Case Repoit: Post-uastiectomy Nutiition

Liz Lancione
ARANARK Bietetic Inteinship
Naich 9
th
, 2u14










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Cancei of the stomach is known as gastiic cancei. It is one of the most
common malignant neoplasms in the woilu (2). A gastiectomy is the iemoval of all
oi pait of the stomach, anu it is a common tieatment foi gastiic cancei. The pyloiic
sphinctei is the sphinctei at the bottom of the stomach, leauing to the uuouenum,
which is the fiist pait of the small intestine. When the pyloiic sphinctei is iemoveu,
it can cause issues with absoiption of ceitain nutiients, because foou will spenu a
uecieaseu amount of time in the stomach. Aftei a gastiectomy, whethei paitial oi
total, timely nutiition inteivention can impiove outcomes anu minimize weight loss
anu ueficiencies (S). The patient in this case iepoit hau theii pyloiic sphinctei
iemoveu uue to the location of hei caicinoiu tumoi that hau causeu an obstiuction
neai the pyloiic sphinctei. The puipose of the gastiostomy tube (u-tube) being
placeu was to ensuie that the stomach can iemain empty as it heals, minimizing
uiscomfoit anu complications such as vomiting. When the vagus neive is not
seveieu uuiing suigeiy, the stomach still piouuces secietions, which can inteifeie
with healing (S). The puipose of the jejunostomy tube (} tube) is to pioviue an
alteinate ioute of nutiition while the site of suigeiy heals. This case stuuy
uemonstiates the use of the Nutiition Caie Piocess (NCP) to tieat a post-
gastiectomy patient anu iestoie theii nutiitional status.

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Like any cancei, gastiic cancei can occui with no cleai cause. Theie aie
howevei some factois that aie statistically linkeu to the uisease. Theie is a
S
ielationship between a uiet high in smokeu, salteu anu pickleu foous anu stomach
cancei, yet this has uecieaseu since iefiigeiation became a wiuely useu methou to
pieseive peiishable foous. A uiet low in fiuits anu vegetables has also been linkeu to
stomach cancei. Infection with the ulcei-causing bacteiia !"#$%&'()"* ,-#%*$ is a
contiibuting cause, along with smoking, peinicious anemia (causeu by inability to
absoib B12), anu long-teim gastiitis, oi inflammation of the stomach (4, S). Baving
someone in the family who has hau stomach cancei also gieatly incieases a peison's
iisk foi ueveloping this cancei.
uastiic cancei is moie common in men than in females, anu occuis mostly in
the elueily. Those who have been tobacco smokeis anu aie obese aie also among
the most commonly affecteu populations by this uisease (4, S).
Theie aie uiffeient types of gastiic cancei, anu they aie categoiizeu by which
type of cell becomes canceious. Auenocaicinoma is the most common type of
stomach cancei. It begins in glanuulai cells, which aie the cells that line the insiue of
the stomach seciete mucus. Auenocaicinoma accounts foi the majoiity of all
stomach canceis. Lymphoma is cancei of the immune cells of the stomach.
Lymphoma in the stomach is iaie. Caicinoiu cancei is cancei of the hoimone-
piouucing cells in the stomach. This type is also iaie, although this type is the type
of tumoi that this paiticulai case piesenteu with. uastiointestinal stiomal tumois
(uISTs) begin in specific neivous system cells founu in the stomach. uIST is iaie as
well (6, 11).
uastiic cancei may be asymptomatic, which is why gastiectomy is a common
methou of tieatment when the cancei has hau time to uevelop. Nany people uo not
4
know that they have stomach cancei until they have a tumoi that iequiies suigeiy.
If symptoms aie piesent, they can incluue fatigue, feeling bloateu aftei eating, eaily
satiety, gastioesophageal ieflux uisease (uERB), uiaiihea, nausea, stomach pain,
peisistent vomiting, anu unintentional weight loss (S).
Comoibiuities of gastiic cancei aie laigely ielateu to the gioup that is
commonly affecteu by the uisease, which, as mentioneu above, incluue the elueily,
obese, anu smokeis. Comoibiuities of these gioups incluue caiuiovasculai
complications, pulmonaiy issues such as chionic obstiuctive pulmonaiy uisease
(C0PB), othei uI issues, othei canceis, obesity, uiabetes, anu anemia (S).

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Post-gastiectomy nutiition iecommenuations aie focuseu on iestoiing
nutiitional status anu ieuucing both complications anu hospital length of stay. Aftei
a uI suigeiy, it is common foi bowel function to ietuin slowly. Naintaining anu
iestoiing nutiitional status by nutiitional suppoit is piioiity if an oial uiet cannot be
initiateu uue to slow ietuin of bowel function. u anu } tube placement uuiing the
initial suigeiy aie helpful in initiating nutiition suppoit because they pioviue a
ioute to the uigestive tiact that bypasses the site of suigeiy to allow healing. The u
tube was placeu in this patient to allow uiaining of the suigeiy site to aiu in
pieventing uiscomfoit, vomiting anu infection. The } tube was placeu because theie
aie many eviuence-baseu iecommenuations suppoiting } tube feeuings aftei a
gastiectomy anu its effectiveness in impioving outcomes. The following section will
S
ieview the eviuence-baseu iecommenuations foi jejunostomy tube feeuing aftei a
gastiectomy in gastiic cancei patients.
A stuuy publisheu in the Chinese Neuical }ouinal by Quan et al founu that
shoit-teim effects of supplementaiy feeuing with enteial nutiition via jejunostomy
tube on post-gastiectomy gastiic cancei patients impioveu outcomes by ieuucing
length of stay, uecieasing postopeiative weight loss, anu impioving postpopeiative
nutiition status. This stuuy compaieu two gioups of post-gastiectomy patients. 0ne
gioup was not tube feu aftei suigeiy, anu the othei was feu thiough a } tube aftei
suigeiy. Compaieu with the pieopeiative assessments that hau been uone of all
patients, the } tube feu gioup lost significantly less weight than the tubeless gioup.
The numbei of patients with a nutiitional iisk scoie gieatei than thiee out of foui
incieaseu in the tube-fiee gioup, anu uecieaseu in the tube feu gioup (7). This is
goou eviuence that postopeiative tube feeuing thiough a jejunostomy tube
impioves the gastiectomy patients' nutiitional status aftei theii pioceuuie.
A ianuomizeu peispective stuuy peifoimeu by Kim et al founu that enteially
feu post-gastiectomy patients hau bettei postopeiative outcomes than paienteially
feu post-gastiectomy patients (8). In this stuuy publisheu in the Koiean }ouinal of
uastioenteiology, gastiic cancei patients weie assigneu to an enteially feu gioup
anu a paienteially feu gioup postopeiatively. Nutiitional paiameteis incluuing
weight, bloou uiea nitiogen, livei function, length of hospital stay anu abuominal
symptoms (such as ciamping anu vomiting) weie compaieu. Although no
significant uiffeiences weie founu between the gioups iegaiuing nutiitional
paiameteis, vomiting anu abuominal uistention weie moie common in the enteially
6
feu gioup. This, obviously, was a negative outcome foi the enteially feu gioup.
Bowevei, incieaseu aspaitate aminotiansfeiase (AST), alanine aminotiansfeiase
(ALT), anu total biliiubin weie moie common in the total paienteial nutiition (TPN)
gioup. This inuicates that the livei function of enteially feu patients was
significantly bettei than paienteially feu patients (1u). Length of hospital stay was
shoitei in the tube feu gioup, but this uiffeience was not statistically significant, as
they only stayeu one uay less than the paienteially feu gioup.
In oiuei to encouiage bowel function to ietuin postopeiatively, tube feeus
aie commonly "tiickleu," oi staiteu at a low iate, such as 1u milliliteis pei houi. The
soonei that bowel function ietuins, the soonei a patient may begin to toleiate oial
feeus. A ianuomizeu clinical tiial by Bui et al founu that eaily oial feeuing impioveu
outcomes in post-gastiectomy patients. In this stuuy, patients weie uiviueu into an
eaily feu gioup anu a uelayeu-feeuing gioup. Patients in the eaily feeuing gioup
began a cleai liquiu uiet 2 uays post-gastiectomy, anu began a soft (low-fibei) uiet
on the Siu uay until they weie uischaigeu. The othei gioup began a liquiu uiet on
the 4th postopeiative uay. The puipose of this stuuy was to measuie which gioup
iequiieu a longei hospital stay. The outcome of this stuuy showeu that the mean
uuiation of hospitalization anu time until flatus weie significantly shoitei in the
eaily feeuing gioup. Quality of life scoies weie also impioveu in the eaily oially feu
gioup (2). Eaily oial feeuing causeu incieaseu stomach ciamping anu othei
uiscomfoit, but the impioveu outcomes of shoitei hospital stay may outweigh the
iisks of uecieaseu quality of life scoies. These scoies weie only lowei in the fiist few
uays immeuiately postopeiatively.
7

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An 84 yeai olu white female was aumitteu to the hospital foi a scheuuleu
pioceuuie of exploiatoiy lapaiotomy, subtotal gastiectomy, gastiostomy tube
placement, anu jejunostomy tube placement uue to gastiic cancei. She hau
pieviously been on home total paienteial nutiition (intiavenous nutiition) foi ovei
six weeks in oiuei to impiove hei nutiitional status. She was unable to toleiate
foou oially uue to a gastiic outlet obstiuction causeu by the tumoi. The hospital
pioblems listeu in hei chait incluueu gastiinoma, gastiic peifoiation, caicinoiu
tumoi of small intestine, along with many otheis that weie not uI ielateu. She hau
an extensive histoiy of meuical issues incluuing knee suigeiy anu chionic knee pain.
The patient's postopeiative couise was piolongeu by slow ietuin of bowel function.
Tube feeus weie initially "tiickleu" at 1u milliliteis pei houi in oiuei to encouiage
the ietuin of bowel function. Nutiition inteivention anu tieatment incluueu giauual
auvancement of } tube feeus with u tube initially to suction, then to giavity,
alteinating with being clampeu. As the patient began toleiating tube feeus, she
began oial intake with cleai liquius anu was auvanceu to soft uiet. The patient was
uischaigeu when she was hemouynamically stable, afebiile, anu toleiating a soft
(low-fibei) uiet with cycleu tube feeus.

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The Nutiition Caie Piocess (NCP) stanuaiuizes nutiition caie by all
iegisteieu uietitians thiough the Acauemy of Nutiition anu Bietetics (12). The NCP
8
was useu to assess, uiagnose, pioviue nutiition inteivention, monitoi anu evaluate
this patient, as it is useu with all othei hospitalizeu patients who iequiie nutiitional
inteivention anu tieatment.
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Piioi to this hospital aumission, the patient hau unueigone many invasive
pioceuuies. Not all of them hau been ielateu to gastiointestinal (uI) issues. This
patient hau pieviously unueigone suigeiies incluuing but not limiteu to: ligation of
fallopian tubes; iemoval of the gallblauuei; multiple uppei uI enuoscopies with
biopsies of suspicious tissues anu polyps; multiple colonoscopies anu
polypectomies; esophagogastiouuouenoscopy; a pievious exploiatoiy lapaiotomy
of the abuomen; suigical iepaii of peifoiateu uuouenum; suigeiy to fiee a bowel
auhesion; enteiolysis; an uppei uI enuoscopy with balloon uilation; an uppei uI
enuoscopy with stent placement (uue to the piesent gastiic outlet obstiuction); anu
gastioscopy. The ieason foi the suigeiy neeueu uuiing this aumission was that the
stent hau been iemoveu, anu the patient's symptoms of oial intake (P0) intoleiance
ietuineu. Attempts to ieplace the stent faileu, hence the neeu foi total paienteial
nutiition in piepaiation foi anothei gastiic suigeiy.
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This pleasant elueily woman has always been a nonsmokei. It is inteiesting
to note that smoking is a contiibuting factoi to gastiic cancei, but this patient hau
not smokeu yet still uevelopeu cancei. She iepoiteu uiinking fewei than two uiinks
pei uay. She is wiuoweu, anu lives alone. She has two uaughteis who aie veiy active
in the patient's caie anu weie piesent often uuiing the patient's hospital couise.
9
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The patient hau been on home total paienteial nutiition (TPN) foi ovei 6
weeks piioi to aumission foi suigeiy uue to the gastiic outlet obstiuction. Since hei
uigestive tiact hau a tumoi that was blocking the stomach fiom emptying, she coulu
not toleiate oial intake. She hau lost significant weight befoie the uiagnosis of
gastiic outlet obstiuction, which showeu a neeu foi nutiition iepletion. A
nonfunctioning uI tiact is an inuicatoi foi neeu foi TPN (9). No foou alleigies
complicateu this case.
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This patient hau no pioblems swallowing. She uiu have uppei uentuies, but
it was noteu that she coulu speak well with them anu the patient iepoiteu that they
uiu not cause chewing issues. When the patient was being assesseu, she was able to
sit up in hei chaii foi long peiious of time. When scieening foi malnutiition
inuicatois, veiy milu claviculai wasting was noteu. In auuition to seveie weight loss
of about 2u lbs since }une (gieatei than 1u% bouy weight lost ovei 6 months), the
patient is categoiizeu to have milu-moueiate (nonseveie) piotein caloiie
malnutiition (1S).
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This patient's usual bouy weight, befoie hei gastiic outlet obstiuction issues
began, was about 172 to 18u pounus. She stanus at S feet S inches tall (6S inches)
anu weigheu 1SS lbs upon initial assessment. Bei initial assessment BNI was 2S.8S
kgm
2
. A bouy mass inuex above 24.9 is classifieu as oveiweight (1u). It is
1u
inteiesting to note that a patient can be oveiweight anu malnouiisheu at the same
time.
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Estimateu eneigy neeus pei uay foi this patient baseu on hei status post
suigeiy, seveie weight loss, anu moueiate malnouiishment weie estimateu at a goal
of 17Su-21uu caloiies pei uay. Bei estimateu piotein neeus pei uay weie 84-1uS
giams. Estimateu fluiu neeus pei uay weie 21uu milliliteis. See Appenuix Table 1
foi calculations of these estimateu uaily neeus.
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The patient hau ielatively goou labs, within noimal ianges at hei initial
assessment. See Table 2 in Appenuix foi abnoimal biochemical uata anu tests that
aie ielevant to this case.
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0sing ARANARK's Nutiition Status Classification Woiksheet the patient was
classifieu as seveiely compiomiseu (status level 4). To auu up to a level 4 status, the
points awaiueu aie: status post uI suigeiy, new tube feeuing, seveie weight loss,
piolongeu NP0 status, anu being TPN uepenuent piioi to aumission (14). See
Appenuix Table S foi the woiksheet anu points awaiueu.

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Pioblem: Alteieu uI Function (NC-1.4)
Etiology: ielateu to gastiic outlet obstiuction causeu by gastiic cancei iequiiing uI
suigeiy
11
SignsSymptoms: As eviuenceu by status post exploiatoiy lapaiotomy, subtotal
gastiectomy, gastiostomy tube placement, jejunostomy tube placement, anu neeu
foi enteial feeus to meet estimateu nutiitional neeus (1S).
This uiagnosis was maue on post-opeiative (P0B) thiee, aftei the patient hau
spent one uay in suigical intensive caie anu two uays on the flooi with an NP0 oiuei
(nothing by mouth) fiom the physician.

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Neuical pioceuuies that weie oiueieu uuiing hospitalization weie mostly
nutiition-ielateu, since iestoiing anu maintaining bowel function was piioiity. The
physician oiueieu that tiickle tube feeus began on 127, which was postopeiative
uay S. Cleai liquiu uiet was initiateu 2u1.
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#1: Bomain: Foou anuoi Nutiient Beliveiy (NB)
Nutiition Inteivention Teim: Enteial Nutiition (NB-2.1)
Nutiition-Relateu Inteivention: Initiate anu toleiate tube feeus of 0smolite 1.2
thiough jejunostomy tube at initial iate of 2u mlhoui; auvance as toleiateu by 2u
ml eveiy 6 houis to goal iate of 7u mlhoui (1S).
This iate at goal woulu pioviue at least 7S% of estimateu neeus calculateu in the
above Nutiient Neeus section. This is the stanuaiu goal foi pioviuing enteial feeus
at this hospital. An oiuei to initiate P0 intake is left to piimaiy seivice to ueteimine
when it is meuically appiopiiate.
12

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#1: FoouNutiition-Relateu Bistoiy: Eneigy Intake (FB-1.1.1.1) Total eneigy
intake shoulu meet 7S% oi gieatei of estimateu neeus: Nonitoi Intake0utput
iecoius.
#2: Nonitoi Biochemical Tests anu Pioceuuies: uastiointestinal Piofile: uastiic
Resiuual volume (BB-1.4.S)
0thei signs to monitoi incluueu abuominal exams (such as uistention anu
bowel sounus), bloou chemistiy if any electiolytes lookeu abnoimal, anu weight.
B*%#$ F-<<-H 5,
Thiee uays post initial assessment anu iecommenuations to initiate tube
feeus, the patient was toleiating } tube feeus at the goal iate. She hau hau some
uifficulty with episoues of emesis uuiing a tiial clamping of the u tube, so the u tube
iemaineu open anu uiaining to giavity to ielieve uiscomfoit. Since then, the
physician oiueieu anothei u tube clamping tiial anu initiation of cleai liquiu uiet,
which the patient was cuiiently toleiating.
PES Statement: Alteieu uI Function (NC-1.4) ielateu to gastiic outlet
obstiuction causeu by gastiic cancei as eviuenceu by status post exploiatoiy
lapaiotomy, subtotal gastiectomy, gastiostomy tube placement, jejunostomy tube
placement, anu neeu foi enteial feeus to meet estimateu nutiitional neeus.
Nutiition Inteivention Peifoimeu:
#1: Enteial Nutiition (NB 2.1)Continue Tube feeus of 0smolite 1.2 thiough
jejunostomy tube at goal iate of 7u mlhoui (1S).
1S
#2: Neals anu Snacks: Composition of mealssnacks: Initiate Cleai Liquiu
Biet, Auvance as toleiateu to geneial soft fibei-iestiicteu uiet, 6 small meals pei uay.
Level of achievementcompliance: piogiessing; patient was cuiiently toleiating
cleai liquius with no uI uiscomfoit.
>+'-.1 F-<<-H 5,
Seven uays post initial assessment, the patient was toleiating full liquius
along with hei } tube feeus. The tube feeus hau been ieuuceu to a iate of Su ml pei
houi because between this follow up anu the last follow up, the } tube hau been
leaking anu tube feeus weie stoppeu. They iestaiteu anu slowly auvanceu, anu weie
cuiiently at Su mlhoui.
PES Statement: Alteieu uI Function (NC-1.4) ielateu to gastiic outlet obstiuction
causeu by gastiic cancei as eviuenceu by status post exploiatoiy lapaiotomy,
subtotal gastiectomy, gastiostomy tube placement, jejunostomy tube placement,
anu neeu foi enteial feeus to meet estimateu nutiitional neeus. In oiuei to assist the
patient in ieaching towaiu hei caloiie goals oially, a supplement was auueu.
Nutiition Inteivention Peifoimeu: Enteial Nutiition (NB 2.1) Continue Tube
feeus of 0smolite 1.2 thiough jejunostomy tube, auvance as toleiateu to goal iate of
7u mlhoui.
#2: Neals anu Snacks: Composition of mealssnacks: Continue on the Full
Liquiu Biet; Auvance as toleiateu to geneial soft fibei-iestiicteu uiet, 6 small meals
pei uay (1S).
#S: Neuical Foou Supplements: Commeicial foou (NB-S.1.2) Will Auu
Chocolate Nagic Cup once pei uay.
14
Level of achievementcompliance: piogiessing; patient was cuiiently toleiating full
liquiu uiet with no uI uiscomfoit.
uoals set: Auvance as toleiateu to geneial soft uiet with 6 small meals pei uay pei
piimaiy caie pioviuei. Consume 7S% oi moie of meals. Consume 7S% oi moie of
nutiition supplement.
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Bischaige was oiueieu foi the patient by the physician 9 uays post initial
assessment, befoie a uischaige follow up coulu be completeu. The uischaige
instiuctions incluueu that she continue on hei tube feeuing iegimen, which hau
been switcheu to a cycleu feeuing scheuule at night. She hau also auvanceu to a soft
uiet, anu was toleiating it well.
Pei a follow up phone call on 211, the patient was complaining of upset
stomach, which iesolveu eventually. An office visit on 217 noteu that hei iecoveiy
was going well. Notes fiom an office visit 22S showeu that the patient was eating
without uifficulty, anu she was given instiuction that she may stait clamping utube
continuously insteau of inteimittently between meals.

8-.'<5#*-.
This patient's case is a goou example of the success of } tube feeuings aftei a
gastiectomy in oiuei to help meet nutiitional neeus. She is cuiiently uoing well anu
no malignancies weie founu at hei follow-up visits. This case exemplifies the issues
faceu of slow bowel function aftei gastiic suigeiy, anu the use of eviuence-baseu
nutiition iecommenuations to initiate tube feeuing aftei suigeiy. Piactice
1S
expeiience gaineu uuiing this patient's case was laigely in the aiea of ieseaiching
eviuence-baseu guiuelines. Nonitoiing anu evaluation of the gastiointestinal
symptoms that the patient enuuieu aftei the suigeiy was impoitant in oiuei to
ueteimine how well the uI tiact was woiking.



















16
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Table 1: Estimateu Nutiient Neeus
!'$5&< 3-1A J+*?C$: KL M? ;5<$*,<*+1 "A /#$*7&$+1 )&*<A 4++1#
Caloiies pei kg 2S-Su 17Su-21uu kcal
uiams Piotein pei kg 1.2-1.S 84-1uS g piotein
Nl Fluiu pei kg Su 21uu ml *oi pei NB
*Fluiu is the iesponsibility of the piimaiy seivice to iestiict oi inciease as meuically
appiopiiate.

Table 2: Abnoimal Biochemical Tests 0pon Initial Assessment
8-7,-.+.$ 6+#5<$ G1+&<
6&.?+
/N,<&.&$*-.
ulucose 11S mgul 6u-99
mgul
Bloou glucose is commonly high aftei suigeiy
Nagnesium 1.6 mgul 1.7-2.8
mgul
Pooi P0 intake
Bemoglobin 11.7 gmul 12.u-1S.u
gmul
Commonly low aftei suigeiy uue to bloou loss
Calcium 8.u mgul 8.S-1u.S
mgul
Pooi P0 intake
17

Table S: Points Awaiueu
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8&$+?-%A
9&$*+.$O# >,+'*F*' 9%-"<+7 9%*-%*$A 9-*.$#
BiagnosisConuition uI Suigeiy S
Feeuing Nouality oi
anticipateu
New Tube Feeus 4
0nintentional Weight Loss Seveie Weight Loss >1u% in 6
months
4
Nutiition Bx oi anticipateu Piolongeu NP0 Intake (<Su%
neeus foi 2 weeks)
4
Feeuing Nouality oi
anticipateu
TPN Bepenuent (piioi to
aumission)
4

This auus up to 19 points, anu the "seveiely compiomiseu" categoiy of nutiition
status classification is anything ovei 12 points (14).







18
Table 4: Neuications to Note
Neuication Neuication Type Neuication Action Foou Inteiactions
Piotonix Pioton-Pump
Inhibitoi
Anti-uERB,
antisecietoiy
Becieases
absoiption of Iion,
Calcium anu
vitamin B12. Nay
cause Biaiihea
Zofian Seiotonin SBTS
ieceptoi agonist
Antiemetic,
Antinauseant
Nay cause uiy
mouth, abuominal
pain, constipation,
uiaiihea.
(16)











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2. Boon Bui, Sung ueun Kim, }ung Bo Shim et al. Effect of eaily oial feeuing aftei
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S. Rauigan, AE. Post-uastiectomy: Nanaging the Nutiition Fall-0ut. 1*'()$('#
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4. Nayo Founuation foi Neuical Euucation anu Reseaich; Biseases anu Conuitions -
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2u
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)!
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12. Nutiition Caie Piocess; Acauemy of Nutiition anu Bietetics;
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1S. Nuellei C, Comphei C, Biuyan NE, anu the Ameiican Society foi Paienteial anu
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