Dear Johnny,

My former consultant published some great papers on the general risks of preoperative weighloss prior to GI surgery (not specifically esophagectomies, but the same rational will apply). You can download them from here (have attached the one that'll probably help answer your q the fastest):

http://www.ncbi.nlm.nih.gov/pubmed/19375611

http://www.ncbi.nlm.nih.gov/pubmed/18504063

http://www.ncbi.nlm.nih.gov/pubmed/18342995

or just search "Schiesser M" and "nutrional risk score".

Based on these findings, that preoperative weightloss correlates clearly with increased postoperative morbidity and mortality risks, we as residents always had to query the patients nutritional risk score. From memory (I can't remember the exact cutoff) we generally chose to "improve" the nutritional status of patients (protein shakes etc.) if the patient showed >10% weightloss in the months following-up to surgery. The problem of course is getting the patient with dysphagia to "eat/drink" more.

Also if I'm not mistaken, we placed jejunal feeding tubes during the diagnostic laparoscopy we often performed (if the patient was going to undergo neo-adjuvant therapy we always performed a diagnostic laparoscopy to rule out occult peritoneal metastasis (including lavage-cytology)). This was generally done to try and improve the patients nutritional status hoping to hereby reduce perioperative complication rates. In pancreatic cancer patients we did the same, where we also put them on "immuno"-protein-shakes (Oral Impact) if they showed relevant waisting prior to surgery.

Not sure how much this info helps, but maybe the papers and respective references will be able to guide you further.

Cheers,

Oliver

Dear Johnny,

My former consultant published some great papers on the general risks of preoperative weighloss prior to GI surgery (not specifically esophagectomies, but the same rational will apply). You can download them from here (have attached the one that'll probably help answer your q the fastest):

http://www.ncbi.nlm.nih.gov/pubmed/19375611

http://www.ncbi.nlm.nih.gov/pubmed/18504063

http://www.ncbi.nlm.nih.gov/pubmed/18342995

or just search "Schiesser M" and "nutrional risk score".

Based on these findings, that preoperative weightloss correlates clearly with increased postoperative morbidity and mortality risks, we as residents always had to query the patients nutritional risk score. From memory (I can't remember the exact cutoff) we generally chose to "improve" the nutritional status of patients (protein shakes etc.) if the patient showed >10% weightloss in the months following-up to surgery. The problem of course is getting the patient with dysphagia to "eat/drink" more.

Also if I'm not mistaken, we placed jejunal feeding tubes during the diagnostic laparoscopy we often performed (if the patient was going to undergo neo-adjuvant therapy we always performed a diagnostic laparoscopy to rule out occult peritoneal metastasis (including lavage-cytology)). This was generally done to try and improve the patients nutritional status hoping to hereby reduce perioperative complication rates. In pancreatic cancer patients we did the same, where we also put them on "immuno"-protein-shakes (Oral Impact) if they showed relevant waisting prior to surgery.

Not sure how much this info helps, but maybe the papers and respective references will be able to guide you further.

Cheers,

Oliver

Thank you very much Oliver

It's a great topic. In short I'd say that if weight loss has been significant due to the esophageal cancer then in all likelihood it will be a locally advanced disease at the very least. In other words, the patient that will likely undergo neoadjuvant therapy. This is a key point for surgeons to be involved from the beginning, because in the face of weight loss and malnutrition we offer options to supplement their diet: open or lap J-tube placement, esophageal covered stent and even a PEG, although we try to avoid manipulating the stomach. Nutrition is followed throughout their neoadjuvant treatment and a decision to proceed with surgery or hold off includes the nutritional status (weight curve, alb, pre alb, transferrin). If within reasonable levels we proceed with esophagectomy but on occasions we've had to delay the resection until nutrition improved which may turn it into a salvage esophagectomy most often requiring a 3-field resection.

Lastly, if the patient presents with an early ca (less than T3) but significant weight loss and malnutrition then there should be a strong suspicion that something else is going on and it has to be investigated thoroughly. Nutrition, as with any surgical intervention but especially for esophagectomy, is a critical component of a good outcome and should prompt aggressive management.

Thank you Julian, this is about the same way we proceed.

Seems you focus on weight loss% together with lab values to decide to go ahead with surgery, probably together with the clinical presentation of the patient. Is it correct to say you won't take a body mass index (BMI) as absolute cut-off to decide on surgery (e.g.

Our unit doesn't have a precise weight cut off for refusing surgery - but we do evaluate patients carefully from a nutritional point of view. We won't resect patients who are grossly malnourished with low albumins etc. We place feeding jejunostomies in patients with severe dysphagia and / or significant weight loss who are suitable for resection. Patients who don't respond to chemo and still have dysphagia get a NG /NJ feeding tube if they don't have a feeding jejunostomy. This allows nutrition during neoadjuvant chemotherapy. All patients see a dietician.

We avoid PEGs - as they can knacker the stomach or more importantly prang its blood supply. Also PEGs can pull tumour cells and implant they into the abdominal wall rendering the patient palliative.

I avoid covered stents pre oesophagectomy, as they

1. often migrate with chemotherapy causing shrinkage

2. make the resection more difficult if they stay insitu (fibrosis etc)

3. some evidence they may compromise survival - free tumour cells in blood after stenting colorectal cancer and progression to surgery in patients who require stenting pre-oesophagectomy is very poor (althought this may be due to their advanced stage

See the attached commentery on the safety of stents in the neoadjuvant setting for oesophageal cancer.

Perhaps a need for a RCT comparing,,,,,,,

NG/J

Feeding jejunostomy

Possibly covered stents

In resectable patients with dysphagia who need chemo or CRT prior to oesophagectomy?

Outstanding points! Thank you for sharing.

It would be interesting to put together a multi-institutional study. My personal experience with fully covered stents is very positive. A point I always try to make is that radiation therapy improves dysphagia in most patients and so, even if they are limited to liquids, I tend to wait 2-4 weeks after radiation therapy beginns before committing to a stent. Most patients do not require one.

I've operated on a couple of patients that were referred to us with partially uncovered stents which we couldn't remove until they came out at the time of the esophagectomy. We didn't find the resection particularly challenging, although it makes sense that the chronic irritation can result in scar around the esophagus.

Thanks again for sharing.

JG

A very nice discussion above..

Just wanted to point out that although nutritional build-up for these patients is very important to improve operative outcomes, these patients are a high-risk group for refeeding syndrome.

The nutritional supplementation should start at approximately half of daily caloric requirements and gradually increased with regular monitoring/replacement of metabolic parameters, esp potassium, magnesium and phosphorus..

regards, raza

Is an excellent discussion,our policy is try not to stent the esophagus unless the tumour is inoperable.similarly try not do do FJ if the tumour is operable.Both these proceedures cause tecqnical difficulties in surgery.Optimise the patient with NJ or TPN

and plan for alp trans hiatal or Thoraco-laparoscpic resection with neck anastamosis and feed the pt from day 2 through FJ.

Hello Mr Moons,

Regarding your question about Esophagectomy in underweight patients.

I will assume that this question is related to Esophageal Cancer patients as this is the most common indication for performing an esophagectomy and not address esophagectomies that are performed in emergent life threatening situations.

Most of the literature related to this issue are looking at nutritional biomarkers rather than actual weight or BMI. A quick google search for albumin or pre-albumin levels and the incidence of postoperative leak rates in esophagectomies are very clear. The lower the biomarkers the higher the leak rate. This is also reflected in overall mortalities for this procedure.

Personally, I test the Albumin and if low, I would prescribe some high protien high calorie nutritional supplement in consultation with a nutritionist familiar with these disorders.

If the patient has severe dysphagia or is unable to take adequate volumes orally, then they should be assessed for an esophageal stent (This needs to be a removable covered type and NOT the permanent metallic ones, ex. HANARO or BOSTON SCIENTIFIC) prior to esophagectomy. In very few cases that are not stentable (ex. Proximal tumors) or that do not tolerate a stent very well, then it would be worthwhile to insert a feeding jujenostomy prior to esophagectomy. This can be done operatively (open or minimal invasively) and conveniently be combined with operative staging as well. This can also be done radiologically by skilled invterventional radiologists.

Most surgeons do not prefer the insertion of a feeding Gastrostomy as they would like to maintain the integrity of the stomach as the future conduit post esophagectomy. However this can also be done and can occassionally be useful for hypertrophic feeds to enlarge and elongate the future conduit if necessary. (This scenario sometimes occurs in pediatric patients requiring esophagectomy).

In brief, Esophageal cancer is a severely debilitating condition, many patients are unable to take their required nutritional intake orally and present in severe cachexia. Coupled with the fact that most centers that deal with this disease give pre operative chemoradiation regime (ex. CROSS regime) that is further taxing to the patient's overall health, the importance of nutrition for these operations could not be overstated.

Specialist dietetic review is crucial. There is an important distinction between patients with weight loss due to dysphagia / poor oral intake and those with systemic carcinomatosis (even if this may be occult).

In the former situation where the weight loss is understandable then options are a stent, NJ tube or feeding jej . This needs to be considered early ie before chemotherapy otherwise the patient will lose ground and never get to surgery.

In the second scenario then full staging is important to maximise the chance of identifying systemic disease. These patients (locally advanced, N2/3, poor diff, poor response to neo adjuvant treatment ) have a high risk of micrometatstatic disease and would likely suffer early recurrence after surgery. Artificially feeding them but ignoring the poor prognostic markers would be be a mistake