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Turner KM, Delman AM, Griffith A, Wima K, Patel SH, Wilson GC, Shah SA, Van Haren RM. Feeding Jejunostomy Tube in Patients Undergoing Esophagectomy: Utilization and Outcomes in a Nationwide Cohort. World J Surg 2023; 47:2800-2808. [PMID: 37704891 DOI: 10.1007/s00268-023-07157-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/15/2023]
Abstract
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.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Azante Griffith
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert M Van Haren
- Department of Surgery, Division of Thoracic Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0558, USA.
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Ongoing Controversies in Esophageal Cancer I. Thorac Surg Clin 2022; 32:541-551. [DOI: 10.1016/j.thorsurg.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Nakai T, Kitadani J, Ojima T, Hayata K, Katsuda M, Goda T, Takeuchi A, Tominaga S, Fukuda N, Nagano S, Yamaue H. Feeding jejunostomy following esophagectomy may increase the occurrence of postoperative small bowel obstruction. Medicine (Baltimore) 2022; 101:e30746. [PMID: 36123872 PMCID: PMC9478262 DOI: 10.1097/md.0000000000030746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This study aimed to clarify the characteristics and treatment of bowel obstruction associated with feeding jejunostomy in patients who underwent esophagectomy for esophageal cancer. In this single-center retrospective study, 363 patients underwent esophagectomy with mediastinal lymph node dissection for esophageal cancer at the Wakayama Medical University Hospital between January 2014 and June 2021. All patients who underwent esophagectomy routinely underwent feeding jejunostomy or gastrostomy. Feeding jejunostomy was used in the cases of gastric tube reconstruction through the posterior mediastinal route or colon reconstruction, while feeding gastrostomy was used in cases of retrosternal route gastric tube reconstruction. Nasogastric feeding tubes and round ligament technique were not used. Postoperative small bowel obstruction occurred in 19 of 197 cases of posterior mediastinal route reconstruction (9.6%), but in no cases of retrosternal route reconstruction because of the feeding gastrostomy (P < .0001). Of the 19 patients who had bowel obstruction after feeding jejunostomy, 10 patients underwent reoperation (53%) and the remaining 9 patients had conservative treatment (47%). The cumulative incidence of bowel obstruction after feeding jejunostomy was 6.7% at 1 year and 8.7% at 2 years. Feeding jejunostomy following esophagectomy is a risk factor for small bowel obstruction. We recommend feeding gastrostomy inserted from the antrum to the jejunum in the cases of gastric tube reconstruction through the retrosternal route or nasogastric feeding tube in the cases of reconstruction through the posterior mediastinal route.
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Affiliation(s)
- Tomoki Nakai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Junya Kitadani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Toshiyasu Ojima
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
- *Correspondence: Toshiyasu Ojima, Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan (e-mail: )
| | - Keiji Hayata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Katsuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Taro Goda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akihiro Takeuchi
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shinta Tominaga
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Naoki Fukuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shotaro Nagano
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
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Lee Y, Lu JY, Malhan R, Shargall Y, Finley C, Hanna W, Agzarian J. Effect of Routine Jejunostomy Tube Insertion in Esophagectomy: A Systematic Review and Meta-Analysis. J Thorac Cardiovasc Surg 2022; 164:422-432.e17. [DOI: 10.1016/j.jtcvs.2021.12.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 12/17/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
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Mei LX, Wang YY, Tan X, Chen Y, Dai L, Chen MW. Is it necessary to routinely perform feeding jejunostomy at the time of esophagectomy? A systematic review and meta-analysis. Dis Esophagus 2021; 34:6245102. [PMID: 33884417 DOI: 10.1093/dote/doab017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/25/2021] [Accepted: 01/30/2021] [Indexed: 12/11/2022]
Abstract
Feeding jejunostomy (FJ) is a routine procedure at the time of esophagectomy in some centers. With the widespread popularization of enhanced recovery after surgery, the necessity of FJ has been increasingly questioned. This study aims to analyze the differences in safety and effectiveness between with (FJ group) or without (no-FJ group) performing FJ at the time of esophagectomy. PubMed, Embase, Web of Science, and Cochrane Library were comprehensively searched for relevant studies, including randomized controlled trials and cohort studies. The primary outcome was the length of hospital stay (LOS). Secondary outcomes were overall postoperative complications, postoperative pneumonia, intestinal obstruction, and weight loss at 3 and 6 months after esophagectomy. Weighted mean differences (WMD) and odds ratios (OR) were calculated for statistical analysis. About 12 studies comprising 2,173 patients were included. The FJ group had a longer LOS (WMD = 2.05, P = 0.01) and a higher incidence of intestinal obstruction (OR = 11.67, P < 0.001) than the no-FJ group. The incidence of overall postoperative complications (OR = 1.24, P = 0.31) and postoperative pneumonia (OR = 1.43, P = 0.13) were not significantly different, nor the weight loss at 3 months (WMD = 0.58, P = 0.24) and 6 months (P > 0.05) after esophagectomy. Current evidence suggests that routinely performing FJ at the time of esophagectomy appears not to generate better postoperative outcomes. FJ may need to be performed selectively rather than routinely. More studies are required to further verify.
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Affiliation(s)
- Li-Xiang Mei
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong-Yong Wang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiang Tan
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lei Dai
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ming-Wu Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Zhuang W, Wu H, Liu H, Huang S, Wu Y, Deng C, Tian D, Zhou Z, Shi R, Chen G, Piessen G, Khaitan PG, Koyanagi K, Ozawa S, Qiao G. Utility of feeding jejunostomy in patients with esophageal cancer undergoing esophagectomy with a high risk of anastomotic leakage. J Gastrointest Oncol 2021; 12:433-445. [PMID: 34012637 PMCID: PMC8107594 DOI: 10.21037/jgo-21-133] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/09/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Feeding jejunostomy is widely used for enteral nutrition (EN) after esophagectomy; however, its risks and benefits are still controversial. We aimed to evaluate the short-term and long-term outcomes of feeding jejunal tube (FJT) in patients undergoing esophagectomy for esophageal squamous cell carcinoma (ESCC) who were deemed high-risk for anastomotic leakage. METHODS We retrospectively analyzed 716 patients who underwent esophagectomy with (FJT group, n=68) or without (control group, n=648) intraoperative placement of FJT. Propensity score matching (PSM) was used for the adjustment of confounding factors. Risk level for anastomotic leakage was determined for every patient after PSM. RESULTS Patients in the FJT group were at higher risk of anastomotic leakage (14.9% vs. 11.3%), and had a statistically non-significant increase of postoperative complications [31.3% vs. 21.8%, odds ratio (OR) =1.139, 95% confidence interval (CI), 0.947-1.370, P=0.141] after PSM. Medical expenditure, length of postoperative hospital stay, and short-term mortality were similar between the FJT and control groups. Placement of FJT appeared to accelerate the recovery of anastomotic leakage (27.2 vs. 37.4 d, P=0.073). Patients in FJT group achieved comparable overall survival (OS) both before [hazard ratio (HR) =0.850, P=0.390] and after (HR =0.797, P=0.292) PSM. CONCLUSIONS FJT showed acceptable safety profile along with potential benefits for ESCC patients with a high presumed risk of anastomotic leakage. While FJT does not impact OS, placement of FJT should be considered in esophagectomy patients and tailored to individual patients based on their leak-risk profile.
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Affiliation(s)
- Weitao Zhuang
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Hansheng Wu
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Huiling Liu
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shujie Huang
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Yinghong Wu
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Cheng Deng
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Dan Tian
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zihao Zhou
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruiqing Shi
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Gang Chen
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guillaume Piessen
- University of Lille, Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Puja G. Khaitan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Guibin Qiao
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Kidane B, Higgins S, Hirpara DH, Kaaki S, Shen YC, Allison F, Waddell TK, Darling GE. From Emergency Department Visit to Readmission After Esophagectomy: Analysis of Burden and Risk Factors. Ann Thorac Surg 2020; 112:379-386. [PMID: 33310147 DOI: 10.1016/j.athoracsur.2020.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/24/2020] [Accepted: 11/16/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Frequent emergency department (ED) visits occur after esophagectomy. We aimed to identify the incidence of and risk factors for conversion from ED visit to inpatient admission. METHODS A retrospective cohort study was performed of consecutive esophagectomies at a tertiary Canadian center (1999 to 2014). Multivariable regression analyses identified factors associated with conversion from ED visit to admission. RESULTS There were 520 esophagectomies with 6% inhospital mortality (n = 31). Of those discharged, 29.7% (n = 145) had one or more emergency visit and 43.4% (n = 63) of these patients were readmitted to the hospital. First-time ED visits resulted in inpatient conversion 23.4% of the time (n = 34); successive ED visits resulted in increasing conversion. On multivariable analysis, anastomotic leak (adjusted odds ratio 2.45; 95% confidence interval, 1 to 6.01; P = .05) was independently associated with higher odds of conversion to admission. Sensitivity analysis using Poisson regression to model conversion as a rate identified that living in regions further away was associated with lower conversion rate to admission (risk ratio 0.35; 95% confidence interval, 0.13 to 0.94; P = .04). CONCLUSIONS Although postesophagectomy ED utilization is high, the majority of visits do not convert to admission. With each increasing ED visit, likelihood of converting to admission increases. Anastomotic leakage was associated with higher odds of conversion to admission, possibly related to development of strictures. Access to urgent outpatient endoscopy may help reduce the incidence of ED visits and admission. Although living in regions further away is associated with lower conversion rates to admission at the index hospital, that may be due to patients utilizing closer local hospitals.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Sean Higgins
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dhruvin H Hirpara
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Suha Kaaki
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Yu Cindy Shen
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Frances Allison
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Kamada T, Ohdaira H, Takeuchi H, Takahashi J, Marukuchi R, Ito E, Suzuki N, Narihiro S, Hoshimoto S, Yoshida M, Urashima M, Suzuki Y. Vertical distance from navel as a risk factor for bowel obstruction associated with feeding jejunostomy after esophagectomy: a retrospective cohort study. BMC Gastroenterol 2020; 20:354. [PMID: 33109092 PMCID: PMC7590660 DOI: 10.1186/s12876-020-01506-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022] Open
Abstract
Background Placement of feeding jejunostomy (PFJ) during esophagectomy is an effective method to maintain adequate nutrition, but is associated with serious complications such as bowel obstruction and jejunal torsion. The purpose of the current study was to analyze the incidence, clinical features, and risk factors of bowel obstruction associated with feeding jejunostomy (BOFJ) after PFJ. Methods This was a retrospective cohort study of 70 patients who underwent esophagectomy with three-field lymph node dissection for esophageal cancer and treated with PFJ between March 2013 and December 2019 in our hospital. Abdominal dissection was performed under hand-assisted laparoscopic surgery (HALS) from March 2013 to March 2015, and was changed to complete laparoscopic surgery in April 2015. We compared patients with and without BOFJ, and the incidence of BOFJ was evaluated. The primary endpoint was incidence of BOFJ after PFJ. Results Six patients (8.5%) were diagnosed with BOFJ, all of whom were symptomatic and in the HALS group. In addition, 3 cases displayed histories of recurrent BOFJ (3, 3, and 5 times). Laparotomy was performed in all cases. Subgroup analysis of the HALS group showed a significant difference only in straight-line distance between the jejunostomy and navel as a significant pre- and perioperative factor (117 mm [101–130 mm] vs. 89 mm [51–150 mm], p < 0.001). Furthermore, dividing straight-line distance between the jejunostomy and navel into VD and HD, only VD differed significantly (107 mm [93–120 mm] vs. 79 mm [28–135 mm], p = 0.010), not HD (48 mm [40–59 mm] vs. 46 mm [22–60 mm], p = 0.199). Conclusions VD between the jejunostomy and navel was associated with BOFJ after PFJ with HALS esophagectomy. PFJ < 9 cm above the navel during HALS esophagectomy might effectively prevent BOFJ.
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Affiliation(s)
- Teppei Kamada
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan.
| | - Hironori Ohdaira
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Hideyuki Takeuchi
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Junji Takahashi
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Rui Marukuchi
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Eisaku Ito
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Norihiko Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Satoshi Narihiro
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Sojun Hoshimoto
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Masashi Yoshida
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
| | - Mitsuyoshi Urashima
- Division of Molecular Epidemiology, Jikei University School of Medicine, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, 537-3, Iguchi329-2763, Japan
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El Asmar A, Ghabi E, Saber T, Abou-Malhab C, Akl B, El Rassi Z. Platelet-to-lymphocyte ratio is correlated with a delay in feeding resumption following a transhiatal esophagectomy with cervical anastomosis. World J Surg Oncol 2020; 18:267. [PMID: 33054830 PMCID: PMC7559741 DOI: 10.1186/s12957-020-02035-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/22/2020] [Indexed: 12/01/2022] Open
Abstract
Introduction The lymphocytic population, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) are prognostic tools predictive of adverse outcomes for several solid tumors and oncologic surgeries, one of which is esophageal adenocarcinoma. Furthermore, delayed resumption of oral feeding postoperatively is associated with significant morbidity. Given the controversies regarding post-op nutritional support in these patients, this study investigates the prognostic role of the lymphocytic percentage, the NLR, and the PLR in predicting prolonged length of hospital stay (LOHS) and ICU stay (LOICUS) as well as delayed oral feeding following transhiatal esophagectomy (THE) for adenocarcinoma of the esophagogastric junction (AEG). Methods Forty consecutive patients who underwent transhiatal esophagectomy performed by a single surgeon for Siewert type II and type III adenocarcinoma of the esophagogastric junction at a tertiary referral center were selected. Retrospective data collection was performed from the patients’ medical records, and statistical analysis was performed using Pearson correlation and Student’s t test and Chi-square testing. Results An increased LOHS was correlated with a lower preoperative lymphocyte percentage (p = 0.043), higher NLR (p = 0.010) and PLR (p = 0.015), and an increased number of packed red blood cell (PRBC) transfusions perioperatively (p = 0.030). An increased LOICUS was correlated with a lower preoperative lymphocyte percentage (p = 0.033), higher NLR (p = 0.018) and PLR (p = 0.044), an increased number of PRBC transfusions (p = 0.001), and patients’ comorbidities (p < 0.05). A delay in feeding resumption was correlated with a lower preoperative lymphocyte percentage (p = 0.022), higher NLR (p = 0.004) and PLR (p = 0.001), an increased PRBC transfusions (p = 0.001), and diabetes mellitus (p = 0.033). Multivariate analysis with automatic linear modeling showed that only the preoperative PLR was a powerful predictor for the delay of feeding resumption (p < 0.01). Conclusion The lymphocyte percentage, PLR, and NLR are found to be associated with prolonged hospitalization and ICU stay and delayed oral feeding following THE for Siewert types II and III AEG. We hope by this series, to have set, at least one preliminary cornerstone, in the creation of a prognostic model, capable of assessing the need for an intraoperative jejunostomy placement, in patients undergoing esophagectomy for distal esophageal carcinoma.
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Affiliation(s)
- Antoine El Asmar
- Institut Jules Bordet, Boulevard de Waterloo 121, 1000, Brussels, Belgium.
| | - Elie Ghabi
- Department of Urology, Saint George Hospital University Medical Center, P.O. Box 166378, Achrafieh, Beirut, 1100 2807, Lebanon
| | - Toufic Saber
- Department of General Surgery, Saint George Hospital University Medical Center, P.O. Box 166378, Achrafieh, Beirut, 1100 2807, Lebanon
| | - Christina Abou-Malhab
- Faculty of Medicine and Medical Sciences, University of Balamand, P.O. Box 166378, Achrafieh, Beirut, 1100 2807, Lebanon
| | - Bernard Akl
- Department of Urology, Saint George Hospital University Medical Center, P.O. Box 166378, Achrafieh, Beirut, 1100 2807, Lebanon
| | - Ziad El Rassi
- Department of General Surgery, Saint George Hospital University Medical Center, P.O. Box 166378, Achrafieh, Beirut, 1100 2807, Lebanon
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A Prospective Randomized Trial Comparing Jejunostomy and Nasogastric Feeding in Minimally Invasive McKeown Esophagectomy. J Gastrointest Surg 2020; 24:2187-2196. [PMID: 31512101 DOI: 10.1007/s11605-019-04390-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/28/2019] [Indexed: 02/06/2023]
Abstract
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.
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Zheng R, Rios-Diaz AJ, Liem S, Devin CL, Evans NR, Rosato EL, Palazzo F, Berger AC. 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. Am J Surg 2020; 221:141-148. [PMID: 32828519 DOI: 10.1016/j.amjsurg.2020.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Richard Zheng
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA.
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Spencer Liem
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Courtney L Devin
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Nathaniel R Evans
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Ernest L Rosato
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam C Berger
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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12
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Shiraishi O, Kato H, Iwama M, Hiraki Y, Yasuda A, Peng YF, Shinkai M, Kimura Y, Imano M, Yasuda T. Simplified percutaneous endoscopic transgastric conduit feeding jejunostomy for dysphagia after esophagectomy. Dis Esophagus 2020; 33:5487254. [PMID: 31069391 DOI: 10.1093/dote/doz042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/13/2019] [Accepted: 04/05/2019] [Indexed: 12/11/2022]
Abstract
Unexpected dysphagia is an important problem affecting life prognosis in patients who have undergone an esophagectomy for esophageal cancer. For nutritional support in patients suffering from dysphagia after a previous esophagectomy, a simplified percutaneous endoscopic transgastric conduit feeding jejunostomy approach was developed that can be performed regardless of the patient's condition. The feasibility of this procedure in 25 patients with esophageal cancer who underwent three-stage esophagectomy with retrosternal gastric conduit reconstruction from April 2009 to December 2016 was evaluated retrospectively. Under fluoroscopy, a percutaneous endoscopic transgastric conduit feeding jejunostomy catheter (9 French) was introduced into the jejunum in the epigastric region using the Seldinger's technique. The following patient data were analyzed retrospectively: operating time, complications, reasons for oral intake difficulty, and clinical data describing patients' nutritional status before and 1 month after percutaneous endoscopic transgastric conduit jejunostomy treatment, such as serum albumin and clinical course. Median patients' age was 68 years (range 50-76 years). Indications for the procedure were late swallowing dysfunction (n = 12), early swallowing dysfunction secondary to surgical complication (n = 8), anastomotic leakage (n = 3), and anorexia (n = 2). Causes of late swallowing dysfunction were radiation injury (n = 8), advanced age (n = 2), or cerebral infarction (n = 2). The median operating time was 29 minutes (range 14-82 minutes). Four patients developed mild erosions at the stoma secondary to bile reflux along the side of the catheter. No patient experienced severe complications such as ileus and peritonitis. Patients were treated for a median of 160 days (range 18-3106 days) with percutaneous endoscopic transgastric conduit jejunostomy. Patient's serum albumin significantly increased from 2.8 to 3.3 g/dl in 1 month. Of the eight patients with early swallowing dysfunction, six successfully regained sufficient oral nutrition after receiving enteral feeding nutritional management. Although all except one late swallowing dysfunction patient could not discontinue tube feeding, five patients were long-term survivors at the time this report was written. This jejunostomy procedure is simple, safe, and useful for patients with unexpected dysphagia and accompanying malnutrition after esophagectomy.
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Affiliation(s)
- Osamu Shiraishi
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Hiroaki Kato
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Mituru Iwama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Yoko Hiraki
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Atsushi Yasuda
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Ying-Feng Peng
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Masayuki Shinkai
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Yutaka Kimura
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Motohiro Imano
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Takushi Yasuda
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
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Koterazawa Y, Oshikiri T, Hasegawa H, Yamamoto M, Kanaji S, Yamashita K, Matsuda T, Nakamura T, Suzuki S, Kakeji Y. Routine placement of feeding jejunostomy tube during esophagectomy increases postoperative complications and does not improve postoperative malnutrition. Dis Esophagus 2020; 33:5475050. [PMID: 30997494 DOI: 10.1093/dote/doz021] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/15/2019] [Accepted: 02/26/2019] [Indexed: 12/11/2022]
Abstract
Esophagectomy for esophageal cancer is a highly invasive procedure, and a feeding jejunostomy tube (FJT) is routinely placed to ensure adequate enteral nutrition. However, the effect of perioperative short-term FJT placement remains controversial, and the aim of this study was to assess risks and benefits of routine FJT placement during esophagectomy and to determine parameters that can identify patients needing long-term FJT. This retrospective study included 393 patients who had undergone esophagectomy with gastric tube reconstruction via the posterior mediastinal route at the Kobe University Hospital and the Hyogo Cancer Center between April 2010 and December 2017. Propensity score matching was used to identify matched patients (139 per group) in the FJT and no-FJT groups. The incidence of postoperative complications and weight loss (3 months post-procedure) was compared in the matched cohort and significant risk factors predicting the need for long-term FJT placement in the whole cohort were identified. In the matched cohort, while weight loss was not different between the FJT and no-FJT groups (11% vs. 10%), the incidence of small bowel obstruction in the FJT group (11.5%) was significantly higher than that in the no-FJT group (0%). Multivariate analysis revealed that age (≥75 years), preoperative therapy, anastomosis leakage, and pulmonary complications were independent risk factors for long-term FJT placement. Routine placement of an FJT during esophagectomy increases small bowel obstruction and does not result in better nutritional status, suggesting that selective long-term FJT placement in high-risk patients should be considered.
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Affiliation(s)
- Yasufumi Koterazawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Masashi Yamamoto
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Kimihiro Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Takeru Matsuda
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Tetsu Nakamura
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Satoshi Suzuki
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
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14
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Shiraishi O, Kato H, Iwama M, Hiraki Y, Yasuda A, Peng YF, Shinkai M, Kimura Y, Imano M, Yasuda T. A simple, novel laparoscopic feeding jejunostomy technique to prevent bowel obstruction after esophagectomy: the "curtain method". Surg Endosc 2019; 34:4967-4974. [PMID: 31820160 DOI: 10.1007/s00464-019-07289-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Feeding jejunostomy (FJ) is a common treatment to support patients with esophageal cancer after esophagectomy. However, severe FJ-related complications, such as bowel obstruction, occasionally occur. We investigated the ability of our simple, novel FJ technique, the "curtain method," to prevent bowel obstruction. METHODS In laparoscopic surgery, the main mechanism of bowel obstruction involves torsion of the mesentery accompanied by migration of the intestine across the fixed FJ through the space surrounded by a triangle comprising the ligament of Treitz, fixed FJ, and spleen rather than adhesion. Our "curtain method" involves closure of this triangle zone with omentum, and the appearance of the lifted omentum resembles a curtain. Sixty patients treated with this modified FJ were retrospectively compared with 13 patients treated with conventional FJ in terms of the incidence of bowel obstruction, peritonitis, stoma site infection, and catheter obstruction. RESULTS From 2013 to 2017, 60 patients underwent esophagectomy and gastric conduit reconstruction accompanied by modified laparoscopic FJ. The median observation period, including the period after tube removal, was 644 days. No FJ-associated bowel obstruction, the prevention of which was the primary aim, occurred in any patient. Likewise, no peritonitis or dislodgement occurred. Eight patients (13%) developed a stoma site infection with granulation. The feeding tube became occluded in 11 patients (18%); however, a new feeding tube was reinserted under fluoroscopy for all of these patients. From 2003 to 2012, 13 patients underwent conventional FJ. The median observation period was 387 days. Three patients (23%) developed bowel obstruction by torsion 71 to 134 days after the first surgery, and all were treated by emergency operations. Other FJ-related complications were not different from those in the modified FJ group. CONCLUSION Our simple, novel technique, the "curtain method," for prevention of laparoscopic FJ-associated bowel obstruction after esophagectomy is a safe additional surgery.
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Affiliation(s)
- Osamu Shiraishi
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan.
| | - Hiroaki Kato
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan
| | - Mitsuru Iwama
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan
| | - Yoko Hiraki
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan
| | - Atsushi Yasuda
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan
| | - Ying-Feng Peng
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan
| | - Masayuki Shinkai
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan
| | - Yutaka Kimura
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan
| | - Motohiro Imano
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan
| | - Takushi Yasuda
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohnohigashi, Osaka-sayama, Osaka, 589-8511, Japan
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15
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Al-Temimi MH, Dyurgerova AM, Kidon M, Johna S. Feeding Jejunostomy Tube Placed during Esophagectomy: Is There an Effect on Postoperative Outcomes? Perm J 2019; 23:18.210. [PMID: 31496496 DOI: 10.7812/tpp/18.210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Mohammed H Al-Temimi
- Department of Surgery, Fontana Medical Center, CA.,Department of Surgery, Baylor University Medical Center, Dallas, TX
| | | | - Michael Kidon
- Touro University of Osteopathic Medicine, Henderson, NV
| | - Samir Johna
- Department of Surgery, Fontana Medical Center, CA
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16
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Abstract
Malnutrition is quite common in patients with esophageal cancer, and can be secondary to tumor related dysphagia or treatment side effects. Traditionally, open feeding jejunostomy tube was performed in all patients undergoing surgical treatment of esophageal cancer. With the advent of minimally invasive approaches, placement of the jejunostomy tube can be currently accomplished with either robotic or laparoscopic assistance. Here, we discuss the technical aspects as well as the pros and cons of a minimally invasive jejunostomy feeding tube placement.
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Affiliation(s)
- Charles Bakhos
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Shrey Patel
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Roman Petrov
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA.,Department of Surgical Oncology, Section of Thoracic Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Abbas Abbas
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA.,Department of Surgical Oncology, Section of Thoracic Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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17
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de Vasconcellos Santos FA, Torres Júnior LG, Wainstein AJA, Drummond-Lage AP. Jejunostomy or nasojejunal tube after esophagectomy: a review of the literature. J Thorac Dis 2019; 11:S812-S818. [PMID: 31080663 DOI: 10.21037/jtd.2018.12.62] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Fernando Augusto de Vasconcellos Santos
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brazil.,Departmet of Surgery, Hospital Governador Israel Pinheiro, Belo Horizonte, MG, Brazil
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18
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Álvarez-Sarrado E, Mingol Navarro F, J Rosellón R, Ballester Pla N, Vaqué Urbaneja FJ, Muniesa Gallardo C, López Rubio M, García-Granero Ximénez E. Feeding Jejunostomy after esophagectomy cannot be routinely recommended. Analysis of nutritional benefits and catheter-related complications. Am J Surg 2018; 217:114-120. [PMID: 30309617 DOI: 10.1016/j.amjsurg.2018.08.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/08/2018] [Accepted: 08/20/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients undergoing esophagectomy for cancer usually deal with malnourishment which increases postoperative morbimortality. The objective of this paper is to analyze the nutritional benefits of feeding jejunostomy (FJ) for early postoperative enteral nutrition (EN) and directly-related complications. MATERIAL AND METHODS Retrospective study of 100 patients undergoing esophagectomy for cancer between 2008 and 2016. RESULTS FJ was placed in 47 patients. 82.98% reached EN requirements in FJ group, with a median EN re-start of 1.9 days and median days to objective requirements of 5 days. 51.06% developed directly-related FJ complication, 91.66% of them mild ones (gastrointestinal or catheter-related). 2 patients (4.25%) required re-intervention. No significant differences were shown in total protein and albumin seric levels during first postoperative week and in anastomotic leak rate between both groups (p > 0.05). CONCLUSIONS Feeding jejunostomies are associated with a great number of complications although most are not life-threatening. Since its nutritional benefit is not proven FJ cannot routinely recommended after esophagectomy. However, the optimal pathway for EN reintroduction, including direct oral intake, is still a matter of debate.
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Affiliation(s)
- Eduardo Álvarez-Sarrado
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - Fernando Mingol Navarro
- Esophago-gastric Surgery Unit, University and Polytechnic La Fe Hospital, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain.
| | - Raquel J Rosellón
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - Neus Ballester Pla
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - Francisco Javier Vaqué Urbaneja
- Esophago-gastric Surgery Unit, University and Polytechnic La Fe Hospital, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain.
| | - Carmen Muniesa Gallardo
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - María López Rubio
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - Eduardo García-Granero Ximénez
- Head of General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain.
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19
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Kidane B, Kaaki S, Hirpara DH, Shen YC, Bassili A, Allison F, Waddell TK, Darling GE. Emergency department use is high after esophagectomy and feeding tube problems are the biggest culprit. J Thorac Cardiovasc Surg 2018; 156:2340-2348. [PMID: 30309674 DOI: 10.1016/j.jtcvs.2018.07.100] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 06/16/2018] [Accepted: 07/09/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Esophagectomy is a complex operation with potential for prolonged recovery. We aimed to identify the incidence of and risk factors for any and frequent emergency department visits within 1 year of esophagectomy. METHODS A retrospective cohort study was performed looking at consecutive esophagectomies at a tertiary Canadian center (1999-2014). Multivariable analyses identified factors associated with any emergency department visits and frequent emergency department use (≥3 visits) within 1 year postesophagectomy. RESULTS There were 520 esophagectomies with in-hospital mortality of 6% (n = 31). Of those discharged, 29.7% (n = 145) had ≥ 1 emergency department visit. Most common causes were feeding tube problems (39.3%; n = 57) and dysphagia/stricture (13.1%; n = 19). Higher income (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42 per $10,000) and use of hybrid/minimally invasive esophagectomy (aOR, 3.24; 95% CI, 1.71-6.11) were independently associated with having emergency department visits. Patients with hybrid/minimally invasive esophagectomy were discharged earlier than others (P < .0001). Living outside of our metropolitan area (aOR, 0.36; 95% CI, 0.27-0.49) and having surgery in the later years of the study period (aOR, 0.91; 95% CI, 0.86-0.97; P = .006) were both independently associated with lower odds of emergency department visits. Forty-three patients (8.8%) were frequent emergency department users, with the most common causes of repeat emergency visits being feeding tube problems. Living outside of our metropolitan area was associated with lower odds of frequent emergency visits (aOR, 0.25; 95% CI, 0.14-0.45). CONCLUSIONS There is high emergency department use within 1 year postesophagectomy. Patients living farther away from our hospital had a lower rate of emergency department use. It is possible that they are utilizing emergency departments nearer to home; this needs further study. Feeding tube problems are the biggest culprits and are potentially modifiable.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Suha Kaaki
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dhruvin H Hirpara
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yu Cindy Shen
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Adam Bassili
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Frances Allison
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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20
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Lahoud J, Bazzi K, Yeo D, Carey S. Survey of nutritional practices in total gastrectomy and oesophagectomy procedures. Nutr Diet 2018; 76:135-140. [DOI: 10.1111/1747-0080.12447] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 05/25/2018] [Accepted: 05/29/2018] [Indexed: 12/18/2022]
Affiliation(s)
- John Lahoud
- School of MedicineThe University of Notre Dame Australia Sydney New South Wales Australia
| | - Khalil Bazzi
- School of MedicineThe University of Notre Dame Australia Sydney New South Wales Australia
| | - David Yeo
- Department of Hepatobiliary and Upper Gastrointestinal SurgeryRoyal Prince Alfred Hospital Sydney New South Wales Australia
- Institute of Academic SurgeryRoyal Prince Alfred Hospital Sydney New South Wales Australia
| | - Sharon Carey
- Department of Nutrition and DieteticsRoyal Prince Alfred Hospital Sydney New South Wales Australia
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21
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Dalton BGA, Friedant AJ, Su S, Schatz TAP, Ruth KJ, Scott WJ. Benefits of Supplemental Jejunostomy Tube Feeding During Neoadjuvant Therapy in Patients with Locally Advanced, Potentially Resectable Esophageal Cancer. J Laparoendosc Adv Surg Tech A 2017; 27:1279-1283. [PMID: 28777676 DOI: 10.1089/lap.2017.0320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Stacey Su
- Fox Chase Cancer Center , Philadelphia, Pennsylvania
| | | | - Karen J Ruth
- Fox Chase Cancer Center , Philadelphia, Pennsylvania
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22
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Weijs TJ, van Eden HWJ, Ruurda JP, Luyer MDP, Steenhagen E, Nieuwenhuijzen GAP, van Hillegersberg R. Routine jejunostomy tube feeding following esophagectomy. J Thorac Dis 2017; 9:S851-S860. [PMID: 28815083 DOI: 10.21037/jtd.2017.06.73] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Malnutrition is an important problem following esophagectomy. A surgically placed jejunostomy secures an enteral feeding route, facilitating discharge with home-tube feeding and long-term nutritional support. However, specific complications occur, and data are lacking that support its use over other enteral feeding routes. Therefore routine jejunostomy tube feeding and discharge with home-tube feeding was evaluated, with emphasis on weight loss, length of stay and re-admissions. METHODS Consecutive patients undergoing esophagectomy for cancer, with gastric tube reconstruction and jejunostomy creation, were analyzed. Two different regimens were compared. Before January 07, 2011 patients were discharged when oral intake was sufficient, without tube feeding. After that discharge with home-tube feeding was routinely performed. Logistic regression analysis corrected for confounders. RESULTS Some 236 patients were included. The median duration of tube feeding was 35 days. Reoperation for a jejunostomy-related complication was needed in 2%. The median body mass index (BMI) remained stable during tube feeding. The BMI decreased significantly after stopping tube feeding: from 25.6 (1st-3rd quartile 23.0-28.6) kg/m2 to 24.4 (22.0-27.1) kg/m2 at 30 days later [median weight loss: 3.0 (1.0-5.3) kg; 3.9% (1.5-6.3%)]. Weight loss was not affected by the duration of tube feeding duration. Routine home-tube feeding did not affect weight loss, admission time or the readmission rate. CONCLUSIONS Weight loss following esophagectomy occurs once that tube feeding is stopped, independently from the time interval after esophagectomy. Moreover routine discharge with home-tube feeding does not reduce length of stay or readmissions. These findings question the value of routine jejunostomy placement and emphasize the need for further research.
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Affiliation(s)
- Teus J Weijs
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hanneke W J van Eden
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Elles Steenhagen
- Division of Internal Medicine and Dermatology, Department of Dietetics, University Medical Center Utrecht, Utrecht, the Netherlands
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Choi AH, O'Leary MP, Merchant SJ, Sun V, Chao J, Raz DJ, Kim JY, Kim J. Complications of Feeding Jejunostomy Tubes in Patients with Gastroesophageal Cancer. J Gastrointest Surg 2017; 21:259-265. [PMID: 27785689 PMCID: PMC5568416 DOI: 10.1007/s11605-016-3297-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 10/03/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Feeding jejunostomy tubes (FJT) in patients undergoing resection of gastroesophageal cancers facilitate perioperative nutrition. Data regarding FJT use and complications are limited. STUDY DESIGN A single institution review was performed for patients who underwent perioperative FJT placement for gastrectomy or esophagogastrectomy from 2007 to 2015. FJT-related and unrelated complications were evaluated. RESULTS FJTs were inserted for total/completion gastrectomy (n = 49/117, 41.9 %), proximal gastrectomy (n = 7/117, 6.0 %), or esophagogastrectomy (n = 61/117, 52.1 %). Ninety percent (n = 106/117) of patients used an FJT at some time point. Although the majority of patients (75.2 %) used FJTs after discharge, 8.5 % (n = 10/117) never used the FJT and 10.3 % (n = 12/117) used the FJT only during hospitalization. Overall, 44.4 % (n = 52/117) had FJT-related complications, including dislodgement (n = 22), clogging (n = 13), and leakage (n = 6). The majority of FJT complications were resolved by telephone triage (13.5 %) or bedside/clinic intervention (57.7 %), but 3.4 % required operative intervention for small bowel obstruction (n = 3) and hemorrhage (n = 1). FJT complications were more common with gastrectomy than esophagogastrectomy (53.6 vs. 36.0 %), perhaps related to longer FJT use in gastrectomy patients (71 vs. 38 days). CONCLUSIONS FJT-related complications are common, occurring more frequently after gastrectomy than esophagogastrectomy. In most patients, complications can be managed by simple measures, rarely requiring operative intervention. Nevertheless, the need for FJTs should be carefully considered to balance nutritional benefits with the risks of insertion and usage.
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Affiliation(s)
- Audrey H Choi
- Department of Surgery, City of Hope, Duarte, CA, USA
| | | | - Shaila J Merchant
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Virginia Sun
- Division of Nursing Research and Education, City of Hope, Duarte, CA, USA
| | - Joseph Chao
- Department of Medical Oncology, City of Hope, Duarte, CA, USA
| | - Dan J Raz
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Jae Y Kim
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Joseph Kim
- Department of Surgery, SUNY Stony Brook, Stony Brook, NY, USA.
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Laparoscopic percutaneous jejunostomy with intracorporeal V-Loc jejunopexy in esophageal cancer. Surg Endosc 2016; 31:2678-2686. [PMID: 27752817 DOI: 10.1007/s00464-016-5285-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/05/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Barbed sutures are widely used in various laparoscopic digestive surgeries. The purpose of this paper is to present our initial experience of laparoscopic percutaneous jejunostomy with unidirectional barbed sutures in esophageal cancer patients and compare it with our early cases using traditional transabdominal sutures. METHODS A total of 118 esophageal cancer patients who underwent laparoscopic percutaneous jejunostomy were identified in a single institution in Taiwan from June 2014 to May 2016. The authors' traditional technique consisted of using transabdominal sutures with bolsters to fix a jejunum loop onto the anterior abdominal wall. A novel technique was introduced using intracorporeal suturing with knotless unidirectional barbed monofilament absorbable sutures (V-Loc) to attain a seal around the feeding catheter. A comparison between these two techniques was performed. RESULTS Twenty cases with barbed V-Loc sutures and 98 cases with transabdominal sutures were identified. The V-Loc sutures appeared to reduce peristomal skin ulcers (19.4 vs. 0 %, p = 0.040), postoperative pain scores during the first 24 h (1.8 ± 1.4 vs. 0.9 ± 1.1, p = 0.007) and on postoperative day 2 (1.7 ± 1.4 vs. 1.0 ± 0.8, p = 0.026) when compared to patients receiving transabdominal sutures. The mean suturing time using V-Loc sutures was 22 min (14-60 min). The mean onset to resumption of enteral feeding was 1.8 ± 0.8 days and the mean duration of postoperative hospital stay was 8 ± 5.1 days, both of which were comparable in the two groups. There was no surgical mortality in our series. CONCLUSIONS In the study cohort, the use of knotless unidirectional barbed sutures instead of traditional transabdominal sutures had similar outcomes and appears to be a feasible option for intracorporeal jejunopexy when performing laparoscopic jejunostomy in patients with esophageal cancer.
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25
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Elshaer M, Gravante G, White J, Livingstone J, Riaz A, Al-Bahrani A. Routes of early enteral nutrition following oesophagectomy. Ann R Coll Surg Engl 2016; 98:461-7. [PMID: 27388543 DOI: 10.1308/rcsann.2016.0198] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- M Elshaer
- West Hertfordshire Hospitals NHS Trust , UK
| | - G Gravante
- University Hospitals of Leicester NHS Trust , UK
| | - J White
- West Hertfordshire Hospitals NHS Trust , UK
| | | | - A Riaz
- West Hertfordshire Hospitals NHS Trust , UK
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26
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Speer EA, Chow SC, Dunst CM, Shada AL, Halpin V, Reavis KM, Cassera M, Swanström LL. Clinical Burden of Laparoscopic Feeding Jejunostomy Tubes. J Gastrointest Surg 2016; 20:970-5. [PMID: 26895952 DOI: 10.1007/s11605-016-3094-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 01/24/2016] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Emily A Speer
- Department of Surgery, Providence Portland Medical Center, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Simon C Chow
- Department of Surgery, Legacy Good Samaritan Hospital, 1040 NW 22nd Ave, Suite 520, Portland, OR, 97210, USA
| | - Christy M Dunst
- Department of Surgery, Providence Portland Medical Center, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA. .,Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA. .,Foundation for Surgical Innovation and Education, 4805 NE Glisan St., Suite 6N60, Portland, OR, 97213, USA.
| | - Amber L Shada
- Department of Surgery, Providence Portland Medical Center, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Valerie Halpin
- Department of Surgery, Legacy Good Samaritan Hospital, 1040 NW 22nd Ave, Suite 520, Portland, OR, 97210, USA
| | - Kevin M Reavis
- Department of Surgery, Providence Portland Medical Center, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St., Suite 6N60, Portland, OR, 97213, USA
| | - Maria Cassera
- Department of Surgery, Providence Portland Medical Center, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St., Suite 6N60, Portland, OR, 97213, USA
| | - Lee L Swanström
- Department of Surgery, Providence Portland Medical Center, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Department of Surgery, Legacy Good Samaritan Hospital, 1040 NW 22nd Ave, Suite 520, Portland, OR, 97210, USA.,Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St., Suite 6N60, Portland, OR, 97213, USA.,Institut Hospitalo Universitaire Strasbourg, 1, Place de l'Hôpital, 97000, Strasbourg, France
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27
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Bowrey DJ, Baker M, Halliday V, Thomas AL, Pulikottil-Jacob R, Smith K, Morris T, Ring A. A randomised controlled trial of six weeks of home enteral nutrition versus standard care after oesophagectomy or total gastrectomy for cancer: report on a pilot and feasibility study. Trials 2015; 16:531. [PMID: 26590903 PMCID: PMC4654827 DOI: 10.1186/s13063-015-1053-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 11/12/2015] [Indexed: 12/21/2022] Open
Abstract
Background Poor nutrition in the first months after oesophago-gastric resection is a contributing factor to the reduced quality of life seen in these patients. The aim of this pilot and feasibility study was to ascertain the feasibility of conducting a multi-centre randomised controlled trial to evaluate routine home enteral nutrition in these patients. Methods Patients undergoing oesophagectomy or total gastrectomy were randomised to either six weeks of home feeding through a jejunostomy (intervention), or treatment as usual (control). Intervention comprised overnight feeding, providing 50 % of energy and protein requirements, in addition to usual oral intake. Primary outcome measures were recruitment and retention rates at six weeks and six months. Nutritional intake, nutritional parameters, quality of life and healthcare costs were also collected. Interviews were conducted with a sample of participants, to ascertain patient and carer experiences. Results Fifty-four of 112 (48 %) eligible patients participated in the study over the 20 months. Study retention at six weeks was 41/54 patients (76 %) and at six months was 36/54 (67 %). At six weeks, participants in the control group had lost on average 3.9 kg more than participants in the intervention group (95 % confidence interval [CI] 1.6 to 6.2). These differences remained evident at three months (mean difference 2.5 kg, 95 % CI −0.5 to 5.6) and at six months (mean difference 2.5 kg, 95 % CI −1.2 to 6.1). The mean values observed in the intervention group for mid arm circumference, mid arm muscle circumference, triceps skin fold thickness and right hand grip strength were greater than for the control group at all post hospital discharge time points. The economic evaluation suggested that it was feasible to collect resource use and EQ-5D data for a full cost-effectiveness analysis. Thematic analysis of 15 interviews identified three main themes related to the intervention and the trial: 1) a positive experience, 2) the reasons for taking part, and 3) uncertainty of the study process. Conclusions This study demonstrated that home enteral feeding by jejunostomy was feasible, safe and acceptable to patients and their carers. Whether home enteral feeding as ’usual practice’ is a cost-effective therapy would require confirmation in an appropriately powered, multi-centre study. Trial registration UK Clinical Research Network ID 12447 (main trial, first registered 30 May 2012); UK Clinical Research Network ID 13361 (qualitative substudy, first registered 30 May 2012); ClinicalTrials.gov NCT01870817 (first registered 28 May 2013)
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Affiliation(s)
- David J Bowrey
- Department of Surgery, University Hospitals of Leicester NHS Trust, Level 6 Balmoral Building, Leicester, UK.
| | - Melanie Baker
- Department of Surgery, University Hospitals of Leicester NHS Trust, Level 6 Balmoral Building, Leicester, UK.
| | - Vanessa Halliday
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Anne L Thomas
- Department of Cancer Studies, University of Leicester, Leicester, UK.
| | | | - Karen Smith
- Department of Health Sciences, University of Leicester, Leicester, UK.
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK.
| | - Arne Ring
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK. .,Current affiliation: Department of Mathematical Statistics and Actuarial Science, University of the Free State, Bloemfontein, South Africa.
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Baker M, Halliday V, Williams RN, Bowrey DJ. A systematic review of the nutritional consequences of esophagectomy. Clin Nutr 2015; 35:987-94. [PMID: 26411750 DOI: 10.1016/j.clnu.2015.08.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 08/14/2015] [Accepted: 08/31/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS As improved outcomes after esophagectomy have been observed over the last two decades, the focus on care has shifted to survivorship and quality of life. The aim of this review was to determine changes in nutrition after esophagectomy and to assess the evidence for extended nutrition support. METHODS A search strategy was developed to identify primary research reporting change in nutritional status a minimum of one month after esophagectomy. RESULTS Changes in nutritional parameters reported by 18 studies indicated a weight loss of 5-12% at six months postoperatively. More than half of patients lost >10% of body weight at 12 months. One study reported a persistent weight loss of 14% from baseline three years after surgery. Three studies reporting on longer term follow up noted that 27%-95% of patients failed to regain their baseline weight. Changes in dietary intake (three studies) indicated inadequate energy and protein intake up to three years after surgery. Global quality of life scores reported in one study correlated with better weight preservation. There were a high frequency of gastrointestinal symptoms reported in six studies, most notably in the first year after surgery, but persisting up to 19 years. Extended enteral nutrition on a selective basis has been reported in several studies. CONCLUSIONS Nutritional status is compromised in the months/years following oesophagectomy and may never return to baseline levels. The causes/consequences of weight loss/impaired nutritional intake require further investigation. The role of extended nutritional support in this population remains unclear.
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Affiliation(s)
- Melanie Baker
- Dept of Surgery, Leicester Royal Infirmary, LE1 5WW, United Kingdom
| | - Vanessa Halliday
- School of Health and Related Research (ScHARR), University of Sheffield, S1 4DA, United Kingdom
| | | | - David J Bowrey
- Dept of Surgery, Leicester Royal Infirmary, LE1 5WW, United Kingdom.
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29
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Feeding jejunostomy tube placement during resection of gastric cancers. J Surg Res 2015; 200:189-94. [PMID: 26248478 DOI: 10.1016/j.jss.2015.07.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 07/02/2015] [Accepted: 07/08/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Feeding tube placement is common among patients undergoing gastrectomy, and national guidelines currently recommend consideration of a feeding jejunostomy tube (FJT) for all patients undergoing resection for gastric cancer. However, data are limited regarding the safety of FJT placement at the time of gastrectomy for gastric cancer. METHODS The 2005-2011 American College of Surgeons National Surgical Quality Improvement Program Participant User Files were queried to identify patients who underwent gastrectomy for gastric cancer. Subjects were classified by the concomitant placement of an FJT. Groups were then propensity matched using a 1:1 nearest neighbor algorithm, and outcomes were compared between groups. The primary outcomes of interest were overall 30-d overall complications and mortality. Secondary end points included major complications, surgical site infection, and early reoperation. RESULTS In total, 2980 subjects underwent gastrectomy for gastric cancer, among whom 715 (24%) also had an FJT placed. Patients who had an FJT placed were more likely to be male (61.6% versus 56.6%, P = 0.02), have recent weight loss (21.0% versus 14.8%, P < 0.01), and have undergone recent chemotherapy (7.9% versus 4.2%, P < 0.01) and radiation therapy (4.2% versus 1.3%, P < 0.01). They were also more likely to have undergone total (compared with partial) gastrectomy (66.6% versus 28.6%, P < 0.01) and have concomitant resection of an adjacent organ (40.4 versus 24.1%, P < 0.01). After adjustment with propensity matching, however, all baseline characteristics and treatment variables were highly similar. Between groups, there were no statistically significant differences in 30-d overall complications (38.8% versus 36.1%, P = 0.32) or mortality (5.8 versus 3.7%, P = 0.08). There were also no differences in major complications, surgical site infection, or early reoperation. Operative time was slightly longer among patients with feeding tubes placed (median, 248 versus 233 min, P = 0.01), but otherwise there were no significant differences in any outcomes between groups. CONCLUSIONS Concomitant placement of FJT at the time of gastrectomy may result in slightly increased operative times but does not appear to lead to increased perioperative morbidity or mortality. Further investigation is needed to identify the patients most likely to benefit from FJT placement.
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Weijs TJ, Berkelmans GHK, Nieuwenhuijzen GAP, Ruurda JP, van Hillegersberg R, Soeters PB, Luyer MDP. Routes for early enteral nutrition after esophagectomy. A systematic review. Clin Nutr 2014; 34:1-6. [PMID: 25131601 DOI: 10.1016/j.clnu.2014.07.011] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/30/2014] [Accepted: 07/26/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early enteral feeding following surgery can be given orally, via a jejunostomy or via a nasojejunal tube. However, the best feeding route following esophagectomy is unclear. OBJECTIVES To determine the best route for enteral nutrition following esophagectomy regarding anastomotic leakage, pneumonia, percentage meeting the nutritional requirements, weight loss, complications of tube feeding, mortality, patient satisfaction and length of hospital stay. DESIGN A systematic literature review following PRISMA and MOOSE guidelines. RESULTS There were 17 eligible studies on early oral intake, jejunostomy or nasojejunal tube feeding. Only one nonrandomized study (N = 133) investigated early oral feeding specifically following esophagectomy. Early oral feeding was associated with a reduced length of stay with delayed oral feeding, without increased complication rates. Postoperative nasojejunal tube feeding was not significantly different from jejunostomy tube feeding regarding complications or catheter efficacy in the only randomised trial on this subject (N = 150). Jejunostomy tube feeding outcome was reported in 12 non-comparative studies (N = 3293). It was effective in meeting short-term nutritional requirements, but major tube-related complications necessitated relaparotomy in 0-2.9% of patients. In three non-comparative studies (N = 135) on nasojejunal tube feeding only minor complications were reported, data on nutritional outcome was lacking. Data on patient satisfaction and long-term nutritional outcome were not found for any of the feeding routes investigated. CONCLUSION It is unclear what the best route for early enteral nutrition is after esophagectomy. Especially data regarding early oral intake are scarce, and phase 2 trials are needed for further investigation. REGISTRATION International prospective register of systematic reviews, CRD42013004032.
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Affiliation(s)
- Teus J Weijs
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands; Department of Surgery, University Medical Center Utrecht, The Netherlands.
| | | | | | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | | | - Peter B Soeters
- Department of General Surgery, Academic Hospital Maastricht, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
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31
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Via MA, Mechanick JI. Malnutrition, Dehydration, and Ancillary Feeding Options in Dysphagia Patients. Otolaryngol Clin North Am 2013; 46:1059-71. [DOI: 10.1016/j.otc.2013.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Ben-David K, Kim T, Caban AM, Rossidis G, Rodriguez SS, Hochwald SN. Pre-therapy laparoscopic feeding jejunostomy is safe and effective in patients undergoing minimally invasive esophagectomy for cancer. J Gastrointest Surg 2013; 17:1352-8. [PMID: 23709367 DOI: 10.1007/s11605-013-2231-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 05/07/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Laparoscopic feeding jejunostomy is a safe and effective means of providing enteral nutrition in the preoperative phase to esophageal cancer patients. DESIGN This research is a retrospective case series. SETTING This study was conducted in a university tertiary care center. PATIENTS Between August 2007 and April 2012, 153 laparoscopic feeding jejunostomies were performed in patients 10 weeks prior to their definitive minimally invasive esophagectomy. MAIN OUTCOME MEASURES The outcome is measured based on the technique, safety, and feasibility of a laparoscopic feeding jejunostomy in the preoperative phase of esophageal cancer patients. RESULTS One hundred fifty-three patients underwent a laparoscopic feeding jejunostomy approximately 1 and 10 week(s) prior to the start of their neoadjuvant therapy and definitive minimally invasive esophagectomy, respectively. Median age was 63 years. Of the patients, 75 % were males and 25 % were females. One hundred twenty-seven patients had gastroesophageal junction adenocarcinoma and 26 had squamous cell carcinoma. All patients completed their neoadjuvant chemoradiation therapy. The median operative time was 65 min. We had no intraoperative complications, perforation, postoperative bowel necrosis, bowel torsion, herniation, intraperitoneal leak, or mortality as a result of the laparoscopic feeding jejunostomy. Four patients were noted to have superficial skin infection around the tube, and 11 patients required a tube exchange for dislodgment, clogging, and leaking around the tube. All patients progressed to their definitive surgical esophageal resection. CONCLUSION A laparoscopic feeding jejunostomy is technically feasible, safe, and can provide appropriate enteral nutrition in the preoperative phase of esophageal cancer patients.
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Affiliation(s)
- Kfir Ben-David
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL 32610-0109, USA.
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Abstract
Esophageal cancer has traditionally been a disease with poor long term outcomes in terms of both survival and quality of life. In combination with surgical and pharmacologic therapy, nutrition support has been demonstrated to improve patient tolerance of treatment, quality of life, and longterm outcomes. An aggressive multi-disciplinary approach is warranted with nutrition support remaining a cornerstone in management. Historically, nutrition support has focused on adequate caloric provision to prevent weight loss and allow for tolerance of treatment regimens. Alterations in metabolism occur in these patients making their use of available calories inefficient and the future of nutritional support may lie in the ability to alter this deranged metabolism. The purpose of this article is to review the current literature surrounding the etiology, treatment, and role of nutrition support in improving outcomes in esophageal cancer.
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