A Systematic Review of Strategies for Preoperative Nutrition for Esophageal Cancer Patients Undergoing Neoadjuvant Therapy: A Comparison of Nasoenteric Nutrition, Surgical Tubes, and Stent Placement

Introduction: Esophageal cancer often presents at a late stage. Along with tumor metabolic burden, dysphagia can lead to malnutrition and worsen outcomes in esophageal cancer. Various nutrition modalities have been trialed for patients undergoing neoadjuvant therapy prior to esophagectomy but there is a lack of consensus as to which strategy is optimal. Methods: A systematic review of Ovid MEDLINE, Ovid Embase, Scopus, Web of Science Core Collection, and Cochrane Library was performed. Studies were included that examined esophageal cancer patients undergoing neoadjuvant therapy, assessing preoperative nutritional strategies including nasoenteric feeds, percutaneous (PEG) or surgical gastrostomy (G-tube) or jejunostomy tubes (J-tube), and esophageal stents. Risk of bias was assessed using the MINORS tool. Results: Of 3393 retrieved records, 23 were included. Nutritional strategies studied included stents (n = 16), J-tube (n = 8), G-tube (n = 3), nasogastric tube (NG, n = 2), and PEG (n = 2). Most feeding strategies showed mixed results regarding improvement, stability or decrease in weight or albumin during neoadjuvant therapy. Complications appeared most severe for endoscopic or surgical tubes (obstruction, migration) and stents (perforation, migration, intolerance), which occasionally required operation. Conclusion: There is significant heterogeneity in the literature on whether preoperative feeding modalities are associated with improved nutritional outcomes in this population. At the same time, endoscopic or surgical feeding tubes and esophageal stents are clearly associated with higher risk complications. Future studies standardizing study designs, done in a prospective comparative fashion may be beneficial, along with identification of patients who would benefit most.