Reintrodução precoce versus tardia de alimentos por via oral em pacientes laringectomizados totais

Abstract

Salivary fistula is the most common complication following totalpharyngolaryngectomy (TPL) or total laryngectomy (TL), occurring in 2.6% to 65.5% of laryngectomized patients. To prevent the development of a pharyngocutaneous fistula, oral feeding is typically reintroduced from the seventh postoperative day in patients subjected to a total laryngectomy. This practice has been followed by most head and neck surgeons (84.5%) for over half a century, with apparently no evidencebasedjustification. However, in some treatment centers, an oral diet is allowed from the first postoperative day. Therefore, the appropriate time for the reintroduction of oral feeding remains controversial. The aims of the present study were as follows: a) to compare the incidence of fistulas among groups with early (first postoperative day) andlate (seventh postoperative day) introduction of an oral diet; b) to determine predictors factors of postoperative salivary fistula; and c) to verify the acceptance of an oral diet in the group receiving early oral feeding. To achieve these goals, a randomized and multicenter study was conducted with 89 patients undergoing TPL or TL performed bysurgeons in the Head and Neck Surgery Group of the Alfa Institute of Gastroenterology at the Hospital das Clínicas, Federal University of Minas Gerais. Study participants were patients from the Hospital das Clínicas at UFMG, Hospital da Baleia in Belo Horizonte and Hospital São João de Deus in Divinópolis, Minas Gerais. The patientswere divided into two groups: the Early group (44 patients) with an oral diet initiated 24 hours after the end of the surgery; and the Late group (45 patients) with an oral diet initiated from the seventh postoperative day. All patients in both groups received commercial polymeric enteral nutrition from the first postoperative day through a nasoenteric tube. Both groups were assessed for the presence or absence of salivaryfistula during the postoperative period. Furthermore, the groups were assessed and compared with respect to nutritional status, hemoglobin levels and the need for blood transfusion, age, gender, tumor stage, surgery performed, duration of surgery, unilateral or bilateral neck dissection and type of neck dissection (elective or therapeutic). Allpatients were also assessed for the acceptance of an oral diet in the postoperative period. The groups were perfectly matched with regards to nutritional status, tumor stage, age, gender and type of surgery. The incidence of salivary fistula consisted of 12 cases (27.3%) in the Early group and six cases (13.3%) in the Late group, with no statisticallysignificant difference between the groups (p = 0.10). Surgical margin involvement by invasive carcinoma was the only predictor of salivary fistula (p = 0.02). An early oral diet did not increased the incidence of salivary fistula. Regarding tolerance of the oral diet, total energy expenditure (TEE) and protein needs in the Early group were notachieved at any time, only oral diet, within the seven days of assessment. All patients required enteral diets to supplement their basal needs. Four and seven postoperative days were required for the patients to achieve 25% and 50% of the TEE, respectively. We therefore concluded that oral diet initiated 24 hours after the end of the laryngectomy does not increased pharyngocutaneous fistula incidence. Surgical margininvolvement by invasive carcinoma is an independent risk factor for salivary fistula. The Early group patients did not adequately tolerate oral diet during the first four postoperative days, thus requiring dietary supplementation through another route.