How to select candidates for microvascular head and neck reconstruction in the elderly? Predictive factors of postoperative outcomes

Postoperative Complications of Free Flap Reconstruction in Moderate-Advanced Head and Neck Squamous Cell Carcinoma: A Prospective Cohort Study Based on Real-World Data

Background

Postoperative complications (POCs) of moderate-advanced head and neck squamous cell carcinoma (HNSCC) after free flap reconstruction have received little attention. We investigated the risk factors that lead to POCs and their impact on management and prognosis.

Patients and Methods

A single-center, prospective cohort study was conducted at Beijing Stomatological Hospital on primary HNSCC patients treated between 2015 and 2020.

Results

In total, 399 consecutive HNSCC patients who underwent radical resection of the primary tumor and free flap reconstruction were enrolled in this study, 155(38.8%) experienced POCs. The occurrence of POCs directly led to worse short-term outcomes and poorer long-term overall survival (P=0.0056). Weight loss before the operation (P=0.097), Tumor site (P=0.002), stage T4b (P=0.016), an ACE-27 index of 2-3 (P=0.040), operation time≥8h (P=0.001) and Clindamycin as antibiotic prophylaxis (P=0.001) were significantly associated with POCs.

Conclusions

The occurrence of POCs significantly leads to worse short-term outcomes and increases the patients’ burden.

Effectiveness of prosthetic rehabilitation and quality of life of older edentulous head and neck cancer survivors following resection of the maxilla: a cross-sectional study

PURPOSE

To evaluate the effectiveness of prosthetic rehabilitation, as well as the quality of life (QOL) of older edentulous maxillectomy patients.

METHODS

Effectiveness of the complete denture obturator prosthesis and QOL of N = 44 older edentulous patients who had resection of the maxilla and were restored with a definitive prosthesis that was in use for a minimum of 1 year was assessed using three instruments: European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30), Head and Neck Cancer Module (QLQ-HN35), and Obturator Functioning Scale (OFS). Data analysis was performed by one-way analysis of variance (ANOVA) on ranks, Spearman rank-order correlation, and hierarchical multivariable rank regression at α = .05 level of significance.

RESULTS

Participants' gender (P < .001), adjuvant treatment (P = .016), surgical approach (P = .017), size of the maxillary defect (P = .028), participants' prosthetic history (P = .047), and dental status of the mandible (P = .038) were significantly related to the self-reported effectiveness of the complete denture obturator prosthesis. Perceived functioning of the prosthesis (P = .001), participants' gender (P = .002), the American Society of Anesthesiologists (ASA) physical status (P = .027), and surgical approach (P = .039) were significant predictors of QOL.

CONCLUSION

Restoration of the edentulous maxillectomy defect is challenging. An effective definitive complete denture obturator appeared to be the strongest predictor for advanced quality of life in older maxillectomy patients. The physical status of the older participants significantly affected the overall QOL, but did not influence the self-reported functioning of the complete denture obturator prosthesis.

Age and Comorbidities Impact Medical Complications and Mortality Following Free Flap Reconstruction

OBJECTIVE

Determine if age correlated with surgical or medical complications following head and neck free flap reconstruction.

STUDY DESIGN

Retrospective review of prospectively collected databases.

METHODS

Patients undergoing head and neck free flap reconstruction at three tertiary care institutions were included (n = 1972). Cohorts were based on age (<65, 65-75, 75-85, and >85). Outcomes reviewed operative duration, length of stay, surgical complications (free flap failure, fistula, hematoma, dehiscence, and infection), and medical complications (thromboembolism, stroke, cardiac, and pulmonary).

RESULTS

Anatomic site (P < .0001) and donor site varied by age (P < .0001). There was no difference in operative duration (P = .3) or length of hospitalization (P = .8) by age. The incidence of medical complications increased with increasing age. Pulmonary complication rates: <65 (3.9%), 65 to 75 (4.8%), 75 to 85 (7.1%), and >85 (11%) (P = .02). Cardiac complication rates: <65 (2.0%), 65 to 75 (7.3%), 75 to 85 (6.1%), and >85 (16.4%) (P < .0001). Mortality increased with age: <65 (0.4%), 65 to 75 (0.8%), 75 to 85 (1.1%), and >85 (4.1%) (P < .003). Medical complications correlated with mortality rates: pulmonary (3.5% vs. 0.6%; OR: 5.5; 95% CI: 1.5-20.0; P = .004); cardiac (3.3% vs. 0.6%; OR: 6.0; 95% CI: 1.6-21.8; P = .002); thromboembolism (4.6% vs. 0.7%; OR: 7.3; 95% CI: 1.6-33.6; P = .003); stroke (42% vs. 0.5%; OR: 149; 95% CI: 40-558; P < .0001); and sepsis (5% vs. 0.7%; OR 7.5; 95% CI: 1.0-60.5; P = .03). Age did not correlate with free flap success (P = .5), surgical complications (hematoma, P = .33; fistula, P = .23; infection, P = .07; and dehiscence, P = .37), or thirty-day readmission (P = .3).

CONCLUSION

Following free flap reconstruction, patient age did not correlate with development of a surgical complication. Patient age did correlate with development of a medical complication. Postoperative medical complications were found to correlate with perioperative mortality.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

The geriatric-8 screening tool for predicting complications in older adults after surgery for locally advanced head and neck cancer with free flap reconstruction

PURPOSE

Radical surgery with free flap reconstruction for locally advanced head and neck cancer (HNC) is quite challenging for older adults. This retrospective study aimed to elucidate the usefulness of the geriatric-8 (G8) screening tool for predicting postoperative complications in older adults with HNC.

METHODS

A retrospective review of 37 older adults with HNC who underwent radical surgery with free flap reconstruction and were assessed by the G8 screening tool was performed. Postoperative complications during hospitalization were classified according to the Clavien-Dindo classification, and possible contributing factors, including the G8 score, for major and minor complications were subjected to univariate and multivariate analyses.

RESULTS

The appropriate G8 cut-off value for both major and minor complications was 12 (area under the curve 0.56 and 0.55, respectively). Multivariate logistic regression analysis showed that both smoking and lower G8 score (≤ 12) were independently associated with the severity of complications (p = 0.043, p = 0.034, respectively).

CONCLUSIONS

The G8 was a possible predictor of major and minor complications in older adults with HNC who underwent radical surgery with free flap reconstruction.

Safety of Reconstructive Microsurgery in the Elderly Population: a Multicentric Prospective Study

BACKGROUND

Safety of reconstructive microsurgery in elderly patients is still a topic of debate, because no conclusive evidence exists that provides indications and risk evaluation in elderly patients. The purpose of this study, which the Italian Society for Plastic, Reconstructive, and Aesthetic Surgery (SICPRE) has promoted, is to evaluate the safety and the complication risk of elective reconstructive microsurgery in elderly patients as well as to identify patient- or procedure-related risk factors. The secondary aim is to evaluate the predictive role for complications of the Geriatric 8 score (G8).

METHODS

A total of 194 consecutive patients from 18 centers, aged 65 or older, who received an elective microsurgical flap between April 2018 and April 2019 were prospectively evaluated. Patient-related, treatment-related, and outcomes data were recorded and statistically analyzed through multiple-adjusted logistic regression models.

RESULTS

Our study showed an increased risk of complications and a longer hospitalization in patients aged ≥75 years with the American Society of Anesthesiologists (ASA) score ≥3 (or G8 score ≤11) as compared to patients >65 years of age and <75 years of age who undergo reconstruction with a microsurgical flap. Instead, flap survival did not significantly vary with age, but was associated only with ASA score ≥3 (or G8 score ≤11) and surgeries that last longer than 480 min; however, flap survival (92.3%) was slightly lower than that commonly reported for in the general population.

CONCLUSIONS

Reconstructive microsurgery in the elderly is generally safe. The ASA score is easier and quicker than the G8 score and equally useful for risk stratification.

The Impact of Healthcare-Associated Infections in Patients Undergoing Oncological Microvascular Head and Neck Reconstruction: A Prospective Multicentre Study

Simple Summary

Healthcare-associated infections (HAIs) result in an increased morbidity and a delay in adjuvant therapy—thus increasing the cancer recurrence rates—in patients undergoing oncological microvascular head and neck reconstruction. HAIs also result in a cost increase for the Health System. We prospectively analysed the incidence, clinical characteristics, risk factors and impacts of these infections in 65 patients undergoing head and neck free-flap reconstruction in three third-level university hospitals in Madrid (Spain). The three of them implemented the same antibiotic prophylactic regimen for surgical interventions. The rate of HAIs was 61.54%. The following complications were significantly more frequent in patients with HAIs: need to reoperate (p = 0.009), duration of hospital admission (p < 0.001) and delay in starting radiotherapy (p = 0.009). This manuscript aims to point out the importance of preventing HAIs in head and neck cancer patients, as they have shown a higher risk of postoperative complications.

Abstract

(1) Background: Healthcare-associated infections (HAIs) after head and neck free-flap reconstruction are a common postoperative complication. Risk factors for HAIs in this context and their consequences have not been adequately described. (2) Methods: Ongoing prospective multicentre study between 02/2019 and 12/2020. Demographic characteristics and outcomes were analysed, focusing on infections. (3) Results: Forty out of 65 patients (61.54%) suffered HAIs (surgical site infection: 52.18%, nosocomial pneumonia: 23.20%, bloodstream infection: 13% and urinary tract infection: 5.80%). Methicillin-resistant Staphylococcus aureus (MRSA) and resistant Pseudomonas aeruginosa, Klebsiella pneumoniae and Enterobacter cloacae were the most frequently implicated. The significant risk factors for infection were: previous radiotherapy (Odds ratio (OR): 5.42; 95% confidence interval (CI), 1.39–21.10), anaemia (OR: 8.00; 95% CI, 0.96–66.95), salvage surgery (eight out of eight patients), tracheostomy (OR: 2.86; 95% CI, 1.01–8.14), surgery duration (OR: 1.01; 95% CI, 1.00–1.02), microvascular reoperation <72 h (eight/eight) and flap loss (eight/eight). The major surgical complications were: a need to reoperate (OR: 6.89; 95% CI, 1.42–33.51), prolonged hospital admission (OR: 1.16; 95% CI, 1.06–1.27) and delay in the initiation of postoperative radiotherapy (OR: 9.07; 95% CI, 1.72–47.67). The sixth month mortality rate in patients with HAIs was 7.69% vs. 0% in patients without HAIs (p = 0.50). (4) Conclusions: HAIs were common after this type of surgery, many of them caused by resistant microorganisms. Some modifiable risk factors were identified. Infections played a role in cancer prognosis by delaying adjuvant therapy.