Major abdominal surgeries, including gastrointestinal resections, hepatobiliary procedures, and colorectal surgeries, are associated with significant postoperative morbidity, prolonged hospital stay, and delayed return of normal physiological function. Traditionally, postoperative management emphasized delayed initiation of oral or enteral feeding until the return of bowel function, based on the belief that early feeding could increase the risk of ileus, anastomotic leak, nausea, vomiting, and aspiration. However, evolving evidence in perioperative care, particularly under Enhanced Recovery After Surgery (ERAS) protocols, has challenged this traditional paradigm by advocating early enteral nutrition as a means to enhance recovery and reduce complications.^[1]

Early enteral feeding refers to the initiation of nutritional support within 24 hours of surgery, while delayed feeding typically begins after the passage of flatus or bowel sounds. Early feeding is believed to maintain gut mucosal integrity, prevent bacterial translocation, reduce catabolic stress response, and improve immune function. The gastrointestinal tract plays a crucial role in immune defense, and prolonged fasting may lead to mucosal atrophy and increased susceptibility to infections. Early enteral nutrition stimulates gut motility, enhances splanchnic blood flow, and promotes faster recovery of bowel function.^[2]

Several randomized controlled trials and meta-analyses have demonstrated that early enteral feeding is associated with reduced postoperative complications, including infections, shorter hospital stay, and improved wound healing. Despite these advantages, concerns persist among clinicians regarding the safety of early feeding, particularly in patients undergoing major abdominal surgeries involving bowel anastomosis. These concerns often lead to variability in clinical practice and delayed initiation of feeding in many centers.^[3]

In recent years, ERAS protocols have strongly recommended early enteral feeding as a standard component of postoperative care. These protocols emphasize multimodal strategies, including minimal fasting, early mobilization, and optimized pain management, to improve patient outcomes. However, the adoption of early feeding practices remains inconsistent, especially in resource-limited settings and tertiary care hospitals in developing countries.^[4]

AIM

To compare the effect of early enteral feeding versus delayed feeding on postoperative recovery following major abdominal surgery.

OBJECTIVES

1. To evaluate the time taken for return of bowel function in early versus delayed feeding groups.
2. To compare postoperative complications between early and delayed feeding groups.
3. To assess the duration of hospital stay and overall recovery outcomes in both groups.

Source of Data The data were collected from patients undergoing major abdominal surgeries admitted to the Departments of General Surgery and Gynecology at a tertiary care hospital. Study Design This was a prospective, comparative, observational study. Study Location The study was conducted in the Departments of General Surgery and Gynecology at a tertiary care teaching hospital Study Duration The study was carried out over a period of 18 months. Sample Size A total of 120 patients undergoing major abdominal surgery were included in the study and were divided into two groups: • Early enteral feeding group (n = 60) • Delayed feeding group (n = 60) Inclusion Criteria • Patients aged 18 years and above. • Patients undergoing elective major abdominal surgery including gastrointestinal, hepatobiliary, colorectal surgeries, and hysterectomy procedures. • Patients who provided informed consent. Exclusion Criteria • Patients undergoing emergency abdominal surgeries. • Patients with severe hemodynamic instability postoperatively. • Patients requiring prolonged ventilatory support. • Patients with contraindications to enteral feeding (e.g., intestinal obstruction, severe ileus). • Patients with severe comorbid conditions affecting recovery. Procedure and Methodology After obtaining ethical clearance and informed consent, eligible patients were enrolled in the study. Both open and laparoscopic abdominal surgeries were included in the study. The surgical approach was recorded because minimally invasive laparoscopic procedures may be associated with faster postoperative recovery and earlier return to normal activity compared to open surgeries. In the early enteral feeding group, feeding was initiated within 24 hours of surgery, starting with clear liquids and gradually progressing to a normal diet as tolerated. In the delayed feeding group, oral intake was started only after the return of bowel sounds or passage of flatus. Postoperative parameters such as time to first bowel sound, passage of flatus, tolerance to feeding, incidence of nausea, vomiting, abdominal distension, surgical site infections, and anastomotic leaks were recorded. Pain management, mobilization, and antibiotic protocols were standardized across both groups. Sample Processing All collected data were systematically recorded in a pre-designed case record form. Clinical observations and laboratory parameters were monitored regularly. Data were verified for completeness and accuracy before analysis. Statistical Methods Data were analyzed using appropriate statistical software. Continuous variables were expressed as mean ± standard deviation and compared using Student’s t-test. Categorical variables were expressed as percentages and analyzed using Chi-square test or Fisher’s exact test. A p-value of <0.05 was considered statistically significant. Data Collection Data were collected prospectively using a structured proforma, including demographic details, clinical history, operative details, and postoperative outcomes. Follow-up data were obtained during hospital stay and until discharge to assess recovery parameters and complications.

Table 1: Overall Effect of Early Enteral Feeding Versus Delayed Feeding on Postoperative Recovery

Table 1 demonstrates the overall effect of early enteral feeding compared to delayed feeding on postoperative recovery. The baseline characteristics such as age (52.4 ± 10.8 vs 53.7 ± 11.3 years; p=0.521), duration of surgery (126.8 ± 32.5 vs 131.6 ± 34.1 minutes; p=0.431), and intraoperative blood loss (328.7 ± 96.4 vs 341.2 ± 102.8 mL; p=0.493) were comparable between the two groups, with no statistically significant differences. However, early feeding resulted in a significantly earlier initiation of oral intake (18.6 ± 4.2 vs 54.3 ± 12.6 hours; p<0.001). Furthermore, patients in the early feeding group showed a significantly higher composite recovery score (82.7 ± 7.9 vs 74.2 ± 9.6; p<0.001) and a shorter overall recovery time (5.6 ± 1.4 vs 7.3 ± 1.9 days; p<0.001).

Table 2: Time Taken for Return of Bowel Function in Early Versus Delayed Feeding Groups

Table 2 compares the time taken for return of bowel function between early and delayed feeding groups. The early feeding group demonstrated significantly faster recovery of bowel activity across all parameters. The time to appearance of bowel sounds was significantly shorter in the early feeding group (21.7 ± 6.8 vs 35.9 ± 9.4 hours; p<0.001). Similarly, time to passage of flatus (31.6 ± 8.9 vs 49.8 ± 12.5 hours; p<0.001) and first stool passage (54.2 ± 14.6 vs 73.7 ± 17.9 hours; p<0.001) were significantly earlier. Additionally, patients receiving early feeding tolerated a full diet sooner (43.8 ± 11.2 vs 68.4 ± 16.1 hours; p<0.001). The duration of postoperative ileus was also significantly reduced in the early feeding group (1.9 ± 0.8 vs 3.1 ± 1.2 days; p<0.001).

Table 3: Comparison of Postoperative Complications Between Early and Delayed Feeding Groups

Table 3 presents the comparison of postoperative complications between the two groups. The incidence of nausea and vomiting was lower in the early feeding group (12.1% vs 25.8%), although this difference did not reach statistical significance (p=0.056). Abdominal distension (13.8% vs 30.6%; p=0.027) and prolonged ileus (8.6% vs 22.6%; p=0.036) were significantly less frequent in the early feeding group. Surgical site infections (6.9% vs 17.7%; p=0.073) and pneumonia (5.2% vs 14.5%; p=0.088) were also lower in the early feeding group but did not show statistical significance. The incidence of anastomotic leak was comparable between groups (3.4% vs 6.5%; p=0.451), indicating that early feeding did not increase this risk. Importantly, the overall complication rate was significantly lower in the early feeding group (20.7% vs 45.2%; p=0.004).

Table 4: Duration of Hospital Stay and Overall Recovery Outcomes in Both Groups

Table 4 evaluates hospital stay and overall recovery outcomes between the two groups. The duration of hospital stay was significantly shorter in the early feeding group (6.3 ± 1.8 vs 8.2 ± 2.4 days; p<0.001). Early feeding also facilitated earlier ambulation (22.4 ± 7.6 vs 31.8 ± 9.1 hours; p<0.001) and was associated with lower pain scores at 48 hours (3.4 ± 1.1 vs 4.2 ± 1.3; p<0.001). Patients in the early feeding group achieved fitness for discharge earlier (5.7 ± 1.6 vs 7.6 ± 2.1 days; p<0.001). A significantly higher proportion of patients experienced good overall recovery in the early feeding group (81.0% vs 54.8%; p=0.002). Although readmission rates were lower in the early feeding group (3.4% vs 9.7%), this difference was not statistically significant (p=0.172).

In the present study, both groups were comparable for age, duration of surgery and blood loss, indicating that postoperative differences were mainly related to feeding protocol rather than baseline variation. Early enteral feeding was started much earlier than delayed feeding, and this was associated with significantly higher composite recovery score and shorter overall recovery time. Similar findings were reported by Canzan et al.(2024)^[1], Barboza et al.(2025)^[2], and Braungart et al.(2020)^[5], who observed that early feeding after gastrointestinal surgery was safe and improved recovery without increasing major morbidity. These studies emphasized that early nutritional support enhances metabolic recovery and reduces catabolic stress.

Return of bowel function was significantly earlier in the early feeding group, as shown by reduced time to bowel sounds, passage of flatus, first stool passage, tolerance of full diet, and shorter postoperative ileus. These findings are consistent with Carmichael et al.(2022)^[6], who demonstrated better tolerance and faster bowel recovery with early oral feeding after gastrointestinal surgery. Similarly, Canzan et al.(2022)^[7] reported that early oral feeding after gastrointestinal surgery may result in faster intestinal recovery and shorter postoperative stay, supporting the beneficial physiological effects of early gut stimulation.

Postoperative complications were overall lower in the early feeding group. Abdominal distension and prolonged ileus were significantly reduced, while nausea/vomiting, surgical site infection, pneumonia, and anastomotic leak were also numerically lower but not statistically significant. Importantly, anastomotic leak was not increased with early feeding, supporting the safety of early enteral nutrition. This agrees with Burcharth et al.(2021)^[8], who emphasized that early feeding does not increase postoperative morbidity when patients are carefully monitored. Atkinson et al.(2020)^[9] also found no significant rise in nausea, vomiting, ileus, anastomotic leakage, wound infection, or pneumonia with early feeding, highlighting its safety profile across surgical populations.

Hospital stay and recovery outcomes were significantly better in the early feeding group, with shorter hospitalization, earlier ambulation, lower pain score at 48 hours, earlier fitness for discharge, and higher rate of good overall recovery. Readmission was lower in the early feeding group but statistically non-significant. These results are comparable with findings of Sindler et al.(2023)^[10], who highlighted early feeding as a key component of Enhanced Recovery After Surgery protocols and demonstrated faster recovery and improved bowel movement following early feeding. Additionally, Ahmad et al.(2025)^[3] and Deng et al.(2022)^[4] also reported shorter hospital stay and improved recovery parameters in early feeding groups, further supporting the present findings.

The present study demonstrates that early enteral feeding following major abdominal surgery is safe, feasible, and significantly beneficial in enhancing postoperative recovery when compared to delayed feeding. Early initiation of feeding within 24 hours was associated with faster return of bowel function, as evidenced by earlier onset of bowel sounds, passage of flatus, and stool. It also resulted in improved tolerance to oral diet and a significantly reduced duration of postoperative ileus. Importantly, early enteral feeding contributed to better overall recovery outcomes, including higher composite recovery scores and shorter recovery time. The incidence of postoperative complications was lower in the early feeding group, with significant reductions in abdominal distension and prolonged ileus, while other complications such as nausea, vomiting, surgical site infection, pneumonia, and anastomotic leak were either comparable or lower, indicating that early feeding does not increase postoperative risk. Furthermore, early feeding was associated with shorter hospital stay, earlier ambulation, lower postoperative pain scores, and earlier fitness for discharge, all of which are important indicators of enhanced recovery. LIMITATIONS OF THE STUDY 1. The study was conducted at a single tertiary care center, limiting generalizability. 2. The sample size, although adequate, was relatively small for subgroup analysis. 3. Non-randomized allocation of patients may introduce selection bias. 4. Variability in types of abdominal surgeries could influence outcomes. 5. Postoperative pain management and mobility levels were not strictly standardized. 6. Nutritional status of patients prior to surgery was not uniformly assessed. 7. Short follow-up period limited assessment of long-term outcomes. 8. Patient-reported outcomes such as quality of life were not evaluated. 9. Compliance with feeding protocol may have varied among patients. 10. Potential confounding factors like comorbidities were not fully stratified.

1. Canzan F, Longhini J, Caliaro A, Cavada ML, Mezzalira E, Paiella S, Ambrosi E. The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: a systematic review and meta-analysis of randomized clinical trials. Frontiers in nutrition. 2024 May 16;11:1369141.
2. Barboza HR, Moosabba MS, Lobo AS. Enhanced Surgical Recovery Nursing Program: A Focus on Initiation of Early Feeding and Mobilization Following Elective Abdominal Surgery. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine. 2025 Oct 18;29(10):823.
3. Ahmad KN, Rahman MA, Pankaj P, Rahman A, Naaz S, Jahan S, Alam MS, Habib S. Effect of Early Versus Delayed Feeding on Recovery in Patients Undergoing Bowel Resection. European Journal of Cardiovascular Medicine. 2025 Jul 1;15(7).
4. Deng H, Li B, Qin X. Early versus delay oral feeding for patients after upper gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials. Cancer Cell International. 2022 Apr 29;22(1):167.
5. Braungart S, Siminas S. Early enteral nutrition following gastrointestinal surgery in children: a systematic review of the literature. Annals of Surgery. 2020 Aug 1;272(2):377-83.
6. Carmichael L, Rocca R, Laing E, Ashford P, Collins J, Jackson L, McPherson L, Pendergast B, Kiss N. Early postoperative feeding following surgery for upper gastrointestinal cancer: a systematic review. Journal of Human Nutrition and Dietetics. 2022 Feb;35(1):33-48.
7. Canzan F, Caliaro A, Cavada ML, Mezzalira E, Paiella S, Ambrosi E. The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: protocol for a systematic review and meta-analysis. PloS one. 2022 Aug 18;17(8):e0273085.
8. Burcharth J, Falkenberg A, Schack A, Ekeloef S, Gögenur I. The effects of early enteral nutrition on mortality after major emergency abdominal surgery: A systematic review and meta-analysis with Trial Sequential Analysis. Clinical Nutrition. 2021 Apr 1;40(4):1604-12.
9. Atkinson C, Monk VC, Ness AR, Lewis SJ, Longman RJ, Thomas SJ, Leary SD, Hollingworth W, Penfold CM. Factors associated with early postoperative feeding: An observational study in a colorectal surgery population. Clinical nutrition ESPEN. 2020 Apr 1;36:99-105.
10. Sindler DL, Mátrai P, Szakó L, Berki D, Berke G, Csontos A, Papp C, Hegyi P, Papp A. Faster recovery and bowel movement after early oral feeding compared to late oral feeding after upper GI tumor resections: a meta-analysis. Frontiers in Surgery. 2023 May 25;10:1092303.