Postoperative Nutritional Therapy
After major visceral surgical procedures, early postoperative enteral nutrition should be aimed for [1, 2]. The S3 guideline on Diagnosis and Therapy of Squamous Cell Carcinomas and Adenocarcinomas of the Esophagus states [3]:
"After esophagectomy, due to the metabolic risk, enteral nutrition should be started within 24 h. Parenteral supplementation can be recommended if less than 60–75 % of the energy amount can be provided enterally (EK)".
In patients with already manifest malnutrition or those without malnutrition who are expected to be unable to take oral nutrition for more than 7 days postoperatively, there is an indication for artificial nutrition. The indication also exists in patients who are unable to consume more than 60 – 75 % of the recommended energy amount orally for more than 10 days. In these patients, artificial nutrition should be started immediately, preferably enterally [1, 3].
The advantages of early postoperative enteral nutrition have been demonstrated by several meta-analyses [1, 4]. Since early oral nutrition is not possible after esophagectomies, it is recommended to implant a transnasal feeding tube with the tip in the jejunum or as a catheter jejunostomy (CJ) intraoperatively [5].
For the implementation of safe and long-term enteral nutrition after esophagectomies via a CJ, significant advantages were shown in an observational study, particularly in the case of anastomotic insufficiency [4]. Another study on early enteral nutrition after esophagectomy showed no difference in catheter-associated risks between a nasoduodenal tube and the CJ [5]. Since nasoduodenal and nasojejunal tubes dislocate significantly more frequently, the CJ is superior for long-term nutrition [6]. With standardized technique and appropriate expertise, open and laparoscopic placement of the CJ has a low complication rate, ranging between 1.5 and 3.3 % [7, 8].
Under strict monitoring of intestinal tolerance, a low flow rate of 10 – 20 ml per hour is recommended at the start of tube feeding; thus, it can take 5 – 7 days until the patient reaches the calorie target [9]. Too rapid an increase in the flow rate can lead to torsion of the small intestinal loop with intestinal necrosis. If less than 60 – 75 % of the energy intake is possible enterally, additional parenteral supplementation should be provided [1].
Technical Aspects of the CJ
The principle of the CJ is submucosal tunneling in the jejunal wall with peritoneal attachment [10]. According to Vestweber, the following factors are important to prevent leakage [11]:
- Fixation or sealing of the catheter at the intestinal puncture site with purse-string suture,
- complete fixation of the jejunal loop to the abdominal wall with peritonealization of the catheter,
- Prevention of torsion of the small intestinal loop by cranial and caudal fixation to the abdominal wall.