Comparisons of nutritional status and complications between patients with and without postoperative feeding jejunostomy tube in gastric cancer: a retrospective study

Introduction

The incidence of gastric cancer has decreased in recent decades, but it remains a major public health concern worldwide (1). It was estimated to be 1,089,103 newly diagnosed cancer cases and 768,793 cancer-related deaths of gastric cancer in 2020 worldwide (2). Gastric cancer is the 2nd leading cause of cancer-related mortality in both Chinese males and Chinese females (3). Surgery continues to be the most effective therapy for gastric cancer (4).

Nutrition is considered a significant risk factor for poor outcomes in gastric cancer patients (5,6). Notably, malnourished patients are at greater risk of adverse clinical outcomes (e.g., longer hospital stays) and have a higher incidence of complications (e.g., wounds and infectious complications) than well-nourished patients (7,8). Malnutrition is common in advanced gastric cancer patients due to the poor absorption of essential nutrients after surgery (9). Nutritional assessment and counseling have been added to the National Comprehensive Cancer Network (NCCN) Guidelines for Gastric Cancer, which recommend monitoring surgically resected patients for nutritional deficiency and treating as indicated (10).

The placement of a feeding jejunostomy tube (FJT) at the time of gastrectomy provides alternative and supplementary access to early postoperative enteral nutrition. Enteral nutrition is superior to total parenteral nutrition postoperatively, as it significantly improves clinical and immunological outcomes, and is also cost effective, as it reduces the duration of hospitalization, and reduces the incidence of postoperative infections and complications (11-13).

While the safety regarding FJT in gastric cancer patients has been previously studied (14-16), few studies have examined the nutritional benefit associated with early nutritional supply with FJT. This clinical study sought to explore the nutritional benefit of FJT placement and potential complications in patients undergoing gastric cancer resection. We present the following article in accordance with the STROBE reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-847/rc).

Methods

Patients

A total of 715 consecutive patients underwent resection of gastric cancer from January 2009 to December 2014 at the Peking Union Medical College Hospital in China. We retrospectively analyzed data on patients’ sex, age, body mass index (BMI), history, tumor-node-metastasis (TNM) stage, preoperative adjuvant therapy, and complications. The TNM classification of gastric cancer was determined using the Union for International Cancer Control 6 system. Total gastrectomy was defined as the resection of the entire stomach, while subtotal gastrectomy included proximal and distal gastrectomy. Safety outcomes included the assessment of major postoperative complications including surgical site infection, intra-abdominal infections, anastomotic leaks, reoperation and gastroparesis. Surgical site infection was defined as superficial and deep surgical site infection. Intra-abdominal infection was defined as the presence of abnormal fluid on radiological examination associated with infectious symptoms. Anastomotic leak was diagnosed when extra-intestinal leakage of orally administered contrast media was observed by radiology or through the abdominal drain. Gastroparesis was diagnosed by upper digestive tract radiography showing residual contrast agent in the stomach, which indicated no mechanical obstruction in gastrointestinal anastomosis and delayed gastric emptying. The perioperative nutritional index and incidence of complications in patients with a FJT were compared to those in patients without a FJT. The levels of albumin, prealbumin, hemoglobin, high sensitivity C-reactive protein (hs-CRP), the neutrophil-to-lymphocyte ratio (NLR), and Onodera’s prognostic nutrition index (OPNI) were recorded at the following 3 timepoints: preoperatively, 1-week postoperatively, and 1-month postoperatively. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the institutional review board of Peking Union Medical College Hospital (No. K1447). Informed consent was waived due to the retrospective nature of this study.

Statistical analysis

The analysis of the data was performed using IBM SPSS Statistics (Version 19.0), and the statistical significance was determined with a 5% two-sided significance level. Comparative analyses between 2 groups were performed using an independent samples t-test for the continuous variables and a chi-squared test or Fisher’s exact test for the categorical variables. Univariate and multivariate logistic regression analyses were conducted to evaluate the association of FJT placement with postoperative complications. A subset analysis of patients who underwent total or subtotal gastrectomy was also performed.

Results

Baseline characteristics

A total of 715 gastric cancer patients underwent resection at our institution during the study period. The patients had a mean age of 60.4±11.7 years, and 516 were male (72.2%) and 199 were female (27.8%). Of the 715 patients, 247 (34.5%) underwent total gastrectomy, and 468 (65.5%) underwent subtotal gastrectomy. Table 1 presents details of patients’ characteristics. The majority of baseline variables were comparable between patients with and without FJT, except that there was more total gastrectomy, preoperative adjuvant chemotherapy, occurrence of gastroparesis and longer hospital stay in the FJT group (Table 1).

Comparison of nutritional status in patients with and without FJT

Of the 247 total gastrectomy cases, 98 (39.7%) had a FJT placed and 149 (60.3%) did not. The FJT group had a lower hemoglobin level (117.15±15.82 versus 122.73±21.24 g/L, P=0.048) and a lower NLR (2.16±1.26 versus 3.05±3.56, P=0.030) than the non-FJT group preoperatively; however, there was no significant difference between the 2 groups 1-week postoperatively. The FJT group had a higher albumin level (39.63±5.31 versus 36.13±5.07 g/L, P=0.005), prealbumin level (181.00±48.32 versus 146.00±38.65 mg/L, P<0.001), hemoglobin level (117.76±17.14 versus 112.05±13.56 g/L, P=0.014), OPNI (47.94±8.02 versus 45.55±5.96, P=0.027) and a lower NLR (1.96±0.95 versus 2.50±1.59, P=0.005) than the non-FJT group 1-month postoperatively (Table 2).

Of the 468 subtotal gastrectomy cases, 87 (18.7%) had a FJT placed and 381 (81.2%) did not. There was no significant difference between the 2 groups preoperatively. However, the FJT group had a lower NLR (5.01±2.94 versus 6.71±4.97, P=0.006) than the non-FJT group 1-week postoperatively. The FJT group also had a higher albumin level (39.12±4.05 versus 37.09±4.72 g/L, P=0.009) than the non-FJT group 1-month postoperatively (Table 3).

Association between FJT and postoperative outcomes

In all patients, the multivariate regression analysis demonstrated that there was no association between FJT placement and an increased risk of surgical site infection [OR (odds ratio) =1.21, P=0.79], intra-abdominal infection (OR =0.38, P=0.11), anastomotic leak (OR =0.58, P=0.53), reoperation (OR =0.22, P=0.23) and gastroparesis (OR =6.35, P=0.08). There was no significant association between FJT and hospitalization for more than 30 days (OR =0.58, P=0.32) (Table 4). In subgroup analysis of subtotal gastrectomy and total gastrectomy, FJT did not appear to increase postoperative complications or hospitalization for more than 30 days (Table 5,6).

Discussion

Malnutrition can be detected in up to 50% of patients with gastrointestinal cancer (17). Poor nutritional status leads to postoperative morbidity and mortality (18). Total gastrectomy has a profound effect on nutritional status, and can potentially result in weight loss, malabsorption, maldigestion, shortened intestinal transit time, and bacterial overgrowth (19-22). This surgical intervention reduces the reservoir into which patients can eat, alters the physiology of digestion, and leads to malnutrition in approximately 80% of patients (23). Further, the severity of malnutrition is increased by radical gastric cancer adjuvant therapies, such as radiotherapy and chemotherapy (6).

Perioperative nutritional support is of great significance in reducing postoperative complications, shortening the duration of hospitalization, and reducing the costs of hospitalization (24). Early enteral nutrition support after gastrointestinal surgery is recommended in the European Society for Clinical Nutrition and Metabolism guidelines as grade of recommendation A (25). A randomized, multicenter, clinical trial of patients with gastrointestinal cancer who were malnourished and were candidates for major elective surgery reported that patients fed enterally had significantly fewer postoperative complications than those fed parenterally (26). The duration of postoperative hospitalization was also significantly shorter in the enteral nutrition group than the parenteral nutrition group. Further, patients fed enterally experienced significantly more adverse effects than those fed parenterally (26).

The technique used for FJT placement is simple, and the procedure can be conducted during the resection of gastric cancer to provide access to early postoperative enteral nutrition (27). The NCCN guidelines recommend that consideration be given to FJT placement to increase the use and completion rate of adjuvant therapy (28).

The present study compared the postoperative early nutrition and complications of patients who underwent a FJT placement during the resection of gastric cancer to a control group who did not undergo a FJT placement. We found nutritional improvement in the FJT group and did not observe major effects on postoperative adverse outcomes. The NLR was measured as an indicator of systemic inflammation (29); the gradual increase in lymphocytes and the gradual decline in neutrophils occurs with systemic inflammatory reaction improvement (30). The OPNI is a simple and effective nutritional assessment and surgical risk prediction index that is currently widely used in gastrointestinal surgery (31,32).

Of the total gastrectomy cases, those with a FJT had a significantly lower hemoglobin level preoperatively than those without a FJT; however, there was no significant difference between the 2 groups 1-week postoperatively, which indicates that the FJT group had a postoperative increase in hemoglobin. Patients with a FJT also had a significantly lower NLR preoperatively than those without a FJT; this could be explained by the high rate of preoperative adjuvant chemoradiotherapy, which may have caused side effects associated with bone marrow suppression. At 1-month postoperatively, the total gastrectomy FJT group had significantly higher albumin, prealbumin, and hemoglobin levels and OPNI, and a significantly lower NLR than the total gastrectomy non-FJT group. Patients who underwent total gastrectomy and received postoperative early enteral nutrition had an improved nutritional index, reduced inflammation, and an improved OPNI 1-month postoperatively.

Of the subtotal gastrectomy cases, there was no significant difference between the FJT group and the non-FJT group preoperatively. Patients with a FJT had a significantly reduced NLR 1-week postoperatively compared to those without a FJT. Early postoperative enteral nutrition reduces the NLR, which may indicate a reduction in the postoperative inflammatory reaction. The nutritional index and OPNI were not significantly improved by FJT placement 1-week postoperatively. The patients with FJT placement had a significantly higher albumin level 1-month postoperatively than the subtotal gastrectomy patients without a FJT.

FJT placement during gastric cancer resection provides access for early postoperative enteral and parenteral sequential enteral nutrition. It avoids the nasal tube nutrition channel, which may cause subjective discomfort and has an increased risk of aspiration. Further, enteral nutrition can still be administered through a FJT to patients with anastomotic leak, gastroparesis, and other postoperative complications. Enteral nutrition contributes to the protection of the intestinal mucosal barrier and reduces the incidence of hepatic dysfunction and infection complications caused by total parenteral nutrition. In the present study, FJT placement was not associated with complications, including surgical site infection, intra-abdominal infection, anastomotic leak, reoperation, gastroparesis, and hospitalization for more than 30 days (33).

The limitation of this study is that the research was conducted in a retrospective cohort and the imbalance between the groups may generate potential bias in the analysis of nutritional outcomes and complication rates. The study was also conducted in a single institute, so the clinical benefit of FJT could be biased by patterns of nutritional supply, tumor stage, ethnicities and standards of clinical evaluation. In a study comparing FJT in gastrectomy or esophagogastrectomy, it was found that FJT complications were more likely to occur with gastrectomy than with esophagogastrectomy (34). So the generalization of the results should be cautious as the optimal nutritional support should be applied depending on clinical settings. Prospective, multi-center clinical studies are warranted to facilitate better clinical decision making.

Conclusions

The application of FJT for early enteral nutritional support can improve the nutritional status of patients after gastrectomy, and it does not significantly increase the incidence rate of postoperative complications.

Acknowledgments

We would like to thank the study patients and their families for the opportunity to review their medical records.

Funding: The study was supported by National High Level Hospital Clinical Research Funding (Nos. 2022-PUMCH-C-048 and 2022-PUMCH-B-005); CAMS Innovation Fund for Medical Sciences (No. 2020-I2M-C&T-B-027).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-847/rc

Data Sharing Statement: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-847/dss

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-847/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the institutional review board of Peking Union Medical College Hospital (No. K1447). Informed consent was waived due to the retrospective nature of this study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: L. Huleatt)