Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_151_библиотеки_им_акад_М_И_Перельмана

Nutritional support in patients following esophagectomy is recognized as an impor­tant element in postoperative recovery given the invasiveness of the procedure and the high likelihood of subsequent weight loss. This is of particular concern consid­ering the potential implications for weight maintenance in a population that may be suffering from nutritional deficiencies at baseline and its implications for outcomes. Although there is variation in terms of the timing, route, and delivery of supplemen­tal nutrition, evidence from several enhanced recovery pathway protocols supports the importance of including elements of enhanced recovery after surgery (ERAS) pathways related to an early oral diet. Several studies looking at ERAS pathways have found that early oral feeding following esophagectomy is safe and associated with decreased hospital length of stay (LOS), return of normal bowel function, and short-term improvement in quality of life without any increase in complications (Mahmoodzadeh et al. 2015; Sun et al. 2018). Until recently, there had been ambiguity regarding the impact of early oral intake on the risk of anastomotic leak. However, the multicenter RCT, Direct Oral Feeding Following Minimally Invasive Esophagectomy (NUTRIENT II) trial, demonstrated no significant differ­ence in the leak rate or other complications in those commencing immediate oral diet compared to those kept nil by mouth until day 5 postoperatively following mini­mally invasive esophagectomy (Berkelmans et al. 2020). It also found that a direct oral diet had a positive effect on functional recovery. The impact of early diet may depend in part on the surgical approach as well as additional factors, and as such, many units continue to advocate for a period of highly restricted oral intake as the exact timing for the initiation of oral intake is unclear, necessitating the delivery of supplemental nutrition. In this context or as an adjunct to support early oral diet, enteral feeding via either jejunostomy or nasojejunal feeding tube is widely accepted as the standard of care, contributing to the preservation of the gut barrier while associated with a lower risk of postoperative complications compared to parenteral nutrition (Findlay et al. 2014). Although the practice is somewhat variable and there is no clear evidence to support the superiority of either method, the most common route of delivery is via the placement of a jejunal feeding tube placed intraoperatively. A 2020 survey within the United Kingdom report ed that more than half of all units routinely placed feeding jejunostomy tubes in patients undergoing esophagectomy (Tham et al. 2020). In spite of the apparent benefits of early oral nutrition, several studies have demonstrated that many patients are unable to main­tain adequate caloric intake in the early postoperative period. A multicenter trial demonstrated that patients on an oral diet alone were only able to meet 60% of their daily caloric intake following esophagectomy, further supporting the view that supplemental enteral nutrition is required (Weijs et al. 2016). The benefits of delivering early enteral feeding via jejunostomy are supported by several studies including the analysis of the Surveillance, Epidemiology, and End Results (SEER) database of nearly 2500 patients undergoing esophagectomy, demonstrating lower 90-day mortality and short er hospital LOS in those with a jejunostomy compared to those without of (Lorimer et al. 2019).