Early feeding after esophagectomy may be too early
The timing of resuming oral diet after esophagectomy is controversial, with little experimental evidence supporting the strategies of early (within the first 2 postoperative days) and conventional (after the fifth postoperative days). Weijs and colleagues have recently reported the results of a longitudinal study of feeding after minimally invasive Ivor Lewis esophagectomy, comparing a group of 50 patients in whom feeding was started early to a retrospective cohort of 50 patients, in whom feeding was delayed until postoperative days 4–7. The primary endpoints, anastomotic leak and pneumonia, were not statistically different in the two groups, the authors conclude that immediate resumption of oral nutrition not increase complications compared to the retrospective cohort.
This conclusion should be considered in light of the results of this trial, as compared to other trials. While the mortality rate of 2% in both groups is excellent, the anastomotic leak rates in both groups are relatively high, particularly in the delayed nutrition group (24%). Furthermore, the pneumonia rates were also high, 28% and 40% in the early and late groups, respectively, as compared to 14% in a larger trial using a prospective database (1). Finally, the study does not attempt to evaluate the complication of early feeding that many experienced surgeons seek to avoid: early conduit distention. Early oral nutrition may be of some value, but if this is achieved at the cost of poor gastric emptying permanently, the overall result is poor.
A prospective randomized trial that compares early to delayed oral feeding would better answer the question than a longitudinal comparison, but the study would need to include analysis of swallowing and gastric emptying for years after surgery. Until then, there is no evidence that early oral feeding is beneficial, as compared to appropriate use of feeding jejunostomy.
Acknowledgements
None.
Footnote
Provenance: This is an invited Commentary commissioned by the Section Editor Feichao Bao (Department of Thoracic Surgery, The First Affiliated Hospital, Zhejiang University, Hangzhou, China).
Conflicts of Interest: The author has no conflicts of interest to declare.
References
- Berry MF, Atkins BZ, Tong BC, et al. A comprehensive evaluation for aspiration after esophagectomy reduces the incidence of postoperative pneumonia. J Thorac Cardiovasc Surg 2010;140:1266-71. [Crossref] [PubMed]
