Gastrostomy in the era of minimally invasive head and neck cancer surgery: Gastrostomy Minimally Invasive Head and Neck

Utility of video fluoroscopic swallow study in advancing oral diet post TORS for oropharyngeal malignancies

OBJECTIVE

TORS is a minimally invasive surgical alternative to chemoradiotherapy for oropharyngeal malignancies. While early postoperative oropharyngeal dysphagia is linked to TORS, this study explores both subjective and objective swallowing outcomes.

STUDY DESIGN

Retrospective and prospective review of the patients who underwent TORS for oropharyngeal malignancy from 2018 to 2023.

SETTING

Single tertiary referral center.

METHODS

Postoperative transnasal feeding tubes were administered to 142 patients undergoing TORS. Data on oncological, clinical, surgical, and pathological parameters, including VFSS records, pain with swallow, and feeding tube removal timing, were collected. Clinical swallow exam (CSE) was conducted on POD-1, with a formal swallow study pursued if inconclusive. Once a safe swallow was confirmed, oral diets were initiated, and the feeding tube removed, with most patients discharged on POD-2.

RESULTS

At an average age of 59.3 years on the day of operation, the palatine tonsil (N = 101) was the predominant subsite. A dobhoff feeding tube was intraoperatively placed in 98 % of patients (N = 139). On POD-1, CSE was conducted in 119 patients, with 26 % (37/119) cleared for total oral diet (NOMS ≥ 4). Additionally, 30 out of 73 VFSS patients were cleared for total oral diet. A total of 54.9 % (78/142) had the feeding tube removed before discharge on POD-2, with a mean time of 6.5 ± 6.6 days. Overall, 71.1 % (101/142) achieved a total oral diet within one week after TORS.

CONCLUSION

Early post-TORS swallowing is vital for oropharyngeal malignancies. VFSS assesses post-operative swallowing safety, allowing most patients to resume total oral nutrition shortly after TORS.

Prophylactic percutaneous endoscopic gastrostomy in patients with head and neck cancer: Influence on nutritional status, utilisation rate and complications

BACKGROUND

Patients with head and neck cancer (HNC) are at high risk for malnutrition because of tumour localisation and therapy. Prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement is common practice to prevent malnutrition.

OBJECTIVE

To investigate the benefits of prophylactic PEG tube placement for HNC patients in terms of the influence on patients' nutritional status, utilisation rate, complications and to identify the predictors of PEG tube utilisation.

METHODS

All consecutive HNC patients who underwent prophylactic PEG tube insertion between 1 January 2011 and 31 December 2012 prior to therapy were enrolled. The PEG tube utilisation rate, complications, the patients' nutritional status and tumour therapy were evaluated with the help of electronic patient charts and telephone interviews.

RESULTS

A total of 181 patients (48 female, median 67.5 years) were included. The PEG utilisation rate in the entire cohort was 91.7%. One hundred and forty-nine patients (82.3%) used the PEG tube for total enteral nutrition, 17 patients (9.4%) for supplemental nutrition and 15 patients (8.3%) made no use of the PEG tube. Peristomal wound infections were the most common complications (40.3%) in this study. A high Nutritional Risk Screening (NRS) score prior to tube insertion was found to be independently associated with PEG utilisation. No significant weight changes were observed across the three patient subgroups.

CONCLUSIONS

The overall PEG tube utilisation rate was high in this study. However, given the high rate of infections, diligent patient selection is crucial in order to determine which patients benefit most from prophylactic PEG tube insertion.

Outcomes following TORS for HPV-positive oropharyngeal carcinoma: PEGs, tracheostomies, and beyond

OBJECTIVES

To review swallowing, airway and speech outcomes following transoral robotic surgery (TORS) ± adjuvant therapy for human papillomavirus associated oropharyngeal squamous cell carcinoma (HPV[+]OPSCC).

METHODS

Patients underwent TORS ± standard adjuvant therapy from 5/1/2007-5/31/2015. Clinical data were recorded and descriptive analysis was performed.

RESULTS

267 patients met criteria. All patients underwent surgery at Mayo, however, only 41/81 and 71/119 patients received RT and CRT at a Mayo Clinic site. A PEG was placed in 77 patients (3 prior to any treatment, 74 reactively during adjuvant therapy), with 3 PEG dependent and 3 partially PEG reliant at last follow-up. Tracheostomy was performed in 30 (11%) patients; 28 were decannulated. Swallow evaluations were completed for 20/81 undergoing RT and 50/119 undergoing CRT at a median of 3.8 and 7.6 months post-treatment, respectively. An unrestricted oral diet was reported by 5% following RT and 12% following CRT on the Functional Oral Intake Scale. HN-PSS normalcy of diet scores indicated a diet beyond soft chewable foods for 27% following RT and 46% following CRT. No restriction of place, food, or companion was reported for the HN-PSS for public eating in 13% after RT and 33% after CRT. Aspiration of thin liquid was present in 17% and 28% following RT and CRT, respectively. HN-PSS understandability of speech was "always understandable" in 60% and 63%, following RT and CRT, respectively. Hoarseness was reported in 56% and 45% following RT and CRT respectively.

CONCLUSION

Long-term PEG and tracheostomy dependence in this cohort is low. However, these outcomes under-represent the decrement in patient speech and swallowing following TORS ± standard adjuvant therapy for HPV(+)OPSCC.

Transoral robotic resection of benign tumors of the upper aerodigestive tract: Experience of the French group of GETTEC

BACKGROUND

The purpose of this study was to assess the current use of transoral robotic surgery (TORS) in benign tumors of the upper aerodigestive tract through a case series and a literature review.

METHODS

This multicentric retrospective study was conducted in 6 French centers between November 2009 and July 2017.

RESULTS

Twenty-one patients had a TORS resection of a tumor at varied locations with differing histopathologic characteristics. The mean postoperative hospital stay was 6.1 days. Eight patients had nasogastric tubes, which were removed after a mean of 5.6 days. Two patients had a prophylactic tracheostomy for an average of 5.5 days. A third tracheostomy was performed secondarily for postoperative bleeding. No recurrences were observed during the 2-year follow-up.

CONCLUSION

This technique caused few complications and resulted in short hospitalization, with satisfactory functional and recurrence outcomes. However, the risk of bleeding and edema must be considered, and the need for a tracheostomy must be approached wisely.