Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Evaluation of Dysphagia and Diminished Airway Protection after Three-Field Esophagectomy and a Remedy Factors influencing bolus dwell times in healthy older adults assessed endoscopically. The effectiveness of the head-turn-plus-chin-down maneuver for eliminating vallecular residue. Surgical complications and long-term survival after esophagectomy for cancer in a nationwide Swedish cohort study. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial Oropharyngeal Dysphagia in Esophageal Cancer Before and After Transhiatal Esophagectomy Effects of Chin-Down Maneuver on the Parameters of Swallowing Function After Esophagectomy With 3-Field Lymphadenectomy Examined by Videofluoroscopy. Effect of Vocal Fold Medialization on Dysphagia in Patients with Unilateral Vocal Fold Immobility Effects of prolonged intensive care unit stay on quality of life and long-term survival after transthoracic esophageal resection Fiberoptic endoscopic evaluation of swallowing in assessing aspiration after transhiatal esophagectomy.
BACKGROUND & AIMS We evaluated the effect of a novel rehabilitative exercise on restoration of deglutition in a group of patients with deglutitive failure caused by abnormal upper esophageal sphincter ( UES ) opening manifested by postswallow residue and aspiration necessitating percutaneous tube feeding . METHODS We studied a total of 27 patients by videofluoroscopy and functional assessment of swallowing scores before and after 6 weeks of a head-raising exercise program . Seven of 27 patients , assigned r and omly , participated in a sham exercise before entering the tested exercise program . Eleven of 27 were r and omized to the real exercise program . RESULTS Although there was no change in swallow function and biomechanics after the sham exercise , following 6 weeks of real exercise , all 11 patients exhibited a significant improvement in their UES opening , anterior laryngeal excursion ( P < 0.01 ) , as well as resolution of postdeglutitive aspiration and were able to resume oral feeding . Similar results were found when the 7 patients in the sham group were crossed over to the real exercise group . Comparison of before and after exercise values for anteroposterior UES opening ( P < 0.01 ) and laryngeal anterior excursion ( P < 0.05 ) , as well as functional outcome assessment of swallowing ( P < 0.05 ) in the entire group of 27 patients also showed significant improvement . Etiology and duration of dysphagia did not affect the outcome . CONCLUSIONS The proposed suprahyoid muscle strengthening exercise program is effective in restoring oral feeding in some patients with deglutitive failure because of abnormal UES opening Background Recently , reports from the West have indicated three-field lymphadenectomy ( 3FL ) for esophageal cancer increases the accuracy of tumor staging and survival . However , this cervical procedure is likely to lead to swallowing dysfunction and aspiration , which are barriers to introducing this procedure in clinical practice . Methods Our goal is to eluci date the etiology of swallowing dysfunction after 3FL and devise a remedy . First , based on evaluation of swallowing function in ten patients with two-field lymphadenectomy ( 2FL ) and ten with 3FL  , we hypothesized that the scarred sternohyoid and sternothyroid muscles might be impairing laryngeal elevation after 3FL ; thus , complete division of the bilateral infrahyoid muscles attached to the sternum ( CDBIMS ) could be an effective remedy . Next , the utility of this additive procedure was examined in 20 patients with 3FL .  Swallowing function was evaluated by the distance of total laryngeal elevation ( TLE ) and the frequency of incomplete airway protection ( IAP ) ( laryngeal penetration or aspiration ) on videofluoroscopic study . Results The average TLE and frequency of IAP were , respectively , 0.37 cm and 70 % in the 3FL group , showing significant deterioration ( p < 0.001 and 0.025 ) , in contrast to 1.79 cm and 20 % in the 2FL group . The 3FL + CDBIMS group showed significant improvements in the average TLE and the frequency of IAP ( 1.70 cm and 25 % ) , compared with the 3FL group ( p < 0.001 and 0.018 ) . Multivariate logistic regression identified additive CDBIMS as a significant suppressor of IAP after 3FL . Conclusions Laryngeal elevation was significantly impaired after 3FL . Adding CDBIMS might improve swallowing function in these patients OBJECTIVES /HYPOTHESIS Scant data exist on normal bolus dwell time assessed during flexible endoscopic evaluation of swallowing ( FEES ) . The purpose of this study was to examine bolus dwell time in healthy older adults . Because it has been previously reported that some healthy older adults aspirate , we also sought to determine if bolus dwell time varied as a function of aspiration status . STUDY DESIGN Prospect i ve . METHODS Seventy-six healthy volunteers from the seventh , eighth , and ninth decades of life participated .  Dwell times were analyzed via FEES as a function of pharyngeal location , liquid type , delivery method , purée type , viscosity , age , and gender . RESULTS Longer dwell times were evidence d with the eldest participants , straw delivery , and the smallest volume . Adults in the ninth decade were 4.8 ( P = .01 ) and 3.8 ( P = .02 ) times more likely to have longer dwell times at the vallecula and 7.1 ( P = .002 ) and 3.8 ( P = 0.02 ) at the pyriform sinus than those in the seventh and eighth decades , respectively . Longer dwell times at the vallecula and pyriform sinuses were 2 and 2.38 times ( P < .0001 ) more likely for straw than cup delivery , respectively . Boluses of 5 mL were 1.5 times ( P < .05 ) more likely to result in longer dwell times than larger volumes . Bolus dwell times did not significantly differ as a function of aspiration status . CONCLUSIONS Advanced age , straw delivery , and small volumes yielded longer dwell times . These variables should be considered before diagnosing an abnormal bolus dwell time in elder patients Purpose When swallowing efficiency is impaired , residue accumulates in the pharynx . Cued or spontaneous swallows in the head neutral position do not always successfully clear residue . We investigated the impact of a novel maneuver on residue clearance by combining a head turn with the chin down posture . Methods Data were collected from 26 participants who demonstrated persistent vallecular residue after an initial head neutral clearance swallow in videofluoroscopy .  Participants were cued to perform a head-turn-plus-chin-down swallow , with the direction of head turn r and omized . Pixel-based measures of residue in the vallecular space before and after the maneuver were made on still frame lateral images using ImageJ software . Measures of % full and the Normalized Residue Ratio Scale ( NRRS ) were extracted . Univariate analyses of variance were used to detect significant reductions in residue . Results On average , pre-maneuver measures showed residue filling 56 - 73 % of the valleculae , depending on stimulus consistency ( NRRS scores : 0.2 - 0.4 ) . More than 80 % of pre-swallow measures displayed NRRS ratios > 0.06 , a threshold previously linked to increased risk of post-swallow aspiration . Conclusion The head-turn-plus-chin-down maneuver achieved significant reductions in residue for thin and nectar-thick fluids , suggesting that this maneuver can be effective in reducing persistent vallecular residue with these consistencies AIMS Acute surgical complications after esophageal resection for cancer may decrease the long-term survival . Previous results on this topic are conflicting and no population -based studies are available . METHODS A prospect i ve , nationwide Swedish study was conducted in 2001 - 2010 . Eligible patients comprised those afflicted by esophageal or cardia cancer and underwent surgical resection in Sweden in 2001 - 2005 . Details concerning patient and tumor characteristics , surgical procedures , and postoperative surgical complications were collected prospect ively . Follow-up for mortality , starting from 90 days after the surgery , was done until May 2010 . Cox proportional-hazards regression was performed to estimate hazard ratios ( HRs ) and 95 % confidence intervals ( CIs ) , adjusted for age , tumor stage , sex , histology , comorbidity , surgical approach and surgical radicality . RESULTS Among 567 included patients who survived at least 90 days postoperatively , 130 ( 22.9 % ) sustained a predefined surgical complication within 30 days of surgery . The adjusted HR of mortality was increased in patients who sustained surgical complications , compared to patients without such complications ( HR 1.29 , 95 % CI 1.02 - 1.63 ) . CONCLUSIONS The occurrence of surgical complications might be an independent predictor for poorer long-term survival in patients resected for esophageal cancer , even in patients who survived the postoperative period BACKGROUND Surgical resection is regarded as the only curative option for resectable oesophageal cancer , but pulmonary complications occurring in more than half of patients after open oesophagectomy are a great concern . We assessed whether minimally invasive oesophagectomy reduces morbidity compared with open oesophagectomy . METHODS We did a multicentre , open-label , r and omised controlled trial at five study centres in three countries between June 1 , 2009 , and March 31 , 2011 . Patients aged 18 - 75 years with resectable cancer of the oesophagus or gastro-oesophageal junction were r and omly assigned via a computer-generated r and omisation sequence to receive either open transthoracic or minimally invasive transthoracic oesophagectomy . R and omisation was stratified by centre . Patients , and investigators undertaking interventions , assessing outcomes , and analysing data , were not masked to group assignment . The primary outcome was pulmonary infection within the first 2 weeks after surgery and during the whole stay in hospital . Analysis was by intention to treat . This trial is registered with the Netherl and s Trial Register , NTR TC 2452 . FINDINGS We r and omly assigned 56 patients to the open oesophagectomy group and 59 to the minimally invasive oesophagectomy group . 16 ( 29 % ) patients in the open oesophagectomy group had pulmonary infection in the first 2 weeks compared with five ( 9 % ) in the minimally invasive group ( relative risk [ RR ] 0·30 , 95 % CI 0·12 - 0·76 ; p=0·005 ) . 19 ( 34 % ) patients in the open oesophagectomy group had pulmonary infection in-hospital compared with seven ( 12 % ) in the minimally invasive group ( 0·35 , 0·16 - 0·78 ; p=0·005 ) . For in-hospital mortality , one patient in the open oesophagectomy group died from anastomotic leakage and two in the minimally invasive group from aspiration and mediastinitis after anastomotic leakage . INTERPRETATION These findings provide evidence for the short-term benefits of minimally invasive oesophagectomy for patients with resectable oesophageal cancer . FUNDING Digestive Surgery Foundation of the Unit of Digestive Surgery of the VU University Medical Centre Although dysphagia is the predominant symptom of esophageal cancer , the nature of the swallowing deficit remains unclear , particularly regarding an oropharyngeal motor component . The present study examined the  oropharyngeal swallow in patients with esophageal cancer before and following transhiatal esophagectomy . Videofluoroscopic data were obtained from ten patients with esophageal cancer before and following transhiatal esophagectomy  as they swallowed 2- , 5- , and 10-cc aliquots of liquid and puree , and 0.5 and 1 tsp of solid . Each swallow was rated on 36 parameters by three independent judges . Swallow-related hyoid bone movement , computed from digitized segments of the videofluoroscopic data , was compared pre- and postsurgically . All patients showed at least mild abnormality of the oropharyngeal swallow preoperatively . Abnormalities involved all stages of swallowing in nine of the ten patients ; however , the oral preparatory/oral stage was relatively more impaired than the pharyngeal stage in the majority of patients . Postsurgically , all patients exhibited at least a mild oropharyngeal swallowing impairment . New or increased postoperative deficits involved the pharyngeal stage of swallowing , whereas oral stage abnormalities were generally improved or unchanged following surgery . Swallow-related hyoid kinematics were highly variable both before and following surgery . Anterior hyoid bone excursion was significantly reduced postoperatively in one patient and significantly increased in one patient . Patients with esophageal cancer exhibit oropharyngeal dysphagia , with different profiles of abnormality before and following esophagectomy OBJECTIVES To determine the effect of the chin-down maneuver after  esophagectomy with 3-field lymphadenectomy ( 3FL ) on pharyngeal residue , upper esophageal sphincter ( UES ) opening , and laryngeal closure . DESIGN Prospect i ve data were collected from a pharyngeal videofluoroscopic swallowing study . SETTING Dysphagia clinics . PARTICIPANTS Patients selected according to the inclusion criteria ( N=14 ; mean age , 65.9y ) from a total of 43 patients who underwent esophagectomy with 3FL from May to December 2014 were enrolled . INTERVENTIONS Videofluoroscopy was conducted in head-neutral and chin-down positions to measure the pharyngeal constriction ratio ( PCR ) , amount of residue in the vallecula and pyriform sinus after the first swallow , UES opening diameter , duration of UES opening , and duration of laryngeal vestibule closure . MAIN OUTCOME MEASURES The aforementioned parameters were compared statistically between the head-neutral and chin-down positions . RESULTS In comparison with the neutral group , the PCR and residue in the pyriform sinus were significantly smaller in the chin-down group ( P<.01 ) . However , the residue in the vallecula did not differ significantly from that of the neutral group ( P=.44 ) . The UES opening diameter , duration of UES opening , and duration of laryngeal vestibule closure were all significantly larger in the chin-down group than in the neutral group ( P<.05 ) . CONCLUSIONS This study demonstrates that use of the chin-down maneuver after esophagectomy with 3FL can help expedite swallowing by strengthening pharyngeal constriction , widening the UES , and enhancing laryngeal closure Objective The effect of vocal fold medialization ( VFM ) on vocal improvement in persons with unilateral vocal fold immobility ( UVFI ) is well established . The effect of VFM on the symptom of dysphagia is uncertain . The purpose of this study is to evaluate dysphagia symptoms in patients with UVFI pre- and post-VFM .  Study Design Case series with chart review . Setting Academic tertiary care medical center . Subjects and Methods The charts of 44 persons with UVFI who underwent VFM between June 1 , 2013 , and December 31 , 2014 , were abstract ed from a prospect ively maintained data base at the University of California , Davis , Voice and Swallowing Center . Patient demographics , indications , and type of surgical procedure were recorded . Self-reported swallowing impairment was assessed with the vali date d 10-item Eating Assessment Tool ( EAT-10 ) before and after surgery . A paired sample s t test was used to compare pre- and postmedialization EAT-10 scores . Results Forty-four patients met criteria and underwent either vocal fold injection ( 73 % ) or thyroplasty ( 27 % ) . Etiologies of vocal fold paralysis were iatrogenic ( 55 % ) , idiopathic ( 29 % ) , benign or malignant neoplastic ( 9 % ) , traumatic ( 5 % ) , or related to the late effects of radiation ( 2 % ) . EAT-10 ( mean ± SD ) scores improved from 12.2 ± 11.1 to 7.7 ± 7.2 after medialization ( P < .01 ) with a follow-up of 119 ± 65 days . Conclusion Patients with UVFI suffer from dysphagia and report significant improvement in swallowing symptoms following VFM . The symptomatic improvement appears to be durable over time Objective : There are few prospect i ve data on the effects of prolonged intensive care unit stay on the quality of life and long-term survival of a homogeneous patient population . Therefore , the aims of this prospect i ve study were a ) to describe the quality of life in patients after having a transthoracic esophageal resection ; and b ) to analyze the influences of a prolonged intensive care unit stay on quality of life and survival in patients after esophageal cancer resection who survived to hospital discharge . Design : Prospect i ve study . Setting : Medical center . Patients : The study population consisted of 109 patients undergoing a transthoracic resection for adenocarcinoma of the middistal esophagus or gastric cardia between April 1994 and February 2000 . Interventions : None . Measurements and Main Results : A comparison was made between patients staying ≤5 days vs. ≥6 days in the intensive care unit and also ≤2 days vs. ≥14 days . Quality of life was assessed in all patients by mailed self-report question naires at baseline ( preoperatively ) , at 5 wks , and at 3 , 6 , 9 , 12 , 18 , 24 , 30 , and 36 months after surgery . Daily physical , emotional , and social functioning was assessed with the generic Medical Outcome Studies Short Form-20 . Disease-specific quality of life was measured by an adapted Rotterdam Symptom Check List . Quality of life data were gathered between July 1994 and March 2003 . Five of the 109 patients died in the hospital and were excluded from the analysis . All five of them were in the intensive care unit ≥6 days . Of the remaining 104 patients , 92 provided baseline scores . The data of the 92 patients were used for the quality of life analyses . For the clinicopathologic and survival analysis , the data of 104 hospital survivors were used . Patients spent a median of 5.5 days ( range 0–71 ) in the intensive care unit . The Medical Outcome Studies Short Form-20 and the Rotterdam Symptom Check List measurements showed no clear differences in long-term quality of life between patients after a short vs. a prolonged postoperative intensive care unit period . The median overall survival  in all patients was 2.0 yrs ( range 0.1–8.0  ) . Median overall survival in patients staying in the intensive care unit ≤5 days was 1.9 yrs ( range 0.3–7.4 yrs ) vs. 2.7 yrs ( range 0.9–7.2 yrs ) in patients staying ≥6 days ( p = .9 , log-rank test ) . Median overall survival in patients staying in the intensive care unit ≤2 days was 1.7 yrs ( range 1.2–2.6 yrs ) vs. 2.0 yrs ( range 0.2–3.8 yrs ) in patients staying ≥14 days ( p = .74 , log-rank test ) . Conclusions : For patients who survived to hospital discharge after transthoracic esophagectomy  , there was no difference in long-term quality of life or survival between those su bmi tted to the intensive care unit for a short period vs. a long period BACKGROUND Pulmonary complications after transhiatal esophagectomy occur commonly and frequently cause severe morbidity and possible mortality . Aspiration , both overt and silent , can also be present with some regularity after this procedure , and it appears intuitive that identification of aspiration with the appropriate measures of avoidance of oral intake and avoidance of oral contrast studies may help reduce the consequences of aspiration pneumonia . STUDY DESIGN In an attempt to help identify patients at risk for aspiration , we prospect ively studied 73 patients who had recently undergone transhiatal esophagectomy using fiberoptic endoscopic evaluation of swallowing ( FEES ) .  Evaluation of premature spillage , pharyngeal residue , pooling , penetration , and aspiration was carried out . RESULTS Twenty-one percent of patients showed evidence of aspiration and were kept npo , with deferral of oral contrast studies . Of all the potential predictors of aspiration studied , only vocal fold immobility was a notable predictor of aspiration . But 40 % of patients who aspirated had normal vocal fold function . Vocal fold immobility was also identified in several patients thought to have completely normal voice quality . There were no complications of FEES . All patients who demonstrated aspiration and all those with vocal fold immobility eventually demonstrated swallowing without aspiration and recovery of cord function . CONCLUSIONS This study demonstrated the safety and efficacy of FEES in evaluation of laryngeal function in the postoperative setting after transhiatal esophagectomy . A FEES is recommended before the contrast study or oral feeding challenge for objective determination of aspiration risk from pharyngeal or laryngeal pathology . Early determination of aspiration status may reduce or eliminate pulmonary complications
The purpose s of this systematic review are to 1 ) qualitatively synthesize the current findings on oropharyngeal swallowing abnormalities identified by instrumental swallowing evaluations , 2 ) describe the reported health-related outcomes in relation to swallowing abnormality following esophagectomy , and 3 ) examine the efficacy of reported rehabilitative interventions for oropharyngeal dysphagia in patients who underwent esophagectomy .