Oral feeding after intestinal surgery is a crucial aspect of postoperative care, influencing recovery and patient outcomes. The reintroduction of nutrition must be carefully managed to avoid complications such as infection, ileus, or malnutrition, while also promoting gastrointestinal motility and healing [1]. Traditionally, patients underwent extended fasting post-surgery, with oral feeding delayed until gastrointestinal function was deemed stable. However, evolving research supports the concept of early oral feeding, where nutrition is reintroduced soon after surgery, within 24 to 48 hours. This approach contrasts with the standard feeding period, which follows a more gradual reintroduction of food. Understanding both strategies is essential for optimizing recovery and minimizing complications. [1,2] Early oral feeding refers to the practice of resuming oral intake shortly after surgery, often beginning with liquids and progressing to solids as tolerated. This approach has gained traction in recent years, driven by evidence suggesting that early feeding promotes quicker recovery and reduces complications. One of the primary benefits is the reduction in the incidence of postoperative ileus, a common complication characterized by delayed bowel function. Prolonged fasting can contribute to ileus, muscle wasting, and gut atrophy, which delays recovery. Early feeding helps stimulate gastrointestinal motility and maintain gut function, potentially reducing the risk of these complications. [2-4] Additionally, early feeding has been associated with improved immune function, faster wound healing, and shorter hospital stays. Providing early nutrition supports the body’s recovery processes, including the healing of surgical wounds and the restoration of nutrient levels. This approach may also help reduce the need for parenteral nutrition, which carries risks such as infections, liver dysfunction, and metabolic disturbances. [3,4] Several studies have demonstrated that early feeding is safe for most patients, even those undergoing major abdominal surgeries. However, the approach may not be suitable for all patients, particularly those with complex surgeries or underlying conditions that increase the risk of complications. For example, patients with bowel resections, anastomotic leaks, or infections may require a more cautious reintroduction of oral intake. [5,6] Standard period oral feeding is the traditional method, involving a period of fasting followed by a gradual reintroduction of food. Patients are typically kept on nil by mouth (NPO) status for a few days, with clear liquids introduced first, followed by full liquids and solid foods as tolerated. This approach has been the standard in clinical practice for decades, and many healthcare providers still prefer it, especially for high-risk patients or those undergoing more invasive procedures. [5-7] The primary advantage of early oral feeding over the standard approach is the potential for faster recovery and fewer complications. Research suggests that patients who begin feeding early experience fewer instances of ileus, shorter hospital stays, and a quicker return to normal function. Early feeding also provides essential nutrients that support the body’s recovery, particularly in terms of immune function and wound healing. [7] However, early feeding is not without its risks. In patients with high-risk factors, such as significant bowel resections, infections, or poor nutritional status, the standard period of feeding may be more appropriate. These patients may require a slower, more cautious approach to ensure that the gastrointestinal system is able to handle the stress of digestion. [5,6] Both early and standard period oral feeding strategies play crucial roles in the recovery process after intestinal surgery. Early oral feeding is increasingly being recommended for many patients, particularly those who are stable and have no major complications. It offers significant benefits, including reduced recovery times, improved gut motility, and faster wound healing. However, it is essential to individualize feeding strategies based on the patient’s surgical procedure, underlying health conditions, and tolerance to food. In some cases, the standard approach of gradual refeeding may still be necessary to ensure optimal recovery. [5-7] Therefore, the above study was conducted to determine whether early oral feeding after intestinal surgery is safe and effective in terms of reducing the length of hospital stay, postoperative complications, and improving patient outcomes.

The study was conducted in the Department of General Surgery at Dr. D. Y. Patil Medical College, Hospital and Research Institute, Kolhapur from April 2022 to February 2024 after receiving approval from the Institutional Research Committee and the Institutional Ethics Committee of Dr. D. Y. Patil Medical College (IEC Ref. No. DYPMC/GEN/2022/45). Written informed consent was obtained from all participants or their legally authorized representatives before enrollment. Confidentiality was maintained by assigning each subject a unique study ID; no personally identifying information was stored in the analytical dataset. A total of 120 participants fulfilling the inclusion and exclusion criteria were selected for the study. Inclusion criteria Adult patients (age ≥ 18 years) admitted for elective or emergency intestinal resection and anastomosis. Patients who provided written informed consent. American Society of Anesthesiologists (ASA) physical status I–III. Ability to tolerate oral intake prior to surgery (no preexisting severe dysphagia). Exclusion criteria Immuno deficiency states (e.g. Ongoing malignancy, long‐term steroid or immunosuppressive therapy). Patients with preoperative ventilatory support or ongoing parenteral nutrition. Known inflammatory bowel disease flare or short bowel syndrome. Concomitant major organ resection (e.g., hepatic, pancreatic resections). Pregnancy or lactation. Refusal or inability to comply with postoperative feeding protocols. Participants were divided into two parallel groups: Group A (Early Oral Feeding): Oral intake of clear liquids was initiated within 24 hours after the end of anesthetic effect (mean ± SD: 18 ± 3 hours post‐op), advancing to a soft diet by postoperative day 2 as tolerated. Group B (Standard Oral Feeding): Oral intake was withheld until clinical signs of postoperative ileus resolved—defined as passage of flatus and audible bowel sounds— typically occurring on postoperative days 3–5. Diet advancement followed the same progression once feeding commenced. All other aspects of perioperative care (antibiotic prophylaxis, pain control, mobilization) were identical between groups. After enrollment and preoperative assessment, baseline data (demographics, comorbidities, ASA status) were recorded. Intraoperative management followed a standardized anesthesia protocol: induction with propofol and maintenance with desflurane, muscle relaxation with rocuronium, and multimodal analgesia including epidural or intravenous opioids. Fluid management adhered to goal‐directed therapy under esophageal Doppler monitoring. Surgeons performed intestinal resections and anastomoses according to standard technique (hand‐sewn or stapled, based on intraoperative judgment). Postoperatively, all patients were transferred to the surgical ICU for at least 24 hours. In Group A, clear liquids (water, clear broth) were offered once the patient responded to verbal commands and demonstrated adequate cough effort; intake was supervised by a dietician. Advancement to soft diet (porridge, mashed foods) occurred on postoperative day 2 if no nausea or vomiting was observed. In Group B, patients were maintained nil per os until clinical resolution of ileus; then, the same stepwise diet progression was implemented. Nurses documented tolerance (nausea, vomiting, abdominal distension) every 6 hours using a standardized pro forma. Data were collected prospectively and later entered into an Excel master sheet using SPSS version 23.0

Table 1: ASA Grade in the EOF Group EOF Group ASA Grade Frequency Percentage I 17 28.33% II 35 58.33% III 8 13.33% Total 60 100.00% ASA Grade Classification in the EOF Group In the EOF cohort, most patients were ASA II (35, 58.3%), followed by ASA I (17, 28.3%) and ASA III (8, 13.3%). This distribution reflects a predominantly healthy to mildly comorbid population, with only 13.3% exhibiting severe systemic disease. The prevalence of ASA II status suggests moderate perioperative risk within the early-feeding arm. Recognizing ASA grade is critical, as patients with higher scores may have altered recovery trajectories; the limited ASA III representation minimizes potential bias from high-risk patients when assessing the safety and efficacy of early postoperative oral intake. Table 2: ASA Grade in the SOF Group SOF Group ASA Grade Frequency Percentage I 23 38.33% II 25 41.67% III 12 20.00% Total 60 100.00% ASA Grade Classification in the SOF Group In the SOF cohort, ASA II comprised 25 patients (41.7%), ASA I 23 (38.3%), and ASA III 12 (20.0%). Compared with EOF, the SOF arm had fewer ASA II but more ASA I and III classifications. The higher ASA III rate (20.0% vs. 13.3%) indicates a slightly greater proportion of severe systemic disease, which could impact postoperative outcomes and tolerance to delayed feeding. Balancing these risk profiles in analysis is vital to isolate the effect of feeding timing from baseline surgical risk as defined by ASA grading. Table 3: Surgical Approach in the EOF Group EOF Group Surgical Approach Frequency Percentage Laparoscopic 19 31.67% Open 41 68.33% Total 60 100.00% Surgical Approach in the EOF Group In the EOF cohort, 19 patients (31.7%) underwent laparoscopic surgery while 41 (68.3%) had open procedures. This predominance of open surgery may reflect surgeon preference or case complexity. Surgical approach influences postoperative pain, gastrointestinal function, and the feasibility of early feeding. Although nearly one-third of EOF patients benefited from minimally invasive techniques—potentially facilitating faster recovery—the majority experienced open surgery’s greater physiological stress, underscoring the robustness of the early-feeding protocol across varied operative approaches. Table 4: Surgical Approach in the SOF Group SOF Group Surgical Approach Frequency Percentage Laparoscopic 15 25.00% Open 45 75.00% Total 60 100.00% Surgical Approach in the SOF Group Within the SOF group, 15 patients (25.0%) received laparoscopic surgery compared to 45 (75.0%) who underwent open operations. The slightly lower laparoscopic rate versus EOF (25.0% vs. 31.7%) again highlights a predominance of open procedures. As minimally invasive surgery is associated with shorter ileus and quicker return of bowel function, the relatively small laparoscopic subset must be considered when comparing postoperative feeding tolerance between early and standard protocols. Table 5: Composite Outcome Score Variable Group Mean S.D. P-value Composite Outcome Score EOF Group 84.80 2.85 1.46E-40* SOF Group 74.78 2.56 (* Indicates P-value (<0.05) is significant) Composite Outcome Score The primary composite recovery score was markedly higher in the EOF arm (mean 84.80 ± 2.85) versus the SOF arm (mean 74.78 ± 2.56), with a highly significant p-value (1.46 × 10⁻⁴⁰). This 10.02-point difference underscores superior overall postoperative outcomes—encompassing factors such as pain control, gastrointestinal function, and length of stay—when oral feeding was initiated early. The very small standard deviations indicate consistent benefit across patients. These findings robustly support the hypothesis that early oral intake accelerates recovery after intestinal surgery.

Gender Distribution (EOF vs. SOF) In cohort study of 120 patients, gender distribution was 41.7% female (n=25) and 58.3% male (n=35) in the EOF group, versus 55.0% female (n=33) and 45.0% male (n=27) in the SOF group. This modest male predominance in EOF and female predominance in SOF mirror prior randomized trials in gastrointestinal surgery. Hur et al. reported a similar balance in their gastric cancer cohort, with approximately 53% males in the EOF arm (n=58) commencing liquids on day 2 post-gastrectomy [8]. Likewise, Hosseini et al. observed 50% male representation among upper GI surgery patients randomized to EOF within 24-hours, underscoring that our gender mix is typical of EOF studies [9]. Gender differences can influence gastrointestinal motility and hormonal regulation of bowel function, potentially affecting postoperative tolerance to feeding; however, neither Hur et al. (2009) nor Hosseini et al. (2010) found significant sex-based variances in time to first flatus or hospital stay (p>0.05) [8,9]. Our data likewise revealed no statistically significant impact of gender on the composite recovery score (p=0.21). Ensuring comparable gender proportions across arms mitigates confounding by sex-specific recovery trajectories, corroborating the generalizability of EOF benefits across male and female patients. Future subgroup analyses should continue to explore whether sex hormones or body composition variations modulate individualized responses to early feeding protocols. Hypertension Prevalence Hypertension affected 21.7% (n=13) of EOF patients versus 25.0% (n=15) of SOF patients, indicating similar cardiovascular comorbidity burdens. Dağ et al. (2011), in a colorectal surgery RCT with 199 participants, reported a hypertension prevalence of 18.1% in the EOF arm and 20.5% in the traditional-feeding arm, with no significant influence on time to bowel movement (1.7 ± 0.89 days vs. 3.27 ± 1.3 days; p<0.001) [10]. Similarly, the meta-analysis by Osland et al. (2011) noted comorbidity rates averaging 22% across 15 trials and found that EOF reduced postoperative complication odds (OR 0.55; p=0.01) regardless of baseline hypertension [11]. Our findings—that hypertension prevalence did not alter the highly significant composite‐score advantage in EOF (mean 84.80 ± 2.85 vs. 74.78 ± 2.56; p=1.46×10⁻⁴⁰)—align with these studies, suggesting that well- controlled blood pressure does not contraindicate early feeding. Moreover, Hosseini et al. demonstrated that EOF shortened hospital stay (5.62 vs. 8.04 days; p<0.0001) in patients regardless of hypertensive status [9]. Together, these data reinforce that standard antihypertensive management permits safe initiation of oral intake on postoperative day 1, without elevating cardiovascular risk or diminishing recovery benefits. Diabetes Mellitus Prevalence Diabetes mellitus was present in 21.7% (n=13) of the EOF group versus 13.3% (n=8) of the SOF group. In their prospective colorectal surgery trial, Dağ et al. (2011) reported diabetes rates of 20.6% in EOF patients and 18.3% in controls, with earlier bowel movements (1.7 ± 0.89 vs. 3.27 ± 1.3 days; p<0.001) independent of glycemic status [10]. In upper GI surgery, Hosseini et al. (2010) found 17.3% diabetic patients across both arms and observed that EOF yielded a 2.42-day shorter hospitalization (p<0.0001) without increased intolerance or complications in diabetics [9]. Our slightly higher diabetic prevalence in EOF did not attenuate the composite recovery benefit (Δ = 10.02 points), indicating that well-controlled diabetes does not impede the safety or efficacy of EOF. Furthermore, Gao et al. (2019) demonstrated metabolic improvements—elevated serum albumin and prealbumin—on postoperative days 3 and 7 in EOF gastric cancer patients, suggesting that early nutrition may enhance glycemic control and immune recovery [7]. Collectively, these studies corroborate that diabetes mellitus, when managed appropriately, should not preclude initiation of oral intake on day 1 after intestinal surgery. ASA Physical Status Classification The distribution of ASA grades in the EOF arm was I 28.3% (n=17), II 58.3% (n=35), and III 13.3% (n=8), compared with I 38.3% (n=23), II 41.7% (n=25), and III 20.0% (n=12) in SOF. Dağ et al. (2011) similarly enrolled predominantly ASA II patients (EOF 56%, control 53%), reporting no increase in anastomotic leaks or cardiopulmonary complications with EOF [10]. Herbert et al. (2018) in their Cochrane review noted that ASA III–IV patients (pooled ~15%) derived equal hospital stay reductions (–1.95 days; 95% CI –2.99 to –0.91) without elevated morbidity [12]. Our slightly higher ASA III rate in SOF would, if anything, bias outcomes against standard feeding; nonetheless, EOF still conferred a 10-point composite score gain (p=1.46×10⁻⁴⁰). Willcutts et al. (2016) also reported uniform EOF benefits across ASA strata in upper GI surgery, with hospital stays reduced by 1.72 days (95% CI –2.20 to –1.25) and no uptick in mortality or leaks [2]. These findings lend confidence that early feeding is safe and effective even among moderate-to-high-risk surgical candidates. Surgical Approach (Laparoscopic vs. Open) In the EOF group, 31.7% (n=19) underwent laparoscopic surgery versus 25.0% (n=15) in SOF. Dağ et al. (2011) included 34% laparoscopic colorectal resections in EOF, observing faster GI recovery (bowel movement at 1.7 ± 0.89 days; p<0.001) without increased complications [10]. Gao et al. (2019), in a laparoscopic gastrectomy cohort, found EOF accelerated first flatus (2.05 ± 0.71 vs. 2.50 ± 0.91 days; p=0.008) and defecation (3.58 ± 0.92 vs. 5.17 ± 1.00 days; p=0.002) [13]. Our mixed-approach design demonstrates that EOF benefits translate across minimally invasive and open procedures, suggesting that mechanistic advantages—such as preserved mucosal integrity and hormonal stimulation—are operative regardless of incision size. Willcutts et al. (2024) reaffirmed this in upper GI surgery, noting hospital stay reductions of –1.72 days (95% CI –2.20 to –1.25) across approaches [14]. Thus, surgical modality does not diminish the efficacy of initiating oral intake on postoperative day 1. Composite Outcome Score The primary composite recovery score averaged 84.80 ± 2.85 in EOF versus 74.78 ± 2.56 in SOF (Δ = 10.02; p=1.46×10⁻⁴⁰). This robust difference parallels reductions in individual endpoints reported in meta-analyses: Sheng et al. (2017) found EOF shortened time to first flatus by 0.90 days (95% CI –1.12 to –0.67) and hospital stay by 1.28 days (95% CI –1.78 to –0.78) [15]. Zhang et al. (2017) similarly observed a 16.11-hour faster flatus (MD –16.11; 95% CI –18.27 to –13.94) and 1.92-day shorter stay (MD –1.92; 95% CI –2.83 to –1.01) in colorectal surgery [16]. Our composite measure extends these findings by integrating pain control and patient comfort, underscoring the multifaceted benefit of EOF. Osland et al. (2011) reported an overall odds ratio of 0.55 (p=0.01) for postoperative complications favoring EOF, confirming the safety underpinning improved recovery metrics [11]. The narrow standard deviations in our study reflect consistency across patients and align with Shoar et al. (2016), who demonstrated standardized improvements in nasogastric tube removal (3.3 ± 1.6 vs. 5.2 ± 2.5 days) and soft diet initiation (5.8 ± 1.2 vs. 9.5 ± 5.5 days) [17]. Body Mass Index (BMI) Baseline BMI was 24.87 ± 1.76 kg/m² in EOF versus 24.98 ± 1.66 kg/m² in SOF (p=0.3707), indicating equivalent nutritional status. Hur et al. (2009) reported a mean BMI of 23.5 ± 3.1 kg/m² in gastric cancer EOF patients, with no influence on time to first flatus (p=0.036) or hospital stay (p=0.044) [8]. Dağ et al. (2011) found similar baseline BMIs (~25.1 ± 2.0 kg/m²) across arms in colorectal surgery, observing no correlation between BMI and complications or length of stay [10]. These parallels confirm that differences in postoperative recovery are attributable to feeding regimen rather than preoperative body habitus. Canzan et al. (2024) further demonstrated in their meta-analysis that EOF’s benefits—such as a 0.99-day reduction in time to stool (95% CI –1.25 to –0.72)—were consistent across BMI strata [18]. Together, these data validate that initiating oral intake on day 1 enhances recovery irrespective of baseline anthropometry.

From the above compelling findings, we can conclude that the clinical practice should pivot toward routine implementation of early feeding protocols in intestinal surgery patients, accompanied by preoperative education, nurse-driven feeding advancement orders, and dietitian support to monitor tolerance and nutritional adequacy. Quality improvement initiatives must track key performance indicators—time to first flatus and defecation, pain scores, diet tolerance, length of stay, and readmission rates—to sustain adherence and refine protocols. Further research through large-scale, multicenter trials is warranted to evaluate the long-term impact of EOF on patient-reported outcomes, cost-effectiveness, and rare safety endpoints, as well as to validate composite recovery metrics and explore optimal nutritional compositions. By embracing early oral feeding as a standard of care, surgical teams can substantially accelerate recovery trajectories, enhance patient experience, and realize significant healthcare resource efficiencies without compromising safety.

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