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3he *omparat)4e study of the out*omes
of early and late oral feed)ng )n )ntest)nal
anastomos)s surger)es )n *h)ldren
"M!D:
5555
6u)*+ 7esponse (ode:
-m)d ,manollah), 8ahram ,9)9)1
,8S37,(3 children, and reduce hospital stay and costs.
8a*+ground: , lea+age of )ntest)nal anastomos)s
)s typ)*ally regarded as a de4astat)ng post0operat)4e
*ompl)*at)on. 3rad)t)onally )ts bel)e4ed that long fast)ng
after )ntest)nal surgery prote*t anastomos)s s)te and
most surgeons appl)ed th)s method. "ost0operat)4e
long fast)ng has many phys)*al and mental ad4erse
effe*ts, espe*)ally )n *h)ldren, but )ts bene t has not
pro4en yet. 3h)s study a)med to *ompare the out*omes
of early and late oral feed)ng )n )ntest)nal rese*t)on
and anastomos)s surgery )n *h)ldren. "at)ents and
Methods: 3h)s random)9ed, double0bl)nd *ontrolled
tr)al e4aluated the out*ome of early0feed)ng follow)ng
)n *h)ldren aged 1 month to 12 years who underwent
)ntest)nal rese*t)on and anastomos)s and *ompared
the results w)th those who had late0feed)ng. 3he results
were anlysed for fe4er, nausea and 4om)t)ng, abdom)nal
d)stens)on, rst passage of gas and stool were also
e4aluated hosp)tal stay t)me, major post0operat)4e
*ompl)*at)ons su*h as anastomos)s lea+age, wound
)nfe*t)on or deh)s*en*e, )ntra0abdom)nal abs*ess
between the two groups. 7esults: 3he mean t)me
of rst oral feed)ng )n the early feed)ng group :study
group; was 2.$ < 0.2 days but )t was $. < 0.1 days
)n the late feed)ng group :*ontrol group;. 3here was
no mortal)ty )n both groups. 3here was no d)fferen*e
)n major *ompl)*at)ons )n both groups :anastomos)s
lea+age;. !n the study group, rst defe*at)on t)me was
shorter than the *ontrol group :.2 days 4. %.% days; and
they had less hosp)tal stay also :$.2 days 4s. #. days;
and lower *ost of hosp)tal)9at)on. (on*lus)on: =arly
oral feed)ng after )ntest)nal rese*t)on and anastomos)s
)n *h)ldren )s a safe method, )t has many bene ts and
does not )n*rease the major or m)nor post0operat)4e
*ompl)*at)ons :anastomos)s lea+age; long t)me fast)ng
)s not ne*essary and has not any bene *)al effe*t and
early feed)ng )n*reases sat)sfa*t)on of the parents and
>ey words: (h)ldren, early feed)ng, )ntest)nal
anastomos)s, late feed)ng
!?37-D@(3!-?
One of the most serious complications after abdominal
surgery is leakage of intestinal anastomosis that
can be lethal and its regarded as a devastating post-
operative complication.[ 1] Anastomosis leakage causes
considerable adverse effects on patients survival.[ ]
!any factors can affect anastomosis site healing or
leakage, for e"ample intraoperative contamination,
circulation of intestinal ends, anemia, surgical technic,
kind of surgery #elective or emergency$, tension in
suture line, etc.[ 1] %here is the traditional belief that
the early feeding of patients &ho under&ent intestinal
resection and anastomosis can be dangerous and
induces stress on anastomosis site and makes it prone
to leakage, and most surgeons prefer to remaining
their patients not permit oral #'(O$ for )-* days post-
operation. but this is not proven yet, even &ithout any
feeding, about + of gastrointestinal and pancreatic
secretions enter the small bo&el daily and transit from
anastomosis site, thus feeding has not an important
additional adverse effect on anastomosis site resting
and even intestinal feeding has many positive effect on
&ound healing and reduction of sepsis.[ ,] (ost-operative
ileus is an important reason for remaining patients
'(O in post-operative period, but post-operative
ileus is a temporary and clinically unimportant
physiologic response, small bo&el movement return
)-- h after surgery, On the other hand, early removal of
nasogastric tube can reduce fluid and electerlytes loss
and accelerates the resolution of post-operative ileus.[ )]
.epartments of (ediatric /urgery, !ohammad 0ermanshahi 1ospital,
12mam 3e4a 1ospital, 0ermanshah 5niversity of !edical /ciences,
0ermanshah, 2ran
,ddress for *orresponden*e:
.r. Omid Amanollahi,
.epartment of (aediatric /urgery,
!ohammad 0ermanshahi 1ospital, 0ermanshah 5niversity of !edical
/ciences, (O 6o"7 891))1*,,,, 0ermanshah, 2ran.
:-mail7 oamanollahi;yahoo.com
:arly feeding is more important among children
because despite the adults they cannot tolerate more
African <ournal of (aediatric /urgery
9) April-<une =1, > ?ol 1= > 2ssue
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Amanollahi and A4i4i7 :arly oral feeding after bo&el anastmosis
than -, days fasting #nutrition only &ith intravenous
crystalloid solutions$ and longer fasting period re@uires
applying total parenteral nutrition #%('$ that has its
o&n problems and complications and additional costs.
day and then restarted. 2n the late feeding group #control
group$, the patients &ere kept fasting completely for
* days and #%('$ &as started from n d day for them.
2n the post-operative period, the patients &ere visited
each 1 h and clinical signs and symptoms such as,
time of first stool, vomiting, abdominal distension,
fever, &ound infection, &ere assessed. All patients &ere
under observe and monitored for signs and symptoms of
anastomosis leakage #e.g., fever, tachycardia, abdominal
tenderness and deterioration of general condition$
and if suspected, more investigations &ere done. All
complications &ere recorded. /tatistical analysis
&as performed &ith /(// 1=.=. %o compare specific
variables t-test and Ahi-s@uare tests &ere used. 2n all
statistical analyses, a ( value of B=.=* &as considered
statistically significant. %he (ermission &as obtained
from the ethical Aommittee of university and the
informed consent &as obtained from patients parents.
/afety and benefits of early oral feeding after intestinal
anastomosis is approved in many similar studies in
the adults.[ *] 2ts safety and usefulness confirmed in fe&
studies in children also.[ 8]
M,3=7!,AS ,?D M=3B-DS
%his double-blind study &as carried out in paediatric
surgical patients from Cebruary =11 to /eptember
=1. /i"ty seven children &ho under&ent intestinal
resection-anastomosis for various reasons &ere
randomi4ed consecutively to early feeding group #study
group$ and late feeding group #control group$. !ost
common reasons for intestinal resection anastomosis
&ere7 colostomy closure, invagination &ith gangren,
midgut volvolus, intestinal obstruction due to adhision
band &ith irreversible 2schemia, complicated meckel
diverticulum, intestinal duplications, strangulated
hernia &ith damaged intestine, intestinal trauma. All
children &ho under&ent small bo&el or colon resection
and anastomosis as elective or emergency &ere included
in the study.
7=S@A3S
On a total of 89 patients included in the study, ,9
patients &ere in the early feeding group #study group$
and ,= patients in the late feeding group #control group$.
%he mean age of the patients in study group &as 19.) D
.), months and ,.9 D ,.8 months in control group.
%here &ere = boys and 19 girls in study group and
1E boys and 11 girls in control group, no significant
difference founded in the age and se" bet&een both
groups [%able 1].
!ost of operations &ere including resection and
anastomosis of small bo&el #*E cases$ and some &ere
colon resection anastomosis, including colostomy
closure and colon trauma #- cases$. %he e"clusion criteria
&ere included comorbidity, septic shock before or after
the operation, anemia, severe abdominal contamination
during the surgery, the severe discrepancy bet&een the
diameter of t&o sides of intestine and technical problem
and difficulty of anastomosis #that Fudged by surgeon$
and severe long lasting post-operative ileus #severe post-
operative abdominal distention and vomiting$.
%he mean time of post-operation fasting &as .* D =.9
days in study group and *., D =.8 days in control group,
that &as significantly shorter in study group [%able 1].
%here &as one case of anastomosises leakage in each
group, both cases of anastomosis leakage under&ent re-
operation and recovered and &e had not any mortality
in t&o groups. %here &as no significant difference
bet&een the minor complications in both groups also
[%able ].
All operations performed by same pediatric surgeon,
using a similar technic, single layer separate stiches
&ith absorbable sutures #vicryl ,-= -and )-=$. Antibiotics
&ere given similarly for both groups after the surgery.
%he passage of first stool &as significantly sooner in
study group, ,.9 D 1.1 days versus ).) D 1.1 days in
control group #( =.=1-$ [%able ]. 6efore the surgery, the patients randomly assigned to
one of the t&o groups7
3able 1: 3he demograph)* data )n the study groups
2n the early feeding group #study group$, patients &ere
initially started on clear fluid only ) h after surgery
and progressed to milk and li@uids and then soft and
regular diet in ne"t day #after )- h$ in case of abdominal
distension and vomiting the regimen &as stopped for 1
"at)ents group =arly feed)ng Aate feed)ng P value
:n C 2; :n C 0;
Age #month$ 19.) D ).8 ,.9 D ,.8 =.,8E
/e" =#male$G
1E#male$G =.)))
19#female$ 11#female$
African <ournal of (aediatric /urgery 9* April-<une =1, > ?ol 1= > 2ssue
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Amanollahi and A4i4i7 :arly oral feeding after bo&el anastmosis
3able 2: 3he *ompar)son of the results of the
)nter4ent)ons )n the study groups
days after the small bo&el and colon resection is &ell
tolerated by most patients and it can be considered as
an important strategy after intestinal surgery.[1 =] Another
similar study &as conducted in !e"ico city. %o determine
the safety and efficacy of early enteral feeding after distal
#ileum- colon$ elective bo&el anastomoses in children.[ 11]
"at)ents group =arly feed)ng Aate feed)ng P value
:n C 2; :n C 0;
2nitial feeding #day$ .* D =.9 *., D =.8 B=.===1
?omiting ) 8 =.E)
.istention 1 9 =.=1
Cirstdefecation
#day after surgery$
,.9 D 1.1 ).) D 1.1 =.=1-
Another similar study in HanFan #2ran$ sho&ed that in
upper gastrointestinal surgery, the early feeding &as
safe and economical.[ 1] Our study is uni@ue because it
involves children in &ide age range and includes both
elective and emergent surgeries on small and large
bo&el. Although, safety and efficacy of the early feeding
method is sho&n in this study, but the limitations
should be considered and it is better that this method
considered for patients &ho are stable and had not sever
post-operative abdominal distention and vomiting and
&hen the intestinal anastomosis is satisfactory from the
technical vie&, that it &ill be Fudged by the surgeon.
1ospital stay #day$ *. D .1 -., D ., B=.===1
/ide effects ) =.8-)
%he hospital stay in study group &as *. D .1 days
but it &as -., D ., days in control group that is
significantly longer #( B =.===1$. %he hospital costs
&ere significantly more e"pensive in control group
also [%able ].
D!S(@SS!-?
2t has long been believed that cessation of oral intake
for at least )-* days postoperation in intestinal resection
anastomosis has a protective role on anastomosis site,
many studies have sho&n that this hypothesis has no
basis on scientific evidence and benefits of post-operative
early oral feeding such as immunologic enhancement,
decrease of surgical infection, prohibition of intestinal
villous atrophie and many psychologic positive effect,
are no& &idely accepted.[ 8] %oleration of long fasting
in children &ho under&ent maFor surgery is very hard
and more problematic than its adult counterpart. Casting
more than -, days in children need to use %(' that has
its o&n problems and costs and complications.
(-?(A@S!-?
%his study sho&ed that the early feeding after intestinal
resection anastomosis in children is a safe method
that improves the condition of the patients &ithout
increasing the post-operative complications and
this increases parents and patients satisfaction. %his
approach reduces hospital cost and stay also.
,(>?-.A=DDM=?3
Ie are grateful to our patients and their parents for
participation in our study.
Although, some similar studies are conducted in the past,
the current study &as one of the fe& studies performed
regarding the children similar studies sho&ed that early
oral feeding after elective gastro-intestinal anastomosis
is &ell tolerated, helps in early resolution of ileus,
decreased &ound infection and short hospital stay.[ 9] A
study conducted in 2ran on 11= patients &ho under&ent
abdominal surgery revealed that even feeding after 8 h
post-operation is &ell tolerated and it doesnt increase
complications.[ -] Another study performed on 8) children
belo& 1 years old &ho under&ent intestinal resection
anastomosis sho&ed that the start of the feeding before
9 h and after *-9 days has not any difference in the
complications.[E] 2n a !eta-analysis and systematic
revie& on 11 studies including -,9 patients, it &as
found that long fasting of the patients after the elective
gastrointestinal surgery is not useful and the start of early
feeding is more beneficial.[* ] Another study in Jermany
on 1== patients &ho under&ent intestine resection
anastomosis sho&ed that the start of the feeding 1-,
7=E=7=?(=S
1. +uFKn <<, 'Lmeth H1, 6arratt-/topper (A, 6ustami 3, 0oshenkov ?(,
3olandelli 31. Cactors influencing the outcome of intestinal
anastomosis. Am /urg =11M997118E-9*.
. 1yman ', !anchester %+, Osler %, 6urns 6, Aataldo (A.
Anastomotic leaks after intestinal anastomosis7 2ts later than you
think. Ann /urg ==9M)*7*)--.
,. .ag A, Aolak %, %urkmenoglu O, Jundogdu 3, Aydin /. A
randomi4ed controlled trial evaluating early versus traditional oral
feeding after colorectal surgery. Alinics #/ao (aulo$ =11M887==1-*.
). Hhou %, Iu N%, Hhou O<, 1uang N, Can I, +i OA. :arly removing
gastrointestinal decompression and early oral feeding improve
patients rehabilitation after colorectostomy. Iorld < Jastroenterol
==8M17)*E-8,.
*. +e&is /<, :gger !, /ylvester (A, %homas /. :arly enteral feeding
versus Pnil by mouthQ after gastrointestinal surgery7 /ystematic
revie& and meta-analysis of controlled trials. 6!< ==1M,,799,-8.
8. :kingen J, Aeran A, Juvenc 61, %u4laci A, 0ahraman 1. :arly
enteral feeding in ne&born surgical patients. 'utrition ==*M171)-8.
9. !ar&ah /, Jodara !/, Joyal !/, !ar&ah '. :arly enteral nutrition
follo&ing gastrointestinal anastomosis. 2nternet < Jastroenterol
==-M9.
-. Canaie /A, Hiaee /A. /afety of early oral feeding after gastrointestinal
African <ournal of (aediatric /urgery
98 April-<une =1, > ?ol 1= > 2ssue
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n for th)s
journal
Amanollahi and A4i4i7 :arly oral feeding after bo&el anastmosis
anastomosis7 a randomi4ed clinical trial. 2ndian < /urg ==*M8971-*-1.1. 1osseini /', !ousavinasab /', 3ahmanpour 1, /otodeh /.
Aomparing early oral feeding &ith traditional oral feeding in upper
gastrointestinal surgery. %urk < Jastroenterol =1=M1711E-).
E. /holadoye %%, /uleiman AC, !shelb&ala (!, Ameh :A. :arly
oral feeding follo&ing intestinal anastomoses in children is safe.
Afr < (aediatr /urg =1ME711,-8.
1=. 6Rhm 6, 1aase O, 1ofmann 1, 1eine J, <unghans %, !Sller <!.
%olerance of early oral feeding after operations of the lo&er
gastrointestinal tract. Ahirurg ===M917E**-8.
()te th)s art)*le as: ,manollah) -, ,9)9) 8. 3he *omparat)4e study of the
out*omes of early and late oral feed)ng )n )ntest)nal anastomos)s surger)es )n
*h)ldren. ,fr F "aed)atr Surg 201G10:2%02.
11. 1ospital 2nfantil de !e"ico Cederico Jome4, :arly Ceeding vs
*-day Casting After .istal :lective 6o&el Anastomoses in Ahildren.
A 3andomi4ed Aontrolled %rial. clinicaltrials.gov>ct>sho&>
'A%=1=--=9. Available from7 &&&.bioportfolio.com>resources>
trial>9==1,.
Sour*e of Support: Eunded by a grant from >ermanshan @n)4ers)ty
of Med)*al S*)en*es and was perm)tted and appro4ed by 7esear*h
(omm)ttee of >ermanshah @n)4ers)ty of Med)*al S*)en*es. (on )*t of
!nterest: ?one de*lared.
African <ournal of (aediatric /urgery 99 April-<une =1, > ?ol 1= > 2ssue