THE EFFECT OF DIET

PROGRESSION TYPES
AFTER COLORECTAL
SURGERY

Everly Saenz
Queens College Dietetic Intern 2021-
2022
 ABSTRACT1

Purpose:
• To determine the efficacies of different diet progressions on gut motility after
colorectal surgery via a systematic review of the literature

Key finding:
• Results from the review indicate that any form of diet progression implemented early
postoperatively will induce gut motility
Enhanced Recovery After Surgery (ERAS)
Protocols1

• Established in 2005
• Designed to improve patient outcomes
• ↓ perioperative stress
• ↓ rates of postoperative complications
• ↑ post-operative recovery
• Overall reduction of complications including rates of
morbidity/mortality and decreased length of stay (LOS)
Postoperative Nutrition Implementation:
The Old vs. The New1-3
Traditional postoperative “nil per os” (NPO)
rationale:
• Concern for poor oral tolerance during
ileus/reduced gut motility
• Assumes protection against anastomotic leaks
from newly made anastomosis
ERAS Society recommendation of
postoperative early feeding:
• Oral feeding may begin as soon as 4 hours after
surgery
• Less nausea
• Accelerated return of bowel function
• No association with anastomotic leak
• No clear recommendation for type of early oral
feeding
SIGNIFICANCE OF THE STUDY1
• To review the practical diet progressions for colorectal
surgeries in order to guide clinicians in making
informed decisions despite the lack of translating
evidence into practice

• To assess the effect of diet on the stimulation of gut

motility post-operatively
DEMOGRAPHICS OF THE META-ANALYSIS1

Relevant criteria for study selections:

• ≥ 18 years old recently undergoing colonic resection
• Primary outcome was POI measured by rate of first bowel movement/flatus
• Secondary outcomes including LOS, mortality, nausea/vomiting

After filtering through the initial literature search:

• 10 randomized controlled studies met the criteria
• 1237 total participants
Grading of Recommendations, Assessment,
Development and Evaluation (GRADE) System1
• For each factor encountered, 1 downgrading level of
classification was applied to the study
• Study design
• Inconsistency of results
• Imprecision
KEY RESULTS OF DIET PROGRESSION
TYPES1 (Pooled Results and Gradings of Studies)
Early feeding (clear liquids solids) vs. Traditional
post-operative fasting (NPO)
• Compared to traditional post-operative fasting, early feeding
found to have:
• ↓ time to first flatus, ↓ time to first bowel movement
(BM), ↓ LOS
• No effect on mortality or nausea
• ↑ vomiting
Quality of Evidence: Low
KEY RESULTS OF DIET PROGRESSION
TYPES1 (cont’d)…
Solids vs. Progression of fluids  solids
• Compared to progression of fluids  solids, solids were found to
have:
• No effect on time to first flatus, first BM, or LOS (excluding
one study which found to ↓ LOS compared to fluids 
solids)
• No effect on mortality or vomiting
• ↓ nausea on post-operative day (POD) 1, however no effect
on POD 2
Quality of Evidence: Low
KEY RESULTS OF DIET PROGRESSION
TYPES1 (cont’d)…
Complete nutrition vs. Hypocaloric nutrition
• Compared to hypocaloric nutrition, complete nutrition found to
have:
• No effect on time to first flatus or first BM
KEY RESULTS OF DIET PROGRESSION
TYPES1 (cont’d)…
Coffee + Diet vs. Water + Diet
• Compared to water and diet, coffee and diet found to have:
• No effect on time to first flatus or LOS
• ↓ time to first BM
KEY RESULTS OF DIET PROGRESSION
TYPES1 (cont’d)…
EN + diet vs. PN + diet
• As compared to parenteral nutrition and diet, enteral nutrition
and diet found to have:
• No effect on LOS
Quality of Evidence: Very- Low
Summary of Findings1
Key Conclusions/Implications1:
• These findings further provide dietitians with a baseline understanding that any form of early

feeding will promote gut motility, shortened length of stay, and decreased time to first flatus and

bowel movements rather than keeping the patient fasted, although practitioners should be aware of

potential for increased vomiting when initiating the progression of a clear liquid diet before

introduction of solids
Key Conclusions/Implications1 (cont’d):

• Although low quality of evidence, coffee may be considered as part of the patients' diet order to

promote decreased time to first bowel movement and increased gut motility. Further research is

needed to determine the effect of different fluids on gut motility.

Key Conclusions/Implications1 (cont’d):

• Translation of evidence into practice may prove to be a barrier of early feeding and diet progression

type, however growing interest of evidence of the benefits of varied diet types and composition will

further supply the dietitian with evidence-based guidelines for superior clinical judgement and

patient care in those undergoing colorectal surgery

REFERENCES

1. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective
colorectal surgery: enhanced recovery after surgery (ERAS) society recommendations:
2018. World J Surg. 2019; 43: 659-695. https://doi.org/10.1007/s00268-018-4844-y
2. Bisgaard T, Kehlet H. Early oral feeding after elective abdominal surgery--what are the
issues?. Nutrition. 2002; 18 (11-12): 944-948. https://doi: 10.1016/s0899-9007(02)00990-5
3. Hogan S, Steffens D, Rangan A, et al. The effect of diets delivered into the gastrointestinal
tract on gut motility after colorectal surgery—a systematic review and meta-analysis of
randomised controlled trials. Eur J Clin Nutr. 2019; 73: 1331-1342.
https://doi.org/10.1038/s41430-019-0474-1
Questions?