The association between the Nutrition-Related index and morbidity following head and neck microsurgery

Impact of various nutritional interventions on the physical and mental state of patients undergoing surgery for oral and maxillofacial tumor: guiding patients' informed choices

PURPOSE

To compare the effects of oral nutritional supplements (ONS), parenteral nutrition (PN), and enteral nutrition (EN) on the recovery of patients who underwent oral and maxillofacial surgery.

METHODS

The shared decision-making process assigned 37, 56, and 35 patients to the ONS, PN, and EN groups, respectively. Details such as demographic data, duration of hospitalization, cost of nutritional therapy, nutritional assessments, patients' satisfaction, and compliance, Hamilton Anxiety Rating Scale (HAM-A) score, and relevant biochemical indices were systematically recorded and compared between the groups.

RESULTS

Patients with healthier biochemical indices and physical states at baseline, including a higher body mass index, preferred ONS. Patients using dentures and those with medical insurance often chose EN, while patients with recurrent disease preferred PN. Patients receiving EN had a similar duration of hospitalization to patients receiving ONS and also had the lowest nutritional costs. Patients receiving ONS had higher lymphocyte counts and levels of hemoglobin, albumin, and C-reactive protein. Patients in the PN group had elevated levels of serum potassium, chlorine, and sodium, while those receiving EN reported higher HAM-A scores, indicating greater anxiety than their counterparts. Predischarge surveys showed higher satisfaction and compliance in the PN and ONS groups than in the EN group. The PN group reported more adverse symptoms. At 7 days post-discharge, patients with EN reported a greater feeling of well-being.

CONCLUSION

ONS is the optimal choice for patients in good preoperative conditions, while PN is preferred during disease recurrence or when financially feasible. EN is suitable for patients using dentures or those with limited finances despite its potential psychological discomfort. Future studies with increased sample sizes and longer follow-up duration are necessary to corroborate our findings. The Trial Registration Number is ChiCTR2100049547. The date of registration is August 2, 2021.

Vascular events in patients with head and neck cancer: A systematic review and meta-analysis

OBJECTIVE

To assess the incidence of vascular events in patients with head and neck cancer.

REVIEW METHODS

Primary studies identified through April 2023. Meta-analysis was performed.

RESULTS

There were 146 studies included in the systematic review. Rates of events were collected in the overall group, those with chemoprophylaxis, and those that underwent surgery, radiation, or chemotherapy. Of 1 184 160 patients, 4.3% had a vascular event. Radiation therapy had highest risk of overall events and stroke when compared to surgery and chemotherapy. Chemotherapy had a higher risk of stroke and overall events when compared to surgery.

CONCLUSIONS

Vascular events occur in 4%-5% of patients with head and neck cancer. Our data does not support the use of routine anticoagulation. Patients undergoing radiation therapy had the highest frequency of events.

Malnutrition in Head and Neck Free Flap Reconstruction as a Predictor of Adverse Outcomes

INTRODUCTION

Malnutrition is associated with increased mortality in patients with head and neck (H&N) cancer. Because albumin levels are used as a surrogate for nutritional status, the purpose of this study is to assess whether malnutrition is associated with adverse postoperative outcomes in H&N free flap reconstruction.

MATERIALS AND METHODS

The 2006-2018 National Surgical Quality Improvement Program Database was queried for patients undergoing flap procedures of the H&N based on Current Procedure Terminology codes. Patients were included if they were operated on by an otolaryngologist or when the primary surgical site was H&N. Nutritional status was categorized as malnourished (preoperative albumin level <3.5 g/dL) or normal (preoperative albumin level ≥3.5 g/dL). Major complications included pulmonary complications, cardiac complications, deep vein thrombosis/pulmonary embolism, and sepsis/septic shock. Minor complications included surgical infection, urinary tract infection, bleeding, and dehiscence. Data were analyzed via univariate chi-square and multivariate regression analyses.

RESULTS

Of the patients, 2532 (83.3%) had normal albumin and 506 (16.7%) had hypoalbuminemia. Patients with hypoalbuminemia were more likely to have smoking history (P = 0.008), pulmonary comorbidity (P < 0.001), renal comorbidity (P = 0.018), disseminated cancer (P < 0.001), steroid use (P < 0.001), recent weight loss (P < 0.001), bleeding disorder (P = 0.023), and preoperative transfusion (P < 0.001). After adjustment for preoperative variance, malnourished patients were more likely to experience death (P < 0.001), return to operating room (P < 0.001), free flap failure (P = 0.008), pulmonary complication (P < 0.001), deep vein thrombosis/pulmonary embolism (P = 0.019), wound disruption (P = 0.042), intraoperative transfusion (P < 0.001), minor complication (P < 0.001), major complication (P < 0.001), and extended length of stay (P < 0.001). Of the patients with normal albumin, 2.1% experienced flap failure compared with 6.3% of patients with hypoalbuminemia. It should be noted that malnourished patients were 3.370 times more likely to experience flap failure (95% confidence interval, 1.383-8.212; P = 0.008) and 3.975 times more likely to experience death (95% confidence interval, 1.700-9.626; P = 0.001) than those with normal albumin.

CONCLUSION

Malnutrition is associated with death, flap failure, minor complications, and other major complications following H&N free flap surgery, even after controlling for preoperative variance. Optimizing preoperative nutrition status before free flap procedures may ameliorate morbidity and mortality in H&N patients.

Enhanced recovery pathways for head and neck surgery with free tissue transfer reconstruction

The enhanced recovery after surgery (ERAS) pathway is designed to facilitate recovery after surgery by packaging evidence-based protocols specific to each aspect of the perioperative period, including the preoperative, intraoperative, postoperative, and post-discharge periods. The ERAS pathway, which was originally developed for use with colonic resection, is now being expanded to include a variety of surgical procedures, and the ERAS Society has published a consensus review of the ERAS pathway for head and neck surgery with free tissue transfer reconstruction (HNS-FTTR). The ERAS pathway for HNS-FTTR consists of various important protocols, including early postoperative mobilization, early postoperative enteral nutrition, abolition of preoperative fasting, preoperative enteral fluid loading, multimodal pain management, and prevention of postoperative nausea and vomiting. In recent years, meta-analyses investigating the utility of the ERAS pathway in head and neck cancer surgery have also been presented, and all reports showed that the length of the postoperative hospital stay was reduced by the implementation of the ERAS pathway. The ERAS pathway is now gaining traction in the field of head and neck surgery; however, the details of its efficacy remain uncertain. We believe the future direction will require research focused on improving the quality of postoperative patient recovery and patient satisfaction. It will be important to use patient-reported outcomes to determine whether the ERAS pathway is actually beneficial.

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

Objectives

Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients.

Methods

Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion.

Results

A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation.

Conclusion

Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol.

Level of Evidence

2a.

Nutritional prehabilitation in head and neck cancer: a systematic review

PURPOSE

Prehabilitation affords an opportunity to support the management of malnutrition that is strongly associated with head and neck cancer. The purpose of this systematic review was to identify the components of nutritional prehabilitation interventions and their effects on nutritional and health outcomes in head and neck cancer patients.

METHODS

A comprehensive search was completed within Medline (including PubMed), CINHAL, Cochrane database, EMBASE, PRoQUEST, clinical trials registries, and grey literature to identify studies involving a nutritional intervention pre-treatment in head and neck cancer patients receiving any form of curative therapy. Nutritional intervention was defined as a specified period pre-treatment and outcome measures had to include assessment of nutritional status or body composition. Quality of included studies was assessed using Cochrane risk of bias 2.

RESULTS

From 557 identified studies, two met the inclusion criteria. Due to the low number of studies, a meta-analysis was not indicated. Both studies conducted a nutritional intervention using an "enriched formula" in malnourished patients prior to surgery. Neither study reported the intervention was effective for reducing weight loss, physical function, surgical complications, or length of stay versus the comparison.

CONCLUSION

There is limited nutritional prehabilitation research within head and neck cancer. An "enriched formula" provided in the prehabilitation period appears no more advantageous than routine standard nutritional formula in mitigating against the weight loss experienced in malnourished head and neck patient. Due to the malnutrition risks on diagnosis and the negative impact of poor nutritional status on clinical and functional outcomes, robust nutritional prehabilitation research is required to inform clinical practice.

Therapeutic Perspectives for the Perioperative Period in Oral Squamous Cell Carcinoma (OSCC)

The perioperative period is the relatively short window of time, usually measured in days or weeks, around the surgical procedure. Despite its short duration, this time period is of great importance for cancer patients. From a biological point of view, the perioperative period is complex. Synchronous with primary tumor removal, surgery has local and distant consequences, including systemic and local inflammation, coagulation and sympathetic activation. Furthermore, the patients often present comorbidities and receive several medical prescriptions (hypnotics, pain killers, anti-emetics, hemostatics, inotropes, antibiotics). Because of the complex nature of the perioperative period, it is often difficult to predict the oncological outcome of tumor resection. Here, we review the biological consequences of surgery of Oral Squamous Cell Carcinoma (OSCC), the most frequent form of primary head and neck tumors. We briefly address the specificities and the challenges of the surgical care of these tumors and highlight the biological and clinical studies that offer insight into the perioperative period. The recent trials examining neoadjuvant immunotherapy for OSCC illustrate the therapeutic opportunities offered by the perioperative period.

Enhanced Recovery After Surgery Nutrition Protocol for Major Head and Neck Cancer Surgery

Objective

To determine whether an enhanced recovery after surgery (ERAS) nutrition protocol is reasonably possible among our head and neck cancer (HNC) population with respect to system feasibility and patient compliance. Second, we aim to identify improvements in patient outcomes as a result.

Methods

Preexperimental research design among patients undergoing major HNC surgery after implementation of the ERAS nutrition protocol from July 2018 to July 2019 as quality improvement (QI). Preoperative clinical nutritional assessment and laboratory values were completed the same day as informed surgical consent in the clinic. Protocol focus was patient consumption of nutritional supplements perioperatively, monitored by our outpatient dietitian. Early postoperative enteral nutrition was initiated with monitoring of nutritional laboratory values. To support our model, we provide preliminary analysis of HNC patient outcomes after implementation of the ERAS nutritional protocol.

Results

Twenty-five patients were enrolled. Preoperatively, 40% of patients were malnourished, and 100% complied with perioperative nutrition supplementation. Health care provider compliance obtaining preoperative laboratory values was 56%. There was a strong negative correlation between modified Nutrition-Related Index (mNRI) and number of complications (P = .01), specifically, fistula rate (P = .04) and unplanned reoperation (P = .04). Enrolled patient average length of stay was 7 ± 4.4 days.

Discussion

Our patients demonstrated compliance with implementation of an ERAS nutrition protocol likely facilitated by dietitian engagement. mNRI potentially reflects risk for head and neck surgery complications.

Implications for Practice

QI processes demand reassessment and modification to ensure efficient and targeted approaches to improving patient care.

The Impact of Healthcare-Associated Infections in Patients Undergoing Oncological Microvascular Head and Neck Reconstruction: A Prospective Multicentre Study

Simple Summary

Healthcare-associated infections (HAIs) result in an increased morbidity and a delay in adjuvant therapy—thus increasing the cancer recurrence rates—in patients undergoing oncological microvascular head and neck reconstruction. HAIs also result in a cost increase for the Health System. We prospectively analysed the incidence, clinical characteristics, risk factors and impacts of these infections in 65 patients undergoing head and neck free-flap reconstruction in three third-level university hospitals in Madrid (Spain). The three of them implemented the same antibiotic prophylactic regimen for surgical interventions. The rate of HAIs was 61.54%. The following complications were significantly more frequent in patients with HAIs: need to reoperate (p = 0.009), duration of hospital admission (p < 0.001) and delay in starting radiotherapy (p = 0.009). This manuscript aims to point out the importance of preventing HAIs in head and neck cancer patients, as they have shown a higher risk of postoperative complications.

Abstract

(1) Background: Healthcare-associated infections (HAIs) after head and neck free-flap reconstruction are a common postoperative complication. Risk factors for HAIs in this context and their consequences have not been adequately described. (2) Methods: Ongoing prospective multicentre study between 02/2019 and 12/2020. Demographic characteristics and outcomes were analysed, focusing on infections. (3) Results: Forty out of 65 patients (61.54%) suffered HAIs (surgical site infection: 52.18%, nosocomial pneumonia: 23.20%, bloodstream infection: 13% and urinary tract infection: 5.80%). Methicillin-resistant Staphylococcus aureus (MRSA) and resistant Pseudomonas aeruginosa, Klebsiella pneumoniae and Enterobacter cloacae were the most frequently implicated. The significant risk factors for infection were: previous radiotherapy (Odds ratio (OR): 5.42; 95% confidence interval (CI), 1.39–21.10), anaemia (OR: 8.00; 95% CI, 0.96–66.95), salvage surgery (eight out of eight patients), tracheostomy (OR: 2.86; 95% CI, 1.01–8.14), surgery duration (OR: 1.01; 95% CI, 1.00–1.02), microvascular reoperation <72 h (eight/eight) and flap loss (eight/eight). The major surgical complications were: a need to reoperate (OR: 6.89; 95% CI, 1.42–33.51), prolonged hospital admission (OR: 1.16; 95% CI, 1.06–1.27) and delay in the initiation of postoperative radiotherapy (OR: 9.07; 95% CI, 1.72–47.67). The sixth month mortality rate in patients with HAIs was 7.69% vs. 0% in patients without HAIs (p = 0.50). (4) Conclusions: HAIs were common after this type of surgery, many of them caused by resistant microorganisms. Some modifiable risk factors were identified. Infections played a role in cancer prognosis by delaying adjuvant therapy.

Nutrition delivery after emergency laparotomy in surgical ward: a retrospective cohort study

PURPOSE

Adequate nutrition after major abdominal surgery is associated with less postoperative complications and shorter hospital length of stay (LOS) after elective procedures, but there is a lack of studies focusing on the adequacy of nutrition after emergency laparotomies (EL). The aim of the present study was to investigate nutrition adequacy after EL in surgical ward.

METHODS

The data from 405 adult patients who had undergone emergency laparotomy in Oulu University Hospital (OUH) between years 2015 and 2017 were analyzed retrospectively. Nutrition delivery and complications during first 10 days after the operation were evaluated.

RESULTS

There was a total of 218 (53.8%) patients who were able to reach cumulative 80% nutrition adequacy during the first 10 postoperative days. Patients with adequate nutrition (> 80% of calculated calories) met the nutritional goals by the second postoperative day, whereas patients with low nutrition delivery (< 80% of calculated calories) increased their caloric intake during the first 5 postoperative days without reaching the 80% level. In multivariate analysis, postoperative ileus [4.31 (2.15-8.62), P < 0.001], loss of appetite [3.59 (2.18-5.93), P < 0.001] and higher individual energy demand [1.004 (1.003-1.006), P = 0.001] were associated with not reaching the 80% nutrition adequacy.

CONCLUSIONS

Inadequate nutrition delivery is common during the immediate postoperative period after EL. Oral nutrition is the most efficient way to commence nutrition in this patient group in surgical ward. Nutritional support should be closely monitored for those patients unable to eat.

TRIAL REGISTRATION NUMBER

Not applicable.

Causes of nutrition deficit during immediate postoperative period after free flap surgery for cancer of the head and neck

PURPOSE

The aim of the present of study was to examine nutrition deficit during the immediate postoperative in-hospital period following free flap surgery for cancer of the head and neck (HNC). Underfeeding and malnutrition are known to be associated with impaired short- and long-time recovery after major surgery.

METHODS

This single-center retrospective cohort study included 218 HNC patients who underwent free flap surgery in Oulu University Hospital, Finland between the years 2008 and 2018. Nutrition delivery methods, the adequacy of nutrition and complication rates were evaluated during the first 10 postoperative days.

RESULTS

A total of 131 (60.1%) patients reached nutritional adequacy of 60% of calculated individual demand during the follow-up period. According to multivariate analysis, nutrition inadequacy was associated with higher ideal body weight (OR 1.11 [1.04-1.20]), whereas adequate nutrition was associated with higher number of days with oral food intake (OR 0.79 [0.67-0.93]).

CONCLUSION

Inadequate nutrition is common after HNC free flap surgery. The present results suggest that more adequate nutrition delivery might be obtained by the early initiation of oral food intake and close monitoring of nutrition support.

Association between nutritional risk index and outcomes for head and neck cancer patients receiving concurrent chemo-radiotherapy

BACKGROUND

Patients receiving chemoradiotherapy for head and neck cancer (HNC) are often malnourished. We assessed the utility of nutritional risk index (NRI) in HNC patients undergoing chemoradiotherapy.

METHODS

A population-based retrospective review of HNC patients treated with curative chemoradiation was performed. Demographics, anthropometrics, overall survival (OS), and the composite treatment complication rate (G-tube dependence, radiation incompletion, 90-day mortality, and unplanned hospitalization) were collected.

RESULTS

Two hundred ninety-two patients were identified. Average pretreatment and posttreatment NRI were 110 (SD 3) and 99 (SD 12), respectively (P < .01). Pretreatment NRI risk category, age, ECOG status, and tumor subsites were associated with OS on multivariate analysis. Pretreatment NRI risk category was associated with risk of treatment related complications.

CONCLUSIONS

There was a significant decrease between pretreatment and posttreatment NRI in HNC patients receiving chemoradiation. Pretreatment NRI risk category may predict OS and composite treatment complications. Investigation of NRI as a prognostic factor is warranted.

Preoperative prognostic nutritional index as a method to predict postoperative complications after major head and neck surgery with free tissue transfer reconstruction

Background

Head and neck (H&N) cancer patients are often malnourished and have diminished immunity. H&N surgery with free tissue transfer reconstruction (HNS-FTTR) is associated with a relatively high incidence of postoperative complications.

Methods

Associations between possible risk factors and postoperative Clavien–Dindo (C–D) grades ≥ II and ≥ IIIa wound healing- or infection-related complications, postoperative overall complications and prolonged hospital stay were investigated in 188 patients who underwent HNS-FTTR during 2014–2018. The preoperative prognostic nutritional index (PNI) was calculated using the serum albumin level and total lymphocyte count.

Results

C–D ≥ II and ≥ IIIa complications were seen in 66 (35.1%) and 37 (19.7%) patients, respectively. Multivariate analysis showed that (i) previous irradiation was significantly associated with C–D ≥ II wound healing- or infection-related complications and prolonged hospital stays [odds ratio (OR) 3.096 and 3.328; P = 0.007 and 0.008, respectively]; and (ii) operation time of ≥9 h 20 min was a significant risk factor for C–D ≥ IIIa wound healing- or infection-related complications, and C–D ≥ IIIa overall complications (OR 2.987 and 2.257; P = 0.021 and 0.047, respectively). (3) Only preoperative PNI ≤ 40 was associated with all occurrences of C–D ≥ II and ≥ IIIa wound healing- or infection-related complications, C–D ≥ II and ≥ IIIa overall complications, and prolonged hospital stays (OR 3.078, 2.918, 2.627, 3.132 and 3.116; P = 0.020, 0.046, 0.036, 0.023 and 0.025, respectively).

Conclusions

PNI, easily calculated, was the lone risk factor significantly predicting all C–D ≥ II and ≥ IIIa postoperative wound healing- or infection-related complications, C–D ≥ II and ≥ IIIa postoperative overall complications and prolonged hospital stay after HNS-FTTR.