Enteral and parenteral nutrition in patients with head and neck cancer

A case of a ‘lost’ nasogastric tube

Objectives:

To present the case of a ‘lost’ nasogastric tube and to highlight the importance of imaging and/or chest X-ray after nasogastric tube insertion, especially in unreliable patients.

Case report:

A 50-year-old man, undergoing radiotherapy treatment for squamous cell carcinoma of the tongue base, was admitted for pain control and nasogastric tube feeding. This patient required multiple nasogastric tubes over a two-week period. The patient repeatedly denied pulling the nasogastric tube out and we were unable to establish the exact mode of nasogastric tube removal. On one such occasion another tube was inserted and a check X-ray showed two feeding tubes; the latest one was lying in the left main bronchus and the old nasogastric tube was observed in the oesophagus, with its upper end jutting above the hypopharynx. It was apparent that the patient had somehow cut the tube and swallowed it.

Conclusion:

This case not only illustrates the importance of flexible nasendoscopy and/or chest X-ray for checking the position of the nasogastric tube, but also highlights that some patients are not tolerant of nasogastric tubes. The use of nasogastric tubes should be avoided in these patients to prevent any self-inflicted injury.

Critical evaluation of the role of nutritional support for radiation therapy patients

Nutritional intake or absorption may be compromised by radiation therapy (RT) when large portions of the gastrointestinal tract are treated. Dietary counseling, oral supplements, tube feedings and intravenous hyperalimentation (IVH) have been employed to limit weight loss and lessen intestinal RT side effects. Unfortunately, no prospective study reviewed has shown improved tumor control or patient survival. Special diets and IVH have also been employed in select patients to relieve chronic malabsorption from severe radiation enteritis.

Constant rate enteral nutrition in bucco-pharyngeal cancer care. A highly efficient nutritional support system

The incidence of protein and calorie malnutrition in bucco-pharyngeal cancer patients is high and therefore nutritional support is indicated. Two methods of tube feeding, fractioned enteral (FEN) versus constant rate enteral nutrition (CREN) have been compared in a prospective study. Based on anthropometrical, biological and immunological criteria, patients on CREN showed a significant improvement of their post-operative protein state in comparison with patients on FEN. This difference was due to a better tolerance to CREN, which allowed a more appropriate protein and calorie intake. Furthermore the time of intravenous infusion was reduced in patients on CREN. In conclusion, CREN is a highly efficient feeding method for patients with head and neck cancer. It has the great advantage of being simple and cheap.

Recent advances in surgery of the larynx and trachea

Recent advances in surgery of the larynx and trachea have occurred in the general areas of diagnosis, pretreatment nutritional therapy, surgical technique, and reconstruction. In diagnosis the routine use of the flexible fiberoptic laryngoscope in the office and the use of computerized tomography have been valuable. The addition of enteral and parenteral nutrition therapy in selected patients with laryngeal cancer has been an advance. In the area of surgical technique, section of the recurrent nerve for the treatment of abductor laryngeal spastic dysphonia has proved successful. In the area of reconstruction the use of the epiglottic flap for repair of the larynx after near-total laryngectomy for glottic cancer and the use of the pectoralis major myocutaneous flap for one-stage pharyngoesophageal reconstruction have been significant advances. An increase in the number of patients with chronic lung disease has created a new interest in tracheal fenestration.

[Postoperative parenteral nutrition of patients with an extensive carcinoma of the larynx (author's transl)]

A comparative clinical evaluation of healing operative wounds and classification of postoperative complications in two analogous groups of patients with an extensive carcinoma of the larynx after radical operations were performed. In group 1 (82 patients) the postoperative nutrition was carried out through the nasoesophageal tube. In group 2 (153 patients) the nutrition was carried out parenterally through a catheter inserted into the subclavian vein with solutions of glucose, fat emulsions, protein hydrolysates, and amino-acidic mixtures. In group 1 healing by the first intention was observed in 51% of patients, healing by the second one in 13%. Stable defects of the pharynx occurred in 26% of patients. Erosive hemorrhage arose in 5%. In group 2 the primary healing was achieved in 77% of patients, the secondary one in 11%. Stable pharyngeal defects appeared in 12% of patients. Erosive hemorrhage occurred only in 1.5% of patients. The duration of stationary treatment of patients by using the parenteral nutrition decreased by 16 days on the average.