Is routine postoperative enteral feeding after oesophagectomy worthwhile?

Abstract

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether, in patients undergoing an oesophagectomy for cancer, immediate postoperative enteral feeding (via percutaneous jejunostomy or nasojejunostomy) provides better patient outcomes as compared to waiting until oral feeding can be instituted. Four randomized controlled trials represented the best evidence to answer the clinical question. The first study randomized 25 patients into enteral feeding via jejunostomy (n = 13) versus a routine diet without jejunostomy (n = 12). The authors found no statistical difference in outcomes including length of stay, anastomotic complications and mortality. They did not report any catheter-related complications. A second study included patients undergoing an oesophagectomy or a pancreatodudenectomy, randomized to immediate postoperative jejunostomy feeding (n = 13) or remaining unfed for 6 days (n = 15). They reported one incident of detachment of the catheter from the abdominal wall. They also noted a statistically significant decrease in vital capacity and FEV1 in enterally fed patients. There was no difference in length of stay or anastomotic complications. They concluded that there was no indication for routine use of immediate postoperative enteral feeding in those patients without significant preoperative malnutrition. A third report randomized their post-oesophagectomy patients into enteral feeding via jejunostomy (n = 20) versus crystalloid only (n = 20). The also found no difference in length of stay, anastomotic leak rate or mortality. One catheter was removed due to concerns over respiratory function. They also concluded that there was no measurable benefit in early enteral feeding. The last of these 4 studies randomized patients into naso-duodenal feeding (n = 71) and jejunostomy feeding groups (n = 79). As in previous trials, they found no statistically significant difference between length of stay or anastomotic leak rates. Mortality was higher in the jejunostomy group, although the team did not attribute the deaths to the catheter. They found both methods equally effective in providing postoperative nutrition. In summary, all the trials concluded that routine postoperative enteral nutrition was feasible, but there was no evidence suggesting that it conferred any clinical benefits.