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TORS: A PERIOPERATIVE NURSING PERSPECTIVE

Emily Sanders, BS, RN, CORLN

DISCLOSURES

I have no conflicts of interest, there are no off-label uses discussed in this presentation. Therefore, I have no disclosures.

OBJECTIVES

•Identify ideal patients that are candidates for TORS

•Examine the pre-operative education that will help the patient understand what the surgery and post-op care will entail

•Discuss common complications and symptom management after TORS

•Review the oncologic and functional outcomes of TORS

•Participate in an interactive discussion on TORS as it relates to nursing

OROPHARYNGEAL SQUAMOUS CELL CARCINOMAS

�Oropharynx

� Soft palate to epiglottis � composed

of tongue base, tonsils, & posterior

pharyngeal wall

�Majority are squamous cell carcinomas

� Incidence of diagnosis is rising

Photo Source: http://www.painneck.com/images/oropharynx-hypopharynx.gif

WAIT – AREN’T LESS PEOPLE SMOKING? WHY IS THE INCIDENCE OF ORAL CANCER RISING??

Yes, current smoking has declined overall

� In 2005, 21 of every 100 adults smoked (20.9%)

� In 2013, 18 out of every 100 adults smoked (17.8%)

� Smokers are more likely to be:

� Men

� Higher in those living below the poverty level

� Higher in those living in the Midwest & South

� Higher among persons with disabilities

Aren’t less kids smoking?

� Yes. Cigarette smoking has declined among middle and high schoolers

� However, electronic cigarettes, hookahs, & smokeless tobacco use has increased

Smoking rates/facts: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

THE ‘NEW’ HEAD & NECK CANCER PATIENT

The demographics of newly diagnosed OPSCCs are evolving to~�HPV-related (human papillomavirus) related disease �HPV serotype 16 and 18; most commonly 16� Younger patients that do not have a significant smoking/drinking history

� Typically non-smokers, social drinkers � Typically from higher socio-economic backgrounds & are educated� 50-64 year old white males

Rising at a rate of 4% per year in the US

About 2/3 of all oropharyngeal cancers diagnosed are HPV-related; the other 1/3 related to smoking/alcohol abuse

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TYPICAL PRESENTATION OF HPV+ CANCERS

Two common presentations:

� 1) A symptomatic mass of the tonsil or base of tongue

�May or may not have lymphadenopathy

� Symptoms may or may not include: pain, globus sensation, hemoptysis, voice or swallowing dysfunction

� 2) An asymptomatic neck mass without a symptomatic primary site

� Present in up to 70% of cases

Next course of action is typically ordering imaging studies (usually a CT scan), and FNA of neck mass (if applicable)

If suspicious or positive for SCC, next course of action is developing a treatment plan.

TREATMENT MODALITIES

HPV+ cancers have significantly higher cure rates than HPV- cancers

As with any cancer, treatment is decided based on tumor staging� Is intent curative or palliative?�Curative1. Primary chemotherapy/radiation therapy2. Surgery�Traditional open approach�Trans-oral surgical approaches� Trans-oral laser surgery (TLS)� Trans-oral robotic surgery (TORS)

�Palliation1. Symptom control

WHAT EXACTLY IS TORS?

� TORS uses the da Vinci surgical robot to resect lesions via the mouth

� FDA approval was granted in 2009 for treatment of T1 & T2 benign and malignant lesions

� Offers access to the oropharynx without the morbidity of open procedures

� Achieves excellent oncologic & functional outcomes

� Much better visualization and easier learning curve than TLS

RELATIVE CONTRAINDICATIONS FOR TORS

�Limitations to intra-oral access (such as trismus)

�Anatomical limitations to neck extension

�Aberrant carotid artery anatomy

�Extensive lesion (ie soft palate involvement) which post resection would impair speech or swallowing

�Patient who would likely require chemoradiotherapy secondary to disease staging or extensive neck disease

ABSOLUTE CONTRAINDICATIONS FOR TORS

Tumor Related Non-Tumor Related

• T4a disease with invasion of mandible, medial pterygoid involvement causing trismus, involvement of intrinsic tongue musculature

• Pharyngeal involvement requiring resection of >50% of the posterior pharyngeal wall

• Fixation of the tumor on palpation• Invasion lateral to constrictors or into pre-

vertebral fascia• Radiological involvement of carotid artery• Unresectable neck disease

• Medication contra-indications for anesthesia or surgery (such as anti-platelet therapy)

WHY SHOULD A PATIENT CHOOSE TORS VERSUS CHEMOTHERAPY & RADIATION?

Chemoradiation has treatment-related toxicity & long term side effects� Mucositis� Xerostomia� Loss of taste� Tissue fibrosis� Stricture� Osteoradionecrosis� Neuropathy� Fatigue� Esophageal stenosis� Renal failure or sepsis (chemotherapy)� Development of a second primary malignancy � Other systemic side effects

Organ preservation does not equate to function preservation!

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TORS AT OUR INSTITUTION

�Neck dissection�Level 2-4 neck dissection

�Ligation of branches of external carotid artery to decrease risk of post operative bleeding

�Patient discharged one day post-operatively with Jackson Pratt drain in place

�TORS performed one week post neck dissection�A dobhoff feeding tube is routinely placed at the end of the operation

�Patient discharged 1-2 days post-operatively

�Why not do the two operation together?1. Robotic operating time

2. Risk of intra-operative fistula into the neck

POTENTIAL COMPLICATIONS OF TORS

�Bleeding

�Post-operative hemorrhage can occur early after surgery or can be a late bleed

�Most common reason for readmission

�Neck hematoma s/p neck dissection

�Dental injury

�Temporary lingual or hypoglossal nerve injury

�Dehydration

�Aspiration pneumonia

�Airway compromise requiring temporary tracheostomy (rare)

NURSE DRIVEN PRE-OP PATIENT EDUCATION

Reinforce physician explanations regarding surgery, length of stay, and potential complications to ensure comprehension

Expose patient to post-operative expectations� Show patient actual Jackson-Pratt drain if having a neck dissection

� Explain home care of drain & that patient will get a ‘drain pack’ from the bedside RN along with instruction prior to discharge

� Show patient actual Dobhoff feeding tube to be placed in stomach

� Explain to patient routine course of action regarding Dobhoff tube

Hand out an educational folder with information about their diagnosis, surgery, & post-op care instructions. Include HPV information sheet if appropriate.

Discuss general post-op course including lidocaine lollipops

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OTHER PRE-OPERATIVE EDUCATION

Speech-Language Pathologist� Reviews importance of swallowing after surgery regardless of pain

� Encourages patient to minimally swallow saliva to maintain swallowing muscle functionality

� Aspiration signs & symptoms reviewed

� Educates patient on ‘routine’ post-op TORS course with regards to SLP involvement

Dietitian� Weighs patient on In-Body body composition scale

� Selects appropriate tube feed formula per patient (provided patient will be dobhoff tube dependent)

� Reviews appropriate diet supplements if patient is able to eat full liquids or soft foods to minimize muscle wasting/loss

IS TORS JUST USED TO TREAT CANCER?

TORS for Obstructive Sleep Apnea (OSA)� Indications

� Patients that fail or cannot tolerate continuous positive airway pressure (CPAP)

� Moderate to severe OSA based on a formal polysomnogram (sleep study)

� Abnormal anatomy that would benefit from surgery

� Sleep endoscopy may be performed to assess the anatomical sites of obstruction

� Procedure is a bilateral lingual tonsillectomy

� Additional tissue is removed as needed

� Supraglottoplasty can be done (optional)

� Post-operative management is the same as TORS for cancer

� Continuous pulse ox is recommended

� Repeat sleep study done 3-6 months after healing is complete

� Surgical response vs. surgical cure

~ THE MAIN EVENT ~

SET-UP OF THE OPERATING ROOM

Components of the daVinci surgical robot. Source: www. intuitivesurgical.com

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VIDEO OF TORS SURGERY

SURGERY IS OVER ~ NOW WHAT?

POST-OP NURSING CARE AFTER TORS

23 hour observation to in-patient ward� Will send to ICU on a rare occasion

NPO with a dobhoff tube � Ice chips/sips of water permitted

All patients receive a specific order set that includes:� Scheduled pain medications

� IV pain meds available for breakthrough pain if necessary

� Patients bring in lidocaine lollipops to use; may keep at bedside

� Alternatively, can order viscous lidocaine to swish & spit in lieu of lidocaine lollipops

� Decadron 8mg IV q8hr x2 doses

� Head of bed elevated

� Rigid suction set up (yankauer tip)

� Patients often use for managing saliva

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POST-OP NURSING CARE AFTER TORS

Nursing Assessment ~ What to look for?�Airway edema – at risk for swelling�Signs/Symptoms�Tongue swelling� Increased hoarseness�Stridor

If airway edema is present, what do I do?� Typical management can include:�Steroids �Heliox�Mixture of helium & oxygen gasses which reduce the resistance to flow within the airways and decreases the work of breathing

�Racemic epinephrine (delivered by aerosol)�Possible need for re-intubation

POST-OP NURSING CARE AFTER TORS

Nursing Assessment ~ What to look for?� Post-op bleeding

� Typically occur early (within 24 hours post-op) or late (10-14 days post op)

� Some blood is expected; patients may cough up blood-streaked mucous

� An acute bleed can be quantified by over a tablespoon of bright red blood

What do I do?� Treat as you would any post-op bleed

� Have someone place call to on-call provider

� Be sure patient is sitting up

� Use rigid suction set up to suction oral cavity to prevent aspiration of blood

� Keep patient calm and be sure the airway is maintained – patient will more than likely be returning to the OR

TIME TO SEND THEM HOME!

DISCHARGE TEACHING

Jackson-Pratt (JP) Drain Care� Nurse teaches patient to milk/strip tubing TID

� Nurse teaches patient to measure output and record amount

� Instructed to call if:

� Clotted off/no output

� Bright red blood in large amounts

� White milk-like drainage (chyle leak)

Drain packs� Alcohol pads to aid in stripping the tubing

� 240ml plastic cup to measure output

� Length of oxygen tubing for patient to use as a necklace when showering so that drain does not hang freely and pull at insertion site

� Drain Care instruction guide handout

DISCHARGE TEACHINGDobhoff tube education� Nurses begin teaching medication administration immediately� Importance of crushing & dissolving meds completely stressed to patient and family, as well as adequate flushes before & after

� First tube feed ALWAYS done with patient and present family to see the process of flushing and administering the tube feed

� Ok to administer room temperature coffee (for caffeine addicts) or beer/alcohol if addiction issues

Supplies given:� Two 60ml cath tip syringes� A triangular graduate� Two gravity bags

Care of supplies� Can re-use syringes as long as they are not cracked� Hand wash with dish soap and air dry� Can purchase a bottle brush from baby section if desired

� Clean gravity bags after each feed with white vinegar & water (no soap!)

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DISCHARGE TEACHING

Hydration� Importance of staying hydrated stressed � patients taught to watch urine and if it becomes dark, start to increase amount of water being administrated via dobhoff tube

� Patients tend to get wrapped up in being sure that they get in all of their prescribed tube feeds that often they forget about the need for water

Medications� Pain medicine

� Typically given Percocet

� Lidocaine lollipops

� Reinforce that the pain gets worse post-op days 2-4 (peaking around day 3) and not to be alarmed, as this is expected

� Stool softener (docusate liquid 100mg BID)

� Patient can also use prune juice (no pulp) via dobhoff tube if preferred

� Miralax also recommended

DISCHARGE TEACHING

Typical post-op surgery instructions:� Fever is greater than 101.5

� Signs/symptoms of dehydration (dark urine)

� Pain not controlled by prescribed pain medication

� Difficulty breathing, chest pain

Call on-call provider and proceed to closest ER if experience bleeding of bright red blood over a tablespoon

Call on-call provider if dobhoff tube will not work/flush or falls out

The patient will receive a call from the office the day after discharge to check on their progress and set up their appointment for the following week with the SLP for the swallow evaluation to determine if they can safely swallow and therefore have their dobhoff tube removed.

QUALITY OF LIFE: OUTCOMES

OUTCOMES

Oncologic Outcomes� Oncologic outcomes are equivalent or superior to the results of other surgical and non-surgical treatments

� Margin status is an important prognostic factor in TORS

� Achieving negative surgical margins is most important for ultimate disease control

When is post-operative therapy indicated?� General indications for chemoradiation include:

� Radiation

� Perineural or lymphovascular spread at the primary site

� Greater than N1 nodal disease

� Chemotherapy

� Positive margins on final pathology that cannot be re-resected

� Extranodal spread

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OUTCOMES

Functional outcomes� Airway function (measured by tracheostomy dependence)

� Tracheostomy avoided in 70-100% of TORS cases

� Feeding tube (nasogastric and PEG) use varies widely by disease stage & institutional practices

� Average duration of nasogastric tube usage was 2-13 days

� Dysphagia is the most common impairment in oropharyngeal cancer survivors

� Measured subjectively; patients fill out MD Anderson Dysphagia Inventory (MDADI)

� Swallowing outcomes are highly dependent on baseline function and TNM staging

� MDADI scores showed no significant difference at 3 months (TORS patients vs. primary chemoradiation)

� MDADI scores were significantly better 6-12 months after TORS than the primary chemoradiation group

� Use of TORS alone had minimal and temporary effects on speech

� TORS plus radiation has significantly fewer negative effects on quality of life than chemoradiation alone

OUTCOME CONCLUSIONS

� The ability to preserve normal tissue and neurovascular supply using TORS contributes to rapid healing and a return to acceptable oropharyngeal function

�In cancer patients, early studies suggest better long term recovery and morbidity reduction after TORS vs treatment with primary chemoradiation

�Research is being done to see if the use of minimally invasive surgery such as TORS may allow consideration of de-intensification of adjuvant radiation and/or chemotherapy

NURSING IMPLICATIONS

What does this mean for nurses?� Prepare for more TORS patients!

Pre-operative nursing� Be sure to educate as much as possible before surgery to adequately prepare the patient and their family

Post-operative nursing� Fine-tune assessment skills to be on the look out for any subtle changes � Specifically airway edema & hemorrhage

� Be sure to educate comprehensively in order to properly prepare the patient and family for care at home after discharge

ACKNOWLEDGEMENTS

A great big thanks to my physician team for their help and support, especially Julia Crawford, MD, as she provided me with the photos and video!

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REFERENCES

Cohen MA, Weinstein GS, O’Malley BW, et al. Transoral Robotic Surgery and Human Papillomavirus Status: Oncologic Results. Head Neck (2011); 33: 573-580.

Crawford, J, Montevechi, F, Vicini, C, Magnuson, JS. Transoral Robotic Sleep Surgery: The Obstructive Sleep Apnea-Hypopnea Syndrome. Otolaryngol Clin N AM 47 (2014); 397-406.

Deschler D, Richmon J, Khariwala S, et al. The “New” Head and Neck Cancer Patient – Young, Nonsmoker, Nondrinker and HPV Positive: Evaluation. Otolaryngology – Head and Neck Surgery (2014); Vol. 15 (3) 375-380.

Gurberg J, Prisman E. Transoral Robotic Surgery for Oropharyngeal Carcinoma: Update. Austin J Otolarynglogy (2014); 1(2):6.

Hutcheson K, Holsinger FC, Kupferman ME, Lewin JS. Functional Outcomes After TORS for Oropharyngeal Cancer: A Systematic Review. Eur Arch Otorhinolaryngol (2015); 272:463-471.

Kelly K, Johnson-Obaseki S, Lumingu J, Corsten M. Oncologic, Functional and Surgical Outcomes of Primary Transoral Robotic Surgery for Early Squamous Cell Cancer of the Oropharynx: A Systematic Review. Oral Oncology (2014); 50: 696-703.

REFERENCES

Leonhardt FD, Quon H, Abrahao M, et al. Transoral Robotic surgery for Oropharyngeal Carcinoma and its Impact on Patient-Reported Quality of Life and Function. Head Neck (2012); 34 (2): 146-154.

Moore EJ, Olsen SM, Laborde RR. Long-term Functional and Oncologic Results of Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma. Mayo Clin Proc (2012); 87(3): 219-225.

Ridge, JA. Surgery in the HPV Era: The Role of Robotics and Microsurgical Techniques. American Society of Clinical Oncology educational book / ASCO American Society of Clinical Oncology Meeting. (2014) 154-9.

Ritter Sansoni E, Gross ND. The Role of Transoral Robotic Surgery in the Management of Oropharyngeal Squamous Cell Carcinoma: a Current Review. Curr Oncol Rep (2015); 17:7.

Schmitt N, Duvvuri U. Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma. Curr Opin Otolaryngol Head Neck Surg (2015); Vol. 23 (00) 1-5.

Weinstein GS, O’Malley Jr. BW, Rinaldo A, et al. Understanding Contraindications for Transoral Robotic Surgery (TORS) for Oropharyngeal Cancer. Eur Arch Otorhinolaryngol (2014).

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