The role of early oral feeding in improving surgical recovery after esophagectomy

Abstract

The feeding route after an esophagectomy was systematically reviewed in Chapter 2. The majority of patients were scheduled for a nil-by-mouth period for 1 week after surgery and received enteral feeding through a jejunostomy or nasojejunal tube. Minor jejunostomy related complications occurred frequently. Major complications were rarely described to be related to the jejunostomy use. The use of nasojejunal tubes showed no reported major complications. However, this route was described to dislocate frequently. Nasogastric decompression and nil-by-mouth regimes are thought to decrease the incidence of these complications. In Chapter 3 a systematic review with meta-analysis was presented studying nasogastric decompression specifically for patients after an esophagectomy. No difference in the incidence of anastomotic leakage, pneumonia, or mortality was observed for patients after esophageal surgery. Patients without nasogastric decompression even had a shorter length of stay. Based on these results, routine nasogastric decompression is not advised to be standard for patients after an esophagectomy. In Chapter 4 a narrative review was presented, documenting all feeding protocols known for patients after an esophagectomy. In Chapter 5, the adherence to postoperative enteral tube feeding protocol in 186 patients receiving esophagectomy was described in a retrospective study. More than half of these patients deviated from the feeding protocol. Main reason for deviation was a postoperative complication that dictated changes in feeding regime, such as anastomotic leakage or chyle leakage. No preoperative risk factors were observed that interfered with the postoperative feeding protocol, concluding that postoperative complications dictate the feeding protocol and not the other way around. The next study addresses the feasibility and safety of direct start of oral intake of patients receiving a minimal invasive esophagectomy (Chapter 6). Patients that received oral feeding directly after surgery had a complication rate comparable to patients receiving enteral tube feeding, showing that direct oral intake following esophagectomy is feasible and safe. In Chapter 7, long-term weight loss following esophagectomy was investigated in a retrospective cohort study. Patients receiving direct oral feeding lost more weight in the first month after surgery compared to patients with enteral tube feeding. In the next 2 months, patients in the enteral tube feeding group lost more weight than patient with an initial oral feeding schedule. In the last chapter a randomized controlled trial was presented Patients were randomly allocated to a “direct oral feeding group” or the “standard of care group”. In the standard of care group patients received five days enteral tube feeding via a surgically placed jejunostomy tube. Functional recovery was reached after a median of 7 days in the direct oral feeding group and after a median of 8 days in the control group. This reduction in time to functional recovery was not significant. Furthermore, the incidence and severity of postoperative complications did not differ between both groups. Importantly, early oral feeding did not result in more anastomotic leakage or (aspiration) pneumonia. The lower caloric intake by patients did not result in more weight loss in the first 3 months after surgery.