Relation between nutritional state and postoperative complications in patients with oral and maxillofacial malignancy

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.

Early postoperative serum albumin levels as predictors of surgical outcomes in head and neck squamous cell carcinoma

BACKGROUND

Malnutrition is a common issue in patients with head and neck squamous cell carcinoma and has a negative effect on surgical outcomes.

OBJECTIVE

We attempted to determine which malnutrition diagnostic variables can be used as predictors of postoperative complications in patients with head and neck squamous cell carcinoma.

METHODS

Forty-one patients undergoing surgery for head and neck squamous cell carcinoma were submitted to a prospective evaluation. Biochemical data, anthropometric measurements and evaluation of body composition were used in the nutritional analysis.

RESULTS

Twenty-two patients (53.6%) developed complications. Serum albumin measured on the first postoperative day was the only variable that significantly differed between groups. A cut-off value of 2.8 g/dL distinguished between patients with a complicated and uncomplicated postoperative course. Normalization of albumin levels occurred more frequently and more rapidly in the noncomplicated group.

CONCLUSION

Serum albumin measured on the first postoperative day was the only variable that was a predicter of postoperative complications after major head and neck squamous cell carcinoma surgery.

Establishment of a new rehabilitation program using masticatory training food for jaw deformity patients

Background/purpose

Patients with jaw deformities may show a reduction in masticatory function as a result of postoperative hypofunction. This study aimed to establish a novel rehabilitation program using a commercially available masticatory training food for patients with jaw deformities after orthognathic surgery.

Materials and methods

Nine patients with mandibular prognathism (the training group: n = 5, and the non-training group: n = 4) and 6 control participants with normal occlusion were included in this study. For the rehabilitation program with masticatory exercise, patients were instructed to chew the training food once a day for 60 days starting from 10 days after the surgery. The effects of the rehabilitation program were assessed by determining the maximum bite force (MBF) and the masticatory performance (MP). Clinical assessments were performed just before orthognathic surgery (Pre) and at 10 days (T0), 1 month (T1), 2 months (T2), and 3 months (T3) after surgery.

Results

Compared with the non-training group, the training group showed a trend toward greater recovery amount of MBF from Pre to T3, and a significantly greater recovery amount in MP (p < 0.05) from Pre to T3. When the time-series change of MP was evaluated in both groups from T0 to T3, a significant difference was observed in the interaction terms (p = 0.03). This result indicates that the effectiveness of the training may be demonstrated by following the postoperative course further.

Conclusion

The rehabilitation using this training food may become a useful method for postoperative hypofunction in patients with jaw deformities.

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

OBJECTIVES/HYPOTHESIS

Despite consensus that preoperative nutritional assessment is of importance in the head and neck surgical oncology population, it remains unclear how exactly malnutrition is associated with perioperative morbidity especially among those undergoing microvascular surgery. We aimed to study this association to help inform preoperative risk stratification, guide the use of nutritional interventions, and ultimately help prevent malnutrition related morbidity.

STUDY DESIGN

Database analysis.

METHODS

Retrospective, linked analysis of the 2011 to 2016 National Surgical Quality Improvement Program. After identifying eligible patients and stratifying according to the Nutrition-Related Index, a univariate screen of preoperative demographic and clinical covariates was performed. Subsequently, propensity score matching was utilized to control for differences in baseline covariates. Perioperative complications and mortality were then analyzed using the propensity score-matched cohorts.

RESULTS

Among 977 identified patients, 276 (28.2%) were malnourished. Malnourished patients had higher rates of comorbidity, were more likely to actively smoke, and were more likely to have primaries in the oropharynx or hypopharynx/larynx. After propensity score matching to control for confounders, malnourished patients had higher rates of pulmonary complications (21.5% vs. 11.6%, P < .01), higher rates of bleeding or need for transfusion (56.6% vs. 43.0%, P < .01), higher rates of venous thromboembolism (3.7% vs. 0.8%, P = .03), and a higher 30-day mortality rates (3.7% vs. 0.0%, P < .01).

CONCLUSIONS

This nationwide analysis finds that 28.2% of patients undergoing surgery for head and neck cancers with free flap reconstruction are malnourished. Malnourishment was found to be independently associated with postoperative pulmonary complications, bleeding or need for transfusion, and 30-day mortality.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:375-380, 2020.

What is the role of nutrition counseling in the management of isolated mandible fractures?

OBJECTIVE

Providing perioperative nutrition counseling may improve operative outcomes. It is unclear, however, whether this benefit translates to oral and maxillofacial surgery patients. The purpose of this study was to measure the effect of nutrition counseling on operative outcomes and patient satisfaction in those undergoing surgery for mandible fractures.

STUDY DESIGN

The investigators implemented a retrospective cohort study. The predictor variable was perioperative nutrition counseling by a registered dietitian (RD). The main outcome variables were weight change, postoperative complications, and results of a survey that evaluated the perioperative experience.

RESULTS

Statistical analyses were conducted on a sample of 200 patients (mean age: 34 ± 14 years; 87% males). Overall, there was no difference in percent weight change between those who received nutrition counseling and those who did not (P = .46). Those who received nutrition counseling had fewer postoperative complications (3% vs 11%; adjusted P = .038). Patients who received nutrition counseling from an RD were more satisfied with the nutrition advice they received (P = .0375).

CONCLUSIONS

The results suggest that perioperative nutrition counseling by an RD in the management of isolated mandible fractures has no effect on weight change but is associated with decreased postoperative complications and increased patient satisfaction with the nutrition advice they receive.

Assessment of postoperative complications using E-PASS and APACHE II in patients undergoing oral and maxillofacial surgery

Background

The prediction of postoperative complications is important for oral and maxillofacial surgeons. We herein aimed to evaluate the efficacy of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) and Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II scoring systems to predict postoperative complications in patients undergoing oral and maxillofacial surgery.

Methods

Thirty patients (22 males, 8 females; mean age: 65.1 ± 12.9 years) who underwent major oral surgeries and stayed in the intensive care unit for postoperative management were enrolled in this study. Postoperative complications were discriminated according to the necessity of the therapeutic intervention by the Medical Department, i.e. according to the Clavien–Dingo classification. E-PASS and APACHE II scores as well as laboratory test values were compared between patients with/without postoperative complications.

Results

Postoperative complications were developed in seven patients. The comprehensive risk score (CRS: 1.13 ± 0.24) and APACHE II score (13.0 ± 2.58) were significantly higher in patients with postoperative complications than in those without ones (p < 0.01, p < 0.05, respectively). The CRS showed an appropriate discriminatory power for predicting postoperative complications (area under the curve: 0.814). Furthermore, a correlation was detected between APACHE II scores and postoperative data until C-reactive protein levels decreased to < 1.0 mg/L (r = 0.43, p < 0.05).

Conclusion

The E-PASS and APACHE II scoring systems were both shown to be useful to predict postoperative complications after oral and maxillofacial surgery.

Assessing the need for a protocol in monitoring weight loss and nutritional status in orthognathic surgery based on patients experiences

BACKGROUND

To investigate retrospectively the orthognathic surgery (OGS) patients experience in weight loss and the influence of gender, age, duration of the surgical procedure, length of hospital stay, location of surgery and use of intermaxillary fixation (IMF) or without IMF on postoperative weight loss.

MATERIAL AND METHODS

A total of 4487 patients treated by OGS where all patients visited the outpatient clinic one, three and six weeks after the surgical procedure. After six weeks, patients filled out a questionnaire in which weight loss was addressed. The patients were asked to give an estimate of their experiences weight loss. The population was first divided in two groups weight loss and no weight loss.

RESULTS

In the weight loss group there is no significant difference in weight loss between patients with IMF and patients without IMF. In the weight loss group there were significantly more females then males. Further, in the subgroup IMF the operation time was significantly longer compared with the subgroup without IMF. The other parameters including age and hospital stay were not different in the groups.

CONCLUSIONS

IMF in orthognathic treatment does not result in a difference self-reported loss of body weight compared to patients without IMF. Treatment protocols should include pre- and post-operative dietician consultations and possible indications for medical nutrition and vitamins. Key words:Assessing, protocol, weight loss, experiences, orthognathic surgery.

Evaluation of changes in anthropometric indexes due to intermaxillary fixation following facial fractures

Background. One of the treatment modalities for facial fractures is closed reduction technique, but treatment with intermaxillary fixation (IMF) interferes with normal nutrition, and malnutrition can affect the patient’s recovery. Anthropometric measurements such as skinfold thickness and body mass index (BMI) are universal indexes for diagnosing malnutrition. Therefore, in this study we explain how treatment with IMF changes the anthropometric indexes.

Methods. In this study 60 patients were treated with 4 weeks of IMF. Skinfold thickness and BMI of these patients were measured and compared before and after the treatment.

Results. Patients’ weight, BMI and skinfold thickness decreased during the IMF period, and this decrease was statistically significant (P < 0.01).

Conclusion. Although no severe and acute malnutrition was seen among our patients, IMF led to mild to moderate malnutrition in some cases, making it necessary to use nutritional supplements.

Capacitance of Membrane As a Prognostic Indicator of Survival in Head and Neck Cancer

BACKGROUND

Evaluation of prognostic value of capacitance of membrane (Cm), parameter measured by bioelectrical impedance (BIA) as an alternative to known clinical factors in patients with Head and Neck Cancer (HNC).

METHODS

A cohort of 75 stage IIIB and IV HNC patients treated in Department of Otolaryngology, Head and Neck Surgery, Medical University of Lublin, Poland were prospectively evaluated. Cm measurements were performed in all patients using a bioelectrical impedance analyzer that was set on a frequency of 50 kHz. Results of Cm measurements were presented in nF. Survival differences were estimated using Kaplan-Meier method.

RESULTS

Significantly higher Cm median was noted in well-nourished(n = 45) compared to malnourished (n = 30) patients (1.41 vs 1.01 respectively; p = 0.0009). Established in ROC curves analysis cut-off value (0.743) was characterized by 98% specificity and 37% sensitivity in the detection of malnutrition. Median overall survival (mOS) in the cohort was 32months. At the time of analysis deaths were recorded in 47 cases (62.7%). In patients who had Cm below the level of 0.743 risk of OS shortening was significantly higher than in other patients (12.1 and 43.4 months respectively; HR = 8.47, 95%CI: 2.91-24.66; χ2 = 15.38, p = 0.0001).

CONCLUSION

Cm is a strong, independent prognostic factor in head and neck cancer.

Predictive Factors for Preoperative Percutaneous Endoscopic Gastrostomy Placement: Novel Screening Tools for Head and Neck Reconstruction

OBJECTIVE

The treatment of head and neck cancer has varying impact on postoperative recovery and return of swallowing function. The authors aim to establish screening tools to assist in preoperatively determining the need for gastrostomy tube placement.

METHODS

The authors prospectively assessed all patients undergoing complex head and neck reconstructive surgery during a 1-year study period. Only patients tolerating an oral diet, without preoperative gastrostomies, were enrolled for study. Eight parameters were assessed including: body mass index (BMI), prealbumin, albumin, smoking history, comorbidities [including coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM)], age, use of microvascular reconstruction, and type of defect. Two specific screening tools were assessed. In the first, a multivariate logistic regression model was employed to determine factor(s) that predict postoperative gastrostomy tube. In a second screening tool, the 8 parameters were scored between 0 to 1 points. The total score obtained for each patient was correlated with postoperative gastrostomy placement.

RESULTS

Out of the 60 study patients enrolled in the study, 24 patients (40%) received a postoperative gastrostomy. In the logistic regression model, albumin level was the only factor that was significantly associated with need for postoperative gastrostomy (P < 0.0023). A score of 4 or greater was determined to have a sensitivity of 83% and specificity of 61% for postoperative gastrostomy.

CONCLUSIONS

Patients with a score of 4 or more with this screening scoring system or those patients with an albumin level <3.5 g/dL were at high risk for postoperative feeding tube placement.

Availability of Outpatient Clinical Nutrition Services for Patients With Cancer Undergoing Treatment at Comprehensive Cancer Centers

Comprehensive cancer centers rely on referral-based clinical nutrition services, which are not always a part of multidisciplinary care. An in-depth comparison of clinical nutrition services among other approaches to cancer care is needed.

Percutaneous endoscopic gastrostomy site metastasis from head and neck squamous cell carcinoma: case series and literature review

Objectives

To present our experience with head and neck squamous cell carcinoma (HNSCC) seeding of percutaneous endoscopic gastrostomy (PEG) sites and to review all reported cases to identify risk factors and develop strategies for complication avoidance.

Materials and methods

The records of 4 patients with PEG site metastasis from HNSCC were identified from the authors’ institution. Thirty-eight further cases were reviewed following a PubMed search and evaluation of references in pertinent articles.

Results

Review of 42 cases revealed the average time from PEG to diagnosis of metastatic disease to be 8 months. Average time to death from detection of PEG disease was 5.9 months. One-year survival following PEG metastasis was 35.5% with an overall mortality of 87.1%.

Conclusion

PEG site metastatic disease portends a poor prognosis. Early detection and aggressive therapy may provide a chance of cure. Changes in PEG technique or in timing of adjunctive therapies are possible avenues in further research to prevent this complication.

A specific approach for elderly patients with head and neck cancer

Approximately 10% of head and neck (HN) tumors occur in patients aged more than or equal to 80 years. In this population, the main challenge for physicians is to deal with the benefit/risk ratio of treatments and tumor-related symptoms. As elderly patients are generally excluded from clinical trials, there is a lack of evidence-based data with regard to the most appropriate multidisciplinary management. The prevalence of frailty and the pattern of comorbidities in this specific population are still unknown. The management of these tumors in a geriatric context is complex due to the high risk of toxicity of locoregional treatments. Thus, physicians often have to adapt to the treatment schedule to decrease potential adverse effects even with a risk of undertreatment. A retrospective series reported that the treatment delivered to elderly patients presenting with HN tumor complies with an institution's policy in less than 50% of cases, emphasizing the need to assess the outcome of personalized/adapted treatment in geriatric patients. The major issue is to determine which adaptation could be carried out, and then, what could be the respective individual benefit/risk ratio of each adaptation. In this review, we will focus on the locoregional management of elderly patients, and develop the issue of adapted local treatment. We will discuss the feasibility of adapted surgery and radiotherapy and provide current evidence-based data that may allow physicians involved in locoregional treatment of elderly patients with HN cancers to be acquainted with practical guidelines. Then, we will highlight the importance of nutritional support in this population in which the prevalence of malnutrition is high.

Comparison of the prevalence of malnutrition diagnosis in head and neck, gastrointestinal, and lung cancer patients by 3 classification methods

BACKGROUND

Malnutrition is prevalent among patients within certain cancer types. There is lack of universal standard of care for nutrition screening and a lack of agreement on an operational definition and on validity of malnutrition indicators.

OBJECTIVE

In a secondary data analysis, we investigated prevalence of malnutrition diagnosis with 3 classification methods using data from medical records of a National Cancer Institute-designated comprehensive cancer center.

METHODS

Records of 227 patients hospitalized during 1998 with head and neck, gastrointestinal, or lung cancer were reviewed for malnutrition based on 3 methods: (1) physician-diagnosed malnutrition-related International Classification of Diseases, Ninth Revision codes; (2) in-hospital nutritional assessment summaries conducted by registered dietitians; and (3) body mass indexes (BMIs). For patients with multiple admissions, only data from the first hospitalization were included.

RESULTS

Prevalence of malnutrition diagnosis ranged from 8.8% based on BMI to approximately 26% of all cases based on dietitian assessment. κ coefficients between any methods indicated a weak (κ = 0.23, BMI and dietitians; and κ = 0.28, dietitians and physicians)-to-fair strength of agreement (κ = 0.38, BMI and physicians).

CONCLUSIONS

Available methods to identify patients with malnutrition in a National Cancer Institute-designated comprehensive cancer center resulted in varied prevalence of malnutrition diagnosis. A universal standard of care for nutrition screening that uses validated tools is needed.

IMPLICATIONS FOR PRACTICE

The Joint Commission on the Accreditation of Healthcare Organizations requires nutritional screening of patients within 24 hours of admission. For this purpose, implementation of a validated tool that can be used by various healthcare practitioners, including nurses, needs to be considered.

Percutaneous endoscopic gastrostomy in head and neck cancer patients: indications, techniques, complications and results

The aim of this study was to review our experience in percutaneous endoscopic gastrostomy (PEG) performed in patients with cancer of the upper aerodigestive tract. Descriptive retrospective study of 142 patients (115 males, 27 females), mean age 62.4 years (25-84 years), with head and neck or esophageal cancer, who underwent PEG tube insertion between January 2006 and December 2008. The studied parameters were indications, success rate, rate and type of complications, and their management. Percutaneous endoscopic gastrostomy was inserted before chemoradiation therapy in 80% and during or after cancer treatment in 20% of the patients. PEG placement was possible in 137 patients (96%). Major complications were observed in 9 (7%) and minor complications in 22 (17%) of the 137 patients. Seven of the 9 patients with a major complication needed revision surgery. The mortality directly related to the procedure was 0.7%. Percutaneous endoscopic gastrostomy tube insertion has a high success rate. In patients with upper aerodigestive tract cancer, PEG should be the first choice for enteral nutrition when sufficient oral intake is not possible. Although apparently easy, the procedure may occasionally lead to severe complications. Therefore, a strict technique and knowledge of clinical signs of possible complications are mandatory.