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American Head & Neck Society
July 21-25, 2012
Metro Toronto Convention Centre
Toronto, ON, Canada

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Presentation: P097
Topic: Larynx/Oral Cavity
Type: Poster
Date: Sunday - Tuesday, July 22 - 24, 2012
Session: Designated Poster viewing times
Authors: Sarah E Ballis, BScMelb BNutrDietMonash APD, Michael S W Lee, MB ChB FRCS, Williams Donna, BScHons NutrDiet
Institution(s): Department of Nutrition & Dietetics and Department of Otolaryngology Head and Neck Surgery, St George's Hospital, London


Patients receiving pharyngo-laryngo-oesophagectomy with laparoscopic gastric transposition for advanced tumours of the hypopharynx have high nutritional needs and encounter barriers to achieving them. Pre and post operative swallowing difficulties, metabolic stress, anatomical change post surgery and tube feeding complications to name a few, make meeting nutritional requirements challenging.

In recent years attention has been put on methods to enhance recovery of patients after elective surgery, but little guidance has been documented in this patient group. We aim to design a nutrition protocol by compiling evidence based recommendations and best practise guidelines to improve nutritional care.


Retrospective case-note review of seven patients who received pharyngo-laryngo-oesophagectomy with laparoscopic gastric transposition between 1/2/2010 and 31/1/2011 highlighted barriers lending to nutritional compromise. These included malnutrition at diagnosis with low pre-operative mean body mass index 20.8 kg/m2 (13.4 - 26 kg/m2), inconsistency in pre-surgical optimization, delays of up to 12 days in initiating jejunal (JEJ) feeding, texture modified oral diets and ad hoc long term follow-up.

We have reviewed best practice guidelines and recommendations from sources encompassing nutrition support methods, head and neck patient management and critical care.

Recommendations relating to nutrition were sort from guidelines produced by The European and American Society’s of Enteral & Partenteral Nutrition (ESPEN and ASPEN), British Association of Parenteral and Enteral Nutrition (BAPEN), American and Australian Dietetic Associations (ADA and DAA) and Canadian Critical Care Network.

Guidelines produced by National Institute for Clinical Excellence (NICE), The Clinical Oncology Society of Australia (COSA) and Scottish Intercollegiate Guidelines Network (SIGN) were reviewed to compile more specific head and neck recommendations.

We also referred to principles outlined in the Enhanced Recovery After Surgery (ERAS) protocol which includes 20 evidence-based care elements aimed at reducing surgical stress and postoperative complications.


Pre-operatively a specialist Dietitian should see all patients with advanced hypopharyngeal tumours and be involved in the multidisciplinary team decision to operate. Prevention of nutritional decline before surgery should achieved. Baseline anthropometric and biochemical parameters should be measured, co-morbid conditions like diabetes optimized, electrolytes normalised and micronutrient deficiencies corrected.

Peri-operative feeding via JEJ should be initiated within 24 hours of surgery and JEJ tube placed using a secure and consistent method. Feeding needs to be built up as tolerated to meet 30kcal and 1.2g protein /kg body weight /day. It is important that intravenous fluids are carefully prescribed to avoid fluid overload and electrolytes levels are monitored daily with blood glucose tightly controlled.

Post discharge follow-up should be fortnightly with close Speech and Language therapy involvement to aid timely and safe transition onto oral diet. JEJ feeding should be weaned carefully and intensive therapy input continued as long as nutrition support is required.


The pilot nutrition protocol is based on clinical evidence and best practice guidance and is aimed at improving nutrition throughout care for patients receiving pharyngo-laryngo-oesophagectomy with laparoscopic gastric transposition. It addresses the pre-, peri- and post operative phases of care. Future work will focus on immune enhancing nutrition and more specific constituents of nutritional formulae.


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