Enhanced Recovery: A Team Approach to Managing Postoperative Ileus - Episode 11
Raoul Concepcion, MD: Sanjay, one of the big things, and I want you to address this, if you don’t mind, is early enteral nutrition, postoperatively. There is the fear with a gastrointestinal anastomosis of, “We can’t stretch the anastomoses.” And the old dogma was, you waited until they had bowel sounds and you gently pushed them. So, they would go 1, 2, 3, 5 days with no postoperative nutrition.
Sanjay Patel, MD: Yes, and sometimes they’d start on TPN (total parenteral nutrition). We’d go, “Well, we better put them on TPN. Nothing has come out.” Earlier in my training, I saw that. I saw a lot of the surgeons just kind of cringing at me like, “What? They’re going to throw up. We can’t feed them. They’re not ready.”
I try to feed them as early as I can. I’ll start chewing gum right after surgery, and then usually about 4, 6 hours after surgery, I’ll start them on some liquids. I think that’s where patient education is key. If you drink something and you start feeling bloated and nauseous, don’t chug another 3 liters of whatever you’re drinking. I think that educating the patients about that certainly can help. They certainly appreciate getting liquids earlier, and I do think that early feeding stimulates the gut. If there’s something in the gut, the gut says, “Well, I better start moving.” I think that’s certainly one of the things that can help with some of these problems that we have with ileus, postoperatively.
Raoul Concepcion, MD: We have early enteral nutrition, and I’m sure early mobilization, getting out of bed? Is that part of your protocol as well?
Traci Hedrick, MD, MS, FACS, FACRS: It is. We give them clears the night of surgery, and then they get solid food the next day. I certainly think the data shows there’s no increase of an anastomotic leak with doing that. What we, as surgeons, fear most is aspiration, which can be fatal, particularly in elderly patients. I would say that all of the aspiration events that I have seen have been in people who clearly developed an ileus. They’re very bloated. It’s usually on the third postoperative day. They just need a nasogastric tube. It’s not been aspiration from them eating a little Jell-O or yogurt the next day after surgery.
Declan Fleming, MD: No, it’s not microaspiration at all. And I think that not adhering to the dogma around ERAS (enhanced recovery after surgery), allowing that there are going to be some people that can’t follow the protocol through, you have to be ready to accommodate for that. I don’t know about for you guys, but for me, my patients, very frequently, are going to self-limit what they do. If they’re not progressing well, I’m going to see it from them. It’s paying attention to that which allows us to intervene in a timely fashion.
John Dalton, MD: My experience with outpatient surgery, for example, may be reticent to the discussion of early feeding and liquids. It’s nice to hear Sanjay talk about the patient who will tell you if they get bloated and can’t eat. I tell patients, “Don’t have anything until you’re hungry.” That may not apply to big surgery like this, but certainly for outpatient scenarios, chewing gum stimulates that. So, as soon as they’re hungry, start with liquids. Then, if that’s staying down, then you can eat. I’m reticent to force people along a pathway dogmatically, but you can let them tell you how they’re doing and progress them as fast as they want to be progressed.
Transcript edited for clarity.