Early Feeding versus Traditional Feeding in Children with Ileostomy Closure.

Context: Elective intestinal anastomosis is a frequently used surgical procedure in pediatric surgery. Aims: This study aimed to compare postoperative complications and hospital stay in children who underwent ileostomy closure with early feeding in the 1st 24 h versus those in whom the oral route was initiated traditionally. Settings and Design: Observational, comparative, cross-sectional, ambispective, and single-center study that included pediatric patients who had undergone ileostomy closure from January 2017 to August 2019. Materials and
Methods: Data were analyzed in SPSS. Statistical analysis was used: the variables were analyzed using the Chi-square test or Fisher's exact test when the former could not be applied.
Results: They were divided into the following two groups: group 1 included patients who started the oral route early (n = 25) and Group 2 included patients who started the oral route late (n = 20). The average in-hospital stay for Group 1 was 5.48 days and that for Group 2 was 8.35 days. In Group 1, the oral route was started with a mean of 9.32 h and in Group 2 at 146.4 h. Those in Group 1 at 32.9 h presented their first evacuation and Group 2 at 131.45 h. Group 1 reached their normal diet on average at 79.96 h and Group 2 at 172.8 h. Conclusions: This comparison between early oral feeding and traditional oral feeding suggests that various benefits exist when enteral nutrition is initiated early after ileostomy closure in pediatric patients. The benefits and importance of initiating early oral feeding in adults have been reported, but there are few studies on pediatric populations. Copyright:

INTRODUCTION

Elective intestinal anastomosis is a frequently used surgical procedure in pediatric surgery.[1] Approximately 60 interventions of this type are reported every year, with an average in-hospital stay of 12 days. The most feared complication at the time of closing the intestinal bypass is the dehiscence of anastomosis, representing a high degree of morbidity and mortality.[23]

Several studies have determined that early initiation of a liquid diet controls the dehiscence of intestinal anastomosis, thereby reducing the length of hospital stay from 7 to 8 days to half, with a significant reduction in the economic costs of national health systems. In addition, due to the reduction in hospital stay, patients are less exposed to acquiring intrahospital diseases that are difficult to manage.[45]

This study aimed to compare postoperative complications and hospital stay in children who underwent ileostomy closure with early feeding in the 1st 24 h versus those in whom the oral route was initiated traditionally.

MATERIALS AND METHODS

This was an observational, comparative, cross-sectional, ambispective, and single-center study that included pediatric patients who had undergone ileostomy closure from January 2017 to August 2019.

The following patients were excluded from the analysis: patients in need of postoperative intubation; patients who underwent ileostomy closure, but experienced vomiting and abdominal distension as well as required fasting before starting the early oral route; patients whose parents declined early initiation of the oral route; and patients with incomplete or missing records. Patients who were transferred to another hospital unit for postoperative recovery were excluded from this study.

A simple randomized sampling was employed for the allocation of patients in both groups, the group that started the oral route early and the one that started the oral route late. All surgical procedures (ileostomy closures) for both the groups were performed by different pediatric surgeons.

Preoperative preparation for both the groups was carried out as follows:

Antimicrobial treatment: clindamycin 40 mg/kg/day and amikacin 15 mg/kg/day

Bowel preparation: macrogol 3350 105.00 g, sodium bicarbonate 1.43 g, sodium chloride 2.8 g, and potassium chloride 0.37 g.

In patients aged ≤12 months, an intestinal anastomosis was made in a single suture layer with polyglactin 910 of 4–0 and 5–0. Whereas, in patients aged >12 months, the anastomosis was made in two layers.

The statistical package SPSS version 25(SPSS Chicago, Illinois, USA), a software developed in Chicago bye IBM p < 0·050 was considered statistically significant. SPPS for MAC 25.0 (SPSS Chicago, Illinois, USA) was used for statistical analyses, was used to analyze the data. The study was approved by the institutional research committee and conducted in accordance with bioethical procedures.

Continuous variables were expressed as mean and standard deviation (SD). To check whether variables were normally distributed, the Kolmogorov–Smirnov test was used. For normally distributed continuous variables, Student's t-test of independent samples was used, and for data not normally distributed, the nonparametric Mann–Whitney test was employed. Discrete variables were expressed as frequency and percentage and were analyzed using the Chi-square test or Fisher's exact test when the former could not be applied. All statistical calculations were performed with two tails, and statistical significance was established with a value of P < 0.05.

RESULTS

From January 2017 to August 2019, 68 children underwent ileostomy closure. Twenty-three children were excluded (13 for being intubated for the postoperative period and 10 having incomplete data), with a final sample size of 45 children. They were divided into the following two groups: group 1 included patients who started the oral route early (n = 25) and Group 2 included patients who started the oral route late (n = 20). Group 1 and Group 2 comprised 48% and 55% of male patients, respectively. The most frequent pathology for which ileostomy was performed in both groups was necrotizing enterocolitis.

The average age at ileostomy closure for Group 1 was 31.48 months (SD, 44.98; minimum [min], 4; maximum [max], 180) and that for Group 2 was 22.95 months (SD, 37.59; min, 1; max, 168).

The average in-hospital stay for Group 1 was 5.48 days (SD, 1.63; min, 3; max, 9) and that for Group 2 was 8.35 days (SD, 4.72; min, 4; max, 8) (P < 0.05).

The oral route in Group 1 was started with a mean of 9.32 h (SD, 2.94; min, 5; max, 15) and that in Group 2 was started with 146.4 h (SD, 111.46; min, 48; max, 384) (P < 0.05). The patients in Group 1 had their first evacuation at 32.9 h (SD, 9.21; min, 16; max, 50) and those in Group 2 had their first evacuation at 131.45 h (SD, 114.35; min, 30; max, 360) (P < 0.05). Moreover, they reached normal diet at approximately 79.96 h (SD, 30.59; min, 45; max, 192). In Table 1, we compare these variables between Group 1 and Group 2.

Table 1

In-hospital stay, after surgery feeding hours, after surgery first evacuation hours and hours to reach normal diet for both groups

	Average/SD		P
	Early feeding (n=25)	Traditional feeding (n=20)
In-hospital stay (days)	5.48/1.63	8.35/4.72	<0.05*
After surgery feeding hours	9.32/2.94	146.4/111.46	<0.05*
After surgery first evacuation hours	32.9/9.21	131.45/114.35	<0.05*
Hours to reach normal diet	79.96/30.59	172.8/113.8	<0.05*

*Mann-Whitney U test. SD: Standard deviation

In Group 2, nine patients required parenteral nutrition (those who had fasted for >72 h).

The patients in Group 2 presented surgical wound infection (10% of patients), sepsis (10%), and dehiscence (10%) as postsurgical complications. In all the three abovementioned complications, multiple loop–loop and loop–wall adhesions were noted. Moreover, 5% of the patients experienced pneumonia. In Group 1, surgical wound infection was the only complication, which accounted for 12% [Table 2].

Table 2

Postoperative complications for both groups

	Early feeding (n=25), n (%)	Traditional feeding (n=20), n (%)
Surgical wound infection	3 (12)	2 (10)
Pneumonia	0	1 (5)
Sepsis	0	2 (10)
Dehiscence	0	2 (10)

Regarding the nutritional level, 13 (52%) patients in Group 1 and 12 (60%) patients in Group 2 exhibited malnutrition. Of all patients with malnutrition, eight (32%) patients presented some complications, whereas only 10% of the patients without malnutrition developed complications.

The average albumin level of the patients in Group 1 was 3.36 (SD, 0.649; min, 2.6; max, 5.1) and that in Group 2 was 3.06 (SD, 0.502; min, 2.3; max, 4) [Table 3].

Table 3

Albumin levels for both groups

	Average/SD		P
	Early feeding (n=25)	Traditional feeding (n=20)
Albumin levels (g/dl)	3.36/0.649	3.06/0.502	0.094*

*t-test. SD: Standard deviation

Regarding the technique of anastomosis, single suture layer and double suture layers were used in 9 and 16 patients of Group 1, respectively. In Group 2, 4 and 16 patients received closure by single and double layers, respectively (P = 0.239).

DISCUSSION

Cochrane studies have not shown any benefit in patients who fasted after gastrointestinal surgery, suggesting an early initiation of the oral route.[6] Fasting has important repercussions, such as atrophy of the villi, decreased activity of disaccharidase, reduction of intestinal mucosa, and loss of deoxyribonucleic acid from the enterocytes, which cause an increase in the permeability of the intestinal mucosa to antigens and macromolecules. Owing to the absence of normal flora, vitamin K production, growth factors, and bile acid metabolism decrease. As a result, colonization of pathological microorganisms can begin, leading to sepsis.[7]

The ESPEN guideline remarks that early enteral nutrition on the first or second postoperative day does not impair healing of anastomoses, but it gives a wide time range to initiate oral feeding.[8] We established early oral feeding in the 1st24 h after surgery.

Our study demonstrated a significant difference in hospital stay in children in whom the oral route was started early, reporting 5.48 days on average, similar to the finding of Surasak Sangkhathat et al.,[9] who reported an average of 4.5 days of in-hospital stay. In contrast, Dávila et al. did not obtain significant difference in hospital stay; patients who started the oral route early had a hospital stay of 6 ± 2.9 days and those who started it traditionally had a hospital stay of 9.8 ± 4.1 days.[10]

The intestinal mucosa epithelium has been shown to heal well within 24 h of surgery.[6] When comparing our study with a similar one carried out in India,[11] we started an oral route earlier, starting on average at 9.32 h against 28.5 h in the study of India. Despite this, 100% of the patients examined by Yadav successfully attained the oral route at 62.3 ± 19.2 h, while it took longer in our patients, presenting an average of 79.96 h.

Considering the results of Shang et al.,[12] the time until the first evacuation in patients who started the oral route early was 76.8 ± 33.6 h, while our patients had their first evacuation in less time (32.9 h on average).

The success of surgery not only depends on technical surgical skills but also on metabolic interventional therapy, including preoperative and postoperative nutrition and early mobilization. Early oral intake after surgery helps the return of gut function and prevents complications and malnutrition.[8] Yadav et al.[11] report the same postoperative complications as those observed in our study, and surgical site infections and fever were the only complications showing statistical significance. According to Shang et al.,[12] the dehiscence of anastomosis also occurred, but it did not present significant effects on the outcomes. Dávila-Pérez et al.[1] revealed that surgical site infections showed significant influence on the outcomes.

Nutritional status is a risk factor for the development of complications after surgery. Yadav et al.[11] reported that the incidence of postoperative complications increased in patients with malnutrition. However, our series did not show the influence of malnutrition because our sample size was small. Nutritional status affects intestinal healing due to the lack of amino acids for collagen synthesis.[13] A study also suggested that short-chain fatty acids (such as acetate, propionate, and butyrate) produced by the fermentation of dietary fibers stimulate the proliferation of epithelial cells and constitute a source of energy; therefore, a diet low in fiber can lead to alterations in intestinal healing.[14]

Serum albumin concentration predicts postoperative outcome and is associated with the nutritional status of patients.[8] As a nutritional variable, albumin levels were compared between the two groups. In our study and the study by Shang et al., albumin was found to have no statistical effect on these patients. However, Shang et al. measured prealbumin levels as it was more sensitive than albumin in assessing protein synthesis in the liver. They reported slightly decreased prealbumin levels in patients who started the oral route early, but no significant differences were found when compared with albumin.[12] Our study did not consider evaluating prealbumin due to lack of reagent in the hospital unit.

The technique of anastomosis did not show any significance between patients who started oral feeding early as compared with those who received traditional enteral nutrition.

CONCLUSIONS

In this study, significance was found in the duration of hospital stay, hours of initiation of the oral route, hours until the first evacuation, and hours to achieve a normal diet in children after the closure of ileostomy where the oral route was started early. No significant differences were found in postoperative complications and malnutrition between the two groups. This comparison between early oral feeding and traditional oral feeding suggests that various benefits exist when enteral nutrition is initiated early after ileostomy closure in pediatric patients. The benefits and importance of initiating early oral feeding in adults have been reported, but there are few studies on pediatric populations. Thus, it is important to expand the sample and perform more studies in children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.