Planned delay of oral intake after esophagectomy reduces the cervical anastomotic leak rate and hospital length of stay

Role of Biomarkers in the Diagnosis of Anastomotic Leakage After Colorectal Surgery: A Systematic Review and Meta-Analysis

Due to its diverse presentation, anastomotic leakage (AL) following colorectal surgery is challenging to detect and frequently discovered when the patient becomes critically ill. When diagnosing AL in its early stages, biomarkers play a large role. This review was conducted to evaluate the diagnostic value of biomarkers in AL after colorectal surgeries. A literature search was undertaken electronically in major search engines such as Medline (PubMed), Google Scholar, ScienceDirect, EMBASE, and CENTRAL (Cochrane Library) databases. Observational studies of both retrospective and prospective nature were included. Origin Pro 2022 (Origin Labs) software was used to assess the prevalence of AL and generate the forest plot. A total of 13 articles fulfilled the eligibility criteria. A pooled prevalence of 9.19% was noted for AL in colorectal surgeries. In the present review, the observed sensitivity for C-reactive protein (CRP) was 80.5% and the specificity was 84% (postoperative day three). In contrast, these were 100% and 83.9% for procalcitonin on postoperative day five. CRP showed the highest diagnostic accuracy and excels at eliminating AL, but combining biomarkers can increase the diagnostic precision of early detection of AL.

A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy

BACKGROUND

The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy.

METHODS

In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance.

RESULTS

Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model.

CONCLUSIONS

This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.

Efficacy of Biomarkers in Predicting Anastomotic Leakage After Gastrointestinal Resection: A Systematic Review and Meta-Analysis

Our systematic review and meta-analysis were designed to evaluate the published literature from 2016 to 2019 on which the role of biomarkers in predicting the anastomotic leakage (AL) in gastroesophageal cancer surgery was investigated. This extensive literature search was conducted on the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) were used to gather the relevant information. No restrictions were made on the type of biomarkers. Wald or likelihood ratio (LRT) fixed effect tests were used to estimate the pooled prevalence to generate the proportions with 95% confidence intervals (CI) and model-fitted weights. For analyzing heterogeneity, the Cochran Q test and I square test were used. The Egger regression asymmetry test and funnel plot were used for publication. In this meta-analysis, a total of 15 studies were recruited with 1892 patients undergoing the resection. The pooled elevated C-reactive protein (CRP) was observed as 13.9% ranging from 11.6% to 16.1%. The pooled prevalence of other biomarkers with AL was observed as 4.4%. Significant heterogeneity was observed between studies that reported CRP and other biomarkers (92% each with chi-squared values of 78.80 and 122.78, respectively). However, no significant publication was observed between studies (p=0.61 and p=0.11, respectively). We concluded our study on this note that different biomarkers are involved in the diagnosis of AL. However, all these biomarkers are poor predictors with insufficient predictive value and sensitivity.

Effect of Early Versus Late Oral Feeding on Postoperative Complications and Recovery Outcomes for Patients with Esophageal Cancer: A Systematic Evaluation and Meta-Analysis

BACKGROUND

This study aimed to systematically evaluate the effect of early oral feeding (EOF) versus late oral feeding (LOF) on postoperative complications and rehabilitation outcomes for patients with esophageal cancer.

METHODS

This study searched relevant literature published up to March 2023 by computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science. A meta-analysis was performed using Review Manager 5.4 software to compare the effects of EOF and LOF on postoperative complications and recovery outcomes of patients with esophageal cancer.

RESULTS

The study included 14 articles, including 9 retrospective studies, 4 randomized controlled trials (RCTs), and 1 prospective study. The 2555 patients included in the study comprised 1321 patients who received EOF and 1234 patients who received LOF. The results of the meta-analysis showed that compared with the LOF group, the EOF group has a shorter time to the first flatus postoperatively (mean difference [MD],  -  1.12; 95% confidence interval [CI], (-  1.25 to -  1.00; P < 0.00001), a shorter time to the first defecation postoperatively (MD, -  1.31; 95% CI, -  1.67 to -   0.95;, P < 0.00001], and a shorter hospital stay postoperatively (MD, -  2.87; 95% CI, -  3.84 to -  1.90; P < 0.00001). The two groups did not differ significantly statistically in terms of postoperative anastomotic leakage rate (P = 0.10), postoperative chyle leakage rate (P = 0.10), or postoperative pneumonia rate (P = 0.15).

CONCLUSION

Early oral feeding after esophageal cancer surgery can shorten the time to the first flatus and the first defecation postoperatively, shorten the hospital stay, and promote the recovery of patients. Moreover, it has no significant effect on the incidence of postoperative complications.

Cessation of Routine Jejunostomy Tube Placement at Time of Minimally Invasive Ivor Lewis Esophagectomy and Impact on Body Mass Index

Jejunostomy tubes are frequently placed at time of esophagectomy. The purpose of this study is to evaluate cessation of routine j-tube placement on postoperative body mass index (BMI), return to the emergency room, and time until adjuvant therapy. We performed a retrospective review of an institutional database for consecutive patients undergoing minimally invasive Ivor Lewis Esophagectomy from 2014-2021 (after January 2019, routine j-tube placement was abandoned). Data was analyzed using Pearson's Chi-squared tests and Student's t test with 2-sided significance level of P < 0.05. In total,179 patients were included, 95 underwent j-tube placement and 84 did not. Cohorts had comparable baseline BMI's (no j-tube: 30.48 vs j-tube: 28.64, P = 0.06) and anastomotic leak rates (2.4% vs 4.2%, P = 0.5). Patients with no jejunostomy tubes were more likely to receive total parenteral nutrition (14.3% vs 5.3%, P < 0.05), but were no more likely to require total parenteral nutrition at discharge and had comparable durations of TPN requirement (7 days vs 12 days, P = 0.53). There was no difference in mean BMI reduction at 2 weeks (2.54 vs 2.09, P = 0.49) and 3-6 months postoperatively (6.11 vs 4.45 P = 0.15). There was no difference in return to the emergency room (8.3% vs 8.4%, P = 0.98) or readmissions (13.1% vs 11.6%, P = 0.76). There was a no difference in mean time to adjuvant therapy (83.5 days vs 72.6 days, P = 0.67). At esophagectomy centers with low anastomotic leak rates, cessation of routine j-tube placement at time of minimally esophagectomy can be undertaken without increasing risk of readmission, time until initiation of adjuvant therapy, or significantly impacting postoperative BMI loss.

Mechanical stretching and chemical pyloroplasty to prevent delayed gastric emptying after esophageal cancer resection-a meta-analysis and review of the literature

BACKGROUND

Delayed gastric emptying (DGE) occurs in up to 40% of patients after esophageal resection and prolongs recovery and hospital stay. Surgically pyloroplasty does not effectively prevent DGE. Recently published methods include injection of botulinum toxin (botox) in the pylorus and mechanical interventions as preoperative endoscopic dilatation of the pylorus. The aim of this study was to investigate the efficacy of those methods with respect to the newly published Consensus definition of DGE.

METHODS

A systematic literature search using CENTRAL, Medline, and Web of Science was performed to identify studies that described pre- or intraoperative botox injection or mechanical stretching methods of the pylorus in patients undergoing esophageal resection. Frequency of DGE, anastomotic leakage rates, and length of hospital stay were analyzed. Outcome data were pooled as odd's ratio (OR) or mean difference using a random-effects model. Risk of bias was assessed using the Robins-I tool for non-randomized trials.

RESULTS

Out of 391 articles seven retrospective studies described patients that underwent preventive botulinum toxin injection and four studies described preventive mechanical stretching of the pylorus. DGE was not affected by injection of botox (OR 0.87, 95% confidence interval [CI] 0.37-2.03, P = 0.75), whereas mechanical stretching resulted in significant reduction of DGE (OR 0.26, 95% CI 0.14-0.5, P < 0.0001).

CONCLUSION

Mechanical stretching of the pylorus, but not injection of botox reduces DGE after esophageal cancer resection. A newly developed consensus definition should be used before the conduction of a large-scale randomized-controlled trial.

Early oral intake and early removal of nasogastric tube post-esophagectomy: A systematic review and meta-analysis

BACKGROUND

Early oral intake (EOI: initiated within 1 day) and early nasogastric tube removal (ENR: removed ≤2 days) post-esophagectomy is controversial and subject to significant variation.

AIM

Our aim is to provide the most up-to-date evidence from published randomized controlled trials (RCTs) addressing both topics.

METHODS

We searched MEDLINE and Embase (1946-06/2019) for RCTs that investigated the effect of EOI and/or ENR post-esophagectomy with gastric conduit for reconstruction. Our main outcomes of interest were anastomotic leak, aspiration pneumonia, mortality, and length of hospital stay (LOS). Pooled mean differences (MD) and risk ratios (RR) estimates were obtained using a DerSimonian random effects model.

RESULTS

Two reviewers screened 613 abstracts and identified 6 RCTs eligible for inclusion; 2 regarding EOI and 4 for ENR. For EOI (2 studies, n = 389), was not associated with differences in risk of: anastomotic leak (RR: 1.01; 95% CI: 0.407, 2.500; I2 : 0%), aspiration pneumonia (RR: 1.018; 95% CI: 0.407, 2.500), mortality (RR: 1.00; 95% CI: 0.020, 50.0). The LOS was significantly shorter in the EOI group: LOS (MD: -2.509; 95% CI: -3.489, -1.529; I2 : 90.44%). For ENR (4 studies, n = 295), ENR (removed at POD0-2 vs. 5-8 days) was not associated with differences in risk of: anastomotic leak (RR: 1.11; 95% CI 0.336, 3.697; I2 : 25.75%) and pneumonia group (RR: 1.11; 95% CI: 0.336, 3.697; I2 : 25.75%), mortality (RR: 0.87; 95% CI: 0.328, 2.308; I2 : 0%)or LOS (MD: 1.618; 95% CI: -1.447, 4.683; I2 : 73.03%).

CONCLUSIONS

Our analysis showed that EOI as well as ENR post-esophagectomy do not significantly increase the risk of anastomotic leak, pneumonia, and mortality. The LOS was significantly shorter in the EOI group, and there was no significant difference in the ENR group. A paucity of RCTs has evaluated this question, highlighting the need for further high-quality evidence to address these vital aspects to post-esophagectomy care.

SYSTEMATIC REVIEW REGISTRATION

CRD42019138600.

Early versus the traditional start of oral intake following esophagectomy for esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Nil by mouth is considered the standard of care during the first days following esophagectomy. However, with the routine implementation of enhanced recovery after surgery, early oral intake is more likely to be the preferred mode of nutrition following esophagectomy. The present study aims to evaluate the safety and effectiveness of early oral intake following esophagectomy for esophageal cancer.

METHODS

Comprehensive literature searches were conducted using PubMed, Web of Science, Embase, and Cochrane Library. Weighted mean differences (WMD) and odds ratios (OR) with 95% confidence intervals (CI) were calculated as the effect sizes for continuous and dichotomous variables, respectively.

RESULTS

Fourteen studies with a total of 1947 patients were included. Length of hospital stay (WMD =  - 3.94, CI: - 4.98 to - 2.90; P < 0.001), the time to first flatus (WMD =  - 1.13, CI: - 1.25 to - 1.01; P < 0.001) and defecation (WMD =  - 1.26, CI: - 1.82 to - 0.71; P < 0.001) favored the early oral intake group. There was no statistically significant difference in mortality (OR = 1.23, CI: 0.45 to 3.36; P = 0.69). Early oral intake also did not increase the risk of pneumonia and overall postoperative complications.

CONCLUSIONS

Current evidence indicates early oral intake following esophagectomy seems to be safe and effective. It may be the preferred mode of nutrition following esophagectomy. However, more high-quality studies are still needed to further validate this conclusion.

Effectiveness of an early, quantified, modified oral feeding protocol on nutritional status and quality of life of patients after minimally invasive esophagectomy: A retrospective controlled study

OBJECTIVES

Previous studies confirmed the safety and feasibility of oral feeding on the first postoperative day (POD) for patients with minimally invasive esophagectomy (MIE). Nonetheless, some clinical concern can lead to delays in early oral feeding on POD 1. To our knowledge, few reports have focused on resolving these clinical concerns. The aims of this study were to evaluate the effects of an early, quantified, modified oral feeding protocol for patients after MIE and to explore its effect on nutritional status and quality of life (QoL).

METHODS

In this prospective controlled trail, 200 patients were selected as the intervention group (IG) from March 2020 to June 2021; 115 patients hospitalized from June 2019 to February 2020 were assigned to the control group (CG). For 2 wk during the postoperative period, IG participants received an early, quantified, modified oral feeding protocol. The recovery of dietary outcomes, nutritional status, and QoL were evaluated after the intervention.

RESULTS

There was no significant difference between the two groups in terms of demographic and clinical characteristics and baseline physical function. After the intervention, patients in the IG showed a more rapid growth in daily total oral caloric intake and the ratio of oral calorie intake to total calorie required by the body (K/R value) from POD 1 to POD 14, and less weight loss (1.5 ± 1 versus 2.1 ± 1.7 kg; P < 0.05), better serum prealbumin (193.0 ± 26.9 versus 139.3 ± 27.2 mg/L; P < 0.05) than the CG with statistical significance. By the second week of the intervention, IG patients reported higher global QoL and function scores and lower symptom scores than patients in the CG. The IG participants presented a shorter time to first flatus and bowel movement (P < 0.001), a shorter postoperative hospital length of stay, and higher activities of daily living scores (P < 0.05) the those in the CG.

CONCLUSIONS

The findings demonstrated that the early, quantified, modified oral feeding protocol can alleviate postoperative body weight loss, improve the patient's nutritional status, and have a positive effect on QoL and early recovery for patients undergoing MIE.

Impact of Early Oral Feeding on Anastomotic Leakage Rate After Esophagectomy: A Systematic Review and Meta-analysis

BACKGROUND

Esophageal cancer occupies a vital position in fatal cancer-related disease, with esophagectomy procedures helping to improve patient survival. The timing when oral intake should be resumed after esophagectomy and whether early oral feeding (EOF) or delayed oral feeding (DOF) should be the optimal regimen are controversial.

METHODS

Databases (PubMed, Embase, Cochrane library) were searched. All records were screened by two authors through full-text reading. Data on the anastomotic leakage rate were extracted and synthesized in meta-analyses. Postoperative pneumonia rate and length of hospital stay were also assessed.

RESULTS

Seven studies from 49 records were included after full-text reading; 1595 patients were totally included in the analysis. No significant difference was observed between the EOF and DOF groups (odds ratio [OR] 1.68; 95% confidence interval [CI] 0.70-4.03; p = 0.2495; I² = 70%). Higher anastomotic leakage rate was observed in EOF compared with DOF (OR 2.89; 95% CI 1.56-5.34; p = 0.0007; I² = 10%) in the open subgroup. No significant difference was observed in the MIE (OR 0.48; 95% CI 0.22-1.02; p = 0.0564; I² = 0%). Patients performed similarly in pneumonia (OR 1.12; 95% CI 0.57-2.21; p = 0.745; I² = 34%). In cervical subgroup, anastomosis leakage may be less in DOF (OR 2.42 95% CI 1.26-4.64; p = 0.0651; I² = 58%), while in thoracic subgroup, there is no obvious difference (OR 0.86 95% CI 0.46-1.61; p = 0.01; I² = 84.9%).

CONCLUSIONS

Anastomotic leakage related to the timing of oral feeding after open esophagectomy, which is more favorable to the DOF regimen. However, timing of oral feeding did not impair anastomotic healing in patients undergoing MIE.

Risk Factors for Postoperative Anastomosis Leak After Esophagectomy for Esophageal Cancer

BACKGROUND/AIM

The present study aimed to identify risk factors for anastomosis leak (AL) after esophagectomy for esophageal cancer.

PATIENTS AND METHODS

One-hundred twenty-two patients who underwent esophagectomy for esophageal cancer between 2008 and 2018 were included. The rate of AL was measured based on the definition of leak as adapted from the Surgical Infection Study Group. To identify the risk factors for AL, logistic regression analysis was used.

RESULTS

AL was found in 44 of the 122 patients (36.1%). Among the factors examined, the lymph node dissection status (p=0.007) and preoperative serum albumin level (p=0.022) were significant independent risk factors for AL. The incidence of AL was 26.7% (20 of 75) among patients who received 2-field lymph node dissection and 51.1% (24 of 47) among those who received 3-field lymph node dissection. The incidence of AL was 29.9% (23 of 77) in the preoperative serum albumin levels ≥4.0 g/dl group and 46.7% (21 of 45) in the serum albumin levels <4.0 g/dl group.

CONCLUSION

Lymph node dissection status and preoperative serum albumin levels were risk factors for AL in patients who received esophagectomy for esophageal cancer.

A nomogram illustrating the probability of anastomotic leakage following cervical esophagogastrostomy

BACKGROUND

Early diagnosis of anastomotic dehiscence following cervical esophagogastrostomy may become difficult. Estimation of an individual probability could help to establish preventive and diagnostic measures. The predictive impact of epidemiological, surgery-related data and laboratory parameters on the development of anastomotic dehiscence was investigated in the immediate perioperative period.

METHODS

Retrospective study in 412 patients with cervical esophagogastrostomy following esophagectomy. Epidemiological data, risk factors, underlying disease, pre-treatment- and surgery-related data, C-reactive protein and albumin levels pre-and post-operatively were evaluated. We applied univariable and multivariable logistic regression analysis and developed a nomogram for individual risk assessment.

RESULTS

There were 345 male, 67 female patients, mean aged 61.5 years; 284 had orthotopic, 128 retrosternal gastric pull-up; 331 patients had carcinoma, 81 non-malignant disease. Mean duration of operation was 184 min; 235 patients had manual, 113 mechanical and 64 semi-mechanical suturing; 76 patients (18.5%) developed anastomotic dehiscence clinically evident at mean 11.4 days after surgery. In univariable testing young age, retrosternal conduit transposition, manual suturing, high body mass index, high ASA and high postoperative levels of C-reactive protein were predictors for anastomotic leakage. These six parameters which had yielded a p < 0.1 in the univariable analysis, were entered into a multivariable analysis and a nomogram allowing the determination of the patient's individual risk was created.

CONCLUSION

By using the nomogram as a supportive measure in the perioperative management, the patient's individual probability of developing an anastomotic leak could be quantified which may help to take preventive measures improving the outcome.

Impact of Child-Pugh class A liver cirrhosis on perioperative outcomes of patients with oesophageal cancer: a propensity score-matched analysis

OBJECTIVES

Advanced-stage (Child-Pugh classes B and C) liver cirrhosis (LC) is a contraindication for oesophagectomy. However, the question as to whether Child-Pugh class A LC may have an impact on perioperative outcomes remains unanswered. This retrospective single-centre study was designed to address this issue.

METHODS

This was a single-centre, retrospective, propensity-matched study. The perioperative outcomes of patients with Child-Pugh class A LC were compared with those of patients without LC after propensity score matching.

RESULTS

Out of a cohort consisting of 811 patients, we identified 51 cases with Child-Pugh class A LC. After the application of propensity score matching, the LC and no-LC groups consisted of 50 and 100 patients, respectively. The presence of LC did not compromise the quality of surgical resection as attested to by similar lymph node yields and R0 rates. However, patients with LC patients were more prone to developing postoperative pneumonia (22% vs 9%, P = 0.027), pleural effusion (38% vs 20%, P = 0.018) and chylothorax (10% vs 1%, P = 0.016) and had longer intensive care unit stay (mean: 6.10 vs 2.58 days, P = 0.002) compared with the no-LC group. Multivariable analysis identified thoracic duct ligation [odds ratio (OR) 12.292, P = 0.042] and a higher number of dissected nodes (OR 4.375, P = 0.037) as independent risk factors for chylothorax and pleural effusion, respectively. The detrimental effect of these variables was limited to the LC group.

CONCLUSIONS

Oesophagectomy portends a higher morbidity in patients with Child-Pugh class A LC. A meticulous management of lymphatic ducts during mediastinal dissection may improve surgical outcomes in this high-risk group.

Delayed Gastric Emptying Post-Esophagectomy: A Single-Institution Experience

OBJECTIVE

Delayed gastric emptying (DGE) is a common functional disorder after esophagectomy in patients with esophageal carcinoma. Management of DGE varies widely and it is unclear how comorbidities influence the postoperative course. This study sought to determine factors that influence postoperative DGE.

METHODS

This retrospective study evaluates patients who underwent esophagectomy with gastric pull-up between 2007 and 2019. The cohort was stratified in various ways to determine if postoperative care and outcomes differed, including patient demographics, comorbidities, intraoperative and postoperative procedures.

RESULTS

During the study period, 149 patients underwent esophagectomy and 37 had diabetes. Overall incidence of DGE, as defined in this study, was 76.5%. Surgery type was significantly different between DGE and normal emptying cohorts (P = 0.005). Comparing diabetic and nondiabetic patients, there was no significant difference noted in DGE (P = 0.25). Additionally, there was no difference in presence of DGE for patients who underwent any intraoperative pyloric procedure compared to those who did not (P = 0.36). Of significance, all 16 patients with chronic obstructive pulmonary disease had a delay in gastric emptying (P = 0.01).

CONCLUSIONS

A higher proportion of patients with DGE post-esophagectomy were identified compared to the literature. There is little consensus on a true definition of DGE, but we believe this definition identifies patients suffering in the immediate postoperative period and in follow-up. There is no evidence to support a different postoperative course for patients with diabetes, but the link between chronic obstructive pulmonary disease and DGE warrants further investigation.

Delayed Gastric Emptying after Esophagectomy: Management and Prevention

The quality of life associated with eating is becoming an increasingly significant problem for patients who undergo esophagectomy as a result of the improved survival rate after esophageal cancer surgery. Delayed gastric emptying (DGE) is a common complication after esophagectomy. Although several strategies have been proposed for the management and prevention of DGE, no clear consensus exists. The purpose of this review is to present a brief overview of DGE and to help clinicians choose the most appropriate treatment through an analysis of DGE by cause. Furthermore, we would like to suggest some tips to prevent DGE based on our experience.

The effect of early oral feeding after esophagectomy on the incidence of anastomotic leakage: an updated review

OBJECTIVE

Early oral feeding (EOF) is considered to be an important component of enhanced recovery after surgery (ERAS), but raises the concern of increased risk of anastomotic leakage (AL) in patients receiving esophagectomy. This review aimed to elucidate the correlation of EOF and the incidence of AL after esophageal resection.

METHODS

We searched PubMed, Web of Science, Scopus, Cochrane Library and Google Scholar from their inception to February 2020 for published articles that compared AL after EOF (oral feeding initiated within postoperative day [POD] 3) vs. conventional feeding regimen (nil-by-mouth with enteral tube nutrition support, until oral feeding since POD 4 and beyond) following esophagectomy.

RESULTS

A total of 11 full articles were included in this review, including 5 registered randomized controlled trials (RCTs) and 6 observational studies that compared EOF with conventional care after esophagectomy. Meta-analysis was not possible due to significant heterogeneity, bias, and small sample sizes. Among the 11 included studies, 9 (including the 5 RCTs) showed that EOF did not increase AL rate, whereas the other 2 retrospective studies indicated that delayed oral feeding resulted in fewer AL.

CONCLUSIONS

EOF after esophagectomy probably does not increase the incidence of AL, and it is a promising strategy in line with the essence of ERAS. However, more and better evidence from high-quality RCTs are still needed.

Feeding protocol deviation after esophagectomy: A retrospective multicenter study

BACKGROUND

Esophagectomy is associated with high postoperative morbidity rates, which can result in decreased quality of life and impaired recovery. Implementation of enhanced recovery after surgery (ERAS) protocols have made a great impact in optimizing postoperative recovery. However, the best timing to start oral intake is still unclear. Conservative feeding protocols have been developed with a nil-by-mouth period in the first postoperative days to reduce postoperative complication rates (e.g. anastomotic leakage and pneumonia). This study aimed to evaluate adherence to the feeding protocol following minimal invasive esophagectomy and identify reasons for protocol deviation.

METHODS

All consecutive patients who underwent an esophagectomy with gastric tube reconstruction between 2014 and 2016 in two high-volume hospitals in the Netherlands were retrospectively analyzed. All patients were planned to receive enteral tube feeding via jejunostomy directly after surgery. Data regarding postoperative feeding related symptoms (e.g. nausea, vomiting, regurgitation) and adherence to the postoperative feeding protocol were gathered.

RESULTS

A total of 186 patients were included. Feeding protocol deviation was observed in 109 patients (59%) and was significantly more common in patients with anastomotic leakage, chyle leakage, and acute respiratory distress. Postoperative feeding related symptoms were present in 107 patients (58%) and were significantly more common in female patients and patients with a cervical anastomosis.

CONCLUSION

In this study, more than half of the patients deviated from the intended feeding protocol after esophagectomy. Postoperative complications appeared to be the main reason for feeding protocol deviation. This study shows that a predefined feeding protocol including an oral fasting period is often violated because of complications.

Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis

Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.

Study protocol for a multicenter prospective cohort study on esophagogastric anastomoses and anastomotic leak (the Oesophago-Gastric Anastomosis Audit/OGAA)

Esophagectomy is a mainstay in curative treatment for esophageal cancer; however, the reported techniques and outcomes can vary greatly. Thirty-day mortality of patients with an intact anastomosis is 2-3% as compared to 17-35% in patients who have an anastomotic leak. The subsequent management of leaks postesophagectomy has great global variability with little consensus on a gold standard of practice. The aim of this multicentre prospective audit is to analyze current techniques of esophagogastric anastomosis to determine the effect on the anastomotic leak rate. Leak rates and leak management will be assessed to determine their impact on patient outcomes. A 12-month international multicentre prospective audit started in April 2018 and is coordinated by a team from the West Midlands Research Collaborative. This will include patients undergoing esophagectomy over 9 months and encompassing a 90-day follow-up period. A pilot data collection period occurred at four UK centers in 2017 to trial the data collection form. The audit standards will include anastomotic leak and the conduit necrosis rate should be less than 13% and major postoperative morbidity (Clavien-Dindo Grade III or more) should be less than 35%. The 30-day mortality rate should be less than 5% and the 90-day mortality rate should be less than 8%. This will be a trainee-led international audit of esophagectomy practice. Key support will be given by consultant colleagues and anesthetists. Individualized unit data will be distributed to the respective contributing sites. An overall anonymized report will be made available to contributing units. Results of the audit will be published in peer-reviewed journals with all collaborators fully acknowledged. The key information and results from the audit will be disseminated at relevant scientific meetings.

Systematic Review of the Role of Biomarkers in Predicting Anastomotic Leakage Following Gastroesophageal Cancer Surgery

Anastomotic leakage (AL) following gastroesophageal cancer surgery remains a serious postoperative complication. This systematic review aims to provide an overview of investigated biomarkers for the early detection of AL following esophagectomy, esophagogastrectomy and gastrectomy. All published studies evaluating the diagnostic accuracy of biomarkers predicting AL following gastroesophageal resection for cancer were included. The Embase, Medline, Cochrane Library, PubMed and Web of Science databases were searched. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2 tool. Twenty-four studies evaluated biomarkers in the context of AL following gastroesophageal cancer surgery. Biomarkers were derived from the systemic circulation, mediastinal and peritoneal drains, urine and mediastinal microdialysis. The most commonly evaluated serum biomarkers were C-reactive protein and leucocytes. Both proved to be useful markers for excluding AL owing to its high specificity and negative predictive values. Amylase was the most commonly evaluated peritoneal drain biomarker and significantly elevated levels can predict AL in the early postoperative period. The associated area under the receiver operating characteristic (AUROC) curve values ranged from 0.482 to 0.994. Current biomarkers are poor predictors of AL after gastroesophageal cancer surgery owing to insufficient sensitivity and positive predictive value. Further research is needed to identify better diagnostic tools to predict AL.

Optimal timing and route of nutritional support after esophagectomy: A review of the literature

Some controversy surrounds the postoperative feeding regimen utilized in patients who undergo esophagectomy. Variation in practices during the perioperative period exists including the type of nutrition started, the delivery route, and its timing. Adequate nutrition is essential for this patient population as these patients often present with weight loss and have altered eating patterns after surgery, which can affect their ability to regain or maintain weight. Methods of feeding after an esophagectomy include total parenteral nutrition, nasoduodenal/nasojejunal tube feeding, jejunostomy tube feeding, and oral feeding. Recent evidence suggests that early oral feeding is associated with shorter LOS, faster return of bowel function, and improved quality of life. Enhanced recovery pathways after surgery pathways after esophagectomy with a component of early oral feeding also seem to be safe, feasible, and cost-effective, albeit with limited data. However, data on anastomotic leaks is mixed, and some studies suggest that the incidence of leaks may be higher with early oral feeding. This risk of anastomotic leak with early feeding may be heavily modulated by surgical approach. No definitive data is currently available to definitively answer this question, and further studies should look at how these early feeding regimens vary by surgical technique. This review aims to discuss the existing literature on the optimal route and timing of feeding after esophagectomy.

Impact of postoperative complications on outcomes after oesophagectomy for cancer

BACKGROUND

To allocate healthcare resources optimally, complication-related quality initiatives should target complications that have the greatest overall impact on outcomes after surgery. The aim of this study was to identify the most clinically relevant complications after oesophagectomy for cancer in a nationwide cohort study.

METHODS

Consecutive patients who underwent oesophagectomy for cancer between January 2011 and December 2016 were identified from the Dutch Upper Gastrointestinal Cancer Audit. The adjusted population attributable fraction (PAF) was used to estimate the impact of specific postoperative complications on the clinical outcomes postoperative mortality, reoperation, prolonged hospital stay and readmission to hospital in the study population. The PAF represents the percentage reduction in the frequency of a given outcome (such as death) that would occur in a theoretical scenario where a specific complication (for example anastomotic leakage) was able to be prevented completely in the study population.

RESULTS

Some 4096 patients were analysed. Pulmonary complications and anastomotic leakage had the greatest overall impact on postoperative mortality (risk-adjusted PAF 44·1 and 30·4 per cent respectively), prolonged hospital stay (risk-adjusted PAF 31·4 and 30·9 per cent) and readmission to hospital (risk-adjusted PAF 7·3 and 14·7 per cent). Anastomotic leakage had the greatest impact on reoperation (risk-adjusted PAF 47·1 per cent). In contrast, the impact of other complications on these outcomes was relatively small.

CONCLUSION

Reducing the incidence of pulmonary complications and anastomotic leakage may have the greatest clinical impact on outcomes after oesophagectomy.

Delay in Oral Feeding is Associated With a Decrease in Anastomotic Leak Following Transhiatal Esophagectomy

The cervical anastomotic leak is a major complication of transhiatal esophagectomy and results in chronic strictures in up to half of patients. A change in postoperative protocol to delaying initiation of oral intake was made with the goal of reducing anastomotic leak rate and associated sequelae. A postoperative protocol change was applied to all patients undergoing elective transhiatal esophagectomy. Rate of anastomotic leak and anastomotic stricture, defined as defect in the esophagogastric anastomosis and narrowing of the anastomosis, respectively, were compared between pre- and post-change groups. Between 2004 and 2013, 203 patients underwent transhiatal esophagectomy with cervical anastomosis. Historically, oral intake was resumed on postoperative day 3, and during the course of the study, a change was made to the protocol to delay oral intake until 15 days postoperatively. Eighty-three patients were in the early oral feeding group (postoperative day 3), and 120 were in the delayed oral intake group (postoperative day 15). There was a statistically significant decrease in the rate of anastomotic leak from 14.5% to 4.2% between the early and delayed intake groups, respectively (P = 0.0089). There was also a trend (P = 0.05) towards a lower rate of anastomotic stricture in all patients in the delayed intake group (15.8%) compared with those in the early feeding group (27.7%). By increasing the time to postoperative oral feeding, we have noted an associated improvement in both immediate and long-term outcomes of elective transhiatal esophagectomy patients.

Impact of supplemental home enteral feeding postesophagectomy on nutrition, body composition, quality of life, and patient satisfaction

The aim of this prospective cohort study is to analyze the impact of supplemental home enteral nutrition (HEN) post-esophageal cancer surgery on nutritional parameters, quality of life (QL), and patient satisfaction. A systematic review reported that over 60% of patients lose >10% of both body weight and BMI by 6 months after esophagectomy. Enteral feeding (EF) is increasingly a modern standard postoperatively; however, the impact of extended HEN postdischarge has not been systematically studied. One hundred forty-nine consecutive patients [mean age 62 ± 9, 80% male,76% adenocarcinoma, 66% on multimodal protocols, and 69% with BMI ≥ 25 kg/m2] were studied. Jejunal EF commenced day 1 postoperatively, and supplemental overnight HEN (764 kcal; 32g protein) continued on discharge for a planned further 4 weeks. Weight, BMI, and body composition analysis (bioimpedance analysis) were measured at baseline, preoperatively and at 1, 3, and 6 months, along with the EORTC QLQ-C30/OES18 QL measures. A patient satisfaction questionnaire addressed eight key items in relation to HEN (max score 100/item). Median (range) total duration of EF was 49 days (28-96). Overall compliance was 96%. At 6 months, compared with preoperatively, 58 (39%) patients lost >10% weight, with median (IQR) loss of 6.8 (4-9) kg, and 62 (41%) patients lost >10% BMI. Lean body mass and body fat were significantly (p < 0.001) decreased. Mean global QL decreased (p < 0.01) from 82 to 72. A high mean satisfaction score (>70 ± 11/100) was reported, >80 for practical training, activities of daily living, pain, anxiety, recovery and impact on caregivers, with lower scores for appetite (33 ± 24) and sleep (63 ± 30). Supplemental HEN for a minimum of one month postdischarge is associated with high compliance and patient satisfaction. Weight and BMI loss may still be substantial, however this may be less than published literature, in addition the impact on HR-QL may be attenuated. HEN has both subjective and objective rationale and merits further validation toward optimizing nutritional recovery and overall wellbeing.

The feeding route after esophagectomy: a review of literature

Enhanced recovery programs effectively optimize perioperative care and reduce postoperative morbidity. In esophagectomy, several components of the ERAS program are successfully introduced. However, timing and type of postoperative feeding remain a matter of debate. Adequate nutritional support is essential in patients undergoing an esophagectomy. These patients often present with weight loss and their eating pattern is strongly altered by the procedure and reconstruction. Total parenteral nutrition (TPN) is associated with severe septic complications and enteral nutrition (EN) does not increase major complications. Therefore, early EN after esophagectomy is favored over TPN. However, with enteral feeding tubes minor complications occur frequently (13-38%) and in some cases this can hamper recovery. Based on experience in other types of upper gastro-intestinal surgery, early start of oral feeding could improve time to functional recovery after surgery. The total length of stay was significantly shorter in four prospective studies (6-12 vs. 8-13 days). However, large randomized controlled trials are lacking and the potential benefit of early oral feeding after esophageal surgery remains elusive. EN is nowadays the optimal feeding route after esophagectomy. TPN should only be used in specific cases in which EN is contraindicated. Early initiation of oral intake is promising and could improve postoperative recovery. However, further research is needed to substantiate these results.

Diabetes mellitus and risk of anastomotic leakage after esophagectomy: a systematic review and meta-analysis

Diabetes mellitus has the probability to impair the anastomotic healing and cause postesophagectomy anastomotic leakages but previous studies showed controversial results. This review aims to summary the impact of diabetes mellitus on the risk of anastomotic leakage after esophagectomy. We searched the PubMed and EMBASE databases to recognize English articles that met our eligibility criteria. Odds ratio with 95% confidence interval serves as the appropriate summarized statistic. Sensitivity analysis, meta-regression analysis, and publication bias tests were also performed to perceive potential bias risks. Finally, 16 observational studies with 12359 surgical patients were included. An overall analysis identified that diabetes mellitus was significantly associated with the risk of anastomotic leakage after esophagectomy (odds ratio = 1.63; 95% confidence interval = 1.25-2.12; P < 0.001). Further subgroup analysis showed a significant impact of diabetes mellitus in surgical populations from the Europe and America (odds ratio = 1.42; 95% confidence interval = 1.22-1.65; P < 0.001) but not in the Asian populations (odds ratio = 2.27; 95% confidence interval = 0.86-6.05; P = 0.1). The robustness of these estimates was confirmed by meta-regression analysis and sensitivity analysis. No significant publication bias exists between studies. In conclusion, this systematic review demonstrates that diabetes mellitus can be a significant risk factor of anastomotic leakage for patients undergoing esophagectomy. Our findings need to be further confirmed and modified by more well-designed worldwide multivariable analyses in the future.

Immediate Postoperative Oral Nutrition Following Esophagectomy: A Multicenter Clinical Trial

BACKGROUND

Immediate start of oral intake is beneficial following colorectal surgery. However, following esophagectomy the safety and feasibility of immediate oral intake is unclear, thus these patients are still kept nil by mouth. This study therefore aimed to determine the feasibility and safety of oral nutrition immediately after esophagectomy.

METHODS

A multicenter, prospective trial was conducted in 3 referral centers between August 2013 and May 2014, including 50 patients undergoing a minimally invasive esophagectomy. Oral nutrition was started postoperatively immediately (clear liquids on postoperative day [POD] 0, liquid nutrition on POD 1 to 6, solid food from POD 7). Nonoral enteral nutrition was started when <50% of caloric need was met on postoperative day POD 5 or when oral intake was impossible. A comparison was made with a retrospective cohort (n = 50) with a per-protocol delayed start of oral intake until POD 4 to 7.

RESULTS

The median caloric intake at POD 5 was 58% of required. In 38% of the patients nonoral nutrition was started, mainly due to complications (36%). The pneumonia rate was 28% following immediate oral intake and 40% following delayed oral intake (p = 0.202). The aspiration pneumonia rate was 4% in both groups. The anastomotic leakage rate was 14% after immediate oral intake versus 24% following delayed oral intake (p = 0.202). The 90-day mortality rate was 2% in both groups. Hospital stay and intensive care unit stay were significantly shorter following immediate oral intake.

CONCLUSIONS

Immediate start of oral nutrition following esophagectomy seems to be feasible and does not increase complications compared to a retrospective cohort and literature. However, if complications arise an alternative nutritional route is required. This explorative study shows that a randomized controlled trial is needed.

Nutritional route in oesophageal resection trial II (NUTRIENT II): study protocol for a multicentre open-label randomised controlled trial

INTRODUCTION

Early start of an oral diet is safe and beneficial in most types of gastrointestinal surgery and is a crucial part of fast track or enhanced recovery protocols. However, the feasibility and safety of oral intake directly following oesophagectomy remain unclear. The aim of this study is to investigate the effects of early versus delayed start of oral intake on postoperative recovery following oesophagectomy.

METHODS AND ANALYSIS

This is an open-label multicentre randomised controlled trial. Patients undergoing elective minimally invasive or hybrid oesophagectomy for cancer are eligible. Further inclusion criteria are intrathoracic anastomosis, written informed consent and age 18 years or older. Inability for oral intake, inability to place a feeding jejunostomy, inability to provide written consent, swallowing disorder, achalasia, Karnofsky Performance Status <80 and malnutrition are exclusion criteria. Patients will be randomised using online randomisation software. The intervention group (direct oral feeding) will receive a liquid oral diet for 2 weeks with gradually expanding daily maximums. The control group (delayed oral feeding) will receive enteral feeding via a jejunostomy during 5 days and then start the same liquid oral diet. The primary outcome measure is functional recovery. Secondary outcome measures are 30-day surgical complications; nutritional status; need for artificial nutrition; need for additional interventions; health-related quality of life. We aim to recruit 148 patients. Statistical analysis will be performed according to an intention to treat principle. Results are presented as risk ratios with corresponding 95% CIs. A two-tailed p<0.05 is considered statistically significant.

ETHICS AND DISSEMINATION

Our study protocol has received ethical approval from the Medical research Ethics Committees United (MEC-U). This study is conducted according to the principles of Good Clinical Practice. Verbal and written informed consent is required before randomisation. All data will be collected using an online database with adequate security measures.

TRIAL REGISTRATION NUMBERS

NCT02378948 and Dutch trial registry: NTR4972; Pre-results.

Stage-directed individualized therapy in esophageal cancer

Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.

Role of Barium Swallow in Diagnosing Clinically Significant Anastomotic Leak following Esophagectomy

BACKGROUND

Barium swallow is performed following esophagectomy to evaluate the anastomosis for detection of leaks and to assess the emptying of the gastric conduit. The aim of this study was to evaluate the reliability of the barium swallow study in diagnosing anastomotic leaks following esophagectomy.

METHODS

Patients who underwent esophagectomy from January 2000 to December 2013 at our institution were investigated. Barium swallow was routinely done between days 5-7 to detect a leak. These results were compared to clinically determined leaks (defined by neck wound infection requiring jejunal feeds and or parenteral nutrition) during the postoperative period. The sensitivity and specificity of barium swallow in diagnosing clinically significant anastomotic leaks was determined.

RESULTS

A total of 395 esophagectomies were performed (mean age, 62.2 years). The indications for the esophagectomy were as follows: malignancy (n=320), high-grade dysplasia (n=14), perforation (n=27), benign stricture (n=7), achalasia (n=16), and other (n=11). A variety of techniques were used including transhiatal (n=351), McKeown (n=35), and Ivor Lewis (n=9) esophagectomies. Operative mortality was 2.8% (n=11). Three hundred and sixty-eight patients (93%) underwent barium swallow study after esophagectomy. Clinically significant anastomotic leak was identified in 36 patients (9.8%). Barium swallow was able to detect only 13/36 clinically significant leaks. The sensitivity of the swallow in diagnosing a leak was 36% and specificity was 97%. The positive and negative predictive values of barium swallow study in detecting leaks were 59% and 93%, respectively.

CONCLUSION

Barium swallow is an insensitive but specific test for detecting leaks at the cervical anastomotic site after esophagectomy.

Drain amylase aids detection of anastomotic leak after esophagectomy

BACKGROUND

Anastomotic leak following esophagectomy is associated with significant morbidity and mortality. As hospital length of stay decreases, the timely diagnosis of leak becomes more important. We evaluated CT esophagram, white blood count (WBC), and drain amylase levels in the early detection of anastomotic leak.

METHODS

The diagnostic performance of CT esophagram, drain amylase >800 IU/L, and WBC >12,000/µL within the first 10 days after surgery in predicting leak at any time after esophagectomy was calculated.

RESULTS

Anastomotic leak occurred in 13 patients (13%). CT esophagram performed within 10 days of surgery diagnosed six of these leaks with a sensitivity of 0.54. Elevation in drain amylase level within 10 days of surgery diagnosed anastomotic leak with a sensitivity of 0.38. When the CT esophagram and drain amylase were combined, the sensitivity rose to 0.69 with a specificity of 0.98. WBC elevation had a sensitivity of 0.92, with a specificity of 0.34. Among 30 patients with normal drain amylase and a normal WBC, one developed an anastomotic leak.

CONCLUSIONS

Drain amylase adds to the sensitivity of CT esophagram in the early detection of anastomotic leak. Selected patients with normal drain amylase levels and normal WBC may be able to safely forgo CT esophagram.

Anastomotic Leakage Following Esophagectomy

Anastomotic leaks remain a significant clinical challenge following esophagectomy with foregut reconstruction. Despite an increasing understanding of the multiple contributing factors, advancements in perioperative optimization of modifiable risks, and improvements in surgical, endoscopic, and percutaneous management techniques, leaks remain a source of major morbidity associated with esophageal resection. The surgeon should be well versed in the principles underlying the cause of leaks, and strategies to minimize their occurrence. Appropriately diagnosed and managed, most anastomotic leaks following esophagectomy can be brought to a successful resolution.

Routes for early enteral nutrition after esophagectomy. A systematic review

BACKGROUND

Early enteral feeding following surgery can be given orally, via a jejunostomy or via a nasojejunal tube. However, the best feeding route following esophagectomy is unclear.

OBJECTIVES

To determine the best route for enteral nutrition following esophagectomy regarding anastomotic leakage, pneumonia, percentage meeting the nutritional requirements, weight loss, complications of tube feeding, mortality, patient satisfaction and length of hospital stay.

DESIGN

A systematic literature review following PRISMA and MOOSE guidelines.

RESULTS

There were 17 eligible studies on early oral intake, jejunostomy or nasojejunal tube feeding. Only one nonrandomized study (N = 133) investigated early oral feeding specifically following esophagectomy. Early oral feeding was associated with a reduced length of stay with delayed oral feeding, without increased complication rates. Postoperative nasojejunal tube feeding was not significantly different from jejunostomy tube feeding regarding complications or catheter efficacy in the only randomised trial on this subject (N = 150). Jejunostomy tube feeding outcome was reported in 12 non-comparative studies (N = 3293). It was effective in meeting short-term nutritional requirements, but major tube-related complications necessitated relaparotomy in 0-2.9% of patients. In three non-comparative studies (N = 135) on nasojejunal tube feeding only minor complications were reported, data on nutritional outcome was lacking. Data on patient satisfaction and long-term nutritional outcome were not found for any of the feeding routes investigated.

CONCLUSION

It is unclear what the best route for early enteral nutrition is after esophagectomy. Especially data regarding early oral intake are scarce, and phase 2 trials are needed for further investigation.

REGISTRATION

International prospective register of systematic reviews, CRD42013004032.

Study protocol for the nutritional route in oesophageal resection trial: a single-arm feasibility trial (NUTRIENT trial)

INTRODUCTION

The best route of feeding for patients undergoing an oesophagectomy is unclear. Concerns exist that early oral intake would increase the incidence and severity of pneumonia and anastomotic leakage. However, in studies including patients after many other types of gastrointestinal surgery and in animal experiments, early oral intake has been shown to be beneficial and enhance recovery. Therefore, we aim to determine the feasibility of early oral intake after oesophagectomy.

METHODS AND ANALYSIS

This study is a feasibility trial in which 50 consecutive patients will start oral intake directly following oesophagectomy. Primary outcomes will be the frequency and severity of anastomotic leakage and (aspiration) pneumonia. Clinical parameters will be registered prospectively and nutritional requirements and intake will be assessed by a dietician. Surgical complications will be registered.

ETHICS AND DISSEMINATION

Approval for this study has been obtained from the Medical Ethical Committee of the Catharina Hospital Eindhoven and the study has been registered at the Dutch Trial Register, NTR4136. Results will be published and presented at international congresses.

DISCUSSION

We hypothesise that the oral route of feeding is safe and feasible following oesophagectomy, as has been shown previously for other types of gastrointestinal surgery. It is expected that early oral nutrition will result in enhanced recovery. Furthermore, complications related to artificial feeding, such as jejunostomy tube feeding, are believed to be reduced. However, (aspiration) pneumonia and anastomotic leakage are potential risks that are carefully monitored.

TRIAL REGISTRATION NUMBER

NTR4136.