Nutritional concepts in the treatment of head and neck malignancies

Cancer cachexia should no longer be a contraindication to adequate antineoplastic treatment. Current methods of nutritional assessment allow one to identify malnutrition and to follow the nutritional status of the patient throughout the cancer-management program. Enteral nutritional repletion and maintenance remain the ideal course of action, but the gastrointestinal tract is not always readily available or advisable for use; in such circumstances, intravenous hyperalimentation (IVH) may be indicated. The properly nourished patient better tolerates cancer therapy, experiences fewer complications of malnutrition (e.g., sepsis and poor wound healing), and has a better-functioning immune system than does his malnourished counterpart. This article reviews methods of nutritional assessment, delineates indications and techniques for nutritional repletion, and summarizes the results obtained.     

Anaesthetic considerations for patients receiving photodynamic therapy in head and neck surgery

Photodynamic therapy is an innovative modality in the treatment of malignant and non-malignant diseases. Owing to its widespread use, there will be an increase in the number of photosensitized patients presenting for both elective and emergency anaesthesia. As one of the few centres involved in providing this specialized treatment for maxillofacial conditions, we would like to highlight its main anaesthetic considerations.     

Changing concepts in head and neck surgical oncology

Preoperative infusion of volume to increase the wedge pressure will maintain stable flow and arterial pressure at the time of aortic declamping. Usually 1,500 ml of balanced salt solution given with 75 g of albumin is sufficient to accomplish this purpose. Pressor or inotropic agents are not required. In our experience 14 percent of patients will have a down-slope in the preoperative myocardial performance curves. In these persons, volume infusions should be adjusted to keep the pulmonary arterial wedge pressure on the ascending portion of the curve. The use of vasodilator agents in normotensive patients has a deleterious effect on cardiac performance.     

Complications in head and neck surgery

Complications of the surgery for head and neck cancer may be catastrophic or noncatastrophic. Recognition of this is frequently as important as the method of resolution. A general classification of complications as anatomic, physiologic, technical, and functional will aid in recognition and prevention of these problems in this difficult group of patients.     

Nutritional status--a prognostic indicator in head and neck cancer

A prospective study into the nutritional status of 114 patients with untreated primary squamous cell carcinoma of the head and neck was undertaken to assess its possible prognostic value for survival. Nutritional status was evaluated by anthropometry, creatinine height index estimation, serum albumin and transferrin assays, and nitrogen balance studies. Weight change and other anthropometric indices found to be the most reliable nutritional parameters were averaged to derive a clinically useful, general nutritional status score. A nutritional deficit was found in 43 of the 114 patients (37.7%) and was associated with neoplasms of the upper gastrointestinal tract in more than 80% of the patients. Life table analysis showed a statistically very highly significant difference between the survival of the adequately nourished patients (57.5% at 2 years) and the survival of the undernourished patients (7.5% at 2 years) (chi 2 = 36.08; P = .0). These results indicate that nutritional deficiency is an important adverse prognostic factor in head and neck cancer. Undernutrition probably exerts its effect, at least in part, by causing secondary immunologic dysfunction.     

Deliberate hypotension in head and neck surgery

The deliberate reduction of blood pressure in an attempt to reduce intraoperative blood loss has generated significant controversy in the 30 years since its clinical introduction. Numerous series have been reported, but few have met generally accepted, current criteria for controlled studies. In this article, the effect of blood pressure reduction on organ perfusion will be presented together with a review of techniques of achieving hypotension. A summary of results is included and, based on this data, recommendations are offered regarding the application and limits of deliberate hypotension.     

Regional anesthesia in head and neck surgery

Regional anesthesia in the head and neck area is a common and effective tool for the plastic surgeon. For short procedures, it offers the advantages of convenience and comfort to the patient. In many procedures, in addition, it offers advantages to the plastic surgeon over general anesthesia. A knowledge of anatomy of the course of the sensory nerves in the head and neck is essential to execute regional anesthesia. Some variability is always present. However, the most important factor in success is practice with a specific technique until it is mastered. No attempt was made in this article to provide an exhaustive reference to all acceptable forms of anesthesia. An attempt was made, however, to indicate one or two successful methods for each type of commonly used block so that when studied and practiced it can be expected to yield consistent results. Some repetition has been unavoidable because the intent has been to provide a relatively self-contained section for each block so that it may be as a reference without having to read the entire article. It is hoped that frequent practice will result in effective local and regional anesthesia in the head and neck area.     

Postoperative drainage in head and neck surgery

INTRODUCTION

A major factor affecting patients’ length of hospitalisation following head and neck surgery remains the use of surgical drains. The optimal time to remove these drains has not been well defined. A routine practice is to measure the drainage every 24 h and remove the drain when daily drainage falls below 25 ml. This study aims to determine whether drainage measurement at shorter intervals decreases the time to drain removal and hence the length of in-patient stays.

PATIENTS AND METHODS

A 6-month prospective observational study was performed. The inclusion criteria were patients whounderwent head and neck surgery without neck dissection and had a closed suction drain inserted. Drainage rates were measured at 8-hourly intervals. Drains were removed when drainage-rate was ≤ 1 ml/h over an 8-h period.

RESULTS

A total of 43 patients were evaluated. The highest drainage rate occurred in the first 8 postoperative hours and decreased significantly in the subsequent hours. The median drainage rates at 8, 16, 24, 32 and 40 postoperative hours were 3.375, 1, 0, 0 and 0 ml/h, respectively. Applying our new removal criteria of ≤ 1 ml/h drainage rate, the drains were removed in 22 (51%) patients at the 16th postoperative hour; 37 (86%) were removed by 24 h after operation. In comparison, only nine (20.9%) patients could potentially be discharged the day after surgery if previous criteria of ≤ 25 ml/24-h were used to decide on drain removal.

CONCLUSIONS

Our 8-hourly drainage-rate monitoring has facilitated safe earlier discharge of an additional 28 (65%) patients on the day after surgery. This has led to improvement in patient care, better optimisation of hospital resources and resulted in positive economic implications to the department.