背景:这是原始Cochrane评论的更新和扩展版本,2014年首次发布。传统上,在进行大型腹部妇科手术后,直到肠功能恢复之前,手术后口服。令人担忧的是,早期口服会导致呕吐和严重的麻痹性肠梗阻,随后的吸入性肺炎,伤口裂开,吻合口漏.然而,临床研究表明,术后早期口服可能有益处。目前,妇科手术可以通过各种途径进行:开腹,阴道,腹腔镜,机器人,或组合。在这个版本中,我们包括通过所有这些途径接受大型妇科手术的妇女,单独或组合。
目的:评估妇科大手术后早期与延迟(传统)开始口服食物和液体摄入的效果。
方法:2023年6月13日,我们搜索了科克伦妇科和生育小组的专业登记册,中部,MEDLINE,Embase,相关出版物的引文清单,和两个审判登记处。我们还联系了该领域的专家进行任何其他研究。
方法:我们纳入了随机对照试验(RCT),比较了妇科大手术后早期和延迟开始口服食物和液体的效果,由腹部执行,阴道,腹腔镜,和机器人方法。早期喂养被定义为术后24小时内口服液体或食物。不管肠道功能的恢复。延迟喂养定义为术后24小时后口服摄入,只有在术后肠梗阻消退的迹象后。主要结果是:术后肠梗阻,恶心,呕吐,抽筋,腹痛,腹胀,腹胀,术后需要鼻胃管,时间到肠鸣音的存在,到第一次肠胃气胀的时间,时间到大便的第一次通过,开始正常饮食的时间,术后住院时间。次要结果是:感染并发症,伤口并发症,深静脉血栓形成,尿路感染,肺炎,满意,和生活质量。
方法:两位综述作者独立选择了研究,评估了偏见的风险,并提取数据。我们以95%的置信区间(CI)计算了二分数据的风险比(RR)。我们使用平均差(MD)和95%CI检查了连续数据。我们使用荟萃分析的森林图测试了不同研究结果之间的异质性,2×2表的同质性的统计检验,和I²值。我们使用GRADE方法评估证据的确定性。
结果:我们纳入了7项随机对照试验(RCT),随机分配902名女性。我们不确定早期喂养与延迟喂养相比是否对术后肠梗阻有影响(RR0.49,95%CI0.21至1.16;I²=0%;4项研究,418名女性;低确定性证据)。我们不确定早期进食是否会影响恶心或呕吐,或两者(RR0.94,95%CI0.66至1.33;I²=67%;随机效应模型;6项研究,742名女性;确定性证据非常低);恶心(RR1.24,95%CI0.51至3.03;I²=74%;3项研究,453名妇女;低确定性证据);呕吐(RR0.83,95%CI0.52至1.32;I²=0%;4项研究,559名妇女;低确定性证据),腹胀(RR0.99,95%CI0.75至1.31;I²=0%;4项研究,559名女性;低确定性证据);需要术后放置鼻胃管(RR0.46,95%CI0.14至1.55;3项研究,453名女性;低确定性证据);或出现肠鸣音的时间(MD-0.20天,95%CI-0.46至0.06;I²=71%;随机效应模型;3项研究,477名妇女;低确定性证据)。这两种喂养方式对肠胃气胀的发作可能没有区别(MD-0.11天,95%CI-0.23至0.02;I²=9%;5项研究,702名女性;中度确定性证据)。早期进食可能会导致粪便首次通过的时间略有减少(MD-0.18天,95%CI-0.33至-0.04;I²=0%;4项研究,507名妇女;中度确定性证据),并可能导致稍早恢复固体饮食(MD-1.10天,95%CI-1.79至-0.41;I²=97%;随机效应模型;3项研究,420名妇女;低确定性证据)。早期喂养组的住院时间可能略短(MD-0.66天,95%CI-1.17至-0.15;I²=77%;随机效应模型;5项研究,603名女性;低确定性证据)。两种喂养方案对高热发病率的影响是不确定的(RR0.96,95%CI0.75至1.22;I²=47%;3项研究,453名妇女;低确定性证据)。然而,感染并发症在早期喂养的女性中可能不太常见(RR0.20,95%CI0.05至0.73;I²=0%;2项研究,183名妇女;中度确定性证据)。伤口并发症的两种喂养方案之间可能没有差异(RR0.82,95%CI0.50至1.35;I²=0%;4项研究,474名妇女;低确定性证据),或肺炎(RR0.35,95%CI0.07至1.73;I²=0%;3项研究,434名女性;低确定性证据)。两项研究测量了参与者的满意度和生活质量。一项研究发现,早期喂养组的满意度可能更高,而另一项研究没有发现差异。两项研究均未发现两组之间的生活质量差异有统计学意义(P>0.05)。
结论:尽管存在一些不确定性,没有证据表明大妇科手术后早期进食的有害影响,测量为术后肠梗阻,恶心,呕吐,或者腹胀.早期喂养的潜在好处包括肠蠕动的启动速度稍快,稍早恢复坚实的饮食,住院时间稍短,感染并发症的发生率较低,和更高的满意度。
BACKGROUND: This is an updated and expanded version of the original Cochrane review, first published in 2014. Postoperative oral intake is traditionally withheld after major abdominal gynaecologic surgery until the return of bowel function. The concern is that early oral intake will result in vomiting and severe paralytic ileus, with subsequent aspiration pneumonia, wound dehiscence, and anastomotic leakage. However, clinical studies suggest that there may be benefits from early postoperative oral intake. Currently, gynaecologic surgery can be performed through various routes: open abdominal, vaginal, laparoscopic, robotic, or a combination. In this version, we included women undergoing major gynaecologic surgery through all of these routes, either alone or in combination.
OBJECTIVE: To assess the effects of early versus delayed (traditional) initiation of oral intake of food and fluids after major gynaecologic surgery.
METHODS: On 13 June 2023, we searched the Cochrane Gynaecology and Fertility Group\'s Specialised Register, CENTRAL, MEDLINE, Embase, the citation lists of relevant publications, and two trial registries. We also contacted experts in the field for any additional studies.
METHODS: We included randomised controlled trials (RCTs) that compared the effect of early versus delayed initiation of oral intake of food and fluids after major gynaecologic surgery, performed by abdominal, vaginal, laparoscopic, and robotic approaches. Early feeding was defined as oral intake of fluids or food within 24 hours post-surgery, regardless of the return of bowel function. Delayed feeding was defined as oral intake after 24 hours post-surgery, and only after signs of postoperative ileus resolution. Primary outcomes were: postoperative ileus, nausea, vomiting, cramping, abdominal pain, bloating, abdominal distension, need for postoperative nasogastric tube, time to the presence of bowel sounds, time to the first passage of flatus, time to the first passage of stool, time to the start of a regular diet, and length of postoperative hospital stay. Secondary outcomes were: infectious complications, wound complications, deep venous thrombosis, urinary tract infection, pneumonia, satisfaction, and quality of life.
METHODS: Two review authors independently selected studies, assessed the risk of bias, and extracted the data. We calculated the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous data. We examined continuous data using the mean difference (MD) and a 95% CI. We tested for heterogeneity between the results of different studies using a forest plot of the meta-analysis, the statistical tests of homogeneity of 2 x 2 tables, and the I² value. We assessed the certainty of the evidence using GRADE methods.
RESULTS: We included seven randomised controlled trials (RCTs), randomising 902 women. We are uncertain whether early feeding compared to delayed feeding has an effect on postoperative ileus (RR 0.49, 95% CI 0.21 to 1.16; I² = 0%; 4 studies, 418 women; low-certainty evidence). We are uncertain whether early feeding affects nausea or vomiting, or both (RR 0.94, 95% CI 0.66 to 1.33; I² = 67%; random-effects model; 6 studies, 742 women; very low-certainty evidence); nausea (RR 1.24, 95% CI 0.51 to 3.03; I² = 74%; 3 studies, 453 women; low-certainty evidence); vomiting (RR 0.83, 95% CI 0.52 to 1.32; I² = 0%; 4 studies, 559 women; low-certainty evidence), abdominal distension (RR 0.99, 95% CI 0.75 to 1.31; I² = 0%; 4 studies, 559 women; low-certainty evidence); need for postoperative nasogastric tube placement (RR 0.46, 95% CI 0.14 to 1.55; 3 studies, 453 women; low-certainty evidence); or time to the presence of bowel sounds (MD -0.20 days, 95% CI -0.46 to 0.06; I² = 71%; random-effects model; 3 studies, 477 women; low-certainty evidence). There is probably no difference between the two feeding protocols for the onset of flatus (MD -0.11 days, 95% CI -0.23 to 0.02; I² = 9%; 5 studies, 702 women; moderate-certainty evidence). Early feeding probably results in a slight reduction in the time to the first passage of stool (MD -0.18 days, 95% CI -0.33 to -0.04; I² = 0%; 4 studies, 507 women; moderate-certainty evidence), and may lead to a slightly sooner resumption of a solid diet (MD -1.10 days, 95% CI -1.79 to -0.41; I² = 97%; random-effects model; 3 studies, 420 women; low-certainty evidence). Hospital stay may be slightly shorter in the early feeding group (MD -0.66 days, 95% CI -1.17 to -0.15; I² = 77%; random-effects model; 5 studies, 603 women; low-certainty evidence). The effect of the two feeding protocols on febrile morbidity is uncertain (RR 0.96, 95% CI 0.75 to 1.22; I² = 47%; 3 studies, 453 women; low-certainty evidence). However, infectious complications are probably less common in women with early feeding (RR 0.20, 95% CI 0.05 to 0.73; I² = 0%; 2 studies, 183 women; moderate-certainty evidence). There may be no difference between the two feeding protocols for wound complications (RR 0.82, 95% CI 0.50 to 1.35; I² = 0%; 4 studies, 474 women; low-certainty evidence), or pneumonia (RR 0.35, 95% CI 0.07 to 1.73; I² = 0%; 3 studies, 434 women; low-certainty evidence). Two studies measured participant satisfaction and quality of life. One study found satisfaction was probably higher in the early feeding group, while the other study found no difference. Neither study found a significant difference between the groups for quality of life (P > 0.05).
CONCLUSIONS: Despite some uncertainty, there is no evidence to indicate harmful effects of early feeding following major gynaecologic surgery, measured as postoperative ileus, nausea, vomiting, or abdominal distension. The potential benefits of early feeding include a slightly faster initiation of bowel movements, a slightly sooner resumption of a solid diet, a slightly shorter hospital stay, a lower rate of infectious complications, and a higher level of satisfaction.