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Enteral feeding in esophageal surgery
Nutrition
Vol. 12, No. 3, 1996
Enteral Feeding in Esophageal Surgery C. DALE MERCER, From the Department
FRCSC,
FACS, AND ANIL MUNGARA
of Surgery, Queen’s University, Hotel Dieu Hospital, Kingston, Ontario, Canada Date accepted:
12 May 1995
ABSTRACT
Malnutrition is frequently associated with esophageal cancer. To maintain and improve nutrition during the stress of esophagectomy early postoperative enteral feeding was used in surgical patients. Minor complications such as jejunal tube dislodgment, metabolic derangements, and feeding-related gastrointestinal complications occurred, all of which were easily corrected. Nutritional status was maintained or improved in most patients and the actual cost compared to a calculated cost .of an equinitrogenous, equicaloric parenteral solution was much less. Nutrition 1996; 12:200-201
INTRODUCTION
Esophageal cancer patients are usually malnourished either because of obstruction of the esophagus or systemic effects of the cancer with profound anorexia. Those patients requiring esophagectomy undergo a major catabolic stress and often preoperative mahnmition cannot he reversed. Therefore, it is vital that adequate nutrition be provided as soon after surgery as possible to allow the patient enough time to begin to improve their nutritional status and to avoid wound- and sepsis-related complications. Enteral feeding in the early postoperative period provides a convenient cost-effective way of supplying calories in these patients.’ Actual costs are compared to calculated costs of an equipotent parenteral feeding in this paper.
40% lipid calories was obtained for each patient. A review of the charts for complications related to the enteral feeding was carried out and these complications were divided into gastrointestinal complications related to the type of feeding, tube-related complications, and metabolic complications. Weight and height measutements, body mass index calculations, and serum albumin measurements
cost
Enteral vs Parenteral Feeding
METHODS Thirty-two patients undergoing palliative or curative esophagec-
tomy for esophageal cancer between 1987 and 1993 were studied to determine the cost and efficacy of jejunal feeding started in the early postoperative period. The surgical procedure consisted of a thoracoabdominal esophagogasttectomy in 27 patients and a total esophagectomy in 5 patients. A red rubber catheter for enteml feeding was placed just distal to the ligament of Treitz in all patients aird enteral feeding was started after radiologic confirmation of tube position within 24 h of surgery in all patients. Different commercial enteral feeds were used during this period of time and the cost per mL of each type was calculated. The. total feeding volume and actual cost of enteml feed for each patient was determined. No patients in this group required patenteral feeding postoperatively. A calculated cost of an equinitrogenous, equicaloric parenteral solution utilizing a standard amino acid solution with 60% glucose calories,
PIG. 1. The actual mean cost of enteral feeding versus the calculated mean cost of isocaloric parenteral feeding.
Correspondence to: Dr. C. Dale Mercer, Department of Surgery, Queen’s University, Hotel Dieu Hospital, Kingston, Ontario K7L 5G2 Canada. This manuscript was originally presented as part of “The Skeleton in the Hospital Closet: 20 Years Later” Malnutrition Conference, October I2, 1994, Los Angeles, California.
Nutrition 12:200-201, 1996 OElsevier Science Inc. 1996 Printed in the USA. All rights reserved.
ELSEVIER
0899-9007/96/$15.06 PII: SO899-9007(96)00038-X
ENTERAL
FEEDING
IN ESOPHAGEAL
SURGERY
201
Serum Al bumin
Body Mass Index 30
25 -
10 -
5-
Preoperative
-
Preoperative
Postoperative
Esophageal
FIG. 2. The mean serum albumin of enteral feeding.
Surgery
level preoperatively
Postoperative
_
vs on completion
were recorded preoperatively and postoperatively at the completion of enteral feeding. RESULTS There
were 20 males and 12 females ranging in age from 42 to 76 yr. Five patients had Stage I, 25 had Stage II, and 2 had Stage III disease. All patients survived and were discharged between 11 and 173 d (mean 34 d) postoperatively eating 6 small solid meals daily. Two patients (6%) had esophagogastric anastomotic leaks treated nonoperatively requiring 133 and 173 d in hospital postoperatively. All other patients except one with a postoperative myocardial infarction were discharged within 3 wk of surgery. Enteral feeding was continued for a mean 24 d (range 9-172 d) , but in those patients without anastomotic leaks, the mean duration was 10 d (range 9-18 d). The mean cost of enteral feeding was $188.71 per patient (range $19.67-$1,926&t) (Fig. l), but in those patients without anastomotic leaks, the mean cost was $50.90 (range $19.67-$130.96). Equicaloric, equinitrogenous parenteral solutions would have required consumption of 49,802 kcal. If this quantity of parenteral solution was provided as a mixture of amino acids and 20% dextrose compromising 60% of the calories at $30.00 per bag and Intralipid comprising 40% of the calories at $4.95 per bottle, the mean cost of parenteral feeding would have been $1,499.39 (Fig. 1). In thosepatients without anastomotic leaks the calculated mean cost of parenteral feeding would be $994.00. Gastrointestinal complications occurred in 7 patients which include aspiration-2, nausea- 1, abdominal distension-4, diarrhea-4, and ileus- 1. These complications resolved by changing the feeding solution or adjusting the rate and quantity of solution. The patient with the prolonged ileus required cessation of the enteral feeding for 4 d prior to restarting the feeding. Mechanical tube-related complications occurred in 4 patients which include tube obstruction-l, tube leakage-l, and tube dislodgement-2. Each problem was corrected with simple bedside replacement of the tube with subsequent radiologic confirma-
Esophageal
Surgery
FIG. 3. The body mass index preoperatively feeding and at discharge.
vs on completion
of enteral
tion of its position. Metabolic complications occurred in 3 patients which include hyperkalemia- 1, hyponatremia- 1, and hyperglycemia- 1. Each problem was corrected easily by changing the solution or adding sodium chloride to the tube feeding, or drug therapy for hyperkalemia. Enteral feeding in all patients except the patient with the prolonged ileus was maintained uninterrupted postoperatively. The mean preoperative serum albumin level was 26 g/L, range 21-33 g/L, while the mean postoperative level at completion of enteral feeding was 27 g/L, range 23-34 g/L, p = NS (Fig. 2). Twenty-six patients maintained or increased their serum albumin during the period of enteral feeding. The mean height was 164.3 cm and the mean weight was 71.2 kg, pmoperatively. Postoperatively at the completion of the enteral feeding the mean weight was 70.3 kg. Body mass index calculated as weight/height* was 26 preoperatively and 27 postoperatively on completion of enteral feeding and again at the time of discharge (Fig. 3). DISCUSSION
Many studies have proven the effectiveness of early postoperative enteral feeding in maintaining and improving nutritional statu~.‘*~~~ Some studies now claim reduction in postoperative septic complications, maintenance of immunocompetence, and improvement of wound healing with enteral feeding compared to parenteral feeding.4 Our study conlirms that early postoperative enteral feeding is possible with only minor complications? We have also shown that in this select population of esophageal cancer patients in whom malnutrition may be prevalent, this type of feeding can prevent further deterioration during the major catabolic stress of a thoracoabdominal esophagectomy. Costs to the health care system are minimized and patient management is simplified. We have not attempted to demonstrate any reduction in septic complications or immune modulation with tbis retrospective review.
REFERENCES 1. Bower RH, Talamini MA, Sax HC, et al. Postoperative enteral versus parenteral nutrition. Arch Surg 1986; 121:1040 2. Peterson VM, Moore EE, Jones TN, et al. Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein reprioritization. Surgery 1988; 194:199 3. McArdle AH, Palmason C, Morency I, et al. A rationale for enteral feeding as the preferable route for hyperalimentation. Surgery
1981;90:616 4. Moore FA, Feliciano’DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. Ann Surg 1992;216:172 symptoms 5. Jones TN, Moore EE, McCroskey BL. Gastrointestinal attributed to jejunostomy feeding after major abdominal trauma: a critical analysis. Crit Care Med 1989; 17:1146
Vol. 12, No. 3, 1996
Enteral Feeding in Esophageal Surgery C. DALE MERCER, From the Department
FRCSC,
FACS, AND ANIL MUNGARA
of Surgery, Queen’s University, Hotel Dieu Hospital, Kingston, Ontario, Canada Date accepted:
12 May 1995
ABSTRACT
Malnutrition is frequently associated with esophageal cancer. To maintain and improve nutrition during the stress of esophagectomy early postoperative enteral feeding was used in surgical patients. Minor complications such as jejunal tube dislodgment, metabolic derangements, and feeding-related gastrointestinal complications occurred, all of which were easily corrected. Nutritional status was maintained or improved in most patients and the actual cost compared to a calculated cost .of an equinitrogenous, equicaloric parenteral solution was much less. Nutrition 1996; 12:200-201
INTRODUCTION
Esophageal cancer patients are usually malnourished either because of obstruction of the esophagus or systemic effects of the cancer with profound anorexia. Those patients requiring esophagectomy undergo a major catabolic stress and often preoperative mahnmition cannot he reversed. Therefore, it is vital that adequate nutrition be provided as soon after surgery as possible to allow the patient enough time to begin to improve their nutritional status and to avoid wound- and sepsis-related complications. Enteral feeding in the early postoperative period provides a convenient cost-effective way of supplying calories in these patients.’ Actual costs are compared to calculated costs of an equipotent parenteral feeding in this paper.
40% lipid calories was obtained for each patient. A review of the charts for complications related to the enteral feeding was carried out and these complications were divided into gastrointestinal complications related to the type of feeding, tube-related complications, and metabolic complications. Weight and height measutements, body mass index calculations, and serum albumin measurements
cost
Enteral vs Parenteral Feeding
METHODS Thirty-two patients undergoing palliative or curative esophagec-
tomy for esophageal cancer between 1987 and 1993 were studied to determine the cost and efficacy of jejunal feeding started in the early postoperative period. The surgical procedure consisted of a thoracoabdominal esophagogasttectomy in 27 patients and a total esophagectomy in 5 patients. A red rubber catheter for enteml feeding was placed just distal to the ligament of Treitz in all patients aird enteral feeding was started after radiologic confirmation of tube position within 24 h of surgery in all patients. Different commercial enteral feeds were used during this period of time and the cost per mL of each type was calculated. The. total feeding volume and actual cost of enteml feed for each patient was determined. No patients in this group required patenteral feeding postoperatively. A calculated cost of an equinitrogenous, equicaloric parenteral solution utilizing a standard amino acid solution with 60% glucose calories,
PIG. 1. The actual mean cost of enteral feeding versus the calculated mean cost of isocaloric parenteral feeding.
Correspondence to: Dr. C. Dale Mercer, Department of Surgery, Queen’s University, Hotel Dieu Hospital, Kingston, Ontario K7L 5G2 Canada. This manuscript was originally presented as part of “The Skeleton in the Hospital Closet: 20 Years Later” Malnutrition Conference, October I2, 1994, Los Angeles, California.
Nutrition 12:200-201, 1996 OElsevier Science Inc. 1996 Printed in the USA. All rights reserved.
ELSEVIER
0899-9007/96/$15.06 PII: SO899-9007(96)00038-X
ENTERAL
FEEDING
IN ESOPHAGEAL
SURGERY
201
Serum Al bumin
Body Mass Index 30
25 -
10 -
5-
Preoperative
-
Preoperative
Postoperative
Esophageal
FIG. 2. The mean serum albumin of enteral feeding.
Surgery
level preoperatively
Postoperative
_
vs on completion
were recorded preoperatively and postoperatively at the completion of enteral feeding. RESULTS There
were 20 males and 12 females ranging in age from 42 to 76 yr. Five patients had Stage I, 25 had Stage II, and 2 had Stage III disease. All patients survived and were discharged between 11 and 173 d (mean 34 d) postoperatively eating 6 small solid meals daily. Two patients (6%) had esophagogastric anastomotic leaks treated nonoperatively requiring 133 and 173 d in hospital postoperatively. All other patients except one with a postoperative myocardial infarction were discharged within 3 wk of surgery. Enteral feeding was continued for a mean 24 d (range 9-172 d) , but in those patients without anastomotic leaks, the mean duration was 10 d (range 9-18 d). The mean cost of enteral feeding was $188.71 per patient (range $19.67-$1,926&t) (Fig. l), but in those patients without anastomotic leaks, the mean cost was $50.90 (range $19.67-$130.96). Equicaloric, equinitrogenous parenteral solutions would have required consumption of 49,802 kcal. If this quantity of parenteral solution was provided as a mixture of amino acids and 20% dextrose compromising 60% of the calories at $30.00 per bag and Intralipid comprising 40% of the calories at $4.95 per bottle, the mean cost of parenteral feeding would have been $1,499.39 (Fig. 1). In thosepatients without anastomotic leaks the calculated mean cost of parenteral feeding would be $994.00. Gastrointestinal complications occurred in 7 patients which include aspiration-2, nausea- 1, abdominal distension-4, diarrhea-4, and ileus- 1. These complications resolved by changing the feeding solution or adjusting the rate and quantity of solution. The patient with the prolonged ileus required cessation of the enteral feeding for 4 d prior to restarting the feeding. Mechanical tube-related complications occurred in 4 patients which include tube obstruction-l, tube leakage-l, and tube dislodgement-2. Each problem was corrected with simple bedside replacement of the tube with subsequent radiologic confirma-
Esophageal
Surgery
FIG. 3. The body mass index preoperatively feeding and at discharge.
vs on completion
of enteral
tion of its position. Metabolic complications occurred in 3 patients which include hyperkalemia- 1, hyponatremia- 1, and hyperglycemia- 1. Each problem was corrected easily by changing the solution or adding sodium chloride to the tube feeding, or drug therapy for hyperkalemia. Enteral feeding in all patients except the patient with the prolonged ileus was maintained uninterrupted postoperatively. The mean preoperative serum albumin level was 26 g/L, range 21-33 g/L, while the mean postoperative level at completion of enteral feeding was 27 g/L, range 23-34 g/L, p = NS (Fig. 2). Twenty-six patients maintained or increased their serum albumin during the period of enteral feeding. The mean height was 164.3 cm and the mean weight was 71.2 kg, pmoperatively. Postoperatively at the completion of the enteral feeding the mean weight was 70.3 kg. Body mass index calculated as weight/height* was 26 preoperatively and 27 postoperatively on completion of enteral feeding and again at the time of discharge (Fig. 3). DISCUSSION
Many studies have proven the effectiveness of early postoperative enteral feeding in maintaining and improving nutritional statu~.‘*~~~ Some studies now claim reduction in postoperative septic complications, maintenance of immunocompetence, and improvement of wound healing with enteral feeding compared to parenteral feeding.4 Our study conlirms that early postoperative enteral feeding is possible with only minor complications? We have also shown that in this select population of esophageal cancer patients in whom malnutrition may be prevalent, this type of feeding can prevent further deterioration during the major catabolic stress of a thoracoabdominal esophagectomy. Costs to the health care system are minimized and patient management is simplified. We have not attempted to demonstrate any reduction in septic complications or immune modulation with tbis retrospective review.
REFERENCES 1. Bower RH, Talamini MA, Sax HC, et al. Postoperative enteral versus parenteral nutrition. Arch Surg 1986; 121:1040 2. Peterson VM, Moore EE, Jones TN, et al. Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein reprioritization. Surgery 1988; 194:199 3. McArdle AH, Palmason C, Morency I, et al. A rationale for enteral feeding as the preferable route for hyperalimentation. Surgery
1981;90:616 4. Moore FA, Feliciano’DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. Ann Surg 1992;216:172 symptoms 5. Jones TN, Moore EE, McCroskey BL. Gastrointestinal attributed to jejunostomy feeding after major abdominal trauma: a critical analysis. Crit Care Med 1989; 17:1146