Nutritional status and dysphagia in patients with oesophageal cancer : the impact of oncological and surgical treatment

The most common symptom of oesophageal cancer is difficulty swallowing, dysphagia, due to the tumour obstructing the oesophageal lumen often resulting in weight loss. In patients diagnosed with oesophageal cancer malnutrition is reported in 60-85%. Neoadjuvant treatment with subsequent oesophagectomy is the standard curative intent treatment in most countries. Neoadjuvant treatment, either neoadjuvant chemoradiotherapy (nCRT) or perioperative chemotherapy (pCT), might cause further symptoms affecting nutritional intake and thereby cause weight loss. Oesophagectomy is an extensive procedure where the oesophagus is removed and most often replaced with a gastric tube conduit affecting patients´ nutritional intake due to the altered anatomy. During recent years different minimally invasive techniques has been introduced in order to minimize the surgical trauma. Most of the patients receive a feeding jejunostomy during surgery securing nutritional intake during the time they, often, are restricted from eating orally and during the time they increase their oral intake.

In Study I we assessed dysphagia in patients undergoing neoadjuvant treatment before oesophagectomy. Patients received either neoadjuvant chemotherapy (nCT) or nCRT, both with induction chemotherapy for 1 week. The dysphagia improved significantly after first cycle of chemotherapy with further improvements after completed neoadjuvant treatment. There was no correlation between dysphagia relief and histological response. In Study II we compared weight development after open Ivor Lewis oesophagectomy to minimally invasive Ivor Lewis oesophagectomy (MIIL) or minimally invasive McKeown oesophagectomy (MIMK). We found no significant difference between weight development after the greater surgical trauma associated with open surgery and the minimally invasive approaches. We saw a non-significant trend towards a lower risk of 10% or more weight loss at 3 months after surgery in case of severe postoperative complications after MIIL compared to open IL. In Study III we assessed the energy intake and the total energy expenditure (TEE) before and after neoadjuvant treatment and at 3 and 6 months after oesophagectomy. We found a negative energy balance at baseline and at 3 months after surgery. Mean weight decreased significantly at all time points compared to baseline with the greatest weight loss at 3 months postoperatively. In Study IV we compared weight and dysphagia development between standard and prolonged waiting time to oesophagectomy after completed nCRT. We also compared patients malnourished or not at baseline in each group for risk of postoperative complications. Patients gained weight during the prolonged time to surgery and almost returned to the same weight as at baseline. Dysphagia improved significantly in both groups, with a further but nonsignificant improvement during the prolonged time to surgery. Malnutrition at baseline did not affect postoperative complications between the groups.

In conclusion, patients´ dysphagia improved during neoadjuvant treatment suggesting nutritional interventions as first line treatment awaiting effect of chemotherapy. There was no difference in weight loss between open and minimally invasive oesophagectomy. Results from this thesis also suggests that early nutritional interventions and follow up regarding energy and protein intake is important to maintain or prevent weight loss during the neoadjuvant treatment and during the first three postoperative months. We did also see a beneficial effect on patients´ weight development after prolonged time to surgery after completed neoadjuvant treatment compared to standard time to surgery.

List of scientific papers

I. Sunde B, Ericson J, Kumagai K, Lundell L, Tsai J, Lindblad M, Rouvelas I, Friesland S, Wang N, Nilsson M. Relief of dysphagia during neoadjuvant treatment for cancer of the esophagus or gastroesophageal junction. Diseases of the Esophagus. 2016, 29 (5), 442-447.
https://doi.org/10.1111/dote.12352

II. Ericson J, Lundell L, Klevebro F, Kamiya S, Nilsson M, Rouvelas I. Long-term weight development after esophagectomy for cancer – comparison between open Ivor Lewis and minimally invasive surgical approaches. Diseases of the Esophagus. 2019, 32 (4), 1-9.
https://doi.org/10.1093/dote/doy075

III. Ericson J, Lundell L, Lindblad M, Klevebro F, Nilsson M, Rouvelas I. Assessment of energy intake and total energy expenditure in a series of patients who have undergone oesophagectomy following neoadjuvant treatment. Clinical Nutrition ESPEN. 2020, 37, 121-128.
https://doi.org/10.1016/j.clnesp.2020.03.007

IV. Ericson J, Klevebro F, Sunde B, Szabo E, Halldestam I, Smedh U, Wallner B, Johansson J, Johnsen G, Kjus Aahlin E, Johannessen H-O, Hjortland G-O, Bartella I, Schröder W, Bruns C, Rouvelas I, Nilsson M. Weight development, dysphagia, and malnutrition in patients with esophageal cancer – randomized comparison between standard and prolonged time to surgery after neoadjuvant chemoradiotherapy. [Manuscript]