Meta Analysis Early Enteral Nutrition Within 24h of Intestinal Surgery Versus Later Commencement of Feeding: A Systematic Review and Meta-Analysis
This review may be edited
Summary
Posted By:	Pip Heighes
E-Mail:	pheighes@nsccahs.health.nsw.gov.au
Posted Date:	11/11/08
Title:	Early Enteral Nutrition Within 24h of Intestinal Surgery Versus Later Commencement of Feeding: A Systematic Review and Meta-Analysis
Authors:	Lewis, S.J., Andersen, H.K. & Thomas, S.
Reference:	J Gastrointest Surg 2008 July
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Abstract:	BACKGROUND: We set out to evaluate early commencement of post-operative enteral nutrition versus traditional management in patients undergoing gastrointestinal surgery. METHODS: Electronic databases were searched, references lists were scanned and authors contacted for additional information. We looked for randomised controlled trials comparing early commencement of feeding (within 24 h) with no feeding in patients undergoing gastrointestinal surgery. Primary endpoints were wound infections, intra-abdominal abscesses, pneumonia, anastomotic leakage, mortality, length of hospital stay and complications of feeding. Data were combined to estimate the common relative risk of post-operative complications and associated 95% confidence intervals. RESULTS: Thirteen trials, with a total of 1,173 patients, fulfilled our inclusion criteria. Mortality was reduced with early post-operative feeding. Early post-operative feeding increased vomiting. The direction of effect is suggestive of a reduction of risk of post-surgical complications and reduced length of hospital stay. CONCLUSION: There is no obvious advantage in keeping patients 'nil by mouth' following gastrointestinal surgery. Early enteral nutrition is associated with reduced mortality, though the mechanism is not clear. This review supports the notion that early commencement of enteral feeding may be of benefit.
Are the Results Valid?
1. Did the overview address a focused clinical question?
	Yes. Population was elective GI surgical patients. Intervention was early enteral feeding, defined as any oral caloric intake or any kind of tube feeding commenced within 24hours of surgery. Control was traditional management, defined as no caloric intake or tube feeding within 24 hours post-op. Outcomes evaluated were pneumonia, wound infections, intra-abdominal abscess, anastomotic leakage, lenght of hospital stay amd 30 day post-op mortality.
2. Were the criteria used to select articles for inclusion appropriate?
	Unclear. Unclear as to what exact inclusion/ exclusion criteria were.
3. Is it unlikely that important, relevant studies were missed?
	Yes. The authors conducted an adequate literature search, using approriate nutrition MeSH headings. They searched Cochrane CENTRAL, Cochnrane specialised group register, Pubmed, EMBASE and LILACS. They also hand searched reference lists of identified articles, abstracts from conference proceedings and relevant scientific meetings and also contacted manufacturers and authors to identify any unpublished data.
4. Was the validity of the included studies appraised?
	Yes. The authors report assessment of two dimensions of methodological quality that have been shown to be associated with biased estimates of treatment effects - adequacy of concealment of patients allocation to treatment groups and double blinding. Authors state trials were considered even when blinding or use of placebo were not described (authors refered to figure 1 however fig 1 does not provide information on blinding methods of included studies). They found 6 of the 11 included RCT's reported concelament of allocation using sealed envelopes and blinding. 1 used an open table with random numbers and in the remaining 6 the method of randomisation was unclear or not stated.
5. Were assessments of studies reproducible?
	Unclear. 3 authors independently applied inclusion criteria, no description of agreement or process for resolving disagreements. No QUOROM flow diagram presented to demonstrate application of study selection process
6. Were the results similar from study to study?
	Mainly. For the outcomes pneumonia, mortality and anastomotic dehiscence there is no evidence of heterogeneity with I2 value of 0% for all three outcomes. However for wound infections the I2 is 42.2% indicating some differences in the results that may need closer evaluation.
What are the Results?
1. What are the overall results of the overview?
	This MA found a statistically significant reduction in mortality associated with the delivery of early EN. Baseline mortality in the control group was 6.9% RR was 0.41, p=0.03, I2 = 0% No other results were significant.
2. How precise were the results?
	For mortality RR 0.41, 95%CI 0.18 to 0.93, p=0.03, I2 = 0%
Will the Results Help Me In Caring For My Patients?
1. Can the results be applied to my patient care
	The patients in the trials included in the MA were elective gastrointestinal surgical patients and most likely not critically ill (note baseline mortality as above). Although of interest, the results are not specifically applicable to Intensive Care and should be interpreted cautiously.
2. Were all clinically important outcomes considered?
	Infections were broken down into wound infections and pneumonia, which is useful as nutrition is believed to help with wound healing. A common barrier to commencing early EN is the perceived risk of aspiration and subsequent development of aspiration pneumonia. The results of this MA show no evidence of this.
3. Are the benefits worth the harms and costs?
	Uncertain. No real exploration of this topic area in this review.
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