What is the recommended trend for resuming nutrition after esophageal and gastric resection?

Resumption of Nutrition Post Esophageal and Gastric Resection

Oral intake, including clear liquids, should be initiated within hours after esophageal and gastric resection in most patients, with gradual progression to a regular diet based on individual tolerance. 1

Early Oral Nutrition Initiation

• Oral nutritional intake should be continued after surgery without interruption in most instances 1
• Clear liquids should be initiated within hours after surgery, even following esophageal and gastric resection 1
• Early oral feeding has been shown to be safe and effective in patients undergoing upper GI surgeries, including esophageal and gastric tumor resections, with evidence of earlier return of bowel function and shorter hospital length of stay 1
• Meta-analyses have demonstrated that early postoperative oral feeding is associated with significant reductions in total complications compared with traditional delayed feeding practices 1

Recommended Progression Pattern

• Begin with clear liquids at room temperature immediately after the procedure 1
• Progress to full liquids (milk, yogurt, soy drinks) within the first few hours if clear liquids are well tolerated 1
• Advance to soft foods and then regular diet as tolerated, typically within days 1
• Small meals five to six times per day help patients tolerate oral feeding and achieve nutritional goals faster during the early phase of recovery 1

Evidence for Early Feeding After Upper GI Surgery

• A meta-analysis of 15 studies (eight RCTs) with 2112 adult patients undergoing upper gastrointestinal surgery showed significantly shorter postoperative length of stay in early orally fed patients without increased complications, particularly anastomotic leaks 1
• Early normal food or enteral nutrition on the first or second postoperative day does not impair healing of anastomoses 1
• Studies specifically examining minimally invasive esophagectomy and total gastrectomy have confirmed the safety and benefits of early oral feeding 1

Special Considerations

• Adapt oral intake according to individual tolerance and the specific type of surgery performed, with special caution in elderly patients 1
• The amount of initial oral intake should be adjusted based on gastrointestinal function and individual tolerance 1
• For patients who cannot tolerate adequate oral intake, enteral nutrition should be considered first, with parenteral nutrition initiated if enteral feeding is not feasible within 72 hours 1
• Perioperative nutritional support therapy is indicated in patients with malnutrition and those at nutritional risk, particularly if it's anticipated that the patient will be unable to eat for more than five days perioperatively 1

Potential Complications and Management

• If dysphagia occurs, patients should be instructed to discontinue eating to prevent regurgitation 1
• For dysphagia management: ensure thorough mastication (chewing ≥15 times per bite), eat slowly, and avoid hard and dry foods 1
• If vomiting occurs: take smaller bites, chew thoroughly, eat slowly (meals lasting ≥15 minutes), separate liquids from solids, and space meals at intervals of ≥2-4 hours 1
• For patients with dumping syndrome: avoid simple sugars and foods with high glycemic index, combine complex carbohydrates with protein and fiber, and separate liquids from solid foods 1

Moving Away from Traditional Dogma

• The traditional dogma of progressing from clear liquids to full liquids to soft diet before regular meals has been challenged by evidence-based medicine 2, 3
• Patient-controlled nutrition, where diet advancement depends on the patient's choice rather than predetermined progression, has shown promising results with shorter time to tolerance of regular diet and reduced hospital stay 2
• Starting with a regular diet as the initial meal (rather than clear liquids) has been shown to be well tolerated and provides significantly more nutrients 3

By implementing these evidence-based recommendations for resumption of nutrition after esophageal and gastric resection, clinicians can help improve patient outcomes, reduce complications, and shorten hospital length of stay.