Swallowing Function and Perioperative Complications After Transoral Robotic Surgery

Importance: Transoral robotic surgery (TORS) yields excellent oncologic outcomes in patients with oropharyngeal squamous cell carcinoma (OPSCC). The outcomes of early swallow rehabilitation with speech-language pathologists (SLP) in this population have not been fully investigated. Objective: To evaluate swallow physiology and patient perception of swallow function in the perioperative period after TORS. Design, Setting, and Participants: This retrospective cohort study reviewed medical records of adult patients with OPSCC who underwent TORS from 2017 to 2024 at a single tertiary care center. Patients were included if they had a histologic diagnosis of SCC and a videofluoroscopic swallow study (VFSS) prior to undergoing treatment with TORS. Exposure: TORS. Main Outcomes and Measures: At various perioperative time points, SLP performed a VFSS that generated a Dynamic Image Grade of Swallowing Toxicity (DIGEST) score and patients completed the MD Anderson Symptom Inventory (MDADI) questionnaire for subjective assessment of swallow function. For most patients, on postoperative day (POD) 1, SLP performed a bedside swallow evaluation and recommended compensatory swallow maneuvers, if necessary. Oral diet was initiated using the International Dysphagia Diet Standardization Initiative (IDDSI) for pureed solids and thin or mildly liquids for 2 weeks. Data on hospital stay and enteral tube placement were collected. Primary outcomes included swallowing at 6 weeks postoperatively assessed before potential adjuvant therapy by VFSS and MDADI. Secondary outcomes included complications and enteral tube feeding requirements. Results: Among the 212 patients included, median age was 61 (IQR, 55-68) years and 31 patients (14.6%) were female. At baseline, 207 patients (97.6%) had normal VFSS scores. A total of 203 patients (95.8%) were evaluated by SLP on POD 1, and the remainder of the patients were evaluated by the surgical team. Median hospital length of stay was 2 days (IQR 1-2 days), and by the time of discharge, 207 patients (97.6%) were tolerating an oral diet. Fourteen patients (6.6%) required enteral feeding tube placement in the immediate postoperative period. At 6 weeks, 21 of the 33 patients (63.6%) with paired baseline and 6-week postoperative MDADI data reported a significant worsened swallowing perception. Six of the 66 patients (9.1%) with a postoperative VFSS at 6 weeks showed an objective decrease in swallowing compared with baseline. Of the 169 patients with diet documented at 6 weeks postoperatively, 95.3% (n = 161) were consuming a soft to regular diet. Conclusions and Relevance: In this cohort study, patients with OPSCC treated with primary TORS had excellent short-term swallowing outcomes. Only a small proportion required a nasogastric tube at discharge, and at 6 weeks although most reported a worsening in swallow perception, they did not have an objective decrease in swallow function as measured by VFSS and most were tolerating a soft to regular diet.