Comparing early enteral versus parenteral nutrition in patients undergoing total gastrectomy – Systematic Review

Contents

Abstract           4 – 5

Introduction           6 – 9

Aims and hypotheses        10

Methods          11 – 17

Results          18 – 36

Discussion          37 – 40

Limitation          41 – 42

Conclusions          43 – 44 References                                                                                                                               45 – 50

Abstract

Total gastrectomy with roux-en-y oesophago-jejunal anastomosis for reconstruction remains the primary therapeutic method for resectable gastric cancer. Recent literature reported on the beneficial effect of early enteric feeding to facilitate early enteral nutrition. There is controversy in the literature regarding the optimal route of feeding post-total gastrectomy- total parenteral nutrition (TPN), early enteric feeding (EEN) with nasojejunal tube or oral diet on post-op day 2-3 as tolerable with support of intravenous fluid.

The aim of this systematic review is to compare differing feeding strategies in the early post-operative period for patients following curative total gastrectomy for malignancy.

A comprehensive search of medical databases including PubMed, Cochrane Library, ScienceDirect, CNKI were performed using the keywords “gastric cancer, total gastrectomy, supplemental tube enteric feeding, total parenteral feeding, NJ feeding”. Selection criteria: randomized controlled trials (RCTs) that compare TPN versus EEN feeding post-operatively for patient who undergone total gastrectomy. Post-operative complications and length of hospital stay were evaluated. Bariatrics surgery and sub-total gastrectomy patients are excluded. Animal studies are also rejected.

PRISMA Flow Diagram used as guidance to carry out this research. Began with identification of records through database search with keywords. Then followed by screening where duplicated studies will be removed. All studies will be screened for eligibility. Those which not matching inclusion criteria has been removed. Finally, inclusion where studies will be for qualitative synthesis. Results of trials are analysed individually under different outcome measures including post-operatively complication, length of hospital stay and cost effectiveness. Risk of bias chart generated by using RevMan5 software.

The main area of potentially difficult is due to some limitations in data analysis for example bias risk and heterogeneity among the included RCTs. Different discharge criteria due to geographical variation also leading to inconsistent outcome measurement. Total of 17 randomized clinical trials included in this systematic review which consisted of total 1093 patients with total gastrectomy. Results concluded that early post-total gastrectomy EEN reduces the length of hospital stay and post-operative infectious/non-infectious complication. EEN is also more cost-effective compare to TPN.

Introduction

Gastric cancer is 3^rd common cause of cancer death worldwide. [1] There are four main types of gastrectomy which all carried out under general anaesthetic – subtotal/partial gastrectomy, total gastrectomy, sleeve gastrectomy and oesophagogastrectomy. This surgery could be done either open or laparoscopically. Total gastrectomy with roux-en-y oesophago-jejunal anastomosis for reconstruction remains the primary therapeutic method for resectable gastric cancer. [2] Nutritional support to reduce morbidity and mortality in patient undergone total gastrectomy is vital and should be optimize to enhance recovery.

Figure 1: Total gastrectomy with Roux-en-y oesophagojejunal anastomosis for reconstruction.

Over the last 20 years, new concept perioperative care or referred to as “enhanced recovery after surgery” (ERAS) has been introduced and the main pillar of ERAS include early enteral feeding (EEN) after surgery. [3] National Institute for Health and Care Excellence (NICE) guideline (CG32) recommended enteral tube feeding for patient who are malnourished or at risk of malnutrition and due to major abdominal procedure unless contraindicated. [4]

Surgeons traditionally preferred total parenteral feeding as opposed to enteral route feeding after surgery, citing that to protect the newly formed anastomosis. Recent literature reported on the beneficial effect of early enteric feeding to facilitate early enteral nutrition (EEN). [5] There is controversy in the literature regarding the optimal route of feeding post-total gastrectomy- total parenteral nutrition (TPN), early enteric feeding with nasojejunal (NJ) tube or oral diet on post-op day 2-3 as tolerable with support of intravenous fluid.

There are still some practice around the world where surgeons not fully convinced that EEN is harmless to anastomoses. Traditionally post-operative management often involves TPN plus intravenous IV fluid for 7-10 days. Therefore, this patient’s population only commence oral diet or (NJ) tube feeding after fasting post total-gastrectomy for 5 – 7 days and this is detrimental to nutritional status of patient who had total gastrectomy. Therefore, this systematic review is to summarize the various studies published in major database comparing different feeding strategies in the early post-operative period which is vital for recovery of patients’ nutritional status. Hence, our first research question is “Is early enteral feeding better in nutritional support for recovery of post total gastrectomy patient compare to total parenteral feeding”

Early enteral nutrition was delivered via a needle catheter jejunostomy which usually commenced within 12 hour postoperatively starting with slow feeding rate and then increasing as tolerated by 10ml/h every 12 hour until maximum feed target feeding rate of 80ml/h was achieved. Intravenous fluid was administered in addition to maintain fluid balance closely.

Besides, there is also non-consistent studies finding whether NJ tube or jejunostomy created whilst on operation is preferred way of enteral feeding compare to early oral diet without NJ tube feeding. Hence this leading to second study question “Which is the preferred route of early enteral feeding? NJ tube feeding, jejunostomy feeding or oral diet?”

Figure 2: Various methods of enteral access (i.e.: nasojejunal tube, jejunostomy) for postoperative nutrition

Deficiencies in evidence around this subject leading to this systematic literature review project. This is to identify studies available electronically from multiple databases, to appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a given research question.

Aim and hypotheses

The aim of this systematic review is to compare differing feeding strategies in the early post-operative period for patients following total gastrectomy for stomach cancer.

Study Question 1

Is early enteral feeding better than total parenteral feeding for postoperative nutrition for patient underwent total gastrectomy?

Study Question 2

Which route of early enteral feeding is the best? Nasojejunal (NJ) feeding vs jejunostomy feeding vs purely oral diet

Methods

Protocol and registration

This systematic review was performed in accordance with the PRISMA guidelines through a systematic search in attempts to identify as much studies as possible. This review has been registered with the International Prospective Register of Systematic Review (PROSPERO). The registration of this systematic review can be found online at this Web address: https://www.crd.york.ac.uk/PROSPERO/registerreview.php Registration number 64479.

Eligibility Criteria

Selection criteria: Randomized controlled trials (RCTs) including prospective and retrospective randomized control trial, cohort studies of comparing enteral and parenteral nutrition post-operatively for patient who undergone total gastrectomy. PICO’s Criteria has been used to select trials to be included in systematic review.