1
|
Agarwal L, Dash NR, Pal S, Madhusudhan KS, Mani V. Single-Center Randomized Trial Comparing Feeding Jejunostomy with Nasojejunal Tube Placement in Patients Undergoing Transhiatal Esophagectomy Post-Neoadjuvant Therapy for Esophageal Cancer. J Gastrointest Cancer 2024; 55:1282-1290. [PMID: 38954187 DOI: 10.1007/s12029-024-01080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus. MATERIALS AND METHODS This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up. RESULTS In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001). CONCLUSION Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.
Collapse
Affiliation(s)
- Lokesh Agarwal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Vignesh Mani
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| |
Collapse
|
2
|
Shi G, Nayak R, Malthaner R, Fortin D, Inculet R, Qiabi M. Risk factors contributing to morbidity associated with feeding tubes placed for esophageal cancer patients undergoing esophagectomy: a single-center retrospective study. J Gastrointest Oncol 2024; 15:1373-1385. [PMID: 39279944 PMCID: PMC11399851 DOI: 10.21037/jgo-23-891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 06/07/2024] [Indexed: 09/18/2024] Open
Abstract
Background Perioperative nutritional optimization of patients undergoing esophagectomy for cancer is important as this population is prone to malnutrition associated with poor outcomes. Nutritional supplementation has been achieved via enteral nutrition through percutaneous feeding tubes such as gastrostomy (G-tubes) and surgical jejunostomy tubes (J-tubes). While they are often routinely placed for patients undergoing esophagectomy, these are associated with adverse events including infections, dislodgement, increased healthcare visits, among others. The morbidity associated with feeding tubes has not been well characterized. We aim to determine factors associated with adverse outcomes after feeding tube placement to guide appropriate use of feeding tubes in esophageal carcinoma patients. Methods Patients who underwent esophagectomy for carcinoma and had at least one feeding tube placed from November, 2017 to October, 2021 at a single institution were retrospectively reviewed. Subgroup analyses were performed testing for relevant characteristics. Univariate and multivariate logistic regression analyses were conducted evaluating outcomes of interest. The primary outcome was the overall rate of tube-related complications. Results A total of 144 patients were included with 212 feeding tubes placed (75 G-tubes; 137 J-tubes). The rate of any adverse event related to feeding tubes was 39%. Of these, 11% were wound infections, 16% required procedural intervention, 11% visited the emergency department (ED), and 2.5% required admission due to feeding tube-related complications. Factors independently associated with adverse events included smoking history [odds ratio (OR), 2.80; 95% confidence interval (CI): 1.34-6.23], being female (OR, 2.98; 95% CI: 1.36-6.72), induction treatment (OR, 2.65; 95% CI: 1.14-6.55), and J-tubes (OR, 2.07; 95% CI: 1.09-4.03). Laparoscopically placed J-tubes were associated with increased unplanned admissions compared to those placed via laparotomy (9.4% vs. 0%, P=0.01). Though not statistically significant, there was a trend toward more complications in those who were high risk for malnutrition [body mass index (BMI) <18 kg/m2, weight loss >10%] and comorbid (Charlson Comorbidity Index 5-6). Conclusions There is significant morbidity related to feeding tubes. The risk profile of these tubes for individual patients should be carefully weighed against the nutritional benefits prior to placement. Patients should be carefully counselled on the possible adverse events and care requirements.
Collapse
Affiliation(s)
- Ge Shi
- Division of General Surgery, Department of Surgery, Western University, London, ON, Canada
| | - Rahul Nayak
- Division of Thoracic Surgery, Department of Surgery, Western University, London, ON, Canada
- Division of Surgical Oncology, Department of Oncology, Western University, London, ON, Canada
| | - Richard Malthaner
- Division of Thoracic Surgery, Department of Surgery, Western University, London, ON, Canada
- Division of Surgical Oncology, Department of Oncology, Western University, London, ON, Canada
| | - Dalilah Fortin
- Division of Thoracic Surgery, Department of Surgery, Western University, London, ON, Canada
- Division of Surgical Oncology, Department of Oncology, Western University, London, ON, Canada
| | - Richard Inculet
- Division of Thoracic Surgery, Department of Surgery, Western University, London, ON, Canada
- Division of Surgical Oncology, Department of Oncology, Western University, London, ON, Canada
| | - Mehdi Qiabi
- Division of Thoracic Surgery, Department of Surgery, Western University, London, ON, Canada
- Division of Surgical Oncology, Department of Oncology, Western University, London, ON, Canada
| |
Collapse
|
3
|
Patel NM, Patel PH, Yeung KTD, Monk D, Mohammadi B, Mughal M, Bhogal RH, Allum W, Abbassi-Ghadi N, Kumar S. Is Robotic Surgery the Future for Resectable Esophageal Cancer?: A Systematic Literature Review of Oncological and Clinical Outcomes. Ann Surg Oncol 2024; 31:4281-4297. [PMID: 38480565 PMCID: PMC11164768 DOI: 10.1245/s10434-024-15148-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/19/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Radical esophagectomy for resectable esophageal cancer is a major surgical intervention, associated with considerable postoperative morbidity. The introduction of robotic surgical platforms in esophagectomy may enhance advantages of minimally invasive surgery enabled by laparoscopy and thoracoscopy, including reduced postoperative pain and pulmonary complications. This systematic review aims to assess the clinical and oncological benefits of robot-assisted esophagectomy. METHODS A systematic literature search of the MEDLINE (PubMed), Embase and Cochrane databases was performed for studies published up to 1 August 2023. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols and was registered in the PROSPERO database (CRD42022370983). Clinical and oncological outcomes data were extracted following full-text review of eligible studies. RESULTS A total of 113 studies (n = 14,701 patients, n = 2455 female) were included. The majority of the studies were retrospective in nature (n = 89, 79%), and cohort studies were the most common type of study design (n = 88, 79%). The median number of patients per study was 54. Sixty-three studies reported using a robotic surgical platform for both the abdominal and thoracic phases of the procedure. The weighted mean incidence of postoperative pneumonia was 11%, anastomotic leak 10%, total length of hospitalisation 15.2 days, and a resection margin clear of the tumour was achieved in 95% of cases. CONCLUSIONS There are numerous reported advantages of robot-assisted surgery for resectable esophageal cancer. A correlation between procedural volume and improvements in outcomes with robotic esophagectomy has also been identified. Multicentre comparative clinical studies are essential to identify the true objective benefit on outcomes compared with conventional surgical approaches before robotic surgery is accepted as standard of practice.
Collapse
Affiliation(s)
- Nikhil Manish Patel
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
- The Upper Gastrointestinal Surgical Oncology Research Group, The Institute of Cancer Research, London, UK
| | - Pranav Harshad Patel
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
- The Upper Gastrointestinal Surgical Oncology Research Group, The Institute of Cancer Research, London, UK
| | - Kai Tai Derek Yeung
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - David Monk
- Department of Upper Gastrointestinal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic London Hospital, London, UK
| | - Borzoueh Mohammadi
- Department of Upper Gastrointestinal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic London Hospital, London, UK
| | - Muntzer Mughal
- Department of Upper Gastrointestinal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic London Hospital, London, UK
| | - Ricky Harminder Bhogal
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
- The Upper Gastrointestinal Surgical Oncology Research Group, The Institute of Cancer Research, London, UK
| | - William Allum
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Nima Abbassi-Ghadi
- Department of Upper GI Surgery, Royal Surrey NHS Foundation Trust, Guildford, Surrey, UK
| | - Sacheen Kumar
- Department of Upper GI Surgery, The Royal Marsden NHS Foundation Trust, London, UK.
- The Upper Gastrointestinal Surgical Oncology Research Group, The Institute of Cancer Research, London, UK.
- Department of Upper Gastrointestinal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic London Hospital, London, UK.
| |
Collapse
|
4
|
Pan S, Cheah L, Bushra R, Ribbits A, Grimes S, O'Neill JR. Impact of early enteral feed composition on the rate of chyle leak post-esophagectomy. Dis Esophagus 2024; 37:doae008. [PMID: 38366666 DOI: 10.1093/dote/doae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/12/2024] [Indexed: 02/18/2024]
Abstract
Patients undergoing esophagectomy are at risk of malnutrition and benefit from perioperative enteral feeding. Esophagectomy carries a risk of chyle leak, and this risk may be influenced by early enteral feed composition. We evaluated the impact of early enteral medium-chain triglyceride-rich feed on the prevalence and severity of chyle leak post-esophagectomy, length of stay, and postoperative weight change. This retrospective study included consecutive patients undergoing esophagectomy at a single center between January 2015 and December 2022. Patients received enteral feed on postoperative days 1-5 with Nutrison Energy or Protein Plus Energy ('standard') (January 2015- June 2021) or Nutrison Peptisorb Plus High Energy High Protein ('HEHP') enteral feed (June 2021 to December 2022). All patients transitioned to 'standard' supplemental jejunal feeding on postoperative day 6 onwards and were discharged on oral IDDSI level 4 diet. Patients who did not commence early enteral feeding were excluded from analysis. A total of 329 patients were included. Patients who received early HEHP feed had fewer chyle leaks (5/52; 9.6%) compared with patients who received standard feed (68/277; 24.5%, P = 0.017). The HEHP group had a shorter total length of hospital stay (P = 0.011). Weight change from preoperative baseline was equivalent in both groups at 6 weeks (P = 0.066) and 3 months (P = 0.400). In the context of routine jejunostomy use and early enteral feeding post-esophagectomy, HEHP feed on postoperative days 1-5 was associated with significantly fewer chyle leaks and shorter length of stay compared with standard feed. No difference was noted in postoperative weight change between groups.
Collapse
Affiliation(s)
- Sally Pan
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lilyanne Cheah
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Raisa Bushra
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alexander Ribbits
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Samantha Grimes
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J Robert O'Neill
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Edinburgh Cancer Research, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
5
|
Davies SJ, Wheelwright S. The impact of jejunostomy feeding on nutritional outcomes after oesophagectomy. J Hum Nutr Diet 2024; 37:126-136. [PMID: 37789732 DOI: 10.1111/jhn.13235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Nutritional status is compromised long-term following oesophagectomy. Controversy surrounds the optimal route for nutrition support postoperatively and there is wide variation in the use of feeding jejunostomy tubes. METHODS A retrospective service evaluation was conducted for all consecutive adults who underwent oesophagectomy for a cancer diagnosis within a specialist centre between April 2016 and July 2019 (n = 165). Nutritional and clinical outcomes were compared for patients who received jejunostomy feeding (n = 24), versus those who did not (n = 141). RESULTS Patients with feeding jejunostomy lost significantly less weight at both 6 and 12 months postoperatively compared to those without jejunostomy (p ≤ 0.001 and p = 0.001, respectively). This remained statistically significant in multiple regression, controlling for age, gender, preoperative tumour staging and adjuvant treatment (p ≤ 0.001 and p = 0.03, respectively). Median length of home enteral feeding was 10 weeks after discharge in the jejunostomy group. We observed minor jejunostomy tube-related complications in four patients (16.7%). Of those readmitted within 90 days of surgery in the non-jejunostomy group, nutritional failure was a factor in 43.2% of these readmissions. "Rescue tube feeding" was required by 8.5% of the non-jejunostomy group within the first postoperative year, including 6.4% within 90 days of surgery. CONCLUSIONS Use of short-term supplementary jejunal feeding in addition to oral intake after hospital discharge is beneficial for maintaining weight after oesophagectomy. We suggest a future randomised-controlled trial to confirm these findings.
Collapse
Affiliation(s)
- Sarah J Davies
- School of Health Sciences, Southampton, UK
- Department of Nutrition & Dietetics, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
- Department of Dietitics/SLT, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Sally Wheelwright
- School of Health Sciences, Southampton, UK
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Brighton, UK
| |
Collapse
|
6
|
Czerwonko ME, Farjah F, Oelschlager BK. Reducing Conduit Ischemia and Anastomotic Leaks in Transhiatal Esophagectomy: Six Principles. J Gastrointest Surg 2023; 27:2316-2324. [PMID: 37752385 DOI: 10.1007/s11605-023-05835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/14/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Transhiatal esophagectomy (THE) is an accepted approach for distal esophageal (DE) and gastroesophageal junction (GEJ) cancers. Its reported weaknesses are limited loco-regional resection and high anastomotic leak rates. We have used laparoscopic assistance to perform a THE (LapTHE) as our preferred method of resection for GEJ and DE cancers for over 20 years. Our unique approach and experience may provide technical insights and perhaps superior outcomes. METHODS We reviewed all patients who underwent LapTHE for DE and GEJ malignancy over 10 years (2011-2020). We included 6 principles in our approach: (1) minimize dissection trauma using laparoscopy; (2) routine Kocher maneuver; (3) division of lesser sac adhesions exposing the entire gastroepiploic arcade; (4) gaining excess conduit mobility, allowing resection of proximal stomach, and performing the anastomosis with a well perfused stomach; (5) stapled side-to-side anastomosis; and (6) routine feeding jejunostomy and early oral diet. RESULTS One hundred and forty-seven patients were included in the analysis. The median number of lymph nodes procured was 19 (range 5-49). Negative margins were achieved in all cases (95% confidence interval [CI] 98-100%). Median hospital stay was 7 days. Overall major complication rate was 24% (17-32%), 90-day mortality was 2.0% (0.4-5.8%), and reoperation was 5.4% (2.4-10%). Three patients (2.0%, 0.4-5.8%) developed anastomotic leaks. Median follow-up was 901 days (range 52-5240). Nine patients (6.1%, 2.8-11%) developed anastomotic strictures. CONCLUSIONS Routine use of LapTHE for DE and GEJ cancers and inclusion of these six operative principles allow for a low rate of anastomotic complications relative to national benchmarks.
Collapse
Affiliation(s)
- Matias E Czerwonko
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, WA, USA.
| | - Farhood Farjah
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Brant K Oelschlager
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, WA, USA
| |
Collapse
|
7
|
Turner KM, Delman AM, Griffith A, Wima K, Patel SH, Wilson GC, Shah SA, Van Haren RM. Feeding Jejunostomy Tube in Patients Undergoing Esophagectomy: Utilization and Outcomes in a Nationwide Cohort. World J Surg 2023; 47:2800-2808. [PMID: 37704891 DOI: 10.1007/s00268-023-07157-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Feeding jejunostomy (JT) tubes are often utilized as an adjunct to optimize nutrition for successful esophagectomy; however, their utility has come into question. The aim of this study was to evaluate utilization and outcomes associated with JTs in a nationwide cohort of patients undergoing esophagectomy. METHODS The NSQIP database was queried for patients who underwent elective esophagectomy. JT utilization was assessed between 2010 and 2019. Post-operative outcomes were compared between those with and without a JT on patients with esophagectomy-specific outcomes (2016-2019), with results validated using a propensity score-matched (PSM) analysis based on key clinicopathologic factors, including tumor stage. RESULTS Of the 10,117 patients who underwent elective esophagectomy over the past decade, 53.0% had a JT placed concurrently and 47.0% did not. Utilization of JTs decreased over time, accounting for 60.0% of cases in 2010 compared to 41.7% in 2019 (m = - 2.14 95%CI: [- 1.49]-[- 2.80], p < 0.01). Patients who underwent JT had more composite wound complications (17.0% vs. 14.1%, p = 0.02) and a higher rate of all-cause morbidity (40.4% vs. 35.5%, p = 0.01). Following PSM, 1007 pairs were identified. Analysis of perioperative outcomes demonstrated a higher rate of superficial skin infections (6.1% vs. 3.5%, p = 0.01) in the JT group. However, length of stay, reoperation, readmission, anastomotic leak, composite wound complications, all-cause morbidity, and mortality rates were similar between groups. CONCLUSIONS Among patients undergoing elective esophagectomy, feeding jejunostomy tubes were utilized less frequently over the past decade. Similar perioperative outcomes among matched patients support the safety of esophagectomy without an adjunct feeding jejunostomy tube.
Collapse
Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Azante Griffith
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert M Van Haren
- Department of Surgery, Division of Thoracic Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0558, USA.
| |
Collapse
|
8
|
Till BM, Mandel J, Unal E, Juckett L, Grenda T, Okusanya O, Palazzo F, Chojnacki K, Evans NR. Cessation of Routine Jejunostomy Tube Placement at Time of Minimally Invasive Ivor Lewis Esophagectomy and Impact on Body Mass Index. Semin Thorac Cardiovasc Surg 2022; 36:112-119. [PMID: 36243237 DOI: 10.1053/j.semtcvs.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022]
Abstract
Jejunostomy tubes are frequently placed at time of esophagectomy. The purpose of this study is to evaluate cessation of routine j-tube placement on postoperative body mass index (BMI), return to the emergency room, and time until adjuvant therapy. We performed a retrospective review of an institutional database for consecutive patients undergoing minimally invasive Ivor Lewis Esophagectomy from 2014-2021 (after January 2019, routine j-tube placement was abandoned). Data was analyzed using Pearson's Chi-squared tests and Student's t test with 2-sided significance level of P < 0.05. In total,179 patients were included, 95 underwent j-tube placement and 84 did not. Cohorts had comparable baseline BMI's (no j-tube: 30.48 vs j-tube: 28.64, P = 0.06) and anastomotic leak rates (2.4% vs 4.2%, P = 0.5). Patients with no jejunostomy tubes were more likely to receive total parenteral nutrition (14.3% vs 5.3%, P < 0.05), but were no more likely to require total parenteral nutrition at discharge and had comparable durations of TPN requirement (7 days vs 12 days, P = 0.53). There was no difference in mean BMI reduction at 2 weeks (2.54 vs 2.09, P = 0.49) and 3-6 months postoperatively (6.11 vs 4.45 P = 0.15). There was no difference in return to the emergency room (8.3% vs 8.4%, P = 0.98) or readmissions (13.1% vs 11.6%, P = 0.76). There was a no difference in mean time to adjuvant therapy (83.5 days vs 72.6 days, P = 0.67). At esophagectomy centers with low anastomotic leak rates, cessation of routine j-tube placement at time of minimally esophagectomy can be undertaken without increasing risk of readmission, time until initiation of adjuvant therapy, or significantly impacting postoperative BMI loss.
Collapse
Affiliation(s)
- Brian M Till
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jenna Mandel
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ece Unal
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Luke Juckett
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tyler Grenda
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Olugbenga Okusanya
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karen Chojnacki
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nathaniel R Evans
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
| |
Collapse
|
9
|
Rates of Anastomotic Complications and Their Management Following Esophagectomy: Results of the Oesophago-Gastric Anastomosis Audit (OGAA). Ann Surg 2022; 275:e382-e391. [PMID: 33630459 DOI: 10.1097/sla.0000000000004649] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to characterize rates and management of anastomotic leak (AL) and conduit necrosis (CN) after esophagectomy in an international cohort. BACKGROUND Outcomes in patients with anastomotic complications of esophagectomy are currently uncertain. Optimum strategies to manage AL/CN are unknown, and have not been assessed in an international cohort. METHODS This prospective multicenter cohort study included patients undergoing esophagectomy for esophageal cancer between April 2018 and December 2018 (with 90 days of follow-up). The primary outcomes were AL and CN, as defined by the Esophageal Complications Consensus Group. The secondary outcomes included 90-day mortality and successful AL/CN management, defined as patients being alive at 90 day postoperatively, and requiring no further AL/CN treatment. RESULTS This study included 2247 esophagectomies across 137 hospitals in 41 countries. The AL rate was 14.2% (n = 319) and CN rate was 2.7% (n = 60). The overall 90-day mortality rate for patients with AL was 11.3%, and increased significantly with severity of AL (Type 1: 3.2% vs. Type 2: 13.2% vs. Type 3: 24.7%, P < 0.001); a similar trend was observed for CN. Of the 329 patients with AL/CN, primary management was successful in 69.6% of cases. Subsequent rounds of management lead to an increase in the rate of successful treatment, with cumulative success rates of 85.4% and 88.1% after secondary and tertiary management, respectively. CONCLUSION Patient outcomes worsen significantly with increasing AL and CN severity. Reintervention after failed primary anastomotic complication management can be successful, hence surgeons should not be deterred from trying alternative management strategies.
Collapse
|
10
|
Mei LX, Wang YY, Tan X, Chen Y, Dai L, Chen MW. Is it necessary to routinely perform feeding jejunostomy at the time of esophagectomy? A systematic review and meta-analysis. Dis Esophagus 2021; 34:6245102. [PMID: 33884417 DOI: 10.1093/dote/doab017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/25/2021] [Accepted: 01/30/2021] [Indexed: 12/11/2022]
Abstract
Feeding jejunostomy (FJ) is a routine procedure at the time of esophagectomy in some centers. With the widespread popularization of enhanced recovery after surgery, the necessity of FJ has been increasingly questioned. This study aims to analyze the differences in safety and effectiveness between with (FJ group) or without (no-FJ group) performing FJ at the time of esophagectomy. PubMed, Embase, Web of Science, and Cochrane Library were comprehensively searched for relevant studies, including randomized controlled trials and cohort studies. The primary outcome was the length of hospital stay (LOS). Secondary outcomes were overall postoperative complications, postoperative pneumonia, intestinal obstruction, and weight loss at 3 and 6 months after esophagectomy. Weighted mean differences (WMD) and odds ratios (OR) were calculated for statistical analysis. About 12 studies comprising 2,173 patients were included. The FJ group had a longer LOS (WMD = 2.05, P = 0.01) and a higher incidence of intestinal obstruction (OR = 11.67, P < 0.001) than the no-FJ group. The incidence of overall postoperative complications (OR = 1.24, P = 0.31) and postoperative pneumonia (OR = 1.43, P = 0.13) were not significantly different, nor the weight loss at 3 months (WMD = 0.58, P = 0.24) and 6 months (P > 0.05) after esophagectomy. Current evidence suggests that routinely performing FJ at the time of esophagectomy appears not to generate better postoperative outcomes. FJ may need to be performed selectively rather than routinely. More studies are required to further verify.
Collapse
Affiliation(s)
- Li-Xiang Mei
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong-Yong Wang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiang Tan
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lei Dai
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ming-Wu Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| |
Collapse
|
11
|
Bartella I, Fransen LFC, Gutschow CA, Bruns CJ, van Berge Henegouwen ML, Chaudry MA, Cheong E, Cuesta MA, Van Daele E, Gisbertz SS, van Hillegersberg R, Hölscher A, Mercer S, Moorthy K, Nafteux P, Nilsson M, Pattyn P, Piessen G, Räsanen J, Rosman C, Ruurda JP, Schneider PM, Sgromo B, Nieuwenhuijzen GA, Luyer MDP, Schröder W. Technique of open and minimally invasive intrathoracic reconstruction following esophagectomy-an expert consensus based on a modified Delphi process. Dis Esophagus 2021; 34:6102597. [PMID: 33846718 DOI: 10.1093/dote/doaa127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/11/2020] [Accepted: 11/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND In recent years, minimally invasive Ivor Lewis (IL) esophagectomy with high intrathoracic anastomosis has emerged as surgical standard of care for esophageal cancer in expert centers. Alongside this process, many divergent technical aspects of this procedure have been devised in different centers. This study aims at achieving international consensus on the surgical steps of IL reconstruction using Delphi methodology. METHODS The expert panel consisted of specialized esophageal surgeons from 8 European countries. During a two-round Delphi process, a detailed analysis and consensus on key steps of intrathoracic gastric tube reconstruction (IL esophagectomy) was performed. RESULTS Response rates in Delphi rounds 1 and 2 were 100% (22 of 22 experts) and 83.3% (20 of 24 experts), respectively. Three essential technical areas of intrathoracic gastric tube reconstruction were identified: first, vascularization of the gastric conduit, second, gastric mobilization, tube formation and pull-up, and third, anastomotic technique. In addition, 3 main techniques for minimally invasive intrathoracic anastomosis are currently practiced: (i) end-to-side circular stapled, (ii) end-to-side double stapling, and (iii) side-to-side linear stapled technique. The step-by-step procedural analysis unveiled common approaches but also different expert practice. CONCLUSION This precise technical description may serve as a clinical guideline for intrathoracic reconstruction after esophagectomy. In addition, the results may aid to harmonize the technical evolution of this complex surgical procedure and thereby facilitate surgical training.
Collapse
Affiliation(s)
- Isabel Bartella
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Laura F C Fransen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Christian A Gutschow
- Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christiane J Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Mark L van Berge Henegouwen
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M Asif Chaudry
- Department of Surgery, The Royal Marsden Hospital, London, UK
| | - Edward Cheong
- Department of Upper GI Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Miguel A Cuesta
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Elke Van Daele
- Department of GI Surgery, University Hospital Ghent, Ghent, Belgium
| | - Suzanne S Gisbertz
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Arnulf Hölscher
- Center for Esophageal and Gastric Cancer Surgery, Markushospital Frankfurt, Frankfurt am Main, Germany
| | - Stuart Mercer
- Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Krishna Moorthy
- Department of Surgery and Cancer, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Magnus Nilsson
- Department of Upper Abdominal Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Piet Pattyn
- Department of GI Surgery, University Hospital Ghent, Ghent, Belgium
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Lille University Hospital, Lille, France
| | - Jari Räsanen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paul M Schneider
- Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Bruno Sgromo
- Department of Upper GI Surgery, Oxford University Hospitals, Oxford, UK
| | | | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Wolfgang Schröder
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| |
Collapse
|
12
|
Schroeder W, Mallmann C, Babic B, Bruns C, Fuchs HF. [Fast-track Rehabilitation after Oesophagectomy]. Zentralbl Chir 2021; 146:306-314. [PMID: 34154009 DOI: 10.1055/a-1487-7086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The multimodal and interprofessional concept of fast-track rehabilitation ("enhanced recovery after surgery", ERAS) is generally applicable to transthoracic oesophagectomy, but is associated with two special features as compared to other oncological procedures. Due to the high comorbidity of oesophageal cancer patients, fast-track pathways have to be considered as one component of perioperative management and cannot be separated from prehabilitation with preoperative conditioning of single organ dysfunctions. Since gastric reconstruction causes a high prevalence of delayed gastric conduit emptying (DGCE), early and sufficient postoperative oral feeding is not easily feasible. There is currently no generally accepted algorithm for the postoperative nutritional management as well as for the prophylaxis/treatment of DGCE. Fast-track prehabilitation does not influence the mortality rate in specialised centres. At present, it is not clear whether a fast-track pathway helps to reduce postoperative morbidity. After modified fast-track rehabilitation, hospital discharge is possible from the 8th postoperative day.
Collapse
Affiliation(s)
- Wolfgang Schroeder
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
| | - Christoph Mallmann
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
| | - Benjamin Babic
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
| | - Christiane Bruns
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
| | - Hans Friedrich Fuchs
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
| |
Collapse
|
13
|
Outcomes of Esophageal Cancer after Esophagectomy in the Era of Early Injection Laryngoplasty. Diagnostics (Basel) 2021; 11:diagnostics11050914. [PMID: 34065599 PMCID: PMC8160664 DOI: 10.3390/diagnostics11050914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 05/16/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: severe weight loss was reported to be related to unilateral vocal fold paralysis (UVFP) after esophagectomy and could thus impair survival. Concomitant radical lymph node dissection along the recurrent laryngeal nerve during esophageal cancer surgery is controversial, as it might induce UVFP. Early intervention for esophagectomy-related UVFP by administering intracordal injections of temporal agents has recently become popular. This study investigated the survival outcomes of esophagectomy for esophageal squamous cell carcinoma (ESCC) after the introduction of early injection laryngoplasty (EIL). (2) Methods: a retrospective review of patients with ESCC after curative-intent esophagectomy was conducted in a tertiary referral medical center. The necessity of EIL with hyaluronic acid was comprehensively discussed for all symptomatic UVFP patients. The survival outcomes and related risk factors of ESCC were evaluated. (3) Results: among the cohort of 358 consecutive patients who underwent esophagectomy for ESCC, 42 (11.7%) showed postsurgical UVFP. Twenty-nine of them received office-based EIL. After EIL, the glottal gap area, maximum phonation time and voice outcome survey showed significant improvement at one, three and six months measurements. The number of lymph nodes in the resected specimen was higher in those with UVFP than in those without UVFP (30.1 ± 15.7 vs. 24.6 ± 12.7, p = 0.011). The Kaplan-Meier overall survival was significantly better in patients who had UVFP (p = 0.014), received neck anastomosis (p = 0.004), underwent endoscopic resection (p < 0.001) and had early-stage cancer (p < 0.001). Multivariate Cox logistic regression analysis showed two independent predictors of OS, showing that the primary stage and anastomosis type are the two independent predictors of OS. (4) Conclusion: EIL is effective in improving UVFP-related symptoms, thus providing compensatory and palliative measures to ensure the patient's postsurgical quality of life. The emerging use of EIL might encourage cancer surgeons to radically dissect lymph nodes along the recurrent laryngeal nerve, thus changing the survival trend.
Collapse
|
14
|
Correia de Sá T, Silva J, Freitas C. Incarcerated paraoesophageal hernia complicated with distal oesophageal perforation: a combined laparoscopic and endoscopic approach. BMJ Case Rep 2021; 14:14/4/e240780. [PMID: 33849872 PMCID: PMC8051381 DOI: 10.1136/bcr-2020-240780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Paraoesophageal hernias are common, but symptoms are not always present nor pathognomonic of this condition, and patients may be suffering for many years before a diagnosis is made. Incarceration and strangulation are rare, but they are life-threatening complications, warranting an emergent surgical repair. Hiatal hernia incarceration causing distal oesophagus perforation is even rarer. To our knowledge, this is the first case report in adult patients. Despite many advances in care, a high grade of suspicion is needed to diagnose this condition, and the mortality rate for an oesophageal perforation remains high, achieving 50% in some series. We present the surgical management of a case of hiatal hernia incarceration with distal oesophagus perforation by combined laparoscopy and upper endoscopy.
Collapse
Affiliation(s)
| | - Jorge Silva
- Gastroenterology Department, Centro Hospitalar Tamega e Sousa EPE, Guilhufe, Portugal
| | - Carla Freitas
- General Surgery, Esophagogastric Surgery Unit, Centro Hospitalar Tamega e Sousa EPE, Guilhufe, Portugal
| |
Collapse
|
15
|
Mallmann C, Drinhaus H, Fuchs H, Schiffmann LM, Cleff C, Schönau E, Bruns CJ, Annecke T, Schröder W. [Perioperative enhanced recovery after surgery program for Ivor Lewis esophagectomy : First experiences of a high-volume center]. Chirurg 2021; 92:158-167. [PMID: 32548695 DOI: 10.1007/s00104-020-01216-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVE Transthoracic esophagectomy is generally accepted as the standard of surgical care for patients with esophageal cancer. Despite improvements in the perioperative management this surgical procedure is associated with a clinically relevant morbidity. Fast-track protocols (synonym: enhanced recovery after surgery, ERAS) are conceived to perioperatively maintain the physiological homoeostasis and thereby to accelerate postoperative rehabilitation and reduce morbidity. In this prospective observational study the initial experiences of a high-volume center with the implementation of an ERAS protocol after transthoracic esophagectomy were analyzed. MATERIAL AND METHODS A total of 26 patients with esophageal cancer and a low index of comorbidities prior to hybrid Ivor Lewis esophagectomy were included in this study. According to an ERAS protocol all patients underwent a standardized perioperative treatment pathway aiming to discharge the patients from the inpatient treatment on postoperative day 10. The primary outcome parameter was the rate of major complications (Clavien-Dindo IIIb/IV), which was compared to a cohort of 52 non-ERAS patients. RESULTS AND CONCLUSION The ERAS programs with the various core elements can be implemented in patients scheduled for transthoracic esophagectomy, although the organizational and personnel expenditure of this fast-track protocol is high. The length of hospital stay appears to be reduced without compromising patient safety. The limiting variable of the ERAS protocol remains the early and adequate enteral feeding load of the gastric conduit before discharge on postoperative day 10.
Collapse
Affiliation(s)
- C Mallmann
- Medizinische Fakultät und Uniklinik, Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - H Drinhaus
- Medizinische Fakultät und Uniklinik, Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Köln, Deutschland
| | - H Fuchs
- Medizinische Fakultät und Uniklinik, Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - L M Schiffmann
- Medizinische Fakultät und Uniklinik, Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - C Cleff
- Medizinische Fakultät und Uniklinik, Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Köln, Deutschland
| | - E Schönau
- UniReha, Zentrum für Prävention und Rehabilitation der Uniklinik Köln, Köln, Deutschland
| | - C J Bruns
- Medizinische Fakultät und Uniklinik, Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - T Annecke
- Medizinische Fakultät und Uniklinik, Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Köln, Deutschland
| | - W Schröder
- Medizinische Fakultät und Uniklinik, Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| |
Collapse
|
16
|
Pattamatta M, Fransen LFC, Dolmans-Zwartjes ACP, Nieuwenhuijzen GAP, Evers SMAA, Kouwenhoven EA, van Det MJ, Hiligsmann M, Luyer MDP. Effect of direct oral feeding following minimally invasive esophagectomy on costs and quality of life. J Med Econ 2021; 24:54-60. [PMID: 33274674 DOI: 10.1080/13696998.2020.1859843] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS Following (minimally invasive) esophagectomy, patients often rely on tube feeding, since oral intake is often delayed. Consequently, additional support by a dietician and home care is needed until oral intake is commenced. In this study, the effects of direct start of oral feeding compared with tube feeding following an esophagectomy was evaluated on treatment costs and health-related quality of life (QoL). METHODS Patients undergoing a minimally invasive esophagectomy were randomized in the NUTRIENT II study between controls (nil-per-mouth during 5 days and subsequent tube feeding) and a group in whom oral feeding was started directly postoperatively. Total hospital costs (including readmission and outpatient costs) and home care data for a period of 6 months after surgery were analyzed. QoL (measured using EORTC-QLQ-C30 and EORTC OG-25) was assessed preoperatively and 6 weeks, 12 weeks, and 6 months postoperatively. RESULTS A total 132 patients were included (n = 65 direct oral feeding group and n = 67 control group). Mean patient hospital costs were €26,014 in the intervention group over a 6-month period compared to €26,989 in the control group (p = .825). Furthermore, people with direct oral feeding required significantly less home care assistance; i.e. 23 (48.9%) intervention patients versus 37 (77.1%) control patients (p = .004). Also, QoL in patients with direct oral feeding progressed more quickly when compared to the control group. LIMITATIONS Hospital costs were derived from a single hospital unit whereas costs from all the participating units may be a better reflection of the cost deviation. Availability of homecare data was limited, leading to difficulty in detecting differences in costs. CONCLUSION This study suggests that direct oral feeding leads to similar total costs and a significantly reduced need for home care assistance. Furthermore, QoL in intervention group increased more quickly when compared to the control group.
Collapse
Affiliation(s)
- Madhuri Pattamatta
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, Eindhoven, The Netherlands
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Laura F C Fransen
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, Eindhoven, The Netherlands
| | | | | | - Silvia M A A Evers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
- Trimbos Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | | | - Marc J van Det
- Department of Surgery, ZGT Hospital Group Twente, Almelo, The Netherlands
| | - Mickael Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, Eindhoven, The Netherlands
| |
Collapse
|
17
|
Koterazawa Y, Oshikiri T, Takiguchi G, Urakawa N, Hasegawa H, Yamamoto M, Kanaji S, Yamashita K, Matsuda T, Nakamura T, Suzuki S, Kakeji Y. Severe weight loss after minimally invasive oesophagectomy is associated with poor survival in patients with oesophageal cancer at 5 years. BMC Gastroenterol 2020; 20:407. [PMID: 33272220 PMCID: PMC7713340 DOI: 10.1186/s12876-020-01543-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 11/17/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patients often experience severe weight loss after oesophagectomy. Enteral nutrition via a feeding jejunostomy tube (FT) is commonly practised. This study aimed to assess the effect of severe weight loss postoperatively and enteral nutrition via an FT on long-term prognosis after oesophagectomy. METHODS This study analysed 317 patients who underwent minimally invasive oesophagectomy at Kobe University Hospital and Hyogo Cancer Center from 2010 to 2015. The patients' body weight was evaluated at 3 months postoperatively. They were organised into the severe weight loss (n = 65) and moderate weight loss (n = 252) groups. Furthermore, they were categorised into the FT group (184 patients who had an FT placed during oesophagectomy) and no-FT group (133 patients without FT). Patients (119 per group) matched for the FT and no-FT groups were identified via propensity score matching. RESULTS The 5-year overall survival (OS) rate in the severe weight loss group was significantly lower (p = 0.024). In the multivariate analysis, tumour invasion depth (pT3-4), preoperative therapy and severe weight loss had a worse OS (hazard ratio = 1.89; 95% confidence interval = 1.12-3.17, hazard ratio = 2.11; 95% confidence interval = 1.25-3.54, hazard ratio = 1.82; 95% confidence interval = 1.02-3.524, respectively). No significant differences in the number of severe weight loss patients and OS were found between the FT and no-FT groups. CONCLUSION Severe weight loss is significantly associated with poor OS. In addition, enteral nutrition via an FT did not improve the severe weight loss and OS.
Collapse
Affiliation(s)
- Yasufumi Koterazawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan.
| | - Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Gosuke Takiguchi
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Naoki Urakawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Masashi Yamamoto
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Kimihiro Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Takeru Matsuda
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Tetsu Nakamura
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Satoshi Suzuki
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, 650-0017, Japan
| |
Collapse
|
18
|
Holmén A, Hayami M, Szabo E, Rouvelas I, Agustsson T, Klevebro F. Nutritional jejunostomy in esophagectomy for cancer, a national register-based cohort study of associations with postoperative outcomes and survival. Langenbecks Arch Surg 2020; 406:1415-1423. [PMID: 33230577 PMCID: PMC8370925 DOI: 10.1007/s00423-020-02037-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/17/2020] [Indexed: 01/13/2023]
Abstract
Purpose Insertion of a nutritional jejunostomy in conjunction with esophagectomy is performed with the intention to decrease the risk for postoperative malnutrition and improve recovery without adding significant catheter-related complications. However, previous research has shown no clear benefit and there is currently no consensus of practice. Methods All patients treated with esophagectomy due to cancer during the period 2006–2017 reported in the Swedish National Register for Esophageal and Gastric Cancer were included in this register-based cohort study from a national database. Patients were stratified into two groups: esophagectomy alone and esophagectomy with jejunostomy. Results A total of 847 patients (45.27%) had no jejunostomy inserted while 1024 patients (54.73%) were treated with jejunostomy. The groups were comparable, but some differences were seen in histological tumor type and tumor stage between the groups. No significant differences in length of hospital stay, postoperative surgical complications, Clavien-Dindo score, or 90-day mortality rate were seen. There was no evidence of increased risk for significant jejunostomy-related complications. Patients in the jejunostomy group with anastomotic leaks had a statistically significant lower risk for severe morbidity defined as Clavien-Dindo score ≥ IIIb (adjusted odds ratio 0.19, 95% CI: 0.04–0.94, P = 0.041) compared to patients with anastomotic leaks and no jejunostomy. Conclusion A nutritional jejunostomy is a safe method for early postoperative enteral nutrition which might decrease the risk for severe outcomes in patients with anastomotic leaks. Nutritional jejunostomy should be considered for patients undergoing curative intended surgery for esophageal and gastro-esophageal junction cancer.
Collapse
Affiliation(s)
- Anders Holmén
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden. .,Department of Surgery, Södersjukhuset, Stockholm, Sweden.
| | - Masaru Hayami
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Szabo
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Thorhallur Agustsson
- Department of Surgery, Södersjukhuset, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet
- Södersjukhuset, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
19
|
Carroll PA, Yeung JC, Darling GE. Elimination of Routine Feeding Jejunostomy After Esophagectomy. Ann Thorac Surg 2020; 110:1706-1713. [DOI: 10.1016/j.athoracsur.2020.04.072] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 01/15/2023]
|
20
|
A Prospective Randomized Trial Comparing Jejunostomy and Nasogastric Feeding in Minimally Invasive McKeown Esophagectomy. J Gastrointest Surg 2020; 24:2187-2196. [PMID: 31512101 DOI: 10.1007/s11605-019-04390-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/28/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Early postoperative enteral nutrition is recommended for patients undergoing esophagectomy; however, the optimum method of tube feeding remains controversial. Thus, the aim of this study is to assess two common enteral nutrition methods after minimally invasive McKeown esophagectomy. METHODS A randomized controlled trial was performed with 120 patients who underwent minimally invasive McKeown esophagectomy from January 2017 to December 2018. The patients were randomly divided so that 58 patients were in the jejunostomy feeding (JF) group and 62 patients were in the nasogastric feeding (NF) group. The postoperative outcomes, including complications, nutritional status, quality of life, and survival rate, were studied and used as the main parameters to compare the abovementioned tube feeding methods. RESULTS The incidence of overall complications was equivalent between the two groups (P = 0.625), except for bowel obstruction (which occurred 4 times in the JF group but did not occur in the NF group). In the first month after surgery (postoperative month 1, POM1), a significantly higher body mass index (BMI) was observed in the JF group (23.6 ± 3.2) than in the NF group (20.9 ± 3.5, P = 0.032). The global quality-of-life scores were better in the JF group than in the NF group (P < 0.001). In addition, there were no significant differences between the two groups in terms of disease-free survival (DFS) (P = 0.816) and overall survival (OS) (P = 0.564). CONCLUSIONS Compared with NF, JF provides more safety, efficacy, and utility as nutritional support for minimally invasive McKeown esophagectomy patients who have a high incidence of anastomotic leakage. However, the higher risk of intestinal obstruction after JF requires attention.
Collapse
|
21
|
Wobith M, Wehle L, Haberzettl D, Acikgöz A, Weimann A. Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period. Nutrients 2020; 12:E2564. [PMID: 32854177 PMCID: PMC7551703 DOI: 10.3390/nu12092564] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/18/2020] [Accepted: 08/18/2020] [Indexed: 12/29/2022] Open
Abstract
The metabolic risk for patients undergoing abdominal cancer resection increases in the perioperative period and malnutrition may be observed. In order to prevent further weight loss, the guidelines recommend for high-risk patients the placement of a needle catheter jejunostomy (NCJ) for supplementing enteral feeding in the early and late postoperative period. Our aim was to evaluate the safety of NCJ placement and its potential benefits regarding the nutritional status in the postoperative course. We retrospectively analyzed patients undergoing surgery for upper gastrointestinal cancer, such as esophageal, gastric, and pancreato-biliary cancer, and NCJ placement during the operation. The nutritional parameters body mass index (BMI), perioperative weight loss, phase angle measured by bioelectrical impedance analysis (BIA) and the clinical outcome were assessed perioperatively and during follow-up visits 1 to 3 months and 4 to 6 months after surgery. In 102 patients a NCJ was placed between January 2006 and December 2016. Follow-up visits 1 to 3 months and 4 to 6 months after surgery were performed in 90 patients and 88 patients, respectively. No severe complications were seen after the NCJ placement. The supplementing enteral nutrition via NCJ did not improve the nutritional status of the patients postoperatively. There was a significant postoperative decline of weight and phase angle, especially in the first to third month after surgery, which could be stabilized until 4-6 months after surgery. Placement of NCJ is safe. In patients with upper gastrointestinal and pancreato-biliary cancer, supplementing enteral nutrition during the postoperative course and continued after discharge may attenuate unavoidable weight loss and a reduction of body cell mass within the first six months.
Collapse
Affiliation(s)
| | | | | | | | - Arved Weimann
- Clinical Nutrition Unit of the Department of General, Visceral, and Oncological Surgery, Klinikum St. Georg gGmbH Leipzig, 04103 Leipzig, Germany; (M.W.); (L.W.); (D.H.); (A.A.)
| |
Collapse
|
22
|
Liu K, Ji S, Xu Y, Diao Q, Shao C, Luo J, Zhu Y, Jiang Z, Diao Y, Cong Z, Hu L, Qiang Y, Shen Y. Safety, feasibility, and effect of an enhanced nutritional support pathway including extended preoperative and home enteral nutrition in patients undergoing enhanced recovery after esophagectomy: a pilot randomized clinical trial. Dis Esophagus 2020; 33:5479246. [PMID: 31329828 DOI: 10.1093/dote/doz030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/08/2019] [Accepted: 03/13/2019] [Indexed: 12/11/2022]
Abstract
The aims of this pilot study are to evaluate the feasibility, safety, and effectiveness of conducting an enhanced nutritional support pathway including extended preoperative nutritional support and one month home enteral nutrition (HEN) for patients who underwent enhanced recovery after esophagectomy. We implemented extended preoperative nutritional support and one month HEN after discharge for patients randomized into an enhanced nutrition group and implemented standard nutritional support for patients randomized into a conventional nutrition group. Except the nutritional support program, both group patients underwent the same standardized enhanced recovery after surgery programs of esophagectomy based on published guidelines. Patients were assessed at preoperative day, postoperative day 7 (POD7), and POD30 for perioperative outcomes and nutritional status. To facilitate the determination of an effect size for subsequent appropriately powered randomized clinical trials and assess the effectiveness, the primary outcome we chose was the weight change before and after esophagectomy. Other outcomes including body mass index (BMI), lean body mass (LBM), appendicular skeletal muscle mass index (ASMI), nutrition-related complications, and quality of life (QoL) were also analyzed. The intention-to-treat analysis of the 50 randomized patients showed that there was no significant difference in baseline characteristics. The weight (-2.03 ± 2.28 kg vs. -4.05 ± 3.13 kg, P = 0.012), BMI (-0.73 ± 0.79 kg/m2 vs. -1.48 ± 1.11 kg/m2, P = 0.008), and ASMI (-1.10 ± 0.37 kg/m2 vs. -1.60 ± 0.66 kg/m2, P = 0.010) loss of patients in the enhanced nutrition group were obviously decreased compared to the conventional nutrition group at POD30. In particular, LBM (48.90 ± 9.69 kg vs. 41.96 ± 9.37 kg, p = 0.031) and ASMI (7.56 ± 1.07 kg/m2 vs. 6.50 ± 0.97 kg/m2, P = 0.003) in the enhanced nutrition group were significantly higher compared to the conventional nutrition group at POD30, despite no significant change between pre- and postoperation. In addition, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 scores revealed that enhanced nutritional support improved the QoL of patients in physical function (75.13 ± 9.72 vs. 68.33 ± 7.68, P = 0.009) and fatigue symptom (42.27 ± 9.93 vs. 49.07 ± 11.33, P = 0.028) compared to conventional nutritional support. This pilot study demonstrated that an enhanced nutritional support pathway including extended preoperative nutritional support and HEN was feasible, safe, and might be beneficial to patients who underwent enhanced recovery after esophagectomy. An appropriately powered trial is warranted to confirm the efficacy of this approach.
Collapse
Affiliation(s)
- K Liu
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University
| | - S Ji
- Department of Cardiothoracic Surgery, Jinling Hospital, Bengbu Medical College, Anhui, China
| | - Y Xu
- Department of Cardiothoracic Surgery, Jinling Hospital
| | - Q Diao
- Department of Medical Imaging, Medical Imaging Center, Jinling Hospital
| | - C Shao
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University
| | - J Luo
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University.,Department of Cardiothoracic Surgery, Jinling Hospital
| | - Y Zhu
- Jiangsu Key laboratory for Molecular Medicine, Medical school of Nanjing University
| | - Z Jiang
- Department of Cardiothoracic Surgery, Jinling Hospital, Bengbu Medical College, Anhui, China
| | - Y Diao
- Medical School, Southeast University, Nanjing
| | - Z Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University.,Department of Cardiothoracic Surgery, Jinling Hospital
| | - L Hu
- Department of Cardiothoracic Surgery, Jinling Hospital
| | - Y Qiang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University.,Department of Cardiothoracic Surgery, Jinling Hospital.,Medical School, Southeast University, Nanjing
| | - Y Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University.,Department of Cardiothoracic Surgery, Jinling Hospital
| |
Collapse
|
23
|
Letter to editor in response to article entitled “Feeding jejunostomy after esophagectomy cannot be routinely recommended. Analysis of nutritional benefits and catheter-related complications”. Am J Surg 2019; 218:1030. [DOI: 10.1016/j.amjsurg.2018.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 12/10/2018] [Indexed: 01/18/2023]
|
24
|
Klevebro F, Johar A, Lagergren J, Lagergren P. Outcomes of nutritional jejunostomy in the curative treatment of esophageal cancer. Dis Esophagus 2019; 32:5212877. [PMID: 30496419 DOI: 10.1093/dote/doy113] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Substantial weight loss and eating problems are common before and after esophagectomy for cancer. The use of jejunostomy might prevent postoperative weight loss, but studies evaluating other outcomes are scarce. This study aims to assess the influence of jejunostomy on postoperative health-related quality of life (HRQOL), complications, reoperation, hospital stay, and survival. This prospective and population-based cohort study included all patients operated on for esophageal or gastroesophageal junction cancer in Sweden in 2001-2005 with follow-up until 31st December 2016. Data regarding patient and tumor characteristics and treatment were prospectively collected. Multivariable logistic regression provided odds ratios (OR) with 95% confidence intervals (CI), whereas Cox regression provided hazard ratios with 95% CI. All risk estimates were adjusted for age, sex, tumor histology, stage, comorbidity, surgical approach, neoadjuvant therapy, and body mass index and weight loss at baseline. Among 397 patients, 181 (46%) received a jejunostomy during surgery. The use of jejunostomy did not influence the HRQOL at 6 months or 3 years after treatment. Jejunostomy users had no statistically significantly increased risk of postoperative complications (OR 1.27; 95% CI 0.86-1.87) or reoperation (OR 1.70; 95% CI 0.88-3.28). Intensive unit care and length of hospital stay was the same independent of the use of jejunostomy. The all-cause mortality was not increased in the jejunostomy group (HR 0.89, 95% CI: 0.74-1.07). This study indicates that jejunostomy does not influence postoperative HRQOL, complications, or survival after esophageal cancer surgery, it can be considered a safe method for early enteral nutrition after esophageal cancer surgery but benefits for the patients need further investigations.
Collapse
Affiliation(s)
- F Klevebro
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Johar
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - P Lagergren
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
25
|
Bouabdallah I, D'Journo XB. Risk factors of post-esophagectomy-induced malnutrition. J Thorac Dis 2019; 11:S1357-S1359. [PMID: 31245132 DOI: 10.21037/jtd.2019.03.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Ilies Bouabdallah
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University, Marseille, France
| | - Xavier Benoit D'Journo
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University, Marseille, France
| |
Collapse
|
26
|
Abstract
Esophagectomy is the mainstay for treating esophageal cancers and other pathology. Even with refinements in surgical techniques and the introduction of minimally invasive approaches, the overall morbidity remains formidable. Complications, if not quickly recognized, can lead to significant long-term sequelae and even death. Vigilance with a high degree of suspicion remains the surgeon's greatest ally when caring for a patient who has recently undergone an esophagectomy. In this review, we highlight different approaches in dealing with anastomotic leaks, chyle leaks, cardiopulmonary complications, and later functional issues after esophagectomy.
Collapse
Affiliation(s)
- Igor Wanko Mboumi
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, University of Wisconsin School of Medicine, 600 Highland Avenue K4/752, Madison, WI 53792-7375, USA
| | - Sushanth Reddy
- Department of Surgery, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Anne O Lidor
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, University of Wisconsin School of Medicine, 600 Highland Avenue K4/752, Madison, WI 53792-7375, USA.
| |
Collapse
|
27
|
Helminen O, Mrena J, Sihvo E. Securing enteral nutrition with routine feeding jejunostomy after esophagectomy: lost effort or a life saver? J Thorac Dis 2019; 11:636-637. [PMID: 31019746 DOI: 10.21037/jtd.2019.02.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Olli Helminen
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Johanna Mrena
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Eero Sihvo
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| |
Collapse
|
28
|
Akiyama Y, Iwaya T, Endo F, Nikai H, Sato K, Baba S, Chiba T, Kimura T, Takahara T, Nitta H, Otsuka K, Mizuno M, Kimura Y, Koeda K, Sasaki A. Evaluation of the need for routine feeding jejunostomy for enteral nutrition after esophagectomy. J Thorac Dis 2018; 10:6854-6862. [PMID: 30746231 DOI: 10.21037/jtd.2018.11.97] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Previous studies have shown that enteral nutrition (EN) helps reduce severe postoperative complications after esophagectomy. However, the incidence of jejunostomy-related complications is approximately 30%. We evaluated the operative outcomes in patients who did not receive EN via feeding jejunostomy after esophagectomy. Methods We retrospectively reviewed 76 consecutive patients with esophageal cancer who received radical esophagectomy. Operative outcomes were compared between 33 patients who received postoperative EN via feeding jejunostomy (group A; from May 2014 to September 2015) and 43 patients who did not receive EN via feeding jejunostomy (group B; from September 2015 to December 2017). Results The American Society of Anesthesiologists performance status score of the patients in group B was significantly higher than that of patients in group A (P=0.002). The postoperative morbidity rate was comparable between the two groups (group A, 30.3% vs. group B, 44.2%, P=0.217). No significant between-group differences were observed in the incidence of infectious complications, postoperative hospital stay, readmission within 30 days after discharge, or pneumonia after discharge within 6 months. The incidence of bowel obstruction was significantly higher in group A than in group B (group A, 9.1% vs. group B, 0%, P=0.044). Two patients in group B required nutritional support via total parenteral nutrition due to bilateral vocal cord palsy or pneumonia. Conclusions Jejunostomy-related bowel obstruction in the patients with feeding jejunostomy was significantly higher than that in the patients without jejunostomy. There was no increase in postoperative complications (including pneumonia) in the patients who did not receive EN via feeding jejunostomy. Our results suggest that routine feeding jejunostomy may not be necessary for all patients undergoing esophagectomy.
Collapse
Affiliation(s)
- Yuji Akiyama
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Fumitaka Endo
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Haruka Nikai
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Kei Sato
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Shigeaki Baba
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Takehiro Chiba
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Toshimoto Kimura
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Masaru Mizuno
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Yusuke Kimura
- Department of Palliative Medicine, Iwate Medical University School of Medicine, Iwate, Japan
| | - Keisuke Koeda
- Department of Medical Safety Science, Iwate Medical University School of Medicine, Iwate, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| |
Collapse
|
29
|
Álvarez-Sarrado E, Mingol Navarro F, J Rosellón R, Ballester Pla N, Vaqué Urbaneja FJ, Muniesa Gallardo C, López Rubio M, García-Granero Ximénez E. Feeding Jejunostomy after esophagectomy cannot be routinely recommended. Analysis of nutritional benefits and catheter-related complications. Am J Surg 2018; 217:114-120. [PMID: 30309617 DOI: 10.1016/j.amjsurg.2018.08.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/08/2018] [Accepted: 08/20/2018] [Indexed: 01/01/2023]
Abstract
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.
Collapse
Affiliation(s)
- Eduardo Álvarez-Sarrado
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - Fernando Mingol Navarro
- Esophago-gastric Surgery Unit, University and Polytechnic La Fe Hospital, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain.
| | - Raquel J Rosellón
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - Neus Ballester Pla
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - Francisco Javier Vaqué Urbaneja
- Esophago-gastric Surgery Unit, University and Polytechnic La Fe Hospital, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain.
| | - Carmen Muniesa Gallardo
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - María López Rubio
- General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril, Martorell, 106, 46026, Valencia, Spain.
| | - Eduardo García-Granero Ximénez
- Head of General Surgery Service, University and Polytechnic La Fe Hospital, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain.
| |
Collapse
|
30
|
Park SY, Kim DJ, Suh JW, Byun GE. Risk Factors for Weight Loss 1 Year After Esophagectomy and Gastric Pull-up for Esophageal Cancer. J Gastrointest Surg 2018; 22:1137-1143. [PMID: 29611091 DOI: 10.1007/s11605-018-3749-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Loss of body weight is regarded as a marker of malnutrition after esophagectomy. This study investigated changes in body weight and risk factors for weight loss after esophagectomy for esophageal cancer. METHODS We retrospectively reviewed records of 181 patients who underwent esophagectomy and gastric pull-up from 2012 to June 2016. Patients with operative mortality and recurrences were excluded. Percent change in body weight was defined as change in body weight (%) = (1-year body weight - preoperative body weight) × 100/preoperative body weight. RESULTS Mean age of patients was 62.98 ± 8.23 years with 164 men (90.6%). Mean preoperative body weight was 63.12 ± 9.42 kg, and body weight at 1 year was 56.04 ± 8.59 kg. Mean change in body weight was - 10.95 ± 7.50%, and 98 (54.1%) patients showed weight loss more than 10% compared to initial body weight. Univariable analysis showed that initial body weight, narrow gastric tube, thoracotomy, laparotomy, and postoperative vocal cord palsy (VCP) were related to more than 10% weight loss. Multivariable analysis showed that initial body weight (odds ratio [OR] = 1.041, p = 0.031) and postoperative VCP (OR = 2.772, p = 0.025) were adverse risk factors for weight loss 1 year after esophagectomy, whereas conduit type, route of reconstruction, postoperative complications, anastomotic complications, minimally invasive esophagectomy, and adjuvant therapy were not. CONCLUSIONS Initial body weight and postoperative VCP were related to weight loss. Patients with VCP need additional nutritional monitoring and support.
Collapse
Affiliation(s)
- Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
| | - Jee Won Suh
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Go Eun Byun
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| |
Collapse
|
31
|
Impact Exerted by Nutritional Risk Screening on Clinical Outcome of Patients with Esophageal Cancer. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7894084. [PMID: 29780831 PMCID: PMC5892299 DOI: 10.1155/2018/7894084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/21/2018] [Indexed: 01/26/2023]
Abstract
Objective Preoperative nutritional status of patients is closely associated with their recovery after the surgery. This study aims to ascertain the impact exerted by the nutritional risk screening on clinical outcome of patients with esophageal cancer. Methods 160 patients with esophageal cancer aged over 60, having got therapy at the First Hospital of Jilin University from Jun 2016 to Feb 2017 were evaluated by adopting the NRS2002. 80 cases of patients got active therapy of nutritional support, and the other patients not supported nutritionally were selected as the control group. The comparison was drawn between two groups in serum albumin, serum immunoglobulin, postoperative complications, hospitalization, and hospitalization expenses. Results For all the patients, in 3 and 7 days after the surgery, the serum albumin in the nutritionally supported group outstripped that in group without nutritional support (P < 0.05) regardless of the nutritional risk. For the patients in the risk of nutrition, the IgA in the nutritionally supported group outstripped that of group without nutritional support (P < 0.05) in 3 and 7 days before the surgery, and the serum IgG outstripped that of the group without nutritional support in 1 and 3 days before the surgery (P < 0.05). In terms of the patients in the risk of nutrition, the average hospitalization of nutritionally supported group was shorter (P < 0.05), and the average hospitalization expenses were lower compared with those of the group without nutritional support. And for the patients in no risk, the hospitalization expenses of supported group surmounted those of group without nutritional support (P < 0.05), whereas the average hospitalization took on no statistic difference (P > 0.05). Conclusion For the patients in the risk of nutrition, preoperative nutritional support can facilitate the nutritional status and immunization-relative result after surgery, which shall also decrease the average hospitalization and hospitalization cost.
Collapse
|