A Myth About Anastomotic Leak

International Surgery Journal
Shakya P et al. Int Surg J. 2016 Feb;3(1):81-83

http://www.ijsurgery.com
pISSN 2349-3305 | eISSN 2349-2902
DOI: http://dx.doi.org/10.18203/2349-2902.isj20151490
Research Article
A myth that early feeding causes bowel anastomotic leakage: is it true?

Prateek Shakya*, Bhuvan C.
Department of General Surgery, Government Medical College, Haldwani, Uttarakhand, India

Received: 01 December 2015
Revised: 02 December 2015
Accepted: 08 December 2015
*Correspondence:
Dr. Prateek Shakya,
E-mail: drprateekshakya@gmail.com
Copyright: the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Traditionally its believed that long fasting after intestinal surgery protect anastomosis site. However
delayed feeding causes mental stress on patients, any beneficial effect of delayed feeding is yet to be proved. Early
feeding should be promoted as longer fasting cause mucosal atrophy of the intestine and fasting patients requires TPN
that has its own problems and complications along with additional costs.
Methods: The aim of study is to evaluate the outcomes of early feeding in bowel anastomosis in terms of intestinal
anastmotic leakage, post operative ileus and hospital stay. We included 100 patients of age group 20-50 yrs who
underwent ileostomy closure and they were randomized blindly into two groups - early vs. late feeding group.
Results: The mean time of first oral normal feed in early feeding group was 2.29 0.37 as compared to delayed
feeding group which was 6.44 0.43 days (p value significant <0.0001). The first defecation was significantly earlier
in the study group as compared to late feeding group (study group mean 4.04 0.21 vs. control group mean 7.9 0.22,
p value <0.0001) and hospital stay is significantly shorter in study group (early group mean 4 0.21 vs. delayed
feeding group 8.08 0.23, p value <0.0001) as compared to late feeding group. There was no mortality and
anastomotic leakage in both groups.
Conclusions: Early feeding does not cause any major complication i.e. anastomotic leakage and promotes overall
patients feeling of wellbeing and decrease hospital stay and costs.
Keywords: Early feeding, Delayed feeding, Anastomotic leakage
INTRODUCTION
In the past around 18th or 19th century there was a concept
of delayed oral feeding only after passage of flatus or
stool. This management has been adopted over the years
with the notion that restriction of oral feeding gives the
GI tract more time to heal & recover & reduces stress on
anastomosis site and prevent leakage thus reducing post
operative complications,1 but even if we do not give oral
feeding, about 2-2.5 L of gastrointestinal and pancreatic
secretions enters the small bowel and transit from the
anastomosis site, thus feeding has no additional adverse
effects on anastomosis site. Early feeding delays post
operative ileus, helps in wound healing and reduction of
sepsis.2 Post operative ileus had been an important reason

for patients kept NPO in post operative period However
after surgery the return of bowel function and motility
occurs within 6-12 hr in small bowel, 12-24 hr in
stomach and within 48-72 hr in large bowel.3 Post
operative starvation changes the metabolism of the body
within 24 hours by increasing insulin resistance and
reducing muscle function.2
The purpose of this study is to evaluate that early feeding
is having any additional advantage over the traditional
feeding in terms of post operative ileus, bowel
anastomosis leakage and hospital stay.
International Surgery Journal | January-March 2016 | Vol 3 | Issue 1
Page 81
in any patient we had not reinserted the nasogastric

feeding tube.
METHODS
A total of One hundred (100) patients who underwent
ileostomy closure in surgical department of Government
medical college Haldwani were included in the study who
were randomized blindly into two groups- early feeding
(study group) vs. late feeding (control group). The
patients of age group 20 yrs to 50 yrs were included in
the study and the patients who were not fit for the surgery
were excluded from the study. All the operations were
performed by single unit of general surgery with same
technique- extra mucosal interrupted single layer bowel
anastomosis using either vicryl 3-0 or 2-0 RB. Pre
operative bowel preparation was same for both groups
and in the post operative period patient was given same
antibiotics and same analgesia. In all the cases
nasogastric tube was removed after 6 hrs of post
operative period. In early feeding groups we started the
feeding after 12-24 hrs of surgery with clear water at the
rate of 50ml/hr well tolerated patients were taken on semi
solid diet after 24- 36 hrs and on normal regular diet after
36 - 48 hr of surgery. Those patients who were not
tolerating had abdominal distention and vomiting feeding
was stop for 12 hrs and refeeding was started afterwards.
In late feeding groups we started the feeding in a
traditional method (after bowel sounds and passage of
flatus) after 5 days and same feeding plan was given in
early feeding group. Patient general vital charting (pulse
rate, blood pressure, fever), assessment of time of
passage of first stool, appearance of bowel sounds and
assessment of complaints like vomiting, abdominal
distension and signs of bowel anastomosis dehiscence
(fever, tachycardia, abdominal distension, guarding,
rigidity, drain content and output) were done at every 12
hourly. All complications were recorded. To compare
specific variables, t-test and Chi-square tests were used.
In all statistical analysis, a p value of <0.05 was
considered statistically significant.
RESULTS
The early feeding group included 28 males & 22 females
with a mean age of 35.6 7.8.whereas late feeding group
consist of 33 males & 17 females with a mean age of
35.4 8.77 there was no significant difference in terms of
genders or age of the patients as shown in Table 1. The
mean time of first oral normal feed was 2.29 0.37 days
in early feeding group and 6.44 0.43 days in late feeding
group that was significantly shorter (p value <0.0001) in
early feeding group. In early feeding group passage of
stool occur significantly earlier 4.04 0.21 days versus
7.9 0.22 days; p value <0.0001, in late feeding group.
Hospital stay in early feeding group is significantly
shorter (4.9 0.33 days; p value <0.0001) as compared to
late feeding group (8.08 0.233). All the result is
summarized in Table 2. No anastomosis leakage and
mortality is noted in both the groups. None of the patients
had symptoms of vomiting and abdominal distention and
Table 1: The demographic data in study groups.

Patients
group
Early
feeding
N=50
Late
feeding
N=50
P value
Age in
years
35.6 7.8
32 4.8
<0.253
Sex
28 (male)
22 (female)
33 (male)
17 (female)
<0.305
Table 2: Comparative result of two groups early vs.

late feeding groups.
Patient group
Initial normal
oral feed days
First defecation
after surgery
Hospital stay
Anastomotic
leakage
Early
feeding
N=50
Late
feeding
N=50
P value
2.29 0.37
6.44 0.43
<0.0001
4.04 0.21
7.9 0.22
<0.0001
4.9 0.33
8.08 0.23
<0.0001
DISCUSSION
The concept that early feeding causes anastomotic
leakage is not true, it has been clearly demonstrated that
mucosal epithelium of the bowel is perfectly sealed after
the first 24 hrs of the post operative period 4 and in our
study we started the feeding at 12-24 hrs and no leakage
is demonstrated. It has been also shown that early feeding
accelerates the wound and anastomosis healing in the
animal model.5 Early feeding reverses the mucosal
atrophy induced by starvation and increases anastomotic
collagen deposition and strength.6-8
Most of the practicing surgeon even today practicing,
keep the patient NPO for 4-5 days after ileostomy closure
and uses nasogastric tubes until resolution of the post
operative ileus .Recently ,this approach has been
questioned and few studies have shown that nasogastric
tube insertion has a limited role in postoperative care of
abdominal surgery.2 In present study ,nasogastric tube
was inserted before surgery and removed after 6 hr of
surgery and this approach was tolerated by all the patients
and in no patients we needed reinsertion of nasogastric
tube.
Early feeding decreases the incidence of postoperative
ileus by stimulating the reflex that produces co ordinate
propulsive activity and elicits the secretion of GI
hormones thus shortening the duration of post operative
ileus instead of causing it.9 In present study, patient of
study group has first defecation
much earlier as
compared to late feeding group.
Page 82
Oral fluid and food intake following surgery improved

the sense of wellbeing.10 In addition early feeding leads
to earlier discharge from the hospital11 and also decreases
the incidence of nosocomial infections, liver dysfunction,
bacterial translocation and secondary malnutrition.4,12
In our study hospital stay of the patient is significantly
low in early feeding group has compared to study group.
CONCLUSION
This study showed that the early feeding after ileostomy
closure is a safe method that improves the condition of
the patients without increasing the post-operative
complications and this increases parents and patients
satisfaction. This approach reduces hospital cost and stay
also.
ACKNOWLEDGMENTS
We are grateful to our patients and their parents for
participation in our study.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
institutional ethics committee
REFERENCES
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Zhuang CL, Ye XZ, Zhang JC, Dong QT, Chen BC,

Yu Z. Early versus Traditional Postoperative Oral
Feeding in Patients Undergoing Elective Colorectal
Surgery: A Meta-Analysis of Randomized Clinical
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Dag A, Colak T, Turkmenoglu O, Gundogdu R,
Aydin S. A randomized controlled trial evaluating
early vs traditional oral feeding after colorectal
surgery. Clinics (Sao Paulo). 2011;66:2001-5.
Amanollahi O, Azizi B. The comparative study of
the outcomesof early and late oral feeding in
intestinal anastomosis surgeries in children African
Journal of Paediatric Surgery. 2013;10(2);74-77.
4.
Stewart BT, Woods RJ, Collopy BT, Fink RJ,

Mackay JR, Keck JO. Early Feeding after Elective
Open Colorectal Resections: A Prospective
Randomized Trial. Australian and New Zealand
Journal of Surgery. 1998;68,2:125-8.
5. Gokpinar I, Gurleyik E, Pehlivan M, Ozcan O,
Ozaydin I, Aslaner A. Early Enteral and Glutamine
Enriched Enteral Feeding Ameliorates Healing of
Colonic Anastomosis: Experi-mental Study. Ulusal
Travma ve Acil Cerrahi Dergisi. 2006;12,1;17-21.
6. Ozerhan IH, Ersoz N, Onguru O, Ozturk M, Kurt B,
Cetiner S. Fascin expression in colorectal
carcinomas. Clinics. 2010;65:15764.
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Coelho JC, Campos AC. Influence of preoperative
feeding on the healing of colonic anastomoses in
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8. Filiz AI, Sucullu I, Kurt Y, Karakas DO, Gulec B,
Akin
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carcinoembryonic antigen in colorectal cancer
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9. Anderson ADG, McNaught, MacFie CE, Tring J,
Barker I. Randomized clinical trial of multimodal
optimization and standard preoperative surgical
care. British Journal of Surgery. 2003;90:1497504.
10. Schilder JM, Hurteau JA, Look KY, Moore DH,
Raff G, Stehman FB. A prospective controlled trial
of early postoperative oral intake following major
abdominal gynecologic surgery. Gynecol Oncol.
1997;67:235.
11. Steed HL, Capstick V, Flood C, Schepansky A,
Schulz J, Mayes DC. A randomized controlled trial
of early versus traditional' postoperative oral intake
after major abdominal gynecologic surgery. Am J
Obstet Gynecol. 2002;186:8615.
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Journal of Surgery. 2007;94(5):555-61.
Cite this article as: Shakya P, Bhuvan C. A myth
that early feeding causes bowel anastomotic
leakage: is it true? Int Surg J 2016;3:81-3.
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International Surgery Journal

Shakya P et al. Int Surg J. 2016 Feb;3(1):81-83

pISSN 2349-3305 | eISSN 2349-2902

A myth that early feeding causes bowel anastomotic leakage: is it true?

Department of General Surgery, Government Medical College, Haldwani, Uttarakhand, India

sepsis.2 Post operative ileus had been an important reason

International Surgery Journal | January-March 2016 | Vol 3 | Issue 1

Shakya P et al. Int Surg J. 2016 Feb;3(1):81-83

in any patient we had not reinserted the nasogastric

Table 1: The demographic data in study groups.

Table 2: Comparative result of two groups early vs.

International Surgery Journal | January-March 2016 | Vol 3 | Issue 1

Shakya P et al. Int Surg J. 2016 Feb;3(1):81-83

Oral fluid and food intake following surgery improved

Zhuang CL, Ye XZ, Zhang JC, Dong QT, Chen BC,

Stewart BT, Woods RJ, Collopy BT, Fink RJ,

International Surgery Journal | January-March 2016 | Vol 3 | Issue 1

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