1
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Brauer PR, Byrne PJ, Prendes BL, Wu SS, Fritz MA, Ku JA, Lamarre ED. Adverse events associated with anastomotic coupling devices in microvascular reconstruction. Am J Otolaryngol 2024; 45:104262. [PMID: 38552339 DOI: 10.1016/j.amjoto.2024.104262] [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: 12/31/2023] [Accepted: 03/17/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE In light of the recent US Food and Drug Administration (FDA) Class 2 safety recall notice for anastomotic coupling devices, it is important to understand related adverse events. The aim of this study was to characterize adverse events in anastomotic coupling devices for microvascular reconstruction. METHODS A retrospective cross-sectional analysis using the 2011 to 2021 US FDA Manufacturer and User Facility Device Experience (MAUDE) database. All reports of adverse events involving anastomotic coupling devices were retrieved from the MAUDE database. Descriptive statistics were used to analyze categorized events. RESULTS There were a total of 293 documented adverse events related to anastomotic coupling devices. These adverse events resulted in 91 (31.1 %) patient injuries and 239 (81.6 %) device malfunctions. The most frequent patient problems were thrombosis/hematoma (n = 38; 41.8 %), unspecified injury (n = 31; 34.1 %), and failure to anastomose (n = 13; 14.3 %). Free flap necrosis was reported in 42 % of thrombosis/hematoma cases (n = 16). The most common malfunctions were devices operating differently than expected (n = 74; 31.0 %), connection problems (n = 41; 17.2 %), and twisted/bent material (n = 19; 7.9 %). There was no significant trend in the number of adverse events over the study period (p > 0.05). CONCLUSIONS Adverse events from anastomotic coupling devices represent an important and modifiable factor in free tissue failure. Adverse events are predominately related to devices operating differently than expected and may result in vascular compromise of the free flap. Reconstructive surgeons should be cognizant of defective anastomotic coupling devices and be prepared to utilize traditional hand-sewn anastomosis.
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Affiliation(s)
- Philip R Brauer
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA.
| | - Patrick J Byrne
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
| | | | - Shannon S Wu
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Fritz
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Jamie A Ku
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Eric D Lamarre
- Head and Neck Institute, The Cleveland Clinic, Cleveland, OH, USA
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2
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Wang SY, Barrette LX, Ng JJ, Sangal NR, Cannady SB, Brody RM, Bur AM, Brant JA. Predicting reoperation and readmission for head and neck free flap patients using machine learning. Head Neck 2024. [PMID: 38357827 DOI: 10.1002/hed.27690] [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: 06/06/2023] [Revised: 01/17/2024] [Accepted: 02/05/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND To develop machine learning (ML) models predicting unplanned readmission and reoperation among patients undergoing free flap reconstruction for head and neck (HN) surgery. METHODS Data were extracted from the 2012-2019 NSQIP database. eXtreme Gradient Boosting (XGBoost) was used to develop ML models predicting 30-day readmission and reoperation based on demographic and perioperative factors. Models were validated using 2019 data and evaluated. RESULTS Four-hundred and sixty-six (10.7%) of 4333 included patients were readmitted within 30 days of initial surgery. The ML model demonstrated 82% accuracy, 63% sensitivity, 85% specificity, and AUC of 0.78. Nine-hundred and four (18.3%) of 4931 patients underwent reoperation within 30 days of index surgery. The ML model demonstrated 62% accuracy, 51% sensitivity, 64% specificity, and AUC of 0.58. CONCLUSION XGBoost was used to predict 30-day readmission and reoperation for HN free flap patients. Findings may be used to assist clinicians and patients in shared decision-making and improve data collection in future database iterations.
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Affiliation(s)
- Stephanie Y Wang
- Department of Otolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Louis-Xavier Barrette
- Department of Otolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jinggang J Ng
- Department of Otolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neel R Sangal
- Department of Otolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Brody
- Department of Otolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA
| | - Andrés M Bur
- Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jason A Brant
- Department of Otolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA
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3
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Barton BM, Mamdani M, Lumley C, Blumberg J, Huang BY, Patel SN. Osseointegration and Bone Resorption of Scapula Tip Free Flaps in Mandibular Reconstruction. Laryngoscope 2023; 133:2597-2602. [PMID: 36651328 DOI: 10.1002/lary.30574] [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: 08/09/2022] [Revised: 11/05/2022] [Accepted: 01/05/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time. METHODS Retrospective chart review of patients receiving STFF from January 2014-January 2017 (n = 25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n = 18). RESULTS Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to -54% (median -0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption. CONCLUSIONS STFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing and functional and cosmetic outcomes, especially in the setting of prior therapies. LEVEL OF EVIDENCE 4 Laryngoscope, 133:2597-2602, 2023.
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Affiliation(s)
- Blair M Barton
- Department of Otorhinolaryngology, Ochsner Medical Center, New Orleans, Louisiana, U.S.A
| | - Mohammed Mamdani
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Catherine Lumley
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Jeffrey Blumberg
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Benjamin Y Huang
- Department of Radiology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Samip N Patel
- Department of Otolaryngology, Mayo Clinic, Jacksonville, Florida, U.S.A
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Mastrolonardo EV, Lu JS, Elliott Z, Knops A, Philips R, Urdang Z, Mady LJ, Curry JM. Evaluating the impact of hemodynamic support measures on head and neck free tissue transfer outcomes: A population-based analysis. Oral Oncol 2023; 143:106461. [PMID: 37331035 DOI: 10.1016/j.oraloncology.2023.106461] [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: 04/15/2023] [Revised: 06/01/2023] [Accepted: 06/09/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVES This study sought to analyze the effects of perioperative blood transfusions and vasopressors on 30-day surgical complications and 1-year mortality after reconstructive surgery in head and neck free tissue transfer (FTT) and to identify predictors of administration of perioperative blood transfusions or vasopressors. MATERIALS AND METHODS TriNetX (TriNetX LLC, Cambridge, USA), an international population-level electronic health record database, was queried to identify subjects that underwent FTT requiring perioperative (intraoperative to postoperative day 7) vasopressors or blood transfusions. Primary dependent variables were 30-day surgical complications and 1-year mortality. Propensity score matching was used to control for population differences, and covariate analysis was used to identify preoperative comorbidities associated with perioperative vasopressor or transfusion requirements. RESULTS 7,631 patients met inclusion criteria. Preoperative malnutrition was associated with increased odds of perioperative transfusion (p = 0.002) and vasopressor requirement (p < 0.001). Perioperative blood transfusion (n = 941) was associated with increased odds of any surgical complication (p = 0.041) within 30 days postoperatively and specifically increased odds of wound dehiscence (p = 0.008) and FTT failure (p = 0.002), respectively. Perioperative vasopressor was (n = 197) was not associated with 30-day surgical complications. Vasopressor requirement was associated with increased hazards-ratio of mortality at 1-year (p = 0.0031). CONCLUSION Perioperative blood transfusion in FTT is associated with increased odds for surgical complications. Judicious use as a hemodynamic support measure should be considered. Perioperative vasopressor use was associated with an increased risk of one-year mortality. Malnutrition is a modifiable risk factor for perioperative transfusion and vasopressor requirement. These data warrant further investigation to assess causation and potential opportunity for practice improvement.
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Affiliation(s)
- Eric V Mastrolonardo
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Joseph S Lu
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Zachary Elliott
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Alexander Knops
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Ramez Philips
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Zachary Urdang
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Leila J Mady
- Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Joseph M Curry
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
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5
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Asaad M, Lu SC, Hassan AM, Kambhampati P, Mitchell D, Chang EI, Yu P, Hanasono MM, Sidey-Gibbons C. The Use of Machine Learning for Predicting Complications of Free-Flap Head and Neck Reconstruction. Ann Surg Oncol 2023; 30:2343-2352. [PMID: 36719569 DOI: 10.1245/s10434-022-13053-3] [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: 04/29/2022] [Accepted: 12/22/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Machine learning has been increasingly used for surgical outcome prediction, yet applications in head and neck reconstruction are not well-described. In this study, we developed and evaluated the performance of ML algorithms in predicting postoperative complications in head and neck free-flap reconstruction. METHODS We conducted a comprehensive review of patients who underwent microvascular head and neck reconstruction between January 2005 and December 2018. Data were used to develop and evaluate nine supervised ML algorithms in predicting overall complications, major recipient-site complication, and total flap loss. RESULTS We identified 4000 patients who met inclusion criteria. Overall, 33.7% of patients experienced a complication, 26.5% experienced a major recipient-site complication, and 1.7% suffered total flap loss. The k-nearest neighbors algorithm demonstrated the best overall performance for predicting any complication (AUROC = 0.61, sensitivity = 0.60). Regularized regression had the best performance for predicting major recipient-site complications (AUROC = 0.68, sensitivity = 0.66), and decision trees were the best predictors of total flap loss (AUROC = 0.66, sensitivity = 0.50). CONCLUSIONS ML accurately identified patients at risk of experiencing postsurgical complications, including total flap loss. Predictions from ML models may provide insight in the perioperative setting and facilitate shared decision making.
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Affiliation(s)
- Malke Asaad
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sheng-Chieh Lu
- Department of Symptom Research, MD Anderson Center for INSPiRED Cancer Care, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abbas M Hassan
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Praneeth Kambhampati
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - David Mitchell
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- McGovern Medical School, Houston, TX, USA.
| | - Edward I Chang
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C Sidey-Gibbons
- Department of Symptom Research, MD Anderson Center for INSPiRED Cancer Care, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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6
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Development of a Risk Prediction Model for Complications Following Forehead Flaps for Nasal and Periorbital Reconstruction. J Craniofac Surg 2023; 34:362-367. [PMID: 36184771 DOI: 10.1097/scs.0000000000009030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 08/20/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Forehead flaps are a workhorse for nasal reconstruction, but complications occur in up to 30% of patients and risk factors are not well characterized. This study aimed to identify risk factors for complications, and provide clinicians a method to stratify patient risk to facilitate shared decision-making. MATERIALS AND METHODS This retrospective study included patients who underwent forehead flaps between 2007 and 2020. Demographic and treatment characteristics were abstracted, in addition to clinical outcomes data. Multivariable regression was conducted, with step-wise variable elimination to determine inclusion in the final model. From the final regression, a risk-stratification scheme was developed. RESULTS One hundred ninety-seven patients underwent forehead flap reconstruction, with a mean age of 68.5 years. Mean follow-up time was 42 months. There were 50 (25.4%) patients who developed a complication, including impaired nasal function (18.8%), flap congestion (5.1%), infection (2.5%), poor donor site healing (2.5%) wound dehiscence (2.0%), and flap congestion (1.5%). On univariate analysis, female sex, immunosuppression, prior radiotherapy, and larger resection area were associated with complications ( P <0.05). On multivariable analysis, female sex [odds ratio (OR): 3.89, P <0.001], hypoalbuminemia (OR: 3.70, P =0.01), and prior wide local excision (OR: 3.62, P =0.04) were predictors of complications. A clinical calculator was developed incorporating these risk factors, with a C-statistic of 0.85, indicating strong predictive value. CONCLUSIONS We conducted the most comprehensive review of risk factors for the development of complications after forehead flap reconstruction. From this analysis, a novel, implementable, risk-stratification scheme was developed to equip surgeons with the ability to provide individualized risk assessment to patients and address preoperative comorbidities to optimize outcomes.
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7
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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.
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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
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8
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Brauer PR, Byrne PJ, Prendes BL, Ku JA, Ciolek PJ, Jia X, Lamarre ED. Association between hypertension requiring medication and 30-day outcomes in head and neck microvascular surgery. Head Neck 2021; 44:168-176. [PMID: 34704643 DOI: 10.1002/hed.26907] [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: 06/29/2021] [Revised: 09/02/2021] [Accepted: 10/15/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hypertension has been shown to be both a protective factor and a risk factor for complications in head and neck reconstructive surgery. METHODS Retrospective analysis of microvascular free tissue transfer patients using the National Surgical Quality Improvement Program database. RESULTS Hypertensive patients (n = 1598; 46.9%) had a significantly higher rate of complications, including pneumonia (p < 0.001), myocardial infarction (p = 0.003), and intra/post-operative transfusion (p < 0.001). In a multivariable model, hypertension was associated with returning to the operating room (OR = 1.45 [95% CI 1.20, 1.76], p < 0.001), post-operative medical complications (OR = 1.53 [95% CI 1.24, 1.90], p < 0.001), and surgical complications (OR = 1.17 [95% CI 1.00, 1.37], p = 0.047). However, no difference in 30-day readmission was found (p > 0.05). CONCLUSIONS Hypertension is a modifiable risk factor for post-operative complications in head and neck free tissue transfer, in which prospective studies are required to establish causation. This study may serve as an impetus for proactive recommendations to manage hypertension before undergoing head and neck microvascular surgery.
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Affiliation(s)
- Philip R Brauer
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick J Byrne
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jamie A Ku
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peter J Ciolek
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xuefei Jia
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric D Lamarre
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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9
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Ali B, Choi EHE, Barlas V, Menon NG, Morrell NT. Unplanned reoperations after microsurgical breast reconstruction: Findings from the American College of Surgeons National Surgical Quality Improvement Program. Microsurgery 2021; 42:135-142. [PMID: 34658057 DOI: 10.1002/micr.30820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 05/18/2021] [Accepted: 09/17/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND While microsurgical breast reconstruction may require multiple planned operations, unplanned reoperations has not been studied. We sought to investigate unplanned reoperations after microsurgical breast reconstruction. METHODS We queried the American College of Surgeons' National Surgical Quality Improvement Program between 2005 and 2018. Current Procedural Terminology code 19364 was used to identify all patients with microsurgical breast reconstruction. Patient demographics, medical comorbidities, preoperative laboratory results, and operative data were analyzed. The primary outcome measure was 30-day unplanned reoperation. RESULTS Of 8449 patients meeting inclusion criteria, 1021 required an unplanned reoperation (12.1%). These patients were more likely to be obese, smokers, hypertensive, on steroids preoperatively, needing concomitant mastectomy, and with prolonged operating room time >9 h (p < .05). Multivariable regression model revealed preoperative steroids intake (OR = 1.92, CI 1.09-3.38, p = .03), concomitant mastectomy (OR = 1.45, CI 1.23-1.71, p < .01), and operating room time >9 h (OR = 1.37, CI 1.16-1.62, p < .01) as independent risk factors. Mastectomy was found to be an independent risk factor for early reoperation, that is, ≤2 days (OR = 1.44, CI 1.14-1.82, p < .01), whereas obesity was an independent risk factor for three reoperations (OR = 3.92, CI 1.14-13.46, p = .03). CONCLUSION Unplanned reoperations within 30-days after microsurgical breast reconstruction are a significant problem. Mastectomy is an independent risk factor for early reoperation whereas obesity is an independent risk factor for multiple reoperations. Identification of such patients preoperatively may help microsurgeons improve patient safety and quality of care.
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Affiliation(s)
- Barkat Ali
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Eun Ho Eunice Choi
- Statistics and Epidemiology and Research Designs, Clinical and Translational Science Center, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Venus Barlas
- School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Nathan G Menon
- Department of Orthopedics, Hand and Microsurgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Nathan T Morrell
- Department of Orthopedics, Hand and Microsurgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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10
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Mady LJ, Poonia SK, Baddour K, Snyder V, Kurukulasuriya C, Frost AS, Cannady SB, Chinn SB, Fancy T, Futran N, Hanasono MM, Lewis CM, Miles BA, Patel U, Richmon JD, Wax MK, Yu P, Solari MG, Sridharan S. Consensus of free flap complications: Using a nomenclature paradigm in microvascular head and neck reconstruction. Head Neck 2021; 43:3032-3041. [PMID: 34145676 DOI: 10.1002/hed.26789] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/10/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We aim to define a set of terms for common free flap complications with evidence-based descriptions. METHODS Clinical consensus surveys were conducted among a panel of head and neck/reconstructive surgeons (N = 11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of "good" or "fair") were eliminated. RESULTS Five out of nineteen terms scored K < 0.74. Eliminated terms included "vascular compromise"; "cellulitis"; "surgical site abscess"; "malocclusion"; and "non- or mal-union." Terms that achieved consensus were "total/partial free flap failure"; "free flap takeback"; "arterial thrombosis"; "venous thrombosis"; "revision of microvascular anastomosis"; "fistula"; "wound dehiscence"; "hematoma"; "seroma"; "partial skin graft failure"; "total skin graft failure"; "exposed hardware or bone"; and "hardware failure." CONCLUSION Standardized reporting would encourage multi-institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk-adjusted benchmarks, and enhance education and communication.
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Affiliation(s)
- Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Seerat K Poonia
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vusala Snyder
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Ariel S Frost
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Tanya Fancy
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Neal Futran
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brett A Miles
- Department of Otolaryngology, Northwell Health, New York, New York, USA
| | - Urjeet Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mario G Solari
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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11
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Miller H, Bush KM, Betances A, Kota R, Wu S, De Leo N, Gaughan J, Bonawitz S. Effect of Daily Dosage of Morphine Milligram Equivalents on Free Flap Complications: A Single-Institution Retrospective Study. J Plast Reconstr Aesthet Surg 2021; 74:2486-2494. [PMID: 33935007 DOI: 10.1016/j.bjps.2021.03.028] [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: 10/22/2020] [Revised: 01/16/2021] [Accepted: 03/11/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There appears to be an association between preoperative opioid use and postoperative complications. We sought to determine whether patients with a history of chronic opiate use (defined as 3 months or more of sustained use) prior to undergoing free flap surgery have higher rates of 30-day complications. METHODS A retrospective review of patients undergoing free flaps from 2015 to 2020 was performed. Patient characteristics were analyzed, including daily preoperative dose of opiates, which were then converted to morphine milligram equivalents; intra-operative variables such as estimated blood loss and operating room time; and 30-day outcomes, including wound and flap complications, return to the operating room, and readmissions. RESULTS One hundred fifty-five patients received 160 free flaps. Of these flaps, 50/160 (31%) were performed on patients with an opiate prescription for at least three months prior to surgery. Using multivariable analysis, morphine milligram equivalents, a surrogate for opioid dose, were significantly associated with flap complications (odds ratio (OR) 1.011, 95% confidence interval (CI) 1.003-1.020, p<0.01), partial flap loss (OR 1.010, 95% CI 1.003-1.019, p<0.01), and surgical site infections (OR 1.017, 95% CI 1.007-1.027, p<0.01). Additionally, estimated blood loss was associated with partial flap loss (OR 4.838, 95% CI 1.589-14.728, p<0.006), and operating room time was also associated with flap complications (OR 1.337, 95% CI 1.152-1.150, p<0.01). CONCLUSION Chronic preoperative opioid use is common for free flap surgery, and according to our single-center experience, higher daily doses are a risk factor for flap complications and surgical site infections. These findings add to the growing body of evidence that opioid use is a modifiable risk factor that may increase surgical morbidity.
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Affiliation(s)
- Henry Miller
- Department of Surgery, Cooper University Hospital, Camden NJ.
| | | | | | - Rasagnya Kota
- Cooper Medical School of Rowan University, Camden NJ
| | - Samantha Wu
- Cooper Medical School of Rowan University, Camden NJ
| | - Nicholas De Leo
- Department of Surgery, Cooper University Hospital, Camden NJ
| | - John Gaughan
- Cooper Research Institute, Cooper University Hospital, Camden NJ
| | - Steven Bonawitz
- Department of Surgery, Cooper University Hospital, Camden NJ
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12
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Hunger S, Krennmair S, Stehrer R, Postl L, Brandner A, Malek M. Closure of the radial forearm free flap donor site with split-thickness skin graft or amniotic membrane: A prospective randomized clinical study. J Craniomaxillofac Surg 2021; 49:403-414. [PMID: 33741237 DOI: 10.1016/j.jcms.2021.02.015] [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: 01/25/2020] [Revised: 11/12/2020] [Accepted: 02/15/2021] [Indexed: 11/18/2022] Open
Abstract
The purpose of this study was to compare the clinical, aesthetic, and functional outcomes between amniotic membrane (test group) and split-thickness skin grafts (control group) used for radial forearm free flap defect closure. The primary outcome measurement for both groups was assessment of the defect closure healing process. In addition, aesthetic (Vancouver Scar Scale) and functional outcomes (skin sensitivity, hand/wrist functionality, grip strength) were evaluated. Fifty eligible patients with radial forearm free flap donor site defects were randomly assigned to two groups receiving either amniotic membrane (test group; n = 25) or split-thickness skin graft (control group; n = 25) for defect covering. Forty-seven of the 50 patients (n = 47) were able to be followed up for 6 months and showed a significantly longer healing process (p < 0.001) with amniotic membrane (64.5 ± 38.4 days; n = 24) than with split-thickness skin grafts (29.2 ± 8.9 days; n = 23); however, there were no differences in the prevalence of healing defects/dehiscence and/or wound infections. Forty-two of the 47 patients (21 in each group) were able to be continually followed up for 12 months, and showed no differences in terms of clinical outcome as well as the subjective and objective aesthetic and functional results evaluated. With regard to the clinical, aesthetic, and functional outcomes evaluated for radial forearm free flap defects, coverage with amniotic membrane offers an excellent alternative treatment approach, avoiding secondary induced donor site morbidity.
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Affiliation(s)
- Stefan Hunger
- Department of Maxillofacial Surgery, Johannes Kepler University, 4020, Linz, Austria.
| | - Stefan Krennmair
- Department of Maxillofacial Surgery, Johannes Kepler University, 4020, Linz, Austria.
| | - Raphael Stehrer
- Department of Maxillofacial Surgery, Johannes Kepler University, 4020, Linz, Austria.
| | - Lukas Postl
- Department of Maxillofacial Surgery, Johannes Kepler University, 4020, Linz, Austria.
| | - Andreas Brandner
- Department of Maxillofacial Surgery, Johannes Kepler University, 4020, Linz, Austria.
| | - Michael Malek
- Department of Maxillofacial Surgery, Johannes Kepler University, 4020, Linz, Austria.
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13
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Henry RK, Reeves RA, Wackym PA, Ahmed OH, Hanft SJ, Kwong KM. Frailty as a Predictor of Postoperative Complications Following Skull Base Surgery. Laryngoscope 2021; 131:1977-1984. [PMID: 33645657 DOI: 10.1002/lary.29485] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 01/23/2021] [Accepted: 02/16/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE/HYPOTHESIS Frailty has emerged as a powerful risk stratification tool across surgical specialties; however, an analysis of the impact of frailty on outcomes following skull base surgery has not been published. The aim of this study was to assess the validity of the 5-factor modified frailty index (mFI-5) as a predictor of perioperative morbidity and mortality in patients undergoing skull base surgery. METHODS A mFI-5 score was calculated for patients undergoing skull base surgeries using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2018. Multivariate logistic regression analysis was used to evaluate the association of increasing frailty with complications in the 30-day postoperative period, with a subanalysis by operative location. RESULTS A total of 17,912 patients who underwent skull base procedures were identified, with 45.5% of patients having a frailty score of one or greater; 44.9% were male and the mean age was 52.0 (±16.1 SD) years. Multivariable regression analysis revealed frailty to be an independent predictor of overall complications (odds ratio [OR]: 1.325, P < .001), life-threatening complications (OR: 1.428, P < .001), and mortality (OR: 1.453, P < .001). Higher frailty also correlated with increased length of stay. When procedures were stratified by operative location, frailty correlated significantly with overall complications for middle, posterior, and multiple-fossae operations but not the anterior fossa. CONCLUSIONS Frailty demonstrates a significant and stepwise association with life-threatening postoperative morbidity, mortality, and length of stay following skull base surgeries. mFI-5 is an objective and easily calculable measure of preoperative risk, which may facilitate perioperative planning and counseling regarding outcomes prior to surgery. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1977-1984, 2021.
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Affiliation(s)
- Roger K Henry
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A
| | - Russell A Reeves
- Department of Radiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - P Ashley Wackym
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A
| | - Omar H Ahmed
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A
| | - Simon J Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, U.S.A
| | - Kelvin M Kwong
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A
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14
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Jacobs D, Kafle S, Earles J, Rahmati R, Mehra S, Judson BL. Prolonged inpatient stay after upfront total laryngectomy is associated with overall survival. Laryngoscope Investig Otolaryngol 2021; 6:94-102. [PMID: 33614936 PMCID: PMC7883619 DOI: 10.1002/lio2.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/12/2020] [Accepted: 07/25/2020] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To investigate factors and complications associated with prolonged inpatient length of stay (LOS) in patients who receive total laryngectomy (TL), and to analyze its effect on short-term and long-term overall survival (OS). METHODS The National Cancer Database (NCDB) was queried from 2004 to 2016 for patients with laryngeal cancer, who received TL within 60 days of diagnosis, and who had an inpatient LOS ≥1 night. Multivariable binary logistic regression and survival analyses on propensity score matched cohorts with Kaplan-Meier analysis and extended Cox regression were utilized. RESULTS Eight thousand two hundred and ninety-eight patients from the NCDB were included. Median inpatient LOS was 8 days after TL (IQR: 7, 12). Prolonged LOS was defined as above the 75th percentile or 13 days or greater. On multivariable analysis, increasing patient age (OR 1.14 per 10 years, P = .003), female sex (OR 1.35, P < .001), and Charlson-Deyo comorbidity score of ≥2 compared to a score of 0 (OR 1.43, P < .001) were associated with prolonged LOS. Patients treated at high surgical case volume centers had a decreased likelihood for prolonged LOS (OR 0.67, P < .001). Ninety-day mortality increased over time in patients who stayed ≥13 days. Prolonged LOS was independently associated with worse OS on multivariable analysis (HR 1.40, 95% CI: 1.22, 1.61) in a matched cohort. CONCLUSIONS Prolonged LOS after TL serves as a strong indicator for postoperative long-term mortality and may help identify patients who warrant closer surveillance. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Daniel Jacobs
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Samipya Kafle
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Joseph Earles
- Division of Otolaryngology, Department of SurgeryYale University School of MedicineNew HavenConnecticutUSA
| | - Rahmatullah Rahmati
- Division of Otolaryngology, Department of SurgeryYale University School of MedicineNew HavenConnecticutUSA
| | - Saral Mehra
- Division of Otolaryngology, Department of SurgeryYale University School of MedicineNew HavenConnecticutUSA
| | - Benjamin L. Judson
- Division of Otolaryngology, Department of SurgeryYale University School of MedicineNew HavenConnecticutUSA
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Reconstruction of Full-thickness Soft Tissue Defects with Integra: Risk Factors and Treatment Algorithm. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3099. [PMID: 33133950 PMCID: PMC7544316 DOI: 10.1097/gox.0000000000003099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 06/30/2020] [Indexed: 11/26/2022]
Abstract
Background: Despite the fact that dermal substitutes are widely used in reconstructive surgery, there have been no studies focused on predictors of complications or delayed matrix take. We propose an algorithm for management of soft tissue reconstruction with Integra dermal matrix, based on our 5-year-long clinical experience. Methods: An estimated 111 patients who underwent Integra reconstruction of full-thickness soft tissue defects of different anatomical sites and etiology were enrolled, and dichotomized in two groups according to complications. Participants were further studied according to the wound healing strategy: healing by secondary intention, skin graft (STSG), and flap surgery. A regression analysis was conducted in the whole sample to identify possible predictors of complications. Results: No significant differences according to complications were observed. The between-group statistical analysis showed significant differences in age, comorbidities, defect area, diagnosis, and defect site. The regression analysis revealed that the timing of split-thickness skin graft (STSG) was not influenced by age, comorbidities, body mass index (BMI), defect area, site, wound etiology, and risk factors in the subjects who underwent a two-step reconstruction. Healing by secondary intention is recommended for small post-oncological defects of the head, especially in elderly and multimorbid patients. Variables that may interfere with dermal substitutes’ incorporation are independent of the timing of STSG placement; therefore, no predictors of complications or delayed matrix take were identified. Conclusions: Our findings showed that Integra can be used in a wide range of patients regardless of their general features, thus acting as a useful alternative to conventional reconstructive techniques in selected cases.
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16
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Reconstruction with Free Flaps of Head and Neck Cancer Defects: A National Cohort Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3018. [PMID: 32983776 PMCID: PMC7489632 DOI: 10.1097/gox.0000000000003018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/08/2020] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to determine the perioperative mortality rate, reintervention rate, and total healthcare costs for head and neck cancer patients who underwent free tissue transfer (FTT) in Colombia. The prognostic factors associated with those results were estimated.
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17
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Liu SW, Woody NM, Wei W, Appachi S, Contrera KJ, Tsai JC, Ghanem AI, Matia B, Joshi NP, Geiger JL, Ku JA, Burkey BB, Scharpf J, Prendes BL, Caudell JJ, Dunlap NE, Adelstein DJ, Porceddu S, Liu H, Siddiqui F, Lee NY, Koyfman S, Lamarre ED. Evaluating compliance with process-related quality metrics and survival in oral cavity squamous cell carcinoma: Multi-institutional oral cavity collaboration study. Head Neck 2020; 43:60-69. [PMID: 32918373 DOI: 10.1002/hed.26454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/01/2020] [Accepted: 08/24/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Process-related measures have been proposed as quality metrics in head and neck cancer care. A recent single-institution study identified four key metrics associated with increased survival. This study sought to validate the association of these quality metrics with survival in a multi-institutional cohort. METHODS Multicenter retrospective study of patients with oral cavity squamous cell (1/2005-1/2015). Baseline patient and disease characteristics and compliance with quality metrics was evaluated. Association between compliance with quality metrics with overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) was evaluated using Cox proportional hazards models. RESULTS Failure to comply with two or more of the quality metrics was associated with worse OS, DFS, and DSS. Adherence to all or all but one of the quality metrics was found to be associated with improved survival. CONCLUSIONS Process-related quality metrics are associated with increased survival in patients with oral cavity squamous cell carcinoma in a multi-institutional cohort.
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Affiliation(s)
- Sara W Liu
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Neil M Woody
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wei Wei
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Swathi Appachi
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jillian C Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ahmed I Ghanem
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI, USA
| | - Brian Matia
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nikhil P Joshi
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jamie A Ku
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brian B Burkey
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph Scharpf
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jimmy J Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Neal E Dunlap
- Department of Radiation Oncology, University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Sandro Porceddu
- Department of Radiation Oncology, Princess Alexandra Hospital/University of Queensland, Brisbane, QLD, Australia
| | - Howard Liu
- Department of Radiation Oncology, Princess Alexandra Hospital/University of Queensland, Brisbane, QLD, Australia
| | - Farzan Siddiqui
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI, USA
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shlomo Koyfman
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric D Lamarre
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
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18
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Karamanos E, Shah AR, Kim JN, Wang HT. Impact of Blood Transfusion in Free Flap Breast Reconstruction Using Propensity Score Matching. J Reconstr Microsurg 2020; 37:315-321. [PMID: 32892332 DOI: 10.1055/s-0040-1716388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Microvascular thrombosis has been associated with cytokine release and inflammatory syndromes which can occur as a result of blood transfusions. This phenomenon could potentially lead to complications in breast free flap reconstruction. The aim of this study was to evaluate the impact of perioperative blood transfusion in free flap breast reconstruction using large population analysis. METHODS The American College of Surgeons National Quality Improvement Program database was queried for delayed free flap breast reconstructions performed in 2016. The study population was divided based on perioperative blood transfusion within 24 hours of the start of the operation. Propensity score matching analysis was used to ensure homogeneity between the two study groups. Primary outcome was unplanned return to the operating room (OR) within 30 days. Secondary outcomes were readmission and complications. RESULTS A total of 1,256 patients were identified. Out of those, 91 patients received a perioperative blood transfusion. All the patients received only one unit of PRBC within the first 24 hours. Those patients were matched with similar patients who did not receive a transfusion on a ratio of 1:3 (273 patients). Patients who received a transfusion had a significantly higher incidence of reoperation (42 vs. 10%, p < 0.001). Patients who received a transfusion were more likely to return to the OR after 48 hours from the initial operation (13 vs. 5%, p = 0.001). All returns to the OR were due to flap-related complications. Perioperative blood transfusion increased the incidence of wound dehiscence (9 vs. 2%, p = 0.041) but had no protective effect on the development of other postoperative complications. CONCLUSION Perioperative blood transfusion in free flap breast reconstruction is associated with an increased probability of flap-related complications and subsequent return to the OR without decreasing the probability of developing other systemic postoperative complications.
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Affiliation(s)
- Efstathios Karamanos
- Department of Surgery, Division of Plastic and Reconstructive Surgery, UT Health San Antonio, San Antonio, Texas
| | - Amita R Shah
- Department of Surgery, Division of Plastic and Reconstructive Surgery, UT Health San Antonio, San Antonio, Texas
| | - Julie N Kim
- Department of Surgery, Division of Plastic and Reconstructive Surgery, UT Health San Antonio, San Antonio, Texas
| | - Howard T Wang
- Department of Surgery, Division of Plastic and Reconstructive Surgery, UT Health San Antonio, San Antonio, Texas
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