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Meta-Analysis
. 2024 Aug 12;8(8):CD004508.
doi: 10.1002/14651858.CD004508.pub5.

Early versus delayed oral feeding after major gynaecologic surgery

Kittipat Charoenkwan  1 , Chalaithorn Nantasupha  1 , Tanarat Muangmool  1 , Elizabeth Matovinovic  2
Affiliations
Meta-Analysis

Early versus delayed oral feeding after major gynaecologic surgery

Kittipat Charoenkwan et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an updated and expanded version of the original Cochrane review, first published in 2014. Postoperative oral intake is traditionally withheld after major abdominal gynaecologic surgery until the return of bowel function. The concern is that early oral intake will result in vomiting and severe paralytic ileus, with subsequent aspiration pneumonia, wound dehiscence, and anastomotic leakage. However, clinical studies suggest that there may be benefits from early postoperative oral intake. Currently, gynaecologic surgery can be performed through various routes: open abdominal, vaginal, laparoscopic, robotic, or a combination. In this version, we included women undergoing major gynaecologic surgery through all of these routes, either alone or in combination.

Objectives: To assess the effects of early versus delayed (traditional) initiation of oral intake of food and fluids after major gynaecologic surgery.

Search methods: On 13 June 2023, we searched the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, the citation lists of relevant publications, and two trial registries. We also contacted experts in the field for any additional studies.

Selection criteria: We included randomised controlled trials (RCTs) that compared the effect of early versus delayed initiation of oral intake of food and fluids after major gynaecologic surgery, performed by abdominal, vaginal, laparoscopic, and robotic approaches. Early feeding was defined as oral intake of fluids or food within 24 hours post-surgery, regardless of the return of bowel function. Delayed feeding was defined as oral intake after 24 hours post-surgery, and only after signs of postoperative ileus resolution. Primary outcomes were: postoperative ileus, nausea, vomiting, cramping, abdominal pain, bloating, abdominal distension, need for postoperative nasogastric tube, time to the presence of bowel sounds, time to the first passage of flatus, time to the first passage of stool, time to the start of a regular diet, and length of postoperative hospital stay. Secondary outcomes were: infectious complications, wound complications, deep venous thrombosis, urinary tract infection, pneumonia, satisfaction, and quality of life.

Data collection and analysis: Two review authors independently selected studies, assessed the risk of bias, and extracted the data. We calculated the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous data. We examined continuous data using the mean difference (MD) and a 95% CI. We tested for heterogeneity between the results of different studies using a forest plot of the meta-analysis, the statistical tests of homogeneity of 2 x 2 tables, and the I² value. We assessed the certainty of the evidence using GRADE methods.

Main results: We included seven randomised controlled trials (RCTs), randomising 902 women. We are uncertain whether early feeding compared to delayed feeding has an effect on postoperative ileus (RR 0.49, 95% CI 0.21 to 1.16; I² = 0%; 4 studies, 418 women; low-certainty evidence). We are uncertain whether early feeding affects nausea or vomiting, or both (RR 0.94, 95% CI 0.66 to 1.33; I² = 67%; random-effects model; 6 studies, 742 women; very low-certainty evidence); nausea (RR 1.24, 95% CI 0.51 to 3.03; I² = 74%; 3 studies, 453 women; low-certainty evidence); vomiting (RR 0.83, 95% CI 0.52 to 1.32; I² = 0%; 4 studies, 559 women; low-certainty evidence), abdominal distension (RR 0.99, 95% CI 0.75 to 1.31; I² = 0%; 4 studies, 559 women; low-certainty evidence); need for postoperative nasogastric tube placement (RR 0.46, 95% CI 0.14 to 1.55; 3 studies, 453 women; low-certainty evidence); or time to the presence of bowel sounds (MD -0.20 days, 95% CI -0.46 to 0.06; I² = 71%; random-effects model; 3 studies, 477 women; low-certainty evidence). There is probably no difference between the two feeding protocols for the onset of flatus (MD -0.11 days, 95% CI -0.23 to 0.02; I² = 9%; 5 studies, 702 women; moderate-certainty evidence). Early feeding probably results in a slight reduction in the time to the first passage of stool (MD -0.18 days, 95% CI -0.33 to -0.04; I² = 0%; 4 studies, 507 women; moderate-certainty evidence), and may lead to a slightly sooner resumption of a solid diet (MD -1.10 days, 95% CI -1.79 to -0.41; I² = 97%; random-effects model; 3 studies, 420 women; low-certainty evidence). Hospital stay may be slightly shorter in the early feeding group (MD -0.66 days, 95% CI -1.17 to -0.15; I² = 77%; random-effects model; 5 studies, 603 women; low-certainty evidence). The effect of the two feeding protocols on febrile morbidity is uncertain (RR 0.96, 95% CI 0.75 to 1.22; I² = 47%; 3 studies, 453 women; low-certainty evidence). However, infectious complications are probably less common in women with early feeding (RR 0.20, 95% CI 0.05 to 0.73; I² = 0%; 2 studies, 183 women; moderate-certainty evidence). There may be no difference between the two feeding protocols for wound complications (RR 0.82, 95% CI 0.50 to 1.35; I² = 0%; 4 studies, 474 women; low-certainty evidence), or pneumonia (RR 0.35, 95% CI 0.07 to 1.73; I² = 0%; 3 studies, 434 women; low-certainty evidence). Two studies measured participant satisfaction and quality of life. One study found satisfaction was probably higher in the early feeding group, while the other study found no difference. Neither study found a significant difference between the groups for quality of life (P > 0.05).

Authors' conclusions: Despite some uncertainty, there is no evidence to indicate harmful effects of early feeding following major gynaecologic surgery, measured as postoperative ileus, nausea, vomiting, or abdominal distension. The potential benefits of early feeding include a slightly faster initiation of bowel movements, a slightly sooner resumption of a solid diet, a slightly shorter hospital stay, a lower rate of infectious complications, and a higher level of satisfaction.

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Conflict of interest statement

Kittipat Charoenkwan: none

Chalaithorn Nantasupha: none

Tanarat Muangmool: none

Elizabeth Matovinovic: none

Figures

1
1
PRISMA flow diagram for study selection
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 1: Postoperative ileus
1.2
1.2. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 2: Nausea or vomiting, or both (random‐effects model)
1.3
1.3. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 3: Nausea (random‐effects model)
1.4
1.4. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 4: Vomiting
1.5
1.5. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 5: Abdominal distension
1.6
1.6. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 6: Postoperative placement of nasogastric tube
1.7
1.7. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 7: Time to the presence of bowel sounds (random‐effects model)
1.8
1.8. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 8: Time to the first passage of flatus
1.9
1.9. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 9: Time to the first passage of stool
1.10
1.10. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 10: Time to the first solid diet (random‐effects model)
1.11
1.11. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 11: Hospital stay (random‐effects model)
1.12
1.12. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 12: Febrile morbidity
1.13
1.13. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 13: Infectious complications
1.14
1.14. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 14: Wound complications
1.15
1.15. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 15: Pneumonia
1.17
1.17. Analysis
Comparison 1: Early versus delayed oral fluids and food after major abdominal gynaecologic surgery, Outcome 17: Satisfaction
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Update of

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References to other published versions of this review

Charoenkwan 2003
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