Importance: Mucocutaneous fistula is a common complication of aerodigestive tract reconstruction after head and neck cancer ablative surgery. It is currently unknown if timing of oral feeding correlates with fistula formation.
Objectives: Our primary aim was to assess the impact of early oral feeding on the post-operative outcomes of patients after free flap reconstruction for head and neck mucosal defects.
Design: This was a retrospective cohort study of 67 patients undergoing free flap reconstruction of head and neck surgical defects involving the aerodigestive tract at Stanford University Hospital between March 1, 2016 and March 1, 2017. We compared rates of post-operative mucocutaneous fistulae and progression to a completely oral diet in patients who were fed on or before the fifth day following surgery to those who were fed >5 days post-operatively.
Main Outcomes and Measures: The primary outcome was development of mucocutaneous fistula. Secondary outcomes were functional oral intake scores (FOIS) assessed by head and neck speech language pathologists by 30, 60, and 90 days post-operatively. FOIS greater than 3 signified no feeding tube dependence nor use of tube supplements.
Results: The mean patient age was 62.0 years (SD 16.1), and 20 patients (29.9%) were female. The indication for microvascular reconstruction was mostly isolated or composite oral cavity/mandibular defects (55 patients, 82.1%). There were 11 (16.7%) patients in the early feeding group, 46 (69.7%) were fed after post-operative day 5, and 9 (13.6%) did not have a PO diet restarted on record. For patients who were fed early, the unadjusted relative risk (RR) of developing a fistula was 0.19 (95% confidence interval (CI) 0.08-0.29). Patients who were fed early had an increased likelihood of progression to a full oral diet by 30 days (probability ratio 3.73, 95% CI 2.23-6.27), 60 days (probability ratio 2.70, 95% CI 1.76-4.15), and 90 days (probability ratio 2.55, 95% CI 1.69-3.88).
Conclusions: Data from this retrospective small cohort suggest that oral postoperative feeding before or on POD5 did not negatively impact fistula rates in free flap patients. The data also suggest that early oral postoperative feeding is associated with advancement to a completely oral diet for both short- and longer-term post-operative periods, implying greater post-operative access to the array of social, nutritive, and other quality-of-life benefits offered by oral feeding.