Investigating surgical recovery after head and neck reconstruction

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. It's been thought that people who undergo surgery for head and neck reconstructive surgeries are more likely to have complications if they're allowed to eat within the first five days after surgery. An international team of researchers looked into that assumption, and we'll hear what they discovered from my guest, Dr. Hani Aiash. He's the assistant dean for interprofessional research at Upstate's College of Health Professions, and he's the senior author of this paper. Welcome back to "The Informed Patient," Dr. Aiash.

[00:00:41] Hani Aiash, MD, PhD: Thank you, Amber.

[00:00:43] Host Amber Smith: Do many surgeons believe patients need to hold off eating for a few days after extensive surgery of the head and neck region?

[00:00:52] Hani Aiash, MD, PhD: Yes, Amber. In the past, there was a belief that initiating oral feeding shortly after surgery or removing feeding tubes early, following significant head and neck reconstruction, led to increased complications. In recent years the consensus among experts regarding the perioperative care of individuals undergoing head and neck cancer free tissue flap reconstruction -- as outlined by the (American) Society for Enhanced Recovery (after surgery) -- in 2017 suggests prompt reinitiation of oral feeding following the surgical procedures. However, and because of tradition, patient recovering from reconstructive oral surgery using a free flap in most of the occasions are kept at NPO for six to 12 days.

[00:01:46] Host Amber Smith: And NPO means nothing oral, nothing going through their mouth?

[00:01:50] Hani Aiash, MD, PhD: Yes.

[00:01:51] Host Amber Smith: So is the thinking that the tissue needs time to heal before it's exposed to food and drink?

[00:01:59] Hani Aiash, MD, PhD: They were thinking like this, but our study proved that no, you can use the early feeding, and we have a very good outcome after this.

[00:02:10] Host Amber Smith: I want to hear more about those results, but let me make sure I understand. Now, the surgeries we're talking about mostly are done to remove cancers?

[00:02:18] Hani Aiash, MD, PhD: Yes. Free flap reconstruction is a surgical technique used in various medical specialties, primary and reconstructive surgery particularly, for areas with significant tissue loss or defects. Indication for free flap reconstruction include trauma, removal of tumors, congenital defects, chronic wounds that don't heal properly, or cosmetic reconstruction, to mention some.

[00:02:46] Host Amber Smith: And the thinking or the fear of letting people eat soon after the surgery, were patients allowed to receive nutrition some other way than going through the mouth during this time?

[00:03:00] Hani Aiash, MD, PhD: Yes. In the old thinking they use parental or IV, or sometimes they use nasogastric tube. But to ensure that they receive adequate nutrition,during this time, two main methods are commonly employed -- enteral feeding, which this method involves delivering nutrition directly into the gastrointestinal tract with nasogastric tube, as I told you, or a nasal incisional tube that can be inserted through the nose and down to the stomach or small intestine, respectively. And parenteral nutrition. This involves delivering nutrients directly into the bloodstream by IV (intravenous) lines.

[00:03:39] Host Amber Smith: So if a patient needed any of those modes of nutrition, they would be in the hospital during that time, correct?

[00:03:47] Hani Aiash, MD, PhD: Yes.

[00:03:48] Host Amber Smith: I see. Now your study appears in the journal, Maxillofacial Plastic Reconstructive Surgery. What made you decide to examine this issue?

[00:03:58] Hani Aiash, MD, PhD: We decided to study this topic, as there is limited research about early feeding shortly after free flap surgery, especially after head and neck cancer. Our study aimed to compile the evidence on the association between early initiation of oral feeding and postoperative complications, like fistula formation, seroma development, and flap failure, and the length of this hospital stay in order to suggest implementation of an early oral feeding protocol after free flap reconstruction among head and neck cancer patients.

[00:04:36] Host Amber Smith: Now you used a few terms I wanted to ask you to define. You said "fistula" formation. What is a fistula?

[00:04:43] Hani Aiash, MD, PhD: The fistula is an unplanned tunnel that forms between two parts of your body that shouldn't be connected. It can happen because of injury, infection, or other reasons.

Flap failure occurs when the surgical flap, which is a piece of tissue, moves from one area of the body to another area during surgery, partially or completely separates from its attachment site. It can happen due to various reasons, such as poor blood supply, infection, tension on wounds.

And hematoma is collection of blood, as you know, that accumulates in the tissue of the neck, while a collection of serous fluid, clear and yellowish fluid, that accumulates in the tissue of the neck is a seroma.

And one infection happens when harmful germs like bacteria, get into the cut or scab or surgical incision.

[00:05:38] Host Amber Smith: You are listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Hani Aiash, assistant dean for interprofessional research at Upstate's College of Health Professions, and the lead author for the research paper we're discussing.

Now your team includes researchers from Saidi Arabia, Peru, Egypt, and Charleston, South Carolina, Reading, Pennsylvania, New York City. You looked back at paperwork for more than a thousand patients. Were all of the patients from those areas?

[00:06:10] Hani Aiash, MD, PhD: Our study is a meta analysis. A meta analysis is a type of research study that combines data from multiple independent studies on a particular topic to provide a more comprehensive and statistically robust analysis, what we call increasing the power.

We have found new studies about these topics from other countries, like our patients came from New Zealand, UK, US, and China, but we are international team. We are working with many people to get these results, and not related to the sample size from these countries.

[00:06:48] Host Amber Smith: And to get the terminology right, early feeding means during the first five days after surgery, and late feeding was five days or later?

[00:06:58] Hani Aiash, MD, PhD: You are right. We use the definition of early feeding using a cutoff point of five days, and as outlined in all the study included in our meta-analysis.

[00:07:09] Host Amber Smith: Well, let's talk about your findings. Did you find that it makes sense to withhold food from patients for up to five days after head and neck reconstructive surgery?

[00:07:18] Hani Aiash, MD, PhD: We have a lot of findings here. We found there is no statistical difference between the complication, between early and late feeding, oral feeding. According to our results, our findings suggest surgeons should consider implementation of early oral feeding protocol after flap reconstructions in patients affected by head and neck cancers.

Also we discovered that there is association between shorter hospital stay.

This can be due to several factors such as faster recovery, as eating shortly after oral surgery helps maintain their nutritional status and energy level, which can aid in the body's healing process, improve patient comfort and satisfaction, promoting psychological wellbeing, enhancing healing of oral tissue. In these cases they benefit from adequate nutrition to support healing and regeneration.

Proper nutrition can help, also, to reduce postoperative swelling and pain. And early nutrition after surgery is usually associated with decreased risk of complications.

[00:08:29] Host Amber Smith: So when we talk about oral feeding, after having a major surgery of the head and neck region, do you start with liquid? Do you start with soft foods? I mean, there's got to be some guidelines, right?

[00:08:42] Hani Aiash, MD, PhD: Yes. We begin with liquid. Then we begin gradually to give soft food, then hard food. But usually we begin with liquid and soft food.

[00:08:50] Host Amber Smith: So what would you like doctors and patients to take away from your study?

[00:08:55] Hani Aiash, MD, PhD: The patient, I will tell them that the main reason for doing research in medicine is to find new ways to improve peoples' health. This research helps doctors and health care professionals provide the best possible care to you, to the patients, leading to the better outcome and quality of care for everyone. However, when having complex situations such as surgery, the physician assessment of their patient's characteristic is vital for deciding the best outcome based on evidence-based medicine that can be tailored especially, specifically for you.

So the patients listen to the doctors, especially when he applies evidence-based medicine, especially if we have research proof that early oral feeding will help you.

For the doctors, I will tell them that to the best of our knowledge, our study is the first meta-analysis addressing the impact of early oral feeding on various postoperative complications, as well as the duration of hospital stay following free flap reconstruction in head and neck. And I believe it's excellent article to have a look at it, especially when we prove that there is no difference between complication between early and late oral feeding --but we have also shortened the hospital stay with early oral feeding.

[00:10:20] Host Amber Smith: So it sounds like based on your study, keeping a patient in the hospital just to feed them soon after the surgery isn't the reason you need to do that. There may be other factors that the surgeons can concentrate on, but keeping them with adequate nutrition shouldn't be one of them.

[00:10:39] Hani Aiash, MD, PhD: Yes. Usually the decision to stay in the hospital after surgery depends on how well the patient is recovering. As you know, we are doing personalized treatment. You cannot paint all the people with the same brush. This is what we call personalized medicine. We are different, and this is why most patients typically stay in hospital for 10 to 14 days after these surgeries. It really depends on each person's unique situation. Some studies have found that this time can be reduced to as little as six days.

[00:11:09] Host Amber Smith: Well, Dr. Aiash, I really appreciate you making time to share your research with us.

[00:11:14] Hani Aiash, MD, PhD: Thank you very much, Amber, for inviting me. Thank you for hosting me.

[00:11:18] Host Amber Smith: My guest has been Dr. Hani Aiash. He's the assistant dean for interprofessional research at Upstate's College of Health Professions. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.