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Oral Cancer

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Factors affecting postoperative removal of nasogastric tube and tracheostomy tube in oral cancer: a retrospective analysis of 234 cases

  • Prateek V. Jain
  • Kapila Manikantan
  • Dipanwita Roy
  • Pattatheyil Arun
Original Article
  • 15 Downloads
Part of the following topical collections:
  1. Rehabilitation and Supportive Care

Abstract

Introduction

Prolonged use of nasogastric and tracheostomy tubes in the postoperative period is a major cause of morbidity after surgery for oral cancer and prolongs discharge from hospital. In this study, we sought to determine the variables that predict prolongation of nasogastric and tracheostomy tubes in patients undergoing surgery for squamous cell carcinoma of the oral cavity.

Methods

Data from 234 patients who underwent surgery for oral squamous cell carcinoma were retrospectively analyzed for patient variables including oral cavity sub-site, T stage, extent of surgical resection, need and type of reconstruction and adjuvant treatment.

Results and discussion

The sample was composed of 234 patients with a mean age of 53.08 years (range 24–85 years) and 29% were women. Median duration for removal of nasogastric tube and tracheostomy tube after surgery was 15 days (n = 234, range 6–897 days) and 7 days (n = 111, range 2–160 days), respectively. Performance of reconstructive procedures (15 vs 9 days, p = 0.003) was the only significant factor affecting nasogastric tube removal. Tracheostomy tube removal was affected by age and tongue as the primary site (19 vs 7 days, p = 0.009). Delay in removal of tracheostomy tube and nasogastric tube delayed discharge of the patients from hospital (12 mean days, range 1–35 days).

Conclusion

Use of flaps for reconstruction impedes oral feeding in postoperative period, while delayed decannulation is seen in older patients and in patients operated for carcinoma of the tongue. Delay in decannulation and nasogastric tube removal prolonged the hospital stay of the patients.

Keywords

Dysphagia Swallowing Tracheostomy 

Introduction

Squamous cell carcinoma (SCC) of the oral cavity is the 5th most common cancer worldwide [10]. Patients are frequently treated with combination therapy that includes surgical resection with or without reconstruction, chemotherapy and radiation therapy. Nasogastric tube (NGT) insertion and tracheostomy are commonly done during surgery as a temporary conduit for nutrition and airway [4].

Delay in removal of these tubes can result in significant morbidity: it can increase the length of hospital stay and delay speech and swallowing rehabilitation, and it is more likely to be associated with other postoperative complications such as higher risk of pneumonia, poorer oral intake and weight loss [1]. It also significantly affects a patient’s quality of life, increases cost related to long-term tube management and predisposes to months and years of potential complications of tracheostomy tube care.

As the life expectancy of these patients is increasing, there is a growing emphasis on functional outcomes and quality of life in the treatment of the oral SCCs [1]. As such, knowledge of the variables that can predict a patient’s dependence on nasogastric tube and tracheostomy tube is potentially very useful: modification of these risk factors can reduce the incidence of dependence on tubes for feeding and breathing, and the knowledge of non-modifiable risk factors would allow for appropriate counseling of the patients about their risk profile.

In this study, we determined the factors that influenced the removal of the nasogastric tube and tracheostomy tube in patients undergoing surgery for oral SCC.

Materials and methods

This was a retrospective cohort study and the study sample was derived from a population of 234 patients who underwent surgery for oral SCC from August 2011 through July 2014. Patients eligible for inclusion in the study underwent tumor resection as their primary modality of treatment. Patients were excluded from study enrollment if their primary lesion did not originate from the oral cavity and if adequate follow-up data could not be obtained or accurately verified.

Days taken for removal of NGT and tracheostomy tube were the two outcome variables analyzed. Evan’s blue dye test was used to decide about removal of tracheostomy tube. The decision of oral feeding was taken after bedside 5-ml water swallow test and the decision of NGT removal was taken by the speech and swallow therapist on clinical judgement after patient starts taking 75% of his daily dietary requirement orally [2]. Other study variables included age, gender, adjuvant treatment with radiation or chemotherapy (any dose or type of radiation or chemotherapy used as a treatment for OSCC after primary resection recorded as yes or no), tumor stage (defined by size of tumor), primary site of tumor, extent of surgical resection and reconstructive procedure.

Patients with tongue as their primary tumor site (N = 112) were assessed later for effect of age, gender, T stage and requirement of reconstructive procedures on removal of NGT and tracheostomy tube.

Descriptive and inferential statistics were performed with SPSS 17 (IBM Corp., Chicago, Illinois, USA). Continuous variables were analyzed using regression analysis, whereas effect of categorical variables on NGT tube and tracheostomy tube removal was analyzed using independent samples t test. Both univariate and multivariate analyses were performed.

Observation and results

In 234 patients who underwent surgery for oral SCC, NGT was inserted in all patients and tracheostomy was performed in 111 patients. Median time for removal of NGT after surgery was 15 days (range 6–897 days) while that for removal of tracheostomy tube was 7 days (range 2–160 days). The mean duration in days for removal of the NGT and tracheostomy tube for various groups of the patients is depicted in Tables 1 and 2.
Table 1

Mean time (days) for removal of NGT (univariate analysis)

Criteria

N (234)

Mean days (95% CI)

p value

Gender

 Males

165

50.68 (− 11.44–112.82)

0.415

 Females

69

22.72 (16.54–28.99)

Primary site

 Tongue

112

25.70 (9.35–42.06)

1.000

 BM/Alveolus/RMT

112

22.59 (16.04–29.14)

 Other

10

11.10 (5.48 – 16.71)

Reconstruction

 Done

161

30.64 (13.87–47.42)

0.003

 Not done

73

9 (6.51–11.48)

Type of flap

 Free flap

85

22.35 (17.44–27.26)

0.392

 Local flap

76

22.76 (16.99–37.52)

Resection of oropharyngeal structures

 Done

211

23.04 (16.19–31.93)

0.441

 Not done

23

28.60 (12.11–49.88)

Mandibulectomy

 Not done

123

22.09 (7.15–37.04)

0.597

 Segmental

75

29.90 (20.73–39.08)

 Marginal

36

15.55 (10.86–20.24)

T staging

 T1, T2

149

21.98 (− 133–176.96)

0.669

 T3, T4

85

25.80 (− 43.62–95.22)

Adjuvant treatment

 Not administered

73

23.86 (14.55–30.87)

0.963

 Administered

161

23.42 (16.35–29.99)

Bold value is statistically significant (p < 0.05)

Table 2

Mean time (days) for removal of tracheostomy tube (Univariate analysis)

Criteria

N (111)

Mean days (95% CI)

p value

Gender

 Males

82

7.72 (5.99–9.44)

0.241

 Females

29

13.10 (7.74–18.46)

Primary site

 Tongue

44

19.09 (9.35–28.83)

0.009

 BM/Alveolus/RMT

65

6.87 (5.76–7.98)

 Other

2

6 (− 6.70–18.70)

Reconstruction

 Done

108

11.89 (7.80–15.99)

0.562

 Not done

3

4.66 (− 1.58–01.91)

Type of flap

 Free flap

70

13.08 (8.55–17.61)

0.414

 Local flap

38

9.48 (0.88–18.08)

Resection of oropharyngeal structures

 Done

96

9.00 (5.88–12.11)

0.256

 Not done

15

12.12 (7.53–16.71)

Mandibulectomy

 Not done

38

15.18 (5.02–25.34)

0.703

 Segmental

56

9.00 (5.18–12.81)

 Marginal

17

12.82 (7.07–18.57)

T staging

 T1, T2

52

15.21 (− 45.67–76.09)

0.129

 T3, T4

59

8.53 (− 2.81–19.87)

Adjuvant treatment

 Not Administered

15

10.85 (5.50–16.89)

0.880

 Administered

96

11.78 (5.86–18.36)

Bold value is statistically significant (p < 0.05)

Delay in removal of tracheostomy tube significantly delayed the removal of NGT (p = 0.002).

Need of reconstruction (p = 0.003) was the only significant factor affecting NGT removal (Table 1) but there no difference was noted between loco-regional flaps and free flaps. There was a trend towards delayed removal of NGT in patients with tongue as the primary sub-site and in patients where resection included oropharyngeal structures such as the base of tongue or soft palate, but this was not statistically significant.

Tracheostomy tube removal was affected by age (p < 0.001) and tongue as primary site (p = 0.009) (Tables 2, 3). Patients who needed reconstructive procedures took a longer period for decannulation. Moreover, free flap reconstruction caused delay in decannulation compared to patients with loco-regional flap but the difference did not show statistical significance.
Table 3

Age and Hospital stay

Factor

NGT removal (N = 234)

Tracheostomy tube removal (N = 111)

Mean days (range)

P value

Mean days (range)

p value

Age (years)

53 (25–85)

0.106

52 (25–81)

< 0.001

Hospital stay (Days)

12 (1–35)

0.040

16 (5–35)

< 0.001

Bold values are statistically significant (p < 0.05)

Delay in the removal of the NGT and tracheostomy tube significantly lengthened the hospital stay of the patients (p = 0.040 and 0.000, respectively) for NGT and tracheostomy tube (Table 3).

For 112 patients with primary lesion in tongue, mean hospital stay was 12 days (Standard deviation 34.91) with mean days for NGT removal was 25.70. Of these 112 patients, 44 patients required tracheostomy with 19.09 days as mean required for tracheostomy removal. Delay in removal in tracheostomy tube and NGT removal affected the hospital stay significantly (p = 0.005 and 0.044, respectively) (see Table 4).
Table 4

Multivariate analysis for patients with tongue as their primary site (N = 112)

Factor

p value for tracheostomy tube removal

p value for NGT removal

Age

0.025

0.554

Gender

0.307

0.718

T stage

0.463

0.711

Flap type

0.347

0.794

Pathological stage

0.217

0.509

Resection of Oropharyngeal structures

0.068

0.085

Days for removal of NGT

0.121

Days for removal of tracheostomy tube

< 0.001

Bold values are statistically significant (p < 0.05)

Requirement of reconstructive procedures was the only significant factor delaying removal of NGT (mean 7.28 days vs 49.38 days, p = 0.027) in patients with tongue as their primary tumor site.

Discussion

Tracheostomy and nasogastric tubes are essential for the support of patients undergoing surgery for oral cancer and minimizing the need of tubes for feeding and breathing is a priority issue for patients. Prolonged nasogastric tube feeding and failure to decannulate tracheostomy tubes are associated with higher risk of pneumonia, poorer oral intake, weight loss as well as fundamental changes in eating patterns, social activities and consequently poorer quality of life [8]. Removal of NGT and tracheostomy tube ensures that the patient regains his vocal cord functions and improves his swallowing [7]. In addition, decannulation improves subject comfort and perceived physical appearance [9].

Delay in the removal of NGT and tracheostomy tube significantly lengthened the hospital stay of the patients. This leads to the increase in the direct and indirect costs for the patient and interferes with postoperative rehabilitation. It can be a result of reluctance on the part of the patients and their relatives to leave hospital for domiciliary care when they are on tubes for breathing and swallowing. The study did not look into the above issues and we emphasize the need of further studies to understand the implications on cost and patient attitudes towards retaining tracheostomy and nasogastric tubes.

Surgical removal of the tumor with adequate margins remains the primary goal of treatment of oral cancer and reconstructive efforts are usually performed along with the ablative surgery to minimize cosmetic and functional impairment. Post-surgical reconstruction often determines how the patient functions for speech and swallowing after surgery [6].

In this study, addition of reconstructive surgery was the only significant factor that affected NGT removal (p = 0.003). The paradox could be explained by the fact that tumors with larger T stages would have been preferentially selected for reconstruction and insensate tissues used for reconstruction would not be functionally as effective as the tissues they replaced. Improvement in swallowing function can only be expected after a period of adaptation which is beyond the purview of this study.

This study also showed a trend towards delayed NGT removal in patients who have tongue as the site of their primary lesion and in patients who required excision of part of base of tongue, tonsil or soft palate. This is probably due to interference with the pharyngeal phase of deglutition or causing aspiration. Tracheostomy tube removal was significantly affected by age (p < 0.001) and when tongue was primary site (p = 0.009). Isaac et al. [4] showed that patients requiring a total glossectomy were five times more likely to have failed decannulation. The effect of advancing age on decannulation demonstrates the tardiness of compensatory mechanisms following loss of functional oral and oropharyngeal tissues to surgery.

Reconstructive procedures resulted in a comparatively delayed decannulation of patients with tracheostomy tubes. The delay was more in patients with free flap reconstruction compared to those with loco-regional flap reconstruction. These delays were, however, not statistically significant.

Performing a mandibulectomy either segmental or marginal did not cause a change in the duration of NGT and tracheostomy tube retention. Inspite of being a more conservative procedure, marginal mandibulectomies did not lead to earlier tube removals, probably due to salivary leak following marginal mandibulectomy [3].

Adjuvant chemo-radiation causes xerostomia, mucositis, and fibrosis in the irradiated region, which can be permanent and management strategies to treat these are often ineffective or partially effective at best. These changes affect swallowing, including reduced speed of tongue movements causing delay in oral transit time and a change in pattern of tongue movement probably contributing to a delay in triggering the pharyngeal swallow [5, 11].

This study failed to show any significant effect of postoperative adjuvant treatment on NGT and tracheostomy tube removal. This can be due to the fact that in majority of patients, NGT and tracheostomy tubes were removed before starting adjuvant treatment. Information about reinsertion of the NGT or tracheostomy tube during or after the adjuvant treatment was not available. Only 18 patients of the 234 patients had NGT when they started their adjuvant treatment.

Delayed removal of tracheostomy tube significantly delayed the removal of NGT. This probably reflects the alteration of physiology of deglutition in operated patients of oral SCC. This emphasizes that the need for tracheostomy was more for aspiration than airway compromise in this group of patients.

The effect of modification of reconstructive technique and choice of flaps, loco-regional or microvascular on the rehabilitation of swallowing and breathing needs further inquiry. The role of non-modifiable risk factors such as age, site and extent of primary lesion and excision of oropharyngeal structures in delaying the removal of tracheostomy tube and NGT also needs further research to allow for appropriate counseling of the patients about their risk profile.

This study was limited by its retrospective design, which precluded the measurement of variables like reinsertion of NGT and/or tracheostomy tube during or after adjuvant treatment.

Conclusion

Surgery for cancer of the oral cavity invariably depends on temporary support for feeding and respiration from tracheostomy and nasogastric tubes. Delayed decannulation can be anticipated in older patients and in patients with primary tongue carcinoma. Reconstructive surgery, considered a necessary adjunct to ablative surgery results in delayed removal of the NGT and tracheostomy tube.

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Prateek V. Jain
    • 1
  • Kapila Manikantan
    • 1
  • Dipanwita Roy
    • 1
  • Pattatheyil Arun
    • 1
  1. 1.Department of Head and Neck SurgeryTata Medical CenterKolkataIndia

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