| Background and ObjectiveEsophageal cancer is the sixth most common malignancy in the world. Its morbidity and mortality rates rank the third among all malignancies in China. Esophageal cancer patients have the highest mortality rates in Taihang mountain area, southeast of Shandong province, Anyang, Handan, and Chaoshan. Surgery is the standard therapy for resectable esophageal cancer. However, patients receiving traditional esophagectomy have slow recovery, long hospitalization period, and decreased postoperative quality of life. In order to reduce the risk of traditional esophagectomy, thoracic surgeons have gradually accepted minimally invasive esophageal surgery in recent years. Some previous studies showed that minimally invasive esophageal surgery could reduce postoperative complications and improve postoperative quality of life. Meanwhile, a minimally invasive surgery-based model for acceleration of rehabilitation is developing.Postoperative rehabilitation of esophageal cancer is always the main problem faced by thoracic surgeons. The rapid recovery of gastrointestinal function is an important step of postoperative rehabilitation of the patient. Severe gastrointestinal disorders cause several complications like anastomotic leak, malnutrition, and delayed healing of the surgical wound. In order to improve gastrointestinal function after the operation, and reduce the occurrence of complications, fasting and postoperative gastrointestinal decompression have been dominant in clinical practice. The reported average length of postoperative stay for patients with esophagectomy was about 12 days. In the past, people believed that intestinal paralysis after abdominal surgery was inevitable, which required intestinal rest and nasogastric decompression. Oral feeding was withheld until full recovery of gastrointestinal function(i.e. the initiation of flatus and defecation), which normally took 3-5 days. However, some studies have contradicted that postoperative intestinal rest and nasogastric decompression were not necessary for intestinal paralysis. In recent years, accelerated rehabilitation surgery is gaining acceptance. Several studies have shown that early oral feeding after colorectal surgery or gastrectomy is both safe and feasible. Accelerated rehabilitation surgery was initially proposed by a Danish doctor, Henrik Kehlet, who advised the postoperative physical convalescence to be shortened from a few weeks to a few days. Several studies confirmed that early oral feeding in accelerated rehabilitation was also safe and feasible after esophageal minimally invasive surgery. It could boost the recovery of gastrointestinal function, shorten the hospitalization period, and save hospitalization expenses.By searching related literature, we found that the key evaluation indicators for gastrointestinal recovery included borborygmus recovery time, postoperative flatus and bowel movement time, electrogastrogram, gastrointestinal hormone level, etc. In this study, we chose the first flatus and bowel movement time, and the levels of two excitatory gastrointestinal hormones to evaluate the recovery of gastrointestinal function. The two excitatory gastrointestinal hormones, gastrin and motilin, are closely related to gastrointestinal recovery, and accelerate gastric and intestinal contractions, gastric emptying, the activity of interdigestive migrating motor complex, thus promoting gastrointestinal motility to a level even higher than before the operation.However, there is insufficient evidence to show that early oral feeding in accelerated rehabilitation surgery can accelerate the rehabilitation of patients, in particular the recovery of their gastrointestinal function. So the objective of this paper was to compare the impact of early and late oral feedings on patients’ gastrointestinal recovery after minimally invasive surgery of esophageal cancer, through prospective clinical studies.Materials and MethodsResearch subjectsThis is a prospective study. From Sep 2014 to Jul 2015, we had performed a total of 110 minimally invasive esophagectomies for esophageal cancer, of which 63 cases were ranomized into the early oral feeding group, while 47 were ranomized into the late oral feeding group. The evaluation indicators included the first time of flatus and bowel movement, and the levels of gastrin and motilin in serum.Experimental equipment and evaluation methodIn this study, we used Multiskan FC automatic microplate reader(Pioneer Medical Instrument Co., Ltd., Beijing, China), and ELISA kit(Guangrui Biotech Co. Ltd, Shanghai, China). A total of 4m L intravenous blood was taken from the elbow of each patient on the day of surgery and the 1st, 3rd, and 5th day after surgery, and stored in coagulation-promoting tube. We waited 10 min for the blood to naturally freeze, centrifuged it for 20 minutes at 2000 RPM, and carefully collected the supernatant. If precipitation occurred during the storage process, we re-centrifuged the liquid.Statistical analysisSPSS17.0(SPSS Inc., Chicago) was used as the statistical software package for the analysis. Categorical variables were verified using Chi-square or Fisher’s exact test. We used t-test for normal distribution of quantitative variables, and Wilcoxon rank-sum test for non-normal distribution. For repeated data comparison, we used variance analysis of repeated measurement. P <0.05 was considered as statistically significant.ResultsFor evaluation indicators, we included the first time of flaus and bowel movement, and the levels of gastrin and motilin in serum. It turned out that the first postoperative gas passing and defecation of early oral feeding patients were on the 2.1±0.8 day and on the 3.4±1.2 day, respectively; while those of late oral feeding patients were on the 3.2±0.9 day and on the 5.5±1.5 day, respectively; and the differences between the two groups were statistically significant(P <0.001). The serum gastrin levels of early oral feeding group were measured to be 205.4±58.8 ng/L, 224.8±57.5 ng/L, 231.3±40.1 ng/L, and 232.0±50.9 ng/L respectively on the day before the operation, on the 1st, 3rd, and 5th day after the operation; while those of late oral feeding group were 201.7±63.4 ng/L, 211.7±41.5 ng/L, 213.9±40.1 ng/L, and 219.6±50.3 ng/L, respectively. The serum motilin levels of early oral feeding group were 422.7±117.8 ng/L, 446.8±103.7 ng/L, 463.4±81.1 ng/L, and 445.0±84.4 ng/L respectively on the day before the operation, on the 1st, 3rd, and 5th day after the operation; while those of late oral feeding group were 418.0±123.1 ng/L, 426.0±81.9 ng/L, 427.1±94.1 ng/L, and 426.6±81.8 ng/L, respectively. Independent samples t test found that two kinds of excitatory gastrointestinal hormones in third day after the early oral feeding group were significantly higher than those in the late oral feeding group(t=2.249, 2.166, =0.027 P=0.033). Considering the changing trends of the two groups’ indicators, we found that the gastrin and motilin levels of early oral feeding group were both significantly higher than that of late oral feeding group(F=5.522, 4.997, P =0.021, 0.027). Single factor analysis showed Oral feeding time, Duration of surgery, Gastrin level third day after operation were significant factors of time to first flatus(P<0.001, =0.003, =0.024). Multiple-variable analysis showed late oral feeding time was independent factor of time to first flatus(OR=44.533, 95%CI: 12.566 ~ 157.823, P<0.001).ConclusionsEarly oral feeding could accelerate the gastrointestinal recovery of patients after minimally invasive esophagectomy, and therefore accelerate the rehabilitation of patients. |
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