Melanie Baker

Causes and management of a high‐output stoma

Aim  Patients with a high‐output stoma (HOS) (> 2000 ml/day) suffer from dehydration, hypomagnesaemia and under‐nutrition. This study aimed to determine the incidence, aetiology and outcome of HOS.

A randomised controlled trial of six weeks of home enteral nutrition versus standard care after oesophagectomy or total gastrectomy for cancer: report on a pilot and feasibility study

BackgroundPoor nutrition in the first months after oesophago-gastric resection is a contributing factor to the reduced quality of life seen in these patients. The aim of this pilot and feasibility study was to ascertain the feasibility of conducting a multi-centre randomised controlled trial to evaluate routine home enteral nutrition in these patients.MethodsPatients undergoing oesophagectomy or total gastrectomy were randomised to either six weeks of home feeding through a jejunostomy (intervention), or treatment as usual (control). Intervention comprised overnight feeding, providing 50 % of energy and protein requirements, in addition to usual oral intake. Primary outcome measures were recruitment and retention rates at six weeks and six months. Nutritional intake, nutritional parameters, quality of life and healthcare costs were also collected. Interviews were conducted with a sample of participants, to ascertain patient and carer experiences.ResultsFifty-four of 112 (48 %) eligible patients participated in the study over the 20 months. Study retention at six weeks was 41/54 patients (76 %) and at six months was 36/54 (67 %). At six weeks, participants in the control group had lost on average 3.9 kg more than participants in the intervention group (95 % confidence interval [CI] 1.6 to 6.2). These differences remained evident at three months (mean difference 2.5 kg, 95 % CI −0.5 to 5.6) and at six months (mean difference 2.5 kg, 95 % CI −1.2 to 6.1). The mean values observed in the intervention group for mid arm circumference, mid arm muscle circumference, triceps skin fold thickness and right hand grip strength were greater than for the control group at all post hospital discharge time points. The economic evaluation suggested that it was feasible to collect resource use and EQ-5D data for a full cost-effectiveness analysis. Thematic analysis of 15 interviews identified three main themes related to the intervention and the trial: 1) a positive experience, 2) the reasons for taking part, and 3) uncertainty of the study process.ConclusionsThis study demonstrated that home enteral feeding by jejunostomy was feasible, safe and acceptable to patients and their carers. Whether home enteral feeding as ’usual practice’ is a cost-effective therapy would require confirmation in an appropriately powered, multi-centre study.Trial registrationUK Clinical Research Network ID 12447 (main trial, first registered 30 May 2012); UK Clinical Research Network ID 13361 (qualitative substudy, first registered 30 May 2012); ClinicalTrials.gov NCT01870817 (first registered 28 May 2013)

A systematic review of the nutritional consequences of esophagectomy.

BACKGROUND & AIMS As improved outcomes after esophagectomy have been observed over the last two decades, the focus on care has shifted to survivorship and quality of life. The aim of this review was to determine changes in nutrition after esophagectomy and to assess the evidence for extended nutrition support. METHODS A search strategy was developed to identify primary research reporting change in nutritional status a minimum of one month after esophagectomy. RESULTS Changes in nutritional parameters reported by 18 studies indicated a weight loss of 5-12% at six months postoperatively. More than half of patients lost >10% of body weight at 12 months. One study reported a persistent weight loss of 14% from baseline three years after surgery. Three studies reporting on longer term follow up noted that 27%-95% of patients failed to regain their baseline weight. Changes in dietary intake (three studies) indicated inadequate energy and protein intake up to three years after surgery. Global quality of life scores reported in one study correlated with better weight preservation. There were a high frequency of gastrointestinal symptoms reported in six studies, most notably in the first year after surgery, but persisting up to 19 years. Extended enteral nutrition on a selective basis has been reported in several studies. CONCLUSIONS Nutritional status is compromised in the months/years following oesophagectomy and may never return to baseline levels. The causes/consequences of weight loss/impaired nutritional intake require further investigation. The role of extended nutritional support in this population remains unclear.

High-output stoma after small-bowel resections for Crohn's disease

Background A 56-year-old Caucasian woman with a history of Crohns disease and multiple bowel resections resulting in a loop jejunostomy was referred to our Nutritional Unit from a neighboring district general hospital for further management. She was first seen in October 2001, and initial assessment indicated that she was malnourished with fluid depletion, evidenced by the high volume of stomal fluid produced. There had been no sudden change in her medication, her Crohns disease was quiescent and there was no evidence of any intra-abdominal sepsis. Despite a high calorific intake through her diet, she continued to lose weight.Investigations Serum urea and electrolytes; magnesium; C-reactive protein; full blood count; urinary spot sodium; anthropometric measurements.Diagnosis High-output stoma with malabsorption as a consequence of repeated small-bowel surgery.Management The patient was treated with oral hypotonic fluid restriction (0.5 l/day), 2 l of oral glucose–saline solution per day, high-dose oral antimotility agents (loperamide and codeine phosphate), a proton-pump inhibitor (omeprazole) and oral magnesium replacement. A year later, the patients loop jejunostomy was closed and an end ileostomy fashioned, bringing an additional 35 cm of small bowel into continuity; macronutrient absorption improved but her problem of dehydration was only slightly reduced. She was stabilized on a twice-weekly subcutaneous magnesium and saline infusion and daily oral 1α-hydroxycholecalciferol.

Six weeks of home enteral nutrition versus standard care after esophagectomy or total gastrectomy for cancer: study protocol for a randomized controlled trial

BackgroundEach year approximately 3000 patients in the United Kingdom undergo surgery for esophagogastric cancer. Jejunostomy feeding tubes, placed at the time of surgery for early postoperative nutrition, have been shown to have a positive impact on clinical outcomes in the short term. Whether feeding out of hospital is of benefit is unknown. Local experience has identified that between 15 and 20% of patients required ‘rescue’ jejunostomy feeding for nutritional problems and weight loss while at home. This weight loss and poor nutrition may contribute to the detrimental effect on the overall quality of life (QoL) reported in these patients.Methods/DesignThis randomized pilot and feasibility study will provide preliminary information on the routine use of jejunostomy feeding after hospital discharge in terms of clinical benefits and QoL. Sixty participants undergoing esophagectomy or total gastrectomy will be randomized to receive either a planned program of six weeks of home jejunostomy feeding after discharge from hospital (intervention) or treatment-as-usual (control). The intention of this study is to inform a multi-centre randomized controlled trial. The primary outcome measures will be recruitment and retention rates at six weeks and six months. Secondary outcome measures will include disease specific and general QoL measures, nutritional parameters, total and oral nutritional intake, hospital readmission rates, and estimates of healthcare costs. Up to 20 participants will also be enrolled in a qualitative sub-study that will explore participants’ and carers’ experiences of home tube feeding.The results will be disseminated by presentation at surgical, gastroenterological and dietetic meetings and publication in appropriate peer review journals. A patient-friendly lay summary will be made available on the University of Leicester and the University Hospitals of Leicester NHS Trust websites. The study has full ethical and institutional approval and started recruitment in July 2012.Trial registrationUKClinical Research Network ID #12447 (Main study); UKCRN ID#13361 (Qualitative sub study); ClinicalTrials.gov #NCT01870817 (First registered 28 May 2013)

Muscle cramps are the commonest side effect of home parenteral nutrition.

BACKGROUND & AIMS Complications resulting from home parenteral nutrition (HPN) reduce a patients quality of life. The major complications of catheter-related sepsis, venous thrombosis and chronic liver disease are well recognised. This study aimed to determine if there were other minor, but common complications that caused patient distress. METHODS All patients (45) from four HPN centres were asked if they had suffered any side effects of parenteral nutrition and whether these side effects related to the timings of the feed or required specific intervention. RESULTS Muscle cramps were the most common minor side effect [12/45 (27%)]. A greater proportion of HPN patients (51%) suffered from muscle cramps than did a control group of patients with inflammatory bowel disease (24%) [p=0.0001]. In the HPN patients, no significant difference in serum electrolyte concentration or in feed composition was noted between those patients with and those without cramps in relation to feeds. Cramps were of sufficient severity to warrant pharmacological intervention in 9 of 12 patients who had cramps in relation to feeds, and parenteral nutrition administration was slowed in 2 of the 12. CONCLUSION Muscle cramps have a high prevalence in patients receiving home parenteral nutrition.

Patient and Family Caregivers’ Experiences of Living With a Jejunostomy Feeding Tube After Surgery for Esophagogastric Cancer

Background:Jejunostomy feeding tubes (JFTs) can be used to provide nutrition support to patients who have had surgery for esophagogastric cancer. Although previous research reports how patients cope with a gastrostomy tube, little is known about the impact of having a JFT. The aim of this qualitative study was to explore how patients and their informal caregivers experience living with a JFT in the first months following surgery. Methods: Participants were purposively sampled from a cohort of patients recruited to a trial investigating home enteral nutrition vs standard care after esophagogastric surgery for cancer. The sampling framework considered age, sex, and marital status. Informal caregivers were also invited to participate. Interviews were audio recorded, transcribed verbatim, and anonymized. Inductive thematic analysis was used to identify key themes related to living with a JFT. Results: Fifteen patient interviews were conducted; 8 also included a family caregiver. Analysis of the data resulted in 2 main themes: “challenges” and “facilitators” when living with a JFT. While “physical effects,” “worries” and “impact on routine” were the main challenges, “support,” “adaptation” and “perceived benefit” were what motivated continuation of the intervention. Conclusion: Findings suggest that participants coped well with a JFT, describing high levels of compliance with stoma care and the feeding regimen. Nonetheless, disturbed sleep patterns and stoma-related problems proved troublesome. A better understanding of these practical challenges, from the patient and family caregiver perspective, should guide healthcare teams in providing proactive support to avoid preventable problems.

Nutritional support and dietary interventions following esophagectomy: challenges and solutions

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Nutrient intake and contribution of home enteral nutrition to meeting nutritional requirements after oesophagectomy and total gastrectomy

Background/Objectives:This study evaluated nutrition after oesophago-gastric resection and the influence of home jejunostomy feeding in the six months after surgery.Subjects/Methods:Data on nutritional intake and physiologic measures were collected as part of a randomised trial with measurements taken before and up to six months after surgery.Results:A total of 41 participants (32 oesophagectomy, 9 total gastrectomy) received home jejunostomy feeding (n=18) or usual care without feeding (n=23). At hospital discharge, oral intakes were adequate for energy and protein in 9% and 6%, respectively. By three and six months, these values had increased to 61% and 55%, 94% and 77% respectively. Six participants (26%) who received usual care required rescue feeding. Six weeks after hospital discharge, energy intakes were met in those who received jejunal feeding because of the contribution of enteral nutrition. Jejunal feeding did not affect oral intake, being similar in both groups (fed: 77% estimated need, usual care: 79%). At three months, inadequate micronutrient intakes were seen in over one third. Compared to baseline values, six weeks after surgery, weight loss exceeding 5% was seen in 5/18 (28%) who received feeding, 14/17 (82%) who received usual care and 5/6 (83%) of those who required rescue feeding, P=0.002. Weight loss averaged 4.1% (fed), 10.4% (usual care) and 9.2% (rescue fed), P=0.004. These trends persisted out to six months.Conclusions:Supplementary jejunostomy feeding made an important contribution to meeting nutrition after oesophago-gastric resection. Importantly, oral nutritional intake was not compromised dispelling the assertion that jejunal feeding deincentivises patients from eating.

OC-113 Contribution of home jejunostomy feeding in meeting energy and protein requirements in the months following oesophagogastric resection for cancer

Introduction Nutritional intake is often compromised in the months following Oesophago-gastric resection. Studies evaluating the role of extended Jejunostomy feeding (JEJ) following hospital discharge are lacking. Method As part of a randomised controlled feasibility study, investigating 6 weeks of home JEJ feeding, energy and protein intake were assessed using 3 day dietary records, analysed using Dietplan6®. Information on JEJ intake and body weight were collected for the same period. Nutritional requirements for energy (Henry equation adjusted for activity level) and protein (1.25 g/kg/d) were calculated. Oral intake was considered adequate if reported intake provided >75% of estimated requirements. Results 54 participants were enrolled. There were 13 early withdrawals leaving 41 for analysis (Oesophagectomy, 32: Total Gastrectomy, 9). 20 participants were randomised to a planned program of home JEJ feeding providing ≥50% of energy and protein requirements, in addition to usual dietary intake. 21 participants in the control group received care as usual with JEJ feeding being stopped on hospital discharge, 7 of which (35%) had to recommence home feeding due to clinical and/or nutritional need. At 6 weeks post hospital discharge, oral energy intake was inadequate in 47% and 50% of the intervention and control group respectively. >5% weight loss was observed in 18/21 (86%) of the control group and 7/20 (35%) of the intervention group. Total calorie intake was adequate in the intervention group up to 3 months because of the contribution from JEJ feeding. Provision of JEJ did not seem to negatively impact on oral intake. At 3 and 6 months post-surgery, further weight loss was seen, and mean energy intakes did not meet 100% of estimated needs in the control group.Abstract OC-113 Table 1 6 wk post discharge 3 months post op 6 months post op Intervention Control Intervention Control Intervention Control Wt loss ≥5% 7/20, 35% 18/21, 86% 9/18, 50% 18/21, 86% 12/16, 75% 18/21, 86% ≥10% 2/20, 10% 10/21, 48% 6/18, 33% 13/21, 62% 8/16, 50% 14/21,67% Energy* Oral 83% (20) 68% (23) 86% (26) 81% (21) 113% (35) 95% (19) JEJ 49% (35) 24% (36) 18% (34) 16% (39) 0 7% (23) Protein* Oral 75% (24) 60% (24) 82% (31) 74% (25) 109% (35) 85% (16) JEJ 46% (30) 21% (35) 16% (29) 13% (33) 0 6% (20)* expressed as a% of estimated requirements (mean, SD) Conclusion This study has shown that oral energy/protein intakes are frequently inadequate in patients after Oesophagectomy/Total Gastrectomy and weight loss is observed. Supplementary JEJ feeding may make an important contribution to nutritional requirements and weight preservation in these early months. Further larger scale studies are required to fully evaluate this treatment. Disclosure of interest M. Baker: None Declared, V. Halliday: None Declared, A. Ring: None Declared, D. Bowrey Grant/ Research Support from: Nutricia/Fresenius Kabi.