Early Versus Delayed Postoperative Feeding After Colorectal Surgery: Evidence, Implementation Gaps, and Implications for Inflammatory Bowel Disease

Purpose of Review Postoperative feeding after colorectal surgery has historically adhered to the principle of “nil per os until flatus or stool,” a practice rooted in theoretical concerns about anastomotic disruption, postoperative ileus, vomiting and aspiration. These concerns became entrenched in practice despite limited prospective evidence to support them. Over the past two decades, enhanced recovery after surgery (ERAS) programs have challenged this dogma, establishing early oral feeding as a core pathway component. This review synthesizes the physiologic rationale for early oral feeding, the clinical trial evidence supporting it, the available evidence and evidence gaps in IBD and high-risk populations, and the cognitive and system-level barriers that perpetuate delayed feeding despite modern guidelines. Recent findings In general elective colorectal surgery, early oral feeding, defined as initiation within 24 h of surgery, reduces length of hospital stay and accelerates return of bowel function without increasing anastomotic leak, wound infection, pneumonia, or mortality. These findings have prompted strong guideline endorsement from major surgical societies. In IBD surgery, disease-specific randomized feeding trials are limited; however, ERAS cohort studies, systematic reviews, and expert consensus support the feasibility and safety of early oral feeding for most patients when integrated into structured care pathways. The key differentiators in IBD are the inflammatory burden of disease, steroid and immunosuppressant exposure, and the high prevalence of malnutrition and sarcopenia. These factors argue for enhanced monitoring and individualized care rather than routine delayed feeding. IBD patients also have independently higher anastomotic leak rates compared with cancer patients, though there is no evidence that delayed feeding mitigates this disease-related risk. Persistent variation in clinical practice is driven more by physician cognitive bias and system-level implementation barriers than by unresolved safety questions. Summary For most patients undergoing colorectal surgery, including those with IBD, early oral feeding should be the default approach, with individualized modification reserved for defined high-risk scenarios. The persistent gap between evidence and practice reflects cognitive biases and system-level implementation barriers rather than genuine safety concerns. Future research should prioritize IBD-specific feeding trials in high-risk subgroups and implementation strategies that help evidence translate into clinical practice.