Safe Management of Anastomotic Leakage After Gastric Cancer Surgery with Enteral Nutrition Via a Nasointestinal Tube

Purpose: Anastomotic leakage is a serious complication after gastric cancer surgery. Despite the superiority of enteral nutrition (EN), total parenteral nutrition (PN) remains the standard therapy for anastomotic leakage. After introduction of EN via a nasointestinal tube for patients with anastomotic leakage in our institution in 2006, standard nutritional therapy was shifted gradually from PN to EN. The present preliminary study evaluates the safety and feasibility of EN via a nasointestinal tube for anastomotic leakage after gastric cancer surgery.

Methods: Retrospective review of all gastric cancer surgeries from 2005 to 2009 (n = 2,588) revealed 53 patients (2.0%) who developed anastomotic leakage and were treated conservatively. EN was performed via a nasointestinal tube inserted using a guidewire under X-ray fluoroscopy. Clinical outcomes and complications following EN were compared with those in patients treated with PN (historical control group). The severity of complications was evaluated according to the Clavien-Dindo classification.

Results: Fifty patients were included in the final analysis (three patients died): 29 patients managed by EN and 21 managed by PN. There were no significant differences in clinical outcomes and the frequency of total complications between the two groups; however, there were fewer tube/catheter-related complications in the EN compared with the PN group (1 vs. 7, respectively; P < 0.01). There was one epistaxis (3.4%; grade I) in the EN group and seven catheter infections (33.3%; grade II) in the PN group. The risk of grade II or higher complications was greater in the PN than the EN group (11 vs. 4, respectively; P < 0.01), with the greatest difference seen in the incidence of catheter infections. On days 7, 10, and 15 after diagnosis of leakage, the white blood cell count and C-reactive protein levels were higher in the PN than in the EN group. The PN group required prolonged intravenous antibiotic infusion (P < 0.01).

Conclusions: Nasointestinal tube insertion with EN can be performed safely for patients with anastomotic leakage. A major advantage of EN is fewer infectious complications. Because EN was not inferior to PN in terms of clinical outcome, we recommended that it is used in patients with anastomotic leakage after gastric cancer surgery.