Early Enteral Nutrition is Associated with Faster Post-Esophagectomy Recovery in Chinese Esophageal Cancer Patients: A Retrospective Cohort Study

Multidisciplinary nutritional management improves nutritional and hospitalized outcomes of patients with esophageal cancer undergoing chemoradiotherapy: A randomized control trial

BACKGROUND

This study aimed to investigate the effects of multidisciplinary whole-course nutrition management on the nutritional status and complications during the course of treatment in patients with esophageal cancer (EC) undergoing chemoradiotherapy.

METHODS

A total of 36 EC patients undergoing chemoradiotherapy were divided into a control group (n = 18) and an intervention group (n = 18). Participants in the control group were given routine nutritional support, whereas those in the intervention group were provided whole-course nutrition management from the nutrition support team. Nutrition-related indicators, that is, serum albumin level (ALB), hemoglobin (Hb), and C reactive protein were assessed before, during, and after treatment in both groups. The incidence of complications (e.g., lymphocytopenia, radiation esophagitis, and myelosuppression), clinical outcomes, length of hospital stay, and hospital costs were also recorded. Differences between the 2 groups were tested using the Mann-Whitney U and chi-square tests.

RESULTS

The ALB and Hb levels of the patients in the control group decreased significantly [ALB: -2.6 (-5.6, 0), P = .01; Hb: -12.0 (-27.0, -2.0), P = .04] and C reactive protein increased [8.9 (2.9, 14.9), P = .02] compared to those before treatment, while the indicators of participants in the intervention group did not change (P > .05). The incidence of grade ≥ II lymphocytopenia was higher in the control group than that in the intervention group (33.3% vs 61.1%, P = .03). Moreover, compared with the control group, the average length of hospital stay decreased by 12 days [47 (40, 50) vs 35 (23, 40), P = .001], and in-patient expenses decreased by 20,504 CNY in the intervention group (P = .004).

CONCLUSION

Multidisciplinary whole-course nutrition management can maintain the nutritional status of patients with EC undergoing chemoradiotherapy. This may lower the incidence of complications, shorten hospital stays, and reduce in-patient expenses.

Effects of Psychiatric Issues and Early Enteral Nutrition Therapy on Anxiety and Quality-of-Life of Patients with Gastric Cancer

Objectives: In this study, we assessed the effects of psychiatric issues and early enteral nutrition therapy on anxiety and quality-of-life of patients with gastric cancer. Methods: We enrolled 60 patients with gastric cancer treated from January 2018 to November 2020 and divided them into 2 groups using a random number table (N=30 per group). All patients received early enteral nutrition therapy. The control group was given routine nursing; treatment of persons in the observation group was supplemented with additional psychiatric nursing. We then compared anxiety-depression scores, treatment compliance, nutritional status indices, and quality-of-life score. Results: The Self-rating Anxiety Scale (SAS) score and the Self-rating Depression Scale (SDS) score significantly declined in both groups after nursing compared with those before nursing (p<.05). After nursing, the SAS score and SDS score were lower in the observation group versus the control group (p<.05). The total rate of treatment compliance in the observation group (93.33%) was higher than that in the control group (73.33%) (p<.05). After nursing, the levels of hemoglobin, albumin, prealbumin, and transferrin were significantly higher in both groups than before nursing (p<.05), but higher in the observation group (p<.05). After nursing, the quality-of-life score was significantly higher in both groups than before nursing (p<.05), but higher in the observation group (p<.05). Conclusion: During enteral nutrition therapy for patients with gastric cancer, psychiatric treatment can effectively alleviate patient anxiety and depression, enhance treatment compliance, improve nutritional status, and enhance quality-of-life.

Impact of oral nutrition supplementation on outcomes of esophageal cancer patients treated with chemotherapy: A retrospective cohort study with propensity score matching

Objective

There is a lack of evidence regarding the outcomes of oral nutrition supplementation (ONS) in patients with esophageal cancer (EC) who received chemotherapy treatment. The aim of this study was to perform a retrospective cohort study by comparing an adequate ONS group with a control group.

Materials and methods

The study was performed in the Oncology Department of West China Hospital of Sichuan University. Patients at nutritional risk were identified from March 2016 to June 2019, and divided into an ONS group and a control group. To control for potential confounding variables, the propensity score method with matching was carried out. The main outcomes were length of stay (LOS) and hospitalization cost. Secondary outcomes included the incidence of pulmonary infection and myelosuppression.

Results

Out of 5,316 hospitalizations, a one-to-one matched sample was created (N = 229). The pathological tumor, node, metastasis (pTNM) stage of patients ranged from II to IV. A total of 69 patients received ONS, and 160 patients did not receive ONS. The incidence of myelosuppression in the ONS group and the control group was 4.3 vs. 17.4% (P = 0.014), respectively. However, ONS was associated with a 2 days increase in LOS, from 7 to 9 days (P < 0.000) and a hospitalization cost increase of $731, from $1134 to $1865 (P = 0.005). No statistical differences were observed in the incidence of pulmonary infection between the two groups. Further subgroup analysis based on body mass index (BMI) showed that at BMI ≤ 18.5 kg/m², the incidence of myelosuppression in the ONS group was lower than that in the control group (3.0 vs. 20.8%, P = 0.022). At BMI > 18.5 kg/m², no statistical differences were observed in the incidence of myelosuppression between the two groups.

Conclusion

Although ONS increases hospitalization cost and LOS, it may be associated with reduced myelosuppression incidence, especially for patients with a BMI ≤ 18.5 kg/m².

Home enteral nutrition for patients with esophageal cancer undergoing esophagectomy: A systematic review and meta-analysis

Introduction

Home enteral nutrition (HEN) is a relatively new nutritional intervention that provides patients with EN support at home through jejunostomy or nasogastric feeding tubes. We conducted this systematic review and meta-analysis to explore the safety and effect of HEN compared with normal oral diet (NOD) in postoperative patients with esophageal cancer (EC).

Methods

EMBASE, Medline, Web of Science, and the Cochrane Library were used to search articles in English-language journals. The intervention effect was expressed using risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures, with 95% confidence intervals (95% CIs). The chi-square test and I-square test were used to test heterogeneity among studies.

Results

Four studies were eventually included in this meta-analysis. Compared with NOD, HEN has a favorable impact on postoperative body mass index (BMI) (weighted mean difference [WMD] = 0.70, 95% CI: 0.09–1.30, P = 0.02), lean body mass (LBM) (WMD = 0.76, 95% CI: 0.04–1.48, P = 0.04), and appendicular skeletal muscle mass index (ASMI) (WMD = 0.30, 95% CI: 0.02–0.58, P = 0.03). Physical function (WMD = 9.26, 95% CI: 8.00–10.53, P < 0.001), role function (WMD = 9.96, 95% CI: 8.11–11.82, P < 0.001), and social function (WMD = 8.51, 95% CI: 3.48–13.54, P = 0.001) of the HEN group were better than those of the NOD group at 3 months, and HEN could reduce the fatigue of patients (WMD = −12.73, 95% CI: −14.8 to −10.66, P < 0.001) and the incidence of postoperative pneumonia (RR = 0.53, 95% CI: 0.34–0.81, P = 0.004). There was no significant difference in albumin between HEN and NOD groups (WMD = 0.05, 95% CI: −0.03 to 0.13, P = 0.20).

Conclusion

HEN improved nutritional status and quality of life (QOL) in postoperative patients with EC and reduced fatigue and the incidence of postoperative pneumonia. All in all, the results of our meta-analysis support the use of HEN after esophagectomy.

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.

Nutritional Status and Feeding Regimen of Patients with Esophagus Cancer-A Study from Vietnam

Background: Esophagus cancer patients are at high risk of malnutrition. This study was performed to assess the nutritional status and dietary intake of newly diagnosed esophageal cancer patients in Vietnam National Cancer Hospital (NCH). Methods: A cross-sectional study was conducted on 206 early esophageal cancer inpatients after gastrostomy from September 2017 to June 2018. The chi-squared test, Fisher exact test, and Mann–Whitney test were performed. The software of the Vietnam National Institute of Nutrition was used to evaluate the dietary intake of patients. Results: All the participants were male with a mean age of 57.1 ± 8.5 years. Overall, 87.4% of patients had dysphagia. Furthermore, 82.5% and 90.8% of patients reported weight loss one and six months pre-diagnosis, respectively. Moreover, 52.9% of patients suffered from mild/moderate malnutrition and 29.6% of patients had severe malnutrition according to the Patient-Generated Subjective Global Assessment (PG-SGA). The body mass index (BMI) and mid upper arm circumference (MUAC) measurement revealed 47.6% and 50% of undernourished patients, respectively. The proportions of patients having malnutrition were 10.7%, 55.8%, and 27.2% according to albumin, prealbumin, and total lymphocyte counts, respectively. The means of energy, protein, lipid, and carbohydrate in the patients’ 24 h preoperative diets were 973.6 ± 443.0 kcal/day, 42.4 ± 21.6 g/day, 31.0 ± 15.5 g/day, and 130.0 ± 64.5 g/day. The total energy, total protein, animal protein, total lipid, and plant lipid in the dietary intake of patients were strongly correlated with age, economic classification, and PG-SGA (each p < 0.05). The total energy intake increased day by day, with the average energy intake of 1343.9 ± 521.3 kcal on the seventh day. Energy and protein response rates increased day by day and were highest at 7 days post-operation at 18.0% and 19.4%. Conclusion: Malnutrition and insufficient intake are noteworthy in esophageal cancer patients. The PG-SGA is strongly correlated with the dietary intake of patients. The results from this study will help medical staff to prevent malnutrition and improve the nutritional status of esophageal cancer inpatients. Furthermore, public awareness should be raised on recognizing weight loss as an early symptom of esophageal cancer and the utilization of preoperative assessment tools for nutritional assessment and malnutrition management.

Comparison of spectral computed tomography imaging parameters between squamous cell carcinoma and adenocarcinoma at the gastroesophageal junction

OBJECTIVE

To compare the spectral computed tomography (CT) imaging parameters between squamous cell carcinoma (SCC) and adenocarcinoma (AC) at the gastroesophageal junction (GEJ).

METHODS

A total of 80 patients were enrolled in this retrospective study. Among them, 35 were diagnosed with SCC (SCC group) and 45 were diagnosed with AC (AC group). All patients underwent an enhanced scan with spectral CT. The following CT imaging parameters were evaluated: iodine concentration (IC), water content (WC), effective atomic number (Eff-Z) and slope of the spectral HU curve (λHU) of lesions. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of spectral CT imaging parameters for diagnosis of SCC and AC.

RESULTS

Patients with SCC had lower IC, Eff-Z, and λHU in arterial phase and venous phase compared with AC (p< 0.05). There were no significant differences in WC between the two groups. ROC curve analyses revealed that IC, Eff-Z, and λHU in arterial phase and venous phase were predictors for diagnosis of SCC and AC (AUC > 0.5). Moreover, the IC, Eff-Z and λHU in venous phase had better differential diagnostic performances than that in arterial phase.

CONCLUSIONS

Spectral CT could be useful in the differential diagnosis of SCC and AC at the GEJ. Therefore, a routine spectral CT scan is recommended for patients with carcinoma of the GEJ.

Nutritional jejunostomy in esophagectomy for cancer, a national register-based cohort study of associations with postoperative outcomes and survival

Purpose

Insertion of a nutritional jejunostomy in conjunction with esophagectomy is performed with the intention to decrease the risk for postoperative malnutrition and improve recovery without adding significant catheter-related complications. However, previous research has shown no clear benefit and there is currently no consensus of practice.

Methods

All patients treated with esophagectomy due to cancer during the period 2006–2017 reported in the Swedish National Register for Esophageal and Gastric Cancer were included in this register-based cohort study from a national database. Patients were stratified into two groups: esophagectomy alone and esophagectomy with jejunostomy.

Results

A total of 847 patients (45.27%) had no jejunostomy inserted while 1024 patients (54.73%) were treated with jejunostomy. The groups were comparable, but some differences were seen in histological tumor type and tumor stage between the groups. No significant differences in length of hospital stay, postoperative surgical complications, Clavien-Dindo score, or 90-day mortality rate were seen. There was no evidence of increased risk for significant jejunostomy-related complications. Patients in the jejunostomy group with anastomotic leaks had a statistically significant lower risk for severe morbidity defined as Clavien-Dindo score ≥ IIIb (adjusted odds ratio 0.19, 95% CI: 0.04–0.94, P = 0.041) compared to patients with anastomotic leaks and no jejunostomy.

Conclusion

A nutritional jejunostomy is a safe method for early postoperative enteral nutrition which might decrease the risk for severe outcomes in patients with anastomotic leaks. Nutritional jejunostomy should be considered for patients undergoing curative intended surgery for esophageal and gastro-esophageal junction cancer.

Enteral immunonutrition versus enteral nutrition for patients undergoing oesophagectomy: a systematic review and meta-analysis

OBJECTIVES

According to retrospective studies, oesophageal carcinoma is the second deadliest gastrointestinal cancer after gastric cancer. Enteral immunonutrition (EIN) has been increasingly used to enhance host immunity and relieve the inflammatory response of patients undergoing oesophagectomy; however, conclusions across studies remain unclear. We aimed to evaluate the effect of EIN on the clinical and immunological outcomes of patients undergoing oesophagectomy.

METHODS

Four electronic databases (MEDLINE, Embase, Web of Science and Cochrane Library) were used to search articles in peer-reviewed, English-language journals. The mean difference, relative risk or standard mean difference with 95% confidence interval were calculated. Heterogeneity was assessed by the Cochran's Q test and I2 statistic combined with the corresponding P-value. The analysis was carried out with RevMan 5.3.

RESULTS

Six articles were finally included, with a total of 320 patients with oesophageal cancer. The meta-analysis results showed that EIN did not improve clinical outcomes (such as infectious complications, pneumonia, surgical site infection, anastomotic leak and postoperative hospital stay) or immune indices [referring to C-reactive protein, interleukin (IL)-6, IL-8, tumour necrosis factor-α]. Descriptive analysis suggested that EIN also increased the serum concentrations of IgG and the percentage of the B-cell fraction. Thus, its impact on IL-8 and IL-6 remains inconsistent.

CONCLUSIONS

The early-stage impact of EIN on immunological status in patients undergoing oesophagectomy is still unclear. According to the results of this meta-analysis, whether EIN could improve the clinical outcomes or biological status after oesophagectomy compared to standard enteral nutrition is uncertain. Since the impact of EIN is unclear, current guidelines that strongly advise the use of EIN should be changed, as the utility of EIN is very uncertain. More appropriately powered clinical studies are warranted to confirm its effectiveness.

Effect of Preoperative Nutritional Risk Screening and Enteral Nutrition Support in Accelerated Recovery after Resection for Esophageal Cancer

Patients with esophageal cancer are often accompanied by malnutrition, especially in patients with obvious swallowing tract. Many studies have shown that preoperative nutritional support can reduce postoperative complications, but there are few studies comparing preoperative enteral nutrition with intravenous nutrition. The aim of the study was to compare the effects of the two nutritional support path in esophageal cancer patients undergoing surgery. We used the nutritional risk screening 2002 (NRS2002) for preoperative nutritional risk screening in patients with esophageal cancer treated at our department between April 2016 and March 2019. A total of 56 patients with an NRS2002 score ≥ 3 and with apparent difficulty swallowing received preoperative parenteral nutrition (PN; n = 29) or enteral nutrition (EN; n = 27). Both groups received 7 day of nutritional support before surgery. Nutritional indicators were measured on preoperative day 7, preoperative day 1, and postoperative day 7. The baseline characteristics, perioperative condition, nutritional status, and postoperative complications of the two groups were compared and analysed. There was no significant difference in baseline characteristics and perioperative nutrition indicators between two groups. Postoperative hospital stay and the costs of nutrition support were significantly reduced in the EN group compared with PN group (P = 0.000). The times of first passing gas and bowel movement were shorter in the EN group compared with PN group (P = 0.001). The incidence of gastrointestinal complications was lower in the EN group compared with PN group (P = 0.039). For esophageal cancer patients with an NRS2002 score ≥ 3 and apparent difficulty swallowing, preoperative EN with a gastric tube is safe and easy to perform. Preoperative EN can shorten the recovery time of gastrointestinal function, reduce the incidence of gastrointestinal complications, finally accelerate postoperative recovery.

A meta-analysis of the effect of early enteral nutrition versus total parenteral nutrition on patients after pancreaticoduodenectomy

BACKGROUND

An appropriate nutritional support is an important consideration for patients undergoing pancreaticoduodenectomy (PD). Recently, early enteral nutrition (EEN) has been considered to be more effective than total parenteral nutrition (TPN) for the early recovery of patients after many digestive tract surgeries. However, there is little evidence to support EEN in patients undergoing PD.

METHODS

A systematic literature review was performed to identify relevant studies before December 2018. Statistical analysis was carried out using Review Manager 5.3.

RESULTS

Nine studies with 1258 patients were included in the meta-analysis. Six studies compared EEN and TPN and three compared two strategies combined vs. a single strategy. The length of hospital stay (LOS) in the EEN group was significantly shorter than that in the TPN group (P < 0.001). There was no difference in the risk of postoperative complications, infections, and mortality between the EEN and TPN groups. In the comparison of two combined strategies vs. one, no significant difference was seen in overall postoperative complications, LOS, or mortality.

CONCLUSION

Compared with TPN, EEN is a safe strategy and can substantially shorten the LOS of patients.

Nutrition in surgical patients: how soon is too soon?

PURPOSE OF REVIEW

Preoperative nutrition support has been extensively studied; however, data on the timing of postoperative nutrition initiation are scarce. The current review focuses on the importance of early nutritional support in surgical patients and their impact on outcomes.

RECENT FINDINGS

Early nutrition support during the postoperative course may be the most important step that can be taken toward preventing subsequent malnutrition-related complications. European Society for Parenteral and Enteral Nutrition guidelines recommends early nutrition to improve outcomes after surgery and accelerates the recovery. Moreover, nutritional support should be personalized, and disease process-based.

SUMMARY

Existing studies appear to focus mostly on abdominal and gastrointestinal surgery. Further prospective observational and randomized clinical trials across different surgical populations will aid surgeons to better understand how early feeds in either form can reduce morbidity, quality of life, and increase recovery rates.

Effectiveness and safety of bovine pericardium patch repair for cervical anastomotic leakage after oesophagectomy for cancer

Background

The objective of this study is to evaluate the effectiveness and safety of bovine pericardium patch (BPP) repair for cervical anastomotic leakage after esophageal squamous cancer.

Methods

Intractable cervical anastomotic leakage developed in 7 patients of esophageal squamous cell carcinoma undergoing cervical anastomosis. These patients received the BPP repair. The necrotic tissue around the cervical anastomosis was removed during the operation, and the defect was repaired with BPP according to the size of the leakage.

Results

The operative duration was 60-90 min (median, 75 min). There were no signs of recurrent anastomotic leakage in each patient undergoing BPP repair. Oral intake was initiated 5-8 days (median, 6 days) after the BPP repair operation without any discomfort.

Conclusions

The BPP repair is a safe and effective processing scheme for patients with cervical anastomotic fistula after resection of esophageal squamous cell carcinoma. This method may be recommended for appropriate patients with intractable cervical anastomotic fistula.

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.

Jejunostomy-technique and controversies

Malnutrition is quite common in patients with esophageal cancer, and can be secondary to tumor related dysphagia or treatment side effects. Traditionally, open feeding jejunostomy tube was performed in all patients undergoing surgical treatment of esophageal cancer. With the advent of minimally invasive approaches, placement of the jejunostomy tube can be currently accomplished with either robotic or laparoscopic assistance. Here, we discuss the technical aspects as well as the pros and cons of a minimally invasive jejunostomy feeding tube placement.

Spectral Computed Tomography for the Quantitative Assessment of Patients With Carcinoma of the Gastroesophageal Junction: Initial Differentiation Between a Diagnosis of Squamous Cell Carcinoma and Adenocarcinoma

OBJECTIVE

This study aimed to distinguish between esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) using spectral computed tomography (CT) and to discuss the accuracy according to an optimal threshold of single and combined parameters.

METHODS

In this monoinstitution study, 61 patients, 35 of whom had ESCC and 26 had EAC confirmed by surgery or esophagoscopy, were recruited from August 2016 to March 2017. Enrolled patients underwent dual-phase chest CT enhancement. The spectral CT parameters (NIC, NICD, NICratio, Zeff, Zeff-C, K40-70 keV, K80-100 keV, and K110-140 keV) were measured during arterial phase (AP) and venous phase (VP). Binary logistic regression was used to calculate combined predictive probability. Thresholds of quantitative parameters and diagnostic accuracy were calculated using receiver operating characteristic curve.

RESULTS

Compared with ESCC, higher NICAP, NICVP, NICD, Zeff AP, Zeff VP, Zeff-C AP, and Zeff-C VP were observed for EAC, whereas NICratio was lower for EAC. Higher K40-70 keV, K80-100 keV, and K110-140 keV were exhibited in EAC than in ESCC. Area under the curve (AUC) of NICAP, K40-70 keV AP, and Zeff AP were 0.720, 0.730, and 0.706, respectively. The area under the curve of new combined predictive value of NICAP and λ40-0 keV AP was 0.804. The sensitivity and specificity were 77.80% and 80.60%, respectively, when the threshold of new predictive value was 0.60.

CONCLUSION

The diagnostic accuracy obtained by using NICAP and K40-70 keV AP combined is better than that obtained using a single parameter in differentiation between a diagnosis of squamous cell carcinoma and adenocarcinoma.