SURGERY | Long-term Nutritional Management

E. Lin , T.R. Ziegler , in Encyclopedia of Human Nutrition (Second Edition), 2005

Nasoenteric tubes

Nasogastric feeding should be reserved for those with intact mental status and protective laryngeal reflexes to minimize risks of aspiration. Indeed, even in intubated patients, nasogastric feedings can often be recovered from tracheal suction. Nasojejunal feedings are associated with less pulmonary complications, but access past the pylorus requires greater effort to accomplish. Blind insertion of nasogastric feeding tubes commonly results in misplacement, and air instillation with auscultation is inaccurate for ascertaining proper positioning. Radiographic confirmation is usually required to verify the position of the nasogastric feeding tube.

Several methods have been recommended for the passage of nasoenteric feeding tubes into the small bowel, including prokinetic agents, right lateral decubitus positioning, gastric insufflation, tube angulation, and clockwise torque. However, the successful placement of feeding tubes by these methods is highly variable and operator dependent. Furthermore, it is time-consuming, and the success rate of intubation past the duodenum into the jejunum by these methods is less than 20%. Fluoroscopy-guided intubation past the pylorus has a greater than 90% success rate and more than half of these intubations result in jejunal placement. Similarly, endoscopy-guided placement past the pylorus has a high success rate, but advancing the tube beyond the second portion of the duodenum by a standard gastroduodenoscope is difficult.

Small bowel feeding is more reliable for delivering nutrition than nasogastric feeding. Furthermore, the risks of aspiration pneumonia can be reduced by 25% with small bowel feeding compared with nasogastric feeding. The benefits of nasoenteric feeding tubes are limited by clogging, kinking, inadvertent displacement or removal, and nasopharyngeal complications. If nasoenteric feeding is required for more than 30   days, access should be converted to a percutaneous one.

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Gastroesophageal Reflux in the Premature Infant

Dara Brodsky MD , in Primary Care of the Premature Infant, 2008

Transpyloric feedings

Nasojejunal feedings can be considered in infants with transient severe GER disease. In the neonatal intensive care unit, this feeding regimen may transiently provide enteral nutrition to premature infants who demonstrate signs of aspiration associated with their reflux disease and are not yet feeding orally. As the infant matures, these feedings possibly can be discontinued.

At present, no data address the risks and benefits of continuous transpyloric feedings in older infants born prematurely. Because a nasogastric tube has been shown to increase the number of reflux episodes in preterm infants, 78 using a chronic nasojejunal tube may actually worsen GER disease. 38 Because of their lack of documented efficacy and their complication risks, nasojejunal tubes are not often used in the community setting.

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Surgical nutrition

William G. Simpson , Steven D. Heys , in Core Topics in General and Emergency Surgery (Fifth Edition), 2014

Nasoenteric tubes

Nasogastric feeding via fine-bore tubes (polyvinyl chloride or polyurethane) may be used in patients who require nutritional support for a short period of time. There has been considerable debate as to whether positioning the feeding tube beyond the pylorus into the duodenum will result in reduction in the risks of regurgitation of gastric contents and pulmonary aspiration (occurs in up to 30% of patients fed this way). This is most likely in patients with impaired gastric motility. In the latter patients, the fine-bore tube can be manipulated through the pylorus into the duodenum, reducing the risk of gastric aspiration. Other complications associated with the use of nasoenteric tubes include:

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pulmonary atelectasis;

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oesophageal necrosis, stricture formation;

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tracheo-oesophageal fistulas;

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sinusitis, postcricoid ulceration.

More recently, double-lumen tubes have been used – one lumen resides in the stomach and is used to aspirate gastric contents, while the distal lumen is placed in the jejunum for feeding, thus reducing risks of aspiration. This can be successful even in patients with relatively high gastric aspirates, previously thought to be a contraindication for feeding via the enteral route.

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Oral Feeding in Patients with Intracerebral Hemorrhage

Hideaki Takahata , in Bioactive Nutraceuticals and Dietary Supplements in Neurological and Brain Disease, 2015

Nonoral Feeding

Nonoral or tube feeding (nasogastric tube and PEG tube placement) has become a well-established clinical practice in stroke patients who are dysphagic and at high risk for aspiration or who cannot meet their nutritional needs orally. Stroke is indeed the primary cause of PEG tube placement (Grant et al., 1998; Suzuki et al., 2010), but there is no clear evidence to suggest that one route is more beneficial than any other in stroke patients. High incidences of chest infection and death are each associated with both methods of tube feeding (Dennis et al., 2005; Grant et al., 1998; Ickenstein et al., 2005). Grant et al. (1998) carried out a retrospective population-based descriptive study employing 81,105 Medicare beneficiaries (aged > 65) who received PEG tube placement and found that the overall mortality rate at 30 days was 23.9%, reaching 63.0% at one year and 81.3% by three years. Suzuki et al. (2010) found that the median survival of PEG patients was 753 days, and the most frequent cause of death was pneumonia (59%).

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Nutritional Needs and Support for the Burned Patient

Joshua S. Carson , ... David N. Herndon , in Total Burn Care (Fifth Edition), 2018

Complications of Nutritional Support

Complications of nasogastric and enteric feeding include nausea and vomiting, epistaxis, sinusitis, nasal necrosis, aspiration leading to pneumonia, tube malpositioning, dislodgment, and feeding-associated diarrhea. Fine-bore tubes are more comfortable but can become blocked easily. Auscultation examination of gastric fluid aspirate and pH testing can be used to confirm tube position, particularly for large-bore nasal tubes, although many units prefer radiologic confirmation. Tubes can also be inserted under endoscopic or fluoroscopic guidance (Table 28.5). (See the preceding section on "delivering enteral nutrition" for a discussion of ways to minimize aspiration risk.)

Unfortunately in burn patients efforts to deliver adequate nutrition enterally are frequently complicated by the degree of feeding intolerance manifested by either diarrhea or ileus (i.e., aperistalsis). GI ileus may reflect an underlying deterioration; therefore monitoring gastric residual volumes serves as an indicator of intercurrent conditions such as sepsis. In burn patients specifically, residuals that increase above the amount of food delivered routinely every hour have been shown to correlate with the development of bacterial sepsis. A full sepsis workup should be considered in any critically ill or injured patient with a sudden increase in gastric residuals over 200 mL. 78

Ileus is derived from mesenteric hypoperfusion prior to adequate resuscitation, and it is reversed once the patient has been resuscitated. Conversely overresuscitation leads to GI edema and should also be avoided. The initiation of immediate enteral feeding allows the delivery of calculated caloric requirements by the third day postinjury. Early enteral feeding is associated with reduction of hypermetabolism and less intense elevations in glucagon, cortisol, and catecholamine levels. 18,20,45,60

Diarrhea probably represents the most common complication of EN and typically presents an ongoing challenge in the management of the massively burned patient. The source of this diarrhea is multifactorial, making it fairly difficult to manage. In the setting of shock, diarrhea can represent mucosal failure from incipient intestinal ischemia. A variety of medications can contribute to this problem, most notably antacid agents and antibiotics. Infectious causes are not particularly common but nonetheless must be ruled out. Clostridium difficile should always be ruled out due to its potential for severe deterioration and the risk for contagion to other patients. Cytomegalovirus enterocolitis can emerge secondary to burn-associated immunosuppression. Naturally, specific pathogens endemic to the individual patient's exposure history should always be considered.

The most common source of diarrhea in burn patients treated with enteral tube feeds is likely the feeds themselves. The high osmolar concentration of these feeds, the volume of feeds required to meet the high caloric requirements of burn patients, and the gut response to stress all combine to result in a state of relative solute overload. Inappropriately rapid administration of hyperosmolar solutions may result in diarrhea, dehydration, electrolyte imbalance, hyperglycemia, and loss of potassium, magnesium, and other ions through diarrhea. Reducing the osmolality by decreasing formula strength while adjusting the rate is the first step in addressing this complication. If aggressive administration of hyperosmolar solute continues, pneumatosis intestinalis with bowel necrosis and perforation can result. Hyperosmolar nonketotic coma can also occur with enteral feedings. In some cases, diarrhea may persist even after converting to isoosmolar feeds, reflecting intestinal failure from shock and/or ischemic insult. In such situations, it may be necessary to convert to TPN with trophic feeds until intestinal function returns.

Support with PN offers a distinctly different profile of side effects. The potential complications associated with the attendant access requirements (i.e., central lines) must be considered, particularly given the decreasing use of central lines for nonnutritional applications in contemporary critical care. And, of course, the PN formula itself can significantly disturb metabolic and electrolyte homeostasis. Without the benefit of first-pass liver metabolism and responsive regulation of absorption by the functional intestinal mucosa, the direct infusion of nutritional elements can result in precipitous, often dangerous shifts in serum chemistry (Table 28.6).

Refeeding syndrome is a rare but dramatic clinical entity occasionally seen when initiating nutritional support in patients with long-standing starvation. It is heralded by the development of refractory hypokalemia, hypomagnesemia, and hypophosphatemia. Electrolyte abnormalities can result in cardiac failure and dysrhythmias, respiratory failure, neurologic disturbances, and renal and hepatic dysfunction. This should not present a concern in patients treated with early initiation of nutrition postinjury and continuous nutritional support.

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Enteric tube placement for gastroparesis: Gastrostomy, gastrojejunostomy and jejunostomy

Malorie Simons , Robert Bulat , in Gastroparesis, 2021

Short term enteral nutrition: nasojejunal access

A trial of nasojejunal (NJ) feeding has been considered a first step before proceeding with percutaneous enteric feeding in gastroparesis. Small bowel dysmotility can occur in patients with gastroparesis and thus a trial of enteric feed tolerance can be a useful way to assess the efficacy of a percutaneous technique before embarking on an invasive procedure. NJ tubes are recommended to stay in place for not more than 4 weeks due to increased risk of nasal trauma after this time [16]. Patient tolerance is generally good, but some cannot tolerate any nasal tube, even a for a short time due to nasopharyngeal discomfort. Due to its visibility, some patients find presence of the tube psychologically stressful [14]. Although NJ feeding is largely considered a bridge to later percutaneous feeding, one retrospective study reports that almost half of patients in one center experienced both weight gain and symptom improvement solely with a three month trial of NJ feeding, resulting in tube removal and successful transition to an oral diet [17].

The NJ feeding tube should be placed past the ligament of Treitz to minimize the amount of feed entering the stomach. This usually requires endoscopic placement, or fluoroscopy to confirm placement. Blind insertion into the stomach requires experience with tube positioning and use of prokinetics to allow passage beyond the pylorus, and runs a significant risk of malposition with concomitant pulmonary and pleural morbidity [14]. Endoscopic placement can be achieved with the "drag-and-pull" method with clipping or suturing into the wall of the small intestine. Suture loops tied to the end of the feeding tube can be secured to the mucosa with standard endoscopic clips (Fig. 29.1) [18]. Alternatively, the "over the guidewire" technique uses a guidewire that is first placed into the small intestine through an endoscope channel, followed by removal of the scope leaving the wire in place, and passage of a feeding tube over the wire. The "drag and pull" method can also be used with a guidewire to prevent dislodgment into the stomach with removal of the scope (Fig. 29.2) [18]. The "over-the-guidewire" has a reported initial placement rate in one study of 90–100%, but is technically more cumbersome [19]. If using fluoroscopy alone, successful placement is approximately 90%; however, the lack of ability to anchor the tube to the small bowel may pose a risk for migration [20]. A randomized trial comparing "drag and pull" using clips with endoscopy-guided "over the guidewire" technique showed fewer repeat endoscopies required in the former technique due to higher success in the initial placement (94 vs 74%) [21].

Figure 29.1.   (A) Drag technique utilizing two knotted sutures at distal end of the J tube, passed nasally, with the sutures captured endoscopically and dragged into the distal duodenum. (B) Technique of tying knotted sutures, which may be superior to unknotted sutures or loops. (C) Technique using guidewire or wires down the lumen as stiffener, which allows further pushing of the tube externally. (D) Technique passing an 8 French tube down the large diameter channel of a theraputic endoscope, the tip of which is in the distal duodenum or jejunum. The scope is withdrawn over the feeding tube, which is then transferred to the nares via an oronasal transfer tube [18].

Figure 29.2.   Drag and pull technique (pediatric colonoscope). (A) Guidewire-stiffened feeding tube passed nasally into stomach, one wire captured with biopsy forceps and dragged below the Ligament of Trietz. (B) Scope withdrawn into stomach, with forceps holding wire in position. Feed tube advanced over wires until it meets biopsy forceps distally, then scope is completely withdrawn, followed by removal of guidewire [18].

Although they can be an effective temporary source of nutrition, NJ tubes have three major disadvantages: migration, clogging and lack of palliative gastric decompression. As described above, NJ tubes are notorious for migrating into the stomach with withdrawal of the endoscope or after an episode of vomiting, but are less likely to do so if clipped [21]. Small diameter tubes (12–16 Fr) are prone to frequent clogging. Prevention includes proper training of the patient and nursing personnel to use frequent water irrigation and avoidance of injecting crushed medication tablets through the tube [14]. Both migration and clogging may require repeat procedures to replace and/or reposition the tubes. NJ tubes do typically allow for palliative gastric decompression. To perform adequate gastric relief, a nasogastric tube usually needs to be at least 18 Fr in diameter. Separate NG and NJ tubes in each nostril are not commonly used due to patient discomfort. Currently, dual lumen NG-J tubes are not widely available for temporary NJ feeds and NG decompression but have been evaluated in post-surgical patients in intensive care units [19,20]. NJ tubes may also result in reflux esophagitis, sinusitis and pressure ulceration [14]. Aspiration and regurgitation may be less likely with jejunal versus duodenal tube placement [22].

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Enteral Nutrition

Neal S. LeLeiko , ... Beth A. Pinkos , in Pediatric Gastrointestinal and Liver Disease (Sixth Edition), 2021

Administration of Formula Feedings

Short-term nasogastric feeding is the procedure of choice for most infants and children who have functioning gastrointestinal tracts and who are either unable or unwilling to take food orally. If a prolonged course of tube feeding is anticipated, then placement of a more permanent gastrostomy tube such as a percutaneous endoscopic gastrostomy (PEG) with a low-profile device should be considered.

Placement of a nasogastric feeding tube is a straightforward procedure that is generally well tolerated. Although placement at home is a skill that most parents and children can master over time, initial placement and confirmation is completed in either the clinic or inpatient setting. The proper position of a nasogastric tube can be confirmed by injecting air while listening over the abdomen. An initial radiograph to confirm correct positioning is often obtained, when clinically indicated. Properly done, the procedure eventually becomes nontraumatic and is generally readily accomplished. Occasionally the nasogastric tube can be ejected from the mouth if the patient vomits. The observation of the tube going into the nose and coming out the mouth may be distressing to the patient or patient's family. The situation should be handled in a calm way, with the tube removed and then replaced.

A few children will vomit several times in the first 12 to 24 hours. For these children, the tube should be immediately and matter-of-factly replaced. Virtually all children tolerate the tube after the first 24 to 36 hours. Most will tolerate it immediately. The cooperation and determination of the nursing and medical staff are of paramount importance. The family's role and attitude is critical as well. Generally speaking, when the importance of the tube to the child's nutrition is explained, the family is supportive. The tube must not be presented as a punishment. Frequently, children are informed that if they do not eat the appropriate amount of calories, they "will need the tube." This approach is unwarranted and leads to poor results. A matter-of-fact, direct approach when tube feeding becomes necessary is much more appropriate.

Once a nasal tube is in place, the patient may, if the physicians are agreeable, eat around the tube. In other words, the child may eat or drink via the mouth and may be supplemented by the nasogastric or nasojejunal tube. Some children, particularly adolescents, have such strong feelings against the tube that they choose to remove the tube and to drink the prescribed formula without the tube. Although this is unusual, it is definitely not rare. Such children should be afforded the opportunity to do this.

The use of nasojejunal feedings has been described as a successful and safe method for the nutritional support of sick, low-birth-weight infants as well as older children. 48-52 Simply, the principle is to deposit the formula beyond the pylorus so that the pyloric sphincter prevents regurgitation. This may be useful in a child with delayed gastric emptying or severe reflux and aspiration prior to the completion of a fundoplication. Theoretically, the relatively large surface area of the intestinal villi should allow for the rapid absorption of iso-osmolar solutions.

Positioning of the tube in the jejunum, however, does allow for some reflux of formula into the stomach. The use of a needle-catheter jejunostomy has been described for adults, although experience in children is still limited. 53

The nasojejunal or jejunostomy infusion should be managed in the same manner as a continuous infusion through a nasogastric tube feeding, with a gradual increase in rate until a child's nutritional requirements are met. Constant infusion over a 24-hour period appears to be essential for success of the transpyloric infusion. 54 Bolus feedings are poorly tolerated. In general, because the formula is passing directly into the jejunum and bypassing the important control mechanisms in the stomach and proximal duodenum, the formula should be designed to be optimally assimilated. Pain, nausea, distension, flatulence, hypermotility, and diarrhea may result from challenging the small intestine with feedings of intact protein, complex carbohydrates, long-chain triglyceride, or even an appropriate formula with too high an osmolarity or volume. Nonetheless, we have generally been surprised at how well jejunostomy feedings are tolerated without the need to resort to specialized formulas. Before beginning any feeding in the premature or newborn infant, the risks of necrotizing enterocolitis must be assessed.

If a prolonged course of enteral feeds is anticipated, a more permanent gastrostomy tube may be indicated. A PEG, or PEG tube, is a relatively straightforward procedure performed by many pediatric gastroenterology providers. This is a generally well-tolerated procedure that, depending on the clinical picture, involves a brief hospitalization for postoperative pain control and advancement of feeds. Ideally, the patient is able to tolerate the goal rate of tube feeds prior to hospital discharge. In most patients, this can be accomplished within 24 to 48 hours. Following maturation of the stoma tract, 3 to 4 months postplacement, the child is returned to the endoscopy or operative suite for removal of the PEG tube and insertion of a low-profile device. As this is a relatively quick procedure, it has been successfully completed in the outpatient setting. Although the PEG placement is somewhat less invasive, initial surgical placement of a g-tube is preferred in select clinical settings such as those patients with complicated comorbidities, infants with very low birth weight, or any patient with abnormal anatomy.

Once established, care must be taken to prevent accidental dislodgment of the gastrostomy feeding tube. Bleeding, significant discomfort, and generalized peritonitis secondary to leakage of formula from the gastrostomy tube site may result from the purposeful or accidental dislodgment of the gastrostomy by the patient. PEG has become a standard procedure for children and infants and is a highly acceptable approach for patients who will require long-term tube feeding.

A low-profile device is ultimately preferred for active patients. These small devices, although expensive, are highly regarded by parents and patients alike. The low-profile device is individually measured and ordered from the manufacturer. The patients and caregivers often prefer this small device as compared with the longer PEG tubes. The low-profile device is supplied as a set, which contains special adapters that fit into the device and allow the gastrostomy feedings to be given. 55

When gastric feeds are not tolerated, but the gastrointestinal tract is otherwise intact and functional, initiation of postpyloric feeds is often pursued. The placement of a postpyloric nasojejunal tube was historically performed at the bedside with the patient in the right lateral position followed by a radiograph to confirm proper location. Direct visualization under fluoroscopy by interventional radiology may be an easier approach that involves fewer attempts and negates the need for repeated confirmatory films should initial manual attempts be unsuccessful. Involvement of interventional radiology is also the preferred method for conversion of a gastrostomy tube to a gastrojejunal tube.

Patients with severe neurologic impairment, severe gastroesophageal disease, in a postoperative period after gastroesophageal surgery, or with severe cardiorespiratory disease may have a functioning gastrointestinal tract but require placement of either a temporary or permanent gastrostomy tube. The considerations of using this route are similar to those for use of the nasogastric tube. In addition, the patient is evaluated for gastroesophageal reflux with a pH/impedance probe. According to the results, a PEG or a surgical gastrostomy is considered. The presence of gastroesophageal reflux does not contraindicate the placement of a gastrostomy. If the reflux is severe, however, a surgical gastrostomy with fundoplication is considered.

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PREOPERATIVE AND POSTOPERATIVE NUTRITIONAL SUPPORT: STRATEGIES FOR ENTERAL AND PARENTERAL THERAPIES

Patricia M. Byers , S. Morad Hameed , in Current Therapy of Trauma and Surgical Critical Care, 2008

Gastrointestinal Access

In patients with adequate gastric emptying, nasogastric feedings with small-bore, flexible, weighted tubes are adequate. These tubes are 5–8 French in diameter, made of polyurethane, and have a stylette for insertion. The tube should be lubricated and the patient should have a topical anesthetic placed in the nostril. The tube is placed through the nostril, advanced through the pharynx and esophagus for approximately 50 cm. Next, 50–100 ml of air are injected, and the tube is advanced along the greater curvature toward the pylorus. An abdominal radiograph should always be obtained prior to initiating feeds through a small-bore tube.

This technique can be modified for postpyloric placement. Intravenous metoclopramide is given prior to the procedure. As the tube is advanced along the greater curvature of the stomach, a point of resistance at the pylorus is met. Gentle pressure is maintained until the pylorus opens and the tube is advanced. Again, an abdominal radiograph is obtained.

If long-term gastrointestinal access is needed, a more invasive approach will be needed. The endoscopic placement of percutaneous gastrostomy tubes is standard and can be performed at bedside in the intensive care unit. This procedure can also be performed safely in patients with a history of previous abdominal surgery, if additional care is taken. First, it is important to know of any gastrointestinal anatomic changes that have resulted from the previous surgery. It is important to obtain abdominal films and review prior scans to be certain that the stomach is approachable through a safe window. During endoscopy, a bright light should be seen in an area accessible for tube placement. A finder needle should be used to ensure that as air is aspirated into the syringe, the needle is visualized in the lumen of the stomach. Gastrostomy tubes may be placed with a push or a pull technique and should have a bolster holding them in place. Combination tubes are made so that an inner jejunostomy portion of the gastrostomy tube can be placed transpylorically. These tubes can also be placed in the radiology suite by the interventional radiology team. It is important to remember that tubes placed by fluoroscopy alone puncture the stomach, but do not fasten it to the abdominal wall. When using the radiology approach, using a postpyloric tube and feeding distally are recommended to guard against gastric distension, until a tract has formed in approximately 3–5 days following puncture.

Patients should have enteral access placed during the primary operative abdominal procedure when it is anticipated that nutritional support will be needed postoperatively. The type of access selected depends on the procedure performed and the gastrointestinal function anticipated. A gastrostomy is easily placed in the left upper quadrant when there is sufficient gastric remnant to do so. Stamm sutures should be placed to bring the stomach up to the abdominal wall. An inner jejunostomy tube can be placed if post-pyloric feedings are desired along with gastric drainage. A jejunostomy tube can also be placed, but may be associated with torsion and potential volvulus. To avoid this risk, it is better whenever possible to access the jejunum via the stomach with long gastrojejunostomy catheters.

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Enteral nutrition

In Meyler's Side Effects of Drugs (Sixteenth Edition), 2016

Gastrointestinal

There is a risk of gastroesophageal reflux during nasogastric feeding, especially in mechanically ventilated and sedated patients [4].

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A 77-year-old man had a ruptured abdominal aortic aneurysm repaired and developed acute renal, respiratory, and heart failure. Six days postoperatively, enteral feeding was started with a standard formulation. This was well tolerated and the volume was increased to 2   l/day continuously. After 9 days, the nasogastric tube was accidentally dislodged. Reinsertion was attempted but failed owing to apparent obstruction at 25   cm. Until this, the patient had been nursed supine. Esophagoscopy showed impacted enteral feed obstructing the esophagus almost completely.

Gastroesophageal reflux during enteral nutrition is caused by a number of factors, including the presence of the nasogastric tube, the supine position, leakage from the tube at the teeth, and the administration of sucralfate. While the cause in this case was not entirely clear, it does show that mechanical obstruction of the esophagus due to reflux can occur without any obvious symptoms.

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Surgery of the Tongue

Robert L. Ferris , in Operative Otolaryngology: Head and Neck Surgery (Second Edition), 2008

POSTOPERATIVE MANAGEMENT

Patients are treated with intravenous perioperative antibiotics over a 24-hour period. Nasogastric tube feedings are begun when bowel sounds are present. In the patient who does not have a skin graft, the nasogastric tube may be removed when the edema has subsided sufficiently that the patient can take an adequate amount of fluids. Patients who have a skin graft in place are fed by nasogastric tube or gavage feeding until the bolster is removed on the fifth day and the tongue regains enough mobility thereafter to permit oral feeding. Frequent suction of the mouth is performed, and the mouth is cleansed three to four times a day with gargles of half-strength hydrogen peroxide and saline solution.

Perioperative antibiotics are used in patients with major clean-contaminated surgical wounds. Great attention has to be paid to management of the neck dissections (see Chapter 78) to make certain that the drains function properly and to detect the formation of hematoma or seroma, chylous leak, or evidence of salivary drainage in the tubes, which may result from wound separation in the oral cavity. Dressings are usually applied to support the wound and to give some compression to the neck flaps. The postoperative care also very much depends on the type of reconstruction. Care of the tracheotomy tube and frequent and vigorous suctioning of the tracheobronchial secretions are enormously important in protecting the patient's airway and helping prevent pneumonia. If there is partial loss of the flap or separation of the intraoral wound with drainage into the neck, every effort must be made to separate the flow of saliva from the oral cavity into the neck to prevent neck infection, particularly in a radical neck dissection in which desiccation and destruction of the carotid artery system may otherwise ensue, possibly leading to carotid rupture.

Patients are downsized to a no. 4 cuffless tracheostomy tube and decannulated when they can tolerate capping of the tracheostomy tube. After the stoma closes, the patient is given instruction in swallowing and essentially uses the same type of swallowing technique as do patients who have undergone supraglottic laryngectomy. The process of swallowing is much downgraded by a total glossectomy, because it essentially converts the first and second phases of swallowing into one phase that is beyond the patient's control. Reconstruction after total glossectomy provides an adynamic conduit between the lips and the pharynx so that the bolus is literally dumped directly into the pharynx. The normal protective features of elevation of the larynx are eliminated because the musculature has been excised. With the bolus spilling into the pharynx and epiglottis area, aspiration is a certainty. The cricopharyngeal myotomy is helpful in trying to eliminate the slight delay in cricopharyngeal opening, which promotes spillover into the larynx.

The patient is taught to take food into the mouth and to do a form of the Valsalva maneuver to close the glottis. As the involuntary stages of swallowing begin, the patient coughs to clear the glottis and then completes the swallowing act and exhales. This new technique of swallowing requires that the patient be able to comprehend and perform the required maneuver and have an effective cough. The texture of food is also important in helping the patient learn to swallow again. The first attempts at feeding are with a nonpourable, puréed diet that holds together so that the bolus may pass more easily into the esophagus without spillage into the airway, as would be likely with thin fluids. Once this aspect is mastered, thin fluids may be attempted. It is often beneficial to use soft drinks with carbonation because the location of this fluid is better "felt" by the patient. Other mechanical adjustments are helpful, such as gulping the bolus with the neck extended. A spoon may be used to actually load the meal directly into the pharynx. This may also be accomplished with a large syringe and a short rubber feeding tube for gavage feedings. Eventually, most of these patients will be able to swallow a thick, puréed diet but not a soft or a normal diet.

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