24 Esophageal Cancer with Enteral Nutrition

4/2/2020 Clinical Case Studies for the Nutrition Care Process https://openpage-ebooks.jblearning.com/wr/viewer.html?&oneTimePasscode=ST-4fb8b7be-b790-461d-9418-250b5aa1081c#book/fb090417-09af-4a6… 1/5 Clinical Case Studies for the Nutrition Care Process ISBN 9781284157208 Case 24 Esophageal Cancer with Enteral Nutrition Case 24 Esophageal Cancer with Enteral Nutrition Learning Objectives Upon completing this case study, readers will be able to: 1. Assess nutritional status in a patient with esophageal cancer. 2. Determine nutritional requirements of a patient with esophageal cancer. 3. Predict possible nutrition-related side effects of chemotherapy and radiation. 4. Calculate an enteral feeding regimen to meet nutritional needs. 5. Manage tube-feeding intolerance. Background Esophageal cancer is the eighth most common cancer worldwide and the sixth most common cause of cancer deaths. In the United States, the incidence had been climbing but has now been gradually declining over the past decade. Risk factors for esophageal cancer include male sex, smoking, gastroesophageal reflux, alcohol, obesity, and human papilloma virus (HPV) infection. There is some evidence that processed meats increase risk; vegetables, fruits, and physical activity are thought to decrease risk. Esophageal cancer is frequently not diagnosed until an advanced stage, and the overall 5-year survival rate is approximately 20%. Patients with esophageal cancer have been noted to have a higher percentage of weight loss than patients with other types of cancer, and malnutrition is common, occurring in up to 60% to 85% of patients. Most patients present with dysphagia and weight loss, symptoms that may not develop until after the disease has progressed to an advanced stage. Nutritional management is complicated by difficulty with oral intake due to obstruction of the esophagus by the tumor. Dysphagia; cancer cachexia; and the effects of chemotherapy, radiation, and surgery all contribute to a unique challenge in maintaining adequate nutrition in this population. Many patients are treated with chemotherapy and radiation prior to surgery. A high- protein, high-calorie consistency modified diet should be attempted during this time, but dysphagia and esophagitis caused by radiation may preclude adequate oral nutrition and hydration. Esophageal stents or laser treatments are sometimes used to facilitate oral intake prior to surgery or for palliation if surgery is not feasible. Nutrition support may be needed during treatment both pre- and postoperatively. While the enteral route is preferred to parenteral, preoperative tube feeding presents a challenge with regard to enteral access. A laparoscopically placed jejunostomy is an option that can be used early in treatment. Placement of a percutaneous endoscopic gastrostomy 1 2 3 , 4 5 3 , 4 , 6 – 8 3 , 5

4/2/2020 Clinical Case Studies for the Nutrition Care Process https://openpage-ebooks.jblearning.com/wr/viewer.html?&oneTimePasscode=ST-4fb8b7be-b790-461d-9418-250b5aa1081c#book/fb090417-09af-4a6… 2/5 (PEG) tube or nasoenteric tube may not be possible due to obstruction of the esophagus by the tumor. Many surgeons avoid the use of a PEG tube, since there is a risk of damage to the stomach or its blood supply, which will eventually be used to create a neo- esophagus during esophagectomy. Additionally, the potential exists for spreading tumor cells during the PEG procedure. If enteral access has not been obtained preoperatively, a surgical jejunostomy tube is frequently placed during the esophagectomy procedure to be used for postoperative nutrition support. The role of the Registered Dietitian Nutritionist (RDN) in caring for patients with esophageal cancer includes recognizing malnutrition, optimizing enteral nutrition, managing gastrointestinal symptoms, monitoring nutritional adequacy, and guiding the transition from enteral to oral feedings. Case Description The patient is a 56-year-old man with a history of gastroesophageal reflux disease, Barrett’s esophagus, and a 30 pack/year history of smoking. He presents with a 3-month history of coughing, sore throat, and progressive difficulty swallowing, first of solid foods and more recently of liquids. He is currently experiencing nausea and early satiety. A biopsy revealed adenocarcinoma of the distal esophagus and gastroesophageal junction. Following chemotherapy with 5-fluorouracil and cisplatin, along with radiation, an esophagectomy and j-tube placement are planned. Nutritional Assessment Data Anthropometric Measurements Height: 5 ′ 8 ″ Weight: 165 lbs Usual weight: 185 lbs (3 months ago) Biochemical Data and Test Results Parameter Value Normal Range (may vary by age, sex, and laboratory) Sodium 140 mEq/L 135–147 mEq/L Potassium 4.3 mEq/L 3.5–5.0 mEq/L Chloride 100 mEq/L 98–106 mEq/L CO 25 mEq/L 21–30 mEq/L BUN 15 mg/dL 8–23 mg/dL Creatinine 0.9 mg/dL 0.7–1.5 mg/dL Glucose 89 mg/dL 70–110 mg/dL Phosphorus 3.2 mg/dL 3.0–4.5 mg/dL Albumin 2.9 mg/dL 3.5–5.5 g/dL Prealbumin 8 mg/dL 16–40 mg/dL 6 , 8 , 9 3 * 2

4/2/2020 Clinical Case Studies for the Nutrition Care Process https://openpage-ebooks.jblearning.com/wr/viewer.html?&oneTimePasscode=ST-4fb8b7be-b790-461d-9418-250b5aa1081c#book/fb090417-09af-4a6… 4/5 6. He is now status post esophagectomy with gastric pull-up and feeding jejunostomy. He is NPO and you are consulted for enteral feeding recommendations. Calculate his energy, protein, and fluid needs, then recommend an enteral formula. Specify the starting rate, how you would advance the feeding, and what your goal rate for formula and flushes would be. Show your work. 7. He remains NPO, receiving full enteral feedings but reports having bloating and fullness. How do you approach this situation? What do you recommend? 8. One week later, there are no signs of anastomotic leak, so an oral diet is started. Explain what an anastomotic leak is. Since he has been cleared to eat, what type of diet should be recommended? 9. How would you transition him from enteral to oral feedings? 10. Write a PES statement based on his initial presentation. Case Study and Answer References 1. World Cancer Research Fund, American Institute for Cancer Research. Diet, Nutrition, Physical Activity and Cancer: a global perspective. The third expert report . https://www.wcrf.org/dietandcancer . 2. American Cancer Society. Key statistics for esophageal cancer. https://www.cancer.org/cancer/esophagus-cancer/about/key-statistics.html . 3. Fessler T, Havrila C. Nutrition support for esophageal cancer patients — strategies for meeting the challenges while improving patient care. Today’s Dietit . 2012;14(1):28-33. 4. Schizas D, Lidoriki I, Moris D, Liakakos T. Nutritional Management of Esophageal Cancer Patients Dimitrios. In: Esophageal Abnormalities . IntechOpen; 2017:89–116. 5. Reim D, Friess H. Feeding challenges in patients with esophageal and gastroesophageal cancers. Gastrointest Tumors . 2016;2(4):166–177. 6. Bower M, Jones W, Vessels B, Scoggins C, Martin R. Role of esophageal stents in the nutrition support of patients with esophageal malignancy. Nutr Clin Pract . 2010;25(3):244–249. 7. Martin RC 2nd, Cannon RM, Brown RE, et al. 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. Oncologist . 2014;19(3):259–265. 8. Kight CE. Nutrition considerations in esophagectomy patients. Nutr Clin Pract . 2008;23(5):521–528. 9. Bower MR, Martin RC 2nd. Nutritional management during neoadjuvant therapy for esophageal cancer. J Surg Oncol . 2009;100(1):82–87. 10. White JV, Guenter P, Jensen G, et al. Convsensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Parenter Enteral Nutr . 2012;36(3):275–283. 11. Kaul V. What Options Exist for Enteral Feeding in Preoperative Patients with Esophageal Cancer Who Have Dysphagia? In: Adler D, ed. Curbside Consulation in GI Cancer for the Gastroenterologist . Slack, Inc.; 2011:7–10. 12. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice recommendations. J Parenter Enteral Nutr . 2009;33(2):122–167. 13. Parrish CR. Enteral feeding: eradicate barriers with root cause analysis and focused intervention. Pract Gastroenterol . 2019;184(February):14–32. 14. Lee ZY, Barakatun-Nisak MY, Noor Airini I, Heyland DK. Enhanced protein-energy provision via the enteral route in critically ill patients (PEP uP Protocol): a review of evidence. Nutr Clin Pract . 2016;31(1):68–79. 15. Kozeniecki M, Fritzshall R. Enteral nutrition for adults in the hospital setting. Nutr Clin Pract . 2015;30(5):634–651. 16. Lord LM. Enteral access devices: types, function, care, and challenges. Nutr Clin Pract . 2018;33(1):16–38. 17. Parrish CR, McCray S. Enteral feeding: dispelling myths. Pract Gastroenterol . 2003;27(9):33–50. 18. Boullata JI, Carrera AL, Harvey L, et al. ASPEN safe practices for enteral nutrition therapy. J Parenter Enteral Nutr . 2017;41(1):15–103.

4/2/2020 Clinical Case Studies for the Nutrition Care Process https://openpage-ebooks.jblearning.com/wr/viewer.html?&oneTimePasscode=ST-4fb8b7be-b790-461d-9418-250b5aa1081c#book/fb090417-09af-4a6… 5/5 19. Chen KN. Managing complications I: leaks, strictures, emptying, reflux, chylothorax. J Thorac Dis . 2014;6(suppl 3):355–363. 20. Dent B, Griffin SM, Jones R, Wahed S, Immanuel A, Hayes N. Management and outcomes of anastomotic leaks after oesophagectomy. Br J Surg . 2016;103(8):1033–1038. 21. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care . http://www.ncpro.org . Accessed September 14, 2019.