A review of post-operative feeding in patients undergoing resection and reconstruction for oral malignancy and presentation of a pre-operative scoring system

Predictive equations in determining resting energy expenditure in patients with head and neck cancer receiving home enteral nutrition

OBJECTIVE

It is important to cover energy targets among patients with head and neck cancer (HNC) to minimize weight and skeletal muscles loss. This study aimed to assess the agreement between indirect calorimetry (IC) and predictive equations for determining resting energy expenditures (REE) in HNC patients receiving home enteral nutrition (HEN).

RESEARCH METHODS AND PROCEDURES

Patients included in the study had to be diagnosed with HNC, be adults, have artificial access to the digestive tract, and participate in HEN. All measurements were conducted in the morning after prior patient preparation. Body weight and height were measured using a scale with an integrated height meter. A phase-sensitive, single-frequency bioimpedance analyzer was utilized to conduct bioelectrical impedance analysis. REE was measured using IC with a canopy hood and calculated using 27 different equations. Differences between variables were analyzed using appropriate t-tests and their nonparametric counterparts. The Bland-Altman test was used to assess the types of differences between measured REE (mREE) and predicted REE (pREE).

RESULTS

The examined patients (n = 71, 73.2% male) had a mean age of 63.99 ± 11.42 years and a BMI of 22.84 ± 3.59 kg/m2. The most common diagnosis was malignant tongue cancer. Most patients had stage III cancer. Treatment included surgery combined with radiotherapy or only chemoradiotherapy in most cases. The median duration of treatment and HEN was 206 days and 97 days, respectively. Men had a significantly higher REE than women. The Owen, Fredrix, Ireton-Jones, Korth, Weijs-Kruizenga, and Marraw,h equations estimated REE without significant statistical differences from IC and showed the smallest percentage error between pREE and mREE. The Korth equation had the smallest average mean difference between pREE and mREE, reducing the REE value average by 7 ± 274 kcal/day. The highest percentage of individual accurate predictions for pREE was obtained with the Fredrix (48%), Weijs-Kruizenga (48%), Korth (45%), and MarraPhA (45%) equations.

CONCLUSION(S)

The predictive equations examined in this study cannot replace IC for determining REE in HNC patients at the individual level. When equations are used, special attention should be given to planning HEN to account for possible discrepancies between pREE and mREE.

Developing symptom-specific dietary leaflets to address radiotherapy side effects using an eDelphi method

INTRODUCTION

Patients suffering from head and neck (HN) cancer undergoing Radiotherapy (RT) suffer from various debilitating side effects that greatly hinder their eating ability. This leads to patients having a poor nutritional status causing weight loss. This study aimed to assess if an e-Delphi method variation allowed efficiently developing dietary advice leaflets addressing these side effects and achieving a consensus among healthcare professionals.

METHODS

An e-Delphi style approach was used. Six participants representing the professions working with HN patients were asked to give feedback on four symptom-specific dietary leaflets. These leaflets were designed based on a previous extensive literature review. After each round, the participants' suggested changes were applied. Before applying major changes to the leaflet, the participants were asked to vote if they agreed with each major change.

RESULTS

Overall consensus was reached after three rounds since all participants voted "highly likely" to use it in their clinical practice. Most suggestions by the participants agreed with the existing literature. The only change (accepted as a result of voting) that contradicted the literature was concerning sugar intake.

CONCLUSION

The participants reached consensus and developed leaflets that were based on literature recommendations for use for patients that, in their opinion, were acceptable for clinical use. This e-Delphi variation proved to be efficient to achieve consensus among healthcare professionals regarding patient information tools.

IMPLICATIONS FOR PRACTICE

This eDelphi method is an efficient and effective way to revise and achieve consensus regarding the development of patient information material.

Nutritional Management of Patients with Head and Neck Cancer-A Comprehensive Review

While surgical therapy for head and neck cancer (HNC) is showing improvement with the advancement of reconstruction techniques, the focus in these patients should also be shifting to supportive pre and aftercare. Due to the highly sensitive and anatomically complex region, these patients tend to exhibit malnutrition, which has a substantial impact on their recovery and quality of life. The complications and symptoms of both the disease and the therapy usually make these patients unable to orally intake food, hence, a strategy should be prepared for their nutritional management. Even though there are several possible nutritional modalities that can be administrated, these patients commonly have a functional gastrointestinal tract, and enteral nutrition is indicated over the parenteral option. However, after extensive research of the available literature, it seems that there is a limited number of studies that focus on this important issue. Furthermore, there are no recommendations or guidelines regarding the nutritional management of HNC patients, pre- or post-operatively. Henceforth, this narrative review summarizes the nutritional challenges and management modalities in this particular group of patients. Nonetheless, this issue should be addressed in future studies and an algorithm should be established for better nutritional care of these patients.

Clinical practice guidelines on nutrition management in head and neck cancer: a systematic quality appraisal using the Appraisal of Guidelines for Research and Evaluation 2nd edition instrument

OBJECTIVE

Several guidelines have been produced for the management of nutrition in patients with head and neck cancer. However, no systematic evaluation of the quality of these guidelines has been performed to date.

METHOD

A comprehensive search was conducted up to August 2020. The quality of guidelines was assessed by four independent reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition.

RESULTS

Nine guidelines were assessed for critical evaluation. Only two guidelines were classified as 'high quality'. The 'scope and purpose' domain achieved the highest mean score (75.5 ± 17.0 per cent), and the lowest domain mean score was 'applicability' (37.6 ± 23.0 per cent).

CONCLUSION

These findings highlight the variability in the methodological quality of guidelines for the management of nutrition in head and neck cancer. These results may help to improve the reporting of future guidelines and guide the selection for use in clinical practice.

Timing of Oral Feeding in Patients Who have Undergone Free Flap Reconstruction for Oral Cancer

OBJECTIVE

Determine the safety and effectiveness of a nasogastric tube removal plan designed to shorten nasogastric tube indwelling time after oral cancer surgery plus free flap reconstruction.

MATERIALS AND METHODS

A parallel randomized clinical trial was conducted from May 2021 to December 2021 at Peking University School of Stomatology. Volunteers (n = 128) were separated into four groups: non-tracheostomy control and intervention groups and tracheostomy control and intervention groups. Control patients received the conventional nasogastric tube removal plan. Non-tracheotomy intervention patients were asked to swallow 5 ml of water on the first postoperative day. If there was no coughing, they were allowed progressively increasing amounts of water for the following 2 days. The nasogastric tube was removed only after ensuring level I/II performance on the Watian water swallowing test, no "wet voice" after drinking water, no marked decrease in blood oxygen saturation after drinking, and satisfactory daily oral nutritional intake. Tracheotomy intervention patients received the same protocol plus an additional Watian water swallowing test after tracheal tube removal.

RESULTS

Nasogastric tube removal time was earlier in the intervention subgroups than in control subgroups: 5.0 ± 2.3 days versus 7.8 ± 3.9 days (p = 0.001) in non-tracheostomy patients and 9.8 ± 1.1 days versus 16.2 ± 13.0 days (p = 0.049) in tracheostomy patients. Incidence of wound complications and daily food intake were comparable between the groups. The incidence of pneumonia was lower in the tracheostomy intervention group than in the tracheostomy control group (12.5% vs. 3.1%, p = 0.162). Pharyngeal pain score was lower in tracheotomy intervention patients than in tracheotomy control patients (p = 0.029). Postoperative hospital stay was shorter in tracheotomy intervention patients than in tracheotomy control patients (p = 0.005).

CONCLUSIONS

On the basis of ensuring safety and effectiveness, patients undergone free flap reconstruction for oral cancer could be offered oral intake early after surgery, which will not increase the incidence of wound complications and pneumonia or adversely affecting the oral intake of the patients; it can also help minimize pharyngeal pain and shorten postoperative hospital stay of patients with a tracheotomy.

LEVEL OF EVIDENCE

II Laryngoscope, 2022.

Skeletal Muscle Depletion and Major Postoperative Complications in Locally-Advanced Head and Neck Cancer: A Comparison between Ultrasound of Rectus Femoris Muscle and Neck Cross-Sectional Imaging

Simple Summary

Skeletal muscle mass (SMM) depletion is gaining popularity as independent predictor of postoperative complications in many surgical scenarios, even in the field of head and neck oncology. In this study, we demonstrate the value of ultrasound scans of the rectus femoris muscle together with the neck CT/MRI at C3 level in terms of estimation of SMM (through muscle cross sectional area), the identification of sarcopenic patients and as a predictor of major surgical morbidity in a cohort of locally-advanced head and neck cancer patients submitted to surgical treatment. This provides important tools for the on-going re-assessment of patients with regards to any pre-habilitation strategy aimed at reducing postoperative complications.

Abstract

Skeletal muscle mass (SMM) depletion has been validated in many surgical fields as independent predictor of complications through cross-sectional imaging. We evaluated SMM depletion in a stage III-IV head and neck cancer cohort, comparing the accuracy of CT/MRI at C3 level with ultrasound (US) of rectus femoris muscle (RF) in terms of prediction of major complications. Patients submitted to surgery were recruited from 2016 to 2021. SMM was estimated on CT/MRI by calculating the sum of the cross-sectional area (CSA) of the sternocleidomastoid and paravertebral muscles at C3 level and its height-indexed value (cervical skeletal muscle index, CSMI) and on US by computing the CSA of RF. Specific thresholds were defined for both US and CT/MRI according to ROC curve in terms of best prediction of 30-day major complications to detect sarcopenic subjects (40–53%). Sixty-five patients completed the study. At univariate analysis, major complications were associated to lower RF CSA, lower CSA at C3 level and lower CSMI, together with previous radiotherapy, higher ASA score and higher modified frailty index (mFI). At multivariate analysis RF CSA (OR 7.07, p = 0.004), CSA at C3 level (OR 6.74, p = 0.005) and CSMI (OR 4.02, p = 0.025) were confirmed as independent predictors in three different models including radiotherapy, ASA score and mFI. This analysis proved the value of SMM depletion as predictor of major complications in a head and neck cancer cohort, either defined on cross-sectional imaging at C3 or on US of RF.

Preoperative Serum Albumin Predicts Wound Dehiscence but Not Infection After Surgery for Oral Squamous Cell Carcinoma

PURPOSE

Inadequate nutrition is common in individuals diagnosed with cancer. The present study evaluated the association between preoperative albumin and postoperative complications in otherwise healthy patients presenting with newly diagnosed squamous cell carcinoma of the oral cavity primarily managed with ablative surgery.

PATIENTS AND METHODS

A retrospective cohort study of patients with newly diagnosed oral squamous cell carcinoma from 2005 to 2019 was performed. Patients referred to and managed by a single surgeon (ERC) and who had not received any nutritional support in the preoperative period were included in the study. The primary predictor variable was preoperative albumin level. Other studied variables were patient demographic data and TNM stage. Complications related to primary ablative surgery represented the primary outcome variable. χ² analysis was completed to assess for significant associations between independent albumin groups (4+, 3.5 to 3.9, and 3.0 to 3.4 g/dL) in relation to postoperative complications. Multivariate logistic regression analysis was completed to control for clinical variables and medical comorbidities when testing the association between albumin and dehiscence.

RESULTS

The patient cohort included 268 individuals; of whom, 154 were men. The average age of the patients at surgery was 63 years. When controlling for all other variables, albumin was the only statistically significant predictor of postoperative dehiscence, P = .005. Patients with albumin of 3.5 to 3.9 g/dL had 3.24 times higher odds of dehiscence (95% confidence interval 1.42 to 7.38) in comparison with participants in the 4+ g/dL group. There was no difference of odds between the 3.0 to 3.4 group and the 4+ reference group.

CONCLUSIONS

Our study demonstrated that among those individuals meeting the inclusion criteria, there is a statistically significant association between lower albumin levels and postoperative complication rates, specifically dehiscence.

Low skeletal muscle mass as predictor of postoperative complications and decreased overall survival in locally advanced head and neck squamous cell carcinoma: the role of ultrasound of rectus femoris muscle

PURPOSE

Skeletal muscle mass (SMM) depletion and sarcopenia as predictors of postoperative complications and poorer overall survival (OS) have been validated in many surgical fields through cross-sectional imaging (CT, MRI), with potential limitations. We evaluated it in a stage III-IV head and neck squamous cell carcinoma (HNSCC) surgical cohort through ultrasound (US) of rectus femoris muscle (RF), a quick, cheap, repeatable alternative.

METHODS

Patients submitted to surgical treatment with curative purpose were recruited and prospectively evaluated through clinical, biometric, biochemical, surgical, pathological and functional prognosticators and with preoperative US of RF with regards to 30-day complications and OS.

RESULTS

Forty-seven patients completed the study. RF cross-sectional area (RF-CSA) was used to identify patients with low SMM (CSA ≤ 0.97 cm²: 18/47, 38.3%). RF-CSA was lower in complicated cases (0.95 ± 0.48 vs 1.41 ± 0.49 cm²; p = 0.003), remaining the only independent predictor of postoperative complications at multivariate analysis, with a model including ASA score and modified Frailty index (OR 9.84; p = 0.004). SMM depletion significantly impaired OS (13.6 ± 2.9 vs 26.3 ± 2.1 months; p = 0.017), being its only independent prognosticator at multivariate Cox regression analysis (OR 4.42; p = 0.033).

CONCLUSION

RF-CSA, evaluated with US, seems a reliable method for identification of patients with low SMM in a stage III-IV HNSCC cohort, defining a subset at high-risk of 30-day complications and poorer OS.

Readability of Patient-Reported Outcome Measures for Head and Neck Oncology

OBJECTIVES/HYPOTHESIS

Patient-reported outcome measures (PROMs) are communication tools to help patients convey their disease experience to medical providers and guide management decisions. However, the utility of healthcare outcome measures is dependent on patient literacy and readability of PROMs. If written for a more advanced literacy level, they can misestimate symptoms and add significant barriers to care, especially in the underserved. However, readability of head and neck (H&N) oncology PROMs has not been assessed. The aim of this study was to evaluate the readability of H&N oncology PROMs to assess whether they meet recommended readability levels.

STUDY DESIGN

Bibliometric review.

METHODS

Three readability measures: Gunning Fog, Simple Measure of Gobbledygook, and FORCAST were used to evaluate the readability level of commonly used H&N PROMs. PROMs with sixth grade readability level or lower were considered to meet the recommendations of health literacy experts.

RESULTS

Eight H&N oncology PROMs were reviewed. None of H&N PROMs met health literacy experts' and National Institutes of Health recommended reading levels. Gunning Fog consistently estimated easiest readability and FORCAST the most difficult.

CONCLUSIONS

PROMs are important clinical tools that drive patient-centric care in H&N oncology. All H&N PROMs are written above recommended reading levels and do not meet suggested standards. Future PROMs should be written with easier readability to accurately convey patients' H&N oncology disease experiences.

LEVEL OF EVIDENCE

4 Laryngoscope, 2020.

Factors pertaining to long-term mortality following emergency visits for head and neck cancer

Background/purpose

Avoiding mortality has been the ultimate goal in the management of head and neck cancer (HNC) patients with emergency department (ED) visits, however, risk factors and causes of mortality are not well studied. The objective of the present study is to verify the factors associated with long-term mortality of patients with HNC who visited ED.

Materials and methods

We retrospectively collected data of 1660 HNC patients who made ED visits from the Longitudinal Health Insurance Database 2000 during 2000–2012 in Taiwan. The multivariate Cox proportional hazard model was used to measure the mortality-associated risk factors in HNC patients who made ED visits.

Results

The prognostic factors associated with mortality risk were age (≥65 vs. < 65 y; HR = 1.58, p < 0.0001), geographic region (central vs. northern; HR = 1.20, p = 0.0384; southern vs. northern; HR = 1.38, p = 0.0001), surgery (yes vs. no; HR = 0.61, p < 0.0001), radiotherapy (yes vs. no; HR = 1.80, p < 0.0001), chemotherapy (yes vs. no; HR = 1.68, p < 0.0001), acute myocardial infarction (yes vs. no; HR = 2.01, p = 0.0303), diabetes mellitus (yes vs. no; HR = 1.60, p < 0.0001), chronic obstructive pulmonary (yes vs. no; HR = 1.51, p = 0.0002), number of ED visits (≥4 vs. 1; HR = 0.69, p = 0.0003), and number of admissions (1 vs. 0; HR = 1.54, p < 0.0001; ≥2 vs. 0; HR = 1.48, p = 0.0002).

Conclusion

Higher mortality was associated with older age, living in southern Taiwan, not having undergone surgery, having received radiotherapy and chemotherapy, comorbidities, and more hospital admissions. A coordinated and extended multidisciplinary approach including ED care is required to improve the long-term survival and further decrease the economic burden of HNC treatment.