Early Oral Feeding Following McKeown Minimally Invasive Esophagectomy: An Open-label, Randomized, Controlled, Noninferiority Trial.

OBJECTIVE: Our objective was to evaluate the impact of early oral feeding (EOF) on postoperative cardiac, respiratory, and gastrointestinal (CRG) complications after McKeown minimally invasive esophagectomy for esophageal cancer. SUMMARY BACKGROUND DATA: Nil-by-mouth with enteral tube feeding is routinely practiced after esophagectomy. METHODS: Patients were randomly allocated to receive oral feeding on the first postoperative day (EOF group) or late oral feeding (LOF group) 7 days after surgery. The primary endpoint was the occurrence of postoperative CRG complications, and the secondary outcomes included bowel function recovery and short-term quality of life (QOL). RESULTS: Between February 2014 and October 2015, 280 patients were enrolled in this study. There were 140 patients in the EOF group and 140 patients in the LOF group. EOF was noninferior to LOF for CRG complications (30.0% in the EOF group vs. 32.9% in the LOF group; 95% confidence interval of the difference: -13.8% to 8.0%). Compared with the LOF group, the EOF group showed significantly shorter time to first flatus (median of 2 days vs. 3 days, P = 0.001) and bowel movement (median of 3 vs. 4 days, P < 0.001). Two weeks after the operation, patients in the EOF group reported higher global QOL and function scores and lower symptom scores than patients in the LOF group. CONCLUSIONS: In patients after McKeown minimally invasive esophagectomy is noninferior to the standard of care with regard to postoperative CRG complications. In addition, patients in the EOF group had a quicker recovery of bowel function and improved short-term QOL.

Early oral feeding following esophagectomy.

Nutritional support for patients with esophagectomy is very important especially for patients with malnutrition. But there is significant variation in nutritional support between different hospitals. Traditionally, 5 to 7 days of nil by mouth is required to allow healing of the anastomosis after esophagectomy; a feeding tube (usually jejunostomy tube) placed before or during the operation provides enteral access for patients with esophagectomy. However, there is no consensus of the timing of oral intake after esophagectomy. We reviewed the published data about early oral feeding (EOF) after esophagectomy. At present, there were only four studies, including two randomized studies, investigating the feasibility and safety of EOF for patients with esophagectomy. The results of the current studies show that EOF after esophagectomy do not increase postoperative complications and motility. However, evidence from large multicenter randomized controlled clinical trials is still lacking. In the future, the long-term outcomes, including body weight loss, quality of life (QOL), laboratory nutritional markers and survival, should be investigated in the field of EOF protocols. EOF after esophagectomy may require the application of the most recent knowledge and the perioperative practice of multi-disciplinary team medical care, according to the situation of each medical center.

Impact of an Early Oral Feeding Protocol on Inflammatory Cytokine Changes After Esophagectomy.

BACKGROUND: The aim of the current study was to investigate the impact of early oral feeding (EOF) on inflammatory cytokine levels after McKeown minimally invasive esophagectomy (MIE) for cancer. METHODS: This study was based on a randomized controlled trial (NCT01998230). Patients with esophageal cancer who received McKeown MIE were randomly allocated into a group that started oral feeding on postoperative day (POD) 1 (EOF group) or a second group that received nil by mouth until 7 days after operation (late oral feeding [LOF] group). We chose 86 patients, 46 patients in the EOF group and 40 patients in the LOF group, in which to analyze inflammatory cytokine levels (interleukin [IL]-6, IL-8, tumor necrosis factor-a [TNF-α], and monocyte chemotactic protein-1 [MCP-1]). RESULTS: The EOF and LOF groups exhibited similar preoperative IL-6, IL-8 TNF-α, and MCP-1 levels. The levels of the four inflammatory cytokines at PODs 1 and 3 were significantly higher than the preoperative levels (all p < 0.001). At POD 5 the levels of all four inflammatory cytokines were decreased compared with those at PODs 1 and 3. At PODs 3 and 5 the levels of IL-6, IL-8, and TNF-α were significantly lower in the EOF group than in the LOF group (all p < 0.05). At POD 3 the MCP-1 levels in the EOF group were significantly lower than those in the LOF group (all p < 0.05). CONCLUSIONS: Compared with conventional rehabilitation programs the EOF protocol may decrease stress response after McKeown MIE.

Early oral feeding following thoracolaparoscopic oesophagectomy for oesophageal cancer.

OBJECTIVES: Nil-by-mouth with enteral tube feeding is widely practised for several days after resection and reconstruction of oesophageal cancer. This study investigates early changes in postoperative gastric emptying and the feasibility of early oral feeding after thoracolaparoscopic oesophagectomy for patients with oesophageal cancer. METHODS: Between January 2013 and August 2013, gastric emptying of liquid food and the feasibility of early oral feeding after thoracolaparoscopic oesophagectomy was investigated in 68 patients. Sixty-five patients previously managed in the same unit who routinely took liquid food 7 days after thoracolaparoscopic oesophagectomy served as controls. RESULTS: The mean preoperative half gastric emptying time (GET1/2) was 66.4 ± 38.4 min for all 68 patients, and the mean GET1/2 at postoperative day (POD) 1 and POD 7 was statistically significantly shorter than preoperative GET1/2 (23.9 ± 15.7 min and 24.1 ± 7.9 min, respectively, both P-values <0.001). Of the 68 patients who were enrolled to analyse the feasibility of early oral feeding, 2 (3.0%) patients could not take food as early as planned. The rate of total complication was 20.6% (14/68) and 29.2% (19/65) in the early oral feeding group and the late oral feeding group, respectively (P = 0.249). Compared with the late oral feeding group, time to first flatus and bowel movement was significantly shorter in the early oral feeding group. CONCLUSIONS: Compared with preoperative gastric emptying, early postoperative gastric emptying for liquid food after oesophagectomy is significantly faster. Postoperative early oral feeding in patients with thoracolaparoscopic oesophagectomy is feasible and safe.