Feeding jejunostomy: does the benefit overweight the risk (a retrospective study from a single centre)

Enteral Access Outcomes in Patients Hospitalized With Cardiac Disease: A Retrospective Cohort Study

INTRODUCTION

Patients admitted with principal cardiac diagnosis (PCD) can encounter difficult inpatient stays that are often marked by malnutrition. In this setting, enteral feeding may improve nutritional status. This study examined the association of PCD with perioperative outcomes after elective enteral access procedures.

METHODS

Adult patients who underwent enteral access procedures between 2018 and 2020 at a tertiary care institution were reviewed retrospectively. Differences in baseline characteristics between patients with and without PCD were adjusted using entropy balancing. Multivariable logistic and linear regressions were subsequently developed to evaluate the association between PCD and nutritional outcomes, perioperative morbidity and mortality, length of stay, and nonelective readmission after enteral access.

RESULTS

912 patients with enteral access met inclusion criteria, of whom 84 (9.2%) had a diagnosis code indicating PCD. Compared to non-PCD, patients with PCD more commonly received percutaneous endoscopic gastrostomy by general surgery and had a higher burden of comorbidities as measured by the Charlson comorbidity index. Multivariable risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups (standardized differences ranged from -2.45 × 10-8 to 3.18 × 108). After adjustment, despite no significant association with in-hospital mortality, percentage change prealbumin, length of stay, or readmission, PCD was associated with an approximately 2.25-day reduction in time to meet goal feeds (95% CI -3.76 to -0.74, P = 0.004) as well as decreased odds of reoperation (adjusted odds ratio 0.28, 95% CI 0.09-0.86, P = 0.026) and acute kidney injury (adjusted odds ratio 0.24, 95% CI 0.06-0.91, P = 0.035).

CONCLUSIONS

Despite having more comorbidities than non-PCD, adult enteral access patients with PCD experienced favorable nutritional and perioperative outcomes.

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.

Factors Influencing Postoperative Complications Following Minimally Invasive Ivor Lewis Esophagectomy: A Retrospective Cohort Study

BACKGROUND

Complications arising following minimally invasive Ivor Lewis esophagectomy often result from inadequate enteral nutrition, highlighting the need for proactive measures to prevent such issues. One approach involves identifying high-risk cases prone to complications and implementing percutaneous endoscopic jejunostomy (PEJ) tube placement during esophageal resection to ensure timely enteral nutrition.

METHODS

In this single-center, retrospective cohort study, we examined patients who underwent minimally invasive esophagectomy for esophageal cancer at a high-volume center. The dataset encompassed demographic information, comorbidities, laboratory parameters, and intraoperative details. Our center utilized the EndoVac system pre-emptively to safeguard the anastomosis from harmful secretions and to enhance local oxygen partial pressure. All patients received pre-emptive EndoVac therapy and underwent esophagogastroduodenoscopy in the early postoperative days. The need for multiple postoperative EndoVac cycles indicated complications, including anastomotic insufficiency and subsequent requirement for a PEJ. The primary objectives were identifying predictive factors for anastomotic insufficiency and the need for multi-cycle EndoVac therapy, quantifying their effects, and assessing the likelihood of postoperative complications.

RESULTS

149 patients who underwent minimally invasive or hybrid Ivor Lewis esophagectomy were analyzed and 21 perioperative and demographic features were evaluated. Postoperative complications were associated with the body mass index (BMI) category, the use of blood pressure medication, and surgery duration. Anastomotic insufficiency as a specific complication was correlated with BMI and the Charlson comorbidity index. The odds ratio of being in the high-risk group significantly increased with higher BMI (OR = 1.074, p = 0.048) and longer surgery duration (OR = 1.005, p = 0.004).

CONCLUSIONS

Based on our findings, high BMI and longer surgery duration are potential risk factors for postoperative complications following minimally invasive esophagectomy. Identifying such factors can aid in pre-emptively addressing nutritional challenges and reducing the incidence of complications in high-risk patients.

Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period

The metabolic risk for patients undergoing abdominal cancer resection increases in the perioperative period and malnutrition may be observed. In order to prevent further weight loss, the guidelines recommend for high-risk patients the placement of a needle catheter jejunostomy (NCJ) for supplementing enteral feeding in the early and late postoperative period. Our aim was to evaluate the safety of NCJ placement and its potential benefits regarding the nutritional status in the postoperative course. We retrospectively analyzed patients undergoing surgery for upper gastrointestinal cancer, such as esophageal, gastric, and pancreato-biliary cancer, and NCJ placement during the operation. The nutritional parameters body mass index (BMI), perioperative weight loss, phase angle measured by bioelectrical impedance analysis (BIA) and the clinical outcome were assessed perioperatively and during follow-up visits 1 to 3 months and 4 to 6 months after surgery. In 102 patients a NCJ was placed between January 2006 and December 2016. Follow-up visits 1 to 3 months and 4 to 6 months after surgery were performed in 90 patients and 88 patients, respectively. No severe complications were seen after the NCJ placement. The supplementing enteral nutrition via NCJ did not improve the nutritional status of the patients postoperatively. There was a significant postoperative decline of weight and phase angle, especially in the first to third month after surgery, which could be stabilized until 4-6 months after surgery. Placement of NCJ is safe. In patients with upper gastrointestinal and pancreato-biliary cancer, supplementing enteral nutrition during the postoperative course and continued after discharge may attenuate unavoidable weight loss and a reduction of body cell mass within the first six months.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

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.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature

Background

Non-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy.

Case presentation

In case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48.

In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28.

Conclusions

The causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

Feeding Jejunostomy after esophagectomy cannot be routinely recommended. Analysis of nutritional benefits and catheter-related complications

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.

Serum Albumin at Diagnosis is an Independent Predictor of Early Mortality in Veteran Patients with Esophageal Cancer

AIMS

To identify independent factors that could predict mortality within 6 months in a cohort of patients with esophageal cancer.

METHODS

Esophageal cancer patients were grouped into early (≤6 months, n = 41) and late (>6 months, n = 81) mortality groups. 52 variables were analyzed by univariable analysis (UA). A multivariable (MVA) regression model was created to identify predictors of early mortality.

RESULTS

When comparing early and late mortality groups, there was no difference in age, BMI, race, histology, or anatomic location between the two groups. UA demonstrated that the early mortality group had a lower mean albumin level (3.3 ± 0.1 g/dl vs. 3.8 ± 0.1 g/dl; P < 0.001), poorer ECOG performance status (1.9 ± 0.2 vs. 1.1 ± 0.1, P = 0.02), higher WBC count (9.6 ± 0.7 K/µL vs. 8.2 ± 0.3 K/µL, P = 0.04), and were less likely to receive surgery (2.4% vs. 22.2%; P = 0.003), neoadjuvant treatment (4.9% vs. 28.4%; P = 0.009) and definitive chemoradiation (7.3% vs. 27.2%; P = 0.01). MVA revealed that only low albumin at diagnosis was an independent predictor of survival (P = 0.016).

CONCLUSION

Albumin level at diagnosis is an independent predictor of early mortality and might be used with other variables to provide prognostic information for patients and to guide treatment.

Routine jejunostomy tube feeding following esophagectomy

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.

Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: the technique and review of outcomes

Background

In recent years, staging laparoscopy has gained acceptance as part of the assessment of resectability of upper gastrointestinal (UGI) malignancies. Not infrequently, we encounter tumours that are either locally advanced; requiring neoadjuvant therapy or occult peritoneal disease that requires palliation. In all these cases, the establishment of enteral feeding during staging laparoscopy is important for patients’ nutrition. This review describes our technique of performing laparoscopic feeding jejunostomy and the clinical outcomes.

Methods

The medical records of all patients who underwent laparoscopic feeding jejunostomy following staging laparoscopy for UGI malignancies between January 2010 and July 2015 were retrospectively reviewed. The data included patient demographics, operative technique and clinical outcomes.

Results

Fifteen patients (11 males) had feeding jejunostomy done when staging laparoscopy showed unresectable UGI maligancy. Eight (53.3%) had gastric carcinoma, four (26.7%) had oesophageal carcinoma and three (20%) had cardio-oesophageal junction carcinoma. The mean age was 63.3 ± 7.3 years. Mean operative time was 66.0 ± 7.4 min. Mean postoperative stay was 5.6 ± 2.2 days. Laparoscopic feeding jejunostomy was performed without intra-operative complications. There were no major complications requiring reoperation but four patients had excoriation at the T-tube site and three patients had tube dislodgement which required bedside replacement of the feeding tube. The mean duration of feeding tube was 127.3 ± 99.6 days.

Conclusions

Laparoscopic feeding jejunostomy is an important adjunct to staging laparoscopy that can be performed safely with low morbidity. Meticulous attention to surgical techniques is the cornerstone of success.

[Management of delayed complications after esophagectomy]

Esophagectomy and subsequent reconstruction represent major physiological insults to the upper gastrointestinal (GI) tract, which as a consequence can lead to malnutrition, dysphagia and reflux. From a technical perspective, operative reconstruction involving gastric pull-up with a 2-3 cm wide tube and an anastomosis cranial to the azygos vein may minimize the symptoms. Overall, the problems tend to improve approximately 6 months after the operation. Newly occurring delayed physical functional impairments with previously known underlying malignant disease may be indicative of cancer relapse. Interventional techniques, such as stent placement or brachytherapy may be better suited for treatment of recurrent disease.

Routes of early enteral nutrition following oesophagectomy

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

Study of Feeding Jejunostomy as an Add on Procedure in Upper Gastrointestinal Surgeries

Jejunostomy is usually indicated as an additional procedure during major surgery of upper digestive tract to administer enteral nutrition in post-operative period. Complications associated with it can be mechanical, infectious, gastrointestinal or metabolic. The aim of the study was to evaluate safety of post-operative feeding jejunostomy in different types of major upper gastrointestinal surgeries. It was a prospective study conducted during the period between August 2009 and September 2011. Post-operative cases of major upper gastrointestinal surgeries who receive jejunostomy feeds were included in the study. Sampling was done by convenient method with sample size of 50 cases. Post-operatively, patients were monitored according to standard orders of enteral nutrition. Total calorie and protein intake through feeding jejunostomy was calculated regularly, and complications were assessed in terms of frequency, type, duration, management, and final outcome in different types of upper gastro intestinal surgeries. Analysis was done using chi square test with the help of statistical package SPSS vers.13. P < 0.05 was considered as significant. Complications observed were gastrointestinal -8 (16 %), mechanical -6 (12 %), infectious -4 (8 %) and metabolic -4 (8 %). Duration of complications ranged from 1 to 7 days (mean, 4 days). All types of complications observed during study were less severe and could be managed by simple measurements. Haemoglobin, serum albumin and weight of the patient at the time of discharge were improved for all patients when compared to pre-operative values. All patients received target calories and proteins through feeding jejunostomy. Considering benefits of enteral feeding via jejunostomy tube with minor and acceptable complications, we conclude that feeding jejunostomy is a preferred route of nutritional administration in those who undergo major upper gastro intestinal surgeries.

Feeding duodenostomy decreases the incidence of mechanical obstruction after radical esophageal cancer surgery

BACKGROUND

Nutritional support influences the outcome of gastroenterological surgery, and enteral nutrition effectively mitigates postoperative complications in highly invasive surgery such as resection of esophageal cancer. However, feeding via jejunostomy can cause complications including mechanical obstruction, which could be life threatening. From 2009, we began enteral feeding via duodenostomy to reduce the likelihood of complications. In this study, we compared duodenostomy with the conventional jejunostomy feeding, mainly looking at the catheter-related complications.

METHODS

The database records of 378 patients with esophageal cancer who underwent radical esophagectomy with retrosternal or posterior mediastinal gastric tube reconstruction in our department from January 1998 to December 2012 were examined. Of the 378 patients, 111 underwent feeding via duodenostomy (FD) and 267 underwent feeding via jejunostomy (FJ), and their records were reviewed for the following catheter-related complications: site infection, dislodgement, peritonitis, and mechanical obstruction.

RESULTS

Mechanical obstruction occurred in 12 patients in the FJ group but none in the FD group (4.5 % vs. 0 %, P = 0.023). Of the 12 cases, 7 (58.3 %) required surgery of which 2 had bowel resection due to strangulated mechanical obstruction. Catheter site infection was seen in 14 cases in the FJ group, of which 2 (14.2 %) had peritonitis following catheter dislocation, while only one case of site infection was seen in the FD group (5.2 % vs. 0.9 %, P = 0.078).

CONCLUSIONS

Feeding via duodenectomy could be the procedure of choice since neither mechanical obstruction nor relaparotomy was seen during enteral feeding through this technique.

Patient and Family Caregivers' Experiences of Living With a Jejunostomy Feeding Tube After Surgery for Esophagogastric Cancer

BACKGROUND

Jejunostomy feeding tubes (JFTs) can be used to provide nutrition support to patients who have had surgery for esophagogastric cancer. Although previous research reports how patients cope with a gastrostomy tube, little is known about the impact of having a JFT. The aim of this qualitative study was to explore how patients and their informal caregivers experience living with a JFT in the first months following surgery.

METHODS

Participants were purposively sampled from a cohort of patients recruited to a trial investigating home enteral nutrition vs standard care after esophagogastric surgery for cancer. The sampling framework considered age, sex, and marital status. Informal caregivers were also invited to participate. Interviews were audio recorded, transcribed verbatim, and anonymized. Inductive thematic analysis was used to identify key themes related to living with a JFT.

RESULTS

Fifteen patient interviews were conducted; 8 also included a family caregiver. Analysis of the data resulted in 2 main themes: "challenges" and "facilitators" when living with a JFT. While "physical effects," "worries" and "impact on routine" were the main challenges, "support," "adaptation" and "perceived benefit" were what motivated continuation of the intervention.

CONCLUSION

Findings suggest that participants coped well with a JFT, describing high levels of compliance with stoma care and the feeding regimen. Nonetheless, disturbed sleep patterns and stoma-related problems proved troublesome. A better understanding of these practical challenges, from the patient and family caregiver perspective, should guide healthcare teams in providing proactive support to avoid preventable problems.

Randomized clinical trial: nasoenteric tube or jejunostomy as a route for nutrition after major upper gastrointestinal operations

BACKGROUND

Curative treatment of upper gastrointestinal tract neoplasms is complex and associated with high morbidity and mortality. In general, the patients are already malnourished, and early postoperative enteral nutrition is recommended. However, there is no consensus concerning the best enteral access route in these cases.

METHODS

A prospective randomized trial was performed from 2008 to 2012 with 59 patients who underwent esophagectomy, total gastrectomy, or pancreaticoduodenectomy. In all, 4 patients declined to participate, and 13 did not meet the inclusion criteria and were excluded. Of the 42 included patients, 21 had nasoenteric tubes, and 21 had a jejunostomy.

RESULTS

The two groups were similar in demographic and clinical aspects. The nasoenteric (NE) and jejunostomy groups underwent early enteral therapy in 71 and 62 % of cases (p > 0.05), respectively. The median length of enteral therapy use was less in the NE group (5.0 vs. 8.5 days), but the difference was not statistically significant. The NE group required introduction of parenteral therapy more frequently than the jejunostomy group (p < 0.05). Complications related to the enteral route occurred in 38.0 and 28.5 % of patients (p > 0.05) in the NE and jejunostomy groups, respectively. In the NE group, there were four losses and four tube obstructions. In the jejunostomy group, there were two losses, four obstructions, and two cases of leakage around the tube. In the latter group, patients who underwent therapy for a longer time had tubal complications (p < 0.05) and longer intensive care unit and hospital stays (p < 0.05).

CONCLUSION

The two enteral routes were associated with the same number of complications. However, the presence of a jejunostomy allowed enteral therapy for longer periods, especially in patients with complications, thus avoiding the need for parenteral nutrition.

Routes for early enteral nutrition after esophagectomy. A systematic review

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.

Perioperative nutritional support of patients undergoing pancreatic surgery in the age of ERAS

OBJECTIVE

The results achieved through the Enhanced Recovery After Surgery (ERAS) approach in gastrointestinal surgery have led to its enthusiastic acceptance in pancreatic surgery. However, the ERAS program also involves an early oral feeding that is not always feasible after pancreatoduodenectomy. The aim of this review was to investigate in the literature whether the difficulty with early oral feeding in these patients was adequately balanced by perioperative enteral or parenteral nutritional support as recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines or whether these recommendations have lost value in the "bundle" of the ERAS.

METHODS

We reanalyzed both ESPEN guidelines and literature regarding the ERAS program in surgical pancreatic patients.

RESULTS

There was a high prevalence of malnutrition (and consequently of postoperative complications) in patients with pancreatic cancer, and there is evidence that many of these patients should be candidates for perioperative nutritional support according to ESPEN guidelines. The start of oral fluid and solid feeding was quite variable in literature reporting the use of ERAS in pancreatic cancer surgery, with a consistent gap between the recommended and the effective start of both the feedings. The use of nasogastric/jejunal tube or of a needle-catheter jejunostomy was discouraged by the ERAS guidelines but their use could prove beneficial in patients who are recognized at high risk for postoperative complications according to the scores available in the literature.

CONCLUSION

The current practice of the ERAS program in these patients appears to neglect some ESPEN recommendations. On the other hand, both ESPEN and ERAS recommendations could be combined for a supplemental benefit for the patient.

Pancreatic surgery: indications, complications, and implications for nutrition intervention

Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.

Utilization and morbidity associated with placement of a feeding jejunostomy at the time of gastroesophageal resection

BACKGROUND

The purpose of the study was to evaluate the utilization and morbidity associated with feeding jejunostomy tubes (JT) placed at the time of gastroesophageal resection (GER).

METHODS

Under institutional review board approval, a prospective database of patients undergoing GER from January 2004 to September 2010 was reviewed. Data analyzed included patient demographics, postoperative complications, JT use, and JT specific complications. Fisher's exact tests explored associations with utilization of a JT following resection.

RESULTS

Seventy-three patients (51 men, 22 women, median age of 59) underwent placement of a JT at the time of GER (total gastrectomy = 28, Ivor-Lewis = 28, subtotal gastrectomy = 8, proximal gastrectomy  = 6, and transhiatal esophagectomy  = 3) of both malignant (97%) and benign (3%) disease processes. Twenty-one JT specific complications (11 minor and 10 major) were identified. Reoperation was required in the management of two complications (small bowel obstructions), while all other complications were easily managed by an interventional radiologist (n = 8), bedside procedure (n = 5), or did not require intervention (n = 6). Eighty-six percent of patients were discharged tolerating a postgastrectomy diet, 10% nothing per orem, and 4% a liquid diet. Inpatient enteral nutrition (EN) was initiated in 68%, but continued on discharge in only 54% secondary to failure to thrive (54%), dysphagia (21%), anastomic leak (15%), chyle leak (3%), esophagostomy (3%), and duodenal stump leak (3%). The mean time to discontinuance of EN and removal of the JT was 44 days (range, 4-203) and 71 days (range, 15-337) respectively. Although only 13% (n = 5) of patients requiring adjuvant therapy were utilizing their JT at the commencement of therapy, 75% (n = 21) required EN during its course. The median time to adjuvant therapy was found to be slightly longer in those who required outpatient EN versus those who did not (61 vs. 90 days, p = 0.08). However, the median time to adjuvant therapy did not differ between those who were and were not receiving EN at the time of adjuvant therapy commencement (80 vs. 92 days, p = 0.2). Age (p = 0.4), number of co-morbidities (p = 0.2), preoperative percent body weight loss (p = 0.9), and clinical stage (p = 0.8) were not significantly associated with outpatient JT use. Patients who suffered a postoperative complication were most likely to require EN (p = 0.002), an association that strengthened as the number of complications increased (p = 0.0008). Although not statistically significant, a trend towards increased outpatient EN was noted in patients who underwent transhiatal esophagectomy and total gastrectomy (p = 0.06).

CONCLUSIONS

JT placement carries a considerable morbidity in patients undergoing GER. However, because it is difficult to preoperatively ascertain who will need prolonged EN, the routine placement of a JT is recommended, particularly in those who will likely require adjuvant therapy or are at high risk for postoperative complications. Despite patient desires for early removal of an unused JT, caution should be taken if adjuvant therapy is being considered.

Delayed presentation of strangulated congenital diaphragmatic hernia: learning from our experience

BACKGROUND

Strangulation is very rare in congenital diaphragmatic hernia (CDH) of the Bochdaleck variety. Here, we share our experience with six cases of delayed presentation of strangulated CDH. The aim of this article is to provide information on how to diagnose and manage this situation using a systematic approach.

MATERIALS AND METHODS

A retrospective review identified six cases of strangulated/obstructed CDH from 1998 to 2011. Demographic data, clinico-radiological findings, management and complications, along with final outcome were recorded.

RESULTS

Small bowel gangrene was found in one patient, gastric perforation in three, transverse colon perforation in one and colonic obstruction in one patient. Video-assisted thoracoscopic surgery (VATS) was used in all but one patients for definitive diagnosis, diaphragmatic repair, pleural lavage and management of empyema. Laparotomy was needed for management of strangulated or perforated bowel. Three patients in this study survived.

CONCLUSION

Clinicians should always consider a diagnosis of obstructed Bochdaleck hernia in children, because X-ray findings are not always typical or even normal in complicated CDH. VATS may be considered as both diagnostic and therapeutic. Preventive measures for empyema or early intervention in the evolving stage can significantly reduce morbidity.

Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group

PURPOSE

Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year.

MATERIALS AND METHODS

The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement).

RESULTS

Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy.

CONCLUSION

The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.