It is generally believed that patients should be fed by nasogastric tube for 7-10 days after undergoing total laryngectomy or laryngopharyngectomy to avoid the occurrence of post-operative salivary fistula. This study challenges this belief and looks into various factors that cause occurrence of salivary fistula, predominantly the timing of resumption of oral feeding. Eighty-nine patients were divided into an ‘early feeding’ group in which oral feeding started 24 hours after surgery and a ‘late feeding’ group in which oral feeding began seven days later. The exact protocols for feeding were observed in the two groups in terms of starting with clear fluids and going on to semi-solids. Various other factors possibly causing the occurrence of post-operative salivary fistula were also assessed. Variables such as gender, pre-operative tracheotomy, presence of chronic co-morbidities, pre- and post-operative haemoglobin levels, nutritional status, tumour location (glottic, supraglottic, transglottic or hypopharyngeal), primary tumour surgery type, duration of surgery and size of the remnant pharynx did not exhibit any statistically significant difference in the development of salivary fistula. The same was the case with the type of neck dissection carried out, jugular vein ligation and blood transfusion requirement. It is interesting that the nutritional status of patients was also insignificant in determining the occurrence of salivary fistula. The only variable which was associated with the development of post-operative salivary fistula was the histopatholgical cancer involvement of the surgical margins. This did not matter if it was carcinoma in situ but the tumour invasion of the surgical margin significantly affected the development of salivary fistula. The results of this study are in agreement with earlier studies quoted from the literature that did not demonstrate that early feeding increases the risk of salivary fistula. The authors contend that early feeding does not add any risks to this complication. Early feeding is therefore recommended as it restores normal physiology, is possibly more hygienic and is, after all, no different from ingesting saliva. It would also encourage early discharge and therefore reduce the cost of the treatment. 

Does early oral feeding increase the likelihood of salivary fistula after total laryngectomy?
Sousa AA, Porcaro-Salles JM, Soares JMA, et al.
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Madhup K Chaurasia

Mid and South Essex NHS Foundation Trust, UK.

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