Outcomes following interventions to sustain body weight in esophageal cancer patients starting preoperative therapy: a retrospective cohort study

Abstract

Background: To improve nutritional status and dysphagia, esophageal cancer patients starting neoadjuvant therapy in advance of curative-intent surgery may receive a jejunostomy tube (J-tube) or esophageal stent, or they may be managed without a feeding modality. We examined percent total weight loss (%TWL), reinterventions, and progression to surgery in relation to these options. Methods: The retrospective cohort study included stage II-III esophageal cancer patients diagnosed during 2010-2017 who received J-tube, stent, or nutritional counseling only, without a procedure, when starting chemotherapy or combined modality chemoradiation. Data were obtained from the electronic medical record and chart review. We compared median %TWL between intervention groups and reinterventions using Chi-square and Kruskal-Wallis tests. Results: Among the 366 patients, median %TWL reached a nadir at 120 days, when it was 7% for patients with no procedure (N=307), 4% for J-tube (N=39), and 16% for stent (N=20) (P=0.01). Individual case analysis revealed 72-80% of the patients in the three groups started chemotherapy or chemoradiation as neoadjuvant curative-intent therapy (P difference=0.79). In J-tube patients, the reasons for intervention was anticipation of weight loss in 49% and mitigation of actual weight loss in 15%, whereas 95% of stent patients received the stent for dysphagia (P<0.001). A complication of the procedure was recorded in 85% of stent patients and 74% of J-tube patients (P<0.001). Among those who received no procedure initially, 25% received one later, compared with 15% of J-tube patients and 70% of stent patients who received a second procedure (P<0.001). Progression to surgery was observed in 65% of patients with no procedure, 51% of patients with J-tube, and 40% of stent patients, P=0.28). Conclusions: For stage II-III esophageal cancer patients starting chemotherapy, this study gives evidence that stents were associated with significant %TWL and risk of reintervention. Although J-tube patients returned to baseline weight sooner than those with no procedure, they experienced complications from their J-tubes. For esophageal cancer patients undergoing curative-intent treatment and with acceptable levels of weight loss, no procedure at all may be superior to placing a J-tube in terms of complications, weight loss, and progression to curative-intent surgery.

Preoperative Esophageal Stenting and 5-Year Survival in Patients Undergoing Esophagectomy for Esophageal Cancer: a Population-Based Nationwide Study from Finland

“… 9 In the recent retrospective study comparing stent and feeding jejunostomy, patients with jejunostomy returned to baseline weight faster, but both groups experienced high complication rates. 31 In our series, 6.7% of stented patients suffered a perforation but this number needs to be compared with complications rates of jejunostomy. A direct comparison between different nutritional strategies in randomized controlled setting is needed before one feeding route can be declared superior to another.…”