Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
Cause Health, Norwegian University of Life Sciences, Ås, Norway.
Cochrane Database Syst Rev. 2024 Aug 12;8(8):CD004508. doi: 10.1002/14651858.CD004508.pub5.
This is an updated and expanded version of the original Cochrane review, first published in 2014. Postoperative oral intake is traditionally withheld after major abdominal gynaecologic surgery until the return of bowel function. The concern is that early oral intake will result in vomiting and severe paralytic ileus, with subsequent aspiration pneumonia, wound dehiscence, and anastomotic leakage. However, clinical studies suggest that there may be benefits from early postoperative oral intake. Currently, gynaecologic surgery can be performed through various routes: open abdominal, vaginal, laparoscopic, robotic, or a combination. In this version, we included women undergoing major gynaecologic surgery through all of these routes, either alone or in combination.
To assess the effects of early versus delayed (traditional) initiation of oral intake of food and fluids after major gynaecologic surgery.
On 13 June 2023, we searched the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, the citation lists of relevant publications, and two trial registries. We also contacted experts in the field for any additional studies.
We included randomised controlled trials (RCTs) that compared the effect of early versus delayed initiation of oral intake of food and fluids after major gynaecologic surgery, performed by abdominal, vaginal, laparoscopic, and robotic approaches. Early feeding was defined as oral intake of fluids or food within 24 hours post-surgery, regardless of the return of bowel function. Delayed feeding was defined as oral intake after 24 hours post-surgery, and only after signs of postoperative ileus resolution. Primary outcomes were: postoperative ileus, nausea, vomiting, cramping, abdominal pain, bloating, abdominal distension, need for postoperative nasogastric tube, time to the presence of bowel sounds, time to the first passage of flatus, time to the first passage of stool, time to the start of a regular diet, and length of postoperative hospital stay. Secondary outcomes were: infectious complications, wound complications, deep venous thrombosis, urinary tract infection, pneumonia, satisfaction, and quality of life.
Two review authors independently selected studies, assessed the risk of bias, and extracted the data. We calculated the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous data. We examined continuous data using the mean difference (MD) and a 95% CI. We tested for heterogeneity between the results of different studies using a forest plot of the meta-analysis, the statistical tests of homogeneity of 2 x 2 tables, and the I² value. We assessed the certainty of the evidence using GRADE methods.
We included seven randomised controlled trials (RCTs), randomising 902 women. We are uncertain whether early feeding compared to delayed feeding has an effect on postoperative ileus (RR 0.49, 95% CI 0.21 to 1.16; I² = 0%; 4 studies, 418 women; low-certainty evidence). We are uncertain whether early feeding affects nausea or vomiting, or both (RR 0.94, 95% CI 0.66 to 1.33; I² = 67%; random-effects model; 6 studies, 742 women; very low-certainty evidence); nausea (RR 1.24, 95% CI 0.51 to 3.03; I² = 74%; 3 studies, 453 women; low-certainty evidence); vomiting (RR 0.83, 95% CI 0.52 to 1.32; I² = 0%; 4 studies, 559 women; low-certainty evidence), abdominal distension (RR 0.99, 95% CI 0.75 to 1.31; I² = 0%; 4 studies, 559 women; low-certainty evidence); need for postoperative nasogastric tube placement (RR 0.46, 95% CI 0.14 to 1.55; 3 studies, 453 women; low-certainty evidence); or time to the presence of bowel sounds (MD -0.20 days, 95% CI -0.46 to 0.06; I² = 71%; random-effects model; 3 studies, 477 women; low-certainty evidence). There is probably no difference between the two feeding protocols for the onset of flatus (MD -0.11 days, 95% CI -0.23 to 0.02; I² = 9%; 5 studies, 702 women; moderate-certainty evidence). Early feeding probably results in a slight reduction in the time to the first passage of stool (MD -0.18 days, 95% CI -0.33 to -0.04; I² = 0%; 4 studies, 507 women; moderate-certainty evidence), and may lead to a slightly sooner resumption of a solid diet (MD -1.10 days, 95% CI -1.79 to -0.41; I² = 97%; random-effects model; 3 studies, 420 women; low-certainty evidence). Hospital stay may be slightly shorter in the early feeding group (MD -0.66 days, 95% CI -1.17 to -0.15; I² = 77%; random-effects model; 5 studies, 603 women; low-certainty evidence). The effect of the two feeding protocols on febrile morbidity is uncertain (RR 0.96, 95% CI 0.75 to 1.22; I² = 47%; 3 studies, 453 women; low-certainty evidence). However, infectious complications are probably less common in women with early feeding (RR 0.20, 95% CI 0.05 to 0.73; I² = 0%; 2 studies, 183 women; moderate-certainty evidence). There may be no difference between the two feeding protocols for wound complications (RR 0.82, 95% CI 0.50 to 1.35; I² = 0%; 4 studies, 474 women; low-certainty evidence), or pneumonia (RR 0.35, 95% CI 0.07 to 1.73; I² = 0%; 3 studies, 434 women; low-certainty evidence). Two studies measured participant satisfaction and quality of life. One study found satisfaction was probably higher in the early feeding group, while the other study found no difference. Neither study found a significant difference between the groups for quality of life (P > 0.05).
AUTHORS' CONCLUSIONS: Despite some uncertainty, there is no evidence to indicate harmful effects of early feeding following major gynaecologic surgery, measured as postoperative ileus, nausea, vomiting, or abdominal distension. The potential benefits of early feeding include a slightly faster initiation of bowel movements, a slightly sooner resumption of a solid diet, a slightly shorter hospital stay, a lower rate of infectious complications, and a higher level of satisfaction.
这是最初于 2014 年发表的 Cochrane 综述的更新和扩展版本。传统上,在主要妇科手术后,患者需要推迟口服摄入食物和液体,直到肠功能恢复。担忧的是,早期口服摄入会导致呕吐和严重的麻痹性肠梗阻,继而导致吸入性肺炎、伤口裂开、吻合口漏和其他并发症。然而,临床研究表明早期术后口服摄入可能有益。目前,妇科手术可以通过各种途径进行:开腹、阴道、腹腔镜、机器人或联合方式。在这一版本中,我们纳入了通过所有这些途径(单独或联合)进行的主要妇科手术的女性。
评估与传统的(延迟)术后开始口服摄入食物和液体相比,主要妇科手术后早期与延迟(传统)开始口服摄入食物和液体对患者的影响。
于 2023 年 6 月 13 日,我们检索了 Cochrane 妇科和生育组的专业注册库、CENTRAL、MEDLINE、Embase、相关出版物的引文列表以及两个试验注册库。我们还联系了该领域的专家以获取任何其他研究。
我们纳入了比较主要妇科手术后通过腹部、阴道、腹腔镜和机器人途径进行的手术,早期与延迟(传统)开始口服摄入食物和液体对患者影响的随机对照试验(RCT)。早期喂养定义为术后 24 小时内口服液体或食物,无论肠功能恢复如何。延迟喂养定义为术后 24 小时后,且只有在术后肠梗阻解决后开始口服摄入。主要结局为:术后肠梗阻、恶心、呕吐、痉挛、腹痛、腹胀、腹部膨隆、腹部肿胀、需要放置术后鼻胃管、肠鸣音出现的时间、首次排气时间、首次排便时间、开始常规饮食的时间和术后住院时间。次要结局为:感染性并发症、伤口并发症、深静脉血栓形成、尿路感染、肺炎、满意度和生活质量。
两名综述作者独立选择研究、评估偏倚风险并提取数据。我们使用 95%置信区间(CI)计算二分类数据的风险比(RR)。我们使用均值差(MD)和 95%CI 检查连续数据。我们使用森林图荟萃分析、2x2 表的同质性检验和 I²值来检验不同研究结果之间的异质性。我们使用 GRADE 方法评估证据的确定性。
我们纳入了 7 项 RCT,共纳入了 902 名女性。我们不确定早期喂养与延迟喂养相比是否会对术后肠梗阻产生影响(RR 0.49,95%CI 0.21 至 1.16;I²=0%;4 项研究,418 名女性;低确定性证据)。我们不确定早期喂养是否会影响恶心或呕吐,或两者都有(RR 0.94,95%CI 0.66 至 1.33;I²=67%;随机效应模型;6 项研究,742 名女性;非常低确定性证据);恶心(RR 1.24,95%CI 0.51 至 3.03;I²=74%;3 项研究,453 名女性;低确定性证据);呕吐(RR 0.83,95%CI 0.52 至 1.32;I²=0%;4 项研究,559 名女性;低确定性证据);腹胀(RR 0.99,95%CI 0.75 至 1.31;I²=0%;4 项研究,559 名女性;低确定性证据);需要放置术后鼻胃管(RR 0.46,95%CI 0.14 至 1.55;3 项研究,453 名女性;低确定性证据);或肠鸣音出现的时间(MD-0.20 天,95%CI-0.46 至 0.06;I²=71%;随机效应模型;3 项研究,477 名女性;低确定性证据)。两种喂养方案在肠鸣音出现的时间上可能没有差异(MD-0.11 天,95%CI-0.23 至 0.02;I²=9%;5 项研究,702 名女性;中度确定性证据)。早期喂养可能会使首次排便的时间略有减少(MD-0.18 天,95%CI-0.33 至-0.04;I²=0%;4 项研究,507 名女性;中度确定性证据),并可能使患者更早开始常规饮食(MD-1.10 天,95%CI-1.79 至-0.41;I²=97%;随机效应模型;3 项研究,420 名女性;低确定性证据)。早期喂养组的住院时间可能会略有缩短(MD-0.66 天,95%CI-1.17 至-0.15;I²=77%;随机效应模型;5 项研究,603 名女性;低确定性证据)。两种喂养方案对发热性发病率的影响不确定(RR 0.96,95%CI 0.75 至 1.22;I²=47%;3 项研究,453 名女性;低确定性证据)。然而,早期喂养可能会使感染性并发症的发生率降低(RR 0.20,95%CI 0.05 至 0.73;I²=0%;2 项研究,183 名女性;中度确定性证据)。两种喂养方案在伤口并发症(RR 0.82,95%CI 0.50 至 1.35;I²=0%;4 项研究,474 名女性;低确定性证据)或肺炎(RR 0.35,95%CI 0.07 至 1.73;I²=0%;3 项研究,434 名女性;低确定性证据)方面可能没有差异。两项研究评估了参与者的满意度和生活质量。一项研究发现早期喂养组的满意度可能更高,而另一项研究则发现两组之间没有差异。两组在生活质量方面都没有发现显著差异(P>0.05)。
尽管存在一些不确定性,但目前尚无证据表明主要妇科手术后早期喂养会导致术后肠梗阻、恶心、呕吐或腹胀等不良后果。早期喂养的潜在益处包括更快地开始排便、更早地开始常规饮食、缩短住院时间、降低感染性并发症的发生率以及提高患者满意度。