A prospective evaluation of short‐term dysphagia after transoral robotic surgery for squamous cell carcinoma of the oropharynx

Abstract

BACKGROUND Transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) has been associated with improved long-term dysphagia symptomatology as compared to chemoradiation. Dysphagia in the perioperative period has been inadequately characterized. The objective of this study is to characterize short-term swallowing outcomes after TORS for OPSCC. METHODS Patients undergoing TORS for OPSCC were prospectively enrolled. The Eating Assessment Tool 10 (EAT-10) was used as a measure of swallowing dysfunction (score > 2) and was administered on post-operative day (POD) 1, POD7, and POD30. Patient demographics, weight, pain level and clinical outcomes were recorded prospectively focused on time to oral diet, feeding tube placement and dysphagia-related readmissions. RESULTS 51 patients were included with pathologic T-stages of T1 (24), T2 (20), T3 (3), Tx (4). Self-reported preoperative dysphagia was unusual (13.7%). The mean EAT-10 score on POD1 was lower than on POD7 (21.5 vs. 26.6, p=0.005) but decreased by POD30 (26.1 to 12.2, p<0.001). 47/51 (92.1%) were discharged on an oral diet but 57.4% required compensatory strategies or modification of liquid consistency. 98.0% of patients were taking an oral diet by POD30. There were no dysphagia-related readmissions. CONCLUSIONS This prospective study shows that most patients who undergo TORS experience dysphagia for at least the first month post-operatively but nearly all can be started on an oral diet. The dysphagia-associated complication profile is acceptable after TORS with a minority of patients requiring temporary feeding tube placement. Aggressive evaluation and management of postoperative dysphagia in TORS patients may help prevent dysphagia-associated readmissions.

Analysis of readmissions after transoral robotic surgery for oropharyngeal squamous cell carcinoma

“…For example, prior studies have demonstrated how certain interventions (including incentive spirometry, chest physiotherapy, and oral care) can reduce postoperative pulmonary complications . In addition, a recent study demonstrated how the implementation of a standardized speech and language pathology‐driven postoperative swallowing assessment and intervention care pathway essentially eliminated 30‐day dysphagia‐related readmissions in TORS patients …”

“…In addition, dysphagia or dehydration accounted for 8.5% of readmissions, as is also consistent with past studies estimating that dysphagia-related readmissions account for 4.7% to 7.8% of readmissions after TORS. 20 In fact, prior studies have shown that virtually all (98%) patients undergoing TORS will eventually tolerate an oral diet, but the majority (57.4%) will experience dysphagia for the first postoperative month and will at least require compensatory strategies. 20 Dysphagia and dehydration were significant contributors to readmission in our cohort; 18.8% of patients readmitted required gastrostomies and 11.9% of individuals received nutrition via nasogastric tube.…”

“…Unfortunately, this study only captured readmissions to the index hospital where TORS was performed and therefore likely grossly underestimated the true incidence of readmission . In addition, there is a growing body of evidence that some patients undergoing TORS do not regain baseline function (swallowing, chewing), pain relief, and quality of life until some period beyond the 30th postoperative day, and this may contribute to ongoing readmissions . For that reason, we conducted this study to estimate the 30‐day all‐cause cumulative readmission rate in a nationwide sample accurately and to identify patient, provider, and systems‐level independent predictors of readmission in this population.…”

“…18 In addition, there is a growing body of evidence that some patients undergoing TORS do not regain baseline function (swallowing, chewing), pain relief, and quality of life until some period beyond the 30th postoperative day, and this may contribute to ongoing readmissions. 19,20 For that reason, we conducted this study to estimate the 30-day all-cause cumulative readmission rate in a nationwide sample accurately and to identify patient, provider, and systemslevel independent predictors of readmission in this population. A secondary analysis was conducted examining the 60-day all-cause cumulative readmission rate to see how readmissions rates changed after the initial postoperative period.…”

Dysphagia in oropharyngeal squamous cell carcinoma in perspective

“…The article by Albergotti et al in this issue of Cancer alludes to the “big picture” ramifications of treatment for HPV oropharyngeal squamous cell carcinoma (OPSCC) on swallowing in its introduction and then focuses on the more modest goal of cataloging and analyzing short‐term sequelae of transoral robotic surgery (TORS) in a prospective manner. The results are not surprising: some OPSCC patients have preoperative swallowing dysfunction; all TORS patients experience postoperative difficulty, which peaks in the immediate postoperative weeks and improves by 30 days; a few patients have longer‐term dysfunction of swallowing; and most patients can cope functionally during this immediate postoperative period without the need for feeding tubes.…”