As previously précised, early postoperative nutritional support following esophagectomy is crucial to meet daily patient nutritional requirement and preserve the best nutritional condition of the patient

TPN was the first route used to provide adequate nutritional support following surgery 10. Compared with postoperative starvation or nil-by-mouth, TPN has improved wound healing and reduced postoperative complications 11.

However, TPN was associated with venous-catheter complications varying from 9.3% to 29.8%, and were listed in Table 112131415 Additionally, TPN was associated with higher incidence of severe complications and increased septic complications requiring active interventions 12. Compared to enteral feeding tube, there were no significant differences in related venous catheter complications 121617. Furthermore, critically ill patients who received early TPN were more likely to develop sepsis with longer recovery time compared to late initiation of TPN 18. The mortality rates were similar in both early and delayed TPN. Altogether, TPN was associated with increased hospital stay length and relatively high costs comparing with enteral nutrition (EN) 161819. Therefore, TPN should be only used when EN is contraindicated or impossible.

In colorectal surgery, the superiority of the enteral feeding in term of potential benefits on the immune response and postoperative outcomes has clearly been demonstrated by the published reports of comparative studies 2021. In addition, the recent evidence suggests that early oral feeding is associated with shorter length of hospital stay, faster return of bowel function (ROBF), and improved quality of life following major gastrointestinal surgery 22 .

Inspired by the better results obtained in colorectal surgery, the enteral feeding was introduced in oesophageal surgery and has become as standard of care following esophagectomy 23. The early postoperative enteral nutrition is introduced 24-48h after surgery and gradually increased in volume to reach the required nutritional volume with five to seven days. The enteral feeding can be provided through oral intake, nasoduodenal tube or tube-jejunostomy.

First described by Delany et al. the jejunostomy tube is generally placed in the proximal jejunum while performing esophagectomy. Multiple modifications have been added to original technique resulting in increased reduction of tube - related complications 2425. The minor tube-related complications include dislocation, rotation, obstruction, entry site leakage or infection and skin erosion. As systematic review including 3,243 patients, reported that these minor complications occurred in 13–38% of patients 26. A reduced rate of major complications has been reported with mortality and reoperation rates of 0–0.5% and 0–2.9%, respectively 26. Gastrointestinal complaints related to nutrient infusion mainly include abdominal cramps and diarrhea that may need to slow down the infusion debt or temporarily suspend the infusion 26.Complications associated with jejunostomy feeding are listed in Table 224272829303132. Although the minor complications associated with jejunostomy feeding that may potentially hamper functional recovery time resulting in a longer hospital stay 32, the postoperative jejunostomy feeding resulted in reduced hospital stay length and life-threatening complications, compared to TPN (Table 3) 12162333. In addition, it was associated with improved short-term survival at 90 days and quality of life, in comparison to TPN 3435. Another advantage of enteral feeding via jejunostomy that it can be continued after discharge from hospital when needed, especially in patients who have a poor oral intake and reduced daily requirement of calories 22. Also, home jejunostomy feeding was associated with reduced costs related to unplanned hospital attendances and re-admissions 36. Overall, Feeding via jejunostomy tube is safe and widely well-tolerated with reduced life - threatening complications and hospital stay length, decreased costs, and improved short-term survival at 90 days and quality of life.

Nasoduodenal or nasojejunal feeding is an alternative route for enteral feeding. A tube is placed during or shortly following surgery via the nasal cavity into the jejunum or duodenum. This nutrition route is less invasive with lower incidence of major complications. The tube dislocation was the most frequent complication and occurred in 20–35% of patients 2632. Tube obstruction and gastrointestinal complaints occurred in 3% and 7%, respectively 26, with sore throat and nasal discomfort 37. As listed in Table 2, the tube-related complications were similar in both nasojejunal feeding and jejunostomy feeding. The nutritional target was reached on the postoperative day 3 (POD 3) which was similar with jejunostomy feeding 32.

Nowadays, there is no evident superiority of one method over other and both nasojejunal and jejunostomy feeding routes can be used in the postoperative setting after esophagectomy.

As part of ERAS protocols, postoperative early oral feeding has become standard of care following various gastrointestinal surgical procedures, especially gastric and colorectal surgery, over the last years. Instead of other ERAS components, reticence still exits about the early initiation of oral feeding following esophagectomy. The most reasons advocated delaying oral feeding after esophagectomy are fear of pneumonia (aspiration) and increase of anastomotic leakage sequelae. Besides, the feasibility and the safety of early oral feeding following esophagectomy have been assessed. A recent prospective multicenter trial (2016), comparing early oral feeding started on POD1 with delayed oral feeding initiated on POD5, revealed that early oral feeding following esophagectomy was feasible , safe and did not result in increased major complications including pneumonia and anastomotic leakage 38. Moreover, a recent randomised trial (2015) comparing early oral feeding started on POD1 with delayed oral feeding after esophagectomy showed a significant short length of stay with no difference in surgical complication rates, in the early oral feeding group 3940. In the other hand, relatively recent studies have shown that early oral feeding after esophagectomy was associated with significant anastomotic leak rates , however, these studies were retrospective 41 Tomaszek, 42. The results of studies comparing early oral feeding with delayed oral feeding are listed in Table 4. Despite the safety and benefits of early feeding on outcomes after esophagectomy, the daily caloric requirement in patients receiving early oral feeding could be a concern 38. In fact, only 58% of the daily caloric needs have been met on POD 5 with a median intake of 1,205 kcal. Additionally, 30% of patients in the early oral feeding group received artificial nutritional support on POD5 because of complication prohibiting oral feeding 38. Conclusively, the current literature has clearly demonstrated that early oral feeding following esophagectomy is feasible, safe and can be considered in patients undergoing esophagectomy. However, further randomised controlled trials are needed to substantiate the published results on early oral feeding following esophagectomy.

Insummary, TPN was associated with high costs, severe catheter-related complications and increased septic complications requiring active intervention. The TPN is only used when EN is contraindicated or not accessible. The EN currently is a standard of care after esophagectomy. EN can be provided through feeding tube including mainly jejunostomy-tube and nasojejunal tube, and both routes were associated with route-related complications. Furthermore, there is no evidence of superiority of one method over the other, and both routes can be used postoperatively.The ERAS programs have successfully been implementation and generalized to a growing list of surgical subspecialties. Postoperative early oral feeding (EOF) is an important element of the ERAS protocols, and safety and benefits on outcomes of EOF has been clearly demonstrated after major gastrointestinal surgical procedures including esophagectomy. Moreover; EOF did not result in increased pneumonia (aspiration) and anastomotic leak rates. Besides, large randomised controlled trials are needed to substantiate the already published results and to assess the potential beneficial impact of early oral feeding on postoperative recovery and quality of life following esophagectomy.

Overall, choosing the feeding route greatly depends on the surgeon preference. We suggest using the early oral feeding as a primary nutritional method after esophagectomy. Furthermore, surgical jejunostomy placement during esophagectomy is safe; and should be placed in selective patients to avoid common jejunostomy-tube related complications. Therefore, routine insertion of jejunostomy feeding is recommended to ensure adequate nutrition in high surgical patients with high-risk to develop post-operative complications, especially anastomotic leak with need to suspend oral feeding. Also, jejunostomy feeding is very useful in patients with long-term reduced appetite and poor oral intake who clearly need dietary supplementation after discharge from hospital. So, the presence of a jejunostomy feeding remains a necessary back-up plan in such special condition.