EARLY VS TRADITIONAL POSTOPERATIVE FEEDING PRACTICES FOLLOWING GASTROINTESTINAL SURGERY: A METAANALYSIS.

Emma Osland AdvAPD MPhil Candidate Dept of Nutrition and Dietetics, Ipswich Hospital

Supervisors
A/Prof
Dept

Shahjahan Khan
of Mathematics and Computing, USQ

Prof

M Ashraf Memon

Dept

of Surgery, Ipswich Hospital Dept of Surgery, School of Medicine, UQ

Acknowledgement
Rossita
Dept

Yunus

of Mathematics and Computing, USQ

Early vs Traditional Postoperative Feeding

Setting the scene

Newly diagnosed pancreatic cancer Has had 6 months of progressive weight loss

80kg to 60kg 25% body weight loss

Poor appetite, vomiting after meals, pain associated with eating = reduced nutritional intake for >6 months Physically deconditioned

Evidence of moderate muscle loss, mild fat loss

Nutritional issues with Gastrointestinal surgery patients

Early vs Traditional Postoperative Feeding

Common reasons for requiring GIT surgery Cancer of the GIT Inflammatory bowel disease (Crohns Disease, UC) Diverticular disease Commonly at risk of malnutriton due to symptoms Poor appetite, poor oral intake Significant weight loss Physically deconditioned Malabsorption of nutrients Nausea/Vomiting and/or diarrhoea

Malnutrition is associated with significantly poorer postoperative outcomes Increased postoperative mortality Increased risk of postoperative complications including Infection Wound breakdown Anastomotic breakdown Malnutrition may increase length of hospital stay due to increased complications and therefore increase cost of health care in these cases

Postoperative Nutritional Philosophies

Traditional practice NBM prior to surgery NBM and gastric decompression until bowel function resumed post surgery Diet progression once gut working

Early vs Traditional Postoperative Feeding

Rationale Initially adopted to combat post operative vomiting and subsequent concerns

Aspiration pneumonia Increase abdominal pressure anastomotic rupture

Clear fluids free fluids soft/light diet full diet

Also thought to protect the anastomosis by allowing gut rest and avoiding food passing the surgical site

Postoperative Nutritional Philosophies

Early post-op feeding

Early vs Traditional Postoperative Feeding

Rationale

Clear fluids to 3-4hrs preanaesthetic Fluids or diet from first postoperative day irrespective of resumption of bowel function No NGT post op Often in the context of multimodal approach including earlier mobilisation, non-opioid analgesia, key-hole surgery

Gut secretes and reabsorbs ~7L fluid/d irrespective of oral intake, so protecting the anastomosis is based on a false premise Many patients already malnourished more postoperative complications Nausea/vomiting is much less of a problem with new anaesthetic agents Some evidence that early feeding reduces the bodys stress response to surgery/trauma

Early vs Traditional Postoperative Feeding

The research

Increasing numbers of studies investigating this topic dating from 1978

Tube feeding early liquids early solids

Individual studies do not demonstrate major adverse outcomes with early feeding Some suggestion of organisational benefits

May decrease length of hospital stay and cost of treatment

Reported adverse outcomes

Nausea, vomiting, NG reinsertion (common) ? Respiratory complications 1 study in thoracotomy patients stopped early

Previously conducted metaanalyses

Early vs Traditional Postoperative Feeding

3 meta-analyses on this topic located in the literature

Lewis et al. Early enteral feeding versus nil by mouth after gastrointestinal surgery: a systematic review and metaanalysis of controlled trials. BMJ, 2001, 323 (7316) 773-776 Anderson et al. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev, 2006 (4): CD002080. Lewis et al. Early enteral nutrition within 24h of intestinal surgery versus later commencement of feeding: A systematic review and metaanalysis. J Gastrointest Surg, July 16 2008

Overall outcomes Early feeding associated with

Significant

reductions in postoperative
Mortality LOS Postoperative

infection
Significant

increase

in vomiting

Previously conducted metaanalyses

Nutritional issues Inclusion of immune-modulating EN products Inclusion of studies feeding both proximal and distal to anastomoses Nutrition provided at 24hrs post op may have included clear fluids little nutritional value Statistical issues Fixed effects model of meta-analysis used in all (2008 publication also includes Random Effects Model results) General issues Appears to contain inconsistencies in inclusion criteria of studies included new RCTs published on this topic since 2006 not

Early vs Traditional Postoperative Feeding

Early vs Traditional Postoperative Feeding

Objectives of the current work

To conduct a meta-analysis investigating the benefit and harm of early vs traditional postoperative feeding in gastrointestinal resectional surgery patients
Utilising

stricter nutritional parameters for inclusion

Proximal

feeding (ie nutrition must come in contact with the surgical site) Nutritionally significant provision in early stages postop
More

thorough literature review Random effects model of meta-analysis

Early vs Traditional Postoperative Feeding

Inclusion Criteria

Randomised controlled trials Primary comparisons made between early (within 24h) and traditional (NBM until bowel function resumed) nutritional management following gastrointestinal resectional surgery Feeding proximal to the anastomosis Elective surgery patients Adults (>18yrs) English language publication Reporting clinically relevant outcomes

Early vs Traditional Postoperative Feeding

Exclusion criteria

Duplicate publications Abstracts from conferences where full papers were not accessible Use of immune-modulating enteral feeding products Studies that utilised IV feeding in any interventional arm

Early vs Traditional Postoperative Feeding

Literature search

Electronic databases
Medline Pubmed EMBASE CINAHL Cochrane Register of Systematic Reviews Science Citation Index Google Scholar

Search terms
Early feeding Colorectal Gastric Gastrointesintal Upper GI Postoperative Randomiz/sed Prospective Oral Enteral Surgery

All available timeframes Limits RCTs, 19-80+

Early vs Traditional Postoperative Feeding

Data extraction

Used QUOROM recommendations

21

point checklist devised by quality reporting in meta-analysis group QUOROM statement

Data extraction form devised and used Jadad score of methodological quality
0

= poor quality; 5 = high quality

Data extracted into Excel spreadsheet on all clinically relevant outcomes Additional data requested from authors if required

Statistical Analysis Summary stats

Early vs Traditional Postoperative Feeding

Odds Ratios for binary outcomes

OR

= odds of event in intervention group/odds of event in control group

ad/bc where a=event in intervention group, b=no event in intervention group, c=event in control group, d= no event in intervention group.

cf RR = risk in intervention/risk in control or [a/(a+b)]/[c/(c+d)]

Amended

estimator of OR used to avoid reciprical

zeros
0.5 added to each cell of 2x2 table Where no events occur cannot compute an OR

Statistical Analysis Summary stats

Early vs Traditional Postoperative Feeding

Weighted Mean Differences for continuous outcomes

Mean difference is assigned a weight. These weightings determine the relative importance of each quantity on the average, based on sample size. To calculate a weighted average:

1. Multiply each value by its weight. 2. Add up the products of value times weight to get the total value. 3. Add the weight themselves to get the total weight.

4. Divide the total value by the total weight.

If only median and range were reported, estimates of mean and SD were made using Hozo et al formulas

Early vs Traditional Postoperative Feeding

Statistical Analysis

Random effects model utilised Inverse weighted approach Assessment of heterogeneity Q statistic I2 index and confidence intervals Subgroup analysis based on year of publication (pre-, post2000)

Funnel plots synthesized Log OR or WMD vs Precision (1/SE) Standard Error Sample size

Estimates obtained by R Plots obtained by rmeta package

Early vs Traditional Postoperative Feeding

Results

87 abstracts of potential relevance

5

non-English abstracts located (despite limits)

potentially relevant but full articles could not be obtained

15 studies eligible for inclusion

1240

patients in total

n=617

traditional management n=623 early postoperative management

Studies

spanning 1979 to 2007

QUOROM statement
Potentially relevant papers identified and retrieved (n=87) RCTs reviewed for more detailed evaluation (n=46)

Early vs Traditional Postoperative Feeding

Papers excluded, with reasons: N= 41, Not RCTs (correspondence, reviews, true observational studies, meta-analyses, editorials)

RCTs excluded (n=15), with reasons:

N=8, not GI resectional surgery (n=6 gynae (incl 3 abstracts), n=1 H&N, n=1 ICU) N=2, Non-English publications N=2, surgical technique (lap vs open) N=2 intestinal repair under emergency conditions N=1, Enteral vs Parenteral RCTs excluded (n=7), with reasons: N = 2, nutrition not primary outcome (ie part of fast track program) N= 4, early nutrition provided >24hrs post operatively or timeframe not stated N=1, traditional group provided with jejunal feeds

Potentially appropriate RCTs to be considered for the meta-analysis (n=31)

RCTs comparing early vs traditional NBM feeding practices as 1 variable (N=24)

RCTs excluded (n=9), with reasons: N= 5, feeding distal to the anastomosis (including n=3 with immunonutrition utilised) N= 2, nutrition provided within Day 1 post op not nutritionally significant N=1 clinically relevant outcomes not reported N=1 published abstract of included study

RCTs comparing early vs traditional feeding practices with minimal loss to follow-up reporting clinically meaning outcomes (n= 15)

Early vs Traditional Postoperative Feeding

Results

Median Jadad score of 2 (range 1-3) 6 studies described randomisation method 6 studies reported withdrawals 1 study reported blinding

Sufficient data for analysis on 8 (of 24 reported) clinical outcomes

Some

clarification/data requested of authors in attempt to assist

Results Postoperative Complications

Study pre 2000 Sagar Ryan Schroeder Binderow Beier-Holgersen Carr Ortiz Hartsell Nessim Stewart subtotal post 2000 Han-Geurts Delaney Lucha Zhou Han-Geurts subtotal POOLED Early Traditional OR L U 3 of 15 2 of 7 4 of 16 0 of 32 8 of 30 0 of 14 17 of 93 1 of 29 3 of 27 10 of 40 48 of 303 5 of 15 7 of 7 7 of 16 0 of 32 19 of 30 4 of 14 18 of 95 1 of 29 4 of 27 12 of 40 77 of 305 0.53 0.03 0.46 1 0.22 0.08 0.96 1 0.75 0.78 0.55 0.08 3.78 0 0.94 0.07 2.91 0.02 61.41 0.05 1.08 0 2.06 0.24 3.77 0.07 13.42 0.11 5.01 0.17 3.56 0.34 0.9

Early vs Traditional Postoperative Feeding

12 of 56 7 of 31 1 of 26 23 of 161 22 of 46 65 of 320 113 of 623

13 of 49 10 of 33 1 of 25 70 of 155 20 of 50 114 of 312

0.76 0.69 0.96 0.21 1.37 0.62

0.18 3.27 0.14 3.38 0.07 12.99 0.06 0.74 0.33 5.61 0.26 1.51 0.87
0.1 2.0 4.0 6.0

191 of 617 0.55 0.35

favour Early

favour Traditional

Results Postoperative Complications

Early vs Traditional Postoperative Feeding

Total (n=1240; N=15)

OR 0.55; 95% CI 0.35, 0.87; p=0.01 Q = 29.07, p=0.01 I2 Index 51.8%, 95% CI 13.15, 73.25% OR 0.55; 95% CI 0.34, 0.90; p=0.01 Q = 10.61, p= 0.3 I2 Index 15%, 95% CI, 0, 45.47% OR 0.62; 95% CI 0.26, 1.51; p=0.29 Q = 17.78, p=0.001 I2 Index 77.5%, 95% CI 45, 90.68%

Pre-2000 subgroup (n=608; N=10)

Post-2000 subgroup (n=632; N=5)

Early vs Traditional Postoperative Feeding

Results - Mortality
Study Early Traditional OR L U pre 2000 Sagar 0 of 15 Ryan 0 of 7 Schroeder 0 of 16 Binderow 0 of 32 Beier-Holgersen 2 of 30 Carr 0 of 14 Ortiz 0 of 93 Hartsell 0 of 29 Nessim 0 of 27 Stewart 0 of 40 subtotal 2 of 303 post 2000 Han-Geurts Delaney Lucha Zhou Han-Geurts subtotal POOLED 0 of 15 0 of 7 0 of 16 0 of 32 4 of 30 1 of 14 0 of 95 1 of 29 0 of 27 1 of 40 7 of 305 1 1 1 1 0.52 0.31 1.02 0.32 1 0.33 0.58 0.02 0.02 0.02 0.02 0.1 0.01 0.02 0.01 0.02 0.01 0.22 53.66 57.31 53.46 51.94 2.65 8.29 52.01 8.24 52.22 8.22 1.54

0 of 56 0 of 31 0 of 26 0 of 161 3 of 46 3 of 320 5 of 623

3 of 49 0 of 33 0 of 25 0 of 155 1 of 50 4 of 312

0.12 1.06 0.96 0.96 2.66 1.03

0.01 0.02 0.02 0.02 0.38 0.27 0.32

2.33 55.24 50.35 48.83 18.77 3.88 1.56

0.1 2.0 4.0 6.0

11 of 617 0.71

favour Early

favour Traditional

Early vs Traditional Postoperative Feeding

Results - Mortality

Total (n=1240; N=15)

OR 0.71; 95% CI 0.32, 1.56; p=0.39 Q = 4.24, p=0.99 I2 Index 0%, 95% CI 0, 0% OR 0.58; 95% CI 0.22, 1.54; p=0.27 Q = 0.85, p= 0.99 I2 Index 0%; 95% CI 0,0% OR 1.03; 95% CI 0.27, 3.88; p=0.96 Q = 2.93, p=0.56 I2 Index 0%, 95% CI 0, 71.6%

Pre-2000 subgroup (n=608; N=10)

Post-2000 subgroup (n=632; N=5)

Results Anastomotic Dehiscence

Study pre 2000 Sagar Schroeder Beier-Holgersen Carr Ortiz Hartsell Nessim Stewart subtotal post 2000 Han-Geurts Delaney Lucha Zhou Han-Geurts subtotal POOLED Early Traditional OR L U 0 of 15 0 of 16 2 of 30 0 of 14 2 of 93 0 of 29 0 of 27 1 of 40 5 of 264 1 of 15 0 of 16 4 of 30 0 of 14 4 of 95 1 of 29 0 of 27 0 of 40 10 of 266 0.31 1 0.52 1 0.56 0.32 1 3.08 0.62 0.01 8.29 0.02 53.46 0.1 2.65 0.02 53.89 0.12 2.68 0.01 8.24 0.02 52.22 0.12 77.8 0.25 1.52

Early vs Traditional Postoperative Feeding

2 of 18 0 of 31 1 of 26 2 of 161 2 of 42 7 of 278 12 of 542

1 of 19 0 of 33 0 of 25 4 of 155 2 of 35 7 of 267

1.87 1.06 3 0.53 0.83 0.93

0.22 15.73 0.02 55.24 0.12 77.17 0.11 2.52 0.14 5.06 0.36 2.43 1.45
0.1 2.0 4.0 6.0

17 of 533 0.75 0.39

favour Early

favour Traditional

Results Anastomotic Dehiscence

Early vs Traditional Postoperative Feeding

Total (n=1075; N=13)

OR 0.75; 95% CI 0.39, 1.4; p=0.39 Q = 3.31, p=0.99 I2 Index 0%, 95% CI 0,0% OR 0.62; 95% CI 0.25, 1.52; p=0.29 Q = 1.50, p=0.98 I2 Index 0%, 95% CI 0,0% OR 0.93; 95% CI 0.36, 2.43; p=0.88 Q =0.98, p=0.83 I2 Index 0%; 95% CI 0,42.23%

Pre-2000 subgroup (n=530; N=8)

Post-2000 subgroup (n=545; N=5)

Results Nasogastric Tube Reinsertion

Study pre 2000 Binderow Hartsell Stewart subtotal Early Traditional OR L U 6 of 32 8 of 27 4 of 92 18 of 151 4 of 32 5 of 27 3 of 103 12 of 162 1.55 1.78 1.46 1.61 0.42 0.52 0.35 0.75 5.78 6.11 6.08 3.44

Early vs Traditional Postoperative Feeding

post 2000 Han-Geurts 9 of 56 Delaney 2 of 31 Lucha 5 of 26 Zhou 3 of 161 Han-Geurts 12 of 61 subtotal 30 of 320 POOLED 48 of 471

9 of 49 3 of 33 3 of 25 1 of 155 7 of 67 21 of 312

0.85 0.74 1.64 2.27 2.68 1.41

0.32 0.13 0.38 0.33 0.89 0.78

2.3 4.04 7.11 15.6 8.11 2.52

33 of 474 1.48 0.93 2.35

0.5 1.0 1.5 2.02.5 3.5

favour Early

favour Traditional

Results Nasogastric Tube Reinsertion

Early vs Traditional Postoperative Feeding

Total (n=945; N=8)

OR 1.48; 95% CI 0.93, 2.35; p=0.09 Q = 3.24, p=0.86 I2 Index 0%, 95% CI 0, 29.95% OR 1.61; 95% CI 0.75, 3.44; p=0.22 Q = 0.05, p= 0.97 I2 Index 0%; 95% CI 0,0% OR 1.41; 95% CI 0.78, 2.52; p=0.25 Q = 3.12, p=0.53 I2 Index 0%, 95% CI 0, 73.77%

Pre-2000 subgroup (n=313; N=3)

Post-2000 subgroup (n=632; N=5)

Early vs Traditional Postoperative Feeding

Results Nausea and Vomiting

Study pre 2000 Binderow Beier-Holgersen Carr Ortiz Hartsell Nessim Stewart POOLED

Early

Traditional

OR

14 of 32 19 of 30 1 of 14 13 of 93 16 of 29 3 of 27 14 of 40 80 of 265

8 of 32 22 of 30 7 of 14 8 of 95 15 of 29 7 of 27 14 of 40

2.26 0.64 0.11 1.73 1.14 0.39 1.00

0.8 0.22 0.02 0.69 0.41 0.1 0.4

6.39 1.88 0.79 4.29 3.15 1.58 2.47

186 of 267 0.93 0.53 1.65

0.1 2.0 4.0 6.0

favour Early

favour Traditional

Early vs Traditional Postoperative Feeding

Results Nausea and Vomiting

Post-2000 subgroup (n=532; N=7)

OR

0.93; 95% CI 0.53, 1.65; p=0.8 Q =10.99, p=0.08 I2 Index 45%, 95% CI 0, 77.01%

Results Length of Hospital Stay

Early vs Traditional Postoperative Feeding
Study pre 2000 Sagar Schroeder Binderow Carr Hartsell Stewart subtotal N Early N Traditional WMD L U 15 16 32 14 29 40 146 16.1(5.27) 10.0(4.00) 6.70(3.25) 9.80(6.60) 7.20(3.30) 12.8(7.25) 15 23.8(11.86) -7.67 -15.57 16 15.0(10.0) -5 -11.86 32 8.00(3.75) -1.3 -6.01 14 9.30(2.80) 0.5 -5.27 29 8.10(2.30) -0.9 -5.52 40 11.5(3.61) 1.33 -3.72 146 -1.05 -2.66 0.23 1.86 3.41 6.27 3.72 6.38 0.56

post 2000 Han-Geurts 56 24.5(21.92) 49 Delaney 31 5.20(2.50) 33 Zhou 161 8.40(3.40) 155 Han-Geurts 46 12.0(1.80) 49 subtotal 294 286 POOLED 440 432

15.6(8.76) 5.80(3.00) 9.60(5.00) 17.5(4.20)

8.9 1.27 16.53 -0.6 -5.19 3.99 -1.2 -5.68 3.28 -5.5 -10.07 -0.93 -0.93 -3.95 2.09 -1.28 -2.94 0.38
-15 -10 -5 0 5 10 15

favour Early

favour Traditional

Results Length of Hospital Stay

Early vs Traditional Postoperative Feeding

Total (n=872; N=10)

WMD -1.28; 95% CI -2.94, 0.38; p=0.13 Q = 61.19, p<0.0001 I2 Index 85%, 95% CI 74.73, 91.34% WMD -1.05; 95% CI -2.66, 0.56; p=0.2 Q = 10.17, p=0.07 I2 Index 50.8%; 95% CI 0, 80.44% OR -0.93; 95% CI -3.95, 2.09; p=0.54 Q = 47.0, p<0.0001 I2 Index 93.6%, 95% CI 56.85, 96.9%

Pre-2000 subgroup (n=292; N=6)

Post-2000 subgroup (n=580; N=4)

Early vs Traditional Postoperative Feeding

Results Passage of Flatus

Study pre 2000 Schroeder Stewart subtotal N Early N Traditional WMD L U

16 2.41(1.33) 16 2.91(1.29) -0.5 -2.09 1.09 40 3.00(1.20) 40 4.00(1.20) -1 -2.41 0.41 56 56 -0.87 -1.33 -0.42

post 2000 Zhou 161 3.00(0.90) 155 3.60(1.20) -0.6 -1.93 0.73 Han-Geurts 43 1.70(0.20) 49 1.40(0.10) 0.3 -1.01 1.61 subtotal 204 204 -0.14 -1.02 0.74 POOLED 260 260 -0.42 -1.12 0.28
-2 -1 0 1

favour Early

favour Traditional

Early vs Traditional Postoperative Feeding

Results Passage of Flatus

Total (n=520; N=4)

WMD -0.42 days; 95% CI -1.12, 0.28; p=0.23 Q = 75.63, p<0.001 I2 Index 96%, 95% CI 29.56, 97.88% WMD -0.87 days; 95% CI -1.33, -0.42; p=0.0002 Q = 0.87, p= 0.35 I2 Index 0%; 95% CI 0,0% WMD -0.14 days; 95% CI -1.02, 0.74; p=0.75 Q = 52.41, p<0.0001 I2 Index 98.1%, 95% CI 95.18, 99.18%

Pre-2000 subgroup (n=112; N=2)

Post-2000 subgroup (n=408; N=2)

Results Passage of Bowel Motion

Early vs Traditional Postoperative Feeding
Study pre 2000 Schroeder Stewart subtotal N Early N Traditional WMD L U

16 3.21(1.50) 40 4.77(2.15) 56

16 4.16(1.33) -0.95 -2.93 1.03 40 5.00(1.80) -0.23 -2.16 1.7 56 -0.55 -1.25 0.15

post 2000 Zhou 161 4.10(1.10) 155 4.80(1.40) -0.7 -2.45 1.05 Han-Geurts 43 4.30(0.30) 49 3.70(0.30) 0.6 -1.13 2.33 subtotal 204 204 -0.04 -1.32 1.23 POOLED 260 260 -0.28 -1.2 0.64
-2 -1 0 1 2

favour Early

favour Traditional

Results Passage of Bowel Motion

Early vs Traditional Postoperative Feeding

Total (n=520; N=4)

WMD -0.28 days; 95% CI -1.20, 0.68; p=0.55 Q = 78.99, p<0.0001 I2 Index 96.2%, 95% CI 92.94, 97.96% WMD -0.55 days; 95% CI -1.25, 0.15; p=0.12 Q = 1.16, p= 0.28 I2 Index 0%; 95% CI 0,0% WMD -0.04 days; 95% CI -1.32, 1.23; p=0.94 Q = 70.15, p<0.0001 I2 Index 97.1%, 95% CI 96.93, 99.34%

Pre-2000 subgroup (n=112; N=2)

Post-2000 subgroup (n=408; N=2)

Early vs Traditional Postoperative Feeding

Funnel plots
Complication rate
0.0 0.0

Mortality rate
0.0 0.1

Days to passing flatus

0.0

Days to first bowel motion

Standard error

Standard error

Standard error

Standard error

0.5

0.5

1.0

0.2

1.0

0.3

1.5

1.5

0.4

0.02

0.10

0.50 2.00 10.00

0.02 0.10 0.50 2.00 10.00 Log odds ratio

-1.0

-0.5

0.0

0.5

1.0

0.5

0.4

0.3

0.2

0.1

-1.0

-0.5

0.0

0.5

1.0

Log odds ratio

Mean difference

Mean difference

Anastomotic leak rate

0.0 0.0

NG reinsertion rate
0.0

Length of stay (days)

0.0

Days to solid diet

Standard error

Standard error

0.5

Standard error

1.0

Standard error

0.4

1.0

0.8

2.0

1.5

0.02

0.10 0.50 2.00 10.00 Log odds ratio

1.2

0.2 0.5

2.0 5.0

3.0

-5

0 Mean difference

0.6

0.4

0.2

-5.5

-4.5

-3.5

-2.5

Log odds ratio

Mean difference

Considerations in interpretationHeterogeneity

Early vs Traditional Postoperative Feeding

A lot of variability between outcomes assessed

Little/none
Mortality, Anastomotic

detected for

dehiscence, NGT reinsertion and Pre-2000 measures of bowel function

Extremely

large detected for

Complications

(but not pre-2000) LOS (less so for pre-2000) Pooled and post-2000 measures of bowel function

Considerations in interpretationHeterogeneity

Early vs Traditional Postoperative Feeding

Possible explanations for heterogeneity, and closer agreement with pre-2000 study subgroup analysis
Changes
Early

to nutritional provision

feeding via NG feeding ~30% of pts pre-2000 = more consistent nutritional provision than oral intake better outcomes from better nutrition?

Changes

to perioperative practices over 28 years Hans-Geurts et al studies (2001, 2007) appear to show quite different results than all others Related to statistical power (N=10 in pre-2000; N=5 in post-2000 subgroup analysis)

Considerations in interpretationPublication Bias

Early vs Traditional Postoperative Feeding

Visually asymmetric irrespective of choice of vertical axis Limitations of assessment of publication bias
Visual

assessment subjective, especially with small number of studies Random effects model known to amplify the presence of publication bias in funnel plots Exclusion of non-English publications bias, abstracts without full articles available Heterogeneity detected

Comparison of outcomes with previous meta-analyses

Early vs Traditional Postoperative Feeding

Possible explanations for differences

Different
7

studies included

different studies in current work Inclusion of Han-Geurts (2001, 2007) studies Differences in inclusion criteria

Immune nutrition provided to up to 21% of patients included Clear fluids allowed as early feeding Feeding distal to the anastomosis

Early vs Traditional Postoperative Feeding

Limitations of the current work

Reporting in included studies

No

quantitative data on oral intake of early feeding interventions!!! data unable to clarified or obtained

Assumptions made
From

Methodological quality generally poor Bias in subgroup analysis

Small

numbers Changes in feeding practices Changes in perioperative practices

Future Directions Clinical Research

Early vs Traditional Postoperative Feeding

Future RCTs investigating this topic need to quantify nutritional intake and anthropometric measures
Allow

determination if early feeding is providing nutritional intake different to traditional group. Multidisciplinary research Quantifiable relationship between nutritional intake and postoperative outcomes

Is there a specific level of nutritional/caloric/protein intake required to reduce LOS or complications? Does the texture of diet provided affect rates of anastomotic dehiscence? What effect does early vs traditional feeding have on weight and lean

Future Directions Statistics Modelling

Early vs Traditional Postoperative Feeding

Development of meta-analysis methods to better deal with situations posed by medical research
Detection

of publication bias in REM, small

numbers More sensitive methods of detecting between study heterogeneity in cases of small numbers Investigation re effect of assuming normal distribution in REM Guidance on investigation of heterogeneity

?Temper promotion of meta-analysis in many

Early vs Traditional Postoperative Feeding

Conclusions

Early feeding after GI surgery appears to be safe and should be part of standard practice
This

meta-analysis supports the results of those previously conducted despite limitations of all!

Need for multidisciplinary research in this area Clinicians should receive better education in statistics
Critical

approach to practice based on a thorough understanding of the recommendations being implemented

Highlights gaps in meta-analysis procedures