[ Vol. 11 No. 1 ] (January - April 2010 )
Strategies to improve perioperative enteral nutrition tolerance

Ravinder Reddy
Division of Clinical Nutrition, Care Hospital - The Institute of Medical Sciences Hyderabad, India


Advances in surgical technology coupled with an increased understanding of the basic sciences have facilitated a tremendous evolution of surgical practice. However, as we reflect upon 500 years of surgical practice, one realizes that less attention has been directed to the challenges of feeding the surgical patient in the perioperative period. It was about 73 years ago (1936) that Studley demonstrated an increased mortality in malnourished patients undergoing surgery.

After any major abdominal surgery, an obligatory feature is the development of postoperative ileus. Despite the established facts most surgeons and anesthetists avoid feeding (both oral and tube feeding) till the patient passes flatus and or has a bowel movement. The routine use of nesogastric decompression and the reluctance to allow feeds is based on the (unapprised) concern for gastric distention and for anastomotic integrity. The average time-delay to commence oral feeds after surgery ranges between 3 to 7 days. During this period, energy and protein administration are practically nil or are suboptimal. These practices predispose surgical patients to further vagaries of protein-energy malnutrition and catabolism.

Early perioperative feeding has been shown to be beneficial and is associated with a positive clinical outcome. Early perioperative nutritional support includes early enteral nutrition (EEN) and supplemental parenteral nutrition (SPN) in the malnourished. EEN reduces infectious complications, especially at the surgical sites, limits the need for intensive care and decreases the overall length of stay in the hospital. However, EEN is not always successful. The biggest limiting factor is the postoperative gut dysfunction and the traditional reluctance to commence early feeds by the surgeons and anesthetists. In addition there are other issues like diarrhea, increased gastric residual volumes which limit the enteral feeds and thereby result in failure to achieve caloric goals.

I. Provision and access to appetising food
II. Nasogastric tube delays normal dietary intake, therefore avoid nasogastric tube in all elective abdominal procedures. Also by avoiding routine gastric decompression after abdominal surgery reduces the incidence of fever, atelectasis, pneumonia and prevents losses of trace elements (zinc and selenium), bile acids, bile salts, lgA and lgE
III. Avoiding bowel preparation. Mechanical bowel preparation promotes inflammation in the bowel wall and delays return of normal gut function
IV. Epidural analgesia for postoperative analgesia. Catecholamines are released after surgery from adrenal medulla and also from local sympathetic nerves in response to apprehension, pain and due to tissue dissection of visceral peritoneum. Epidural analgesia at the mid-thoracic level will attenuate these responses and reduce postoperative ileus
V. Control of postoperative nausea and vomiting is essential to resume normal dietary intake. Use of antiemetics will enhance resumption of early dietary intake
VI. Adequate perioperative fluid balance speeds up the return of bowel function and enhance enteral feeds tolerance. This can be achieved by are
i. A strict perioperative fluid regime
ii. Avoiding overnight fasting
iii. Avoiding mechanical bowel preparation
VII. Avoid opioids analgesia as they have a paralytic effect on the gut, which is about 4 times stronger than their analgesic effect! Non-steroidal anti-inflammatory drugs and paracetamol are better alternatives.
VIII. Adequate perioperative fluid balance speeds up the return of bowel function and enhance enteral feeds tolerance. This can be achieved by are
i. Minimal incisions, gentle manipulation an handling of tissues, especially stomach and intestines
ii. Intraoperative warming
iii. Minimal use of drains, tubes, catheters and their removal as soon as possible
IX. Postoperative laxatives significantly speeds up the time of return of bowel movement. Magnesium oxide 1200 mg per day, in divided doses is used routinely in all the enhanced recovery protocols. It is a safe and an effective laxative18.
X. Optimization of patient factors18. Correct hyperglycemia & electrolytes (potassium and magnesium), correction of blood pressure and optimization of co-morbidities.
XI. Precautions against loose stools. The commonest cause of diarrhea in patients with loose stools are medications, which should be reviewed in all cases of diarrhea. The hang time of enteral feed should not exceed 6 to 8 hours and strict hand-antisepsis should be maintained by the personnel preparing the feed.
XII. Precautions against aspiration should be meticulously followed. They are:
i. Always administer feeds with the head end elevated by 350. Maintain this position for and hour.
ii. Minimize use of narcotics
iii. Use smaller than 16 F tubes
iv. Advocate continuous feeds
v. Stop feeding if the patient develops abdominal distension or experiences abdominal discomfort, and if the residual volumes are increasing.
vi. Feed into the small bowel (third part of duodenum or beyond) in patients with two or more risk factors. patients
vii. Use sucralfate whenever possible
viii. Use mouthwash and other measures to optimize oral health

Early and safe enteral or oral nutrition interventions in the postoperative period have evolved dramatically during the last few years. Like any other form of intervention, the practice of commencing early nutrition following surgery should be based on evidence based principles. However, early commencement of diet may not successful in view of gut dysmotility and hence the strategies to increase the tolerance should begin in the preoperative period. The strategies include preoperative optimization of the patient, changing the traditional preoperative practices and inculcating evidence-based intraoperative methods and adapting maneuvers to feed even in the presence of postoperative ileus.

Preoperative patient education and counselling has shown to be beneficial in the postoperative recovery, including tolerance to early feeds. Enhanced recovery protocols combine several interventions18. Their effect of postoperative gut function is impressive and ERAS protocols increases the tolerance to solid food and nutritional supplements very early after surgery.

This article reviews the various strategies to increase the tolerance to enteral feeds in the perioperative period.



  1. Studley HO: Percentage weight loss, a basic indicator of surgical risk in patients with chronic peptic ulcer. JAMA 1936, 106:458-460.
  2. McWhirter JP, Pennington CR: The incidence and recognition of malnutrition in hospital. BMJ 1994, 308:945-8
  3. Torosian M. Perioperative nutrition support for patients undergoing gastrointestinal surgery: critical analysis and recommendations. World J Surg 1999; 23:565
  4. Neumayer L, Smout R, Horn H, Horn S, Early and sufficient feeding reduces length of stay and charges in surgical patients. J Surg Res 2001; 95:73
  5. Soop M, et al. Randomised clinical trial of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol. Br J Surg 2004. 91: 1138-Carl F, Schricker T. Modulation of the catabolic response to surgery. Nutrition 2000; 16 (9):777-780
  6. Desborough JP. The stress response to trauma and surgery. Br J Anaesthesia 2000; 85 (1):109-117
  7. Preston T, Shenkin A, et al. Fibrinogen synthesis is elevated in fasting cancer patients with an acute phase response. J Nutrition 1998; 128:1355-1360
  8. van der Hulst RR, et al. Gut permeability, intestinal morphology, and nutritional depletion. Nutrition 1998, 14:1-6
  9. John VP, John LM, Jennie PH. A meta-analysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalised patients. Critical Care Medicine 2005. 33 (1):213-220
  10. Slim K, et al. Meta-analysis of randomized clinical trials of colorectal surgery with and without mechanical bowel preparation. Br J Surg, 2004. 91 (9):1125-30
  11. N Puri, N Baghla, A Talwar. Effects of clear fluids ingested before elective surgery on pulmonary aspiration of gastric contents. Gastroenterology Today. 2006 (10) 3; 140-142
  12. Nelson R, et al. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg 2005. 92(6): 673-680
  13. Jeejeebhoy KN. Total parenteral nutrition: potion or poison? Am J Clin Nutr 2001; 74:160-163
  14. Woodcock N, et al. Enteral versus parenteral nutrition: a pragmatic study. Nutrition 2001; 17:1-12
  15. Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med 1991, 325:525
  16. Howard M, Frankel EF, Parrish CR (Editor). The Hitchhikers Guide to Parenteral Nutrition Management for Adult Patients. Practical Gastroenterology. 2006. Nutrition Issues in Gastroenterology, Series # 40
  17. Alexander JW. Immunonutrition: the role of _ 3 fatty acids. Nutrition 1998; 14(7-8): 627
  18. Andrews FJ, Griffiths RD. Glutamine: essential for immune nutrition in the critically ill. Br J Nutr 2002;87 (Suppl 1):S3
  19. Braga M, et al. Perioperative Immunonutrition in patients undergoing cancer surgery: results of a randomized double-blind phase 3 trial. Arch Surg 1999; 134:428


PENSA 2009

“Energizing Nutrition Support Practice for Life”
June 5-7 2009, Shangri-La Hotel, Kuala Lumpur, Malaysia 
Page: 52-53