Removal Of Feeding Tube Research Articles

Energy and protein nutrition adequacy in general wards among intensive care unit survivors: A systematic review and meta-analysis.

Adequate energy and protein provision is mandatory to optimize survival chances in critical illness, prevent loss of muscle mass, and reduce length of stay. Data are available concerning feeding adequacy in intensive care unit (ICU) participants, but little is known about the adequacy in post-ICU participants. This systematic review aimed to evaluate feeding adequacy in post-ICU participants and addressed causes of feeding interruption leading to suboptimal adequacy. For this systematic review, a bibliographic search was performed in PubMed, Scopus, and Web of Science. Randomized controlled studies, non-randomized controlled studies, and observational studies conducted between January 1990 and November 2023 fulfilling the inclusion criteria were withheld. Eight studies were included. Outcomes reported were energy and protein adequacy, barriers, and feeding routes. Energy and protein requirements were determined in various ways, including indirect calorimetry and standardized and weight-based formulas. Energy adequacy ranged from 52% to 102% and protein adequacy between 63% and 86%. Participants were mainly fed with enteral nutrition (EN) or a combination of oral nutrition and EN. The main barrier reported for inadequate nutrition intake was feeding tube removal. Next to different ways in calculating targets and reporting results, a wide range in energy and protein adequacy was observed, but with constant protein underfeeding. Participants fed with EN or a combination of EN and oral nutrition had the best adequacy; inappropriate tube removal is a common barrier leading to inadequate therapy. Standardized reporting and larger studies are needed to guide nutrition care for post-ICU participants.

Structured Tube Weaning Using the Hunger Provocation Method in Infants with Single Ventricle Heart Defects: A Multicenter Study.

Despite improvement in hemodynamics, children with single ventricle heart disease remain on feeding tubes long after stage 2 palliation (S2P). Use of a hunger provocation method in a multidisciplinary team setting has been successful at weaning these children from feeding tubes. The objective of this study is to describe patient characteristics and outcomes in the single ventricle population who underwent a formal tube weaning process using a standardized hunger provocation method. Single ventricle patients after S2P from six centers were included. Patient data collected included baseline demographics, swallow evaluation results, and feeding characteristics such as percent oral intake at the start of tube wean. Tube wean data included tube weaning process and duration, interruptions to the tube wean, adverse events, and weights before, during, and after the tube wean. 94% (60 of 64) of patients achieved oral independence. The median time to tube wean was 12.5days. 62% of patients had transient weight loss during the tube wean. 61% of the cohort was taking less than 10% goal volumes by mouth with 90% of those patients successfully tube weaned. All patients with history of aspiration were successfully tube weaned. 75% of successfully weaned patients were above baseline weight at 1-month post-tube wean. The most common cause of tube wean interruption was contraction of a viral illness. Use of a standardized tube weaning process via hunger provocation method is both feasible and safe in the single ventricle population, resulting in successful feeding tube removal in a timely manner with minimal adverse effects.

Dysphagia in COVID-19 Patients on Extracorporeal Membrane Oxygenation.

Patients on extracorporeal membrane oxygenation (ECMO) are infrequently nourished via oral feeding due to aspiration risks. Patients with COVID-19 and on ECMO represent a subpopulation that has additional factors that may affect their swallow function. This study aimed to describe the swallow function and ability to maintain oral feeding in patients with COVID-19 while on ECMO. A retrospective study of patients with COVID-19 who started veno-venous ECMO at the beginning of the COVID-19 pandemic (March 2020 and August 2020) was conducted at a tertiary care hospital. Clinical swallow evaluations and videofluoroscopic swallow studies (VFSS) were analyzed using standardized measurement scales. Pearson's correlation coefficient (r) identified relationships between ECMO and swallowing function at different time points. 19 patients were included; all underwent clinical swallow evaluation and 4 underwent VFSS while on ECMO. Mean age was 43.2 years (standard deviation: 9.2), mean duration of ECMO was 65.7 days (58.7), and mean duration of intubation was 14.4 days (8.6). All patients were able to undergo swallow function evaluation, regain swallow function, and resume oral feeding while cannulated. Duration of ECMO and time to feeding tube removal was positively correlated (r = 0.747, p < 0.001) with patients demonstrating less functional swallowing independence and requiring a more modified diet upon oral diet initiation. Clinical swallow evaluation and videofluoroscopic swallowing evaluation are possible for COVID-19 patients actively on ECMO. Patient swallow function can improve, and oral diet can be achieved while on ECMO, demonstrating benefit of SLP surveillance and swallowing assessment prior to ECMO decannulation.

Utility of video fluoroscopic swallow study in advancing oral diet post TORS for oropharyngeal malignancies

ObjectiveTORS is a minimally invasive surgical alternative to chemoradiotherapy for oropharyngeal malignancies. While early postoperative oropharyngeal dysphagia is linked to TORS, this study explores both subjective and objective swallowing outcomes. Study designRetrospective and prospective review of the patients who underwent TORS for oropharyngeal malignancy from 2018 to 2023. SettingSingle tertiary referral center. MethodsPostoperative transnasal feeding tubes were administered to 142 patients undergoing TORS. Data on oncological, clinical, surgical, and pathological parameters, including VFSS records, pain with swallow, and feeding tube removal timing, were collected. Clinical swallow exam (CSE) was conducted on POD-1, with a formal swallow study pursued if inconclusive. Once a safe swallow was confirmed, oral diets were initiated, and the feeding tube removed, with most patients discharged on POD-2. ResultsAt an average age of 59.3 years on the day of operation, the palatine tonsil (N = 101) was the predominant subsite. A dobhoff feeding tube was intraoperatively placed in 98 % of patients (N = 139). On POD-1, CSE was conducted in 119 patients, with 26 % (37/119) cleared for total oral diet (NOMS ≥ 4). Additionally, 30 out of 73 VFSS patients were cleared for total oral diet. A total of 54.9 % (78/142) had the feeding tube removed before discharge on POD-2, with a mean time of 6.5 ± 6.6 days. Overall, 71.1 % (101/142) achieved a total oral diet within one week after TORS. ConclusionEarly post-TORS swallowing is vital for oropharyngeal malignancies. VFSS assesses post-operative swallowing safety, allowing most patients to resume total oral nutrition shortly after TORS.

Enteral nutrition on discharge from intensive care and 30-day unplanned readmission: An exploratory, retrospective study of association

Individuals who survive critical illness are often malnourished with inadequate oral nutrient intake after leaving the intensive care unit (ICU). Enteral nutrition (EN) improves nutrient intake but there is limited evidence on the impact of maintaining EN after discharge from the ICU. The objective of this exploratory study was to understand the association between EN maintenance after ICU and 30-day unplanned hospital re-admission, to inform on future prospective research into the effects of post-ICU nutrition. This was a single-centre, retrospective study of ICU patients, requiring ventilation, who received EN for at least 3 days in ICU and were discharged to the ward. 102 patients met the inclusion criteria; 45 (44.1%) maintained EN and 57 (55.9%) discontinued EN after ICU discharge; there were no significant differences in demographics or clinical measures at ICU admission. Reason for EN discontinuation was documented in 38 (66.7%) patients, with 27 (71%) discontinuing EN due to a routine ward practice of feeding tube removal. Unplanned 30-day hospital re-admission occurred in 17 (16.7%) patients overall, 5 (11.1%) in the EN group and 12 (21.1%) in the non-EN group (crude odds ratio [OR] 0.47, 95% CI 0.15, 1.45, p=0.188). After adjusting for age, sex, BMI and length of stay, there was a persistent trend to lower re-admission rates in the EN group (OR 0.37, 95% CI 0.09, 1.57, p=0.176). EN maintenance after ICU discharge was associated with a trend to lower 30-day unplanned hospital re-admission rates. The clinically relevant reduction of about 50% in unplanned re-admission rates in this exploratory study warrants larger, prospective studies of post-ICU nutrition strategies based on clear discontinuation criteria to optimize nutrition and evaluate patient-centred outcomes.

Caregiver-reported use of physical restraints among community-dwelling older adults with severe dementia in Singapore.

Older adults with severe dementia are at increased risk of being physically restrained in nursing homes and acute care settings, but little is known about restraint use among those cared for at home. This study explores caregiver-reported use of restraints among community-dwelling older adults with severe dementia. Using cross-sectional data from 215 family caregivers, we describe restraint use among older adults with severe dementia living at home. We then use multivariable logistic regression to identify factors associated with restraint use. Nearly half (47%) of caregivers reported on older adults who had been subject to restraints. Most caregivers reporting restraint use suggested safety reasons, such as prevention of falls (68%), wandering (30%), and removal of catheters or feeding tubes (29%); and 44% indicated doctors or other health care providers were involved in the decision to restrain. Feeding tubes (OR = 4.16, 95% CI: 1.27-13.59) and physically aggressive agitation behaviors (OR = 1.93, 95% CI: 1.09-3.40) were associated with higher odds of restraint use among older adults with severe dementia. Caregivers who received strong emotional support from friends (OR = 0.45, 95% CI: 0.21-0.95) were less likely to report restraint use while serving as a caregiver to others (OR = 2.77, 95% CI: 1.36-5.63) increased the odds of restraint use. The pervasiveness of restraint use is concerning and suggests a lack of evidence-based guidance and support for both caregivers and healthcare providers to prevent restraint use among older adults with severe dementia cared for at home.

Chemoradiotherapy with concurrent durvalumab for the palliative treatment of oligometastatic esophageal and gastroesophageal carcinoma with dysphagia: A single arm phase 2 clinical trial, PALEO.

TPS4172 Background: Many patients diagnosed with esophageal cancer have dysphagia from their primary tumor and de novo metastatic disease. While multiple therapies are available, there is no accepted standard or sequence of therapies to both relieve dysphagia and control distant disease. Our preceding Phase I clinical trial showed that a 2 week hypofractionated chemoradiotherapy (CRT) protocol (30Gy/10# with concurrent weekly carboplatin and paclitaxel) is well tolerated and provides rapid dysphagia relief. Immune checkpoint inhibition has activity in esophageal and gastroesophageal (GEJ) cancer and concurrent radiotherapy may improve T cell priming through tumor antigen release. In PALEO, patients begin durvalumab concurrent with primary tumor CRT, and receive stereotactic body radiotherapy (SBRT) (24Gy/3#) to a single metastasis to maximize the breadth of tumor antigen exposure. Tissue and blood-based studies are planned to identify biomarkers for response, including immunosequencing to test for post-radiotherapy expansion in T cell receptor diversity. Methods: Eligible patients have biopsy-proven esophageal or GEJ cancer, either squamous cell or adenocarcinoma histology, with oligometastatic (1-5 metastases on FDG-PET scan outside the primary tumor radiotherapy field) or locoregionally advanced disease unsuitable for surgery, dysphagia (Mellow score &gt;0), and ECOG PS 0-2. Key exclusion criteria are prior treatment, tumor HER2 positivity, prior thoracic radiotherapy, tracheo-esophageal fistula, esophageal stent in situ and contraindications to immunotherapy. Patients begin durvalumab 1500mg q4w with CRT to the primary tumour (30Gy/10# with weekly carboplatin AUC2 and paclitaxel 50mg/m2), and continuing to disease progression, unacceptable toxicity or 2 years. SBRT to one metastasis (24Gy/3#) is delivered in week 7. Trial primary endpoint is progression free survival rate at 6 months (PFS6) with the aim to rule out a PFS6 rate of 50% in favor of 67.5%, with 80% power and a one-sided 0.05 significance level. Secondary endpoints include dysphagia relief, nutritional status change (patient weight, removal of enteral feeding tubes, PG-SGA score), quality of life, response rate, toxicity, overall survival and exploratory translational endpoints. PALEO is sponsored by the Australasian Gastro-Intestinal Trials Group (AGITG) for conduct at 8 sites in Australia and New Zealand. 6 of planned 54 patients have been enrolled. ACTRN12619001371189. Clinical trial information: Clinical trial information: ACTRN12619001371189 .

Comparison of postoperative complications in early versus delayed tracheostomy decannulation in patients undergoing oral cancer surgery with microvascular reconstruction

The purpose of this study was to determine the relationship of early and delayed tracheostomy decannulation protocols on the length of stay, time to oral feeding and incidence of postoperative complications in patients undergoing microvascular reconstruction for oral cancer.A review of all patients who underwent surgical management of oral squamous cell carcinoma (OSCC) over the study period from 01/07/2017 to 31/06/2021 was performed. Patients who underwent elective tracheostomy as part of their microvascular reconstruction were included. Two cohorts were identified based on distinct postoperative tracheostomy decannulation protocols; early (Within 7 days) and delayed (≥7 days). Time to oral feeding, length of stay and complication rates was determined for both groups for statistical analysis.A total of 103 patients with OSCC were included in the study. The overall complication rate was 35.9% and were more likely in node positive patients (53.7% vs 23.2%; p = 0.003) and in cases where the geniohyoid muscle complex was disrupted during tumour resection (66.7% vs 31.9%; p = 0.026). Early decannulation was significantly associated with shorter length of hospital stay (10 days vs 15 days) and earlier removal of nasogastric feeding tubes (7 vs 10 days). There was no difference in the overall complication rate between the two groups (33.3% vs 37.5%; p = 0.833).Early decannulation in appropriately selected patients is recommended as it significantly reduces the length of hospital stay and aids in early resumption of oral intake. Furthermore, this approach is not associated with increased rates of complications.

Use of feeding tubes in 112 cats in an internal medicine referral service (2015-2020).

The aims of this study were to describe diseases, complications and outcomes associated with the use of feeding tubes in a population of sick cats with appetite disturbance managed at an internal medicine referral service. Clinicopathological data from cats receiving nasoenteral (NE) or oesophagostomy (O) tubes were studied. Cats were categorised according to their underlying disease and divided into subgroups (NE or O tube). The following factors associated with survival were analysed: disease category, type of tube and return to appetite. Included in the study were 112 cats, representing 118 cases. Of the 118 cases, 98 (83%) and 20 (17%) received NE or O tubes, respectively. The most common underlying conditions were digestive (13.5%), hepatobiliary (11%) and upper urinary tract (11%) disorders. Hepatobiliary (50%) and upper respiratory tract (30%) conditions were predominant in the O tube group. Digestive (15%) and upper urinary tract (12%) diseases were more common in the NE tube group. Complications following tube placement occurred in 22/118 cases (18.6%). The global survival rate was 73% and did not differ between NE (71.4%) and O tube (80%) groups (P = 1.00) or disease categories (P = 0.61). Return of appetite before feeding tube removal occurred in 56 cases (47%), within a median of 3 days (range 1-30) and was not associated with mirtazapine administration (P = 1.00). Appetite returned earlier for cats with NE tubes (3 days, range 1-17) than for those with O tubes (33 days, range 5-60; P <0.05). Voluntary food intake was positively associated with survival (odds ratio 15.17). After discharge and feeding tube retrieval, return of appetite was observed in 67% of cases. Feeding tubes were predominantly placed for the management of appetite disturbance in cats with digestive, hepatobiliary and upper urinary tract diseases. While complications were frequent, they were mostly mild, easily managed and did not preclude feeding tube use. Return to appetite occurred in a large proportion of cats during or after assisted enteral feeding and was associated with survival.

Predictors of complete oral feeding resumption after feeding tube placement in patients with stroke and dysphagia: Asystematic review.

The aim was to synthesise and discuss predictors of complete oral feeding resumption after feeding tube placement in stroke patients with dysphagia. This was a systematic review, following the PRISMA 2020 checklist. Eight databases (PubMed, Web of Science, Embase, Cochrane, CINAHL, CNKI, WanFang and Vip) were searched for eligible studies from inception up to June 2021. The JBI Manual for Evidence Synthesis was used to guide this systematic review. Any cross-sectional survey, longitudinal study, cohort study or case-control study that explored the recovery from tube feeding to complete oral feeding in patients with dysphagia after stroke was included. Qualitative studies, review articles, case reports and conference abstracts were excluded. Two reviewers independently screened and appraised the studies. The Newcastle-Ottawa scale was used for quality assessment. Content analysis was used to categorise factors predicting feeding tube removal in stroke patients with dysphagia. This review included a total of 15 studies consisting of 1746 participants, of which 2 were case-control studies and 13 were cohort studies. Four studies were rated as having low risk of bias, and the other 11 had high risk of bias. The factors examined in the studies were categorised into demographic characteristics (age and sex), swallowing function (instrumental assessments and non-instrumental assessments), stroke characteristics (stroke severity, past stroke history and location of the stroke), functional status (cognitive function and physical function) and clinical measures (body mass index, geriatric nutritional risk index, white blood cell count and C-reactive protein level). The major limitation of this review is the failure to identify predictors of different tube feeding types. Although the current evidence is insufficient to support or oppose the predictive effect of any single factor, these factors are still valuable data for clinical staff that provide information that researchers can use in developing prognostic models. Rigorously designed and high-quality research is needed to further explore the predictive value of these factors. This review was registered prospectively with PROSPERO [CRD42021272552]. Healthcare providers should strengthen the monitoring of swallowing function in patients with stroke to promote complete oral feeding resumption. As the predictive value of the identified factors is still uncertain, large, well-designed, studies are needed to better clarify the importance of these predictors. No patient or public was involved in the design, analysis, preparation or writing of this review.

Abstract WMP34: Early Oral Feeding Following Removal Of Feeding Tube In Stroke Patients Based On The Modified Volume-viscosity Swallow Test

Objective: Dysphagia is common in patients with acute ischemic stroke patients (AIS). Feeding tubes are often placed to prevent aspiration pneumonia and supply nutrition when swallow function impaired are detected. However, little is known about when and how to start oral feeding in AIS. The purpose of this study is to establish a feasibility and effective intervention for early oral feeding following removal of feeding tube in patients with AIS. Methods: A total of 37 patients with AIS who were removed feeding tubes and start oral feeding in our hospital from 2017 to 2021 were retrospectively analyzed. An intervention program for early oral feeding, which consisted of the modified volume-viscosity swallow test (V-VST) and mechanical soft diet, was fully operationalized from October 2020 to July 2021. Outcomes were compared between an early oral feeding intervention group of 17 patients and a historical control group of 20 patients from July 2017 to September 2020. We compared the baseline characteristics between the groups. To analyze aspiration pneumonia probability, the Kaplan-Meier method were used. Results: The length of stay in hospital was significantly longer in the control group compared with the early oral feeding group (16.70±5.24 vs 12.88±4.46; P=0.024). Patients in the control group tolerated tube feeding longer days ( 9.45±2.93 vs 6.59±3.57; P=0.011 ). A log-rank test found no significant difference in aspiration pneumonia between the two groups ( P =0.111). Conclusions: Our data suggest that the intervention for early oral feeding can be used safely and possibly.

Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer.

BackgroundUnintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer‐associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients.MethodsWe retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017–August 2019) were compared with patients who underwent resection before protocol implementation (January 2015–July 2017). Patients undergoing surgery during the month of protocol initiation were excluded.ResultsOf the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30‐day readmission, or mortality rates between groups.ConclusionsResults of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.

The longitudinal impact of division-wide implementation of an enhanced recovery after thoracic surgery programme.

Data regarding enhanced recovery after thoracic surgery (ERATS) are sparse and inconsistent. This study aims to evaluate the effects of implementing an enhanced ERATS programme on postoperative outcomes, patient experience and quality of life (QOL). We conducted a prospective, longitudinal study evaluating 9 months before (pre-ERATS) and 9 months after (post-ERATS) a 3-month implementation of an ERATS programme in a single academic tertiary care centre. All patients undergoing major thoracic surgeries were included. The primary outcomes included length of stay (LOS), adverse events (AEs), 6-min walk test scores at 4 weeks, 30-day emergency room visits (without admission) and 30-day readmissions. The process-of-care outcomes included time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and removal of urinary catheter. Perioperative anaesthesia-related outcomes were examined as well as patient experience and QOL scores. The pre-ERATS group (n = 352 patients) and post-ERATS group (n = 352) demonstrated no differences in demographics. Post-ERATS patients had improved LOS (4.7 vs 6.2 days, P < 0.02), 6-min walk test scores (402 vs 371 m, P < 0.05) and 30-day emergency room visits (13.7% vs 21.6%, P = 0.03) with no differences in AEs and 30-day readmissions. Patients experienced shorter mean time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and urinary catheter removal. There were no differences in postoperative analgesia administration, patient satisfaction and QOL scores. ERATS implementation was associated with improved LOS, expedited feeding, ambulation and chest tube removal, without increasing AEs or readmissions, while maintaining a high level of patient satisfaction and QOL.

Oncological and Functional Outcomes of Supracricoid Partial Laryngectomy

Objective: The aim of this study is to review the oncological outcomes of T1-T4 glottic or supraglottic tumor patients who underwent supracricoid partial laryngectomy in our clinic. Material and Methods: A total of 43 patients with laryngeal squamous cell carcinoma who underwent supracricoid partial laryngectomy between January 2014 and December 2016 in the Otorhinolaryngology Department of Istinye University Hospital were retrospectively analyzed. Postoperative data of these patients regarding surgical margin, nasogastric feeding tube removal time, decannulation time, postoperative radiotherapy, local regional recurrence, and distant metastases were recorded. Results: Cricohyoidoepiglotopexy was applied to 16 patients by preserving both arytenoids and applied to 7 patients with a single arytenoid; Cricohyoidopexy was applied to 14 patients with both arytenoids preserved, and 6 patients were treated with a single arytenoid. The five-year survival was compared for Cricohyoidopexy/Cricohyoidoepiglotopexy with single arytenoid to double arytenoid preservation and found to be 80%-76% (p=0.56). The mean 5-year survival was 88% in the post-operative radiotherapy group, and 86% in the non- radiotherapy group. The study compared patients with Cricohyoidopexy/Cricohyoidoepiglotopexy with a single arytenoid to those with double arytenoid preservation; the mean decannulation time was 54.23±34.12 to 35.62±27.08 (p=0.05). Postoperative radiotherapy prolonged the decannulation time (51.16±38.5 versus 32.68±20.1; p=0.043). The duration of nasogastric tube placement in the Cricohyoidopexy/Cricohyoidoepiglotopexy with a single arytenoid group was 50.3±14.3 and double arytenoid preservation was 35.17±32.9 (p=0.088). Nasogastric tube removal time was 53.29±50.2 in the post-operative radiotherapy group and was 30.24±16.8 in patients who did not receive post-operative radiotherapy (p=0.040). Conclusion: Supracricoid partial laryngectomy with Cricohyoidoepiglotopexy and Cricohyoidopexy had satisfactory oncological outcomes, and laryngeal function was preserved by rebuilding the neolarynx.

Pediatric Malignant Mandibular Tumors: Personal Experience and Literature Options Discussion

Introduction: Mandibular defects reconstruction could result challenging in childhood, due to facial and mandibular growth patterns. For these reasons, the choice of the most suitable reconstructive option in pediatric patients, affected by mandibular malignancies, still objects of debate. Objective: The aim of our study was to compare our reconstructive schedules to the existing literature in order to give a personal contribute to the present panorama. Methods: We performed, in October 2019, a retrospective evaluation of pediatric patients treated for biopsy-proven mandibular malignancies at our Institute between January 2013 and December 2016. All of them received multimodal therapy in accordance with standard guidelines and their demographic, clinical, treatment, and outcome parameters were collected and analyzed. Results: We observed a shorter duration of surgery, a faster tracheostomy tube and feeding-tube removal, and a minor hospitalization in patients who received grafts transfer compared to those who underwent microsurgical mandibular reconstruction. After a 36-month period of follow-up, osteochondral grafts showed a pattern of growth similar to the mandibular epiphysis (condilylion-gonion linear and vertical ratio ranging to 0.96–1.03 and 1–1.02 at orthopantomogram, respectively). No bone consolidation delays and functional impairment were recorded. Conclusions: Free flaps mandibular reconstruction in children needs to be better assessed and proximal fibular epiphyseal free flap indication might deserve further studies. Osteochondral grafts find indication for lateral defects, 50–55 mm in maximum length and located in the mandibular ramus, without massive teeth or soft tissue defect. Condyle involvement does not represent an absolute contraindication to rib graft use.

Evaluating the risks and benefits of ketorolac in transoral robotic surgery.

Transoral Robotic Surgery (TORS) is increasingly used for oropharyngeal neoplasms and obstructive sleep apnea. Post-operative pain and bleeding remain concerns. Ketorolac has proved to be a safe alternative or addition to narcotics in other operations, but has not been thoroughly evaluated in TORS. A retrospective review was carried out on all TORS cases at our institution between April 2012 and March 2019, with the vast majority of cases performed starting in 2017. Post-operative bleed rates were compared between those who received Ketorolac and those who did not. Secondary outcomes evaluated included post-operative pain scores and need for feeding tube upon discharge. A total of 81 TORS cases were evaluated, with 37 patients receiving Ketorolac. Six (7.4%) patients reported post-operative bleeding, with one major and five minor bleeds. The patient with major bleeding requiring operative intervention did not receive Ketorolac. All five patients with minor bleeding received Ketorolac, but no bleeds occurred in the immediate post-operative setting while receiving Ketorolac. The average time of bleeding was 8days post-operative. There were no significant differences in pain scores or time to feeding tube removal. This preliminary study shows that Ketorolac use in the postoperative pain management after TORS does not increase major bleeding risk without benefits in pain management. There was increased risk of minor bleeding not requiring intervention, but this was not significant. Future prospective studies are needed to determine if it improves pain and swallowing and decreases narcotic requirements following TORS.

Temporary feeding tube dependency in pediatric patients: A retrospective analysis of risk factors and preventative practices

Prolonged temporary tube feeding places pediatric patients at risk of tube dependency. This chart audit aimed to identify current temporary tube feeding practice within an Australian tertiary hospital, risk factors of prolonged temporary tube feeding, and the likelihood of high risk patients receiving tube dependency preventative practices. A retrospective chart audit was conducted of the medical records of 187 pediatric inpatients who had temporary feeding tubes placed in an Australian tertiary hospital between November 2014 and March 2017. Information was collected on patient demographics and tube feeding practices. The Kaplan Meier estimate, Cox regression and logistic regression were used to determine the median time until feeding tube removal, predictors of prolonged temporary tube feeding, and the relationship between these predictors and utilization of preventative practices. The Kaplan Meier estimate of median tube feeding duration was 6.43 months (95% CI: 5.17-7.90). Predictors of prolonged tube feeding were prematurity (p=0.003), feeding difficulties requiring speech pathology referral (p=0.002), and referral for long-term feeding tubes (p=0.002). There was a low prevalence of preventative clinical practices including documentation of tube exit plans (5.3%, n=10) and referral for long-term feeding tubes (27.3%, n=51). Exhibiting risk factors for prolonged tube feeding did not increase the likelihood of receiving preventative clinical practices. The prolonged duration of temporary tube feeding within this sample highlights the need for improved utilization of tube dependency preventative practices within high risk groups.

Versatility and Reliability of Islanded Pedicled Nasolabial Flap in Head and Neck Cancer Reconstruction.

Reconstruction of head and neck cancer ablative defects is challenging. A modification of the nasolabial flap (islanded pedicled nasolabial flap [ipNLF]) is an easy and reliable option for reconstruction of small- to medium-sized defects of the head and neck, especially in resource-constrained and high-volume centers. We present the retrospective analysis of 27 consecutive patients reconstructed with ipNLF at two high-volume cancer centers, Homi Bhabha Cancer Hospital, Varanasi, India; and Army Hospital Research and Referral, New Delhi, India. The functional outcomes measured were duration of weaning of feeding and tracheotomy tubes and speech assessment (speech intelligible rating score [SIR]) postsurgery. Complications assessed were flap loss, orocutaneous fistula, donor site wound dehiscence, oral incompetence, and angle of mouth deviation. The most common ablative defect was of the oral cavity (22 patients), followed by the oropharynx (4 patients) and hypopharynx (1 patient). The mean operating time for flap harvesting and insetting was 57.7 minutes. The mean durations for postoperative feeding tube and tracheotomy removal were 10 and 5 days, respectively. Twenty-four subjects had SIR scores of I or II. None of the subjects had flap loss, orocutaneous fistula, or donor site wound dehiscence. Twenty-five subjects had no oral incompetence, and 26 subjects had no or minimal angle of mouth deviation. This is the largest series of ipNLF to date and emphasizes the versatility, reliability, reproducibility and excellent functional and acceptable cosmetic outcomes of this flap for the reconstruction of judiciously chosen head and neck ablative defects. 2C Laryngoscope, 130: 1967-1972, 2020.

Review of complications resulting from bedside enteral feeding tube removal in the first 3 months following insertion in the Regional Acquired Brain Injury Unit in Northern Ireland (RABIU)

Review of complications resulting from bedside enteral feeding tube removal in the first 3 months following insertion in the Regional Acquired Brain Injury Unit in Northern Ireland (RABIU)

Volume-Based Feeding Enhances Enteral Delivery by Maximizing the Optimal Rate of Enteral Feeding (FEED MORE).

The importance of enteral nutrition (EN) in critically ill patients is well documented. However, actual administration of EN frequently does not amount to prescribed nutrition goals. Persistent underfeeding may lead to impaired immune response, increased mortality, and higher costs. Traditionally, EN uses a rate-based approach, utilizing slow titration to goal and a final fixed hourly rate, regardless of interruptions in feeding. Volume-based feeding (VBF) establishes a 24-hour EN goal volume, and the rate varies to achieve this daily goal when interruptions occur. This was a retrospective, single-center, quasi-experimental study comparing traditional rate-based feeding (RBF) to VBF in adult patients admitted to the medical and neurosurgical intensive care units (ICUs). The primary outcome was mean percentage of total goal energy received after EN initiation until 7 days, transfer from ICU, removal of feeding tube, or oral diet order placed. Secondary outcomes included mean percentage of total goal protein received, percentage of patients meeting 80% of nutrition goals, incidence of gastric residual volumes >400mL, and incidence of moderate hyperglycemia (>250mg/dL). The study enrolled 189 patients. Mean percentage of goal energy delivered (75% RBF, 102% VBF; P < .001) and goal protein delivered (68% RBF, 87% VBF; P < .001) was significantly higher with VBF compared with RBF. VBF demonstrated a significant increase in energy and protein delivery with no major safety or tolerability issues. VBF should be considered for use in ICU patients to optimize nutrition delivery.