Early enteral nutrition after head and neck surgery with free tissue transfer reconstruction.

OBJECTIVE: Early enteral nutrition is essential for enhancing recovery after surgery. However, to date, no detailed study has been conducted on the feasibility of early enteral nutrition in patients undergoing head and neck surgery with free tissue transfer reconstruction (HNS-FTTR) and the risk factors for difficulty with early enteral nutrition. METHODS: We retrospectively analyzed 102 patients who underwent HNS-FTTR at our institution; 61 underwent free jejunal reconstruction (FJ) and 41 did not. We investigated the achievement of early enteral nutrition within 24 and 48 h after surgery and the discontinuation of enteral nutrition after its initiation within 7 days after surgery. RESULTS: Enteral nutrition could be started in 81/102 (79.4%) and 99/102 (97.1%) patients within 24 and 48 h, respectively. Cases of difficulty with early enteral nutrition accounted for 21/102 (20.6%) patients. The multivariate analysis revealed that FJ was a significant independent risk factor for difficulty with early enteral nutrition (odds ratio: 4.054, P = 0.042). The risk factors for difficulty with early enteral nutrition in patients who underwent FJ were also investigated, and the multivariate analysis showed that blood loss of ≥158 mL was a significant independent risk factor (odds ratio: 3.505, P = 0.044). CONCLUSIONS: Early enteral nutrition seemed to be provided with no problems in patients without FJ. FJ was a significant risk factor for difficulty with early enteral nutrition. Increased intraoperative blood loss was a significant risk factor for difficulty with early enteral nutrition in patients undergoing FJ; therefore, patients' abdominal symptoms and gastric residual volume should be carefully monitored in such cases.

Shoulder function after neck dissection: Assessment via a shoulder-specific quality-of-life questionnaire and active shoulder abduction.

OBJECTIVE: Neck dissection results in a high probability of postoperative shoulder functional impairment, even when the spinal accessory nerve is preserved. Therefore, surgeons must inform patients about the expected functional and qualitative recovery of shoulder function after surgery. METHODS: The present study included a prospective cohort of 66 patients (85 neck dissection sides) who underwent neck dissection between December 2015 and July 2017 at a single institution. The active shoulder abduction angles of the affected side and the patient-reported shoulder-specific quality-of-life recovery score of the Western Ontario Rotator Cuff (WORC) questionnaire were examined at 1, 3, 6, 9, and 12 months postoperatively. Additionally, the association between these outcomes and risk factors for shoulder impairment were investigated. RESULTS: The average active shoulder abduction angles were significantly improved at 3 and 6 months postoperatively compared with 1 month postoperatively (96.5 ± 4.3° at 1 month versus 110.1 ± 4.7° at 3 months, p = 0.035, and versus 142.0 ± 4.6° at 6 months, p < 0.0001). The proportion of patients who were unable to abduct their shoulders by 150° or more was significantly lower at 6 months postoperatively (41.5%) compared with 1 month postoperatively (82.4%, p < 0.0001). The WORC score significantly improved from 60.4 ± 2.4% at 1 month postoperatively to 67.9 ± 2.6% at 6 months postoperatively (p = 0.036). Multivariate analysis revealed that postoperative radiotherapy was a significant risk factor for shoulder impairment at 3 and 6 months postoperatively (p = 0.003 and p = 0.027, respectively), and that level V dissection and head and neck irradiation were significant risk factors for a worse shoulder outcome at 6 and 9 months postoperatively (respective p values for level V dissection and head and neck irradiation were p = 0.049 and p = 0.030 at 6 months postoperatively, and p = 0.016 and p = 0.013 at 9 months postoperatively). CONCLUSION: Satisfactory functional and qualitative recovery of shoulder function was achieved at 6 months after neck dissection. Postoperative radiotherapy was a predictor of poor shoulder function in the early postoperative period; both level V dissection and head and neck irradiation were predictors of poor shoulder function at 6 and 9 months after neck dissection.

Enhanced recovery after surgery program involving preoperative dexamethasone administration for head and neck surgery with free tissue transfer reconstruction: Single-center prospective observational study.

BACKGROUND: There are few reports on Enhanced Recovery After Surgery (ERAS)-based perioperative management following head and neck surgery with free tissue transfer reconstruction (HNS-FTTR). Here, we prospectively evaluated our ERAS program involving preoperative glucocorticoid administration in HNS-FTTR. METHODS: This prospective study included 60 patients who underwent HNS-FTTR at the Miyagi Cancer Center from June 2017 to December 2018. Their treatment plan included receiving perioperative management in accordance with our head and neck ERAS program. Major outcomes of hospitalization periods, early mobilization, early enteral nutrition, and patient satisfaction were assessed, and blood date and vital signs were compared with control patients who underwent HNS-FTTR from January 2014 to September 2016 at our institution before ERAS was implemented. RESULTS: The duration of hospital stay and the duration until completion of the discharge criteria was a median of 25 days and 17 days, respectively. Early mobilization was achieved in 86.0% of the patients at postoperative-day (POD)1 and 96.5% at POD2. Enteral nutrition was started in 80.1% at POD1 and 100% at POD2. Postoperative pain was controlled at mean VAS scores of 1.51-3.13. Clavien-Dindo grade II or higher postoperative complications were evident in 27.6% of the patients. The mean QOR40 score was 179.6 preoperatively, 146.1 at POD3, and 167.8 at POD7. Compared with the control group, there were significantly lower C-reactive protein levels, higher albumin levels, a lower body temperature, a lower neutrophil-to-lymphocyte ratio, less body weight fluctuation, and fewer incidences of decreased blood pressure in the ERAS group. CONCLUSION: Patients who underwent HNS-FTTR with ERAS-based perioperative management achieved early mobilization, early enteral nutrition, favorable pain control, remarkable recovery of patient satisfaction at POD7, and there was evidence of better hemodynamic stability and less inflammatory response compared with control patients.

A Case of Ectopic Thyroid Presenting as a Superior Mediastinal Mass.

We report a very rare case of an ectopic thyroid in the superior mediastinum, which was detected incidentally using imaging. The case was a 50-year-old woman patient. She had an orthotopic thyroid and normal thyroid function. This superior mediastinum mass obviously lacked continuity with the orthotopic thyroid. Its computed tomography density was lower than that of the orthotopic thyroid, and an enhancement was heterogeneously observed. In the cytodiagnosis, only large and small lymphocytes were observed, and malignant diseases such as malignant lymphoma could not be ruled out, so surgical resection was performed through a cervical incision. Combined resection of the thyroid was unnecessary, and ligation of the feeding vessels from the thorax side was able to be carried out without incident.

Preoperative prognostic nutritional index as a method to predict postoperative complications after major head and neck surgery with free tissue transfer reconstruction.

BACKGROUND: Head and neck (H&N) cancer patients are often malnourished and have diminished immunity. H&N surgery with free tissue transfer reconstruction (HNS-FTTR) is associated with a relatively high incidence of postoperative complications. METHODS: Associations between possible risk factors and postoperative Clavien-Dindo (C-D) grades ≥ II and ≥ IIIa wound healing- or infection-related complications, postoperative overall complications and prolonged hospital stay were investigated in 188 patients who underwent HNS-FTTR during 2014-2018. The preoperative prognostic nutritional index (PNI) was calculated using the serum albumin level and total lymphocyte count. RESULTS: C-D ≥ II and ≥ IIIa complications were seen in 66 (35.1%) and 37 (19.7%) patients, respectively. Multivariate analysis showed that (i) previous irradiation was significantly associated with C-D ≥ II wound healing- or infection-related complications and prolonged hospital stays [odds ratio (OR) 3.096 and 3.328; P = 0.007 and 0.008, respectively]; and (ii) operation time of ≥9 h 20 min was a significant risk factor for C-D ≥ IIIa wound healing- or infection-related complications, and C-D ≥ IIIa overall complications (OR 2.987 and 2.257; P = 0.021 and 0.047, respectively). (3) Only preoperative PNI ≤ 40 was associated with all occurrences of C-D ≥ II and ≥ IIIa wound healing- or infection-related complications, C-D ≥ II and ≥ IIIa overall complications, and prolonged hospital stays (OR 3.078, 2.918, 2.627, 3.132 and 3.116; P = 0.020, 0.046, 0.036, 0.023 and 0.025, respectively). CONCLUSIONS: PNI, easily calculated, was the lone risk factor significantly predicting all C-D ≥ II and ≥ IIIa postoperative wound healing- or infection-related complications, C-D ≥ II and ≥ IIIa postoperative overall complications and prolonged hospital stay after HNS-FTTR.

Enhanced Recovery After Surgery program with dexamethasone administration for major head and neck surgery with free tissue transfer reconstruction: initial institutional experience.

OBJECTIVES: Enhanced Recovery After Surgery (ERAS) protocols promote recovery after various invasive surgeries. Likewise, preoperative glucocorticoid administration can reduce complications after some surgeries. However, the effects of ERAS protocols and glucocorticoid administration in patients undergoing major surgery for head and neck cancer have not been well described. The aim of this study was to evaluate the effect of an ERAS protocol with preoperative glucocorticoid administration in major surgery for head and neck cancer. METHODS: This retrospective study included 28 patients who underwent major head and neck surgery with free tissue transfer reconstruction at our institution from September 2016 to May 2017, after implementation of an ERAS protocol with preoperative glucocorticoid administration. Outcomes in that group were compared with those in a control group that underwent surgery from January 2015 to September 2016, before implementation of the protocol. RESULTS: Analysis revealed significantly less body weight fluctuation, lower C-reactive protein levels, higher albumin levels, and lower body temperature in the ERAS group than in the control group postoperatively. CONCLUSIONS: Patients undergoing major surgery for head and neck cancer who were treated with the ERAS protocol and preoperative glucocorticoid administration had evidence of better hemodynamic stability and less inflammatory response than control patients.

Retrospective observational study of occult cervical lymph-node metastasis in T1N0 tongue cancer.

Objective: Delayed neck metastasis is the most significant prognostic factor for early tongue cancer. The main strategies for controlling cervical lymph nodes in Japan are elective neck dissection or watchful waiting. Elective neck dissection offers significantly better survival, but adversely impacts patient quality of life; consequently, here we investigated how to identify high-risk patients warranting elective neck dissection. Methods: We retrospectively evaluated 67 patients with T1N0 oral tongue squamous cell carcinoma who underwent primary treatment in our department from April 2001 to March 2015. All the patients underwent watchful waiting alone for neck management. We investigated the rates of occult neck metastasis, prognosis and circumstances of recurrence, and associations with pathological tumor thickness, depth and muscle invasion by the primary tumor. Correlation between the thickness in pathological specimens and that at magnetic resonance imaging was additionally investigated. Results: Neck recurrence was evident in 20 patients, of which 19 developed within 1 year. Therefore, the rate of occult neck metastasis was 29.9%. Patients with muscle invasion, tumor thickness ≥2 mm or tumor depth ≥2 mm on surgical specimens were significantly more likely to develop delayed neck metastasis. Prognosis was significantly worse for patients with muscle invasion or tumor thickness ≥2 mm. Thickness using magnetic resonance imaging was well correlated with pathological thickness. Conclusions: Patients with tumors ≥2 mm in thickness or muscle invasion developed neck metastasis, suggesting that elective neck dissection may be warranted for patients with these findings. For preoperative assessment of the need for elective neck dissection, magnetic resonance imaging would be a potential modality for T1N0 tongue cancer.

Carcinoma ex pleomorphic adenoma of the parotid gland: a multi-institutional retrospective analysis in the Northern Japan Head and Neck Cancer Society.

CONCLUSION: The 3-year progression-free survival rate of non-invasive salivary duct carcinoma (SDC) or adenocarcinoma not otherwise specified (NOS) was significantly better than that of invasive SDC or adenocarcinoma NOS in Carcinoma ex pleomorphic adenoma (CXPA). The presence of invasion is an important prognostic factor for SDC and adenocarcinoma NOS in CXPA. OBJECTIVES: CXPA is a rare parotid gland malignant tumor for which therapy is not yet standardized. The purpose of this study was to review the characteristics of CXPA patients and to analyze their outcomes in the Northern Japan Head and Neck Cancer Society. METHOD: The medical records of 33 patients who had been provided initial treatment in 12 institutes of northern Japan from 2002-2011 were reviewed as a multi-institutional retrospective study. RESULTS: The 3-year overall and progression-free survival rate of all patients was 79.9% and 76.8%, respectively. Both the 3-year overall and progression-free survival rates were 87.5% for patients with non-invasive SDC or adenocarcinoma NOS. The 3-year overall and progression-free survival rates for patients with invasive SDC or adenocarcinoma NOS were 60.4% and 30.5%, respectively. The progression-free survival rates for patients with invasive SDC or adenocarcinoma NOS was significantly poor (p < 0.05).

Diagnostic potential of 1-step nucleic acid amplification assay in patients with head and neck squamous cell carcinoma based on CK19 expression in a primary lesion.

BACKGROUND: The purpose of this study was to investigate the effects of CK19 expression in the primary lesions of head and neck squamous cell carcinoma on the diagnosis of the cervical lymph node (CLN) metastasis using the 1-step nucleic acid amplification assay. METHODS: Primary lesions and 54 CLNs were resected from 21 patients with head and neck squamous cell carcinoma between 2009 and 2011. Each CLN was tested by the 1-step nucleic acid amplification assay, and the CK19 mRNA copy number obtained was compared to the corresponding histopathological results. RESULTS: In the primary lesion CK19-positive group, the sensitivity and specificity of the 1-step nucleic acid amplification assay against hematoxylin-eosin staining were 86% and 100%, respectively. The p value by Fisher's exact test was < .0001, indicating statistical significance. CONCLUSION: These results suggest that 1-step nucleic acid amplification offers similar diagnostic potential to that of histopathological diagnosis of CLN biopsy in patients with a CK19-positive primary lesion. © 2015 Wiley Periodicals, Inc. Head Neck 38: E239-E245, 2016.

Stiffness of salivary gland and tumor measured by new ultrasonic techniques: Virtual touch quantification and IQ.

OBJECTIVE: To evaluate normal salivary gland stiffness and compare the diagnostic performance of virtual touch quantification (VTQ) and virtual touch imaging quantification (VTIQ) for head and neck tumor. METHODS: A total of 92 measurements were examined, comprising 77 normal salivary glands, 11 benign tumors and four malignant tumors. Examinations were made to evaluate normal salivary gland stiffness and compare the diagnostic performances of new ultrasonic techniques regarding head and neck tumor. RESULTS: The mean values of VTQ and VTIQ for the normal salivary group (NSG) were 1.92 and 2.06m/s, respectively. The VTQ and VTIQ values were correlative, and there were no statistical differences in each mean value between the normal parotid glands and submandibular glands. For the benign tumor group (BTG), four of the 11 values were non-numeric and were considered above the measurable range. The mean VTIQ value for the BTG was 4.24m/s. For the malignant tumor group (MTG), all four VTQ values were non-numeric. The mean VTIQ value for the MTG was 6.52m/s. For the mean VTIQ values, significant differences were observed among the three groups. The optimum VTQ cutoff value to detect malignant tumors was above the measurable range, and that of VTIQ was 4.83m/s. CONCLUSION: The VTQ and VTIQ values were correlative for the salivary glands, and the stiffnesses of normal parotid glands were almost same as those of submandibular glands. VTQ and VTIQ values could be applied for the preoperative diagnosis in salivary gland lesions.

Usefulness of sentinel node navigation surgery in the management of early tongue cancer.

OBJECTIVE: To determine the validity of sentinel node navigation surgery (SNNS) in early stage tongue cancer, the occurrence rate of postoperative cervical metastasis (POCM) after lead plate technique (LPT) introduction and survival rates in patients who underwent SNNS were analyzed. METHODS: SNNS was performed in 29 patients (stage I: 14, stage II: 15) from 2000 to 2007. Tc-labeled phytate was prepared as a radiotracer a day before SNNS. The sentinel node (SN) was then examined pathologically during surgery. For cases where metastasis in SN was positive, neck dissection was performed. Occurrence of POCM after LPT introduction was compared with that before LPT introduction. 'Wait and see' policy was performed in 52 patients (stage I: 27, stage II: 25) from 1987 to 1999 as a historical control. The observation period of SNNS cases and 'wait and see' policy cases ranged from 10 months to 165 months (median: 91 months) and from 7 months to 268 months (median: 87 months), respectively. RESULTS: Six of the 29 SNNS cases (21%) were proven metastatic SNs. Before LPT introduction, POCM occurred in 2 of the 15 cases, while we had no occurrences after LPT introduction. The 5-year overall survival rate of the 29 patients who underwent SNNS and the 52 patients with 'wait and see' policy were 96% and 84%, respectively, and there was statistical significance in the two groups (p<0.05). CONCLUSIONS: As the survival rate of the patients with the SNNS tended to be better than that with the 'wait and see' policy in our cases, SNNS could avoid unnecessary neck dissection. SNNS provides useful information regarding decision-making for neck dissection in early stage tongue cancer.