Nutrition following esophagectomy, what’s best?

Esophagectomy is the cornerstone for treatment of esophageal cancer. However, it is associated with substantial short-term and long-term morbidity and mortality. Improvement in surgical technique, introduction of fast-track programs and centralization of care have resulted in improved outcomes and reduced morbidity (1-3). However, the best route for nutrition directly postoperatively is still a matter of debate where risk of complications such as anastomotic leakage and (aspiration) pneumonia and adequate nutritional intake are important factors. In previous studies we have shown that oral intake directly postoperatively is feasible and safe and is not accompanied with an increased risk of complications (4). In addition, early start of oral intake is associated with reduced complications (5). Although caloric intake is markedly less compared to standard tube feeding and patients inevitably experience weight loss due to the surgery, it is important to avoid malnutrition, even though reduced caloric intake may seem logical following esophagectomy and gastric conduit reconstruction (6). However, it remains questionable whether caloric intake needs to be artificially maintained at a level that patients cannot meet when on an oral diet after this type of surgery.

Na et al. recently published a study comparing early oral feeding with late oral feeding after an esophagectomy (7). A jejunostomy was given to all patients who underwent an esophagectomy with gastric tube reconstruction. From the first to the fifth day, both groups were fed similarly, gradually increasing the amount of cc/hour up to a 100. Between day 5 and 7 all the patients received an esophagography. Afterwards, the early oral feeding group started oral feeding with a soft blended diet 3 days after esophagography. Supplemental enteral feeding was given through jejunostomy tube, which gradually decreased to a minimal amount. The jejunostomy was removed upon discharge and patients were allowed to start a regular diet. The late oral feeding group were allowed to start with clear and full liquids after the esophagography and were enterally fed through jejunostomy by gravity feeding. The late group transitioned to a soft blended diet after 4 to 5 weeks after surgery with supplemental enteral feeding through jejunostomy. Six weeks postoperatively the late group had to proceed to a regular diet and the jejunostomy tube was removed. In this study was found that the late group experienced significantly less body weight loss at both 4 to 5 weeks and 4 months after surgery compared to the early group. Additionally, the late group had a higher calorie and protein intake and a lower prevalence of malnutrition (7).

Malnutrition is a common issue for patients with esophageal cancer, with 40–60% of patients being malnourished before hospital admission (8). Preoperatively patients experience weight loss for multiple reasons such as, dysphagia, odynophagia reflux, or choking on food, which makes some patients reluctant to eat. Malnutrition increases the rate of postoperative complications and slows postoperative recovery (9,10). However, weight loss is also an integral part of the esophagectomy, and it is common for esophagectomy patients to lose 10–15% of body weight in the first year (11). Although enteral nutrition via tube feeding reduces weight loss as Na et al. describe (7), it is also shown that when tube feeding stops, the weight loss continues until a new equilibrium is reached (12). When patients are fed orally directly postoperatively, weight loss is much higher compared to patients fed with tube feeding. One of the issues that arises with early oral feeding is that the patient has an insufficient caloric intake. Jejunostomy tube feeding can meet the postoperative nutritional requirements in full, whereas patients with early oral intake generally have a caloric intake of 1,100–1,200 kcal with a presumed caloric need (based on the body composition directly postoperatively) ranging between 1,900 and 2,300 kcal (7,13). One of the presumed benefits of additional tube feeding is reduction of weight loss. However, previous studies demonstrated that, although initial weight was lower in patients receiving additional feeding, no significant differences were observed between the patients at 6 and 12 months after esophagectomy (14,15). These findings suggest that the long-term impact of an esophagectomy on weight loss is comparable, irrespective of jejunostomy use. Although patients with additional tube feeding via a jejunostomy initially experience less weight loss compared to those who begin early oral feeding, they tend to lose more weight after the jejunostomy is removed (14). Moreover, most patients experience the greatest weight loss within the first 6 months after esophagectomy, regardless of whether they had additional nutrition or not (14,16). Some patients experience difficult with oral intake postoperatively. This might be related to recurrent laryngeal nerve palsy, although a direct correlation is still unclear (17). In patients that cannot meet nutritional requirements due to insufficient oral intake due to for example stenosis, additional feeding via jejunostomy may be beneficial (18).

However, feeding via a jejunostomy also induces a risk of complications. The incidence of complications following jejunostomy is 7–51% and severe complications such as intestinal obstruction or herniation occur in a minority (0–4%) of patients (19,20). This also depends on whether the jejunostomy is used or not (18). Alternatively, a nasojejunal tube can be used, however, dislocation is a common complication, occurring in 20–35% of the patients (21).

So, what is the optimal course of action following an esophagectomy? Can patients be fastened or have less caloric intake for a short period of time until oral intake is re-started? These questions are challenging to address; however, evidence is emerging that reduction of caloric intake may be beneficial in specific clinical settings. In critically ill patients it is shown that late initiation of parenteral feeding was associated with faster recovery and fewer complications compared to early start of parenteral feeding (22,23). More importantly, patients receiving late parenteral nutrition have an increased likelihood of begin discharged alive earlier form the intensive care unit (23). In addition, critically ill patients who start later with parenteral nutrition have less infections (24).

Next, adequate protein intake is considered to be important for patients in their recovery. It is even suggested that increased protein intake would aid in recovery, especially in critically ill patients. However, recently, high protein enteral nutrition was compared with standard enteral protein nutrition of equal caloric value in critically ill patients. It was found that high protein enteral feeding resulted in worse health-related quality of life and did not improve functional outcomes after intensive care unit admission (25). These results need further analyses and are in sharp contrast with what is generally believed.

In esophagectomy patients, the NUTRIENT II trial examined the impact of direct oral feeding compared to delayed oral feeding and artificial feeding via tube feeding. The long-term results in this study also were unexpected. In the group that started oral intake after esophagectomy, it was found that caloric intake was significantly lower without leading to body mass index (BMI) differences between groups on the short-term. Moreover, direct oral feeding appeared to positively influence overall survival and significantly improved 5-year disease free survival. These findings suggest a potential association between direct oral intake and survival, although the underlying mechanisms remain unclear (26).

In conclusion, in patients who underwent esophagectomy, it is still elusive how to deal with the weight loss accompanying the surgery. Malnutrition is best avoided, however whether maintaining an artificial caloric intake via tube feeding is the best solutions remains unclear. Anatomical changes of the esophagectomy and gastric tube reconstruction induce weight loss on itself, and the patients will reach a new weight equilibrium postoperatively. There is emerging evidence that reduction of caloric intake may benefit patients in specific clinical situations and further research is necessary to provide more insight into the best postoperative strategy.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Clinical Trials Review. The article has undergone external peer review.

Peer Review File: Available at https://actr.amegroups.com/article/view/10.21037/actr-24-235/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://actr.amegroups.com/article/view/10.21037/actr-24-235/coif). M.D.L. reports consulting fees from Galvani Bioelectronics and Medtronic. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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