Long Term Use of Feeding Jejunostomy Following Oesophagectomy FMS Macharg, Y Soon, S Singh and SR Preston Regional Oesophago-Gastric Unit Royal Surrey County Hospital & St Luke’s Cancer Centre

Current problems Oesophagectomy significantly impacts on a patients’ ability to recover adequate dietary intake in the early post-op stages Oesophagectomy significantly impacts on a patients’ ability to recover adequate dietary intake in the early post-op stages Issues with re-establishing oral intake include: Issues with re-establishing oral intake include: Partial or complete loss of appetite Partial or complete loss of appetite Post-prandial pain Post-prandial pain Nausea and vomiting Nausea and vomiting Reflux Reflux Dysphagia – anastomotic strictures Dysphagia – anastomotic strictures Adjuvant chemotherapy Adjuvant chemotherapy Dumping syndrome Dumping syndrome Practice varies widely across the country, however, enteral feeding tubes are often removed on discharge or at first clinic review Practice varies widely across the country, however, enteral feeding tubes are often removed on discharge or at first clinic review

Use of feeding jejunostomy Current unit policy Current unit policy 9Fr Freka feeding jejunostomy placed at time of surgery if not already placed at staging laparoscopy 9Fr Freka feeding jejunostomy placed at time of surgery if not already placed at staging laparoscopy Enteral nutrition commenced on POD0 with sterile water and standard 1.0kcal/ml feed on POD1 Enteral nutrition commenced on POD0 with sterile water and standard 1.0kcal/ml feed on POD1 Feed commenced onto standard progression protocol and discontinued on discharge if oral intake tolerated Feed commenced onto standard progression protocol and discontinued on discharge if oral intake tolerated Feeding tubes should remain in situ on discharge until weight stabilises Feeding tubes should remain in situ on discharge until weight stabilises

Aim & Methods To retrospectively review our post-operative patients and identify how many required prolonged supplementary nutrition support To retrospectively review our post-operative patients and identify how many required prolonged supplementary nutrition support Retrospective dietetic notes review Retrospective dietetic notes review Inclusion criteria: Inclusion criteria: Surgical procedure – oesophagectomy (open, lap- assisted and MIO) Surgical procedure – oesophagectomy (open, lap- assisted and MIO) Date of surgery – January 2009 and December 2010 Date of surgery – January 2009 and December 2010

Results 86 oesophagectomies were carried out on the unit during the study period (68 men and 18 women, median age 64) 86 oesophagectomies were carried out on the unit during the study period (68 men and 18 women, median age 64) All had intensive support from a specialist dietitian throughout their treatment pathway All had intensive support from a specialist dietitian throughout their treatment pathway 76 (88%) had a jejunostomy in situ for their post-op care 76 (88%) had a jejunostomy in situ for their post-op care 13 (15%) patients had the tube placed at their staging laparoscopy 13 (15%) patients had the tube placed at their staging laparoscopy All patients were commenced on the standard post-operative nutrition protocol All patients were commenced on the standard post-operative nutrition protocol 10 (12%) patients did not have an enteral feeding tube placed 10 (12%) patients did not have an enteral feeding tube placed Either due to surgeons choice or anatomical difficulties Either due to surgeons choice or anatomical difficulties Managed with parenteral nutrition until oral intake was re-introduced Managed with parenteral nutrition until oral intake was re-introduced

Results 94% of patients (68) who had a feeding tube sited still had the tube in situ on discharge 94% of patients (68) who had a feeding tube sited still had the tube in situ on discharge 1 pulled out by confused patient, 1 accidently removed on ITU, 1 removed without a reason and 1 removed due to a leak at the jej site 1 pulled out by confused patient, 1 accidently removed on ITU, 1 removed without a reason and 1 removed due to a leak at the jej site 7 patients excluded due to follow-up at a different Trust 7 patients excluded due to follow-up at a different Trust Of the 61 patients remaining: Of the 61 patients remaining: 28 did not require any additional supplementary nutrition. The tube remained in situ for a median of 2 months (range 1-6) 28 did not require any additional supplementary nutrition. The tube remained in situ for a median of 2 months (range 1-6) 30 patients where unable to meet their nutritional requirements orally and recommenced feed within 3 months of surgery. Tube in situ for a median of 6 months (range 3-24) 30 patients where unable to meet their nutritional requirements orally and recommenced feed within 3 months of surgery. Tube in situ for a median of 6 months (range 3-24) 3 patients were advised to recommence feed but declined 3 patients were advised to recommence feed but declined Of those with the option to continue enteral feeding: 54% required supplementary nutrition support

Reasons for recommencing enteral nutrition Failure to thrive – loss of weight with significant impact on rehabilitation and activity level Failure to thrive – loss of weight with significant impact on rehabilitation and activity level Decreased oral intake due to GI toxicity from adjuvant chemotherapy Decreased oral intake due to GI toxicity from adjuvant chemotherapy Food phobia Food phobia Dysphagia due to anastomotic stricture Dysphagia due to anastomotic stricture

Conclusions Failure to thrive post-oesophagectomy is multi- factorial and often difficult to prevent Failure to thrive post-oesophagectomy is multi- factorial and often difficult to prevent Nutrition support can relieve the pressure on patients to achieve adequate oral intake Nutrition support can relieve the pressure on patients to achieve adequate oral intake A significant number of patients require nutrition support within three months of discharge A significant number of patients require nutrition support within three months of discharge Retention of jejunostomy on discharge should be considered for all patients and for 2-3 months post- operatively Retention of jejunostomy on discharge should be considered for all patients and for 2-3 months post- operatively

Subsequent change to practice All patients are now discharged on enteral nutrition support following oesophagectomy All patients are now discharged on enteral nutrition support following oesophagectomy

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