Hyperglycemia and risk of adverse outcomes following microvascular reconstruction of oncologic head and neck defects

Glycated haemoglobin and the risk of postoperative complications in people without diabetes: a prospective population-based study in UK Biobank

The aim of our study was to clarify the association between glycated haemoglobin (HbA1c ) and postoperative outcomes in people without an existing diagnosis of diabetes. Half a million adults were recruited into the UK Biobank prospective cohort study between March 2006 and October 2010. We divided participants into three groups: no diagnosis of diabetes and HbA1c  < 42 mmol.mol-1 ; no diagnosis of diabetes and elevated HbA1c (≥ 42 mmol.mol-1 with no upper limit); and prevalent diabetes (regardless of HbA1c concentration) at recruitment. We followed up participants by linkage with routinely collected hospital data to determine any surgical procedures undertaken after recruitment and the associated postoperative outcomes. Our main outcome measure was a composite primary outcome of 30-day major postoperative complications and 90-day all-cause mortality. We used logistic regression to estimate the odds of the primary outcome by group. We limited analyses to those who underwent surgery within one year of recruitment (n = 26,653). In a combined effects logistic regression model, participants not known to have diabetes with HbA1c  ≥ 42 mmol.mol-1 had increased odds of the primary outcome (OR [95% CI] 1.43 [1.02-2.02]; p = 0.04), when compared with those without diabetes and HbA1c  < 42 mmol.mol-1 . This effect was attenuated and no longer statistically significant in a direct effects model with adjustment for hyperglycaemia-related comorbidity (OR [95% CI] 1.37 [0.97-1.93]; p = 0.07). Elevated pre-operative HbA1c in people without diabetes may be associated with an increased risk of complications, but the association is likely confounded by end-organ comorbidity. In contrast to previous evidence, our findings suggest that to prevent adverse postoperative outcomes, optimisation of pre-existing morbidity should take precedence over reducing HbA1c in people without diabetes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical consequences of head and neck free-flap reconstructions in the DM population

Diabetes mellitus (DM) is a common comorbidity and risk factor for postoperative complications in head and neck (H&N) microsurgical reconstructions. Our study focused on the association between DM and individual complications regarding both surgical and medical aspects. A meta-analysis of English-language articles comparing a series of complications between DM and non-DM H&N free-flap recipients was performed by comprehensive meta-analysis (CMA). Twenty-seven articles presented 14,233 H&N free-flap reconstructions, and a subset of 2329 analyses including diabetic cases was included for final analysis. Total postoperative (RR = 1.194, p < 0.001; OR = 1.506, p = 0.030) and surgical (RR = 1.550, p = 0.001; OR = 3.362, p < 0.001) complications were increased in DM subjects. Free-flap failure/necrosis (RR = 1.577, p = 0.001; OR = 1.999, p = 0.001) and surgical site infections (OR = 2.414, p < 0.001) were also increased in diabetic recipients. However, return to the operating room, dehiscence, fistulas, plate exposures, readmissions, and mortalities were not increased in DM patients. DM increased various complications in H&N free-flap reconstructions. Surgical indications should be cautiously evaluated, and aggressive treatments should be implemented for high-risk recipients.

The impact of preoperative glycated hemoglobin levels on outcomes in oral squamous cell carcinoma

OBJECTIVES

This study aimed to investigate the association between preoperative glycated hemoglobin (HbA1c) levels and the treatment outcomes of oral cavity squamous cell carcinoma (OSCC).

METHODS

Three hundred and fifty-eight OSCC patients were consecutively enrolled between July 2004 and July 2016. Clinicopathological parameters and survival outcomes were analyzed following HbA1c stratification of 6.5% (HbA1c ≥ 6.5%: n = 74, 20.6%) and 7.0% (HbA1c ≥ 7.0%: n = 53, 14.8%).

RESULTS

Higher HbA1c levels were associated with elevated body mass index, lower albumin levels, wider surgical margins, and prolonged hospital stays (HbA1c 6.5%: p = .001, .048, .030, .009, respectively; HbA1c 7.0%: p = .092, .032, .009, .015, respectively). Survival rates stratified by HbA1c 6.5% were as follows: locoregional recurrence-free survival, p = .014; distant metastasis-free survival, p = .013; second primary cancer-free survival, p = .015; overall survival, p = .014; disease-specific survival, p = .002 and HbA1c 7.0%: locoregional recurrence-free survival, p = .013; distant metastasis-free survival, p = .013; second primary cancer-free survival, p = .014; overall survival, p = .015; disease-specific survival, p = .004. Multivariate analyses identified HbA1c as an independent prognostic factor for overall and disease-specific survival (HbA1c 6.5%: p = .014 and .002, respectively; HbA1c 7.0%: p = .036 and .013, respectively).

CONCLUSIONS

Oral squamous cell carcinoma patients with higher preoperative HbA1c levels had longer hospitalization and worse survival outcomes.

Double free flaps in oral cavity and oropharynx reconstruction: Systematic review, indications and limits

The simultaneous use of two different free flaps, harvested from distinct donor sites, has demonstrated a reasonable degree of safety and success rates in head and neck composite defects reconstruction. Unfortunately, their relatively low frequent use, together with the lack of proper statistics on their management strategies, make their indications weak of robust conclusions to better define their role in common practice. The aim of the present study was to review the literature of the last 15 years regarding simultaneous free flap transposition, presenting advantages, disadvantages, and results of this technique, with the final purpose to propose an up-to-date panorama for the use of double free flap for complex head and neck defects reconstruction. Depending on which factors are present, surgeons may choose to select an approach that is theoretically safer, but yields less-than-ideal functional outcomes, such as local flap. Two free flaps may be necessary when the defect contains both a large, complex bony defect, large soft tissue needs, and proper surgical planning and meticulous monitoring continues to be the cornerstone of success.

Influence of Hyperglycemia on Treatment Outcomes of Oral Cavity Squamous Cell Carcinoma

PURPOSE

The present study investigated the association between perioperative hyperglycemia and the treatment and survival outcomes of patients with oral cavity squamous cell carcinoma (OSCC).

PATIENTS AND METHODS

From 2004 to 2016, 385 patients with OSCC were enrolled and stratified into normoglycemic (<180 mg/dL) and hyperglycemic (≥180 mg/dL) groups. The clinicopathologic characteristics and treatment outcomes of OSCC were subsequently analyzed.

RESULTS

Of the 385 patients, 61 (15.8%) were in the hyperglycemic group. Hyperglycemia was significantly associated with pT stage, pN stage, overall pathologic stage, extranodal extension, albumin level, and tumor depth (P = .004, P = .042, P = .008, P = .001, P = .004, and P = .011, respectively). Patients with hyperglycemia also required a longer hospital stay (P = .003). The 5-year overall survival and disease-specific survival were poorer in the hyperglycemic group than in the normoglycemic group (P = .001 and P = .002, respectively). Multivariate analysis revealed that hyperglycemia is a significant adverse prognostic indicator for OSCC (hazard ratio, 1.709; 95% confidence interval, 1.003 to 2.912; P = .049).

CONCLUSIONS

Hyperglycemia is associated with more advanced disease and poorer survival rates in patients with OSCC. It correlates with adverse clinicopathologic characteristics and longer hospital stay. Screening for hyperglycemia and maintenance of normal glycemic status during the treatment course is imperative in the treatment of OSCC.

Controversies in free tissue transfer for head and neck cancer: A review of the literature

BACKGROUND

Microvascular free tissue transfer provides superior functional outcomes when reconstructing head and neck cancer defects. Careful patient selection and surgical planning is necessary to ensure success, as many preoperative, intraoperative, and postoperative patient and technical factors may affect outcome.

AIMS

To provide a concise, yet thorough, review of the current literature regarding free flap patient selection and management for the patient with head and neck.

MATERIALS AND METHODS

PubMed and Cochrane databases were queried for publications pertaining to free tissue transfer management and outcomes.

RESULTS

Malnutrition and tobacco use are modifiable patient factors that negatively impact surgical outcomes. The use of postoperative antiplatelet medications and perioperative antibiotics for greater than 24 hours have not been shown to improve outcomes, although the use of clindamycin alone has been shown to have a higher risk of flap failure. Liberal blood transfusion should be avoided due to higher risk of wound infection and medical complications.

DISCUSSION

There is a wide range of beliefs regarding proper management of patients undergoing free tissue transfer. While there is some data to support these practices, much of the data is conflicting and common practices are often continued out of habit or dogma.

CONCLUSION

Free flap reconstruction remains a highly successful surgery overall despite as many different approaches to patient care as there are free flap surgeons. Close patient monitoring remains a cornerstone of surgical success.

Free Flap Outcomes of Microvascular Reconstruction after Repeated Segmental Mandibulectomy in Head and Neck Cancer Patients

This is the first study to investigate the impact of a second fibula flap or a soft tissue flap combined with bridging plate for a repeated segmental mandibulectomy reconstruction on flap outcomes in head and neck cancer patients. A retrospective comparative analysis (2007–2016) of 61 patients who underwent a second segmental mandibulectomy was performed. 20 patients underwent a fibula flap reconstruction whereas 41 had a soft tissue flap and plate reconstruction. No significant difference was seen in the operative time, total hospital stay, flap loss, re-exploration rates, plate exposure rate, or recipient site infection rate. On multivariate analysis, patients reconstructed with a soft tissue flap and bridging plate (odds ratio (OR) 3.997; 95% confidence interval (CI), 1.046–15.280, p = 0.043) and complications developed in previous surgery (OR 4.792; 95% CI, 1.120–20.493, p = 0.035) were shown to be independent predictors of a prolonged nasogastric tube dependence. The utilization of a soft tissue flap with plate is associated with comparative results of acute complication rate within 1 week, recipient site infection rate, and plate exposure rate to free fibula flaps alone. Free fibula flaps may result in a decreased risk for prolonged tube dependence compared to free soft tissue flap reconstructions.

Perioperative Management of Diabetes Mellitus: Novel Approaches

PURPOSE OF REVIEW

Several studies have demonstrated the benefits of glycemic control in the perioperative period and there is ongoing interest in development of systematic approaches to achieving glycemic control. This review discusses currently available data and proposes a new approach to the management of hyperglycemia in the perioperative period.

RECENT FINDINGS

In a recent study, we demonstrated that early preoperative identification of patients with poorly controlled diabetes and proactive treatment through various phases of surgery improves glycemic control, lowers the risk of surgical complications, and decreases the length of hospital stay. Implementation of a perioperative diabetes program that systematically identifies and treats patients with poor glycemic control early in the preoperative period is feasible and improves clinical care of patients undergoing elective surgery.