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Patterns of Enteral Feeding Access in Esophagectomy: An Analysis of SEER-Medicare
Patrick D. Lorimer*2, Kendall Walsh2, Yimei Han1, Anthony J. Crimaldi3, Joshua S. Hill2, Jonathan C. Salo2
1Biostatistics, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC; 2Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC; 3Radiation Oncology, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC
Background
The perioperative care of esophagectomy patients presents challenges in achieving sufficient nutrition due to alterations in the physiology of eating. Enteral nutrition via a surgically placed feeding tube is commonly used to mitigate weight loss. The present study utilizes a large national dataset to further understand patterns of feeding tube use in this population.
Methods
SEER-Medicare was queried for patients with esophageal cancer (1992-2008) who underwent esophagectomy. Patients who had a feeding tube placed were identified. The association between feeding tube use, postoperative mortality (at 30, 60, and 90 days as well as 6-month mortality), and patient characteristics. Multivariable analysis was performed using a generalized linear model after stepwise selection of covariates.
Results
2,510 patients met inclusion criteria. 63% had feeding tubes placed, of whom 8% were prior to esophagectomy and 92% were at the time of esophagectomy. Rate of feeding tube placement varied by anastomotic site: cervical 67%, thoracic 44% and abdominal 54%. Feeding tube placement increased over time (p<0.01). For each year of diagnosis after 1992, there was an 8.8% increase in likelihood of a feeding tube being placed (OR 0.08 95% CI [0.06, 0.10]). Feeding tube placement was also more common in patients receiving preoperative radiation therapy (72%) than those who did not (28%, p<0.01), (Odds Ratio 1.64, [1.32, 2.03]). There was no difference in feeding tube utilization based on demographics or comorbidities. Differences in mortality between patients who did and did not have feeding tubes existed at 30 days (6.9% vs. 9.6%), 60 days (10.8% vs. 14.4%), and 90 days (14.3% vs. 17.7%). The odds of mortality in patients who received feeding tubes had was decreased at 30 days (OR 0.64, 95% CI [0.45, 0.92]), 60 days (OR 0.69, [0.52, 0.92]) and 90 days (OR 0.75, [0.58, 0.98]) when compared with patients who did not. No difference in survival was observed at 6 months with respect to feeding tube use. No difference in length of stay or discharge destination was noted between those who received a feeding tube and those who did not.
Conclusions
Placement of feeding tubes in patients undergoing esophagectomy resulted in a decrease in short term mortality in our cohort. Use of feeding tubes has increased over time as has radiation therapy and both increase the rate of tube placement independently. Feeding tube placement was not associated with a higher rate of non-home discharges or with an increased length of stay. Given the decrease in postoperative mortality we recommend providers consider placement of feeding tubes in patients undergoing esophagectomy.
 
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