Next Article in Journal
Effect of a Multispecies Synbiotic Supplementation on Body Composition, Antioxidant Status, and Gut Microbiomes in Overweight and Obese Subjects: A Randomized, Double-Blind, Placebo-Controlled Study
Next Article in Special Issue
Impact of Nutritional Status on Postoperative Outcomes in Cancer Patients following Elective Pancreatic Surgery
Previous Article in Journal
Beyond Binge Eating: The Impact of Implicit Biases in Healthcare on Youth with Disordered Eating and Obesity
Previous Article in Special Issue
Effects on Serum Hormone Concentrations after a Dietary Phytoestrogen Intervention in Patients with Prostate Cancer: A Randomized Controlled Trial
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Nutrients
Volume 15
Issue 8
10.3390/nu15081864
nutrients-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

Nutritional Management of Patients with Head and Neck Cancer—A Comprehensive Review

by
Dinko Martinovic
1,
Daria Tokic
2,
Ema Puizina Mladinic
1,
Mislav Usljebrka
1,
Sanja Kadic
1,
Antonella Lesin
1,
Marino Vilovic
3,
Slaven Lupi-Ferandin
1,
Sasa Ercegovic
1,
Marko Kumric
3,
Josipa Bukic
4 and
Josko Bozic
3,*
1
Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
2
Department of Anesthesiology and Intensive Care, University Hospital of Split, 21000 Split, Croatia
3
Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
4
Department of Pharmacy, University of Split School of Medicine, 21000 Split, Croatia
*
Author to whom correspondence should be addressed.
Nutrients 2023, 15(8), 1864; https://doi.org/10.3390/nu15081864
Submission received: 22 February 2023 / Revised: 7 April 2023 / Accepted: 11 April 2023 / Published: 13 April 2023
(This article belongs to the Special Issue Nutritional Status and Interventions for Patients with Cancer)
Versions Notes

Abstract

:
While surgical therapy for head and neck cancer (HNC) is showing improvement with the advancement of reconstruction techniques, the focus in these patients should also be shifting to supportive pre and aftercare. Due to the highly sensitive and anatomically complex region, these patients tend to exhibit malnutrition, which has a substantial impact on their recovery and quality of life. The complications and symptoms of both the disease and the therapy usually make these patients unable to orally intake food, hence, a strategy should be prepared for their nutritional management. Even though there are several possible nutritional modalities that can be administrated, these patients commonly have a functional gastrointestinal tract, and enteral nutrition is indicated over the parenteral option. However, after extensive research of the available literature, it seems that there is a limited number of studies that focus on this important issue. Furthermore, there are no recommendations or guidelines regarding the nutritional management of HNC patients, pre- or post-operatively. Henceforth, this narrative review summarizes the nutritional challenges and management modalities in this particular group of patients. Nonetheless, this issue should be addressed in future studies and an algorithm should be established for better nutritional care of these patients.

1. Introduction

Head and neck cancers (HNC) represent epithelial malignancies in the paranasal sinuses, nasal cavity, oral cavity, pharynx, and larynx, all of which significantly impact the morbidity and mortality of the affected population [1]. Hence, the National Cancer Institute’s (NCI’s) Surveillance, Epidemiology, and End Results (SEERs) refer to more than 65,000 new cases annually, with more than 14,500 death cases associated with the disease [2].
Most cases of HNC are head and neck squamous cell carcinoma (HNSCC), which is the sixth most widespread malignancy worldwide with an estimated 3% of all cancer cases [3]. The most significant risk factors that contribute to its pathogenesis are tobacco usage, alcohol consumption, and infection with a high-risk human papilloma virus [4]. Furthermore, the most lethal among the HNSCC is the oral squamous cell carcinoma (OSCC), which accounts for 90% of all oral malignancies and has an estimated 2–3% death rate of all cancer-related deaths [5].
Even though there are several different treatment modalities for HNC, due to the complex anatomy along with the highly important functions in the head and neck region, management of HNC should be multidisciplinary, with the focus not only on therapy but also on supportive pre and aftercare [6]. One of the significant reasons for the high HNC disease burden is malnutrition and nutritional deficits in these patients, which have a substantial impact on health outcomes as well as the overall quality of life [7]. Malnutrition can be referred to by following several different criteria, including more than 5% weight loss in three months or more than 10% in a six-month period, or a BMI less than 20 kg/m2, while albumin levels less than 35 g/L can be suggestive of malnutrition as well [8,9,10].
Problems with nutrition already start with disease onset, with various studies showing 25–65% of HNC patients presenting themselves with malnutrition, with more than 10% weight loss from the normal body mass [11,12,13]. High levels of variability and difficulties to obtain exact data are probably driven by different malnutrition definitions and different methods of malnutrition assessment [14]. However, there could be several reasons for the still significant percentages of malnutrition in these patients even before treatment, including chronic malnutrition, which is associated with alcohol and tobacco usage, trismus, obstruction of the respiratory and digestive system with aspiration, odynophagia, and dysphagia [6,13]. Hence, Kubrak et al. showed in a large cohort of HNC patients that independent predictors of weight loss in a naive population were tumor stage, dietary intake categories, and performance status [15].
Different treatment modalities can only further worsen the nutritional status of HNC patients. These modalities include chemotherapy, radiation therapy, surgical procedures, specialized targeted therapies, and different combination therapies [16]. While surgical procedures are a potential cause of disrupted food intake, mostly based on tumor location and resection type and size, radiotherapy, and chemotherapy are connected to various symptoms that further impair oral food intake and often cause treatment withdrawal [17,18]. Furthermore, according to several studies, malnutrition in HNC patients during therapy can be present in substantially high percentages, up to 80% [19,20,21]. Mucositis is commonly associated with chemotherapy and radiotherapy and is characterized by inflamed lesions in the area of the mouth and throat. These complications are connected to infections, dysphagia, and pain, among others [22]. Xerostomia and impaired parathyroid gland function are two of the most common adverse effects of radiotherapy that significantly reduce the quality of life of patients and are often associated with thick saliva. This causes further negative effects on chewing, swallowing, and speaking, with an accompanying increase in infections [23,24]. Other adverse effects of therapeutic modalities that significantly impair weight maintenance and the proper healing process include nausea, vomiting, constipation, depression, dysgeusia, and odynophagia [6].
Adequate nutritional support in HNC patients is of vital importance, as malnutrition is associated with a decreased therapeutic and immunological response with a higher incidence of infections and post-surgical complications. Furthermore, it causes treatment breaks with a higher economic burden and decreased functional performances that cumulatively lead to decreased quality of life and higher mortality rates. Interestingly, overweight and obese people with higher BMIs are at the same risk of all of the mentioned complications [6,13,25,26,27]. Hence, studies have shown that weight loss before treatment was one of the main independent survival predictors, while nutritional support before surgery can lead to significant beneficial changes in quality of life with fewer post-operative infectious complications [28,29].
These considerations were leading to the development of various screening tools in order to diagnose vulnerable patients and to prevent treatment complications and negative health outcomes. Moreover, the Nutritional Risk Screening 2002 (NRS 2002) and Malnutrition Universal Screening Tool (MUST) were accepted by the European Society for Clinical Nutrition and Metabolism (ESPEN) for hospital usage [19]. The newest edition of the ESPEN clinical guidelines for clinical nutrition in cancer, which is dedicated to all healthcare professionals that participate in cancer patient care, has a total of 43 recommendations and short commentaries regarding cancer patient management. Even though general recommendations are included that can be of use in HNC patient care, with some specialized parts that address this population specifically, there is still a need for comprehensive, detailed guidelines that involve only the HNC patient population [30].
Another important practice that should be implemented regularly in HNC patient management is involving enhanced recovery after surgery (ERAS) protocols. These specialized, evidence-based protocols were initially presented in the perioperative care of colorectal surgery, and up to today investigations have shown numerous beneficial health outcomes with managed patients in different surgical branches [31,32]. The ERAS protocol with published recommendations was introduced for HNC surgical procedures with free flap reconstruction in 2017, with a special focus on perioperative nutritional care [33]. According to these recommendations, Moore et al. performed a clinical investigation on 25 HNC surgery patients that received perioperative nutritional supplementation. Results have shown that processes still need some modifications to ensure specialized approaches for patient care improvement [34].
These data suggest that even though some nutritional guidelines for HNC surgery exist, there is still a potential need for new investigations, modifications, and better clinical utilizations.

2. Nutritional Modalities

Patients with head and neck cancer, due to the location of the tumor in the upper airway and digestive tract, can have difficulties masticating and swallowing food. Tumor-related dysphagia can significantly compromise the nutrition status of those patients and put them at risk of malnutrition at the time of diagnosis. Due to inadequate nutrition intake, these patients are prone to weight loss, decrease in muscle mass, fatigue, and anemia, which ultimately leads to cancer cachexia syndrome. Studies indicate that impaired nutrition status is noticed in 25–27% of these patients at the time of diagnosis and before the start of treatment [35,36,37,38]. It was also shown that pretreatment weight loss is a strong survival predictor and pretreatment cachexia is connected to poor survival [29,38,39]. Additionally, sarcopenia that occurs as a result of cancer cachexia has been connected with unfavorable treatment outcomes in patients with head and neck cancer [40]. Cancer treatment can further aggravate treatment-related dysphagia, resulting in reduced food intake and deteriorating nutrition status [35,36,37]. Severe weight loss (more than 10% of body weight) during treatment has been observed in the absence of intensive nutrition support in up to 58% of patients [38,41,42].
Nutrition support is a crucial part of head and neck cancer control, supporting better disease outcomes. Oral intake of food is the preferred method of nutrition, but in cases when adequate nutritional intake cannot be maintained by mouth, enteral or parenteral nutrition is necessary. Enteral nutrition is preferred over parenteral nutrition, being physiologically natural. It also maintains gastrointestinal integrity, protecting it from atrophy, and also supports gut immune function (Table 1). Enteral nutrition implies the administration of food into the gastrointestinal tract through a tube or stoma.
Furthermore, it is important to plan the nutritional management of these patients during pre-treatment care. Although head and neck cancer patients have restricted oral intake, their gastrointestinal tract is usually functional. Therefore, enteral nutrition is indicated in patients that are unable to feed orally but have a functioning and accessible gastrointestinal tract. It can be short-termed or long-termed and can be administrated into the stomach—gastric or into the intestine—post-pyloric [43]. It is a safe and effective nutrition manner to provide nutrition that can be easily administered by patients and their families at home. The main contraindication for applying enteral nutrition is the non-functional gastrointestinal (GI) tract. Numerous studies have shown that administrating feeding tubes before the start of treatment in these patients ensures better overall outcomes. It acts beneficially in the prevention of weight loss and sarcopenia, dehydration, reduced hospital admission, and improved quality of life [44,45,46,47,48,49]. Improvements in nutrition parameters, including anthropometrics and laboratory data, have also been observed [50].

3. Enteral Nutrition

Several factors must be considered in determining which type and modality of enteral nutrition are administrated. The site of feeding and expected duration is primary, but it is also important to consider timing and rate of initiation, feeding modality, risk of complications, and possible contraindications. An individual approach and careful assessment are key in ensuring clinically appropriate and nutritionally complete enteral nutrition. The following options are available: nasogastric tube, nasojejunal tube, gastrostomy, and jejunostomy (Table 2) [51].

3.1. Nasogastric Tube

A nasogastric tube (NGT) is a plastic catheter inserted through the nose, passing the oropharynx and esophagus to the stomach [52]. It is the most commonly used type of enteral nutrition (EN) in HNC patients with a functional gastrointestinal tract if the tumor is obstructive, thereby impacting swallow function [53]. Generally, NGTs are used for a shorter period (<4 weeks) and can be administered perioperatively (prophylactic) or postoperatively (reactive) [54].
Prophylactic enteral feeding is used when nutrition support is anticipated for an extended time after more invasive surgical procedures and in severely malnourished patients. The National Comprehensive Cancer Network (NCCN) published indications for prophylactic tube placement, summarized in Table 1 [55].
Nutritional status seems to be maintained or enhanced with tube implantation, according to Langius et al.’s systematic study, which found that prophylactic tube feeding increases nutritional intake and nutritional status compared to oral consumption alone [56].
If oral intake is not possible after 4–6 weeks, percutaneous endoscopic gastrostomy (PEG) is indicated [54]. The literature showed similar nutritional and clinical outcomes in patients with NGTs and PEGs. However, complications such as increased tube dislodgement and chest infection were noticed after a long period in patients with NGTs. Additionally, compared to patients with gastrostomies, patients with nasogastric tubes reported greater body image problems, difficulty with feeding, and considerable social activity interruption [57,58].
Still, NGTs remain a routine modality of enteral nutrition because there are no notable differences in overall complication rates. They are easily placed, significantly less expensive, and the transition from enteral nutrition back to oral nutrition is shorter than PEG tubes [59].

3.2. Nasojejunal Tube

Oroenteric or nasoenteric feeding tubes are intended for enteral nutrition into small intestine regions, meaning the duodenum and jejunum. Application of nutrients in the small intestine is indicated for short-term feeding in patients that have impaired gastric motility since they are at risk for gastric emptying delay, reflux, and aspiration. It is also instructed to avoid gastric feeding in patients with severe acute pancreatitis and promote enteral nutrition [60].
Enteric feeding tubes can be placed blindly at the bedside without the use of any technology. When placing the tube, the distal end must surpass the duodenojejunal flexure, otherwise, it can inevitably retract back to the stomach. Nasojejunal feeding tubes can be of various sizes. Usually, they are small-bore with flexible tips that are intended to ensure spontaneous passage into the small intestine and protect from injury of mucosa or perforation. The tubes are also provided with stylets or guide wires providing structure for easier placement [61,62]. Studies suggest that blinded positioning of a small-bore feeding tube by a well-trained and experienced clinician has a success rate of 80% or more [63].
Possible complications of the application of nasojejunal tube and nasojejunal tube feeding are epistaxis, sinusitis, oesophageal ulceration or strictures, blockage, malposition or injury, and perforation of the gastrointestinal (GI) tract. Malposition implies placing the tube outside the GI tract. Placing it in the bronchopulmonary tree can cause infection, effusion, or empyema [51,63,64,65,66]. As a rare occurrence, but a very severe complication, it can malposition intracranially. To reduce the risk of malposition or injury, tubes can be placed using endoscopy or fluoroscopy, or magnetic guidance. Several studies show that using technology for placement increases success rates by 90% [66,67,68,69]. In addition, it is important to verify the proper position of the tube after placement using an abdominal X-ray.
There are indications that jejunal feeding may assist in the increased delivery of nutrients since there are fewer interruptions compared to gastric feeding, which is often interrupted by the application of medication and lavage [70,71]. It is propounded that post-pyloric tubes are more comfortable for patients than gastric tubes, so they are a good alternative for patients that show discomfort with NGT, decreasing removal of the tube by the patients [72]. Preferred modality of post-pyloric feeding should be continuous to avoid discomfort and dumping syndrome that occurs with bolus feeding. However, for HNC patients, a NGT is still the preferred option over the nasojejunal tubes, and the latter are usually only reserved for patients who have impaired gastric motility.

3.3. Percutaneous Endoscopic Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is nowadays considered the “golden standard” for feeding and nutrition support in oral/maxillofacial surgery patients undergoing extensive surgery treatments. PEG tube placement is a well-accepted and frequently conducted procedure worldwide that has replaced surgical and radiological gastrostomy techniques [73]. Morbidity linked with PEG can vary from 5 to 10.3%, of which 3% are major adverse events [74].
The main indication for PEG in oral and maxillofacial patients is providing oral intake and meeting metabolic requirements due to the closeness of the cancer and organs that are in charge of normal food intake [6,75]. It is important to highlight that patients with maxillofacial region tumors are usually excessive smokers and/or alcohol consumers, with inadequate eating habits prior to diagnosis or treatment [76]. This group of patients often faces postoperative swallowing disorders, changed anatomy of the oral cavity due to surgery, impaired function of the tongue, dysphagia, odynophagia, dysgeusia, xerostomia, and nausea [6]. Malnutrition and weight loss are connected with poorer treatment outcomes, poor quality of life, and consequently elevated rates of morbidity and mortality [77].
The PEG can be permanent or temporary depending on the patient’s requirements. Since the nasoenteric tubes are usually used in patients with preserved airway reflexes who require enteral feeding for less than 30 days, PEG is currently the method of choice for medium to long-term enteral feeding [36]. It is important to emphasize the fact that preventively placed PEG tubes resulted in lower complication rates in comparison to therapeutically inserted PEGs [78].
Regarding the insertion techniques, there are three most commonly used methods: the “pull”, “push” (guide wire), and introducer (Russel) methods. All of them have the same concept of insertion through the abdominal wall at the spot where the abdominal wall and stomach are the closest. According to several studies, the success rate of PEG is 84–96% [79,80]. Since it could be unable to perform oral percutaneous gastrostomy for 4–7% of head and neck cancer patients, transnasal endoscopy is a method of choice. Oropharyngeal obstruction, severe trismus, or airway endangerment are the main causes of the transnasal approach.
Nasoenteric tubes contribute to a higher number of complications such as irritation, nasal decubitus, patient discomfort, ulceration, bleeding, esophageal reflux, and aspiration pneumonia [81]. They are also connected to poorer acceptance and psychological or social problems. Interestingly, compared to PEG, nasoenteric tubes have a lower feeding efficacy [82]. There is some strong evidence in the literature that the initiation of PEG feeding, as soon as the medical indication has been set up, can prevent further weight loss and contribute to patients’ quality of life.
The most common contraindications for the PEG placement are systemic, such as coagulation disorders, hemodynamic instability, or sepsis; disturbances at the site of placement in the abdomen, such as abdominal wall infection, ascites, peritonitis; and peritoneal carcinomatosis; and interposed organs such as the colon or liver [75,83].
The PEG tube insertion process is commonly considered harmless; however, some complications can take place. The mortality rate is expectedly higher in patients with underlying comorbidities [84]. Minor complications consist of wound infection, which is, according to the literature, somewhere between 5% and 25%. Since this probably occurs due to contamination by oral flora, antibiotic prophylaxis is recommended [85,86]. Granuloma formation is the next most common complication and is due to friction and excess moisture around the tube [87]. Moreover, some of the other possible minor complications are tube leakage into the abdominal cavity and consequent development of peritonitis; stoma leakage; tube obstruction; pneumoperitoneum; gastric outlet obstruction, and peritonitis [84,88].
Major complications are aspiration pneumonia; however, that is more often in neurologic patients due to feeding a large amount of content and being in the prone position than in OMFS patients; hemorrhage (retroperitoneal bleeding due to injuries of the gastric artery, splenic and mesenteric veins, and rectus sheath hematoma); necrotizing fasciitis, which is a potentially lethal complication; buried bumper syndrome (characterized by excessive tension amid internal and external bumpers that cause ischemia and necrosis of the gastric wall and consequently, the tube moves toward the abdominal wall), and perforation of the bowel [75,88,89,90].
Furthermore, it is important to highlight an interesting and unusual complication of PEG placement in HNC patients: the seeding of the tumor. It was observed that the seeding occurs during the “pull” or “push” method of PEG insertion when the tube collides with the tumor, directly transferring tumor cells [91]. Unfortunately, diagnosis is set when the tumor metastasis is large and visible. However, questions regarding this complication are still emerging and some studies imply that the hematogenous or lymphatic spread is actually responsible for the metastasis [92].

3.4. Radiologically Inserted Gastrostomy

Endoscopically placed percutaneous gastrostomy was very soon followed by the development of radiological techniques for fluoroscopic percutaneous placement [93]. Radiologically inserted gastrostomy implies a procedure where gastrostomy is inserted directly into the stomach under X-ray guidance. Indications and complications are similar to PEG, with the only difference being in the performed technique.
A preliminary CT (computed tomography) scan or ultrasound examination can be performed to rule out an overlapping colon or left hepatic lobe. Sometimes, 100–200 mL of barium sulfate can be orally administered to patients the night before the procedure to sketch the colon. On the day of the procedure, air or CO2 gas is insufflated in the stomach via a nasogastric tube to extend the stomach. Afterward, gastric fixation is required and a gastropexy is conducted, which is followed by a gastric puncture. Gastropexy can reduce the spilling of the gastric contents around gastrostomy into the peritoneum and is performed in 93% of cases according to a prospective multicenter survey of the United Kingdom [94,95]. The position in the stomach is confirmed by aspirating air or injecting a contrast medium. After the tube placement, contrast is injected to prove the proper position [96,97].
Minor complications are similar to PEG, except for tube displacement, which happens in 1% of cases. According to Cherian et al., there are no differences in major complications between PEG and RIG at 6.8% and 8.5%, respectively [98]. Moreover, a meta-analysis from Wollman et al. found that the success rate of the tube placement is higher in RIG compared to PEG, while also major complications occurred less often in RIG [99]. Another meta-analysis proved that major complications were more frequent in PEG patients (2.19%) than RIG patients (0.07%), but with no significant statistical difference [100]. Additionally, RIG can be placed in cases of esophageal/oropharyngeal obstruction and since there is no gastroscopy involved, there is no need for antibiotic prophylaxis.

3.5. Surgical Gastrostomy

Surgical gastrostomy is nowadays considered a rudimentary technique due to safer and less invasive characteristics of PEG. However, in certain situations, especially in HNC patients, surgical gastrostomy is still a viable option. It is conducted for indications such as when HNC prevents access for gastroscopy, severe strictures of the esophagus or impossibility to set stomach to adjacent to the abdominal wall due to obesity, previous surgery, or hepatosplenomegaly [101].
Surgical gastrostomy can be conducted in two ways: with open laparotomy or by laparoscopy. Laparoscopy is the less invasive and surgically better method due to the better exposure of the stomach since in open laparotomy the incision is commonly very small [102]. Nevertheless, the literature has shown that even laparoscopy gastrostomy placement has significantly more complications compared to PEG [103,104].

3.6. Jejunostomy

The jejunostomy feeding tube is a method of nutrition through access to the jejunum. It is used when a gastrostomy tube is not technically possible or contraindicated. It can be administrated endoscopically, radiologically, or by surgery. When placing these feeding tubes, minimally invasive techniques are always preferred [105].
Jejunostomy, as gastrostomy, is preferred for long-term enteral nutrition greater than six weeks. Benefits to this technique compared to the NGT and PEG are lessening the risk of tube malposition, lower risk of aspiration since the gastroesophageal sphincter is not held open by a tube, no nasal discomfort, and pressure injury of the nares [72].
Despite having some advantages, there are also complications including infections, nausea, vomiting, diarrhea, abdominal distension, bowel obstruction, and metabolic abnormalities [106,107]. This method of enteral nutrition is not suitable for patients with bowel obstruction distal to the placement site. Regarding HNC patients, jejunostomy is usually indicated in those patients that have other conditions that prevent using oral or gastric nutrition. When feeding jejunely, a continuous and slow rate is advised due to the loss of the stomach reservoir [51].

4. Parenteral Nutrition

Parenteral nutrition represents an intravenously delivered nutritionally balanced synthetic mixture of sterile nutrients [108]. It has to be slowly introduced, starting with 15–20 calories per kg of body weight a day with a maximum of 1000 calories a day. As it is initiated and the caloric levels rise toward the target level, the patient needs to be monitored because of possible drops in potassium, phosphorous, and magnesium levels [109]. Multiple meta-analyses have shown more infectious complications in patients using parenteral nutrition, yet estimated caloric requirements can be more easily accomplished [110]. Moreover, several studies imply that better outcomes occur when at least one part of a patient’s nutrition is via the enteral route [6,111,112]. However, when the intake of food and nutrient absorption becomes almost impossible due to a defective, unavailable, or ruptured gastrointestinal tract, parenteral nutrition is the best and only choice [111]. Hence, the main indication of PN is when there is no other way to meet the required calorie intake. Several other indications are severe catabolic state due to the severity of the patient’s condition (such as sepsis and polytrauma), gastrointestinal malformations (congenital in children or after surgery or cancer), severe vomiting, and diarrhea [113,114,115,116]. Moreover, parenteral nutrition can be used in cases of prolonged chyle leaks that can take place after extensive left neck surgery (the thoracic duct is located nearby) [117]. This type of nutrition is also recommended for terminal care patients [118].
Parenteral nutrition is contraindicated in patients with a functional gastrointestinal tract, patients that do not have access to an intravenous line, and in patients that need therapy for fewer than 5 days if they are not severely malnourished [119]. As soon as the adequate gastrointestinal function is reached, patients are gradually transitioned from parenteral to enteral or oral nutrition to avoid biliary sludge and GI mucosal atrophy. When enteral or oral intake reaches 500 calories a day, parenteral nutrition ought to be decreased, while when more than 60% of caloric needs are achieved via oral or enteral intake, parenteral nutrition should be canceled [119]. Parenteral nutrition is rarely applied to patients with HNC because, in most cases, the lower GI tract is functional. A study performed by Ryu et al. revealed that total parenteral nutrition was USD 11.81 more expensive than certain types of enteral nutrition (feeding via NGT) on a daily basis [120]. Research conducted by Scolapio et al. revealed that many patients would prefer the parenteral type of feeding more than enteral (NGT feeding) if they were unable to eat [118].
When it comes to HNC, patients often deal with morphological malformations, caused both by malignancy and/or treatment [112]. While severe illness such as cancer causes metabolic changes and malnutrition, demanding and extensive surgeries impact and exhaust organism as well [111]. Therefore, intensive follow-up treatment is required in order to enable the patient to recover as soon and as best as possible. When it comes to the nutritional deficits of patients after head and neck surgery, the problem that often occurs is in the upper gastrointestinal area. Some of the surgeries require manipulation and extensive resection in the intraoral space and that can lead to several complications. As previously mentioned, the most common are odynophagia, dysphagia, mucositis, xerostomia, and edema [6]. These complications can induce malnutrition, in which case it is of vital importance to adequately approach this problem. When malnutrition occurs for more than two weeks, there is a risk of developing refeeding syndrome; metabolic changes followed by hypokalemia, hypomagnesemia, and hypophosphatemia; and life-threatening conditions such as cardiac and respiratory distress [121]. To avoid this dangerous state, it is necessary to recognize the nutritional needs of the patient at the time and adjust if enteral feeding is in any way compromised. For parenteral nutrition, an interdisciplinary approach is needed (physicians, nutritionists, and educated staff in the surgical department) in order to reduce potential complications and give the patient the necessary care [119]. In the current literature, there are not many studies regarding this subject. Ackerman et al. evaluated and presented nutrition management for HNC patients, where they discussed and pointed out that prevention of undernutrition is the key to avoiding poor treatment outcomes [6]. On the other hand, there are no specific guidelines when it comes to the nutrition of head and neck cancer patients. While ESPEN brings relevant guidelines on nutrition covering most of the conditions and diseases, on the other hand, when it comes to parenteral nutrition in surgery, ESPEN recommends the formula of 25 kcal/kg ideal body weight [122].

5. Conclusions

HNC patients are, due to the anatomical region involved, a highly sensitive group of patients regarding their nutritional management. While oral intake is the most superior way of feeding, that is rarely possible in this particular group. Since they most commonly have a functional gastrointestinal tract, enteral nutrition should be indicated over the parenteral possibility. However, according to the relevant literature, it is still debatable which enteral modality should be administrated. While PEG is starting to be deemed the “golden standard” for these patients, on the other hand, NGT is still considered a highly viable choice. Moreover, even though the literature is very scarce regarding the importance of the pre-surgery preparation and planning of the nutritional route, we believe that it is an integral part of a faster recovery after surgery. Furthermore, none of the relevant sources give any recommendations or guidelines for the nutritional management of these patients. Henceforth, this issue should be given more focus in future studies and an algorithm should be established for an improvement of nutritional support in this particular group of patients.

Author Contributions

Conceptualization, D.M., D.T., E.P.M., S.L.-F. and J.B. (Josko Bozic); software, D.T., M.U., S.K., A.L. and M.K.; investigation, D.M., D.T., M.K., S.E. and J.B. (Josipa Bukic); writing—original draft preparation, D.M., D.T., E.P.M., M.U., S.K., A.L. and M.V.; writing—review and editing, D.M., D.T., E.P.M., M.U., S.K., A.L. and J.B. (Josipa Bukic); visualization, M.K., S.E., M.V. and J.B. (Josipa Bukic); supervision, J.B. (Josko Bozic), S.L.-F. and S.E.; project administration, J.B. (Josko Bozic), S.L.-F. and M.V. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Argiris, A.; Eng, C. Epidemiology, staging, and screening of head and neck cancer. Cancer Treat Res. 2003, 114, 15–60. [Google Scholar] [PubMed]
  2. Howlader, N.N.A.; Krapcho, M.; Miller, D.; Brest, A.; Yu, M.; Ruhl, J.; Tatalovich, Z.; Mariotto, A.; Lewis, D.R.; Chen, H.S.; et al. EER Cancer Statistics Review, 1975–2016. Available online: https://seer.cancer.gov/csr/1975_2016/ (accessed on 1 February 2023).
  3. Siegel, R.L.; Miller, K.D.; Wagle, N.S.; Jemal, A. Cancer statistics, 2023. CA Cancer J. Clin. 2023, 73, 17–48. [Google Scholar] [CrossRef]
  4. Johnson, D.E.; Burtness, B.; Leemans, C.R.; Lui, V.W.Y.; Bauman, J.E.; Grandis, J.R. Head and neck squamous cell carcinoma. Nat. Rev. Dis. Primers 2020, 6, 92. [Google Scholar] [CrossRef]
  5. Bugshan, A.; Farooq, I. Oral squamous cell carcinoma: Metastasis, potentially associated malignant disorders, etiology and recent advancements in diagnosis. F1000Research 2020, 9, 229. [Google Scholar] [CrossRef] [PubMed]
  6. Ivkovic, N.; Martinovic, D.; Kozina, S.; Lupi-Ferandin, S.; Tokic, D.; Usljebrka, M.; Kumric, M.; Bozic, J. Quality of Life and Aesthetic Satisfaction in Patients Who Underwent the “Commando Operation” with Pectoralis Major Myocutaneus Flap Reconstruction-A Case Series Study. Healthcare 2022, 10, 1737. [Google Scholar] [CrossRef] [PubMed]
  7. Ackerman, D.; Laszlo, M.; Provisor, A.; Yu, A. Nutrition Management for the Head and Neck Cancer Patient. Cancer Treat Res. 2018, 174, 187–208. [Google Scholar]
  8. Bonilha, S.F.; Tedeschi, L.O.; Packer, I.U.; Razook, A.G.; Nardon, R.F.; Figueiredo, L.A.; Alleoni, G.F. Chemical composition of whole body and carcass of Bos indicus and tropically adapted Bos taurus breeds. J. Anim. Sci. 2011, 89, 2859–2866. [Google Scholar] [CrossRef]
  9. Platek, M.E.; Popp, J.V.; Possinger, C.S.; Denysschen, C.A.; Horvath, P.; Brown, J.K. Comparison of the prevalence of malnutrition diagnosis in head and neck, gastrointestinal, and lung cancer patients by 3 classification methods. Cancer Nurs. 2011, 34, 410–416. [Google Scholar] [CrossRef] [Green Version]
  10. Hickson, M. Malnutrition and ageing. Postgrad. Med. J. 2006, 82, 2–8. [Google Scholar] [CrossRef] [Green Version]
  11. van Wayenburg, C.A.; Rasmussen-Conrad, E.L.; van den Berg, M.G.; Merkx, M.A.; van Staveren, W.A.; van Weel, C.; van Binsbergen, J.J. Weight loss in head and neck cancer patients little noticed in general practice. J. Prim. Health Care 2010, 2, 16–21. [Google Scholar] [CrossRef]
  12. Eley, K.A.; Shah, R.; Bond, S.E.; Watt-Smith, S.R. A review of post-operative feeding in patients undergoing resection and reconstruction for oral malignancy and presentation of a pre-operative scoring system. Br. J. Oral Maxillofac. Surg. 2012, 50, 601–605. [Google Scholar] [CrossRef]
  13. Alshadwi, A.; Nadershah, M.; Carlson, E.R.; Young, L.S.; Burke, P.A.; Daley, B.J. Nutritional considerations for head and neck cancer patients: A review of the literature. J. Oral Maxillofac. Surg. 2013, 71, 1853–1860. [Google Scholar] [CrossRef]
  14. Saroul, N.; Pastourel, R.; Mulliez, A.; Farigon, N.; Dupuch, V.; Mom, T.; Boirie, Y.; Gilain, L. Which Assessment Method of Malnutrition in Head and Neck Cancer? Otolaryngol. Head Neck Surg. 2018, 158, 1065–1071. [Google Scholar] [CrossRef]
  15. Kubrak, C.; Martin, L.; Gramlich, L.; Scrimger, R.; Jha, N.; Debenham, B.; Chua, N.; Walker, J.; Baracos, V.E. Prevalence and prognostic significance of malnutrition in patients with cancers of the head and neck. Clin. Nutr. 2020, 39, 901–909. [Google Scholar] [CrossRef]
  16. Anderson, G.; Ebadi, M.; Vo, K.; Novak, J.; Govindarajan, A.; Amini, A. An Updated Review on Head and Neck Cancer Treatment with Radiation Therapy. Cancers 2021, 13, 4912. [Google Scholar] [CrossRef]
  17. Larsson, M.; Hedelin, B.; Johansson, I.; Athlin, E. Eating problems and weight loss for patients with head and neck cancer: A chart review from diagnosis until one year after treatment. Cancer Nurs. 2005, 28, 425–435. [Google Scholar] [CrossRef] [PubMed]
  18. Trotti, A.; Bellm, L.A.; Epstein, J.B.; Frame, D.; Fuchs, H.J.; Gwede, C.K.; Komaroff, E.; Nalysnyk, L.; Zilberberg, M.D. Mucositis incidence, severity and associated outcomes in patients with head and neck cancer receiving radiotherapy with or without chemotherapy: A systematic literature review. Radiother. Oncol. 2003, 66, 253–262. [Google Scholar] [CrossRef] [PubMed]
  19. Gorenc, M.; Kozjek, N.R.; Strojan, P. Malnutrition and cachexia in patients with head and neck cancer treated with (chemo)radiotherapy. Rep. Pract. Oncol. Radiother. 2015, 20, 249–258. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  20. Unsal, D.; Mentes, B.; Akmansu, M.; Uner, A.; Oguz, M.; Pak, Y. Evaluation of Nutritional Status in Cancer Patients Receiving Radiotherapy: A Prospective Study. Am. J. Clin. Oncol. 2006, 29, 183–188. [Google Scholar] [CrossRef] [PubMed]
  21. Langius, J.A.E.; Doornaert, P.; Spreeuwenberg, M.D.; Langendijk, J.A.; Leemans, C.R.; van Bokhorst-de van der Schueren, M.A.E. Radiotherapy on the neck nodes predicts severe weight loss in patients with early stage laryngeal cancer. Radiother. Oncol. 2010, 97, 80–85. [Google Scholar] [CrossRef]
  22. Sroussi, H.Y.; Epstein, J.B.; Bensadoun, R.J.; Saunders, D.P.; Lalla, R.V.; Migliorati, C.A.; Heaivilin, N.; Zumsteg, Z.S. Common oral complications of head and neck cancer radiation therapy: Mucositis, infections, saliva change, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Med. 2017, 6, 2918–2931. [Google Scholar] [CrossRef]
  23. Deasy, J.O.; Moiseenko, V.; Marks, L.; Chao, K.S.; Nam, J.; Eisbruch, A. Radiotherapy dose-volume effects on salivary gland function. Int. J. Radiat. Oncol. Biol. Phys. 2010, 76, 090. [Google Scholar] [CrossRef] [Green Version]
  24. Paterson, C.; Caldwell, B.; Porteous, S.; McLean, A.; Messow, C.M.; Thomson, M. Radiotherapy-induced xerostomia, pre-clinical promise of LMS-611. Support Care Cancer 2016, 24, 629–636. [Google Scholar] [CrossRef] [Green Version]
  25. Bozzetti, F.; Cotogni, P. Nutritional Issues in Head and Neck Cancer Patients. Healthcare 2020, 8, 102. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  26. Langius, J.A.; van Dijk, A.M.; Doornaert, P.; Kruizenga, H.M.; Langendijk, J.A.; Leemans, C.R.; Weijs, P.J.; Verdonck-de Leeuw, I.M. More than 10% weight loss in head and neck cancer patients during radiotherapy is independently associated with deterioration in quality of life. Nutr. Cancer 2013, 65, 76–83. [Google Scholar] [CrossRef]
  27. Farhangfar, A.; Makarewicz, M.; Ghosh, S.; Jha, N.; Scrimger, R.; Gramlich, L.; Baracos, V. Nutrition impact symptoms in a population cohort of head and neck cancer patients: Multivariate regression analysis of symptoms on oral intake, weight loss and survival. Oral Oncol. 2014, 50, 877–883. [Google Scholar] [CrossRef] [PubMed]
  28. Bertrand, P.C.; Piquet, M.A.; Bordier, I.; Monnier, P.; Roulet, M. Preoperative nutritional support at home in head and neck cancer patients: From nutritional benefits to the prevention of the alcohol withdrawal syndrome. Curr. Opin. Clin. Nutr. Metab. Care 2002, 5, 435–440. [Google Scholar] [CrossRef]
  29. Mick, R.; Vokes, E.E.; Weichselbaum, R.R.; Panje, W.R. Prognostic factors in advanced head and neck cancer patients undergoing multimodality therapy. Otolaryngol. Head Neck Surg. 1991, 105, 62–73. [Google Scholar] [CrossRef] [PubMed]
  30. Muscaritoli, M.; Arends, J.; Bachmann, P.; Baracos, V.; Barthelemy, N.; Bertz, H.; Bozzetti, F.; Hütterer, E.; Isenring, E.; Kaasa, S.; et al. ESPEN practical guideline: Clinical Nutrition in cancer. Clin. Nutr. 2021, 40, 2898–2913. [Google Scholar] [CrossRef] [PubMed]
  31. Halawa, A.; Rowe, S.; Roberts, F.; Nathan, C.; Hassan, A.; Kumar, A.; Suvakov, B.; Edwards, B.; Gray, C. A Better Journey for Patients, a Better Deal for the NHS: The Successful Implementation of an Enhanced Recovery Program after Renal Transplant Surgery. Exp. Clin. Transpl. 2018, 16, 127–132. [Google Scholar]
  32. Muller, S.; Zalunardo, M.P.; Hubner, M.; Clavien, P.A.; Demartines, N. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009, 136, 842–847. [Google Scholar] [CrossRef] [Green Version]
  33. Dort, J.C.; Farwell, D.G.; Findlay, M.; Huber, G.F.; Kerr, P.; Shea-Budgell, M.A.; Simon, C.; Uppington, J.; Zygun, D.; Ljungqvist, O.; et al. Optimal Perioperative Care in Major Head and Neck Cancer Surgery with Free Flap Reconstruction: A Consensus Review and Recommendations from the Enhanced Recovery after Surgery Society. JAMA Otolaryngol. Head Neck Surg. 2017, 143, 292–303. [Google Scholar] [CrossRef] [Green Version]
  34. Moore, C.; Pegues, J.; Narisetty, V.; Spankovich, C.; Jackson, L.; Jefferson, G.D. Enhanced Recovery after Surgery Nutrition Protocol for Major Head and Neck Cancer Surgery. OTO Open 2021, 5, 2473974X211021100. [Google Scholar] [CrossRef] [PubMed]
  35. Schattner, M. Enteral nutritional support of the patient with cancer: Route and role. J. Clin. Gastroenterol. 2003, 36, 297–302. [Google Scholar] [CrossRef]
  36. Mekhail, T.M.; Adelstein, D.J.; Rybicki, L.A.; Larto, M.A.; Saxton, J.P.; Lavertu, P. Enteral nutrition during the treatment of head and neck carcinoma: Is a percutaneous endoscopic gastrostomy tube preferable to a nasogastric tube? Cancer 2001, 91, 1785–1790. [Google Scholar] [CrossRef]
  37. Lees, J. Incidence of weight loss in head and neck cancer patients on commencing radiotherapy treatment at a regional oncology centre. Eur. J. Cancer Care 1999, 8, 133–136. [Google Scholar] [CrossRef] [PubMed]
  38. Orell-Kotikangas, H.; Österlund, P.; Mäkitie, O.; Saarilahti, K.; Ravasco, P.; Schwab, U.; Mäkitie, A.A. Cachexia at diagnosis is associated with poor survival in head and neck cancer patients. Acta Otolaryngol. 2017, 137, 778–785. [Google Scholar] [CrossRef] [PubMed]
  39. Economopoulou, P.; de Bree, R.; Kotsantis, I.; Psyrri, A. Diagnostic Tumor Markers in Head and Neck Squamous Cell Carcinoma (HNSCC) in the Clinical Setting. Front. Oncol. 2019, 9, 827. [Google Scholar] [CrossRef] [PubMed]
  40. Brown, T.E.; Banks, M.D.; Hughes, B.G.M.; Lin, C.Y.; Kenny, L.M.; Bauer, J.D. Comparison of Nutritional and Clinical Outcomes in Patients with Head and Neck Cancer Undergoing Chemoradiotherapy Utilizing Prophylactic versus Reactive Nutrition Support Approaches. J. Acad. Nutr. Diet. 2018, 118, 627–636. [Google Scholar] [CrossRef]
  41. Newman, L.A.; Vieira, F.; Schwiezer, V.; Samant, S.; Murry, T.; Woodson, G.; Kumar, P.; Robbins, K.T. Eating and weight changes following chemoradiation therapy for advanced head and neck cancer. Arch. Otolaryngol. Head Neck Surg. 1998, 124, 589–592. [Google Scholar] [CrossRef] [Green Version]
  42. Beaver, M.E.; Matheny, K.E.; Roberts, D.B.; Myers, J.N. Predictors of weight loss during radiation therapy. Otolaryngol. Head Neck Surg. 2001, 125, 645–648. [Google Scholar] [CrossRef]
  43. Doley, J. Enteral Nutrition Overview. Nutrients 2022, 14, 2180. [Google Scholar] [CrossRef] [PubMed]
  44. Yanni, A.; Dequanter, D.; Lechien, J.R.; Loeb, I.; Rodriguez, A.; Javadian, R.; Van Gossum, M. Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy. Eur. Ann. Otorhinolaryngol. Head Neck Dis. 2019, 136, S27–S33. [Google Scholar] [CrossRef] [PubMed]
  45. Silander, E.; Nyman, J.; Bove, M.; Johansson, L.; Larsson, S.; Hammerlid, E. Impact of prophylactic percutaneous endoscopic gastrostomy on malnutrition and quality of life in patients with head and neck cancer: A randomized study. Head Neck 2012, 34, 1–9. [Google Scholar] [CrossRef] [PubMed]
  46. Rutter, C.E.; Yovino, S.; Taylor, R.; Wolf, J.; Cullen, K.J.; Ord, R.; Athas, M.; Zimrin, A.; Strome, S.; Suntharalingam, M. Impact of early percutaneous endoscopic gastrostomy tube placement on nutritional status and hospitalization in patients with head and neck cancer receiving definitive chemoradiation therapy. Head Neck 2011, 33, 1441–1447. [Google Scholar] [CrossRef]
  47. Salas, S.; Baumstarck-Barrau, K.; Alfonsi, M.; Digue, L.; Bagarry, D.; Feham, N.; Bensadoun, R.J.; Pignon, T.; Loundon, A.; Deville, J.L.; et al. Impact of the prophylactic gastrostomy for unresectable squamous cell head and neck carcinomas treated with radio-chemotherapy on quality of life: Prospective randomized trial. Radiother. Oncol. 2009, 93, 503–509. [Google Scholar] [CrossRef]
  48. Raykher, A.; Schattner, M.; Friedman, A. Safety and efficacy of pretreatment placement of PEG tubes in head and neck cancer patients undergoing chemoradiation treatment. Clin. Nutr. 2004, 23, 757. [Google Scholar]
  49. Nguyen, N.P.; North, D.; Smith, H.J.; Dutta, S.; Alfieri, A.; Karlsson, U.; Lee, H.; Martinez, T.; Lemanski, C.; Nguyen, L.M.; et al. Safety and effectiveness of prophylactic gastrostomy tubes for head and neck cancer patients undergoing chemoradiation. Surg. Oncol. 2006, 15, 199–203. [Google Scholar] [CrossRef]
  50. Anwander, T.; Bergé, S.; Appel, T.; von Lindern, J.J.; Martini, M.; Mommsen, J.; Kipnowski, J.; Niederhagen, B. Percutaneous endoscopic gastrostomy for long-term feeding of patients with oropharyngeal tumors. Nutr. Cancer 2004, 50, 40–45. [Google Scholar] [CrossRef]
  51. Scott, R.; Bowling, T.E. Enteral tube feeding in adults. J. R. Coll. Physicians Edinb. 2015, 45, 49–54. [Google Scholar] [CrossRef]
  52. Sánchez-Sánchez, E.; Ruano-Álvarez, M.A.; Díaz-Jiménez, J.; Díaz, A.J.; Ordonez, F.J. Enteral Nutrition by Nasogastric Tube in Adult Patients under Palliative Care: A Systematic Review. Nutrients 2021, 13, 1562. [Google Scholar] [CrossRef]
  53. Bossola, M. Nutritional interventions in head and neck cancer patients undergoing chemoradiotherapy: A narrative review. Nutrients 2015, 7, 265–276. [Google Scholar] [CrossRef] [PubMed]
  54. Arends, J.; Bodoky, G.; Bozzetti, F.; Fearon, K.; Muscaritoli, M.; Selga, G.; van Bokhorst-de van der Schueren, M.A.; von Meyenfeldt, M.; Zürcher, G.; Fietkau, R.; et al. ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology. Clin. Nutr. 2006, 25, 245–259. [Google Scholar] [CrossRef] [PubMed]
  55. Pfister, D.G.; Ang, K.K.; Brizel, D.M.; Burtness, B.A.; Cmelak, A.J.; Colevas, A.D.; Dunphy, F.; Eisele, D.W.; Gilbert, J.; Gillison, M.L.; et al. Head and neck cancers. J. Natl. Compr. Cancer Netw. 2011, 9, 596–650. [Google Scholar] [CrossRef] [Green Version]
  56. Langius, J.A.; Zandbergen, M.C.; Eerenstein, S.E.; van Tulder, M.W.; Leemans, C.R.; Kramer, M.H.; Weijs, P.J. Effect of nutritional interventions on nutritional status, quality of life and mortality in patients with head and neck cancer receiving (chemo)radiotherapy: A systematic review. Clin. Nutr. 2013, 32, 671–678. [Google Scholar] [CrossRef]
  57. Bossola, M.; Antocicco, M.; Pepe, G. Tube feeding in patients with head and neck cancer undergoing chemoradiotherapy: A systematic review. JPEN J. Parenter. Enter. Nutr. 2022, 46, 1258–1269. [Google Scholar] [CrossRef]
  58. Soria, A.; Santacruz, E.; Vega-Piñeiro, B.; Gión, M.; Molina, J.; Villamayor, M.; Mateo, R.; Riveiro, J.; Nattero, L.; Botella-Carretero, J.I. Gastrostomy vs nasogastric tube feeding in patients with head and neck cancer during radiotherapy alone or combined chemoradiotherapy. Nutr. Hosp. 2017, 34, 512–516. [Google Scholar] [CrossRef] [Green Version]
  59. Corry, J.; Poon, W.; McPhee, N.; Milner, A.D.; Cruickshank, D.; Porceddu, S.V.; Rischin, D.; Peters, L.J. Randomized study of percutaneous endoscopic gastrostomy versus nasogastric tubes for enteral feeding in head and neck cancer patients treated with (chemo)radiation. J. Med. Imaging Radiat. Oncol. 2008, 52, 503–510. [Google Scholar] [CrossRef]
  60. Compher, C.; Bingham, A.L.; McCall, M.; Patel, J.; Rice, T.W.; Braunschweig, C.; McKeever, L. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition. JPEN J. Parenter. Enter. Nutr. 2022, 46, 12–41. [Google Scholar] [CrossRef] [PubMed]
  61. Vanek, V.W. Ins and outs of enteral access. Part 1: Short-term enteral access. Nutr. Clin. Pract. 2002, 17, 275–283. [Google Scholar] [CrossRef]
  62. Bankhead, R.; Boullata, J.; Brantley, S.; Corkins, M.; Guenter, P.; Krenitsky, J.; Lyman, B.; Metheny, N.A.; Mueller, C.; Robbins, S.; et al. Enteral nutrition practice recommendations. JPEN J. Parenter. Enter. Nutr. 2009, 33, 122–167. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  63. Miller, K.R.; McClave, S.A.; Kiraly, L.N.; Martindale, R.G.; Benns, M.V. A tutorial on enteral access in adult patients in the hospitalized setting. JPEN J. Parenter. Enter. Nutr. 2014, 38, 282–295. [Google Scholar] [CrossRef] [PubMed]
  64. Baskin, W.N. Acute complications associated with bedside placement of feeding tubes. Nutr. Clin. Pract. 2006, 21, 40–55. [Google Scholar] [CrossRef]
  65. Sparks, D.A.; Chase, D.M.; Coughlin, L.M.; Perry, E. Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: A critical review. JPEN J. Parenter. Enter. Nutr. 2011, 35, 625–629. [Google Scholar] [CrossRef] [PubMed]
  66. Kozeniecki, M.; Fritzshall, R. Enteral Nutrition for Adults in the Hospital Setting. Nutr. Clin. Pract. 2015, 30, 634–651. [Google Scholar] [CrossRef]
  67. Bear, D.E.; Champion, A.; Lei, K.; Smith, J.; Beale, R.; Camporota, L.; Barrett, N.A. Use of an Electromagnetic Device Compared with Chest X-ray to Confirm Nasogastric Feeding Tube Position in Critical Care. JPEN J. Parenter. Enter. Nutr. 2016, 40, 581–586. [Google Scholar] [CrossRef]
  68. Welpe, P.; Frutiger, A.; Vanek, P.; Kleger, G.R. Jejunal feeding tubes can be efficiently and independently placed by intensive care unit teams. JPEN J. Parenter. Enter. Nutr. 2010, 34, 121–124. [Google Scholar] [CrossRef] [Green Version]
  69. Stayner, J.L.; Bhatnagar, A.; McGinn, A.N.; Fang, J.C. Feeding tube placement: Errors and complications. Nutr. Clin. Pract. 2012, 27, 738–748. [Google Scholar] [CrossRef]
  70. Li, Z.; Qi, J.; Zhao, X.; Lin, Y.; Zhao, S.; Zhang, Z.; Li, X.; Kissoon, N. Risk-Benefit Profile of Gastric vs Transpyloric Feeding in Mechanically Ventilated Patients: A Meta-Analysis. Nutr. Clin. Pract. 2016, 31, 91–98. [Google Scholar] [CrossRef]
  71. Mahadeva, S.; Malik, A.; Hilmi, I.; Qua, C.S.; Wong, C.H.; Goh, K.L. Transnasal endoscopic placement of nasoenteric feeding tubes: Outcomes and limitations in non-critically ill patients. Nutr. Clin. Pract. 2008, 23, 176–181. [Google Scholar] [CrossRef]
  72. Boullata, J.I.; Carrera, A.L.; Harvey, L.; Escuro, A.A.; Hudson, L.; Mays, A.; McGinnis, C.; Wessel, J.J.; Bajpai, S.; Beebe, M.L.; et al. ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: See text]. JPEN J. Parenter. Enter. Nutr. 2017, 41, 15–103. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  73. Lucendo, A.J.; Friginal-Ruiz, A.B. Percutaneous endoscopic gastrostomy: An update on its indications, management, complications, and care. Rev. Esp. Enferm. Dig. 2014, 106, 529–539. [Google Scholar] [PubMed]
  74. McClave, S.A.; Chang, W.K. Complications of enteral access. Gastrointest. Endosc. 2003, 58, 739–751. [Google Scholar] [CrossRef] [PubMed]
  75. Rahnemai-Azar, A.A.; Rahnemaiazar, A.A.; Naghshizadian, R.; Kurtz, A.; Farkas, D.T. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World J. Gastroenterol. 2014, 20, 7739–7751. [Google Scholar] [CrossRef]
  76. Koehler, J.; Buhl, K. Percutaneous endoscopic gastrostomy for postoperative rehabilitation after maxillofacial tumor surgery. Int. J. Oral Maxillofac. Surg. 1991, 20, 38–39. [Google Scholar] [CrossRef]
  77. Platek, M.E. The role of dietary counseling and nutrition support in head and neck cancer patients. Curr. Opin. Support Palliat. Care 2012, 6, 438–445. [Google Scholar] [CrossRef]
  78. Baschnagel, A.M.; Yadav, S.; Marina, O.; Parzuchowski, A.; Lanni, T.B., Jr.; Warner, J.N.; Parzuchowski, J.S.; Ignatius, R.T.; Akervall, J.; Chen, P.Y.; et al. Toxicities and costs of placing prophylactic and reactive percutaneous gastrostomy tubes in patients with locally advanced head and neck cancers treated with chemoradiotherapy. Head Neck 2014, 36, 1155–1161. [Google Scholar] [CrossRef]
  79. Barkmeier, J.M.; Trerotola, S.O.; Wiebke, E.A.; Sherman, S.; Harris, V.J.; Snidow, J.J.; Johnson, M.S.; Rogers, W.J.; Zhou, X.H. Percutaneous radiologic, surgical endoscopic, and percutaneous endoscopic gastrostomy/gastrojejunostomy: Comparative study and cost analysis. Cardiovasc. Interv. Radiol. 1998, 21, 324–328. [Google Scholar] [CrossRef]
  80. Laasch, H.U.; Wilbraham, L.; Bullen, K.; Marriott, A.; Lawrance, J.A.; Johnson, R.J.; Lee, S.H.; England, R.E.; Gamble, G.E.; Martin, D.F. Gastrostomy insertion: Comparing the options—PEG, RIG or PIG? Clin. Radiol. 2003, 58, 398–405. [Google Scholar] [CrossRef]
  81. Sigmon, D.F.; An, J. Nasogastric Tube. In StatPearls; StatPearls Publishing LLC.: Treasure Island, FL, USA, 2022. [Google Scholar]
  82. Baeten, C.; Hoefnagels, J. Feeding via nasogastric tube or percutaneous endoscopic gastrostomy. A comparison. Scand. J. Gastroenterol. Suppl. 1992, 194, 95–98. [Google Scholar] [CrossRef]
  83. Foutch, P.G.; Talbert, G.A.; Waring, J.P.; Sanowski, R.A. Percutaneous endoscopic gastrostomy in patients with prior abdominal surgery: Virtues of the safe tract. Am. J. Gastroenterol. 1988, 83, 147–150. [Google Scholar] [PubMed]
  84. Zopf, Y.; Maiss, J.; Konturek, P.; Rabe, C.; Hahn, E.G.; Schwab, D. Predictive factors of mortality after PEG insertion: Guidance for clinical practice. JPEN J. Parenter. Enter. Nutr. 2011, 35, 50–55. [Google Scholar] [CrossRef]
  85. Ahmad, I.; Mouncher, A.; Abdoolah, A.; Stenson, R.; Wright, J.; Daniels, A.; Tillett, J.; Hawthorne, A.B.; Thomas, G. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy--a prospective, randomised, double-blind trial. Aliment. Pharm. 2003, 18, 209–215. [Google Scholar] [CrossRef] [PubMed]
  86. Allison, M.C.; Sandoe, J.A.; Tighe, R.; Simpson, I.A.; Hall, R.J.; Elliott, T.S. Antibiotic prophylaxis in gastrointestinal endoscopy. Gut 2009, 58, 869–880. [Google Scholar] [CrossRef] [PubMed]
  87. Warriner, L.; Spruce, P. Managing overgranulation tissue around gastrostomy sites. Br. J. Nurs. 2012, 21, S14–S16, S18, S20 passim. [Google Scholar] [CrossRef]
  88. Schurink, C.A.; Tuynman, H.; Scholten, P.; Arjaans, W.; Klinkenberg-Knol, E.C.; Meuwissen, S.G.; Kuipers, E.J. Percutaneous endoscopic gastrostomy: Complications and suggestions to avoid them. Eur. J. Gastroenterol. Hepatol. 2001, 13, 819–823. [Google Scholar] [CrossRef]
  89. Lau, G.; Lai, S.H. Fatal retroperitoneal haemorrhage: An unusual complication of percutaneous endoscopic gastrostomy. Forensic. Sci. Int. 2001, 116, 69–75. [Google Scholar] [CrossRef]
  90. Klein, S.; Heare, B.R.; Soloway, R.D. The “buried bumper syndrome”: A complication of percutaneous endoscopic gastrostomy. Am. J. Gastroenterol. 1990, 85, 448–451. [Google Scholar]
  91. Sinclair, J.J.; Scolapio, J.S.; Stark, M.E.; Hinder, R.A. Metastasis of head and neck carcinoma to the site of percutaneous endoscopic gastrostomy: Case report and literature review. JPEN J. Parenter. Enter. Nutr. 2001, 25, 282–285. [Google Scholar] [CrossRef]
  92. Brown, M.C. Cancer metastasis at percutaneous endoscopic gastrostomy stomata is related to the hematogenous or lymphatic spread of circulating tumor cells. Am. J. Gastroenterol. 2000, 95, 3288–3291. [Google Scholar] [CrossRef]
  93. Hoffer, E.K.; Cosgrove, J.M.; Levin, D.Q.; Herskowitz, M.M.; Sclafani, S.J. Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: A prospective, randomized comparison. J. Vasc. Interv. Radiol. 1999, 10, 413–420. [Google Scholar] [CrossRef]
  94. Ryan, J.M.; Hahn, P.F.; Boland, G.W.; McDowell, R.K.; Saini, S.; Mueller, P.R. Percutaneous gastrostomy with T-fastener gastropexy: Results of 316 consecutive procedures. Radiology 1997, 203, 496–500. [Google Scholar] [CrossRef]
  95. Lowe, A.S.; Laasch, H.U.; Stephenson, S.; Butterfield, C.; Goodwin, M.; Kay, C.L.; Glancy, S.; Jackson, S.; Brown, D.; McLean, P.; et al. Multicentre survey of radiologically inserted gastrostomy feeding tube (RIG) in the UK. Clin. Radiol. 2012, 67, 843–854. [Google Scholar] [CrossRef] [PubMed]
  96. Shin, J.H.; Park, A.W. Updates on percutaneous radiologic gastrostomy/gastrojejunostomy and jejunostomy. Gut Liver 2010, 4 (Suppl. S1), S25–S31. [Google Scholar] [CrossRef] [PubMed]
  97. Ho, S.G.; Marchinkow, L.O.; Legiehn, G.M.; Munk, P.L.; Lee, M.J. Radiological percutaneous gastrostomy. Clin. Radiol. 2001, 56, 902–910. [Google Scholar] [CrossRef] [PubMed]
  98. Cherian, P.; Blake, C.; Appleyard, M.; Clouston, J.; Mott, N. Outcomes of radiologically inserted gastrostomy versus percutaneous endoscopic gastrostomy. J. Med. Imaging Radiat. Oncol. 2019, 63, 610–616. [Google Scholar] [CrossRef] [PubMed]
  99. Wollman, B.; D’Agostino, H.B.; Walus-Wigle, J.R.; Easter, D.W.; Beale, A. Radiologic, endoscopic, and surgical gastrostomy: An institutional evaluation and meta-analysis of the literature. Radiology 1995, 197, 699–704. [Google Scholar] [CrossRef]
  100. Yuan, T.W.; He, Y.; Wang, S.B.; Kong, P.; Cao, J. Technical success rate and safety of radiologically inserted gastrostomy versus percutaneous endoscopic gastrostomy in motor neuron disease patients undergoing: A systematic review and meta-analysis. J. Neurol. Sci. 2020, 410, 116622. [Google Scholar] [CrossRef]
  101. Anselmo, C.B.; Tercioti Junior, V.; Lopes, L.R.; Coelho Neto Jde, S.; Andreollo, N.A. Surgical gastrostomy: Current indications and complications in a university hospital. Rev. Col. Bras. Cir. 2013, 40, 458–462. [Google Scholar] [CrossRef] [Green Version]
  102. Murayama, K.M.; Schneider, P.D.; Thompson, J.S. Laparoscopic gastrostomy: A safe method for obtaining enteral access. J. Surg. Res. 1995, 58, 1–5. [Google Scholar] [CrossRef]
  103. Bravo, J.G.; Ide, E.; Kondo, A.; de Moura, D.T.; de Moura, E.T.; Sakai, P.; Bernardo, W.M.; de Moura, E.G. Percutaneous endoscopic versus surgical gastrostomy in patients with benign and malignant diseases: A systematic review and meta-analysis. Clinics 2016, 71, 169–178. [Google Scholar] [CrossRef]
  104. Kim, J.; Lee, M.; Kim, S.C.; Joo, C.U.; Kim, S.J. Comparison of Percutaneous Endoscopic Gastrostomy and Surgical Gastrostomy in Severely Handicapped Children. Pediatr. Gastroenterol. Hepatol. Nutr. 2017, 20, 27–33. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  105. Bakhos, C.; Patel, S.; Petrov, R.; Abbas, A. Jejunostomy-technique and controversies. J. Vis. Surg. 2019, 5, 3. [Google Scholar]
  106. Holmes, J.H.T.; Brundage, S.I.; Yuen, P.; Hall, R.A.; Maier, R.V.; Jurkovich, G.J. Complications of surgical feeding jejunostomy in trauma patients. J. Trauma 1999, 47, 1009–1012. [Google Scholar] [CrossRef] [PubMed]
  107. Myers, J.G.; Page, C.P.; Stewart, R.M.; Schwesinger, W.H.; Sirinek, K.R.; Aust, J.B. Complications of needle catheter jejunostomy in 2,022 consecutive applications. Am. J. Surg. 1995, 170, 547–550. [Google Scholar] [CrossRef]
  108. Inayet, N.; Neild, P. Parenteral nutrition. J. R. Coll. Physicians Edinb. 2015, 45, 45–48. [Google Scholar] [CrossRef]
  109. Kraft, M.D.; Btaiche, I.F.; Sacks, G.S. Review of the refeeding syndrome. Nutr. Clin. Pract. 2005, 20, 625–633. [Google Scholar] [CrossRef]
  110. Ridley, E.J.; Davies, A.R.; Parke, R.; Bailey, M.; McArthur, C.; Gillanders, L.; Cooper, D.J.; McGuinness, S.; for the Supplemental Parenteral Nutrition Clinical Investigators. Supplemental parenteral nutrition versus usual care in critically ill adults: A pilot randomized controlled study. Crit. Care 2018, 22, 12. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  111. Muthanandam, S.; Muthu, J. Understanding Cachexia in Head and Neck Cancer. Asia Pac. J. Oncol. Nurs. 2021, 8, 527–538. [Google Scholar] [CrossRef]
  112. Mäkitie, A.A.; Alabi, R.O.; Orell, H.; Youssef, O.; Almangush, A.; Homma, A.; Takes, R.P.; López, F.; de Bree, R.; Rodrigo, J.P.; et al. Managing Cachexia in Head and Neck Cancer: A Systematic Scoping Review. Adv. Ther. 2022, 39, 1502–1523. [Google Scholar] [CrossRef]
  113. Gotthardt, D.N.; Gauss, A.; Zech, U.; Mehrabi, A.; Weiss, K.H.; Sauer, P.; Stremmel, W.; Büchler, M.W.; Schemmer, P. Indications for intestinal transplantation: Recognizing the scope and limits of total parenteral nutrition. Clin. Transpl. 2013, 25, 49–55. [Google Scholar] [CrossRef] [PubMed]
  114. Maudar, K.K. Total Parenteral Nutrition. Med. J. Armed Forces India 1995, 51, 122–126. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  115. Chowdary, K.V.; Reddy, P.N. Parenteral nutrition: Revisited. Indian J. Anaesth. 2010, 54, 95–103. [Google Scholar] [CrossRef]
  116. Weimann, A.; Ebener, C.; Holland-Cunz, S.; Jauch, K.W.; Hausser, L.; Kemen, M.; Kraehenbuehl, L.; Kuse, E.R.; Laengle, F. Surgery and transplantation—Guidelines on Parenteral Nutrition, Chapter 18. Ger. Med. Sci. 2009, 18, 000069. [Google Scholar]
  117. Shah, R.D.; Luketich, J.D.; Schuchert, M.J.; Christie, N.A.; Pennathur, A.; Landreneau, R.J.; Nason, K.S. Postesophagectomy chylothorax: Incidence, risk factors, and outcomes. Ann. Thorac. Surg. 2012, 93, 897–903. [Google Scholar] [CrossRef] [Green Version]
  118. Scolapio, J.S.; Picco, M.F.; Tarrosa, V.B. Enteral versus parenteral nutrition: The patient’s preference. J. Parenter. Enter. Nutr. 2002, 26, 248–250. [Google Scholar] [CrossRef] [Green Version]
  119. Druyan, M.E.; Compher, C.; Boullata, J.I.; Braunschweig, C.L.; George, D.E.; Simpser, E.; Worthington, P.A.; American Society for Parenteral and Enteral Nutrition Board of Directors. Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients: Applying the GRADE system to development of A.S.P.E.N. clinical guidelines. JPEN J. Parenter. Enter. Nutr. 2012, 36, 77–80. [Google Scholar] [CrossRef] [PubMed]
  120. Ryu, J.; Nam, B.H.; Jung, Y.S. Clinical outcomes comparing parenteral and nasogastric tube nutrition after laryngeal and pharyngeal cancer surgery. Dysphagia 2009, 24, 378–386. [Google Scholar] [CrossRef] [PubMed]
  121. Marinella, M.A. Refeeding syndrome: An important aspect of supportive oncology. J. Support Oncol. 2009, 7, 11–16. [Google Scholar]
  122. Braga, M.; Ljungqvist, O.; Soeters, P.; Fearon, K.; Weimann, A.; Bozzetti, F. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clin. Nutr. 2009, 28, 378–386. [Google Scholar] [CrossRef] [PubMed]
Table
Table 1. Main characteristics and differences between enteral and parenteral nutrition.
Table 1. Main characteristics and differences between enteral and parenteral nutrition.
Enteral NutritionParenteral Nutrition
CheaperExpensive
Lower infection rateHigher infection rate
Need of monitoring for optimal nutritionDelivery of optimal nutrition
No gut atrophyGut atrophy
Shorter hospitalization rateLonger hospitalization rate
Fewer complicationsMore complications
Table
Table 2. Enteral nutrition modalities and their characteristics.
Table 2. Enteral nutrition modalities and their characteristics.
Enteral Nutrition MethodTermAdvantagesDisadvantages
Nasogastric tubeShort termSimple placement; cheapDiscomfort; potential displacement; risk of aspiration
Nasojejunal tubeShort termCan be used in patients with impaired gastric motility; reduced aspiration risk; cheapDiscomfort; potential displacement; require skilled specialist; no bolus feeding
Gastrostomy
PEGLong termCan be used for a prolonged time; minimally invasive techniqueNeeds sedation; invasive technique; potential displacement; stoma complications; tumor seeding
RIGLong termCan be used for a prolonged time; minimally invasive technique; no sedation neededInvasive technique; stoma complications; potential displacement due to smaller tubes
surgicalLong termCan be used for a prolonged time; no tube displacementRequires surgery under general anesthesia; stoma complications
JejunostomyLong termCan be used for a prolonged time; no risk of aspiration; less discomfortBy-passes the stomach; continuous slow rate of feeding; potential bowel obstruction
Abbreviations: PEG—percutaneous endoscopic gastrostomy; RIG—radiologically inserted gastrostomy.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Martinovic, D.; Tokic, D.; Puizina Mladinic, E.; Usljebrka, M.; Kadic, S.; Lesin, A.; Vilovic, M.; Lupi-Ferandin, S.; Ercegovic, S.; Kumric, M.; et al. Nutritional Management of Patients with Head and Neck Cancer—A Comprehensive Review. Nutrients 2023, 15, 1864. https://doi.org/10.3390/nu15081864

AMA Style

Martinovic D, Tokic D, Puizina Mladinic E, Usljebrka M, Kadic S, Lesin A, Vilovic M, Lupi-Ferandin S, Ercegovic S, Kumric M, et al. Nutritional Management of Patients with Head and Neck Cancer—A Comprehensive Review. Nutrients. 2023; 15(8):1864. https://doi.org/10.3390/nu15081864

Chicago/Turabian Style

Martinovic, Dinko, Daria Tokic, Ema Puizina Mladinic, Mislav Usljebrka, Sanja Kadic, Antonella Lesin, Marino Vilovic, Slaven Lupi-Ferandin, Sasa Ercegovic, Marko Kumric, and et al. 2023. "Nutritional Management of Patients with Head and Neck Cancer—A Comprehensive Review" Nutrients 15, no. 8: 1864. https://doi.org/10.3390/nu15081864

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop