Background Malnutrition is highly prevalent in patients with Upper Gastrointestinal (UGI) cancer and is associated with poor outcomes. However, there are no evidence-based guidelines for nutrition support specific to UGI cancer surgery. Methods Databases including MEDLINE, PUBMED, CINAHL, Web of Science, Cochrane Central and Clinicaltrials.gov were systematically searched. Abstracts of studies investigating the effect of preoperative nutrition support on nutritional status, functional status, body composition, quality of life and treatment outcomes in adult patients undergoing oesophageal, gastric or pancreatic cancer resection were identified. Screening of studies, quality assessment using the Downs and Black checklist, data extraction, and appraisal of evidence using GRADE were performed by two reviewers. Due to heterogeneity of the studies, results were synthesised narratively. The protocol was registered in PROSPERO (CRD42018111930). Results Nine studies with a total of 442 oesophageal and 418 gastric patients were included. Individualised dietary counselling, and enteral feeding in neoadjuvant therapy for oesophageal cancer demonstrated positive effects for weight maintenance and surgical complications, however the GRADE evidence quality was very low. Preoperative nutrition support in gastric cancer decreased the incidence of surgical site infections, length of stay and hospital costs, but GRADE assessment was unable to be completed due to only one study reporting on each outcome measure. Conclusions This review demonstrates the lack of strong evidence to determine the most optimal methods of nutrition support prior to UGI cancer resection. Current surgical oncology guidelines should be utilised until further research from high quality trials enable the development of specific clinical practice guidelines.

A systematic review of the effect of preoperative nutrition support on nutritional status and treatment outcomes in upper gastrointestinal cancer resection

This narrative review aims to evaluate the evidence for the different nutritional approaches employed during neoadjuvant therapy in patients with loco-regional esophageal cancer. Patients with esophageal cancer are often malnourished and difficult to optimise nutritionally. Whilst evidence suggests neoadjuvant therapy can offer a survival advantage, associated toxicity can exacerbate poor nutritional status. There is currently no accepted standard of care regarding optimal nutritional approach.A systematic literature search was undertaken. Studies describing the utilization of an additional nutritional intervention in patients with esophageal cancer receiving neoadjuvant therapy prior to esophagectomy were included. Primary outcome measure was 30-day postoperative mortality after esophagectomy. Secondary outcome measures were loss of weight during neoadjuvant therapy, completion rate of intended neoadjuvant therapy, complications from nutritional intervention, 30-day postoperative morbidity after esophagectomy and quality of life during neoadjuvant treatment. Given the heterogeneity of retrieved articles results were presented as a narrative review.Twenty-five studies were included of which 16 evaluated esophageal stenting, four feeding jejunostomy, three gastrostomy, one naso-gastric feeding, and one comparative study of esophageal stenting to feeding jejunostomy. 30-day postoperative mortality was only reported in two of the 26 included studies limiting comparison between nutritional strategies. All studies of esophageal stents reported improvements in dysphagia with reported weight change ranging from -5.4kg to + 6kg but none reported 30-day postoperative mortality. In patients undergoing oesophageal stenting for their neoadjuvant treatment overall migration rate was 29.9%. Studies of laparoscopically inserted jejunostomy were all retrospective reviews that demonstrated an increase in weight ranging from 0.4 to 11.8kg and similarly no study reported 30-day post-operative mortality. Only one comparative study was included that compared esophageal stents to jejunostomy. This study reported no significant difference between the two groups in respect to complication rates (stents 22% vs jejunostomy 4%, P = 0.11) or increase in weight (stents 4.4kg vs jejunostomy 4.2kg, P = 0.59). Quality of life was also poorly reported.This review demonstrates the uncertainty on the optimal nutritional approach for patients with resectable esophageal cancer undergoing neoadjuvant treatment prior to esophagectomy. A prospective, multicenter, observational cohort study is needed to determine current practice and inform a prospective clinical trial.

Nutritional optimization during neoadjuvant therapy prior to surgical resection of esophageal cancer - A narrative review.

Enteral nutrition and quality of life in patients undergoing chemoradiotherapy for esophageal carcinoma: a comparison of nasogastric tube, esophageal stent, and ostomy tube feeding

Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET).

Purpose Esophageal stenting is often considered to relieve dysphagia in patients with locoregionally advanced esophageal cancer. We sought to determine the effects of stenting on the incidence of acute toxicity and oncologic outcomes in patients undergoing chemoradiation therapy (CRT). Methods and Materials The data from patients treated with curative intent CRT for locoregionally advanced esophageal cancer at the University of Utah were retrospectively analyzed. The χ2 or Fisher exact test was used to compare the demographic and tumor characteristics between patients with and without esophageal stenting before RT. Univariate and multivariate analyses using logistic regression modeling were used to identify the predictors of acute toxicities. A propensity score–matched analysis with shared frailty Cox hazard regression was performed according to stent status to identify the stent effect on survival. Acute toxicities were graded using the Common Terminology Criteria for Adverse Events, version 4. Results From 2005 to 2013, 103 consecutive patients received CRT. Of the 103 patients, 28 had a stent in place during CRT. The median dose was 50.4 Gy for all patients. Grade ≥3 acute toxicities were seen in 71% of the stent versus 27% of the no-stent patients (P Conclusions In patients undergoing CRT with curative intent, esophageal stenting was associated with significantly increased grade ≥3 acute toxicities, fewer patients proceeding to esophagectomy, and worse overall survival.

Toxicity and Outcomes in Patients With and Without Esophageal Stents in Locally Advanced Esophageal Cancer

Purpose.To determine whether self-expanding plastic stent (SEPS) placement significantly improves quality of life and maintains optimal nutrition while allowing full-dose neoadjuvant therapy (NAT) in patients with esophageal cancer. PatientsandMethods. Aprospective,dual-institution,singlearm, phase II (http://ClinicalTrials.gov: NCT00727376) evaluation of esophageal cancer patients undergoing NAT prior to resection. All patients had a self-expanding polymer stent placed prior to NAT. The European Organisation for ResearchandTreatmentofCancerQLQ-C30andQLQ-OG25, Functional Assessment of Cancer Therapy–Anorexia, and Functional Assessment of Cancer Therapy–General surveys were administered prior to stenting, within 1 week post-stent placement, and at the completion of neoadjuvant therapy. Results. Fifty-two patients were enrolled; 3 (5.8%) had stent migrations requiring replacement.There wereno instances of esophageal erosion or perforation. All patients received some form of neoadjuvant therapy.Thirty-six (69%) received chemoradiation;34(93%)ofthesepatientsreceivedtheplanneddose ofchemotherapy,and27(75%)receivedthefullplanneddoseof radiotherapy. There were 16 (31%) patients receiving chemotherapyalone;12 (74%) ofpatients in thechemotherapy-alone group completed the planned dose of therapy. Conclusion. Placement of SEPS appears to provide significant improvement in qualityof life relatedtodysphagia andeating restriction in patients with esophageal cancer undergoing neoadjuvant therapy. Consideration of SEPS instead of percutaneous feeding tube should be initiated as a first line in dysphagia palliation and NAT nutritional support. The Oncologist 2014;19:1–7

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Evaluation of Quality of Life Following Placement of Self-Expanding Plastic Stents as a Bridge to Surgery in Patients Receiving Neoadjuvant Therapy for Esophageal Cancer

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Evaluation of Quality of Life Following Placement of Self-Expanding Plastic Stents as a Bridge to Surgery in Patients Receiving Neoadjuvant Therapy for Esophageal Cancer