1
|
Gardiner L, Smith B, Kubik M, Solari M, Smith K, de Almeida JR, Sridharan S. Long-term outcomes in virtual surgical planning for mandibular reconstruction: A cost-effectiveness analysis. Microsurgery 2024; 44:e31206. [PMID: 38943374 DOI: 10.1002/micr.31206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 05/02/2024] [Accepted: 06/07/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVE This study is an economic evaluation comparing virtual surgical planning (VSP) utilization to free hand mandibular reconstruction (FHR) for advanced oral cavity cancer, for which the cost effectiveness remains poorly understood. The proposed clinical benefits of VSP must be weighed against the additional upfront costs. METHODS A Markov decision analysis model was created for VSP and FHR based on literature review and institutional data over a 35-year time horizon. Model parameters were derived and averaged from systematic review and institutional experience. VSP cost and surgical time saving was incorporated. We accounted for long-term risks including cancer recurrence and hardware failure/exposure. We calculated cost in US dollars and effectiveness in quality-adjusted-life-years (QALYs). A health care perspective was adopted, discounting costs and effectiveness at 3%/year. Deterministic and probabilistic sensitivity analyses tested model robustness. RESULTS In the base case scenario, total VSP strategy cost was $49,498 with 8.37 QALYs gained while FHR cost was $42,478 with 8.27 QALY gained. An incremental cost-effectiveness ratio (ICER), or the difference in cost/difference in effectiveness, for VSP was calculated at $68,382/QALY gained. VSP strategy favorability was sensitive to variations of patient age at diagnosis and institutional VSP cost with one-way sensitivity analysis. VSP was less economically favorable for patients >75.5 years of age or for institutional VSP costs >$10,745. In a probabilistic sensitivity analysis, 55% of iterations demonstrated an ICER value below a $100,000/QALY threshold. CONCLUSIONS/RELEVANCE VSP is economically favorable compared to FHR in patients requiring mandibular reconstruction for advanced oral cancer, but these results are sensitive to the patient's age at diagnosis and the institutional VSP cost. Our results do not suggest if one "should or should not" use VSP, rather, emphasizes the need for patient selection regarding which patients would most benefit from VSP when evaluating quality of life and long-term complications. Further studies are necessary to demonstrate improved long-term risk for hardware failure/exposure in VSP compared to FHR.
Collapse
Affiliation(s)
- Lauren Gardiner
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brandon Smith
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark Kubik
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mario Solari
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kenneth Smith
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John R de Almeida
- Department of Otolaryngology-Head Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
2
|
Pachyn E, Aumiller M, Freymüller C, Linek M, Volgger V, Buchner A, Rühm A, Sroka R. Investigation on the influence of the skin tone on hyperspectral imaging for free flap surgery. Sci Rep 2024; 14:13979. [PMID: 38886457 PMCID: PMC11183063 DOI: 10.1038/s41598-024-64549-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024] Open
Abstract
Hyperspectral imaging (HSI) is a new emerging modality useful for the noncontact assessment of free flap perfusion. This measurement technique relies on the optical properties within the tissue. Since the optical properties of hemoglobin (Hb) and melanin overlap, the results of the perfusion assessment and other tissue-specific parameters are likely to be distorted by the melanin, especially at higher melanin concentrations. Many spectroscopic devices have been shown to struggle with a melanin related bias, which results in a clinical need to improve non-invasive perfusion assessment, especially for a more pigmented population. This study investigated the influence of skin tones on tissue indices measurements using HSI. In addition, other factors that might affect HSI, such as age, body mass index (BMI), sex or smoking habits, were also considered. Therefore, a prospective feasibility study was conducted, including 101 volunteers from whom tissue indices measurements were performed on 16 different body sites. Skin tone classification was performed using the Fitzpatrick skin type classification questionnaire, and the individual typology angle (ITA) acquired from the RGB images was calculated simultaneously with the measurements. Tissue indices provided by the used HSI-device were correlated to the possible influencing factors. The results show that a dark skin tone and, therefore, higher levels of pigmentation influence the HSI-derived tissue indices. In addition, possible physiological factors influencing the HSI-measurements were found. In conclusion, the HSI-based tissue indices can be used for perfusion assessment for people with lighter skin tone levels but show limitations in people with darker skin tones. Furthermore, it could be used for a more individual perfusion assessment if different physiological influencing factors are respected.
Collapse
Affiliation(s)
- Ester Pachyn
- Department of Urology, Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, Fraunhoferstrasse 20, 82152, Planegg, Germany.
| | - Maximilian Aumiller
- Department of Urology, Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, Fraunhoferstrasse 20, 82152, Planegg, Germany
- Department of Urology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Christian Freymüller
- Department of Urology, Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, Fraunhoferstrasse 20, 82152, Planegg, Germany
- Department of Urology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Matthäus Linek
- Department of Urology, Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, Fraunhoferstrasse 20, 82152, Planegg, Germany
| | - Veronika Volgger
- Department of Otorhinolaryngology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Alexander Buchner
- Department of Urology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Adrian Rühm
- Department of Urology, Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, Fraunhoferstrasse 20, 82152, Planegg, Germany
- Department of Urology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Ronald Sroka
- Department of Urology, Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, Fraunhoferstrasse 20, 82152, Planegg, Germany
- Department of Urology, University Hospital, LMU Munich, 81377, Munich, Germany
| |
Collapse
|
3
|
Cosset T, Tonnerre D, Gorphe P, Dupret-Bories A, Dufour X, Carsuzaa F. Free-flap reconstruction methods in head-and-neck oncologic surgery: A CROSS practice survey of members of the French GETTEC Head-and-Neck Tumor Study Group. Eur Ann Otorhinolaryngol Head Neck Dis 2024:S1879-7296(24)00053-X. [PMID: 38658260 DOI: 10.1016/j.anorl.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To survey practices concerning the use of anticoagulants and antiplatelets in microvascular free-flap reconstruction following oncological surgery of the head and neck. METHODS A survey of practices was carried out between September 2022 and March 2023. An online questionnaire was sent to members of the French GETTEC Head-and-Neck Tumor Study Group in all French centers practicing head-and-neck cancer surgery with reconstruction using microvascular free-flaps. The questionnaire asked surgeons about their practices regarding the use of intra- and postoperative anticoagulants and antiplatelets, preoperative management of comorbidities, and prevention of postoperative complications. RESULTS Sixty-one percent of the 38 respondents (23/38) used intraoperative intravenous heparin injection, associated to flap irrigation with heparin for 76% of surgeons (29/38) and/or a heparin solution bath for 37% (14/38). Postoperative anticoagulation was used by 95% of surgeons (36/38), and antiplatelets by 40% (15/38). Postoperatively, 40% (15/38) carried out monitoring using an implantable micro-Doppler probe, associated to analysis of clinical characteristics of the flap. CONCLUSION Reconstructive surgery using microvascular free-flaps involves numerous factors that can influence success. Prospective studies, particularly concerning the management of anticoagulants, could enable a national consensus on methods for free-flap reconstruction.
Collapse
Affiliation(s)
- T Cosset
- Service ORL, chirurgie cervicofaciale et audiophonologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
| | - D Tonnerre
- Service ORL, chirurgie cervicofaciale et audiophonologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
| | - P Gorphe
- Département d'ORL et de chirurgie cervicofaciale, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - A Dupret-Bories
- Service ORL et chirurgie cervicofaciale et audiophonologie, IUCT Oncopole, 1, avenue Irène-Joliot-Curie, 31100 Toulouse, France
| | - X Dufour
- Service ORL, chirurgie cervicofaciale et audiophonologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
| | - F Carsuzaa
- Service ORL, chirurgie cervicofaciale et audiophonologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France.
| |
Collapse
|
4
|
Thariat J, Carsuzaa F, Beddok A, Deneuve S, Marcy PY, Merlotti A, Dejean C, Devauchelle B. Reconstructive flap surgery in head and neck cancer patients: an interdisciplinary view of the challenges encountered by radiation oncologists in postoperative radiotherapy. Front Oncol 2024; 14:1379861. [PMID: 38665951 PMCID: PMC11043495 DOI: 10.3389/fonc.2024.1379861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Background Major advances have been made in reconstructive surgery in the last decades to reduce morbidity in head and neck cancer. Flaps are now present in 80% of patients with oral cavity cancer to cover anatomic, functional, and cosmetic needs. However, gaps in interdisciplinary innovation transfer from surgery to postoperative radiotherapy (poRT) remain challenging. We aimed to provide an interdisciplinary view of the challenges encountered by radiation oncologists in planning head and neck postoperative radiotherapy. Methods A systematic and critical review was conducted to address areas of optimization in surgery and radiology that may be relevant to poRT. Results Despite extensive surgical literature on flap techniques and salvage surgery, 13 retrospective series were identified, where flap outcomes were indirectly compared between surgery alone or poRT. These low-evidence studies suggest that radiotherapy accelerates flap atrophy, fibrosis, and osteoradionecrosis and deteriorates functional outcomes. Preliminary evidence suggests that tumor spread occurs at the flap-tissue junction rather than in the flaps. One prospective 15-patient study showed 31.3% vs. 39.2% flap volume reduction without or with poRT. In an international consensus, experts recognized the needs for optimized flap-sparing poRT against flap-related functional deterioration and bone damage. CT, MRI, and PET-CT modalities show potential for the delineation of the junction area between native tissues and flap for flap segmentation and to characterize flap-specific changes quantitatively and correlate them with patterns of relapse or complications. Conclusion Flap management in poRT is insufficiently documented, but poRT seems to damage flaps. Current gaps in knowledge underscore the need for prospective flap assessment and interdisciplinary trials investigating flap morbidity minimization by flap-sparing poRT planning.
Collapse
Affiliation(s)
- Juliette Thariat
- Department of Radiotherapy, Centre François-Baclesse, Caen, France
- Corpuscular Physics Laboratory, IN2P3, Ensicaen, CNRS UMR 6534, Caen, France
- Faculté de Médecine de Caen, Université de Normandie, Caen, France
| | - Florent Carsuzaa
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Arnaud Beddok
- Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Orsay, France
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sophie Deneuve
- Surgical Oncology Department, Centre Léon Bérard, UNICANCER, Lyon, France
- Inserm, U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon Bérard, Lyon, France
| | - Pierre-Yves Marcy
- Polyclinics ELSAN Group, Department of Radiodiagnostics and Interventional Imaging, PolyClinics Les Fleurs, Ollioules, France
| | - Anna Merlotti
- Radiotherapy Department, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | | | - Bernard Devauchelle
- Departement of Maxillofacial Surgery, University Hospital of Amiens Picardy, Research Unit, UR7516 CHIMERE, University of Picardy Jules Verne, Institut Faire Faces, Amiens, France
| |
Collapse
|
5
|
Philips R, Best KA, Agarwal A, Sagheer H, Selman Y, Sweeney L, Wax M, Krein H, Heffelfinger R, Luginbuhl A, Curry J. A Survey of Microvascular Technique Preferences Among American Head Neck Society Members. Laryngoscope 2024; 134:1265-1277. [PMID: 37610286 DOI: 10.1002/lary.30995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE To identify practices in microvascular techniques in routine and challenging scenarios. STUDY DESIGN Cross-sectional study. METHODS A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021. RESULTS The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2-13) and median flaps per year was 35 (22-50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029). CONCLUSIONS This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length. LEVEL OF EVIDENCE 5 Laryngoscope, 134:1265-1277, 2024.
Collapse
Affiliation(s)
- Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Keisha A Best
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Aarti Agarwal
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Hamad Sagheer
- Department of Anesthesiology, University of Florida, Gainesville, Florida, U.S.A
| | - Yamil Selman
- Head and Neck Surgical Oncology, Memorial Healthcare System, Hollywood, Florida, U.S.A
| | - Larissa Sweeney
- Department of Otolaryngology-Head and Neck Surgery, University of Miami, Miami, Florida, U.S.A
| | - Mark Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| |
Collapse
|
6
|
Dang S, Green K, Bottegal M, Khan NI, Solari MG, Sridharan SS, Kubik MW. Co-surgery in head and neck microvascular reconstruction. Am J Otolaryngol 2024; 45:104062. [PMID: 37769506 DOI: 10.1016/j.amjoto.2023.104062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/12/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE Co-surgery with two attending reconstructive surgeons is becoming increasingly common in breast microvascular reconstruction due to case complexity and the potential for improved outcomes and operative efficiency. The impact of co-surgery on outcomes in head and neck microvascular reconstruction has not been studied. METHODS Our multidisciplinary head and neck reconstruction team (Otolaryngology, Plastic Surgery) at the University of Pittsburgh transitioned to a practice of co-surgery on head and neck free flaps. In this study, we compare outcomes of two surgeon head and neck reconstruction to single surgeon reconstruction in a prospectively maintained database. RESULTS 384 patients met our inclusion criteria from 2020 to 2022. Cases were performed by a single surgeon in 77.8 % of cases (299/384) and two surgeons in 22.1 % (85/384). The mean age was 62.5 years. There was no difference between the single surgeon cohort and the co-surgery cohort in terms of flap survival, procedure time, ischemia time, hospital length of stay, recipient site complications, or rates of return to the operating room. Donor site complications were less common in the co-surgery cohort (0 % vs 4.7 %, p = 0.021). For our reconstructive team, the transition to co-surgery has increased total surgeon fee collection per free flap by 28 % and increased surgeon flap related RVU production by 35 %. CONCLUSION Co-surgery is feasible and safe in head and neck microvascular reconstruction. Benefits may include reduced complications, increased reimbursement, and improved interdisciplinary collaboration.
Collapse
Affiliation(s)
- Sophia Dang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Katerina Green
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Matthew Bottegal
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Nayel I Khan
- Department of Otolayrngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Mario G Solari
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Shaum S Sridharan
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mark W Kubik
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| |
Collapse
|
7
|
Shaikh N, Noor K, Jafary H, Chung J, Fancy T, Stokes W. Effect of 2 Teams and Operative Time on Complications After Oral Cavity Free Flap Reconstruction. Ann Otol Rhinol Laryngol 2023; 132:1430-1437. [PMID: 37012707 DOI: 10.1177/00034894231164802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
OBJECTIVE Evaluate the effects of operative time and 2 team approach on complications after soft tissue free flap reconstruction for oral tongue cancer. METHODS Patients with oncologic glossectomy with myocutaneous or fasciocutaneous free flap reconstruction were included from the 2015 to 2018 American College of Surgery National Surgical Quality Improvement Program. The primary predictive variables assessed were operative time and 2 team approach; control variables included age, sex, body mass index (BMI), 5-question-modified frailty index (mFI-5), American Society of Anesthesiologists (ASA) class, and total work relative value units (wRVU). Outcomes assessed included 30-day mortality, 30-day reoperation, hospital length of stay beyond 30 days, readmission, medical and surgical complications, and non-home discharge. Multivariable logistic/linear regression models were used to predict surgical outcomes. RESULTS Microvascular soft tissue free flap reconstruction of the oral cavity after glossectomy was performed on 839 patients. Operative time was independently associated with readmission, prolonged length of stay, surgical complications, medical complications, and non-home discharge. A 2-team approach was independently associated with prolonged length of stay and medical complications. The mean operative time of the 1-team and 2-team approach was 8.73 and 9.13 hours. The 1-team approach did not significantly increase operative time (P = .16). CONCLUSIONS In the largest study to date of operative time on post-surgical outcomes after glossectomy and soft tissue free flap reconstruction, we found longer operative times increased rates of postoperative complications and non-home discharge. The 1-team approach is non-inferior to the 2-team approach with respect to operating time and complications.
Collapse
Affiliation(s)
- Noah Shaikh
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| | - Kinza Noor
- School of Medicine, West Virginia, Morgantown, WV, USA
| | - Haseeb Jafary
- Marshall University School of Medicine, Huntington, WV, USA
| | - Jeffson Chung
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| | - Tanya Fancy
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| | - William Stokes
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| |
Collapse
|
8
|
Hicks MD, Vasudev M, Bishop JL, Garcia N, Chowdhury F, Pham TT, Heslop G, Greene B, Jeyarajan H, Grayson JW, Goddard JA, Tjoa T, Haidar Y, Thomas CM. Effect of Perioperative Antithrombotics on Postoperative Transfusion and Hematoma in Head and Neck Free Flaps. OTO Open 2023; 7:e86. [PMID: 37854346 PMCID: PMC10580001 DOI: 10.1002/oto2.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 07/30/2023] [Accepted: 09/05/2023] [Indexed: 10/20/2023] Open
Abstract
Objective To explore if antiplatelet or anticoagulant therapy increases the risk of transfusion requirement or postoperative hematoma formation in patients undergoing microvascular reconstruction for head and neck defects. Study Design Retrospective cohort study. Setting Departments of Otolaryngology-Head and Neck Surgery at the University of Alabama at Birmingham, the University of Colorado, and the University of California Irvine. Methods A multi-institutional, retrospective review on microvascular reconstruction of the head and neck between August 2013 to July 2021. Perioperative antithrombotic data were collected to examine predictors of postoperative transfusion and hematoma. Results A total of 843 free flaps were performed. Preoperative hemoglobin, hematocrit, operative time, and flap type were positive predictors of postoperative transfusion in both bivariate (P < .0001) and multivariate analyses (P < .0001). However, neither anticoagulation nor antiplatelet therapy were predictive of postoperative transfusion rates and hematoma formation. Conclusion Antithrombotic regimens do not increase the risk of postoperative transfusion or hematoma in head and neck microvascular reconstruction. Based on this limited data, perioperative antithrombotic regimens can be considered in patients who may otherwise be at risk for these postoperative complications.
Collapse
Affiliation(s)
- Melanie D. Hicks
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Milind Vasudev
- School of MedicineUniversity of California Irvine School of MedicineIrvineCaliforniaUSA
| | - Jessica L. Bishop
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Natalie Garcia
- School of MedicineUniversity of Alabama at Birmingham Heersink School of MedicineBirminghamAlabamaUSA
| | - Farshad Chowdhury
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Tiffany T. Pham
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Gabriela Heslop
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Benjamin Greene
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Hari Jeyarajan
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jessica W. Grayson
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Julie A. Goddard
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Tjoson Tjoa
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California IrvineIrvineCaliforniaUSA
| | - Yarah Haidar
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California IrvineIrvineCaliforniaUSA
| | - Carissa M. Thomas
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- O'Neal Comprehensive Cancer CenterBirminghamAlabamaUSA
| |
Collapse
|
9
|
Flagg CA, Stevens JR, Chinn S. Practice Trends and Evidence-Based Practice in Microvascular Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00071-3. [PMID: 37221115 DOI: 10.1016/j.otc.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Microvascular and free flap reconstruction are important to the otolaryngology-head and neck surgery practice. Herein, the reader will find an up-to-date discussion of various evidence-based practice trends related to microvascular surgery, including surgical techniques, anesthetic and airway considerations, free flap monitoring and troubleshooting, surgical efficiency, and both patient-related and surgeon-related risk factors that may affect outcomes.
Collapse
Affiliation(s)
- Candace A Flagg
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, TX, USA.
| | - Jayne R Stevens
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, TX, USA
| | - Steven Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Rogel Cancer Center, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| |
Collapse
|
10
|
Plonowska-Hirschfeld KA, Zebolsky AL, Lindeborg MM, McNeill C, Knott PD, Seth R, Park AM, Heaton CM. Restarting Therapeutic Antibiotics Following Postoperative Prophylaxis in Head and Neck Microvascular Free Tissue Transfer. Otolaryngol Head Neck Surg 2023; 168:357-365. [PMID: 35972809 DOI: 10.1177/01945998221117794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/18/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine factors associated with restarting therapeutic antibiotics within 30 days of head and neck microvascular free tissue transfer (HN-MFTT). STUDY DESIGN Retrospective study of consecutive HN-MFTTs performed from January 2015 to July 2020. SETTING Tertiary academic medical center. METHODS Thirty-day postoperative antibiotic use and post-HN-MFTT surgical and medical complications were assessed. Univariable analyses and multivariable logistic regression were used to evaluate risk factors associated with restarting antibiotics. RESULTS overall 482 patients with 501 HN-MFTTs were stratified by duration of prophylaxis: ≤24 hours (n = 136, 27.1%), 25-72 hours (n = 54, 10.8%), and >72 hours (n = 311, 62.1%). Antibiotics were restarted in 199 patients (209 procedures, 42%). The most common indications for antibiotic reinitiation were flap recipient site infection (n = 59, 28%); hospital-acquired pneumonia (n = 44, 21%); and wound dehiscence, fluctuance, or change in quality of drain output (n = 44, 21%). Shorter antibiotic prophylaxis (≤24 hours) (odds ratio [OR], 1.95; 95% CI, 1.2-3.0; P = .003), osteocutaneous flaps (OR, 2.15; 95% CI, 1.3-3.4; P = .001), and prior immunotherapy/chemotherapy (OR, 2.29; 95% CI, 1.2-4.3; P = .01) were associated with reinitiation of antibiotics for surgical infections. Restarting antimicrobials for nosocomial infections was associated with aerodigestive defects (OR, 2.45; 95% CI, 1.1-5.2; P = .019), cardiovascular disease (OR, 3.00; 95% CI, 1.5-5.9; P = .001), and medical comorbidities approximated by American Society of Anesthesiologists class 3 or 4 (OR, 2.83; 95% CI, 1.5-5.4; P = .002). CONCLUSION Aerodigestive reconstruction, 24-hour postoperative antimicrobial prophylaxis, American Society of Anesthesiologists class 3 and 4, prior chemotherapy/immunotherapy, cardiovascular disease, and osteocutaneous flaps are associated with reinitiation of antibiotics within 30 days of HN-MFTT.
Collapse
Affiliation(s)
| | - Aaron L Zebolsky
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Michael M Lindeborg
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Christian McNeill
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - P Daniel Knott
- Division of Facial Plastics and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Rahul Seth
- Division of Facial Plastics and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Andrea M Park
- Division of Facial Plastics and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Chase M Heaton
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| |
Collapse
|
11
|
Stevens MN, Freeman MH, Shinn JR, Kloosterman N, Carr S, Mannion K, Rohde SL. Preoperative Predictors of Free Flap Failure. Otolaryngol Head Neck Surg 2023; 168:180-187. [PMID: 35412879 DOI: 10.1177/01945998221091908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure. STUDY DESIGN Retrospective cohort study of 1070 patients. SETTING Head and neck surgical oncology service at a tertiary care center from 2005 to 2019. METHODS Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (<8 days from surgery). RESULTS In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure. CONCLUSION Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.
Collapse
Affiliation(s)
- Madelyn N Stevens
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael H Freeman
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Austin, Texas, USA
| | | | - Shane Carr
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
12
|
Tu CH, Hong SF. Preoperative anemia: Predictor of free flap reconstruction complications in head and neck cancer. CHINESE J PHYSIOL 2023; 66:21-27. [PMID: 36814153 DOI: 10.4103/cjop.cjop-d-22-00115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Free flap reconstruction has been the mainstay among reconstruction surgeries for head and neck cancer. Intraoperative and postoperative hemoglobin (Hb) levels were both possible risk factors of flap failure and had been discussed widely. However, few investigations of preoperative Hb were seen in the previous study with its effect to flap condition remain uncertain and no conclusions in the literature. Patients who underwent free flap reconstruction after head and neck surgery in our institution between May 2014 and May 2019 were enrolled. The postoperative flap condition was observed carefully, and re-exploration was performed if necessary. We then retrospectively collected patient data with several intraoperative and postoperative indices. A total of 598 patients were enrolled in our study. The total major flap complication rate was 10.6%, with an overall success rate of 89.4%. They were predominantly male (95%), and most of them underwent free flap reconstruction for the first time (91%). A total of 81 (13%) patients received radiotherapy before reconstruction. Among all factors, the preoperative Hb level and free flap type showed significance in univariate and multivariate analyses. A previous history of radiotherapy, body mass index, nutrition status, or poorly controlled diabetes mellitus showed no significant results in either univariate or multivariate analysis. Our study showed that a lower preoperative Hb level affects free flap survival. Meanwhile, preoperative radiotherapy history has no significant influence in either univariate or multivariate analysis.
Collapse
Affiliation(s)
- Cheng Hung Tu
- Department of ENT Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - San Fu Hong
- Department of ENT Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan
| |
Collapse
|
13
|
Deane EC, Liu AQ, Nguyen S, Anderson DW, Durham JS, Prisman E. Synchrony in head and neck surgery: Feasibility and outcomes of simultaneous scapular free flap reconstruction. Head Neck 2021; 44:760-769. [PMID: 34936161 DOI: 10.1002/hed.26963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/15/2021] [Accepted: 12/10/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The scapula free flap is a versatile option in head and neck reconstruction but is less amenable to simultaneous harvest and ablation. METHODS Retrospective series (2015-2021) of consecutive scapula flaps. Cases categorized as simultaneous versus sequential, compared for operative time, oncological and patient-reported outcomes. RESULTS Seventy consecutive scapula free flaps were performed (n = 21 simultaneous, n = 49 sequential). Mandible reconstruction was performed in 51.0% and 61.9% of sequential and simultaneous cases, respectively; 49.0% and 38.1% addressed bony maxillary defects. Simultaneous surgery reduced operative time by 37.9% (151 min, p < 0.00001) and there were fewer tracheostomies performed (p < 0.005). Rates of positive margins and free flap compromise were equivalent (n = 1, 4.8% vs. n = 2, 4.1%). There was no difference in patient-reported outcomes. CONCLUSIONS This series demonstrates feasibility, efficacy, and outcomes of bony scapula reconstruction of maxillofacial defects comparing simultaneous and sequential approaches. Benefits of the two-team approach are highlighted including decreased operative time.
Collapse
Affiliation(s)
- Emily C Deane
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alice Q Liu
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sally Nguyen
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald W Anderson
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - James Scott Durham
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eitan Prisman
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
14
|
Laehn SJ, LoGuidice JA, Hettinger PC, Rein LE, Peppard WJ. Postoperative depth of sedation and associated outcomes in free flap transfers to the head and neck. Head Neck 2021; 44:391-398. [PMID: 34799940 DOI: 10.1002/hed.26929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 09/23/2021] [Accepted: 11/05/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND To evaluate the impact of postoperative depth of sedation in free flap transfers to the head and neck. METHODS A single center, retrospective cohort of 92 patients were stratified by depth of sedation, light sedation (RASS -1 or greater) or deep sedation (RASS less than -1), and analyzed for postoperative flap and medical complications. RESULTS Of the 92 patients 45 were included in the light sedation and 47 in the deep sedation group. Flap complication requiring return to the operating room occurred in 8 (22.2%) patients in light sedation compared to 12 (27.7%) (p = 0.450) patients in deep sedation. A composite outcome of flap and medical complications occurred less frequently in the light sedation group 14 (31.8%) compared to deep sedation 32 (69.6%) (p < 0.001). CONCLUSION There was no difference in return to the operating room between the two groups. Light sedation had reduced incidence of medical complications compared to deep.
Collapse
Affiliation(s)
| | - John Anthony LoGuidice
- Department of Plastic Surgery, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Lisa Egner Rein
- Department of Biostatistics, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - William John Peppard
- Division of Trauma and Acute Care Surgery, Department of Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Pharmacy, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
15
|
Smith JD, Correll JA, Stucken CL, Stucken EZ. Ear, Nose, and Throat Surgery: Postoperative Complications After Selected Head and Neck Operations. Surg Clin North Am 2021; 101:831-844. [PMID: 34537146 DOI: 10.1016/j.suc.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Unanticipated complications of ENT surgeries may have profound functional and esthetic consequences for patients. Herein, we provide a broad overview of postoperative complications after ENT surgery, illustrating their unique nature, impact, and principles of management. The discussion is organized by subspecialty to highlight the great anatomic complexity of the head and neck and the importance of critical neurovascular and sensory structures that make ENT an impactful, yet challenging surgical specialty.
Collapse
Affiliation(s)
- Joshua D Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Jason A Correll
- University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Emily Z Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| |
Collapse
|
16
|
Aponte-Ortiz JA, Greenberg-Worisek AJ, Marinelli JP, May M, Spears GM, Labott JR, Mecham JC, Moore EJ, Visscher SL, Borah BJ, Janus JR. Cost and clinical outcomes of postoperative intensive care unit versus general floor management in head and neck free flap reconstructive surgery patients. Am J Otolaryngol 2021; 42:103029. [PMID: 33857778 DOI: 10.1016/j.amjoto.2021.103029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/04/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare clinical, surgical, and cost outcomes in patients undergoing head and neck free-flap reconstructive surgery in the setting of postoperative intensive care unit (ICU) against general floor management. METHODS Retrospective analysis of head and neck free-flap reconstructive surgery patients at a single tertiary academic medical center. Clinical data was obtained from medical records. Cost data was obtained via the Mayo Clinic Rochester Cost Data Warehouse, which assigns Medicare reimbursement rates to all professional billed services. RESULTS A total of 502 patients were included, with 82 managed postoperatively in the ICU and 420 on the general floor. Major postoperative outcomes did not differ significantly between groups (Odds Ratio[OR] 1.54; p = 0.41). After covariate adjustments, patients managed in the ICU had a 3.29 day increased average length of hospital stay (Standard Error 0.71; p < 0.0001) and increased need for take-back surgery (OR 2.35; p = 0.02) when compared to the general floor. No significant differences were noted between groups in terms of early free-flap complications (OR 1.38;p = 0.35) or late free-flap complications (Hazard Ratio 0.81; p = 0.61). Short-term cost was $8772 higher in the ICU (range = $5640-$11,903; p < 0.01). Long-term cost did not differ significantly. CONCLUSION Postoperative management of head and neck oncologic free-flap patients in the ICU does not significantly improve major postoperative outcomes or free-flap complications when compared to general floor care, but does increase short-term costs. General floor management may be appropriate when cardiopulmonary compromise is not present.
Collapse
Affiliation(s)
- Jaime A Aponte-Ortiz
- Center for Clinical and Translational Science, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; University of Puerto Rico School of Medicine, PO Box 365067, San Juan, PR 00936-5067, USA. http://t.co/JAO_MDMS
| | | | - John P Marinelli
- Mayo Clinic School of Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Matthew May
- Department of Otolaryngology- Head and Neck Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Grant M Spears
- Biomedical Statistics and Informatics, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Joshua R Labott
- Mayo Clinic School of Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Jeffrey C Mecham
- Mayo Clinic School of Medicine, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA. http://t.co/Jffmchm
| | - Eric J Moore
- Department of Otolaryngology- Head and Neck Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA. http://t.co/EricJMooreMayo
| | - Sue L Visscher
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Bijan J Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; Division of Health Care Policy and Research, Department of Health Sciences, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Jeffrey R Janus
- Department of Otolaryngology- Head and Neck Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
| |
Collapse
|
17
|
Kejner AE, Patel R, McMullen C, Sykes KJ, Shnayder Y. Burnout in microvascular reconstructive otolaryngology - head and neck surgeons: Potential modifiable workplace factors. Head Neck 2021; 43:3522-3529. [PMID: 34459517 DOI: 10.1002/hed.26847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/17/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Burnout has been previously assessed in head and neck microvascular reconstructive surgeons (HNMVS), but not in the context of modifiable workplace factors. METHODS Anonymous, cross-sectional survey. The Abbreviated Maslach Burnout Inventory - Human Services Survey for Medical Personnel (aMBI-HSS) was utilized to assess emotional exhaustion (EE), depersonalization (DP), and personal achievement (PA). Modifiable risk factors were also evaluated. RESULTS High risk of burnout by EE, DP, and PA was demonstrated in 24%, 9%, and 27% of respondents, respectively. EE was associated with <10% dedicated research time, lack of autonomy over clinic schedule, inadequate inpatient support, and lack of supportive clinical partner. DP was associated with >3 operative days, difficulty balancing academic commitments, and lack of supportive clinical partner. Dedicated research time and two or fewer days of block time were protective. CONCLUSIONS Burnout was associated with several modifiable workplace factors. Addressing these may prevent moderate to severe burnout in HNMVS.
Collapse
Affiliation(s)
- Alexandra E Kejner
- Department of Otolaryngology, University of Kentucky, Lexington, Kentucky, USA
| | - Rusha Patel
- Department of Otolaryngology, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Caitlin McMullen
- Department of Head and Neck - Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Kevin J Sykes
- Department of Otolaryngology, University of Kansas, Kansas City, Kansas, USA
| | - Yelizaveta Shnayder
- Department of Otolaryngology, University of Kansas, Kansas City, Kansas, USA
| |
Collapse
|
18
|
Mortality Within 30 Days After Head and Neck Free Flap Reconstruction: A Systematic Review. J Craniofac Surg 2021; 32:1738-1741. [PMID: 34081420 DOI: 10.1097/scs.0000000000007548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
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.
Collapse
|
19
|
Başaran B, Ünsaler S, Kesimli MC, Aslan İ. Free Flap Reconstruction of the Head and Neck Region: A Series of 127 Flaps Performed by Otolaryngologists. Turk Arch Otorhinolaryngol 2021; 59:103-110. [PMID: 34386796 PMCID: PMC8329401 DOI: 10.4274/tao.2021.2021-1-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/18/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: To determine flap success rate and complications in patients who underwent microvascular free tissue reconstruction after major head and neck ablative surgery and to report the improvement in the results. Methods: Medical records of 124 patients who were operated on in 2012 to 2019 were retrospectively reviewed. Indications for different free flap types, success rates and re-exploration rates, donor site morbidities, and reasons for flap loss were analyzed. Patients were divided into two groups to identify the effects of the anticoagulant and the antiaggregant treatments on postoperative results. Results: There were 127 flaps in 124 patients, including two different free flaps each in three patients that were harvested and used in the same surgical session. Of the total 127 flaps, 82 (64.6%) were radial forearm flaps, 39 (30.7%) were fibula flaps, and 6 (4.7) were rectus abdominis flaps. Four patients were re-explored for flap perfusion problems, and 18 patients were re-explored for hematoma drainage (n=22/124, %17.3). The rate of hematoma and re-exploration was higher in patients who received anticoagulant and antiaggregant treatments synchronously (p=0.02). Three flaps were lost, and the overall success rate was 97.6%. Two patients died from perioperative complications. No major complications were observed at the donor site; minor complications were observed in 30 patients. Conclusion: The success rate for the 127 flaps in 124 patients were found comparable to those reported in the literature. These results show that successful outcomes can be achieved with experience and a head and neck team dedicated to improving the results in microsurgical reconstruction, and flap failure rarely occurs if perioperative care of the patients is given meticulously.
Collapse
Affiliation(s)
- Bora Başaran
- Department of Otolaryngology Head and Neck Surgery, İstanbul University-İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Selin Ünsaler
- Department of Otolaryngology Head and Neck Surgery, Koç University School of Medicine, İstanbul, Turkey
| | - Mustafa Caner Kesimli
- Department of Otolaryngology Head and Neck Surgery, İstinye University Faculty of Medicine, İstanbul, Turkey
| | - İsmet Aslan
- Department of Otolaryngology Head and Neck Surgery, İstanbul University-İstanbul Faculty of Medicine, İstanbul, Turkey
| |
Collapse
|
20
|
Sayre KS, Kovatch KJ, Hanks JE, Stucken CL, Ward BB. Current Practices in Microvascular Reconstruction by Oral and Maxillofacial Surgeons. J Oral Maxillofac Surg 2021; 79:1963-1969. [PMID: 34022137 DOI: 10.1016/j.joms.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/01/2021] [Accepted: 04/08/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE Microvascular free tissue transfer (MFTT) is a reliable reconstructive option with variation in perioperative care and a general lack of clinical practice guidelines. Oral and maxillofacial surgeons' (OMSs) current MFTT perioperative practices in the United States have not been described. This study describes these practices including surgeon practice environment, operative practices, perioperative management, and success. METHODS The study design is cross sectional. The sample is composed of OMSs who completed an Oral/Head and Neck Oncologic and Microvascular Surgery Fellowship prior to 2018 in the United States. Data were collected by means of a survey of the study sample. Descriptive statistics were reported. RESULTS Forty surgeons responded to the survey for a response rate of 33.9%. Respondents were 97.5% (n = 39) male and worked in private (n = 8), combination (n = 10), and academic practices (n = 23). Surgeons in private and academic practice performed an average of 23.3 (SD 13.9) and 48.6 (SD 28.6) flaps per year, respectively. The 2-team approach was used by 88.2% of surgeons. Immediate dental implants were placed in osteocutaneous free flaps by 28.6% (n = 2) of private practice surgeons and 70% (n = 14) of academic surgeons. Postoperatively, most patients went to an intensive care unit (ICU) (82.7%, average duration 2.6 days). Anticoagulation or antiplatelet medications were routinely used with the most common choice being aspirin (77.4%, n = 24). Antibiotics were universally administered, often for 3 days or longer (74.2%, n = 23). Self-reported success rates were 95.3% (SD 4.1) and 96.0% (SD 1.7) in private and academic settings, respectively. CONCLUSION This is the first report of practice trends by microvascular OMSs in the United States. The results of this study suggest that there is variation in MFTT operative and perioperative practices by individual surgeons and practice environment with minimal variation in self-reported success rates.
Collapse
Affiliation(s)
- Kelly S Sayre
- Former Resident, Section of Oral & Maxillofacial Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI; Current Fellow, Oral Oncologic and Microvascular Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Kevin J Kovatch
- Former Resident, Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine, Ann Arbor, MI; Current Fellow, Head and Neck Oncologic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - John E Hanks
- Former Resident, Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine, Ann Arbor, MI; Current Assistant Professor, Otolaryngology, Veterans Administration Medical Center, Boston University, Boston, MA
| | - Chaz L Stucken
- Assistant Professor, Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine, Ann Arbor, MI
| | - Brent B Ward
- Chalmers J. Lyons Professor and Chair, School of Dentistry, Section Head, Department of Surgery, Michigan Medicine, Ann Arbor, MI.
| |
Collapse
|
21
|
Feng AL, Nasser HB, Rosko AJ, Casper KA, Malloy KM, Stucken CL, Prince ME, Chinn SB, Spector ME. Revisiting pedicled latissimus dorsi flaps in head and neck reconstruction: contrasting shoulder morbidities across mysofascial flaps. ACTA ACUST UNITED AC 2021; 8. [PMID: 34337111 PMCID: PMC8323836 DOI: 10.20517/2347-9264.2021.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Free tissue transfer has become the gold standard for reconstruction within the head and neck. However, there are still many instances where pedicled locoregional flaps are the optimal reconstructive option. When myofascial tissue is needed, several options have been described throughout the literature. Various trapezius flaps have been used, although these have variable vascular anatomy and significant donor site morbidity. The pectoralis major myofascial flap has become a mainstay in head and neck reconstruction for its ease of harvest and reliability but suffers from similar issues with donor site morbidity. The pedicled latissimus dorsi flap (PLDF) is another reliable option that has been used for multiple different ablative sites within the head and neck. The thin, pliable structure of the latissimus dorsi makes it a viable option for many defects, and recent reports also support its feasibility for use in an interdisciplinary two-team approach. Furthermore, the donor site morbidity of the PLDF is minimal compared to other similar myofascial options. In this article, we describe the surgical considerations and operative techniques for PLDF transfer along with a review of its associated donor site morbidity.
Collapse
Affiliation(s)
- Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Hassan B Nasser
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Mark E Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| |
Collapse
|
22
|
Kushida-Contreras BH, Manrique OJ, Gaxiola-García MA. Head and Neck Reconstruction of the Vessel-Depleted Neck: A Systematic Review of the Literature. Ann Surg Oncol 2021; 28:2882-2895. [PMID: 33550502 DOI: 10.1245/s10434-021-09590-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/28/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Damage of the vascular system secondary to radical neck dissection and/or radiotherapy or other treatments has a negative impact on microsurgical reconstruction. The search for adequate recipient vessels is hindered by the complexity of previous procedures. METHODS A systematic review of microsurgical head and neck reconstruction in the vessel-depleted neck was performed. The issues analyzed were indications for surgery, more frequently performed flaps, vascular systems used as recipient vessels, outcomes, and complications. RESULTS The eligibility criteria were fulfilled by 57 studies published between September 1993 and January 2020. In 8235 patients, 8694 flaps were performed, 925 of which were for a vessel-depleted neck. The most commonly used flap was the anterolateral thigh flap, used in 195 cases (30%), followed by the radial forearm free flap, used in 157 cases (24%). The potential recipient vessels were numerous for arteries (26 options) and veins (31 options). For the 712 flaps with an identifiable recipient artery, the superficial temporal artery was the most commonly used vessel (n = 142, 20%). The superficial temporal vein was the most commonly used vessel for 639 flaps with an identifiable recipient vein (n = 118, 18.5%). Complications amounted to 11%; 80 out of 716 flaps in papers that reported them. Flap losses were reported in 2% of cases. CONCLUSIONS Major microsurgical head and neck reconstruction for postoncologic defects depends on appropriate recipient vessels. Vein availability is paramount. Understanding the complexity of this problem is useful for preoperative planning, precise decision-making, and an accurate surgical approach.
Collapse
Affiliation(s)
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, NY, USA
| | - Miguel Angel Gaxiola-García
- Plastic and Reconstructive Surgery Department, Mexico's Children Hospital (Hospital Infantil de México "Federico Gómez"), Mexico City, Mexico.
| |
Collapse
|
23
|
Rauso R, Chirico F, Federico F, Francesco Nicoletti G, Colella G, Fragola R, Pafundi PC, Tartaro G. Maxillo-facial reconstruction following cancer ablation during COVID-19 pandemic in southern Italy. Oral Oncol 2020; 115:105114. [PMID: 33334689 PMCID: PMC7837107 DOI: 10.1016/j.oraloncology.2020.105114] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 11/22/2020] [Indexed: 11/30/2022]
Abstract
In COVID-19 pandemic era, one major concern is related to ensure optimal management to oncologic patients, even though a context of radical uncertainty. The aim of our effort is to guarantee high-quality and timely care, minimizing COVID-19 infection risk, according to our head and neck (HN) reconstructive mission, still more challenging because of the criticality of the period. Thus, our reconstructive decision algorithm is changed. Microvascular free flaps, reported to be the gold standard for surgical reconstruction, represent extremely specialized procedures necessitating an extended resource allocation not affordable in the adversities of the period. Therefore, we are obliged to define a paradigm shift in our approach, based on free-style reconstructive surgery principles of propeller flap concept. According to our experience, we believe that this viable and feasible surgical technique could represent a reconstructive landmark in this pandemic era, since any guideline is missing, besides HN reconstructive surgery is most likely heading towards a new reconstructive approach.
Collapse
Affiliation(s)
- Raffaele Rauso
- Maxillo-Facial Surgery, Maxillo-Facial Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Fabrizio Chirico
- Maxillo-Facial Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy.
| | - Francesco Federico
- Maxillo-Facial Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | | | - Giuseppe Colella
- Maxillo-Facial Surgery, Maxillo-Facial Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Romolo Fragola
- Maxillo-Facial Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Pia Clara Pafundi
- Advanced Medical and Surgical Sciences Department, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Gianpaolo Tartaro
- Maxillo-Facial Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| |
Collapse
|
24
|
Silva AK, Rodriguez ED, Jacobson AS, Levine JP. Breaking Down Silos: Collaboration in Head and Neck Reconstruction Research. J Reconstr Microsurg 2020; 37:161-166. [PMID: 32871604 DOI: 10.1055/s-0040-1716322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Collaboration has been shown to be beneficial when we have complex problems and highly specialized groups, such as in head and neck reconstruction. Otolaryngology, plastic surgery, and oral maxillofacial surgeons perform head and neck reconstruction research. While the specialties represent unique backgrounds, the degree of interdisciplinary collaboration and subtopic focus is unknown. We sought to describe the frequency of interinstitutional interdisciplinary collaboration and examine the association of specialty with research subtopics. METHODS Oral presentations from 2014 to 2018 focused on head and neck reconstruction or associated principles at the main reconstructive academic meetings in otolaryngology (American Head and Neck Society), plastic surgery (American Society for Reconstructive Microsurgery), and oral maxillofacial surgery (American Association of Oral and Maxillofacial Surgeons) were reviewed. Author specialty and institution data were recorded. All abstracts were assigned a research subtopic, chosen based on identified themes. Subtopic frequencies among the specialties were compared. RESULTS Thirteen of 88 (15%) US institutions participate in interdisciplinary collaboration in head and neck reconstruction research. Of the remaining institutions, 23 (31%) have researchers performing parallel work and not collaborating. Certain research subtopics were more often presented by each specialty, representing differing interests. CONCLUSION Collaboration among head and neck reconstruction research at the US institutions is low compared with the potential. Specialties focus on different research subtopics, and therefore can benefit from working together.
Collapse
Affiliation(s)
- Amanda K Silva
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Eduardo D Rodriguez
- Department of Plastic and Reconstructive Surgery, NYU Langone Health, New York, New York
| | - Adam S Jacobson
- Department of Otolaryngology, NYU Langone Health, New York, New York
| | - Jamie P Levine
- Department of Plastic and Reconstructive Surgery, NYU Langone Health, New York, New York
| |
Collapse
|
25
|
Morse E, Salehi PP, Mehra S. Re: "Value of Intensive Care Unit-Based Postoperative Management for Microvascular Free Flap Reconstruction in Head and Neck Surgery" by Yalamanchi et al. Facial Plast Surg Aesthet Med 2020; 23:151. [PMID: 32845717 DOI: 10.1089/fpsam.2020.0403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Elliot Morse
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA.,Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical Center, New York, New York, USA.,Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital, New York, New York, USA
| | - Parsa P Salehi
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saral Mehra
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
26
|
Jung S, Na S, Kim HB, Joo HJ, Kim J. Inhalation sedation for postoperative patients in the intensive care unit: initial sevoflurane concentration and comparison of opioid use with propofol sedation. Acute Crit Care 2020; 35:197-204. [PMID: 32772035 PMCID: PMC7483012 DOI: 10.4266/acc.2020.00213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/17/2020] [Indexed: 12/02/2022] Open
Abstract
Background Although the use of volatile sedatives in the intensive care unit (ICU) is increasing in Europe, it remains infrequent in Asia. Therefore, there are no clinical guidelines available. This study investigates the proper initial concentration of sevoflurane, a volatile sedative that induces a Richmond agitation-sedation scale (RASS) score of –2 to –3, in patients who underwent head and neck surgery with tracheostomy. We also compared the amount of postoperative opioid consumption between volatile and intravenous (IV) sedation. Methods We planned a prospective study to determine the proper initial sevoflurane concentration and a retrospective analysis to compare postoperative opioid consumption between volatile sedation and propofol sedation. Patients scheduled for head and neck surgery with tracheostomy and subsequent postoperative sedation in the ICU were enrolled. Results In this prospective study, the effective dose 50 (ED50) of initial end-tidal sevoflurane concentration was 0.36% (95% confidence interval [CI], 0.20 to 0.60%), while the ED 95 was 0.69% (95% CI, 0.60 to 0.75%) based on isotonic regression methods. In this retrospective study, remifentanil consumption during postoperative sedation was significantly lower in the sevoflurane group (2.52±1.00 µg/kg/hr, P=0.001) than it was in the IV propofol group (3.66±1.30 µg/kg/hr). Conclusions We determined the proper initial end-tidal concentration setting of sevoflurane for patients with tracheostomy who underwent head and neck surgery. Postoperative sedation with sevoflurane appears to be a valid and safe alternative to IV sedation with propofol.
Collapse
Affiliation(s)
- Seungho Jung
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sungwon Na
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Bin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Ji Joo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
27
|
Bertelsen C, Hur K, Nurimba M, Choi J, Acevedo JR, Jackanich A, Sinha UK, Kochhar A, Kokot N, Swanson M. Enhanced Recovery After Surgery-Based Perioperative Protocol for Head and Neck Free Flap Reconstruction. OTO Open 2020; 4:2473974X20931037. [PMID: 32537554 PMCID: PMC7268136 DOI: 10.1177/2473974x20931037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022] Open
Abstract
Objectives Evaluate an enhanced recovery after surgery (ERAS)–based free flap management protocol implemented at our center. Study Design Prospective cohort study of patients after implementation of an ERAS-based perioperative care protocol for patients undergoing free flap reconstruction of the head and neck as compared with a historical control group. Setting Tertiary care academic medical center. Participants and Methods All patients undergoing free flap reconstruction were prospectively enrolled in the ERAS protocol group. A retrospective control group was identified by randomly selecting an equivalent number of patients from a records search of those undergoing free flap surgery between 2009 and 2015. Blood transfusion, complications, 30-day readmission rates, intensive care unit (ICU) and hospital length of stay, and costs of hospitalization were compared. Results Sixty-one patients were included in each group. Patients in the ERAS group underwent less frequent flap monitoring by physicians and had lower rates of intraoperative (70.5% vs 86.8%, P = .04) and postoperative (49.2% vs 27.2%, P = .026) blood transfusion, were more likely to be off vasopressors (98.3% vs 50.8%, P < .01) and ventilator support (63.9% vs 9.8%, P < .01) at the conclusion of surgery, and had shorter ICU stays (2.11 vs 3.39 days, P = .017). Length of stay, readmissions, and complication rates did not significantly differ between groups. Conclusion ERAS-based perioperative practices for head and neck free flap reconstruction can reduce time on the ventilator and in the ICU and the need for vasopressors, blood transfusions, and labor-intensive flap monitoring, without adverse effects on outcomes.
Collapse
Affiliation(s)
- Caitlin Bertelsen
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kevin Hur
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Margaret Nurimba
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Janet Choi
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joseph R Acevedo
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anna Jackanich
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Uttam K Sinha
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Amit Kochhar
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Niels Kokot
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mark Swanson
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
28
|
A Sequential Thoracoacromial Artery Perforator Flap for Reconstructing the Donor Site of Sternocleidomastoid Myocutaneous Flaps. Ann Plast Surg 2020; 84:657-664. [DOI: 10.1097/sap.0000000000002042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
29
|
Kiong KL, Guo T, Yao CMKL, Gross ND, Hanasono MM, Ferrarotto R, Rosenthal DI, Myers JN, Hanna EY, Lai SY. Changing practice patterns in head and neck oncologic surgery in the early COVID-19 era. Head Neck 2020; 42:1179-1186. [PMID: 32459061 DOI: 10.1002/hed.26202] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 04/14/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The novel coronavirus 2019 (COVID-19) pandemic has changed health care, challenged by resource constraints and fears of transmission. We report the surgical practice pattern changes in a Head and Neck Surgery department of a tertiary cancer care center and discuss the issues surrounding multidisciplinary care during the pandemic. METHODS We report data regarding outpatient visits, multidisciplinary treatment planning conference, surgical caseload, and modifications of oncologic therapy during this pandemic and compared this data to the same interval last year. RESULTS We found a 46.7% decrease in outpatient visits and a 46.8% decrease in surgical caseload, compared to 2019. We discuss the factors involved in the decision-making process and perioperative considerations. CONCLUSIONS Surgical practice patterns in head and neck oncologic surgery will continue to change with the evolving pandemic. Despite constraints, we strive to prioritize and balance the oncologic and safety needs of patients with head and neck cancer in the face of COVID-19.
Collapse
Affiliation(s)
- Kimberley L Kiong
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Theresa Guo
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Christopher M K L Yao
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M Hanasono
- Department of Plastics and Reconstructive Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Renata Ferrarotto
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.,Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
30
|
|
31
|
Torabi SJ, Chouairi F, Dinis J, Alperovich M. Head and Neck Reconstructive Surgery: Characterization of the One-Team and Two-Team Approaches. J Oral Maxillofac Surg 2019; 78:295-304. [PMID: 31622570 DOI: 10.1016/j.joms.2019.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To the best of our knowledge, no studies have compared the patient profiles for 1- versus 2-team surgery within head and neck oncosurgery. PATIENTS AND METHODS A retrospective study of the data from 2968 patients who had undergone concurrent head and neck extirpative and reconstructive surgery in the National Surgical Quality Improvement Program (2010 to 2017) was conducted. Patients were stratified into 1- and 2-team surgery groups, and the demographic data were compared. Univariate analyses of the outcomes before and after propensity score matching were conducted. RESULTS Most ablative and reconstructive head and neck procedures (68.5%) were performed using a 1-team approach. The patients who had undergone 2-team surgery were more likely to have a higher American Society of Anesthesiologists classification (P < .001), to require mandibulectomy (P < .001) or glossectomy (P < .001), and to receive a microvascular free flap (P < .001) but were less likely to require parotidectomy (P < .001) or to receive a rotational flap (P < .001). Before propensity score matching, the patients undergoing 2-team surgery had longer operative times (P < .001), longer postoperative stays (P < .001), greater rates of a return to the operating room (P = .001), and an increased rate of complications (P < .001). After propensity score matching, the 2-team approach continued to have longer operative times (P < .001) and an increased incidence of complications (P < .001) but no significant differences in the length of stay or rate of return to the operating room after Bonferroni's correction. CONCLUSIONS Nationally, most head and neck ablative and reconstructive surgeries were completed by 1 team. More complicated reconstructive procedures involving microvascular free flaps have been more commonly performed by 2 teams, resulting in slightly longer operative times and greater associated complication rates.
Collapse
Affiliation(s)
- Sina J Torabi
- Medical Student, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Fouad Chouairi
- Medical Student, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Jacob Dinis
- Medical Student, Department of Surgery, Yale University School of Medicine, New Haven, CT; and Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT
| | - Michael Alperovich
- Assistant Professor, Section of Plastic and Reconstructive Surgery Department of Surgery, Yale University School of Medicine, New Haven, CT.
| |
Collapse
|
32
|
Optimizing value in head and neck cancer free flap surgery. Curr Opin Otolaryngol Head Neck Surg 2019; 27:413-419. [DOI: 10.1097/moo.0000000000000570] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
33
|
Alcázar Sánchez-Elvira L, Bacian Martínez S, Del Toro Gil L, Gómez Tello V. Postoperative management in the Intensive Care Unit of head and neck surgery patients. Med Intensiva 2019; 44:46-53. [PMID: 31174894 DOI: 10.1016/j.medin.2019.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/30/2019] [Accepted: 05/03/2019] [Indexed: 01/26/2023]
Abstract
Patient care after major head and neck surgery has changed in recent years. Tumors are the most common reasons for this type of surgery, though it is also used to treat benign conditions. Recent advances in equipment and surgical techniques have improved the postoperative course in this field, allowing early recovery, less pain and infection, a shorter hospital stay, and even better aesthetic results. This is due to the use of minimally invasive techniques, which are gaining relevance. Such techniques allow complex procedures in the head and neck region, through natural orifices or small incisions, with minimal damage and sequelae for the patients. Despite these advances, however, the complexity of the treatment intervention requires multidisciplinary patient management, mostly in the Intensive Care Unit, in order to monitor the possible occurrence of complications. Potential risk factors include previous comorbidity, the type of surgery involved (e.g., bilateral cervical lymphadenectomy), multiple transfusions, and the appearance of early complications requiring repeat surgery. Despite the existence of several studies, there are no standardized protocols for the postoperative period in surgeries of this kind. This causes many specialists to resort to accelerated recovery protocols (ERAS: "Enhanced Recovery After Surgery") that have already been established in other surgical specialties.
Collapse
Affiliation(s)
| | - S Bacian Martínez
- Departamento de Cirugía Máxilofacial,Hospital HLA Universitario Moncloa, Madrid, España
| | - L Del Toro Gil
- Departamento de Otorrinolaringología,Hospital HLA Universitario Moncloa, Madrid, España
| | - V Gómez Tello
- Departamento de Medicina Intensiva, Hospital HLA Universitario Moncloa, Madrid, España; Servicio de Urgencias, Hospital HLA Universitario Moncloa, Madrid, España; Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, España
| |
Collapse
|