Temporary Feeding Tube Research Articles

The swallowing and speech after transoral robotic surgery-does the site impact the outcome?

Transoral robotic surgery (TORS) has been introduced to head and neck surgery as a minimally invasive techqniques to improve the functional outcomes of patients. Compare the functional outcome for swallowing and speech in each site of TORS within the head and neck. Retrospective cohort study for patients who underwent TORS within the head and neck unit. Patients were assessed at four different time points (one day, one month, six months and twelve months, respectively) with bedside/office testing. Methods of testing for swallowing assessment were by the International Dysphagia Diet Standardization Initiative (IDDSI), and speech assessments were carried out using the Understandability of Speech score (USS). Outcomes were compared to patient-specific pre-treatment baseline levels. 68 patients were included. 75% and 40% of the patients resumed normal fluid intake and normal diet immediately after surgery. 8.8% required a temporary feeding tube, with 1% required gastrostomy. There was a steep improvement in diet between 3 and 6 months. Fluid and diet consistency dropped significantly following the majority of transoral robotic surgery with more noticeable diet changes. Early deterioration in diet is temporary and manageable with a modified diet. Rapid recovery of swallowing is achieved before the first year. There is no long-term effect on speech.

Development and clinical feasibility of a reduced-dose radiograph in children for feeding tube placement.

Temporary feeding tubes are commonly used but may lead to complications if malpositioned. Radiographs are the gold standard for assessing tube position, but clinician concern over radiation risks may curtail their use. We describe development and use of a reduced dose feeding tube radiograph (RDFTR) targeted for evaluation of feeding tube position. Age-based abdominal radiograph was adapted to use the lowest mAs setting of 0.32 mAs with field of view between carina and iliac crests. The protocol was tested in DIGI-13 line-pair plates and anthropomorphic phantoms. Retrospective review of initial clinical use compared dose area product (DAP) for RDFTR and routine abdomen, chest, or infant chest and abdomen. Review of RDFTR reports assessed tube visibility, malpositioning, and incidental critical findings. Testing through a line-pair phantom showed loss of spatial resolution from 2.2 line pairs to 0.6 line pairs but preserved visibility of feeding tube tip in RDFTR protocol. DAP comparisons across 23,789 exams showed RDFTR reduced median DAP 72-93% compared to abdomen, 55-78% compared to chest, and 76-79% compared to infant chest and abdomen (p<0.001). Review of 3286 reports showed tube was visible in 3256 (99.1%), malpositioned in airway 8 times (0.2%) and in the esophagus 74 times (2.3%). The tip was not visualized in 30 (0.9%). Pneumothorax or pneumoperitoneum was noted seven times (0.2%) but was expected or spurious in five of these cases. RDFTR significantly reduces radiation dose in children with temporary feeding tubes while maintaining visibility of tube tip.

Outcomes following proton therapy for pediatric esthesioneuroblastoma.

Pediatric esthesioneuroblastoma (EN) can infiltrate skull base anatomy, presenting challenges due to high radiation doses and pediatric tissue sensitivity. This study reports outcomes of pediatric EN treated with proton radiotherapy (PT). Using an IRB-approved prospective outcomes registry, we evaluated patient, tumor, and treatment-related variables impacting disease control and toxicity in pediatric nonmetastatic EN treated with modern multimodality therapy, including PT. Fifteen consecutive patients (median age 16) comprising Kadish stage B (n=2), C (n=9), and D (n=4) tumors were assessed, including six with intracranial involvement, four with cranial nerve deficits, and four with cervical lymphadenopathy. Before radiation, two had subtotal and 13 had gross total resections (endoscopic or craniofacial). Two underwent neck dissection. Eleven received chemotherapy before radiation (n=5), concurrent with radiation (n=4), or both (n=2). Median total radiation dose (primary site) was 66Gy/CGE for gross disease and 54Gy/CGE (cobalt Gray equivalent) for microscopic disease. Median follow-up was 4.8years. No patients were lost to follow-up. Five-year disease-free and overall survival rates were 86% (no local or regional recurrences). Two patients developed vertebral metastases and died. Two required a temporary feeding tube for oral mucositis/dysphagia. Late toxicities included symptomatic retinopathy, major reconstructive surgery, cataracts, chronic otitis media, chronic keratoconjunctivitis, hypothyroidism, and in-field basal cell skin cancer. A multimodality approach for pediatric EN results in excellent local control. Despite the moderate-dose PT, serious radiation toxicity was observed; further dose and target volume reductions may benefit select patients. Longer follow-up and comparative data from modern photon series are necessary to fully characterize any relative PT advantage.

Pediatric Esthesioneuroblastoma Treated with Proton Radiotherapy

Given its tendency to abut and infiltrate critical skull base anatomy, pediatric esthesioneuroblastoma (EN) presents a local control challenge, particularly given the high dose of radiation historically utilized in adult patients and the sensitivity of developing pediatric normal tissue. The purpose of this study was to report the outcomes of pediatric EN treated with proton radiotherapy. Using an IRB-approved, single institutional prospective outcomes registry, we analyzed disease control and toxicity in pediatric patients with non-metastatic EN treated with a multimodality approach, including proton radiotherapy, between March 2008 and March 2022. Of the 15 patients, 8 were female, and 7 were male. The median age was 16 years (range, 3-21 years). Patients were Kadish stage B (n = 2), C (n = 8), and D (n = 5) and Hyams low-grade (n = 9), high-grade (n = 5), and not specified (n = 1). Six patients had intracranial involvement, 4 had cranial nerve deficits, and 4 had positive cervical lymph nodes. Prior to radiation, 2 patients had a subtotal resection and 13 had a gross total resection via either endoscopic (n = 8) or craniofacial (n = 7) approaches. Two patients underwent neck dissection (one unilateral and one bilateral). A total of 11 patients received chemotherapy before (n = 5), concurrent (n = 4) with radiation, or both (n = 2). The median total radiation dose delivered to the primary site was 66 Gy/CGE (range, 59.4-72.8 Gy/CGE) for patients with gross disease and 54 Gy/CGE (range, 54-74.4 Gy/CGE) for patients with microscopic disease. With a median follow-up of 4.8 years (range, 0.1-12.2 years), both the 5-year disease free and overall survival rates were 86%. There were no local or regional recurrences. Two patients with Kadish D, high grade tumors developed vertebral metastases and died with disease. Serious acute toxicity included 2 patients requiring a temporary feeding tube for oral mucositis/dysphagia. Serious late toxicity included symptomatic retinopathy (n = 3), major reconstructive surgery (n = 2), cataracts requiring intervention (n = 2), chronic otitis media (n = 2), chronic keratoconjunctivitis (n = 2), hypothyroidism (n = 2), and in-field basal cell skin cancer (n = 1). A multimodality approach to pediatric EN results in excellent local control. Despite the use of moderate dose proton therapy, serious radiation toxicity was observed and thus select patients may benefit from further dose and target volume reduction. Longer follow-up and comparative data from modern photon series are necessary to fully characterize any relative advantage of proton therapy.

Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.

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.

Head and Neck Adenoid Cystic Carcinoma: Focus on Outcomes of Intensity Modulated Proton Therapy

In this study, we report cancer control outcomes and toxicity from intensity modulated proton therapy (IMPT) in patients treated for adenoid cystic carcinoma (ACC) of the head and neck. This study combines 2 prospective protocols evaluating IMPT in head and neck cancer. This analysis included patients with ACC, treated with IMPT in the adjuvant or definitive setting between December 2010 and June 2018. Patients with recurrent or metastatic disease were excluded. Locoregional control (LRC), disease free survival (DFS) and overall survival (OS) were estimated using the Kaplan Meier Method. Patterns of failure as well as toxicities were prospectively collected. Cox regression analysis was performed to determine prognostic factors. Toxicities were graded as per Common Terminology Criteria for Adverse Events version 4.01. 60 patients met the inclusion criteria for this analysis. Median follow-up was 2.9 years. Median age was 50 years (range 18-82) and 58% of patients were female. Primary treatment sites included: Peri-orbital (30%), oral cavity (17%), paranasal sinuses (17%), parotid gland (15%), nasopharynx (12%), oropharynx (7%), larynx (1 patient), and trachea (1 patient). As per AJCC 8th Ed, 22%, 18%, 17%, 44% of patients had T1, T2, T3 and T4 stage; only 1 patient had nodal involvement. Treatments involved surgery followed by chemo-IMPT, surgery followed by IMPT and definitive chemo-IMPT in 47%, 30%, and 23% of patients. Most frequent chemotherapy regimen included Cisplatin (63%) and Carboplatin (17%). Median dose was 64 Cobalt Gray Equivalent (range: 60-70 CGE). In patients treated with definitive chemo-IMPT, adjuvant chemo-IMPT and adjuvant RT alone, 3-year LRC was 83%, 92% and 90%, respectively (p=0.5); 3-year DFS was 44%, 87% and 90%, respectively (p=0.09); and 3-year OS was 80%, 85% and 100%, respectively (p=0.5). Acute toxicities included grade 3 dermatitis, mucositis, and dysphagia in 7%, 7%, and 1 patient; there was no grade 4 toxicity. There was a 7% rate of temporary feeding tubes and no permanent feeding tube. Chronic toxicities included 1 patient who developed optic neuropathy after treatment for a peri-orbital tumor. This is the largest cohort of head and neck ACC treated with IMPT. We report excellent cancer outcomes in patients treated with adjuvant IMPT +/- chemotherapy. In addition, Outcomes of patients treated with upfront chemo-IMPT were acceptable, despite typically high risk, more advanced disease. The acute and late toxicity profiles were highly favorable.

Early Tube Feeding for Fracture Patients Speeds Discharge

Early Tube Feeding for Fracture Patients Speeds Discharge

Outcomes after Surgical Resection of Head and Neck Paragangliomas: A Review of 61 Patients

We reviewed the postoperative functional outcome following surgical resection of paragangliomas in patients with and without preoperative cranial nerve dysfunction. Patients who underwent surgical resections of head and neck paragangliomas were reviewed with functional outcomes defined as feeding tube and/or tracheostomy dependence, need for vocal cord medialization, and incidence of cerebral vascular accidents as primary end points. Secondary end points included pre- and postoperative function of lower cranial nerves and the impact of this dysfunction on long-term functional status. Sixty-one patients were identified: 27 with carotid paraganglioma (CP), 21 with jugular paraganglioma (JP), 8 with tympanic paragangliomas, 4 with vagal paragangliomas (VPs), and 1 with aortopulmonary paraganglioma. Following resection, 8 patients were feeding tube dependent, 14 patients required vocal cord medialization, 2 patients suffered strokes, but no patients required tracheostomy tubes. Twenty percent of patients (4/20) with JP and postoperative cranial neuropathies were feeding tube dependent, and 80% of patients (4/5) with CP and postoperative cranial nerve dysfunction were feeding tube dependent. Cranial nerve deficits were more common in patients with JP relative to those with CP. However, when cranial nerve dysfunction was present, our patients with CP had a higher incidence of temporary feeding tube dependence. Overall, 98% of patients were able to resume oral nutrition.

Transoral resection of tonsillar squamous cell carcinoma

The tonsillar fossa is the most common subsite of the oropharynx to be afflicted with squamous cell carcinoma (SCCA). Accepted treatments include any combination of surgery, radiotherapy, and chemotherapy. We review the oncologic and functional outcomes of patients with tonsillar carcinoma who underwent transoral tumor resection and neck dissection with or without postoperative radiotherapy or chemoradiotherapy. Retrospective chart review. From 1996 through January 2005, 102 patients with tonsillar SCCA underwent transoral resection. Overall survival, disease-specific survival, local control, and locoregional control rates were analyzed using the Kaplan-Meier method. Immediate and long-term speech and swallowing function and treatment-related morbidity were analyzed. Twenty-six patients had surgery only, 71 had surgery and radiotherapy, and five had surgery and chemoradiotherapy. Twenty patients had stage III disease, 63 had stage IVA disease, and two had stage IVB disease. The Kaplan-Meier overall survival estimate was 92.2% at 2 years and 85.0% at 5 years. The 5-year local control estimate was 91.8%, and the 5-year Kaplan-Meier disease-specific survival estimate was 93.9%. The median hospital stay was 3 days. Tracheostomy was required for 14 patients, and 13 of these patients had decannulation. Temporary feeding tubes were placed in 35 patients. Sixteen patients received a percutaneous endoscopic gastrostomy tube; of these, 12 had the tubes removed. Transoral resection of tonsillar SCCA with or without postoperative adjuvant therapy provided excellent locoregional control and minimized treatment-related morbidity. We believe that transoral resection is the optimal treatment for patients with oropharyngeal SCCA.

Jugular Foramen Schwannomas: Diagnosis, Management, and Outcomes

To describe the presentation, radiographic findings, and surgical management of seven patients who have been diagnosed and treated with jugular foramen schwannomas at the University of Utah. Retrospective chart review. The charts of seven patients diagnosed with jugular foramen schwannomas were reviewed for presentation symptoms, radiographic findings, and physical examination findings. For the six who underwent surgical excision, the surgical procedure used, cranial nerve function results, audiometric results, perioperative complications, and other follow-up data are presented. Seven patients were identified from ages 24 to 69 years. Six of the seven underwent surgical excision. Primary presentation symptoms included dizziness, hearing loss, dysphagia, diplopia, tongue paresis, and hoarseness. The choice of surgical approach was based on the size and location of the tumor. All patients had complete excision of their tumors. The nerve of origin included the glossopharyngeal, vagus, and spinal accessory nerves. Preoperative cranial nerve dysfunction continued postoperatively for lower cranial nerves but resolved in patients who were noted to have preoperative dysfunction of cranial nerve V and VI. The rate of new lower cranial nerve injury was 15% and was only seen in the cranial nerves that were determined to be the nerve of origin. In two cases, a temporary feeding tube was required. No recurrences have been noted to date. Jugular foramen schwannomas can be successfully diagnosed preoperatively with computed tomography and magnetic resonance imaging. These tumors can be successfully managed with surgery and low morbidity.