Memorial Case

Study
Esophagectomy & Reconstruction
 65 yo Female

Date of Admission: 4/9/19

B.R. Admit Weight: 96.9 kg

Height: 5’ 6”

Past Medical History: Hiatal Hernia,

GERD, and HTN
Surgical History
• Hiatal Hernia Repair Surgery
October 6, • Complications arose
2018

• Esophageal Necrosis
• Mediastinal Abscess
October 24,
2018 • Sepsis

• Esophagostmy, gastrostomy
October • J tube placed for nutrition
2018
 Surgical History Cont.
• esophagogastric anastomosis • EGD with esophageal stent
with a substernal stomach April 19, placement
April 9, 2019 2019
conduit

• Pectoralis major flap for closure

April 18, April 23,
2019 2019

• Drainage of neck abscess

• No obvious anastomotic issue • Continued NPO likely for a few
April 18,
Current
more weeks to ensure healing
2019 • Initiation of antibiotics

Attending Physician: Stephen Hazelrigg M.D.

 • Common treatment for advanced
esophageal cancer, and is used
occasionally for Barrett's esophagus.
• Usually the esophagus is replaced using
Esophagectomy another organ, most commonly the
stomach but occasionally the large
intestine.
 • Timing and reintroduction of oral diet
• Value of postoperative nutritional
Nutritional support
• Feeding Access Route
Considerations • Postsurgical gastrointestinal symptoms
Timing and • Direct start of oral nutrition following
esophagectomy is feasible. (Weijs et
Reintroduction al., 2016; Paul et al., 2016)
of Oral Diet
 • Discharge with home tube feeding is
not correlated with a reduced length of
Value of stay or readmissions. (Weijs et al.,
2017)
Postoperative • Home feedings via jejunostomy is likely
Nutritional where meaningful nutritional
improvements can be made. (Paul et
Support al., 2016)
 • The best feeding route following
Feeding Access esophagectomy is unclear. Orally, vs
jejunostomy vs nasojejunal tube.
Route (Weijs et al., 2015)
 • Improving nutrition and related quality
Postsurgical of life in the early months might
Gastrointestinal improve the long-term outcome. (Paul
et al., 2016)
Symptoms
 • Nocturnal feedings for 12 hours of
Jevity 1.5 at rate of 100 mL/hr to
provide 1200 mL, 1800 kcal, and 115 g
protein.
Feeding Prior
• Pt reported 40lbs weight loss since TF
to Admit initiated 6 months ago.
• Severe weight loss, 15.8%
• Weight stabilized at 98.6 kg 2
months ago
 Ht: 65” Wt: 96.9 BMI: 36
IBW: 59 kg ABW: 68.5 kg

Calculated • Calories: 2055-2398

• 30-35 kcal/kg adjusted body weight
Energy Needs
• Protein: 103-137 gm
• 1.5-2 gm/kg adjusted body weight
 • Goal Rate: Jevity 1.5 at 65 mL/hr +
beneprotein TID to provide
2123 kcal and 105 gm protein, 2117 mL
Goal Rate and eefree water
• After esophageal leak, added 3
Advancment additional beneprotein and Juven BID
to provide
2378 kcal and 123 gm protein, 1817 mL
eefree water
 • Goal Rate: Jevity 1.5 at 65 mL/hr +
beneprotein TID to provide
2123 kcal and 105 gm protein, 2117 mL
Goal Rate and eefree water
• After esophageal leak, added 3
Advancment additional beneprotein and Juven BID
to provide
2378 kcal and 123 gm protein, 1817 mL
eefree water
 Labs and
Medications
 • Pt has ongoing diarrhea
• Beneprotein administration
Complications • Antibiotics
 • Continued NPO likely for a few more weeks to ensure
healing
• Going home:

Prognosis and Oral diet advancement vs einocturnal tube feedings

Reflection • Clarify timing of beneprotein and juven from the

beginning
• Try a different rate of TF to increase protein without
beneprotein administration
 • Weijs TJ, Berkelmans GHK, Nieuwenhuijzen GAP, Dolmans
ACP, Kouwenhoven EA, Rosman C, et al. (2016) Direct
postoperative oral nutrition following esophagectomy; A
multicentre clinical trial. The Annals of Thoracic Surgery
102(4), 1141-1148

References • Weijs TJ, Berkelmans GH, Nieuwenhuijzen GA, Ruurda JP,

Hillegersberg RV, Soeters PB, et al. (2015). Routes for
early enteral nutrition after esophagectomy. A systematic
review. Journal of Clinical Nutrition 34,1-6.
• Weijs TJ, van Eden HWJ, Ruurda JP, Luyer MDP,
Steenhagen E, Nieuwenhuijzen GAP, et al. (2017). Routine
jejunostomy tube feeding following esophagectomy.
Journal of Thorasic Disease, 9(8) 851-860.