Nutrition Support for Esophageal Cancer Patients

Other signs of dysphagia include:

• Coughing or choking when eating or drinking
• Bringing food back up, sometimes through the nose
• Sensation that food is stuck in your throat or chest
• Persistent drooling of saliva
• Being unable to chew food properly
• A gurgly, wet-sounding voice when eating or drinking

Everyone needs food and nutrients to live. Sometimes a person cannot eat any or enough food because of an illness. Others may have a decreased appetite, difficulties in swallowing, or some type of surgery that interferes with eating. The rate of malnutrition in esophageal cancer patients is as high as 78.9%, and weight loss often continues throughout treatment.

“Before you can really treat [patients], many of them look emaciated where they’re not getting enough nutrition,” Dr. Raja Flores, a thoracic surgeon with Mount Sinai Health System, told SurvivorNet. “So, what we like to do is fatten them up a little bit, maybe put a tube in their intestine, give them food that way, start treating with some chemotherapy and radiation, and give them time to try and open up [to reduce the issues eating/swallowing].”

When nutrition needs to be supplemented, there are several ways to go about this, including “enteral nutrition” or “tube feeding.”

What is enteral feeding?

Enteral feeding tubes allow liquid food to enter your stomach or intestine through a tube. A soft, flexible tube can be inserted through the patients nose, mouth or surgically, creating an opening in the abdominal wall called an ostomy. An enterostomy tube in the stomach is called a gastrostomy. A tube in the small intestine is called a jejunostomy (or J-tube).

In general, feeding tubes entering the body through the nose or mouth are considered for short-term use (no more than four to six weeks) while gastrostomy or jejunostomy tubes can be used long-term.

Enteral feeding may be needed before or during treatment to prevent further weight loss and improve nutrition. This can make treatment easier to tolerate.

What are the types of feeding tubes?

There are a variety of feeding tubes that may be used to supplement nutrition at different points during the treatment process. These include:

• Orogastric Tube (OGT) – Thin soft tube passed through the patient’s mouth, through the esophagus and into the stomach.
• Nasogastric Tube (NGT) This tube is also passed through the patient’s nose, down the back of the throat, through the esophagus and into the stomach.
• Nasojejunal feeding tube – A nasojejunal tube is a thin, soft tube that is put in through the nose, goes through the stomach and ends in the jejunum (a part of the small intestine).
• Gastrostomy tube – a feeding tube which is inserted endoscopically or surgically through the abdominal wall and directly into the stomach.
• Jejunostomy tube (or J-tube) – a feeding tube which is inserted surgically through the abdominal wall and directly into the small bowel.

Enteral Feeding Formulas

The term "enteral feeding formulas" refers to the nutritional liquids that are put through enteral feeding tubes. Enteral feeding formulas need to support an entire diet, so they're packed with all the vitamins, minerals, calories, and protein that people need to survive and thrive. There are many kinds of enteral feeding formulas, to support many different nutritional needs, but you should never decide which enteral feeding formula to use without a doctor's suggestion or consent.

Your care provider will usually work with a home care company to arrange for your tube feeding formula and supplies to be delivered to your home. They will also teach you and your caregiver how to use your tube feeding pump.

Types of enteral feeding

There are three main ways that this type of feeding is done, each with a different administration schedule.

Pump Feeding

Pump feeding involves adding formula to a bag (or using a bag that comes pre-prepared with formula), which will release nutrients over an extended period. This kind of feeding usually takes 16-24 hours, and is typically used on bedridden patients.

Gravity Feeding

Gravity feeding is a little quicker, but still takes some time. This kind of feeding is usually done through the night, so that the person being fed can go about the rest of their day in the morning.

Bolus Feeding

This is the quickest feeding option, and is done multiple times a day. Formula is poured into a bag, and held by hand (instead of left on a pole). It takes around 15-20 minutes to consume 8 ounces this way, so this kind of feeding typically happens twice at breakfast, twice at lunch, and twice at dinner. Since the feeding pattern is similar to traditional mealtimes, many parents like this method better than the other options.

What are the risks of tube feeding?

The risks of home tube feeding are small, but complications can occur. These may include:

• Clogged, damaged or displaced tube.
• Aspiration, which is food going into the lungs
• Infection at the tube insertion site
• Gastrointestinal problems including constipation, nausea and diarrhea
• Leaking of stomach contents at the tube site
• Pain at the tube site
• Skin irritation at the tube insertion site

Procedure for placing the tube

The tubes can be placed in a variety of ways, with some being quite a bit more invasive than others.

Nasogastric tube or Orogastric tube

Placement of a nasogastric tube or orogastric tube, while uncomfortable, is fairly straightforward and painless. Anesthesia isn't required.

Typically a nurse will measure the length of the tube, lubricate the tip, place the tube in your nose or mouth and advance until the tube is in the stomach. The tube is usually secured to your skin using soft tape.

Nasoenteric or oroenteric

Tubes that end in the intestines often require endoscopic placement. This means using a thin tube called an endoscope, which has a tiny camera on the end, is used to place the feeding tube.

The person placing the tube will be able to see where they're putting it via the camera on the endoscope. The endoscope is then removed, and placement of the feeding tube may be confirmed with aspiration of gastric contents and X-ray.

It's common practice to wait 4 to 12 hours before using the new feeding tube. Some people will be wake up during this procedure, while others may require conscious sedation. There's no recovery from the tube placement itself, but it may take an hour or two for the sedation medications to wear off.

Gastrostomy or jejunostomy

Placement of gastrostomy or jejunostomy tubes is also a procedure that may require conscious sedation, or occasionally general anesthesia. An endoscope is used to visualize where the tube needs to go, and then a tiny cut is made in the abdomen to feed the tube into the stomach or intestines. The tube is then secured to the skin.

Many endoscopists choose to wait 12 hours before using the new feeding tube. Recovery may take five to seven days.

Diet and Nutrition During Treatment for Esophageal Cancer

It's important to get enough nutrition before, during, and after your cancer treatment. Getting enough nutrition can help you:

• Maintain your strength
• Keep your weight stable
• Fight infection
• Have fewer side effects
• Heal after surgery

Before you start treatment, a clinical dietitian nutritionist will plan your diet to make sure you get enough nutrition during and after your treatment. If you're having chemotherapy and radiation therapy before your surgery, your clinical dietitian nutritionist can:

• Help you manage your symptoms by changing your diet.
• Help you get enough nutrition.
• Teach you about helpful diets to follow and foods to eat during your treatment.

Tube Feeding Rates

Your tube feeding rate is the amount of formula you get through your feeding tube per hour. It's measured in milliliters (mL) per hour. Your goal feeding schedule is the tube feeding rate and number of hours that gives you the right amount of calories, protein, and fluids. Your inpatient clinical dietitian nutritionist will calculate your goal feeding schedule based on your height and weight.

At first, you will have a low tube feeding rate. Your tube feeding rate will slowly be increased to your goal rate or schedule.

High-Calorie, High-Protein Liquid Nutritional Supplements

Your doctor or clinical dietitian nutritionist may also suggest taking high-calorie or high-protein nutritional supplements. If they do, take the supplements between meals. If you take them with a meal, they can be filling and may keep you from eating more of your food. You can buy most of these supplements at any supermarket or pharmacy. If you don't see a product in the store, ask a pharmacist or store manager to order it for you. You can also order these products online. Some popular brands are:

• Ensure
• Impact
• Boost

For caregivers: How Do I Give a Feeding?

If you are caring for someone who was recently diagnosed with esophageal cancer (or will be helping with tube feeding for the first time), the process can seen a bit intimidating. Typically, assisting with tube feeding can be broken down into several steps, including:

1. Wash your hands with soap and water.
2. Check the doctor's orders for the feeding plan and instructions on how to flush the tube.
3. Gather the supplies and equipment, which may include a feeding pump, feeding administration set, IV pole, farrell valve system bag (if ordered by your doctor), formula, bottle or container to measure formula, small syringe (3 or 5 ml), and water.
4. Open the feeding administration set and the Farrell bag.
5. Connect the bags at the "Y" junction on the Farrell bag tubing.
6. Add the formula to the bag.
7. Prime, or fill, the tubing of the feeding administration set with formula.
8. Close the clamp at the end of the Farrell bag tubing.
9. Put the tubing into the feeding pump.
10. Turn the pump on.
11. Refer to feeding pump instructions for pump programming. This may include setting the rate (how quickly feedings are going in) and the dose (how much formula will be given).
12. Check to make sure the NJ tube is in the correct place.
13. Give a small amount of water to flush the tube to make sure it is open (doctors orders should let you know how much water to use).
14. Connect the feeding administration set tubing to the feeding tube.
15. Open the clamp on the tubing.
16. Start the feeding pump.

There are several situations that warrant a call to your doctor right away if they occur during the tube feeding process, including if the feeding does not go in, if the tube moves or comes out, if you have pain, redness, swelling, excessive itching or leaking at the ostomy site, and if you begin vomiting.

Questions to Ask Your Doctor

• Will I need a feeding tube and which type would work best for me?
• How long will I need this supplemental nutrition?
• Should I also consider nutritional supplements now or in the future?

Learn more about SurvivorNet's rigorous medical review process.

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