Intestinal anastomosis are common procedures in both elective and emergency general surgery.Intestinal anastomosis can be described as follows: Sutured: (1) interrupted or continuous; (2) single or 2-layer; (3) end to-end or side-to-side (or any combination); (4) various suture materials; (5) extramucosal or full-thickness sutures; and (6) size of and spacing between each suture Stapled: (1) side-to-side or end-to-end (or any combination); (2) staple lines oversewen, buried or not; and (3) Various stapling devices¹ A period of starvation (nil orally) is a common practice after most gastrointestinal surgeries. Postoperative dysmotility predominantly affects the stomach and colon, with the small bowel’s normal function recovers 4-8 hours following surgeries². The reason for keeping the patient ―nil orally‖ is to prevent postoperative nausea and vomiting and to protect the patient’s anastomosis repair, allowing time to heal before being stressed by food.Proper and adequate nutrition following GI anastomosis are always been major concerns in post op care. Patients who undergo gastrointestinal surgery are at risk of nutritional depletion from inadequate  nutritional intake; both preoperatively and postoperatively, the stress of surgery and the subsequent increase in metabolic rate^3,4. Malnutrition in hospitalized patients is well documented, with rates up to 50 percent in certain populations⁵.Nutritional depletion leads to altered body composition, tissue wasting, and impaired organ function, increasing the risk of infections and cardio-respiratory issues.

This condition is linked to heightened intestinal permeability and reduced villous height, which may contribute to systemic inflammation and multi-organ failure^6,7.Proper nutrition remains a key concern in postoperative care, often involving routine nasogastric tube use and delayed oral feeding to prevent post operative nausea and vomiting⁸ and ensure anastomotic healing⁹. Traditionally, this meant fasting with intravenous fluids until flatus was passed, but newer studies indicate that early postoperative enteral feeding, even within 12 hours of gastrointestinal surgery^10,11 is safe and well tolerated. This shift challenges the old assumption that oral feeding risks complications or compromises anastomotic integrity.Early feeding after gastrointestinal anastomosis can prevent morphologic and functional trauma related alterations of the gut and will help to modulate immune and inflammatory responses¹² besides being less expensive than total parenteral nutrition¹³. Early Enteral Nutrition can reduce pulmonary complications in patients with emergency gastrointestinal surgery^14,15.

AIM

To compare the early and late enteral feeding after intestinal resection and anastomosis in terms of complications, length of hospital stay, morbidity and mortality.

The study, conducted over 12 months from May 2023 to April 2024 at the Department of Surgery, S.P. Medical College and P.B.M. Hospital in Bikaner, utilized a hospital-based comparative design with convenience sampling. The study focused on patients undergoing intestinal resection and anastomosis.

The sample size, calculated using the formula

Sample size = SD2(Zα/2 + Zβ) /d2 SD (Standard deviation) =

4 from previous studyZα/2 = 1.96 for 95% confidence interval Zβ = 0.842 at 80% power d = effect size = difference between mean values = 1.6 

 So formula for sample size were

Sample size = 2SD2(Zα/2 + Zβ )2 /d2

                    = 2 (4)2(1.96 + 0.84 )2 /(1.6)2

                    = 98

So, a total of 100 patients were studied.

Inclusion criteria covered all patients over 18 years of age undergoing either emergency or elective intestinal resection and anastomosis. Exclusion criteria included diabetic patients with fasting blood sugar >200 mg/dl, those on immunosuppressive medications, HIV-positive patients, individuals with psychiatric issues, those with a history of radiotherapy, patients with permanent ileostomy/colostomy, and those unwilling to participate.

Table-1: Distribution of both group according to their age (years)

In group A maximum 50.00% were observed in 18-40 years whereas minimum were 12% in 61 - 80 years age group. In group B maximum 48% were observed in 18– 40 year whereas minimum were 14% in 61 – 80 years age group. Mean age in group A was 45.74±10.1 years whereas 45.80± 11.65 years in group B. (p>0.05) 

Table 2: Comparison of type of surgery between both groups

In both groups Maximum 80% were elective surgery whereas 20% were emergency surgeries performed. (p>0.05)

Table-3: Distribution of both group according to their initiation of diet after surgery

In group A mean time to initiate diet was 21.65 ± 7.84 hrs whereas in group B was 81.23 ± 5.65 hrs, the difference was found to be statistically significant. (p<0.05) 

Table-4: Comparison of time for bowel sounds and resolution of ileus between early and late groups

The mean time to resolution from ileus in the patients of early group (group A) was 33.56± 8.48 hrs while mean time to resolution from ileus of late group (group B) was 76.89 ± 7.64 hrs. (p<0.05) The mean time to return of bowel sounds in the patients of early group (group A) was 31.45± 6.58 hrs while mean time to return of bowel sounds of late group (group B) was 74.78 ± 6.98 hrs. (p<0.05)

Fig1:  Comparison of complication in both groups

As per complication in group A most common 14% had nausea/vomiting/ abdominal distension and least common were 2% anastomotic leak and systemic complications whereas in group B most common complication 20% was surgical site infection and least common complication 4% anastomotic leak and. (p=0.103)

Table 5: Comparison of Mean hospital stay (days) between early and late groups

In group A maximum 90.00% had 5 to 10 days of hospital stay whereas minimum 10% had 1 to 5 days. In group B maximum 72% had hospital stay of 5 - 10 days whereas minimum 28% had >10 days of stay.  Mean duration in group A was 5.95± 1.58 days whereas 8.75±2.56 day in group B. (p<0.05) 

Table 6:Need of additional surgery in early and late groups

In group A 3 (6%) patient needed additional surgery compared to group B where 5 (10%) patients need additional surgery. Most of additional surgery in both groups were due to wound dehiscence due to surgical site infection (resuturing) and secondly due to anastomotic leak (needs re exploration). (p=0.712) 

In our study, in group A maximum 50.00% were observed in 18-40 years whereas minimum were 12% in 61 - 80 years age group. In group B maximum 48% were observed in 18– 40 year whereas minimum were 14% in 61 – 80 years age group. Mean age in group A was 45.74±10.1 years whereas 45.80± 11.65 years in B group. In group A 70% were male whereas 66% in group B. Maximum 66% were rural in group A whereas 60% rural in group B. Both groups were comparable in terms of socio demography. Similarly Thapa PB et al. (2011)¹⁷ found that the mean age of patients in early feeding group was 50.9 years (SD±18.44) with a male to female ratio of 6:14 in early feeding group and the mean age of the conventional feeding group was 47.3 years (SD±16.75) with the male to female ratio was 8:12.

In our study, in both groups Maximum 80% were elective surgery whereas 20% were emergency surgeries performed. In group A (early Group), maximum 42% had elective ileostomy closure, followed by 30% elective colostomy closure whereas minimum 2% had gastro jejunostomy and LAR followed by 10% hemicolectomy (R/L) and 14% ileo-ileal RA. In group B (Late Group), maximum 38% had elective ileostomy closure, followed by 30% elective colostomy closure whereas minimum 2% had gastro jejunostomy followed by 4% LAR, 6% hemicolectomy (R/L) and 16% ilio ileal RA . (p>0.05) Soni DK et al (2022)¹⁵ found that around two-thirds of the participants were operated as routine surgery (n=42, 60%) and the rest (n=28, 40%) were operated as emergency surgery. Most common was perforation peritonitis (45.70% in early and 34.30% in late group) followed by closure of stoma (Ileostomy/colostomy) (14.3%) created for gut perforation or obstruction distal to stoma and Kochs abdomen in the conventional method. Most common cause of operation in Marwah et al in (2007)¹⁸ and in S. Chatterjee et al in (2012)¹⁹ was closure of stoma.

In our study, the mean time to resolution from ileus in the patients of early group (group A) was 33.56± 8.48 hrs while mean time to resolution from ileus of late group (group B) was 76.89 ± 7.64 hrs (p<0.05). Similarly WANG WY et al (2021)²⁰  found that the early enteral nutrition group showed better results in the time to first postoperative flatus (mean difference: 0.96). Also Behzad Nematihonar et al (2018)²¹ The times to first passage of flatus (2.66 ± 0.71 days vs. 3.9 ±0.071 days) and stool (3.9 ± 0.92 days vs. 5.4 ± 0.77 days) were significantly quicker in early feeding group.

In group A 96% tolerated the feed whereas in group B 98.00% cases tolerated food. (p>0.05). In group A maximum 8% had surgical site infections and minimum 2% systemic complications whereas in group B maximum 20% was surgical site infection and minimum 6% anastomotic leak and nausea/vomiting/ diarrhea. (p=0.103). Similarly Deepak Kumar Soni et al (2022)¹⁵ found that they had a complication rate of 11.4 % as compared to late enteral feeding group (25.7%). Also WANG WY et al (2021)²⁰ observed that there were no between-group differences in the incidences of vomiting, distension, ileus, anastomosis leak, infection, reoperation, and interruptions of enteral nutrition. Our study was in line with Behzad Nematihonar et al (2018)²¹ found that anastomosis leakage and abscess formation were not seen in early feeding group. 

In group A all cases were discharged from hospital whereas in group B 96% were discharged and deaths were 4%. (p>0.05) In group A maximum 90.00% had 5 to 10 days of hospital stay whereas minimum 10% had 1 to 5 days. In group B maximum 72% had hospital stay of 5 - 10 days whereas minimum 28% had >10 days of stay. Mean duration in group A was 5.95± 1.58 days whereas 8.75±2.56 day in group B (p<0.05). Similarly Deepak Kumar Soni et al (2022)¹⁵ in their study found that the mean hospital stay for patients given early enteral feeding was significantly lower as compared to controls (10.26±3.09 versus 13.4±2.186). Also WANG WY et al (2021)²⁰ observed that the length of hospital stay (mean difference: 1.53, 95% confidence interval: 2.56 ~ −0.42), compared with the delayed enteral nutrition group. Also Behzad Nematihonar et al (2018)²¹ found that hospital stay was also significantly shorter in the early feeding group (4 ± 0.64 days vs. 6.1 ± 0.84 days). 

In group A 3 (6%) patient needed additional surgery compared to group B where 5 (10%) patients need additional surgery. Most of additional surgery in both groups were due to wound dehiscence due to surgical site infection (resuturing) and secondly due to anastomotic leak (needs re exploration). There was less complication in early group thus less chances to reoperate. 

We concluded that early feeding after GI resection and anastomosis had early resolution of ileus with less complications like anastomotic leak and wound infections. Early feeding enables shorter length of hospital stay, leading to lower cost of treatment. However, we need a larger multi-centric study to demonstrate statistically significant differences in the outcomes to further validate the study findings.

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