Postoperative Early Standard and Sequential Nutritional Support in the Treatment of Gastroesophageal Anastomotic Fistula: a Case Report△

Chang-zhen Zhu, Kang Li, Jian-chun Yu, Wei-ming Kang*, Zhi-qiang Ma, and Xin Ye

Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China

CASE REPORT

Postoperative Early Standard and Sequential Nutritional Support in the Treatment of Gastroesophageal Anastomotic Fistula: a Case Report△

Chang-zhen Zhu, Kang Li, Jian-chun Yu, Wei-ming Kang*, Zhi-qiang Ma, and Xin Ye

Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China

enteral nutrition; parenteral nutrition; gastroesophageal anastomotic fistula

Chin Med Sci J 2015; 30(2)：131-134

GASTROESOPHAGEAL anastomotic fistula is a serious and potentially life-threatening complication after the resection of esophagus, gastric and cardia tumor.1 Before 1987, the incidence of gastroesophageal anastomotic fistula is about 2%-4% in China, and the mortality rate is as high as 50% or more.2 In the last 30 years, with the rapid development of clinical nutrition support method, nutritional support, especially the standard clinical use of enteral nutrition therapy, has improved the conservative treatment success rate of intrathoracic anastomotic fistula and shortened the healing time of fistula.3-5 Herein, we report a woman with post-surgical intrathoracic anastomotic fistula who had undergone proximal gastric resection for lower esophageal leiomyoma was treated with standard and sequential nutritional support.

CASE DESCRIPTION

A 46-year-old woman had complained of repeated belching for 2 months and black stool for 10 days. The gastroscopic results from a local hospital showed a mass lesion in her gastric cardia, about 4 cm in size, with smooth surface. On January 11, 2014, transesophageal echocardiography revealed a visible lesion presenting a low and homogeneous echo in the anterior gastric wall near the cardia, about 5.0 cm x 1.6 cm in size, with smooth mucosal surface. Abdominal CT with gastric reconstruction images showed a soft tissue density masses located in the esophagus and gastric cardia with the largest cross-sectional area of4.7 cm x 2.7 cm.

The initial diagnosis was gastric stromal tumor. She underwent a laparoscopic proximal gastrectomy combined with needle catheter jejunostomy under the general anesthesia on January 14, 2014. Meanwhile, a peritoneal cavity drainage tube was placed. The postoperative pathological diagnosis was a lower esophageal and cardia leiomyoma. Immunohistochemistry showed: desmin (+), smooth muscle actin (SMA) (+), CD117 (-), CD34 (+), discovered on GIST-1 (DOG-1) (-), S-100 (-), Ki-67 labeling index ＜ 1%.

The history of past illness showed that her heart, lung, liver and renal function were normal and she had no diabetes and other metabolic diseases, and no drug and food allergies. Physical examination: height 165 cm, weight 72 kg, body mass index (BMI) 26.4 kg/m2, and Nutritional Risk Screening (NRS) 2002 score 3; status of clinical nutrition: total protein 71 g/L, albumin 43 g/L, prealbumin 298 g/L, transferrin 2.17 g/L, lymphocyte count 1.77x109/L, hemoglobin 141 g/L, prognostic nutritional index-Onodera prognostic nutrition index (OPNI) 51.85; liver function: alanine aminotransferase (ALT) 17 U/L, aspartate aminotransferase (AST) 13 U/L, total bilirubin (TBIL) 11.6 mmol/L, direct bilirubin (DBIL) 2.4 mmol/L; inflammation index: C reactive protein 1.39 mg/L and neutrophil/ lymphocyte ratio (NLR) 1.64; tumor marker series (-).

The first day after operation, she did not feel uncomfortable. Peritoneal drainage (250 ml) was pale red, and the color of gastric drainage (180 ml) was dark brown. The second day, she complained of progressively worsening chest tightness, shortness of breath and fever (about 39˚C). The color of gastric juice (50 ml) and peritoneal fluid (370 ml) were both dark brown. On 3 days postoperatively, OPNI was decreased to 30.05, and NLR rose to 23, the highest level. The enhanced chest CT showed a large number of effusion accumulated in the bilateral pleural cavity. Upper gastrointestinal contrast imaging manifested that contrast medium partly spilled into the right pleural cavity. The diagnosis of intrathoracic stomach-esophageal fistula was made.

Treatment schemes were as follows: (1) Fasting, gastrointestinal decompression, anti acid, antibiotics, maintaining a semi-recumbent position. (2) Drainage: abdominal cavity drainage + gastric drainage + bilateral pleural cavity drainage + fistula drainage. (3) Sequential nutrition therapy: 2000 ml (2510.4 kJ) glucose saline was intravenously infused on the day of operation. Postoperative day one, 250 ml short peptide enteral nutrition fluids (Enteral Nutritional Suspension, Peptison, Nutricia Pharmaceutical Co., Ltd., 4.184 kJ/ml) were given at a rate of 30 ml/h through jejunal nutrient canal to recover gastrointestinal function (1037 kJ, ratio of glucose to fat 82:18). For the patient could tolerate well, postoperative day two, the liquid volume of enteral nutrition was increased to 500 ml with a pump speed of 50 ml/h (2092 kJ, ratio of glucose to fat 82:18). The patient had no discomfort after the procedure. On postoperative day 3-5, enteral nutrition liquid was increased to 1000 ml, and the pump speed to 80 ml/h. Shortage of liquid was replenished with glucose saline by intravenous infusion or with the water by the jejunum nutrition tuber. She complained of abdominal distention (4184 kJ, ratio of glucose to fat 82:18). On postoperative day 6, when the abdominal distention disappeared, 1500 ml of the whole protein nutrient fluids (Enteral Nutritional Emulsion, Fresubin, Huarui Pharmaceutical Co., Ltd., 4.184 kJ/ml) were pumped into the jejunum with the maximum speed of 120 ml/h (6276 kJ, ratio of glucose to fat 82:18). Enteral nutrition was continued until oral diet intake was normal.

On 35 days after operation, chest tightness, shortness of breath, and fever disappeared. Intrathoracic anastomotic drainage was less than 5 ml/24 hours. The nutritional, liver function and inflammatory parameters were shown as follows: albumin 32 g/L, prealbumin 213 g/L, transferrin 2.70 g/L, lymphocyte count 1.90x109/L, hemoglobin 100 g/L, OPNI 39.70; ALT 28 U/L, AST 18 U/L, TBIL 6.3 mmol/L, DBIL 1.9 mmol/L; C reactive protein (-) and NLR 2.60. Upper gastrointestinal radiography image was normal. One week (postoperative day 42) later, this patient could orally eat liquid diet without discomfort, and fistula drainage tube was discharged. The fistula smooth drainage tube was removed 2 weeks later. OPNI gradually returned to normal level (47.4 at discharge). When this patient discharged, NLR had fallen to 0.86. The patient had been followed up for one year, and her diet, nutritional status, body weight returned to the preoperative levels.

DISCUSSION

Given that the position of anastomosis is higher, the possibility of occurrence of excision anastomotic leakage is high after operation of the abdomen.6Therefore, we placed needle puncture jejunostomy tube for postoperative enteral nutrition if necessary. We confirmed that jejunostomy tube is an effective method to establish long-term gastrointestinal nutrition pathway for critically ill patients. Early standardized enteral and parenteral nutrition support through jejunal nutrient tube aftergastrointestinal operation can improve postoperative prealbumin level in serum, and benefit the recovery of immune function and tissue injury.7

Postsurgical gastroesophageal intrathoracic anastomotic fistula is one of severe complications that is frequently accompanied by malnutrition.8It has been shown when the accumulated energy loss are greater than 41.84 kJ, patient will have a major organ failure and mortality rate will rise markedly.8Adequate drainage and nutritional support, especially enteral nutrition, are the basic principles for the treatment of gastroesophageal anastomotic fistula.

Compared with parenteral nutrition, enteral nutrition treatment for the patients with esophagus stomach anastomotic fistula has been showed to be easier to restore a positive nitrogen balance; to recover serum albumin, prealbumin, hemoglobin and transferrin levels and liver functions.9For our case, standard and sequential nutritional support for 35 days improved her nutritional status and liver function. However, there is a debate about the problem of effect of different nutritional support ways on fistula healing time. Zhang9found that enteral nutrition could not shorten the time of fistula healing compared with parenteral nutrition. But Jia10considered that the fistula healing time of enteral nutrition was significantly shorter than that of parenteral nutrition. These differences may be related to differences in sample size and anastomotic fistula position.

OPNI as a parameter for nutritional assessment and operation risk prediction has been widely used to evaluate nutritional status and operation risk of patients who will receive gastrointestinal surgery.11According to the Onokazu Temple standards,12OPNI is greater than 50, revealing patient is in normal nutritional status; 45-50, manifesting patient is with mild malnutrition, but can tolerate gastrointestinal operation; 40-45, suggesting patient with moderate malnutrition, and risk of gastrointestinal operation is high; OPNI is less than 40, indicating patient with severe malnutrition, and cannot tolerate operation. As for this patient, her preoperative OPNI was 51.85, which means operation tolerance is good. Because of anastomotic fistula, his OPNI value was decreased to the lowest level 30.05, indicating that her nutrition and immune status was decreased. With the use of enteral nutrition, OPNI gradually returned to the normal level (47.4 at discharge).

NLR is an effective indicator of prognosis. It has been suggested that gradual increase of neutrophils and gradual decrease of neutrophils are synchronous with the improvement of systemic inflammatory reaction.11The prognosis of patients with low NLR was often better than those with high NLR.11On the contrary, if decrease of neutrophil and increase of lymphocytes were continuous for one week, patient may have more severe complications.11The preoperative NLR of this patient was 1.64. At the early stage of anastomosis fistula, NLR rose to the highest, representing the period of acute inflammation reaction. With the use of enteral nutrition, although NLR had been fluctuating, the overall trend was downward. When she was discharged, NLR fell to 0.86, representing that inflammatory reaction receded and prognosis was good.

In summary, for patient with intrathoracic esophagogastric anastomotic fistula, on the basis of adequate drainage, enteral nutrition could promote the synthesis of protein, alleviate liver damage, improve nutritional status, shorten fistula healing time, and reduce inflammatory reaction.

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for publication November 24, 2014.

Tel: 86-10-69152215, E-mail: kangweiming@163.com

△Supported by a grant from the Health Research Development Program of Beijing (2014-3-4014) and a grant from the National High Technology Research and Development Program of China (2010AA023007).