The Nature, Severity and Impact of Chronic Oropharyngeal Dysphagia following Oesophageal Cancer Surgery

Abstract

Introduction: People with oesophageal cancer often experience dysphagia from before diagnosis to many years beyond treatment which may be directly secondary to the tumour obstructing the oesophagus, from tumour related dysmotility, or from the treatment itself [1-4]. An increasing body of evidence has started to investigate oropharyngeal dysphagia acutely post oesophageal cancer surgery however a paucity of research exists around the presence, nature, severity, and impact of chronic oropharyngeal dysphagia (COD). This thesis intended to identify 1) how COD presents post-oesophageal cancer surgery, 2) the impact of chronic dysphagia and aerodigestive symptoms on quality of life minimum 12 months post oesophageal cancer surgery and 3) if there is evidence to guide oropharyngeal dysphagia rehabilitation in adults with oesophageal cancer.

Methods: Ethical approval was received from the St. James�s Hospital/Tallaght University Hospital Research and Ethics Committee to conduct a mixed-methodology observational cross-sectional study to answer questions 1 and 2. Participants were recruited from the Irish National Centre for Oesophageal Cancer via purposive sampling. Swallowing outcomes were measured from videofluoroscopy using the Dynamic Imaging Grade of Swallowing Toxicity v2, Penetration-Aspiration Scale, and MBSImpairment Profile. The Iowa Oral Performance Instrument measured tongue pressure and endurance. Patient reported outcomes were collected: swallowing (EAT-10, MDQ-2 week), quality of life (MDADI, EORTC-18), reflux (Reflux Symptom Index), sarcopenia (SARC-F), oral intake status (Functional Oral Intake Scale). An interview was completed. Quantitative and qualitative analyses were conducted. A systematic review was completed using the Template for Intervention Description Replication [5-8].

Results: 30 males, 10 females (mean age 66, mean 52 months post transhiatal or transthoracic oesophageal resection) were included. 1) 35% of participants had chronic oropharyngeal dysphagia (COD), with 5% continuing to aspirate. All participants had impaired pharyngeal swallow physiology on the MBSImP; 40 (100%) had impaired swallow initiation, 36 (90%) had pharyngeal residue, 32 (80%) had reduced anterior hyoid excursion, and 28 (70%) had impaired laryngeal elevation. There was a statistically significant difference in aspiration PAS (6-8) versus no aspiration (PAS 1-5) across surgical groups (�2(2)= 7.07, p<0.029), with only participants from the transhiatal group aspirating (n=2). Tongue strength and function were largely within normal parameters however 72.5% of participants had abnormal amounts of oral residue. In addition, 80% had impaired oesophageal clearance, which was worse for those who had oesophagogastric junction (OGJ) tumours (�2(2)=8.199 , p = .017) and/or a thoracic site of anastomosis (�2(1)= 4.339 , p = .037). Oesophageal transit time was also higher for OGJ tumours (�2(2)=6.043, p = .049). 2) Quality of life was impacted minimum 12 months post oesophageal cancer surgery and is correlated with tongue strength across three different measures. Key themes relating to the impact of aerodigestive symptoms on QoL, identified through reflexive thematic analysis, were isolation, fear, altered work capacity, and avoidance of social situations. 3) There is a low-volume (4 studies) of low-quality evidence to support exercise-based dysphagia rehabilitation in adults undergoing surgery for oesophageal cancer.

Conclusion: A high proportion of oesophageal cancer surgery survivors continue to present with COD and disrupted oesophageal bolus flow for many years. When quality of life is impacted by aerodigestive symptoms including dysphagia, it appears to significantly impact day-to-day living. There are many potential causes of this dysphagia such as surgical complications, altered oesophagus and gastric pull-up, neo-adjuvant treatment, brain remapping, ageing, sarcopenia etc. In this increasing group of survivors, access to specialists for the long-term management of swallowing disorders is needed in the community to reduce symptoms and their burden.

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