Traditionally, postoperative diet advancement following abdominal surgery has adhered to a rigid, stepwise approach. This approach typically starts with a clear liquid diet, progressing to a full liquid diet, then a soft diet, before finally allowing regular meals. However, recent evidence suggests that this approach may be unnecessarily restrictive and that a more patient-centered approach, termed Patient-Controlled Nutrition (PCN), may be more beneficial. PCN challenges the conventional surgical dogma and allows patients to dictate the pace and type of diet advancement based on their individual tolerance and preference.
The Problem with Traditional Diet Advancement
The traditional method of postoperative diet advancement stems from concerns about disrupting gastrointestinal (GI) motility during convalescence and the risk of postoperative nausea and vomiting. Surgeons have historically relied on clinical signs and symptoms, physical examinations, and laboratory or radiologic findings to predict tolerance to early oral feeding (EOF) and to evaluate whether oral intake can be advanced to a regular diet. In patients not eligible for EOF, regular monitoring of bowel sounds and confirmation of flatulence and/or bowel movements have been regarded as evidence that the patient is ready to advance their diet. This cautious approach often leads to delayed diet advancement, prolonged hospital stays, and unnecessary patient discomfort.
Moreover, liquid and soft diets are often unpalatable, leading to reduced patient satisfaction and potentially impacting nutritional intake. The purpose of a clear liquid diet is to leave no residue in the intestinal tract and to provide oral hydration during acute illness or before and after surgery. However, a regular diet has been shown to neither interfere with oral hydration nor promote dietary intolerance.
The Rise of Early Oral Feeding (EOF)
In recent years, numerous clinical studies have supported the idea that early oral feeding (EOF) following abdominal surgery is associated with accelerated patient recovery. The Enhanced Recovery After Surgery (ERAS) protocols, which aim to optimize perioperative care and reduce recovery time, often include EOF as a key component. Especially in minimally invasive abdominal surgery, EOF has become usual practice to accelerate patient recovery.
Patient-Controlled Nutrition (PCN): A Novel Approach
Patient-Controlled Nutrition (PCN) represents a paradigm shift in postoperative diet management. PCN empowers patients to make informed decisions about their diet, allowing them to advance to a regular diet as soon as they feel ready. The most reliable indicator of tolerability to postoperative oral feeding is currently the subjective condition of the patients themselves. In practice, patients usually want to choose the time and type of diet themselves, as long as surgical complications that require fasting do not occur. This approach recognizes that patients are the best judges of their own comfort and tolerance levels.
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A retrospective pilot study was conducted to evaluate the feasibility and effects of PCN. This study was carried out with a total of 179 consecutive patients who underwent a laparoscopic appendectomy between August 2014 and July 2016. In the PCN group, diet was advanced depending on the choice of the patients themselves; in the traditional group, diet was progressively advanced to a full liquid or soft diet and then a regular diet as tolerated. Time to tolerance of a regular diet (P < 0.001) and postoperative hospital stay (P < 0.001) showed statistically significant differences between the groups. Multivariate analysis using linear regression showed that the traditional nutrition pattern was the only factor associated with postoperative hospital stay (P < 0.001).
Evidence Supporting PCN
Several studies have challenged the necessity of the traditional stepwise diet advancement. For example, a prospective randomized study regarding type of initial diet was performed in patients undergoing GI operations, and it showed no significant difference between the groups given a clear liquid or solid diet soon after removal of a nasogastric tube. In one study, with this individualized and patient-oriented concept, solid meals were safely initiated by the second operative day in 81.3% of patients who had undergone elective colon cancer surgery.
In the present study, patients who could select their diet depending on comfort level (PCN group) were tolerable to regular diet 5.5 ± 3.9 hours after surgery on average whereas the traditional group took 18.3 ± 3.8 hours. Korean patients are usually discharged from hospital to home after they are able to tolerate a regular diet, so delayed advancement of the diet may often prolong postoperative hospital stay.
PCN in Laparoscopic Appendectomy: A Case Study
To further investigate the feasibility and effectiveness of PCN, a study was conducted involving 179 patients undergoing laparoscopic appendectomy. The patients were divided into two groups: a PCN group, where diet was advanced based on patient choice, and a traditional group, where diet was advanced according to the conventional stepwise approach.
The results of the study demonstrated statistically significant differences between the two groups. The PCN group exhibited a significantly shorter time to tolerance of a regular diet (P < 0.001) and a shorter postoperative hospital stay (P < 0.001). These findings suggest that PCN is not only feasible but also potentially beneficial in terms of accelerating recovery and reducing hospital stay.
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Challenging Surgical Dogma: The Case of Nasogastric Tubes
The shift towards PCN mirrors the evolution of other surgical practices. One piece of representative surgical dogma is the routine use of nasogastric tubes to decompress the gastrointestinal (GI) tract after abdominal surgery. Indeed, for more than half a century, surgeons have relied on nasogastric decompression after GI surgery to hasten recovery. However, a meta-analysis in 1995 and another in 2005 for the routine use of nasogastric tubes showed little evidence of benefit [1, 2]. Just as the routine use of nasogastric tubes has been questioned and often abandoned, the traditional approach to postoperative diet advancement is now being challenged by evidence-based practices like PCN.
Implementing PCN: Key Considerations
While PCN offers numerous potential benefits, it is essential to implement it safely and effectively. The following considerations are crucial:
- Patient Selection: PCN may not be appropriate for all patients. Patients with complicated appendicitis, such as gangrenous or perforated appendicitis or appendicitis with the presence of a periappendiceal abscess, were excluded. Patients undergoing complex abdominal surgeries or those with underlying medical conditions may require a more cautious approach to diet advancement.
- Patient Education: Patients should be educated about the principles of PCN and empowered to make informed decisions about their diet. They should understand the importance of listening to their bodies and advancing their diet at a pace that feels comfortable.
- Monitoring and Support: Healthcare providers should closely monitor patients on PCN and provide support as needed. This includes assessing their tolerance to diet advancement, managing any symptoms such as nausea or vomiting, and addressing any concerns they may have.
- Clear Guidelines: Establish clear guidelines for patients on PCN, including examples of appropriate food choices for each stage of diet advancement and instructions on when to seek medical advice.
The Role of ERAS Protocols
PCN aligns well with the principles of Enhanced Recovery After Surgery (ERAS) protocols. The ERAS program in colonic surgery includes 17 fast track (FT) elements: preoperative counseling, preoperative feeding, synbiotics, no bowel preparation, no premedication, fluid restriction, perioperative high oxygen concentrations, active prevention of hypothermia, epidural analgesia, minimally invasive/transverse incisions, no routine use of nasogastric tubes, no use of drains, enforced postoperative mobilization, enforced postoperative oral feeding, no systemic opioid use, use of standard laxatives, and early removal of the bladder catheter. At least four FT elements should be chosen for implementation of the ERAS program. All studies regarding the ERAS program included enforced postoperative oral feeding and enforced postoperative mobilization [18]. Indeed, enforced postoperative oral feeding could be one of the most important elements of the ERAS program. By incorporating PCN into ERAS protocols, healthcare providers can further optimize patient recovery and reduce hospital stay.
Overcoming Barriers to Implementation
Despite the growing evidence supporting PCN, several barriers may hinder its widespread adoption. These include:
- Resistance to Change: Some surgeons and healthcare providers may be resistant to changing established practices, particularly those that have been ingrained in surgical dogma for many years.
- Lack of Awareness: Many healthcare providers may be unaware of the evidence supporting PCN and the potential benefits it offers.
- Concerns about Patient Safety: Some healthcare providers may have concerns about patient safety, particularly the risk of postoperative complications such as nausea, vomiting, or ileus.
Overcoming these barriers requires a concerted effort to educate healthcare providers about the benefits of PCN, address their concerns, and provide them with the tools and resources they need to implement PCN safely and effectively.
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Additional Post-operative Dietary Guidelines
Following a total gastrectomy or other major abdominal surgeries, specific dietary guidelines are often recommended to aid in recovery and prevent complications such as dumping syndrome. These guidelines typically involve a phased approach to reintroducing foods, focusing on small, frequent meals, and prioritizing protein intake.
Phase 1 (First 6-8 weeks):
- Frequency: Eat at least 6-8 small meals each day.
- Composition: Choose high-calorie, high-protein foods and fluids.
- Texture: Chew foods completely, into puree form, before swallowing.
- Avoidances: Foods high in insoluble fiber, gas-producing foods, foods and drinks with added sugars, and sugar alcohols (sorbitol, mannitol, erythritol, xylitol).*Note: Caffeinated fluids can contribute to dehydration
Phase 2 (After 6-8 weeks, as tolerated):
- Gradually introduce foods from Phase 2, ensuring they are consumed with a source of protein.
- Incorporate fats and oils to increase caloric intake.
- Baked goods made without added sugars can be included, consumed with protein or at the end of a protein-containing meal.
- Be cautious with sugar-sweetened condiments.
General Post-operative Recommendations:
- Medications: Take pain medication with food to minimize nausea.
- Hydration: Drink plenty of fluids and eat fruits to prevent constipation.
- Activity: Gradually increase activity as tolerated, following your surgeon's instructions.
- Wound Care: Keep the surgical incision clean and dry, following your surgeon's specific instructions regarding dressing changes.