The effect of diets delivered into the gastrointestinal tract on gut motility after colorectal surgery—a systematic review and meta-analysis of randomised controlled trials

Abstract

Background/objectives

Despite best practice guidelines, feeding methods after colorectal surgery vary due to the difficulties translating evidence into practice. The aim was to determine the effectiveness of diets delivered into the gastrointestinal tract (GIT) on gut motility following colorectal surgery.

Subjects/methods

EMBASE, MEDLINE, CINAHL, Web of Science and PubMed were systematically searched. Randomised controlled trials investigating effectiveness of a diet on gut motility after colorectal surgeries were included. Outcomes included postoperative ileus, length of stay, mortality, nausea and vomiting.

Results

A total of 756 potential studies were identified; of these, 10 trials reporting on 1237 unique patients were included. There is evidence that early feeding reduces time (days) to first flatus (mean difference (MD):−0.64; 95% CI:−0.84 to −0.44) and bowel movements (MD:−0.64; 95% CI:−1.01 to −0.26), when compared to traditional postoperative fasting. Introducing solids versus the progression of fluids to solids had no effect on time (days) to first flatus (MD:0.13; 95% CI:−1.99 to 1.74) or bowel movement (MD:0.20; 95% CI:−0.50 to 0.98). Complete nutrition compared to hypocaloric nutrition had no effect on time to first flatus (MD:−0.60; 95% CI:−1.66 to 0.46) or bowel movement (MD:−0.20; 95% CI:−1.59 to 1.19), whereas coffee and diet compared to water and diet significantly decreased time (days) to first bowel movement (MD:−0.60; 95% CI:−0.97 to −0.19) but had no effect on time to first flatus (MD:−0.20; 95% CI:−0.57 to 0.09).

Conclusions

Any form of early postoperative diet provided into the GIT early after colorectal surgery is likely to stimulate gut motility, resulting in earlier return of bowel function and shorter length of stay.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    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; Cd004080. https://doi.org/10.1002/14651858.CD004080.pub2.

  2. 2.

    Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J Gastrointest Surg. 2009;13:569–75.

    Article  PubMed  Google Scholar 

  3. 3.

    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. Brit Med J. 2001;323:773–6.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Osland E, Yunus RM, Khan S, Memon MA. Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN J Parent Enter Nutr. 2011;35:473–87. https://doi.org/10.1177/0148607110385698. 2

    Article  Google Scholar 

  5. 5.

    Zhuang CL, Ye XZ, Zhang CJ, Dong QT, Chen BC, Yu Z. Early versus traditional postoperative oral feeding in patients undergoing elective colorectal surgery: a meta-analysis of randomized clinical trials. Dig Surg. 2013;30:225–32. https://doi.org/10.1159/000353136.

    Article  PubMed  Google Scholar 

  6. 6.

    Bernardes LFM, Diogo A. Early enteral feeding after upper digestive tract surgeries and clinical assessment of post-operative ileus. Biosci J. 2008;24:100–7.

    Google Scholar 

  7. 7.

    Flores-Funes D, Campillo-Soto A, Pellicer-Franco E, Aguayo-Albasini JL. The use of coffee, chewing-gum and gastrograffin in the management of postoperative ileus: a review of current evidence. Cirugia Esp. 2016;94:495–501. https://doi.org/10.1016/j.ciresp.2016.05.020.

    Article  Google Scholar 

  8. 8.

    Kasparek MS, Mueller MH, Glatzle J, Enck P, Becker HD, Zittel TT, et al. Postoperative colonic motility increases after early food intake in patients undergoing colorectal surgery. Surgery. 2004;136:1019–27. https://doi.org/10.1016/j.surg.2004.03.011.

    Article  PubMed  Google Scholar 

  9. 9.

    Gianotti L, Nespoli L, Panelli M, Nespoli A. Early oral feeding after colorectal resection is safe and feasible also outside a fast track programme. Surg Infect. 2011;12:A11. https://doi.org/10.1089/sur.2011.9918.

    Article  Google Scholar 

  10. 10.

    Russ A, Stein S, Crawshaw B, Champagne B. Improved postoperative outcomes with a modified GI diet after laparoscopic colorectal resection. Dis Colon Rectum. 2014;57:e318–e319.

    Google Scholar 

  11. 11.

    Funder JA, Tolstrup R, Jepsen BN, Iversen LH. Postoperative paralytic ileus remains a problem following surgery for advanced pelvic cancers. J Surg Res. 2017;218:167–73.

    Article  PubMed  Google Scholar 

  12. 12.

    Story SK, Chamberlain RS. A comprehensive review of evidence-based strategies to prevent and treat postoperative ileus. Dig Surg. 2009;26:265–75. https://doi.org/10.1159/000227765.

    Article  PubMed  Google Scholar 

  13. 13.

    Murphy MM, Tevis SE, Kennedy GD. Independent risk factors for prolonged postoperative ileus development. J Surg Res. 2016;201:279–85. https://doi.org/10.1016/j.jss.2015.10.047.

    Article  PubMed  Google Scholar 

  14. 14.

    Chapman SJ, Thorpe G, Vallance AE, Harji DP, Lee MJ, Fearnhead NS, et al. Systematic review of definitions and outcome measures for return of bowel function after gastrointestinal surgery. Bjs Open. 2019;3:1–10. https://doi.org/10.1002/bjs5.102.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    van Bree SH, Bemelman WA, Hollmann MW, Zwinderman AH, Matteoli G, El Temna S, et al. Identification of clinical outcome measures for recovery of gastrointestinal motility in postoperative ileus. Ann Surg. 2014;259:708–14. https://doi.org/10.1097/SLA.0b013e318293ee55.

    Article  PubMed  Google Scholar 

  16. 16.

    Chapman SJ, Pericleous A, Downey C, Jayne DG. Postoperative ileus following major colorectal surgery. Br J Surg. 2018;105:797–810. https://doi.org/10.1002/bjs.10781.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 Updated March 2011. The Cochrane Collaboration. Bristol: UK; 2011. http://handbook.cochrane.org.

  18. 18.

    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg (Lond, Engl). 2010;8:336–41. https://doi.org/10.1016/j.ijsu.2010.02.007.

    Article  Google Scholar 

  19. 19.

    Bosio RM, Pigazzi A. Emerging and evolving technology in colon and rectal surgery. Clin Colon Rectal Surg. 2015;28:152–7.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Kim YJ. The future medical science and colorectal surgeons. Ann Coloproctology. 2017;33:207–9.

    Article  Google Scholar 

  21. 21.

    Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr (Edinb, Scotl). 2017;36:49–64. https://doi.org/10.1016/j.clnu.2016.09.004.

    CAS  Article  Google Scholar 

  22. 22.

    Higgins JPT, Sterne JAC, Savović J, Page MJ, Hróbjartsson A, Boutron I et al. A Revised Tool for Assessing Risk of Bias in Randomized Trials. In: Chandler J, McKenzie J, Boutron I, Welch V, editors. Cochrane Methods. Cochrane Database of Systematic Reviews. Briston: UK; 2016.

  23. 23.

    Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. Brit Med J. 2004;328:1490.

    Article  PubMed  Google Scholar 

  24. 24.

    Borenstein M, Hedges L, Higgins J, & Rothstein H. Comprehensive meta-analysis. 3rd edn. Englewood: Biostat; 2013.

  25. 25.

    da Fonseca LM, da Luz MMP, Lacerda A, Correia M, da Silva RG. A simplified rehabilitation program for patients undergoing elective colonic surgery-randomized controlled clinical trial. Int J Colorectal Dis. 2011;26:609–16. https://doi.org/10.1007/s00384-010-1089-0.

    Article  PubMed  Google Scholar 

  26. 26.

    Dag A, Colak T, Turkmenoglu O, Gundogdu R, Aydin S. A randomized controlled trial evaluating early versus traditional oral feeding after colorectal surgery. Clin (Sao Paulo, Braz). 2011;66:2001–5.

    Article  Google Scholar 

  27. 27.

    El Nakeeb A, Fikry A, El Metwally T, Fouda E, Youssef M, Ghazy H, et al. Early oral feeding in patients undergoing elective colonic anastomosis. Int J Surg. 2009;7:206–9. https://doi.org/10.1016/j.ijsu.2009.03.003.

    Article  PubMed  Google Scholar 

  28. 28.

    Feo CV, Romanini B, Sortini D, Ragazzi R, Zamboni P, Pansini GC, et al. Early oral feeding after colorectal resection: a randomized controlled study. ANZ J Surg. 2004;74:298–301. https://doi.org/10.1111/j.1445-1433.2004.02985.x.

    Article  PubMed  Google Scholar 

  29. 29.

    Zhou T, Wu XT, Zhou YJ, Huang X, Fan W, Li YC. Early removing gastrointestinal decompression and early oral feeding improve patients’ rehabilitation after. World J Gastroenterol. 2006;12:2459–63. https://doi.org/10.3748/wjg.v12.i15.2459.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Han-Geurts IJ, Hop WC, Kok NF, Lim A, Brouwer KJ, Jeekel J. Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery. Br J Surg. 2007;94:555–61. https://doi.org/10.1002/bjs.5753.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Lau C, Phillips E, Bresee C, Fleshner P. Early use of low residue diet is superior to clear liquid diet after elective colorectal surgery a randomized controlled trial. Ann Surg. 2014;260:641–9. https://doi.org/10.1097/sla.0000000000000929.

    Article  PubMed  Google Scholar 

  32. 32.

    Soop M, Carlson GL, Hopkinson J, Clarke S, Thorell A, Nygren J, et al. Randomized clinical trial of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol. Br J Surg. 2004;91:1138–45. https://doi.org/10.1002/bjs.4642. e-pub ahead of print 2004/09/28.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Muller SA, Rahbari NN, Schneider F, Warschkow R, Simon T, von Frankenberg M, et al. Randomized clinical trial on the effect of coffee on postoperative ileus following elective colectomy. Br J Surg. 2012;99:1530–8. https://doi.org/10.1002/bjs.8885.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Boelens PG, FFBM Heesakkers, MDP Luyer, KWY VanBarneveld, IHJT DeHingh, GAP Nieuwenhuijzen, et al. Reduction of postoperative ileus by early enteral nutrition in patients undergoing major rectal surgery: prospective, randomized, controlled trial. Ann Surg. 2014;259:649–55. https://doi.org/10.1097/SLA.0000000000000288.

    Article  PubMed  Google Scholar 

  35. 35.

    Kruse C, Muller SA, Warschkow R, Luthi C, Brunner W, Marti L, et al. Does caffeine reduce postoperative bowel paralysis after elective laparoscopic colectomy? (CaCo trial): study protocol for a randomized controlled trial. Trials. 2016;17:186. https://doi.org/10.1186/s13063-016-1297-1.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr. 2006;25:224–44.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Carroll JS, Quijada MA. Redirecting traditional professional values to support safety: changing organisational culture in health care. Qual Saf Health Care. 2004;13(Suppl 2):ii16–21. https://doi.org/10.1136/qhc.13.suppl_2.ii16.

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Scott T, Mannion R, Davies HT, Marshall MN. Implementing culture change in health care: theory and practice. Int J Qual Health Care: J Int Soc Qual Health Care. 2003;15:111–8.

    Article  Google Scholar 

  39. 39.

    Bauer JJ, Gelernt IM, Salky BA, Kreel I. Is routine postoperative nasogastric decompression really necessary? Ann Surg. 1985;201:233–6.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Johnson Casto C, Krammer J, Drake J. Postoperative feeding: a clinical review. Obstet Gynecol Surv. 2000;55:571–3. e-pub ahead of print 2000/09/07.

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Silk DB, Gow NM. Postoperative starvation after gastrointestinal surgery. Early feeding is beneficial. Brit Med J. 2001;323:761–2.

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Kahokehr A, Sammour T, Zargar-Shoshtari K, Thompson L, Hill AG. Implementation of ERAS and how to overcome the barriers. Int J Surg (Lond, Engl). 2009;7:16–9. https://doi.org/10.1016/j.ijsu.2008.11.004.

    Article  Google Scholar 

  43. 43.

    Martin D, Roulin D, Grass F, Addor V, Ljungqvist O, Demartines N, et al. A multicentre qualitative study assessing implementation of an Enhanced Recovery After Surgery program. Clin Nutr (Edinb, Scotl). 2018;37(6 Pt A):2172–7. https://doi.org/10.1016/j.clnu.2017.10.017.

    CAS  Article  Google Scholar 

  44. 44.

    Braga M, Gianotti L, Gentilini O, Liotta S, Di Carlo V. Feeding the gut early after digestive surgery: results of a nine-year experience. Clin Nutr (Edinb, Scotl). 2002;21:59–65. https://doi.org/10.1054/clnu.2001.0504. e-pub ahead of print 2002/03/09.

    CAS  Article  Google Scholar 

  45. 45.

    Austin KK, Young JM, Solomon MJ. Quality of life of survivors after pelvic exenteration for rectal cancer. Dis colon rectum. 2010;53:1121–6. https://doi.org/10.1007/DCR.0b013e3181e10c46.

    Article  PubMed  Google Scholar 

  46. 46.

    Jakobsson J, Idvall E, Kumlien C Patient characteristics and surgery-related factors associated with patient-reported recovery at 1 and 6 months after colorectal cancer surgery. Eur J Cancer Care. 2017;26:1–11. https://doi.org/10.1111/ecc.12715.

    Article  Google Scholar 

  47. 47.

    Bekker R, Koole G, Roubos D. Flexible bed allocations for hospital wards. Health Care Manag Sci. 2017;20:453–66.

    Article  PubMed  Google Scholar 

  48. 48.

    Buttigieg SC, Abela L, Pace A. Variables affecting hospital length of stay: a scoping review. J health Organ Manag. 2018;32:463–93. https://doi.org/10.1108/jhom-10-2017-0275.

    Article  PubMed  Google Scholar 

  49. 49.

    Gan TJ. Risk factors for postoperative nausea and vomiting. Anesth Analg. 2006;102:1884–98. https://doi.org/10.1213/01.ane.0000219597.16143.4d.

    Article  PubMed  Google Scholar 

  50. 50.

    Hamilton E, Ravikumar R, Bartlett D, Hepburn E, Hwang M-J, Mirza N, et al. Dexamethasone reduces emesis after major gastrointestinal surgery (DREAMS). Trials. 2013;14:249. https://doi.org/10.1186/1745-6215-14-249.

    Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Liu L, Xie YH, Zhang W, Chai XQ. Effect of transversus abdominis plane block on postoperative pain after colorectal surgery: a meta-analysis of randomized controlled trials. Med Princ Pract. 2018;27:158–65.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Affiliations

Authors

Contributions

All authors made substantial contributions to conception and design of the study. SH and SC completed the review protocol, the search strategy, screening of potentially eligible studies and extracting and analysing data. SH and DS conducted the meta-regression analysis and created the ‘Summary of Findings’ tables. All authors analysed and interpreted the results. SH was a major contributor of drafting the manuscript and all other authors were involved in revising it critically for important intellectual content. All authors provided final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Sophie Hogan.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Search Strategy

Search Strategy

EMBASE and MEDLINE via Ovid 1. (‘colorectal surgery’/exp OR ‘colorectal surgery’ OR ‘rectum’/exp OR ‘rect*’ OR ‘rect* surgery’).mp.
  2. (‘gastrointestinal motility’/exp OR ‘gastrointestinal motility’ OR ‘recovery of function’/exp or ‘recovery of function’ OR ‘enhanced recovery’ OR ‘fast track’).mp.
  3. (‘ileus’/exp OR ‘ileus’ OR ‘postoperative ileus’).mp.
Web of Knowledge via Web of Science 1. TOPIC: ‘colorectal surgery’ OR TITLE: ‘colorectal surgery’ OR TOPIC: ‘rect*’ OR TITLE: ‘rect*’ OR TOPIC: ‘rect* surgery’ OR TITLE: ‘rect* surgery’
  2. TOPIC: ‘gastrointestinal motility’ OR TITLE: ‘gastrointestinal motility’ OR TOPIC: ‘recovery of function’ OR TITLE: ‘recovery of function’ OR TOPIC: ‘enhanced recovery’ OR TITLE: ‘enhanced recovery’ OR TOPIC: ‘fast track* OR TITLE: ‘fast track*’
  3. TOPIC: ‘ileus’ OR TITLE: ‘ileus’ OR TOPIC: ‘postoperative ileus’ OR TITLE: ‘postoperative ileus’
Cinahl via Ebsco 1. ‘colorectal surgery’ OR (MH ‘rectum’) OR ‘rect*’ OR ‘rect* surgery’
  2. (MH ‘gastrointestinal motility;) OR ‘gastrointestinal motility’ OR ‘recovery of function’ OR ‘enhanced recovery’ OR ‘fast track*’
  3. ‘ileus’ OR ‘postoperative ileus’
PubMed https://www.ncbi.nlm.nih.gov/pubmed/ 1. ‘colorectal surgery’[MeSH] OR ‘colorectal surgery’[tiab] OR ‘rectum’[MeSH] OR ‘rect*’ OR ‘rect* surgery’
  2. ‘gastrointestinal motility’[MeSH] OR ‘gastrointestinal motility’ OR ‘recovery of function’[MeSH] OR ‘recovery of function’ OR ‘enhanced recovery’ OR ‘fast track’
  3. ‘ileus’[MeSH] OR ‘ileus’ OR ‘postoperative ileus’

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hogan, S., Steffens, D., Rangan, A. et al. The effect of diets delivered into the gastrointestinal tract on gut motility after colorectal surgery—a systematic review and meta-analysis of randomised controlled trials. Eur J Clin Nutr 73, 1331–1342 (2019). https://doi.org/10.1038/s41430-019-0474-1

Download citation