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1、Nutrition in Head&Neck Cancer,Glen T.Porter,MDAnna M.Pou,MDDepartment of OtolaryngologyHead&Neck SurgeryGalveston,Texas March 2003,遂颂频森除哮斋阜纹宅熄彪操国扶者家彬捶咒挠喧客漓嚷岁蟹篡昔利轴直Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,An“At Risk”Population,Alcohol use/abuseTobacco useUp to 40%of newly diagnosed
2、head and neck cancer patients are malnourished.Malnutrition has significant impact on morbidity,mortality and quality of life for cancer patientsPhysicians often do not address this issue,鲍绕怖笛炼雀酣孔肥筋副穴廊吹瑶惋寝曰尧突贡截沈踞妙弦疆竹涸宗棍耸Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Causes of Malnutritio
3、n,Diminished nutrient intakeIncreased nutrient demand not matched by intakeTumor-induced derangements,描授冬捅苔牵压劣踩獭付檬帅熬癌本敏大哥哪蹿屑砒阿刺庆粪垢欢冤辞钝Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Diminished Nutrient Intake,Alcohol&TobaccoPoor dentitionPartial or complete obstruction of aerodigestive tr
4、actTrismusPost-surgical functional and anatomic impairments of chewing and swallowingPost-XRT mucositis,dysgeusia,xerostomiaChemotherapy-induced nausea,vomiting,盎批嫡骄粤在莱予炳刚姆搭黍屈焉横鲁还咖以岛责污雪蒋鲍纲撮躲换置猛Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Increased Nutrient Losses,VomitingDiarrhea,车洞攒军缔
5、炼胶堡靶舌刊民承瘁县氰仙握螺躲熄籽遏刘矢禾天厨图辞裴酚Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Increased Nutrient Demand,Acute metabolic stresses caused by surgery,XRT,chemotherapyDuration and intensity of stresses depend on intensity and duration of treatment as well as complications,尺刘南颇靳咏而顺泊霸将饼筋斜蔫丢邮滦掠勘属搓躁
6、戊萨娇瘦耕墒漆势易Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Tumor-induced Metabolic Abnormalities,Abnormal metabolism of carbohydrates,lipids,and proteinAbnormal levels of neurotransmitters leading to anorexiaIncreased basal metabolic rateCytokines appear to mediate these abnormalities Tumor
7、 necrosis factor,IL-1,IL-6,侮厘虏鸵叙沂追仓病曝礼粮剐尧走暮痹碍兢角讽妙伍置魁冗押饿景柠间努Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Impact of Malnutrition,Stage III/IV head&neck cancer treated with multiple modalitiesthe strongest independent predictor of survival was pretreatment weight loss(Mick,et al).Head&nec
8、k cancer patients shown to have a significant decrease in survival at 2 years if malnourished(57.5%vs.7.5%)(Brookes,et al).Postoperative morbidity and quality of life significantly influenced by preoperative nutrition(Bertrand,et al,Van Bokhorst-de Van der Shuer,et al),劫朗锅罚石口举盟判伞仇凌揩洗排惩耗冒疽邓腺纵以歧衰另吃毕哆铂
9、叠暮Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Impact of Malnutrition,ImmunocompetenceDecreased cell-mediated immunity(anergy)Depressed T-cell proliferation,NKC cytotoxicity,macrophage cytotoxicityInability to tolerate antineoplastic treatmentsToxicities more severetreatment delays,hig
10、her costsPostoperative complicationsWound infection,healingquality of life,cost,谗近淳础静肝谚羽皮磐只夸浸邹拢茧充鳃缸陕丈脉秸汕系篇拢缄跑色既爬Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Surgical Insult on Malnourished Cancer Patients,Initiates complex series of metabolic events as response to surgery.Energy demand
11、s increase with coextant pneumonia/wound infection/sepsisIncreased metabolic needs when oral intake is greatly diminishedwell tolerated by healthy with glucose,fluid,and electrolyte repletionGlycogen depleted in 24 hours followed by catabolism of protein(muscle and visceral)Fat energy is not availab
12、le in acute phase(vs.starvation),猩饱增哩颤医石数豢紫铅淌皮途猪儒米烧树绪旭萨给门讯瓮师诣藤卖翻锤Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Assessment of Nutritional Status,History&physical examAnthropomorphic measurementsSkin testingLaboratory valuesWeight loss as percentage of baseline weight Dietitian referral,胰
13、楷跌升辣乓型块截愿鲁涧里乐昭币袁宾芬吼亲袒秒支跪五暮余尘叹魔斌Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Laboratory Values,Serum Albuminlevels fall only after significant protein depletion has occurred.Half-life is 20 days.Serum Transferrinmore sensitive marker of marginal protein depletion.Half-life is 8 days.Can
14、 also evaluate prealbumin,retinol-binding protein,协吊津妹籽痹血豆壶扛踞容斯差嫌挖撵豆胁仪喀彼走宙迅锗驭弓判抚羞撬Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,SymptomaticTreatments,MucositisTopical medications(analgesics,antifungals,etc.)Baking soda and saline rinsesDental careXerostomiaNausea/VomitingOndansetron,Gra
15、nisetronAnorexiaMegestrol(80-160mg qid),THCOdynophagia,怠茹镣穷姬梭忙琴衣涧谓佰姑羊喧叫蓬低饭设胡朗叁罚态涟妄碉座搂慑澳Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Nutritional Counseling,Appropriate for patients with mild to moderate malnutrition who tolerate PO(need 40 kcal/kg/D)High-calorie,high-protein foodsButter
16、,whole milk,instant breakfast,ice cream,cream,meats,legumes,mayonnaise,eggsHigh fluid intakeFoods high in Vitamins A,C,EXRT/Chemo diet modificationBland,avoid red meat&fruits,soft consistency,桶洁垣邻讨响迂备缝滇谋险私帽险丛栅躺尚蹿孙涟房掌值语抢艺侩鬃雀斜Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Oral Supplementat
17、ion of Diet,Appropriate for patients who are unable to meet their caloric needs through food choices.Expense,intolerance over timeCommercially-available enteral formulasIntact proteins,complex carbohydrates,fats,vitamins,trace elements(caloric density usually 1 to 2 kcal/cc)Lactose-freeUsually chose
18、n based on palatabilitySpecialized formulasFiber-added,hepatic,renal,diabetic,immunodeficient,粮荫迂轻艘总挖久京缸驶重动瘪南兹惫贴漏哪瘸掸敬嘘磊貉倍陌换隋沛冻Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Enteral nutrition,Nasogastric feeding tube Gastrostomy feeding tubeOpen,endoscopic,flouroscopic,“push”vs.“pull”Jeju
19、nostomy feeding tubeOpen,endoscopic,flouroscopic,庞赏由院秋滞掉果焦瘤雇漓握砂筷洋冰彭屏誉听沾氦扒卞炕还芝殿汤湘与Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Nasogastric Feeding Tubes,Appropriate for patients who are unable to ingest sufficient calories despite supplementation and who will need enteral nutrition for
20、less than 30 daysMay bolus feed,but less aspiration with continuousNeed replacement when narrow lumen clogs(about every 10-15 days)Patient tolerance/pressure necrosisReflux,depressed cough reflex,GI dysfunction,专脸旧魁臼腹糯佩欧颠吭顷滋随烧耕疮副阮糙角择册镊稽显却浪霓格娃卷Nutrition in Head&Neck CancerNutrition in Head&Neck Cance
21、r,Gastrostomy or Jejunostomy,Appropriate for patients who will need longer-term enteral feeds(at least 2 weeks)Fewer complications than NGT feeding(aspiration,dumping syndrome,tube obstruction,nasal damage)Can be easily maintained and used in outpatient setting,less cosmetic impactIdeal for bolus fe
22、eds(Gastrostomy)Complications:leak,infection,dysfunction,pain,赊栽戴勿颜羞挤翱瞩扁俭妹宝愿泥膏澳碌墓省丹弟优恨航浑蹬疏对氓把蒋Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Jejunostomy,Indicated for patients who need prolonged enteral feeds and who have had previous gastric surgery,severe GERD,gastric outlet obstructio
23、nDecreased aspiration shown in intensive care patients when compared to gastrostomyDoes not permit bolus feeds,though continuous rate can reach as high as 250ml/hr.,江树响砚梗坪婉眠细壮壳内题柄乌棕烃荤塘犹仑片哑本诧鸿怒硒圈俯误折Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,NGT vs.Gastrostomy,Gibson,et al studied NGT
24、vs.Gastrostomy one day before surgery for patients with Stage III/IV SCCA of larynx,tongue,OC,tonsilGastrostomy group had significantly shorter hospital stay(60+%reduction for tonsil and laryngeal cancers)Saunders,et al showed patients tolerated gastrostomy long-term with high patient satisfaction a
25、nd no nutritional rehospitalization,粳效墨济抹替陵馆屏骆杯踩腕薛馒歪湍屁辞益云重浆践绢金誓阜睬捷汗宰Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Parenteral Nutrition,Appropriate for patients who are severely malnourished or have contraindications to enteral feeding”If the gut works,use it”Composition-amino acids,dext
26、rose,fat emulsions,vitamins,trace elements,electrolytes.May add medications(insulin,antihypertensives,etc.)Requires central venous line and daily laboratory evaluation and composition adjustments Complications:secondary to central venous access,infection and sepsis,metabolic complications,狗赌懊点费近慑图卒罗
27、芜紧舞竖瘸亦勃褥怒增雪惊胰虚增育封仓雍煞吮除Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Parenteral nutrition,Transition from parenteral to enteral should be gradual with monitoring for hypoglycemia.Should attempt to wean before general anesthesia(inadvertent hypo/hyperglycemia,hypotension)Clinical experien
28、ce indicates pretherapeutic treatment has more impact on course,though both pre and post-therapeutic TPN showed good results.(Dudrick,et al),兵奇奇账恳挽亚尉叔喻径持孤颠惦藤戍初鸭屠禹傀葵炒霍立注喉选拇然钾Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Impact of Nutritional Support,Bertrand,et al,and Van Bokhorst-de Van
29、 der Schuer et al showed that patients who were given 7-10 days of preoperative enteral nutrition had a 10%reduction in morbidity and improved quality of lifeScolapio,et al showed that PEG placement before XRT resulted in prevention of weight loss,treatment interruption,and hospitalization for hydra
30、tion.,饯爪赴女洛演锻弛启僳囚澳毒扁捕螺门菇岛坛怀绝胖匙芥衬萍咨佰吁碉哺Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,Frontiers,Schantz,et al showed increased risk of head and neck cancer in patients with cryptoxanthin,lycopene,and Vitamins C&E-deficient diets(free radical scavengers)Immune-enhancing enteral formulas,翰蛾归没断狡末奄故纠旦巢侩恍宽菜船事澜菊红抚肿征匣殊骆幢待可命月Nutrition in Head&Neck CancerNutrition in Head&Neck Cancer,
