Research ArticleComparison of the Outcomes of Three DifferentNutritional Supports in Patients with Oral and MaxillofacialMalignant Tumors following Surgery

Chen Zou ,1 Xuan Zhou ,2 Shuhan Zhuang,3 Guowei Huang ,2 and HongwuWang 4

1Department of Nutrition, Tianjin Stomatological Hospital, No. 75 Dagu Road, Heping District, Tianjin 300041, China2Department of Nutrition and Food Science, School of Public Health, Tianjin Medical University, No. 22 Qixiangtai Road,Heping District, Tianjin 300070, China

3Chinese Internal Medicine, Graduate School, Tianjin University of Traditional Chinese Medicine, No. 10 Boyanghu Road,Jinghai District, Tianjin 301617, China

4Department of Public Health, Tianjin University of Traditional Chinese Medicine, No. 10 Boyanghu Road, Jinghai District,Tianjin 301617, China

Correspondence should be addressed to Guowei Huang; huangguowei@tmu.edu.cn and Hongwu Wang; tjwanghw@163.com

Received 9 March 2018; Revised 11 May 2018; Accepted 4 September 2018; Published 1 November 2018

Academic Editor: Andreas Sandner-Kiesling

Copyright © 2018 Chen Zou et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. This study aimed to compare the physical and mental states and the clinical effects of parenteral nutrition combinedwith enteral nutrition (PN+EN), total enteral nutrition (TEN), and total parenteral nutrition (TPN) after surgery in patients withmaxillofacial malignant tumors. Methods. A total of 112 patients were divided into three groups, with 58, 33, and 21 patientsin the PN+EN, TPN, and TEN groups, respectively. The psychological survey contained the Faces Pain Scale-Revised (FRS-R),visual analog scale (VAS), numerical rating scale (NRS), Hamilton anxiety rating scale (HAMA), and short-form 36 health surveyquestionnaire (SF-36). Spirit symptoms, length of hospital stay, nutritional assessments, and related biochemical indices wererecorded and compared.Results.The traditional Chinesemedicine (TCM) symptoms of anxiety and dysphoria were least frequentlyidentified in the TPN group.The levels of lymphocytes, hemoglobin (HB), albumin (ALB), and prealbumin (PA) were significantlyhigher in the PE+EN group, whereas white blood cell count, neutrophil count, HB, PA, and ALB were significantly lower in theTPN group. Better psychological scores were observed in the TPN group.The PE+EN group had a shorter length of stay and higherSGA categories. Potassium, sodium, and chlorine levels were significantly lower in the TEN group (all P < 0.05). Conclusions.As anauxiliary method, TCM symptoms can help to identify spirit disequilibrium earlier and are associated with blood indices. Withoutthe consideration of cost and long length of hospital stay, patients in the TPN group had the bestmental status, with PN+EN therapybeing an alternative.

1. Introduction

The application of vascular pedicled skin flap transfer in therepair of jawdefects in patientswithmaxillofacialmalignancycan restore jaw continuity and facial shape but may also helppatients to chew, swallow, and correctly pronounce words [1].

However, operation time for flap transplantation is longand vasoconstriction of the vascular smooth muscle causedby the stimulation of the epicardial membrane during theoperation, postoperative pain, cold, and other factors lead

to the stimulation of the sympathetic nervous system, caus-ing cvasospasm, tissue and vascular injury, hypercoagulableblood, and keeping head motionless 1-3 days after the oper-ation. Therefore, the quality of life of patients is reduced,especially in the first three days. Thus, the treatment of oraland maxillofacial malignant tumors includes not only cureand survival rates but also the mental state of the patients [2].

The modern medical model has been transformed toa biological-psychosocial-medical model. The resection ofthe oropharyngeal and laryngopharynx tumors destroys the

HindawiEvidence-Based Complementary and Alternative MedicineVolume 2018, Article ID 5627141, 11 pageshttps://doi.org/10.1155/2018/5627141

2 Evidence-Based Complementary and Alternative Medicine

body’s original physiological structure, thus making it moredifficult to place the tube. Studies have shown that patientswith head and neck tumors face a significant psychologicalburden in the perioperative period [3, 4]

The head is the commonly exposed body part in humansand plays an important role in individual image; however,the side effects of malignant oral and maxillofacial tumortreatment may result in barriers to basic functions such asspeaking and swallowing [5] and as patients in the intensivecare period cannot express their wishes in a timely manner,passive acceptance of a gastric tube may occur [6, 7]. Thepresence of a gastric tube may have a greater negativeimpact onmental health status and patients may feel anxious,depressed, and even suicidal [8].

Moreover, in the intensive care period, psychologicalquestionnaires cannot be used to assess patients because oftheir poor physical and mental states. However, this periodis crucial for the formulation and adjustment of specifictreatment plans. In traditional Chinese medicine (TCM)theory, the exterior symptoms and signs may reflect thefundamental pathology of the internal organs. In otherwords,the status of the internal organs can be determined byobserving exterior symptoms such as the complexion or thetongue [9, 10]. The TCM theory of essence, qi, and spiritindicates that expression, mood, and speech reflect mentaland physical health [11, 12]. Therefore, the present study usedTCMas an auxiliarymethod by observing the color and lusterof the complexion and the symptoms of spirit disequilibrium.

Specific psychological survey methods were used to eval-uate the social support, anxiety scale, survival satisfaction,and life happiness seven days after the surgery when thephysical state of patients generally improves.

Correct nutritional support can help patients improvetheir nutritional status, prevent complications, facilitaterecovery from inflammation, increase the survival rate of theflap, and shorten the hospitalization time [13].

To identify and solve problems and to provide guidancein a timely manner, it is necessary to adjust the patient’sfeeding program according to patient blood indices and spiritsymptoms. The present study assessed the effects of differentnutritional support in patients with maxillofacial malignanttumor using both traditional measures and TCM symptomsto evaluate patient feelings and mental status.

2. Methods

2.1. Study Population. A total of 112 patients were treated bytheDepartment ofOral andMaxillofacial Surgery at the studyhospital between March 2016 and December 2017.

The inclusion criteria were ages between 40 and 70 (theage range with a high incidence of maxillofacial malignancy),an initial nutritional assessment report score< 3.0 points, andprovision of informed consent. The operations often involvedjaw and tumor resection, neck dissection, peroneal musculo-cutaneous flap preparation, and peroneal musculocutaneousflap transfer repair.

The exclusion criteria included the presence of severeendocrine and metabolic diseases or other malignancies,

blood system diseases, chronic cardiopulmonary insuffi-ciency, severe liver and kidney dysfunction, abnormal intra-operative bleeding, or the occurrence of severe postoperativecomplications.

This study was approved by the Independent EthicsCommittee of the study hospital (no. TSHhMEC2017002).All patients provided informed consent. This study wasregistered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn) as ChiCTR-OPC-17013869.

2.2. Nutritional Support. The 112 patients were divided intothree groups by the nutrition support team (NST) accordingto the nutritional support they received:

(1) Parenteral nutrition combined with enteral nutri-tion (PN+EN) group: after surgery in the head, the headwas immobilized for 48 to 72 hours. Between one andthree days postoperatively, PN was provided as follows: 20-25 kcal/(kg⋅d) with a glucose-to-lipid ratio of 6:4 or 5:5;calorie-to-nitrogen ratio of 120-150:1; and vitamins, traceelements, and electrolytes as needed. We added insulin basedon patients’ blood glucose levels, with a glucose-to-insulinratio of 8-10:1 g/U. If the patient had diabetes, the glucose-to-insulin ratio was 4-5:1 g/U. PN + EN was administeredfour days after the operation and the proportion of PNwas decreased gradually. The EN dosage was the standard20 kcal/(kg⋅d) at a drip rate of 50ml/h. If no reflux, diarrhea,abdominal distension, or other gastrointestinal side effectsoccurred, after 2-3 days, EN was injected continuously at25 kcal/(kg⋅d) at a drip rate of 100ml/h.

(2) Total enteral nutrition (TEN) group: throughoutthe postsurgical period, a high-energy nutrient mixture(1 kcal/ml, Nedicia) was administered via continuous dripthrough a nasal feeding tube with an initial drip rate of50ml/h. If no reflux, diarrhea, abdominal distension, or othergastrointestinal side effects occurred, 2 to 3 days later the driprate was increased to 100ml/h.

(3) Total parenteral nutrition (TPN) group: severalpatients could not receive nasal feeding due to the location ornature of their wounds and were given the corresponding 20-25 kcal/(kg⋅d) and increased calories based on their condition[14].

2.3. Psychological Status Assessment. The psychological sur-veys administered after maxillofacial surgery included theFaces Pain Scale-Revised (FRS-R) [15], visual analog scale(VAS) [16], numerical rating scale (NRS) [17, 18], Hamiltonanxiety rating scale (HAMA) [19], oral-facial body dysmor-phic disorder self-scale (OFBDDSS) [20, 21], self-overallappearance evaluation scores [22], and short-form 36 healthsurvey questionnaire (SF-36) [23, 24]. The surveys wereconducted seven days after surgery by the NST. Higher scoresindicated poorer patient mental state and feelings.

2.4. Biochemical Indices. Blood indices were assessed oneand seven days after surgery, including measurement ofthe circulating levels of lymphocytes (LYM), hemoglobin(HB), albumin (ALB), and prealbumin (PA) and white blood(WBC) and neutrophil (NE) counts. Potassium (K), sodium

Evidence-Based Complementary and Alternative Medicine 3

(NA), and chlorine (CL) levels were measured and comparedbetween groups 13 days after surgery.

2.5. Nutritional Status Assessment. Scored Patient-GeneratedSubjectiveGlobalAssessment (PG-SGA)was performed aftersurgery. Part A was completed by the patients, includinga history questionnaire (weight assessment, dietary intake,symptoms, activities and functions, etc., in four parts); Part Bincluded the disease and its relationship to nutritional needs(age score added); Part C included metabolic requirements;and Part D included a physical examination. The four partsare summed, with scores of 0-1 indicating no need for nutri-tional intervention and routine nutritional status; 2-3 pointsindicates the need for patient and family education guidanceby dietitians, nurses or physicians, and drug interventionappropriate for symptoms and laboratory examination; 4-8 points indicate the need for nutrition intervention andtreatment of symptoms; and more than 9 points indicatesan urgent need to improve the symptoms of the treatmentmeasures and to provide appropriate nutrition support. Thequalitative evaluation of the rating results includes 0-1 pointsfor good nutrition (A); 2-8 points for moderate malnutrition(B); and 9 points for severe malnutrition (C) [25, 26].

2.6. TCM Symptoms. The symptoms of spirit disequilibriumincluding observed anxiety, dysphoria, restlessness, deliriousspeech, and intolerance were observed. Physical conditionwas assessed based on pale complexion and skin with orwithout luster.

2.7. Length of Hospitalization. The length of hospitalizationwas defined as the total number of days from hospitaladmission to discharge after the wound had healed well andthe sutures were removed.

2.8. Statistical Analyses. Shapiro-Wilk and Levene’s tests wereused to assess the normality and homogeneity of the data.Continuous variables were expressed as means and stan-dard deviations. One-way analysis of variance (ANOVA)or Kruskal-Wallis tests were used to compare data betweengroups. Chi-squared or Fisher’s exact tests were carried outto assess dichotomous variables from the three groups. Thepairwise comparisons among the means were performedusing the Bonferroni method. Statistical significance was setat P < 0.05 and all 𝑃 values were two-sided. All analyseswere performed using SPSS Predictive Analytics Software forWindows, version 22.0 (Released 2009; SPSS Inc., Chicago,IL).

3. Results

A total of 112 participants were enrolled in this study, includ-ing 58 patients in the PN+EN group, 21 patients in the TENgroup, and 33 patients in the TPN group. Comparisons of thethree groups are shown in Table 1. There were no significantdifferences in age, sex, smoking history, educational level,or medical history (including hypertension, hyperlipidemia,diabetes, heart disease, cerebrovascular disease, and jointdisease) among the three groups (P > 0.05). The distribution

of alcohol consumption differed significantly among thegroups (P = 0.042).

The TCM symptoms of spirit disequilibrium wereobserved 3-4 days after surgery. The comparisons shownin Table 2 revealed that anxiety and dysphoria were morefrequently identified in the TEN and PN+EN groups thanin the TPN group (P < 0.05). No significant differences inrestlessness, delirious speech, or intolerance were observedin the groups.

Table 3 shows the comparisons of blood indices of thethree groups one and seven days after surgery. The levelsof LYM, HB, ALB, and PA were significantly higher inparticipants in the PE+EN group than those in the othergroups (all P < 0.05), while the WBC and NE counts and HB,PA, and ALB levels were significantly lower in the TPN groupthan those in the other groups on postoperative day seven (allP < 0.05). Comparison of the blood indices on day seven withthose on day one after surgery revealed significant changes inall indices in the PE+EN group (all P < 0.05).

The results of psychological surveys seven days aftersurgery, including Wong-Banker FPS-R scores, VAS, NRS,SF-36, and HAMA and subscales scores, are shown in Tables4 and 5. There were significant differences in Wong-BankerFPS-R, VAS, NRS, and HAMA scores among the groups. Thescores were significantly lower in the TPN group than thosein the other groups (all P < 0.05), which indicates a betterpsychological status. No significant difference was found inthe OFBDDSS, self-overall appearance evaluation, and SF-36scores among the groups.

Table 6 displays the mean hospital length of stay for theparticipants. The PE+EN group had a significantly shorterlength of hospitalization than those of the other groups. TheSGA categories indicated that the patients in the PE+ENgroup had a significantly better nutritional status than thosein the other groups (P < 0.05). Evaluation of complexion andluster revealed the highest rate of pale complexion in the TPNgroup on the 13th day after surgery (P < 0.05). The levels ofK, NA, and CL were significantly lower in Group TEN thanthose in the other groups (all P < 0.05).

4. Discussion

Thepresent study assessed the effects of disease and treatmenton the quality of life of patients in order to maintain thehealth of patients after malignant tumor treatment, reduceunnecessary injuries, reduce complications, and ensure theirquality of life [2].However, the traditionalmethods of feedingare unacceptable for patients with maxillofacial malignanttumors. Because oral and maxillofacial surgery is mostlyperformed by general anesthesia and tracheal intubation, inorder to avoid affecting general anesthesia, tracheal intuba-tion, and field exposure, the gastric tube is not usually placedafter the operation, and retention of the gastric tube afteroperation is a common postoperative nutritional approachfor head and neck tumor surgery. Head and neck tumors,especially malignant tumors in the mouth, require the gastrictube to be retained after the operation because of the largesurgical area, the wound in the oral cavity, postoperativeinfection prevention and wound healing, and postoperative

4 Evidence-Based Complementary and Alternative Medicine

Table1:Ba

selin

echaracteristicso

fthe

threeg

roup

sbefores

urgery.

Items

PN+E

Ngrou

p(n=5

8)TP

Ngrou

p(n=3

3)TE

Ngrou

p(n=2

1)Testvalues

Pvalues

Age

(years)(Mean±SD

)54.50±10.38

57.64±10.33

53.90±9.9

31.2

200.299

Lifesty

leSm

oker

Ever

15(13.39%)

9(8.04%

)3(

2.68%)

6.769

0.343

Occasionally

15(13.39%)

5(4.46%

)6(5.36%

)Re

gularly

14(12.50%)

5(4.46%

)7(6.25%

)Quitte

d14

(12.50%)

14(12.50%)

5(4.46%

)Drin

king

Ever

7(6.25%

)3(2.68%

)0

11.920

0.04

2∗Occasionally

35(31.2

5%)

20(17.8

6%)

17(15.18%)

Regu

larly

4(3.57%

)0

3(2.68%)

Quitte

d12

(10.71%)

10(8.93%

)1(0.89%)

Gender,Female

24(21.3

8%)

13(11.6

1%)

9(8.04%

)0.114

0.966

Educationallevel

≤9years

20(17.8

6%)

8(7.14%)

8(7.14%)

6.434

0.171

11-12

years

16(14

.29%

)15

(13.39%)

10(8.93%

)>12

years

22(19

.64%

)10

(8.93%

)3(

2.68%)

MedicalHistory

Hypertension

10(8.93%

)4(3.57%

)3(

2.68%)

0.422

0.937

Hyperlip

emia

6(5.36%

)1(0.89%)

1(0.89%)

1.528

0.551

Diabetes

9(8.04%

)7(6.25%

)0

5.328

0.076

Heartdisease

3(2.68%)

2(1.79%

)1(0.89%)

0.295

0.975

CerebrovascularDise

ase

8(7.14%)

6(5.36%

)2(1.79%

)0.763

0.723

Jointd

isease

4(3.57%

)3(2.68%

)0

1.617

0.443

Pathologicaltype

Malignant

amelob

lasto

ma

8(7.14%)

2(1.79%

)3(

2.68%)

14.665

0.799

Malignant

mixed

tumor

4(3.57%

)5(4.46%

)1(0.89%)

Malignant

lymph

oma

1(0.89%)

2(1.79%

)0

Ossify

ingfib

roma.

5(4.46%

)3(2.68%

)4(3.57%

)Ba

salcellcarcino

ma

5(4.46%

)4(3.57%

)2(1.79%

)Oralcancerinvadem

andible.

10(8.93%

)3(2.68%

)6(5.36%

)Mucoepiderm

oidcarcinom

a5(4.46%

)5(4.46%

)1(0.89%)

Adenocarcino

ma

2(1.79%

)1(0.89%)

1(0.89%)

Adenoidcysticc

arcino

ma

3(2.68%)

2(1.79%

)1(0.89%)

Squamou

scellcarcino

ma

9(8.04%

)5(4.46%

)1(0.89%)

Odo

ntogenicKe

ratocyst

6(5.36%

)1(0.89%)

1(0.89%)

∗Sign

ificantlydifferent

amon

ggrou

ps(P<0.05).

Values

ared

emon

strated

asn(%

)for

chi-s

quareo

rFish

er’sexacttests,

andas

them

ean,

SDforo

ne-w

ayANOVA

test.

SD:stand

arddeviations.

Evidence-Based Complementary and Alternative Medicine 5

Table 2: TCM symptoms of spirits disequilibrium of the three groups after surgery (3-4 day).

TCM symptoms PN+EN group (n=58) TPN group (n=33) TEN group (n=21) Test values P valuesAnxiety 6 (5.36%) 2 (1.79%) 6 (5.36%) 5.534 0.044∗Dysphoria 2 (1.79%) 2 (1.79%) 5 (4.46%) 7.120 0.018∗Restlessness 3 (2.68%) 3 (2.68%) 3 (2.68%) 2.052 0.422Delirious speech 1 (0.89%) 0 1 (0.89%) 1.788 0.426Intolerance 1 (0.89%) 0 1 (0.89%) 1.788 0.426∗ Significantly different among groups (P < 0.05).Values are demonstrated as n (%) for chi-square or Fisher’s exact tests.TCM, traditional Chinese medicine.

dysphagia. After the operation, the intubation of the stomachtube also has a relative risk before the tracheal tube isremoved. On one hand, the indwelling of the stomach tubewill weaken the pharynx reflex and oral secretions or stomachcontents can accumulate in the mouth after anesthesia.However, postoperative swelling of the wound caused thestenosis of the pharynx and the tissue was damaged afterthe operation, causing hyperemia and edema of the mucousmembrane of the nasopharynx and an increased sensitivityto pain. In general, patients with a gastric tube are placedin a semisupine position to reduce diaphragm stimulationby the gastric tube, help the blood flow in the head andneck, reduce wound swelling, and promote wound healing[27]. During gastric tube placement, gastric tube stimulationof the nasopharynx can trigger the stress reaction of thesympathetic nervous and hypothalamic-pituitary systems,causing hemodynamic changes and stimulating the vagusnerve to induce severe nausea, vomiting, tears, and otherdiscomfort. Patients often experience tracheal tube backpressure due to indirect compression of the esophagus walland tracheal tube on the inner wall of the trachea, causingesophageal cavity stenosis that is detrimental to the passageof the gastric tube [27–29].

In the clinical setting, patients often experience pharyn-geal cavity stenosis caused by postoperative swelling, generalanesthesia, and pharyngeal edema after tracheal intubationand large defects in the mouth and neck, which can affectswallowing function.

During the process of placing the gastric tube, patientsmight feel pain and upset, which brings some difficultiesin setting up the tube [30]. The antireset tube can causenasal cavity bleeding in patients, increasing the risk ofcatheterization. At the same time, oral cancer patients willenter a peak period of wound swelling within 24-72h afterskin flap repair, which makes tube placement more difficult,resulting in a sharp increase in blood pressure, muscle strain,and other reactions, which affect the healing of skin flap.

Consideration of the psychological factors is increasing inthe field of gastric tube implantation [13]. Incorrect stomachtube insertion causes physical pain as well as great mentaltension and psychological fear [31]. Both the physiologicaland psychological quality of life of the patient should be con-sidered. Unplanned extubation may occur due to slippage ofthe stomach gastric fixation, patients with irritability, removalof the nasal tube, nausea, frequent vomiting, severe coughcausing vomiting, or lack of systematic health education

resulting in automatic or passive nasal gastric tube extrusion[32, 33].

In China, clinical nutrition has been established in mosthospitals, but the equipment, personnel, and other resourcesare still not sufficient [34]. Our nutrition support team (NST)are comprised with clinicians, nutritionists, pharmacists, andtrained nurses [35]. Upon receiving patient blood reports,these segments work together to adjust the nutritional sup-porting plans, as long as required by the patient [36]. Clinicalnutrition interventions are an indispensable treatment forpatients who have undergone oral surgery and an importantlink in patient prognosis.

TheTCMsymptomsof spirit disequilibriumobserved at 3or 4 days after surgerymanifested as anxiety and upsetmentalstatus in the HAMA and subscales scores assessment sevendays after surgery revealed that anxiety and dysphoria weremost frequently identified in the TEN group and could beearlier identified based on TCM symptoms. The levels of HB,PA, andALBwere the lowest in the TPN group on the seventhday after surgery. In addition, the rate of pale complexion wasthe highest in the TPN group on the 13th day after surgery.These two observations indicate that lower levels of HB, PA,and ALB may lead to a pale complexion.

Comparison of the psychological status assessment find-ings between the three patient groups revealed that parenteralnutrition does not affect the external image of the patient,resulted in less suffering, and was more favorable for thepatients to accept if it were economically feasible. The costof parenteral nutrition treatments is high.

Considering the economic feasibility, treatment effects,and follow-up therapies, PN+EN can be an alternative. Thiscombination nutrition can be adjusted for changing situa-tions, resulting in a flexible solution to provide nutritionalsupport to patients and a shorter length of hospitalization.However, this solution requires several days of stomach tubeintubation.

5. Limitations

First, because of the time required to complete the treatment,most patients were not willing to undergo total enteralnutrition treatments; thus, the sample size of the TEN groupwasmuch smaller than those of the other two groups. Second,assessments of psychological status were not conductedbefore surgery as a baseline due to limited professionalresources and poor patient cooperation. Third, additional

6 Evidence-Based Complementary and Alternative Medicine

Table3:Re

sults

oftheb

lood

indiceso

fthe

threeg

roup

s.

Items

Group

Postop

erative1

dPo

stop

erative7

dTestvalues

Pvalues

WBC

PN+E

N16.13±1.8

19.6

8±1.5

120.358

0.00

0∗(×109)

TPN

15.51±

1.87

7.99±0.94

23.642

0.00

0∗TE

N16.73±

1.64

10.30±1.3

717.191

0.00

0∗Testvalues

2.257

15.661

——

——

Pvalues

0.113

0.00

0∗——

——

NE

PN+E

N7.5

9±1.0

55.81±0.51

10.027

0.00

0∗(×109)

TPN

7.59±0.94

5.51±0.69

8.168

0.00

0∗TE

N7.8

9±0.75

6.18±0.84

8.312

0.00

0∗Testvalues

0.680

4.910

——

——

Pvalues

0.510

0.010∗

——

——

LYM

PN+E

N1.2

4±0.24

1.82±0.40

7.046

0.00

0∗(×109)

TPN

1.11±

0.32

1.74±0.33

6.394

0.00

0∗TE

N1.0

8±0.31

1.08±0.28

0.013

0.990

Testvalues

2.277

29.051

——

——

Pvalues

0.109

0.00

0∗——

——

HB

PN+E

N116

.47±18.00

122.79±12.43

2.385

0.024∗

(g/L)

TPN

98.47±5.73

111.17±9.0

74.697

0.00

0∗TE

N111

.52±12.22

112.35±10.93

0.352

0.728

Testvalues

9.835

8.181

——

——

Pvalues

0.00

0∗0.00

1∗——

——

PAPN

+EN

252.66±31.68

266.28±23.82

2.777

0.010∗

(mg/L)

TPN

230.32±30.59

243.11±38.77

1.370

0.188

TEN

243.15±33.89

244.70±39.98

0.185

0.855

Testvalues

2.792

3.695

——

——

Pvalues

0.069

0.030∗

——

——

ALB

PN+E

N38.01±

4.00

40.26±2.70

2.716

0.011∗

(g/L)

TPN

33.64±3.51

35.12±5.58

1.067

0.300

TEN

36.02±3.11

37.21±

3.57

1.497

0.151

Testvalues

8.367

10.273

——

——

Pvalues

0.00

1∗0.00

0∗——

——

∗Sign

ificantlydifferent

amon

ggrou

ps(P<0.05).Va

lues

aredemon

strated

asthemean±sta

ndarddeviations

foro

ne-w

ayANOVA

test.

Thepairwise

comparis

onsa

mon

gthemeans

were

perfo

rmed

usingthe

Bonferroni

metho

d.WBC

,whitebloo

dcell;NE,

neutroph

il;LY

M,lym

phocytes;H

B,hemoglobin.

PA,prealbu

min;A

LB,album

in.

Evidence-Based Complementary and Alternative Medicine 7

Table4:FP

S-R,

VAS,NRS

,and

SF-36scores

ofthethree

grou

psaft

ersurgery(7

day).

Items

PN+E

Ngrou

p(n=5

8)TP

Ngrou

p(n=3

3)TE

Ngrou

p(n=2

1)Testvalues

Pvalues

Won

g-Ba

nker

FPS-Rscores

5.0(4.0,5.0)

2.0(2.0,3.0)

5.0(4.0,5.0)

64.205

0.00

0∗VA

Sscores

5.0(5.0,6.0)

2.0(2.0,3.0)

6.0(6.0,7.0)

81.016

0.00

0∗NRS

scores

5.0(5.0,6.0)

3.0(2.0,3.0)

6.0(5.0,6.0)

69.809

0.00

0∗OFB

DDSS

scores

57.12±14.59

52.58±12.52

53.95±9.5

21.3

620.260

Self-o

verallappearance

evaluatio

nscores

5.50±0.82

5.18±0.77

5.48±0.68

1.858

0.161

SF-36scores

40.15±3.68

39.00±2.69

40.91±

3.36

0.765

0.472

∗Sign

ificantlydifferent

amon

ggrou

ps(P<0.05).

Values

ared

emon

strated

asn(%

)for

chi-s

quareo

rFish

er’sexacttests,

asthem

ean±sta

ndarddeviations

foro

ne-w

ayANOVA

testandas

Median,

(Quartil25,Q

uartil75)for

Kruskal-W

ailsHtest.

FPS-R,

FacesP

ainScale-Re

vised;VA

S,visualanalogue

scale;NRS

,Num

ericalratin

gscale;OFB

DDSS,O

ral-F

acialB

odyDysmorph

icDiso

rder

Self-Scale;SF-36,short-form

36health

survey

questio

nnaire.

8 Evidence-Based Complementary and Alternative Medicine

Table5:HAMAandsubscalesscoreso

fthe

threeg

roup

safte

rsurgery

(7day).

Items

PN+E

Ngrou

p(n=5

8)TP

Ngrou

p(n=3

3)TE

Ngrou

p(n=2

1)Testvalues

Pvalues

HAMAscores

14.00(12.75,16.00

)10.00(9.00,12.00)

17.00

(15.00

,17.5

0)46

.103

0.00

0∗7-14

scores

(patientsm

ayhave

anxiety)

34(30.36%)

32(28.57%)

4(3.57%

)37.854

0.00

0∗

15-21scores

(patientsd

efinitelyhave

anxiety)

24(21.4

3%)

1(0.89%)

17(15.1

8%)

Anx

ious

stateof

mind

2.00

(1.00,2.00

)1.0

0(1.00,1.0

0)2.00

(1.00,2.00

)21.14

80.00

0∗Tension

2.0(1.75.0,2.00

)1.0

0(1.00,1.0

0)2.00

(2.00,2.00

)35.474

0.00

0∗Fear

2.00

(2.00,2.00

)1.0

0(1.00,1.0

0)2.00

(2.00,2.00

)45.492

0.00

0∗Insomnia

1.00(1.00,2.00

)1.0

0(0.00,1.0

0)1.0

0(0.00,1.0

0)22.590

0.00

0∗Cognitiv

efun

ction

1.00(0.00,1.0

0)0.00

(0.00,1.0

0)0.00

(0.00,0.00

)28.728

0.00

0∗Depressivem

ood

0.00

(0.00,0.00

)0.00

(0.00,1.0

0)1.0

0(0.00,1.0

0)11.059

0.00

4∗Muscularsystem

symptom

s1.0

0(1.00,2.00

)1.0

0(1.00,1.0

0)1.0

0(1.00,2.00

)15.403

0.00

0∗Sensationsyste

msymptom

s1.0

0(1.00,2.00

)1.0

0(1.00,2.00

)2.00

(1.00,2.00

)9.1

240.010∗

Cardiovascularsystem

symptom

s.0.00

(0.00,1.0

0)0.00

(0.00,0.00

)1.0

0(0.00,1.0

0)14.971

0.00

1∗

Respira

tory

syste

msymptom

s0.00

(0.00,1.0

0)0.00

(0.00,1.0

0)2.00

(1.50,2.00

)44

.930

0.00

0∗

Gastro

intestinalsystem

symptom

s0.00

(0.00,0.00

)1.0

0(1.00,1.0

0)1.0

0(0.50,1.0

0)48.342

0.00

0∗

Genito

urinarytract

symptom

0.00

(0.00,0.00

)0.00

(0.00,0.00

)0.00

(0.00,0.00

)0.377

0.828

Plantn

ervous

syste

msymptom

s1.0

0(1.00,2.00

)1.0

0(1.00,1.0

0)1.0

0(0.50,1.0

0)17.636

0.00

0∗

Behaviors

2.00

(1.00,2.00

)1.0

0(1.00,1.0

0)2.00

(1.00,2.00

)12.384

0.002∗

∗Sign

ificantlydifferent

amon

ggrou

ps(P<0.05).Va

lues

ared

emon

strated

asn(%

)for

chi-s

quareo

rFish

er’sexacttestsandas

Median(Q

uartil25,Q

uartil75)for

Kruskal-W

ailsHtest.

HAMA,H

amilton

anxietyratin

gscale.

Evidence-Based Complementary and Alternative Medicine 9

Table6:Indexeso

fthe

threeg

roup

safte

rsurgery

(13day).

Items

PN+E

Ngrou

p(n=5

8)TE

Ngrou

p(n=2

1)TP

Ngrou

p(n=3

3)Testvalues

Pvalues

BMI(kg/m2)

22.13±1.9

221.67±2.65

21.64±2.06

0.711

0.493

Leng

thof

hospita

lization(days)

16.90±3.81

21.15±3.12

21.95±3.17

15.344

0.00

0∗K(m

mol/L)

4.10±0.33

3.25±0.56

4.29±0.29

46.912

0.00

0∗Na(

mmol/L)

133.84±5.40

128.94±9.7

3135.26±7.2

74.053

0.022∗

CL(m

mol/L)

107.8

5±4.23

103.34±3.56

107.33±

5.15

7.077

0.002∗

SGAcategorie

sAgrade

9(8.04%

)0

028.13

90.00

0∗Bgrade

46(41.0

7%)

20(17.8

6%)

11(9.82%

)Cgrade

3(2.68%

)13

(11.6

1%)

10(8.93%

)TC

Msymptom

sPalecomplexion

1(0.89%)

2(1.79%

)6(5.36%

)11.859

0.00

1∗Skin

with

outluster

7(6.25%

)3(2.68%

)5(4.46%

)2.451

0.280

∗Sign

ificantlydifferent

amon

ggrou

ps(P<0.05).Va

lues

ared

emon

strated

asn(%

)for

chi-s

quareo

rFish

er’sexacttests,

asthem

ean±sta

ndarddeviations

foro

ne-w

ayANOVA

test.

Abbreviatio

ns:B

MI,bo

dymassind

ex;K

,potassiu

m;N

A,sod

ium;C

L,chlorin

e;SG

A,sub

jectiveglob

alassessment;TC

M,traditio

nalC

hinese

medicine.

10 Evidence-Based Complementary and Alternative Medicine

follow-up studies on the quality of life are necessary toconfirm our findings. More studies will be carried on in thefuture. Finally, our study did not include biomarker data orformal TCM questionnaire (in development); hence, furtherstudies including advanced biomarker tests and formal TCMquestionnaires are required.

6. Conclusions

As an auxiliary method, TCM symptoms can help identifyspirit disequilibrium earlier, which may be associated withblood indices. Despite the high cost and long length ofhospitalization, patients who received parenteral nutritionhad the best mental status. However, given the considerationsof high cost and hospitalization duration, PN+EN may bean alternative, offering a lower cost, shorter length of hospi-talization, and satisfactory clinical effects; however, patientsrequire intubation with a stomach tube for several days.

Data Availability

This study was registered at the Chinese Clinical Trial Reg-istry (http://www.chictr.org.cn) as ChiCTR-OPC-17013869.All the results will be uploaded to the net when the studysubject is finished.

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper.

Authors’ Contributions

Xuan Zhou and Chen Zou contributed equally to this paper.

Acknowledgments

This work was mainly sponsored by the National KeyBasic Research Program of China (973 Program) [no.2011CB505406] and the State Administration of TraditionalChinese Medicine Twelve-Five Focus on Cultivating Subjectsof Chinese Preventive Medicine [(2012)170].

References

[1] W. L. Chen, J. S. Li, Z. H. Yang, Z. Q. Huang, and J. Q. Wang,“Extended vertical lower trapezius islandmyocutaneous flap forrepairing extensive oropharyngeal defects,” Journal of Oral andMaxillofacial Surgery, vol. 67, no. 6, pp. 1349–1353, 2009.

[2] S. M. Gondivkar, A. R. Gadbail, S. C. Sarode, and S. Patil,“Quality of life assessment should be part of oral healthevaluations in day-to-day practice,” Journal of ContemporaryDental Practice, vol. 18, no. 10, pp. 857-858, 2017.

[3] H. Y. Chen, D. B. Wu, Y. L. Peng, Y. S. Meng, and H. Y.Yang, “Psychological analysis and nursing intervention forperioperative patients with mouth cancer,” Chinese Journal ofModern Nursing, vol. 19, no. 11, pp. 1267–1269, 2013.

[4] P. Bruggemann, A. J. Szczepek, K. Klee, S. Grabel, B. Mazurek,and H. Olze, “In patients undergoing cochlear implantation,psychological burden affects tinnitus and the overall outcome of

auditory rehabilitation,” Frontiers in Human Neuroscience, vol.11, 2017.

[5] O. Bissinger, A. Rau, S. Koerdt, K. D. Wolff, M. R. Kesting, andC. Gotz, “Evaluating tumour after care in oral squamous cellcarcinoma: Insights into patients’ health related quality of life,”Journal of Cranio-Maxillo-Facial Surgery, vol. 45, no. 2, pp. 262–266, 2017.

[6] H. Y. Sroussi, J. B. Epstein, R. J. Bensadoun et al., “Commonoral complications of head and neck cancer radiation therapy:mucositis, infections, saliva change, fibrosis, sensory dysfunc-tions, dental caries, periodontal disease, and osteoradionecro-sis,” Cancer Medicine, vol. 6, no. 12, pp. 2918–2931, 2017.

[7] V. Sahni, “Psychological impact of facial trauma,” Craniomax-illofacial Trauma&Reconstruction, vol. 11, no. 1, pp. 15–20, 2018.

[8] H. Baumeister and M. Harter, “Psychological comorbidity inpatients with musculoskeletal diseases,” Bundesgesundheitsblatt- Gesundheitsforschung - Gesundheitsschutz, vol. 54, no. 1, pp.52–58, 2011.

[9] Y. Cui, S. Liao, and H. W. Wang, “ROC-boosting: a featureselection method for health identification using tongue image,”Computational and Mathematical Methods in Medicine, vol.2015, Article ID 362806, 2015.

[10] Y. Cui, S. Liao, H. Wang, H. Liu, H. W. Wang, and L. Q. Yin,“Relationship between hyperuricemia and haar-like featureson tongue images,” BioMed Research International, vol. 2015,Article ID 363216, 10 pages, 2015.

[11] X. Zhou, F. Xu, J. Gao et al., “Development and preliminaryvalidation of the questionnaire (the first edition) based ontcm for detecting health status in China,” Evidence-BasedComplementary and Alternative Medicine, vol. 2015, Article ID863685, 12 pages, 2015.

[12] X. Zhou, S. Cao, X. Y. Feng, Z. W. Zhao, and H. W. Wang,“Theory of essence, qi, and spirit combined with pyramid-likesolid structure to explore the health status of human body,”Journal of Tianjin University of Traditional Chinese Medicine,vol. 35, no. 3, pp. 145–148, 2016.

[13] S. Bishop andW. M. Reed, “The provision of enteral nutritionalsupport during definitive chemoradiotherapy in head and neckcancer patients,” Journal of Medical Radiation Sciences, vol. 62,no. 4, pp. 267–276, 2015.

[14] C. Zou, X. Zhou, M. Liu, and G. W. Huang, “The Influence ofdifferent nutrition treatment approaches in the fibula muscleflap reconstruction of the mandibular defect postoperativepatients,”Parenteral &Enteral Nutrition, vol. 25, no. 1, pp. 37–42,2018.

[15] L. J. Ware, C. D. Epps, K. Herr, and A. Packard, “Evaluationof the revised faces pain scale, verbal descriptor scale, numericrating scale, and iowa pain thermometer in older minorityadults,” Pain Management Nursing, vol. 7, no. 3, pp. 117–125,2006.

[16] P. Vittayakittipong, “Donor-site morbidity after fibula free flaptransfer: A comparison of subjective evaluation using a visualanalogue scale and point evaluation system,” InternationalJournal of Oral andMaxillofacial Surgery, vol. 42, no. 8, pp. 956–961, 2013.

[17] S. Oxberry, V. Middleton, and M. Bennett, “What does a goodquality of life for cancer patients mean on a numerical ratingscale?” Clinical Oncology, vol. 17, no. 2, p. 129, 2005.

[18] P. E. Bijur, C. T. Latimer, and E. J. Gallagher, “Validation ofa verbally administered numerical rating scale of acute painfor use in the emergency department,” Academic EmergencyMedicine, vol. 10, no. 4, pp. 390–392, 2003.

Evidence-Based Complementary and Alternative Medicine 11

[19] E. Thompson, “Hamilton rating scale for anxiety (HAM-A),”Occupational Medicine, vol. 65, no. 7, p. 601, 2015.

[20] Z. Cai and F. Dai, “The design of self-assessment scale andclinical application of orthodontics in the oral andmaxillofacialfeatures,” Chinese Journal of Orthodontics, vol. 1, no. 1, p. 25,2004.

[21] L. G. Lu, T. N. Chen, J. G. Chen, and W. G. Lin, “A self ratingscale of body image,” Chinese Mental Health Journal, no. 5, pp.299–302, 2000.

[22] Y. Ma, Z. M. Yin, Y. Lu, S. W. Hao, and Z. L. Xu, “The differencebetween self evaluation and other evaluation of facial beautyand impact of self-esteem on it,” Chinese Journal of HealthPsychology, vol. 23, no. 11, pp. 1688–1693, 2015.

[23] N. Deng, W. He, R. Li, W. L. Li, N. Gao, and W. Zhang,“Assessment of the quality of life of oral cancer patients afterreconstruction with free anterolateral thigh perforator flaps,”West China journal of stomatology, vol. 33, no. 2, pp. 197–200,2015.

[24] H. T. Al-Ahmad and Z. B. Al-Bitar, “The effect of tem-poromandibular disorders on condition-specific quality of lifein patients with dentofacial deformities,” Oral Surgery, OralMedicine, Oral Pathology, Oral Radiology, and Endodontology,vol. 117, no. 3, pp. 293–301, 2014.

[25] M. A. Kuzu, H. Terzioglu, V. Genc et al., “Preoperative nutri-tional risk assessment in predicting postoperative outcome inpatients undergoing major surgery,” World Journal of Surgery,vol. 30, no. 3, pp. 378–390, 2006.

[26] P. S. Anthony, “Nutrition screening tools for hospitalizedpatients,” Nutrition in Clinical Practice, vol. 23, no. 4, pp. 373–382, 2008.

[27] C. Motsch, S. Kahl, and K. Nebelung, “Fundamentals of enteralfeeding, tube techniques, PEG,” Laryngo-Rhino-Otologie, vol.80, no. 8, pp. 449–457, 2001.

[28] S. X. Geng, “Clinical study of difficulties in stomach intubationmethod,” China Practical Medicine, vol. 4, no. 13, pp. 201-202,2009.

[29] M. H. DeLegge, “Enteral access and associated complications,”Gastroenterology Clinics of North America, vol. 47, no. 1, pp. 23–37, 2018.

[30] S. Merrick and D. Farrell, “Head and neck cancer patients’experiences of percutaneous endoscopic gastrostomy feeding:A Q-methodology study,” European Journal of Cancer Care, vol.21, no. 4, pp. 493–504, 2012.

[31] J. Penrod, J. M. Morse, and S. Wilson, “Comforting strategiesused during nasogastric tube insertion,” Journal of ClinicalNursing, vol. 8, no. 1, pp. 31–38, 1999.

[32] A. P. Chen and M. Cai, “Unplanned extraction and relatedresearch progress of ICU patients,” Chinese Journal of Nursing,vol. 42, no. 10, pp. 934–937, 2007.

[33] M. E. McCall, A. Adamo, K. Latko, A. K. Rieder, N. Durand,and T. Nathanson, “Maximizing nutrition support practiceand measuring adherence to nutrition support guidelines in acanadian tertiary care ICU,” Journal of Intensive Care Medicine,vol. 33, no. 3, pp. 209–217, 2018.

[34] J.Wang, X. X. Zuo, Y. Zhang, and T. T. Shen, “The present situa-tion and improvement strategy of clinical nutrition departmentin hospital in China,” People’s Military Surgeon, vol. 58, no. 3, pp.342-343, 2015.

[35] J. Wang and Y. R. Zhao, “The role of clinical nutrition depart-ment in clinical treatment,” Parenteral & Enteral Nutrition, vol.24, no. 6, pp. 326-327, 2017.

[36] A. Wong, G. Goh, M. D. Banks, and J. D. Bauer, “A systematicreview of the cost and economic outcomes of home enteralnutrition,” Clinical Nutrition, vol. 37, no. 2, pp. 429–442, 2018.

Stem Cells International

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

MEDIATORSINFLAMMATION

of

EndocrinologyInternational Journal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Disease Markers

Hindawiwww.hindawi.com Volume 2018

BioMed Research International

OncologyJournal of

Hindawiwww.hindawi.com Volume 2013

Hindawiwww.hindawi.com Volume 2018

Oxidative Medicine and Cellular Longevity

Hindawiwww.hindawi.com Volume 2018

PPAR Research

Hindawi Publishing Corporation http://www.hindawi.com Volume 2013Hindawiwww.hindawi.com

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwww.hindawi.com Volume 2018

Journal of

ObesityJournal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Computational and Mathematical Methods in Medicine

Hindawiwww.hindawi.com Volume 2018

Behavioural Neurology

OphthalmologyJournal of

Hindawiwww.hindawi.com Volume 2018

Diabetes ResearchJournal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Research and TreatmentAIDS

Hindawiwww.hindawi.com Volume 2018

Gastroenterology Research and Practice

Hindawiwww.hindawi.com Volume 2018

Parkinson’s Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwww.hindawi.com

Submit your manuscripts atwww.hindawi.com