Is early enteral nutrition initiated within 24 hours better for the postoperative course in esophageal cancer surgery?

Feeding via duodenostomy can reduce intestinal obstruction after radical resection of esophageal cancer better than jejunostomy

Background

Enteral nutrition (EN) is superior to parenteral nutrition (PN) in improving the nutritional status of esophageal cancer (EC) patients and accelerating postoperative recovery. Therefore, feeding via jejunostomy (FJ) is currently placed during esophagectomy to maintain the postoperative nutrition supply. However, FJ have some serve complications. The aim of this study was to explore the value of feeding via duodenostomy (FD) in reducing the complications associated with FJ.

Methods

In this retrospective cohort study, the clinical data of 154 patients with EC who underwent surgical treatment in our center from January 1, 2020, to June 30, 2020 were collected. A concurrent, nonrandomized control group of 154 patients underwent thoraco-laparoscopic esophagectomy (TLE) was enrolled consisting of 82 males and 72 females. These patients were randomly divided into two groups according to the different ostomy method applied, including 80 cases in the FD group and 74 cases in the FJ group. The ostomy-related complications during the 180-day follow-up and indicators including perioperative nutritional markers, length of stay (LoS), and operative time were recorded.

Results

After 1 week, the albumin level in the FD group was noninferior to that in the FJ group (36.8 vs. 36.3 g/L; P=0.792), and the prealbumin level also showed no significant difference (178 vs. 176 g/L; P=0.347). Four weeks later, there was significant difference in levels of albumin (42 vs. 41 g/L; P=0.018) but no significant difference prealbumin (225 vs. 222.89 g/L; P=0.493). The LoS was similar between the 2 groups (7 vs. 7.21 days; P=0.697). In terms of the time of stoma creation, it was significantly longer in the FD group than in the FJ group (20 vs. 12 minutes; P<0.001); however, it did not bring a significant impact on the overall procedure length (240 vs. 230.69 minutes; P=0.057). The incidence of postoperative complications (e.g., intestinal obstruction) was significantly lower in the FD group than in the FJ group (P=0.017).

Conclusions

The method of FD is safe, effective and acceptable. It is worthwhile to use in clinic practice.

PROGRAM OF INTESTINAL REHABILITATION AND EARLY POSTOPERATIVE ENTERAL NUTRITION: A PROSPECTIVE COHORT STUDY

Background:

Some factors can act on nutritional status of patients operated for a gastrointestinal cancer. A timely and appropriate nutritional intervention could have a positive effect on postoperative outcomes.

Aim:

To determine the effect of a program of intestinal rehabilitation and early postoperative enteral nutrition on complications and clinical outcomes of patients underwent gastrointestinal surgery for cancer.

Methods:

This is a prospective study of 465 patients underwent gastrointestinal surgery for cancer consecutively admitted in an oncological intensive care unit. The program of intestinal rehabilitation and early postoperative enteral nutrition consisted in: 1) general rules, and 2) gastrointestinal rules.

Results:

The mean age of analysed patients was 63.7±9.1 years. The most frequent operation sites were colon-rectum (44.9%), gynaecological with intestinal suture (15.7%) and oesophagus-gastric (11.0%). Emergency intervention was performed in 12.7% of patients. The program of intestinal rehabilitation and early postoperative enteral nutrition reduced major complication (19.2% vs. 10.2%; p=0.030), respiratory complications (p=0.040), delirium (p=0.032), infectious complications (p=0.047) and gastrointestinal complications (p<0.001), mainly anastomotic leakage (p=0.033). The oncological intensive care unit mortality (p=0.018), length of oncological intensive care unit (p<0.001) and hospital (p<0.001) stay were reduced as well.

Conclusions:

Implementing a program of intestinal rehabilitation and early postoperative enteral nutrition is associated with reduction in postoperative complications and improvement of clinical outcomes in patients undergoing gastrointestinal surgery for cancer.

Program of gastrointestinal rehabilitation and early postoperative enteral nutrition: a prospective study

Nutritional depletion is commonly observed in patients undergoing surgical treatment for a gastrointestinal malignancy. An appropriate nutritional intervention could be associated with improved postoperative outcomes. The study was aimed to determine the effect of a program of gastrointestinal rehabilitation and early postoperative enteral nutrition upon complications and clinical outcomes in patients who experienced gastrointestinal surgery for cancer. This is a prospective study (2013 January-2015 December) of 465 consecutive patients submitted to gastrointestinal surgery for cancer and admitted to an Oncological Intensive Care Unit. The program of gastrointestinal rehabilitation and early postoperative enteral nutrition consisted on: (1) general rules: pain relive, early mobilization, antibiotic prophylaxis, deep vein thrombosis prophylaxis and respiratory physiotherapy; and (2) gastrointestinal rules: gastric protection, control of postoperative nausea and vomiting, early nasogastric tube remove and early enteral nutrition. The most frequent surgical sites were colorectal (44.9%), gynecological with intestinal suturing (15.7%) and esophagus/stomach (11.0%). Emergency surgery was performed in 12.7% of patients. The program of intestinal rehabilitation and early postoperative enteral nutrition reduced major complications (19.2 vs. 10.2%; p = 0.030), respiratory complications (p = 0.040), delirium (p = 0.032), infectious complications (p = 0.047) and gastrointestinal complications (p < 0.001). Intensive care unit mortality (p = 0.018), length of intensive care unit stay (p < 0.001) and length of hospitalization (p < 0.001) were reduced as well. A program of gastrointestinal rehabilitation and early postoperative enteral nutrition is associated with reduced postoperative complications and improved clinical outcomes in patients undergoing gastrointestinal surgery for cancer.

Early traditional Chinese medicine bundle therapy for the prevention of sepsis acute gastrointestinal injury in elderly patients with severe sepsis

This study aimed to study the effect of early traditional Chinese medicine bundle therapy on the prevention of sepsis-associated acute gastrointestinal injury (AGI). This was a multicenter, prospective, observational, non-randomized cohort study of 296 consecutive patients with severe sepsis during 2013/3 and 2014/11; 150 patients received standard treatments (controls) and 146 received traditional Chinese medicine bundle therapy (intervention group) (herbal decoction gavage based on syndrome differentiation, Chinese acupuncture, application of mirabilite, and defecation mixture). D-lactic acid, diamine oxidase, endotoxin, gastrin, motilin, and intra-abdominal pressure were measured. AGI was categorized into four levels. Compared with controls, D-lactic acid, diamine oxidase, endotoxin, gastrin, and intra-abdominal pressure in the intervention group were decreased, and motilin was increased on day 7. AGI incidence in the intervention group was lower than in controls. GIF scores of the intervention AGI II and III groups were lower than in controls. The APACHE II scores of the intervention AGI II, III, and IV groups were lower than in controls. Compared with controls, mechanical ventilation time and ICU stay in the intervention group were shorter, and 28-day overall and AGI-attributed mortality were lower. For elderly patients with severe sepsis, early traditional Chinese medicine bundle therapy could decrease AGI incidence and improve prognosis.

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

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

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

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

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances

BACKGROUND

A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

OBJECTIVES

To evaluate the effectiveness and safety of PEG compared with NGT for adults with swallowing disturbances.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to January 2014, and contacted the main authors in the subject area. There was no language restriction in the search.

SELECTION CRITERIA

We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%.

MAIN RESULTS

We included 11 randomised controlled studies with 735 participants which produced 16 meta-analyses of outcome data. Meta-analysis indicated that the primary outcome of intervention failure, occurred in lower proportion of participants with PEG compared to NGT (RR 0.18, 95% CI 0.05 to 0.59, eight studies, 408 participants, low quality evidence) and this difference was statistically significant. For this outcome, we also subgrouped the studies by endoscopic gastrostomy technique into pull, and push and not reported. We observed a significant difference favouring PEG in the pull subgroup (RR 0.07, 95% CI 0.01 to 0.35, three studies, 90 participants). Thepush subgroup contained only one clinical trial and the result favoured PEG (RR 0.05, 95% CI 0.00 to 0.74, one study, 33 participants) techniques. We found no statistically significant difference in cases where the technique was not reported (RR 0.43, 95% CI 0.13 to 1.44, four studies, 285 participants).There was no statistically significant difference between the groups for meta-analyses of the secondary outcomes of mortality (RR 0.86, 95% CI 0.58 to 1.28, 644 participants, nine studies, very low quality evidence), overall reports of any adverse event at any follow-up time point (ITT analysis, RR 0.83, 95% CI 0.51 to 1.34), 597 participants, 6 studies, moderate quality evidence), specific adverse events including pneumonia (aspiration) (RR 0.70, 95% CI 0.46 to 1.06, 645 participants, seven studies, low quality evidence), or for the meta- analyses of the secondary outcome of nutritional status including weight change from baseline, and mid-arm circumference at endpoint, although there was evidence in favour of PEG for meta-analyses of mid-arm circumference change from baseline (MD 1.16, 95% CI 1.01 to 1.31, 115 participants, two studies), and levels of serum albumin were higher in the PEG group (MD 6.03, 95% CI 2.31 to 9.74, 107 participants).For meta-analyses of the secondary outcomes of time on enteral nutrition, there was no statistically significant difference (MD 14.48, 95% CI -2.74 to 31.71; 119 participants, two studies). For meta-analyses of quality of life measures (EuroQol) outcomes in two studies with 133 participants, for inconvenience (RR 0.03, 95% CI 0.00 to 0.29), discomfort (RR 0.03, 95% CI 0.00 to 0.29), altered body image (RR 0.01, 95% CI 0.00 to 0.18; P = 0.001) and social activities (RR 0.01, 95% CI 0.00 to 0.18) the intervention favoured PEG, that is, fewer participants found the intervention of PEG to be inconvenient, uncomfortable or interfered with social activities. However, there were no significant differences between the groups for pain, ease of learning to use, or the secondary outcome of length of hospital stay (two studies, 381 participants).

AUTHORS' CONCLUSIONS

PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT. There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration. Future studies should include details of participant demographics including underlying disease, age and gender, and the gastrostomy technique.

Is the Geriatric Nutritional Risk Index a Significant Predictor of Postoperative Complications in Patients with Esophageal Cancer Undergoing Esophagectomy?

Background: The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced for predicting the risk of nutrition-related complications. The GNRI has mainly been reported as a simple and accurate tool to assess the nutritional status and prognosis of elderly patients. So far, there have been no reports of the GNRI in patients with gastrointestinal cancer. Our objective was to examine the association between the GNRI and short-term outcomes, especially postoperative complications, in patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. Materials and Methods: The present study enrolled 122 consecutive patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. The GNRI at admission to the hospital was calculated as follows: (1.489 × albumin in g/l) + (41.7 × present/ideal body weight). The characteristics and short-term outcomes were compared between two groups: the high (GNRI ≥90) and the low (GNRI <90) GNRI group. The mortality and morbidity rates, especially the rates regarding respiratory complications and anastomotic leakage, were investigated. Results: The mean age of the 122 patients was 63.9 ± 9.1 years (range 43-83). There were no significant differences in either patient or operative characteristics. The low GNRI group had a significantly higher rate of respiratory complications (p = 0.002). A multivariate analysis demonstrated that the GNRI was the only independent significant factor predicting respiratory complications (hazard ratio 3.41, 95% confidence interval 1.19-9.76; p = 0.022). Conclusion: The GNRI is considered to be a clinically useful marker that can be used to assess the nutritional status and predict the development of postoperative respiratory complications in patients with esophageal cancer undergoing esophagectomy and gastric tube reconstruction.