Long Term Use of Feeding Jejunostomy Following Oesophagectomy

1. 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

2. Current problems • 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: • Partial or complete loss of appetite • Post-prandial pain • Nausea and vomiting • Reflux • Dysphagia – anastomotic strictures • Adjuvant chemotherapy • Dumping syndrome • Practice varies widely across the country, however, enteral feeding tubes are often removed on discharge or at first clinic review

3. Use of feeding jejunostomy • Current unit policy • 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 • 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

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

5. Results • 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 • 76 (88%) had a jejunostomy in situ for their post-op care • 13 (15%) patients had the tube placed at their staging laparoscopy • All patients were commenced on the standard post-operative nutrition protocol • 10 (12%) patients did not have an enteral feeding tube placed • Either due to surgeons choice or anatomical difficulties • Managed with parenteral nutrition until oral intake was re-introduced

6. Of those with the option to continue enteral feeding: 54% required supplementary nutrition support Results • 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 • 7 patients excluded due to follow-up at a different Trust • 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) • 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

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

8. Conclusions • 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 • 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

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

10. Thank you Any Questions?