Early postoperative care for free flap head & neck reconstructive surgery - a national survey of practice

Tracheostomy Incidence and Complications: A National Database Analysis

OBJECTIVE

To describe the incidence of tracheostomy-related complications and identify prognostic risk factors.

STUDY DESIGN

Administrative database analysis.

SETTING

Outpatient and inpatient insurance claims records obtained from a national database.

METHODS

PearlDiver, a private analytics database of insurance claims from Medicare, Medicaid, and commercial insurance companies, was used to identify patients who underwent tracheostomies and associated complications between January 2010 and October 2021 by CPT and ICD-9/ICD-10 codes.

RESULTS

A total of 198,143 tracheostomies were identified from PearlDiver, and at least 1 tracheostomy-related complication occurred within 90 days of the procedure in 22,802 (10.3%) of these cases. The proportion of tracheostomy-related complications was 2.3 times higher in 2019 compared to 2010 (95% confidence interval [CI]: 2.18-2.52). The risk of developing tracheostomy-complications was associated with the hospital region (highest in the Midwest as compared to the West [odds ratio [OR] = 1.32; 95% CI: 1.25-1.39]), provider specialty (highest for otolaryngologists as compared to nonsurgical physicians [OR = 2.22; 95% CI: 2.10-2.34]), insurance plan type (lowest for cash payment compared to Medicaid [OR = 0.70, 95% CI: 0.50-0.94]), and Elixhauser Comorbidity Index (ECI) (highest in patients with ECI of 7+ compared to 0-1 [OR = 2.96; 95% CI: 2.17-3.24]), but was not significantly associated with patient age (OR = 0.99; 95% CI: 0.99-0.99), or gender (OR = 1.04; 95% CI: 1.01-1.07).

CONCLUSIONS

Complications after tracheostomy are common and sicker patients are at higher risk for complications. Identifying factors associated with increased risk for complications could help to improve patient and family counseling, guide quality improvement initiatives, and inform future studies on tracheostomy outcomes.

Recent developments in delirium after oral and maxillofacial free-flap reconstruction

Postoperative delirium (POD), a common complication following surgery and anesthesia, is particularly prone to occur after reconstruction surgery in the oral and maxillofacial region. The occurrence of POD seriously affects the incidence of postoperative complications, the survival of free flaps, the length of hospital stays, and brings great pain to patients and their families, and even increases perioperative mortality. Currently, a large number of studies have reported on the risk factors for POD after oral and maxillofacial free-flap reconstruction. Multiple independent risk factors have been identified, including age, history of excessive alcohol consumption, and perioperative nutritional status. This review summarizes the relevant literature and hopes to provide insights for the prevention of POD in high-risk patients.

Tracheostomy Avoidance in Flap Reconstruction of the Upper Aerodigestive Tract is Safe in Selected Patients

OBJECTIVE

Assess the impact of tracheostomy on postoperative morbidity and mortality and examine factors that predicted tracheostomy in head and neck flap patients.

STUDY DESIGN

Retrospective cohort January 2017 to December 2021.

SETTING

Single tertiary center.

METHODS

Adult patients undergoing head and neck flap reconstruction were included, excluding cutaneous reconstruction, laryngectomy, or with tracheostomy present at surgery. Patients were routinely extubated immediately following surgery. Univariate and multivariable analyses examined associations between tracheostomy and postoperative outcomes and identified predictors of tracheostomy.

RESULTS

We included 193 patients, 69 (35.8%) with tracheostomy and 124 (64.2%) without. Tracheostomy avoidance was associated with no difference in 30-day mortality (P = .531) and with decreased likelihood of 30-day complications (0.019), unplanned return to the operating room (0.021), and discharge to a facility (<0.001) and with 2.2 decrease in length of stay on multivariable analysis (confidence interval [CI]: 0.62-3.82, P = .007). Four patients (2.1%) required reactive tracheostomy with no resulting mortalities. Significant associations with tracheostomy on multivariable analysis included bilateral neck dissections (odds ratio [OR]: 3.13, CI 1.12-9.06, P = .030), number of resected mandibular subsites (OR: 2.65, CI: 1.50-5.67, P = .0023), specimen volume (OR: 1.87, CI: 1.29-2.71, P = .001), body mass index < 20 (OR: 3.80, CI: 1.24-11.64, P = .019), mandibulectomy (OR: 0.04, CI: 0.01-0.22, P < .001), forearm flap (OR: 0.15, CI: 0.05-0.41, P < .001), oral cavity site (OR: 0.21, CI: 0.06-0.73, P = .014), and age > 70 (OR: 0.33, CI: 0.14-0.81, P = .016).

CONCLUSION

Tracheostomy avoidance is safe in properly selected patients undergoing head and neck flap reconstruction. Multiple factors predicted tracheostomy, which may guide patient selection at other centers.

Can Prophylactic Tracheostomy be Avoided in Advanced Oral Cancer Surgery for Airway Management? An Experience and Guidelines from a Tertiary Care Facility

Aim

To evaluate the surgical and postoperative management strategies that contribute to minimizing the need for prophylactic tracheostomy for airway management in advanced oral cancer surgery.

Methods

A retrospective review of the patients who underwent surgery for advanced oral cancer, in our institution from February 2015 to January 2024.

Results

In the present review, 66 patients (males, n = 54; females, n = 12; mean age 50.3 years) who were operated for advanced oral cancer (T3, T4 oral squamous cell carcinoma and osteosarcoma of the mandible requiring mandibular resection) in our institution were included. 60 patients (90.9%) had reconstruction after segmental resection of the mandible without the need for prophylactic tracheostomy. Out of these, eighteen patients (27.27%) required segmental resection of the mandible crossing midline. Six patients (9.1%) underwent prophylactic tracheostomy, of which two patients had unilateral tumor and four patients had tumor crossing midline. Comparison of hospital stays between patients who underwent prophylactic tracheostomy and those who did not yielded mean durations of 13.3 days and 7.6 days, respectively.

Conclusion

Except a subset of patients with old age, obesity, bulky neck, and those with respiratory compromise, following the present guidelines, prophylactic tracheostomy can be avoided in patients undergoing surgery for advanced oral cancer.

Is There an Over-Indication for Elective Tracheostomy in Patients With Oral Cavity Cancer?

OBJECTIVES

Temporary tracheostomies (TT) are often used in oral oncologic surgery to secure the postoperative airway. Our primary objective was to determine if there was an over-indication for elective tracheostomy in our population. If so, our secondary objective was to ascertain which patients could have possibly avoided TT.

MATERIALS AND METHODS

We performed a retrospective study of patients with oral and oropharyngeal squamous cell carcinoma in which resection with curative intent and TT were performed. Variables collected included demographics, comorbidities, and complications. Additionally, we retrospectively applied the Cameron and TRACHY tracheostomy scoring systems to evaluate overall tracheostomy recommendations.

RESULTS

A total of 116 elective tracheostomies were performed between January 2019 and December 2020. According to the Cameron and TRACHY scoring systems, recommendations for tracheostomy coincided in only 54.3% and 45.7%, respectively. Tumor anatomy and type of reconstruction were associated with less time until decannulation. Additionally, in patients without TT recommendation determined by both scores with tumor anatomy and location, as well as T and N stages were also associated with less time until decannulation.

CONCLUSION

There appears to be an over-indication for elective tracheostomy in our patients with oral cavity and oropharyngeal cancer. The patients that could have potentially avoided elective TT were those with lateral anatomy, without flap or with fasciocutaneous flap, location in the mandibular alveolus or anterior tongue, as well as N0/N1 and T1/T2 patients.

Application of delayed extubation for the free-flap reconstruction of oral and maxillofacial defects in patient with oral diseases

Tracheostomy and delayed extubation (DE) are two methods for managing patients' airways postoperatively after oral and maxillofacial free flap transplantation. We aimed to determine the safety of both the tracheostomy and DE by conducting a retrospective study in patients undergoing oral and maxillofacial free-flap transfer from September, 2017 to September, 2022. The primary outcome was incidence of postoperative complication. Secondary outcome was measured as factors leading to perioperative performance of airway management. Ninety-five of 148 patients received delayed extubation perioperatively. In comparison to the tracheostomy group, the DE group had fewer overall postoperative complications (p = 0.028). During the postoperative period, fewer patients from the DE group required a return to the operating room, in comparison to those from the tracheostomy group (p = 0.045). The duration of surgery (p = 0.006), time in ICU (p = 0.015), duration of artificial nutrition (p < 0.001), duration of hospitalization (p < 0.001) in the DE group were all significantly shorter when compared with the tracheostomy group. In conclusion, when used in appropriate cases of oral and maxillofacial free flap transplantation patients, delayed extubation can be a safe and effective alternative to tracheostomy.

Realities and challenges of head and neck free flap reconstruction in sub-Saharan Africa

PURPOSE OF REVIEW

With an increased need to decentralize and train more head and neck ablative and reconstructive surgeons in sub-Saharan Africa, we assess the realities and challenges of free flap reconstruction in sub-Saharan Africa to provide context of its use as a reconstructive option.

RECENT FINDINGS

Head and neck free flap reconstruction has been performed by local teams as well as visiting teams in Sub Saharan Africa with good results. Free flap success rates are similar to high income regions at 89% vs. 85-100%. However, flap salvage rates are significantly lower (45% compared to 64.1% reported in high income regions). This has been attributed to resource constraints.

SUMMARY

With increasing efforts to increase free flap reconstructive capacity in sub-Saharan Africa, these efforts need to be in the context of available healthcare resources including infrastructure and workforce outside of the surgical team. As training of head and neck ablative and reconstructive surgeons is expanded, reconstructive training needs take the healthcare resource availability into account.

Airway management following head and neck microvascular reconstruction: is tracheostomy mandatory?

OBJECTIVES

Airway management following maxillofacial microvascular reconstruction is a fundamental part of the perioperative management. In oral cavity microvascular reconstruction, the airway is potentially compromised by airway edema, flap edema or bulkiness, hematoma formation, or upper airway sequelae from surgery. Classical teaching advocates elective tracheostomy in patients undergoing maxillofacial free flap reconstruction, while others keep patients intubated overnight (delayed extubation). The optimal method for perioperative airway management is still debated. This study aim was to evaluate the morbidity associated with elective tracheostomy in patients undergoing maxillofacial microvascular reconstruction and to recognize those patients who can avoid elective tracheostomy.

METHODS

Retrospective review of patients who underwent maxillofacial microvascular free flap reconstruction, between November 1^st 2010 and October 31^st 2019 in our center.

RESULTS

One-hundred and nine patients underwent microvascular reconstruction in the maxillofacial region. Sixty-one patients underwent an elective tracheostomy upon the primary surgery. Forty-eight patients were left intubated overnight. Seven patients underwent a late tracheostomy which was performed upon a neck re-exploration for postoperative complications, except for one patient which was due to failed extubation attempt. Patients who didn't receive an elective tracheostomy were younger and had a shorter duration of postoperative hospitalization. Seven patients suffered from tracheostomy- related complications, all of them underwent elective tracheostomy and none were from the late tracheostomy group.

CONCLUSIONS

Our results suggest, the routine use of elective tracheostomy in maxillofacial microvascular free flap reconstruction is unnecessary. Elective tracheostomy should be considered on case-to-case basis.

LEVEL OF EVIDENCE: 4

Critical Importance of the First Postoperative Days After Head and Neck Free Flap Reconstruction: An Analysis of Timing of Reoperation Using the National Surgical Quality Improvement Program Database

BACKGROUND

Head and neck free flaps remain associated with considerable rates of take-back and prolonged hospital length of stay. However, there have been no studies on a national level benchmarking the timeline and predictors of head and neck free flap take-back.

METHODS

Patients undergoing head and neck free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012-2019 database were analyzed to determine the rates of take-back. Timing and rates of unplanned head and neck free flap take-backs were stratified by tissue type and postoperative day (POD) over the first month. Weibull survival models were used to compare rates of take-backs among time intervals. Multivariable logistic regression was used to identify the independent predictors of take-back.

RESULTS

Three thousand nine hundred six head and neck free flaps were analyzed. The mean daily proportion of patients experiencing take-back during PODs 0 to 1 was 0.95%; this dropped significantly to a mean daily proportion of 0.54% during POD 2 (P < 0.01). In addition, there were significant drops in take-back when comparing POD 2 (0.54%) to POD 3 (0.26%) and also when comparing POD 4 (0.20%) with PODs 5 to 30 (0.032% per day) (P < 0.05). The soft tissue and osseous flap populations demonstrated a similar trend in unplanned take-back.

CONCLUSION

This is the first national study to specifically analyze the timing of take-back in the head and neck reconstruction population. These data highlight the importance of flap monitoring during the first 5 PODs, with ERAS pathway optimization aiming for discharge by the end of the first postoperative week.

[Clinical analysis of selective tracheostomy necessary for patients undergoing head and neck surgery with free flap reconstruction]

OBJECTIVE

To discover the factors that may affect the use of selective tracheostomy among patients who have undergone head and neck surgeries with free flap reconstruction, so that the patients will not need tracheostomy nor receive the unnecessary treatment.

METHODS

Five hundred and thirty-three patients who had undergone head and neck surgery with free flap reconstruction operated by the same team of surgery at Department of Oral and Maxillofacial Surgery at Peking University School of Stomatology from 2015 to 2016 were reviewed. Three hundred and twenty-one (60.2%) of these patients underwent selective tracheostomy. All the patients' demographic information, operation-related information, prior treatments, comorbidities and complications were recorded and analyzed.

RESULTS

The patients with defects of the tongue, mouth floor, oropharynx and bilateral mandible, who underwent neck dissection and with previous radiotherapy and smoking habit were more likely to get selective tracheostomy. Usage of bulky soft tissue flap might also add to the risk of airway obstruction and the need of selective tracheostomy, while other factors were not significantly related to the risk of postoperative airway obstruction and the patients could be kept safe without selective tracheostomy. Most cases without tracheostomy were kept safe except one case, while 8.39% of the patients with tracheostomy suffered from tracheostomy related complications, mainly pneumonia and hemorrhage of the tracheostomy wound, yet none led to serious consequences or even death.

CONCLUSION

Selective tracheostomy is not necessary for patients who have undergone head and neck surgeries with free flap reconstruction except that there are defects at the tongue, oropharynx and mandible. Neck dissection, bulky soft tissue flap reconstruction, previous radiotherapy and smoking habit may also add to the risk of postoperative airway obstruction, while a favorable decision would involve a combination of all the above factors to assure the safety of the postoperative airway for the patients undergone head and neck surgeries with free flap reconstruction.

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

Background

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

Methods

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

Results

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

Conclusions

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

Immersive virtual reality (VR) training increases the self-efficacy of in-hospital healthcare providers and patient families regarding tracheostomy-related knowledge and care skills: A prospective pre-post study

BACKGROUND

Virtual reality (VR)-based simulation in hospital settings facilitates the acquisition of skills without compromising patient safety. Despite regular text-based training, a baseline survey of randomly selected healthcare providers revealed deficiencies in their knowledge, confidence, comfort, and care skills regarding tracheostomy. This prospective pre-post study compared the effectiveness of regular text- and VR-based intervention modules in training healthcare providers' self-efficacy in tracheostomy care skills.

METHODS

Between January 2018 and January 2020, 60 healthcare providers, including physicians, nurses, and respiratory therapists, were enrolled. For the intervention, a newly developed head-mounted display (HMD) and web VR materials were implemented in training and clinical services. Subsequently, in-hospital healthcare providers were trained using either text or head-mounted display virtual reality (HMD-VR) materials in the regular and intervention modules, respectively. For tracheostomy care skills, preceptors directly audited the performance of trainees and provided feedback.

RESULTS

At baseline, the degree of trainees' agreement with the self-efficacy-related statements, including the aspects of familiarity, confidence, and anxiety about tracheostomy-related knowledge and care skills, were not different between the control and intervention groups. At follow-up stage, compared with the regular group, a higher percentage of intervention group' trainees reported that they are "strongly agree" or "somewhat agree" that the HMD-VR simulation increases their self-efficacy, including the aspects of familiarity and confidence, and reduced their anxiety about tracheostomy-related knowledge and care skills. After implementation, a higher degree of trainees' average satisfaction with VR-based training and VR materials was observed in the intervention group than in the regular group. Most reported that VR materials enabled accurate messaging and decreased anxiety. The increasing trend of the average written test and hands-on tracheostomy care skills scores among the intervention group trainees was significant compared to those in the regular group. The benefits of HMD-VR simulations and web-VR material-based clinical services for in-hospital healthcare providers and patient families persisted until 3 to 4 weeks later.

CONCLUSION

The current study suggests that VR materials significantly enhance trainees' self-efficacy (increased familiarity, increased confidence, and reduced anxiety) and their satisfaction with the training, while motivating them to use acquired knowledge and skills in clinical practice.

Postoperative care in ICU versus non-ICU after head and neck free-flap surgery: a systematic review and meta-analysis

OBJECTIVE

Admission to the intensive care unit (ICU) has long been considered as routine by most head and neck surgeons after microvascular free-flap transfer. This study aimed to answer the question 'Is there a difference in the flap survival and postoperative complications rates between admission to intensive care unit (ICU) versus Non-ICU following microvascular head and neck reconstructive surgery?'.

DESIGN

Systematic review, and meta-analysis.

METHODS

The PubMed, Embase, Scopus and Cochrane Library electronic databases were systematically searched (till April 2021) to identify the relevant studies. Studies that compared postoperative nursing of patients who underwent microvascular head and neck reconstructive surgery in ICU and non-ICU were included. The outcome variables were flap failure and length of hospital stay (LOS) and other complications. Weighted OR or mean differences with 95% CIs were calculated.

RESULTS

Eight studies involving a total of 2349 patients were included. No statistically significant differences were observed between ICU and non-ICU admitted patients regarding flap survival reported (fixed, risk ratio, 1.46; 95% CI 0.80 to 2.69, p=0.231, I²=0%), reoperation, readmission, respiratory failure, delirium and mortality (p>0.05). A significant increase in the postoperative pneumonia (p=0.018) and sepsis (p=0.033) was observed in patients admitted to ICU compared with non-ICU setting.

CONCLUSION

This meta-analysis showed that an immediate postoperative nursing in the ICU after head and neck microvascular reconstructive surgery did not reduce the incidence of flap failure or complications rate. Limiting the routine ICU admission to the carefully selected patients may result in a reduction in the incidence of postoperative pneumonia, sepsis, LOS and total hospital charge.

Identification of patients for a delayed extubation strategy versus elective tracheostomy for postoperative airway management in major oral cancer surgery: A prospective observational study in seven hundred and twenty patients

OBJECTIVES

Tracheostomy (TT) and delayed extubation (DE) are two approaches to postoperative airway management in patients after major oral cancer surgery. We planned a study to determine the safety of overnight intubation followed by extubation the next morning (DE) compared to elective TT and to identify factors that were associated with a safe DE (maintenance of a patent airway).

MATERIAL AND METHODS

We conducted a prospective observational study in a tertiary referral cancer care center. We included adult patients undergoing elective major oral cancer surgery under general anesthesia with tracheal intubation. The decision regarding postoperative airway management using either TT or DE was made according to the usual practice at our center.

RESULTS

We screened a total of 4477 patients, 720 patients were included. DE was performed in 417 patients (58.4%) and TT in 303 patients (42.4%). On multivariable analysis, T1-T2 tumor stage, absence of extensive resection, primary closure or reconstruction using fasciocutaneous flap, absence of preoperative radiation, no neck dissection or unilateral neck dissection and shorter duration of anesthesia were independent predictors for a safe DE. Overall complications (4.3% versus 22.5%, p = 0.00) and airway complications (1.7% versus 8.7%, p = 0.00) were lower in the DE compared to the TT group respectively. DE was associated with a shorter hospital stay (7.2 ± 3.7 versus 11.5 ± 7.2 days, p = 0.00), time to oral intake and speech compared to TT.

CONCLUSIONS

A DE strategy after major oral cancer surgery is a safe alternative to TT in a select group of patients.

The degree of agreement between score-based decision and clinician's discretion regarding the need for tracheotomy in oral cancer surgery: A retrospective analysis

In oral cancer surgery, the decision to perform a tracheotomy is often determined by the surgeon. In this study, we investigated the competency of clinical scoring systems in identifying patients who require tracheotomy and examined the degree of agreement between the surgeon's decision and the indications of various scoring systems. We identified 110 patients who were surgically treated for oral cancer. Of these, 67 patients (44 men and 23 women) who underwent resection and reconstruction were retrospectively analyzed. To derive the score, we evaluated the endpoint of the airway management score using clinical records and images. We divided the patients into two groups based on the Cameron and Gupta scores (tracheotomy and no-tracheotomy groups) and evaluated the degree of agreement with the surgeon's decision by calculating the κ coefficient. The κ coefficients of the Gupta and Cameron scores were 0.61 (95% confidence interval [CI]: 0.40-0.82) and 0.60 (95% CI: 0.38-0.82), respectively. The clinical evaluation of the κ coefficient indicated that the Cameron and Gupta scores agreed fairly with the surgeon's decision. In this study, the Cameron and Gupta scores fairly agreed with the decision of experienced surgeons and were confirmed as acceptable guides for making clinical judgments.

The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part I: Summary and brief description of monitoring methods

Micro-vascular flaps have been used for the repair of challenging defects for over 45 years. The risk of failure is reported to be around 5-10% which despite medical and technical advances in recent years remains essentially unchanged. Precise, continuous, sensitive and specific monitoring together with prompt notification of vascular compromise is crucial for the success of the procedure. In this review, we provide a classification and brief description of the reported methods for monitoring the micro-vascular flap and a summary of the benefits over direct visual monitoring. Over 40 different monitoring techniques have been reported but their comparative merits are not always obvious. One looks for early detection of a flap's compromise, improved flap salvage rate and a minimal false-positive or false-negative rate. The cost-effectiveness of any method should also be considered. Direct visualisation of the flap is the method most generally used and still seems to be the simplest, cheapest and most reliable method for flap monitoring. Considering the alternatives, only implantable Doppler ultrasound probes, near infrared spectroscopy and laser Doppler flowmetry have shown any evidence of improved flap salvage rates over direct visual monitoring.

Postoperative Management After Total Pharyngolaryngectomy Using the Free Ileocolon Flap: A 5-Year Surgical Intensive Care Unit Experience

INTRODUCTION

Management after total pharyngolaryngectomy with free ileocolon flaps can be challenging. Adequate postoperative surgical guidelines are essential to avoid complications. Factors, such as agitation, hypotension, or prolonged mechanical ventilation, might compromise final outcomes. Herein, we describe our experience in the early postoperative care of patients after total pharyngolaryngectomy with immediate reconstruction using the free ileocolon flap.

METHODS

This is a retrospective review of all patients who underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. Demographics, etiology of resection, neoadjuvant therapy, surgical time, method of sedation, postoperative use of vasopressors, length of intensive care unit (ICU) stay, time of discontinuation of mechanical ventilation, and complications were recorded and analyzed.

RESULTS

Between 2010 and 2015, a total of 34 patients underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. The most common cause of total pharyngolaryngectomy was cancer. Twenty-eight patients had neoadjuvant therapy (radiation). The average surgical time was 11.5 hours (range, 8-14.5 hours), average length of ICU stay was 3 days (range, 2-15 days) with an average time for mechanical ventilation cessation of 3 days (range, 1-20 days). Midazolam and dexmedetomidine were the most common sedatives used during surgery and in the ICU period. Three patients required vasopressors due to hypotension, 2 had unplanned self-extubation from the tracheostomy site, 2 experienced postoperative bleeding, 1 had pneumonia, 4 required unplanned return to the operating room, 2 had partial flap loss, and 1 had complete flap loss.

CONCLUSIONS

Overall, a majority of patients recovered well postoperatively with minimal complications and low rate of reoperation. Our research provides a foundation to develop a risk-stratified approach to determine the need for an ICU admission or early transfer to floor care.

Evaluation of Scoring Systems for Airway Management After Oral Cancer Surgery: A Retrospective Study

OBJECTIVE

Postoperative airway obstruction following oral cancer surgery is difficult to predict. Scoring systems used to assess the need for tracheotomy use risk factors as criteria. We aimed to examine whether these clinical scoring systems can predict airway obstruction following oral cancer surgery.

METHODS

We assessed 95 patients who underwent oral cancer surgery without tracheotomy under general anesthesia between January 2007 and April 2019. We reviewed multiple factors from the patients' medical records, including age, sex, tumor site, body mass index, tumor stage, type of surgery, airway management method, Cameron and Gupta scores, and postoperative airway complications.

RESULTS

Tumors were located in the maxilla (n = 14), buccal mucosa (n = 13), mandible (n = 14), floor of the mouth (n = 6), and tongue (n = 48). Twenty-seven patients (28.4%) were graded as Stage 1, 37 patients (38.9%) as Stage 2, 9 patients (9.5%) as Stage 3, and 3 (3.2%) patients as Stage 4. Nine patients (9.5%) had local recurrences, and ten patients (10.5%) had neck metastases. Postoperative oxygen administration alone failed to improve dyspnea in 4 patients (4.2%). The median Cameron scores between patients with and without airway trouble were not significantly different (P = 0.226). However, a significant difference was observed in median Gupta scores between patients with and without airway trouble (P = 0.01). We created a receiver operating characteristic curve to predict postoperative airway trouble based on the preoperative Gupta score; the area under the curve was 0.856 (95% confidence interval: 0.61-1). A Gupta score cutoff value of 3.0 had a sensitivity of 92.3% and specificity of 75.0%.

CONCLUSIONS

Screening based on the Gupta score appears to be effective in predicting postoperative airway obstruction. We propose that this screening tool can be used to better plan tracheotomy and other airway management strategies during preoperative patient assessment.

Inhalation sedation for postoperative patients in the intensive care unit: initial sevoflurane concentration and comparison of opioid use with propofol sedation

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.

Scoring system for selective tracheostomy in head and neck surgery with free flap reconstruction

BACKGROUND

Selective tracheostomy is an effective but invasive airway management method for patients undergoing head and neck free flap reconstruction. Studies have shown that not all patients need tracheostomy. Several systems evaluating the need for tracheostomy have been proposed, but none is used clinically.

METHODS

A total of 533 cases underwent head and neck free flap reconstruction at Peking University School of Stomatology were reviewed for system development. Another 131 cases undergone the same surgery were included for system verification. Patients' demographic and surgical-related information were analyzed.

RESULT

A total of 321 cases in the development cohort and 68 cases in the system cohort underwent tracheostomy. The score was estimated: score = ∑(|log₂ OR|). Patients scoring >3 required tracheostomy, those scoring <2 should avoid tracheostomy, and those scoring 2 or 3 need further evaluation.

CONCLUSION

This scoring system can help determine the need for selective tracheostomy in patients undergoing head and neck free flap reconstruction.

Improvement of the patient early mobilization protocol after oral and maxillofacial free flap reconstruction surgery

OBJECTIVE

There is lack of standardized management and mobilization strategies after oral and maxillofacial reconstruction surgery. We used prospective randomized controlled trials to explore improvements in postoperative mobilization protocol in such patients.

METHODS

A total of 149 patients were randomly divided into tracheotomy control group A (38 cases) and test group A (37 cases), nontracheotomy control group B (38 cases) and test group B (36 cases). Test group patients sat up in bed on the 2^nd day after surgery and performed off-bed activity on the 3^rd day, whereas control group patients sat up in bed on the 4^th day postoperatively and performed off-bed activity on the 6^th day. Objective evaluation included free flap success rate, postoperative complications, sleep time, and catheter removal time, among other parameters. Subjective evaluation included postoperative pain and comfort evaluation.

RESULTS

The success rate of free flaps was 97.3% in test group A and 100% in the other groups. In terms of mean sleep time, 4.6 ± 1.0 h in test group A, which was longer than 4.1 ± 1.0 h in control group A (P = 0.034); 5.7 ± 1.4 h in test group B, which was longer than 4.9 ± 1.7 h in control group B (P = 0.026). Early activity makes catheter removal time (tracheal incision, nasogastric tube, urethral catheter) shorter and gets higher comfort evaluation scores in both test groups versus control groups (P < 0.05).

CONCLUSIONS

The early mobilization protocol for patients undergoing free flap reconstruction was safe, and can effectively improve sleep, shorten the catheter indwelling time, and increase the patient's comfort level.

Intraoperative Use of Vasopressors Does Not Increase the Risk of Free Flap Compromise and Failure in Cancer Patients

OBJECTIVE

To examine the effects of vasopressors on free flap outcomes.

BACKGROUND

Most micro-surgeons avoid the use of vasopressors during free flap surgery due to concerns of vasoconstriction, which could potentially lead to vascular thrombosis and flap failure. Previous studies lack the statistical power to draw meaningful conclusions.

METHODS

All free flaps between 2004 and 2014 from a single institution were reviewed retrospectively. Vasopressors were given intraoperatively as an intravenous bolus when blood pressure dropped >20% from baseline. The timing of intraoperative vasopressor administration was divided into 3 phases: from anesthesia induction to 30 minutes before the start of flap ischemia (P1); end of P1 to 30 minutes after revascularization (P2); end of P2 to end of surgery (P3). Agents included phenylephrine, ephedrine and calcium chloride.

RESULTS

A total of 5671 free flap cases in 4888 patients undergoing head and neck, breast, trunk, or extremity reconstruction were identified. Vasopressors were used intraoperatively in 85% of cases. The overall incidence of pedicle compromise was 3.6%, with a flap loss rate of 1.7%. A propensity score matching analysis showed that intraoperative use of any agents at any time of surgery was not associated with increased overall pedicle compromise [51/1584 (3.2%) vs 37/792 (4.7%); P = 0.074] or flap failure rates [26/1584 (1.6%) vs 19/792 (2.4%); P = 0.209]. Rather, there was less risk of venous congestion [33/1584 (2.1%) vs 31/792 (3.9%); P = 0.010].

CONCLUSIONS

Intraoperative use of phenylephrine, ephedrine, or calcium chloride as an intravenous bolus does not increase flap compromise and failure rates in cancer patients.

Prediction of decannulation, oral intake recovery, overall survival and lung metastasis following oral malignant tumor resection and reconstruction

The present study investigated whether tongue base and mandibular bone defects were associated with the rate of decannulation and oral intake recovery, and survival time, including overall and lung metastasis-free survival time, in patients that underwent oral malignant tumor (OMT) resection with reconstruction. A total of 105 patients that underwent OMT resection with laryngeal preservation and reconstruction were recruited. The extent of defects was classified according to Urken's classification. The rates of decannulation and oral intake recovery were assessed with the Kaplan-Meier method. It was identified that 4-5 section segmental mandibulectomy (SM) and total glossectomy (TG) were significantly associated with a lower rate of decannulation and oral intake recovery by univariate and multivariate analysis using a Cox's proportional model. Patients in the high risk group (4-5 sections or TG) were significantly less likely to achieve decannulation and unaided oral intake. Patients in the high risk group exhibited a significantly shorter overall and lung metastasis-free survival time. Following multivariate analysis adjusted for the clinical stage (IV/I-III), past history of or postoperative radiotherapy (yes/no) and age (per year), the high risk group was associated with a significantly rate of decannulation and unaided oral intake. In conclusion, TG or wide SM is a prognostic parameter for functional and survival outcomes, including lung metastasis, in OMT.

Elective Tracheostomy in Head and Neck Surgery: Our Experience

INTRODUCTION

Tracheostomy is commonly used to secure the airway during the immediate postoperative period in maxillofacial oncological operations. We conducted a study to review the utility of elective tracheostomy in head and neck surgery.

AIM

To review the incidence of intraoperative, perioperative and postoperative complications and its management in elective tracheostomy and to analyse its utility in head and neck surgery.

MATERIALS AND METHODS

The study included review of 50 patients, who were treated for head and neck cancers in the Department of Oral And Maxillofacial Surgery of our centre between January 2011 to December 2014.

RESULTS

The study showed a male predilection with mean tracheostomy time of 25 minutes and operative time of 11 hours. The patients had an ICU stay of two days and elective ventilation of one day with mild tracheal secretion seen postoperatively. No other complications were noted intraoperatively or postoperatively.

CONCLUSION

Elective tracheostomy even though an invasive tool when used properly in selected patients, can be safe and beneficial to the patients.

EKG Electrode as a Tactile Locator of Stoma after Decannulation: A Pilot Study

Objective

We aimed to evaluate the use of an electrocardiogram (EKG) electrode over decannulation dressings covering the stoma to improve speech intelligibility and volume and reduce air escape by facilitating identification of the “sweet spot” of the dressing. No objective data exist for patient outcomes with use of the EKG electrode dressing.

Methods

This prospective study included head and neck oncology patients at a tertiary hospital who received a tracheostomy. A standard tracheostomy decannulation dressing was placed followed by an EKG electrode. A speech pathologist evaluated speech volume via sound-level meter and captured speech intelligibility for random sentence-level speech. A blinded reviewer scored speech samples for intelligibility. Patients completed a 4-question satisfaction survey.

Results

Four patients completed the study. Based on the survey, the patients favored the button, with the lowest scores being 8.5 out of 10. Speech understanding was 48.5% without the button and 83% with the button. Normal speech volume was 73.75 dB without the button and 77.75 dB with the button. Loud speech volume was 80.75 dB without the button and 87 dB with the button.

Discussion

This pilot study shows objective benefits of the EKG button as well as improved patient satisfaction. Inexpensive and low maintenance, the EKG electrode provides better occlusion of stoma dressing with easier localization.

Implications for Practice

Dissemination of our results will aim to improve quality and patient outcomes following decannulation.

Airway and head and neck high dependency unit: a single-centre experience

OBJECTIVE

Dedicated otolaryngology high dependency units are uncommon. This paper reports the first experiences of such a facility in the UK, assessing reason for admission, duration of stay, occupancy rate and need for care escalation. The study sought to assess the presence of similar units in the UK.

METHODS

A retrospective review of high dependency unit admissions over an 18-month period and a national survey of otolaryngology departments in the UK were conducted to establish the overall presence and location of similar high dependency units.

RESULTS

A total of 128 patients were admitted during the study period, mainly following surgery and because of airway compromise. The average duration of stay was 2-3 days (range, 1-12 days). The occupancy rate was 31.7 per cent. No patients required their care to be escalated to the intensive care unit. Seven similar high dependency units were identified in the UK.

CONCLUSION

The care provided prevented the need for escalation of care to an intensive care unit. This challenges the need for patient management on intensive care units following major surgery or airway compromise for those not requiring assisted ventilation. High dependency units similar to ours are not widespread.

Enhanced recovery after surgery (ERAS) for head and neck oncology patients

OBJECTIVES

To describe the development of an enhanced recovery after surgery (ERAS) protocol for people undergoing surgery for head and neck cancer.

DESIGN

Service improvement project.

PARTICIPANTS

Head and neck oncology patients.

METHODS

The programme was developed in a series of structured meetings over a 6-month period. Stakeholders included oral and maxillofacial surgeons, otolaryngologists, anaesthetists, dieticians, physiotherapists, speech and language therapists (SALT) and nursing staff. Based on evidence within current literature and a consensus among the group, an ERAS programme for head and neck surgery patients was formulated. A 12-month study of compliance with the ERAS programme was undertaken from February 2014 to January 2015.

RESULTS

The process has resulted in the realisation of a head and neck ERAS programme. Key elements include a patient diary, nutritional optimisation, avoiding tracheostomy when possible, goal-directed fluid therapy intra-operatively and a specific head and neck postoperative pain management protocol. Overall compliance was high. Important areas showed lower levels of compliance - only 55% of people were given an explanation of the ERAS programme preoperatively, 75% took preoperative carbohydrate drinks, 10% had individualised goal-directed fluid therapy, and 7% were mobilised in the first 24 h after surgery. The mean length of hospital stay was 14.55 days (sd 7.48).

CONCLUSIONS

The ERAS programme developed is now embedded in the care pathway for people undergoing head and neck cancer surgery in our unit. The mean length of hospital stay has reduced since the introduction of the programme.

Intraoperative goal-directed hemodynamic management in free tissue transfer for head and neck cancer

BACKGROUND

The purpose of this study was to determine the effect of algorithmic physiologic management on patients undergoing head and neck free tissue transfer and reconstruction.

METHODS

Ninety-four adult patients were randomized to treatment and control groups. The blood pressure of the control group was managed consistent with contemporary standards. The treatment group was managed using an algorithm based on blood pressure and calculated physiologic values derived from arterial waveform analysis. Primary outcome was intensive care unit (ICU) length of stay.

RESULTS

ICU length of stay was decreased in the treatment group (33.7 vs 58.3 hours; p = .026). The complication rate was not increased in the treatment group.

CONCLUSION

The goal-directed hemodynamic management algorithm decreased the ICU length of stay. Judicious use of vasoactive drugs and goal-directed fluid administration has a role in improving perioperative outcomes for patients undergoing head and neck free tissue transfer. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1974-E1980, 2016.

Single cannula versus double cannula tracheostomy tubes in major oral and oropharyngeal resections

OBJECTIVE

To compare the outcomes of two types of tracheostomy tubes used in major head and neck surgery.

METHODS

A retrospective study was conducted of prospectively collected data. The post-operative safety and adequacy of a single cannula tracheostomy tube was compared to a double cannula tracheostomy tube in patients undergoing tracheostomy during major oral and oropharyngeal resections.

RESULTS

Out of 46 patients with the single cannula tube, 7 (15 per cent) experienced significant obstruction warranting immediate tube removal, while another 9 (20 per cent) needed a change of tube or tube re-insertion for continued airway protection. In contrast, out of 50 patients with the double cannula tube, the corresponding numbers were 0 (p = 0.004) and 1 (2 per cent; p = 0.007) respectively.

CONCLUSION

Insertion of a double cannula (instead of a single cannula) tracheostomy tube in the course of major oral and oropharyngeal resections offers better airway protection during the post-operative period.

Preparing for a Face Transplant: Development of a Comprehensive Nursing Educational Program

To date, more than 30 face transplants have been performed worldwide. This innovative procedure has restored the functional and aesthetic aspects of the face in patients with cancer, congenital, and trauma-related deformities where the results of traditional reconstructive surgery have been deficient. The importance of nursing involvement in the care of these patients is undeniable; however, little has been published about how to properly prepare a nursing department to undertake such an important role. Although the care of patients undergoing face transplants has many similarities to the care of patients undergoing traditional head and neck flap procedures, patients undergoing face transplant provide unique challenges, including immunosuppression, allograft rejection, communication impairment, and psychosocial needs. Staff at New York University's Langone Medical Center have devised a specific plan of action to properly inform, educate, and prepare the nursing staff for this exciting endeavor.

The evaluation of a scoring system in airway management after oral cancer surgery

BACKGROUND

The purpose of this retrospective study was to investigate the usefulness of tracheostomy scoring system in the decision of postoperative airway management in oral cancer patients.

MATERIALS AND METHODS

A total of 104 patients were reviewed in this retrospective study, who underwent radical resection with or without neck dissection and free flap reconstruction due to oral cancer. The patients were classified into three groups according to the timing of the extubation; extubated groups (n = 51), overnight intubation group (n = 45), and tracheostomy group (n = 8). Cameron's score was used to evaluate the relation between the state of the patient's airway and the type of the operation.

RESULTS

Tracheostomy was performed in eight patients (8/104, 7.7 %). A total of 22 patients (21.2 %) had more than 5 points of which 17 patients (77.3 %) did not have a tracheostomy and any postoperative emergency airway problems. The tracheostomy scores were significantly different among the three groups. Hospital stay showed a significant correlation with the tracheostomy score.

CONCLUSIONS

The scoring system did not quite agree with the airway management of the authors' clinic; however, it can be one of the clinical factors predicting the degree of the postoperative airway obstruction and surgical aggressiveness for recovery. The further studies are needed for clinically more reliable scoring systems.

Microsurgical reconstruction of the head and neck--current concepts of maxillofacial surgery in Europe

INTRODUCTION

Microvascular surgery following tumour resection has become an important field of oral maxillofacial surgery (OMFS). This paper aims to evaluate current microsurgical practice in Europe.

METHODS

The questionnaire of the DOESAK collaborative group for Microsurgical Reconstruction was translated into English, transformed into an online based survey and distributed to 200 OMFS units with the aid of the European Association for Cranio-Maxillo-Facial Surgery (EACMFS).

RESULTS

65 complete and 72 incomplete questionnaires were returned. Hospitals from the United Kingdom, France, Italy, the Netherlands, Spain, Belgium, Greece, Slovenia and Lithuania participated. 71% of contributing centres were university hospitals, 87% out of these perform microvascular tumour surgery at least on a two-weekly base. Overall complication rate was at around five percent. Most frequently used transplants were the radial forearm flap and the fibular flap. The perioperative management varied widely. Success factors for flap survival, however, were uniformly rated, with the surgical skill being the most important factor, followed by the quality of postoperative management. Medication seems to play a less important role.

CONCLUSION

Within Europe microvascular surgery is a common and safe procedure for maxillofacial reconstructive surgery in the field of OMFS. While there is a major accordance for the surgical procedure itself and the most frequently used flaps, perioperative management shows a wide variety of protocols with low presumed impact on surgical outcome.

Perioperative anaesthetic practice for head and neck free tissue transfer -- a UK national survey

BACKGROUND

Anaesthetic management of microvascular head and neck free flap surgery is based on physiological principles, but data on how these affect clinical outcomes in this challenging group are limited. There are no evidence-based guidelines available in this area.

METHODS

To establish current perioperative anaesthetic practice by surveying all UK centres performing head and neck free flap surgery. Anaesthetists from 73 centres performing head and neck microvascular reconstructive surgery in the UK were asked to complete a structured online survey. The survey included general questions, a hypothetical clinical scenario with multiple choice questions and questions about perioperative management. The main outcomes measured were protocols of pre-operative assessment, perioperative fluid and blood pressure strategies, monitoring and post-operative management.

RESULTS

Seventy-three units were contacted, and fifty-five responded (75%). Most respondents performed up to two cases per month. Opinion was divided as to how best to manage intra-operative blood pressure, fluid balance, pre-operative assessment and monitoring. Notably 52% preferred crystalloid infusion to increase blood pressure, while 35% stated crystalloids were contraindicated.

CONCLUSIONS

Currently in the UK, anaesthetic perioperative management for head and neck free flap transfer is varied, reflecting the paucity of high-quality data in this area; but some techniques, in particular avoidance of excessive crystalloid use, is associated with improved flap outcome.

Replacing tracheostomy with overnight intubation to manage the airway in head and neck oncology patients: towards an improved recovery

In maxillofacial head and neck oncology, tracheostomy is often used to secure the airway, but not without risk. This study compared the existing practice of two units: one where tracheostomy was routinely done with one where overnight intubation was used. From both units we retrospectively analysed 50 consecutive patients who had intraoral resection, neck dissection, and microvascular reconstruction for head and neck cancer. When compared with tracheostomy, overnight intubation resulted in a shorter mean stay in the intensive therapy unit (ITU) (1.4 compared with 3.7 days), a shorter overall hospital stay (12.9 compared with 18.0 days), less time to first oral intake (8.9 compared with 12.8 days), and a lower rate of lower respiratory tract infection (LRTI) (10% compared with 38%). This study supports the discontinuation of routine tracheostomy and the adoption of a more selective practice to improve recovery.