Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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RIP Drip and Suck
- Paul Moynagh (8 October 2001)
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All GI surgeries are not the same
- Sabapathy P Balasubramanian (17 October 2001)
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Anaesthetic tecnhique and gastrointestinal surgery
- W J Fawcett, W E J Jewsbury (18 October 2001)
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Meta-analysis was not appropriate
- P B Goodfellow, N J Everitt (19 October 2001)
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Early enteral feeding after gastrointestinal surgery
- F Bozzetti, L Mariani (23 October 2001)
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Pharmacology of "Nil by mouth" after surgery
- Walter Nimmo (25 October 2001)
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Enteral does not mean oral
- Peter Emery (30 November 2001)
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Paul Moynagh, retired Consultant Orthopaedic Surgeon - previously Chase Farm Hospital, Enfield
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Excellent! Another nail in the coffin which lays to rest the century long general medical fashion that motion and activity is detrimental to healing. I should firstly confess that 'drip and suck' is not my business, it being over 30 years since, as a general surgical registrar, I last cut and cared for a patient's belly. The excuse for this retired orthopod's cheek in commenting is an interest in the history of how 'Rest' came in the first place to be so widely adopted as benificial - nay essential - to recovery from virtually all medical or surgical conditions. Whether by resting the whole patient, such as by bed rest or prolonged convalescence, or by the rest of a part, as with a splint or by nasogastric suction, all specialisms became so indoctrinated in this dogma most of us have had to be pushed kicking and screaming to abandon it once we were shown the evidence it has no scientific foundation. Until very recently it would have been unthinkable to repair a hernia as a day case and return the patient to work in a fortnight; to treadmill exercise an infarcted heart only days after coming out of intensive care; or for a mother to walk about and go home the day her baby was born. Only in the last few years have we orthopods learnt to abandon bed rest for back pain. So we can now also safely feed an anastomosis - goodbye drip and suck! For most conditions the fashion to rest our patients seems to have started in the latter part of the 19th century, rising to a zenith of zealous application by the second quarter of the 20th, and then taking since the 1960s to slowly debunk it. As I have yet to discover when and who invented and pioneered nasogastric suction for this purpose, and what arguments they used to explain their rationale (old surgical texts are remarkably bashful in explaining why), I am hoping that someone here can assist me by telling me something about the inception of this technique. |
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Sabapathy P Balasubramanian, Clinical Research Lecturer, Surgical Oncology Royal Hallamshire Hospital
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Sir This was a well intentioned and neatly done study. However, the meta- analysis has included patients undergoing a number of different gastrointestinal procedures. More than giving rest to any part of the bowel, most surgeons are wary of food passing across the anastamotic site in the very early postoperative period (ie. within 24 hours). This is reflected in the fact that most of the trials in this review included patients undergoing lower gastrointestinal procedures (where liquid enteral nutrition is almost completely absorbed before the colon is reached) and for the majority of upper GI and hepatobiliary procedures, the entry of nutrition was distal to the pathologic or anastomotic site (i.e. naso jejunal, jejunostomy etc). In such cases, very early feeding is reasonable and is actually practised in a number of centres. What needs to be done therefore, is large studies in patients undergoing similar procedures and an attempt to determine if the anastomosis can bear the brunt of food passage in the very early postoperative period. |
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W J Fawcett, Consultant Anaesthetist Royal Surrey County Hospital, Guildord GU2 7XX, W E J Jewsbury
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Editor - In the paper from Lewis et al [1] and the accompanying editorial [2] we were surprised that there is no mention of the anaesthetic technique used during gastrointestinal surgery. There are several areas where anaesthesia affects the return of gastrointestinal function and thus resumption of feeding. There is a wealth of modern data in this area. Epidural anaesthesia is frequently employed for this type of surgery. Epidurals, when continued into the postoperative period, have a number of well recognised benefits including superlative pain relief, a reduction in pulmonary thromboembolism, lower incidence of pulmonary complications and suppression of the neuroendocrine stress response. In addition, however, there is considerable data confirming a reduction in post operative ileus and improvement in gastrointestinal function after surgery, with mean time intervals from surgery to first flatus and first bowel movement occurring earlier in the epidural group compared to control groups receiving parenteral morphine [3,4]. The most effective method appears to be thoracic epidural analgesia with plain bupivicane [4] . The anaesthetic technique has been postulated to have a detrimental effect on outcome - it has been suggested, with epidural anaesthesia, that unopposed parasympathetic activity may contribute to anastomotic leakage. There is now no evidence to support this [5]. Another area is the use of neostigmine to antagonise neuromuscular blockade, which may increase bowel motility, also resulting in anastomotic leakage. It is now recognised, however, that in many cases modern neuromuscular blocking drugs need not be antagonised or that a reduced dosage of antagonist can be given [6]. Holte and Kehlet’s excellent review [4] on prevention of postoperative ileus recommends the use of continuous thoracic epidural anaesthesia for at least 48 hours, and the avoidance of opioid analgesia where possible. Their multimodal approach, in conjunction with early feeding, avoidance of nasogastric intubation and possibly the use of prokinetic drugs, surely provide the direction over the next ten years for surgeons and anaesthetists in the management of patients following gastrointestinal surgery. Dr WJ Fawcett
Dr WEJ Jewsbury
Department of Anaesthesia,
Royal Surrey County Hospital,
Egerton Road,
Guildford GU2 7XX
Surrey
References. 1. Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus nil by mouth after gastrointestinal surgery. Systemic review and meta-analysis of controlled trials. BMJ 2001;323:773-6 2 Silk DBA, Menzies Gow N. Postoperative starvation after gastrointestinal surgery. BMJ 2001;323:761-2 3. Carli F, Trudel JL, Belliveau P. The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Dis Colon Rectum. 2001;44:1083-9. 4. Holte K, Kehlet H. Postoperative ileus a preventable event. Br J Surg 2000;87:1480-1493. 5. Holte K, Kehlet H. Epidural analgesia and risk of anastomotic leakage. Regional Anesthesia & Pain Medicine. 2001;26:111-7. 6. Hunter JM, Is it always necessary to anatagonise neuromuscular block? Do children differ from adults? Br J Anaesth 1996;77:707-9 |
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P B Goodfellow, Specialist Registrar, Consultant Surgeon Chesterfield and North Derbyshire Hospital, N J Everitt
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Dear Editor We read the paper by Lewis et al 1 with interest. We agree with the authors regarding the need for an adequately powered clinical trial to determine the benefit of early enteral feeding. However we believe that to subject the disparate papers included in their study to meta-analysis to justify this was inappropriate. The papers included four different feed types and four different routes of administration. Only three papers used the same feed and route combination. Feeding proximal to the anastomosis was analysed with feeding distal to the anastomosis, which if the authors believe that food “stresses” an anastomosis was particularly inappropriate. In four of the papers (compromising greater than 50% of all patients) in which enteral feeding was purported to start within 24 hours of surgery, this actually comprised clear enteral fluids only, with nutrition withheld until these were tolerated2-5. Moreover, it cannot be assumed that patients assigned to receive true nutrition actually received their metabolic requirements. The authors considered anastomotic leakage a crucial endpoint. However, data regarding site of anastomosis was available for only 8 of the 11 studies, and, in 2 of the 6 where the anastomosis was distal to the site of feeding, anastomotic leakage was not recorded. The authors state that when combined “the effects of early enteral feeding failed to reach conventional levels of significance, but eight of nine studies … reported benefit”. In so doing they have ignored their own statistics in favour of anecdote. Hospital stay for post-operative patients is not normally distributed, and therefore the median and not the mean is the appropriate measure of spread. The significance of the small reduction in hospital stay might not be maintained if non-parametric analysis were performed. The definition of infection in the papers assessed was not clearly defined it was therefore inappropriate to analyse a group presumed to comprise “all infections”. To conclude, the authors themselves state the trials included are “clinically heterogeneous”, “small and of doubtful methodological quality” and have “inadequate reporting”, all of which make them unsuitable for meta-analysis. There is now the risk that this published article will be seen as an evidence based medicine resource, which it is not. P B Goodfellow N J Everitt Chesterfield and North Derbyshire Royal Hospital 1. 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. BMJ 2001;323:773-776. 2. Ortiz H, Armendariz P, Yarnoz C. Is early postoperative feeding feasible in elective colon and rectal surgery? Int J Colorectal Dis 1996;11(3):119-21. 3. 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(1):73-7. 4. Stewart BT, Woods RJ, Collopy BT, Fink RJ, Mackay JR, Keck JO. Early feeding after elective open colorectal resections: a prospective randomized trial. Aust N Z J Surg 1998;68(2):125-8. 5. Hartsell PA, Frazee RC, Harrison JB, Smith RW. Early postoperative feeding after elective colorectal surgery. Arch Surg 1997;132(5):518-20; discussion 520-1. |
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F Bozzetti, Surgeon and Oncologist, Biostatistician Istituto Nazionale Tumori, L Mariani
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Dear Sir, we refer to the interesting meta-analysis by Lewis et al. (1) on early enteral feeding versus "nil by mouth" in postoperative patients. We have appreciated the wise conclusions of the authors: "there seems to be no clear advantage to keeping patients nil by mouth after elective gastrointestinal resection". Less prudent sounds the subtitle of the accompanying editorial (2): "early feeding is beneficial". The point is that such affirmative statement of the Editorialists, more than the cautious phrase of the authors, stimulates the reader to raise some questions that cannot find a practical answer from this study. They are: which diet is beneficial? through which route? and, mainly, compared with which intravenous feeding? Looking at Table 1, we note that at least 4 types of diet have been used in the 11 studies (standard, elemental, oral(!), and immune-enhancing), through 4 different routes (oral, nasoduodenal, nasojejunal, jejunostomy), giving origin to 7 different combinations. More relevant is the fact that there is no indication of the type (quality/quantity) of the intravenous nutrition in the control groups. This is not an omission of the authors, but simply a consequence of the fact that the original studies were more concerned with feasibility, safety, and tolerance of the enteral feeding than with its effect on postoperative outcome. The control diet was consequently only defined as conventional or traditional treatment or routine intravenous crystalloid solutions or hypocaloric fluids. Moreover in one study (3) the control group was not a "nil by mouth" arm, in that a placebo was administered through a nasoduodenal feeding tube! This issue is not an academic one. In a recent randomised clinical trial from UK, Lobo et al. (4) have shown, in postoperative patients, that a salt and water restricted therapy (water <=2 L, Na <=77 mmol/day) was significantly better in reducing postoperative gastric emptying times, time for passage of flatus and stools and postoperative stay when compared with "standard" management (water ~3 L and Na ~154 mmol/day). Therefore, in the absence of clear information on the composition of the intravenous support of the control arm, we are allowed to speculate that the advantage of early feeding, as reported in this meta-analysis, may not reflect a true benefit, but simply the lack of detriment due to the intravenous "standard" therapy. Finally, we agree with the suggestions of both the authors and the Editorialists to assess the role of an early enteral feeding by means of a suitably designed randomised clinical trial. The results of such a study, sponsored by the Italian Society of Parenteral and Enteral Nutrition and involving 317 malnourished cancer patients candidate to elective gastrointestinal surgery, randomised to two postoperative isoenergetic and isoprotein nutritional regimens given by enteral or parenteral route, are being published in a next issue of The Lancet (5). Bozzetti F, Mariani L
REFERENCES 1 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. BMJ 2001; 323:773-776 2 Silk DBA., Menzies Gow N. Postoperative starvation after gastrointestinal surgery. BMJ 2001;323:761-762 3 Beier-Holgersen R., Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut 1996; 39: 833-835 4 Lobo DN., Bostock KA., Neal KR., Perkins AC., Rowlands BJ., Allison SP. Effect of salt and water balance on gastrointestinal function and outcome after abdominal surgery: a prospective randomised controlled study. Clin Nutr 2001; 20 (suppl 3):35-36 5 Bozzetti F, Braga M., Gianotti L., Gavazzi C., Mariani L. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a multicentre trial. Lancet 2001;358 (in press) |
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Walter Nimmo, CEO Inveresk Research
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Editor The consequences of 'nil by mouth' both before and after surgery may depend on whether the patient's regularly-prescribed drugs are continued or terminated as a consequence of the 'nil by mouth' order (1,2). Aside from the fact that stopping a therapeutically useful drug deprives the patient of that drug's therapeutic utility (2,3), there is also the matter of 'rebound' effects upon sudden discontinuation of some drugs. It has been clear for over a decade that the sudden discontinuation of the most widely-used class of beta adrenergic receptor antagonists, eg propranolol, atenolol, metoprolol, results in hazardous 'rebound' effects, characterised by exaggerated responses to endogenous catecholamines (3). It is not difficult to imagine that the vasospastic consequences such rebound effects have, besides their well-documented propensity to trigger incident coronary insufficiency (4), may have adverse effects on the blood supply to the site of a newly-made intestinal anastomosis. The hazards of sudden withdrawal of powerful medicines are not limited simply to the sudden withdrawal of beta receptor antagonists, but include central alpha blockers, shorter half-life SSRI antidepressants, and any orally-administered opioid agent that the patient may have been prescribed. A further type of hazard may occur when the 'nil by mouth' period ends, if drugs known to have 'first-dose' effects are abruptly resumed without a repeat of the stepwise increase in dose that is done routinely when the drug is given first, but is overlooked easily as necessary when a suddenly halted drug is re-started, thus exposing the patient to a period of over-dose effects. Thus, the effects of a 'nil by mouth' order on a patient's pharmacological status are as diverse as the indications for oral pharmacotherapy in ambulatory care. The review by Lewis, Sylvester, and Thomas makes not a single mention of the clinical pharmacological aspects of the order (5). The consequences of a 'nil by mouth' order are carefully managed in some institutions, not in others, which is an aspect of the topic reviewed that should not have been ignored completely. The word 'drug', and related terms, do not appear in the article. WALTER S NIMMO
JOHN URQUHART
References: 1. Wyld R, Nimmo W S. Do patients fasting before and after operation receive their prescribed drug treatment? Brit Med J 1988; 296:744. 2. Packer M, Gheorghiade M, Young JB, Constantini PJ, Adams KF, Cody RJ, Mith LK, Van Voorhees L, Gourley LA, Jolly MK. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. N Engl J Med 1993; 329: 1-7. 3. Rangno RE, Langlois S. Comparison of withdrawal phenomena after propranolol, metoprolol, and pindolol. Am Heart J 1982; 104: 473-8. 4. Anon. Long-term use of beta blockers: the need for sustained compliance. WHO Drug Information 4(2): 52-3, 1990. 5. Lewis SJ, Egger M, Sylvester PA and Thomas S Brit Med J 2001; 323 :773 Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials |
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Peter Emery, Senior Lecturer Dept of Nutrition, King's College London, 150 Stamford Street, London SE1 9NN
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Sir, This article contains interesting and useful data but the presentation is unnecessarily confusing. The title, abstract and introduction all refer to studies of enteral nutrition but it turns out that the authors have also included a number of studies of oral feeding. The word enteral is derived from the greek enteron, usually translated as gut. Thus enteral feeding means delivering nutrients directly to the gut, and includes the use of naso-gastric/duodenal/jejunal tubes and gastrostomies and jejunostomies. The consumption of food or fluids through the mouth is correctly described as oral feeding. I am aware of the recent trend, both in clinical practice and now in the literature, to use the term eneteral as if it covered both oral and enteral feeding, mainly to distinguish these from parenteral nutrition. One consequence of this is that when people need to refer specifically to enteral feeding they use the term “enteral tube feeding”, which is a tautology. Surely in science and medicine we have a duty to maintain clarity and precision, since the alternative will be highly dangerous. This must include insistence on correct terminology. |
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