Routes for early enteral nutrition after esophagectomy. A systematic review

Nutritional support via feeding jejunostomy in esophago-gastric cancers: proposal of a common working strategy based on the available evidence

Malnutrition is common in patients affected by esophago-gastric cancers and has a negative impact on both clinical and economic outcomes. Yet not all patients at risk of malnutrition are routinely assessed and receive appropriate support. Further, available research does not provide a mean for standardization of timing, route, and dosage for nutritional support, and this is particularly true for enteral nutrition via feeding jejunostomy. Herein, we provide an overview of the current evidence and use the gathered knowledge as a starting point for a consensus proposal. As a result, we aim to facilitate the development of appropriate and uniformed interventions, thus fulfilling the need for a multimodal therapeutic approach in these set of cancer patients.

Clinical implementation of minimally invasive esophagectomy

BACKGROUND

Minimally invasive surgery is becoming the method of choice for the resection of esophageal cancer worldwide.

METHODS

Retrospective analysis of prospectively collected clinical data in a tertiary care center with a detailed description of the course of the program.

RESULTS

A total of 136 transthoracic esophageal resections were performed between 2010 and 2023. The study group included 116 operations, 69 of which were fully minimally invasive and 47 hybrid. 80.0% of the study group underwent surgery using a multimodality approach. The median operation time was 431 min (± 103). The R0 resection rate was 100%. Forty-two patients (36.2%) had no postoperative complications. The postoperative Clavien-Dindo > IIIb morbidity was 27%. The postoperative 90-d mortality rate was 1.7%. The average number of lymph nodes removed in the last quarter of cancer patients was 31. The anastomotic insufficiency rate for reoperation was 4% (Ivor-Lewis 4.2%, McKeown 5%).

CONCLUSIONS

With extensive expertise in high-end minimally invasive abdominal and thoracic surgery, implementation of a minimally invasive esophageal resection program with a clinical and oncologic outcome within generally accepted limits is feasible.

Patient-Reported Outcomes after Surgical, Endoscopic, or Radiological Techniques for Nutritional Support in Esophageal Cancer Patients: A Systematic Review

Several techniques exist to maintain oral and/or enteral feeding among esophageal cancer (EC) patients, but their impact on patient-reported outcomes (PROs) remains unclear. This systematic review aimed to assess the impact of nutritional support techniques on PROs in EC patients. We searched Medline, Web of Science, and CINAHL Complete from inception to 3 April 2024. Eligible studies included those evaluating EC patients, reporting PROs using standardized measures, and providing data on different nutritional support techniques or comparing them to no intervention. The reference lists of the included studies were also screened for additional eligible articles. The Mixed Methods Appraisal Tool was used to evaluate the quality of the included studies. Of the 694 articles identified from databases and 224 from backward citation, 11 studies met the inclusion criteria. Nine studies evaluated the overall quality of life (QoL), four assessed pain, and one evaluated depression. Among those submitted to esophagectomy, jejunostomy may be associated with higher QoL scores and less postoperative pain, compared to a nasojejunal tube, but no significant differences were found when compared to no intervention. For patients undergoing chemotherapy or receiving palliative/symptomatic treatment, expandable metal stents (SEMSs) were associated with higher levels of emotional functioning when compared with laparoscopic gastrostomy. Moreover, percutaneous endoscopic gastrostomy or SEMSs were associated with a higher QoL compared with nasogastric tubes. This review underscores the importance of considering PRO measures when evaluating nutritional support techniques in cancer patients, though further robust evidence is needed to fully understand these associations.

Effectiveness of long-term tube feeding intervention in preventing skeletal muscle loss after minimally invasive esophagectomy

PURPOSE

Esophageal cancer is a lethal tumor typically treated by neoadjuvant chemotherapy and surgery. For patients undergoing esophagectomy, postoperative enteral nutrition is important in preventing complications. Sarcopenia is associated with poor postoperative outcomes in esophageal cancer. In this study, we evaluated the benefits of tube feeding intervention and compared its short- and long-term outcomes in patients who underwent esophagectomy.

METHODS

Propensity score matching was performed in 303 patients who underwent esophagectomy at Kobe University Hospital between 2010 and 2020. Patients were divided into feeding and nonfeeding jejunostomy tube groups (n = 70 each). The feeding jejunostomy tube group was further divided into long-term (≥ 60 days) and short-term (< 60 days) subgroups. The groups were then retrospectively compared regarding postoperative albumin levels, body weight, and psoas muscle area and volume.

RESULTS

In the long-term feeding jejunostomy tube group, anastomotic leakage (p = 0.013) and left laryngeal nerve palsy (p = 0.004) occurred frequently. There were no significant between-group differences in postoperative albumin levels, body weight, or psoas muscle area. However, significant psoas muscle volume recovery was confirmed in the long-term jejunostomy tube group at 6 months postoperatively (p = 0.041).

CONCLUSIONS

Tube feeding intervention after minimally invasive esophagectomy may attenuate skeletal muscle mass loss and help prevent sarcopenia.

Postoperative nutrition in the setting of enhanced recovery programmes

Patients undergoing major surgery for gastrointestinal cancer are at high risk of developing or worsening malnutrition and sarcopenia. In malnourished patients, preoperative nutritional support may not be sufficient and so postoperative support is advised. This narrative review addresses several aspects of postoperative nutritional care in the setting of enhanced recovery programmes. Early oral feeding, therapeutic diet, oral nutritional supplements, immunonutrition, and probiotics are discussed. When postoperative intake is insufficient, nutritional support favouring the enteral route is recommended. Whether this approach should use a nasojejunal tube or jejunostomy is still a matter of debate. In the setting of enhanced recovery programmes with early discharge, nutritional follow-up and care should be continued beyond the short time in hospital. In enhanced recovery programmes, the main specific aspects of nutrition are patient education, early oral intake, and post-discharge care. The other aspects do not differ from conventional care.

S3-Leitlinie Heimenterale und heimparenterale Ernährung der Deutschen Gesellschaft für Ernährungsmedizin (DGEM)

Medizinische Ernährungstherapie, die enterale und parenterale Ernährung umfasst, ist ein wesentlicher Teil der Ernährungstherapie. Medizinische Ernährungstherapie beschränkt sich nicht auf die Krankenhausbehandlung, sondern kann effektiv und sicher auch zu Hause eingesetzt werden. Dadurch hat sich der Stellenwert der Medizinischen Ernährungstherapie deutlich erhöht und ist zu einem wichtigen Bestandteil der Therapie vieler chronischer Erkrankungen geworden. Für Menschen mit chronischem Darmversagen, z. B. wegen Kurzdarmsyndrom ist die Medizinische Ernährungstherapie sogar lebensrettend. In der Leitlinie wird die Evidenz für die Medizinische Ernährungstherapie in 161 Empfehlungen dargestellt. Die Leitlinie wendet sich in erster Linie an Ärzte, Ernährungsfachkräfte und Pflegekräfte, sie dient der Information für Pharmazeuten und anderes Fachpersonal, kann aber auch für den interessierten Laien hilfreich sein.

Nursing staff adherence to guidelines on nutritional management for critically ill patients with cancer: A service evaluation

BACKGROUND

Critically ill patients with cancer are at high risk of developing malnutrition, negatively affecting their outcome.

AIM

To critically analyse nursing staff's adherence to nutrition management guidelines for critically unwell patients with cancer and identify barriers which prevent this. Two areas of nutrition management were evaluated: early initiation (<48 h from admission) of enteral nutrition (EN) and continuation of EN without interruption.

STUDY DESIGN

A retrospective data analysis was performed on mechanically ventilated adult patients admitted to a single cancer centre. Data from electronic patient records (EPR) were collected. Health care professionals' (HCP) documentation was analysed, and a nursing staff focus group (n = 5) was undertaken.

RESULTS

Sixty-four patient records were included. Early EN was not administered in 67% (n = 43) of cases. The reasons for the three longest interruptions to EN feed were as follows: delays in EN tube insertion, gastric residual volumes (GRVs) less than the recommended feed discontinuation threshold and endotracheal intubation. Four main themes relating to barriers to practice were identified from the focus group data analysis: HCPs' approach towards nutrition management, the patient's physiological condition and stability, multi-disciplinary team (MDT) communication and guidance on nutrition management, and practical issues with patient care.

CONCLUSIONS

Multi-disciplinary communication difficulties, lack of clear guidelines and inadequate awareness of the importance of nutrition for critically ill patients with cancer were barriers identified preventing optimal nutrition management.

RELEVANCE TO CLINICAL PRACTICE

Nursing education is fundamental to help break down the barriers to practice which prevent critically ill patients from receiving optimal nutrition management.

Will synchronous esophageal and lung resection increase the incidence of anastomotic leaks? A multicenter retrospective study

BACKGROUND

Reports on combined resection for synchronous lung lesions and esophageal cancer (CRLE) cases are rare and mostly individual cases. Furthermore, the feasibility of CRLE has always been a controversial topic. In the current study, the authors retrospectively analyzed the feasibility of CRLE and established an individualized prediction model for esophageal anastomotic leaks after CRLE by performing a multicenter retrospective study.

METHODS

Patients who underwent esophagectomy between January 2009 and June 2021 were extracted from a four-center prospectively maintained database, and those with CRLE at the same setting were matched in a 1:2 propensity score-matched (PSM) ratio to esophagectomy alone (EA) patients. A nomogram was then established based on the variables involved in multivariate logistic regression analysis. Internal validation of the nomogram was conducted utilizing Bootstrap resampling. Decision and clinical impact curve analysis were computed to assess the practical clinical utility of the nomogram. A prognosis analysis for CRLE and EA patients by Kaplan-Meier curves was conducted.

RESULTS

Of the 7152 esophagectomies, 216 cases of CRLE were eligible, and 1:2 ratio propensity score-matched EA patients were matched. The incidence of anastomotic leaks following CRLE increased significantly ( P =0.035). The results of the multivariate analysis indicated the leaks varied according to the type of lung resection (anatomic>wedge resection, P =0.016) and site of resected lobe (upper>middle/low lobe; P =0.027), and a nomogram was established to predict the occurrence of leaks accurately (area under the curve=0.786). Although no statistically significant difference in overall survival (OS) was observed in the CRLE group ( P =0.070), a trend toward lower survival rates was noted. Further analysis revealed that combined upper lobe anatomic resection was significantly associated with reduced OS ( P =0.027).

CONCLUSION

Our study confirms that CRLE is feasible but comes with a significantly increased risk of anastomotic leaks and a concerning trend of reduced survival, particularly when upper lobe anatomic resections are performed. These findings highlight the need for careful patient selection and surgical planning when considering CRLE.

Benefit of a laparoscopic jejunostomy feeding catheter insertion to prevent bowel obstruction associated with feeding jejunostomy after esophagectomy

The placement of a jejunostomy catheter during esophagectomy may cause postoperative bowel obstruction. The proximity of the jejunostomy site to the midline might be associated with bowel obstruction, and we have introduced laparoscopic jejunostomy (Lap-J) to reduce jejunostomy's left lateral gap. We evaluated 92 patients who underwent esophagectomy for esophageal cancer between February 2013 and August 2022 to clarify the benefits of Lap-J compared to other methods. The patients were classified into two groups according to the method of feeding catheter insertion: jejunostomy via small laparotomy (J group, n = 75), and laparoscopic jejunostomy (Lap-J group, n = 17). Surgery for bowel obstruction associated with the feeding jejunostomy catheter (BOFJ) was performed on 11 in the J group. Comparing the J and Lap-J groups, the distance between the jejunostomy and midline was significantly longer in the Lap-J group (50 mm vs. 102 mm; P < 0.001). Regarding surgery for BOFJ, the distance between the jejunostomy and midline was significantly shorter in the surgery group than in the non-surgery group (43 mm vs. 52 mm; P = 0.049). During esophagectomy, Lap-J can prevent BOFJ by placing the jejunostomy site at the left lateral position to the midline and reducing the left lateral gap of the jejunostomy.

The impact of jejunostomy feeding on nutritional outcomes after oesophagectomy

BACKGROUND

Nutritional status is compromised long-term following oesophagectomy. Controversy surrounds the optimal route for nutrition support postoperatively and there is wide variation in the use of feeding jejunostomy tubes.

METHODS

A retrospective service evaluation was conducted for all consecutive adults who underwent oesophagectomy for a cancer diagnosis within a specialist centre between April 2016 and July 2019 (n = 165). Nutritional and clinical outcomes were compared for patients who received jejunostomy feeding (n = 24), versus those who did not (n = 141).

RESULTS

Patients with feeding jejunostomy lost significantly less weight at both 6 and 12 months postoperatively compared to those without jejunostomy (p ≤ 0.001 and p = 0.001, respectively). This remained statistically significant in multiple regression, controlling for age, gender, preoperative tumour staging and adjuvant treatment (p ≤ 0.001 and p = 0.03, respectively). Median length of home enteral feeding was 10 weeks after discharge in the jejunostomy group. We observed minor jejunostomy tube-related complications in four patients (16.7%). Of those readmitted within 90 days of surgery in the non-jejunostomy group, nutritional failure was a factor in 43.2% of these readmissions. "Rescue tube feeding" was required by 8.5% of the non-jejunostomy group within the first postoperative year, including 6.4% within 90 days of surgery.

CONCLUSIONS

Use of short-term supplementary jejunal feeding in addition to oral intake after hospital discharge is beneficial for maintaining weight after oesophagectomy. We suggest a future randomised-controlled trial to confirm these findings.

Effect of Early Versus Late Oral Feeding on Postoperative Complications and Recovery Outcomes for Patients with Esophageal Cancer: A Systematic Evaluation and Meta-Analysis

BACKGROUND

This study aimed to systematically evaluate the effect of early oral feeding (EOF) versus late oral feeding (LOF) on postoperative complications and rehabilitation outcomes for patients with esophageal cancer.

METHODS

This study searched relevant literature published up to March 2023 by computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science. A meta-analysis was performed using Review Manager 5.4 software to compare the effects of EOF and LOF on postoperative complications and recovery outcomes of patients with esophageal cancer.

RESULTS

The study included 14 articles, including 9 retrospective studies, 4 randomized controlled trials (RCTs), and 1 prospective study. The 2555 patients included in the study comprised 1321 patients who received EOF and 1234 patients who received LOF. The results of the meta-analysis showed that compared with the LOF group, the EOF group has a shorter time to the first flatus postoperatively (mean difference [MD],  -  1.12; 95% confidence interval [CI], (-  1.25 to -  1.00; P < 0.00001), a shorter time to the first defecation postoperatively (MD, -  1.31; 95% CI, -  1.67 to -   0.95;, P < 0.00001], and a shorter hospital stay postoperatively (MD, -  2.87; 95% CI, -  3.84 to -  1.90; P < 0.00001). The two groups did not differ significantly statistically in terms of postoperative anastomotic leakage rate (P = 0.10), postoperative chyle leakage rate (P = 0.10), or postoperative pneumonia rate (P = 0.15).

CONCLUSION

Early oral feeding after esophageal cancer surgery can shorten the time to the first flatus and the first defecation postoperatively, shorten the hospital stay, and promote the recovery of patients. Moreover, it has no significant effect on the incidence of postoperative complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The feasibility of a "no tube, no fasting" fast-track recovery protocol after esophagectomy for esophageal cancer patients aged 75 and over

Objective

For elderly patients aged ≥75 with esophageal cancer, whether surgical treatment is safe and effective and whether it is feasible to use a relatively radical "no tube, no fasting" fast-track recovery protocol remain topics of debate. We conducted a retrospective analysis to shed light on these two questions.

Methods

We retrospectively collected the data of patients who underwent McKeown minimally invasive esophagectomy (MIE) combined with early oral feeding (EOF) on postoperative day 1 between April 2015 and December 2017 at Medical Group 1, Ward 1, Department of Thoracic Surgery of our hospital. Preoperative characteristics, postoperative complications, operation time, intraoperative blood loss, duration of anastomotic leakage (day), hospital stay, and survival were evaluated.

Results

Twenty-three elderly patients with esophageal cancer underwent surgery with EOF. No significant difference was observed in intraoperative measures. The incidence of postoperative complications was 34.8% (8/23). Two patients (8.7%) were terminated early during the analysis of the feasibility of EOF. For all 23 patients, the mean hospital stay was 11.4 (5-42) days, and the median survival was 51 months.

Conclusion

Patients aged ≥75 with resectable esophageal cancer can achieve long-term survival with active surgical treatment. Moreover, the "no tube, no fasting" fast-track recovery protocol is safe and feasible for elderly patients.

Hospital Variation in Feeding Jejunostomy Policy for Minimally Invasive Esophagectomy: A Nationwide Cohort Study

The purpose of this study was to investigate hospital variation in the placement, surgical techniques, and safety of feeding jejunostomies (FJ) during minimally invasive esophagectomy (MIE) in the Netherlands. This nationwide cohort study analyzed patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) that underwent MIE for cancer. Hospital variation in FJ placement rates were investigated using case-mix corrected funnel plots. Short-term outcomes were compared between patients with and without FJ using multilevel multivariable logistic regression analysis. The incidence of FJ-related complications was described and compared between hospitals performing routine and non-routine placement (≥90%−<90% of patients). Between 2018−2020, an FJ was placed in 1481/1811 (81.8%) patients. Rates ranged from 11−100% among hospitals. More patients were discharged within 10 days (median hospital stay) without FJ compared to patients with FJ (64.5% vs. 50.4%; OR: 0.62, 95% CI: 0.42−0.90). FJ-related complications occurred in 45 (3%) patients, of whom 23 (1.6%) experienced severe complications (≥Clavien−Dindo IIIa). The FJ-related complication rate was 13.7% in hospitals not routinely placing FJs vs. 1.7% in hospitals performing routine FJ placement (p < 0.001). Significant hospital variation in the use of FJs after MIE exists in the Netherlands. No effect of FJs on complications was observed. FJs can be placed safely, with lower FJ-related complication rates, in centers performing routine placement.

Cancers œsophagiens : nouveautés et défis des prises en charge chirurgicales

Surgical resection of esophageal carcinoma is one of the mainstays of curative treatment for these cancers. During the last decade, numerous improvements in surgical approaches and perioperative management of these patients have resulted in a decrease in postoperative morbidity and mortality. Thus, centralization of patients with esophagogastric adenocarcinoma in high volume center, development of minimally invasive surgery and improvements in surgical imaging have led to reduce mortality rate, major pulmonary complication rate and postoperative chylothorax rate. Optimization of postoperative management with enhanced recovery programs has meanwhile reduced the rate of major postoperative complication and the hospital length of stay. The objective of this review is to give an overview of novelties and challenges regarding surgical management of patients with esophageal carcinoma.

Cessation of Routine Jejunostomy Tube Placement at Time of Minimally Invasive Ivor Lewis Esophagectomy and Impact on Body Mass Index

Jejunostomy tubes are frequently placed at time of esophagectomy. The purpose of this study is to evaluate cessation of routine j-tube placement on postoperative body mass index (BMI), return to the emergency room, and time until adjuvant therapy. We performed a retrospective review of an institutional database for consecutive patients undergoing minimally invasive Ivor Lewis Esophagectomy from 2014-2021 (after January 2019, routine j-tube placement was abandoned). Data was analyzed using Pearson's Chi-squared tests and Student's t test with 2-sided significance level of P < 0.05. In total,179 patients were included, 95 underwent j-tube placement and 84 did not. Cohorts had comparable baseline BMI's (no j-tube: 30.48 vs j-tube: 28.64, P = 0.06) and anastomotic leak rates (2.4% vs 4.2%, P = 0.5). Patients with no jejunostomy tubes were more likely to receive total parenteral nutrition (14.3% vs 5.3%, P < 0.05), but were no more likely to require total parenteral nutrition at discharge and had comparable durations of TPN requirement (7 days vs 12 days, P = 0.53). There was no difference in mean BMI reduction at 2 weeks (2.54 vs 2.09, P = 0.49) and 3-6 months postoperatively (6.11 vs 4.45 P = 0.15). There was no difference in return to the emergency room (8.3% vs 8.4%, P = 0.98) or readmissions (13.1% vs 11.6%, P = 0.76). There was a no difference in mean time to adjuvant therapy (83.5 days vs 72.6 days, P = 0.67). At esophagectomy centers with low anastomotic leak rates, cessation of routine j-tube placement at time of minimally esophagectomy can be undertaken without increasing risk of readmission, time until initiation of adjuvant therapy, or significantly impacting postoperative BMI loss.

Feeding jejunostomy following esophagectomy may increase the occurrence of postoperative small bowel obstruction

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.

Role of intraoperative feeding jejunostomy in esophageal cancer surgery

Background

Feeding jejunostomy was routinely placed during esophagectomy to ensure postoperative enteral feeding. Improved anastomosis technique and early oral feeding strategy after esophagectomy has led to question the need for the routine placement of feeding jejunostomy. The aim of this study is to evaluate role of feeding jejunostomy during Ivor Lewis operation.

Methods

We retrospectively reviewed 414 patients who underwent the Ivor Lewis operations from January 2015 to December 2018.

Results

61 patients (14.7%) received jejunostomy insertion. The most common indication for jejunostomy was neoadjuvant concurrent chemoradiation therapy (CCRT). 48 patients (79%) had jejunostomy removed within 60 days after the surgery and the longest duration of jejunostomy inserted state was 121 days. About two-third of the patients with jejunostomy had never prescribed with an enteral feeding product. Among 353 patients without intraoperative feeding jejunostomy, 11(3.1%) received delayed jejunostomy insertion. Graft-related problems (6 patients), cancer progression (3 patients), acute lung injury (1 patient), and swallowing difficulty (1 patient) were reasons for delayed feeding jejunostomy insertion. Complication rate was relatively high as 24 patients (33.3%) out of 72 patients with jejunostomy insertion had complications and 7 patients (9.7%) visited ER more than twice with jejunostomy-related complications.

Conclusion

Only 3.6% patients who underwent the Ivor Lewis operation during 4-year span had anastomosis leakage. Although one-third of the patients with jejunostomy were benefited with alternative method of feeding after discharge, high complication rate regarding jejunostomy should be also considered. We believe feeding jejunostomy should not be applied routinely with prophylactic measures and should be reserved to very carefully selected patients with multiple high-risk factors.

Nasogastric tube drainage and pyloric intervention after oesophageal resection: UK practice variation and effect on outcomes

BACKGROUND

Over 1500 patients with oesophageal cancer undergo a resection in the UK each year. At surgery, patients commonly have a nasogastric tube (NGT) placed and may undergo a pyloric intervention. There is conflicting evidence on the use of both NGTs and pyloric interventions during oesophageal resections. We performed a national survey of oesophageal centres and assessed practice variation.

MATERIAL AND METHODS

An electronic survey was distributed to all resection centres in England, Wales and Scotland. Variations in practice regarding NGTs and pyloric intervention were assessed, and compared to nationally reported centre volumes and length-of-stay data.

RESULTS

Most centres (31/39, 79%) responded to the survey. All centres reported routine NGT use. The majority of centres (19/31, 61%) did not perform pyloric interventions. When used, surgical pyloroplasty was the most frequent strategy (8/31, 26%). Routine post-operative radiological assessment was utilised in 9/31 (29%) of centres. Criteria for NGT removal and dietary progression was highly variable, with every centre reporting different protocols. There were no significant differences in practice between high and low volume centres. There were also no trends seen when comparing centres above vs at-or-below the median length-of-stay. The majority (68%) of centres were willing to take part in a trial assessing NGT use and pyloric interventions.

CONCLUSIONS

Pyloric intervention use varies widely, with no clear link to outcomes. NGT use remains standard practice despite evidence for safe omission. Surgeons require and recognise the need for a trial to assess requirement for NGTs and pyloric intervention after oesophageal resection.

Clinical Benefits of Routine Feeding Jejunostomy Tube Placement in Patients Undergoing Esophagectomy

BACKGROUND

Routine placement of a feeding jejunostomy tube (FJT) following esophagectomy remains controversial due to the risk of complications including small bowel obstruction (SBO). This study aimed to evaluate FJT placement following esophagectomy.

METHODS

This retrospective cohort study included consecutive 229 patients undergoing thoracoscopic esophagectomy between January 2010 and June 2020. Short-term outcomes, postoperative nutritional status, incidence of SBO, and long-term outcomes were compared between patients according to FJT placement.

RESULTS

The total operative duration was significantly longer in the FJT group compared to the no FJT group (P < 0.0001); however, no differences in overall or severe postoperative morbidity were observed. Body weight loss at discharge was significantly attenuated in patients with FJT (5% vs 7%, P = 0.001). Serum cholinesterase levels were significantly higher in patients with FJT (P = 0.002), while no difference was observed in serum albumin levels. At 6-month follow-up, no statistically significant differences were observed in serological markers or percentage body weight. The incidence of SBO was significantly higher in the FJT group (P = 0.006). The 5-year incidence of SBO was 12%. Patients in the FJT group had higher progression-free and overall survival compared to patients in the no FJT group (P = 0.041 and P = 0.033, respectively). A similar trend toward better survival in the FJT group was observed after propensity score matching.

CONCLUSIONS

Routine placement of FJT significantly improves postoperative nutritional status and may contribute to improved long-term survival but is associated with increased long-term risk of SBO.

ESPEN practical guideline: Home enteral nutrition

This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.

Effectiveness of an early, quantified, modified oral feeding protocol on nutritional status and quality of life of patients after minimally invasive esophagectomy: A retrospective controlled study

OBJECTIVES

Previous studies confirmed the safety and feasibility of oral feeding on the first postoperative day (POD) for patients with minimally invasive esophagectomy (MIE). Nonetheless, some clinical concern can lead to delays in early oral feeding on POD 1. To our knowledge, few reports have focused on resolving these clinical concerns. The aims of this study were to evaluate the effects of an early, quantified, modified oral feeding protocol for patients after MIE and to explore its effect on nutritional status and quality of life (QoL).

METHODS

In this prospective controlled trail, 200 patients were selected as the intervention group (IG) from March 2020 to June 2021; 115 patients hospitalized from June 2019 to February 2020 were assigned to the control group (CG). For 2 wk during the postoperative period, IG participants received an early, quantified, modified oral feeding protocol. The recovery of dietary outcomes, nutritional status, and QoL were evaluated after the intervention.

RESULTS

There was no significant difference between the two groups in terms of demographic and clinical characteristics and baseline physical function. After the intervention, patients in the IG showed a more rapid growth in daily total oral caloric intake and the ratio of oral calorie intake to total calorie required by the body (K/R value) from POD 1 to POD 14, and less weight loss (1.5 ± 1 versus 2.1 ± 1.7 kg; P < 0.05), better serum prealbumin (193.0 ± 26.9 versus 139.3 ± 27.2 mg/L; P < 0.05) than the CG with statistical significance. By the second week of the intervention, IG patients reported higher global QoL and function scores and lower symptom scores than patients in the CG. The IG participants presented a shorter time to first flatus and bowel movement (P < 0.001), a shorter postoperative hospital length of stay, and higher activities of daily living scores (P < 0.05) the those in the CG.

CONCLUSIONS

The findings demonstrated that the early, quantified, modified oral feeding protocol can alleviate postoperative body weight loss, improve the patient's nutritional status, and have a positive effect on QoL and early recovery for patients undergoing MIE.

Risk Factors for Failure of Direct Oral Feeding Following a Totally Minimally Invasive Esophagectomy

Recently, it has been shown that directly starting oral feeding (DOF) from postoperative day one (POD1) after a totally minimally invasive Ivor-Lewis esophagectomy (MIE-IL) can further improve postoperative outcomes. However, in some patients, tube feeding by a preemptively placed jejunostomy is necessary. This single-center cohort study investigated risk factors associated with failure of DOF in patients that underwent a MIE-IL between October 2015 and April 2021. A total of 165 patients underwent a MIE-IL, in which DOF was implemented in the enhanced recovery after surgery program. Of these, 70.3% (n = 116) successfully followed the nutritional protocol. In patients in which tube feeding was needed (29.7%; n = 49), female sex (compared to male) (OR 3.5 (95% CI 1.5–8.1)) and higher ASA scores (III + IV versus II) (OR 2.2 (95% CI 1.0–4.8)) were independently associated with failure of DOF for any cause. In case of failure, this was either due to a postoperative complication (n = 31, 18.8%) or insufficient caloric intake on POD5 (n = 18, 10.9%). In the subgroup of patients with complications, higher ASA scores (OR 2.8 (95% CI 1.2–6.8)) and histological subtypes (squamous-cell carcinoma versus adenocarcinoma and undifferentiated) (OR 5.2 (95% CI 1.8–15.1)) were identified as independent risk factors. In the subgroup of patients with insufficient caloric intake, female sex was identified as a risk factor (OR 5.8 (95% CI 2.0–16.8)). Jejunostomy-related complications occurred in 17 patients (10.3%). In patients with preoperative risk factors, preemptively placing a jejunostomy may be considered to ensure that nutritional goals are met.

Assessment of button-type jejunostomy for nutritional management after esophagectomy in 201 cases

BACKGROUND

Many surgeons preferably place a trans-nasal feeding tube or a feeding enterostomy for post-operative nutritional management after esophagectomy. Various types of tubes (such as nasogastric, transgastric, transduodenal, or transjejunal tubes) have been used for enteral feeding; however, the appropriate enteral feeding routes have not yet been proposed. Therefore, this study aimed to evaluate the feasibility and safety of button-type jejunostomy.

METHODS

We reviewed 201 patients who underwent esophagectomy with placement of a button-type jejunostomy at the Jikei University Hospital (Tokyo, Japan) between 2008 and 2019. The analyzed variables included clinicopathological characteristics, operative data, jejunostomy-related characteristics, and postoperative complications. Postoperative bodyweight loss was examined 6 months and 1 year after the operation.

RESULTS

Refractory enterocutaneous fistula and bowel obstruction occurred in 13 (6.5%) and 14 (7.0%) patients, respectively. The body mass index at button-type jejunostomy removal was significantly lower and the duration of button-type jejunostomy placement was significantly longer in patients with a refractory enterocutaneous fistula (p = 0.023 and p < 0.001, respectively). Bowel obstruction was significantly more likely to develop in patients with a non-squamous cell carcinoma (p = 0.021) and in patients who underwent open abdominal procedures (p < 0.001). After 1 year, the median bodyweight losses were 12.1% and 15.6% in patients with short and long jejunostomy placement durations (p = 0.642), respectively.

CONCLUSION

A button-type jejunostomy is durable and allows easy self-management for maintaining the bodyweight without any adverse events. However, it is strongly recommended that the button be removed within a year to prevent refractory enterocutaneous fistula formation.

Assessing the Prognostic Value of Extranodal Extension in Esophageal Cancer from the Pathological Staging Perspective

BACKGROUND

Extranodal extension (ENE) is a prognostic factor for several types of malignant tumors, including esophageal cancer. Although the prognostic value of ENE has been investigated in esophageal cancer, its clinical utility warrants further investigation.

MATERIALS AND METHODS

This retrospective single-center study evaluated 105 patients who underwent esophagectomy and had histologically node-positive metastasis between January 2007 and June 2017. The abilities of ENE to predict overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan-Meier method and log-rank test, as well as Cox proportional hazard models. Subgroup analyses of ENE's prognostic value were performed according to each pathological tumor-node-metastasis category.

RESULTS

Significant differences according to ENE status were observed in the Kaplan-Meier analyses of OS (p = 0.001) and DFS (p = 0.001), as well as in the Cox proportional hazards models for OS (p = 0.009) and DFS (p = 0.012). Relative to patients without ENE, patients with ENE had significantly poorer OS if they also had pT3 status, pN1 status, or pathological stage III disease. However, no significant differences were observed in the subgroup analyses of pN3 status and pathological stage IV disease.

CONCLUSIONS

Among patients with esophageal cancer, ENE status can predict a poor prognosis and may be useful for patient stratification. However, the prognostic value of ENE status may be limited to patients with specific pathological factors.

A Meta-analysis of Jejunostomy Versus Nasoenteral Tube for Enteral Nutrition Following Esophagectomy

BACKGROUND

Postoperative nutritional therapy is of paramount importance for patients undergoing esophagectomy. The jejunostomy and nasoenteral tube are the popular routes for nutritional therapy. However, which one is the preferred route is unclear. This study aims to analyze the differences in safety and efficacy of the two routes for nutritional therapy.

MATERIALS AND METHODS

PubMed, Web of Science, Cochrane Library, and EMBASE (till September 17, 2020) were searched. The primary outcome was postoperative pneumonia. Secondary outcomes were the length of hospital stays (LOS), bowel obstruction, catheter dislocation, anastomotic leakage, overall postoperative complications, and postoperative albumin. Weighted mean differences (WMD) and odds ratios (OR) were calculated for statistical analysis.

RESULTS

Ten studies involving a total of 1,531 patients in the jejunostomy group and 1,375 patients in the nasoenteral tube group were included. Compared with patients in the nasoenteral tube group, those in the jejunostomy group had a lower incidence of postoperative pneumonia (OR = 0.68, P < 0.001), shorter LOS (WMD = -0.85, P < 0.001), and lower risk of catheter dislocation (OR = 0.15, P = 0.001). There were no significant differences in the incidence of anastomotic leakage (OR = 0.84, P = 0.43), overall postoperative complications (OR = 0.87, P = 0.59), and postoperative albumin (WMD = -0.40, P = 0.24). However, patients in the jejunostomy group had a higher risk of bowel obstruction (OR = 8.42, P = 0.002).

CONCLUSIONS

Jejunostomy for enteral nutrition showed superior outcomes in terms of postoperative pneumonia, LOS, and catheter dislocation. Jejunostomy may be the preferred enteral nutritional route following esophagectomy.

Association between low-fat enteral nutrition after esophagectomy and a lower incidence of chyle leakage: A call for more and better evidence

Objective

Reliable methods to prevent chyle leakage after esophagectomy are needed. This retrospective study was performed to evaluate the correlation between low-fat nutrition and the incidence of chyle leakage after esophagectomy.

Methods

This multicenter retrospective case–control study involved patients who underwent Ivor Lewis esophagectomy from December 2012 to August 2017. Tube feeding was started on postoperative day 1 with a normal fat-containing formula (control group, 203 patients) or low fat-containing formula (241 patients).

Results

The patients in the control group and low-fat group had a similar incidence of chyle leakage (7 [3.4%] vs. 19 [9.4%], respectively) and anastomotic leakage (4 [2.0%] vs. 11 [5.4%], respectively). The multivariate logistic regression indicated that high-volume surgeon experience (performance of ≥100 esophagectomies per year) was correlated with a lower incidence of chyle leakage (odds ratio, 0.280; 95% confidence interval, 0.110–0.712), whereas low-fat nutrition was correlated with an increased risk of anastomotic leakage (odds ratio, 5.995; 95% confidence interval, 1.201–29.925).

Conclusion

Prophylactic low-fat enteral nutrition following esophagectomy might not decrease the risk of chyle leakage. More and better evidence is needed.

Impact of Early Oral Feeding on Anastomotic Leakage Rate After Esophagectomy: A Systematic Review and Meta-analysis

BACKGROUND

Esophageal cancer occupies a vital position in fatal cancer-related disease, with esophagectomy procedures helping to improve patient survival. The timing when oral intake should be resumed after esophagectomy and whether early oral feeding (EOF) or delayed oral feeding (DOF) should be the optimal regimen are controversial.

METHODS

Databases (PubMed, Embase, Cochrane library) were searched. All records were screened by two authors through full-text reading. Data on the anastomotic leakage rate were extracted and synthesized in meta-analyses. Postoperative pneumonia rate and length of hospital stay were also assessed.

RESULTS

Seven studies from 49 records were included after full-text reading; 1595 patients were totally included in the analysis. No significant difference was observed between the EOF and DOF groups (odds ratio [OR] 1.68; 95% confidence interval [CI] 0.70-4.03; p = 0.2495; I² = 70%). Higher anastomotic leakage rate was observed in EOF compared with DOF (OR 2.89; 95% CI 1.56-5.34; p = 0.0007; I² = 10%) in the open subgroup. No significant difference was observed in the MIE (OR 0.48; 95% CI 0.22-1.02; p = 0.0564; I² = 0%). Patients performed similarly in pneumonia (OR 1.12; 95% CI 0.57-2.21; p = 0.745; I² = 34%). In cervical subgroup, anastomosis leakage may be less in DOF (OR 2.42 95% CI 1.26-4.64; p = 0.0651; I² = 58%), while in thoracic subgroup, there is no obvious difference (OR 0.86 95% CI 0.46-1.61; p = 0.01; I² = 84.9%).

CONCLUSIONS

Anastomotic leakage related to the timing of oral feeding after open esophagectomy, which is more favorable to the DOF regimen. However, timing of oral feeding did not impair anastomotic healing in patients undergoing MIE.

Nasojejunal Feeding Is Safe and Effective Alternative to Feeding Jejunostomy for Postoperative Enteral Nutrition in Gastric Cancer Patients

Background and Aim  Carcinoma of the stomach is one of the leading causes of mortality worldwide. Surgery for gastric cancer in the form of total or distal gastrectomy is definitive treatment. Feeding jejunostomy (FJ) though improves postoperative nutritional status and outcome, it is not devoid of its complications. In this study, we present the outcomes of nasojejunal (NJ) feeding and FJ and complications associated with them.

Materials and Methods  It is both retrospective and prospective observational study in patients with gastric cancer undergoing surgery. Patients were divided into two groups: those who underwent FJ and those who underwent NJ route of feeding placed intraoperatively.

Results  A total of 279 patients of gastric cancer who underwent surgery were taken into study, of which, 165 were male and 114 females. FJ was done in 42 and NJ in 237 patients, respectively. Gastrectomy + NJ was done in 128 patients, gastrectomy + FJ in 27 patients, gastrojejunostomy + NJ in 109 patients, and FJ in 15 patients. We had three patients of bile leaks in FJ group, of which one patient had intraperitoneal leak who needed re-exploration; rest of the two had peri-FJ external leaks, who were managed conservatively. Most of the complications of NJ group were minor.

Conclusion  Our study of 279 patients in gastric cancer has shown that FJ is sometimes associated with major complications with increased hospital stay and morbidity when compared with NJ tube feeding without any difference in nutritional outcomes. Hence, NJ route of postoperative enteral nutrition can be considered as an alternative to FJ wherever feasible in view of its technical safety and minor complications and morbidity.

Comparison of laparoscopy versus mini-laparotomy for jejunostomy placement in patients with gastric adenocarcinoma

BACKGROUND

Optimal nutrition is challenging for patients with gastric and gastroesophageal adenocarcinoma and often requires feeding tube placement prior to preoperative therapy. Feeding jejunostomy (FJ) placement via mini-laparotomy is technically easier to perform than laparoscopic FJ. The purpose of this study was to compare outcomes in patients with gastric adenocarcinoma undergoing laparoscopic versus mini-laparotomy FJ placement.

METHODS

A retrospective cohort study was performed of patients with gastric adenocarcinoma receiving laparoscopic versus mini-laparotomy FJ at a single tertiary referral center from 2000 to 2018. 30-day outcomes included complications, conversion to laparotomy, reoperation, length of stay, and readmission.

RESULTS

A total of 656 patients met the inclusion criteria and were studied. The majority of patients were male (68.1%) with a mean age of 60.6 years. The difference in surgical approach remained relatively stable over time. Overall, 82 (12.5%) patients experienced complications, and three (0.5%) patients died postoperatively. While readmission and conversion to open laparotomy did not differ between groups, overall complications (10.5% vs. 20.8%, p = 0.002), Clavien-Dindo ≥ 3 complications (4.0% vs. 8.9%, p = 0.021), length of stay (4.1 vs. 5.6 days, p < 0.001), and reoperation (0.9% vs. 4.0%, p = 0.002) favored the laparoscopic over mini-laparotomy group.

CONCLUSION

The current study helps clarify the risk of FJ placement in patients with gastric adenocarcinoma requiring nutritional support. Laparoscopic FJ placement has lower overall morbidity and length of stay compared to mini-laparotomy. However, caution is needed in preventing and identifying the rare causes of postoperative mortality that may be associated with laparoscopic FJ placement.

Vertical distance from navel as a risk factor for bowel obstruction associated with feeding jejunostomy after esophagectomy: a retrospective cohort study

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.

Routine intraoperative jejunostomy placement and minimally invasive oesophagectomy: an unnecessary step?†

OBJECTIVES

Adequate nutrition is challenging after oesophagectomy. A jejunostomy is commonly placed during oesophagectomy for nutritional support. However, some patients develop jejunostomy-related complications and the benefit over oral nutrition alone is unclear. This study aims to assess jejunostomy-related complications and the impact of intraoperative jejunostomy placement on weight loss and perioperative outcomes in patients with oesophageal cancer treated with minimally invasive Ivor Lewis oesophagectomy (MIE).

METHODS

From a prospectively maintained database, patients were identified who underwent MIE with gastric reconstruction. Between 2007 and 2016, a jejunostomy was routinely placed during MIE. After 2016, a jejunostomy was not utilized. Postoperative feeding was performed according to a standardized protocol and similar for both groups. The primary outcomes were jejunostomy-related complications, relative weight loss at 3 and 6 months postoperative and perioperative outcomes, including anastomotic leak, pneumonia and length of stay, respectively.

RESULTS

A total of 188 patients were included, of whom 135 patients (72%) received a jejunostomy. Ten patients (7.4%) developed jejunostomy-related complications, of whom 30% developed more than 1 complication. There was no significant difference in weight loss between groups at 3 months (P = 0.73) and 6 months postoperatively (P = 0.68) and in perioperative outcomes (P-value >0.999, P = 0.591 and P = 0.513, respectively).

CONCLUSIONS

The use of a routine intraoperative jejunostomy appears to be an unnecessary step in patients undergoing MIE. Intraoperative jejunostomy placement is associated with complications without improving weight loss or perioperative outcomes. Its use should be tailored to individual patient characteristics. Early oral nutrition allows patients to maintain an adequate nutritional status.

Surgical Adjuncts During Esophagectomy

Esophagectomy is a major operation whereby intraoperative technique and postoperative care must be optimal. Even in expert hands, the complication rate is as high as 59%. Here the authors discuss the role of surgical adjuncts, including enteral access, nasogastric decompression, pyloric drainage procedures, and anastomotic buttressing as adjuncts to esophagectomy and whether they reduce perioperative complications.

Impact on Short-Term Complications of Early Oral Feeding in Patients with Esophageal Cancer After Esophagectomy

To evaluate early oral feeding (EOF) in short-term outcomes of patients with esophageal cancer after esophagectomy. 179 patients with esophageal cancer who underwent esophagectomy between January 2016 and February 2018 were enrolled for this study. 87 patients with EOF without nasogastric tube or nasogastric tube was removed within 24 h, were selected as the experimental group, whereas 92 patients who received nasojejunal tube feeding were set as the control group. All laboratory testing, clinical features, and hospitalization expenses were compared between the two groups. No statistical significance was observed between the two groups in hemoglobin, albumin, and prealbumin levels after esophagectomy. Notably, there was no significant difference in the incidence of severe pneumonia and anastomotic leakage between the two groups. Admittance period, postoperative defecation time, and medical expenses were significantly decreased among patients with EOF (P < 0.001). Multivariate Cox multiple-factor regression analysis revealed that there was no correlation between EOF and the risk of anastomotic leakage. EOF might not be a risk factor for increasing the incidence of severe pneumonia and anastomotic leakage in patients with esophageal cancer after esophagectomy, and it could reduce the hospitalization period as well as control medical expenses.

The effect of early oral feeding after esophagectomy on the incidence of anastomotic leakage: an updated review

OBJECTIVE

Early oral feeding (EOF) is considered to be an important component of enhanced recovery after surgery (ERAS), but raises the concern of increased risk of anastomotic leakage (AL) in patients receiving esophagectomy. This review aimed to elucidate the correlation of EOF and the incidence of AL after esophageal resection.

METHODS

We searched PubMed, Web of Science, Scopus, Cochrane Library and Google Scholar from their inception to February 2020 for published articles that compared AL after EOF (oral feeding initiated within postoperative day [POD] 3) vs. conventional feeding regimen (nil-by-mouth with enteral tube nutrition support, until oral feeding since POD 4 and beyond) following esophagectomy.

RESULTS

A total of 11 full articles were included in this review, including 5 registered randomized controlled trials (RCTs) and 6 observational studies that compared EOF with conventional care after esophagectomy. Meta-analysis was not possible due to significant heterogeneity, bias, and small sample sizes. Among the 11 included studies, 9 (including the 5 RCTs) showed that EOF did not increase AL rate, whereas the other 2 retrospective studies indicated that delayed oral feeding resulted in fewer AL.

CONCLUSIONS

EOF after esophagectomy probably does not increase the incidence of AL, and it is a promising strategy in line with the essence of ERAS. However, more and better evidence from high-quality RCTs are still needed.

The decrease of BMI and albumin levels influences the rate of anastomotic leaks in patients following reconstruction after emergency diverting esophagectomy

OBJECTIVES

Diverting esophagectomies in cases of benign esophageal perforations remain rare but potentially life saving procedures. Usually, an esophagostoma and a feeding jejunostomy or gastrostomy are created, and patients are given time to recover from the emergency situation. However, little is known about morbidity and mortality as well as the optimal timing for a staged reconstruction.

METHODS

Patients with benign esophageal perforations were selected from our retrospective database. Perforations in esophageal malignancies were excluded to avoid bias on patients' general outcome. Clinical parameters and especially, the influence of the nutritional status indicated by the BMI (Body Mass Index) as well as serum albumin levels (g/l) were analyzed.

RESULTS

A total of 24 patients with diverting esophagectomies were identified. Of these, 13 (54.2%) patients received a staged reconstruction after a median of 143.0 days. Patients presenting for their staged reconstruction demonstrated a significantly decreased level of their BMI (p = 0.026) as compared to their prior hospitalization. Interestingly, the relative decrease of BMI (8.5 kg/m² vs. 4.3 kg/m²) and albumin levels (6.5 g/l vs. 0.0 g/l) was significantly different in patients with or without anastomotic leaks between both surgeries (p = 0.021; p = 0.034, respectively). In addition, higher rates of overall complications were associated with an increased rate of malnutrition.

CONCLUSIONS

The relative amount of malnutrition indicated by BMI or serum albumin levels influences the rate of anastomotic leaks and general complications in patients with staged reconstruction after diverting esophagectomy for non-malignant esophageal perforations. Hence, reconstruction should be done as fast as possible to reduce the amount of malnutrition and a frequent assessment of the nutritional status must be done during recovery from the emergency surgery.

Surgical management of gastric adenocarcinoma. Official expert recommendations delivered under the aegis of the French Association of Surgery (AFC)

Gastric adenocarcinoma (GA) is the 5^th most common cancer in the world; in France, however, its incidence has been steadily decreasing. Twenty-five experts brought together under the aegis of the French Association of Surgery collaborated in the drafting of a series of recommendations for surgical management of GA. As concerns preoperative evaluation and work-up, echo-endoscopy aimed at clarifying lymph node status should be performed in all candidates for surgical resection and exploratory laparoscopy in cases of GA cT3/T4 and/or N+ for peritoneal carcinomatosis. On the other hand, PET-scan should not be performed systematically, but only when the other modalities for diagnosis prove insufficient. Laparotomy remains the route of choice to achieve total or partial gastrectomy with D2 lymph node lymphadenectomy for advanced lesions (>T2N0). To limit the risk of dumping syndrome and esophageal reflux and as a way of reestablishing continuity, construction of a jejunal pouch on Roux-en-Y following total gastrectomy is recommended. In cases of peritoneal carcinosis in GA with a low peritoneal cancer index (PCI) (<7) in a patient in good general condition whose disease is controlled by chemotherapy, macroscopically complete cytoreduction with intraperitoneal hyperthermal chemotherapy will probably be required, and it will have to take place in an expert center. Only in the event of Child A cirrhosis may gastrectomy with D2 lymphadenectomy be considered. Palliative gastrectomy or surgical bypass for distal stomach obstruction in a patient in good general condition may also be envisioned.

The enhanced recovery after surgery (ERAS) protocol to promote recovery following esophageal cancer resection

Esophageal cancer surgery, comprising esophagectomy with radical lymphadenectomy, is a complex procedure associated with considerable morbidity and mortality. The enhanced recovery after surgery (ERAS) protocol which aims to improve perioperative care, minimize complications, and accelerate recovery is showing promise for achieving better perioperative outcomes. ERAS is a multimodal approach that has been reported to shorten the length of hospital stay, reduce surgical stress response, decrease morbidity, and expedite recovery. While ERAS components straddle preoperative, intraoperative, and postoperative periods, they need to be seen in continuum and not as isolated elements. In this review, we elaborate on the components of an ERAS protocol after esophagectomy including preoperative nutrition, prehabilitation, counselling, smoking and alcohol cessation, cardiopulmonary evaluation, surgical technique, anaesthetic management, intra- and postoperative fluid management and pain relief, mobilization and physiotherapy, enteral and oral feeding, removal of drains, and several other components. We also share our own institutional protocol for ERAS following esophageal resections.

Routine placement of feeding jejunostomy tube during esophagectomy increases postoperative complications and does not improve postoperative malnutrition

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.

Patient-reported experience and outcome measures during treatment for gastroesophageal cancer

OBJECTIVE

Gastroesophageal cancer has high mortality, and continuous assessment of patient-reported data is salient for optimisation of supportive care. We aimed to evaluate our multidisciplinary concept with respect to patient-reported variables.

METHODS

At diagnosis and later during the treatment, three areas of patient-reported measures were evaluated: the given information and care, fatigue (Multidimensional Fatigue Inventory [MFI-20]), dysphagia (Ogilvie dysphagia score) and weight loss.

RESULTS

Of 130 outpatients, planned for a surgical procedure and given a contact nurse (CN), 106 responded. During treatment, 81% of the patients were satisfied with their CN. The given information was considered very good or good by >90% and easily understood. Half of the patients reported need for supportive care, which was rated good by 85%. All dimensions of the MFI-20 test, except mental fatigue, worsened during the treatment period. At diagnosis, 61% of the patients experienced eating problems, leading to 7% weight loss. Although dysphagia improved, weight loss reached 13% at the end of treatment.

CONCLUSION

A multidisciplinary concept can be of value in giving appropriate and understandable information, leading to high satisfaction with the provided care. However, as fatigue and weight loss increased during the treatment period, patients need structured multidisciplinary support.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Optimal timing and route of nutritional support after esophagectomy: A review of the literature

Some controversy surrounds the postoperative feeding regimen utilized in patients who undergo esophagectomy. Variation in practices during the perioperative period exists including the type of nutrition started, the delivery route, and its timing. Adequate nutrition is essential for this patient population as these patients often present with weight loss and have altered eating patterns after surgery, which can affect their ability to regain or maintain weight. Methods of feeding after an esophagectomy include total parenteral nutrition, nasoduodenal/nasojejunal tube feeding, jejunostomy tube feeding, and oral feeding. Recent evidence suggests that early oral feeding is associated with shorter LOS, faster return of bowel function, and improved quality of life. Enhanced recovery pathways after surgery pathways after esophagectomy with a component of early oral feeding also seem to be safe, feasible, and cost-effective, albeit with limited data. However, data on anastomotic leaks is mixed, and some studies suggest that the incidence of leaks may be higher with early oral feeding. This risk of anastomotic leak with early feeding may be heavily modulated by surgical approach. No definitive data is currently available to definitively answer this question, and further studies should look at how these early feeding regimens vary by surgical technique. This review aims to discuss the existing literature on the optimal route and timing of feeding after esophagectomy.

Bowel obstruction associated with a feeding jejunostomy and its association to weight loss after thoracoscopic esophagectomy

Background

Our aim was to clarify the incidence of bowel obstruction associated with a feeding jejunostomy (BOFJ) after thoracoscopic esophagectomy and its association to characteristics and postoperative change in body weight.

Methods

We reviewed 100 consecutive patients who underwent thoracoscopic esophagectomy with gastric tube reconstruction and placement of a jejunostomy feeding catheter for esophageal cancer. The incidence of BOFJ was evaluated and the change in body weight after surgery was compared between patients with and without BOFJ.

Results

BOFJ developed in 17 patients. Compared to patients without BOFJ, those with BOFJ had a higher preoperative body mass index (23.3 kg/m² versus 20.9 kg/m², P = 0.022), and greater postoperative body weight loss rate: 3 month, decrease to 84.2% of initial body weight versus 89.3% (P = 0.002). Patients with BOFJ had shorter distance between the jejunostomy and midline (40 mm versus 48 mm, P = 0.011) compared to patients without BOFJ. On multivariate analysis, higher preoperative body mass index (odds ratio (OR) = 9.248; 95% confidence interval (CI) = 1.344–63.609; p = 0.024), higher postoperative weight loss at 3 months (OR = 8.490; 95% CI = 1.765–40.837, p = 0.008), and shorter distance between the jejunostomy and midline (OR = 8.160; 95% CI = 1.675–39.747, p = 0.009) were independently associated with BOFJ.

Conclusion

Patients of BOFJ had greater preoperative body mass, shorter distance between jejunostomy and midline, and greater postoperative weight loss.