Elsevier

Clinical Nutrition

Volume 25, Issue 3, June 2006, Pages 386-393
Clinical Nutrition

ORIGINAL ARTICLE
Post-oesophagectomy early enteral nutrition via a needle catheter jejunostomy: 8-year experience at a specialist unit

https://doi.org/10.1016/j.clnu.2005.12.003Get rights and content

Summary

Background & Aims

The purpose of this study was to prospectively evaluate post-operative jejunostomy feeding in terms of nutritional, biochemical, gastrointestinal and mechanical complications in patients undergoing upper gastrointestinal surgery for oesophageal malignancy.

Methods

The study included 205 consecutive patients who underwent oesophagectomy for malignancy. All patients had a needle catheter jejunostomy (NCJ) inserted at the conclusion of laparotomy. Patients were followed prospectively to record nutritional intake, type of feed administered, rate progression, tolerance, weight changes and complications either mechanical, biochemical or gastrointestinal.

Results

Ninety-two per cent of patients were successfully fed exclusively by NCJ post-oesophagectomy, and 94% of patients were tolerating a maintenance regimen of 2000 ml feed over 20 h by day 2 post-operatively. Patients spent a median of 15 days on jejunostomy feeding post-surgery (range 2–112 days); however, 26% required prolonged jejunostomy feeding (>20 days). Minor gastrointestinal complications were effectively managed by slowing the rate of infusion, or administering medication. Three (1.4%) serious complications of jejunostomy feeding occurred, all requiring re-laparotomy, one resulting in death. NCJ feeding was extremely effective in preventing severe post-operative weight loss in the majority of oesophagectomy patients post-op. However, oral intake was generally poor at discharge with only 65% of requirements being met orally. Sixteen patients (8%) patients required home jejunostomy feeding. By the first post-operative month, a further 6% (12) patients were recommenced on jejunostomy feeding.

Conclusion

NCJ feeding is an effective method of providing nutritional support post-oesophagectomy, and allows home support for the subset that fail to thrive. Serious complications, most usually intestinal ischaemia or intractable diarrhoea, are rare.

Introduction

There is an emerging consensus that early post-operative nutritional support benefits the surgical patient at high risk of complications by decreasing septic morbidity, maintaining immunocompetence and improving wound healing.1 An increasing body of literature indicates functional advantages of early post-operative enteral feeding in ameliorating the stress response and in diminishing the risk of major post-operative infections.2, 3, 4 Of all elective complex major operations, the procedure of oesophagectomy is associated with the highest risk of sepsis-related complications and mortality,5 and this risk, as well as the large metabolic, endocrine and neuroendocrine response to this surgery makes it a particularly good model for studies of nutritional support or nutrient immunomodulation.

Needle catheter jejunostomy (NCJ) was first described in 1973.6 It is useful after oesophagectomy as normal food intake is delayed until any concerns about anastomotic healing and gastric emptying are abated, the average being approximately the 10th post-operative day. NCJ allows provision of nutrition, fluid and electrolytes early after surgery and permits a safe means of administering many medications that might otherwise require central venous access or monitoring if given intravenously.7 Once some oral feeding is permitted, patients almost uniformly experience early satiety and tend to eat smaller meals. Previous reports have estimated that the mean time required to achieve what the patients considered to be a socially acceptable diet was 6 months, and that a significant amount of adjustment and experimentation with diet is necessary in the first 3 months following surgery.8 In this regard, the presence of an NCJ provides a useful backup for patients who require supplementary enteral nutrition during this period of adjustment.

The use of the NCJ is not without risk, however, and as an adjunct to oesophageal resection serious complications, sometimes life-threatening, are well described.9, 10 This unit, a tertiary centre for oesophageal cancer, has a long experience with NCJ feeding post-oesophagectomy, and an academic interest in the immunologic benefits of enteral nutrition,11, 12 and this study reports a prospective audit evaluation of nutritional and biochemical effects of early feeding, and detailing mechanical and other complications.

Section snippets

Patients and methods

All patients who underwent oesophagectomy from 1997 to 2004 had an NCJ placed at the time of surgery. NCJ was inserted at conclusion of laparotomy by standard method where a 10 Ch feeding catheter was inserted through a cannula percutaneously in the left upper quadrant and inserted into the jejunum about 15–20 cm from Duodenal-jejunal flexure through a purse string suture. The spot was subsequently buried with seromuscular sutures continued proximally to create a 5 cm long subserosal tunnel. The

Nutritional status at diagnosis (Table 1)

Two hundred and five patients had an NCJ inserted at the time of oesophagectomy. The median age at diagnosis was 62 years (range 29–83 years). The median BMI at diagnosis was 25.5 kg/m2 (range 16–42 kg/m2). Even though 57% of oesophagectomy patients were overweight or obese at diagnosis, 74% were actively losing weight and 34% had experienced clinically severe weight loss at diagnosis (defined as >10% in 6 months or >5% in 1 month13), with 29% losing >10% of their body weight in less than 6

Discussion

The study herein confirms that early feeding via a needle catheter jejunostomy following an oesophagectomy, although not without risks, is a safe procedure allowing early delivery of enteral nutrition avoids the need for TPN with its attendant risks and expense. In addition to providing a safe, effective route for delivering enteral nutrition and avoids the need for parenteral preparations, and thus reducing real costs and cost in terms of nursing time.

There is not uncommonly a long period of

Acknowledgements

We would like to acknowledge the assistance of our Clinical Dietitians Ms. Aisling McHugh, Ms. Deirdre Mc Cormack, Ms. Eva Copeland, Ms. Edel Duffy, Ms. Gillian Mc Geown and Ms. Denise Mc Govern. We are also grateful to Fresenius Kabi Ltd., Ireland for financial assistance with this study. Fresenius Kabi had no role in the collection, analysis or interpretation of data, or the decision to submit the paper for publication.

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