ORIGINAL ARTICLEPost-oesophagectomy early enteral nutrition via a needle catheter jejunostomy: 8-year experience at a specialist unit
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.
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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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2022, Clinical Nutrition ESPENCitation Excerpt :Jejunostomy feeding tubes can be associated with minor complications including skin excoriation, leakage and dislodgement [23]. Although the risk of major complications requiring operative management including bowel obstruction have been reported as less than 5% in most studies and they are generally considered ‘safe’ [23,24], surgeons may be reluctant to insert jejunostomy feeding tubes because of these risks and also the resources required to manage the common minor complications. However, recent studies have demonstrated the benefits of continuation of enteral nutrition post discharge on nutritional status and quality of life in gastric and oesophageal cancer patients [25,26].
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