March 9, 2014 Case patient was admitted 1/24/2014 for scheduled subtotal gastrectomy with G and Jtube placements. Postop course was prolonged by slow return of bowel function. Treatment included gradual advancement of Jtube feeds with Gtube initially to suction, then to gravity, alternating with being clamped. As the patient began tolerating tube feeds, she began PO. Patient was discharged when she was hemodynamicaly stable, afebrile, and tolerating soft diet with cycled tube feeds. Etiology Can occur with no clear cause Relationship between a diet high in smoked, salted and pickled foods and stomach cancer Family history of gastric cancer
Epidemiology: Male Elderly Cigarette smokers Obese Pathology: Adenocarcinoma: Begins in glandular cells (cells that line the inside of the stomach secrete mucus). Accounts for majority of all stomach cancers. Lymphoma: Cancer in immune cells of the stomach. Lymphoma in the stomach is rare. Carcinoid cancer: Cancer of the hormone- producing cells in the stomach. This type is rare. Gastrointestinal stromal tumor (GIST): Begins in specific nervous system cells found in your stomach. GIST is rare. Clinical Signs/Symptoms: May be asymptomatic Fatigue Feeling bloated after eating Early satiety GERD Diarrhea Nausea Stomach pain Persistent vomiting Unintentional weight loss
Comorbidities: Cardiovascular Pulmonary (COPD) Other GI issues Other cancer Obesity Diabetes Anemia Short-term effects of supplementary feeding with enteral nutrition via jejunostomy catheter on post-gastrectomy gastric cancer patients METHODS: Study compared two groups of post- gastrectomy patients, one was not tube fed and the other was fed through a jtube after surgery. RESULTS: Compared with the assessments of the patients preoperatively, the jtube fed group lost significantly less weight than the tubeless group. The number of patients with a nutritional risk score greater than three increased in the tube-free group and decreased in the jtube fed group! Quan et al. Short-term effects of supplementary feeding with enteral nutrition via jejunostomy catheter on post-gastrectomy gastric cancer patients. Chinese Medical Journal. 2011: 124(20): 3297-3301
The Comparison between Early Enteral Nutrition and Total Parenteral Nutrition after Total Gastrectomy in Patients with Gastric Cancer: The Randomized Prospective Study METHODS: Gastric cancer patients were assigned to an enterally fed group and a parenterally fed group postoperatively. Nutritional parameters, liver function, LOS and abdominal symptoms were compared. Chung, JB; Kim, CB; Kim, HU. The Comparison between Early Enteral Nutrition and Total Parenteral Nutrition after Total Gastrectomy in Patients with Gastric Cancer: The Randomized Prospective Study. Korean K Gastroenterol Vol 59 No. 6, 407-413
The Comparison between Early Enteral Nutrition and Total Parenteral Nutrition after Total Gastrectomy in Patients with Gastric Cancer: The Randomized Prospective Study RESULTS: No significant differences were found between the groups regarding liver function or nutritional parameters, but vomiting and abdominal distention were more common in the EN group, but increased AST, ALT, and total bilirubin were more common in the TPN group. Length of hospital stay was shorter in the EN group but not statistically significant. Effect of early oral feeding after gastric cancer surgery: A result of randomized clinical trial METHODS: Patients in the early feeding group began a clear liquid diet 2 days post-gastrectomy, and began a soft diet on the 3 rd day until they were discharged. The other group began a liquid diet on the 4 th postop day. The study was to measure which group had a longer hospital stay. Hur et al, Effect of early oral feeding after gastric cancer surgery: A result of randomized clinical trial. Surgery, Korea 2010: 10. 003. 561-568
Effect of early oral feeding after gastric cancer surgery: A result of randomized clinical trial RESULTS: Duration of hospitalization and time until flatus were significantly shorter in the early feeding group. Quality of life scores were also improved in the early orally fed group. 84 year old female Diagnosis: Gastric Outlet Obstruction Procedures: Exploratory laparotomy, subtotal gastrectomy, gastrostomy tube placement, jejunostomy tube placement Hospital Problems: Gastrinoma, gastric perforation, carcinoid tumor of small intestine and others not GI related
Past Medical History Diverticulosis of Colon Acute duodenal ulcer with hemorrhage Calculus of gallbladder without cholecystitis Hyperlipidemia Jejunal ulcer Carcinoid tumor Extensive non-GI related
Past Surgical History Ligate fallopian tube Removal of gallbladder Upper GI endoscopies, biopsies (multiple) Colonoscopies (multiple) & polypectomy Esophagogastroduodenoscopy Exploratory of abdomen Repair perforated duodenum Freeing bowel adhesion, enterolysis Upper GI endoscopy with balloon dilation Upper GI endoscopy with stent placement Gastroscopy
Social History Nonsmoker Widowed Less than 2 drinks/day Lives alone Two daughters very active in patient care Patient on Home TPN for over 6 weeks PTA due to gastric outlet obstruction Weight lost due to inability to tolerate food due to gastric outlet obstruction No food allergies No problems swallowing
Upper dentures Clavicular wasting mild to moderate Able to sit up in chair for long periods of time History of knee surgeries and chronic knee pain
Height 55 Weight 155 lbs (70 kg) BMI 25.83 kg/m2 Usual Body Weight 172 lbs in June 2013 Changes in Weight About 20 lb weight loss in 6 months (10%, severe) Component Result Ideal Range Explanation Glucose 113 mg/dl 60-99 mg/dl Blood glucose is commonly high after surgery Magnesium 1.6 mg/dl 1.7-2.8 mg/dl Poor PO intake Hemoglobin 11.7 gm/dl 12.0-15.0 gm/dl Commonly low after surgery due to blood loss Calcium 8.0 mg/dl 8.5-10.3 mg/dl Poor PO intake Initial Assessment Estimated Energy Needs per Day 25-30 kcal/kg body weight is 1750-2100 kcal.
Estimated Protein Needs per Day 1.2-1.5 g/kg body weight is 84-105 grams.
Estimated Fluid Needs per Day 30 ml/kg body weight is 2100 milliliters. Severely compromised secondary to GI Surgery New tube feeding Weight loss NPO status TPN dependent prior to admission
Not malnourished Problem: Altered GI Function (NC-1.4) Etiology: related to gastric outlet obstruction caused by gastric cancer Signs/Symptoms: As evidenced by status post exploratory laparotomy, subtotal gastrectomy, gastrostomy tube placement, jejunostomy tube placement, and need for enteral feeds to meet estimated nutritional needs.
Patient seen 3 days post admit to floor NPO with NG Medical Procedures: Trickle tube feeds began 1/27 Initiated clear liquid diet 2/01 Surgical Procedures: Exploratory laparotomy Subtotal gastrectomy Gastrostomy tube placement Jejunostomy tube placement Domain: Food and/or Nutrient Delivery (ND) Nutrition Intervention Term: Enteral Nutrition (ND-2.1) Nutrition-Related Intervention: Initiate and tolerate tube feeds Meet goal rate to provide at least 75% of estimated needs Initiate PO diet per primary service Initiate and tolerate tube feeding Meet at least 75% of estimated nutrition needs Attain/maintain minimum estimated nutritional needs Monitor Biochemical Tests and Procedures: Intake/Output Residuals Electrolytes Blood chemistry Abdominal exams Initiate and tolerate PO diet
3 days post initial assessment PES Statement: Altered GI Function (NC-1.4) related to gastric outlet obstruction caused by gastric cancer as evidenced by status post exploratory laparotomy, subtotal gastrectomy, gastrostomy tube placement, jejunostomy tube placement, and need for enteral feeds to meet estimated nutritional needs. Nutrition Intervention Performed: Clear liquid plus tube feeding Goals set: advance as tolerated to general soft diet, 6 small meals Level of achievement/compliance: good 7 days post initial assessment PES Statement Altered GI Function (NC-1.4) related to gastric outlet obstruction caused by gastric cancer as evidenced by status post exploratory laparotomy, subtotal gastrectomy, gastrostomy tube placement, jejunostomy tube placement, and need for enteral feeds to meet estimated nutritional needs. Nutrition Intervention Performed: Full liquid plus tube feeding Goals set: Advance as tolerated to general soft diet with 6 small meals per day Level of achievement/compliance: good
Discharged 9 days post initial assessment Follow up phone call 2/11 Pt complaining of upset stomach, resolved eventually Office visit 2/17 Recovery is going well Office visit 2/25 Patient eating without difficulty May start clamping Gtube continuously instead of intermittently. This patients case is a good example of the success of Jtube feedings after a gastrectomy in order to help meet nutritional needs. She is currently doing well and no malignancies were found at her follow-up visits.