In colorectal surgery, fast track protocols have been extensively studied. In our department, clear fluids are started on the first post-op day, sometimes even on the evening of the day of surgery. If they are well tolerated, liquid diet is the next step, and then soft diet on day 3-4. There is no increased risk of anastomotic leak, as it was initially thought, since the normal intestinal content passes through the anastomosis regardless of oral intake. what the surgeon fears is paralytic ileus, however oral intake may be beneficial, concerning gut mobility. It certainly contributes towards avoiding bacterial translocation and septic complications, by preventing mucosal atrophy associated with prolonged fasting.

Completely agree with Dr. Manatakis. In case of elective surgery we start directly with low residue diet on POD1. It was demonstrated that it is beneficial compared to clear liquid diet in terms of faster restoration of bowel function, less nausea with no differences in complication rate.

@ Dr Julianov and Dr Taha

Do you routinely take any measures to prevent or minimize post operative paralytic ileus after colorectal surgery? Are they successful?

Sometimes ileus, PONV, abdominal distention and the need for nasogastric tube is more irritating to the patient than pain. Not to mention all the associated complications. 

Would you suggest a step-by-step approach to post-operative refeeding, taking in mind bowel sounds, passing gas and stools, or to strictly follow the protocol (e.g. POD 1 clear fluids, POD 2 liquid diet, POD 3 soft diet)? Is it sometimes too fast-track?

I am asking this, because of all the perioperative interventions, in an ERAS protocol, restoration of normal diet seems not to work quite often. And seeing a patient vomiting, with an NG tube in and out, is annoying to both the patient and the surgeon.

10% - 15% of patients will develop paralytic ileus and PONV after colorectal surgery. In our experience, right colectomies seem to fare a bit worse than left and more distal colectomies. These patients get NG tube more often then not. The other 85% however dont need NG tube, start chewing gum right after surgery, and eating normal diet also the night of surgery. Just as reported in the litterature there certainly hasnt been any increase in complication rates.

Dear Dr.Manatakis,

In elective colorectal surgery we usually start directly with low residue/soft diet on POD1. Additionally the patients with left-sided resection received 3-4 spoons of liquid paraffin till first bowel emptying.  Ambulation on POD1 is important and we have a rehabilitation team for this purpose. We do not use NG tube in elective cases including those with PONV. In case of clinically significant delay of restoration of bowel function (abdominal distension+no flatus±vomiting) we use azithromycin in order to stimulate the peristalsis. The NG intubation was necessary in about 2% of our patients when the above measures are ineffective. Usually they are elderly patients with complicated diabetes, significant cardiopulmonary or neurologic comorbidities. As well known avoiding perioperative fluid overload, electrolyte imbalance and hypoalbuminemia are also directly related to restoration of GI motility and we respect that.

Why not. There is no scientific proof about adverse effects.

Regarding the original question - there is a grade I evidence from RCT some of them conducted before 20 years and others recently published:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234758/pdf/annsurg00041-0085.pdf

http://www.ncbi.nlm.nih.gov/pubmed/25203881

And remember that any expert opinion here had the lowest level of evidece :)

@ Dr Bendavid

indeed right hemicolectomies do a bit worse. Is it because we manipulate the duodenum to mobilise the colon? And do you have any evidence on chewing gum?

Following extensive reading of available evidence at the time, we started ERAS/FAST TRACK protocol around 5 years ago. In colorectal surgery we initiate oral fluids when the patient feels that he/she wants to drink but not earlier than 6 hours after in recovery. That prevents nausea and vomitting secondary to anaesthetic meds. The next day they recieve light oral meal. If they can tolerate oral diet we proceed and if not we make a step back. It can be well tolerated by around 70-80% of pateints. Majority of the remaining 20-30% of pateints start oral intake in the next 2 days with good tolerance. The important thing is that we remove the NGT tube in the OR or in the first 2 hours when in recovery. We did not observe any major complications caused by this approach in means of increased N&V frequency or anastomotic leaks/dehisence. And indded most of our patients can leave hospital earlier than it used to be 5 years ago. 

This reference is the best I can suggest to answer the question. In my experioece, I agree with the above regarding right hemicolectomies and chewing gum if patient isn't tolerating fluids particuarly well.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg. 2013 Feb;37(2):259-84. doi: 10.1007/s00268-012-1772-0.

Do you do some bowel preparation before the surgery? Does this matters to early feeding of the patient?

Dear dr Ribeiro, when you follow FAST TRACK protocol you do not starve your patients more than 6 hours before surgery. Patients are also allowed some glucose-rich drink (for example pre-op drink) 2 hours before surgery. We do not clean bowel in any other means than enema once in the early morning 2 hours before surgery but only in rectal cancer patients. Others do not get bowel prep. It works really well, though in laparoscopic cases seems more problematic. 

In my opinion bowel prep, especially osmotic can make more harm than good for bowel function return.

As I wrote above ERAS approach leads to fast bowel function recovery in around 80-90% of cases. Remaining ones need more time - but still there are fewer post-op ileus cases than we used to see before introduction of FAST TRACK. 

We have enough evidence in the literature to suggest that early postoperative feeding is safe...and definitely on postoperative day 1 if not by 6 hours...At our institute we routinely follow early postopeartive feeding irrespective of preoperative bowel preparation

The most important  issue is the condition of anastomosis.If it is a safe anastomosis with no previous history of radiation therapy to pelvis,you can proceed with oral intake with impunity. 

                  With thanks.

In children we would normally feed after flatus is passed which is normally within hours to a day or so post op. After any surgery on bowel there is always a period of stasis which in most will resolve within hours. 

We have abandoned preop and post op fasting for two years now. Patients are fed liquids until 2h preop, and regular diet is reintroduced on the night of the surgery. this has no negative influence on the outcome of the anastomosis, and i enforce the same protocol for colon as well as small bowel resections. Our hospita stay as well as our complications rates have diminished significantly since the introduction of these measures, which are part of our fast track protocol. It works really well and only about 10 to 15% of patients need an ng tube installed post op for ileus.

 With literature evidence and our practice

Following lap colorectal case, we start small amount of oral liquid 6 to 8 hrs after surgery. For open cases usually on 1st postop day. But we increase the oral intake depending on clinical findings. Of course, in some cases we had to stop for 2 to 3 days and restart again.

 Early oral feeding doesn,t seem to influence anastomotic leak.Nausea and vomiting due to ileous or other reason is major obstacle to initiate oral feeding.The sooner the patient can tolerate the oral feeding,more faster he will be dischargable.

In my experience I would plan to have elective right colon resection patients home at day three.

Starvation has many detriments and no advantages. Avoiding mechanical bowel preparation, minimal pre-operative fasting with carbohydrate loading (Pre-load or similar up to 2 hours prior to surgery) combined with early (immediate) post operative introduction of feeding leads to better outcomes. Anastomotic failure is due to poor blood supply which if not directly technical due to poor surgery is due to perioperative circulatory factors - low flow states etc. The risk of this is mitigated by good pre-operative risk stratification and special measures such as intraoperative Dopplers for high risk groups. So I think you can see that I am saying that starvation has no relevance in reducing anastomotic failure rates.