Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Prospective Study of Malabsorption and Malnutrition After Esophageal and Gastric Cancer Surgery Helen M. Heneghan, MD, PhD, Alexandra Zaborowski, MD, Michelle Fanning, BSc, Aisling McHugh, BSc, Suzanne Doyle, PhD, Jenny Moore, RN, Nayarasamy Ravi, MD, and John V. Reynolds, MD Objective: To study malabsorption and malnutrition after curative resection of esophageal and gastric cancer. Design: Prospective cohort study. Background: Improved cure rates for esophageal and gastric cancer have increased focus on health-related quality of life (HR-QL) in survivorship. Although malnutrition is well described in long-term follow-up, and gastro- intestinal symptoms are common, data on gut and pancreatic-related mal- absorption are scant. Methods: Disease-free patients at least 18 months after esophageal or gastric oncologic resections represented the study cohort. A modified Gastrointes- tinal Symptom Rating Scale questionnaire was completed, and weight, fecal elastase (FE), albumin, vitamins, and micronutrients measured preoperatively and at 1, 6, and 18 to 24 months postoperatively. Small intestinal bacterial overgrowth (SIBO) and changes in body composition were also evaluated postoperatively. Results: At a median follow-up of 23 months, 45 of 66 patients in a consecutive series were disease-free. Mean weight (78  19 vs 67  16 kg), body mass index (27  5 vs 24  5 kg/m 2 ), Vitamin A (1.7  0.6 vs 1.2  0.4 umol/L), and Vitamin E (28  7 vs 20  7 umol/L) were signifi- cantly decreased (P < 0.01) at last follow-up compared with preoperatively. Malabsorption was evident in 73% of patients, of whom 44% had FE < 200 mg/g and 38% had evidence of SIBO. Total body fat-free mass (175  96 vs 84  71, P < 0.001) and skeletal muscle index (44  8 vs 39  8, P ¼ 0.007) were significantly decreased at 18 to 24 months. Conclusions: Malabsorption and malnutrition are prevalent in survivorship of esophageal and stomach cancer. This may be underappreciated, and both gut and pancreatic insufficiency represent modifiable targets in the inter- disciplinary approach to recovery of HR-QL. Keywords: esophageal cancer, esophagectomy, gastrectomy, gastric cancer, malabsorption, malnutrition (Ann Surg 2015;262:803–808) I n the modern era, advances across the spectrum of care in esophageal and gastric cancer have resulted in improved survivorship in patients who can be treated with curative intent. 1–4 With improved oncologic outcomes, the recovery of health-related quality of life (HR- QL) and well-being in survivorship is an emerging focus of research interest. 5,6 The maintenance of body weight is a recognized significant challenge after major upper gastrointestinal (UGI) cancer surgery, and symptoms including anorexia, diarrhea, and dumping are common. However, the interplay between nutrition and gastrointestinal function in long-term follow-up of patients is rarely studied. 7,8 The etiology of malnutrition and malabsorption is likely com- plex and multifactorial. Modifiable factors impacting on malabsorption include exocrine pancreatic insufficiency (EPI), bile acid malabsorption (BAM), and small intestinal bacterial overgrowth (SIBO). After vagal denervation, EPI results from loss of endogenous neuroendocrine signals which stimulate the pancreas to release digestive enzymes. 9 Similarly, BAM may result from both vagotomy and disruption of the enterohepatic circulation of bile acids. 10 SIBO reflects an altered gut microbiome as a result of diminished gastric acid secretion, anatomical alterations of the gut, and compromised intestinal motility. 11 If ident- ified, these are correctable with pancreatic enzyme replacement therapy (PERT), colesevelam, and antibiotics, respectively. 9,12,13 In this study, we aimed to prospectively evaluate the incidence and severity of malabsorption and malnutrition in disease-free survivors and to assess linked factors in pathophysiology. We also investigated the relationship between the development of malab- sorption and changes in body composition postoperatively, particu- larly the loss of skeletal muscle mass (sarcopenia), given the established association between sarcopenia and poorer prognosis after treatment for various cancers. 14,15 In a consecutive series, we report herein that malnutrition, malabsorption, and body composition changes are prevalent, and that targetable gut and pancreatic-related factors may represent an opportunity to impact on gastrointestinal recovery and nutritional well-being. METHODS Study Population and Setting Between January and July 2013, a consecutive series of patients undergoing esophagectomy or gastrectomy with curative intent at the National Esophageal and Gastric Centre at St James’s Hospital, Dublin, were studied. Ethical approval and patient consent were obtained. To avoid confounding variables from disease recur- rence, the study cohort was exclusively disease-free patients at a minimum follow-up of 18 months postoperatively. Baseline Assessment and Follow-up Measurements Preoperatively, all patients had baseline anthropometric, hem- atological, and biochemical investigations. Patient-reported preoper- ative weight loss was noted. Where indicated and recommended by a multidisciplinary team, patients received multimodal treatment as previously described. 3 Unit policy is for patients undergoing esoph- agectomy to receive supplemental jejunal feeding for 6 weeks post- operatively, whereas gastrectomy patients received total parenteral nutrition immediately postoperatively, until oral intake was tolerated. At 1, 6, and 18 to 24 month visits, patients had a complete nutritional assessment including measurement of weight, fecal elas- tase (FE), vitamins and micronutrients, thyroid function, IgA, and anti-tissue transglutaminase antibodies. All patients completed a From the Department of Surgery, Trinity College Dublin, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin, Ireland. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com). Reprints: John V. Reynolds, MD, Academic Head of Department of Clinical Surgery, Department of Surgery, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin 8, Ireland. E-mail: reynoldsjv@stjames.ie. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001445 Annals of Surgery  Volume 262, Number 5, November 2015 www.annalsofsurgery.com | 803 P APER OF THE 22ND ANNUAL ESA MEETING