COMPREHENSIVE CLINICAL CASE STUDY:

NUTRITION SUPPORT THROUGH GASTRIC

ADENOCARCINOMA AND SUBSEQUENTIAL GASTRECTOMY

By Lauren Cole

April 3, 2015
Sage Graduate School Dietetic Internship
Vassar Brothers Medical Center
Preceptor: Kayleigh Diaz, RD

Table of Contents

Introduction of Patient and Case......................................................................................................3

Etiology and Pathophysiology of Disease State .............................................................................4
Timeline of Medical Events and Nutrition Interventions with Table...........................................5-7
Evidence-Based Practice Literature Review....................................................................................7
Table of Guidelines vs. Interventions ..........................................................................................7-9
Compare/Contrast Guidelines vs. Interventions ........................................................................9-10
Conclusion/Recommendations for Future Practice..................................................................10-11
References................................................................................................................................12-13

Introduction of Patient and Case

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.

Etiology and Pathophysiology of Condition

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.

Timeline of Medical Events and Nutrition Interventions

Cancer obviously has many nutritional implications. Decreased oral intake, weight loss,
nausea, vomiting, and nutritional deficiencies are all concerns related to this disease. Specifically
with gastric cancer and subsequent surgery, nutrition concerns are related to dumping syndrome,
early satiety, gastroparesis, and malabsorption of fat, vitamain B12, vitamin D, calcium, and iron.3
Cancer patients have increased nutritional needs and meeting these needs can be challenging.
However, in this case, the patient received a j-tube during his surgery as this problem was
foreseen. It was easily determined that nutrition support would be the best intervention post
surgery due to his inability to consume adequate oral intake.
Therefore, the dietitian was consulted for nutrition support recommendations on postop
day (POD) #1. A thorough assessment began by collecting information from the interdisciplinary
team, reviewing the medical record, and during the patient interview. The dietitian followed this
patient and documented on his nutritional status five times throughout his 12-day hospital stay.

Table 1: Timeline of Medical Events

Date

Postop
Day #

Medical Event/Nutrition
Intervention

Nutrition Note

2/23/15

Distal subtotal gastrectomy,

gastrojejunostomy, myocutaneous
falciform ligament flap to
duodenal stump, liver biopsy, and
j-tube placement.

2/24/15

Nutrition Assessment: j-tube

initiation

Pt admitted with Stage IIB gasric adenocarcinoma. Pt

POD#1 s/p distal subtotal gastrectomy,
gastrojejunostomy, myocutaneous falciform ligament
flap to duodenal stump, liver biopsy, and j-tube
placement. Pt with NGT for low intermittent suction.
Pt sitting up in chair, appears lethargic, falling asleep.
Plan to initiate j-tube feedings. Recd Jevity 1.5 @
goal rate of 50 mL/hr to provide pt with 1800 kcal (26
kcal/kg) and 77 g protein (1.13 g/kg). Recd to initiate
TF @ 20 mL/hr and advance as tolerated by 10 mL
q6hrs. Do not check residuals as this is a j-tube. Last

BM 2/22. Will monitor TF initiation and tolerance.

Estimated needs: 1700-2050 kcal/day (25-30 kcal/kg)
and 70-80 g protein/day (1.0-1.2 g/kg)
PES: Inadequate oral intake, enteral related to tube
feed not yet initiated as evidenced by estimated intake
from tube feed not meeting estimated nutritional
requirements, providing 0 kcals.
Intervention: Recommend initiation of a tube feed.
Monitor/Evaluate: TF tolerance, intake, plan of care
2/27/15

Nutrition Reassessment: advance jtube rate, start clear liquid diet

3/1/15

Ultra-sounded guided paracentesis,

continue j-tube feedings, fullliquid diet initiated

3/2/15

Nutrition Reassessment: j-tube

feedings suspended because of
leak, NPO, TPN recommendations

Pt tolerating Jevity 1.5 at 10 mL/hr. No

nausea/vomiting. No abdominal distention or bloating
per pt. Per pt and MD notes to start clear liquid diet
and to increase TF rates. Recd TF increase to goal of
Jevity 1.5 @ 50 mL/hr. Will continue to monitor TF
tolerance and PO intiation.

Pt with j-tube feedings of Jevity 1.5 at 30 mL/hr on

hold since 02:30 last night due to j-tube leak,
distended abdomen/firm abdomen. Full liquid diet and
ensure plus QID is ordered although per RN, pt is
NPO as he is currently in interventional radiology due
to j-tube leak. If TPN to initiate, recd goal TPN of
D20/AA6% at 65 mL/hr with 250 mL 20% intralipid
to provide pt with 1935 kcal (28 kcal/kg), 94 g protein
(1.38 g/kg) and GIR 3.2. Recd to initiate TPN at 30
mL/hr and increase to goal as tolerated. Last BM 3/1,
loose, +BS, +flatus. Recd to reinitiate PO and TF via
j-tube when medically feasible. Will monitor daily.
Revised estimated needs: 1700 2387 kcal/day (25-35
kcal/kg) and 82 102 g/day (1.2-1.5 g/kg)

3/3/15

TPN initiated

3/4/15

Nutrition Reassessment: continue

full-liquid diet, TPN, and j-tube
restarted. Recommend nutrition
supplement and calorie count to
begin

Leaking around j-tube has slowed. Midline incision

output: 200 mL, output around j-tube: 800 mL. Pt now
on full liquid diet, ensure plus proposed TID, pt
continues to receive TPN D20/AA6% at 65 mL/hr
with 250 mL 20% intralipid and j-tube feedings of
Jevity 1.5 at 10 mL/hr restarted. TPN is providing pt
with 1935 kcal (28 kcal/kg) and 94 g protein (1.38
g/kg). TF is providing an additional 360 kacl and 15 g
protein. Pt agreeable to Ensure Plus. Will start calorie
count tomorrow (3/5) to monitor PO intake and
possible plan to discontinue TPN and cap j-tube once
pt is meeting >50% nutritional needs with meals and
Ensure Plus TID.

3/5/15

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Calorie-count begin

3/6/15

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Nutrition Reassessment: TPN and

j-tube feedings stopped. Patient
discharged against nutritional
recommendations.

Pt on full liquid diet with Ensure Plus TID. TPN has

been discontinued, pt to finish current bag of TPN.
TFs have also been discontinued. This is against
nutritional recommendations. Pt ate first meal last
night per calorie count. Pt meeting only 25% of kcal
and protein needs by mouth. Pt not likely to meet
nutritional needs by mouth at home but provided pt
with full liquid diet education and handout. To meet
100% of needs with Ensure Plus, pt to drink 7
cans/day. Discussed with pt that if he consumes other
full liquids like soup, yogurt, pudding, that he can
drink 5 Ensure Plus/day to meet needs. Pt reports last
BM this AM. Wt on 3/5 69 kg. Wt on 2/25 66 kg.

Evidenced-Based Practice Literature Review:

A literature review of thirteen sources was complete to determine the most recent and
relevant recommendations for gastric cancer patients receiving a gastrectomy. The articles
addressed pre and post surgery nutritional recommendation, enteral nutrition, parenteral
nutrition, and oral diet recommendations. The articles suggest that there is a lot of controversy
over the feeding recommendations after gastric cancer surgery. According to guidelines, it would
be most beneficial if there were preoperative nutrition interventions to improve nutritional status
before surgery, especially if the patient is malnourished. The goal after surgery is aimed at
maintaining the patients nutritional status during such as catabolic period.9 The guidelines
suggest that the earlier you can offer a soft foods diet the better the health outcomes, with
decreased length of hospitalization and improved quality of life.
Table 2: Practice Guidelines Versus the Interventions That Took Place
Practice Guideline

Intervention That Took Place

After a subtotal gastrectomy for gastric cancer, early

oral feedings (soft diet by POD#3) can result in a shorter
hospitalization, less abdominal pain, less nausea, better
postop bowel movement, and a better health-related
quality of life when compared to delaying oral feedings
(soft diet by POD#6).4, 5

On POD#1 j-tube feedings were initiated. On POD#4 a

clear liquid diet was initiated. On POD#6 a full liquid
diet was initiated. The patient was never ordered a soft
foods diet.

Post gastrectomy, early enteral feeding on POD#1

through an NJ tube can provide minimal complications,
be cost-effective, and improve patient outcomes. On
POD#3-4, NJ feedings can be reduced as oral intake is
increased.6

On POD#1 j-tube feedings were initiated. On POD#4 a

clear liquid diet was initiated. J-tube feeds were never
tolerated well and on POD#7 had to be temporarily
discontinued because of a leak. On POD#8 TPN was
initiated.

Nutrition assessments specifically for identifying

malnutrition pre and post gastrectomy using objective
measurements and subjective scoring system are
essential for early nutrition intervention.7, 8

No malnutrition screening was complete for this patient.

Preoperative malnutrition is a risk factor for poor

outcomes after abdominal surgery. Many patients benefit
from perioperative nutrition interventions prior to major
oncological surgery. It is encouraged to use the Nutrition
Risk Score that is recommended by the European
Society of Parenteral and Enteral Nutrition (ESPEN) to
assess patients that need nutritional interventions before
surgery.9

To our knowledge, no nutrition interventions took place

prior to surgery.

Nutrition treatments for gastric cancer patients can

include parenteral nutrition (PN) and enteral nutrition
(EN), used alone or in combination, to increase
nutritional status and to decrease morbidity and
mortality.10

Both PN and EN were used alone and in combination

during this patients hospital stay.

Nasojejunal decompression is not necessary after

gastrectomy as it has been shown to delay the recovery
of gut function.11

No nasojejunal decompressions were done on this

patient.

J-tube placement at the time of gastrectomy for gastric

adenocarcinoma is not recommended as it increases
postop complications and infectious complications.12

J-tube placement occurred at the time of the

gastrectomy.

Post-gastrectomy, short-term EN supplementation for

about 3 months via a j-tube can be nutritionally
beneficial, decreasing risk of malnutrition and weight
loss for gastric cancer patients.13

The patient went home without instruction to use the jtube for feedings.

Patients clearly malnourished or those unable to meet

60 percent of daily requirements by POD 6 should be
given individualized nutritional support. Suggesting
EN when oral intake is not possible and PN only when
the gut is not working or inaccessible.14

The patient was unable to meet 60% of nutrient

requirements until POD#9, after TPN was initiated on
POD#8.

Cigarette smoking is positively correlated with gastric

cancer. Alcohol intake is not correlated with increased
risk for gastric cancer, rather esophageal cancer.15

The patient had a history of cigarette smoking for 44

years.

Nutritional counseling is recommended for patients with

gastric cancer. In some studies it has shown that
nutrition counseling can improve weight maintenance
and quality of life, even without initiating oral
supplements.16

The patient was not scheduled for nutrition counseling

upon discharge.

Early oral feeding after total gastrectomy for cancer is

feasible and safe, offering at least a single oral meal on
POD#1 through POD#6. Patients that received early
feeding also experienced less abdominal fluid
collections.17

The patient did not receive an oral diet until POD#4. On

POD#6 paracentesis was performed to remove 120 cc of
fluid.

Compare/Contrast of Guideline vs. Intervention

Many of the interventions varied from the recommended practices. The main goal of all
of the researched guidelines is simple: optimize nutritional status in a nutritionally at risk
population. The articles suggest that this can be achieved through pre op nutritional intervention,
early post op feedings, enteral and/or parenteral nutrition when needed, and nutrition counseling
at all stages. One of the articles also suggest that j-tube placement during a gastrectomy increases
complication in regard to post op recovery and infection. Overall, suboptimal intakes and
malnutrition are concerns that need to be addressed via nutrition intervention.
To our knowledge, the patient did not have any pre op nutritional interventions. Ideally
the patient should have consumed a high energy, high protein diet with possibly supplemental
beverages before surgery, which would have been the responsibility of the surgeon and an
outpatient dietitian to initiate. As one of the references suggested, the patient did indeed have
complications with his j-tube placement coinciding with his gastrectomy. In this situation, his
tube was unsuccessful in providing him the nutritional support he needed. There was no reason
as to why the patient was not offered a soft diet within the first few days of his surgery. Perhaps
if the oral diet were initiated earlier, he wouldnt have had complications that led him to begin
TPN.
Overall, the patient was desperate to go home. He had been through a lot during his
hospitalization and felt like he would do better at home. It was a big change for him to be

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.

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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.

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