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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.

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Long Term Use of Feeding Jejunostomy Following Oesophagectomy


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long term use of feeding jejunostomy following oesophagectomy

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
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
use of feeding jejunostomy
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
aim methods
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
results
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
results1

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
reasons for recommencing enteral nutrition
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
conclusions
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
subsequent change to practice
Subsequent change to practice
  • All patients are now discharged on enteral nutrition support following oesophagectomy
thank you

Thank you

Any Questions?