Postoperative complications and weight loss following jejunostomy tube feeding after total gastrectomy for advanced adenocarcinomas

Ultra-Proximal Jejunostomy Application after McKeown-Type Esophagectomy: A Retrospective Case-Series Study

Background

Jejunostomy is the main form of enteral nutritional support after McKeown-type esophagectomy. However, this requires the jejunum to be secured to the abdominal wall, which can lead to catheter-related complications. Here, we present a new type of jejunostomy, ultra-proximal jejunostomy, which does not require fixation of the jejunum to the abdominal wall.

Methods

Patients who underwent McKeown-type esophagectomy between January 2021 and March 2022 were included in this study. Postoperative outcomes of patients who underwent ultra-proximal jejunostomy are also presented.

Results

Forty-three patients were able to receive enteral nutritional support via an ultra-proximal jejunostomy after McKeown-type esophagectomy, and no cases of enteral fistulas were observed. The pain in the left lower abdomen largely disappeared after the removal of the jejunostomy tube in all patients, and there was no difficulty in removing the tube. To date, none of these patients have experienced bowel obstruction or jejunal torsion.

Conclusion

An ultra-proximal jejunostomy is a safe and feasible method and a better option for enteral nutrition support after McKeown-type esophagectomy.

Comparisons of nutritional status and complications between patients with and without postoperative feeding jejunostomy tube in gastric cancer: a retrospective study

Background

Feeding jejunostomy tube (FJT) enables early postoperative nutritional supply for gastric cancer patients undergoing surgery. However, the nutritional benefit of FJT may be accompanied by potential risk of increased complications, so both the nutritional improvement and the complication rates associated with FJT should be assessed.

Methods

From January 2009 to December 2014, 715 consecutive patients underwent gastric cancer resection at the Peking Union Medical College Hospital in China. The perioperative nutritional index and incidence of complications in patients with FJT placement were retrospectively compared to those in patients without FJT placement. Nutritional data including albumin, prealbumin, hemoglobin, and high sensitivity C-reactive protein, the neutrophil-to-lymphocyte ratio (NLR), and Onodera's prognostic nutrition index (OPNI) were recorded at the following 3 timepoints: preoperatively, 1-week postoperatively, and 1-month postoperatively. Postoperative complications including surgical site infection, intra-abdominal infections, anastomotic leaks and gastroparesis were assessed. Multivariate logistic regression was used to study the association between FJT and complications.

Results

A total of 715 patients were included in the study. The mean age was 60.4 years and 72.2% were male. The overall characteristics between FJT and no-FJT groups were comparable. Of the 247 total gastrectomy cases, 98 (39.7%) had a FJT placed. Compared to the total gastrectomy patients without a FJT, the 98 patients with a FJT had a lower hemoglobin level (P=0.048) and NLR (P=0.030) preoperatively, and higher albumin (P=0.005), prealbumin (P<0.001), and hemoglobin (P=0.014) levels, a higher OPNI (P=0.027), and a lower NLR (P=0.005) 1-month postoperatively. Of the 468 subtotal gastrectomy cases, 87 (18.6%) had a FJT placed. Compared to the subtotal gastrectomy patients without a FJT, these 87 patients had a lower NLR (P=0.006) 1-week postoperatively, and a higher albumin level (P=0.009) 1-month postoperatively. In the multivariate analysis, FJT placement was not associated with postoperative adverse outcomes, including surgical site infection [odds ratio (OR) =1.21, P=0.79], intra-abdominal infection (OR =0.38, P=0.11), anastomotic leak (OR =0.58, P=0.53), reoperation (OR =0.22, P=0.23), gastroparesis (OR =6.35, P=0.08), or hospitalization for more than 30 days (OR =0.58, P=0.32).

Conclusions

Early enteral nutritional support by FJT after gastrectomy tended to improve the nutritional status of patients, while it did not appear to increase the incidence rate of postoperative complications.

Jejunostomy in the palliative treatment of gastric cancer: A clinical prognostic score

BACKGROUND

Clinical stage IV gastric cancer (GC) may need palliative procedures in the presence of symptoms such as obstruction. When palliative resection is not possible, jejunostomy is one of the options. However, the limited survival of these patients raises doubts about who benefits from this procedure.

AIM

To create a prognostic score based on clinical variables for 90-d mortality for GC patients after palliative jejunostomy.

METHODS

We performed a retrospective analysis of Stage IV GC who underwent jejunostomy. Eleven preoperative clinical variables were selected to define the score categories, with 90-d mortality as the main outcome. After randomization, patients were divided equally into two groups: Development (J1) and validation (J2). The following variables were used: Age, sex, body mass index (BMI), American Society of Anesthesiologists classification (ASA), Charlson Comorbidity index (CCI), hemoglobin levels, albumin levels, neutrophil-lymphocyte ratio (NLR), tumor size, presence of ascites by computed tomography (CT), and the number of disease sites. The score performance metric was determined by the area under the receiver operating characteristic (ROC) curve (AUC) to define low and high-risk groups.

RESULTS

Of the 363 patients with clinical stage IVCG, 80 (22%) patients underwent jejunostomy. Patients were predominantly male (62.5%) with a mean age of 62.4 years old. After randomization, the binary logistic regression analysis was performed and points were assigned to the clinical variables to build the score. The high NLR had the highest value. The ROC curve derived from these pooled parameters had an AUC of 0.712 (95%CI: 0.537-0.887, P = 0.022) to define risk groups. In the validation cohort, the diagnostic accuracy for 90-d mortality based on the score had an AUC of 0.756, (95%CI: 0.598-0.915, P = 0.006). According to the cutoff, in the validation cohort BMI less than 18.5 kg/m2 (P < 0.001), CCI ≥ 1 (P = 0.001), ASA III/IV (P = 0.002), high NLR (P = 0.012), and the presence of ascites on CT exam (P = 0.004) were significantly associated with the high-risk group. The risk groups showed a significant association with first-line (P = 0.012), second-line chemotherapy (P = 0.009), 30-d (P = 0.013), and 90-d mortality (P < 0.001).

CONCLUSION

The scoring system developed with 11 variables related to patient's performance status and medical condition was able to distinguish patients undergoing jejunostomy with high risk of 90 d mortality.

Should Pyloric Lymph Nodes Be Dissected for Siewert Type II and III Adenocarcinoma of the Esophagogastric Junctions: Experience from a High-Volume Center in China

BACKGROUND

The optimal extent of lymph node (LN) dissection remains controversial in adenocarcinoma of the esophagogastric junction (AEG), especially in Siewert types II and III. The aim of this study was to analyze clinicopathological characteristics of patients with Siewert type II and III AEGs to clarify whether pyloric (no. 5 and no.6) lymphadenectomy is essential in these patients.

METHODS

A retrospective analysis was performed in the Third Affiliated Hospital of Soochow University from September 2008 to December 2012, and clinicopathological characteristics on all patients with Siewert type II and III AEGs, who underwent curative total gastrectomy with lymphadenectomy were collected. The index of estimated benefit from lymph node dissection (IEBLD) was used to evaluate the efficacy of lymph node dissection of no. 5 and no. 6. Both clinicopathological characteristics and IEBLDs were set as the standards in the assessment of the value of pyloric lymph nodes dissection.

RESULTS

A total of 216 patients with AEG (Siewert type II: 141, Siewert type III: 75) were included into the study. Type III AEG had a larger tumor size and relatively advanced T stage compared to Type II AEG. The 5-year overall survival (OS) rates in type II and type III AEGs were almost similar (type II 50.4% vs. type III 46.7%, p = 0.782). There was a very low incidence of pyloric lymph nodes metastases in type II AEG (no. 5 is 1.4% and no. 6 is 0.7%). Hence, the IEBLDs of no. 5 and no. 6 lymph node were negligible regardless of the T stage and tumor differentiation. In type III AEG, metastasis rates of no. 5 and no. 6 lymph node were 9.3 and 5.3%, respectively. The IEBLDs of no. 5 and no. 6 lymph node were 2.7 and 1.3, respectively.

CONCLUSIONS

Based on the IEBLDs of pyloric lymph nodes, dissection of no. 5 and no. 6 lymph nodes were worthwhile for Siewert type III AEG but not essential for Siewert type II AEG.