Relationship between postoperative complications and survival after free flap reconstruction for oral cavity squamous cell carcinoma

Enhanced recovery after surgery (ERAS) protocol improves patient outcomes in free flap surgery for head and neck cancer

BACKGROUND

In recent years, enhanced recovery after surgery (ERAS) guidelines have been developed to optimize pre-, intra-, and postoperative care of surgical oncology patients. The aim of this study was to compare management outcome of patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction at our institution before and after the implementation of the ERAS guidelines.

METHODS

This retrospective study comprised 283 patients undergoing HNC surgery with free flap reconstruction between 2013 and 2020. Patients operated before and after the implementation of the ERAS protocol in October 2017 formed the pre-ERAS group (n = 169), and ERAS group (n = 114), respectively.

RESULTS

In the pre-ERAS group the mean length of stay (LOS) and intensive care unit length of the stay (ICU-LOS) were 20 days (range 7-79) and 6 days (range 1-32), and in the ERAS group 13 days (range 3-70) and 5 days (range 1-24), respectively. Both LOS (p < 0.001) and ICU-LOS (p = 0.042) were significantly reduced in the ERAS group compared to the pre-ERAS group. There were significantly fewer medical complications in the ERAS group (p < 0.003). No difference was found between the study groups in the surgical complication rate or in the 30-day or 6-month mortality rate after surgery.

CONCLUSIONS

We found reduced LOS, ICU-LOS, and medical complication rate, but no effect on the surgical complication rate after implementation of the ERAS guidelines, which supports their use in major HNC surgery.

Impact of comorbidities on immediate post-operative complications in oral cavity free flap patients

PURPOSE

To examine the relationship between comorbidities and the development of immediate post-operative complications in patients undergoing oral cavity composite resection (OCCR) with free flap (FF) reconstruction.

MATERIALS AND METHODS

Retrospective analysis was completed on all consecutive OCCRs with FF reconstruction performed at a single quaternary care facility between 1999 and 2020. Comorbidities, immediate post-operative complications, patient demographics, and tumor characteristics were collected. Odds ratios (OR) with 95 % confidence intervals were calculated for associations between comorbidities and immediate post-operative complications.

RESULTS

320 patients who underwent OCCR with FF reconstruction were included. One hundred twenty-one (37.8 %) patients developed a post-operative complication during their initial hospital admission. The most common complications were non-pneumonia cardiopulmonary events (14.1 %), pneumonia (9.4 %), and wound infection (8.4 %). Other complications included flap compromise, bleeding, and fistula. On multivariate analysis, patients without comorbid conditions were less likely to develop a post-operative complication (OR 0.64; 0.41-0.98). Atrial fibrillation (OR 2.94; 1.17-7.39) and cerebrovascular disease (OR 2.28; 1.08-4.84) were associated with increased odds of developing any complications. Furthermore, cerebrovascular disease (OR: 2.33; 1.04-5.39) and peripheral vascular disease (OR: 2.7; 1.2-6.08) were independently associated with pneumonia.

CONCLUSION

In this retrospective review of patients undergoing OCCR with FF reconstruction for oral cavity SCC, lack of identifiable comorbidities appeared to be protective for post-operative complications while atrial fibrillation and cerebrovascular disease were associated with increased odds of any complication. Pre-existing vascular disease was also associated with an increased risk of pneumonia.

Risk factors for evaluating early mortality after microvascular reconstruction of head and neck cancers

BACKGROUND

Free tissue transfer reconstruction carries significant complication rates in surgical head and neck oncology. A registry-based approach offers a possibility to investigate the factors affecting increased morbidity and early mortality, that is, death within 6 months of treatment.

METHODS

A retrospective registry review was conducted on a series of 317 consecutive microvascular free tissue transfers in head and neck cancer patients performed during 2013-2017 at the Helsinki University Hospital (Helsinki, Finland). All surviving patients had a minimum follow-up of 2 years (range 24-84 months).

RESULTS

Overall, 36 (11.4%) early deaths occurred in this series. In multivariable logistic regression analysis, patients aged 75 years and older (p = 0.019), Adult Comorbidity Evaluation-27 (ACE-27) score of 3 (p = 0.048), tumor class T3 (p = 0.005), lymph node class N2 (p = 0.014), or thrombocyte count of 360 (× 10⁹ L) or more (p = 0.001) were more likely to die within 6 months of surgery. Of these 36 patients, 27 (75%) had a complication warranting hospital care and most (n = 22, 61%) had several complications.

CONCLUSIONS

Early postoperative mortality most frequently affects patients aged 75 years and above, with a high ACE-27 score, advanced tumor stage, or high thrombocyte count. Therefore, preoperative assessment and patient selection should have a crucial role in this patient population.

Maxillofacial free flap surgery outcomes in critical care: a single-center investigation looking for clues to improvement

Background

Maxillofacial surgery for free flap reconstructions is associated with many complications due to technical complexity and comorbidity of patients. With a focus on critical care, the authors studied the impact of complications to highlight predictors of poor postoperative outcomes in order to implement optimization protocols.

Methods

This case-control study analyzed the relationship between perioperative variables and postoperative medical and surgical complications of patients who underwent head and neck surgery using fibular and forearm free flaps. The primary objective was the incidence of prolonged intensive care unit (ICU) length of stay (LOS). Secondary objectives were the incidence of ICU readmissions, postoperative infections, and 1-year mortality. A univariable logistic regression model was used. A study of mortality was performed with survival analysis. Regarding our primary objective, we performed a Benjamini-Hochberg procedure and a multivariable Poisson regression with defined variables of interest.

Results

The data of 118 hospital stays were included. Prolonged ICU LOS was observed in 47% of cases and was associated with chronic obstructive pulmonary disease, pneumopathies, intraoperative blood transfusion, and surgical duration. Medical and surgical complications were associated with prolonged ICU LOS. After the Benjamini-Hochberg procedure, infectious complications, complications, major complications, total number of pneumopathies, and operative time remained significant. At least one complication was experienced by 71% of patients during the hospitalization, and 33% of patients suffered from major complications. Infectious complications were the most common (40% of patients) and were mainly caused by pneumonia (25% of patients); these complications were associated with low preoperative hemoglobin level, intraoperative blood transfusion, accumulation of reversible cardiovascular risk factors, chronic alcohol consumption, and duration of surgery. Pneumonia was specifically associated with chronic obstructive pulmonary disease. The ICU readmission rate was 10% and was associated with lower preoperative hemoglobin level, pneumopathies, surgical duration, and use of a fibular flap. The 1-year mortality was 12%, and the survival analysis showed no association with prolonged ICU LOS. Poisson regression showed that ICU LOS was prolonged by smoking history, lower preoperative hemoglobin level, intraoperative blood transfusion, major complication, and pneumopathies.

Conclusions

Practices such as blood management and respiratory prehabilitation could be beneficial and should be evaluated as a part of global improvement strategies.

Mortality Within 30 Days After Head and Neck Free Flap Reconstruction: A Systematic Review

OBJECTIVE

The aim of this systematic review is to analyze the 30-day postoperative mortality in patients undergoing free flap reconstruction for head and neck cancer published in literature and to identify associated factors.

METHODS

The authors performed a literature search between January 1950 and February 2020 in PubMed, EMBASE, and Scopus, using a combination of Medical Subject Headings headings and text keywords related to head and neck cancer; microsurgery or free flap reconstruction; and 30-day mortality. Inclusion criteria were: original studies in English reporting on 30-day mortality after head and neck free flap reconstruction in adult population.

RESULTS

Thirty-one publications reported on a total of 13,447 patients who underwent head and neck free flap reconstruction. The published 30-day postoperative mortality ranged from 0% to 6.3%, with an average of 1.21%. A number of studies examined the association between mortality and body mass index, American Society of Anesthesiologists, and comorbidity score and age. One study found that underweight patients had significantly higher mortality. Two studies found no association between the American Society of Anesthesiologists score and 30-day postoperative mortality; however, 1 study reported significantly higher mortality with increased comorbidity score. Regarding association with age, 3 studies found significant higher mortality in older patients, while 5 studies found no difference.

CONCLUSIONS

The average 30-day postoperative mortality in patients undergoing head and neck free flap reconstruction is 1.21% and is; therefore, not negligible. Careful patient selection and preoperative optimization are essential in order to reduce mortality in head neck free flap reconstruction.

Applying the British Association of Oral and Maxillofacial Surgeons quality outcomes metrics to a UK oncology and reconstructive surgery service - benchmarking the data

The British Association of Oral and Maxillofacial Surgery is soon to implement the Quality Outcomes in Oral in Maxillofacial Surgery (QOMS) to provide a platform for quality management across the specialty in the UK. The initial oncology and reconstruction audits for QOMS involves data collection on specific procedures and metrics. The aim of this report is to determine their appropriateness using extant audit datasets in our institution that overlap substantially with the QOMS audits. Pre-existing datasets comprising information on patients treated for oral cavity SCC with curative intent were analysed. Data on surgical margins, lymphadenectomy lymph node yield, delay between surgery and adjuvant radiotherapy, duration of hospital stay, and complications including flap failures were analysed. All statistical analyses were performed with SPSS 25. Run charts describing longitudinal data were generated using SPC for Excel version 6. Twenty three patients (3.1%) of 701 resections had a positive surgical margin reported. Seventeen (4.3%) of patients had less than 18 LNs in the ND specimen analysed. Mean time to start date of adjuvant therapy was 62 days. Only 9% of patients commenced adjuvant therapy within 6 weeks. The median duration of stay was 18 days. In 1153 free flaps a failure rate of 4.3% was identified. A total of 1349 complications (CD I-V) were recorded in the 1111 patients undergoing major surgery with free flap reconstruction. The QOMS selected metrics for oncology and reconstruction are clinically relevant, readily measurable, and likely to be actionable by the surgical team.

Impact of Early Mobilization on Recovery after Major Head and Neck Surgery with Free Flap Reconstruction

Simple Summary

For patients diagnosed with head and neck cancer (HNC), surgery to remove the tumour is a standard treatment. The surgery is complex-in most cases, the mouth and throat need to be rebuilt using tissue from another area of the body to restore appearance and function. Recovery from HNC surgery is challenging, and complications occur frequently. It is recommended that patients get out of bed and move (are “mobilized”) as early as possible after surgery (within 24 h) to improve recovery. However, evidence for this recommendation mainly comes from other types of cancer. Therefore, this study investigated whether early mobilization impacts recovery in patients undergoing HNC surgery. We found that delaying mobilization (after 24 h) was linked with more complications and a longer stay in the hospital. Helping patients mobilize within 24 h after HNC surgery should be a priority for healthcare teams.

Abstract

Surgery with free flap reconstruction is a standard treatment for head and neck cancer (HNC). Because of the complexity of HNC surgery, recovery can be challenging, and complications are common. One of the foundations of enhanced recovery after surgery (ERAS) is early postoperative mobilization. The ERAS guidelines for HNC surgery with free flap reconstruction recommend mobilization within 24 h. This is based mainly on evidence from other surgical disciplines, and the extent to which mobilization within 24 h improves recovery after HNC surgery has not been explored. This retrospective analysis included 445 patients from the Calgary Head and Neck Enhanced Recovery Program. Mobilization after 24 h was associated with more complications of any type (OR = 1.73, 95% CI [confidence interval] = 1.16–2.57) and more major complications (OR = 1.76; 95% CI = 1.00–3.16). When accounting for patient and clinical factors, mobilization after 48 h was a significant predictor of major complications (OR = 2.61; 95% CI = 1.10–6.21) and prolonged length of stay (>10 days; OR = 2.85, 95% CI = 1.41–5.76). This comprehensive analysis of the impact of early mobilization on postoperative complications and length of stay in a large HNC cohort provides novel evidence supporting adherence to the ERAS early mobilization recommendations. Early mobilization should be a priority for patients undergoing HNC surgery with free flap reconstruction.

Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies

Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients.

METHODS

Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient's reconstructive journey.

RESULTS

Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest.

CONCLUSION

The authors reflect on the causes and propose preventative strategies in each peri-operative stage.

Microvascular reconstruction for maxillofacial defects: a retrospective analysis of outcomes and complications in 121 consecutive cases

Background

Microvascular reconstruction is the treatment of choice after oral cancer ablation surgery. There are few published studies of free flap survival among Korean populations. This study aimed to determine the survival rate after 121 consecutive cases of maxillofacial microvascular reconstruction and to analyze the complications associated with microsurgery.

Methods

This study included consecutive patients who underwent microsurgical reconstruction with free flaps, from January 2006 through September 2019, performed by a single surgeon at the oral and maxillofacial surgery department of a tertiary medical center. A total of 121 cases were reviewed retrospectively. The flap survival rate, flap type, radiotherapy history, complications, and treatment results were analyzed.

Results

Four different flap types were used for microvascular reconstruction: radial forearm (n = 65), fibula (n = 34), latissimus dorsi (n = 21), and serratus anterior muscle with rib bone free flap (n = 1). Total necrosis of the flap was found in four cases (two latissimus dorsi flaps and two fibular flaps). The free flap survival rate was 97.5%. Nineteen patients received radiotherapy before surgery, and none of them experienced flap failure. The mean operation time was 334 ± 83.1 min, and the mean ischemic time was 48.9 ± 12.7 min.

Conclusions

The success rate was reliable and comparable with previous studies. The success rate was not affected by radiation therapy. Free flaps can be safely used even after radiation treatment.

Complications and outcome after free flap surgery for cancer of the head and neck

We retrospectively studied 136 patients who had free flap reconstruction for cancer of the head and neck at a single centre (2008-2015) to evaluate complications, assess factors associated with them, and analyse their impact on outcome. Preoperative and perioperative data, and surgical and medical complications were recorded, and the impact of the complications on duration of hospital stay and survival were assessed. A total of 86 (63%) patients had complications. Compared with those who did not, they had a higher rate of alcohol abuse (21/86, compared with 5/50, p=0.039), longer operations (median (IQR) 565 (458-653 compared with 479 (418-556) minutes, p<0.001), and greater intraoperative loss of blood (725 (400-1150) compared with 525 (300-800) ml, p=0.042). Complications were more common in patients who had fibular flaps and T4 disease (22/86 compared with 4/50, p=0.010; 47/80 compared with 16/47, p=0.015, respectively). Those who had complications also stayed in hospital longer (median (IQR) 9 (7-12) compared with 15 (10-21) days, p<0.001). Cumulative mortality was higher in patients with late complications (those that occurred after the fourth postoperative day) (61% compared with 36%, p=0.004). In conclusion, complications in more than half the patients were related to alcohol abuse, a more complicated intraoperative course, and fibular flaps. Complications were associated with a longer hospital stay, and survival was higher in those who did not have late complications than in those who did.

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

IMPORTANCE

Postoperative complications after head and neck surgery carry the potential for significant morbidity. Estimating the risk of complications in an individual patient is challenging.

OBJECTIVE

To develop a statistical tool capable of predicting an individual patient's risk of developing a major complication after surgery for oral cavity squamous cell carcinoma.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective case series derived from an institutional clinical oncologic database, augmented by medical record abstraction, at an academic tertiary care cancer center. Participants were 506 previously untreated adult patients with biopsy-proven oral cavity squamous cell carcinoma who underwent surgery between January 1, 2007, and December 31, 2012.

MAIN OUTCOMES AND MEASURES

The primary end point was a major postoperative complication requiring invasive intervention (Clavien-Dindo classification grades III-V). Patients treated between January 1, 2007, and December 31, 2008 (354 of 506 [70.0%]) comprised the modeling cohort and were used to develop a nomogram to predict the risk of developing the primary end point. Univariable analysis and correlation analysis were used to prescreen 36 potential predictors for incorporation in the subsequent multivariable logistic regression analysis. The variables with the highest predictive value were identified with the step-down model reduction method and included in the nomogram. Patients treated between January 1, 2007, and December 31, 2008 (152 of 506 [30.0%]) were used to validate the nomogram.

RESULTS

Clinical characteristics were similar between the 2 cohorts for most comparisons. Thirty-six patients in the modeling cohort (10.2%) and 16 patients in the validation cohort (10.5%) developed a major postoperative complication. The 6 preoperative variables with the highest individual predictive value were incorporated within the nomogram, including body mass index, comorbidity status, preoperative white blood cell count, preoperative hematocrit, planned neck dissection, and planned tracheotomy. The nomogram predicted a major complication with a validated concordance index of 0.79. Inclusion of surgical operative variables in the nomogram maintained predictive accuracy (concordance index, 0.77).

CONCLUSIONS AND RELEVANCE

A statistical tool was developed that accurately estimates an individual patient's risk of developing a major complication after surgery for oral cavity squamous cell carcinoma.

Usefulness of serum C-reactive protein level for predicting flap complication after performing free microvascular head and neck reconstruction

BACKGROUND

Free microvascular head and neck reconstruction requires minimal complication and safety. However, clinical observation of the wound in head and neck area is very difficult because of its narrow and inaccessible anatomy. Serum C-reactive protein (CRP) level is commonly used as a marker of acute inflammatory response and quantitative test that shows predictable kinetics. Therefore, awareness of natural CRP trend of free microvascular head and neck reconstruction may help in the early diagnosis of postoperative complications. The goal of this study is to describe the time course of serum CRP level and prove the usefulness of CRP as a predictor of postoperative flap wound complication after performing free microvascular reconstruction in head and neck area.

METHODS

Between June 2009 and November 2012, we retrospectively analyzed the data of 25 patients who received free microvascular tissue transfer for head and neck reconstruction at Ajou University Hospital. The characteristics of patients and surgical information were analyzed. From the first day after surgery, CRP levels were daily measured for 2 weeks. The average CRP values were daily calculated for the normal group and the complicated group and compared between each groups. The amount of time taken to reach the peak CRP level and to reach half of the peak was compared.

RESULTS

A total of 25 patients were included in this study. The amount of time taken to reach the peak of the CRP level is significantly less in the normal group (2.9 d) than the complicated group (7 d) (P < 0.001). Furthermore, the amount of time to reach half of the peak was significantly different between groups (7.2 d vs. 10.1 d, respectively, P < 0.05). In the normal group (17/25), there were 14 cases which reached peak CRP level before postoperative day 4. However, in the complicated group (8/25), there was only 1 case which reached peak CRP level before postoperative day 4 (P < 0.05). The complication rate is 32.7 times higher when CRP value reaches peak on or after postoperative day 4 (95% confidence interval, 30.26-35.14; P = 0.002). Patients in the complicated group showed significantly elevated CRP levels compared to those in the normal group at day 6 to 9 and day 12 to 13 (P < 0.05).

CONCLUSION

In head and neck reconstructions, the high probability of flap wound complications are indicated through the result of having highest CRP values on or after postoperative day 4, slow normalization of plasma CRP level, and secondary rise in serial CRP values.