Factors Influencing the Incidence of Severe Complications in Head and Neck Free Flap Reconstructions

Background:

Complications after head and neck free-flap reconstructions are detrimental and prolong hospital stay. In an effort to identify related variables in a tertiary regional head and neck unit, the microvascular reconstruction activity over the last 5 years was captured in a database along with patient-, provider-, and volume-outcome–related parameters.

Methods:

Retrospective cohort study (level of evidence 3), a modified Clavien-Dindo classification, was used to assess severe complications.

Results:

A database of 217 patients was created with consecutively reconstructed patients from 2009 to 2014. In the univariate analysis of severe complications, we found significant associations (P < 0.05) between type of flap used, American Society of Anesthesiologists classification, T-stage, microscope use, surgeon, flap frequency, and surgeon volume. Within a binomial logistic regression model, less frequently versus frequently performed flap (odds ratio [OR] = 3.2; confidence interval [CI] = 2.9–3.5; P = 0.000), high-volume versus low-volume surgeon (OR = 0.52; CI = −0.22 to 0.82; P = 0.007), and ASA classification (OR = 2.9; CI = 2.4–3.4; P = 0.033) were retained as independent predictors of severe complications. In a Cox-regression model, surgeon (P = 0.011), site of reconstruction (P = 0.000), T-stage (P = 0.001), and presence of severe complications (P = 0.015) correlated with a prolonged hospitalization.

Conclusions:

In this study, we identified a correlation of patient-related factors with severe complications (ASA score) and prolonged hospital stay (T-stage, site). More importantly, we identified several provider- (surgeon) and volume-related (frequency with which a flap was performed and high-volume surgeon) factors as predictors of severe complications. Our data indicate that provider- and volume-related parameters play an important role in the outcome of microvascular free-flap procedures in the head and neck region.

Development and Feasibility of a Specialty-Specific National Surgical Quality Improvement Program (NSQIP): The Head and Neck-Reconstructive Surgery NSQIP

IMPORTANCE

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) serves the need for continual quality assessment in general surgery. Previously, no parallel mechanism specific to head and neck oncologic surgery existed.

OBJECTIVE

To address the need for continual quality assessment in subspecialty surgery by adapting the ACS NSQIP platform for complex head and neck oncologic surgical procedures.

DESIGN, SETTING, AND PARTICIPANTS

With an institutional ACS NSQIP team's guidance, surgeons from the departments of head and neck surgery and plastic and reconstructive surgery developed disease- and procedure-specific preoperative, intraoperative, and postoperative variables specific to head and neck surgery requiring reconstruction. Collection occurred with 100% sampling and standard ACS NSQIP 30-day follow-up. After a pilot period, long-term functional outcomes were added to this platform. A total of 312 patients underwent head and neck surgery requiring reconstruction at an academic medical center between August 1, 2012, and June 30, 2013.

EXPOSURES

Development of a specialty-specific head and neck surgery ACS NSQIP platform.

MAIN OUTCOMES AND MEASURES

The feasibility of adapting the ACS NSQIP platform to capture complex head and neck surgery metrics in all patients.

RESULTS

Head and neck surgery-specific preoperative, intraoperative, and postoperative variables were added to the ACS NSQIP platform and evaluated in 312 patients (201 [64.4%] male). Only 42 patients (13.5%) had no preoperative risk factors, and 136 (43.6%) had 3 or more risk factors. The mean (SD) duration of operation was 9.4 (3.0) hours (range, 1.7-19.3 hours). The mean (SD) postoperative length of stay was 7.9 (4.7) days (range, 1-40 days), 58 patients (18.6%) had an unplanned return to the operating room, 23 patients (7.4%) were readmitted within 30 days, and 3 patients (1.0%) died within 30 days. More than half of the patients (160 [51.3%]) did not experience a postoperative occurrence.

CONCLUSIONS AND RELEVANCE

To our knowledge, this is the first comprehensive complex oncologic surgery outcomes platform derived from ACS NSQIP methods. The initial pilot demonstrates the ability to systematically capture head and neck surgery-specific variables with complete sampling. With multi-institutional expansion, increased accrual, and long-term patient-reported outcomes, we hope to set risk-adjusted benchmarks that may underpin quality improvement efforts in complex head and neck surgery.

Third party assessment of resection margin status in head and neck cancer

BACKGROUND

Definitive assessment of primary site margin status following resection of head and neck cancer is necessary for prognostication, treatment determination and qualification for clinical trials. This retrospective analysis determined how often an independent reviewer can assess primary tumor margin status of head and neck cancer resections based on review of the pathology report, surgical operative report, and first follow-up note alone.

METHODS

We extracted from the electronic medical record pathology reports, operative reports, and follow-up notes from head and neck cancer resections performed at Stanford Hospital. We classified margin status as definitive or not. We labeled any pathology report clearly indicating a positive, negative, or close (<5mm) margin as definitive. For each non-definitive pathology report, we reviewed the operative report and then the first follow-up note in an attempt to clarify margin status. We also looked for associations between non-definitive status and surgeon, year, and primary site.

RESULTS

743 unique cases of head and neck cancer resection were extracted. We discarded 255 as non-head and neck cancer cases, or cases that did not involve a definitive resection of a primary tumor site. We could not definitively establish margin status in 20% of resections by independent review of the medical record. There was no correlation between margin determination and surgeon, site, or year of surgery.

CONCLUSION

A substantial fraction (20%) of primary site surgical margins could not be definitively determined via independent EMR review. This could have implications for subsequent patient care decisions and clinical trial options.

Is long-term survival possible after margin-positive resection of retroperitoneal sarcoma (RPS)?

BACKGROUND/OBJECTIVES

For various reasons, some patients undergo a gross margin positive resection (R2) leading to a dilemma in care. We hypothesized that there is a subset of patients who have long-term survival (LTS, ≥5 years) after R2 resection for retroperitoneal sarcoma (RPS).

METHODS

National Cancer Database data from 1998 to 2011 were reviewed to identify patients with RPS who had R2 resections. Logistic and Cox regression models were used to compare LTS with short-term survival.

RESULTS

Of 12,028 patients, R2 resection rate was 3.28% (4.9% in 1998; 2.5% in 2011). Median survival for RPS with R2 resection was 21 months versus 69 months for those with R0/R1 resections (P < 0.001). Of 272 patients with available survival, 24% (n = 64) survived ≥5 years with 64% alive at follow-up. LTS was most often seen in younger patients (<65 years) with well-differentiated liposarcoma. Chemotherapy appeared to improve survival in the first 3 postoperative years, but paradoxical effects were seen in LTS (Hazards Ratio [HR] 0.69, 95%CI: 0.50-0.95, P = 0.024) in first 3 years versus (HR 2.15, 95%CI: 1.21-3.81, P = 0.009).

CONCLUSION

Long-term survival is possible for a subset of patients after an R2 resection for RPS, especially with favorable histology characteristics. Benefits of chemotherapy in margin positive settings need to be investigated. J. Surg. Oncol. 2016;113:823-827. © 2016 Wiley Periodicals, Inc.

The importance of margins in head and neck cancer

An estimated 200,000 deaths each year worldwide are due to cancer of the head and neck, mostly mucosal squamous cell carcinoma and nonmelanoma skin cancer. The status of surgical margins is important for prognosis and need for adjuvant therapy. We will discuss how margin status impacts outcomes and therapy, and the conundrum of determining margin status.

Improved prognosis for patients with oral cavity squamous cell carcinoma: Analysis of the National Cancer Database 1998-2006

BACKGROUND

Improvements in prognosis have been reported for oral cavity squamous cell carcinoma (OCSCC) in international cohorts. We sought to quantify improvement in survival of OCSCC and to determine factors associated with survival in the United States using a large administrative database.

METHODS

Retrospective cohort study of 13,655 patients with OCSCC in the National Cancer Database diagnosed during time periods 1998-2003 and 2004-2006. Statistical methods included chi-square and Cox regression.

RESULTS

Patients with early (Stages I and II) and late stage (Stages III and IV) disease had improvements of 36.2% and 16.0% in three-year overall survival, respectively. Receipt of adjuvant chemoradiation increased from 8.3% to 36.4% for late stage disease, while receipt of adjuvant therapy in early stage disease remained stable. Patients with early stage disease increased from 64.1% for years 1998-2003 to 67.4% during 2004-2006 (p<.001). Being diagnosed between 2004 and 2006 was associated with decreased mortality in early and late stage disease (HR 0.67 and 0.87, p<.001, respectively). Other treatment factors associated with improved survival for patients of all stages included treatment in a high-volume center (HR 0.91, p=.002) and undergoing neck dissection (HR 0.90, p=.001).

CONCLUSIONS

Three-year overall survival has increased dramatically for OCSCC patients. Advanced stage patients have been increasingly treated with chemoradiotherapy, while treatment of early stage patients has remained relatively unchanged. While other factors such as negative surgical margins and undergoing neck dissection may be partly responsible for improvements in early stage patients, further study is needed to understand the observed survival improvements.