Enhanced Patient Comfort and Satisfaction with Early Oral Feeding after Thoracoscopic Lung Cancer Resection

Background

Lung cancer has topped the ranking of cancer-induced morbidity and mortality worldwide, becoming the most common cancer in China according to a report published by an international cancer research organization [1]. At present, thoracoscopic surgery is always considered the main treatment of lung cancer [2], and along with the increase in lung cancer morbidity, the popularity of video-assisted thoracic surgery has also been growing rapidly [3,4]. Clinically, since lung surgery involves the respiratory system, discomfort such as throat pain, throat edema, hoarseness, and cough caused by endotracheal intubation during the operation may increase the incidence of choking and aspiration during postoperative eating, thus leading to lung infection [5]. The traditional view is that the first postoperative meal should be after the patient’s first flatus [6] because early postoperative eating will raise the incidence of nausea and vomiting after surgery.

Compelling evidence indicates that feeding through the digestive system soon after surgery is safe and leads to positive outcomes [7,8]. In recent decades, fast-track rehabilitation has become more and more popular in clinical practice [9,10]. Several studies have shown that early postoperative eating is safe and helps alleviate postoperative thirst and hunger, accelerate recovery of gastrointestinal function, and reduce postoperative discomfort [11,12]. The European adult and child perioperative fasting guidelines state that if the patient’s vital signs are normal after surgery, the postoperative drinking time should be flexibly adjusted according to the patient’s needs [13]. Patients have been fasting for at least 8 h before the operation, so they are suffering from hunger, thirst and other discomfort. Several hours earlier seems minimal for other persons, but for patients undergoing fasting, every minute counts. Shortening the time for observation is important for both the doctors and patients, and early feeding can shorten the hospital stay [7]. However, research reports show that only 2% of doctors accept the concept of early eating, and the implementation rate of early postoperative diet is still low [14]. In fact, early enteral nutrition is recommended not only for postoperative patients, but also for most critically ill patients, with certain precautions [15,16]. Clinical research on early resumption of eating has mainly focused on patients after gastrointestinal surgery, and there have been few studies on early eating after non-gastrointestinal surgery. In addition, there are few reports of patient-reported outcomes in these studies. Patient-reported outcomes are data that are not “processed” by the medical staff and directly come from the patient’s report on their health status, which truly reflects the actual situation of the patient [17]. Implementing an early diet program is crucial for lung cancer patients to resume eating and drinking soon after surgery. Therefore, this study aimed to compare patient-reported outcomes in 211 patients who underwent early feeding at 1 h and 4 h after thoracoscopic lung cancer resection at a tertiary hospital in Guangzhou, China.

Material and Methods

PARTICIPANTS:

Participant recruitment was carried out before the surgery. The criteria for inclusion were: patients undergoing their first thoracoscopic lung cancer resection under general anesthesia; age ≤70 years old; no mental illness or communication disorder; normal swallowing function and gastrointestinal tract before the operation; and voluntarily participated in the trial and provided signed informed consent. Patients were excluded if the operation was changed to thoracotomy due to the patient’s condition; operation time ≥4 h; patients undergoing lung sleeve resection or total pneumonectomy; transferred to intensive care unit after operation; and intraoperative fluid infusion ≥1500 ml. All patients used an analgesia pump after the operation.

In consideration of the human resources of the department and the actual situation of the clinic, to ensure data accuracy, only the patients who were sent to the operating room before 12: 00 (noon) were included in this trial. To ensure the safety of the trial, the patients with long operative time, high operation risk, or older age are excluded from the trial. The number of patients required to be recruited was estimated using Power and Sample Size Calculation 11 software. We set the test standard α as 0.05 and β was set as 0.1. The total sample capacity of this trial was 214 patients, 107 in each group. All surgical procedures were conducted by the same surgical team, and all patients received standard anesthesia.

INTERVENTION AND DATA COLLECTION:

The patients were randomly assigned to either the early feeding group or the conventional group. The early feeding group consisted of patients who had their tracheal intubation removed for 1 h, had normal vital signs, and expressed a desire to eat. Before being given drinking water, their degree of wakefulness was assessed by Steward recovery score [18]; water swallowing was only allowed when the test score was over 6 [19]. If the swallowing function assessment result was grade I to II, the patient was instructed to drink less than 100 ml of warm water and was then observed for 1 h. If there was no gastrointestinal discomfort, a small amount of liquid or semi-liquid diet could be given if the patient wanted it.

The conventional group included patients who received routine postoperative care and had their first drink 4 h after extubation. After their wakefulness and swallowing ability were evaluated using the Steward recovery score and the water swallowing test, patients were given less than 100 ml of warm water to drink, and they could have liquid or semi-liquid nutrients 6 h after extubation.

The researcher in charge distributed questionnaires to evaluate patient symptoms and discomfort, including hunger, thirst, nausea, vomiting, and pain. Patients were reminded to complete the questionnaires at 1, 2, 4, and 8 h after their tracheal intubation was removed. Basic verbal instructions on how to fill out the questionnaires were provided to the patients.

PRIMARY AND SECONDARY OUTCOMES:

The primary outcomes included the degree of hunger and thirst and the severity of nausea, vomiting, and pain. The severity of nausea and vomiting was graded according to a Word Health Organization scoring system [20] with the following criteria: Grade 1 is no nausea and vomiting; Grade 2 is nausea and 1 episode of vomiting; Grade 3 is 2–5 episodes of transient vomiting; and Grade 3 is 6–10 episodes of vomiting requiring treatment [20]. The severity of pain was evaluated using the MD Anderson Symptom Inventory [21], which is a subjective measure of pain intensity in adults. It is a segmented numeric version of the visual analog scale in which a respondent selects a whole number from 0 (no pain at all) to 10 (worst imaginable pain). Hunger and thirst were evaluated and graded as follows: Grade 0 indicated no hunger or thirst; Grade 1 indicated slight hunger or thirst; Grade 2 indicated moderate hunger or thirst that was bearable; and Grade 3 indicated intolerable hunger or thirst, or the presence of dehydration or hypoglycemia. All scores were collected through paper-based patient-reported outcomes. The secondary outcomes, assessed by the physician in charge, included postoperative complications, the duration of chest tube drainage, and the number of days spent in the hospital.

STATISTICAL ANALYSIS:

SPSS 25.0 was used for data entry and analysis. Measurement data are expressed as mean±standard deviation, and enumeration data are expressed as frequency and percentage. The t test was used to compare data that conformed to a normal distribution, while the chi-squared test and rank sum test were utilized for comparing categorical data. For data that did not conform to normal distribution, the Mann-Whitney U test was used. Two-way repeated-measures ANOVA was used to assess changes in postoperative nausea and vomiting, pain, hunger, and thirst over time. A P value less than 0.05 was considered statistically significant.

Results

PATIENT DEMOGRAPHICS AND CLINICAL CHARACTERISTICS:

The sociodemographic and clinical features of the included patients are summarized in Table 1. The average age of the patients in the early feeding group was 55.37±10.59 years, whereas the average age in the conventional group was 53.80±11.12 years. There was no significant difference in age between the 2 groups (P =0.30). No difference was found in the preoperative duration of water deprivation or the duration of fasting between the early feeding group and the conventional group (P=0.470 and P=0.201, respectively). All enrolled patients were diagnosed with lung cancer; most underwent wedge resection (87/211), and the rest underwent radical resection (32/211), segmentectomy (30/211), or lobectomy (61/211). There were no significant differences between the intervention and conventional groups in patient age (P=0.901), sex ratio (P=0.825), and surgical procedures (P=0.987), and there was no significant no difference between the 2 groups in amount of intraoperative blood loss or duration of operation (P=0.731 and P=0.885, respectively).

THE DEGREES OF POSTOPERATIVE NAUSEA, VOMITING, AND PAIN: Data on the postoperative outcomes are shown in Table 2. No significant differences were found in the degrees of postoperative nausea and vomiting after extubation for 1, 2, 4, and 8 h (P=0.689, P=0.127, P=0.591, and P=0.497, respectively) (Figure 2A). There were no significant differences in pain between the 2 groups after extubation for 1, 2, 4, and 8 h (P=0.424, P=0.089, P=0.057, and P=0.890, respectively) (Figure 2B), and there was no significant difference between groups in time of first flatus (P=0.142).

THE DEGREES OF POSTOPERATIVE HUNGER AND THIRST SCORES: In terms of hunger and thirst scores, no difference was found in the scores after extubation for 1 h between the early feeding group and the conventional group (P=0.689). The hunger and thirst scores in the early feeding group decreased over time, while the scores in the conventional group tended to increase before feeding and then decreased after feeding (Figure 2C). However, the hunger and thirst scores after extubation for 2 h and 4 h were higher in the conventional group than in the early feeding group (both P<0.001). The hunger and thirst scores after extubation for 8 h did not differ between groups (P=0.210).

POSTOPERATIVE COMPLICATIONS AND OTHER MEASUREMENTS:

Postoperative complications included arrhythmia and subcutaneous emphysema. There were 2 patients with arrhythmia and 4 patients with subcutaneous emphysema in the early feeding group, while there were 3 patients with arrhythmia and 2 patients with subcutaneous emphysema in the conventional group. No difference was observed in the types of complications in the 2 groups (P=0.567), and no other types of complications were found. No patients in either group developed signs or symptoms of choking, postoperative aspiration, gastrointestinal obstruction, asphyxia, aspiration pneumonia, or wound breakdown. The duration of chest tube drainage was comparable between the 2 groups (P=0.783), and the duration of hospital stay was similar between groups (P=0.696).

Discussion

LIMITATIONS:

There were several limitations to our study. First, it was conducted in a specific cohort at a single center, limiting the applicability of the findings to other patient groups undergoing major surgery. To further evaluate and compare the feasibility of early feeding in thoracic surgery patients, larger multicenter randomized studies are needed. Second, this study did not specify the exact volume of food and drink consumed, and well-designed studies with larger sample sizes are needed to address this issue. Third, preoperative treatment like chemotherapy and radiotherapy might be confounding factors in the study. Last but not least, selection bias may still exist, since we excluded patients with operation time ≥4 h.

Conclusions

The current clinical routine of postoperative diet may cause patients to experience more hunger, thirst, and discomfort after surgery, which is not conducive to their fast-track rehabilitation. Early oral feeding after thoracoscopic lung cancer resection is safe. An early diet and drinking regimen cause no more adverse effects than a traditional diet and can be well tolerated, providing greater comfort and satisfaction to patients.