Published online Dec 15, 2019. doi: 10.4251/wjgo.v11.i12.1182
Peer-review started: February 26, 2019
First decision: July 31, 2019
Revised: August 29, 2019
Accepted: November 4, 2019
Article in press: November 4, 2019
Published online: December 15, 2019
Malnourishment and sarcopenia are well documented phenomena in oesophageal cancer. Neo-adjuvant chemotherapy is now the mainstay of treatment prior to oesophagectomy and is associated with improved survival compared to surgery alone. Patients undergoing neo-adjuvant chemotherapy prior to oesophagectomy have complex nutritional needs. The use of multiple strategies to manage disease progression including radiation, chemotherapy and surgical resection present an additional nutritional burden to these patients who are often malnourished at presentation.
There are various indicators of nutritional status that predict an individual’s ability to tolerate neo-adjuvant chemotherapy and surgery for oesophageal cancer. Lower body mass index (BMI), skeletal muscle depletion, sarcopenia and sarcopenic obesity are associated with dose-limiting toxicity during treatment with neo-adjuvant chemotherapy. The period preceding surgery is the ideal time to ensure patients are in the best possible state for surgery. The use of enteral feeding via jejunostomy, particularly in oesophageal cancer, is a reliable method to optimise nutrition. The associated risks of insertion do not significantly outweigh the conferred benefits. The present study is the first to our knowledge to examine the changes of body composition from regular enteral feeding via jejunostomy during neo-adjuvant therapy for oesophageal cancer.
The aim of this study is to examine the effect of regular enteral feeding via jejunostomy on overall body composition in a cohort of patients with oesophageal cancer undergoing neo-adjuvant chemotherapy prior to oesophagectomy. The effect of regular jejunostomy feeding on the development of dose-limiting toxicity during neo-adjuvant chemotherapy was also examined.
Patients having potentially curative, locally advanced oesophageal and oesophago-gastric junctional cancer without evidence of metastasis were considered for this study. All patients were routinely staged with a combination of computed tomography (CT), endoscopic ultrasound and laparoscopy according to the International Union Against Cancer system. All patients were assessed by a dietician prior to starting regular jejunostomy feeding. After assessment by the dietitian, each patient had the feeding regimen tailored to their individual nutritional needs. Weight and height were recorded according to standard methods. CT has proven to be accurate for measuring human body composition. Regional muscle tissue was measured by CT from electronically stored images, which had been done previously for diagnostic purposes. CT scans were performed at two time points: The first at diagnosis prior to commencement of chemotherapy and the second after completion of neo-adjuvant chemotherapy prior to surgery. The third lumbar vertebra was chosen as a landmark, and two consecutive slices were assessed to measure cross-sectional area of muscle and adipose tissue as described. The average value of two images was computed for each patient.
During the study period, 15 patients underwent regular jejunostomy feeding during neo-adjuvant chemotherapy prior to surgery. The time interval between the start of chemotherapy and surgery was 107 ± 21.6 d. During this period, there was no change in weight and BMI. However, body composition analysis revealed a statistically significant loss of skeletal muscle despite regular feeding during neo-adjuvant chemotherapy. Lumbar skeletal muscle index decreased. Adipose tissue index remained largely unchanged.
This observational study of 15 patients undergoing neo-adjuvant chemotherapy prior to oesophagectomy confirmed that formal nutritional intervention provided through the use of feeding jejunostomy had a positive effect on maintaining mean overall weight and BMI.
This study has shown that nutritional supplementation does serve to maintain overall weight and BMI. Looking more specifically at body composition, skeletal muscle mass decreased despite this nutritional support, and the proportion of sarcopenic patients increased. It is the authors’ opinion that multimodal intervention incorporating a combination of regular nutritional support and exercise during the period of neo-adjuvant chemotherapy may lead to improvement in treatment tolerance and optimising surgical candidacy in patients with oesophageal cancer. This would be best investigated by means of a prospective multi-centre, multi-arm randomised controlled trial.