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Conrad H, Elkamel A, Maltagliati A, Wang K, Hsu CH, Linville W, Lada M, Sridhar P, Worrell S. Outcomes of jejunostomy-tube placement in surgical patients with esophageal cancer. JTCVS OPEN 2025; 24:496-509. [PMID: 40309706 PMCID: PMC12039437 DOI: 10.1016/j.xjon.2025.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 12/09/2024] [Accepted: 12/23/2024] [Indexed: 05/02/2025]
Abstract
Objective Patients with esophageal cancer who undergo esophagectomy are at high risk for malnutrition. Jejunostomy tubes are often placed to provide enteral access for nutritional support. Traditionally, jejunostomy placement occurs at the time of esophagectomy. However, benefits have been described in patients with earlier jejunostomy placement. The purpose of this study is to determine outcomes of surgical patients with esophageal cancer on the basis of jejunostomy tube placement as well as to analyze the effect of placement timing on these factors. Methods This is a retrospective, multi-institutional study including 2 academic hospital systems. Patients with esophageal cancer who underwent esophagectomy were included. Patients who received a jejunostomy tube were compared with patients who did not receive a jejunostomy tube. Further analysis comparing early and routine jejunostomy placement timing was then performed. Results Of 327 included patients, 48.32% (158) had a jejunostomy tube and 51.68% (169) did not have any form of enteral access. For every day a patient had a jejunostomy tube in place, there was a reduction in hospital length of stay (LOS) and intensive care unit LOS (P ≤ .001 and < .001). Conclusions Jejunostomy tube placement in patients with esophageal cancer undergoing esophagectomy significantly enhances nutritional outcomes, particularly in malnourished patients, and reduces 90-day mortality and recurrence rates. Patients with esophageal cancer who underwent esophagectomy and received an early jejunostomy tube had shorter hospital and intensive care unit LOS. Early placement of jejunostomy tubes should be considered to optimize nutritional support and improve overall patient resilience before surgery. Further prospective studies are warranted to confirm these findings and refine guidelines for jejunostomy tube placement in patients with esophageal cancer.
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Affiliation(s)
- Hope Conrad
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Ahmed Elkamel
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Anthony Maltagliati
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Kevin Wang
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Chiu-Hsieh Hsu
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Wendy Linville
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester, Rochester, NY
| | - Michal Lada
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester, Rochester, NY
| | - Praveen Sridhar
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Stephanie Worrell
- Division of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
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Pu XS, Bao T, Wang YJ, Li KK, Yang Q, He XD, He Y, Yu J, Xie XF, Chen X, Guo W. Laparoscopic jejunostomy during McKeown minimally invasive esophagectomy: a propensity score analysis. Surg Endosc 2025; 39:1801-1810. [PMID: 39821455 DOI: 10.1007/s00464-024-11519-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2024] [Accepted: 12/30/2024] [Indexed: 01/19/2025]
Abstract
BACKGROUND Nutrition is a key factor limiting the rapid recovery of patients undergoing esophagectomy, but there is as yet no consensus on the optimal route of nutritional support. This study aimed to evaluate the potential benefits of laparoscopic jejunostomy (Lap-J) in comparison to conventional nasoenteral tube (NT) feeding in patients who underwent McKeown minimally invasive esophagectomy (MIE). METHODS A total of 577 consecutive patients with esophageal squamous cell carcinoma (ESCC) who underwent McKeown MIE were included in this single-center retrospective study. They were divided into two groups based on whether or not an intraoperative jejunostomy tube (JT) was placed, and baseline information was made consistent between the 2 groups using propensity score matching (PSM). RESULTS After exclusion and matching, 149 patients were included in each of the 2 groups. Compared with NT, patients who received JT had a shorter postoperative length of stay (11d vs 9d, P = 0.002), lower perioperative albumin loss rate (0.17 vs 0.13, P = 0.023), and lower rates of postoperative pneumonia (23 vs 3, P < 0.001) and pleural effusion (16 vs 5, P = 0.027). There was no significant difference in the occurrence of anastomotic leakage (AL) between the 2 groups. But in the group of patients with AL, the jejunostomy group had a significantly lower rate of perioperative albumin loss (0.20 (0.14-0.26) vs 0.12 (0.08-0.16) P = 0.03) and readmission (8 (40.0) vs. 2 (7.4) P = 0.019). CONCLUSIONS Lap-J during the McKeown MIE has demonstrated good safety and feasibility, and it contributes to the recovery of AL, making its outcome safe and simple. TRIAL REGISTRATION National clinical trials registry: NCT06192212, registered January 4th, 2024.
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Affiliation(s)
- Xiang-Shu Pu
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Tao Bao
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Ying-Jian Wang
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Kun-Kun Li
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Qian Yang
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Xian-Dong He
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Yan He
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Jun Yu
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Xian-Feng Xie
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Xu Chen
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China
| | - Wei Guo
- Department of Thoracic Surgery, Army Medical Center of PLA (Daping Hospital), Army Medical University, Changjiang Route #10, Daping, Chongqing, 400042, People's Republic of China.
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3
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Bongbong DN, Abdou W, Said ET, Gabriel RA. National trends in perioperative epidural analgesia use for surgical patients. J Clin Anesth 2024; 99:111642. [PMID: 39357395 PMCID: PMC11969687 DOI: 10.1016/j.jclinane.2024.111642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 08/18/2024] [Accepted: 09/23/2024] [Indexed: 10/04/2024]
Abstract
STUDY OBJECTIVE Newer regional anesthesia techniques and minimally invasive surgeries have yielded decreased postoperative pain scores, potentially leading to decreased need for perioperative epidural analgesia. Limited literature is available on trends in usage rates of epidurals. The objective of this study was to identify trends in perioperative epidural analgesia rates among multiple fields of surgery. METHODS All patients undergoing general, thoracic, urologic, plastic, vascular, orthopedic, or gynecological surgery in 2014-2020 were included from the National Surgical Quality Improvement Program database of over 700 hospitals in the U.S. and 11 different countries. Annual trends in epidural analgesia for all surgeries and each surgical specialty were assessed by mixed effects multivariable logistic regression. The odds ratios (OR) and 99 % confidence intervals (CI) were reported. RESULTS There were 3,111,435 patients from 2014 to 2020 that were included in the final analysis, in which 107,209 (3.4 %) received perioperative epidural analgesia. Among all surgeries combined, epidural use throughout the study period decreased (OR 0.98 per year, 99 % CI 0.97-0.98, P < 0.001). When only analyzing the surgeries with the top 5 most frequent epidural use per specialty, there was no statistically significant trend in epidural utilization (OR 0.99 per year, 99 % CI 0.99-1.00, P = 0.09). However, there was an increasing trend in epidural utilization in general surgery (OR 1.05 per year, 99 % CI 1.03-1.07, P < 0.001) and vascular surgery (OR 1.08 per year, 99 % CI 1.05-1.10, P < 0.001). CONCLUSION Rates of perioperative epidural analgesia use has decreased in recent years overall, however, among surgeries within the general surgery and vascular surgery specialty, utilization has increased for procedures that have the highest rates of usage.
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Affiliation(s)
- Dale N Bongbong
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Waseem Abdou
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Engy T Said
- Division of Regional Anesthesia, Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA; Division of Perioperative Informatics, Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA; Division of Biomedical Information, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Rodney A Gabriel
- Division of Regional Anesthesia, Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA; Division of Perioperative Informatics, Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA; Division of Biomedical Information, Department of Medicine, University of California, San Diego, La Jolla, CA, USA.
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Fontes F, Fernandes D, Almeida A, Sá I, Dinis-Ribeiro M. Patient-Reported Outcomes after Surgical, Endoscopic, or Radiological Techniques for Nutritional Support in Esophageal Cancer Patients: A Systematic Review. Curr Oncol 2024; 31:6171-6190. [PMID: 39451764 PMCID: PMC11505681 DOI: 10.3390/curroncol31100460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 10/06/2024] [Accepted: 10/10/2024] [Indexed: 10/26/2024] Open
Abstract
Several techniques exist to maintain oral and/or enteral feeding among esophageal cancer (EC) patients, but their impact on patient-reported outcomes (PROs) remains unclear. This systematic review aimed to assess the impact of nutritional support techniques on PROs in EC patients. We searched Medline, Web of Science, and CINAHL Complete from inception to 3 April 2024. Eligible studies included those evaluating EC patients, reporting PROs using standardized measures, and providing data on different nutritional support techniques or comparing them to no intervention. The reference lists of the included studies were also screened for additional eligible articles. The Mixed Methods Appraisal Tool was used to evaluate the quality of the included studies. Of the 694 articles identified from databases and 224 from backward citation, 11 studies met the inclusion criteria. Nine studies evaluated the overall quality of life (QoL), four assessed pain, and one evaluated depression. Among those submitted to esophagectomy, jejunostomy may be associated with higher QoL scores and less postoperative pain, compared to a nasojejunal tube, but no significant differences were found when compared to no intervention. For patients undergoing chemotherapy or receiving palliative/symptomatic treatment, expandable metal stents (SEMSs) were associated with higher levels of emotional functioning when compared with laparoscopic gastrostomy. Moreover, percutaneous endoscopic gastrostomy or SEMSs were associated with a higher QoL compared with nasogastric tubes. This review underscores the importance of considering PRO measures when evaluating nutritional support techniques in cancer patients, though further robust evidence is needed to fully understand these associations.
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Affiliation(s)
- Filipa Fontes
- Precancerous Lesions and Early Cancer Management Group IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Centre (Porto.CCC) & RISE@CI-IPOP (Health Research Network), Rua Doutor António Bernardino de Almeida, 4200-072 Porto, Portugal;
- Public Health and Forensic Sciences, and Medical Education Department, Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
| | - Davide Fernandes
- Department of Imaging Sciences and Radioncology, Portuguese Oncology Institute of Porto, Rua Doutor António Bernardino de Almeida, 4200-072 Porto, Portugal; (D.F.); (A.A.)
| | - Ana Almeida
- Department of Imaging Sciences and Radioncology, Portuguese Oncology Institute of Porto, Rua Doutor António Bernardino de Almeida, 4200-072 Porto, Portugal; (D.F.); (A.A.)
- Oncology Nursing Research Unit IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Centre (Porto.CCC) & RISE@CI-IPOP (Health Research Network), Rua Doutor António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Inês Sá
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Rua Doutor António Bernardino de Almeida, 4200-072 Porto, Portugal;
| | - Mário Dinis-Ribeiro
- Precancerous Lesions and Early Cancer Management Group IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Centre (Porto.CCC) & RISE@CI-IPOP (Health Research Network), Rua Doutor António Bernardino de Almeida, 4200-072 Porto, Portugal;
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Rua Doutor António Bernardino de Almeida, 4200-072 Porto, Portugal;
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Hedberg J, Sundbom M, Edholm D, Aahlin EK, Szabo E, Lindberg F, Johnsen G, Førland DT, Johansson J, Kauppila JH, Svendsen LB, Nilsson M, Lindblad M, Lagergren P, Larsen MH, Åkesson O, Löfdahl P, Mala T, Achiam MP. Randomized controlled trial of nasogastric tube use after esophagectomy: study protocol for the kinetic trial. Dis Esophagus 2024; 37:doae010. [PMID: 38366900 PMCID: PMC11144291 DOI: 10.1093/dote/doae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/11/2024] [Accepted: 01/29/2024] [Indexed: 02/18/2024]
Abstract
Esophagectomy is a complex and complication laden procedure. Despite centralization, variations in perioparative strategies reflect a paucity of evidence regarding optimal routines. The use of nasogastric (NG) tubes post esophagectomy is typically associated with significant discomfort for the patients. We hypothesize that immediate postoperative removal of the NG tube is non-inferior to current routines. All Nordic Upper Gastrointestinal Cancer centers were invited to participate in this open-label pragmatic randomized controlled trial (RCT). Inclusion criteria include resection for locally advanced esophageal cancer with gastric tube reconstruction. A pretrial survey was undertaken and was the foundation for a consensus process resulting in the Kinetic trial, an RCT allocating patients to either no use of a NG tube (intervention) or 5 days of postoperative NG tube use (control) with anastomotic leakage as primary endpoint. Secondary endpoints include pulmonary complications, overall complications, length of stay, health related quality of life. A sample size of 450 patients is planned (Kinetic trial: https://www.isrctn.com/ISRCTN39935085). Thirteen Nordic centers with a combined catchment area of 17 million inhabitants have entered the trial and ethical approval was granted in Sweden, Norway, Finland, and Denmark. All centers routinely use NG tube and all but one center use total or hybrid minimally invasive-surgical approach. Inclusion began in January 2022 and the first annual safety board assessment has deemed the trial safe and recommended continuation. We have launched the first adequately powered multi-center pragmatic controlled randomized clinical trial regarding NG tube use after esophagectomy with gastric conduit reconstruction.
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Affiliation(s)
- Jakob Hedberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - David Edholm
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Eirik Kjus Aahlin
- Department of GI and HPB Surgery, Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | - Eva Szabo
- Department of Surgery, Örebro University, Örebro, Sweden
| | - Fredrik Lindberg
- Department of Surgical and Perioperative Sciences Surgery, Umeå University, Umeå, Sweden
| | - Gjermund Johnsen
- Department of Gastrointestinal Surgery, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dag Tidemann Førland
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Jan Johansson
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Joonas H Kauppila
- Department of Surgery, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Lars Bo Svendsen
- Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Stockholm, Sweden
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholn, Sweden
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Oscar Åkesson
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Per Löfdahl
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tom Mala
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Michael Patrick Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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6
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Davies SJ, Wheelwright S. The impact of jejunostomy feeding on nutritional outcomes after oesophagectomy. J Hum Nutr Diet 2024; 37:126-136. [PMID: 37789732 DOI: 10.1111/jhn.13235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Nutritional status is compromised long-term following oesophagectomy. Controversy surrounds the optimal route for nutrition support postoperatively and there is wide variation in the use of feeding jejunostomy tubes. METHODS A retrospective service evaluation was conducted for all consecutive adults who underwent oesophagectomy for a cancer diagnosis within a specialist centre between April 2016 and July 2019 (n = 165). Nutritional and clinical outcomes were compared for patients who received jejunostomy feeding (n = 24), versus those who did not (n = 141). RESULTS Patients with feeding jejunostomy lost significantly less weight at both 6 and 12 months postoperatively compared to those without jejunostomy (p ≤ 0.001 and p = 0.001, respectively). This remained statistically significant in multiple regression, controlling for age, gender, preoperative tumour staging and adjuvant treatment (p ≤ 0.001 and p = 0.03, respectively). Median length of home enteral feeding was 10 weeks after discharge in the jejunostomy group. We observed minor jejunostomy tube-related complications in four patients (16.7%). Of those readmitted within 90 days of surgery in the non-jejunostomy group, nutritional failure was a factor in 43.2% of these readmissions. "Rescue tube feeding" was required by 8.5% of the non-jejunostomy group within the first postoperative year, including 6.4% within 90 days of surgery. CONCLUSIONS Use of short-term supplementary jejunal feeding in addition to oral intake after hospital discharge is beneficial for maintaining weight after oesophagectomy. We suggest a future randomised-controlled trial to confirm these findings.
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Affiliation(s)
- Sarah J Davies
- School of Health Sciences, Southampton, UK
- Department of Nutrition & Dietetics, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
- Department of Dietitics/SLT, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Sally Wheelwright
- School of Health Sciences, Southampton, UK
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Brighton, UK
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7
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Turner KM, Delman AM, Griffith A, Wima K, Patel SH, Wilson GC, Shah SA, Van Haren RM. Feeding Jejunostomy Tube in Patients Undergoing Esophagectomy: Utilization and Outcomes in a Nationwide Cohort. World J Surg 2023; 47:2800-2808. [PMID: 37704891 DOI: 10.1007/s00268-023-07157-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Feeding jejunostomy (JT) tubes are often utilized as an adjunct to optimize nutrition for successful esophagectomy; however, their utility has come into question. The aim of this study was to evaluate utilization and outcomes associated with JTs in a nationwide cohort of patients undergoing esophagectomy. METHODS The NSQIP database was queried for patients who underwent elective esophagectomy. JT utilization was assessed between 2010 and 2019. Post-operative outcomes were compared between those with and without a JT on patients with esophagectomy-specific outcomes (2016-2019), with results validated using a propensity score-matched (PSM) analysis based on key clinicopathologic factors, including tumor stage. RESULTS Of the 10,117 patients who underwent elective esophagectomy over the past decade, 53.0% had a JT placed concurrently and 47.0% did not. Utilization of JTs decreased over time, accounting for 60.0% of cases in 2010 compared to 41.7% in 2019 (m = - 2.14 95%CI: [- 1.49]-[- 2.80], p < 0.01). Patients who underwent JT had more composite wound complications (17.0% vs. 14.1%, p = 0.02) and a higher rate of all-cause morbidity (40.4% vs. 35.5%, p = 0.01). Following PSM, 1007 pairs were identified. Analysis of perioperative outcomes demonstrated a higher rate of superficial skin infections (6.1% vs. 3.5%, p = 0.01) in the JT group. However, length of stay, reoperation, readmission, anastomotic leak, composite wound complications, all-cause morbidity, and mortality rates were similar between groups. CONCLUSIONS Among patients undergoing elective esophagectomy, feeding jejunostomy tubes were utilized less frequently over the past decade. Similar perioperative outcomes among matched patients support the safety of esophagectomy without an adjunct feeding jejunostomy tube.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Azante Griffith
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert M Van Haren
- Department of Surgery, Division of Thoracic Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0558, USA.
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8
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Czerwonko ME, Farjah F, Oelschlager BK. Reducing Conduit Ischemia and Anastomotic Leaks in Transhiatal Esophagectomy: Six Principles. J Gastrointest Surg 2023; 27:2316-2324. [PMID: 37752385 DOI: 10.1007/s11605-023-05835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/14/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Transhiatal esophagectomy (THE) is an accepted approach for distal esophageal (DE) and gastroesophageal junction (GEJ) cancers. Its reported weaknesses are limited loco-regional resection and high anastomotic leak rates. We have used laparoscopic assistance to perform a THE (LapTHE) as our preferred method of resection for GEJ and DE cancers for over 20 years. Our unique approach and experience may provide technical insights and perhaps superior outcomes. METHODS We reviewed all patients who underwent LapTHE for DE and GEJ malignancy over 10 years (2011-2020). We included 6 principles in our approach: (1) minimize dissection trauma using laparoscopy; (2) routine Kocher maneuver; (3) division of lesser sac adhesions exposing the entire gastroepiploic arcade; (4) gaining excess conduit mobility, allowing resection of proximal stomach, and performing the anastomosis with a well perfused stomach; (5) stapled side-to-side anastomosis; and (6) routine feeding jejunostomy and early oral diet. RESULTS One hundred and forty-seven patients were included in the analysis. The median number of lymph nodes procured was 19 (range 5-49). Negative margins were achieved in all cases (95% confidence interval [CI] 98-100%). Median hospital stay was 7 days. Overall major complication rate was 24% (17-32%), 90-day mortality was 2.0% (0.4-5.8%), and reoperation was 5.4% (2.4-10%). Three patients (2.0%, 0.4-5.8%) developed anastomotic leaks. Median follow-up was 901 days (range 52-5240). Nine patients (6.1%, 2.8-11%) developed anastomotic strictures. CONCLUSIONS Routine use of LapTHE for DE and GEJ cancers and inclusion of these six operative principles allow for a low rate of anastomotic complications relative to national benchmarks.
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Affiliation(s)
- Matias E Czerwonko
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, WA, USA.
| | - Farhood Farjah
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Brant K Oelschlager
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, WA, USA
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9
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Lee Y, Lu JY, Malhan R, Shargall Y, Finley C, Hanna W, Agzarian J. Effect of Routine Jejunostomy Tube Insertion in Esophagectomy: A Systematic Review and Meta-Analysis. J Thorac Cardiovasc Surg 2022; 164:422-432.e17. [DOI: 10.1016/j.jtcvs.2021.12.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 12/17/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
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10
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Mei LX, Wang YY, Tan X, Chen Y, Dai L, Chen MW. Is it necessary to routinely perform feeding jejunostomy at the time of esophagectomy? A systematic review and meta-analysis. Dis Esophagus 2021; 34:doab017. [PMID: 33884417 DOI: 10.1093/dote/doab017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/25/2021] [Accepted: 01/30/2021] [Indexed: 12/11/2022]
Abstract
Feeding jejunostomy (FJ) is a routine procedure at the time of esophagectomy in some centers. With the widespread popularization of enhanced recovery after surgery, the necessity of FJ has been increasingly questioned. This study aims to analyze the differences in safety and effectiveness between with (FJ group) or without (no-FJ group) performing FJ at the time of esophagectomy. PubMed, Embase, Web of Science, and Cochrane Library were comprehensively searched for relevant studies, including randomized controlled trials and cohort studies. The primary outcome was the length of hospital stay (LOS). Secondary outcomes were overall postoperative complications, postoperative pneumonia, intestinal obstruction, and weight loss at 3 and 6 months after esophagectomy. Weighted mean differences (WMD) and odds ratios (OR) were calculated for statistical analysis. About 12 studies comprising 2,173 patients were included. The FJ group had a longer LOS (WMD = 2.05, P = 0.01) and a higher incidence of intestinal obstruction (OR = 11.67, P < 0.001) than the no-FJ group. The incidence of overall postoperative complications (OR = 1.24, P = 0.31) and postoperative pneumonia (OR = 1.43, P = 0.13) were not significantly different, nor the weight loss at 3 months (WMD = 0.58, P = 0.24) and 6 months (P > 0.05) after esophagectomy. Current evidence suggests that routinely performing FJ at the time of esophagectomy appears not to generate better postoperative outcomes. FJ may need to be performed selectively rather than routinely. More studies are required to further verify.
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Affiliation(s)
- Li-Xiang Mei
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong-Yong Wang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiang Tan
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lei Dai
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ming-Wu Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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11
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De Luis Román D, Domínguez Medina E, Molina Baena B, Matía-Martín P. Oligomeric Formulas in Surgery: A Delphi and Consensus Study. Nutrients 2021; 13:nu13061922. [PMID: 34205024 PMCID: PMC8227417 DOI: 10.3390/nu13061922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/28/2021] [Accepted: 05/29/2021] [Indexed: 01/04/2023] Open
Abstract
Nutritional management of patients with intestinal failure often includes the use of oligomeric formulas. Implementing the use of oligomeric formulas in surgical patients with maldigestion or malabsorption could be a nutritional strategy to be included in clinical protocols. We aim to generate knowledge from a survey focused on the effectiveness of nutritional therapy with oligomeric formulas with Delphi methodology. Each statement that reached an agreement consensus among participants was defined as a median consensus score ≥7 and as an interquartile range ≤3. The use of oligomeric formulas in surgical patients, starting enteral nutrition in the post-operative phase in short bowel syndrome and in nonspecific diarrhea after surgical procedures, could improve nutritional therapy implementation. Stakeholders agreed that early jejunal enteral nutrition with oligomeric formula is more effective compared to intravenous fluid therapy and it is useful in patients undergoing upper gastro-intestinal tract major surgery when malabsorption or maldigestion is suspected. Finally, oligomeric formulas may be useful when a feeding tube is placed distally to the duodenum. This study shows a practical approach to the use of oligomeric formulas in surgical patients with intestinal disorders and malabsorption, and it helps clinicians in the decision-making process.
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Affiliation(s)
- Daniel De Luis Román
- Center of Investigation Endocrinology and Nutrition, Hospital Clínico Universitario de Valladolid, Medicine School University, 47002 Valladolid, Spain;
| | - Eduardo Domínguez Medina
- Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), 15782 Santiago de Compostela, Spain;
| | | | - Pilar Matía-Martín
- Endocrinology and Nutrition Unit, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
- Correspondence: ; Tel.: +34-639851411
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12
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Zhuang W, Wu H, Liu H, Huang S, Wu Y, Deng C, Tian D, Zhou Z, Shi R, Chen G, Piessen G, Khaitan PG, Koyanagi K, Ozawa S, Qiao G. Utility of feeding jejunostomy in patients with esophageal cancer undergoing esophagectomy with a high risk of anastomotic leakage. J Gastrointest Oncol 2021; 12:433-445. [PMID: 34012637 PMCID: PMC8107594 DOI: 10.21037/jgo-21-133] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/09/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Feeding jejunostomy is widely used for enteral nutrition (EN) after esophagectomy; however, its risks and benefits are still controversial. We aimed to evaluate the short-term and long-term outcomes of feeding jejunal tube (FJT) in patients undergoing esophagectomy for esophageal squamous cell carcinoma (ESCC) who were deemed high-risk for anastomotic leakage. METHODS We retrospectively analyzed 716 patients who underwent esophagectomy with (FJT group, n=68) or without (control group, n=648) intraoperative placement of FJT. Propensity score matching (PSM) was used for the adjustment of confounding factors. Risk level for anastomotic leakage was determined for every patient after PSM. RESULTS Patients in the FJT group were at higher risk of anastomotic leakage (14.9% vs. 11.3%), and had a statistically non-significant increase of postoperative complications [31.3% vs. 21.8%, odds ratio (OR) =1.139, 95% confidence interval (CI), 0.947-1.370, P=0.141] after PSM. Medical expenditure, length of postoperative hospital stay, and short-term mortality were similar between the FJT and control groups. Placement of FJT appeared to accelerate the recovery of anastomotic leakage (27.2 vs. 37.4 d, P=0.073). Patients in FJT group achieved comparable overall survival (OS) both before [hazard ratio (HR) =0.850, P=0.390] and after (HR =0.797, P=0.292) PSM. CONCLUSIONS FJT showed acceptable safety profile along with potential benefits for ESCC patients with a high presumed risk of anastomotic leakage. While FJT does not impact OS, placement of FJT should be considered in esophagectomy patients and tailored to individual patients based on their leak-risk profile.
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Affiliation(s)
- Weitao Zhuang
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Hansheng Wu
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Huiling Liu
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shujie Huang
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Yinghong Wu
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Cheng Deng
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Dan Tian
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zihao Zhou
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruiqing Shi
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Gang Chen
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guillaume Piessen
- University of Lille, Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Puja G. Khaitan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Guibin Qiao
- Department of Thoracic Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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13
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Mann D, Benbow JH, Gower NL, Trufan S, Watson M, Colcord ME, Squires MH, Raj VS, Hill JS, Salo JC. Swallowing dysfunction after minimally invasive oesophagectomy. BMJ Support Palliat Care 2020; 12:235-242. [PMID: 33093039 DOI: 10.1136/bmjspcare-2020-002626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/25/2020] [Accepted: 08/28/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Patients undergoing oesophagectomy frequently experience malnutrition, which in combination with the catabolic effects of surgery can result in loss of muscle mass and function. Safe swallowing requires preservation of muscle mass. Swallowing dysfunction puts postoperative patients at risk for aspiration and pneumonia. Modified Barium Swallow Study (MBSS) enables assessment of postoperative swallowing impairments. The current study assessed incidence and risk factors associated with swallowing dysfunction and restricted diet at discharge in patients after oesophagectomy in a high-volume surgical centre. METHODS Patients with an MBSS after oesophagectomy were identified between March 2015 to April 2020 at a high-volume surgical centre. Swallowing was quantitatively evaluated on MBSS with the Rosenbek Penetration-Aspiration Scale (PAS). Muscle loss was evaluated clinically with preoperative hand grip strength (HGS). Univariable and multivariable logistic and linear regression analyses were performed. RESULTS 129 patients (87% male; median age 66 years) underwent oesophagectomy with postoperative MBSS. Univariate analysis revealed older age, preoperative feeding tube, lower preoperative HGS and discharge to non-home were associated with aspiration or penetration on MBSS. Age and preoperative feeding tube remained as independent predictors in the multivariable analysis. Both univariate and multivariable analyses revealed increased age and preoperative feeding tube were associated with diet restrictions at discharge. CONCLUSIONS Swallowing dysfunction after oesophagectomy is correlated with increased age and need for preoperative enteral feeding tube placement. Further research is needed to understand the relationship between muscle loss and aspiration with the goal of enabling preoperative physiological optimisation and patient selection.
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Affiliation(s)
- Della Mann
- Department of Supportive Oncology, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Jennifer H Benbow
- LCI Research Support, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Nicole L Gower
- LCI Research Support, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Sally Trufan
- Department of Biostatistics, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Michael Watson
- Department of Surgery, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Madison E Colcord
- LCI Research Support, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Malcolm H Squires
- Department of Surgery, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Vishwa S Raj
- Department of Physical Medicine & Rehabilitation, Levine Cancer Institute, Charlotte, North Carolina, USA.,Department of Supportive Care, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Joshua S Hill
- Department of Surgery, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Jonathan C Salo
- Department of Surgery, Levine Cancer Institute, Charlotte, North Carolina, USA
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