Evaluation of a Preoperative Adverse Event Risk Index for Patients Undergoing Head and Neck Cancer Surgery

The efficacy of the National Surgical Quality Improvement Program surgical risk calculator in head and neck surgery: A meta-analysis

BACKGROUND

The National Surgical Quality Improvement Program surgical risk calculator (SRC) estimates the risk for postoperative complications. This meta-analysis assesses the efficacy of the SRC in the field of head and neck surgery.

METHODS

A systematic review identified studies comparing the SRC's predictions to observed outcomes following head and neck surgeries. Predictive accuracy was assessed using receiver operating characteristic curves (AUCs) and Brier scoring.

RESULTS

Nine studies totaling 1774 patients were included. The SRC underpredicted the risk of all outcomes (including any complication [observed (ob) = 35.9%, predicted (pr) = 21.8%] and serious complication [ob = 28.7%, pr = 17.0%]) except mortality (ob = 0.37%, pr = 1.55%). The observed length of stay was more than twice the predicted length (p < 0.02). Discrimination was acceptable for postoperative pneumonia (AUC = 0.778) and urinary tract infection (AUC = 0.782) only. Predictive accuracy was low for all outcomes (Brier scores ≥0.01) and comparable for patients with and without free-flap reconstructions.

CONCLUSION

The SRC is an ineffective instrument for predicting outcomes in head and neck surgery.

The use of artificial intelligence in reconstructive surgery for head and neck cancer: a systematic review

OBJECTIVES

The popularity of artificial intelligence (AI) in head and neck cancer (HNC) management is increasing, but postoperative complications remain prevalent and are the main factor that impact prognosis after surgery. Hence, recent studies aim to assess new AI models to evaluate their ability to predict free flap complications more effectively than traditional algorithms. This systematic review aims to summarize current evidence on the utilization of AI models to predict complications following reconstructive surgery for HNC.

METHODS

A combination of MeSH terms and keywords was used to cover the following three subjects: "HNC," "artificial intelligence," and "free flap or reconstructive surgery." The electronic literature search was performed in three relevant databases: Medline (Ovid), Embase (Ovid), and Cochrane. Quality appraisal of the included study was conducted using the TRIPOD Statement.

RESULTS

The review included a total of 5 manuscripts (n = 5) for a total of 7524 patients. Across studies, the highest area under the receiver operating characteristic (AUROC) value achieved was 0.824 by the Auto-WEKA model. However, only 20% of reported AUROCs exceeded 0.70. One study concluded that most AI models were comparable or inferior in performance to conventional logistic regression. The highest predictors of complications were flap type, smoking status, tumour location, and age.

DISCUSSION

Some models showed promising results. Predictors identified across studies were different than those found in existing literature, showing the added value of AI models. However, the algorithms showed inconsistent results, underlying the need for better-powered studies with larger databases before clinical implementation.

Evaluation of a new two-step frailty assessment of head and neck patients in a prospective cohort

PURPOSE

Assessing frailty, in head and neck cancer (HNC) patients is key when choosing appropriate treatment. Optimal screening is challenging, as it should be feasible and should avoid over-referral for comprehensive geriatric assessment (CGA) This study aims to evaluate the association between geriatric assessment using a new two-step care pathway, referral to geriatrician and adverse outcomes.

METHODS

This institutional retrospective analysis on a prospective cohort analysed the multimodal geriatric assessment (GA) of newly diagnosed HNC patients. Uni- and multivariable logistic regression was performed to study the association between the screening tests, and referral to the geriatrician for complete geriatric screening, and adverse outcomes.

RESULTS

This study included 539 patients, of whom 276 were screened. Patients who underwent the GA, were significantly older and more often had advanced tumour stages compared to non-screened patients. Referral to the geriatrician was done for 30.8% of patients. Of the 130 patients who underwent surgery, 26/130 (20%) experienced clinically relevant postoperative complications. Of the 184 patients who underwent (radio)chemotherapy, 50/184 (27.2%) had clinically relevant treatment-related toxicity. Age, treatment intensity, polypharmacy and cognitive deficits, were independently associated with referral to geriatrician. A medium to high risk of malnutrition was independently associated with acute radiation induced toxicity and adverse outcomes in general.

CONCLUSION

The current study showed a 30.8% referral rate for CGA by a geriatrician. Age, treatment intensity, cognitive deficits and polypharmacy were associated with higher rates of referral. Furthermore, nutritional status was found to be an important negative factor for adverse treatment outcomes, that requires attention.

Second free jejunum transfer after flap loss does not affect oral intake: A retrospective case-control study

PURPOSE

Free jejunum transfer is one of the standard procedures for restoring oral intake after total pharyngo-laryngo-esophagectomy. Flap loss leading to a second free jejunum transfer rarely occurs. This study investigated the impact of a second free jejunum transfer on post-operative oral intake.

METHODS

A retrospective review was conducted on patients who underwent a first free jejunum transfer between July 1998 and December 2019. A total of 367 patients were included in the study. Among them, 17 patients who underwent a second free jejunum transfer because necrosis constituted the second free jejunum transfer group, whereas 350 patients who did not require a second free jejunum transfer formed the first free jejunum transfer group. The incidence of dysphagia requiring tube feeding and post-operative complications was compared between the two groups. Moreover, risk factors for dysphagia and complications were estimated.

RESULTS

There were no statistically significant differences in the incidence of dysphagia post-operation between the two groups. A second free jejunum transfer was a statistically significant factor for complications at 2- and 6-months post-operation; however, there were no significant differences in complication rates at the 12-month follow-up. Furthermore, there were no significant differences in the incidence of severe complications between the two groups.

CONCLUSION

Although a second free jejunum transfer increases early complications, it is not associated with major complications and does not negatively impact oral intake. These findings support the conclusion that free jejunum transfer is safe and helps maintain post-operative quality of life.

Chronic heart failure in patients undergoing major head and neck surgery: A hospital-based study

OBJECTIVE

To investigate the effects of chronic heart failure on various post-operative outcomes in head and neck cancer patients undergoing major cancer surgery.

STUDY DESIGN

For this retrospective cohort study of patients undergoing major head and neck cancer surgery, a sample of 10,002 patients between 2017 and 2019 were identified through the Nationwide Inpatient Sample.

SETTING

Patients were selected as undergoing major head and neck cancer surgery, defined as laryngectomy, pharyngectomy, glossectomy, neck dissection, mandibulectomy, and maxillectomy, then separated based on pre-surgical diagnosis of chronic heart failure.

METHODS

The effects of pre-operative chronic heart failure on post-surgical outcomes in these patients were investigated by univariable and multivariable logistic regression using ICD-10 codes and SPSS.

RESULTS

A diagnosis of chronic heart failure was observed in 265 patients (2.6 %). Patients with chronic heart failure had more preexisting comorbidities when compared to patients without chronic heart failure (mean ± SD; 4 ± 1 vs. 2 ± 1). Multivariable logistic regression showed that chronic heart failure patients had significantly greater odds of dying during hospitalization (OR 2.86, 95 % CI 1.38-5.91) and experiencing non-routine discharge from admission (OR 1.89, 95 % CI 1.41-2.54) after undergoing major head and neck cancer surgery.

CONCLUSION

Chronic heart failure is associated with greater length of stay and hospital charges among head and neck cancer patients undergoing major head and neck cancer surgeries. Chronic heart failure patients have significantly greater rates of unfavorable post-operative outcomes, including death during hospitalization and non-routine discharge from admission.

Association of Age and Frailty With 30-Day Outcomes Among Patients Undergoing Oral Cavity Cancer Surgery

OBJECTIVE

To evaluate the impact of age and frailty on 30-day outcomes following surgery for oral squamous cavity carcinoma (OSCC).

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

American College of Surgeons' National Quality Improvement Program (NSQIP) database.

METHODS

Patients who underwent OSCC resection were queried via NSQIP (2015-2020). Cases were stratified by age (18-65, 65-75, and older than 75) as well as by modified frailty index scores (mFI 0, mFI 1, and mFI 2+) for comparative analyses. Univariate and multivariable analyses were conducted to examine demographics, perioperative outcomes, and 30-day postoperative adverse events.

RESULTS

A total of 3238 patients who underwent OSCC surgery were identified and categorized as nongeriatric ("NGA," age 18-65), younger geriatric ("YGA," age 65-75), and older geriatric ("OGA," age >75) adults. Compared to NGA, geriatric patients had higher the American Society of Anesthesiologists classification, higher modified frailty index scores, and more comorbidities such as hypertension, congestive heart failure, chronic obstructive disease, and diabetes (p < .001). YGAs and OGAs were also less likely to undergo neck dissection (p < .001), composite resection (p = .006), and free flap reconstruction compared to NGAs (p < .001). When controlling for confounders, age was not independently associated with an increased risk of poor outcomes. On the other hand, frailty was found to be independently associated with a higher risk of adverse events (odds ratio: 1.40 [1.15-1.70], p < .001 for mFI 1, odds ratio: 1.45 [1.04-2.02], p = .027 for mFI 2+).

CONCLUSION

A higher mFI score, not older age, is associated with an increased risk of 30-day complications following OSCC surgery.

Multiphasic exercise prehabilitation for patients undergoing surgery for head and neck cancer: a hybrid effectiveness-implementation study protocol

Head and neck cancer (HNC) treatment often consists of major surgery followed by adjuvant therapy, which can result in treatment-related side effects, decreased physical function, and diminished quality of life. Perioperative nutrition interventions and early mobilization improve recovery after HNC treatment. However, there are few studies on prehabilitation that include exercise within the HNC surgical care pathway. We have designed a multiphasic exercise prehabilitation intervention for HNC patients undergoing surgical resection with free flap reconstruction. We will use a hybrid effectiveness-implementation study design guided by the RE-AIM framework to address the following objectives: (1) to evaluate intervention benefits through physical function and patient-reported outcome assessments; (2) to determine the safety and feasibility of the prehabilitation intervention; (3) to evaluate the implementation of exercise within the HNC surgical care pathway; and (4) to establish a post-operative screening and referral pathway to exercise oncology resources. The results of this study will provide evidence for the benefits and costs of a multiphasic exercise prehabilitation intervention embedded within the HNC surgical care pathway. This paper describes the study protocol design, multiphasic exercise prehabilitation intervention, planned analyses, and dissemination of findings. Trial registration: https://clinicaltrials.gov/NCT04598087.

Next-generation sequencing identifies CDKN2A alterations as prognostic biomarkers in recurrent or metastatic head and neck squamous cell carcinoma predominantly receiving immune checkpoint inhibitors

Background

This study aimed to identify potential biomarkers in patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) and further probe the prognostic implications of CDKN2A mutations, particularly within a subset receiving immunotherapy.

Methods

In this retrospective single-center study, we evaluated the next-generation sequencing (NGS) data from Foundation Medicine (FM) for patients with recurrent or metastatic HNSCC between January 1, 2019, and December 31, 2021. Patients were stratified based on CDKN2A loss-of-function (LOF) versus wild-type (WT) categorizations, with a focused subgroup analysis on those administered immunotherapy.

Results

The study encompassed 77 patients, of which 62 had undergone immunotherapy. The median duration of follow-up was 22.6 months. For the CDKN2A LOF group, the median overall survival (OS) was 16.5 months, contrasted with 30.0 months in the CDKN2A WT group (P=0.014). Notably, female gender (hazard ratio [HR]=4.526, 95% confidence interval [CI]: 1.934-10.180, P=0.0003) and CDKN2A LOF (HR=2.311, 95% CI: 1.156-4.748, P=0.019) emerged as independent risk factors for mortality in patients with recurrent or metastatic HNSCC. Within the immunotherapy subset, the median OS was 11.7 months for the CDKN2A LOF group, and 22.5 months for the CDKN2A WT group (P=0.017). Further, the female gender (HR=4.022, 95% CI: 1.417-10.710, P=0.006), CDKN2A LOF (HR=4.389, 95% CI: 1.782-11.460, P=0.002), and a combined positive score below 1 (HR=17.20, 95% CI: 4.134-79.550, P<0.0001) were identified as significant predictors of mortality among patients with recurrent or metastatic HNSCC receiving immunotherapy.

Conclusion

Alterations manifesting as LOF in the CDKN2A gene stand as robust indicators of unfavorable survival outcomes in HNSCC patients, including the subset that underwent immunotherapy.

Development and External Validation of the Spinal Tumor Surgery Risk Index

BACKGROUND

Patients undergoing surgical procedures for spinal tumors are vulnerable to major adverse events (AEs) and death in the postoperative period. Shared decision making and preoperative optimization of outcomes require accurate risk estimation.

OBJECTIVE

To develop and validate a risk index to predict short-term major AEs after spinal tumor surgery.

METHODS

Prospectively collected data from multiple medical centers affiliated with the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2020 were reviewed. Multiple logistic regression was used to assess sociodemographic, tumor-related, and surgery-related factors in the derivation cohort. The spinal tumor surgery risk index (STSRI) was built based on the resulting scores. The STSRI was internally validated using a subgroup of patients from the American College of Surgeons National Surgical Quality Improvement Program database and externally validated using a cohort from a single tertiary center.

RESULTS

In total, 14 982 operations were reviewed and 4556 (16.5%) major AEs occurred within 30 days after surgery, including 209 (4.5%) deaths. 22 factors were independently associated with major AEs or death and were included in the STSRI. Using the internal and external validation cohorts, the STSRI produced an area under the curve of 0.86 and 0.82, sensitivity of 80.1% and 79.7%, and specificity of 74.3% and 73.7%, respectively. The STSRI, which is freely available, outperformed the modified frailty indices, the American Society of Anesthesiologists classification, and the American College of Surgeons risk calculator.

CONCLUSION

In patients undergoing surgery for spinal tumors, the STSRI showed the highest predictive accuracy for major postoperative AEs and death compared with other current risk predictors.

Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction

It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.

Head and neck cancer surgery in elderly patients: the role of frailty assessment

OBJECTIVES

To study whether any risk model, frailty index, patients' comorbidities, or demographic characteristics correlate with postoperative morbidity in elderly patients who underwent surgery for head and neck cancer (HNC). A secondary objective was to compare between frailty indexes that are used at our medical center.

METHODS

A retrospective analysis of head and neck cancer patients operated between 2007 and 2021 was performed.

RESULTS

One hundred and fifteen patients were included and divided into three age groups: 50-69 years, 70-79 years and ≥ 80 years. Although most elderly patients had a significantly higher rate of comorbidities and lower Norton scores, no statistically significant difference was found between the groups in postoperative morbidity rates, intensive care unit (ICU) or internal medicine department admissions, re-hospitalization in 1-3 months, and in falling risk (MFS-Morse Fall Scale). On multivariate analysis there was a positive correlation between preoperative cerebrovascular accident (CVA), dementia, and cardiac arrhythmias, and the probability for developing postoperative complication. The latter findings were not related to the patients' age.

CONCLUSIONS

In this study, we did not find higher postoperative morbidity rates among elderly population in comparison to younger age groups, and therefore, our current evaluation system could not assist in identifying elderly at risk. However, prediction of operative risk based on physiologic reserve or frailty is an important tool in the evaluation of elderly head and neck cancer patients. Future studies are needed to assess the role of frailty index in the elderly head and neck cancer population.

The impact of operability status on outcomes in patients with T4 larynx cancer undergoing larynx preservation

BACKGROUND

Large analyses of T4 larynx cancer (LC) have raised concerns that larynx preservation (LP) contributes to reduced survival compared with laryngectomy (LGX). The role of operability has not been previously considered as a confounder.

METHODS

We queried the National Cancer Database for T4M0 LC diagnosed 2004-2015. Patients were categorized as undergoing LGX, chemoradiotherapy but operable (LP-operable), and chemoradiotherapy inoperable (LP-inoperable). Overall survival (OS) was estimated by Kaplan-Meier. Cox multivariate analysis (MVA) identified variables associated with OS.

RESULTS

We identified 1405 LGX, 164 LP-operable and 1969 LP-inoperable patients. Compared with LGX, MVA demonstrated worse OS among LP-inoperable (HR 1.28 95%CI 1.17-1.40, p < 0.01) but not LP-operable patients (HR 1.12 95%CI 0.91-1.39, p = 0.28).

CONCLUSIONS

LP-operable patients did not have significantly worse OS than those undergoing LGX.

Evaluation of Tongue Functions After Free Flap Reconstruction

Squamous cell carcinoma of the tongue is the most common malignancy of the oral cavity, the lateral border being the commonest site. The treatment strategies mandate surgery followed by appropriate reconstruction as the first line of management. There are many suitable methods of reconstruction of tongue defects after surgery, but the principle of an ideal reconstruction method should provide not only satisfactory structural cosmesis, but also good restoration of function. We present our experience with the skin lined free flaps reconstruction for defects of the tongue and floor of mouth, and present analyses of the functional outcomes of reconstruction. This prospective longitudinal study included 93 patients and was conducted in a tertiary care center in Punjab. All patients underwent free flap reconstruction after tumor removal. The functional outcome of the tongue following reconstruction was evaluated 9 months after the completion of treatment. Functions were assessed and matched with sexes and age-matched normal individuals. The data obtained were analyzed by the student 't' test and the p values < 0.05 were considered statistically significant. The duration of swallowing in patients with FRF flap and ALT flap when compared to the normative was significant (< 0.05). There were changes in configuration and volume of the oral cavity after surgery which generates resonant and articulatory alterations, thus the intelligibility of the patient's speech is lowered. There is also a restriction in the tongue movements and reduction in the sensations of the reconstructed part of the tongue. Both the free ALT flap and the FRF flap can provide acceptable functional restoration of the tongue after radical tumor resection.

Sex-Specific Cut-Off Values for Low Skeletal Muscle Mass to Identify Patients at Risk for Treatment-Related Adverse Events in Head and Neck Cancer

A low skeletal muscle index (SMI), defined with cut-off values, is a promising predictor for adverse events (AEs) in head and neck squamous cell cancer (HNSCC) patients. The aim was to generate sex-specific SMI cut-off values based on AE to diagnose low SMI and to analyse the relationship between low SMI and AEs in HNSCC patients. In this present study, HNSCC patients were prospectively included in a large oncological data-biobank and SMI was retrospectively measured using baseline neck scans. In total, 193 patients were included and were stratified according to treatment modality: (chemo-)radiotherapy ((C)RT) (n = 135) and surgery (n = 61). AE endpoints were based on the occurrence of clinically relevant toxicities (Common Terminology Criteria for Adverse Events grade ≥ III) and postoperative complications (Clavien–Dindo Classification grade ≥ II). Sex-specific SMI cut-off values were generated with receiver operating characteristic curves, based on the AE endpoints. The relationship of the baseline characteristics and AEs was analysed with logistic regression analysis, with AEs as the endpoint. Multivariable logistic analysis showed that low SMI (OR 3.33, 95%CI 1.41–7.85) and tumour stage (OR 3.45, 95%CI 1.28–9.29) were significantly and independently associated to (C)RT toxicity. Low SMI was not related to postoperative complications. To conclude, sex-specific SMI cut-off values, were generated based on the occurrence of AEs. Low SMI and tumour stage were independently related to (C)RT toxicity in HNSCC patients.

Prognostic value of the veterans affairs frailty index in older patients with non-small cell lung cancer

BACKGROUND

Older patients with non-small cell lung cancer (NSCLC) are a heterogeneous population with varying degrees of frailty. An electronic frailty index such as the Veterans Affairs Frailty Index (VA-FI) can potentially help identify vulnerable patients at high risk of poor outcomes.

METHODS

NSCLC patients ≥65 years old and diagnosed in 2002-2017 were identified using the VA Central Cancer Registry. The VA-FI was calculated using administrative codes from VA electronic health records data linked with Medicare and Medicaid data. We assessed associations between the VA-FI and times to mortality, hospitalization, and emergency room (ER) visit following diagnosis by Kaplan-Meier analysis and multivariable stratified Cox models. We also evaluated the change in discrimination and calibration of reference prognostic models after adding VA-FI.

RESULTS

We identified a cohort of 42,204 older NSCLC VA patients, in which 55.5% were classified as frail (VA-FI >0.2). After adjustment, there was a strong association between VA-FI and the risk of mortality (HR = 1.23 for an increase of four deficits or, equivalently, an increase of 0.129 on VA-FI, p < 0.001), hospitalization (HR = 1.16 for four deficits, p < 0.001), and ER visit (HR = 1.18 for four deficits, p < 0.001). Adding VA-FI to baseline prognostic models led to statistically significant improvements in time-dependent area under curves and did not have a strong impact on calibration.

CONCLUSION

Older NSCLC patients with higher VA-FI have significantly elevated risks of mortality, hospitalizations, and ER visits following diagnosis. An electronic frailty index can serve as an accessible tool to identify patients with vulnerabilities to inform clinical care and research.

Anaesthesia for reconstructive free flap surgery for head and neck cancer

Head and neck cancer surgery presents significant challenges for the anaesthetist. A thorough multidisciplinary preoperative assessment and optimisation of the patient is essential, including nutritional and psychological evaluation. The incidence of a difficult airway is high, and the anaesthetist must be skilled in advanced airway techniques. Surgery is extensive, often requiring reconstructive surgery with either a pedicled or free flap. Detailed knowledge of flap physiology and anatomy is needed, and anaesthesia comprises careful management of mean arterial pressure, fluid administration, temperature control and oxygenation. The Enhanced Recovery after Surgery Society and the Society for Head and Neck Anaesthesia consensus recommendations provide guidance on current best practice. Despite continued debate, it now appears that this constitutes goal-directed fluid therapy, coupled with judicious vasopressor therapy sufficient to achieve an adequate mean arterial pressure. Emerging techniques such as prehabilitation and postoperative near-infrared spectroscopy flap monitoring provide hope of improved outcomes going forward.

Validation of a risk prediction calculator in Australian patients undergoing head and neck microsurgery reconstruction

BACKGROUND

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) surgical risk calculator (SRC) is an open access calculator predicting patients' risk of postoperative complications. This study aims to assess the validity of the SRC in patients undergoing microsurgical free flap reconstruction at an Australian tertiary referral centre.

METHODS

This is a retrospective cohort study of 200 consecutive patients treated up to November 2020. SRC-predicted rates of postoperative complications and hospital length of stay (LOS) were compared to those observed for the ablative and reconstructive components of the procedure. The performance of the SRC was assessed using Brier scores, area under the receiver operating characteristic (ROC) curve (AUC), and the Hosmer-Lemeshow test.

RESULTS

For both ablative and reconstructive components, the SRC discriminates well for pneumonia and urinary tract infection, and it is calibrated well for readmission and sepsis, but it does not discriminate and calibrate well for any single outcome. SRC-predicted hospital LOS and actual LOS did not correlate well for the reconstructive component, but they correlated strongly for the ablative component.

CONCLUSIONS

The SRC is a poor predictor of postoperative complication rates and hospital LOS in patients undergoing head and neck microsurgical reconstruction.

Surgical wound classification in otolaryngology: A state‐of‐the‐art review

Objective

To describe the issues related to the assignment of surgical wound classification as it pertains to Otolaryngology—Head & Neck surgery, and to present a simple framework by which providers can assign wound classification.

Data Sources

Literature review.

Conclusion

Surgical wound classification in its current state is limited in its utility. It has recently been disregarded by major risk assessment models, likely due to inaccurate and inconsistent reporting by providers and operative staff. However, if data accuracy is improved, this metric may be useful to inform the risk of surgical site infection. In an era of quality‐driven care and reimbursement, surgical wound classification may become an equally important indicator of quality.

In its current state, surgical wound classification has been disregarded as a key metric, likely due to habitual inaccuracies in procedure categorization.

A new paradigm for surgical wound classification specific to Otolaryngology—Head & Neck Surgery is presented.

The possibility of surgical wound classification serving as an important indicator of quality of care is discussed and contextualized in current health care trends.

Cervical paraspinal skeletal muscle index outperforms frailty indices to predict postoperative adverse events in operable head and neck cancer with microvascular reconstruction

OBJECTIVE

Sarcopenia is increasingly being recognized as a negative prognostic factor in patients with head and neck cancer (HNC). We associate a sarcopenia biomarker measured radiographically from computed tomography (CT) of the neck to postoperative adverse events in patients with operable HNC.

PATIENTS AND METHODS

A prospective cohort of treatment-naïve HNC patients undergoing surgery with microvascular reconstruction was performed. Cervical paraspinal skeletal muscle index (CPSMI) was calculated using preoperative CT neck imaging and adjusted for height and sex. Postoperative adverse events, including Clavien-Dindo Grade 3+ complications and fistula, were recorded within 30-days of the index surgery. Multivariate logistic regression was used to evaluate the association between CPSMI and postoperative complications. The modified frailty index (mFI) and Risk Assessment Index (RAI) were compared with CPSMI outcomes.

RESULTS

A total of 127 patients with mucosal HNC were included in the study. The mean age was 60.5 years, and 87 (68.5%) patients were male. Sixty Clavien-Dindo grade 3+ events occurred; 17 patients developed an oro/pharyngocutaneous fistula. Low CPSMI was independently associated with Clavien-Dindo Grade 3+ events (OR 2.80, 95% CI of 1.18-6.99) and fistula (OR of 6.10, 95% CI of 1.53-24.3) when adjusted for multiple factors. CPSMI outperformed the mFI and RAI frailty indices to predict postoperative adverse events (p < .05).

CONCLUSION

Low CPSMI is independently associated with postoperative adverse events and outperforms current frailty indices inoperable HNC with microvascular reconstruction.

Above and Beyond Age: Prediction of Major Postoperative Adverse Events in Head and Neck Surgery

OBJECTIVE

Major postoperative adverse events (MPAEs) following head and neck surgery are not infrequent and lead to significant morbidity. The objective of this study was to ascertain which factors are most predictive of MPAEs in patients undergoing head and neck surgery.

METHODS

A cohort study was carried out based on data from patients registered in the National Surgical Quality Improvement Program (NSQIP) from 2006 to 2018. All patients undergoing non-ambulatory head and neck surgery based on Current Procedural Terminology codes were included. Perioperative factors were evaluated to predict MPAEs within 30-days of surgery. Age was classified as both a continuous and categorical variable. Retained factors were classified by attributable fraction and C-statistic. Multivariate regression and supervised machine learning models were used to quantify the contribution of age as a predictor of MPAEs.

RESULTS

A total of 43 701 operations were analyzed with 5106 (11.7%) MPAEs. The results of supervised machine learning indicated that prolonged surgeries, anemia, free tissue transfer, weight loss, wound classification, hypoalbuminemia, wound infection, tracheotomy (concurrent with index head and neck surgery), American Society of Anesthesia (ASA) class, and sex as most predictive of MPAEs. On multivariate regression, ASA class (21.3%), hypertension on medication (15.8%), prolonged operative time (15.3%), sex (13.1%), preoperative anemia (12.8%), and free tissue transfer (9%) had the largest attributable fractions associated with MPAEs. Age was independently associated with MPAEs with an attributable fraction ranging from 0.6% to 4.3% with poor predictive ability (C-statistic 0.60).

CONCLUSION

Surgical, comorbid, and frailty-related factors were most predictive of short-term MPAEs following head and neck surgery. Age alone contributed a small attributable fraction and poor prediction of MPAEs.

LEVEL OF EVIDENCE

3.

Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Frailty and restrictions in geriatric domains are associated with surgical complications but not with radiation-induced acute toxicity in head and neck cancer patients: A prospective study

OBJECTIVES

We aimed to evaluate the association between frailty screening and geriatric assessment (GA) on short term adverse events in patients treated for head and neck cancer (HNC) for the first time in a prospective study.

MATERIALS AND METHODS

Newly diagnosed HNC patients undergoing curative treatment were prospectively included in OncoLifeS, a data biobank. Prior to the start of treatment, frailty was assessed with a GA, Groningen Frailty Indicator (GFI) and Geriatric-8 (G8). The GA included comorbidity (Adult Comorbidity Evaluation - 27), nutritional status (Malnutrition Universal Screening Tool), functional status ((instrumental) Activities of Daily Living), mobility (Timed Up & Go), psychological (Geriatric Depression Scale 15) and cognitive (Mini Mental State Examination) measures. Clinically relevant postoperative complications (Clavien-Dindo ≥ grade 2) and acute radiation-induced toxicity (Common Terminology Criteria for Adverse Events version 4.0 ≥ grade 2) were defined as outcome measures. Univariable and multivariable logistic regression analyses were performed, yielding odds ratios (ORs) and 95% confidence intervals (95%CIs).

RESULTS

Of the 369 included patients, 259 patients were eligible for analysis. Postoperative complications occurred in 41/148 (27.7%) patients and acute radiation-induced toxicity was present in 86/160 (53.7%) patients. Number of deficit domains of GA (OR = 1.71, 95%CI = 1.14-2.56), GFI (OR = 2.54, 95%CI = 1.02-6.31) and G8 (OR5.59, 95%CI = 2.14-14.60) were associated with postoperative complications, but not with radiation-induced toxicity.

CONCLUSION

Frailty and restrictions in geriatric domains were associated with postoperative complications, but not with radiation-induced acute toxicity in curatively treated HNC patients. The results of this prospective study further emphasizes the importance of geriatric evaluation, particularly before surgery.

Preoperative Risk Index Among Patients Undergoing Thyroid or Parathyroid Surgery

Importance

Frailty represents a multidimensional syndrome that is increasingly being used to stratify risk in surgical patients. Current frailty risk models are limited among those undergoing thyroid or parathyroid surgery.

Objective

To develop and compare preoperative risk indices to determine factors associated with short-term major postoperative adverse events in patients undergoing thyroid or parathyroid surgery.

Design, Setting, and Participants

This cohort study evaluated 154 895 patients in the American College of Surgeons National Surgical Quality Improvement Program who underwent thyroid or parathyroid surgery from January 1, 2007, to December 31, 2016.

Exposures

Preoperative frailty-related and surgical factors from a derivation cohort were evaluated using simple and multiple logistic regression. Variables potentially associated with postoperative adverse events were subsequently combined into a personalized preoperative Cervical Endocrine Surgery Risk Index (CESRI) and compared with existing risk models using the validation cohort.

Main Outcomes and Measures

Composite variable of any major postoperative adverse event, including death, within 30 days of surgery.

Results

Of the 154 895 operations reviewed, 3318 patients (2.1%; 2296 women and 1022 men; mean [SD] age, 56.1 [15.6] years) experienced a major postoperative adverse event, with 163 deaths (0.1%). Older age (age, ≥80 years: odds ratio [OR], 2.35; 95% CI, 1.74-3.13), inpatient status (OR, 3.55; 95% CI, 3.08-4.11), male sex (OR, 1.49; 95% CI, 1.29-1.71), current tobacco smoking (OR, 1.25; 95% CI, 1.05-1.48), dyspnea (OR, 1.58; 95% CI, 1.29-1.91), recent weight loss (OR, 1.88; 95% CI, 1.23-2.78), functional dependence (OR, 2.77; 95% CI, 2.05-3.69), obesity (OR, 1.33; 95% CI, 1.10-1.60), anemia (OR, 2.14; 95% CI, 1.82-2.52), leukocytosis (OR, 1.73; 95% CI, 1.38-2.14), hypoalbuminemia (OR, 1.87; 95% CI, 1.56-2.23), use of anticoagulation (OR, 2.16; 95% CI, 1.64-2.81), and length of surgery (>4 hours: OR, 2.92; 95% CI, 2.37-3.59) were independently associated with major adverse events or death on multiple regression analysis (C statistic, 0.77; 95% CI, 0.76-0.78). The area under the curve of the CESRI to determine major adverse events, including death, using the validation cohort was 0.63 (95% CI, 0.61-0.64), with a sensitivity of 0.66 (95% CI, 0.64-0.68) and specificity of 0.66 (95% CI, 0.65-0.66). The CESRI outperformed other risk models for determining adverse events (CESRI vs 5-Factor Modified Frailty Index: delta C index, 0.11; 95% CI, 0.09-0.13; CESRI vs American Society of Anesthesiologists Physical Status Classification System: delta C index, 0.05; 95% CI, 0.03-0.07; CESRI vs American College of Surgeons Risk Calculator: delta C index, 0.02; 95% CI, 0.01-0.03; and CESRI vs Head and Neck Surgery Risk Index: delta C index, 0.04; 95% CI, 0.03-0.06).

Conclusions and Relevance

This study suggests that the CESRI is able to determine major postoperative adverse events in patients undergoing thyroid or parathyroid surgery.

Early Adverse Events Following Transcervical Hypopharyngeal Diverticulum Surgery

Objective:

To describe rates of short-term morbidity following transcervical surgical treatment of hypopharyngeal diverticulum (HD) and analyze predictors of adverse events.

Methods:

The 2005 to 2017 National Surgical Quality Improvement Program database was queried to identify patients diagnosed with HD undergoing open transcervical diverticulectomy.

Results:

A total of 597 patients with a mean age of 71.4 ± 12.3 years were included. Thirty-day adverse events were experienced by 63 (10.6%) subjects, including 6.5% unplanned reoperations, 4.2% surgical complications, 4.4% medical complications, 2.7% readmissions, and 0.7% deaths. Medical complications notably included pneumonia (2.0%), reintubation (1.2%), sepsis (1.2%), intubation >48 hours (0.5%), urinary tract infection (0.5%), or deep vein thrombosis (0.5%), while surgical complications included organ/space infection (2.0%) and superficial (1.3%) or deep (1.0%) surgical site infection. Gender, race, functional status, diabetes, dyspnea, hypertension, steroid use, and recent weight loss were not associated with adverse events. Length of operation and hospitalization were both higher among those with adverse events (127.4 ± 107.9 vs 95.7 ± 59.8 minutes, P = 0.027, and 7.4 ± 7.4 vs 2.8 ± 3.6 days, P < 0.001). On multivariable logistic regression, high American Society of Anesthesiologists (ASA) class (OR = 2.02, P = 0.017), smoking (OR = 2.10, P = 0.044), and operation time (OR = 1.01; P = 0.005) were independent predictors of adverse events. Obesity was not associated with length of stay, readmission/reoperation, or complications. However, increased age was associated with shorter operations ( P = 0.020), higher length of hospitalization ( P < 0.001), and higher mortality ( P = 0.027) and readmission rates ( P = 0.023).

Conclusion:

Understanding clinical factors associated with complications following open surgery for HD such as ASA score, smoking status, length of operation, and age can help optimize surgical outcomes for at-risk patients.

Perioperative considerations in nonagenarians

OBJECTIVE

The nation's aging population presents novel perioperative challenges. Potential benefits of operative interventions must be scrutinized in relation to recoverable quality of life. The purpose of this study is to evaluate common risk calculators used for medical decision making in a nonagenarian patient population.

METHODS

Retrospective medical record review was performed on patients 90 years or older who underwent operative interventions requiring anesthesia at a large academic medical center between January 1, 2013, and December 31, 2017. GraphPad 8.2.1 was used for statistical analysis.

RESULTS

Significant differences were found when data were stratified by age for elective versus emergent cases (P value < .0001), ability to return to baseline function (P value  = .0062), and mortality (P value < .0001). Significant differences were found in emergent and elective cases, ability to return to baseline function, readmissions, and mortality (all P values < .0001) when stratified by American Society of Anesthesiologists score. Ability of patients to return to baseline functionality after intervention was influenced by their preintervention level of functionality (P value = .0008). American College of Surgeons and Portsmouth Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity risk calculators underestimated the need for rehabilitation and overestimated mortality for this population (all P values < .0001).

CONCLUSION

Perioperative cares of the extreme geriatric population are complex and should be approached collaboratively. Rehabilitation and postoperative assistance resources should be assessed and used fully. Input from palliative care teams should be sought appropriately. End-of-life and escalation-of-care discussions should ideally be organized prior to emergent interventions. Frailty and risk calculators should be used and considered for formal implementation into the preoperative workflow.

A model to predict postoperative complications for otorhinolaryngology and maxillofacial surgery procedures in elderly patients

PURPOSE

All kinds of ear, nose, and throat and maxillofacial surgery (ENT/MFS) procedures are being increasingly performed in the elderly although old age is a major risk factor for increased postoperative complications. With only scarce evidence on the topic, surgeons are asked to critically evaluate their procedures' indications and outcomes to balance the treatment risks and benefits. Our primary aim was to identify predictive factors for surgical outcomes in this setting and to create a predictive model for a tailored risk assessment.

METHODS

We analyzed a case series of 435 patients from an institutional clinical database at our academic tertiary care center. Multivariate logistic regression was used to identify all possible covariates and nomograms using stepwise backward method were generated. The performance was assessed by calibration curves and c-index.

RESULTS

Overall complication rate was 18.3% within the first 30 days and the need for re-intervention was 5.9%. For those under general anesthesia, we identified specific risk factors and developed three risk-predicting models of overall, early, and late complications. All of the nomograms showed satisfactory accuracy with a c-index of 0.83, 0.75, 0.86, and 0.82, respectively.

CONCLUSION

Using clinical preoperative variables, we constructed a model for predicting major adverse events in ENT/MFS patients. In our experience, patients over 65 showed a non-negligible risk for postoperative complications depending on several factors. Such tools might help in decision-making, by increasing the risk-awareness of clinicians, to better address peri-operative and post-operative care of these patients.

Evidence-Based Guidelines for Management of Head and Neck Mucosal Malignancies during the COVID-19 Pandemic

OBJECTIVE

Due to the current coronavirus disease 2019 (COVID-19) pandemic, otolaryngologists face novel challenges when treating patients with head and neck cancer. The purpose of this review is to evaluate the current evidence surrounding the treatment of these patients during this pandemic and to provide evidence-based recommendations with attention to increased risk in this setting.

DATA SOURCES

A review of the literature was performed with PubMed. Because recently published articles on this topic may not yet be indexed into PubMed, otolaryngology journals were hand searched for relevant articles. Guidelines from national organizations were reviewed to identify additional relevant sources of information.

REVIEW METHODS

Two groups of search terms were created: one with terms related to COVID-19 and another with terms related to head and neck cancer and its management. Searches were performed of all terms in each group as well as combinations of terms between groups. Searches and subsequent exclusion of articles were performed in accordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Additional articles were identified after relevant journals and guidelines from national organizations were reviewed.

CONCLUSIONS

Patients with head and neck mucosal malignancy require continued treatment despite the current pandemic state. Care must be taken at all stages of treatment to minimize the risk to patients and health care workers while maintaining focus on minimizing use of limited resources.

IMPLICATIONS FOR PRACTICE

Patient care plans should be guided by best available evidence to optimize outcomes while maintaining a safe environment in the setting of this pandemic.