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  • The nutrition support team NST estimated his nutritional sta

    2019-06-12

    The nutrition support team (NST) estimated his nutritional status and began the intervention. An inadequate calorie intake (due to swallowing difficulty) induced malnutrition in the patient; his bodyweight (BW) loss exceeded 8% in 3 months, his body mass index (BMI) was 21 kg/m2, triceps skinfold thickness (TSF) was 5.7 mm, arm circumference (AC) was 20 cm, the serum albumin level was 2.7 g/dL, the PG-SGA was 13, and poor nutrient intake reduced the patient\'s food intake to approximately 10 kcal/kg BW. While surgery remains the primary option for operable esophageal cancer cases, early postoperative enteral feeding and various routes of feeding remain debatable topics. The NST administered an EN formula with an elemental diet (Peptamen) through the jejunostomy tube (J tube) and provided meals according to the patient\'s digestive status. For nutritional adequacy and the intestinal tolerance of a balanced peptide-based elemental diet, enteral feeding by gravity was set at 120 mL of the formula/meal, 5 meals per day (600 kcal/600 cc/d or 10 kcal/kg BW), and was gradually increased to 300 mL of the formula/meal, 6 meals per day (1800 kcal/1800 cc/d or 30 kcal/kg BW). Within 1 month, the feeding rate was gradually increased from 200 to 1800 cc/d over a 4–6-day period. The patient relied on tube feeding for the majority of the nutrition requirements during treatment, and we found that his swallowing function improved within weeks, and he regained the ability to eat certain soft solid and liquid foods (Fig. 3). After 1 month, his PG-SGA score improved from 13 to 5, and the total retinoid x receptor intake (including oral feeding) was increased from 10 to 30 kcal/kg BW. His BMI increased to 22 kg/m2 (BW = 62.5 kg) (Fig. 4), TSF to 7.0 mm, AC to 21.7 cm, and serum albumin level to 3.1 g/dL. His wound healed completely. Intensive nutritional support improved PG-SGA scores from 13 to 5 by improving his dietary intake, quality of life, and BW, and the Global Assessment grade improved from B to A.
    Discussion Most epidemiological studies have identified smoking tobacco and drinking alcohol as the main risk factors for esophageal squamous cell carcinoma or unspecified esophageal cancer, usually with a monotonic and strong dose–response relationship. Prevention includes smoking cessation and eating a healthy diet. Avoiding tobacco and alcohol is one of the best approaches to limiting the risk of esophageal cancer. In our case, the patient expressed a desire for smoking cessation and to learn more about a healthy diet. Traditional postoperative care for patients undergoing major gastrointestinal (GI) surgery involves bowel rest and the avoidance of enteral feeding (nil via oral). Early EN after major GI surgery has recently received considerable attention. Sagar et al (1979) examined the enteral diet in the early postoperative period against conventional therapy after major GI surgery, and found that EN group patients fared considerably better compared with conventional group patients, both clinically and metabolically, and these patients lost less weight. The authors strongly recommended an early enteral diet for quicker recovery and a shorter hospital stay. Semi-elemental formulas contain peptides of varying chain lengths and fat primarily as medium chain triglycerides (MCT). The di- and tripeptides of semi-elemental formulas have specific uptake transport mechanisms and are thought to be absorbed more efficiently than individual amino acids or whole proteins, the nitrogen sources in elemental and polymeric formulas respectively. Silk et al found that individual and free amino acid residues, as found in elemental formulas, were poorly absorbed while amino acids provided as dipeptides and tripeptides were better absorbed. A randomized study reported that EN definitely reduces infection-related and other postoperative complications. In a meta-analysis, Lewis et al concluded that early EN was beneficial compared with delayed EN in relation to postoperative complications, hospital stay, and mortality. Although many challenges exist when caring for esophageal cancer patients at our hospital, Registered dietitians (RDs) follow patients during hospitalization through scheduled clinic visits. RDs choose a peptide-based elemental formula that is fed at a low rate through a bag, and advance the feeding rate gradually over several days to prevent feeding complications. Our patient tolerated early enteral feeding well, and recovery was satisfactory, as shown by the improvements in BMI, TSF, AC, serum albumin, and PG-SGA score.