From the Guidelines
Feeding can typically be restarted immediately after small bowel resection, as oral nutrition should be initiated as soon as possible to reduce overall complications and shorten hospital stay. This approach is supported by recent evidence, including a 2023 meta-analysis on early oral feeding for upper GI surgeries, which reported earlier return of bowel function and shorter hospital LOS with no increase in complications 1. The process usually begins with clear liquids and advances to a regular diet as tolerated, guided by the return of bowel function indicated by passing flatus or having a bowel movement.
For patients who cannot tolerate oral intake, enteral nutrition via a feeding tube may be initiated within 24 hours post-surgery. According to the ASPEN guidelines, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice for patients who require postoperative artificial nutrition 1. Parenteral nutrition is reserved for cases where enteral feeding is contraindicated or not feasible, and recent data suggests that early PN is safe and effective, with similar outcomes to EN 1.
Early feeding promotes faster recovery by stimulating intestinal blood flow, maintaining gut barrier function, reducing bacterial translocation, and enhancing wound healing. It also helps prevent complications like ileus and reduces hospital stay. However, the exact timing should be individualized based on the extent of resection, underlying condition, and presence of complications such as anastomotic leaks or prolonged ileus. Patients should be monitored for signs of feeding intolerance including abdominal distension, vomiting, or increased nasogastric tube output.
Some key points to consider when restarting feeding after small bowel resection include:
- Initiating oral nutrition as soon as possible to reduce complications and shorten hospital stay
- Using enteral nutrition via a feeding tube for patients who cannot tolerate oral intake
- Reserving parenteral nutrition for cases where enteral feeding is contraindicated or not feasible
- Monitoring patients for signs of feeding intolerance and adjusting the feeding plan as needed
- Individualizing the feeding plan based on the extent of resection, underlying condition, and presence of complications.
From the Research
Timing of Feeding After Small Bowel Resection
- The timing of feeding after small bowel resection depends on several factors, including the length of bowel remaining and the presence of complications 2.
- With more than 60 to 80 cm of bowel remaining, refeeding can usually be progressive until a full oral diet is reached 2.
- In cases where less than 60 to 80 cm of bowel remains, parenteral nutrition is often started immediately, and enteral feeding is gradually increased over time as the intestinal remnant adapts 2.
Factors Influencing Feeding Tolerance
- The use of volume expanders and blood loss during operation have been identified as factors that may contribute to intolerance of early feeding 3.
- Patients with a history of colorectal neoplasms may tolerate early oral feeding, but those with small-bowel resection, perioperative complications, prior radiation, or small-bowel obstruction may require a more cautious approach 3.
Management of Short Bowel Syndrome
- Total parenteral nutrition (TPN) is often necessary for patients with short bowel syndrome, particularly those with massive intestinal loss 4, 5.
- TPN can be tapered progressively over time as enteral feeding is increased, and some patients may be able to transition to oral feeding 2, 6.
- Small bowel transplantation is a viable option for patients with massive intestinal loss, offering the potential for complete weaning from parenteral nutrition and improved quality of life 5.