Beruflich Dokumente
Kultur Dokumente
By Lauren Cole
April 3, 2015
Sage Graduate School Dietetic Internship
Vassar Brothers Medical Center
Preceptor: Kayleigh Diaz, RD
Table of Contents
The patient was admitted to the hospital on February 23, 2015 after a planned distal
subtotal gastrectomy. The patient is a 64-year-old male diagnosed with stage IIB gastric
adenocarcinoma. He has a past medical history of gastroesophageal reflux disease (GERD),
hypertension (HTN), and being a former smoker and marijuana user of 44 years who quit in
November of 2014. His height is 180 cm, admit weight is 68.2 kg, body mass index (BMI) of
21.05, and his calculated ideal body weight is 78.2 kg. This patient is currently retired and lives
at home with his spouse.
As a result of his gastric adenocarcinoma, he required a distal subtotal gastrectomy. This
procedure required a gastrojejunostomy, total ornentectomy, and myocutaneous falciform
ligament flap to the duodenal stump. During this surgery he also underwent a liver biopsy and
jejunostomy feeding tube (j-tube) placement. Due to the nature of the surgery, the patient needed
nutrition support to meet his energy needs. The patients nutrition history prior to admission was
fairly normal. The patient experienced no weight loss and reported that he ate well and remained
active prior to admission. He reported after his diagnosis of gastric cancer his radiation treatment
affected his appetite11: between the cycles he had good appetite but during active therapy he had
poor appetite.
The patient had a complicated nutritional hospital course; involving j-tube feedings, total
parenteral nutrition (TPN), and trials of supplemental nutritional beverages and oral diets. Many
of his hospital concerns were related to his feeding tolerance. The patient was eventually
discharged home on March 7, 2015 after a 12-day length of stay. He was ordered to continue
following a full liquid diet and follow up with his surgeons upon discharge.
The main diagnosis of the patient reviewed was stage IIB gastric adenocarcinoma, also
known as stomach cancer. Cancer classification can reveal which part of the body the disease
originates from. For instance, when it begins in the glandular cells it is called adenoma, when in
the immune system it is called lymphoma, when in the hormonal system it is called carcinoid
syndrome, and when in the nervous system it is called a gastrointestinal stromal tumor. Over
90% of gastric cancers are adenocarcinoma.1 Cancer can further be defined by staging. This
patient was in stage IIB, meaning the cancer had developed deeper within the layers of the
stomach and lymph nodes, but had not yet spread to other organs or tissues. Those with stage II
gastric cancer have an approximate 70-80% five-year prognosis.2 While the incidence of gastric
cancer is decreasing, it is the second leading cause of cancer-related deaths worldwide, with
about 740,000 deaths in 2008.2 Prognosis for advanced stages is poor because of the delayed
diagnosis, as symptoms usually do not present themselves early enough for intervention.
Symptoms are often nonspecific, such as dyspepsia, loss of appetite, abdominal pain,
early satiety, and dysphagia.2 Risk factors include those older than 60 years of the male gender
and Caucasian ethnicity with a medical history of GERD, Helicobacter pylori (H.pylori), family
history of gastric cancer, diet high in salt, smoked and preserved foods, and diet low in fruits,
vegetables, and Vitamin A, C, E, and selenium.1,2 Treatment options for this type of cancer
include surgery to remove the cancerous tissue and/or radiation and chemotherapy to help shrink
the size of the tumor and to control it from spreading. In this case, the patient received radiation
before his surgery to help shrink the size of the tumor and then underwent a subtotal gastrectomy,
where the part of his cancerous stomach closest to the small intestines was removed and an
anastomosis was created between his stomach and the proximal loop of the jejunum.
Postop
Day #
Medical Event/Nutrition
Intervention
Nutrition Note
2/23/15
2/24/15
3/1/15
3/2/15
3/3/15
TPN initiated
3/4/15
3/5/15
10
Calorie-count begin
3/6/15
11
The patient went home without instruction to use the jtube for feedings.
j-
inactive for so long. He stated, Ill do anything to get me out, and the doctor felt like he would
recover better at home. From a nutritional standpoint, this was very concerning. Thus far, the
patient was unable to meet nutritional needs via oral intake during his stay. The patient did not
advance to solid foods over his hospitalization nor have a full day without nutrition support. Our
recommendation to the doctor was that he continue his recovery as an inpatient until his calorie
count showed he could consume >75% of his needs via oral intake. However, the doctor
disagreed and planned for the patients discharge. Therefore, we provided the patient with the
education he needed to meet his nutritional needs at home. We educated him on the full-liquid
diet. We recommended that he consume 7 cans of Ensure Plus daily, providing 2450 kcal and 91
g protein, until he could consume soft foods. We suggested that he try soft foods as soon as his
intake improved and slowly advance his diet to food rather than the supplement. The patient
seemed agreeable to drink the Ensure Plus, but also seemed in denial of his acuity and need for
nutrition intervention.
Conclusion/Recommendations
The patient was followed from admission to discharge, a total of 12 days. He was
admitted for a gastrectomy with a complicated post op hospital stay. After his surgery, j-tube
feedings and an oral diet were prescribed. Due to his complications with the j-tube and
inadequate oral intake, the patient began TPN. During his hospital stay, the only time the patient
met his nutritional needs was when he was receiving TPN. During this time, the patient also
began receiving j-tube feedings at a low rate and was ordered a full liquid diet. On POD#11,
TPN and enteral feedings were stopped. The patient was discharged on a full liquid diet and
instructed to consume 7 cans of Ensure Plus daily at home.
10
A patients nutritional status during cancer often indicates their prognosis. Many surgeons
delay the initiation of an oral diet after gastrectomy in fear of complications related to the newly
structured GI tract.17 However, the guidelines above state that this can be detrimental to recovery.
Looking back, I would have liked to be able to collaborate with the doctors and surgeons more
and advocate for earlier oral feeding. The literature supports that earlier oral feeding optimizes
nutritional status and overall patient outcomes. When providing the j-tube feeding
recommendations I would have liked to see if an elemental formula, such as Vital, would have
been better tolerated as it is easier to digest. Overall, the clinical outcomes of gastric cancer are
dependent on pre op and post op care. In Western countries, pre op screening is even more
essential as the patients receiving surgery are at an advanced age.10 The reality is that the patient
reviewed was in denial of his need for medical and nutritional intervention. In the future, I would
recommend that after a patient undergoes a gastrectomy, soft foods should begin within the first
few days after surgery and upon discharged it be imperative for that patient to be scheduled for
follow-up with an outpatient dietitian.
11
References
1. Escott-Stump S. Nutrition and Diagnosis-Related Care. 7th Edition. Baltimore, MD:
12
12. Patel SH, Kooby DA, Stanley CA, Maithel SK. An assessment of feeding jejunostomy tube
placement at the time of resection for gastric adenocarcinoma. Journal of Surgical Oncology.
2013;107:728-734.
13. Wu Q, Yu JC, Kang WN, Ma ZQ. Short-term effects of supplementary feeding with enteral
nutrition via jejunostomy catherter on post-gastrectomy gastric cancer patients. Chin Med J
(Engl). 2011;124(20):3297-301.
14. Mortensen K, Nilsson M, Slim K, Schafer M, Mariette C, Braga M, Carli F, et al. Consensus
guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery
(ERAS) Society recommendations. Br J Surg 2014;101:1209 1229.
15. Steevens J, Schouten LS, Goldbohm RA, van den Brandt PA. Alcohol consumption, cigarette
smoking and risk of subtypes of oesophageal and gastric cancer: a prospective cohort study.
Gu. 2010;59:39-48.
16. Dy SM, Lorenz KA, Naeim A, et al.: Evidence-based recommendations for cancer fatigue,
anorexia, depression, and dyspnea. J Clin Oncol 2008;26(23):3886-3895.
17. Sierzega M, Choruz R, Pietruszka S, Kulig P, Kolodziejczyk P, Kulig J. Feasibility and
outcomes of early oral feeding after gastrectomy for cancer. J Gastrointest Surg.
2015;19:473-479.
13