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postoperative malnutrition is relatively common in patients who undergo esophagectomy . in cases where preoperative radiotherapy and chemotherapy are administered during esophageal cancer treatment , preoperative dysphagia and weight loss
oral diet can not be initiated for at least 1 week after esophagectomy , the malnutrition can be aggravated by insufficient nutritional support .
early enteral feeding has been advocated in esophagectomy patients as it could reduce postoperative morbidity .
pump - assisted continuous drip infusions are the preferred method for jejunostomy feeding . typically , continuous feeding is initiated at 20 - 50 ml / h and increased as tolerated by 10 - 25 ml / h every 4 to 24 hours until the target rate is achieved .
continuous feeding enables to maintain the lowest possible hourly feed rate , thereby to meet nutrient requirements while obtaining better gastrointestinal tolerance due to the lower feed rate . also , better control of glucose levels to continuous carbohydrate input can be achieved .
we established a jejunostomy feeding protocol to provide better nutritional support for esophagectomy patients in our institution 3 years ago . according to that protocol ,
we treated patients with continuous jejunostomy feeding , using an enteral feeding pump for 16 hours a day , except bedtime to increase their feeding tolerance ; it was initiated on postoperative day ( pod ) 2 , considering that no contraindications for jejunostomy were present .
the target calorie intake was achieved in 6 - 7 days with this protocol , which is longer than that required with recently reported feeding protocols [ 2,5 - 11 ] .
therefore , we attempted to initiate early feeding , within 24 hours postoperatively , and continued the feeding for 24 hours per day ( table 1 ) . in the present study
, we aimed to reduce the time required to achieve the target calorie intake , without any complications , by using the new protocol .
we report the cases of 3 patients who received continuous 24-hour jejunostomy feeding after esophagectomy .
the requirement for informed consent for this case report was waived by the institutional review board of the seoul national university hospital .
the mean age of the patients was 61.7  8.9 ( range , 56 - 72 ) years .
all the patients were men who were diagnosed with esophageal cancer . however , the cases differed with regard to the preoperative treatments , operative methods , and postoperative complications .
patient 1 first received neoadjuvant concurrent chemoradiotherapy ( ccrt ) , and thereafter , underwent a hybrid mckeown operation ( robot - assisted thoracic esophageal dissection and stomach conduit preparation via laparotomy ) and feeding jejunostomy .
since no postoperative complications were observed , other than increased glutamate oxaloacetate transaminase ( got ) and glutamate pyruvate transaminase ( gpt ) values , oral diet was initiated on pod 7 .
patient 2 underwent neoadjuvant ccrt , followed by a mckeown operation ( esophagectomy and stomach conduit preparation ) , excision of a jejunal gastrointestinal stromal tumor , and feeding jejunostomy . since an oral diet could not be initiated due to postoperative anastomotic leakage , nutritional support was sustained by feeding jejunostomy until pod 48 , after which oral nutrition could be initiated . in patient 3 ,
neoadjuvant ccrt was discontinued due to the development of esophagopulmonary fistula , after which the patient was hospitalized and received feeding jejunostomy , followed by antibiotic treatment and nutritional support .
after 1 month of supportive treatment , esophagectomy through a left thorcoabdominal incision and en bloc left lower lobectomy were performed .
however , no oral feeding was permitted due to the presence of a minor chylothorax and anastomotic leakage after the operation ; therefore , jejunostomy feeding was initiated under close observation .
table 3 illustrates the jejunostomy feeding rates and the postoperative outcomes . in the present cases
, we adopted the new protocol with early and 24-hour continuous jejunostomy feeding ( table 1 ) ; moreover , early jejunostomy feeding was initiated within 24 hours postoperatively in the patients , who were considered to be fit for feeding . for jejunostomy feeding
, we used a fiber - free standard formula and maintained the feeding rate using feeding pumps .
as noted in table 2 , patient 3 had already undergone jejunostomy feeding using the previous protocol , after being hospitalized in a condition wherein an oral diet was not possible . after surgery , the patient underwent early postoperative 24-hour continuous jejunostomy that was initiated on the evening of pod 1 according to the new protocol .
the target caloric requirement was achieved in all the subjects within 5 days of the commencement of feeding .
none of these patients showed any feeding - associated complications such as diarrhea or abdominal discomfort .
the mean duration of hospital stay was 41.0  22.7 ( range , 15 - 57 ) days and the mean postoperative weight loss was 6.6  5.3 ( 9.6%  7.2% ) kg . moreover , the time taken to achieve the target caloric intake was reduced from 6 - 7 days to less than 5 days .
therefore , it is essential to provide proper nutritional support for such patients postoperatively , in order to minimize complications , shorten the recovery period , identify appropriate measures to prevent / modify a poor nutritional state , and ultimately improve the quality of life .
table 4 shows the recently reported jejunostomy feeding protocols used in patients in whom initiation of an early oral diet after gastrointestinal surgery was difficult [ 2,5 - 11 ] . the protocols in most of the previous studies aimed to reach the target calorie requirement as quickly as possible , by starting with 10 - 40 ml / h on the first day after the operation , followed by increases every 6 - 8 hours during 20 - 24 hours of continuous feeding .
haverkort et al .   reported that 24% of their patients failed to reach a target caloric requirement 12 months after esophagectomy .
a total of 48% of patients continued tube feeding and reached their target calorie and protein requirements after hospital discharge . at 6 months
postoperatively , only 2 patients still received night tube feeding , and at 12 months postoperatively , only 1 patient still received night tube feeding .
thus , the patients received continuous tube feeding until the target caloric requirement was achieved .
as reported by gerritsen et al . , european nutritional guidelines recommend the use of enteral feeding involving jejunostomy or nasojejunal feeding after pancreaticoduodenectomy .
examined the benefits of feeding and the associated complications , with the aim of providing early nutritional support using jejunostomy feeding and nasoduodenal tube feeding after esophagectomy .
feeding was initiated on pod 1 and helped the patient achieve the target caloric requirement within 3 days ; moreover , catheter - related complications had an incidence of 30 - 35% . although our previous protocol invoving 16-hour continuous feeding through jejunostomy until oral feeding was found to be a good method for nutritional support , it had limitations due to later stage initiation and it took longer to achieve the target caloric intake , as compared to protocols reported in other recent studies wherein early feeding was started on pod 1 and the patient 's caloric target was reached within 3 days
accordingly , we attempted to initiate 24-hour continuous feeding on pod 1 , which successfully reduced the time required to achieve the target caloric requirement from 6 - 7 days to less than 5 dyas .
although the clinical conditions and surgical outcomes of the 3 patients were highly varied and the cases were difficult to manage , all the patients successfully adapted to 24-hour jejunostomy feeding without any complications .
night jejunostomy feeding is advantageous in that it can reduce abdominal fullness caused by combined feeding through per os and jejunostomy .
if a patient can adapt to night jejunostomy feeding , he or she can continue oral feeding in daytime and jejunostomy feeding at night .
this strategy would help to increase the total calorie intake and improve the nutritional status of patients who require additional jejunostomy feeding .
moreover , we believe that this new approach is useful for increasing the patients ' total nutritional intake and expediting their recovery . in conclusion , we noted that the protocol of early and 24-hour continuous jejunostomy feeding could be safely applied for enhancing nutritional support after esophagectomy .
however , further studies on the efficacy and advantages of this novel protocol in patients who received esophagectomy are necessary .
esophagectomy can result in various postoperative nutrition - related complications that may impair the nutritional status of the patient . in our institution 
 , we usually initiate 16-hour continuous jejunostomy feeding using an enteral feeding pump on postoperative day 2 as a routine protocol after esophagectomy . 
 the target calorie intake was achieved in 6 - 7 days with this protocol , which is longer than that required with other recently reported feeding protocols . 
 accordingly , early jejunostomy feeding protocol , which starts on postoperative day 1 and continues for 24 hours was attempted . in the present report 
 , we described 3 cases of early 24-hour continuous jejunostomy feeding after esophagectomy . 
 the use of this new protocol reduced the duration required to achieve the target calorie intake as less than 5 days without any enteral feeding - related complications .