures on improving nutrition care in illness from Abbott, Fresenius, and Medtronics.

Figures

**Fig. 1**
Flow diagram of the study selection process. N, number; RCT, randomized controlled trial; GI, gastrointestinal

**Fig. 2**
Analysis of primary outcome, mortality. CI, confidence interval

**Fig. 3**
Number of patients with a surgical site infection. CI, confidence interval

**Fig. 4**
Sensitivity analysis: trials with less certainty regarding protein content. CI, confidence interval

See this image and copyright information in PMC

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References

1. Alazawi W, Pirmadjid N, Lahiri R, Bhattacharya S. Inflammatory and immune responses to surgery and their clinical impact. Ann Surg. 2016;264(1):73–80. doi: 10.1097/SLA.0000000000001691. - DOI - PubMed
1. Anup R, Aparna V, Pulimood A, Balasubramanian KA. Surgical stress and the small intestine: role of oxygen free radicals. Surgery. 1999;125(5):560–569. doi: 10.1016/S0039-6060(99)70209-6. - DOI - PubMed
1. Beier-Holgersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut. 1996;39(6):833–835. doi: 10.1136/gut.39.6.833. - DOI - PMC - PubMed
1. Bradburn MJ, Deeks JJ, Berlin JA, Russell LA. Much ado about nothing: a comparison of the performance of meta-analytical methods with rare events. Stat Med. 2007;26(1):53–77. doi: 10.1002/sim.2528. - DOI - PubMed
1. Cao A. Application of early intestinal nutrition after colon and rectal cancer. Today Nurse. 2009;9:42–43.

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[1] Alazawi W, Pirmadjid N, Lahiri R, Bhattacharya S. Inflammatory and immune responses to surgery and their clinical impact. Ann Surg. 2016;264(1):73–80. doi: 10.1097/SLA.0000000000001691. - DOI - PubMed

[2] Alazawi W, Pirmadjid N, Lahiri R, Bhattacharya S. Inflammatory and immune responses to surgery and their clinical impact. Ann Surg. 2016;264(1):73–80. doi: 10.1097/SLA.0000000000001691. - DOI - PubMed

[3] Anup R, Aparna V, Pulimood A, Balasubramanian KA. Surgical stress and the small intestine: role of oxygen free radicals. Surgery. 1999;125(5):560–569. doi: 10.1016/S0039-6060(99)70209-6. - DOI - PubMed

[4] Anup R, Aparna V, Pulimood A, Balasubramanian KA. Surgical stress and the small intestine: role of oxygen free radicals. Surgery. 1999;125(5):560–569. doi: 10.1016/S0039-6060(99)70209-6. - DOI - PubMed

[5] Beier-Holgersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut. 1996;39(6):833–835. doi: 10.1136/gut.39.6.833. - DOI - PMC - PubMed

[6] Beier-Holgersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut. 1996;39(6):833–835. doi: 10.1136/gut.39.6.833. - DOI - PMC - PubMed

[7] Bradburn MJ, Deeks JJ, Berlin JA, Russell LA. Much ado about nothing: a comparison of the performance of meta-analytical methods with rare events. Stat Med. 2007;26(1):53–77. doi: 10.1002/sim.2528. - DOI - PubMed

[8] Bradburn MJ, Deeks JJ, Berlin JA, Russell LA. Much ado about nothing: a comparison of the performance of meta-analytical methods with rare events. Stat Med. 2007;26(1):53–77. doi: 10.1002/sim.2528. - DOI - PubMed

[9] Cao A. Application of early intestinal nutrition after colon and rectal cancer. Today Nurse. 2009;9:42–43.

[10] Cao A. Application of early intestinal nutrition after colon and rectal cancer. Today Nurse. 2009;9:42–43.

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Early oral protein-containing diets following elective lower gastrointestinal tract surgery in adults: a meta-analysis of randomized clinical trials

Affiliations

Early oral protein-containing diets following elective lower gastrointestinal tract surgery in adults: a meta-analysis of randomized clinical trials

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Abstract

Conflict of interest statement

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