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NSAID administration post colorectal surgery increases anastomotic leak rate: systematic review/meta-analysis.
Modasi, A, Pace, D, Godwin, M, Smith, C, Curtis, B
Surgical endoscopy. 2019;(3):879-885
Abstract
BACKGROUND Current enhanced recovery guidelines suggest that opioid sparing medications should be used for analgesia whenever possible following colorectal surgery. The present study aims to assess whether post-operative NSAID use is associated with an increased anastomotic leak rate after a colonic or rectal anastomosis. METHODS A systematic review was performed for studies investigating anastomotic leak rate following NSAID use vs control after colonic or rectal anastomosis. Meta-analysis was performed to assess for overall risk of anastomotic leak with NSAID use, as well as sub-group analysis to compare selective vs non-selective NSAIDs and drug-specific NSAID safety profiles. RESULTS Seven studies were included in the final review. Use of an NSAID post-operatively was associated with an overall increased risk of anastomotic leakage [OR 1.58 (1.23, 2.03), P = 0.0003]. Non-selective NSAIDs were associated with an increased risk [OR 1.79 (1.47, 2.18), P < 0.00001], but selective NSAIDs were not. The non-selective NSAID diclofenac was associated with an increased leak rate [OR 2.79 (1.96, 3.96), P < 0.00001], but ketorolac was not [OR 1.36 (0.89, 2.06), P = 0.16]. CONCLUSIONS Great caution must be taken when prescribing NSAIDs following colonic or rectal anastomotic creation. The safety profile varies within the NSAID class and further research is needed to clarify which NSAIDs are safe for use and which are not.
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Colonic immune cells in irritable bowel syndrome: A systematic review and meta-analysis.
Bashashati, M, Moossavi, S, Cremon, C, Barbaro, MR, Moraveji, S, Talmon, G, Rezaei, N, Hughes, PA, Bian, ZX, Choi, CH, et al
Neurogastroenterology and motility. 2018;(1)
Abstract
BACKGROUND & AIMS Increases in mucosal immune cells have frequently been observed in irritable bowel syndrome (IBS) patients. However, this finding is not completely consistent between studies, possibly due to a combination of methodological variability, population differences and small sample sizes. We performed a meta-analysis of case-control studies that compared immune cell counts in colonic biopsies of IBS patients and controls. METHODS PubMed and Embase were searched in February 2017. Results were pooled using standardized mean difference (SMD) and were considered significant when zero was not within the 95% confidence interval (CI). Heterogeneity was assessed based on I2 statistics where I2 ≤ 50% and I2 > 50% indicated fixed and random effect models, respectively. KEY RESULTS Twenty-two studies on 706 IBS patients and 401 controls were included. Mast cells were increased in the rectosigmoid (SMD: 0.38 [95% CI: 0.06-0.71]; P = .02) and descending colon (SMD: 1.69 [95% CI: 0.65-2.73]; P = .001) of IBS patients. Increased mast cells were observed in both constipation (IBS-C) and diarrhea predominant IBS (IBS-D). CD3+ T cells were increased in the rectosigmoid (SMD: 0.53 [95% CI: 0.21-0.85]; P = .001) and the descending colon of the IBS patients (SMD: 0.79, 95% CI [0.28-1.30]; P = .002). This was possibly in relation to higher CD4+ T cells in IBS (SMD: 0.33 [95% CI: 0.01-0.65]; P = .04) as there were no differences in CD8+ T cells. CONCLUSIONS & INFERENCES Mast cells and CD3+ T cells are increased in colonic biopsies of patients with IBS vs non-inflamed controls. These changes are segmental and sometimes IBS-subtype dependent. The diagnostic value of the quantification of colonic mucosal cells in IBS requires further investigation.
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Goal-directed fluid therapy versus conventional fluid therapy in colorectal surgery: A meta analysis of randomized controlled trials.
Xu, C, Peng, J, Liu, S, Huang, Y, Guo, X, Xiao, H, Qi, D
International journal of surgery (London, England). 2018;:264-273
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OBJECTIVES This meta-analysis was conducted to compare the effects of goal-directed fluid therapy (GDFT) versus conventional fluid therapy (CFT) in colorectal surgery on patients' postoperative outcome and to detect whether the results differ between studies with the Enhanced Recovery After Surgery (ERAS) protocol and those without, between studies using different devices for GDFT, or between different surgical approaches (laparoscopy or laparotomy). METHODS The Cochrane Library, PubMed, Embase, Wanfang Data and ClinicalTrials.com were searched for studies from January,1990 to February, 2018. Randomized controlled trials (RCTs) comparing both two abovementioned fluid therapy protocols in colorectal surgery were included. The primary outcome was 30-day mortality after surgery. Secondary outcomes were length of hospital stay (LOS), complication rate, ICU admission and gastrointestinal indicators. RESULTS Eleven studies were included, including a total of 1281 patients: the GDFT group included 624 patients and the control group included 657 patients. No significant differences were found between groups in 30-day mortality (relative risk, RR 0.86,0.28 to 2.63, P = 0.79), LOS (weighted mean difference, WMD 0.22,-0.1 to 0.55, P = 0.18), and ICU admission (RR 0.42, 0.17 to 1.04, P = 0.06). However, the GDFT group had a lower complication rate (RR 0.84,0.71 to 0.99, P = 0.04). In subgroup analyses, time to first flatus and time to tolerate an oral diet were shorter in GDFT group than the control group in studies who did not use the ERAS protocol. No publication bias was identified according to Begg's test. CONCLUSION Compared with conventional fluid therapy, GDFT may not improve patients' postoperative outcome in colorectal surgery. However, the improvement of gastrointestinal function associated with GDFT over conventional fluid therapy was significant in the surgeries that did not use the ERAS protocol.
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Nonsteroidal anti-inflammatory drugs reduce the time to recovery of gut function after elective colorectal surgery: a systematic review and meta-analysis.
Milne, TGE, Jaung, R, O'Grady, G, Bissett, IP
Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2018;(8):O190-O198
Abstract
AIM: Postoperative ileus causes significant patient morbidity after abdominal surgery. Some evidence suggests nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce time to gut recovery, but there has not been a meta-analysis to assess their efficacy. This systematic review and meta-analysis aimed to determine the benefit of NSAIDs for recovery of postoperative gut function in patients undergoing elective colorectal surgery. METHOD MEDLINE, EMBASE, CENTRAL and reference lists were searched with no date or language restrictions. Randomized controlled trials comparing the use of NSAIDs with placebo in the perioperative or postoperative period were identified. Included studies reported outcomes relevant to gut function: time to pass flatus or stool and time to tolerate an oral diet. The mean difference in time from surgery until passage of flatus, stool and tolerance of diet were meta-analysed using a random-effects model in RevMan 5.3. RESULTS This study identified 992 relevant articles. Five randomized controlled trials on patients undergoing elective colorectal surgery met our inclusion criteria and were meta-analysed. Compared with placebo, NSAIDs significantly improved the time to pass flatus (mean difference -9.44 h, 95% CI: -17.22, -1.65, I2 = 70%, P = 0.02), time to pass stool (mean difference -12.09 h, 95% CI: -17.16, -7.02, I2 = 0%, P < 0.001) and time to tolerate a diet (mean difference -11.95 h, 95% CI: -18.66, -5.24, I2 = 0%, P < 0.001). CONCLUSION NSAIDs significantly improve time to gut recovery after elective colorectal surgery. Current evidence is not adequate to identify whether selective or nonselective drugs should be recommended. Further high-power studies using selective drugs are required.
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Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications.
Herbert, G, Perry, R, Andersen, HK, Atkinson, C, Penfold, C, Lewis, SJ, Ness, AR, Thomas, S
The Cochrane database of systematic reviews. 2018;(10):CD004080
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BACKGROUND This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation. OBJECTIVES To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA). MAIN RESULTS We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I2 = 81, %, Chi2 = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I2 = 0%, Chi2 = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I2 = 0%, Chi2 = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence). AUTHORS' CONCLUSIONS This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.
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Effect of gum chewing on ameliorating ileus following colorectal surgery: A meta-analysis of 18 randomized controlled trials.
Liu, Q, Jiang, H, Xu, D, Jin, J
International journal of surgery (London, England). 2017;:107-115
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BACKGROUND AND OBJECTIVE Chewing gum, as an alternative to sham feeding, had been shown to hasten the recovery of gut function following abdominal surgery. However, conclusions remained contradictory. We sought to conduct an updated meta-analysis to evaluate the efficacy of gum chewing in alleviating ileus following colorectal surgery. METHODS We searched PubMed, EMBASE, and Cochrane Library Databases through February 2017 to identify randomized controlled trials (RCTs) evaluating the efficacy of the additional use of chewing gum following colorectal surgery. After screening for inclusion, data extraction, and quality assessment, meta-analysis was conducted by the Review Manager 5.3 software. The outcomes of interest were the time to first flatus, time to first bowel movement, length of hospital stay, and some clinically relevant parameters. We also performed subgroup analyses according to the type of surgical approaches or on trials that adopted enhanced recovery after surgery (ERAS) protocol or sugared gum. RESULTS A total of 18 RCTs, involving 1736 patients, were included. Compared with standardized postoperative care, Chewing gum resulted in a shorter passage to first flatus [WMD = -8.81, 95%CI: (-13.45, -4.17), P = 0.0002], earlier recovery of bowel movement [WMD = -16.43, 95%CI: (-22.68, -10.19), P < 0.00001], and a reduction in length of hospital stay [WMD = -0.89, 95%CI: (-1.72, -0.07), P = 0.03]. Chewing gum was also associated with a lower risk of postoperative ileus [OR = 0.41, 95%CI: (0.23, 0.73), P = 0.003]. No evidence of significant advantages in overall postoperative complication, nausea, vomiting, bloating, readmission and reoperation towards the addition of chewing gum was observed. Subgroup analyses all favored gum chewing. However, the findings are hampered by the significant heterogeneity between trials. CONCLUSIONS Based on current evidence, chewing gum offers an inexpensive, well-tolerated, safe and effective method to ameliorate ileus following colorectal surgery. However, tightly controlled, randomized and considerably larger multicenter trials are warranted to further validate our findings.
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Split-Dose Preparations Are Superior to Day-Before Bowel Cleansing Regimens: A Meta-analysis.
Martel, M, Barkun, AN, Menard, C, Restellini, S, Kherad, O, Vanasse, A
Gastroenterology. 2015;(1):79-88
Abstract
BACKGROUND & AIMS There are different regimens of preparing the colon for colonoscopy, including polyethylene glycol (PEG), sodium phosphate, picosulfate, or oral sulfate solutions. We performed a meta-analysis to determine the efficacy of split-dose vs other colon preparation regimens, the optimal products for use, and the most effective preparation volumes. METHODS We performed systematic searches of MEDLINE, EMBASE, Scopus, CENTRAL, and ISI Web of knowledge databases, from January 1980 to March 2014, for published results from randomized trials that assessed split-dose regimens vs day-before colonoscopy preparation. We excluded studies that included pediatric or hospitalized patients, or patients with inflammatory bowel disease. The primary outcome was efficacy of bowel cleansing. Secondary outcomes included side effects or complications, outcomes of procedures, patients' willingness to repeat the procedure, and the amount of time required for patients to resume daily activities. RESULTS We identified 47 trials that fulfilled our inclusion criteria (n = 13,487 patients). Split-dose preparations provided significantly better colon cleansing than day-before preparations (odds ratio [OR], 2.51; 95% confidence interval, 1.86-3.39), as well as day-before preparations with PEG (OR, 2.60; 95% confidence interval, 1.46-4.63), sodium phosphate (OR, 9.34; 95% confidence interval, 2.12-41.11), or picosulfate (OR, 3.54; 95% confidence interval, 1.95-6.45). PEG split-dose preparations of 3 L or more yielded greater bowel cleanliness than lower-volume split-dose regimens (OR, 1.89; 95% confidence interval, 1.01-3.46), but only in intention-to-treat analysis. A higher proportion of patients were willing to repeat split-dose vs day-before cleansing (OR, 1.90; 95% confidence interval, 1.05-3.46), and low-volume split-dose preparations vs high-volume split-dose preparation (OR, 4.95; 95% confidence interval, 2.21-11.10). There were no differences between preparations in other secondary outcome measures. However, there was variation among studies in definitions and main and secondary outcomes. CONCLUSIONS Based on meta-analysis, split-dose regimens increase the quality of colon cleansing and are preferred by patients compared with day-before preparations. Additional research is required to evaluate oral sulfate solution-based and PEG low-volume regimens further.
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Comparison of fast track protocol and standard care in patients undergoing elective open colorectal resection: a meta-analysis update.
Yin, X, Zhao, Y, Zhu, X
Applied nursing research : ANR. 2014;(4):e20-6
Abstract
OBJECTIVE We conducted a systematic review of randomized controlled trials assessing the clinical results of fast track protocol (FTP) and standard care (SC) in patients undergoing elective open colorectal resection using meta-analysis. METHOD A literature search for electronic databases and references for eligible studies was conducted through Medline, Embase and Cochrane library between 1966 and 2013. RESULT A total of 9 randomized controlled trials (n=947 patients) were included. From the pooled results, we obtained: FTP showed significantly better results compared to SC in terms of postoperative complications, total hospital stay as well as time for flatus, defecation, and soft diet. However, no difference in the incidence of readmission was observed. Postoperative rate of death within 4 weeks did not differ significantly between two groups. CONCLUSION The current evidence of this meta-analysis suggested that fast track protocol after colorectal surgery pathways might be able to reduce postoperative complication rates, length of hospital stay as well as time for gut function recovery without affecting readmission rate or mortality compared to standard care.
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Early versus traditional postoperative oral feeding in patients undergoing elective colorectal surgery: a meta-analysis of randomized clinical trials.
Zhuang, CL, Ye, XZ, Zhang, CJ, Dong, QT, Chen, BC, Yu, Z
Digestive surgery. 2013;(3):225-32
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BACKGROUND The safety and effectiveness of early oral feeding after colorectal surgery has not been determined. We performed a meta-analysis to evaluate surgical outcomes following early oral feeding compared with traditional oral feeding in patients undergoing elective colorectal surgery. METHODS MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify randomized clinical trials comparing the outcomes following early oral feeding versus traditional oral feeding in patients undergoing elective colorectal surgery. The trials must have reported at least one of the following end points: anastomotic dehiscence, pneumonia, wound infection, nasogastric tube reinsertion, vomiting, mortality, length of hospital stay, hospital costs, and quality of life. RESULTS Seven trials, which included a total of 587 patients, met our inclusion criteria. Compared with traditional oral feeding, early oral feeding reduced the length of hospital stay (weighted mean difference -1.58 days; 95% CI -2.77 to -0.39; p = 0.009) and the total postoperative complications (relative risk 0.70; 95% CI 0.50-0.98; p = 0.04). There were no significant differences in the risk of anastomotic dehiscence, pneumonia, wound infection, rate of nasogastric tube reinsertion, vomiting, or mortality. CONCLUSIONS Early oral feeding is safe and effective in patients undergoing elective colorectal surgery.
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Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications.
Andersen, HK, Lewis, SJ, Thomas, S
The Cochrane database of systematic reviews. 2006;(4):CD004080
Abstract
BACKGROUND The role of early postoperative enteral nutrition after gastrointestinal surgery is controversial. Traditional management consist of 'nil by mouth', where patients receive fluids followed by solids when tolerated. Although several trials have implicated lower incidence of septic complications and faster wound healing upon early enteral feeding, other trials have shown opposite results. The immediate advantage of caloric intake could be a faster recovery with fewer complications, to be evaluated systematically. OBJECTIVES To evaluate whether early commencement of postoperative enteral nutrition compared to traditional management (no nutritional supply) is associated with fewer complications in patients undergoing gastrointestinal surgery SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials, PUBMED, EMBASE, and LILACS from 1979 (first RCT published) to March 2006. We manually scanned the references from the relevant articles, and consulted primary authors for additional information. SELECTION CRITERIA We looked for randomised controlled trials (RCT's) comparing early commencement of feeding (within 24 hours) with no feeding in patients undergoing gastrointestinal surgery. Early enteral nutrition is defined as all oral intakes (i.e. registered oral intake, supplemented oral feeding) and any kind of tube feeding (gastric, duodenal or jejunal) containing caloric content. No feeding is traditional management, defined as none caloric oral intake or any kind of tube feeding before bowel function. The definition 'no nutrition' includes non caloric placebo and water. DATA COLLECTION AND ANALYSIS The three authors independently assessed the identified trials, and extracted the relevant data using a specifically developed data extraction sheet. Primary end points of interest were: Wound infections and intraabdominal abscesses, postoperative complications such as acute myocardial infarction, postoperative thrombosis or pneumonia, anastomotic leakages, mortality, length of hospital stay, and significant adverse effects. We combined data to estimate the common relative risk of postoperative complications, and calculated the associated 95% confidence intervals. For analysis, we used fixed effects model (risk ratios to summarise the treatment effect) whenever feasible. The treatment effect on length of stay was estimated using effect size (presented as mean +/- SD). Some outcomes were not analysed but presented in a descriptive way. We used a random effects model to estimate overall risk ratio and effect size. MAIN RESULTS We identified thirteen randomised controlled trials, with a total of 1173 patients, all undergoing gastrointestinal surgery. Individual clinical complications failed to reach statistical significance, but the direction of effect indicates that earlier feeding may reduce the risk of post surgical complications. Mortality was the only outcome showing a significant benefit, but not necessarily associated with early commencement of feeding, as the reported cause of death was anastomotic leakage, reoperation, and acute myocardial infarction. AUTHORS' CONCLUSIONS Although non-significant results, there is no obvious advantage in keeping patients 'nil by mouth' following gastrointestinal surgery, and this review support the notion on early commencement of enteral feeding.