2022 Short Report
Source: data.gov.uk (2023-02-06)

National Oesophago-Gastric Cancer Audit (NOGCA) Short Report 2022. The National Oesophago-Gastric Cancer Audit evaluates the quality of care given to patients with Oesophago-Gastric (OG) cancer and patients with oesophageal high grade dysplasia (HGD). The audit aims to support NHS services to improve the quality of care delivered to these patients.

The National Oesophago-Gastric Cancer Audit is a collaborative, national clinical audit run by the Association of Upper Gastrointestinal Surgery of Great Britain & Ireland (AUGIS), British Society of Gastroenterologists (BSG), Royal College of Radiologists, NHS Digital, and the Clinical Effectiveness Unit at the Royal College of Surgeons of England. The audit is part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), that is managed by the Healthcare Quality Improvement Partnership.

The 2022 Short Report describes postoperative nutritional management among patients with oesophago-gastric cancer in England

The report does not contain individual patient information, nor does it contain any patient identifiable data.

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NOGCA short report 
 
Postoperative nutritional management among 
patients with oesophago-gastric cancer in England  
 
 
 
 
  
 
 
NOGCA: short report 2022  
 
Date of publication: 11th August 2022 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The National Oesophago-Gastric Cancer Audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) 
as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). HQIP is led by a consortium of the 
Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices. Its aim is to promote quality 
improvement in patient outcomes, and in particular, to increase the impact that clinical audit, outcome review 
programmes and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, 
manage, and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising around 40 
projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The 
programme is funded by NHS England, the Welsh Government and, with some individual projects, other devolved 
administrations and crown dependencies www.hqip.org.uk/national-programme  
 
 

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CONTENTS 
 
GLOSSARY ...................................................................................................................... 2 
EXECUTIVE SUMMARY ................................................................................................... 3 
INTRODUCTION ............................................................................................................... 4 
METHODS ........................................................................................................................ 4 
RESULTS ......................................................................................................................... 5 
CONCLUSION .................................................................................................................. 8 
REFERENCES ................................................................................................................ 10 
 
 
 
 
GLOSSARY 
 
Oral nutrition – nutrition that is taken by mouth; nutritional products that are eaten or 
drunk to supplement inadequate intake of normal food and drink. 
 
Enteral nutrition – nutrition that is delivered directly into the stomach or small bowel by 
a tube; used when nutritional requirements cannot be met by mouth but the digestive 
tract is otherwise working. Includes nasoenteral, gastrostomy and jejunostomy tubes. 
 
Parenteral nutrition – nutrition that is delivered directly into the blood stream through a 
drip; used when patients are unable to absorb nutrients through the digestive tract. 
 
 
 
 
 
Please cite as: National Oesophago-Gastric Cancer Audit. Postoperative nutritional management 
among patients with oesophago-gastric cancer in England (NOGCA Short Report). London: Royal 
College of Surgeons of England, 2022  
 
 
 
 
© 2022 Healthcare Quality Improvement Partnership (HQIP)  
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EXECUTIVE SUMMARY 
 
It is well established that poor nutritional status is directly associated with adverse outcomes from surgery. This 
is particularly pertinent in oesophago-gastric (OG) cancer as patients face a number of nutritional challenges on 
diagnosis and throughout their treatment pathway. However, evidence-based guidelines about optimal timing 
and modality of nutritional intervention in OG cancer, particularly in perioperative care, is lacking. This short 
report provides insight into current postoperative nutritional practices in ten (27.8%) OG cancer specialist 
centres across England, among 617 patients who underwent curative surgery after being diagnosed with OG 
cancer between April 2019 and March 2020.   
 
For patients who had oesophagectomy, the most commonly reported nutritional management strategy was 
enteral nutrition delivered via a jejunostomy during the admission and continued on discharge (51.0%). The 
majority of oesophagectomy patients (83.9%) had a jejunostomy or received parenteral nutrition during their 
surgical admission. This is consistent with the NICE recommendation that people undergoing curative surgery 
for oesophageal or gastro-oesophageal junctional cancers should be offered immediate enteral or parenteral 
nutrition.  Among patients undergoing curative gastrectomy, oral nutrition during admission and on discharge 
was the most commonly reported nutritional management strategy (60.9%).  There was substantial variation in 
nutritional practices across surgical centres, reflecting the lack of evidence on the role of specific nutritional 
management strategies in improving surgical outcomes.  
 
The majority of patients (86.2%) were assessed and advised by a specialist OG dietitian before their treatment 
began, and a further 6.5 % were seen by a general dietitian (or one whose role was unspecified). The remaining 
patients had no contact with a dietitian, either because it was considered not required (7.1%) or because no 
dietitian was available (0.2%).  Almost all patients (98.9%) were assessed and advised by a specialist OG 
dietitian after surgery, in line with NICE recommendations. However, the findings suggest that a small number 
of patients were not assessed by a dietitian either before or after surgery.  
 
Only specialist centres with high levels of data completeness were included in this report. It is possible that 
centres with good nutritional practices are over-represented in the findings. The current audit dataset also 
does not enable centres to describe more complex patterns of nutritional management, such as the use of 
multiple interventions during the perioperative period and the duration of nutrition support.   
 
Despite these limitations, the observed organisation-level variation in nutritional management highlights the 
need for clearer evidence-based guidance in this area, to reduce variation in care and improve outcomes. 
 
Recommendations 
1. Review the nutritional management of patients undergoing surgery for OG cancer to ensure that all 
patients have access to appropriate dietetic input as recommended by NICE (Audience: 
multidisciplinary teams, NHS commissioners). 
2. Review processes for the collection and submission of nutrition data for NOGCA and improve the 
completeness of data items where it is currently low (Audience: clinical leads, multidisciplinary teams, 
local audit teams). 
3. Work with specialist dietitians to increase engagement with the audit and to refine the NOGCA 
nutrition data items (Audience: NOGCA team, specialist OG dietitians). 
 

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INTRODUCTION  
 
Curative surgery for oesophago-gastric (OG) cancer involves the partial or total removal of 
the oesophagus (oesophagectomy) or stomach (gastrectomy). People who undergo these 
procedures are unable to eat a normal diet for an extended period after surgery and are at 
significant risk of malnutrition and weight loss. A number of nutritional management 
strategies (oral, enteral and/or parenteral) are used to support patients during the 
perioperative period, along with dietary counselling on food choices and eating habits.  
 
Guidance from the National Institute for Health and Care Excellence (NICE) on the 
assessment and management of OG cancer (NICE 2018) recommends that people 
undergoing curative surgery for OG cancer should be offered:  
 nutritional assessment and tailored specialist dietetic support before, during and 
after surgery, and 
 immediate enteral or parenteral nutrition after surgery for oesophageal or gastro-
oesophageal junctional cancers. 
 
A number of other clinical guidelines outline the importance of optimising nutritional status 
throughout the multimodal pathways for surgery and oncology patients (Arends et al 2017; 
Lobo et al 2020; Low et al 2019; Weimann et al 2021). Studies suggest that providing some 
form of nutritional support improves outcomes, such as reducing surgical complications and 
postoperative length of stay (Yan et al 2017). However, evidence about optimal 
management strategies to provide nutrition support for people after OG surgery and 
throughout their oncological pathway is lacking, and NICE have highlighted this as a priority 
area for research (NICE 2018). 
 
The objective of this short report is to describe current postoperative nutritional practices in 
OG cancer specialist centres. Whilst all specialist centres in England and Wales were eligible 
for inclusion, only centres in England met the inclusion criteria. The findings of this report 
can inform the design of future research to identify optimal nutritional management 
strategies to improve patient care and outcomes among people with OG cancer.   
 
METHODS 
 
The National Oesophago-Gastric Cancer Audit (NOGCA) collects information to assess the 
quality of care received by people diagnosed with OG cancer in England and Wales.  NOGCA 
added new items to its dataset in 2019 to capture patterns of nutrition support for patients 
with OG cancer. The data items focused on primary nutritional management (oral, enteral 
or parenteral) at two time points: during the surgical admission and on discharge. The audit 
also collected information about the involvement of specialist dietetic support at two points 
in the care pathway: (i) between diagnosis and treatment, and (ii) postoperatively.   
 
The study included patients diagnosed with OG cancer between 1 April 2019 and 31 March 
2020, who had a record of curative surgery. Submission of nutrition data was not mandatory 
during the period for which data are available. Of the 36 NHS specialist surgical centres 
participating in the audit, 15 did not provide any information about postoperative nutrition 

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management. Among the 21 remaining centres, only 10 (all in England) provided valid 
information about nutrition support for more than 80% of patients who had curative 
surgery. The analysis described in this report is limited to the data from these 10 NHS 
specialist centres. 
 
The postoperative nutrition interventions that clinical staff could record in the NOGCA 
dataset were: (i) the primary form of nutrition support used during the surgical admission, 
(ii) the primary form of nutrition support on discharge, and (iii) the frequency of specialist 
dietitian involvement. Postoperative nutritional practices were described for the whole 
cohort and by type of procedure (oesophagectomy versus gastrectomy). Due to the 
relatively small number of gastrectomy procedures, nutritional management strategies by 
patient and surgery characteristics (age, sex, clinical stage, use of enhanced recovery after 
surgery protocols) were only described for patients undergoing oesophagectomy. 
Differences in the use of nutritional management strategies across surgical centres were 
also explored. The statistical significance of differences in the proportions across patient 
subgroups was assessed using Chi-squared tests. 
 
RESULTS 
 
Patient cohort 
 
The 10 NHS specialist surgical centres included in this report were distributed across seven 
of the 21 English Cancer Alliance regions:  
 East Midlands 
 East of England – North 
 Northern 
 South East London 
 Thames Valley 
 Wessex 
 West Midlands 
 
Of the 658 patients diagnosed with OG cancer in 2019-20 who had curative surgery at one 
of the included surgical centres, 617 (93.8%) had complete information about postoperative 
nutrition. Of these, 410 (66.5%) had undergone oesophagectomy and 207 (33.5%) had 
gastrectomy. A quarter of patients (24.8%) were aged under 60 years, 79.4% were male, and 
a third (32.8%) had stage 1-2 disease. 
 
Information about the use of Enhanced Recovery after Surgery (ERAS) protocols was 
available for 604 patients. Among these, 73.7% of patients were on an ERAS pathway while 
the remaining 26.3% followed a standard surgical pathway. 
 
Nutritional management strategies 
 
The postoperative nutritional management strategies that were most commonly recorded 
in the NOGCA dataset are described in Table 1. 
 

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For patients undergoing curative oesophagectomy, the most common nutritional 
management strategy was enteral nutrition support delivered via a jejunostomy during the 
admission and continued on discharge, and was used for 51.0% of patients. This was 
followed by the combination of parenteral nutrition during admission and oral nutrition on 
discharge (16.8%), oral nutrition during admission and on discharge (14.4%), and enteral 
nutrition via a jejunostomy during admission and oral nutrition on discharge (11.9%). The 
majority of oesophagectomy patients (n=344, 83.9%) had enteral or parenteral nutrition 
during the admission, while 16.1% (n=66) received oral nutrition. The NOGCA data items did 
not distinguish between the use of oral nutritional supplements and oral dietary intake. 
 
Among patients undergoing curative gastrectomy, oral nutrition during admission and on 
discharge was the most commonly reported nutritional management (60.9%).  This was 
followed by enteral nutrition via a nasojejunal tube during admission and oral nutrition on 
discharge (12.1%). In contrast to patients who had oesophagectomy, only 10.1% of patients 
had enteral nutrition via a jejunostomy during admission and continued on discharge 
(10.1%) and 7.2% had parental nutrition during admission and oral nutrition on discharge. 
 
 
Table 1: Common postoperative nutritional management strategies among patients 
undergoing curative resection for OG cancer diagnosed 2019-20, by type of procedure  
 
Nutritional management 
Oesophagectomy 
Gastrectomy 
All patients 
During admission 
On discharge 
N (%) 
N (%) 
N (%) 
Jejunostomy 
Jejunostomy 
209 (51.0%) 
21 (10.1%) 
230 (37.3%) 
Oral  
Oral  
59 (14.4%) 
126 (60.9%) 
185 (30.0%) 
Parenteral  
Oral 
69 (16.8%) 
15 (  7.2%) 
84 (13.6%) 
Jejunostomy  
Oral 
49 (11.9%) 
1 (  0.5%) 
50 (  8.1%) 
Nasojejunal  
Oral 
2 (  0.5%) 
25 (12.1%) 
27 (  4.4%) 
Other combination 
22 (  5.4%) 
19 (  9.2%) 
41 (  6.6%) 
Total 
410 
207 
617 
 
Among patients who had oesophagectomy, postoperative nutritional practices did not differ 
by patient age (p=0.229), sex (p=0.711) or clinical stage (p=0.848). However, nutritional 
management strategies were different for patients on an ERAS pathway compared to those 
on a standard surgical pathway (p<0.001). Notably, the use of a jejunostomy to deliver 
nutrition during admission and on discharge was more common among patients on a 
standard pathway (72.9%) than among those following an ERAS protocol (42.8%), while the 
combination of parenteral nutrition during admission and oral nutrition on discharge was 
less common among patients on a standard pathway (3.1%) than among ERAS patients 
(21.7%). 
 
There were substantial organisation-level differences in nutritional practices across surgical 
centres (Figure 1). 
 

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Figure 1: Common postoperative nutritional management strategies (during admission + on 
discharge) among patients undergoing curative oesophagectomy for OG cancer diagnosed 
2019-20, by NHS specialist surgical centre 
 
 
 
Dietetic involvement 
 
Information about pre-treatment dietetic support (between diagnosis and primary 
treatment) was available for 494 patients. Of these, 86.2% (n=426) were assessed and 
advised by a specialist OG dietitian and a further 6.5 % (n=32) were seen by a general 
dietitian (or one whose role was unspecified). Among the remaining patients, 7.1% (n=35) 
had no contact with a dietitian as it was considered to not be required. One patient had no 
pre-treatment dietetic involvement because no dietitian was available.   
 
Among 616 patients with complete information about postoperative dietetic involvement, 
98.9% (n=609) were assessed and advised by a specialist OG dietitian, while 0.8% (n=5) were 
seen by a general or unspecified dietitian. Only two patients (0.3%) were reported to have 
had no postoperative contact with a dietitian; of these two patients, one had received pre-
treatment assessment and advice from a specialist dietitian, but one had no pre-treatment 
contact with a dietitian due to lack of staff. 
 
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Cambridge University Hospitals NHS Foundation Trust n=44
University Hospital Southampton NHS Foundation Trust
n=33
Portsmouth Hospitals NHS Trust n=28
Guy’s and St Thomas’ NHS Foundation Trust n=66
University Hospitals Coventry and Warwickshire NHS Trust
n=22
Norfolk and Norwich University Hospitals NHS Foundation
Trust n=23
University Hospitals Birmingham NHS Foundation Trust
n=68
The Newcastle Upon Tyne Hospitals NHS Foundation Trust
n=53
Oxford University Hospitals NHS Foundation Trust n=49
University Hospitals of Leicester NHS Trust n=24
% of all patients undergoing curative oesophagectomy
Nasojejunal+oral
Jejunostomy+jejunostomy
Jejunostomy+oral
Oral+oral
Parenteral+oral
Other

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CONCLUSION 
 
This analysis of patients who had curative surgery at 10 NHS specialist surgical centres in 
England found that 84% of patients undergoing oesophagectomy received enteral nutrition 
via a jejunostomy or parenteral nutrition during their surgical admission. This is consistent 
with the NICE recommendation that people undergoing curative surgery for oesophageal or 
gastro-oesophageal junctional cancers should be offered immediate enteral or parenteral 
nutrition.  The majority of patients undergoing gastrectomy received oral nutrition during 
their surgical admission, while a sizeable minority had enteral nutrition (delivered via 
nasojejunal or jejunostomy tube). 
 
The analysis highlights substantial variation in nutritional practices for oesophagectomy 
patients across the surgical centres, with many using mainly enteral nutrition via a 
jejunostomy during the surgical admission and others using mainly parenteral nutrition, 
while patients in some centres were reported to have primarily received oral nutrition 
during and after surgery. These organisation-level differences probably reflect the lack of 
evidence on the role of specific nutritional management strategies in improving surgical and 
oncological outcomes, and emphasise the need for research to identify optimal nutritional 
management for OG cancer patients.  
 
Almost all patients undergoing curative surgery at the 10 specialist surgical centres included 
in this report were assessed postoperatively by a specialist OG dietitian, in line with NICE 
recommendations. The majority of patients for whom data were available (86%) were also 
assessed and advised by a specialist dietitian before their treatment began. However, the 
findings suggest that a small number of patients are not assessed by a dietitian either before 
or after surgery. The care pathways for such patients should be reviewed. 
 
Recommendation 1: Review the nutritional management of patients undergoing 
surgery for OG cancer to ensure that all patients have access to appropriate dietetic 
input as recommended by NICE (Audience: multidisciplinary teams, NHS 
commissioners). 
 
However, there are limitations with the study that need to be considered when interpreting 
the report findings. First, limited data on postoperative nutritional management were 
submitted to NOGCA after the introduction of the data items. Only specialist centres with 
high levels of data completeness were included in this report, and it is possible that centres 
with good nutritional practices and access to specialist dietetic support are over-
represented in the current findings. 
 
Recommendation 2: Review processes for the collection and submission of nutrition 
data for NOGCA and improve the completeness of data items where it is currently 
low (Audience: clinical leads, multidisciplinary teams, local audit teams). 
  

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Second, the current audit dataset does not capture more complex patterns of nutritional 
management, such as the use of multiple interventions during the perioperative period and 
the duration of nutrition support following surgery.   
 
Recommendation 3: Work with specialist dietitians to increase engagement with the 
audit and to refine the NOGCA nutrition data items (Audience: NOGCA team, 
specialist OG dietitians). 
 
Despite some limitations, this report provides insight into current postoperative nutritional 
practices for OG cancer across specialist centres covering several regions in England. The 
demonstration of organisation-level variation in nutritional practices highlights the need for 
research to identify optimal nutrition strategies, which can inform the development of 
evidence-based guidance in this area. This would be expected to reduce the variation in care 
and improve outcomes for patients.  
 
As data quality improves, next steps for the Audit will be to repeat this analysis to describe 
nutritional management across all OG cancer specialist centres, and to explore the 
relationships between nutritional management strategies and surgical outcomes.  

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REFERENCES 
 
Arends et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr 2017 Feb; 36:11-48. doi: 
10.1016/j.clnu.2016.07.015 
 
Lobo et al. Perioperative nutrition: recommendations from the ESPEN expert group. Clin Nutr 2020 Nov; 
39:3211-27. doi: 10.1016/j.clnu.2020.03.038 
 
Low et al. Guidelines for perioperative care in oesophagectomy; enhanced recovery after surgery (ERAS) 
society recommendations. World J Surg 2019;43(2):299-330. doi: 10.1007/s00268-018-4786-4 
 
National Institute for Health and Care Excellence. Oesophago-gastric cancer: assessment and management in 
adults: NICE guideline NG83. London: NICE, 2018. Available from: https://www.nice.org.uk/guidance/ng83 
 
Yan X et al. Optimal postoperative nutrition support for patients with gastrointestinal malignancy: A systematic 
review and meta-analysis. Clin Nutr. 2017 Jun;36(3):710-721. doi: 10.1016/j.clnu.2016.06.011  
 
Weimann et al. ESPEN practical guideline: clinical nutrition in surgery. Clin Nutr 2021; 40:4745-4761. doi: 
10.1016/j.clnu.2021.03.031 
 
 
 
This report was prepared by 
Clinical Effectiveness Unit (CEU/RCS) 
Min Hae Park, Assistant Professor 
Hussein Wahedally, Statistician / Data Manager 
David Cromwell, Professor of Health Services 
Research 
 
NHS Digital 
Joanna Geisler, Programme Manager 
Rose Napper, Audit Coordinator 
 
Royal College of Radiologists (RCR) 
Tom Crosby, Consultant Clinical Oncologist  
Betsan Thomas, Consultant Clinical Oncologist 
 
Association of Upper Gastrointestinal Surgery of 
Great Britain and Ireland (AUGIS) 
Nick Maynard, Consultant Surgeon 
 
British Society of Gastroenterology (BSG) 
Nigel Trudgill, Consultant Gastroenterologist 
 
Fiona Huddy, Specialist Oesophago-gastric Dietitian 
British Dietetic Association 
 
The Royal College of Surgeons of England is an independent professional body committed to enabling 
surgeons to achieve and maintain the highest standards of surgical practice and patient care. As part of this, 
it supports Audit and the evaluation of clinical effectiveness for surgery. Registered Charity no: 212808 
Association of Upper GI Surgery of Great Britain and Ireland is the speciality society that represents upper 
gastrointestinal surgeons. It is one of the key partners leading the Audit. Registered Charity no: 1093090 
British Society of Gastroenterology is the speciality society of gastroenterologists. It is one of the key 
partners leading the Audit. Registered Charity no: 1149074 
Royal College of Radiologists is the professional body for clinical radiologists and clinical oncologists. It is 
one of the key partners leading the Audit. Registered Charity no: 211540 
NHS Digital is the trading name for the Health and Social Care Information Centre (HSCIC). They provide 
'Information and Technology for better health and care'. The Clinical Audit and Registries Management 
Service of NHS Digital manages a number of national clinical audits in the areas of cancer, diabetes and heart 
disease.  It manages the Audit on behalf of the RCS.