xRead - Swallowing Disorders in the Adult Patient (October 2024)
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restrictions, and acquisition of postoperative contrast esophagography. Advances in suspension devices, endoscopes, instru mentation, and lasers have vastly improved the feasibility of surgical management of ZD while minimizing the risk of postoperative complications. 6,7 There are different compli cation pro fi les with different approaches. Minor complica tions such as dental and pharyngeal mucosal injuries are most common in endoscopic approaches, whereas open approaches demonstrate a higher risk for more serious complications (i.e., hematoma, RLN injury, leak). 15 In this study, complications occurred in 9.4% of patients. Overall, open surgery was a signi fi cant risk factor to experiencing a complication. We observed more minor complications with endoscopic surgery and more severe complications following open surgeries. This pattern is in line with the literature. 15 The four patients who experi enced leak (three with open and one with endoscopic) were managed with oral dietary restriction and extended hospi tal observation. One patient developed mediastinitis. Using this data, an algorithm was generated to guide manage ment of postoperative complications (Fig. 2). The algorithm suggests that if there is concern for leak, patients should be admitted, made npo, and evaluated for de fi nitive diagno sis. Following imaging and repeated clinical assessment, patients may be discharged or observed with appropriate restrictions and return precautions. According to Bock et al. in 2011, an ABEA member ship survey (26.2% response rate) regarding perioperative management of patients undergoing surgery for ZD, 65% of respondents reported discharge within 23 h with 33% reporting routine discharge between 2 and 4 days. 6 In a follow up survey of the ABEA a decade later (6.6% response rate), respondents reported hospital LOS <23 h in 52.9% for open cases and 66.7% for endoscopic cases, consistent with prior arguments that open procedures warranted longer LOS. 9 LOS for this cohort was typically <23 h with 81.2% discharged in <23 h regardless of surgical approach (Fig. 2). An additional 8.7% were observed for up to 48 h. Documented complications were not signi fi cantly differ ent between patients with 1-day versus 2-day observation (i.e., the 23-h group and the 48-h group). However, there was a signi fi cant difference between open versus endo scopic approaches. Open procedures were signi fi cantly associated with longer LOS ( p = 0.002) in patients with out complications. This suggests that routine practice patterns may still re fl ect the prior literature from ABEA. Postoperative complications were also signi fi cantly asso ciated with LOS >48 h ( p < 0.0001). In the 10% of patients with LOS >48 h, 15 had complications (9 endo scopic, 6 open). Even so, most of the patients who had a prolonged LOS were discharged by day four. This study supports that both the approach and complications play an important role in postoperative decision-making. According to the ABEA members survey in 2011, 42% allow liquid consumption on POD 1, 23% delay po intake until more than 48 h. One meta-analysis, Ver donck and Morton, suggests that after endoscopic sur gery, patients can be discharged on POD one or two with soft diet. 15 Here, the vast majority of patients were sent McKeon et al.: Postop Management of ZD, Contemp. Perspective 2681
TABLE III. Postoperative Course in Patients Without Complications.
Patients Without Complications
Total ( N = 270)
Endo ( N = 220)
Open ( N = 50)
p -Value
Length of stay, N (%) <23-h observation 233 (86.3)
197 (89.6)
36 (72.0) 6 (12.0) 8 (16.0)
p = 0.002
48-h
22 (8.1)
16 (7.3)
>48-h observation 15 (5.5)
7 (3.2)
Diet on discharge, N (%) Full
14 (5.2)
11 (5.0)
3 (6.0)
p = 0.26
Restricted npo/NGT Unknown
241 (89.3)
195 (88.6)
46 (92.0)
3 (1.1)
2 (0.9)
1 (2.0)
12 (4.4)
12 (5.5)
0
NGT = nasogastric tube; npo = nil-per-os.
Most (89.3%) patients were discharged on a restricted diet with or without a tapered advancement. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. Only 5.4% of patients were permitted a full/ regular diet prior to discharge (Table III). There was no difference in dietary restrictions between endoscopic ver sus open among those without complications ( p = 0.26). A greater proportion of patients with postoperative compli cations were npo with NGT after their hospitalization compared to those without a postoperative complication (21.4% vs. 1.2%, p < 0.0001). Nine patients were npo upon discharge, six following complications. Of those, four had undergone endoscopic approach with complication and two had an open approach with complication. Duration of dietary restriction was 1 – 2 weeks in 44.1% of patients and <1 week in 37% of patients. DISCUSSION ZD is a surgical disease impacting a not insigni fi cant proportion of the population. 12 – 14 Both open and endo scopic approaches are reliable and effective treatment modalities based on patient reported outcomes. 9,11 Surgi cal intervention is not without risk and should be evalu ated in the context of the patients ’ age, symptoms, and overall health via shared decision-making. 13,15,16 Ina pre vious work of the POUCH Collaborative, open approaches were associated with greater improvement in dysphagia scores than endoscopic approaches based on patient reported outcome measures; however, open approaches were also associated with a higher complication rate. 11 The latter was corroborated in the current study. In addi tion to fewer complications, endoscopic intervention for ZD has been advocated for decreased length of hospital stay and earlier time to oral intake; however, these pur ported advantages are based primarily on expert opin ion. 6,8,9 This study seeks to evaluate postoperative management practices after surgical management of ZD in 11 high-volume centers to determine factors that con tribute to hospital LOS, postoperative dietary
Laryngoscope 134: June 2024
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