PROSPERO

International prospective register of systematic reviews

Dysphagia presentation and rehabilitation following esophagectomy: a systematic review

Asako Kaneoka, Sky Yang, Haruhi Inokuchi, Rumi Ueha, Hiroharu Yamashita, Yasuyuki Seto, Nobuhiko
Haga

Citation
Asako Kaneoka, Sky Yang, Haruhi Inokuchi, Rumi Ueha, Hiroharu Yamashita, Yasuyuki Seto,
Nobuhiko Haga. Dysphagia presentation and rehabilitation following esophagectomy: a systematic
review. PROSPERO 2017 CRD42017056330 Available from:
http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017056330

Review question
1. What are the predominant physiological changes identified by using videofluoroscopic or videoendoscopic
swallowing studies to the swallowing mechanism following esophagectomy?
2. What are the swallowing-related symptoms which have been reported to be identified by using
videofluoroscopic or videoendoscopic swallowing evaluations?
3. Which of those physiological changes and swallowing symptoms are highly prevalent?
4. Is there any evidence to suggest that rehabilitative interventions are effective in improving swallowing
function in patients who underwent esophagectomies?

Searches
The first author of this study (AK) will perform a comprehensive search from February 14, 2017 through
February 28, 2017 using MEDLINE [PubMed], EMBASE, Web of Science, CINAHL, Cochrane Database of
Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL). To reduce investigator
selection bias, all relevant search terms are defined a priori.
The following is the search algorithm for searching MEDLINE: (esophageal cancer OR esophagus cancer)
AND (esophagectomy OR esophageal surgery OR esophageal resection OR esophagus/surgery [MeSH
Terms]) AND (dysphagia OR swallow OR deglutition OR deglutition disorders OR swallowing disorders OR
oropharyngeal dysphagia) AND (modified barium swallow OR videofluoroscopy OR instrumental swallow OR
VFSS OR FEES OR videofluoroscopic swallow study OR endoscopy OR videoendoscopy OR fiberoptic
endoscopic evaluation of swallowing OR endoscopic evaluation of swallowing).
Search will be restricted to human studies. No language or publication date restriction will be imposed. To
ensure a comprehensive search, AK will scan reference lists of included studies and previously published
review articles. Further, authors and experts in the field will be contacted for relevant published or
unpublished data.
Studies will be included that met the following criteria: 1) were published or unpublished original research
articles; 2) retrospective and prospective studies; 3) studied adult (16 years or older) patients; 4) with a
diagnosis of esophageal cancer; 5) treated with first-time esophagectomy with or without perioperative
chemotherapy/chemoradiotherapy; 6) examined swallowing function of the patients using instrumental
evaluations; and 7) reported any symptoms of dysphagia and/or swallowing kinematic variables and/or
rehabilitative interventions using clearly described method(s).

Types of study to be included

Published or unpublished original research articles; retrospective and prospective studiesOriginal reports that
profiled fewer than 10 patients will be excluded. Studies that did not utilize instrumental evaluations to
assess swallowing function will be excluded because no screening protocol has been shown to provide high
predictive value for presence of aspiration against instrumental evaluations.

Condition or domain being studied

Radical resection of the esophageal cancer with lymph node dissection has been the mainstay of treatment
for esophageal cancer. Major complications include anastomotic leak, pulmonary complications, recurrent

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International prospective register of systematic reviews

nerve damage, dysphagia, and other gastrointestinal symptoms. Above all, the presence of dysphagia has
been reported to increase the risk of pneumonia and mortality following esophagectomy. Thus, it is crucial to
provide patients with adequate dysphagia management in order to achieve better health outcomes after
resection of esophageal cancer.
In this review, dysphagia is defined as abnormal swallowing physiology of the oral, pharyngeal and
esophageal phase identified using endoscopic or fluoroscopic swallowing tests. Swallowing kinematic
measurements are defined to be any displacement measures of relevant structures for swallowing and/or
time variables of swallowing motion identified by using endoscopic or fluoroscopic swallowing tests.
Rehabilitative interventions include compensatory swallowing strategies (e.g. head-turn, chin-tuck, or effortful
swallow), non-swallowing tasks (e.g. thermal tactile stimulation, tongue strength training), or diet and liquid
texture modification.

Participants/population
Adult (16 years or older) patients with a diagnosis of esophageal cancer treated with first-time
esophagectomy with or without perioperative chemotherapy/chemoradiotherapy, examined swallowing
function of the patients using instrumental evaluations
Studies that included patients with a history of disorders in the central nervous system such as stroke and
traumatic brain injury, previous neck surgery or radiotherapy will also be excluded. Whenever studies
pertained to overlapping patients, studies with larger sample size and more comprehensive data will be
included.

Intervention(s), exposure(s)
Examined swallowing function of the patients using instrumental evaluations; and reported any symptoms of
dysphagia and/or swallowing kinematic variables and/or rehabilitative interventions using clearly described
method(s).

Comparator(s)/control
Not applicable.

Primary outcome(s)
The reported frequencies of dysphagic symptoms (expressed as percentages) will be presented
descriptively. The prevalence of aspiration, penetration, and residue are also compiled due to their
inextricable interactions with swallow physiology and frequent reporting in the literature.

Secondary outcome(s)
Swallowing kinematic measurements, and types of rehabilitative interventions

Data extraction (selection and coding)

Full-text articles meeting the eligibility criteria will be reviewed by AK and HI. AK will extract the details of
included studies to a standardized form and HI will check the extracted data. The following data will be
extracted and recorded:
(1) study characteristics: the name of author, the year of publication, the country in which the study was
performed, number of patients included, number of patients by gender, by histology, by cancer stage, by
route of surgical approach, by route of reconstruction, by type of anastomosis, extent of lymph node
dissection, presence of postoperative radiotherapy/chemoradiotherapy, exclusion criteria that has been set
by each study, nutrition status, diet levels, alternative nutrition route (nasogastric tube, percutaneous
endoscopic gastrostomy, and other compensatory strategies for nutrition intake), and nutrition status as
measured by Body Mass Index or other metrics, the presence of tracheostomy tube, and quality of life
measures;
(2) Dysphagia characteristics: instrumental evaluation(s) used, timing of swallowing evaluation performed
from surgery, types of instrumental evaluations used, type and size of test boluses given, swallowing
abnormalities and swallowing kinematic measurements.

Risk of bias (quality) assessment

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International prospective register of systematic reviews

To ascertain the validity of eligible studies, AK and HI will independently appraise the methodological quality
using the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) checklist as we
anticipate that publications will be a variety of non-randomized designs. The 22 criteria specified by TREND
will be given a rating of 1 (satisfies the criteria) or 0 (does not satisfy the criteria), yielding a maximum quality
rating of 22.

Strategy for data synthesis

We anticipate that sources of heterogeneity (e.g. subjects, surgical and non-surgical treatment protocols,
research design) in the studies that are included in this review will prohibit a meta-analysis of the data.
Therefore, the reported frequencies of dysphagic symptoms (expressed as percentages) will be presented
descriptively. The prevalence of aspiration, penetration, and residue are also compiled due to their
inextricable interactions with swallow physiology and frequent reporting in the literature.

Analysis of subgroups or subsets

None planned

Contact details for further information

Ms Kaneoka
asakokaneoka@gmail.com

Organisational affiliation of the review

The University of Tokyo Hospital

Review team members and their organisational affiliations

Ms Asako Kaneoka. The University of Tokyo Hospital, Rehabilitation Center
Ms Sky Yang. The University of California, San Francisco, Department of Otolaryngology Head and Neck
Surgery
Dr Haruhi Inokuchi. The University of Tokyo Hospital, Rehabilitation Center
Dr Rumi Ueha. The University of Tokyo, Department of Otolaryngology
Dr Hiroharu Yamashita. The University of Tokyo, Department of Gastrointestinal Surgery
Dr Yasuyuki Seto. The University of Tokyo, Department of Gastrointestinal Surgery
Dr Nobuhiko Haga. The University of Tokyo, Department of Gastrointestinal Surgery

Anticipated or actual start date

14 February 2017

Anticipated completion date

18 May 2017

Funding sources/sponsors
None.

Conflicts of interest
None known

Language
English

Country
Japan

Stage of review
Review_Ongoing

Subject index terms status

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International prospective register of systematic reviews

Subject indexing assigned by CRD

Subject index terms

Deglutition Disorders; Esophagectomy; Humans; Medicine

Date of registration in PROSPERO

31 January 2017

Date of publication of this version

31 January 2017

Details of any existing review of the same topic by the same authors
Stage of review at time of this submission
The review has not started

Stage Started Completed

Preliminary searches No No
Piloting of the study selection process No No

Formal screening of search results against eligibility criteria No No

Data extraction No No
Risk of bias (quality) assessment No No

Data analysis No No

Versions
31 January 2017

PROSPERO
This information has been provided by the named contact for this review. CRD has accepted this information in good
faith and registered the review in PROSPERO. CRD bears no responsibility or liability for the content of this registration
record, any associated files or external websites.

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