P-OGC84 Impact of routine feeding via jejunostomy after oesophagectomy

Background Oesophageal cancer is the 8th most common cancer worldwide, with oesophagectomy remaining the mainstay curative treatment, despite significant associated morbidity and mortality. Postoperative weight loss remains a significant problem and is directly correlated to poor prognosis. Measures such as the Enhanced Recovery After Surgery (ERAS) programme and intraoperative jejunostomy feed placement have looked to tackle this. Our aim was to investigate the impact of supplemental jejunostomy feed in practice on mortality, length of hospital stays and postoperative weight loss in a high-volume regional centre. Methods Patients undergoing oesophagectomy between January 2012 - December 2014 and January 2016 - December 2019 in a national tertiary oesophagogastric unit were included retrospectively. Variables measured included comorbidities, operation, histopathology, weights (pre- and post-operatively), length of hospital stay, postoperative complications and mortality. Survival data were analysed using R Studio, Inc. Results 566 patients were included. Median age at diagnosis was 66 years (30-85). Majority of cases included were adenocarcinoma (72.6%), or squamous cell carcinoma (22.3%). Within the two study groups, severe weight loss > 10% of pre-operative weight was seen in 38.6% and 4.87% of patients discharged without and with jejunostomy feeds at 3 months, respectively. At 6 months, severe weight-loss was seen in 47.6% and 0.64% of patients discharged without and with jejunostomy feeds, respectively. Median length of stay was 15 days (7-92) and 12 days (6-338) for patients discharged without and with jejunostomy feeds, respectively. Overall median survival in patients discharged without jejunostomy was 52 months (p = 0.035), and in those discharged with jejunostomy, 48 months (p = 0.044). Conclusions Postoperative malnutrition has associated poor outcomes. Perioperative nutritional support, to include postoperative jejunal feeding post-discharge can reduce weight loss, and influence survival as well as length of hospital stay. Further randomised trials are needed in order to optimise recovery and morbidity in patients post-oesophagectomy.

Cushing’s Disease Presenting With Severe Weight Loss, Anorexia and Refractory Psychotic Depression

Introduction: In this paper we report an unusual case of Cushing’s disease presenting with psychotic depression, paranoia, anorexia leading to severe weight loss culminating in 18% of her body weight. Case: A 22 year old female admitted with first episode psychosis to her local hospital displaying psychotic depressive symptoms, low mood, severe anorexia and mood congruent delusions regarding food contamination. Clinical manifestations of Cushing’s were recognised: cushingoid facies, facial plethora, hirsutism with striae and proximal myopathy. The degree of weight loss (70kg to 57kg) and paranoid ideation surrounding food necessitated caloric supplementation parenterally. Laboratory indices notable for hypokalaemia of 2.7nmol/l, male range testosterone level of 10.7nmol/l, DHEAS>27.1umol and suppressed gonadotrophins. Urine Free Cortisol was >25 times normal. Late night salivary cortisol was 13.4nmol/L(<2.6nmol/L). ACTH was raised at 74.0pg/ml in keeping ACTH dependent Cushing’s. MRI pituitary showed a bulky pituitary. CRF testing and Inferior Petrosal Sinus Sampling both indicated pituitary dependent Cushing’s disease. Following Metyrapone therapy and nutritional treatment the patient condition improved. She proceeded to transphenoidal pituitary exploration. Intraoperatively a very soft central lesion was excised and neuropathology confirmed a corticotroph adenoma. Post-operative morning cortisol at day 3 was 31nmol/l indicating early remission. 3 months post-operative there was remarkable improvement in mood, weight, cessation of anti-psychotics with normal diet and return of menses. She remained severely hypocortisolaemic 6 months post-op Conclusion: Cushing’s disease may present with severe psychiatric manifestation and significant weight loss. Clinicians need to be vigilant of psychosis as the primary presentation of Cushing’s disease.

Severe weight loss during, but not before, simultaneous chemotherapy and radiation therapy for stage III and IV squamous cell carcinoma of the head and neck (SCCHN) is associated with increased survival

Background: Severe weight loss commonly occurs before and during chemo-irradiation for Stage III and IV SCCHN. Nevertheless, the effects of severe weight loss on short and long term outcomes are unknown. Objective: To evaluate effects of pre-treatment weight loss versus weight loss during chemotherapy/radiation for advanced operable SCCHN on toxicity, tumor response, recurrent tumor and survival. Methods: Records of 52 patients with Stage III and IV, clinically operable SCCHN who underwent primary high-dose radiotherapy and concomitant chemotherapy (cisplatin, 20mg/M2/four consecutive days during weeks 1, 4, and 7 of radiotherapy) (CTRT) were examined retrospectively in two groups: <7.5% weight loss in three months during CTRT (NON-SEVERE; n=12) and >7.5% weight loss (SEVERE; n=41). Data included tumor site, grade, stage, pre-CTRT weight loss, CTRT toxicity, response (CCR = Clinical Complete; HCR = Histologic Complete without residual tumor), surgeries, recurrence, and overall and disease-free survival. Statistical analysis: Chi-square, ANOVA, and Kaplan-Meier. Results: Per study design, weight loss was greater in the SEVERE group versus NON-SEVERE (-17.3% +- 7.9% versus -2.9% +- 4.2%, p<0.0001). Pre-CTRT weight loss, age, stage, grade, toxicity of CTRT and post-CTRT surgery did not vary significantly. SEVERE tongue/hypopharynx primary site was increased (66% versus 18%, p<0.05). CCR and HCR were achieved in 5/11 (45%) of NON-SEVERE and 29/41 (71%) SEVERE. SCCHN recurred in 1/11 (9%) NON-SEVERE and 12/41 (29%) SEVERE patients. Kaplan-Meier Overall 60 month survival was 56% SEVERE and 14% NON-SEVERE (p<0.001). Disease-Free survival was 65% SEVERE and 22% NON-SEVERE (p<0.001). Conclusions: In spite of greater tongue/hypopharynx primaries and independent of pre-treatment weight loss, SEVERE Stage III/IV SCCHN CTRT toxicity, post-CTRT operations, and tumor recurrence did not increase. SEVERE CCR/HCR was excellent and SEVERE overall and disease-free survivals exceeded NON-SEVERE significantly. The pathophysiological mechanisms underlying these new and clinically important findings are not clear from the data.

Severe weight loss after minimally invasive oesophagectomy is associated with poor survival in patients with oesophageal cancer at 5 years

Background Patients often experience severe weight loss after oesophagectomy. Enteral nutrition via a feeding jejunostomy tube (FT) is commonly practised. This study aimed to assess the effect of severe weight loss postoperatively and enteral nutrition via an FT on long-term prognosis after oesophagectomy. Methods This study analysed 317 patients who underwent minimally invasive oesophagectomy at Kobe University Hospital and Hyogo Cancer Center from 2010 to 2015. The patients’ body weight was evaluated at 3 months postoperatively. They were organised into the severe weight loss (n = 65) and moderate weight loss (n = 252) groups. Furthermore, they were categorised into the FT group (184 patients who had an FT placed during oesophagectomy) and no-FT group (133 patients without FT). Patients (119 per group) matched for the FT and no-FT groups were identified via propensity score matching. Results The 5-year overall survival (OS) rate in the severe weight loss group was significantly lower (p = 0.024). In the multivariate analysis, tumour invasion depth (pT3-4), preoperative therapy and severe weight loss had a worse OS (hazard ratio = 1.89; 95% confidence interval = 1.12–3.17, hazard ratio = 2.11; 95% confidence interval = 1.25–3.54, hazard ratio = 1.82; 95% confidence interval = 1.02–3.524, respectively). No significant differences in the number of severe weight loss patients and OS were found between the FT and no-FT groups. Conclusion Severe weight loss is significantly associated with poor OS. In addition, enteral nutrition via an FT did not improve the severe weight loss and OS.

Decline of nutritional status in the first week of hospitalisation predicts longer length of stay and hospital readmission during 6-month follow-up

Nutritional status (NS) monitoring is an essential step of the nutrition care process. To assess changes in NS throughout hospitalisation and its ability to predict clinical outcomes, a prospective cohort study with patients over 18 years of age was conducted. The Subjective Global Assessment (SGA) was performed within 48 h of admission and 7 d later. For each patient, decline in NS was assessed by two different methods: changes in SGA category and severe weight loss alone (≥2 % during the first week of hospitalisation). Patients were followed up until discharge to assess length of hospital stay (LOS) and in-hospital mortality and contacted 6 months post-discharge to assess hospital readmission and death. Out of the 601 patients assessed at admission, 299 remained hospitalised for at least 7 d; of those, 16·1 % had a decline in SGA category and 22·8 % had severe weight loss alone. In multivariable analysis, decline in SGA category was associated with 2-fold (95 % CI 1·06, 4·21) increased odds of prolonged LOS and 3·6 (95 % CI 1·05, 12·26) increased odds of hospital readmission at 6 months. Severe weight loss alone was associated with 2·5-increased odds (95 % CI 1·40, 4·64) of prolonged LOS. In conclusion, deterioration of NS was more often identified by severe weight loss than by decline in SGA category. While both methods were associated with prolonged LOS, only changes in the SGA predicted hospital readmission. These findings reinforce the importance of nutritional monitoring and provide guidance for further research to prevent short-term NS deterioration from being left undetected.