The effect of early oral feeding compared to standard oral feeding following total laryngectomy: a systematic review

Abstract

Background: Pharyngocutaneous fistula is reported to be the most common early complication following total laryngectomy with significantly increased morbidity and mortality rates as well as increased resource utilisation. Postoperatively, the presence of a pharyngocutaneous fistula can double the length of an average patient hospital stay. Multiple risk factors for pharyngocutaneous fistula have been investigated in the literature. Common clinical practice is to delay the introduction of oral feeding following surgery to reduce the formation of a pharyngocutaneous fistula. Objectives: The objective of this review was to identify and synthesize the best available evidence on the effects of early oral feeding compared to standard oral feeding following total laryngectomy on the incidence of pharyngocutaneous fistula, and on hospital length of stay. Inclusion criteria: This review considered both experimental and descriptive studies of adults who commenced early oral feeding following total laryngectomy surgery. The intervention of interest was early oral feeding defined as oral intake in the first six days postoperatively and this was compared to standard care defined as oral intake from day seven onwards. Outcome measures included the incidence of pharyngocutaneous fistula and hospital length of stay. Methods: A comprehensive search strategy was undertaken across 10 major databases. Retrieved studies were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Data was then extracted and, where possible, pooled in statistical meta-analysis. Statistical pooling was not possible for data from descriptive studies and findings were presented in narrative form. Results: On the basis of appraisal, eight studies were of suitable methodological quality including three experimental and five descriptive studies. Experimental studies supported that early oral feeding does not increase the incidence of pharyngocutaneous fistula in the clinical context of primary total laryngectomy and this was substantiated by meta-analysis. Descriptive studies also supported these findings. Hospital length of stay could not be synthesized beyond the individual studies and as a result, findings were inconclusive. Conclusions: Early oral feeding prior to day seven in non-irradiated or non-extensively irradiated patients undergoing primary total laryngectomy does not result in increased pharyngocutaneous fistula formation. This conclusion is supported by meta-analysis. There is a lack of high quality primary research relating to early oral feeding in more extensive total laryngectomy procedures requiring flap reconstruction or salvage laryngectomy.