Diseases of the Esophagus (2015) ••, ••–•• DOI: 10.1111/dote.12337

Original article

Early enteral nutrition compared with parenteral nutrition for esophageal cancer patients after esophagectomy: a meta-analysis J. Peng, J. Cai, Z.-X. Niu, L.-Q. Chen Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China

SUMMARY. Early postoperative enteral nutrition (EN) after esophagectomy in esophageal cancer patient has been reported to be correlated with a better rehabilitation than parenteral nutrition (PN). However, a robust conclusion has not been achieved. Therefore, we performed a meta-analysis to compare the postoperative EN and PN in patients with esophageal cancer undergoing esophagectomy. Three electronic databases were searched for eligible studies to be included in the meta-analysis. The summary relative risk/weighted mean difference (RR/ WMD) estimates and corresponding 95% confidence interval (CI) were calculated using fixed- and random-effects models. Ten studies met the inclusion criteria. The analysis demonstrated that the early postoperative EN could significantly decrease the pulmonary complications (RR = 0.37, 95% CI = 0.22–0.62, P = 0.00, test for heterogeneity: I2 = 0.0%, P = 0.89) and anastomotic leakage (RR = 0.46, 95% CI = 0.22–0.96, P = 0.04, test for heterogeneity: I2 = 0.0%, P = 0.66) compared with PN. On the eighth postoperative day, the EN group had a higher levels of albumin (WMD = 1.84, 95% CI = 0.47–3.21, P = 0.01, test for heterogeneity: I2 = 84.5%, P = 0.00) and prealbumin (WMD = 12.96, 95% CI = 3.63–22.29, P = 0.01, test for heterogeneity: I2 = 0.0%, P = 0.63) compared with the PN group. However, there was no difference in digestive complications between these two approaches (RR = 1.30, 95% CI = 0.79–2.13, P = 0.30, test for heterogeneity: I2 = 0.0%, P = 0.97). For patients with esophageal cancer following esophagectomy, the early postoperative EN support could decrease the morbidity of severe complications, such as pulmonary complications and anastomotic leakage, and maintain patients at a better nutritional status than parenteral nutrion support. KEY WORDS: enteral nutrition, esophageal cancer, esophagectomy, meta-analysis, parenteral nutrition.

INTRODUCTION Patients with esophageal cancer tend to have varying degrees of malnutrition because of the reduced food intake as a result of dysphagia, preoperative diet restrictions, and nutrition consumption by tumors.1 Furthermore, the preoperative nutritional status of patients undergoing major surgery has been shown partially impact on postoperative rehabilitation,2 and malnutrition is associated with increased morbidity and mortality in hospitalized patients.3,4 Thus, for the patients with esophageal cancer, the poor preoperative nutritional status may increase the risk of postoperative complications.5 However, surgery is still the Address correspondence to: Prof Long-Qi Chen, MD, PhD, Department of Thoracic Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan 610041, China. Email: [email protected] Jun Peng and Jie Cai contributed equally to this work, and should be regarded as co-first authors. © 2015 International Society for Diseases of the Esophagus

mainstay of therapy for all curable esophageal cancer.6 Esophagectomy and esophageal substitution is one of the most invasive and time-consuming surgeries among gastrointestinal surgical procedures. It will induce a strong stress response in the human body.7 Therefore, after the surgery the patients’ nutritional status will be deteriorated,2 and the postoperative nutritional support is particularly important. An increasing number of studies have demonstrated that following gastrointestinal surgery, early postoperative enteral nutrition (EN) is superior to parenteral nutrition (PN), resulting in a reduced length of hospitalization and severe postoperative complication rate.4,8–11 However, some studies have found that early EN may be related to an increased incidence of aspiration pneumonia and may further complicate anastomotic leakage, resulting in mediastinitis, which carries a high mortality rate.12–15 Some publications showed no significant advantages compared with PN.1,16 In the present study, we 1

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conducted a meta-analysis based on eligible published studies to quantitatively review the effect of early EN compared with PN in esophageal cancer patients undergoing an esophagectomy.

METHODS Search strategy The electronic databases PubMed, Embase and Web of Knowledge were searched for studies to be included in current meta-analysis. An upper date limit of May 19, 2014 was applied, and no lower date limit was used. An initial search strategy was based on combinations of the following terms: ‘Esophageal neoplasms’, ‘Esophageal squamous cell carcinoma’, ‘Esophageal adenocarcinoma’, ‘Esophageal cancer’, ‘Esophagectomy’, ‘Esophageal surgery’, ‘Parenteral nutrition’, ‘Enteral nutrition’, and ‘Enteral feeding’. In addition, the reference lists of the included publications and relevant review articles were also reviewed for additional relevant studies. The search was performed independently by two investigators (J. P. and J. C.).

Inclusion and exclusion criteria Inclusion criteria for eligible studies were as follows: (i) randomized controlled trial; (ii) patients with esophageal cancer; (iii) the EN support started on the first postoperative day; (iv) the outcome should include at least one of the following topics: total postoperative complications, digestive complications, pulmonary complications, anastomotic leakage, and postoperative nutritional status; and (v) no patient accepted preoperative EN or PN. The total postoperative complications refer to all the complications reported by the study. They included the digestive complications, pulmonary complications, anastomotic leakage, wound infection, anastomotic stenosis, and cardiovascular complications. The digestive complications referred to nausea, vomit, diarrhea, and delayed gastric emptying. The pulmonary complications referred to the pneumonia and acute respiratory distress syndrome. Two reviewers (J. P. and J. C.) independently determined study eligibility. When studies had the same authors or overlapped study population, only the study with complete data was selected to avoid duplication of data. Disagreements were resolved by consensus. Our initial selection of all candidate articles relied on careful reading of their titles and abstracts. Articles that could not be classified based on title and abstract were reviewed by the full text. The primary studies required for meta-analysis were categorized based on full-text review.

Data extraction Information was carefully extracted from all included publications using a prespecified data collection form with the following items: first author, year of publication, country, number of patients, the approach of PN and EN, postoperative nutritional support duration, and the results we cared. The data were extracted by two independent reviewers (J. P. and J. C.), and disagreements were resolved by consensus. Risk of bias assessment The assessment of risk of bias in included studies was based on the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions version 5.2.0. We assessed the selection bias, performance bias, attrition bias, and reporting bias. Two reviewers (J. C. and Z.-X. N.) independently assessed the risk of bias. Any disagreement was resolved by discussion between the two reviewers. Statistical analysis The summary relative risk (RR) and weighted mean difference (WMD) estimates and corresponding 95% confidence intervals (CIs) were calculated under a fixed-effects model or a random-effects model. An RR was considered statistically significant if the 95% CI did not overlap with the value 1, and the WMD was considered statistically significant if the 95% CI did not overlap with the value 0. The heterogeneity of all included studies was assessed by the Q-test and statistical value I2. If I2 ≤50%, the studies with fine homogeneity were considered, and then the fixedeffects model with Mantel–Haensel method was used for secondary analysis. Otherwise, the following techniques were employed to explain it: (i) random-effects model with the DerSimonian and Laird method was adopted if there were limited included studies, or (ii) sensitivity analysis performed by excluding the trials that potentially biased results. Assessment of publication bias was performed for each of the pooled study groups using both the Egger’s test and Begg’s test. A P-value >0.05 showed no publication bias in the study. All statistical analyses were carried out using STATA version 12.0 (Stata Corporation, College Station, TX, USA).

RESULTS Study characteristics A total of 240 studies were reviewed. After an initial exclusion of the articles that were obviously out of the scope of our meta-analysis, we identified 18 potential studies for further detailed evaluation. Upon further © 2015 International Society for Diseases of the Esophagus

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Fig. 1 Meta-analysis flowchart.

review, 10 studies finally met our inclusion criteria for this meta-analysis. Detailed search steps were described in Figure 1. The 10 studies17–26 were published between 2001 and 2014; all of them were randomized controlled studies. The sample size of the included studies varied from 24 to 164. Six studies reported the postoperative complications between the EN group and PN group, five of them compared the digestive complications, three of them compared the anastomotic leakage, and all of six studies reported the pulmonary complications. Eight of the 10 studies reported the postoperative albumin and prealbumin level to reflect the postoperative nutritional status. Most of the studies chose the nasojejunal feeding tube to conduct the EN and central vein to conduct the PN. The major characteristics of the 10

included publications were shown in Table 1. The assessments of the risk bias were presented in Figure 2. Total postoperative complications We found six studies17–20,24,25 with a total of 504 participants compared the total postoperative complications between the EN and PN group. The random-effects meta-analysis showed no significant difference in total postoperative complications between the two groups (RR = 0.60, 95% CI = 0.35– 1.04, P = 0.07; test for heterogeneity: I2 = 73.9%, P = 0.00). A sensitivity analysis found that the study by Wu et al.24 was the main origin of heterogeneity, with the heterogeneity largely disappeared following the exclusion of that study (I2 = 32.1%, P = 0.21).

Table 1 Characteristics of studies included in the meta-analysis

First author

Year

Country

Number of patients (E/P)

Approaches of EN

Approaches of PN

NS duration

Zhao Xiao Yu Liu Fujita Feng Seike Xie Wu Aiko

2014 2014 2013 2013 2012 2012 2011 2007 2006 2001

China China China China Japan China Japan China China Japan

30/30 64/56 50/46 15/15 76/88 20/15 14/15 60/60 53/53 13/11

Nasojejunal feeding tube Nasojejunal feeding tube Nasojejunal feeding tube Nasojejunal feeding tube Nasojejunal feeding tube Nasojejunal feeding tube Nasojejunal feeding tube Nasoduodenal feeding tube Nasoduodenal feeding tube Jejunostomy

Central vein Central vein Central vein NG Peripheral vein Central vein Central vein Peripheral vein Peripheral vein Central vein

POD1-7 POD1-7 POD1-7 POD1-7 POD1-6 NG POD1-7 POD1-7 POD1-7 NG

E, enteral nutrition group; NG, not give; NS, nutritional support; P, parental nutrition group; POD, postoperative day. © 2015 International Society for Diseases of the Esophagus

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Fig. 2 Summaries of risk of bias in 10 included studies.

While the fixed-effects meta-analysis of the remaining five studies still showed no significant difference between the two groups (RR = 0.76, 95% CI = 0.54– 1.06, P = 0.11) (Fig. 3). Using both the Egger’s test and Begg’s test, we did not observe any evidence of publication bias for the summary estimates (Table 2). Digestive and pulmonary complications Meta-analysis of five studies17–21 with a total of 409 patients showed no significant difference in digestive

complications between the EN and PN groups (RR = 1.30, 95% CI = 0.79–2.13, P = 0.30, test for heterogeneity: I2 = 0.0%, P = 0.97) (Fig. 4). There were six studies with a total of 504 participants reported the postoperative pulmonary complications. A significant advantage favoring EN group was observed (RR = 0.37, 95% CI = 0.22–0.62, P = 0.00, test for heterogeneity: I2 = 0.0%, P = 0.89) (Fig. 5). We did not find any publication bias for the summary estimate (Table 2).

Fig. 3 Fixed-effects meta-analysis compared the total postoperative complications between the enteral nutrition (EN) and parenteral nutrition (PN). © 2015 International Society for Diseases of the Esophagus

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Table 2 Statistical results of the meta-analysis Test of heterogeneity Number of studies TPC DC PC AL Albumin POD1 POD3 POD7 POD8 Prealbumin POD1 POD8

RR/WMD (95% CI)

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Test of publication bias

P

I (%)

P

Begg’s test

Egger’s test

5 5 6 3

0.76 (0.54–1.06) 1.30 (0.79–2.13) 0.37 (0.22–0.62) 0.46 (0.22–0.96)

0.11 0.30 0.00 0.04

32.1 0.0 0.0 0.0

0.21 0.97 0.89 0.66

0.81 0.81 0.26 1

0.93 0.69 0.62 0.32

4 3 4 4

−0.75 (−1.92–0.43) 1.65 (−1.88–5.18) 1.62 (−1.17–4.41) 1.84 (0.47–3.21)

0.21 0.36 0.26 0.01

0.0 81.2 69.6 84.5

0.55 0.01 0.02 0.00

0.73 1 1 0.73

0.78 0.77 0.83 0.09

3 3

−2.71 (−9.89–4.48) 12.96 (3.63–22.29)

0.46 0.01

20.3 0.0

0.29 0.63

0.30 1

0.22 0.04

AL, anastomotic leakage; CI, confidence interval; DC, digestive complications; PC, pulmonary complications; POD, postoperative day; RR, relative risk; TPC, total postoperative complications; WMD, weighted mean difference.

Postoperative anastomotic leakage We found three studies with a total of 330 participants reported the postoperative anastomotic leakage. The fixed-effects meta-analysis of the three studies showed the EN group had a lower incidence of anastomotic leakage than the PN group (RR = 0.46. 95% CI = 0.22–0.96, P = 0.04, test for heterogeneity: I2 = 0.0%, P = 0.66) (Fig. 6). There was no publication bias in this part (Table 2). Postoperative nutritional status There were four studies reported the albumin level on the first postoperative day (POD1), POD7, and

POD8, respectively. Additionally, three studies further reported the POD3 results. The fixed-effects meta-analysis of these studies found a higher albumin level on POD7 (WMD = 1.77, 95% CI = 0.44–3.10, P = 0.01, test for heterogeneity: I2 = 69.6%, P = 0.02) and POD8 (WMD = 2.98, 95% CI = 2.76–3.20, P = 0.00, test for heterogeneity: I2 = 84.5%, P = 0.00) in the EN group, but no differences were found on POD1 (WMD = –0.75, 95% CI = –1.92–0.43, P = 0.21, test for heterogeneity: I2 = 0.0%, P = 0.55) and POD3 (WMD = 0.87, 95% CI = –0.05–1.80, P = 0.06, test for heterogeneity: I2 = 81.2%, P = 0.01). However, these results showed considerable heterogeneities. Considering the included studies in this part was limited, we used the random-effects method to do this

Fig. 4 Forest plot compared the digestive complications between the enteral nutrition (EN) and parenteral nutrition (PN). © 2015 International Society for Diseases of the Esophagus

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Fig. 5 Forest plot compared the pulmonary complications between the enteral nutrition (EN) and parenteral nutrition (PN).

meta-analysis again and found a similar tendency as the fixed-effects method (POD3: WMD = 1.65, 95% CI = –1.88–5.18, P = 0.36; POD7: WMD = 1.62, 95% CI = –1.17–4.41, P = 0.26; POD8: WMD = 1.84, 95% CI = 0.47–3.21, P = 0.01) (Fig. 7). We found three studies that reported the prealbumin level on POD1 and POD8. There was no

significant difference between the EN and PN group on POD1 (WMD = –2.71, 95% CI = –9.89–4.48, P = 0.46, test for heterogeneity: I2 = 20.3%, P = 0.29). However, on POD8 the prealbumin level in EN group was higher than that in the PN group (WMD = 12.96, 95% CI = 3.63–22.29, P = 0.01, test for heterogeneity: I2 = 0.0%, P = 0.63) (Fig. 8).

Fig. 6 Forest plot compared the anastomotic leakage between the enteral nutrition (EN) and parenteral nutrition (PN). © 2015 International Society for Diseases of the Esophagus

Early EN versus PN after esophagectomy

Fig. 7 Random-effects meta-analysis compared the postoperative albumin level between the enteral nutrition (EN) and parenteral nutrition (PN).

Fig. 8 Fixed-effects meta-analysis compared the postoperative prealbumin level between the enteral nutrition (EN) and parenteral nutrition (PN). © 2015 International Society for Diseases of the Esophagus

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A slightly publication bias was found in the prealbumin part on POD8 (Begg’s test P = 1, Egger’s test P = 0.04) (Table 2).

DISCUSSION This meta-analysis included 10 randomized controlled trials to compare the early postoperative EN with PN in patients with esophagectomy for esophageal cancer. Our results demonstrated that early postoperative EN could decrease the morbidity of pulmonary complications and anastomotic leakage. And the EN group had a more quickly improvement in postoperative nutritional status while there was no difference in the incidence of digestive complications. After surgery small bowel recovers its ability to absorb nutrients almost immediately.4 There are evidences that the early enteral feeding has been shown to preserve the integrity of gut mucosa and to keep up its immunological function.27–29 After the esophagectomy, the intestinal ischemia or intestinal paralysis and lack of the intestinal stimulation and oral nutrition can increase the atrophy, damage the permeability of intestinal mucosa. As a result, the gut bacteria and endotoxins can easily migrate and enter the blood stream.30 Previous studies have reported the early postoperative EN could decrease the level of serum endotoxins.18,26 The meta-analysis conducted by Mazaki et al.8 found that EN was beneficial in the reduction of infectious complication (RR = 0.69, 95% CI = 0.56–0.86; P = 0.001). In our current metaanalysis, we found that early postoperative EN group had lower pulmonary complication rate (RR = 0.37, 95% CI = 0.22–0.62, P = 0.00). This was consistent with previous reports. Anastomotic leakage is one of the life-threatening complications after esophagectomy.31 The metaanalysis conducted by Mazaki et al.8 found that EN could decrease the rate of anastomotic leakage in patients with gastrointestinal surgery (RR = 0.67, 95% CI = 0.47–0.95, P = 0.03). Our summary result showed early postoperative EN was associated with a 54% reduction in the risk of anastomotic leakage. We also found that the albumin and prealbumin levels of EN group were recovered more quickly than PN group. Noble et al.32 have demonstrated that in the patients with anastomotic leakage, the albumin level was significantly lower than patients without anastomotic leakage and the postoperative albumin level was associated with the occurrence of anastomotic leakage. Three limitations have to be considered in interpreting our findings. At first, the present metaanalysis is complicated by heterogeneity issues. In the meta-analysis of postoperative nutrition status, the heterogeneity is prominently. Considering the limited included studies in this part, we only used the

random-effects methods to analyze it again. We found a similar tendency between the two methods. Secondly, some included studies had a small sample size and poor quality. Thirdly, some articles reported the postoperative differences in another nutritional and inflammatory index, such as gastrointestinal infection, interleukin 6 or ferritin. However, there was not enough data for us to analyze. In conclusion, our results demonstrated that although early postoperative EN could not decrease the digestive complications for esophageal cancer patients undergoing esophagectomy, but it could decrease the morbidity of life-threatening complications, such as pulmonary complication and anastomotic leakage, and maintain patients at a better nutritional status than PN group. The current findings favored the early use of EN in esophageal cancer patients after esophagectomy. References 1 Wheble G A, Benson R A, Khan O A. Is routine postoperative enteral feeding after oesophagectomy worthwhile? Interact Cardiovasc Thorac Surg 2012; 15: 709–12. 2 Markides G A, Alkhaffaf B, Vickers J. Nutritional access routes following oesophagectomy–a systematic review. Eur J Clin Nutr 2011; 65: 565–73. 3 Pichard C, Thibault R, Heidegger C-P, Genton L. Enteral and parenteral nutrition for critically ill patients: a logical combination to optimize nutritional support. Clin Nutr Suppl 2009; 4: 3–7. 4 Gabor S, Renner H, Matzi V et al. Early enteral feeding compared with parenteral nutrition after oesophageal or oesophagogastric resection and reconstruction. Br J Nutr 2005; 93: 509–13. 5 Page R D, Oo A Y, Russell G N, Pennefather S H. Intravenous hydration versus naso-jejunal enteral feeding after esophagectomy: a randomised study. Eur J Cardiothorac Surg 2002; 22: 666–72. 6 Schweigert M, Dubecz A, Stein H J. Oesophageal cancer – an overview. Nat Rev Gastroenterol Hepatol 2013; 10: 230–44. 7 Kobayashi K, Koyama Y, Kosugi S et al. Is early enteral nutrition better for postoperative course in esophageal cancer patients? Nutrients 2013; 5: 3461–9. 8 Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg 2008; 12: 739–55. 9 Shiraishi T, Kawahara K, Yamamoto S, Maekawa T, Shirakusa T. Postoperative nutritional management after esophagectomy: is TPN the standard of nutritional care? Int Surg 2005; 90: 30–5. 10 Ryan A M, Rowley S P, Healy L A, Flood P M, Ravi N, Reynolds J V. Post-oesophagectomy early enteral nutrition via a needle catheter jejunostomy: 8-year experience at a specialist unit. Clin Nutr 2006; 25: 386–93. 11 Barlow R, Price P, Reid T D et al. Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection. Clin Nutr 2011; 30: 560–6. 12 Lassen K, Revhaug A. Early oral nutrition after major upper gastrointestinal surgery: why not? Curr Opin Clin Nutr Metab Care 2006; 9: 613–17. 13 Athanassiadi K A. Infections of the mediastinum. Thorac Surg Clin 2009; 19: 37–45, vi. 14 Manba N, Koyama Y, Kosugi S et al. Is early enteral nutrition initiated within 24 hours better for the postoperative course in esophageal cancer surgery? J Clin Med Res 2014; 6: 53–8. 15 Watters J M, Kirkpatrick S M, Norris S B, Shamji F M, Wells G A. Immediate postoperative enteral feeding results in © 2015 International Society for Diseases of the Esophagus

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impaired respiratory mechanics and decreased mobility. Ann Surg 1997; 226: 369–77, discussion 77–80. Burt M E, Stein T P, Brennan M F. A controlled, randomized trial evaluating the effects of enteral and parenteral nutrition on protein metabolism in cancer-bearing man. J Surg Res 1983; 34: 303–14. Zhao G, Cao S, Zhang K et al. Effect of early enteral nutrition on immune response and clinical outcomes after esophageal cancer surgery. Zhonghua Wei Chang Wai Ke Za Zhi 2014; 17: 356–60. Xiao-Bo Y, Qiang L, Xiong Q et al. Efficacy of early postoperative enteral nutrition in supporting patients after esophagectomy. Minerva Chir 2014; 69: 37–46. Liu S Y, Chen X F, Wang F, Zheng Q F, Wang J J. Perioperative nutrition support for esophageal cancer complicated with diabetes mellitus. Zhonghua Wei Chang Wai Ke Za Zhi 2013; 16: 864–7. Fujita T, Daiko H, Nishimura M. Early enteral nutrition reduces the rate of life-threatening complications after thoracic esophagectomy in patients with esophageal cancer. Eur Surg Res 2012; 48: 79–84. Feng H Q, Dai L, Ma S H, Kang X Z, Yang Y Q, Chen K N. Impact of early enteral nutrition on the intestinal motility of patients after esophagectomy. Zhonghua Wei Chang Wai Ke Za Zhi 2012; 15: 957–9. Seike J, Tangoku A, Yuasa Y, Okitsu H, Kawakami Y, Sumitomo M. The effect of nutritional support on the immune function in the acute postoperative period after esophageal cancer surgery: total parenteral nutrition versus enteral nutrition. J Med Invest 2011; 58: 75–80. Xie T P, Zhao Y F, Peng L, Zhu J, Li Q. Effect of early enteral nutrition on liver functions in patients following esophageal cancer surgery. Chin J Clin Nutr 2007; 15: 95–8, (Chinese).

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24 Wu P R, Xu L, Zhang Z M. Comparative study of postoperative early enteral nutrition and parenteral nutrition in esophageal carcinoma. Zhonghua Wei Chang Wai Ke Za Zhi 2006; 9: 320–2. 25 Aiko S, Yoshizumi Y, Sugiura Y et al. Beneficial effects of immediate enteral nutrition after esophageal cancer surgery. Surg Today 2001; 31: 971–8. 26 Yu G, Chen G, Huang B, Shao W, Zeng G. Effect of early enteral nutrition on postoperative nutritional status and immune function in elderly patients with esophageal cancer or cardiac cancer. Chin J Cancer Res 2013; 25: 299–305. 27 Scurlock C, Mechanick J I. Early nutrition support in the intensive care unit: a US perspective. Curr Opin Clin Nutr Metab Care 2008; 11: 152–5. 28 Quan H, Wang X, Guo C. A meta-analysis of enteral nutrition and total parenteral nutrition in patients with acute pancreatitis. Gastroenterol Res Pract 2011; 698248: 2011. 29 Gramlich L, Kichian K, Pinilla J, Rodych N J, Dhaliwal R, Heyland D K. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition 2004; 20: 843–8. 30 Tanaka K, Yano M, Motoori M et al. Impact of perioperative administration of synbiotics in patients with esophageal cancer undergoing esophagectomy: a prospective randomized controlled trial. Surgery 2012; 152: 832–42. 31 Schweigert M, Solymosi N, Dubecz A et al. Endoscopic stent insertion for anastomotic leakage following oesophagectomy. Ann R Coll Surg Engl 2013; 95: 43–7. 32 Noble F, Curtis N, Harris S et al. Risk assessment using a novel score to predict anastomotic leak and major complications after oesophageal resection. J Gastrointest Surg 2012; 16: 1083–95.

Early enteral nutrition compared with parenteral nutrition for esophageal cancer patients after esophagectomy: a meta-analysis.

Early postoperative enteral nutrition (EN) after esophagectomy in esophageal cancer patient has been reported to be correlated with a better rehabilit...
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