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Intravenous hyperalimentation in head and neck tumour surgery: Indications and precautions
INTRAVENOUS HYPERALIMENTATION IN HEAD AND NECK TUMOUR SURGERY: INDICATIONS AND PRECAUTIONS
By ROBERT L. RUBERG, M.D. Division of Plastic Surgery, Ohio State University College of Medicine, Room N-809, University Hospitals, 410 W. Tenth Avenue, Columbus, Ohio 43210, USA
and STANLEY J. DUDRICK, M.D. The Program in Surgery, University of Texas Medical School at Houston, Texas, USA
MAJORhead and neck surgical procedures often result in temporary prevention of oral nutritional intake. Nasogastric or cervical pharyngostomy (Royster et al., 1968). tubes are usually all that is required, but in certain circumstances intravenous hyperalimentation (Dudrick et al., 1970; Dudrick and Rhoads, 1971) is the only way to achieve wound healing, positive nitrogen balance, and weight gain until oral feeding can be resumed (Copeland et al., 1975). We have reviewed 25 head and neck surgery patients nourished in this way in order to define the indications for and the precautions to be taken with intravenous hyperalimentation in such patients. INDICATIONS Preoperative
Certain patients receiving preoperative radiotherapy preparation. stop eating because of mouth pain or swallowing impairment. Parenteral feeding will rapidly reverse wasting, achieve positive nitrogen balance and make the patient as fit as possible for operation. Illustrative case. A q&year-old man was admitted with a carcinoma of the floor of the mouth. He began a course of radiotherapy to total 5,000 rad prior to the proposed resection. After I month he developed such mouth pain and difliculty in swallowing from the radiation, that a subclavian catheter was placed and he was fed approximately 2,500 calories per day intravenously for 3 weeks. He maintained his weight while the radiotherapy was completed, and successfully tolerated the subsequent operation. We feel this favourable outcome was partly due to the improved nutritional state from the intravenous feeding.
Postoperative
Three such dysfunctions which made gastrointestinal dysfunction. tube feeding unsatisfactory or impossible were encountered: diarrhoea and malabsorption, known oesophageal varices, and repeated vomiting with inhalation of vomit. Intravenous hyperalimentation was the only alternative.
Illustrative case. A 62-year-old man with a carcinoma of the pharynx had a radical resection of the tumour combined with radical neck dissection, tracheostomy and cervical oesophagostomy. He experienced a series of severe wound complications, 151
152
BRITISH
JOURNAL
OF PLASTIC
SURGERY
FIG. I. Broken down neck wound following laryngectomy
and radical neck dissection. just survived a carotid blow-out.
FIG. 2.
The rapidly healing neck wound following 4 weeks of intravenous
The patient has
hyperalimentation.
culminating in the development of an orocutaneous fistula and a carotid rupture, which he survived. Although early in his course he appeared to tolerate his tube feeding, as his condition deteriorated he began to have significant diarrhoea after each feed. In addition, gastric contents were identified in his tracheostomy drainage on a number of occasions. His tube feedings were stopped and intravenous hyperalimentation of about 2,700 calories per day was administered during the next 44 weeks. He had then improved to such an extent that he was able to resume tube feedings without recurrence of his previous complications. Renal or hepatic failure. In patients with renal or hepatic failure we have used a special intravenous nutritional regimen consisting of highly concentrated glucose as an energy source and only the essential amino acids as a nitrogen source (Dudrick et al., 1970; Abel et al., 1973). In renal failure this regimen results in a reduction of blood urea nitrogen levels, while in hepatic failure it aids in the utilisation of endogenous nitrogen in the form of ammonia. Illustrative case. A q&year-old male with a history of alcoholism underwent a laryngectomy and radical neck dissection for a carcinoma of the larynx. Postoperatively his wound broke down (Fig. I) and he survived a carotid rupture. About a week postoperatively he began to bleed from oesophageal varices and went into hepatic coma. He was started on the liver failure hyperalimentation regimen, and continued exclusively
INTRAVENOUS
HYPERALIMENTATION
IN HEAD AND NECK SURGERY
I53
on intravenous feedings for I month during which his wound healing progressed (Fig. 2), his mental state cleared, and he was able to resume oral feeding. PRECAUTIONS
All of the head and neck surgery patients reviewed were fed by standard methods of parenteral hyperalimentation delivered through an indwelling subclavian catheter (Dudrick and Ruberg, 1971). Recent studies show more conclusively that long-term feeding with this technique does not result in excessively high infection rates (Copeland et al., 1974). However, specific precautions must be taken with head and neck surgery patients: the feeding catheter is placed on the side opposite the patient’s lesion or neck dissection; the catheter is handled with meticulous aseptic technique during dressing changes; because of occasional soiling of the catheter with tracheotomy secretions or wound drainage, a sterile plastic drape is placed over the catheter dressings. CONCLUSION
In certain patients with head and neck cancer intravenous hyperalimentation is the most rapid if not the only way of restoring or maintaining the patient’s nutritional state. With suitable precautions parenteral feeding may safely be continued for as long as is necessary. REFERENCES ABEL, R. M., BECK, C. H., ABBOTT,W. M., RYAN, J. A., Jr., BARNETT,G. 0. and FISCHER, J. E. (1973). Improved survival from acute renal failure after treatment with intravenous essential L-amino acids and glucose. New England Journal of Medicine, 288, COPE:~&
E M III MACFADYEN B V Jr McGom C. and DUDRICK S J. (1974) The hse’ of &pe&limentation in pa&nts.‘with poten& sepsis. Surge&, .&necoZogj and Obstetrics, 138, 377. COPELAND,E. M., MACFADYEN,B. V., Jr., MACCOMB, W. S., GUILLANOMDEGUI, O:, JESSE, R. H. and DUDRICK, S. J. (1975). Intravenous hyperalimentation in patients with head and neck cancer. Cancer, 35, 606. DUDRICK, S. J., LONG, J. M:, STEIGER,E. M. and RHOADS, J. E. (1970). Intravenous hyperalimentation. Medzcal Clinics of North America, 50~ 1031. DUDRICK, S. J. and RHOADS,J. E. (1971). New horizons for mtravenous feeding. Journal of the American Medical Association, 215, 939.
DUDRICK, S. J. and RUBERG,R. L. (1971). Gastroenterology,
61, 901.
Principles
and practice of parenteral
nutrition.
DUDRICK, S. J., STEIGER,E. and LONG, J. M. (1970). Renal failure in surgical patients. Treatment with intravenous essential amino acids and hypertonic glucose. Surgery, 68, 108.
ROYSTER,J. P., NOONE, R. B., Gm, .W. P: and THEOGARAJ,S. D. (1968). Cervical $ry6,r~torny for feeding after maxillofacial surgery. American Journal of Surgery,
,
30/2-n
*
By ROBERT L. RUBERG, M.D. Division of Plastic Surgery, Ohio State University College of Medicine, Room N-809, University Hospitals, 410 W. Tenth Avenue, Columbus, Ohio 43210, USA
and STANLEY J. DUDRICK, M.D. The Program in Surgery, University of Texas Medical School at Houston, Texas, USA
MAJORhead and neck surgical procedures often result in temporary prevention of oral nutritional intake. Nasogastric or cervical pharyngostomy (Royster et al., 1968). tubes are usually all that is required, but in certain circumstances intravenous hyperalimentation (Dudrick et al., 1970; Dudrick and Rhoads, 1971) is the only way to achieve wound healing, positive nitrogen balance, and weight gain until oral feeding can be resumed (Copeland et al., 1975). We have reviewed 25 head and neck surgery patients nourished in this way in order to define the indications for and the precautions to be taken with intravenous hyperalimentation in such patients. INDICATIONS Preoperative
Certain patients receiving preoperative radiotherapy preparation. stop eating because of mouth pain or swallowing impairment. Parenteral feeding will rapidly reverse wasting, achieve positive nitrogen balance and make the patient as fit as possible for operation. Illustrative case. A q&year-old man was admitted with a carcinoma of the floor of the mouth. He began a course of radiotherapy to total 5,000 rad prior to the proposed resection. After I month he developed such mouth pain and difliculty in swallowing from the radiation, that a subclavian catheter was placed and he was fed approximately 2,500 calories per day intravenously for 3 weeks. He maintained his weight while the radiotherapy was completed, and successfully tolerated the subsequent operation. We feel this favourable outcome was partly due to the improved nutritional state from the intravenous feeding.
Postoperative
Three such dysfunctions which made gastrointestinal dysfunction. tube feeding unsatisfactory or impossible were encountered: diarrhoea and malabsorption, known oesophageal varices, and repeated vomiting with inhalation of vomit. Intravenous hyperalimentation was the only alternative.
Illustrative case. A 62-year-old man with a carcinoma of the pharynx had a radical resection of the tumour combined with radical neck dissection, tracheostomy and cervical oesophagostomy. He experienced a series of severe wound complications, 151
152
BRITISH
JOURNAL
OF PLASTIC
SURGERY
FIG. I. Broken down neck wound following laryngectomy
and radical neck dissection. just survived a carotid blow-out.
FIG. 2.
The rapidly healing neck wound following 4 weeks of intravenous
The patient has
hyperalimentation.
culminating in the development of an orocutaneous fistula and a carotid rupture, which he survived. Although early in his course he appeared to tolerate his tube feeding, as his condition deteriorated he began to have significant diarrhoea after each feed. In addition, gastric contents were identified in his tracheostomy drainage on a number of occasions. His tube feedings were stopped and intravenous hyperalimentation of about 2,700 calories per day was administered during the next 44 weeks. He had then improved to such an extent that he was able to resume tube feedings without recurrence of his previous complications. Renal or hepatic failure. In patients with renal or hepatic failure we have used a special intravenous nutritional regimen consisting of highly concentrated glucose as an energy source and only the essential amino acids as a nitrogen source (Dudrick et al., 1970; Abel et al., 1973). In renal failure this regimen results in a reduction of blood urea nitrogen levels, while in hepatic failure it aids in the utilisation of endogenous nitrogen in the form of ammonia. Illustrative case. A q&year-old male with a history of alcoholism underwent a laryngectomy and radical neck dissection for a carcinoma of the larynx. Postoperatively his wound broke down (Fig. I) and he survived a carotid rupture. About a week postoperatively he began to bleed from oesophageal varices and went into hepatic coma. He was started on the liver failure hyperalimentation regimen, and continued exclusively
INTRAVENOUS
HYPERALIMENTATION
IN HEAD AND NECK SURGERY
I53
on intravenous feedings for I month during which his wound healing progressed (Fig. 2), his mental state cleared, and he was able to resume oral feeding. PRECAUTIONS
All of the head and neck surgery patients reviewed were fed by standard methods of parenteral hyperalimentation delivered through an indwelling subclavian catheter (Dudrick and Ruberg, 1971). Recent studies show more conclusively that long-term feeding with this technique does not result in excessively high infection rates (Copeland et al., 1974). However, specific precautions must be taken with head and neck surgery patients: the feeding catheter is placed on the side opposite the patient’s lesion or neck dissection; the catheter is handled with meticulous aseptic technique during dressing changes; because of occasional soiling of the catheter with tracheotomy secretions or wound drainage, a sterile plastic drape is placed over the catheter dressings. CONCLUSION
In certain patients with head and neck cancer intravenous hyperalimentation is the most rapid if not the only way of restoring or maintaining the patient’s nutritional state. With suitable precautions parenteral feeding may safely be continued for as long as is necessary. REFERENCES ABEL, R. M., BECK, C. H., ABBOTT,W. M., RYAN, J. A., Jr., BARNETT,G. 0. and FISCHER, J. E. (1973). Improved survival from acute renal failure after treatment with intravenous essential L-amino acids and glucose. New England Journal of Medicine, 288, COPE:~&
E M III MACFADYEN B V Jr McGom C. and DUDRICK S J. (1974) The hse’ of &pe&limentation in pa&nts.‘with poten& sepsis. Surge&, .&necoZogj and Obstetrics, 138, 377. COPELAND,E. M., MACFADYEN,B. V., Jr., MACCOMB, W. S., GUILLANOMDEGUI, O:, JESSE, R. H. and DUDRICK, S. J. (1975). Intravenous hyperalimentation in patients with head and neck cancer. Cancer, 35, 606. DUDRICK, S. J., LONG, J. M:, STEIGER,E. M. and RHOADS, J. E. (1970). Intravenous hyperalimentation. Medzcal Clinics of North America, 50~ 1031. DUDRICK, S. J. and RHOADS,J. E. (1971). New horizons for mtravenous feeding. Journal of the American Medical Association, 215, 939.
DUDRICK, S. J. and RUBERG,R. L. (1971). Gastroenterology,
61, 901.
Principles
and practice of parenteral
nutrition.
DUDRICK, S. J., STEIGER,E. and LONG, J. M. (1970). Renal failure in surgical patients. Treatment with intravenous essential amino acids and hypertonic glucose. Surgery, 68, 108.
ROYSTER,J. P., NOONE, R. B., Gm, .W. P: and THEOGARAJ,S. D. (1968). Cervical $ry6,r~torny for feeding after maxillofacial surgery. American Journal of Surgery,
,
30/2-n
*