Timing of postoperative oral feeding after head and neck mucosal free flap reconstruction

Abstract

Objective: Fistula remains a common complication of upper aerodigestive tract reconstruction. Optimal timing of oral feeding is unknown and the impact of early feeding on swallow function and fistula rates remains controversial. The purpose of this study is to better understand the effects of "early feeding" on fistula rate and swallow in patients with free flap reconstruction of upper aerodigestive tract defects.Methods: Retrospective cohort study. One hundred and four patients undergoing free flap reconstruction of mucosalized head and neck defects. Two groups, early feeding (oral intake on or before postoperative day 5) and late-feeding (oral intake after postoperative day 5). Primary outcome was incidence of salivary fistula.Secondary outcomes included Functional Oral Intake Scale scores.Results: Fistula rate was 16.5% in late-feeding group and 0% in early-feeding group (P = .035). Patients who were fed early had an association with progression to a full oral diet by 30 days (P = .027).Discussion: This cohort analysis suggests that in properly selected patients with free flap reconstruction for mucosal defects, early feeding may not increase risk of salivary fistula and may improve swallow functional outcomes earlier.

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

“…Two studies had an equal number of patients enrolled in each group, 8,19 one had more patients in the early feeding group, 21 and two had more patients enrolled in the late feeding group. 20,22 The average age was not statistically different between the two groups in any of the four studies for which it was analyzed, with overall mean ages by study ranging from 48.3 to 62.9 years old. 8,19 Two of the retrospective cohort studies agreed on a definition of "early feeding" as on or before postoperative day 5, 20,21 while the third defined it as strictly before the fifth post-operative day.…”

“…19 This review only extracted data from patients in the oral cavity defect group of Stramiello et al in order to maintain consistency between studies. 20 Heterogeneity was estimated using chi-square test, with the I 2 statistic providing an indication of statistical heterogeneity between studies. Homogeneity was considered to exist in cases where I 2 < 50% and p ≥ 0.1, in which case a fixed-effect model was used.…”

“…8,20,22 Notably, in Stramiello et al, 21/24 (87.5%) patients in the early feeding group and 65/80 (81.3%) in the late feeding group had an indication of cancer for their surgery, but the specific pathology of those undergoing oral cavity reconstruction was not provided. 20…”

“…All studies took place within the past 2 years except for Guidera et al, which was published in 2013. 21 Three of these investigations were retrospective cohort studies, [20][21][22] one was a prospective cohort with 200 patients collected sequentially for each arm, 8 and one was a randomized controlled trial. 19 Total subject enrollments ranged from 54 to 415, 21,22 for a total of 1085 patients who underwent free flap reconstruction for oral cavity defects included in the meta-analysis.…”

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

“…Kerwala et al found that early oral feeding on POD1 after free flap is not associated with increased dehiscence or fistula formation, however is associated with a decrease in LOS by more than 7 days 241 . Stramiello et al found that early oral feeding (on or before POD5) in properly selected patients did not increase the risk of salivary fistula after free flap, and may expedite swallowing function recovery 242 . The ERAS program described by Coyle et al advocates for tube feeds within 12 h after surgery 187 …”