R. E. Sargent1, A. M. Blakely1, T. Ng1, T. J. Miner1 1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA
Introduction: Adequate nutrition following major upper gastrointestinal cancer resection is critical in order to achieve optimal recovery from the operation and to facilitate initiation of adjuvant therapy when indicated. Feeding jejunostomy tubes (FJT) are often placed at time of resection in order to secure enteral access. FJT utilization rates and need for parenteral nutrition (PN) were assessed.
Methods: Retrospective review of prospectively-maintained database was performed of adult patients who underwent esophagectomy or gastrectomy (subtotal or total) for cancer with curative intent, January 2001 to June 2014. Esophagectomy approach, extent of gastrectomy, FJT placement and utilization at discharge, administration of PN, and complications were evaluated.
Results: 287 patients underwent resection, comprised of 182 esophagectomy (n=107 transhiatal, 58.7%; n=56 Ivor-Lewis, 30.7%) and 105 gastrectomy (n=63 subtotal [SG], 60.0%; n=42 total [TG], 40.0%). 181 of 182 esophagectomy patients underwent FJT, compared with 47 of 105 gastrectomy patients (99.5% vs. 44.8%, p<0.0001), of whom most had undergone TG (n=39, 92.9% vs. n=8 SG, 12.9%, p<0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups (14.7 days vs. 17.1, p=0.076). Upon discharge, 81 esophagectomy patients (48.6%) were taking enteral feeds, with 53 (29.3%) fully and 28 (15.4%) partially dependent. Meanwhile, 20 of 39 TG patients (51.3%) were either fully (n=3, 15.0%) or partially (n=17, 85.0%) dependent on tube feeds, compared with 5 of 8 SG (62.5%) patients, all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients (6.4% vs. 29.3%, p=0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy (n=11, 23.4% vs. n=7, 3.9%, p=0.0001). Four esophagectomy patients required PN due to chylothorax. FJT-specific complications requiring reoperation within 30 days of resection occurred more commonly in the gastrectomy group (n=6), all after TG, compared to 1 esophagectomy patient (12.8% vs. 0.6%, p=0.0003). Six of 7 patients (85.7%) who experienced tube-related complications required PN.
Conclusion: Esophageal and gastric malignancies are distinct pathologies, and resection of each is associated with a unique complication profile. Such complications may preclude feeding jejunostomy use and therefore require parenteral nutrition. Reliance on tube feeds was more common following esophagectomy, while major tube-related complications occurred more frequently following gastrectomy. The type of upper gastrointestinal resection should inform the decision to place a feeding jejunostomy tube, considering potential resection- and tube-related complications, in order to optimize postoperative utilization rates.