The clinical context explains why timing matters so much. Large tumours of the oral cavity often leave what surgeons call volume defects, gaps in tissue that must be reconstructed with flap transfers, in which a segment of tissue, sometimes with its own blood supply, is moved to rebuild the affected area. After such operations, patients cannot eat normally while the wounds and swallowing musculature heal. Roughly 60 percent of head and neck cancer patients are already malnourished at presentation, and poor nutrition is an independent risk factor for surgical complications, morbidity and mortality. Every additional day of fasting therefore compounds an existing problem, deepening the metabolic stress that major surgery already imposes on the body.

Enhanced recovery after surgery, or ERAS, is the modern framework designed to counter that stress. These multimodal perioperative pathways combine early mobilisation, standardised anaesthetic and analgesic regimens, and careful nutritional optimisation, and they have been shown to shorten hospital stays and reduce costs. A central ERAS principle is avoiding prolonged fasting: solids are permitted up to six hours before anaesthesia, and fluids, including carbohydrate-loading drinks, up to two hours before. The ERAS Society consensus guidelines for head and neck surgery recommend that postoperative tube feeding should begin within 24 hours of surgery in patients who cannot yet tolerate oral intake. The most recent guidance from ESPEN, the European Society of Parenteral and Enteral Nutrition, goes further, stating that oral or tube feeding should start as soon as possible within the first few hours after surgery in conscious and haemodynamically stable patients.

The physiological rationale is well established. Prolonged preoperative fasting raises the risk of hyperglycaemia, metabolic stress and insulin resistance, the hallmark of the catabolic response to injury. Carbohydrate loading before surgery has been shown to blunt postoperative insulin resistance, reduce protein and nitrogen losses, improve muscle function and shorten length of stay. Early postoperative nutrition works in the same direction, limiting nitrogen and muscle loss during the critical healing window. Evidence from gastrointestinal surgery, where most of this research has been conducted, has found no benefit to keeping patients nil-by-mouth, and a Cochrane review concluded that early enteral nutrition reduced hospital stay by almost two days, with no differences in complications, including pneumonia, and only weak evidence of increased vomiting.

What remained unclear was whether these findings translate to head and neck flap surgery, where the airway, the swallow and a freshly transplanted flap all sit in close proximity. Few studies have examined the timing of tube feeding in this population, and a gap existed specifically around feeding earlier within the 24-hour window, including on the same day as surgery. The UCLH team, led by head and neck dietitian Florence Cook together with oral and maxillofacial surgeons and perioperative medicine consultants, set out to close that gap using the Plan-Do-Study-Act cycle, the four-stage improvement model, borrowed from industrial engineering, in which a change is planned, tested, studied and then adapted or adopted.

The planning stage revealed both an opportunity and a hidden inefficiency. Although the unit’s existing ERAS protocol already required feeding within 24 hours, the usual practice was to wait until the morning surgical review before commencing feeds. Discussions among stakeholders noted that operating finish times had improved, with midnight finishes now uncommon, making same-day feeding more feasible. Patient and public involvement feedback added that earlier feeding might support the energy levels patients need to mobilise the next day. The team also spotted that many patients were being sent for a chest x-ray to confirm nasogastric tube position before anyone attempted a pH aspirate test, contrary to national guidance that specifies pH testing first. Five of seven consultants agreed to trial early enteral nutrition; two declined, citing concerns about the risk-benefit ratio and nausea or vomiting. High-risk patients, such as those at risk of vomiting or delayed gastric emptying, were excluded at the operating surgeon’s discretion.

The protocol that emerged after three rounds of revision was deliberately conservative in one respect: the feed itself did not change. Patients received the established starter regimen, a 1.5 kcal/ml standard polymeric formula beginning at 20 ml per hour and increasing in 30 ml per hour steps as long as gastric aspirates stayed below 200 ml, with target rates scaled to body weight. A pre-written electronic record template ensured feeding instructions were consistent. The protocol was approved through clinical governance and rolled out on 27 May 2025, with prospective data collected over six months on fasting times, nutritional intake, complications graded by the Clavien-Dindo system, length of stay and weight change.

The results were striking. Of 45 included patients, 23 received early enteral nutrition and 22 received usual care. The early group’s median perioperative fasting time was 0.7 days compared with 1.3 days in the usual group, and feeding began a median of 4.3 hours after surgery versus 18.5 hours, differences that were highly statistically significant. Within the first 24 hours, the early group received a median of 215 ml of feed, delivering 322.5 kcal and 13.5 g of protein, while the usual-care group received nothing. Weight loss at discharge was also markedly lower in the early group, a median of 1 percent versus 5.6 percent. Crucially, safety signals were reassuring: there were no significant differences in Clavien-Dindo complications of grade three or above, in vomiting during the first 24 or 72 hours, or in gastric aspirates. Length of stay was similar between groups, and 96 percent of all patients met the ERAS target of feeding within 24 hours, an adherence rate higher than reported in previous studies.

The authors are careful about what these numbers can and cannot show. The project was a non-randomised, single-centre quality improvement exercise with a small sample and a short timeframe, so causation cannot be established and the findings may not generalise to every unit. Six patients recommended for early feeding did not receive it, for reasons including an immediate return to theatre and displaced feeding tubes, and the usual-care group contained more sarcoma cases. Even so, the pattern aligns with a growing international literature: a Japanese before-and-after study found early feeding on postoperative day one was safe and feasible without increased complications, and a randomised trial of feeding started during the operation itself reported no excess adverse events or flap failure, with some indication of enhanced wound regeneration.

The practical consequences of the project extend beyond the feeding schedule. In the Act phase of the cycle, the findings were presented to the wider surgical team, who agreed to establish early enteral nutrition as an option in the local ERAS protocol. The audit also exposed the overuse of chest x-rays for tube position checking: only 16 percent of patients had a pH aspirate attempted first, and the early-feeding group needed fewer x-rays overall, 53 versus 73, prompting further improvement cycles. The team now calls for high-quality randomised trials to confirm the safety and potential metabolic benefits of very early feeding in head and neck surgery, and for a mapping exercise of current practice, noting that as fast-track protocols become usual care, such trials may become difficult to run. For now, the message for patients facing flap reconstruction is a simple one: the era of waiting until the morning after surgery for the first calories may be coming to an end.

Subject of Research: Timing of early enteral nutrition after reconstructive head and neck flap surgery

Article Title: Early enteral feeding following flap surgery for head and neck defects: a quality improvement project using the Plan-Do-Study-Act cycle

Article References: Cook, F., Niemann, A., Ambler, G., Sahovaler, A., & Ward, P. (2026). Early enteral feeding following flap surgery for head and neck defects: a quality improvement project using the Plan-Do-Study-Act cycle. Supportive Care in Cancer, 34(10), Article 1008. https://doi.org/10.1007/s00520-026-11231-7

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11231-7

Keywords: head and neck cancer, flap reconstruction, enteral nutrition, ERAS, enhanced recovery, quality improvement, Plan-Do-Study-Act, nasogastric feeding, perioperative nutrition, fasting, Clavien-Dindo complications, Supportive Care in Cancer

Osteomyelitis of the foot is a familiar adversary in medicine, particularly among patients with diabetes and peripheral neuropathy, where loss of protective sensation allows small wounds to deepen unnoticed until bacteria reach bone. The standard playbook combines targeted antibiotics with surgical removal of infected bone, an approach widely accepted as effective for most cases of diabetic foot osteomyelitis. But the operation itself is only the opening act. Wound care after amputation remains one of the most deceptively difficult phases of treatment, because the surgeon is working with tissue that is already infected, poorly perfused, and dependent on a patient’s long-term cooperation. In this case, the toe was amputated at a secondary hospital, yet the story took a turn that clinicians see all too often: after seven days of hospitalization, dissatisfied with the service and the wound dressing care he was receiving, the patient discharged himself against medical advice.

Several days later he arrived at an outpatient clinic with an oozing wound at the amputation stump. Examination revealed loss of the cutaneous layer, with swollen subcutaneous tissue exposed to the air. Encouragingly, his white blood cell count and C-reactive protein levels were within normal limits, no microbial growth was identified in cultures, and no peripheral necrosis or vascular disease was detected. The wound was not systemically infected. But it refused to dry. The volume of exudate did not decrease, and a transparent yellow discharge, suspicious for synovial fluid leaking from the disrupted joint, persisted day after day. That detail mattered enormously. A dehisced stump with no protective skin barrier, sitting over a joint capsule that might be leaking synovial fluid, is an open invitation for bacteria to colonize the wound and seed the deeper structures. The treating team concluded that flap reconstruction was indispensable, not merely to close a hole but to rebuild the biological wall separating the outside world from the joint.

The operation they chose was the Limberg flap, also known as a rhomboid flap, a workhorse of reconstructive surgery first described decades ago and still prized for its elegant geometry. The technique recruits a diamond-shaped segment of adjacent healthy skin and subcutaneous tissue, transposes it across a pivot point, and uses the laxity of surrounding skin to fill the defect while distributing mechanical tension along the closure lines. Here, the surgeons first performed a rhomboid-shaped debridement, excising necrotic and swollen tissue to leave a clean 3.5 by 3.5 centimeter defect, then raised the Limberg flap with its pivot point at the medial side of the proximal phalanx stump. The geometry was constrained by the previous surgery and the scarcity of healthy adjacent tissue, meaning that mechanical tension on the flap was unavoidable, a compromise the team accepted because no better local option existed.

Perioperative care was built to protect the fragile reconstruction. The patient received a prophylactic first-generation cephalosporin to guard against infection, a prostaglandin E1 analogue to promote vasodilation, and antiplatelet therapy to enhance blood supply to the flap, a rational combination given that microvascular perfusion determines whether transferred skin lives or dies. In the immediate aftermath, the strategy appeared to work. Exudate dropped markedly, and the suspicious synovial fluid leakage stopped entirely, confirming that the flap had successfully sealed the joint. One week after surgery, however, mild edematous changes appeared in the flap, and the tissue eventually became necrotic. The reconstruction had partially failed, a consequence of the tension under which it was placed and the compromised local conditions.

What happened next is arguably the most instructive part of the case. Rather than rushing back to the operating room for another flap or a skin graft, the team pivoted to conservative management: daily dressing changes with intermittent debridement of the necrotic material. Although the skin flap did not fully survive, it continued to serve as a physical barrier and provided structural support to the adjacent tissue, promoting recovery and the formation of healthy granulation tissue beneath it. Over the following two months, healthy tissue gradually covered the lesion, and the wound healed by secondary intention. The authors point out that this outcome echoes a concept recognized in the literature, in which even a failed flap can function as a biological dressing, reducing contamination and inflammation and facilitating the development of healthy tissue before any subsequent grafting. In other words, a partially necrotic flap is not always a wasted operation; sometimes it is scaffolding.

The case also shines a light on how often amputation wounds go wrong in broader populations. Stump-related complications are dominated by wound infection and poor healing, which account for roughly 70 percent of problems, followed by poorly fashioned stumps at 20 percent and phantom pain at 10 percent. Research has linked smoking to both immediate and late complications, preoperative infection to immediate and intermediate complications, and amputations performed for peripheral vascular disease or trauma to late complications. One study of 739 patients who underwent lower-limb amputation found that 8.3 percent were readmitted within 30 days because of stump-related complications, and 61 percent of those complications required surgical intervention, with readmission rates of 35.9 percent after above-knee amputation and 68.7 percent after below-knee amputation. In the present patient, the authors suggest that both his smoking history and the underlying osteomyelitis likely contributed to the wound breakdown, and they note that pre-emptive vascular examinations to identify peripheral vascular disorders would have aided wound care planning from the start.

The report also engages with a genuine technical controversy in modern wound care: the use of topical negative pressure therapy, or TNP, in which vacuum sealing drainage systems actively draw fluid from a wound to promote granulation. While TNP has advanced the management of soft-tissue defects and amputation wounds, its application over open joints remains contested, with variable reported outcomes. In this case, the authors argue that applying negative pressure directly to the wound could have caused excessive drainage of synovial fluid and potential joint disruption. Their proposed sequence for similar situations is therefore deliberate: flap reconstruction first, to close the joint and reestablish the skin barrier, followed by TNP dressing only afterward, once the joint is protected. This ordering, they suggest, captures the benefits of vacuum therapy without exposing a leaking joint to its risks.

Perhaps the most sobering threads running through the case are the ones that have nothing to do with surgical technique. The patient’s poor sanitary conditions, his ingrown toenails, his self-discharge against medical advice, and his refusal to return to the hospital where the amputation was performed all shaped the clinical course as powerfully as any incision. The authors emphasize that understanding patient needs and providing clear explanations of wound status at every visit are essential for building trust, and that consistent wound care until complete recovery is non-negotiable, yet the high cost of treatment often limits access to appropriate care. This patient was a type I medical aid recipient in South Korea, with his basic wound care almost fully covered by government support, a fact the authors credit with making the prolonged dressing regimen feasible. They call for greater coordination among healthcare systems, insurance providers, and government assistance programs to reduce the burden of medical poverty, arguing that patient compliance, trust in clinicians, and financial support together determine whether complicated wounds heal. The case, prepared in accordance with the SCARE reporting criteria, ultimately delivers a double lesson: a well-executed Limberg flap can rescue a failing amputation stump even when the flap itself partially dies, but surgery is only one pillar of recovery, and the quieter work of daily dressings, repeated debridement, and sustained patient engagement is what carries the wound across the finish line.

Subject of Research: Management of a complicated post-amputation stump wound using Limberg flap reconstruction and persistent wound care following toe osteomyelitis

Article Title: Complicated post-amputation stump wound managed with a Limberg flap and persistent wound care: a case report

Article References: Complicated post-amputation stump wound managed with a Limberg flap and persistent wound care: a case report. (n.d.). https://doi.org/10.1186/s44452-026-00028-6

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00028-6

Keywords: osteomyelitis, amputation, Limberg flap, wound care, flap reconstruction, debridement, stump complications, topical negative pressure, patient compliance, diabetic foot, reconstructive surgery, synovial fluid leakage