Early Post-operative Feeding: An Investigation of Early Functional Outcomes for Oral Cancer Patients Treated with Surgical Resection and Free Flap Reconstruction

Abstract

Traditionally patients can remain nil by mouth (NBM) for up to 12 days after oral tumour resection with free flap reconstruction to reduce the risk of flap dehiscence, poor healing and fistulae. The literature reports that patients could on average remain an inpatient for up to 20 days post-surgery. An evaluation of the impact of a defined early oral feeding protocol was undertaken investigating functional outcomes and complications rates. We prospectively reviewed tracheostomy use, length of hospital stay, non-oral feeding status and swallowing function using the Performance Status Scale for Head and Neck Cancer (PSS-HN) within a defined early feeding protocol. Twenty-nine patients underwent surgical resection with free flap reconstruction for advanced primary oral cancer between January 2018 and December 2019. Average age was 59.5 (range 24–88). Tumour sites included oral tongue (n = 10), maxilla (n = 6), mandible (n = 6), floor of mouth (n = 5) and buccal mucosa (n = 2). Median time to decannulation was 7 days (range 3–20 days, n = 11). The majority of patients were able to tolerate at least oral fluids on day 1 post-operatively (86%, n = 25). In addition to oral intake, non-oral feeding was required in 90% (n = 26), the majority of which included a nasogastric tube (NGT) placed intraoperatively 54% (n = 14), others required gastrostomy 46% (n = 12). Median time to nasogastric tube removal was 6 days (range 3–15 days). Median length of hospital stay was 10 days (range 3–51). Mean PSS-Normalcy of Diet (NOD) score at point of hospital discharge was 36.55 (95% CI 30.9–42.2). Flap failure was noted in 3% (n = 1). The adoption of an early oral feeding protocol suggests that there is the potential for a shorter hospital stay and earlier swallowing rehabilitation.

Early oral feeding and its impact on postoperative outcomes in head and neck cancer surgery: a meta-analysis

“…Brady et al [ 32 ] demonstrated that early oral feeding was associated with a significant reduction in the length of hospital stay, with a median length of 10 days in comparison to previous studies conducted at the same center where patients received delayed feeding and subsequently had a longer hospital stay, with a median length of 20 days. A recent study conducted by Le et al [ 25 ] produced similar findings; 415 patients were included, with 71 patients allocated to the early feeding group (< 5 days) and 344 patients allocated to the late feeding group (> 5 days).…”

The role of the speech and language therapist in the rehabilitation of speech, swallowing, voice and trismus in people diagnosed with head and neck cancer

“…Rehabilitation continues with surgical healing and introduction of appropriate exercises and compensatory strategies as agreed with surgical colleagues. Following surgery, the emergence of early post-operative feeding protocols 42 and the prevention of respiratory complications from aspiration are paramount with the use of compensatory swallow strategies and adherence to a strict oral care protocol. 43 Intensive SLT input in the weeks after surgery aims to optimise voice and swallow safety with biofeedback techniques using flexible nasendoscopy.…”

Early feeding after free flap reconstruction of the oral cavity: A systematic review and meta‐analysis

“…6 In order to prevent fistula formation, surgeons have traditionally waited 6-14 days prior to initiating oral feeding, as it has been conceptualized that overuse of the oral mechanism in the early post-operative phase places excessive stress on the interface between the flap and oral mucosa. 7,8 While common practice, there is surprisingly little evidence for this in the literature, with its origination commonly traced to a pair of trials produced in the 1970s that each displayed higher rates of pharyngocutaneous fistula formation for patients beginning oral intake within the first 3 weeks following total laryngectomy. 9 Evolving knowledge of oral wound healing has called this conceptualization into question, as it has been shown that only marginal increases in wound strength occur between post-operative day 1 and the end of the traditional "nothing by mouth" period at post-operative day 14.…”

“…Common recipient site complications include microvascular thrombosis, flap failure, hematoma formation, wound dehiscence, salivary leak, and development of orocutaneous fistula 6 . In order to prevent fistula formation, surgeons have traditionally waited 6–14 days prior to initiating oral feeding, as it has been conceptualized that overuse of the oral mechanism in the early post‐operative phase places excessive stress on the interface between the flap and oral mucosa 7,8 . While common practice, there is surprisingly little evidence for this in the literature, with its origination commonly traced to a pair of trials produced in the 1970s that each displayed higher rates of pharyngocutaneous fistula formation for patients beginning oral intake within the first 3 weeks following total laryngectomy 9 …”