Nutritional outcomes in patients undergoing transoral robotic surgery for head and neck cancers compared to conventional open surgery. Systematic review

This systematic review examined nutritional outcomes in patients undergoing transoral robotic surgery (TORS), compared to open surgery (OS) for head and neck cancer. PUBMED, CINAHL, and Web of Science were systematically reviewed. Target nutritional outcomes included: weight, nutritional status, use of enteral feeding, swallowing function/ability, and time to oral diet. Risk of bias was assessed using the risk of bias in non-randomized studies tool, and certainty of evidence was assessed using grading of recommendations, assessment, development, and evaluation (GRADE). Eight studies were included (total n = 608). Compared to OS, TORS probably reduces short- and long-term enteral feeding use or duration (GRADE “moderate” certainty), may reduce time to full swallow ability (GRADE “low” certainty), but it remains uncertain whether TORS reduces long-term patient reported swallowing function or time to oral feeding (GRADE “very-low” certainty). No studies examined nutritional status or weight. There is limited body of evidence examining nutrition outcomes following TORS. Further studies are warranted, which may improve the certainty of evidence and assist in determining the optimal nutrition care for these patients.     

Endoscopic video‐assisted transoral resection of lateral oropharyngeal tumors

Endoscopic, video‐assisted transoral resection of oropharyngeal tumors is a novel technique carried out using common instruments present in most otolaryngology departments. The technique facilitates oropharyngeal resection akin to transoral robotic surgery (TORS) without the need for a robot. A dual surgeon approach, analogous to that of endoscopic skull base surgery is used. Each surgeon can actively participate in the resection with several key advantages over current techniques. The technique is applicable to departments internationally especially where the use of a robot is prohibited by cost or availability. This is especially important given the resection of oropharyngeal tumours offers the opportunity of single modality treatment or reduced intensity adjuvant treatment compared to traditional non‐surgical therapy.     

Prophylactic arterial ligation following transoral robotic surgery: A systematic review and meta‐analysis

Prophylactic arterial ligation has been proposed to reduce the severity of postoperative hemorrhage following transoral robotic surgery (TORS). Previous studies have shown a trend toward a reduction in major and severe bleeding. Search strategies were implemented in multiple databases and completed in August 2018. Inclusion and exclusion criteria were designed to capture studies examining adults undergoing TORS for oropharyngeal cancer. Four retrospective studies were selected appropriate for analysis by two reviewers who independently extracted data. PRISMA guidelines were followed. A random‐effects model was used for meta‐analysis. Meta‐analysis of 619 patients in four retrospective reviews showed that the pooled RR of major and severe bleeding events was significantly lower in prophylactically ligated patients (RR, 0.28; 95% CI, 0.08‐0.92; I² = 0). Prophylactic arterial ligation of external carotid artery branches is associated with a decreased risk of major and severe bleeding events, although confounding factors remain incompletely analyzed.     

Transoral robotic surgery: role in the management of upper aerodigestive tract tumors

The toxicity associated with concomitant chemoradiation for the management of laryngeal and pharyngeal carcinoma has been well documented. Minimally invasive surgical techniques offer the potential to extirpate the malignancy as a single-modality therapy and provide essential information that may direct subsequent treatment. In selected patients, radiation doses may be reduced and systemic chemotherapy may be withheld after tumor extirpation. Transoral laser microsurgery has proven effective, although inability to manipulate and suture tissue by this modality limits ablation and reconstruction of extensive defects. Transoral robotic surgery is a relatively new technique that provides several unique advantages, which include a 3-dimensional magnified view, ability to see and work around curves or angles, and the availability of 2 or 3 robotic arms that can be used to reconstruct extensive defects using either local, regional, or free flaps. Preliminary data suggest that transoral robotic surgery may provide a technique for ablation and reconstruction of pharyngeal defects that may be superior to other transoral techniques. It may also provide a means for personalizing therapy for oropharyngeal and supraglottic carcinoma.