Effect of prior radiotherapy on postsurgical wound infection

Shoulder arthroplasty after prior external beam radiation therapy: a matched cohort analysis

BACKGROUND

External beam radiation therapy (XRT) is a commonly used therapeutic modality for the treatment of various chest wall and axillary malignancies. Despite the known risk of local soft tissue dysfunction, and possibly compromised bone ingrowth for cementless implants, there remains limited data on the impact of prior XRT in a shoulder arthroplasty (SA) cohort. This study evaluated the outcomes of primary SA in patients with prior XRT compared to a matched cohort (MC).

METHODS

Over a 27-year time period (1993-2020), 80 primary SAs (7 hemiarthroplasties [HAs], 29 anatomic total shoulder arthroplasties [aTSAs], and 44 reverse shoulder arthroplasties [rTSAs]) with previous XRT to the upper chest or axillary region and a minimum of 2-year follow-up were included. This cohort was matched (1:2) according to age, sex, body mass index (BMI), implant, and year of surgery with patients who had undergone HA or TSA for osteoarthritis or RSA for cuff tear arthropathy. Clinical outcomes including pain, active shoulder range of motion (ROM), strength, complications, and reoperations inclusive of revision surgery were assessed.

RESULTS

The XRT cohort consisted of 71 (88.8%) women with a mean age of 70.9 (range, 43-87) years, BMI of 30.9 ± 7.6, and follow-up period of 6.6 years (range, 2.0-28.2). In these patients, SA led to substantial improvements in pain, ROM, and strength across the entire cohort. When compared to the MC, the XRT group demonstrated a lower final postoperative forward elevation (FE) (111° vs. 126°; P = .013) and less improvements in pain (5.3 vs. 6.2; P = .002), FE (34° vs. 54°; P = .002), and external rotation (13° vs. 24°; P < .001). There were 14 (17.5%) complications and 7 reoperations in the XRT group, with rotator cuff failure after HA or TSA (n = 4 of 36; 11.1%) as the most common complication and no instances of loose humeral components. The XRT group had a higher rate of complications (17.5% vs. 8.1%; P = .03) but not reoperations (8.8% vs. 3.1%; P = .059). When evaluated by implant, rTSA demonstrated the lowest rate of reoperations followed by aTSA and HA (2.3% vs. 10.3% vs. 42.9%; P = .002).

CONCLUSIONS

Primary SA is an effective treatment modality for the improvement of pain, motion, and strength in patients with a history of prior XRT. However, when compared to patients without prior XRT, less clinical improvement and a higher rate of postoperative complications were observed.

The impact of external beam radiation therapy on shoulder surgical outcomes: a case series study

HYPOTHESIS

External beam radiation therapy (XRT) is a commonly used treatment adjunct in patients with breast cancer and is known to cause soft tissue dysfunction. However, data on XRT as a preoperative risk factor for shoulder surgery is limited. The purpose of this study was to assess whether prior history of breast cancer treated with XRT has an impact on surgical complications or outcomes. We hypothesize that patients treated with XRT will have a higher rate of surgical complications and lower outcomes.

METHODS

A 20-year retrospective chart review across a large, academic health care system was performed. Inclusion criterion comprised any patient with history of breast cancer of the upper-outer or axillary region treated with XRT. Patients also must have undergone a surgical procedure to the ipsilateral shoulder with at least 1-year postoperative follow-up. Patients were stratified by demographics, hand dominance, and surgery type. Postoperative outcomes including range of motion (ROM) and visual analog scale (VAS) scores for pain were also collected.

RESULTS

Eighteen patients were identified (100% female) with an average age of 66.3 years (standard deviation 10.5 years). Ten shoulders underwent rotator cuff repair (RCR), 4 total shoulder arthroplasty (TSA), 3 reverse shoulder arthroplasty (RSA), and 1 arthroscopic superior labrum anterior to posterior (SLAP) repair. Four patients treated with RCR (40%) experienced postoperative complications related to their procedure. These included scapular winging, adhesive capsulitis, stiffness, and one retear. Two patients treated with shoulder arthroplasty (28.6%) experienced postoperative complications that included lymphedema and periprosthetic fracture following a mechanical fall in one RSA patient and periprosthetic infection in a TSA patient. ROM across all groups improved, most significantly in forward flexion and internal rotation among RCR patients (P < .001). Furthermore, a statistically significant improvement in VAS scores was achieved in each group (6.2 ± 2.14 preoperation, 1.06 ± 1.75 postoperation; P < .001).

CONCLUSION

When compared to national averages, complication rates in our cohort were higher (40% vs. 10%-17% in RCR patients and 28.6% vs. 4%-14% in arthroplasty patients). On further scrutiny, many of these complications were independent of a history of XRT and many resolved with appropriate therapy. Most importantly, functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT. Thus, our results suggest that performing shoulder surgery after ipsilateral XRT for breast cancer is likely safe and may offer improved pain and ROM compared to forgoing surgery without necessarily increasing the risk for postoperative complication.

Influence of Preoperative Radiation Therapy on the Occurrence of Pharyngocutaneous Fistula After Total Laryngectomy

Introduction

Chemo-radiotherapy (CRT) has increasingly been employed for the treatment of laryngeal cancer at T3 or higher rather than total laryngectomy (TL), in order to preserve the larynx. However, TL is still frequently performed in patients with advanced laryngeal cancer, especially T4 disease. When CRT is performed for advanced cancer, there is a certain rate of residual disease or relapse, and TL is conducted as salvage surgery for those patients, but TL following CRT is associated with a high incidence of postoperative complications.

Objective

The purpose of this study was to investigate the influence of preoperative radiation therapy on the occurrence of postoperative complications of TL, particularly pharyngocutaneous fistula (PCF).

Methods

We retrospectively investigated 142 patients who underwent TL for laryngeal cancer whether postoperative complications were related to a history of radiation therapy or neck dissection. Detailed investigation of the 32 patients who underwent radiation therapy was also conducted.

Results

PCF was significantly higher after radiation therapy. Neck dissection was not related. As the time from radiation therapy to TL decreased, the incidence rate of postoperative PCF increased and the time to closure became significantly longer. Preoperative laboratory tests did not show a significant difference in Hb and Alb, but the lymphocyte count was significantly lower in patients with PCF.

Multiple Free Flap Reconstructions of Head and Neck Defects Due to Oral Cancer

Objective:

We studied complications following multiple free flap reconstructions in the head and neck.

Methods:

In this cohort, 26 patients (14 men and 12 women) who underwent multiple microvascular free flap reconstructions were included in the study. The reasons for secondary reconstruction were recurrence of tumor (12 cases), necrosis of transferred skin and/or bone (6 cases), reconstruction plate fracture or exposure (4 cases), and others (4 cases). A third reconstruction in 4 cases and a fourth reconstruction in 1 case were performed.

Results:

No flap necrosis occurred. Postsurgical infections occurred at only secondary reconstructions in 7 patients. Although 4 cases with a history of external radiation therapy were anastomosed at contralateral side, those 4 cases suffered from severe pre-and postsurgical infection of the ipsilateral side. Postsurgical infection occurred in 2 cases with anastomoses at the ipsilateral side of the neck and required drainage after secondary surgery.

Conclusions:

A history of external radiation therapy and the existence of severe preoperative infection affected complications after multiple reconstructions.

Predictors of wound complications after laryngectomy: A study of over 2000 patients

OBJECTIVES: To identify risk factors for and the rate of wound complications after laryngectomy in a large, prospectively collected national dataset, and to generate a predictive model.

STUDY DESIGN: We used the National Surgical Quality Improvement Program (NSQIP) registry created by the Department of Veterans Affairs (VA) to identify patients undergoing total laryngectomy from 1989 to 1999 (n = 2063). We linked these data to inpatient and outpatient VA administrative records to capture data for prior radiation. Over 20 preoperative and intraoperative risk factors were analyzed using bivariate techniques. Those significant at the P < 0.01 level were analyzed with logistic regression and conjunctive consolidation to identify independent predictors of wound complications.

RESULTS: The overall wound complication rate was 10.0%. In adjusted analyses, prolonged operative time (> 10 hours, odds ratio = 2.10, 95% confidence interval: 1.32-3.36), exposure to prior radiation therapy (OR =1.63, 1.07-2.46), presence of diabetes (OR = 1.78, 1.04-3.04), preoperative hypoalbumine-mia (OR =1.90, 1.32-2.74), anemia (OR =1.59, 1.07-2.36), and thrombocytosis (OR =1.48, 1.04-2.10) were independently associated with postoperative wound complications. A prognostic model using three variables—prior radiation therapy, diabetes, and hypoalbuminemia—provided excellent risk stratification into three tiers (6.3%, 13.7%, 21.7%).

CONCLUSIONS: Preoperative radiation, prolonged operative time, low albumin, and diabetes were independently associated with postoperative wound infections. These results will help to identify patients at risk for wound complications, thus allowing for heightened surveillance and preventive measures where possible.

A cemented acetabular component with a reinforcement cross provides excellent medium-term fixation in total hip arthroplasty after pelvic irradiation

Conventional cemented acetabular components are reported to have a high rate of failure when implanted into previously irradiated bone. We recommend the use of a cemented reconstruction with the addition of an acetabular reinforcement cross to improve fixation.

We reviewed a cohort of 45 patients (49 hips) who had undergone irradiation of the pelvis and a cemented total hip arthroplasty (THA) with an acetabular reinforcement cross. All hips had received a minimum dose of 30 Gray (Gy) to treat a primary nearby tumour or metastasis. The median dose of radiation was 50 Gy (Q1 to Q3: 45 to 60; mean: 49.57, 32 to 72).

The mean follow-up after THA was 51 months (17 to 137). The cumulative probability of revision of the acetabular component for a mechanical reason was 0% (0 to 0%) at 24 months, 2.9% (0.2 to 13.3%) at 60 months and 2.9% (0.2% to 13.3%) at 120 months, respectively. One hip was revised for mechanical failure and three for infection.

Cemented acetabular components with a reinforcement cross provide good medium-term fixation after pelvic irradiation. These patients are at a higher risk of developing infection of their THA.

Cite this article: Bone Joint J 2015;97-B:177–84.

Utility of the gastro-omental free flap in head and neck reconstruction

PURPOSE OF REVIEW

In the current era of organ-preservation therapies, surgical salvage and reconstruction of defects following ablation of mucosa and soft tissue in the head and neck is extremely challenging because of the toxic effects of chemoradiation and intensive radiotherapy on wounds. The anatomical, physiological and immunological properties of the gastro-omental flap make it an ideal reconstructive technique in head and neck surgery.

RECENT FINDINGS

Several case series published in the past 12 months highlight the utility of this flap in inhospitable wounds and particularly in restoration of circumferential pharyngeal defects. The gastro-omental flap produces satisfactory functional results and morbidity in this group of high-risk patients.

SUMMARY

The gastro-omental free flap provides an alternative to traditional reconstructive techniques that is ideally suited to high-risk complex wounds in the head and neck.

Risk factors for surgical-site infections in head and neck cancer surgery

OBJECTIVE

The aim of this study was to identify risk factors for surgical-site infections (SSIs) in patients with head and neck cancer submitted to major clean-contaminated surgery.

STUDY DESIGN

This is a prospective study conducted in a tertiary cancer center hospital.

SUBJECTS AND METHODS

This study includes 258 patients submitted to a major clean-contaminated head and neck oncologic surgery.

RESULTS

The overall SSI rate was 38.8%. The univariate analysis showed the following significant risk factors: race, tobacco consumption, clinical stage, comorbidities, time duration of the surgical procedure, and flap reconstruction. The final model by logistic regression identified the following independent predictors for SSI: tobacco consumption (odds ratio [OR] = 2.96), presence of metastatic lymph nodes (OR = 2.05), flap reconstruction (OR = 2.20), and antimicrobial prophylaxis exceeding 48 hours (OR=1.89).

CONCLUSION

The high-risk patients for SSI in head and neck oncologic surgery were those with cancer at advanced stages, those who were smokers, those presenting comorbidities, those who needed major reconstruction of the surgical wound, or those who were submitted to inadequate antibiotic prophylaxis.

Multivariate analysis of risk factors for wound infection in head and neck squamous cell carcinoma surgery with opening of mucosa. Study of 260 surgical procedures

The goal of this prospective study was to determine risk factors for wound infections (WI) for patients with head and neck cancer who had undergone surgical procedures with opening of upper aerodigestive tract mucosa in multimodal therapeutic approaches. Two hundred and sixty consecutive surgical procedures were studied at Oscar Lambret Cancer Center over a 36-month period. Twenty-five variables were recorded for each patient. Statistical evaluation used chi2 test analysis (categorical data) and Mann-Whitney test (continuous variables). Multivariate analysis was performed with logistic regression model. The overall rate of WI was 45% (117/260). Univariate analysis indicated that five variables were significantly related to the likelihood of WI: male sex (p = 0.03), previous chemotherapy (p = 0.009), duration of previous hospital stay (p = 0.013), hypopharyngeal location (p = 0.003), post-laryngectomy tracheostoma (p < 0.001). Multivariate analysis identified only one major risk factor for WI: post-laryngectomy tracheostoma (Odd Ratio 1.9 [95% CI 1.3-3]; 33% versus 64%; p = 0.001). Despite antibiotic prophylaxis, WI occurrence is high. This study identified one major risk factor, post-laryngectomy tracheostomy. Long-term curative antibiotherapy must be evaluated in cancer head and neck surgery requiring post-laryngectomy tracheostoma.

Prevention and treatment of postsurgical head and neck infections

Postoperative wound infection is an important cause of postsurgical morbidity. Efforts to reduce the incidence of wound infection are enhanced through appropriate preoperative preparation, adherence to excellent surgical technique, and the provision of outstanding postoperative care. Many head and neck surgical procedures are undertaken in an environment contaminated by saliva containing a large inoculum of potentially pathogenic bacteria. Prospective randomized clinical trials have demonstrated that perioperative antibiotic prophylaxis reduces the risk for postoperative wound infection. Effective antibiotic prophylaxis requires that the antibiotic be effective against normal oral flora. Antibiotics should be administered before wound contamination. The dose of the antibiotic should exceed the minimal inhibitory concentration needed for the normal flora. The antibiotic administration can cease within 24 hours of surgery.

Risk factors for wound infection in head and neck cancer surgery: A prospective study

BACKGROUND

The goal of this prospective study is to determine risk factors for wound infections (WI) for patients with head and neck cancer who underwent surgical procedure with opening of upper aerodigestive tract mucosa.

METHODS

One hundred sixty-five consecutive surgical procedures were studied at Oscar Lambret Cancer Center within a 24-month interval. Twenty-five variables were recorded for each patient. Statistical evaluation used Chi2 test analysis (categorical data) and Mann-Whitney test (continuous variables).

RESULTS

The overall rate of WI was 41.8%. Univariate analysis indicated that five variables were significantly related to the likelihood of WI: tumor stage (p =.044), previous chemotherapy (p =.008), duration of preoperative hospital stay (p = 022), permanent tracheostomy (p =.00008), and hypopharyngeal and laryngeal cancers (p =.008).

CONCLUSIONS

Despite antibiotic prophylaxis, WI occurrence is high. These data inform the head and neck surgeon, when a patient is at risk for WI and may help to design future prospective studies.

Limitações da viabilidade do retalho miocutâneo de músculo grande peitoral em cabeça e pescoço: estudo de 72 casos

O emprego do retalho miocutâneo do músculo peitoral maior é rotina nos procedimentos reconstrutivos no tratamento das neoplasias das vias aerodigestivas superiores nos estádios III e IV. Assim, no Serviço de Cirurgia de Cabeça e Pescoço do Hospital Heliópolis, de 1983 a 1994, a utilização deste retalho foi necessária em 66 pacientes portadores de carcinoma epidermóide e em seis com outras neoplasias malignas. Quanto à localização, as lesões acometiam a cavidade oral em trinta pacientes (41,6%), a hipofaringe em 16 pacientes (22,2%), tegumentos em 13 pacientes (18,0%), a orofaringe em dez pacientes (13,8), a laringe em dois pacientes (2,7%), a rinofaringe em um paciente (1,3%). Para a reconstrução foram empregados 72 retalhos, sendo que em 49 casos (68,0%) ocorreram complicações, enquanto que, em 23 pacientes, houve evolução sem a ocorrência das mesmas. Do grupo de pacientes que evoluíram com complicações, em 45 deles (91,2%) não houve necessidade de procedimentos complementares. Quanto às complicações, tivemos 18 necroses parciais (27,2%), 34 deiscências parciais (51,5%), 28 fístulas (42,4%), 34 infecções (51,5%) e dois hematomas (3,0%), sendo na grande maioria dos casos concomitantes (X2 = 20; p=0,22). Quanto aos 49 pacientes que apresentaram complicações, três eram portadores de neoplasias malignas do estádio clínico III e 46 do estádio IV (x2=2; p=0,15), sendo que, em 70,6% dos casos, o tratamento radioterápico já havia sido indicado previamente (Teste de Fisher: p=0,0785). Concluem os autores que, como fatores de risco para o aparecimento de complicações, os níveis séricos de a1bumina abaixo de 3,5g% e hemoglobina 12mg% foram aqueles com significado estatístico (respectivamente p=0,0048 e 0,0037).

Timing of edentulation and extraction in the management of oral cavity and oropharyngeal malignancies

BACKGROUND

Pretreatment dental evaluation is an essential element in the management of the head and neck cancer patient. Frequently, the dental condition requires edentulation or multiple extractions prior to radiotherapy. These extractions may be carried out at the time of oncologic resection. Such practice is routine for some surgeons but resisted by others who fear increased postoperative wound complications. To date, no study evaluating the safety and efficacy of extractions at the time of surgical resection has been reported. This paper retrospectively examines the postoperative course of head and neck cancer patients with varying strategies of dental management.

METHODS

Retrospective analysis of patients with surgically treated oral cavity or oropharyngeal malignancies and dental extractions or edentulation at a tertiary oncology center from 1985 to 1994 was made. Postoperative wound infection, fistula, and length of stay data were compared for patients undergoing concurrent extraction and those having dental extractions in the postoperative period.

RESULTS

Thirty-two patients underwent ablative resection with concurrent extraction, whereas 23 had postsurgical extractions. The infection and fistula rates were 16% and 9% in the concurrent group and 35% and 26% for patients having postsurgical extractions. Mean postoperative stays were significantly shorter for patients undergoing concurrent extraction (15 +/- 8 days) compared with those of the postsurgical group (27 +/- 14 days).

CONCLUSIONS

Patients whose extractions were performed concurrent with the oncologic resection experienced fewer postoperative wound complications and had significantly shorter postoperative hospitalizations than did the postsurgical group.

Short-term versus long-term antimicrobial prophylaxis in oncologic head and neck surgery

BACKGROUND

Although antimicrobial prophylaxis is mandatory in major clean-contaminated oncologic surgery of the head and neck, both the choice of specific antimicrobial compounds and the treatment duration are still discussed.

METHODS

A prospective, randomized trial was carried out to compare efficacy and tolerability of clindamycin-cefonicid administered for 1 day versus 3 days in reducing the rate of wound and systemic infections. The following potential risk factors for surgical wound infection were evaluated: type of surgery, stage of disease, preoperative tracheostomy, preoperative radiotherapy, and diabetes mellitus.

RESULTS

One-hundred sixty-two patients were evaluable; 81 received 1-day chemoprophylaxis, while the remaining 81 were treated according to the 3-day schedule. During the first 20 days after surgery, wound infections occurred in 2 (2.5%) and 3(3.7%) patients, respectively, in the 1-day and 3-day treatment groups, so that no significant difference was found among the two evaluated chemoprophylaxis schedules.

CONCLUSION

A 3-day schedule did not prove useful in preventing wound and systemic infections. All presumed risk factors were not associated with an increased rate of wound infections, although preoperative radiotherapy was associated with a greater severity of infections and a higher risk of late wound complications.

Clindamycin/cefonicid in head and neck oncologic surgery: one-day prophylaxis is as effective as a three-day schedule

The aim of our study was to evaluate the optimal duration of antibiotic prophylaxis in major oncologic surgery of the head and neck using a novel broad spectrum drug combination: clindamycin and cefonicid. A prospective randomized study was carried out on 126 evaluable patients undergoing clean-contaminated (skin to mucosa) surgery for cancer of larynx, pharynx or oral cavity. Cases at high surgical risk (because of need of pedicled or microvascular free flaps reconstruction), were excluded from the study. Within 20 days after surgery, only one case of wound infection was recorded among the 62 patients treated with the one-day schedule, versus three cases registered among the 64 subjects receiving three-day chemoprophylaxis. Episodes of systemic infections and eventual wound complications occurring in the first 20 days after surgery have also been recorded. The role of potential risk factors for postoperative complications has been evaluated. According to our findings, a three-day antibiotic regimen is not more effective than a short-term (one-day) schedule in preventing wound or systemic infection in clean-contaminated head and neck cancer surgery without flap reconstruction.

Risk factors for complications in clean-contaminated head and neck surgical procedures

BACKGROUND

Contamination of a head and neck surgical wound with oropharyngeal secretions has been shown to dramatically increase the incidence of wound complications. Appropriate perioperative antibiotic prophylaxis has significantly reduced contaminated wound infection rates in several previous reports. The current study examined multiple patient parameters to determine risk factors for all perioperative complications following clean-contaminated head and neck surgical procedures.

METHODS

Retrospective review of medical records from 159 patients who underwent clean-contaminated major head and neck surgical procedures at the University of Washington between 1985 and 1991. More than 30 preoperative and operative parameters were evaluated, and all complications were recorded. The data were examined using a multivariate statistical analysis.

RESULTS

An overall complication rate of 63% included 22% with wound infections (oro/pharyngocutaneous fistula or purulent drainage), 22% with other types of infections, and 51% with noninfectious complications. The overall perioperative mortality rate was 1.2% (two patients). Prior radiotherapy, operative time, perioperative transfusion, and flap reconstruction were all associated with a significantly higher overall complication rate (p < or = 0.05). Only prior radiotherapy therapy correlated with an increase in wound infection rate (p = 0.05).

CONCLUSIONS

Prior radiotherapy significantly increases the risk of perioperative complications and wound infections following clean-contaminated head and neck surgical procedures. Other factors reflecting the complexity of the procedure also influence the overall complication rate.