Early oral feeding following thoracolaparoscopic oesophagectomy for oesophageal cancer

Optimal time to initiate early oral feeding in postoperative patients with upper gastrointestinal malignancy: A network meta-analysis

BACKGROUND

With the development of enhanced recovery after surgery, early oral feeding is likely to become the preferred mode of nutrition after surgery for upper gastrointestinal tract malignancies. However, the optimal time to initiate early oral feeding remains unknown.

OBJECTIVE

We aimed to compare the effects of different introduction times of early oral feeding in patients with upper gastrointestinal malignancies in terms of safety, tolerance, and effectiveness and to identify the optimal time for early oral feeding after surgery.

METHODS

A random-effects meta-analysis was performed to identify evidence from relevant randomized controlled trials. Ten electronic databases were searched for randomized controlled trials from their earliest records to May 2023. Data were analyzed using the Stata 16.0 software.

RESULTS

A total of 22 randomized controlled trials including 2510 patients and seven time points for oral feeding after surgery were considered. Regarding safety, oral feeding initiated on postoperative day 3 may be the safest (high-quality evidence) compared with other times. Regarding tolerance, oral feeding initiated on postoperative day 5 may be the most well-tolerated (moderate-quality evidence) compared with other times. Regarding effectiveness, oral feeding initiated on postoperative day 3 may be the most effective (moderate-quality evidence) compared with other times.

CONCLUSIONS

Early oral feeding is safe, tolerable, and effective in postoperative patients with upper gastrointestinal malignancies. The optimal time to initiate early oral feeding after surgery was most likely postoperative day 3. The results of this meta-analysis provide evidence-based guidelines for clinical decision-making.

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.

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.

The Feasibility of Early Oral Feeding After Neoadjuvant Chemotherapy Combined With "Non-Tube No Fasting"-Enhanced Recovery

BACKGROUND

This study aimed to investigate the feasibility of early oral feeding (EOF) after neoadjuvant chemotherapy (nCT) combined with "non-tube no fasting"-enhanced recovery after minimally invasive esophagectomy (MIE).

METHODS

This retrospective study investigated patients who underwent nCT combined with non-tube no fasting-enhanced recovery after MIE in the Department of Thoracic Surgery, Ward I, of the authors' hospital from January 2014 to August 2017. These patients were divided into an early oral feeding (EOF) group (n = 112) and a late oral feeding (LOF) group (n = 69). The postoperative complications were compared between the two groups.

RESULTS

The study enrolled 181 patients (112 patients in the EOF group and 69 patients in the LOF group). No significant differences were found between the two groups in the incidence rates of complications such as anastomotic leakage (P = 0.961), pneumonia (P = 0.450), respiratory failure (P = 0.944), heart failure (P = 1.000), acute respiratory distress syndrome (ARDS) (P = 0.856), and unplanned reoperation (P = 0.440), whereas the time to the first postoperative flatus/bowel movement (P < 0.001) and the postoperative length of stay (P < 0.001) were significantly better in the EOF group than in the LOF group..

CONCLUSIONS

In this study, EOF after nCT combined with non-tube no fasting-enhanced recovery after MIE did not significantly increase complications, but significantly shortened the time to the first postoperative flatus/bowel movement and the postoperative length of stay.

Effect of an Early Oral Food Intake Strategy on the Quality of Life of Postoperative Patients With Esophageal Cancer

Objective

To explore the early oral food intake on the quality of life of postoperative patients with esophageal cancer.

Methods

A total of 100 patients with esophageal cancer were randomized into an observation group and a control group, with 50 patients in each group. The patients in the control group were routinely indwelt with a gastric tube and fasted for seven days. If no abnormality was found in examinations, the patients were instructed to attempt drinking water and gradually try eating liquid, semi-liquid, and common foods. The patients in the observation group were subjected to the early oral food intake strategy. The recovery and gastrointestinal symptoms of the patients were evaluated using the six-minute walk test and gastrointestinal symptom rating scale (GSRS) at discharge. The quality of life of patients was evaluated using the QLQ-C30 scale and QLQ-OES18 scale during the return visit to the hospital one month after discharge.

Results

The GSRS score of the observation group was markedly lower than that of the control group. The six-minute walk distance in the observation group was significantly higher than that in the control group; the difference was statistically significant (P < 0.01). In comparing the QLQ-C30 scores of the two groups, the scores in physical function, emotional function, and general health condition in the observation group were higher than those in the control group. In comparing the QLQ-OES18 scores of the two groups, the scores in dysphagia, eating, reflux, pain domains, and choking symptoms in the observation group were lower than those in the control group; the differences were statistically significant (P < 0.01), and there were no statistically significant differences in other symptoms and related functions between the two groups (P > 0.05).

Conclusion

The early oral food intake strategy can reduce gastrointestinal symptoms, promote recovery of postoperative patients with esophageal cancer, and improve quality of life.

Early oral intake and early removal of nasogastric tube post-esophagectomy: A systematic review and meta-analysis

BACKGROUND

Early oral intake (EOI: initiated within 1 day) and early nasogastric tube removal (ENR: removed ≤2 days) post-esophagectomy is controversial and subject to significant variation.

AIM

Our aim is to provide the most up-to-date evidence from published randomized controlled trials (RCTs) addressing both topics.

METHODS

We searched MEDLINE and Embase (1946-06/2019) for RCTs that investigated the effect of EOI and/or ENR post-esophagectomy with gastric conduit for reconstruction. Our main outcomes of interest were anastomotic leak, aspiration pneumonia, mortality, and length of hospital stay (LOS). Pooled mean differences (MD) and risk ratios (RR) estimates were obtained using a DerSimonian random effects model.

RESULTS

Two reviewers screened 613 abstracts and identified 6 RCTs eligible for inclusion; 2 regarding EOI and 4 for ENR. For EOI (2 studies, n = 389), was not associated with differences in risk of: anastomotic leak (RR: 1.01; 95% CI: 0.407, 2.500; I2 : 0%), aspiration pneumonia (RR: 1.018; 95% CI: 0.407, 2.500), mortality (RR: 1.00; 95% CI: 0.020, 50.0). The LOS was significantly shorter in the EOI group: LOS (MD: -2.509; 95% CI: -3.489, -1.529; I2 : 90.44%). For ENR (4 studies, n = 295), ENR (removed at POD0-2 vs. 5-8 days) was not associated with differences in risk of: anastomotic leak (RR: 1.11; 95% CI 0.336, 3.697; I2 : 25.75%) and pneumonia group (RR: 1.11; 95% CI: 0.336, 3.697; I2 : 25.75%), mortality (RR: 0.87; 95% CI: 0.328, 2.308; I2 : 0%)or LOS (MD: 1.618; 95% CI: -1.447, 4.683; I2 : 73.03%).

CONCLUSIONS

Our analysis showed that EOI as well as ENR post-esophagectomy do not significantly increase the risk of anastomotic leak, pneumonia, and mortality. The LOS was significantly shorter in the EOI group, and there was no significant difference in the ENR group. A paucity of RCTs has evaluated this question, highlighting the need for further high-quality evidence to address these vital aspects to post-esophagectomy care.

SYSTEMATIC REVIEW REGISTRATION

CRD42019138600.

Early versus the traditional start of oral intake following esophagectomy for esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Nil by mouth is considered the standard of care during the first days following esophagectomy. However, with the routine implementation of enhanced recovery after surgery, early oral intake is more likely to be the preferred mode of nutrition following esophagectomy. The present study aims to evaluate the safety and effectiveness of early oral intake following esophagectomy for esophageal cancer.

METHODS

Comprehensive literature searches were conducted using PubMed, Web of Science, Embase, and Cochrane Library. Weighted mean differences (WMD) and odds ratios (OR) with 95% confidence intervals (CI) were calculated as the effect sizes for continuous and dichotomous variables, respectively.

RESULTS

Fourteen studies with a total of 1947 patients were included. Length of hospital stay (WMD =  - 3.94, CI: - 4.98 to - 2.90; P < 0.001), the time to first flatus (WMD =  - 1.13, CI: - 1.25 to - 1.01; P < 0.001) and defecation (WMD =  - 1.26, CI: - 1.82 to - 0.71; P < 0.001) favored the early oral intake group. There was no statistically significant difference in mortality (OR = 1.23, CI: 0.45 to 3.36; P = 0.69). Early oral intake also did not increase the risk of pneumonia and overall postoperative complications.

CONCLUSIONS

Current evidence indicates early oral intake following esophagectomy seems to be safe and effective. It may be the preferred mode of nutrition following esophagectomy. However, more high-quality studies are still needed to further validate this conclusion.

Timing of oral intake after esophagectomy: A narrative review of the literature and case report

Esophagectomy, a treatment modality for esophageal cancer, is associated with high rates of morbidity, the most common being anastomotic leaks and pulmonary complications. The current standard of care for nutrition support after esophagectomy includes a period of nothing by mouth with enteral nutrition support via jejunostomy tube owing to the concern of increasing the risk of anastomotic leak as a result of early postoperative oral intake. However, the optimal timing of oral diet initiation remains controversial. This narrative review presents a patient who incurred an anastomotic leak following esophagectomy after initiation of oral intake on postoperative day 5 and evaluates the current literature on the timing of oral diet initiation after esophagectomy. A systematic literature search was performed to assess current evidence evaluating early oral diet (EOD) initiation after esophagectomy. Over the past 5 years, 11 studies have evaluated the impact of EOD initiation after esophagectomy in comparison with a conventional feeding regimen, including a period of nothing by mouth with enteral or parenteral nutrition support. The available evidence suggests that EOD initiation does not increase rates of complications after esophagectomy. However, the evidence is limited by the lack of a standardized definition of what constitutes EOD initiation, patient selection bias, variations in nutrition support provided in the studies, and lack of statistical analyses evaluating the impact of potential confounding variables. Additional research with larger, high-quality randomized controlled trials is needed to determine the optimal timing of diet initiation after esophagectomy.

Early postoperative feeding following surgery for upper gastrointestinal cancer: A systematic review

Nutrition post major upper gastrointestinal (UGI) cancer surgery is a significant consideration known to affect postoperative recovery and the ability to tolerate adjuvant treatment. This systematic review assessed the effect of early oral feeding (EOF), compared to traditional timing of oral feeding, following major surgery for UGI cancer on postoperative complications, postoperative length of hospital stay (LOS), nutritional status and quality of life (QOL). The literature was searched up to March 9th 2020 using CINHAL, PubMed, MEDLINE, Embase, Scopus and Web of Science databases. Quality assessment was completed using the Academy of Nutrition and Dietetics quality criteria checklist. Fifteen articles were included, consisting of seven randomised controlled trials, six cohort studies and two non-randomised trials, with a total of 2517 participants. The type and timing of EOF varied considerably across studies with limited reporting of energy and protein intakes from oral or enteral feeding. Fourteen studies assessed postoperative complications of which 13 reported no difference between EOF and standard care. Fourteen studies assessed postoperative LOS and of these, 13 reported a reduced length of stay in the EOF group. Four of 15 studies assessing nutritional status found no difference between groups. Three of 15 studies assessed QOL with inconsistent findings. This review found EOF reduced postoperative LOS and did not increase postoperative complications. However, the optimal timing for the introduction of EOF could not be established. Furthermore, the type of EOF varied considerably making comparison across studies challenging and demonstrates a need for internationally standardised definitions.

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.

Factors associated with the costs of hospitalization after esophagectomy: a retrospective observational study at a three-tertiary cancer hospital in China

Background

Esophageal cancer represents a major health threat in China. Esophagectomy is the standard treatment for respectable esophageal cancer. This study aimed to investigate the costs of hospitalization in esophageal cancer patients undergoing esophagectomy, and to analyze the factors influencing these costs.

Methods

A retrospective observational study which enrolled 196 patients who underwent esophagectomy from September, 2018, to April, 2019, in the Affiliated Cancer Hospital of Zhengzhou University were conducted

Results

The median inpatient cost was ￥72,772 (range, ￥49,796–128,771). Materials accounted for 39.7% of the direct medical costs, which was the highest proportion for any of the cost components. Minimally invasive esophagectomy (MIE, OR: 0.031; 95% CI: 0.005–0.209), cardiopathy comorbidity (OR: 0.344; 95% CI: 0.136–0.872), and anastomotic leak (OR: 0.012; 95% CI: 0.001–0.131) were risk factors for higher cost, while early oral feeding (OR: 3.979; 95% CI: 1.430–11.067) was a protective factor.

Conclusions

Understanding the factors associated with high hospitalization costs will help to reduce healthcare expenditure. By controlling complications and promoting early oral feeding, the economic burden on esophagectomy patients can be relieved. Further research based on a longitudinal design is needed to investigate the full costs of hospitalization associated with esophageal cancer.

Platelet-to-lymphocyte ratio is correlated with a delay in feeding resumption following a transhiatal esophagectomy with cervical anastomosis

Introduction

The lymphocytic population, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) are prognostic tools predictive of adverse outcomes for several solid tumors and oncologic surgeries, one of which is esophageal adenocarcinoma. Furthermore, delayed resumption of oral feeding postoperatively is associated with significant morbidity. Given the controversies regarding post-op nutritional support in these patients, this study investigates the prognostic role of the lymphocytic percentage, the NLR, and the PLR in predicting prolonged length of hospital stay (LOHS) and ICU stay (LOICUS) as well as delayed oral feeding following transhiatal esophagectomy (THE) for adenocarcinoma of the esophagogastric junction (AEG).

Methods

Forty consecutive patients who underwent transhiatal esophagectomy performed by a single surgeon for Siewert type II and type III adenocarcinoma of the esophagogastric junction at a tertiary referral center were selected. Retrospective data collection was performed from the patients’ medical records, and statistical analysis was performed using Pearson correlation and Student’s t test and Chi-square testing.

Results

An increased LOHS was correlated with a lower preoperative lymphocyte percentage (p = 0.043), higher NLR (p = 0.010) and PLR (p = 0.015), and an increased number of packed red blood cell (PRBC) transfusions perioperatively (p = 0.030). An increased LOICUS was correlated with a lower preoperative lymphocyte percentage (p = 0.033), higher NLR (p = 0.018) and PLR (p = 0.044), an increased number of PRBC transfusions (p = 0.001), and patients’ comorbidities (p < 0.05). A delay in feeding resumption was correlated with a lower preoperative lymphocyte percentage (p = 0.022), higher NLR (p = 0.004) and PLR (p = 0.001), an increased PRBC transfusions (p = 0.001), and diabetes mellitus (p = 0.033). Multivariate analysis with automatic linear modeling showed that only the preoperative PLR was a powerful predictor for the delay of feeding resumption (p < 0.01).

Conclusion

The lymphocyte percentage, PLR, and NLR are found to be associated with prolonged hospitalization and ICU stay and delayed oral feeding following THE for Siewert types II and III AEG. We hope by this series, to have set, at least one preliminary cornerstone, in the creation of a prognostic model, capable of assessing the need for an intraoperative jejunostomy placement, in patients undergoing esophagectomy for distal esophageal carcinoma.

The Improved Mediastinal Drainage Strategy for the Enhanced Recovery System After Esophagectomy

BACKGROUND

The improved drainage strategy was the transperitoneal placement of a single mediastinal drainage tube after esophagectomy. This study aimed to explore its effect on the incidence of postoperative complications, pain scores, and hospital stay.

METHODS

Data from 108 patients who underwent minimally invasive esophagectomy were retrospectively analyzed. Patients were divided into 2 groups: those in group A were treated with transthoracic placement of mediastinal drain and those in group B were treated with transperitoneal placement. The incidence of postoperative complications, pain scores, and postoperative hospital stay were compared.

RESULTS

The maximum pain scores in group B were significantly lower than those in group A from the first to the fourth postoperative days (PODs): POD1, 3.9 ± 0.7 vs 2.3 ± 0.7; POD2, 3.5 ± 0.8 vs 2.1 ± 0.7; POD3, 3.3 ± 0.8 vs 1.7 ± 0.8; and POD4, 3.1 ± 0.7 vs 1.7 ± 0.8 (all P < .001). Compared with group A, there were fewer postoperative analgesic drug users in group B (44.6% vs 17.9%; P = .005), fewer cases of pleural effusion (10.7% vs 0%; P = .045), and fewer cases of closed thoracic drainage due to pleural effusion or pneumothorax (14.3% vs 0%; P = .014). There were no significant differences in the incidence of anastomotic leakage, mediastinitis, major pulmonary complications, major abdominal complications, surgical site infection, and total postoperative complications, without statistical differences in postoperative hospital stay and 30-d mortality (all P > .05).

CONCLUSIONS

The transperitoneal placement of a single mediastinal drain can reduce postoperative pain and the incidence of pleural effusion, without increasing the incidence of other major postoperative complications and postoperative hospital stay.

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.

Effect of Chin-down-plus-larynx-tightening maneuver on swallowing function after minimally invasive esophagectomy: A randomized controlled trail

Background

The incidence of swallowing abnormality was high after minimally invasive esophagectomy (MIE) for esophageal cancer (EC). Few reports, however, focused on interventions for dysphagia after esophagectomy.

Aim

The purpose of this research was to estimate the effect of Chin‐down‐plus‐larynx‐tightening maneuver on swallowing function for patients receiving esophagectomy.

Method

This was a 2‐arm, parallel‐group, single‐blind randomized clinical trial, performed in patients suffered from EC from November 2018 to January 2020. Patients were randomly assigned to the intervention group (IG) or the control group (CG). The participants in CG received routine care, and the IG received Chin‐down‐plus‐larynx‐tightening maneuver during feeding. The incidence of choking cough, swallowing function, and dietary outcomes were evaluated before and after intervention for 7 days.

Results

A total of 237 EC cases were enrolled and randomized to the IG (n = 118) or CG (n = 119). There was no significant difference between the two groups in terms of demographic and clinical characteristics. Postoperative choking cough occurred in 5 of 118 cases (4.24%) in IG and 18 of 119 cases (19.4%) in CG, the differences showed statistically significant (P < .001). The analysis showed that the participants in the IG compared with the CG have more total caloric intake of 24 hours and higher K/R (the ratio of calories oral achieved to total calories required of body) significantly from D1 to D7 of intervention (P < .05).

Conclusion

The findings suggest that the Chin‐down‐plus‐larynx‐tightening maneuver can improve swallowing function recovery and oral total food intake and calories in EC patients undergoing MIE.

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.

Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis

Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.

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.

Early oral feeding following esophagectomy

Nutritional support for patients with esophagectomy is very important especially for patients with malnutrition. But there is significant variation in nutritional support between different hospitals. Traditionally, 5 to 7 days of nil by mouth is required to allow healing of the anastomosis after esophagectomy; a feeding tube (usually jejunostomy tube) placed before or during the operation provides enteral access for patients with esophagectomy. However, there is no consensus of the timing of oral intake after esophagectomy. We reviewed the published data about early oral feeding (EOF) after esophagectomy. At present, there were only four studies, including two randomized studies, investigating the feasibility and safety of EOF for patients with esophagectomy. The results of the current studies show that EOF after esophagectomy do not increase postoperative complications and motility. However, evidence from large multicenter randomized controlled clinical trials is still lacking. In the future, the long-term outcomes, including body weight loss, quality of life (QOL), laboratory nutritional markers and survival, should be investigated in the field of EOF protocols. EOF after esophagectomy may require the application of the most recent knowledge and the perioperative practice of multi-disciplinary team medical care, according to the situation of each medical center.

Early Oral Feeding Following McKeown Minimally Invasive Esophagectomy: An Open-label, Randomized, Controlled, Noninferiority Trial

OBJECTIVE

Our objective was to evaluate the impact of early oral feeding (EOF) on postoperative cardiac, respiratory, and gastrointestinal (CRG) complications after McKeown minimally invasive esophagectomy for esophageal cancer.

SUMMARY BACKGROUND DATA

Nil-by-mouth with enteral tube feeding is routinely practiced after esophagectomy.

METHODS

Patients were randomly allocated to receive oral feeding on the first postoperative day (EOF group) or late oral feeding (LOF group) 7 days after surgery. The primary endpoint was the occurrence of postoperative CRG complications, and the secondary outcomes included bowel function recovery and short-term quality of life (QOL).

RESULTS

Between February 2014 and October 2015, 280 patients were enrolled in this study. There were 140 patients in the EOF group and 140 patients in the LOF group. EOF was noninferior to LOF for CRG complications (30.0% in the EOF group vs. 32.9% in the LOF group; 95% confidence interval of the difference: -13.8% to 8.0%). Compared with the LOF group, the EOF group showed significantly shorter time to first flatus (median of 2 days vs. 3 days, P = 0.001) and bowel movement (median of 3 vs. 4 days, P < 0.001). Two weeks after the operation, patients in the EOF group reported higher global QOL and function scores and lower symptom scores than patients in the LOF group.

CONCLUSIONS

In patients after McKeown minimally invasive esophagectomy is noninferior to the standard of care with regard to postoperative CRG complications. In addition, patients in the EOF group had a quicker recovery of bowel function and improved short-term QOL.

Impact of an Early Oral Feeding Protocol on Inflammatory Cytokine Changes After Esophagectomy

BACKGROUND

The aim of the current study was to investigate the impact of early oral feeding (EOF) on inflammatory cytokine levels after McKeown minimally invasive esophagectomy (MIE) for cancer.

METHODS

This study was based on a randomized controlled trial (NCT01998230). Patients with esophageal cancer who received McKeown MIE were randomly allocated into a group that started oral feeding on postoperative day (POD) 1 (EOF group) or a second group that received nil by mouth until 7 days after operation (late oral feeding [LOF] group). We chose 86 patients, 46 patients in the EOF group and 40 patients in the LOF group, in which to analyze inflammatory cytokine levels (interleukin [IL]-6, IL-8, tumor necrosis factor-a [TNF-α], and monocyte chemotactic protein-1 [MCP-1]).

RESULTS

The EOF and LOF groups exhibited similar preoperative IL-6, IL-8 TNF-α, and MCP-1 levels. The levels of the four inflammatory cytokines at PODs 1 and 3 were significantly higher than the preoperative levels (all p < 0.001). At POD 5 the levels of all four inflammatory cytokines were decreased compared with those at PODs 1 and 3. At PODs 3 and 5 the levels of IL-6, IL-8, and TNF-α were significantly lower in the EOF group than in the LOF group (all p < 0.05). At POD 3 the MCP-1 levels in the EOF group were significantly lower than those in the LOF group (all p < 0.05).

CONCLUSIONS

Compared with conventional rehabilitation programs the EOF protocol may decrease stress response after McKeown MIE.

Feasibility of a single mediastinal drain through the abdominal wall after esophagectomy

This study evaluated the safety and effectiveness of a single mediastinal drainage tube in the thoracic and abdominal cavity after minimally invasive esophagectomy (MIE). This study was undertaken to determine if the procedure could be included in a fast-track surgery program for resectable esophageal carcinoma (EC).From June 17 to November 30, 2015, clinical data for 78 eligible patients who had undergone a fast-track surgery program and MIE were retrospectively analyzed. Twenty-eight patients had a chest tube and mediastinal drainage tube. Thirty-four patients had only a mediastinal drainage tube through the intercostal space. The remaining 30 patients had a single mediastinal drainage tube in the thoracic and abdominal cavity through the abdominal wall. The complication rates and pain scores for each of the groups were compared. The statistical calculations were performed using SPSS 17.0 for Windows (SPSS Inc., Chicago, IL). The quantitative data among the groups were compared using 1-way analysis of variance (ANOVA). The Chi-square, Mann-Whitney U and Fisher exact tests were used for qualitative data analysis.There were no significant differences in the anastomotic leak rates, postoperative days and total complication rates (P = .861). The lowest visual analog scale (VAS) scores of the drainage tubes were observed in the group with a single mediastinal drain through the abdominal wall (P <.001).The results of this study suggested that a single mediastinal drainage tube in the thoracic and abdominal cavity after MIE may be safe and efficient. This clinical practice is a part of our fast-track surgery program.

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.

The long-term effects of early oral feeding following minimal invasive esophagectomy

A nil-by-mouth regime with enteral nutrition via an artificial route is frequently applied following esophagectomy. However, early initiation of oral feeding could potentially improve recovery and has shown to be beneficial in many types of abdominal surgery. Although short-term nutritional safety of oral intake after an esophagectomy has been documented, long-term effects of this feeding regimen are unknown. In this cohort study, data from patients undergoing minimal invasive Ivor-Lewis esophagectomy between 04-2012 and 09-2015 in three centers in Netherlands were collected. Patients in the oral feeding group were retrieved from a previous prospective study and compared with a cohort of patients with early enteral jejunostomy feeding but delayed oral intake. Body mass index (BMI) measurements, complications, and nutritional re-interventions (re- or start of artificial feeding, start of total parenteral nutrition) were gathered over the course of one year after surgery. One year after surgery the median BMI was 22.8 kg/m2 and weight loss was 7.0 kg (9.5%) in 114 patients. Patients in the early oral feeding group lost more weight during the first postoperative month (P = 0.004). However, in the months thereafter this difference was not observed anymore. In the early oral feeding group, 28 patients (56%) required a nutritional re-intervention, compared to 46 patients (72%) in the delayed oral feeding group (P = 0.078). During admission, more re-interventions were performed in the delayed oral feeding group (17 vs. 46 patients P < 0.001). Esophagectomy reduces BMI in the first year after surgery regardless of the feeding regimen. Direct start of oral intake following esophagectomy has no impact on early nutritional re-interventions and long-term weight loss.

Nutrition in peri-operative esophageal cancer management

Nutritional status and dietary intake are increasingly recognized as essential areas in esophageal cancer management. Nutritional management of esophageal cancer is a continuously evolving field and comprises an interesting area for scientific research. Areas covered: This review encompasses the current literature on nutrition in the pre-operative, peri-operative, and post-operative phases of esophageal cancer. Both established interventions and potential novel targets for nutritional management are discussed. Expert commentary: To ensure an optimal pre-operative status and to reduce peri-operative complications, it is key to assess nutritional status in all pre-operative esophageal cancer patients and to apply nutritional interventions accordingly. Since esophagectomy results in a permanent anatomical change, a special focus on nutritional strategies is needed in the post-operative phase, including early initiation of enteral feeding, nutritional interventions for post-operative complications, and attention to long-term nutritional intake and status. Nutritional aspects of pre-optimization and peri-operative management should be incorporated in novel Enhanced Recovery After Surgery programs for esophageal cancer.

The feeding route after esophagectomy: a review of literature

Enhanced recovery programs effectively optimize perioperative care and reduce postoperative morbidity. In esophagectomy, several components of the ERAS program are successfully introduced. However, timing and type of postoperative feeding remain a matter of debate. Adequate nutritional support is essential in patients undergoing an esophagectomy. These patients often present with weight loss and their eating pattern is strongly altered by the procedure and reconstruction. Total parenteral nutrition (TPN) is associated with severe septic complications and enteral nutrition (EN) does not increase major complications. Therefore, early EN after esophagectomy is favored over TPN. However, with enteral feeding tubes minor complications occur frequently (13-38%) and in some cases this can hamper recovery. Based on experience in other types of upper gastro-intestinal surgery, early start of oral feeding could improve time to functional recovery after surgery. The total length of stay was significantly shorter in four prospective studies (6-12 vs. 8-13 days). However, large randomized controlled trials are lacking and the potential benefit of early oral feeding after esophageal surgery remains elusive. EN is nowadays the optimal feeding route after esophagectomy. TPN should only be used in specific cases in which EN is contraindicated. Early initiation of oral intake is promising and could improve postoperative recovery. However, further research is needed to substantiate these results.

Nasogastric decompression following esophagectomy: a systematic literature review and meta-analysis

Routine use of nasogastric tubes for gastric decompression has been abolished in nearly all types of gastro-intestinal surgery after introduction of enhanced recovery after surgery programs. However, in esophagectomy the routine use of nasogastric decompression is still a matter of debate. To determine the effects of routine nasogastric decompression following esophagectomy compared with early or peroperative removal of the nasogastric tube on pulmonary complications, anastomotic leakage, mortality, and postoperative recovery. A systematic literature review and meta-analysis of studies comparing early or peroperative versus late removal of nasogastric tubes. A total of seven comparative studies were included (n = 608). In two randomized trials, and one retrospective cohort study, peroperative removal of the nasogastric tube was compared with routine nasogastric decompression. In one randomized trial early removal of the nasogastric tube (on postoperative day 2) was compared with removal of the nasogastric tube on the 6th-10th postoperative day. In the remaining three trials a fast-track protocol without a nasogastric tube was compared with conventional care with a nasogastric tube during the first postoperative days. Peroperative or early removal of the nasogastric tube did not result in a significantly different rate of anastomotic leakage, pulmonary complications or mortality in individual studies, nor in the meta-analysis. In the meta-analysis, hospital stay was significantly shorter with peroperative or early removal of the nasogastric tube when all studies were included, but not when the meta-analysis was limited to randomized trials. This systematic review did not find a difference in adverse outcomes between nasogastric decompression or no nasogastric decompression following esophagectomy.

Enhanced recovery after gastro-intestinal surgery: The scientific background

Enhanced recovery programs (ERP) are without any doubt a major innovation in the care of surgical patients. This multimodal approach encompasses elements of both medical and surgical care. The goal of this in-depth review is to analyze the surgical aspects of ERP, underlining the scientific rationale behind each element of ERP after surgery and in particular, the role of mechanical bowel preparation before colorectal surgery, the place of minimal access surgery, the utility of nasogastric tube, abdominal drainage, bladder catheters and early re-feeding. Publication of factual data has allowed many dogmas to be discarded.

Stage-directed individualized therapy in esophageal cancer

Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.

Embedded Three-Layer Esophagogastric Anastomosis Reduces Morbidity and Improves Short-Term Outcomes After Esophagectomy for Cancer

BACKGROUND

There exists great controversy regarding the use of esophagogastric anastomotic techniques in the treatment of esophageal cancer. The aim of this study was to compare two types of cervical esophagogastric anastomoses with respect to the reduction of postoperative anastomotic leaks, stenosis, and gastroesophageal reflux.

METHODS

From June 2010 to September 2013, 339 patients who underwent two different cervical esophagogastric anastomotic procedures after thoracolaparoscopic esophagectomy for esophageal cancer were identified.

RESULTS

A total of 166 patients with esophageal cancer were treated using an embedded three-layer anastomosis (embedded group), and 173 were treated using a conventional two-layer anastomosis (conventional group). The rates of anastomotic leak (2.4% [4 of 166] versus 7.5% [13 of 173], p = 0.031) and benign anastomotic stricture (4.8% [8 of 166] versus 12.7% [22 of 173], p = 0.010) were significantly lower in the embedded group compared with the conventional group. The mean reflux scores were significantly higher among the patients in the conventional group compared with the patients in the embedded group at 1 month (25.2 versus 19.0, p = 0.001), 3 months (27.8 versus 21.4, p = 0.001), and 6 months (23.4 versus 17.8, p < 0.001) of follow-up. The mean scores for dysphagia were significantly lower among the patients in the embedded group compared with the patients in the conventional group at both 3 months (22.7 versus 29.8, p = 0.012) and 6 months (16.0 versus 21.3, p = 0.008) of follow-up.

CONCLUSIONS

The new embedded three-layer esophagogastric anastomosis offers several advantages and reduces the incidence of postoperative complications such as anastomotic leak, stricture, and gastroesophageal reflux.

A video demonstration of the Li's anastomosis-the key part of the "non-tube no fasting" fast track program for resectable esophageal carcinoma

The main obstacle of fast track surgery for esophagectomy is early oral feeding. The main concern of early oral feeding is the possibility of increasing the incidence of anastomotic leakage. Dr. Yin Li used the Li's anastomosis to ensure oral feeding at will the first day after esophagectomy. This safe and efficient anastomosis method significantly reduced the anastomotic leak rate, the number of post-operative days and stricture. Importantly, the "non-tube no fasting" fast track program for esophageal cancer patients was conducted smoothly with Li's anastomosis. This article was focused on the surgical procedure of Li's anastomosis.