Early enteral nutrition reduces the rate of life-threatening complications after thoracic esophagectomy in patients with esophageal cancer

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.

ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.

Nutrition management by a multidisciplinary team for prevention of nutritional deficits and morbidity following esophagectomy

This study evaluated the effects of perioperative nutrition management by a multidisciplinary team on nutrition and postoperative complications of patients with esophageal cancer. A total of 239 patients with esophageal cancer who underwent esophagectomy and gastric conduit reconstruction for esophageal or esophagogastric junction cancer between February 2019 and February 2020 were included in the study. They were divided into the experimental group (120 patients) and the control group (119 patients) using the random number table method. Control group patients received routine diet management and experimental group patients received perioperative nutrition management by a multidisciplinary team. The differences of nutriture and postoperative complications between the two groups were compared. At 3 and 7 days after surgery, the experimental group patients had higher total protein and albumin levels (P<0.05), shorter postoperative anal exhaust time (P<0.05), lower incidence of postoperative gastrointestinal adverse reactions, pneumonia, anastomotic fistula, hypoproteinemia (P<0.05), and lower hospitalization costs (P<0.05) than the control group. Nutrition management by a multidisciplinary team effectively improved the nutriture of patients, promoted the rapid recovery of postoperative gastrointestinal function, reduced postoperative complications, and reduced hospitalization costs.

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.

Residing in a food desert is associated with an increased risk of readmission following esophagectomy for cancer

Background

Nutritional status is related to treatment outcomes for esophageal cancer. Residing in a food desert (FD) has been associated with worse outcomes in breast and colon cancer. We assessed the association of residing in a FD on 30-day outcomes of esophageal cancer patients who received tri-modality therapy.

Methods

A retrospective review of patients who underwent esophagectomy (1/2015 to 7/2020, in New Hampshire, USA) was performed. Patients were excluded if they did not undergo neo-adjuvant treatment, required treatment outside of standard Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) protocol, or lacked both pre and post neo-adjuvant treatment computed tomography (CT) scans for review. Demographics, nutrition parameters, treatment characteristics, 30-day complications and 90-day mortality were reviewed. FD status was defined by the United States Department of Agriculture (USDA) Food Access Research Atlas and cross-referenced with patients' home zip code. Readmission was defined as readmission to any hospital for any reason within 30-day of discharge. Univariable analysis was conducted using Student's t-test or Wilcoxon rank-sum for continuous variables, and Fisher's exact test for categorical variables. Multivariable logistic regression was then used to model readmission status on FD status adjusted for measures statistically associated with readmission status at the P<0.10 in univariable analyses.

Results

Seventy-eight patients were included in the analysis. Overall pre-treatment prevalence of sarcopenia was 11.5% (9/78) and did not vary by FD status. Univariable analysis, demonstrated few significant differences between those who were readmitted and those who were not. On unadjusted analysis, patients who lived in a FD were 5 times more likely to be readmitted [5.16; 95% confidence interval (CI): 1.70-15.67] compared to those who did not. Residing in a FD remained a significant risk factor for readmission after adjustment for operative time, discharge to a rehabilitation facility and development of a grade III/IV complication [adjusted odds ratio (OR): 6.38; 95% CI: 1.45-28.08].

Conclusions

Our data suggest that residing in a FD is a prognostic factor for readmission after tri-modality therapy for esophageal cancer. Clinicians need to be aware that previously established nutritional markers may not completely capture nutritional status and living in a FD may significantly increase the risk of readmission in these patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Decrease of voriconazole trough levels during therapy with enteral nutrition: a case report

Background

Voriconazole (VRCZ) is the first-line therapy for chronic pulmonary aspergillosis and is available in both intravenous and oral formulations. The bioavailability of the oral form is estimated to be over 90% in healthy volunteers. Some drugs are reported to interact with enteral nutrition (EN), but there are few reports about the trough levels of VRCZ during EN therapy. Here, we describe changes in the VRCZ trough levels in a patient receiving continuous EN therapy.

Case presentation

The patient was a 58-year-old man with esophageal cancer and a history of partial pulmonary resection due to aspergilloma. He was taking oral VRCZ tablets and his VRCZ trough level was about 2 μg/mL before esophageal cancer surgery. Following esophagectomy, VRCZ was restarted on postoperative day 16. Crushed VRCZ tablets were administered via a jejunostomy tube because of swallowing difficulty. He was also receiving EN, which was interrupted only during the administration of VRCZ. When we checked his VRCZ level 5 days after restarting VRCZ, the trough level was 0.80 μg/mL. After increasing the VRCZ dose, reducing EN, and changing the administration route from jejunostomy tube to oral, his trough level increased to 1.87 μg/mL.

Conclusions

A decrease in the VRCZ trough level was observed when VRCZ was administered via a jejunostomy tube while the patient was receiving continuous EN. Careful monitoring of VRCZ levels is needed in such cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40780-021-00237-4.

Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer

Background

Unintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer‐associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients.

Methods

We retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017–August 2019) were compared with patients who underwent resection before protocol implementation (January 2015–July 2017). Patients undergoing surgery during the month of protocol initiation were excluded.

Results

Of the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30‐day readmission, or mortality rates between groups.

Conclusions

Results of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Esophageal cancer surgery: review of complications and their management

Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.

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.

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.

Jejunostomy at the time of esophagectomy is associated with improved short-term perioperative outcomes: analysis of the NSQIP database

Adequate preoperative and perioperative nutrition has been shown to improve outcomes for patients undergoing esophagectomy. The most effective way to provide enteral nutrition for patients after esophagectomy is via jejunostomy tube. There is an open debate whether a feeding jejunostomy tube is necessary at the time of esophagectomy. This study evaluated short term surgical outcomes for patients undergoing esophagectomy with and without concurrent jejunostomy tube placement. Esophageal cancer patients were identified from the NSQIP database who underwent esophagectomy between 2005 through 2016. Patients were classified into 2 cohorts: patients with concurrent jejunostomy tube placement and those without jejunostomy placement at the time of esophagectomy. Clinical and demographic data was collected. Differences in short term outcomes were assessed by univariate and multivariable analysis, including prolonged hospital stay (>30 days), in-hospital mortality, and 30-day mortality for both cohorts. We identified 8,632 patients that underwent esophagectomy for esophageal cancer with 80% males and mean age of 63.2±10.6 years. Twenty percent (n=1,723) had preoperative weight loss in the 6-month period preceding surgery. Forty-five percent (n=3,900) patients had jejunostomy placement at the time of esophagectomy. Overall, the rate of prolonged hospital stay (P=0.006), in-hospital mortality (P<0.001) and 30-day mortality (P<0.001) were significantly higher in patients without concurrent jejunostomy in both univariable and multivariable models. This study demonstrates that patients with jejunostomy placement at the time of esophagectomy have improved short term perioperative outcomes.

A simple, novel laparoscopic feeding jejunostomy technique to prevent bowel obstruction after esophagectomy: the "curtain method"

BACKGROUND

Feeding jejunostomy (FJ) is a common treatment to support patients with esophageal cancer after esophagectomy. However, severe FJ-related complications, such as bowel obstruction, occasionally occur. We investigated the ability of our simple, novel FJ technique, the "curtain method," to prevent bowel obstruction.

METHODS

In laparoscopic surgery, the main mechanism of bowel obstruction involves torsion of the mesentery accompanied by migration of the intestine across the fixed FJ through the space surrounded by a triangle comprising the ligament of Treitz, fixed FJ, and spleen rather than adhesion. Our "curtain method" involves closure of this triangle zone with omentum, and the appearance of the lifted omentum resembles a curtain. Sixty patients treated with this modified FJ were retrospectively compared with 13 patients treated with conventional FJ in terms of the incidence of bowel obstruction, peritonitis, stoma site infection, and catheter obstruction.

RESULTS

From 2013 to 2017, 60 patients underwent esophagectomy and gastric conduit reconstruction accompanied by modified laparoscopic FJ. The median observation period, including the period after tube removal, was 644 days. No FJ-associated bowel obstruction, the prevention of which was the primary aim, occurred in any patient. Likewise, no peritonitis or dislodgement occurred. Eight patients (13%) developed a stoma site infection with granulation. The feeding tube became occluded in 11 patients (18%); however, a new feeding tube was reinserted under fluoroscopy for all of these patients. From 2003 to 2012, 13 patients underwent conventional FJ. The median observation period was 387 days. Three patients (23%) developed bowel obstruction by torsion 71 to 134 days after the first surgery, and all were treated by emergency operations. Other FJ-related complications were not different from those in the modified FJ group.

CONCLUSION

Our simple, novel technique, the "curtain method," for prevention of laparoscopic FJ-associated bowel obstruction after esophagectomy is a safe additional surgery.

Enteral and parenteral nutrition in cancer patients, a comparison of complication rates: an updated systematic review and (cumulative) meta-analysis

INTRODUCTION

Weight loss in cancer patients is a worrisome constitutional change predicting disease progression and shortened survival time. A logical approach to counter some of the weight loss is to provide nutritional support, administered through enteral nutrition (EN) or parenteral nutrition (PN). The aim of this paper was to update the original systematic review and meta-analysis previously published by Chow et al., while also assessing publication quality and effect of randomized controlled trials (RCTs) on the meta-conclusion over time.

METHODS

A literature search was carried out; screening was conducted for RCTs published in January 2015 up until December 2018. The primary endpoints were the percentage of patients achieving no infection and no nutrition support complications. Secondary endpoints included proportion of patients achieving no major complications and no mortality. Review Manager (RevMan 5.3) by Cochrane IMS and Comprehensive Meta-Analysis (version 3) by Biostat were used for meta-analyses of endpoints and assessment of publication quality.

RESULTS

An additional seven studies were identified since our prior publication, leading to 43 papers included in our review. The results echo those previously published; EN and PN are equivalent in all endpoints except for infection. Subgroup analyses of studies only containing adults indicate identical risks across all endpoints. Cumulative meta-analysis suggests that meta-conclusions have remained the same since the beginning of publication time for all endpoints except for the endpoint of infection, which changed from not favoring to favoring EN after studies published in 1997. There was low risk of bias, as determined by assessment tool and visual inspection of funnel plots.

CONCLUSIONS

The results support the current European Society of Clinical Nutrition and Metabolism guidelines recommending enteral over parenteral nutrition, when oral nutrition is inadequate, in adult patients. Further studies comparing EN and PN for these critical endpoints appear unnecessary, given the lack of change in meta-conclusion and low publication bias over the past decades.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Jejunostomy or nasojejunal tube after esophagectomy: a review of the literature

Patients undergoing esophagectomy for cancer are a difficult to treat group of patients. At diagnosis they will present some degree of malnutrition in up to 80% and the causes are from multifactorial origin: the inability of food ingestion, advanced age, taste disturbances, and morbidity related to neoadjuvant treatment. In order to restaure the nutritional status, enteral nutritional support is preferable to parenteral support because of the risks of septic complications associated with venous catheters. During the postoperative period, the oral route is often inaccessible in these patients due to swallowing disorders and eventually mechanical ventilation, and if possible, often it does not provide sufficient caloric amounts for postoperative energy balance. For these reasons, it is usually recommended additional nutritional support. There are few studies in the literature that specifically address which is the most adequate route for enteral nutrition in patients undergoing esophagectomy. Nasojejunal catheters present a higher incidence of local complications, such as displacement and occlusion, whereas jejunostomy is more associated with reinterventions for the treatment of complications secondary to extravasation. Although there is weak evidence in the literature and a lack of randomized, prospective and multicenter studies evaluating the best enteral nutrition route in the postoperative period of esophagectomy, the use of the nasoenteric catheter seems to be adequate due to its simplicity of positioning and low rates of severe complications. In this paper a review is performed of the evidence about this subject.

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.

Enteral Feeding Access Has an Impact on Outcomes for Patients with Esophageal Cancer Undergoing Esophagectomy: An Analysis of SEER-Medicare

BACKGROUND

Optimal nutrition after esophagectomy is challenging due to alterations in eating, both from the tumor and during surgical recovery. Enteral nutrition via feeding tube is commonly used. The impact of feeding tubes on post-esophagectomy outcomes was examined in a large national data set.

METHODS

Patients with esophageal cancer (1998-2013) undergoing esophagectomy were extracted from the Surveillance Epidemiology and End Results-Medicare database. Chi-square and t tests were used to compare categorical and continuous variables. Time trend analyses were performed with Cochran-Armitage survival using log-rank and multivariable analysis with generalized linear modeling.

RESULTS

The study examined 2495 patients. The majority had enteral feeding access (71%, n = 1794) during the perioperative period. Mortality among the patients with feeding tubes was lower at 30 days (5.4% vs 8.4%), 60 days (9.0% vs 13.0%), and 90 days (12.2% vs 15.8%). In the multivariable analysis, the patients with feeding tubes had improved short-term survival at 30 days (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.46-0.93), 60 days (OR, 0.64; 95% CI, 0.49-0.85), and 90 days (OR, 0.70; 95% CI, 0.54-0.90). The hospital stay was shorter for the patients undergoing enteral feeding tube placement (17.9 vs 19.5 days; p = 0.04). Discharge destination (home vs health care facility) showed no difference.

CONCLUSIONS

Feeding tubes in patients undergoing esophagectomy were associated with an increase in short-term survival up to 90 days after surgery. Feeding tube placement was not associated with higher rates of non-home discharges and did not prolong the hospital stay.

C-reactive protein to albumin ratio is a key indicator in a predictive model for anastomosis leakage after esophagectomy: Application of classification and regression tree analysis

Background

Anastomotic leakage (AL), a serious complication after esophagectomy, might impair patient quality of life, prolong hospital stay, and even lead to surgery‐related death. The aim of this study was to show a novel decision model based on classification and regression tree (CART) analysis for the prediction of postoperative AL among patients who have undergone esophagectomy.

Methods

A total of 450 patients (training set: 356; test set: 94) with perioperative information were included. A decision tree model was established to identify the predictors of AL in the training set, which was validated in the test set. A receiver operating characteristic curve was also created to illustrate the diagnostic ability of the decision model.

Results

A total of 12.2% (55/450) of the 450 patients suffered AL, which was diagnosed at median postoperative day 7 (range: 6–16). The decision tree model, containing surgical duration, postoperative lymphocyte count, and postoperative C‐reactive protein to albumin ratio, was established by CART analysis. Among the three variables, the postoperative C‐reactive protein to albumin ratio was identified as the most important indicator in the CART model with normalized importance of 100%. According to the results validated in the test set, the sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of the prediction model were 80%, 98.8%, 88.9%, 97.6%, and 96.8%, respectively. Moreover, the area under the receiver operating characteristic curve was 0.95.

Conclusion

The decision model based on CART analysis presented good performance for predicting AL, and might allow the early identification of patients at high risk.

Safety and efficacy of hydroxyethyl starch 6% 130/0.4/9 solution versus 5% human serum albumin in thoracic esophagectomy with 3-field lymph nodes dissection

PURPOSE

We investigated the safety and efficacy of administering hydroxyethyl starch 6% 130/0.4/9 (HES130/0.4/9) versus 5% human serum albumin (HSA), perioperatively, to patients undergoing thoracic esophagectomy with 3-field lymph-node dissection for esophageal cancer.

METHODS

The subjects of this study were 262 patients, scheduled to undergo thoracic esophagectomy for esophageal cancer, who were assigned to one of two groups based on the fluid replacement therapy. We compared the intraoperative and immediate postoperative hemodynamics and incidence of complications in the two groups.

RESULTS

Neither group suffered any adverse events. No significant differences were observed in systolic/diastolic blood pressure, heart rate, incidence of postoperative complications, postoperative urine output, or serum creatinine levels, between the groups. A mild postoperative increase (×1.5 increase) in serum creatinine levels was seen in 9.5% and 9.5% of patients in the HSA and HES130/0.4/9 groups, respectively (p = 0.99), and a moderate postoperative increase (×2.0 increase) was seen in 4.4% and 3.1%, respectively (p = 0.84). Univariate and multivariate analyses revealed that the administration of hydroxyethyl starch was not associated with a postoperative increase in serum creatinine levels.

CONCLUSION

Hydroxyethyl starch 6% 130/0.4/9 was well tolerated and comparable to albumin with respect to its effect on renal function during thoracic esophagectomy with 3-field lymph-node dissection.

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.

ESPEN guideline on clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.

Enteral versus parenteral nutrition and enteral versus a combination of enteral and parenteral nutrition for adults in the intensive care unit

BACKGROUND

Critically ill people are at increased risk of malnutrition. Acute and chronic illness, trauma and inflammation induce stress-related catabolism, and drug-induced adverse effects may reduce appetite or increase nausea and vomiting. In addition, patient management in the intensive care unit (ICU) may also interrupt feeding routines. Methods to deliver nutritional requirements include provision of enteral nutrition (EN), or parenteral nutrition (PN), or a combination of both (EN and PN). However, each method is problematic. This review aimed to determine the route of delivery that optimizes uptake of nutrition.

OBJECTIVES

To compare the effects of enteral versus parenteral methods of nutrition, and the effects of enteral versus a combination of enteral and parenteral methods of nutrition, among critically ill adults, in terms of mortality, number of ICU-free days up to day 28, and adverse events.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase on 3 October 2017. We searched clinical trials registries and grey literature, and handsearched reference lists of included studies and related reviews.

SELECTION CRITERIA

We included randomized controlled studies (RCTs) and quasi-randomized studies comparing EN given to adults in the ICU versus PN or versus EN and PN. We included participants that were trauma, emergency, and postsurgical patients in the ICU.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence with GRADE.

MAIN RESULTS

We included 25 studies with 8816 participants; 23 studies were RCTs and two were quasi-randomized studies. All included participants were critically ill in the ICU with a wide range of diagnoses; mechanical ventilation status between study participants varied. We identified 11 studies awaiting classification for which we were unable to assess eligibility, and two ongoing studies.Seventeen studies compared EN versus PN, six compared EN versus EN and PN, two were multi-arm studies comparing EN versus PN versus EN and PN. Most studies reported randomization and allocation concealment inadequately. Most studies reported no methods to blind personnel or outcome assessors to nutrition groups; one study used adequate methods to reduce risk of performance bias.Enteral nutrition versus parenteral nutritionWe found that one feeding route rather than the other (EN or PN) may make little or no difference to mortality in hospital (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.80 to 1.77; 361 participants; 6 studies; low-certainty evidence), or mortality within 30 days (RR 1.02, 95% CI 0.92 to 1.13; 3148 participants; 11 studies; low-certainty evidence). It is uncertain whether one feeding route rather than the other reduces mortality within 90 days because the certainty of the evidence is very low (RR 1.06, 95% CI 0.95 to 1.17; 2461 participants; 3 studies). One study reported mortality at one to four months and we did not combine this in the analysis; we reported this data as mortality within 180 days and it is uncertain whether EN or PN affects the number of deaths within 180 days because the certainty of the evidence is very low (RR 0.33, 95% CI 0.04 to 2.97; 46 participants).No studies reported number of ICU-free days up to day 28, and one study reported number of ventilator-free days up to day 28 and it is uncertain whether one feeding route rather than the other reduces the number of ventilator-free days up to day 28 because the certainty of the evidence is very low (mean difference, inverse variance, 0.00, 95% CI -0.97 to 0.97; 2388 participants).We combined data for adverse events reported by more than one study. It is uncertain whether EN or PN affects aspiration because the certainty of the evidence is very low (RR 1.53, 95% CI 0.46 to 5.03; 2437 participants; 2 studies), and we found that one feeding route rather than the other may make little or no difference to pneumonia (RR 1.10, 95% CI 0.82 to 1.48; 415 participants; 7 studies; low-certainty evidence). We found that EN may reduce sepsis (RR 0.59, 95% CI 0.37 to 0.95; 361 participants; 7 studies; low-certainty evidence), and it is uncertain whether PN reduces vomiting because the certainty of the evidence is very low (RR 3.42, 95% CI 1.15 to 10.16; 2525 participants; 3 studies).Enteral nutrition versus enteral nutrition and parenteral nutritionWe found that one feeding regimen rather than another (EN or combined EN or PN) may make little or no difference to mortality in hospital (RR 0.99, 95% CI 0.84 to 1.16; 5111 participants; 5 studies; low-certainty evidence), and at 90 days (RR 1.00, 95% CI 0.86 to 1.18; 4760 participants; 2 studies; low-certainty evidence). It is uncertain whether combined EN and PN leads to fewer deaths at 30 days because the certainty of the evidence is very low (RR 1.64, 95% CI 1.06 to 2.54; 409 participants; 3 studies). It is uncertain whether one feeding regimen rather than another reduces mortality within 180 days because the certainty of the evidence is very low (RR 1.00, 95% CI 0.65 to 1.55; 120 participants; 1 study).No studies reported number of ICU-free days or ventilator-free days up to day 28. It is uncertain whether either feeding method reduces pneumonia because the certainty of the evidence is very low (RR 1.40, 95% CI 0.91 to 2.15; 205 participants; 2 studies). No studies reported aspiration, sepsis, or vomiting.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine whether EN is better or worse than PN, or than combined EN and PN for mortality in hospital, at 90 days and at 180 days, and on the number of ventilator-free days and adverse events. We found fewer deaths at 30 days when studies gave combined EN and PN, and reduced sepsis for EN rather than PN. We found no studies that reported number of ICU-free days up to day 28. Certainty of the evidence for all outcomes is either low or very low. The 11 studies awaiting classification may alter the conclusions of the review once assessed.

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

We retrospectively examined a large cohort of esophageal carcinoma patients who received early enteral nutrition (EEN) to clarify the validity of EEN compared with total parenteral nutrition (TPN). Included were a total of 665 consecutive patients with histologically confirmed carcinoma of the esophagus or esophagogastric junction; and all patients underwent esophagectomy. The patients were divided into two groups: TPN (n = 262) and EEN (n = 403). The TPN group consisted of patients who only received intravenous nutrition support after operation. The postoperative length of hospital stay (PLOS), anastomotic leakage, mortality after surgery, and hospital charges were reviewed and analyzed. Compared with the TPN group, the EEN group had significantly shorter mean PLOS (15.6 days vs. 22.5 days; P < 0.01). Multivariable linear regression analysis revealed EEN to be associated with shorter PLOS even after adjustment for tumor histology, tumor location, type of esophagectomy, and postoperative albumin infusion. Hospital charges were also significantly less for those in the EEN group than the TPN group. There was no significant difference between the two groups regarding the complication of anastomotic leakage and clinical outcome after surgery. These findings suggest that EEN reduces PLOS and hospital charges of Chinese esophageal cancer patients who had an esophagectomy.

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.

Thermogenesis induced by amino acid administration prevents intraoperative hypothermia and reduces postoperative infectious complications after thoracoscopic esophagectomy

Minimally invasive thoracoscopic esophagectomy has potential advantages in minimizing the impairment of respiratory function and reducing surgical stress. However, thoracoscopic esophagectomy occasionally results in anesthesia-induced hypothermia, particularly in cases involving artificial pneumothorax with CO2. Thermogenesis induced by amino acid administration has been reported during anesthesia. Here, we tested the efficacy of amino acid treatment for the prevention of hypothermia, and we investigated the potential of this treatment to reduce postoperative infectious complications after thoracoscopic esophagectomy. We conducted a randomized trial in patients with esophageal cancer who underwent thoracoscopic esophagectomy in the prone position in two groups and analyzed the incidences of hypothermia and surgical complications. One-hundred and thirty patients were randomized. Administration of amino acids resulted in a significant increase in core body temperature. In the saline (n = 60) and amino acid (n = 70) administration groups, 30% and 14.2% of patients, respectively, experienced infectious surgical complications (P = 0.029), and 21.6% and 22.8% of patients, respectively, experienced noninfectious surgical complications (P = 0.86). Univariate analysis revealed that blood loss and amino acid administration were significant factors for infectious surgical complications. Multivariate analysis revealed that amino acid administration was an independent factor reducing infectious surgical complications (P = 0.025, 95% confidence interval: 0.105-0.864). Administration of amino acids prevents hypothermia and reduces postoperative infectious complications after thoracoscopic esophagectomy.

Nutritional route in oesophageal resection trial II (NUTRIENT II): study protocol for a multicentre open-label randomised controlled trial

INTRODUCTION

Early start of an oral diet is safe and beneficial in most types of gastrointestinal surgery and is a crucial part of fast track or enhanced recovery protocols. However, the feasibility and safety of oral intake directly following oesophagectomy remain unclear. The aim of this study is to investigate the effects of early versus delayed start of oral intake on postoperative recovery following oesophagectomy.

METHODS AND ANALYSIS

This is an open-label multicentre randomised controlled trial. Patients undergoing elective minimally invasive or hybrid oesophagectomy for cancer are eligible. Further inclusion criteria are intrathoracic anastomosis, written informed consent and age 18 years or older. Inability for oral intake, inability to place a feeding jejunostomy, inability to provide written consent, swallowing disorder, achalasia, Karnofsky Performance Status <80 and malnutrition are exclusion criteria. Patients will be randomised using online randomisation software. The intervention group (direct oral feeding) will receive a liquid oral diet for 2 weeks with gradually expanding daily maximums. The control group (delayed oral feeding) will receive enteral feeding via a jejunostomy during 5 days and then start the same liquid oral diet. The primary outcome measure is functional recovery. Secondary outcome measures are 30-day surgical complications; nutritional status; need for artificial nutrition; need for additional interventions; health-related quality of life. We aim to recruit 148 patients. Statistical analysis will be performed according to an intention to treat principle. Results are presented as risk ratios with corresponding 95% CIs. A two-tailed p<0.05 is considered statistically significant.

ETHICS AND DISSEMINATION

Our study protocol has received ethical approval from the Medical research Ethics Committees United (MEC-U). This study is conducted according to the principles of Good Clinical Practice. Verbal and written informed consent is required before randomisation. All data will be collected using an online database with adequate security measures.

TRIAL REGISTRATION NUMBERS

NCT02378948 and Dutch trial registry: NTR4972; Pre-results.

Optimal postoperative nutrition support for patients with gastrointestinal malignancy: A systematic review and meta-analysis

OBJECTIVE

To improve clinical outcomes, parenteral nutrition, standard enteral nutrition and immuno-enhanced nutrition are widely used in the gastrointestinal tumor patients undergoing surgery, but the optimal management of postoperative nutrition support remains uncertain.

METHODS

We systematically searched the PUBMED, EMBASE and CNKI to identify latent studies which the effects of standard EN compared with PN or IEN on gastrointestinal tumor patients until the end of November, 2015. The quality of included trials was assessed according to the handbook for Cochrane reviewer. Statistical analysis was carried out by RevMan5.1 software.

RESULTS

30 randomized controlled trials containing 3854 patients were contained in our meta-analysis, the results indicated that postoperative SEN could absolutely reduce the incidence of postoperative infectious (P < 0.00001) and non-infectious complications (P = 0.0003), together with its positive effect on the length of hospital stay (P < 0.00001). Additionally, enteral nutrition enhanced with immune stimulation was confirmed to be better, with a significant difference between groups in terms of total infectious (P < 0.00001) and non-infectious complications (P = 0.04), and IEN could also significantly shorten the length of hospital stay (P < 0.00001).

CONCLUSION

Early use of Enteral nutrition in digestive tumor patients after surgery could significantly reduce the postoperative complications and shorten the length of hospital stay, IEN should be the optimal management, while the use of parenteral nutrition should be restrict to few patients with severe intolerance to enteral nutrition.

Immediate Postoperative Oral Nutrition Following Esophagectomy: A Multicenter Clinical Trial

BACKGROUND

Immediate start of oral intake is beneficial following colorectal surgery. However, following esophagectomy the safety and feasibility of immediate oral intake is unclear, thus these patients are still kept nil by mouth. This study therefore aimed to determine the feasibility and safety of oral nutrition immediately after esophagectomy.

METHODS

A multicenter, prospective trial was conducted in 3 referral centers between August 2013 and May 2014, including 50 patients undergoing a minimally invasive esophagectomy. Oral nutrition was started postoperatively immediately (clear liquids on postoperative day [POD] 0, liquid nutrition on POD 1 to 6, solid food from POD 7). Nonoral enteral nutrition was started when <50% of caloric need was met on postoperative day POD 5 or when oral intake was impossible. A comparison was made with a retrospective cohort (n = 50) with a per-protocol delayed start of oral intake until POD 4 to 7.

RESULTS

The median caloric intake at POD 5 was 58% of required. In 38% of the patients nonoral nutrition was started, mainly due to complications (36%). The pneumonia rate was 28% following immediate oral intake and 40% following delayed oral intake (p = 0.202). The aspiration pneumonia rate was 4% in both groups. The anastomotic leakage rate was 14% after immediate oral intake versus 24% following delayed oral intake (p = 0.202). The 90-day mortality rate was 2% in both groups. Hospital stay and intensive care unit stay were significantly shorter following immediate oral intake.

CONCLUSIONS

Immediate start of oral nutrition following esophagectomy seems to be feasible and does not increase complications compared to a retrospective cohort and literature. However, if complications arise an alternative nutritional route is required. This explorative study shows that a randomized controlled trial is needed.

Early Oral Feeding After Surgery for Upper Gastrointestinal Malignancies: A Prospective Cohort Study

OBJECTIVES

Poor nutritional status following abdominal surgeries for esophageal and gastric cancers remains a major challenge in postoperative care. Our study aimed to investigate the efficacy of starting early oral feeding (EOF) in patients undergoing surgical resection of upper gastrointestinal malignancies.

METHODS

A total of 180 consecutive patients with a diagnosis of esophageal or gastric malignancies undergoing elective surgical resection between January 2008 and February 2011 were enrolled in this prospective cohort study. Seventy-two patients were assigned to the EOF group, and 108 patients received late oral feeding (LOF). Postoperative endpoints were compared between the two groups.

RESULTS

Nasogastric tubes were removed from patients on average 3.3±1.6 days after the surgery in the EOF group and 5.2±2.5 days in the LOF group (p < 0.001). The soft diet regimen was started and tolerated significantly sooner in the EOF group (5.8±1.2 days) than the LOF group (9.5±5.5 days). Hospital stay was significantly shorter in the EOF group compared to the LOF group (6.7±3.1 days vs. 9.1±5.8 days, p < 0.001). Surgical complications and rehospitalization occurred less in EOF group compared with the LOF group. However, the differences were not significant (p > 0.050).

CONCLUSIONS

EOF is safe following esophageal and gastric cancer surgery and results in faster recovery and hospital discharge.

Early enteral nutrition compared with parenteral nutrition for esophageal cancer patients after esophagectomy: a meta-analysis

Early postoperative enteral nutrition (EN) after esophagectomy in esophageal cancer patient has been reported to be correlated with a better rehabilitation than parenteral nutrition (PN). However, a robust conclusion has not been achieved. Therefore, we performed a meta-analysis to compare the postoperative EN and PN in patients with esophageal cancer undergoing esophagectomy. Three electronic databases were searched for eligible studies to be included in the meta-analysis. The summary relative risk/weighted mean difference (RR/WMD) estimates and corresponding 95% confidence interval (CI) were calculated using fixed- and random-effects models. Ten studies met the inclusion criteria. The analysis demonstrated that the early postoperative EN could significantly decrease the pulmonary complications (RR = 0.37, 95% CI = 0.22-0.62, P = 0.00, test for heterogeneity: I(2) = 0.0%, P = 0.89) and anastomotic leakage (RR = 0.46, 95% CI = 0.22-0.96, P = 0.04, test for heterogeneity: I(2) = 0.0%, P = 0.66) compared with PN. On the eighth postoperative day, the EN group had a higher levels of albumin (WMD = 1.84, 95% CI = 0.47-3.21, P = 0.01, test for heterogeneity: I(2) = 84.5%, P = 0.00) and prealbumin (WMD = 12.96, 95% CI = 3.63-22.29, P = 0.01, test for heterogeneity: I(2) = 0.0%, P = 0.63) compared with the PN group. However, there was no difference in digestive complications between these two approaches (RR = 1.30, 95% CI = 0.79-2.13, P = 0.30, test for heterogeneity: I(2) = 0.0%, P = 0.97). For patients with esophageal cancer following esophagectomy, the early postoperative EN support could decrease the morbidity of severe complications, such as pulmonary complications and anastomotic leakage, and maintain patients at a better nutritional status than parenteral nutrion support.

Early Enteral Nutrition Versus Parenteral Nutrition After Resection of Esophageal Cancer: a Retrospective Analysis

This study aimed to compare the clinical outcomes and hospitalization cost between early enteral nutrition (EEN) and parenteral nutrition (PN) after resection of esophageal cancer. A total of 79 patients with esophageal cancer who underwent surgical treatment in our hospital from July 2010 to July 2013 were enrolled in this study. They were divided into EEN group (n = 39) and PN group (n = 40) based on the nutrition support modes. The clinical factors such as time to first fecal passage, postoperative albumin infusion, differences of serum albumin value, hospital stay, systematic inflammatory response syndrome (SIRS) duration, complications, initial hospitalization cost, and mortality were retrospectively compared. The EEN group had a significantly shorter hospital stay, lower initial hospitalization cost, earlier first fecal passage, and shorter duration of SIRS than PN group (P < 0.05). The dose of albumin infusion was significantly smaller in EEN group (P < 0.05) and the decreased value of serum albumin (Δalb) was more prominent in PN group compared with EEN group (P < 0.05). The percentage of patients having any postoperative complication was much higher in PN group than EEN group (P < 0.05), but there was no significant difference in in-hospital morbidity between two groups. Pneumonia was found significantly more frequent in PN group compared with EEN group (P < 0.05). Early EN started within 48 h after esophagectomy is safe, economic, and superior for reduction of postoperative complication, for promoting early recovery of intestinal movement, and for early recovery from systemic inflammation.

A Prospective Randomized Trial of Enteral Nutrition After Thoracoscopic Esophagectomy for Esophageal Cancer

BACKGROUND

Several studies have reported that postoperative enteral nutrition (EN) reduced complications and decreased weight loss and hospital stay periods; however, the majority of patients analyzed in these studies underwent open thoracic surgery. No studies have been conducted regarding EN in patients after thoracoscopic esophagectomy as a less invasive surgery. The aim of this study was to investigate the efficacy of EN after thoracoscopic esophagectomy.

METHODS

Fifty patients who underwent thoracoscopic esophagectomy for esophageal cancer were divided into two groups: parenteral nutrition (PN; n = 25) and EN (n = 25). The rate of weight loss at postoperative day (POD) 14, levels of prealbumin at POD 10, postoperative complications until POD 14, and other perioperative data were collected for each group.

RESULTS

This study analyzed data for 47 patients. The rate of weight loss at POD 14 was significantly lower in the EN group (3.0 ± 3.2 %) than in the PN group (5.1 ± 3.7 %; p = 0.020). Prealbumin levels were 21.0 ± 7.5 mg/dL in the PN group and 18.4 ± 5.8 mg/dL in the EN group at POD 10, with no significant differences between the groups. However, the incidence of postoperative pneumonia was higher in the PN group (30.4 %) than in the EN group (12.5 %).

CONCLUSIONS

EN could suppress weight loss and reduce the incidence of pneumonia after thoracoscopic esophagectomy.

A comparison of postoperative early enteral nutrition with delayed enteral nutrition in patients with esophageal cancer

We examined esophageal cancer patients who received enteral nutrition (EN) to evaluate the validity of early EN compared to delayed EN, and to determine the appropriate time to start EN. A total of 208 esophagectomy patients who received EN postoperatively were divided into three groups (Group 1, 2 and 3) based on whether they received EN within 48 h, 48 h-72 h or more than 72 h, respectively. The postoperative complications, length of hospital stay (LOH), days for first fecal passage, cost of hospitalization, and the difference in serum albumin values between pre-operation and post-operation were all recorded. The statistical analyses were performed using the t-test, the Mann-Whitney U test and the chi square test. Statistical significance was defined as p < 0.05. Group 1 had the lowest thoracic drainage volume, the earliest first fecal passage, and the lowest LOH and hospitalization expenses of the three groups. The incidence of pneumonia was by far the highest in Group 3 (p = 0.019). Finally, all the postoperative outcomes of nutritional conditions were the worst by a significant margin in Group 3. It is therefore safe and valid to start early enteral nutrition within 48 h for postoperative esophageal cancer patients.