January 2012 Issue

Nutrition Support for Esophageal Cancer Patients — Strategies for Meeting the Challenges While Improving Patient Care
By Theresa Fessler, MS, RD, CNSC, and Carole Havrila, RD, CSO
Today’s Dietitian
Vol. 14 No. 1 P. 28

Kim, age 49, presents with swallowing difficulties and a 20-lb weight loss that occurred over the past six months. Her physician’s diagnostic workup reveals adenocarcinoma of the esophagus. Before starting chemoradiation therapy, the surgical team places a portacath (central IV line) and a jejunostomy feeding tube (J tube) so Kim can receive enteral nutrition (EN). The physician’s goal is to eventually perform an esophagectomy.

As Kim’s treatments progress, she experiences nausea and diarrhea. She decreases her intake of food and even liquids as her throat pain worsens. An RD reduces the rate of Kim’s tube feedings due to complaints of fullness and nausea. Over the course of therapy, Kim loses an additional 11 lbs, and she needs to improve her nutritional status and strength before surgery.

Scenarios such as this are common, and they present a huge challenge for RDs to ensure adequate oral nutrition and EN. According to the American Cancer Society, there were an estimated 17,000 esophageal cancer cases last year. Esophageal cancer is three to four times more prevalent in men than in women, with a lifetime risk of approximately one in 125 for men and one in 400 for women.1 The five-year survival rate for esophageal cancer patients is approximately 16%2 for all stages, and in cases of early-stage disease, it can be up to 37%.1 

The rate of malnutrition in this population is as high as 78.9%, and weight loss often continues throughout treatment.3 Esophageal tumors can cause dysphagia, epigastric or retrosternal pain, odynophagia, and regurgitation.2,4 Gastrointestinal (GI) side effects of chemotherapy and radiation worsen the ability to tolerate oral food and tube feeding.

While there are many challenges to caring for these patients, this article will discuss how RDs can play an integral role in their successful recovery by recognizing malnutrition, managing GI complications, monitoring nutritional adequacy, and guiding the transition from tube feeding to an oral diet.

Treatment and Associated Side Effects
The treatment course for esophageal cancer depends on tumor location, size, and stage. Some patients undergo esophagectomy followed by chemotherapy or chemoradiation, and others receive neoadjuvant chemotherapy and radiation before esophagectomy.2 Typically, patients spend seven to 10 days in the hospital and continue the remainder of treatment as outpatients. Some people with extensive disease who aren’t candidates for aggressive treatment will receive palliative therapy to improve dysphagia to allow them to eat.2 Sometimes physicians use esophageal stents to relieve obstruction and allow for soft solid and liquid food intake.5

Chemotherapy agents most commonly used for esophageal cancer include cisplatin, 5-fluorouracil, epirubicin, capecitabine, and Taxotere. Side effects include anorexia, nausea, vomiting, diarrhea, and mouth sores. Scheduled antiemetics, antidiarrheals, and pain medicines along with dietary adjustments help manage these symptoms. Concurrent radiation therapy is common. Patients receive weekly radiation treatments for six to seven weeks, and side effects of esophagitis and worsening dysphagia typically are experienced by the second week. Patients use narcotic pain medications and cocktails that contain lidocaine to help manage these symptoms.2

At our health system in Virginia, RDs follow patients during their hospitalization and outpatient treatment course through scheduled clinic visits and telephone follow-up.

Enteral Nutrition Support
During and after therapy, the healthcare team provides patients with EN because the upper GI tract can no longer receive full nutrition. Dietitians should recommend parenteral nutrition (PN) only if the small bowel isn’t functional or if enteral access isn’t possible.2,3  The goals of EN include nutritional repletion, hydration, weight maintenance or gain (as appropriate), improvement in energy levels, and postoperative wound healing. Many patients rely on tube feeding for the majority of their nutrition needs during treatment. Others find that swallowing function improves within weeks of starting chemoradiation due to tumor shrinkage, and they regain their ability to eat.2 

Typically, surgeons place J tubes either before chemotherapy and radiation or during the esophagectomy procedure. J tubes allow early postoperative feeding beyond the area of surgical anastamosis and are preferred to gastrostomy tubes because a gastrostomy could complicate the surgeon’s use of the stomach to form a new esophagus.2 In a 2009 prospective study of 204 postesophagectomy patients published in World Journal of Surgery, Gupta reported that J tube feeding provided effective, early postoperative nutrition and prolonged support for those who had anastamotic leak or other complications, and that more than 84% of study participants had no feeding complications.

RDs should choose a high-protein formula fed at a low rate through a pump and advance the feeding gradually over several days. A 1.5 kcal/mL (instead of 1 kcal/mL) product can offer more nutrition when the rate is low during the early post-op period. When EN tolerance is established, patients are transitioned to nocturnal feeding cycles. In our experience, most patients at home prefer to receive EN at night to be free of the feeding pump and to have less fullness when advancing to an oral diet during the day.

Refeeding syndrome is a risk for patients who’ve lost a significant amount of body weight and for those with little or no nutritional intake for at least seven days or who’ve used alcohol excessively. These extremely malnourished patients should be underfed for several days to prevent dangerous intercellular shifts in potassium, magnesium, and phosphorus levels. In these cases, RDs should adjust caloric intake gradually over three to five days if serum electrolyte levels are in normal range and provide extra vitamin supplementation.6

Twenty-five to 30 kcals/kg is usually sufficient for weight maintenance; however, if the patient must gain weight, energy needs can be as high as 35 to 40 kcals/kg. Protein requirements are generally 1.5 g/kg.7 Water, in the amount of 30 mL/kg, is sufficient, but more may be needed if patients have diarrhea or chest tube drainage or if they’re thirsty. RDs should ensure patients are receiving adequate water intake and the goal amount of EN formula.

In addition to closely monitoring oral and EN intake pre- and post-op, RDs help manage feeding-related complications following surgery.

Postsurgical Feeding-Related Complications
The most common postsurgical complications are anastamotic leak, which delays the ability to advance an oral diet until it heals or is repaired and, less commonly, esophageal stricture, which may require dilation.4,8

Rarely, injury occurs to the thoracic duct, causing chylothorax, or leakage of chyle. Chyle is a white fluid that contains 5 to 30 g of fat per liter, most of which is triglycerides; 20 to 30 g of protein per liter; lymphocytes; electrolytes; and fat-soluble vitamins, among other components. The fat content comes from intestinal lacteals after digestion and the absorption of long-chain fatty acids. Chyle normally enters the bloodstream via the thoracic duct. Chyle leakage is drained via a chest tube or thoracentesis, and patients lose the fluid and nutrients that it contains.9

The treatment goal for chylothorax is to limit dietary fat to minimize chyle flow and promote spontaneous healing. If closure doesn’t occur on its own, the patient may need surgery. A nearly fat-free diet high in protein and carbohydrate typically is well tolerated. The EN product used for a patient with a chyle leak must be a low-fat, elemental-type formula that’s very low in long-chain fatty acids and contains a significant proportion of fat content in the form of medium-chain triglycerides (MCTs). MCTs are absorbed in the intestine and transported to the portal system without entering the lymphatic system. In some cases, PN may be required if chyle drainage doesn’t subside.9

Gastrointestinal Complications
While not as serious or potentially life threatening as postsurgical feeding-related complications, managing GI problems is another challenge. Complaints we often hear from caregivers are “I can only get four cans of EN into him. He complains he’s too full and bloated” or “She’s nauseated. What can I do?” Patients often say, “I have bowel movements every day, but they’re watery. I think the tube feeding is causing my diarrhea.”

If RDs have knowledge of the postoperative anatomy, they can better understand the GI complications patients encounter. For example, the stomach is smaller and no longer in its original position. Dumping syndrome can occur in some patients due to rapid emptying of ingested food into the duodenum, causing nausea and diarrhea.8 Conversely, gastric emptying is slowed in some patients because the vagus nerve is transected during the esophagectomy procedure. Pyloromyotomy or pyloroplasty often are performed to help facilitate gastric emptying, but these procedures don’t always eliminate nausea and bloating and, in some cases, may even contribute to dumping syndrome.10 In addition, gastric reflux is more likely to occur because of the lack of a gastroesophageal sphincter.2

Even though most of these complications relate to gastric function, often dietitians hear more complaints about tolerance of EN through a J tube, which is generally worse for patients on chemotherapy.     

When bloating, fullness, or nausea occur, RDs can make several adjustments to the EN regimen. They can decrease the feeding rate, use two shorter feeding cycles instead of one longer cycle, choose a more concentrated formula to decrease volume, elevate the patient’s upper body, and recommend antinausea medications. Patients who complain of bloating and gas sometimes better tolerate fiber-free formulas. RDs should ask patients about bowel regularity. Use of adequate water flushes and sometimes fiber can help. Some patients have received prune juice through the J tube to relieve constipation. If needed, physicians can order stool softeners or laxatives.

If diarrhea is an issue, RDs should first evaluate the medication list, as several can cause loose stools. They should ensure patients aren’t using stool softeners or laxatives, decrease or eliminate enteral potassium and magnesium supplements, and use crushed tablets instead of liquid sorbitol-containing medications when possible. Also, dietitians can recommend physicians test for infection, such as Clostridium difficile. If infection is ruled out, the doctor can order antidiarrheal medications. Physicians can prescribe antibiotics in the case of small bowel bacterial overgrowth. RDs can advise adding soluble fiber, slowing the feeding rate, dividing the EN regimen into two smaller feeding cycles, and using elemental EN formulas if they suspect maldigestion.11

Oral Diet Advancement
After an esophagectomy, patients must receive nothing by mouth for one week. Once the surgery team has ruled out anastamotic leak, the diet is advanced to clear and then full liquids. Patients may be discharged on full liquids and remain on this diet for one week until advancement to the postesophagectomy diet. Near the time of hospital discharge, RDs educate patients and caregivers about the home EN regimen and oral diet advancement.

The postesophagectomy diet consists of small, frequent meals of soft, moist foods that are easy to swallow and don’t become tough or gummy (such as meats and breads) and the avoidance of carbonated beverages. If dumping syndrome occurs, patients should avoid sugars and limit fluids with meals. The patient should keep his or her upper body elevated during and after eating to reduce reflux.2 

RDs monitor patients’ weight, tolerance, and appetite as they advance their oral diet.  Typically, we ask patients or caregivers to decrease the intake of EN tube feedings by one can per night for several days. If oral intake improves and weight stabilizes or increases (depending on individual goals), we ask patients to decrease tube feedings by an additional can per night until they’re completely weaned off EN. Later, other foods are reintroduced at the surgeon’s discretion.

Immunonutrition
Some evidence has supported the use of immunomodulating EN formulas to reduce postoperative infectious morbidity and hospital length of stay for patients who have elective GI surgery. These formulas contain added nutrients such as arginine, omega-3 fatty acids, and nucleotides. In a 2011 review, “Immunonutrition in Patients Undergoing Esophageal Cancer Resection,” published in Diseases of the Esophagus, Mudge and colleagues found that there are few studies and even fewer randomized controlled trials (RCTs) that have examined immunonutrition for postesophagectomy patients. Of the RCTs published, study sample sizes are too small to draw definitive conclusions about clinical outcomes. To prove that immunonutrition is beneficial for esophageal cancer patients, more research is needed in the form of RCTs with sufficient sample sizes and isonitrogenous and isocaloric EN control groups to evaluate relevant outcomes.

Esophageal cancer and its treatment can cause severe and complex nutrition issues. But the good news is that early intervention by RDs and consistent nutrition follow-up throughout the treatment course can help patients transition to successful recoveries.

— Theresa Fessler, MS, RD, CNSC, is a nutrition support specialist at the University of Virginia Health System in Charlottesville and a freelance writer.

— Carole Havrila, RD, CSO, is an oncology nutrition specialist at the University of Virginia’s Emily Couric Clinical Cancer Center in Charlottesville.

 

Risk Factors for Esophageal Cancer1
• Squamous cell: Alcohol use, cigarette smoking, and other tobacco use                  

• Adenocarcinoma: Gastroesophageal reflux disease and Barrett’s esophagus

• Other risk factors: Obesity and low fruit and vegetable intake

 

Terms and Definitions8
• Esophagectomy: Surgical removal of the cancerous area of the esophagus 

• Esophageal reconstruction: After esophagectomy, the stomach is pulled upward in the thorax to join the shorter remnant of the esophagus (sometimes called gastric pull-up). In some situations, the stomach can’t be used, and a portion of the colon, or jejunum, is used to create a neoesophagus, called colonic interposition or jejunal interposition.

• Partial gastrectomy: Removal of part of the stomach. This is done if the esophageal tumor is at the lower end of the esophagus or if the cancer has spread into the stomach.

• Pyloromyotomy: Incision of the longitudinal and circular muscles of the pylorus to help the stomach empty into the small bowel

• Pyloroplasty: Incision and resuturing of the pylorus to widen the pyloric outlet

• Vagus nerve: Tenth cranial nerve with 13 main branches for parasympathetic control of multiple vital organs, including the larynx, trachea, bronchi, lungs, heart, and most of the gastrointestinal system

— Additional information taken from The FreeDictionary Medical Dictionary (http://medical-dictionary.thefreedictionary.com)

 

References
1. American Cancer Society. Esophagus cancer. http://www.cancer.org/Cancer/EsophagusCancer/DetailedGuide. Accessed November 2011.

2. Kight CE. Nutrition considerations in esophagectomy patients. Nutr Clin Pract. 2008;23(5):521-528.

3. Baker A, Wooten LA, Malloy M. Nutritional considerations after gastrectomy and esophagectomy for malignancy. Curr Treat Options Oncol. 2011;12(1):85-95.

4. Herbella FAM, Patti MG. Esophageal cancer treatment and management: medical care. http://emedicine.medscape.com/article/277930-treatment. Updated September 2, 2011. Accessed October 29, 2011.

5. Bower MR, Martin RC 2nd. Nutritional management during neoadjuvant therapy for esophageal cancer. J Surg Oncol. 2009;100(1):82-87.

6. Kraft MD, Btaiche IF, Sacks GS. Review of the refeeding syndrome.  Nutr Clin Pract. 2005;20(6):625-633.

7. Roberts S, Mattox T. Cancer. In: The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach—The Adult Patient. Silver Spring, Md.: American Society for Parenteral and Enteral Nutrition; 2007, pp 649-675.

8. Law S, Wong J. Cancer of the esophagus. In: Zinner MJ, Ashley SW. (eds.) Maingot’s Abdominal Operations, 11th ed. New York: McGraw-Hill; 2007.

9. McCray S, Parrish CR. Nutritional management of chyle leaks: an update. Practical Gastroenterology. 2011;35(4):12-32.

10. Lanuti M, de Delva PE, Wright CD, et al. Post-esophagectomy gastric outlet obstruction: role of pyloromyotomy and management with endoscopic plyloric dilatation. Eur J Cardiothorac Surg. 2007;31(2):149-153.

11. Malone AM, Seres DS, Lord L. Complications of enteral nutrition In: The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach—The Adult Patient. Silver Spring, Md.: American Society for Parenteral and Enteral Nutrition; 2007, pp. 246-263.