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Jejunostomy Feeding Tubes Placed Prior to Neoadjuvant Chemoradiotherapy Are Safe and Improve Therapeutic Efficiency During Trimodality Therapy for Esophageal Cancer
Mustapha A. El Lakis*, Donald Low
General and Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA
Background: The aim of this study is to assess the safety and impact of selective placement of Jejunostomy feeding tube (JFT) before Neoadjuvant Chemoradiotherapy (NCRT) in esophageal cancer patients and to compare outcomes to patients having JFT placed at time of esophageal resection (ER).
Methods: An IRB-approved prospective database of patients undergoing ER following NCRT in a tertiary care center from 2009 to 2014 was retrospectively examined.
Results: One hundred and nine patients underwent placement of JFT; 44 before NCRT (G1), 65 at ER (G2). In G1, JFT were inserted using a laparoscopic-assisted (43%) or open (57%) technique for severe dysphagia and weight loss (73%), failure to thrive (16%), dysphagia and failure to thrive (9%) and for anticipated nutritional issues due to extended radiation field (2%). Forty patients from G1 had 92 concomitant procedures with the JFT placement; port-a-Cath (40), diagnostic laparoscopy (22), peritoneal washings cytology (21) and biopsy (4). The length of stay in G1 after the JFT placement was 1.5 day and 2 insertion-related complications (Clavien-Dindo grade1). Forty three patients (98%) successfully completed all planned components of NCRT.
When compared to patients having JFT at esophagectomy (G2), G1 demonstrated more advanced cancer stage, higher ASA and ECOG scores (p<0.001). G1 patients presented more commonly with dysphagia (95.5 vs 63%) and weight loss (82% vs 38%) (p<0.001) and a lower Albumin level at esophagectomy. Presenting weight loss was 7.7 vs 3.2 Kg in G1 and G2 respectively (p<0.001).
In all 109 patient (G1 and G2), 40 complications were identified following JFT insertion (12 procedure-related, 27 tube-related). Reoperation was required in the management of 3 complications (Small Bowel Obstruction) while others required no intervention (n=10) or were Clavien-Dindo Grades 1 or 2 (n=29). All patients had enteric feeding for a mean of 3.1 months. JFT was clinically important in patients who developed anastomotic leak (4%) and anastomotic stricture (25%).
A propensity matched group consisting of 28 patients from G1 and 23 patients from G2 was also done. Patients were matched for age, presenting weight loss, comorbidities, ASA, ECOG and cancer stage. Analysis showed a mean hospital LOS after esophagectomy of 7.9 vs 10.3 days (p=0.13), percent weight loss during NCRT of 0.08 % vs 0.3% (p=0.88) in G1 vs G2 respectively and equal percent weight loss between the two groups at 2.8 months following esophagectomy.
Conclusion: JFT can improve nutrition associated with trimodality therapy. Complications can occur but are typically minor. JFT placement at the time of esophagectomy is common and can facilitate recovery and management of complications. JFT placement prior to NCRT increases the likelihood of completing NCRT, and when done with other necessary procedures can ultimately be cost effective.
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