Esophageal Cancer

Medical Nutrition Therapy

Kaitlyn Kavan, Dietetic Intern

Memorial Medical Center Case Study
R. S.

● 79 YOM

● Past medical history = risk factors

○ Previous smoker
○ GERD

● Admitting diagnosis
○ Esophageal cancer
■ Chemotherapy and radiation treatment
■ Esophagectomy
Esophagectomy + Gastrectomy
Medications

Scheduled
Enoxaparin anticoagulant
Multivitamin with mineral
Pantoprazole proton-pump inhibitor

PRN
Metoclopramide gut-motility stimulator
Ondansetron antiemetic

Continuous
Hydromorphone-bupivacaine epidural
D5W ½ NS with KCl; Dextrose 10% 10,000 mL fluid/electrolyte replenishment
RDN Documentation

11/6: Admitted

11/8: Initial Assessment- Documented weight loss PTA and new tube placement

11/9: Re-assessment; TF order placed

11/10: Re-assessment

11/13: Re-assessment

11/14: Re-assessment; Nocturnal TF recommendations; Discharge education

11/15: Discharged
11/8: Assessment- Documented weight loss PTA and new tube placement

● Esophagectomy (11/6) ● Admit weight = 80.7 kg

○ G/J tube ● Height = 5’ 6” BMI = 31
○ Chest tube ● % IBW = 125%
○ PIV; CIV
● AdjBW = 69 kg
○ Epidural

● Trophic feeds of Jevity 1.5 @ 10 mL/hr

● Weight loss
○ 25 kg (24%) since July 2017
severe
○ Dysphagia secondary to
chemotherapy and radiation
treatment General Bed
Admitting Physician: Dr. Crabtree
○ “Lived off” supplement drink
Resident: Dr. Feimster
Nutrition Diagnoses

Inadequate oral intake

related to head and neck cancer, recent esophagectomy,
as evidenced by NPO status, J-tube for nutrition

Unintentional weight loss

related to catabolic disease, dysphagia,
as evidenced by pt report of 25 kg weight loss, 24%, x 4 months
Estimated Energy Needs and
Tube Feeding Recommendations

2070 kcal/day (30 kcal/kg AdjBW 69 kg)

97 g PRO/day (1.5 g PRO/kg IBW 64.5 kg)

Jevity 1.5 @ goal rate of 65 mL/hr + 2 beneprotein packets per day

2098 kcal
99 g PRO
1157 mL free water

Supplementation recommendation = 100 mg thiamine daily due to refeeding syndrome risk

Review of Lab Trends
11/9: Re-assessment; TF order placed

Patient

● No complaints
● TF running at 20 mL/hr
● Low phosphorus; magnesium WDL; potassium marginally WNL

Physician/Orders

● NPO
● MD request to place TF orders
● Jacquie called to recommend: thiamine, phosphorus repletion
11/10: Re-assessment

Patient

● Tolerating TF at goal rate

● Comfortable, no complaints
● Stable labs reported

Physician/Orders

● NPO
● MD discontinued thiamine
○ Concerned about clogging j-tube
11/13: Re-assessment

Patient

● Tolerating TF at goal rate

● No complaints, regular bowel movements
● Low potassium

Physician/Orders

● Clear liquid diet- “sips for comfort” (11/12)

● Epidural removed (11/11); Chest tube removed (11/13)

Noted would follow-up to place D/C recommendations

11/14: Re-assessment; Nocturnal TF recommendations; Discharge
education

Patient

● Tolerating TF at goal rate

● PO intake
● Potassium trending up from yesterday

Physician/Orders

● Full liquid diet

○ Ensure Enlive TID + PRN (Chocolate)
● Pt to discharge the next morning
● MD passed off TF management
○ Nocturnal feedings
Nocturnal/Discharge Tube Feedings

Jevity 1.5 @ goal rate of 85 mL/hr x 12 hours/day

With 2 beneprotein packets per day; 80 mL water flushes 6x/day
1580 kcal 76% estimated energy needs
77 g PRO 79% estimated PRO needs
1375 mL free water

+ Boost - TID 720 kcals 30-45 g PRO

= 2300 kcals, 107-122 g PRO

Home Recovery

Slow process Prevalence of weight loss

● Full liquid diet until December 1 ● 5-12% at six months considered usual
● Boost TID + other ● On top of preoperative weight loss
● Nocturnal TF

Continued diet advancement ● Dysphagia

● Pain
● Soft foods, mild, sit well with patient ● Poor appetite
● Progress as tolerated ● Reflux
● Adjust TF
Future Intervention

“Peripheral vein infusions of amino acids facilitate recovery after

esophagectomy for esophageal cancer: Retrospective cohort analysis”

● TF plus amino acid IV administration

● Compared amino acid group and control group

● No immediate effect seen, however the amino acid group had:

○ Higher albumin levels - postoperative day 14 and day 30
○ Smaller weight loss of 3%, rather than 6% - postoperative 3 months

○ TF administered postoperative day 1; D5W infusing at same rate

■ Either amino acid solution or 10% sugar maintenance solution administered (control)
○ PIV administration was discontinued on postoperative day 8
■ Days 1-3: 1.0 g/kg Days 4-7: 0.7 g/kg
References

Konosu, M., Iwaya, T., Kimura, Y., Akiyama, Y., Shioi, Y., Endo, F., Nitta, H...Sasaki, A. (2017).
Peripheral vein infusions of amino acids facilitate recovery after esophagectomy for
esophageal cancer: Retrospective cohort analysis. Annals of Medicine and Surgery, 14, 29-
35.

Mahan, L. K., Escott-Stump, S., & Raymond, J. L. (2012). Krause’s food and the nutrition care
process. (13th ed.). St. Louis, MO: Elsevier Saunders

Paul, M., Baker, M., Williams, R. N., and Bowrey, D. J. (2017). Nutritional support and dietary
interventions following esophagectomy: challenges and solutions. Nutrition and Dietary
Supplements, 9, 9-21.