Early vs delayed oral feeding after esophagectomy for esophageal cancer: a systematic review and meta-analysis of randomized controlled trials assessing safety, clinical recovery, and quality of life outcomes.

BACKGROUND

Esophagectomy traditionally involves delayed oral feeding (DOF) due to anastomotic leakage concerns. Enhanced Recovery After Surgery protocols favor early feeding, but its safety remains controversial. This study compared early oral feeding (EOF) and DOF after esophagectomy.

METHODS

PubMed, Embase, and Scopus were systematically searched from inception of the study to October 2025 for randomized controlled trials comparing EOF (0-3 days) and DOF (≥5 days) after esophagectomy. The primary outcomes were anastomotic leakage and pneumonia. The secondary outcomes included complications, hospital outcomes, gastrointestinal (GI) recovery, and quality of life (QOL). Effect sizes were calculated as mean differences (MDs) or standardized MDs (SMDs) for continuous variables and risk ratios (RRs) for dichotomous variables, with 95% CIs, using Review Manager (version 5.4; Cochrane Collaboration).

RESULTS

A total of 13 trials involving 1468 patients were included in the study. Early feeding showed no increase in anastomotic leakage (RR, 0.89 [95% CI, 0.55-1.45]; I² = 0%), with consistent safety across anastomotic locations and surgical approaches. Early feeding significantly reduced pneumonia (RR, 0.66 [95% CI, 0.47-0.92]; P =.01) and accelerated GI recovery: time to first bowel movement (MD, -0.50 days [95% CI, -0.55 to -0.46]; P <.00001) and first flatus (MD, -0.61 days [95% CI, -0.95 to -0.26]; P =.0006). Hospital stay was reduced by 1.89 days (95% CI, -3.06 to -0.72; P =.002) with lower medical expenses (SMD, -1.19 [95% CI, -2.07 to -0.30]; P =.009). QOL improved: global health status (MD, 9.08 [95% CI, 3.88-14.29]; P =.0006), dysphagia (MD, -6.15 [95% CI, -9.97 to -2.34]; P =.002), pain (MD, -3.60 [95% CI, -5.32 to -1.89]; P <.00001), and swallowing difficulties (MD, -1.39 [95% CI, -1.53 to -1.26]; P <.00001).

CONCLUSION

EOF after esophagectomy seems safe and effective, reducing complications while accelerating recovery. However, further high-quality multicenter trials are needed to validate these findings.