As this nationwide survey aimed to investigate the practice and attitudes towards early postoperative resumption of oral intake along with the understanding of ERAS, it was conducted to collect baseline data that would help establish a proper strategy for the widespread implementation of early postoperative oral intake in clinical practice. We found that early resumption of oral intake after non-abdominal surgery has been relatively well adopted. However, the implementation and conception of ERAS after gastrointestinal and hepato-pancreato-biliary surgery are discrepant, and the approach to recovery for these two types remains relatively conserved. In addition, a better understanding of ERAS would encourage practitioners to commence oral intake earlier in these patients. Therefore, consideration should be given to feasible solutions to the obstacles that may undermine the implementation of ERAS. Finally, a comprehensive and surgery-specific care protocol is urgently required to reduce variation and improve postoperative outcomes in China.
Postoperative resumption of oral intake is highly variable among gastrointestinal, hepato-pancreato-biliary and non-abdominal surgery. Indeed, after abdominal and intestinal surgery, due to the disruption of normal bowel motility, postoperative ileus may occur. For this reason, the timing of postoperative oral intake has long been debated(21, 22). Traditional management usually includes remaining fasting until bowel sound or passage of flatus or stool, which are clinical parameters used to confirm resolution of ileus, and then commencing on clear fluids typically 2 to 5 days postoperation and finally progressing to a solid diet as tolerated(23). However, these old-school parameters are dispensable evidence of resumed bowel function(24) and an early oral diet has been shown to be safe at 4 hours after surgery in patients with nondiverted colorectal anastomosis(25). It seems that gastrointestinal surgery is associated with a higher risk of postoperative ileus, so multimodal preventive strategies should be adopted to facilitate the recovery of gastrointestinal function if delayed gastric emptying or ileus occurs after surgery, including the use of nasogastric tubes prophylactically and remedially(7). Moreover, different surgical methods may have different levels of risk, such as gastrointestinal surgery. Esophagojejunostomy is probably a more vulnerable reconstruction than distal or subtotal gastric resection, so patients undergoing the former may need a longer period of postoperative fasting(26). Therefore, for gastrointestinal(6, 7, 27, 28) and hepato-pancreato-biliary(8, 9) surgeries, almost all ERAS programs recommend that patients should be allowed to resume a normal diet (may through enteric feeding tubes if needed(28))after surgery without restrictions according to their tolerance, even though none of them mention a specific number of hours or days postoperatively. To further explore early intake after surgery, more large-scale high-quality studies are needed. Our results confirm this clinical need.
After non-abdominal surgery, clinical practitioners had closer responses regarding the perception and practice of the resumption of oral intake, showing the best implementation and most confidence in ERAS. Indeed, for non-abdominal surgeries, most ERAS guidelines recommended that patients should be encouraged to resume oral liquids and a solid diet as soon as possible(10, 12–14), preferably within 24 hours after surgery(11). However, it`s worth noting that most literature cited by above guidelines were retrospective studies or data from intestinal surgery. This arises for a simple reason—namely, that the return to normal food intake is essential component to resuming to normal activities, even though no randomized controlled trials have investigated the direct association of early oral intake with ERAS in these surgery types.
Interestingly, most clinicians had more positive perceptions of ERAS than reported in terms of practice. We found that 4% of respondents considered that early oral intake after hepato-pancreato-biliary surgery is appropriate, although in practice, they were not sure of the most suitable course of action. Besides, most respondents agreed with the benefits of early oral intake; however, they still chose a conserved strategy in practice. More than half postponed the resumption of oral take due to concerns about choking cough (54%), postoperative nausea and vomiting (67%) and aspiration (73%). In thirty percentage of free text comments, respondents stated that they were concerned of a potential return to the operating room, as fed patients are at risk for aspiration. However, modern anesthetic techniques should mitigate the risk of aspiration in this uncommon scenario(29). While a Cochrane systematic review(30) of colorectal surgery published in 2019 suggests that there is sufficient evidence to indicate that early enteral intake leads to a reduced postoperative length of hospital stay and risk of dying, all referred studies were of low quality. A lack of convincing data is the first stumbling block to ERAS implementation. However, the reality that scientific study does not always allow direct clinical correlation also cannot be ignored.
Among the three kinds of surgeries, respondents with a better understanding of ERAS guidelines were more likely to commence early oral intake after surgery. However, the numbers were not promising; our survey found that only 36% of respondents stated that they chose the timing of postoperative oral intake based on guidelines, while 55% chose the timing of postoperative oral intake based on clinical experience. This may be the reflection of the low consensus on the risk and significance of early postoperative oral intake. The current level of implementation of early oral intake in the hospital context is still low and based on type of surgery performed, the physician-patient relationship, and adherence to treatment(31). Indeed, many other factors may influence clinical complication endpoints, such as the fitness of the patient, experience of the surgeon, resection sites, pain control, and success of the operation in resolving the underlying pathology(32, 33).
Reestablishment of oral intake as soon as possible after surgery has been incorporated into an increasing number of ERAS programs(4, 5). The concept of ERAS involves a multidisciplinary team approach to solve the problems that cause complications and delay recovery by implementing evidence-based care protocols and changes in management through interactive and ongoing audits(34). Our survey found that 22% practitioners considered that the timing of resumption of oral intake should be only decided and supervised by surgeons and nurses in the wards. But teamwork means engagement of all relevant stakeholders. Surgeons should break down entrenched surgical dogmas, and the collaboration of ward nurses is equally important for driving this program forward(35, 36). As an anesthesiologist, our analgesic techniques should aim not only to provide optimal pain control but also to facilitate the tolerance of oral intake(37, 38) and to prevent postoperative nausea and vomiting using multimodal approaches(39, 40). Nonetheless, since early postoperative intake does provide benefit, the identification and implementation of strategies to improve uptake of this ERAS component should be a priority.
As a first nationwide survey focused on the practice and attitudes towards early postoperative resumption of oral intake, there were also some limitations. First, this is a survey designed and conducted by anesthesiologists. Although respondents consisted of practitioners from anesthesiology, surgery and non-surgical departments, 89% of them are anesthesia related. Considering the feasibility of the study, we did not employ a strict probability sampling method during the study design, which may cause a population bias. Second, the survey or the questions were designed upon current clinical practice of mainland China, so the choices may not reflect current worldwide status of each question. Third, we did not collect the information about practitioners’ affiliations, nor did we differ or exclude the respondents who are majored in ambulatory surgery. Finally, all results were from perioperative health care practitioners’ answers, but not from the patients. As is known that patients may delayed their resumption of postoperative oral intake despite physicians’ arrangements.