"To eat or not to eat...".

One object of science is to examine generally held beliefs in a purposeful manner using the scientific method. In the multicenter prospective clinical trial reported in this issue by Lassen et al, the commonly held belief that patients should not receive oral intake immediately after major upper abdominal gastrointestinal operations is examined. The use of nasogastric tube decompression during the early postoperative period is highly variable, usually based on physician bias. It is known, however, that recovery of normal gastrointestinal peristalsis after major abdominal surgery is immediate in the small intestine and returns next in the stomach and the large intestine. Thus, the teaching of decades was that when patients pass flatus, they are ready for oral intake. In fact, standard practice 30 years ago was to wait for that event even to remove the nasogastric tube. This approach to perioperative care was taken as a means to avoid aspiration, gastric and intestinal distension and increased anastomotic and abdominal wall incision stresses. A number of clinical trials have questioned this traditional teaching. The introduction of abdominal laparoscopy supported the recognition that the extent of gastrointestinal manipulation was a substantial factor leading to abnormal gastrointestinal function after a major operation. Others have taken an approach using methods of multimodel rehabilitation to hasten return of bowel function and decrease the duration of hospitalization. For example, Khoo et al randomized 70 patients who underwent elective colorectal resection to multimodal therapy with intravenous fluid restriction, unrestricted oral intake with prokinetic agents, early ambulation, and fixed regimen epidural analgesia, or to more standard care. Median stay was significantly reduced in the multimodal group compared with controls. Wolff et al reviewed 4 clinical trials evaluating alvimopan (12 mg twice daily) versus placebo administered perioperatively. Postoperative ileus-related morbidity was less in the treated patients compared with results in placebo-treated controls. Herroeder et al administered systemic lidocaine perioperatively, noting a shortened time to return of bowel function and decreased length of hospital stay in treated patients. Thus, aggressive approaches have led to protocol-driven methods to reduce postoperative intestinal ileus-related morbidity and length of hospital stay. In addition, numerous studies have shown that enteral nutrition via nasoenteral or jejunostomy tubes could be given immediately after an operation without increased anastomotic complications due to feeding. For example, Kaur et al randomized 100 patients with perforation peritonitis to early nasoenteral feeding or to delayed oral intake, noting that return of bowel function was earlier and the rate of complications was less in the nasoenterally fed group compared with the controls. However, others have noted higher rates of complications in enterally fed patients and, thus, prospective studies have not been uniform in demonstrating beneficial clinical outcomes of immediate postoperative jejunostomy feeding in surgical patients. In 2005 Lassen, et al reviewed the standards of perioperative care for patients undergoing upper gastrointestinal operations in major surgical centers located in 5 northern European countries. They noted marked heterogeneity in clinical practices related to the use and duration of nasogastric decompression and the timing of initiation of oral intake after surgery.