Individualized Risk Estimation for Postoperative Complications After Surgery for Oral Cavity Cancer

Surgical site complications of isolated salvage neck dissection post-radiotherapy and post-chemoradiotherapy - A cohort analysis (1997-2017)

INTRODUCTION

This study aims to quantify surgical site complications (SSC) after isolated salvage neck dissection (ND) compared with primary ND.

PATIENTS AND METHODS

Between 1997 and 2017 in the Netherlands Cancer Institute - Antoni van Leeuwenhoek, a total of 323 isolated NDs were performed in 308 patients: primary ND (n = 144), post-radiotherapy (RT) ND (n = 53) and post-chemoradiotherapy (CRT) ND (n = 126). Patient, tumor and therapy characteristics were recorded. SSCs were scored according to the Clavien-Dindo Classification (CDC).

RESULTS

101 NDs (31%) were complicated by at least one SSC. In total, 189 different SSCs occurred. Translated to CDC, 45 complications were grade 2, 25 grade 3a and 31 grade 3b. No significant difference in occurrence of SSC (CDC >1) was found between all groups. However, post-CRT, selective (SND) and modified radical ND and radical ND (MRND/RND) (p = 0.005), resection of sternocleidomastoid muscle (SCM) (p = 0.039) and duration of super selective ND surgery (p = 0.048) were significantly associated with more SSC. SCM muscle removal was associated with more surgical site infection (p = 0.045) and necrosis (p = 0.036). From week 10 post-RT/CRT, no difference in complication frequency with primary ND was seen.

CONCLUSION

Post-CRT SND, MRND/RND and SCM muscle resection were associated with an increased incidence of SSCs. If oncologically possible, limit the extent of ND and when an MRND is inevitable, preserve the SCM muscle for optimal prevention of SSC. Concerning SSC, optimal timing of salvage ND is minimal 10 weeks after RT/CRT.

Postoperative Complications of Free Flap Reconstruction in Moderate-Advanced Head and Neck Squamous Cell Carcinoma: A Prospective Cohort Study Based on Real-World Data

Background

Postoperative complications (POCs) of moderate-advanced head and neck squamous cell carcinoma (HNSCC) after free flap reconstruction have received little attention. We investigated the risk factors that lead to POCs and their impact on management and prognosis.

Patients and Methods

A single-center, prospective cohort study was conducted at Beijing Stomatological Hospital on primary HNSCC patients treated between 2015 and 2020.

Results

In total, 399 consecutive HNSCC patients who underwent radical resection of the primary tumor and free flap reconstruction were enrolled in this study, 155(38.8%) experienced POCs. The occurrence of POCs directly led to worse short-term outcomes and poorer long-term overall survival (P=0.0056). Weight loss before the operation (P=0.097), Tumor site (P=0.002), stage T4b (P=0.016), an ACE-27 index of 2-3 (P=0.040), operation time≥8h (P=0.001) and Clindamycin as antibiotic prophylaxis (P=0.001) were significantly associated with POCs.

Conclusions

The occurrence of POCs significantly leads to worse short-term outcomes and increases the patients’ burden.

Advanced Lung Cancer Inflammation Index Predicts Survival Outcomes of Patients With Oral Cavity Cancer Following Curative Surgery

Aim

The aim of our study was to investigate the prognostic value of preoperative advanced lung cancer inflammation index (ALI) and to establish prognostic nomograms for the prediction of survival outcomes in patients with oral cavity squamous cell carcinoma (OSCC).

Materials and Methods

A total of 372 patients who received primary curative surgery for OSCC during 2008–2017 at a tertiary referral center were enrolled. We used the receiver operating characteristic curve to determine the optimal cutoff point of ALI. Through a Cox proportional hazards model and Kaplan–Meier analysis, we elucidated the ALI–overall survival (OS) and ALI–disease-free survival (DFS) associations. Prognostic nomograms based on ALI and the results of multivariate analysis were created to predict the OS and DFS. We used the concordance indices (C-indices) and calibration plots to assess the discriminatory and predictive ability.

Results

The results revealed that the ALI cutoff was 33.6, and 105 and 267 patients had ALI values of <33.6 and ≥33.6, respectively. ALI < 33.6 significantly indicated lower OS (44.0% vs. 80.1%, p < 0.001) and DFS (33.6% vs. 62.8%; p < 0.001). In multivariate analysis, ALI < 33.6 was independently associated with poor OS and DFS (both p < 0.001). The C-indices of established nomograms were 0.773 and 0.674 for OS and DFS, respectively; moreover, the calibration plots revealed good consistency between nomogram-predicted and actual observed OS and DFS.

Conclusion

ALI is a promising prognostic biomarker in patients undergoing primary surgery for OSCC; moreover, ALI-based nomograms may be a useful prognostic tool for individualized OS and DFS estimations.

Association of Surgical and Hospital Volume and Patient Characteristics With 30-Day Readmission Rates

Importance

Thirty-day readmission rates have been suggested as a marker for quality of care. By investigating the factors associated with readmissions in all otolaryngology subspecialties we provide data relevant for the development of risk stratification systems to improve outcomes.

Objective

To establish the association of surgical and hospital volume and patient characteristics with 30-day readmission rates to guide the development of otolaryngology-specific risk stratification models.

Design, Setting, and Participants

A retrospective cohort study including adult patients who underwent inpatient otolaryngology surgery in New York State between 1995 and 2015 was conducted using the Statewide Planning and Research Cooperative System (SPARCS). Regression techniques were used to describe relationships of patient-level factors, hospital, and surgeon volume to 30-day readmission rates in New York State.

Main Outcomes and Measures

The main outcome measures were patient-, surgeon-, and hospital-level risk factors for readmission. Secondary outcome measures were rate of readmissions by subspecialty procedure and by diagnosis on readmission.

Results

We identified 254 257 cases of otolaryngology surgery (147 065 women [58%], mean [SD] age 50 [17] years). The 30-day readmission rate was 6%. In a multivariable model, odds ratios (ORs) identified Medicaid insurance (OR, 1.46; 99% CI, 1.36-1.57), Medicare insurance (OR, 1.32; 99% CI, 1.24-1.42), bottom quartile income (OR, 1.08; 99% CI, 1.01-1.15), patient comorbidities measured by the Charlson Comorbidity Index (CCI) (CCI >1; OR, 2.31; 99% CI, 2.16-2.47), length of stay (LOS) (LOS >10 days; OR, 2.29; 99% CI, 2.00-2.45), rhinology (OR, 1.37; 99% CI, 1.24-1.51), laryngology (OR, 1.98; 99% CI, 1.62-2.43), and head and neck cancer (OR, 1.27; 99% CI, 1.17-1.37) procedures as readmission predictors. High-volume surgeons were protective of 30-day readmission (OR, 0.67; 99% CI, 0.635-0.708) relative to low volume. Hospital volume was not significantly associated to readmissions. The most common causes of readmission included wound- (2682 patients, 18%), respiratory- (1776 patients, 12%), cardiovascular- (1210 patients, 8%), and volume- (1089 patients, 7%) related disorders.

Conclusions and Relevance

This study evaluated the combined effects of patient-, surgeon-, and hospital-level factors on 30-day readmission after otolaryngology surgery. Socioeconomic factors, patient comorbidities, surgeon volumes, and procedure were significantly associated with 30-day readmission. Though the cause of 30-day readmission is multifactorial, a large portion is driven by socioeconomic factors. Addressing these disparities at the system level is necessary to address the described readmission disparities. The development of risk-stratification models based on patient-, procedure-, and surgeon-level factors may help facilitate resource distribution.

Sequelae of Index Complications following Inpatient Head and Neck Surgery: Characterizing Secondary Complications

Objective To characterize patterns of secondary complications after inpatient head and neck surgery. Study Design Retrospective cohort study. Setting National Surgical Quality Improvement Program (2005-2015). Subjects and Methods We identified 18,584 patients who underwent inpatient otolaryngologic surgery. Four index complications were studied: pneumonia, bleeding or transfusion event (BTE), deep/organ space surgical site infection (SSI), and myocardial infarction (MI). Each patient with an index complication was matched to a control patient based on propensity for the index event and event-free days. Rates of 30-day secondary complications and mortality were compared. Results Index pneumonia (n = 254) was associated with several complications, including reintubation (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.2-26.4), sepsis (OR, 8.8; 95% CI, 4.5-17.2), and death (OR, 5.3; 95% CI, 1.9-14.9). Index MI (n = 50) was associated with increased odds of reintubation (OR, 17.2; 95% CI, 3.5-84.1), ventilatory failure (OR, 5.8; 95% CI, 1.8-19.1), and death (OR, 24.8; 95% CI, 2.9-211.4). Index deep/organ space SSI (n = 271) was associated with dehiscence (OR, 7.2; 95% CI, 3.6-14.2) and sepsis (OR, 38.3; 95% CI, 11.6-126.4). Index BTE (n = 1009) increased the odds of cardiac arrest (OR, 3.9; 95% CI, 1.8-8.5) and death (OR, 2.9; 95% CI, 1.6-5.1). Conclusions Our study is the first to quantify the effect of index complications on the risk of specific secondary complications following inpatient head and neck surgery. These associations may be used to identify patients most at risk postoperatively and target specific interventions aimed to prevent or interrupt further complications.

Nomograms predicting long-term overall survival and cancer-specific survival in head and neck squamous cell carcinoma patients

This study aimed to develop nomograms to predict long-term overall survival and cancer-specific survival in patients with head and neck squamous cell carcinoma (HNSCC). We conducted prognostic analyses and developed nomograms predicting survival outcome using HNSCC patient data collected from the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute. An external dataset of 219 patients was used to validate the nomograms. Of 36,179 HNSCC patients, 9,627 (26.6%) died from HNSCC and 4,229 (11.7%) died from other causes. Median follow-up was 28 months (1-107 months). Nomograms predicting overall survival (OS) and cancer-specific survival (CSS) were developed according to 10 clinicopathologic factors (age, race, sex, tumor site, tumor grade, surgery, radiotherapy and TNM stage), with concordance indexes (C-indexes) of 0.719 and 0.741, respectively. External validation C-indexes were 0.709 and 0.706 for OS and CSS, respectively. Our results suggest that we successfully developed nomograms predicting five- and eight-year HNSCC patient OS and CSS with high accuracy. These nomograms could help clinicians tailor surgical, adjuvant therapeutic and follow-up strategies to more effectively treat HNSCC patients.

Preoperative Nomograms Predict Patient-Specific Cervical Spine Surgery Clinical and Quality of Life Outcomes

BACKGROUND

Clinical and quality of life (QOL) outcomes vary depending on the patient's demographics, comorbidities, presenting symptoms, pathology, and surgical treatment used. While there have been individual predictors identified, no comprehensive method incorporates a patient's complex clinical presentation to predict a specific individual postoperative outcome.

OBJECTIVE

To create tool that predicts patient-specific outcomes among those undergoing cervical spine surgery.

METHODS

A total of 952 patients at a single tertiary care institution who underwent anterior or posterior cervical decompression/fusion between 2007 and 2013 were retrospectively reviewed. Outcomes included postoperative emergency department visit or readmission within 30 d, reoperation within 90 d for infection, and changes in QOL outcomes. Nomograms were modeled based on patient demographics and surgical variables. Bootstrap was used for internal validation.

RESULTS

Bias-corrected c-index for emergency department visits, readmission, and reoperation were 0.63, 0.78, and 0.91, respectively. For the QOL metrics, the bias-corrected adjusted R-squared was EQ-5D (EuroQOL): 0.43, for PHQ-9 (Patient Health Questionnaire-9): 0.35, and for PDQ (Pain/Disability Questionnaire): 0.47. Variables predicting the clinical outcomes varied, but included race and median income, body mass index, comorbidities, presenting symptoms, indication for surgery, surgery type, and levels. For the QOL nomograms, the predictors included similar variables, but were significantly more affected by the preoperative QOL of the patient.

CONCLUSION

These prediction models enable referring physicians and spine surgeons to provide patients with personalized expectations regarding postoperative clinical and QOL outcomes following a cervical spine surgery. After appropriate validation, use of patient-specific prediction tools, such as nomograms, has the potential to lead to superior spine surgery outcomes and more cost effective care.

Complications following transoral robotic surgery (TORS): A detailed institutional review of complications

OBJECTIVES

To report the complications occurring following TORS and to identify the factors predictive of complications.

METHODS

Following IRB approval a retrospective analysis of all TORS operations at our institution was performed. Postoperative complications within 45days were collected and graded with the Clavien-Dindo system. Complications were categorized into groups: all complications, not related to TORS and TORS related. Unadjusted odds ratios were calculated to test association between patients with and without a complication.

RESULTS

122 TORS operations were carried out between June 2010 and August 2015. 77% were male, with a median age of 57. There were 92 primary tumor resections, 10second head and neck primary resections, 13 salvage procedures and 7 other indications. Surgical resection involved 1, 2 or >3 sub-sites in 36%, 28% and 36% patients, respectively. Overall, there were 107 complications (66 TORS related, 41 non-TORS related) that occurred in 57 patients (47%). A major complication occurred in 23 patients (18%). 19 patients had a TORS related major complication and 6 patients experienced a non-TORS related major complication. There was a temporal trend in TORS related major complication rate decreasing from 33% in 2010 to 10% in 2015. Statistical analysis showed that the odds of having any complication were 3 times greater in patients over 60years old (p=0.017), and 2.5 times greater when there were more than 2 subsites resected (p=0.022).

CONCLUSIONS

Age over 60years and a larger extent of resection were the significant factors predictive of major complications.

Complications in Mandibular Midline Distraction

Mandibular midline distraction (MMD) is a relatively new surgical technique for correction of transverse discrepancies of the mandible. This study assesses the amount and burden of complications in MMD. A retrospective cohort study was performed on patients who underwent MMD between 2002 and 2014. Patients with congenital deformities or a history of radiation therapy in the area of interest were excluded. Patient records were obtained and individually assessed for any complications. Complications were graded using the Clavien-Dindo classification system (CDS). Seventy-three patients were included of which 33 were males and 40 were females. The mean follow-up was 2.1 years. Twenty-nine patients had minor complications, grades I and II. Two patients had a grade IIIa and three patients had a grade IIIb complication. Common complications were pressure ulcers, dehiscence, and (transient) sensory disturbances of the mental nerve. This study shows that although MMD is a relatively safe method, complications can occur. Mostly the complications are mild, transient, and manageable without the need for any reoperation.

Complications Associated with Mortality after Head and Neck Surgery: An Analysis of the NSQIP Database

Objective

To determine which complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, correlate with 30-day mortality in surgery for malignancies of the head and neck.

Study Design

Retrospective review of prospectively collected national database.

Setting

NSQIP.

Subjects and Methods

NSQIP data from 2005 to 2014 were queried for ICD-9 codes head and neck malignancies. Multivariate logistic regression was used to examine the correlation of individual complications with 30-day mortality.

Results

In total, 15,410 cases met criteria with 3499 complications in 2235 cases. After controlling for patient and surgical variables, postoperative pneumonia ( P = .02; odds ratio [OR], 2.39; 95% confidence interval [CI], 1.15-4.72), progressive renal insufficiency ( P < .001; OR, 21.28; 95% CI, 4.22-87.94), bleeding requiring transfusion ( P = .02; OR, 2.10; 95% CI, 1.12-3.84), sepsis ( P = .02; OR, 2.86; 95% CI, 1.15-6.46), septic shock ( P = .045; OR, 2.87; 95% CI, 0.98-7.81), stroke ( P < .001; OR, 19.81; 95% CI, 6.23-56.03), and cardiac arrest ( P < .001; OR, 135.59; 95% CI, 65.00-286.48) were independently associated with increased odds of 30-day mortality.

Conclusion

The NSQIP database has been extensively validated and used to examine surgical complications, yet there is little analysis on which complications are associated with death. This study identified complications associated with increased risk of 30-day mortality following head and neck cancer surgery. These associations may be used as a measure of complication severity and should be considered when using the NSQIP database to evaluate outcomes in head and neck surgery.