Multimodal Prehabilitation in Head and Neck Cancer Patients Undergoing Surgery: A Feasibility Study

BACKGROUND

Head and neck cancer (HNC) incidence is increasing, and surgery is frequently indicated as curative treatment. Unfortunately, complications and long-term functional impairment are common. Recent promising results of multimodal prehabilitation in colorectal cancer surgery show improved recovery and functional outcomes. The objective of this study is to assess the feasibility of multimodal prehabilitation, which is composed of high-intensity training, a protein-enriched diet, cessation of intoxications, mental support and speech support therapy, in HNC surgery.

METHODS

A feasibility study was conducted at a large teaching hospital, Northwest Clinics, Alkmaar, the Netherlands, between July 2022 and December 2023. The primary outcome was feasibility, defined as participation, dropout and adherence rate. The secondary outcome was functional capacity 6 weeks postoperatively.

RESULTS

The participation rate was 60% (30 of 50 patients), mainly limited due to the travel distance to the physiotherapist. A dropout rate of 7% was present, as two patients discontinued prehabilitation. Of the remaining 28 patients, 27 patients (96%) attended at least six sessions at the community physiotherapist practice. All functional tests increased by prehabilitation, with the 6-min walking test being significant (p ≤ 0.05). Six weeks postoperatively, all but steep ramp tests remained higher than baseline.

CONCLUSION

Feasibility of multimodal prehabilitation in HNC surgery patients in this study is limited by its participation rate of 60%. Addressing participation, a widespread network of oncologic physiotherapists or home-based multimodal prehabilitation by an app could possibly potentiate participation. More studies are needed to assess the optimal form of multimodal prehabilitation in this challenging population.

Low Skeletal Muscle Mass: A Strong Predictive Factor for Surgical Complications After Free Forearm Flap Reconstruction in Oral Cancer Patients

BACKGROUND

Low skeletal muscle mass (SMM) is a predictive factor for complications in patients undergoing major head and neck cancer surgery. This study aims to identify the predictive value of low SMM for postoperative complications in patients who underwent free forearm flap (FAFF) reconstructions after oral cancer resections.

METHODS

A retrospective study was performed with all patients who underwent FFAF between 2003 and 2020 for an oral cavity reconstruction after cancer ablation. Free flap related, any postoperative complications and hospital stay were investigated.

RESULTS

Low SMM was associated with an increased risk of free flap associated complications (OR 2.14; 95% CI 1.02-4.39, p = 0.029). Low SMM was associated with severe complications (Clavien-Dindo ≥ III) (OR 1.46; 95% CI 1.20-2.09, p = 0.02).

CONCLUSIONS

Low SMM is a strong predictive factor for free flap related surgical complications in patients undergoing FAFF reconstruction after resection of oral cancer.

Effect of immunonutrition during concurrent chemoradiotherapy on acute oral mucositis in head and neck cancer patients: A prospective randomized study

OBJECTIVE

Immunonutrition (IN) supplements, designed to modulate immune system, may help reduce treatment-related toxicities. This study aimed to evaluate the efficacy of IN in reducing acute oral mucositis (OM) and other side effects in head and neck cancer patients undergoing concurrent chemoradiotherapy (CCRT).

METHODS

A multicenter, prospective, open-label randomized controlled study was conducted to assess the impact of IN on reducing OM and other side effects in head and neck cancer patients undergoing CCRT. Patients were randomized into either IN or control arms. Those in the IN arm received IN sachets starting one week before radiotherapy until treatment completion, while the control arm received no supplement. Treatment outcomes were evaluated using Common Terminology Criteria for Adverse Events (CTCAE) version 5 and patient-reported outcomes via National Cancer Institute's Patient-Reported Outcomes of CTCAE (NCI-PRO-CTCAE). Mixed-effects logistic regression was performed to analyze outcomes between the groups, adjusting for chemotherapy regimens, while Chi-squared tests were used for group comparisons at specific timepoints.

RESULTS

A total of 87 patients were analyzed with 46 in IN arm and 41 in control arm. Physician evaluations showed similar rates of grade 2 or higher OM, dermatitis, esophagitis, and hematologic toxicities across both arms. Patient-reported outcomes also showed no significant differences in the severity of oral mucositis or its interference with daily activities. A significant reduction of dermatitis was observed at week 3 in the IN arm (9.8% vs. 34.8%, p =  0.03), but this effect was not sustained in later weeks.

CONCLUSION

IN supplementation during CCRT did not result in statistically significant reductions in acute oral mucositis and other radiation toxicities. Further research with larger sample sizes, compliance monitoring, and optimized supplementation protocols is warranted to better understand the potential benefits of IN.

Sarcopenia predicts postoperative complications in head and neck cancer: a systematic review and meta-analysis

PURPOSE

We performed this systematic review and meta-analysis to explore the impact of preoperative sarcopenia on postoperative complication risks after head and neck cancer (HNC) surgery.

METHODS

We identified eligible studies by searching Ovid-MEDLINE, Ovid-Embase, EBM Reviews-Cochrane Central Register of Controlled Trials, Web of Science Core Collection, and Scopus. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.

RESULTS

Twenty-one studies with a total of 3480 patients met our inclusion criteria. The presence of sarcopenia significantly increased the incidence of overall postoperative complications (OR = 1.72, 95% CI 1.23, 2.41; P = 0.002; I2 = 59%). Subgroup analyses showed a higher risk of postoperative complications in the populations in which sarcopenia was diagnosed with low L3-skeletal muscle index (L3-SMI) or low cross-sectional area of the rectus femoris, but not in the group that sarcopenia was diagnosed with low C3-SMI. Preoperative sarcopenia also substantially increased the risk of severe postoperative complications (OR = 2.26), pharyngocutaneous fistulas (OR = 2.15), free flap-related complications (OR = 1.63), and surgical site infections (OR = 1.84). We also found a tendency toward a higher incidence of wound complications and 30-day mortality in patients with sarcopenia.

CONCLUSION

Preoperative sarcopenia is a negative prognostic indicator for postoperative complications in patients with HNC after surgery. To reduce the incidence of postoperative complications and improve poor prognosis, further attention needs to be paid to the evaluation and management of preoperative sarcopenia.

Pre-rehabilitation interventions for patients with head and neck cancers: A systematic review and meta-analysis

OBJECTIVE

To investigate the effect of pre-rehabilitation interventions such as nutrition and exercise for patients with head and neck cancer (HNC).

METHODS

Web of Science, PubMed, Scopus, Google Scholar, and Cochrane databases were searched up to December 2022. Quality of life, length of hospital stay, postoperative complications, change in body mass index or muscle mass, and functional assessments were the primary outcomes. PRISMA guidelines were adhered to, and the study was registered on PROSPERO. The Cochrane Collaboration tool and Newcastle Ottawa scale assessed the quality of included studies. Pooled data are presented as odds ratios (OR) and 95% confidence intervals (CI). Analysis was conducted using RevMan5.4.

RESULTS

A total of 31 articles were included for quantitative analysis and 15 for qualitative synthesis. Nutrition alone resulted in significant weight retention (2.60; 2.32, 2.88, p < 0.00001), length of stay (-4.00; -6.87, -1.13), p = 0.0006) and complications (0.64; 0.49, 0.83, p = 0.0009). Nutrition and psychoeducation resulted in a significant reduction in mortality rate (0.70; 0.49, 1.00, p = 0.05 and 0.60; 0.48, 0.74, p < 0.00001), and exercise resulted in a significant reduction in dysphagia (0.55; 0.35, 0.87, p = 0.01). Exercise with nutrition resulted in significant improvements in weight loss, length of stay, complications, and dysphagia. Randomized controlled trials (RCTs) had a moderate risk of bias and cohort studies were of fair to good quality.

CONCLUSION

Prehabilitation programs based on exercise, nutrition, or psychoeducation demonstrated improved post-interventional outcomes in HNC, such as quality of life, and mortality and morbidity. Studies with longer follow-ups and larger sample sizes, and investigations comparing nutritional supplements with exercise programs are needed.

The effect of preoperative oral nutritional supplementation on surgical site infections among adult patients undergoing elective surgery: A systematic review and meta-analysis

INTRODUCTION

Mixed findings are reported on the effect of oral nutritional supplements in reducing Surgical Site Infections (SSIs).

MATERIAL AND METHODS

PubMED, EMBASE and Cochrane were searched. Studies from inception to July 2022 were included if they involved adults undergoing elective surgery and compared preoperative macronutrient oral nutritional supplements to placebo/standard diet.

RESULTS

Of 372 unique citations, 19 were included (N ​= ​2480): 13 RCTs (N ​= ​1506) and 6 observational studies (N ​= ​974). Moderate-certainty evidence suggested that nutritional supplements SSI risk (OR 0.54, 95% C.I. 0.40-0.72, N ​= ​2718 participants). In elective colorectal surgery, this risk-reduction was 0.43 (95% C.I. 0.26-0.61, N ​= ​835 participants) and among patients who received Impact 0.48 (95% C.I. 0.32-0.70, N ​= ​1338).

CONCLUSION

Oral nutritional supplements prior to adult elective surgery may significantly reduce SSIs, with an overall 50% protective effect. This protective effect persisted in subgroup analysis of colorectal surgery patients and the use of Impact.

Immunonutrition in major oncologic head and neck surgery: Analysis of complications, plasmatic equilibrium, and costs

BACKGROUND

Malnutrition, in patients with solid tumors, is associated with a worse clinical outcome and about 40% of patients affected by head and neck cancers (HNC) are malnourished at the time of cancer diagnosis. We investigated the potential benefit of a standardized immunonutritional protocol (INP) to patients with HNC receiving major ablative surgery.

METHODS

An observational study was conducted enrolling 199 patients: 50 treated with the INP and 149 with standard enteral nutrition. Complication rates, need for medications, and costs were considered as outcomes.

RESULTS

INP played a protective role in development of major surgical complications (OR 0.23, p = 0.023), albumin administration (RR 0.38, p = 0.018), and antibiotic duration (p < 0.001) and is cost-effective in patients with moderate or severe malnutrition (-6083€ and -11 988€, p < 0.05).

CONCLUSIONS

Our study supports the utility of INP, and accurate nutritional screening can help to identify malnourished patients who would receive the most benefits from this protocol.

Therapeutic Perspectives for the Perioperative Period in Oral Squamous Cell Carcinoma (OSCC)

The perioperative period is the relatively short window of time, usually measured in days or weeks, around the surgical procedure. Despite its short duration, this time period is of great importance for cancer patients. From a biological point of view, the perioperative period is complex. Synchronous with primary tumor removal, surgery has local and distant consequences, including systemic and local inflammation, coagulation and sympathetic activation. Furthermore, the patients often present comorbidities and receive several medical prescriptions (hypnotics, pain killers, anti-emetics, hemostatics, inotropes, antibiotics). Because of the complex nature of the perioperative period, it is often difficult to predict the oncological outcome of tumor resection. Here, we review the biological consequences of surgery of Oral Squamous Cell Carcinoma (OSCC), the most frequent form of primary head and neck tumors. We briefly address the specificities and the challenges of the surgical care of these tumors and highlight the biological and clinical studies that offer insight into the perioperative period. The recent trials examining neoadjuvant immunotherapy for OSCC illustrate the therapeutic opportunities offered by the perioperative period.

Sarcopenia and microvascular free flap reconstruction

PURPOSE OF REVIEW

This article reviews the recent literature regarding the impact of sarcopenia on microvascular free flap reconstruction outcomes.

RECENT FINDINGS

Malnutrition, and consequent muscle loss, is a prevalent issue among head and neck cancer patients. However, diagnosis remains challenging due to a paucity of reliable objective measures. Traditional markers, such as albumin, have been used in the past to assess nutritional status, but cancer-related inflammation limits their predictive value. Recently, developments in the diagnosis of sarcopenia through the novel use of computed tomography (CT) cross-sectional muscle mass indices to evaluate body composition have proven effective and accessible.

SUMMARY

Literature shows compelling evidence that sarcopenia is associated with higher rates of surgical complications that delay recovery and increase mortality. The use of CT imaging to quantify muscle loss offers an objective way to evaluate nutritional status, which is predictive of postoperative rates of complications. Research on ways to optimize muscle mass prior to surgery is limited, however, immunonutrition is emerging as a promising intervention that can attenuate sarcopenia-related inflammation to improve outcomes.

The efficacy of immunonutrition in improving tolerance to chemoradiotherapy in patients with head and neck cancer, receiving nutritional counseling: study protocol of a randomized, open-label, parallel group, bicentric pilot study

Background:

Nutritional support, including nutritional counseling and oral nutritional supplements (ONSs), has been recommended at the earliest opportunity in head and neck (H&N) cancer patients. The limited available evidence on the efficacy of immunonutrition during chemoradiotherapy (CT-RT) in H&N cancer patients is positive with regard to some secondary endpoints, but is still scanty, particularly with regard to toxicity and treatment tolerance. We hypothesize that early systematic provision of ONSs with a high-protein–high-calorie mixture containing immunonutrients (Impact) compared to standard high-calorie–high-protein nutritional blends, in addition to nutritional counseling, may be beneficial to patients with H&N cancer during CT-RT. Hence, we designed the present study to evaluate the efficacy, in terms of treatment tolerance, toxicity and response, body weight, body composition, protein-calorie intake, quality of life (QoL), fatigue, muscle strength and immunological profile of the early systematic provision of ONSs enriched in immunonutrients compared to isonitrogenous standard blends, in H&N cancer patients undergoing CT-RT.

Methods:

This is a pragmatic, bicentric, randomized (1:1), parallel-group, open label, controlled, pilot clinical trial.

Discussion:

Many efforts are still to be taken to improve the efficacy of nutritional support in oncology. Immunonutrition represents a promising approach also in H&N cancer patients, but the evidence on its efficacy in improving clinical outcomes during CT-RT is still inconclusive. The present pilot study, which guarantees the early provision of nutritional assessment and support to all the enrolled patients in accordance with the recent guidelines and recommendations, could represent one of the first proofs of the clinical effectiveness of early oral immunonutrition in cancer patients undergoing CT-RT and could stimulate further large randomized trials, potentially resulting in the improvement of supportive care quality.

Trial registration:

This study is registered on ClinicalTrials.gov Identifier: NCT04611113.

Enhanced Recovery After Surgery Nutrition Protocol for Major Head and Neck Cancer Surgery

Objective

To determine whether an enhanced recovery after surgery (ERAS) nutrition protocol is reasonably possible among our head and neck cancer (HNC) population with respect to system feasibility and patient compliance. Second, we aim to identify improvements in patient outcomes as a result.

Methods

Preexperimental research design among patients undergoing major HNC surgery after implementation of the ERAS nutrition protocol from July 2018 to July 2019 as quality improvement (QI). Preoperative clinical nutritional assessment and laboratory values were completed the same day as informed surgical consent in the clinic. Protocol focus was patient consumption of nutritional supplements perioperatively, monitored by our outpatient dietitian. Early postoperative enteral nutrition was initiated with monitoring of nutritional laboratory values. To support our model, we provide preliminary analysis of HNC patient outcomes after implementation of the ERAS nutritional protocol.

Results

Twenty-five patients were enrolled. Preoperatively, 40% of patients were malnourished, and 100% complied with perioperative nutrition supplementation. Health care provider compliance obtaining preoperative laboratory values was 56%. There was a strong negative correlation between modified Nutrition-Related Index (mNRI) and number of complications (P = .01), specifically, fistula rate (P = .04) and unplanned reoperation (P = .04). Enrolled patient average length of stay was 7 ± 4.4 days.

Discussion

Our patients demonstrated compliance with implementation of an ERAS nutrition protocol likely facilitated by dietitian engagement. mNRI potentially reflects risk for head and neck surgery complications.

Implications for Practice

QI processes demand reassessment and modification to ensure efficient and targeted approaches to improving patient care.

Nutritional Support in Head and Neck Radiotherapy Patients Considering HPV Status

Malnutrition is a common problem in patients with head and neck cancer (HNC), including oropharyngeal cancer (OPC). It is caused by insufficient food intake due to dysphagia, odynophagia, and a lack of appetite caused by the tumor. It is also secondary to the oncological treatment of the basic disease, such as radiotherapy (RT) and chemoradiotherapy (CRT), as a consequence of mucositis with the dry mouth, loss of taste, and dysphagia. The severe dysphagia leads to a definitive total impossibility of eating through the mouth in 20-30% of patients. These patients usually require enteral nutritional support. Feeding tubes are a commonly used nutritional intervention during radiotherapy, most frequently percutaneous gastrostomy tube. Recently, a novel HPV-related type of OPC has been described. Patients with HPV-associated OPC are different from the HPV- ones. Typical HPV- OPC is associated with smoking and alcohol abuse. Patients with HPV+ OPC are younger and healthy (without comorbidities) at diagnosis compared to HPV- ones. Patients with OPC are at high nutritional risk, and therefore, they require nutritional support in order to improve the treatment results and quality of life. Some authors noted the high incidence of critical weight loss (CWL) in patients with HPV-related OPC. Other authors have observed the increased acute toxicities during oncological treatment in HPV+ OPC patients compared to HPV- ones. The aim of this paper is to review and discuss the indications for nutritional support and the kinds of nutrition, including immunonutrition (IN), in HNC, particularly OPC patients, undergoing RT/CRT, considering HPV status.

Effect of nutritional support in patients with lower respiratory tract infection: Secondary analysis of a randomized clinical trial

Background

In polymorbid patients with bronchopulmonary infection, malnutrition is an independent risk factor for mortality. There is a lack of interventional data investigating whether providing nutritional support during the hospital stay in patients at risk for malnutrition presenting with lower respiratory tract infection lowers mortality.

Methods

For this secondary analysis of a randomized clinical trial (EFFORT), we analyzed data of a subgroup of patients with confirmed lower respiratory tract infection from an initial cohort of 2028 patients. Patients at nutritional risk (Nutritional Risk Screening [NRS] score ≥3 points) were randomized to receive protocol-guided individualized nutritional support to reach protein and energy goals (intervention group) or standard hospital food (control group). The primary endpoint of this analysis was all-cause 30-day mortality.

Results

We included 378 of 2028 EFFORT patients (mean age 74.4 years, 24% with COPD) into this analysis. Compared to usual care hospital nutrition, individualized nutritional support to reach caloric and protein goals showed a similar beneficial effect of on the risk of mortality in the subgroup of respiratory tract infection patients as compared to the main EFFORT trial (odds ratio 0.47 [95%CI 0.17 to 1.27, p = 0.136] vs 0.65 [95%CI 0.47 to 0.91, p = 0.011]) with no evidence of a subgroup effect (p for interaction 0.859). Effects were also similar among different subgroups based on etiology and type of respiratory tract infection and for other secondary endpoints.

Conclusion

This subgroup analysis from a large nutrition support trial suggests that patients at nutritional risk as assessed by NRS 2002 presenting with bronchopulmonary infection to the hospital likely have a mortality benefit from individualized inhospital nutritional support. The small sample size and limited statistical power calls for larger nutritional studies focusing on this highly vulnerable patient population.

Clinical trial registration

Registered under ClinicalTrials.gov Identifier no. NCT02517476.

Perioperative immunonutrition in esophageal cancer patients undergoing esophagectomy: the first meta-analysis of randomized clinical trials

Although several randomized controlled trials have been published in recent years, the effect of perioperative immunonutrition in esophageal cancer (EC) patients remains unclear. This initial meta-analysis was conducted to assess whether perioperative enteral immunonutrition reduces postoperative complications in patients undergoing esophagectomy for EC. Relevant randomized controlled trials published before 1st September 2019 were retrieved from the Cochrane Library, PubMed, and EMBASE databases. After the literature was screened, two researchers extracted the information and data from eligible studies according to predefined selection criteria. Obtained data were pooled and analyzed by RevMan 5.3 software. The results were presented as risk ratios (RRs) with 95% confidence intervals (CIs). The heterogeneity among studies was tested by I2 test. Seven high-quality randomized controlled trials were included, with a total of 606 patients, 311 of whom received immunonutrition before and after surgery, while 295 received perioperative standard nutrition. No significant difference was observed between the two groups in the incidence of postoperative infection complications, including total infection complications (RR = 0.97, CI: 0.78-1.20, P = 0.76), pneumonia (RR = 0.97, CI: 0.71-1.33, P = 0.84), wound infection (RR = 0.80, CI: 0.46-1.40, P = 0.44), sepsis (RR = 1.35, CI: 0.67-2.71, P = 0.40), and urinary tract infection (RR = 0.87, CI: 0.54-1.40, P = 0.56). The prevalence of anastomotic leakage in the two groups was 9.4 and 5.4%, but the difference was not statistically significant (RR = 0.59, CI: 0.33-1.04, P = 0.07). Perioperative enteral immunonutrition provided no benefit in terms of the incidence of infection complications and anastomotic leakage in EC patients undergoing esophagectomy. Further large-scale randomized controlled trials are needed to confirm this conclusion.

Genomics and precision surgery for head and neck squamous cell carcinoma

The identification of the biological determinants that shape the response of tumors to medical therapies offers perspectives for better patient stratification and therapeutic targeting. Here, we discuss how genomics could help to improve the surgical treatment of head and neck squamous cell carcinoma (HNSCC). We examine the potential use of genomic analyses for: i) refining and standardizing the indications for surgery, ii) the choice of surgical procedure, and iii) the follow-up of patients with resected tumors. We highlight the studies that used genomics to explore the contribution of tumor biology to the outcome of surgery. We discuss the important developments that are challenging current surgical practice in HNSCC, such as neoadjuvant immunotherapy and the analysis of circulating DNA. Genomic analyses provide practical tools that could help improve the pathological diagnosis and staging of HNSCC, and increase the appreciation of the importance of tumor biology in the outcome of surgery. Identification of biomarkers will likely contribute to a move toward precision surgery of HNSCC, i.e. the personalization of surgical practice based on tumor biology.

Preoperative Nutrition Status and Postoperative Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex surgery to treat peritoneal surface malignancy (PSM). PSM and gastrointestinal (GI) resection from CRS can lead to significant GI symptoms and malnutrition. There is limited research into the nutrition status of this patient group and the impact of malnutrition on morbidity.

OBJECTIVE

This study aims to determine if preoperative malnutrition, assessed using the Subjective Global Assessment (SGA), is associated with postoperative morbidity and increased length of stay (LOS) in patients undergoing CRS/HIPEC for PSM.

METHODS

This study prospectively assessed the nutritional status of patients undergoing CRS/HIPEC using a validated nutrition assessment tool. Preoperative clinical symptoms, Peritoneal Cancer Index (PCI), intraoperative blood transfusions, operative time, GI resections, postoperative morbidity, and LOS, as well as pre- and postoperative nutritional interventions, were recorded. The impact of preoperative nutritional status was assessed in relation to postoperative complications and hospital LOS.

RESULTS

The study included 102 participants; 34 patients (33%) were classified as malnourished (SGA = B or C). Preoperative weight loss (15% vs. 74%; p ≤ 0.001) and the presence of clinical symptoms (18% vs. 47%; p = 0.002) were significantly higher in malnourished patients. While PCI, intraoperative blood transfusions, and GI resections were independent predictors of morbidity, malnutrition was significantly associated with infectious complications and LOS. For each grade of worsening malnutrition, LOS increased by an average of 7.65 days.

CONCLUSIONS

Preoperative malnutrition is prevalent in patients undergoing CRS/HIPEC and postoperative morbidity is common. Malnutrition is linked to LOS and plays a role in postoperative outcomes such as infection. Clear pre- and postoperative nutrition pathways are needed to optimize nutrition support and postoperative recovery.

Effect of preoperative immunonutrition on complications after salvage surgery in head and neck cancer

Background

Patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma are at high risk of postoperative complications due to the adverse effects of radiotherapy on wound healing. Malnutrition is an additional risk factor and we tested the hypothesis that preoperative administration of immunonutrition would decrease complications in this high risk population.

Methods

This single armed study with historical control included consecutive patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma. We compared outcomes before and after implementation of preoperative immunonutrition and adjusted the regression analysis for gender, age, body mass index, Nutritional Risk Screening (NRS 2002), tobacco and alcohol consumption, tumor localization, tumor stage, and type of surgery. The primary endpoint was overall complications from surgery within a follow-up of 30 days.

Results

Ninety-six patients were included (intervention group: 51, control group: 45). Use of preoperative immunonutrition was associated with a significant reduction in overall complications (35% vs. 58%, fully-adjusted odds ratio 0.30 (95%CI 0.10–0.91, p = 0.034). Length of hospital stay was also significantly reduced (17 days vs. 6 days, p = < 0.001). No differences in mortality and hospital readmission were found. These results remained robust in multivariate analysis.

Conclusions

In patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma, preoperative immunonutrition exhibited favorable effects on the complication rate and consequently reduced the length of hospital stay. By improving both tissue regeneration and immune response, immunonutrition may help to improve surgical outcomes in this high-risk population.