Surgery is a purposeful intervention involving the removal, repair, or alteration of body tissues to treat diseases such as malignancies, inflammatory disorders, traumatic injuries, and structural abnormalities. It is one of the most widely used healthcare interventions worldwide, with approximately 300 million major surgical procedures performed annually [1]. Advances in surgical techniques, minimally invasive procedures, perioperative care, and technological innovations have substantially improved surgical precision and patient outcomes. Nevertheless, surgery remains a significant physiological stressor that induces neuroendocrine, inflammatory, and metabolic responses. Resection and anastomosis, whether performed electively or in an emergency setting, are associated with postoperative stress and a hypercatabolic state characterized by increased energy expenditure, insulin resistance, and protein breakdown. These responses may adversely affect nutritional status, immune function, wound healing, and recovery [2]. Consequently, appropriate perioperative nutritional management has become an important component of modern surgical care. Early identification of nutritional risk and timely nutritional support through oral, enteral, or parenteral routes when indicated can help minimize the adverse effects of postoperative catabolism [3]. Historically, prolonged postoperative starvation was considered routine following gastrointestinal surgery. Patients were commonly kept nil per oral (NPO) or nil by mouth (NBM), while nasogastric decompression was continued until the apparent resolution of postoperative ileus [4]. This practice was based on the assumption that withholding oral intake would protect the intestinal anastomosis, prevent nausea and vomiting, and allow adequate time for healing. However, subsequent evidence has challenged this traditional concept. Experimental studies have demonstrated increased collagen deposition and improved strength of intestinal anastomoses with early feeding [5,6], while beneficial effects on wound healing have also been reported [7]. Postoperative ileus is generally a temporary physiological response to abdominal surgery, and intestinal function may recover relatively early after surgery [4]. Therefore, waiting for complete resolution of ileus before initiating oral or enteral nutrition may unnecessarily prolong nutritional deprivation. Early removal of nasogastric tubes can also reduce fluid and electrolyte losses and facilitate recovery of gastrointestinal function. Clinical evidence has increasingly supported early enteral nutrition following gastrointestinal surgery. Systematic reviews and meta-analyses have reported reductions in infectious complications, wound infection, anastomotic complications, and hospital stay with early feeding, although an increased incidence of vomiting has been observed in some patients [8]. Thus, the rationale for delaying enteral feeding solely to protect the anastomosis remains uncertain. Early enteral nutrition subsequently became an important component of Enhanced Recovery After Surgery (ERAS) protocols. Kehlet and colleagues demonstrated that early feeding, combined with effective analgesia, early mobilization, and minimally invasive surgical techniques, could facilitate accelerated postoperative recovery [9]. Subsequent studies established early resumption of oral intake as an important component of multimodal perioperative pathways [10-13]. Early nutritional support should therefore be considered within a broader strategy aimed at addressing the increased metabolic demands and catabolism associated with surgical trauma [14]. Nutritional optimization should begin during the preoperative period through screening for malnutrition and appropriate nutritional conditioning. Avoidance of unnecessary prolonged fasting and appropriate preoperative carbohydrate administration may reduce surgical stress and postoperative insulin resistance [15]. However, postoperative deterioration in nutritional status may occur even after preoperative optimization, emphasizing the importance of early postoperative nutritional support [16-18]. Prehabilitation, combining physical training, protein supplementation, and psychological preparation, may further improve preoperative functional capacity and facilitate recovery. Thus, early enteral feeding represents a significant departure from conventional postoperative NBM and intravenous fluid management. The present study aims to evaluate the advantages, disadvantages, safety, and clinical outcomes of early oral feeding compared with conventional oral feeding in patients undergoing resection and anastomosis or primary repair of the small and large bowel, stomach, and hepatobiliary system. The study also compares postoperative complications between the two feeding approaches to assess whether early oral feeding provides better postoperative recovery and outcomes.

This retrospective and prospective comparative study was conducted in the Department of Surgery at a tertiary care teaching hospital (Sheth L.G. Hospital), Ahmedabad, over a period from March 2022 to June 2024. Patients admitted to the surgical wards who fulfilled the predefined eligibility criteria were enrolled after obtaining informed consent. The study included patients aged 10–65 years who underwent gastric or hepatobiliary surgery, primary repair of the bowel, or resection and anastomosis of the small or large bowel, performed in either elective or emergency settings, irrespective of the underlying indication for surgery. Patients younger than 10 years or older than 65 years were excluded from the study. A total of 70 patients were included and divided into two groups of 35 patients each according to the timing of postoperative oral/enteral feeding. Group A (early feeding group) comprised patients in whom enteral/oral feeding was initiated within 2–3 postoperative days, whereas Group B (conventional/late feeding group) comprised patients who were kept nil by mouth until the fourth postoperative day and in whom oral feeding was subsequently initiated. Preoperative evaluation included detailed history and clinical examination, routine hematological and biochemical investigations, including serum albumin, and other investigations as clinically indicated. Patients with Hemoglobin levels below 10 g/dL were appropriately optimized with blood transfusion as clinically indicated. In elective cases, blood glucose and blood pressure were optimized before surgery using insulin and antihypertensive therapy, respectively, and were appropriately monitored and managed during the postoperative period. Patients aged >50 years undergoing planned surgery received preoperative chest physiotherapy and incentive spirometry exercises for at least 3 days. Prophylactic antibiotic therapy with weight-adjusted intravenous ceftriaxone was administered approximately 45 minutes before surgery. Following surgery, all patients received standardized postoperative monitoring and supportive care. Vital signs, return of bowel sounds, nasogastric tube output, postoperative pain, respiratory status, nausea and vomiting, wound status, and other clinically relevant complications were assessed regularly. Chest physiotherapy was provided when indicated, and early mobilization was encouraged in all patients. Detailed clinical information, operative findings, postoperative course, investigations, treatment, and follow-up data were recorded using a structured proforma. The principal postoperative outcomes assessed were duration of postoperative ileus, anastomotic complications including anastomotic leakage, intra-abdominal collections, and duration of hospital stay. Additional postoperative complications, including wound infection, respiratory complications, deep-vein thrombosis, nausea, and vomiting, were also documented. All patients were managed and followed up at the same institution until discharge, with postoperative outcomes compared between the early and conventional feeding groups. Statistical analysis was performed using appropriate qualitative and quantitative statistical methods, with the choice of test determined according to the distribution and nature of the variables.

In the present study, 70 patients undergoing gastrointestinal resection and anastomosis were enrolled and equally allocated into two groups of 35 patients each. Early oral feeding was initiated in the first group, while conventional late oral feeding was initiated in the second group. The groups were compared with respect to sociodemographic characteristics, intraoperative findings, postoperative complications, and clinical outcomes. Table 1. Demographic characteristics of study participants Parameters Early Feeding N (%) Late Feeding N (%) Total N (%) Age Group 00-10 00 (0.0) 01 (2.9) 01 (1.4) 11-20 04 (11.4) 06 (17.1) 10 (14.3) 21-30 09 (25.7) 02 (5.7) 11 (15.7) 31-40 07 (20.0) 06 (17.1) 13 (18.6) 41-50 06 (17.1) 08 (22.9) 14 (20.0) 51-60 05 (14.3) 06 (17.1) 11 (15.7) 61-70 02 (5.7) 04 (11.4) 06 (8.6) 71-80 01 (2.9) 01 (2.9) 02(2.9) 81-90 01 (2.9) 01 (2.9) 02 (2.9) Mean Age Mean + SD 40.5 + 17.6 43.3 + 19.3 Gender Male 27 (77.1) 21 (60.0) 48 (68.6) Female 08 (22.9) 14 (40.0) 22 (31.4) Type of Surgery Emergency 16 (45.7) 22 (62.9) 38 (54.3) Planned 19 (54.3) 13 (37.1) 32 (45.7) Comorbidities Diabetes 07 (20.0) 07 (20.0) 14 (20.0) Hypothyroidism 01 (2.9) 01 (2.9) 02 (2.9) Hypertension 03 (8.6) 05 (14.3) 08 (11.4) Tuberculosis 01 (2.9) 02 (5.7) 03 (4.3) COPD 00 (0.0) 02 (5.7) 02 (2.8) Level of Anastomosis Stomach 13 (37.1) 03 (8.6) 16 (13) Proximal bowel 19 (54.3) 13 (37.1) 32 (26) Large intestine 07 (20.0) 10 (28.6) 17 (13.82) Stoma 10 (28.6) 03 (8.6) 13 (10.56) Distal ileum 05 (14.3) 22 (62.8) 27 (21.95) Sepsis 06 (17.1) 12 (34.3) 18 (14.63) Table 1 summarizes the demographic and clinical characteristics of the 70 participants, equally divided into early-feeding (n=35) and late-feeding (n=35) groups. The 41–50-year age group was most represented (20.0%), with mean ages of 40.5 ± 17.6 years and 43.3 ± 19.3 years in the early- and late-feeding groups, respectively. Overall, there was a male predominance (68.6%). Emergency surgeries constituted 54.3% of procedures and were more frequent in the late-feeding group (62.9%) than in the early-feeding group (45.7%). Diabetes mellitus was the most common comorbidity (20.0%), followed by hypertension (11.4%). Proximal bowel anastomosis was most frequent in the early-feeding group (54.3%), whereas distal ileal involvement predominated in the late-feeding group (62.8%). Sepsis was reported in 18 (14.63%) participants, with a higher proportion in the late-feeding group (34.3%) compared with the early-feeding group (17.1%). Overall, the two groups showed differences mainly in the type of surgery, anastomotic level, and occurrence of sepsis. Table 2. Operative findings of study patients Operative findings Early feeding N (%) Late feeding N (%) Total N (%) Dilatation of stomach and bowel 10 (28.6) 12 (34.3) 22 (20.0) Presence of perforation 08 (22.8) 05 (14.3) 14 (20.0) Feeding jejunostomy 03 (8.6) 01 (2.9) 04 (5.7) TPN given 00 (0.0) 05 (14.3) 05 (7.1) Disparity between two ends of anastomosis 03 (8.6) 06 (17.1) 09 (12.8) Past history of abdominal surgery 03 (8.6) 03 (8.6) 06 (8.6) Table 2 presents the operative findings among the 70 study participants, categorized into early- and late-feeding groups. Dilatation of the stomach and bowel was the most common finding, observed in 22 (20.0%) cases, with a slightly higher proportion in the late-feeding group (34.3%) than in the early-feeding group (28.6%). Perforation was noted in 14 (20.0%) cases, occurring more frequently in the early-feeding group (22.8%) than in the late-feeding group (14.3%). Feeding jejunostomy was performed in 4 (5.7%) participants, while TPN was administered to 5 (7.1%), all of whom belonged to the late-feeding group. Disparity between the two anastomotic ends was observed in 9 (12.8%) cases and was more frequent in the late-feeding group (17.1%). A past history of abdominal surgery was present in 6 (8.6%) participants, with equal distribution between the two groups (8.6% each). Overall, dilatation, perforation, and anastomotic disparity were the predominant operative findings. Table 3. Comparison of post-operative parameters Post-Operative Parameter Early Feeding Late Feeding P Value VAS Score Day 1 5.7 + 0.9 6.7 + 0.8 <0.001 Day 2 4.8 + 0.8 5.7 + 0.8 <0.001 Day 3 3.7 + 0.8 5.0 + 1.0 <0.001 Day 4 2.9 + 0.8 3.9 + 1.1 <0.001 Day 5 1.8 + 0.6 2.9 + 1.0 <0.001 Day 6 1.0 + 1.0 2.0 + 1.0 <0.001 Day 7 0.2 + 0.4 0.9 + 1.3 0.001 Post-operative regaining of bowel functions Peristalsis on day 2.7 + 0.5 4.3 + 0.5 <0.001 Flatulence on day 3.7 + 0.8 4.9 + 0.7 <0.001 Stool Pass on day 4.4 + 0.8 6.5 + 1.3 <0.001 Length of hospital stay < 1 week 24 (68.6) 04 (12.5) <0.001 1-2 weeks 09 (25.7) 24 (75.0) >2 weeks 02 (5.7) 04 (12.5) Outcome Discharged 35 (100.0) 32 (91.4) 0.23 Death 00 (0.0) 03 (08.6) Table 3 compares postoperative parameters between the early-feeding and late-feeding groups. The mean VAS pain scores were significantly lower in the early-feeding group on postoperative days 1–7, with statistically significant differences observed throughout the postoperative period (p<0.001 on days 1–6; p=0.001 on day 7). Recovery of bowel function was also significantly earlier in the early-feeding group. Peristalsis, passage of flatus, and stool passage occurred earlier among patients receiving early feeding (2.7 ± 0.5, 3.7 ± 0.8, and 4.4 ± 0.8 days, respectively) compared with the late-feeding group (4.3 ± 0.5, 4.9 ± 0.7, and 6.5 ± 1.3 days, respectively), with all differences being statistically significant (p<0.001). A significant difference was also observed in length of hospital stay (p<0.001). Most patients in the early-feeding group (68.6%) were discharged within one week, compared with only 12.5% in the late-feeding group. Conversely, a hospital stay of 1–2 weeks was more common in the late-feeding group (75.0%) than in the early-feeding group (25.7%). Regarding outcome, all patients in the early-feeding group were discharged (100%), compared with 91.4% in the late-feeding group. Three deaths (8.6%) occurred in the late-feeding group; however, the difference in overall outcome was not statistically significant (p=0.23). Overall, early feeding was associated with lower postoperative pain, earlier return of bowel function, and shorter hospital stay. Table 4. Post operative complications among study groups Post-Operative Parameter Early feeding N (%) Late feeding N (%) Total N (%) Complications Abdominal Distension 01 (2.9) 04 (11.4) 05 (7.1) Vomiting 02 (5.7) 03 (8.6) 05 (7.1) Paralytic Ileus 00 (0.0) 03 (8.6) 03 (4.3) Wound Infection 03 (8.6) 09 (25.7) 12 (17.1) Intra-abdominal Collection 01 (2.9) 06 (17.1) 07 (10.0) Anastomotic Dehiscence 00 (0.0) 03 (8.6) 03 (4.3) Pneumonia 01 (2.9) 04 (11.4) 05 (7.1) DVT 00 (0.0) 01 (2.9) 01 (1.4) Ryles tube profile Vomiting 02 (5.8) 03 (8.6) 05 (7.1) Ryles tube re-Insertion 02 (5.8) 03 (8.6) 05 (7.1) Mean days of re-insertion of Ryles Tube 2.5 2.6 2.55 Table 4 compares postoperative complications between the early- and late-feeding groups. Overall, postoperative complications were more frequent in the late-feeding group. Wound infection was the most common complication (17.1%), followed by intra-abdominal collection (10.0%). Abdominal distension, vomiting, paralytic ileus, anastomotic dehiscence, and pneumonia were also more frequent in the late-feeding group. DVT was reported in one patient (1.4%), occurring in the late-feeding group. Ryles tube reinsertion was required in 5 (7.1%) patients, with a mean duration of 2.5 days in the early-feeding group and 2.6 days in the late-feeding group. Overall, the findings indicate a higher frequency of postoperative complications among patients receiving late feeding.

Early enteral feeding following gastrointestinal (GIT) anastomosis is increasingly recognized as a safe and physiologically beneficial approach. The present study compared early and late feeding following gastrointestinal anastomosis in 70 patients, with particular emphasis on postoperative recovery, complications, hospital stay, and mortality. In the present study, males predominated (68.6%), with a mean age of 40.5 ± 17.6 years in the early-feeding group and 43.3 ± 19.3 years in the late-feeding group. Similar age and gender distributions have been reported by Rizk et al. [19], Khaled Mohammed Sharaf et al. [20], Behzad Nematihonar et al. [21], and Asif Imran et al. [22]. The demographic and preoperative characteristics were comparable between the two groups, supporting their comparability. Early feeding was associated with significantly earlier recovery of bowel function. Peristalsis, passage of flatus, and stool occurred at mean postoperative days 2.7, 3.7, and 4.4, respectively, compared with 4.3, 4.9, and 6.5 days in the late-feeding group (p<0.001). These findings are consistent with observations reported by Asif Imran et al. [22] and Rizk et al. [19], supporting the beneficial effect of early enteral feeding on gastrointestinal recovery. Postoperative pain was also significantly lower in the early-feeding group throughout the first seven postoperative days (p<0.001). This finding suggests better overall postoperative recovery among patients receiving early enteral nutrition. The frequency of postoperative complications was generally higher in the late-feeding group. Wound infection occurred in 8.6% of patients in the early-feeding group compared with 25.7% in the late-feeding group. Similarly, vomiting, abdominal distension, paralytic ileus, anastomotic dehiscence, and pneumonia were more frequent following late feeding. Comparable trends have been reported by Asif Imran et al. [22], Khaled Mohammed Sharaf et al. [20], and Behzad Nematihonar et al. [21]. These findings suggest that early feeding does not increase postoperative morbidity and may be associated with fewer postoperative complications. The mean duration of hospital stay was shorter with early feeding (7.5 days) than with late feeding (10.6 days). Similar reductions in hospital stay following early enteral feeding have been reported by Asif Imran et al. [22] and Arif et al. [23]. Early restoration of enteral nutrition may therefore contribute to faster functional recovery and earlier discharge. Although mortality was absent in the early-feeding group and occurred in three patients (8.6%) in the late-feeding group, the difference was not statistically significant (p=0.23). Mortality is influenced by several factors, including comorbidities, severity of illness, type of surgery, and preoperative clinical status; therefore, this finding should be interpreted cautiously. Overall, the present study demonstrates that early enteral feeding following GIT anastomosis is associated with earlier return of bowel function, lower postoperative pain, fewer postoperative complications, and shorter hospital stay, without evidence of increased mortality. These findings support the use of early feeding as a component of postoperative recovery following gastrointestinal anastomosis, while emphasizing the need for individualized feeding decisions according to the patient's clinical condition and operative findings

Early enteral feeding following gastrointestinal resection and anastomosis or primary repair of perforation was found to be safe, feasible, and well tolerated. It was associated with lower postoperative pain, earlier recovery of bowel function, fewer postoperative complications, and a shorter hospital stay compared with late feeding. The benefits appeared particularly evident in patients undergoing anastomosis involving the stomach, proximal small intestine, and large intestine, whereas feeding decisions in distal ileal anastomosis and extensive local or systemic sepsis should be individualized. Overall, early enteral feeding may facilitate faster functional recovery, early mobilization, and cost-effective postoperative care.

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