Randomized clinical trial: nasoenteric tube or jejunostomy as a route for nutrition after major upper gastrointestinal operations. World J Surg. 2014;38:2241-2246. [PMID: 24806623 DOI: 10.1007/s00268-014-2589-9]

Feeding Jejunostomy Tube in Patients Undergoing Esophagectomy: Utilization and Outcomes in a Nationwide Cohort

BACKGROUND

Feeding jejunostomy (JT) tubes are often utilized as an adjunct to optimize nutrition for successful esophagectomy; however, their utility has come into question. The aim of this study was to evaluate utilization and outcomes associated with JTs in a nationwide cohort of patients undergoing esophagectomy.

METHODS

The NSQIP database was queried for patients who underwent elective esophagectomy. JT utilization was assessed between 2010 and 2019. Post-operative outcomes were compared between those with and without a JT on patients with esophagectomy-specific outcomes (2016-2019), with results validated using a propensity score-matched (PSM) analysis based on key clinicopathologic factors, including tumor stage.

RESULTS

Of the 10,117 patients who underwent elective esophagectomy over the past decade, 53.0% had a JT placed concurrently and 47.0% did not. Utilization of JTs decreased over time, accounting for 60.0% of cases in 2010 compared to 41.7% in 2019 (m = - 2.14 95%CI: [- 1.49]-[- 2.80], p < 0.01). Patients who underwent JT had more composite wound complications (17.0% vs. 14.1%, p = 0.02) and a higher rate of all-cause morbidity (40.4% vs. 35.5%, p = 0.01). Following PSM, 1007 pairs were identified. Analysis of perioperative outcomes demonstrated a higher rate of superficial skin infections (6.1% vs. 3.5%, p = 0.01) in the JT group. However, length of stay, reoperation, readmission, anastomotic leak, composite wound complications, all-cause morbidity, and mortality rates were similar between groups.

CONCLUSIONS

Among patients undergoing elective esophagectomy, feeding jejunostomy tubes were utilized less frequently over the past decade. Similar perioperative outcomes among matched patients support the safety of esophagectomy without an adjunct feeding jejunostomy tube.

Can we predict the need for nutritional support following pancreatoduodenectomy?

BACKGROUND

The practice of routine placement of a tube jejunostomy at the time of pancreatoduodenectomy has given way to a more selective approach. However, the indications of establishing enteral access at the time of surgery remain poorly defined. This study aimed to assess the preoperative and intraoperative factors associated with the need for nutritional support after pancreatoduodenectomy, to guide decision-making for the establishment of intraoperative feeding access.

METHODS

Retrospective study, analyzing the data of 562 consecutive patients, who underwent pancreatoduodenectomy between March 2013 to December 2020. Univariate and multiple logistic regression analysis was carried out to ascertain the factors associated with the initiation of and need for nutritional support for more than 7 days postop. The utility of tube jejunostomy was studied in patients in whom it was performed.

RESULTS

Of 562 patients, 105 (18.7%) needed nutritional support. A tube jejunostomy was performed in 46 (8.2%) patients, parenteral nutrition was used in 83 (14.8%), and nasojejunal tube placed in 28 (4.9%) patients. On logistic regression analysis, age, serum albumin <3.0 gm/dl and operative blood loss were independently associated with the initiation of supportive nutrition, while preoperative gastric outlet obstruction (OR 3.105, 95% CI1.201-8.032, p = 0.019) and serum albumin <3.0 gm/dl (OR 2.669, 95% CI 1.131-6.300, p = 0.025) were associated with the need for prolonged nutritional support. The maximal benefit of tube jejunostomy was in patients with mental health disorders (83.3%).

CONCLUSION

Tube jejunostomy for nutritional support after pancreatoduodenectomy can be considered in patients with preoperative gastric outlet obstruction, serum albumin <3.0 gm/dl and mental health disorders.

Jejunostomy in the palliative treatment of gastric cancer: A clinical prognostic score

BACKGROUND

Clinical stage IV gastric cancer (GC) may need palliative procedures in the presence of symptoms such as obstruction. When palliative resection is not possible, jejunostomy is one of the options. However, the limited survival of these patients raises doubts about who benefits from this procedure.

AIM

To create a prognostic score based on clinical variables for 90-d mortality for GC patients after palliative jejunostomy.

METHODS

We performed a retrospective analysis of Stage IV GC who underwent jejunostomy. Eleven preoperative clinical variables were selected to define the score categories, with 90-d mortality as the main outcome. After randomization, patients were divided equally into two groups: Development (J1) and validation (J2). The following variables were used: Age, sex, body mass index (BMI), American Society of Anesthesiologists classification (ASA), Charlson Comorbidity index (CCI), hemoglobin levels, albumin levels, neutrophil-lymphocyte ratio (NLR), tumor size, presence of ascites by computed tomography (CT), and the number of disease sites. The score performance metric was determined by the area under the receiver operating characteristic (ROC) curve (AUC) to define low and high-risk groups.

RESULTS

Of the 363 patients with clinical stage IVCG, 80 (22%) patients underwent jejunostomy. Patients were predominantly male (62.5%) with a mean age of 62.4 years old. After randomization, the binary logistic regression analysis was performed and points were assigned to the clinical variables to build the score. The high NLR had the highest value. The ROC curve derived from these pooled parameters had an AUC of 0.712 (95%CI: 0.537-0.887, P = 0.022) to define risk groups. In the validation cohort, the diagnostic accuracy for 90-d mortality based on the score had an AUC of 0.756, (95%CI: 0.598-0.915, P = 0.006). According to the cutoff, in the validation cohort BMI less than 18.5 kg/m2 (P < 0.001), CCI ≥ 1 (P = 0.001), ASA III/IV (P = 0.002), high NLR (P = 0.012), and the presence of ascites on CT exam (P = 0.004) were significantly associated with the high-risk group. The risk groups showed a significant association with first-line (P = 0.012), second-line chemotherapy (P = 0.009), 30-d (P = 0.013), and 90-d mortality (P < 0.001).

CONCLUSION

The scoring system developed with 11 variables related to patient's performance status and medical condition was able to distinguish patients undergoing jejunostomy with high risk of 90 d mortality.

A Prospective Randomized Trial Comparing Jejunostomy and Nasogastric Feeding in Minimally Invasive McKeown Esophagectomy

BACKGROUND

Early postoperative enteral nutrition is recommended for patients undergoing esophagectomy; however, the optimum method of tube feeding remains controversial. Thus, the aim of this study is to assess two common enteral nutrition methods after minimally invasive McKeown esophagectomy.

METHODS

A randomized controlled trial was performed with 120 patients who underwent minimally invasive McKeown esophagectomy from January 2017 to December 2018. The patients were randomly divided so that 58 patients were in the jejunostomy feeding (JF) group and 62 patients were in the nasogastric feeding (NF) group. The postoperative outcomes, including complications, nutritional status, quality of life, and survival rate, were studied and used as the main parameters to compare the abovementioned tube feeding methods.

RESULTS

The incidence of overall complications was equivalent between the two groups (P = 0.625), except for bowel obstruction (which occurred 4 times in the JF group but did not occur in the NF group). In the first month after surgery (postoperative month 1, POM1), a significantly higher body mass index (BMI) was observed in the JF group (23.6 ± 3.2) than in the NF group (20.9 ± 3.5, P = 0.032). The global quality-of-life scores were better in the JF group than in the NF group (P < 0.001). In addition, there were no significant differences between the two groups in terms of disease-free survival (DFS) (P = 0.816) and overall survival (OS) (P = 0.564).

CONCLUSIONS

Compared with NF, JF provides more safety, efficacy, and utility as nutritional support for minimally invasive McKeown esophagectomy patients who have a high incidence of anastomotic leakage. However, the higher risk of intestinal obstruction after JF requires attention.

Is the placement of jejunostomy tubes in patients with esophageal cancer undergoing esophagectomy associated with increased inpatient healthcare utilization? An analysis of the National Readmissions Database

BACKGROUND

Patients undergoing esophagectomy often receive jejunostomy tubes (j-tubes) for nutritional supplementation. We hypothesized that j-tubes are associated with increased post-esophagectomy readmissions.

STUDY DESIGN

We identified esophagectomies for malignancy with (EWJ) or without (EWOJ) j-tubes using the 2010-2015 Nationwide Readmissions Database. Outcomes include readmission, inpatient mortality, and complications. Outcomes were compared before and after propensity score matching (PSM).

RESULTS

Of 22,429 patients undergoing esophagectomy, 16,829 (75.0%) received j-tubes. Patients were similar in age and gender but EWJ were more likely to receive chemotherapy (24.2% vs. 15.1%, p < 0.01). EWJ was associated with decreased 180-day inpatient mortality (HR 0.72 [0.52-0.99]) but not with higher readmissions at 30- (15.2% vs. 14.0%, p = 0.16; HR 0.9 [0.77-1.05]) or 180 days (25.2% vs. 24.3%, p = 0.37; HR 0.94 [0.79-1.10]) or increased complications (p = 0.37). These results were confirmed in the PSM cohort.

CONCLUSION

J-tubes placed in the setting of esophagectomy do not increase inpatient readmissions or mortality.

The Optimal Feeding Enterostomy Creation During Esophagectomy to Reduce the Long-Term Risk of Small Bowel Obstruction

BACKGROUND

Although feeding jejunostomy (FJ) is commonly created during esophagectomy for postoperative enteral nutrition, it can be a cause of postoperative small bowel obstruction (SBO). We introduced a technique of feeding enterostomy using the round ligament of the liver (FERL) to reduce SBO. In this study, we aimed to clarify the efficacy of FERL in reducing the postoperative SBO compared with FJ.

METHODS

We assessed 400 consecutive patients who underwent esophagectomy with gastric tube reconstruction between 2011 and 2016, before and after the introduction of FERL (FJ, n = 200; FERL, n = 200). The cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy were compared between the FJ and the FERL groups.

RESULTS

Thoracoscopic and laparoscopic surgery was more frequent in the FERL group than in the FJ group (p < 0.001). The cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy in the FERL group were significantly less frequent than those in the FJ group (p < 0.001 and p = 0.006, respectively). When stratifying by the abdominal surgical approach, the cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy in a laparoscopic approach were less frequent in the FERL group than those in the FJ group (both p < 0.001).

CONCLUSIONS

The FERL technique can reduce the incidences of postoperative SBO and SBO associated with feeding enterostomy in patients undergoing esophagectomy.

Jejunostomy at the time of esophagectomy is associated with improved short-term perioperative outcomes: analysis of the NSQIP database

Adequate preoperative and perioperative nutrition has been shown to improve outcomes for patients undergoing esophagectomy. The most effective way to provide enteral nutrition for patients after esophagectomy is via jejunostomy tube. There is an open debate whether a feeding jejunostomy tube is necessary at the time of esophagectomy. This study evaluated short term surgical outcomes for patients undergoing esophagectomy with and without concurrent jejunostomy tube placement. Esophageal cancer patients were identified from the NSQIP database who underwent esophagectomy between 2005 through 2016. Patients were classified into 2 cohorts: patients with concurrent jejunostomy tube placement and those without jejunostomy placement at the time of esophagectomy. Clinical and demographic data was collected. Differences in short term outcomes were assessed by univariate and multivariable analysis, including prolonged hospital stay (>30 days), in-hospital mortality, and 30-day mortality for both cohorts. We identified 8,632 patients that underwent esophagectomy for esophageal cancer with 80% males and mean age of 63.2±10.6 years. Twenty percent (n=1,723) had preoperative weight loss in the 6-month period preceding surgery. Forty-five percent (n=3,900) patients had jejunostomy placement at the time of esophagectomy. Overall, the rate of prolonged hospital stay (P=0.006), in-hospital mortality (P<0.001) and 30-day mortality (P<0.001) were significantly higher in patients without concurrent jejunostomy in both univariable and multivariable models. This study demonstrates that patients with jejunostomy placement at the time of esophagectomy have improved short term perioperative outcomes.

Feeding Jejunostomy Tube Placed during Esophagectomy: Is There an Effect on Postoperative Outcomes?

BACKGROUND

Feeding jejunostomy (FJ) tubes are routinely placed during esophagectomy. However, their effect on immediate postoperative outcomes in this patient population is not clear.

OBJECTIVES

To evaluate the effect of FJ tube placement during esophagectomy on postoperative morbidity and mortality.

METHODS

The National Surgical Quality Improvement Program database was used to evaluate the effect of FJ tube placement during esophagectomy on 30-day postoperative morbidity and mortality rates. A propensity score-matched cohort was used to compare postoperative outcomes of patients with and without FJ tubes.

RESULTS

An FJ tube was placed in 45% of 2059 patients undergoing esophagectomy. The anastomotic leak rate was 13.5%. Patients with FJ tubes were more likely to have preoperative radiation therapy (59.6% vs 54.9%, p = 0.041), transhiatal esophagectomy (21.5% vs 19.2%, p = 0.012), a malignant diagnosis (93.2% vs 90.4%), and longer operative time (393 min vs 348 min, p < 0.001). In a case-matched cohort, mortality (2% vs 2.4%, p = 0.618) and severe morbidity (38.2% vs 34.6%, p = 0.128) were comparable between patients with and without FJ tubes. FJ tube placement was associated with higher overall morbidity (46% vs 38.6%, p = 0.002), superficial wound infection (6.3% vs 2.9%, p = 0.001), and return to the operating room (16.7% vs 12.5%, p = 0.016). In a subgroup of patients with anastomotic leak, FJ was associated with shorter hospital stay (20.1 days vs 24.3 days, p = 0.046).

CONCLUSION

These mixed findings support selective rather than routine FJ tube placement during esophagectomy.

Jejunostomy or nasojejunal tube after esophagectomy: a review of the literature

Patients undergoing esophagectomy for cancer are a difficult to treat group of patients. At diagnosis they will present some degree of malnutrition in up to 80% and the causes are from multifactorial origin: the inability of food ingestion, advanced age, taste disturbances, and morbidity related to neoadjuvant treatment. In order to restaure the nutritional status, enteral nutritional support is preferable to parenteral support because of the risks of septic complications associated with venous catheters. During the postoperative period, the oral route is often inaccessible in these patients due to swallowing disorders and eventually mechanical ventilation, and if possible, often it does not provide sufficient caloric amounts for postoperative energy balance. For these reasons, it is usually recommended additional nutritional support. There are few studies in the literature that specifically address which is the most adequate route for enteral nutrition in patients undergoing esophagectomy. Nasojejunal catheters present a higher incidence of local complications, such as displacement and occlusion, whereas jejunostomy is more associated with reinterventions for the treatment of complications secondary to extravasation. Although there is weak evidence in the literature and a lack of randomized, prospective and multicenter studies evaluating the best enteral nutrition route in the postoperative period of esophagectomy, the use of the nasoenteric catheter seems to be adequate due to its simplicity of positioning and low rates of severe complications. In this paper a review is performed of the evidence about this subject.

Enteral Feeding Access Has an Impact on Outcomes for Patients with Esophageal Cancer Undergoing Esophagectomy: An Analysis of SEER-Medicare

BACKGROUND

Optimal nutrition after esophagectomy is challenging due to alterations in eating, both from the tumor and during surgical recovery. Enteral nutrition via feeding tube is commonly used. The impact of feeding tubes on post-esophagectomy outcomes was examined in a large national data set.

METHODS

Patients with esophageal cancer (1998-2013) undergoing esophagectomy were extracted from the Surveillance Epidemiology and End Results-Medicare database. Chi-square and t tests were used to compare categorical and continuous variables. Time trend analyses were performed with Cochran-Armitage survival using log-rank and multivariable analysis with generalized linear modeling.

RESULTS

The study examined 2495 patients. The majority had enteral feeding access (71%, n = 1794) during the perioperative period. Mortality among the patients with feeding tubes was lower at 30 days (5.4% vs 8.4%), 60 days (9.0% vs 13.0%), and 90 days (12.2% vs 15.8%). In the multivariable analysis, the patients with feeding tubes had improved short-term survival at 30 days (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.46-0.93), 60 days (OR, 0.64; 95% CI, 0.49-0.85), and 90 days (OR, 0.70; 95% CI, 0.54-0.90). The hospital stay was shorter for the patients undergoing enteral feeding tube placement (17.9 vs 19.5 days; p = 0.04). Discharge destination (home vs health care facility) showed no difference.

CONCLUSIONS

Feeding tubes in patients undergoing esophagectomy were associated with an increase in short-term survival up to 90 days after surgery. Feeding tube placement was not associated with higher rates of non-home discharges and did not prolong the hospital stay.

Evaluation of the need for routine feeding jejunostomy for enteral nutrition after esophagectomy

Background

Previous studies have shown that enteral nutrition (EN) helps reduce severe postoperative complications after esophagectomy. However, the incidence of jejunostomy-related complications is approximately 30%. We evaluated the operative outcomes in patients who did not receive EN via feeding jejunostomy after esophagectomy.

Methods

We retrospectively reviewed 76 consecutive patients with esophageal cancer who received radical esophagectomy. Operative outcomes were compared between 33 patients who received postoperative EN via feeding jejunostomy (group A; from May 2014 to September 2015) and 43 patients who did not receive EN via feeding jejunostomy (group B; from September 2015 to December 2017).

Results

The American Society of Anesthesiologists performance status score of the patients in group B was significantly higher than that of patients in group A (P=0.002). The postoperative morbidity rate was comparable between the two groups (group A, 30.3% vs. group B, 44.2%, P=0.217). No significant between-group differences were observed in the incidence of infectious complications, postoperative hospital stay, readmission within 30 days after discharge, or pneumonia after discharge within 6 months. The incidence of bowel obstruction was significantly higher in group A than in group B (group A, 9.1% vs. group B, 0%, P=0.044). Two patients in group B required nutritional support via total parenteral nutrition due to bilateral vocal cord palsy or pneumonia.

Conclusions

Jejunostomy-related bowel obstruction in the patients with feeding jejunostomy was significantly higher than that in the patients without jejunostomy. There was no increase in postoperative complications (including pneumonia) in the patients who did not receive EN via feeding jejunostomy. Our results suggest that routine feeding jejunostomy may not be necessary for all patients undergoing esophagectomy.

ACERTO guidelines of perioperative nutritional interventions in elective general surgery

ABSTRACT Objective: to present recommendations based on the ACERTO Project (Acceleration of Total Post-Operative Recovery) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures. Methods: review of relevant literature from 2006 to 2016, based on a search conducted in the main databases, with the purpose of answering guiding questions previously formulated by specialists, within each theme of this guideline. We preferably used randomized controlled trials, systematic reviews and meta-analyzes but also selected some cohort studies. We contextualized each recommendation-guiding question to determine the quality of the evidence and the strength of this recommendation (GRADE). This material was sent to authors using an open online questionnaire. After receiving the answers, we formalized the consensus for each recommendation of this guideline. Results: the level of evidence and the degree of recommendation for each item is presented in text form, followed by a summary of the evidence found. Conclusion: this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons, the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery. The prescription of these recommendations can accelerate the postoperative recovery of patients submitted to elective general surgery, with decrease in morbidity, length of stay and rehospitalization, and consequently, of costs.

Benefits of Supplemental Jejunostomy Tube Feeding During Neoadjuvant Therapy in Patients with Locally Advanced, Potentially Resectable Esophageal Cancer

BACKGROUND

Standard treatment for locally advanced esophageal cancer includes neoadjuvant therapy followed by surgical resection. However, many patients experience a period of decreased oral intake during neoadjuvant treatment and are at risk for malnutrition. We hypothesize that use of jejunostomy tube (j-tube) feedings during neoadjuvant therapy in selected patients may be associated with better perioperative outcomes.

METHODS

A prospectively collected database at a single institution was retrospectively analyzed. The study period was from 2005 to 2015. Patients who underwent j-tube placement before neoadjuvant therapy before definitive resection for esophageal cancer were included in the analysis. Perioperative outcomes were compared between patients who adhered to recommended tube feeds during neoadjuvant therapy (users) and patients who did not adhere (nonusers).

RESULTS

During the study period, 94/301 patients received a j-tube before or during neoadjuvant therapy for esophageal cancer. Seventy-three patients utilized tube feeds regularly during the neoadjuvant phase, while 21 patients did not. The groups did not differ significantly with respect to clinical factors such as dysphagia on presentation, postneoadjuvant therapy performance status, or Charlson Comorbidity Index. Perioperative pneumonia rates were lower in j-tube users compared to nonusers (6.8% [5 of 73] versus 23.8% [5 of 21]), respectively, P = .036); this difference remained significant with adjustment for type of surgery (odds ratio = 0.16, P = .018).

CONCLUSIONS

j-Tube users had a significantly lower incidence of pneumonia within 30 days of curative resection when compared to nonusers. j-Tube feedings during neoadjuvant therapy for selected patients with locally advanced esophageal cancer should be encouraged.

Critical analysis of feeding jejunostomy following resection of upper gastrointestinal malignancies

AIM

To assess nutritional recovery, particularly regarding feeding jejunostomy tube (FJT) utilization, following upper gastrointestinal resection for malignancy.

METHODS

A retrospective review was performed of a prospectively-maintained database of adult patients who underwent esophagectomy or gastrectomy (subtotal or total) for cancer with curative intent, from January 2001 to June 2014. Patient demographics, the approach to esophagectomy, the extent of gastrectomy, FJT placement and utilization at discharge, administration of parenteral nutrition (PN), and complications were evaluated. All patients were followed for at least ninety days or until death.

RESULTS

The 287 patients underwent upper GI resection, comprised of 182 esophagectomy (n = 107 transhiatal, 58.7%; n = 56 Ivor-Lewis, 30.7%) and 105 gastrectomy [n = 63 subtotal (SG), 60.0%; n = 42 total (TG), 40.0%]. 181 of 182 esophagectomy patients underwent FJT, compared with 47 of 105 gastrectomy patients (99.5% vs 44.8%, P < 0.0001), of whom most had undergone TG (n = 39, 92.9% vs n = 8 SG, 12.9%, P < 0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups (14.7 d vs 17.1 d, P = 0.076). Upon discharge, 87 esophagectomy patients (48.1%) were taking enteral feeds, with 53 (29.3%) fully and 34 (18.8%) partially dependent. Meanwhile, 20 of 39 TG patients (51.3%) were either fully (n = 3, 7.7%) or partially (n = 17, 43.6%) dependent on tube feeds, compared with 5 of 8 SG patients (10.6%), all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients (6.4% vs 29.3%, P = 0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy (n = 11, 23.4% vs n = 7, 3.9%, P = 0.0001). FJT-specific complications requiring reoperation within 30 d of resection occurred more commonly in the gastrectomy group (n = 6), all after TG, compared to 1 esophagectomy patient (12.8% vs 0.6%, P = 0.0003). Six of 7 patients (85.7%) who experienced tube-related complications required PN.

CONCLUSION

Nutritional recovery following esophagectomy and gastrectomy is distinct. Operations are associated with unique complication profiles. Nutritional supplementation alternative to jejunostomy should be considered in particular scenarios.

Routes of early enteral nutrition following oesophagectomy

Introduction Oesophagectomy for cancer is a challenging procedure with a five-year overall survival rate of 15-20%. Early enteral nutrition following oesophagectomy is a crucial component of the postoperative recovery and carries a significant impact on the outcome. Different methods of enteral feeding were conducted in our unit. The aim of this study was to examine the efficacy and safety of nasojejunal tube (NJT), jejunostomy tube (JT) and pharyngostomy tube (PT) feeding after oesophagectomy. Methods A retrospective review was carried out of prospectively collected data on patients with oesophageal cancer who underwent an oesophagectomy between 2011 and 2014. The primary outcome was feeding tube related complications such as occlusion, dislocation and leak. The secondary outcomes were length of stay and 30-day morbidity. Results A total of 90 oesophagectomies were included in the study. A NJT was inserted in 41 patients (45.6%), a JT was used in 14 patients (15.5%) and a PT was the route for enteral nutrition in 35 patients (38.9%). In total, five patients (5.5%) developed tube related complications. There were no tube related complications in the NJT group but one JT patient (7.1%) developed tube related cellulitis (p=0.189) and four PT patients (11.4%) developed tube related haemorrhage (p=0.544), tube dislocation (p=0.544) or cellulitis (p=0.189). The median length of stay and 30-day postoperative morbidity were similar between the groups. Conclusions NJT feeding is a less invasive, feasible route for early enteral nutrition following oesophagectomy. A randomised controlled trial is recommended to verify these findings.

Clinical Burden of Laparoscopic Feeding Jejunostomy Tubes

INTRODUCTION

Feeding jejunostomies (J tubes) provide enteral nutrition when oral and gastric routes are not options. Despite their prevalence, there is a paucity of literature regarding their efficacy and clinical burden.

METHODS

All laparoscopic J tubes placed over a 5-year period were retrospectively reviewed. Clinical burden was measured by number of clinical contact events (tube-related clinic visits, phone calls, ED visits) and morbidity (dislodgement, clogging, tube fracture, infection, other). Tube replacements were also recorded.

RESULTS

One hundred fifty-one patients were included. Fifty-nine percent had associated malignancy, and 35 % were placed for nutritional prophylaxis. Mean time to J tube removal was 146 days. J tubes were expected to be temporary in >90 % but only 50 % had sufficient oral intake for removal. Tubes were removed prematurely due to patient intolerance in 8 %. Mortality was 0 %. Morbidity was 51 % and included clogging (12 %), tube fracture (16 %), dislodgement (25 %), infection (18 %) and "other" (leaking, erosion, etc.) in 17 %. The median number of adverse events per J tube was 2(0-8). Mean number of clinic phone calls was 2.5(0-22), ED visits 0.5(0-7), and clinic visits 1.4(0-13), with 82 % requiring more than one J tube-related clinic visit. Unplanned replacements occurred in 40 %.

CONCLUSION

While necessary for some patients, J tubes are associated with high clinical burden.

Feeding Challenges in Patients with Esophageal and Gastroesophageal Cancers

BACKGROUND

Patients undergoing treatment for esophagogastric or esophageal cancer are exposed to a considerably high risk of malnutrition due to early obstruction of the gastrointestinal passage. Presently most of the patients undergo modern multimodal therapies which require chemoradiation or chemotherapy ahead of surgery. Therefore reconstruction of the obstructed gastrointestinal passage is considerably delayed. Surgery as the only curative option after neoadjuvant treatment is the mainstay of therapy in this setting. However, many patients are at risk for the development of postoperative complications associated with the complexity of the surgical procedure. Therefore enteral feeding as a prerequisite to avoid malnutrition represents a special therapeutic challenge.

SUMMARY

This review describes the recent literature on the incidence and influence of perioperative malnutrition on oncologic outcome, measures to determine patients at risk, possible strategies to reduce or avoid malnutrition by supportive enteral/parenteral nutrition, implementation of the enhanced recovery after surgery programs and feeding routes, but also surgical and adjuvant procedures in the curative and palliative setting for patients undergoing treatment for gastroesophageal cancers.

KEY MESSAGES

Appropriate identification of patients at risk is crucial to avoid malnutrition. Early nutritional interventions during multimodal/neoadjuvant treatment may be beneficial for weight loss reduction although the evidence is not conclusive. Pouch reconstructions during surgery should be applied in order to increase quality of life and eating capacity. Reduction of postoperative complications could provide potential benefits. In palliative patients, insertion of self-expanding metal stents can reduce dysphagia and improve quality of life, but does not prolong overall survival. Further evidence is required to determine the value of the procedures and measures described in this review.

PRACTICAL IMPLICATIONS

Nutritional risk scoring should be performed for every gastroesophageal cancer patient. Sophisticated reconstruction methods and early recovery programs should be enforced to reduce perioperative starvation periods. Self-expanding metal stents should be used for palliative patients.

Outcomes of laparoscopic feeding jejunostomy tube placement in 299 patients

BACKGROUND

Jejunostomy catheters for jejunal feeding are an effective method to improve nutritional status in malnourish patients. However, this procedure is commonly being performed using an open approach, which can be associated with more postoperative pain and prolonged recovery. The objective of this study was to assess the outcomes of patients who underwent placement of feeding jejunostomy using a laparoscopic approach.

METHODS

A retrospective review was performed of patients who underwent laparoscopic jejunostomy tube placement between 1998 and 2014. Main outcome measures included indication for catheter placement, rate of conversion rate to open surgery, perioperative and late morbidity and in-hospital mortality.

RESULTS

Two hundred and ninety-nine consecutive patients underwent laparoscopic jejunostomy during the study period. The mean age was 64 years, and 81% of patients were male. The mean BMI was 26.2 kg/m(2). The most common indications for catheter placement were resectable esophageal cancer (78%), unresectable esophageal cancer (10%) and gastric cancer (6%). There were no conversions to open surgery. The 30-day complication rate was 4.0% and included catheter dislodgement (1%), intraperitoneal catheter displacement (0.7%), catheter blockage (1%) or breakage (0.3%), site infection requiring catheter removal (0.7%) and abdominal wall hematoma (0.3%). The late complication rate was 8.7% and included jejuno-cutaneous fistula (3.7%), jejunostomy tube dislodgement (3.3%), broken or clogged J-tube (1.3%) and small bowel obstruction (0.3%). The 30-day mortality was 0.3% for a patient with stage IV esophageal cancer who died in the postoperative period secondary to respiratory failure.

CONCLUSION

In this large consecutive series of feeding jejunostomy, the laparoscopic approach is feasible and safe and associated with a low rate of small bowel obstruction and no intraabdominal catheter-related infection.