Malnutrition and refeeding syndrome prevention in head and neck cancer patients: from theory to clinical application

Can the Malnutrition Universal Screening Tool (MUST) Predict Healing Complications Following Microvascular Reconstruction of the Head and Neck?

Study Design

Retrospective cohort study.

Objective

Malnutrition has been found to have negative effects on the immune system and inflammatory responses, impairing the wound healing process. Free flap failure is a serious complication in patients undergoing microvascular reconstruction, as it increases patient morbidity, length of stay in the hospital, patient, and hospital costs, as well as causes the need for further surgical interventions1. Malnutrition is estimated to be present in 35-50% of head and neck cancer patients with higher rates in those experiencing hypo-oropharyngeal disease. This is often caused by functional and pain limitations from due to disease burden causing odynophagia and dysphagia. The Malnutrition Universal Screening Tool (MUST) is recommended for risk screening and provides three scores for risk classification: high, intermediate, and low2. We argue that the use of MUST as a preoperative assessment tool is useful to predict postoperative surgical site infection and delayed wound healing in patients that will undergo reconstruction with free flaps for head and neck defects.

Methods

A retrospective cohort study was designed to include all subjects who underwent head and neck microvascular free tissue transfer at a single institution between 2013 and 2019. Primary and secondary reconstructions were included, for benign or malignant pathology, osteonecrosis, osteomyelitis, congenital defects, and trauma. The nutritional risk was evaluated using MUST, which analyzes body mass index, weight loss, and acute disease effect, to classify patients as low, intermediate, and high risk. We further divided the subjects into two comparison groups- low-intermediate and high risk. The primary outcome was surgical site complications and delayed wound healing. Data was analyzed as frequencies and means with standard deviations, as well as Fisher's exact test and t-test. P-values <0.05 were considered statistically significant. Analyses were done utilizing IBM SPSS Statistics Version 29.

Results

131 subjects were included for data analysis, with 54 being considered low MUST risk, 12 intermediate risk (66 low-intermediate), and 65 were high risk. The mean BMI overall was 25.5 ±5.3, and 27.2 in the low-intermediate group, and 23.7 in the high-risk group. Eighty-two subjects experienced <5-pound weight loss in the preceding 6 months to surgery, while 17 lost between 5-10 pounds, and 23 lost 10< pounds. Cancer/osteonecrosis was the etiology for 54 (82%) subjects of the low-intermediate group, and 61 (92%) of the high-risk group (P = .089). The subjects classified in High-risk group according to the MUST score had 11% more surgical site complications (P = .120) and 13.7% more delayed wound healing and dehiscence(P = .09); only 3 subjects in the study presented total flap loss and they were all in the High-risk group. Surgical site complication, delayed wound healing rates and partial or total flap loss were not increased by any specific medical comorbidity or history such as radiation or chemotherapy.

Conclusions

In conclusion, Subjects with high MUST score had increased complications and poor wound healing, and subjects with acute disease effect that induces a phase of nil per os for > 5 day have higher risk of total flap loss and surgical site complication.

Potentially Lethal But Rarely Considered. Risk of Developing Refeeding Syndrome in Primary Oral Squamous Cell Carcinoma

Presurgical preparation and postoperative care are cornerstones of all surgical procedures. Surgeons should be especially vigilant with malnourished cancer patients. Refeeding syn-drome (RFS) is a serious, potentially fatal complication of initiating appropriate nutrition in malnourished patients or after a period of starvation, although no standard precise definition has been proposed. The rarity of its une-quivocally life-threatening course means that its risk may be underestimated in clinical practice. The study's main goal was to assess the degree of malnutrition and the risk of RFS in the presurgical status of patients with oral cavity cancer and to identify risk factors for the occurrence of RFS. This single-center prospective observational study included patients diagnosed with oral squamous cell carcinoma. We investigated the relationship of RFS with age, BMI, features of the malignant tumor process selected internal medicine comorbidities, inflam-matory markers, renal and hepatic parameters, plasma levels of diverse electrolytes, and microelements were assessed. In the work, we utilized the National Institute for Health and Clinical Excellence (NICE) criteria. The study included 90 patients: 35 women and 55 men, aged 64.2±10.5. A robust statistical correlation at a significance level of p < 0.05 was demonstrated between advanced age, lower BMI, lymph node metastases, and a relatively low LDH as positive predictors of the onset of RFS and confirmed the high predictive value of the NRS-2002 scale. This paper seeks to call attention to RFS and identify critical issues that may be useful for its prevention.

Refeeding Syndrome Awareness among Physicians of King Abdullah Medical City in Makkah, Saudi Arabia

Background: Refeeding syndrome (RFS) is a lethal condition of metabolic disturbances that arise from the sudden switch of metabolism from a state of starvation to one of nourishment. Quick recognition would reduce health complications. Physicians who are unaware of the syndrome will not identify and treat it. As nutritional risk is associated with the risk of RFS, physicians should be aware of it. Aim: To determine whether the physicians of King Abdullah Medical City (KAMC) in Makkah know of RFS and, if so, have skills in diagnosis and managing the syndrome. Methods: One hundred and fifty-nine physicians of KAMC were recruited in a cross-sectional study. They were asked to complete a questionnaire by face-to-face interview. The questionnaire was designed to capture physicians’ knowledge and ability to manage RFS based on the awarding of certain scoring points. Results: The level of knowledge among physicians had a significant association between knowledge and age (p = 0.021) and medical specialty (p = 0.010). Additionally, the most knowledgeable physicians were those who work in critical care (21.4%). Around 18% of physicians were not able to manage RFS. Conclusions: Lacking knowledge of RFS and how to manage it leads to critical life-threatening complications. Physicians need nutritional education to help them diagnose RFS and consult dietitians to avoid its complications.

Is the risk of refeeding syndrome a problem in reaching nutritional requirements? A cohort of patients on enteral nutrition support

BACKGROUND

refeeding syndrome (RS) is a metabolic complication associated with nutritional support. The lack of management protocols for patients on nutritional support may lead to the development of RS or undernourishment.

OBJECTIVE

to evaluate adherence to the algorithm for total enteral nutritional support (ASNET), and the efficacy of reaching nutrient requirements in patients at risk of RS.

METHODS

a cohort study: screening and nutritional evaluation of patients and risk of RS were performed. Adults admitted to hospital for noncritical illness who received exclusively enteral nutrition (EN) were eligible. Patients with RS, intestinal failure or chronic diarrhea were excluded. Adherence to ASNET was evaluated along with the efficacy of nutritional support to reach the optimal protein and energy requirement (OPER) and any associated complications. Patient follow-up ended when the feeding route was changed or upon discharge.

RESULTS

a total of 73 patients were included (mean age, 62 ± 16 yrs; BMI, 18.5 ± 4.2 kg/m2), and 55 % were men. All had nutritional risk of developing RS (57, low; 15, high; 1, very high); 34 % had adequate adherence to ASNET, and 33 % managed to cover the total requirement between 4 and 6 days. OPER was reached by 38 % by the fourth day of EN, and adequate adherence to ASNET increased the probability of achieving it (RR, 2.2; 95 % CI, 1.6-3.2, p < 0.0001) without increasing the associated complications. Nonetheless, 36 % developed complications, of whom 96 % did not adhere to ASNET.

CONCLUSION

adherence to ASNET in patients at risk of RS allowed the achievement of OPER safely by day four with fewer associated complications.

Mapping Health-Related Quality of Life, Anxiety, and Depression in Patients with Head and Neck Cancer Diagnosed with Malnutrition Defined by GLIM

Patients with cancer deal with problems related to physical, psychological, social, and emotional functions. The aim was to investigate malnutrition defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria in relation to health-related quality of life, anxiety, and depression in patients with head and neck cancer. This was a prospective observational research study with 273 patients followed at the start of treatment, seven weeks, and one year. Data collection included nutritional status and support, and the questionnaires: European Organization for Research and Treatment of Cancer Head and neck cancer module (EORTC QLQ-H&N35) and the Hospital Anxiety and Depression Scale (HADS). Malnutrition was defined using the GLIM criteria. The study showed that patients with malnutrition had significantly greater deterioration in their health-related quality of life at seven weeks. On a group level, health-related quality of life was most severe at this time point and some scores still implied problems at one year. Significantly, more patients reported anxiety at the start of treatment whereas significantly more patients reported depression at seven weeks. Over the trajectory of care, the need for support often varies. Psychosocial support is imperative and at the end of treatment extra focus should be put on nutritional interventions and managing treatment-related symptoms to improve nutritional status and health-related quality of life. In the long-term, head and neck cancer survivors need help to find strategies to cope with the remaining sequel.

The Refeeding Syndrome: a neglected but potentially serious condition for inpatients. A narrative review

The Refeeding Syndrome (RFS) is a potentially serious, but still overlooked condition, occurring in individuals who are rapidly fed after a period of severe undernourishment. RFS derives from an abnormal electrolyte and fluid shifts leading to many organ dysfunctions. Symptoms generally appear within 2-5 days of re-feeding and may be absent/mild or severe and life threating, depending on the pre-existing degree of malnutrition and comorbidities. The lack of a standard definition and the nonspecificity of the symptoms make both incidence estimate and diagnosis difficult. In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) proposed a unifying definition for the RFS and its severity classification. The awareness of the condition is crucial for identifying patients at risk, preventing its occurrence, and improving the management. The objectives of this narrative review were to summarize the current knowledge and recommendations about the RFS and to provide useful tips to help physicians to recognize and prevent the syndrome.

Adherence to intensive nutrition care in head and neck cancer patients undergoing radiotherapy

PURPOSE

The aim of this study was to determine the prevalence and effect of adherence to intensive nutritional care on nutritional outcomes and survival in head and neck cancer patients undergoing radiotherapy.

METHODS

Three-hundred and seventeen head and neck cancer patients referred to intensive nutrition support during radiotherapy were retrospectively analyzed. Patients who missed less than 25% of their appointments with the dietitian were considered adherent. Primary outcome was percentage weight loss during treatment. Secondary outcomes were overall survival and patients' capacity to accomplish their caloric and protein recommendations. Logistic regression was used to examine predictors of weight loss and Kaplan-Meier to estimate survival.

RESULTS

Less than half of the patients (n = 145, 45.7%) were adherent. Statistically significant less weight loss in the adherent group (42.8% vs 55.8%; p = 0.02) was found, despite no difference in energy or protein intake. Logistic regression models after adjusting for other variables demonstrated that adherence resulted in 43% protection from significant weight loss (odds ratio 0.57, 95% CI 0.34-0.97). Overall survival was not different between groups.

CONCLUSION

Findings demonstrated that patients who were adherent to weekly contacts with the dietitian had less weight loss, but not better survival or nutritional intake. Additional investigation of factors that may act as barriers or enablers for adherence could help improve the outcomes in this population.

[Whole-course, individualized, and standardized sequential nutrition therapy for radical resection of tongue cancer: a case report]

Surgery, radiotherapy, and chemotherapy are the main treatments for tongue cancer, but the nutritional status of patients is not considered. Nutritional treatment is often not standard or by experience. This article reports a patient with tongue cancer who underwent preoperative chemotherapy and postoperative nutrition treatment. The entire process of individualized and sequential nutrition therapy was adopted, and the nutritional status of the patient was significantly improved. This paper describes the methods of nutrition therapy and evaluation and discusses the treatment process and key points in combination with relevant literature.

Refeeding syndrome in hematological cancer patients - current approach

Introduction: According to estimates based on the GLOBOCAN database of the International Agency for Research on Cancer, in 2018 alone, 18 100 000 cancers were globally diagnosed. Importantly, the majority of cancer patients experience unintended weight loss that leads to many adverse clinical consequences, including malnutrition and cancer cachexia. At the same time, each nutritional intervention must be carried out individually, as it can lead to critical complications, resulting in a threat to the health and life of the cachectic patient. An example of this type of risk is refeeding syndrome.Areas covered: Three factors seem to be crucial in this case: early identification of patients at risk of malnutrition, the introduction of an individualized diet regimen and constant monitoring of nutritional intervention. It seems equally important to spread awareness about the possibility of refeeding syndrome and knowledge about its patomechanisms and consequences among medical staff. This should lead to minimizing the risk of refeeding syndrome.Expert opinion: It should be noted that current guidelines on the pathogenesis, risk factors and methods of prevention and treatment of refeeding syndrome require further modifications, that would harmonize the management regimen in both prevention and therapy of refeeding syndrome.

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.