Objective To determine whether an enhanced recovery after surgery (ERAS) nutrition protocol is reasonably possible among our head and neck cancer (HNC) population with respect to system feasibility and patient compliance. Second, we aim to identify improvements in patient outcomes as a result. Methods Preexperimental research design among patients undergoing major HNC surgery after implementation of the ERAS nutrition protocol from July 2018 to July 2019 as quality improvement (QI). Preoperative clinical nutritional assessment and laboratory values were completed the same day as informed surgical consent in the clinic. Protocol focus was patient consumption of nutritional supplements perioperatively, monitored by our outpatient dietitian. Early postoperative enteral nutrition was initiated with monitoring of nutritional laboratory values. To support our model, we provide preliminary analysis of HNC patient outcomes after implementation of the ERAS nutritional protocol. Results Twenty-five patients were enrolled. Preoperatively, 40% of patients were malnourished, and 100% complied with perioperative nutrition supplementation. Health care provider compliance obtaining preoperative laboratory values was 56%. There was a strong negative correlation between modified Nutrition-Related Index (mNRI) and number of complications ( P = .01), specifically, fistula rate ( P = .04) and unplanned reoperation ( P = .04). Enrolled patient average length of stay was 7 ± 4.4 days. Discussion Our patients demonstrated compliance with implementation of an ERAS nutrition protocol likely facilitated by dietitian engagement. mNRI potentially reflects risk for head and neck surgery complications. Implications for Practice QI processes demand reassessment and modification to ensure efficient and targeted approaches to improving patient care.

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Bezoars are concrete masses found within the gastrointestinal tract that can lead to obstructions. One of the most common forms of bezoars is trichobezoar, composed of swallowed hair. Many bezoars are confined to the stomach; however, a small occurrence of trichobezoars extends past the pylorus and into the duodenum, or small bowel, termed Rapunzel syndrome. In the literature, there have been few cases of recurrent Rapunzel syndrome. Our case is a 13-year-old female with recurrent Rapunzel syndrome requiring three operative interventions.