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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, University of New Mexico Hospital, Albuquerque, New Mexico.
Address reprint requests to: Dorothy Kammerer-Doak, MD University of New Mexico Hospital Department of Obstetrics and Gynecology 2211 Lomas Boulevard, NE Albuquerque, NM 87131 E-mail: dorothy.kammerer-doak{at}lovelace.com
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Abstract |
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Methods: Women who had major gynecologic surgery for benign conditions were randomly allocated to early feeding of low residue diets 6 hours postoperatively or traditional dietary management of clear liquids with normal bowel sounds, and regular diet with passage of flatus. Demographic and perioperative data were collected, and patients answered questionnaires on their perception of bowel function and pain using the McGill Pain Scale. Power analysis found that 130 women were needed to find a twofold greater incidence of ileus in the early feeding group with 80% power and 
= .05.
Results: Complete data were available for 139 women, 67 allocated to the early feeding group and 72 to the late feeding group. The incidence of postoperative ileus for the study population was 4.4% and did not differ between groups (early 3% versus late 5.8%, P = .68). There were no differences in patient demographics, surgical procedures, anesthesia used, and intraoperative complications between groups. With the exception of more complaints of nausea in the late feeding group (23% versus 13%, P = .04), there were no differences in other postoperative variables, including other perioperative complications, pain medicine requirements, fluid and caloric intake, median pain scores, and gastrointestinal function. The low incidence of perioperative complications made the power to detect differences between groups low.
Conclusion: Low residue diet 6 hours after major gynecologic surgery for benign indications was not associated with increased postoperative gastrointestinal complaints, including ileus.
Standard care for postoperative feeding after gynecologic surgery is not well established; however, some gynecologists withhold oral feedings in the immediate postoperative period until flatus is passed, even when patients are hungry. A recent randomized trial at our institution compared regular diet 6 hours after cesarean with oral feeding after return of bowel function and found no difference in gastrointestinal symptoms or paralytic ileus between groups.1 Two other studies showed similar findings of the safety of early feeding after cesarean.2,3 Trials with gynecologic oncology4–6 and colorectal patients7,8 also found tolerance of accelerated postoperative diet, with the early feeding group receiving a clear liquid diet on the first postoperative day and subsequently advancing to a regular diet. However, the frequency, severity, and prevention of ileus after major nonlaparoscopic gynecologic surgery for benign indications have not been studied.
We conducted a randomized controlled trial that compared an early regular diet to conventional postoperative dietary management to determine gastrointestinal function after major nonlaparoscopic gynecologic surgery for benign indications. Our secondary purpose was to evaluate the incidence and severity of postoperative ileus after gynecologic surgery.
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Materials and Methods |
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After completion of surgery, surgeons called a research nurse who assigned patients to early or late feeding groups using a random number table with pseudorandomization and disguised block length of six with 1:1 ratio. Surgeons were not masked to feeding groups after surgery. Women in the early feeding group were offered a low-residue diet within 6 hours of arrival on the ward. The late feeding group received only ice chips in the immediate postoperative period with advancement to clear liquids when normal bowel sounds were detected and a regular diet after passage of flatus or bowel movements. Women with normal postoperative courses were discharged when they could tolerate a regular diet.
Demographic information collected included patients’ age, gravidity, parity, race, body mass index, hormonal status, medical and surgical histories, and indications for surgery. Subjects had several different types of major gynecologic surgeries, including abdominal and vaginal approaches, and were randomly allocated to feeding groups regardless of approach, to eliminate bias. After analysis of outcome based solely on feeding group allocation, surgical procedures were analyzed and women were stratified by vaginal surgery alone and abdominal surgery alone or in combination with vaginal surgery to explore whether women who had abdominal surgery had different outcomes than those who had vaginal surgery only. We also noted duration of surgery, blood loss as estimated by the anesthesiologist, type of anesthesia, and intraoperative complications. Postoperative variables recorded included length of hospitalization (day of surgery until discharge), length of time intravenous (IV) fluids were given, amount of narcotics given (converted to the equivalent dosage of morphine sulfate), types and amounts of nonsteroidal anti-inflammatory medications given, total calories and amount of fluids consumed, length of time until bowel sounds were auscultated, and when flatus and bowel movement were first passed. Given the common clinical practice of morning and evening patient assessment, bowel function variables, including normal bowel sounds and passage of flatus and bowel movements, were treated as ordinal not continuous variables and recorded as occurring on a specific postoperative day. Women were not given oral or rectal bowel stimulants after surgery. Postoperative complications included febrile morbidity (temperature greater than 38.0F on two occasions 6 hours apart at least 24 hours after surgery), reoperation, blood transfusion, and postoperative ileus. Ileus was defined as hypoactive bowel sounds, abdominal distension, and nonpassage of flatus or bowel movements with or without nausea or vomiting after the first postoperative day. Severe or paralytic ileus was defined as symptoms longer than 24 hours or requiring nasogastric tube placement. Postoperative ileus was managed by IV hydration, no oral intake, antiemetics, and radiologic evaluation of the abdomen. If vomiting was unresponsive to antiemetics, a nasogastric tube was placed and removed after symptoms resolved.
On postoperative day 1 and discharge day, women rated their pain using the McGill Pain Scale (0–5).9 On the day of discharge they answered questions about nausea, vomiting, cramping, distension, desire for oral feeding, and first day of flatus passage or bowel movement.
The main outcome variable of the study was postoperative ileus. We did a power analysis based on an average incidence of postoperative ileus reported in the literature of approximately 25%,1–3,6,10 with a doubling of that rate considered clinically significant. With 80% power and = 0.05, 130 women were needed to show a twofold greater incidence of postoperative ileus in the early feeding group. Fisher exact test was used to analyze discrete variables such as postoperative ileus. Continuous variables were analyzed using Student t test. Nonparametric (ie, pain scale) and non-normally distributed data were evaluated using the Wilcoxon rank-sum test. After analysis solely based on feeding group assignment, data also were stratified by surgical route, vaginal versus abdominal, and analyzed using linear regression analysis. Repeated measures analysis of variance was used to assess differences in caloric and fluid intake among different meals.
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Results |
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Indications for surgery were similar between groups, with only endometriosis more common in the early feeding group (10% versus 1%, P = .03). A variety of vaginal and abdominal surgeries were done, including vaginal and abdominal hysterectomies, adnexal procedures, anterior and posterior colporrhaphies with hysterectomies or uterosacral vaginal vault suspensions, paravaginal defect repairs, Burch retropubic urethropexies, and suburethral sling urethropexies with other reparative procedures. Surgeries involved entering the peritoneal cavity vaginally or abdominally, except in one woman who had Burch retropubic urethropexy only. There were no differences in types of procedures each group had, and there was equal distribution of vaginal and abdominal surgeries (48% vaginal and 52% abdominal). General endotracheal anesthesia was used in 130 of 139 cases (94%). There was no significant difference between groups in anesthesia used, including regional anesthesia (early 9%, late 6%, P = .52).
Perioperative complications did not differ between groups (Table 1
). The early feeding group tolerated a low-residue diet 6 hours postoperatively without increased incidence of emesis or ileus compared with traditional postoperative dietary management. The incidence of postoperative ileus was similar between groups (two women in the early group and four in the late group [3.0% versus 5.8%, P = .68], one of which was severe and required nasogastric tube placement [0% versus 1.4%, P = 1.0]). Among the 139 participants, the overall incidence was 4.4% for postoperative ileus and 0.7% for severe postoperative ileus.
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Analysis of oral intake on the first postoperative day showed that total fluids and fluid intake at lunch alone differed significantly between groups. As expected, the late feeding group was more likely to have liquids only on the first postoperative day and consumed more fluids at lunch (early 233 ± 217 versus late 434 ± 337 mL, P = .001) and during the whole day (early 690 ± 511 versus 979 ± 594 mL, P = .01). However, the total calories consumed for the day did not differ between groups (early 621 ± 424 versus late 499 ± 401 kcal, P = .14). Overall calories at each meal increased significantly as the first postoperative day progressed (mean kcal, breakfast 160, lunch 229, dinner 255, P < .004).
Patient report of bowel function return based on questionnaire data showed no differences between groups in mean day to passage of flatus, mean day to first bowel movement, and abdominal symptoms of crampy pain, distension, or vomiting (Table 2). However, more women in the late feeding group complained of nausea (23% versus 13%, P = .04, Table 2). Pain scores from the McGill Pain Scale did not differ between groups on the first postoperative day (early median score 2 [range 0–4], late 2 [0–5], P = .84) or on the day of discharge (early 2 [0–4], late 1 [0–4], P = .57).
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). However, time to first bowel movement and pain ratings on postoperative day 1 and at discharge did not differ when stratified by surgical approach.
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Discussion |
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Tradition dictates advancement of postoperative diet based on physical signs of bowel function and not postoperative gastrointestinal physiology. Animal and human radiographic and physiologic studies do not support the traditional practice of initiation of oral feeding based on auscultation of normal bowel sounds and passage of flatus and bowel movement.1–4,11,12 After surgery, return of bowel function and motility usually occurs within 6–12 hours in the small bowel, 12–24 hours in the stomach, and 48–72 hours in the colon.13 Physiologic studies have found that myoelectric and motor activity in the stomach is not affected after abdominal surgery.12 Schilder et al4 showed bowel activity before flatus was passed, which illustrates that patients tolerate fluid secretions of 1–2 L from the stomach and pancreas immediately after surgery. Studies also have shown tolerance to clear liquids on postoperative day 1 after gynecologic oncology and gastrointestinal surgeries.4–8,12
Our study documents a further advance in postoperative treatment of women who have had major gynecologic surgery for benign indications. We found that by offering regular food 6 hours after surgery, oral intake could be individualized to patients’ needs, without increased incidence of ileus, rather than following a rigid protocol. There were no differences in postoperative complications, including ileus, or gastrointestinal symptoms between groups, except for more nausea in the late feeding group. Consumption of food postoperatively might stimulate bowel peristalsis and earlier return of function, explaining the decreased nausea in the early feeding group. That finding is supported by Resnick et al’s review of postoperative ileus and documentation of normal bowel physiology.14
Women in this trial had procedures of different lengths and approaches. However, our results can be generalized to major vaginal and abdominal gynecologic surgery for benign indications because a randomized trial eliminates possible bias introduced by differences in type of procedure and surgical route. To address whether there were any differences between groups in tolerance of accelerated diet or return of bowel function related to abdominal or vaginal approach, data were stratified by feeding group and surgical approach, and no differences were noted. When stratified solely by surgical approach, not by feeding group, differences in return of bowel function between the abdominal and vaginal routes were found, as reported elsewhere.11,14 Despite the differences, feeding group assignment did not affect bowel function, indicating that women who had major gynecologic surgery for benign indications, regardless of surgical approach, did not have more gastrointestinal symptoms with early feeding.
There is little information on postoperative ileus in gynecologic patients. We found an overall incidence of 4.4% for ileus and 0.7% for severe ileus among our 139 subjects. Our original power analysis was based on published studies mainly for nongynecologic major surgery, which reported ileus rates of 13.5–60%.3,6,10 We choose the lower end of that range, 25%, based on our clinical experience. This study confirmed that high rates of postoperative ileus are probably not representative of modern surgical techniques or of most women who have major gynecologic surgery for benign indications. A power analysis using the rates of postoperative ileus in our early and late feeding groups, 3.0% versus 5.8%, respectively, would require 1822 women to show a significant difference between groups; thus the power of our findings to detect a twofold difference between groups was only 38%. Despite the low incidence of postoperative ileus, which did not fulfill the original power calculation, the low rate of gastrointestinal complaints and lack of symptoms in the early feeding group show clinically significant safety and tolerance of a regular diet 6 hours after surgery. In light of the current emphasis on patient quality of life and individual choice, offering regular food immediately postoperatively is an important improvement.
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Footnotes |
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Received January 27, 2000. Received in revised form April 26, 2000. Accepted May 18, 2000.
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References |
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2. Burrows WR, Gingo AJ Jr, Rose SM, Zwick SI, Kosty DL, Dierker LJ, et al. Safety and efficacy of early postoperative solid food consumption after cesarean section. J Reprod Med 1995;40:463–7.[Medline]
3. Soriano D, Dulitzki M, Keidar N, Barkai G, Mashiach S, Seidman DS. Early oral feeding after cesarean section. Obstet Gynecol 1996;87:1006–8.[Abstract]
4. Schilder JM, Hurteau JA, Look KY, Moore DH, Raff G, Stehman FB, et al. A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery. Gynecol Oncol 1997;67:235–40.[Medline]
5. Cutillo G, Maneschi F, Franchi M, Giannice R, Scambia G, Benedetti-Panici P. Early feeding compared with nasogastric decompression after major oncologic gynecologic surgery: A randomized study. Obstet Gynecol 1999;93:41–5.
6. Pearl ML, Valea FA, Fischer M, Mahler L, Chalas E. A randomized controlled trial of early postoperative feeding in gynecologic oncology patients undergoing intra-abdominal surgery. Obstet Gynecol 1998;92:94–7.[Abstract]
7. Hartsell PA, Frazee RC, Harrison JB, Smith RW. Early postoperative feeding after elective colorectal surgery. Arch Surg 1997;132: 518–20.[Abstract]
8. Reissman P, Teoh TA, Cohen SM, Weiss EG, Nogueras JJ, Wexner SD. Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial. Ann Surg 1995;222:73–7.[Medline]
9. Melzack R. The McGill pain questionnaire: Major properties and scoring methods. Pain 1975;1:277–99.[Medline]
10. LaRosa JA, Saywell RM Jr, Zollinger TW, Oser TL, Erner BK, McClain E. The incidence of adynamic ileus in postcesarean patients. J Reprod Med 1993;38:293–300.[Medline]
11. Livingston EH, Passaro EP Jr. Postoperative ileus. Digest Dis Sci 1990;35:121–32.
12. Bufo AJ, Feldman S, Daniels GA, Lieberman RC. Early postoperative feeding. Dis Colon Rectum 1994;37:1260–5.[Medline]
13. Finan MA, Barton DP, Fiorica JV, Hoffman MS, Roberts WS, Gleeson N, et al. Ileus following gynecologic surgery. South Med J 1995;88:539–42.[Medline]
14. Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: Part I. Am J Gastroenterol 1997;92:751–62.[Medline]
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