Effect on parenteral nutrition of an improved recovery oral nutrition protocol after radical uncomplicated cystectomy

Abstract

Background After radical cystectomy, postoperative ileus (POI) is a relatively common complication resulting in delayed oral nutritional intake with prolonged recovery and hospital stay. However, it is questionable whether nutritional support by routine use of parenteral nutrition (PN) is justifiable or cost effective. Purpose To monitor the effect of an enhanced recovery oral nutrition protocol (ERONP). Materials and methods Patients undergoing elective radical uncomplicated cystectomy were included in this before-after prospective interventional study. Exclusion criteria were preoperative contraindications for enteral nutrition (EN). Before implementation there were no restrictions on PN. After implementation patients were fed with progressively increasing amounts of fluids and easily digestible food. PN could only be initiated if oral intake was still insufficient after 5 days. Outcome measures were use of PN, time to removal of ureteral stents, institution of oral diet, interval from surgery to discharge and urgent readmission rate. Results From 98 patients, two patients were excluded for preoperative contraindications. 48 patients suited the inclusion criteria for each group. Before implementation, early PN was initiated in 47/48 patients, while after implementation PN was initiated in only 1/48 patients (p=0.00). Considering the time to institution of oral diet 8.1±3.7 to 4.1±1.7 days (p=0.00), time to removal of ureteral stents 13.5 (IQR=5) to 11.0 (IQR=4) days (p=0.00), and time to discharge 19.3±5.6 to 15.1±4.3 days (p=0.00), there was an overall significant reduction with the new diet. There was no difference in urgent readmission rate (4/48 vs 3/48; p=0.70). Conclusions The implementation of ERONP led to a reduction in PN and improved recovery after uncomplicated cystectomy.