Association Between Preoperative Nutritional Status and Postoperative Outcome in Head and Neck Cancer Patients

Prognostic utility of preoperative platelet-to-albumin ratio in surgically treated oral cavity cancer patients

BACKGROUND

This study aimed to explore the prognostic utility of the preoperative platelet-to-albumin ratio (PAR) among patients with oral cavity squamous cell carcinoma (OSCC).

METHODS

We retrospectively reviewed of 355 patients with surgically-treated OSCC between 2008 and 2017. The optimal PAR cutoff for patient stratification was determined through X-tile analysis. Prognostic variables for disease-free survival (DFS) and overall survival (OS) were identified using Cox proportional hazards models. We developed a PAR-based nomogram to predict personalized OS.

RESULTS

We determined the optimal PAR cutoff to be 7.45. A PAR of ≥7.45 was an independent negative prognostic factor for DFS and OS (hazard ratio = 1.748 and 2.386; p = 0.005 and p < 0.001, respectively). The developed nomogram demonstrates the practical utility of PAR and accurately predicts personalized OS.

CONCLUSIONS

The preoperative PAR is a promising and cost-effective prognostic biomarker for patients with surgically-treated OSCC; the PAR-based nanogram accurately predicts OS for such patients.

Management of Enlarging Tracheoesophageal Fistula with Voice Prosthesis in Laryngectomized Patients

Management of Enlarging tracheoesophageal fistula (TEF) with Voice Prosthesis in Laryngectomized Head and Neck Cancer Patients.

OBJECTIVES

An enlarging TEF following voice prosthesis placement impacts patient quality of life, risks airway compromise, and can lead to aspiration pneumonia. Pharyngoesophageal strictures have previously been reported to be associated with TEF enlargement and leakage. We describe a series of patients with enlarging TEFs after Tracheoesophageal puncture (TEP) for voice prosthesis who required pharyngoesophageal reconstruction.

METHODS

Retrospective case series of laryngectomized H&N cancer patients with primary or secondary TEP who underwent surgical management for enlarging TEF site between 6/2016-11/2022.

RESULTS

Eight patients were included. The mean age was 62.8 years old. Seven patients had a history of hypothyroidism. Of seven with prior H&N radiation history, two had both historical and adjuvant radiation. Two of the eight TEPs were placed secondarily. Mean time from TEP to enlarging TEF diagnosis was 891.3 days. Radial forearm-free flaps were used in five patients. Six had stenosis proximal to the TEF whereas one had distal stenosis and one had no evidence of stenosis. Mean length of stay was 12.3 days. Mean follow-up was 400.4 days. Two required a second free flap for persistent fistula.

CONCLUSION

Surgical reconstruction of enlarging TEFs due to TEP/VP placement is effective in combination with addressing underlying pharyngeal/esophageal stenosis contributing to TEF enlargement and leakage. Radial forearm-free flaps have the additional benefit of a long vascular pedicle to access more distant and less-irradiated recipient vessels. Many fistulae are resolved after the first flap reconstruction, but some may require subsequent reconstruction in case of failure.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:198-206, 2024.

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

Objectives

Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients.

Methods

Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion.

Results

A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation.

Conclusion

Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol.

Level of Evidence

2a.

Preoperative Nutritional Laboratory Values, Demographics, and Wound Healing Following Facial Trauma Surgery: Which Variables Predict Postoperative Complications?

In individuals who have sustained maxillofacial trauma, inadequate nutrition is often a sequela and may lead to complications. The purpose of this study was to investigate the association between preoperative laboratory values and postoperative complications in patients with maxillofacial trauma requiring surgical intervention. A retrospective cohort study of patients with maxillofacial trauma requiring surgical repair from 2014 to 2020 was performed at a single academic Level I Trauma Center. The primary predictor variables were preoperative laboratory values including serum albumin, white blood cell count, absolute neutrophil count, and lymphocyte count. Complications related to surgical reconstruction of facial injuries represented the primary outcome variable. The patient cohort included 152 patients, of whom 50 (32.9%) were female. When controlling for all other variables, female gender (odds ratio=2.08, 95% confidence interval, 1.02-4.21; P =0.04) and number of procedures performed ( P =0.02) were the only statistically significant predictors of postoperative complications. There were no significant differences between the complication groups for age ( P =0.89), injury severity score ( P =0.59), hospital length of stay ( P =0.30), serum albumin ( P =0.86), hemoglobin ( P =0.06), white blood cell count ( P =0.20), absolute neutrophil count ( P =0.95), lymphocyte count ( P =0.23), or absolute neutrophil/lymphocyte count ratio ( P =0.09). In this study, it was found that only gender and the number of procedures performed significantly predicted postoperative complications, while preoperative nutritional laboratory values did not. Further study with a larger cohort of patients is likely required.

Practice Trends and Evidence-Based Practice in Microvascular Reconstruction

Microvascular and free flap reconstruction are important to the otolaryngology-head and neck surgery practice. Herein, the reader will find an up-to-date discussion of various evidence-based practice trends related to microvascular surgery, including surgical techniques, anesthetic and airway considerations, free flap monitoring and troubleshooting, surgical efficiency, and both patient-related and surgeon-related risk factors that may affect outcomes.

Oral Dysfunction in Patients with Oral Cancer Could Occur Before Treatment and Require Early Nutritional Improvement: A Cross-Sectional Study

Patients with oral cancer have poor nutritional status before treatment. However, there have been no reports of the detailed evaluation of preoperative oral function in patients with oral squamous cell carcinoma (OSCC). Therefore, this study aimed to evaluate the preoperative oral function of patients with OSCC and examine the relationship with nutritional status. Oral function measurements (microorganisms, oral dryness, occlusal force, tongue pressure, masticatory function, Eating Assessment Tool, and Postoperative Oral Dysfunction Scale) and Mini Nutritional Assessment-Short Form (MNA-SF) data were collected from 51 patients with OSCC (men: 37, women: 14, mean age: 72.1 years) who visited the Shimane University Hospital, Department of Oral and Maxillofacial Surgery, from September 2019 to September 2021. The tongue was the most prevalent primary gingiva site [22 patients (43.1%)], and 36 patients (70.6%) had advanced cancer. Comparisons between nutritional status and each related factor revealed significant differences in the number of individuals in the household, cancer stage, presence of pulmonary disease, number of teeth, microorganisms (grade), and masticatory function (mg/dL) (p < 0.05). Multiple regression analysis using the total MNA-SF score as the dependent variable with adjustment for confounding factors showed significant association between oral dryness and tongue pressure (p < 0.05). No significant association was found for the Eating Assessment Tool or Postoperative Oral Dysfunction scale. Patients with OSCC may have decreased oral function because of the tumor at the time of diagnosis, which causes a decline in nutritional status. Preoperative interventions are necessary to improve nutrition based on the state of oral function.

Prognostic Value of Neutrophil Percentage-to-Albumin Ratio in Patients with Oral Cavity Cancer

This study investigated preoperative neutrophil percentage-to-albumin ratio (NPAR) for predicting oral cavity squamous cell carcinoma (OSCC) survival. We retrospectively analyzed 368 patients who received curative OSCC surgery between 2008 and 2017. Receiver operating characteristic curve analyses were employed to identify the optimal NPAR cutoff (16.93), and the patients were then separated into low-NPAR and high-NPAR groups. Intergroup differences in survival were determined through Kaplan−Meier analysis and log-rank tests. Disease-free survival (DFS) and overall survival (OS) predictors were identified using Cox proportional-hazards models. A nomogram integrating independent prognostic factors was proposed to increase the accuracy of OS prediction. A high NPAR (≥16.93) was associated with worse median OS and DFS than was a low NPAR (both p < 0.001); this finding was confirmed through multivariate analyses (hazard ratio (HR) for OS = 2.697, p < 0.001; and HR for DFS = 1.671, p = 0.008). The nomogram’s favorable predictive ability was confirmed by the calibration plots and concordance index (0.784). The preoperative NPAR is thus a promising prognostic biomarker in patients with OSCC after external validation in a larger cohort. Our nomogram can facilitate clinical use of the NPAR and provides accurate individualized OS predictions.

Prognostic impact of preoperative Geriatric Nutritional Risk Index in oral squamous cell carcinoma

OBJECTIVES

To investigate the prognostic impact of preoperative Geriatric Nutritional Risk Index (GNRI) values in older adults undergoing radical surgery for oral squamous cell carcinoma (OSCC).

SUBJECTS AND METHODS

This retrospective study included 61 patients ≥ 65 years old with OSCC (43 men, 18 women; age: 72.1±5.4 years) who underwent radical surgery between 2013 and 2020. Factors influencing overall survival (OS) and disease-free survival (DFS) were examined.

RESULTS

Receiver operating characteristic curve analysis indicated that the optimal GNRI value for classifying patients into low-GNRI (<93.7; OS: n=19 [31.1%], DFS: n=42 [68.9%]) and high-GNRI groups (≥93.7; OS, n=19 [31.1%]; DFS, n=42 [68.9%]) was 93.7. OS and DFS rates were significantly lower in the low-GNRI group than in the high-GNRI group. Univariate analysis indicated that alcohol use, preoperative serum C-reactive protein level, lymphatic invasion, postoperative treatment, and GNRI were significantly correlated with OS, while lymphatic invasion, postoperative treatment, and GNRI were significantly correlated with DFS. In multivariate analysis, only GNRI was significantly correlated with OS. DFS and postoperative treatment were independent predictors of DFS.

CONCLUSIONS

Preoperative GNRI may be a significant prognostic factor in older adults with OSCC. GNRI assessment and nutritional intervention may improve prognosis in patients at high nutritional risk.

The Glasgow Prognostic Score Before Curative Resection May Predict Postoperative Complications in Patients with Gastric Cancer

PURPOSE

Despite improvements in surgical techniques and devices and perioperative care of gastric cancer (GC), the rate of postoperative complications still has not decreased. If patients at high risk for postoperative complications could be identified early using biomarkers, these complications might be reduced. In this study, we investigated usefulness of the preoperative Glasgow Prognostic Score (GPS) as a predictive factor for complications after surgery in patients with stage II/III GC.

METHODS

This study retrospectively analyzed the outcomes of 424 patients who underwent curative surgery for pathological stage II/III GC from February 2007 to July 2019 at a single center. The GPS was assessed within 4 days before surgery. To identify independent risk factors for postoperative complications, univariate and multivariate analyses were performed using a Cox proportional hazards model.

RESULTS

The numbers of patients with a GPS of 0, 1, and 2 were 357, 55, and 12, respectively. The rate of complications after surgery was significantly higher among patients with a GPS of 1 or 2 than among patients with a GPS of 0 (p = 0.008). Multivariate analysis identified a GPS of 1 or 2 as an independent predictive factor for postoperative complications (p = 0.037).

CONCLUSION

The preoperative GPS may be a useful predictive factor for postoperative complications in patients with stage II/III GC. Being aware of the risk of complications after surgery as indicated by the GPS before surgery may promote safe and minimally invasive surgery that we expect will improve outcomes in patients with a GPS of 1 or 2.

Enhanced Recovery After Surgery Nutrition Protocol for Major Head and Neck Cancer Surgery

Objective

To determine whether an enhanced recovery after surgery (ERAS) nutrition protocol is reasonably possible among our head and neck cancer (HNC) population with respect to system feasibility and patient compliance. Second, we aim to identify improvements in patient outcomes as a result.

Methods

Preexperimental research design among patients undergoing major HNC surgery after implementation of the ERAS nutrition protocol from July 2018 to July 2019 as quality improvement (QI). Preoperative clinical nutritional assessment and laboratory values were completed the same day as informed surgical consent in the clinic. Protocol focus was patient consumption of nutritional supplements perioperatively, monitored by our outpatient dietitian. Early postoperative enteral nutrition was initiated with monitoring of nutritional laboratory values. To support our model, we provide preliminary analysis of HNC patient outcomes after implementation of the ERAS nutritional protocol.

Results

Twenty-five patients were enrolled. Preoperatively, 40% of patients were malnourished, and 100% complied with perioperative nutrition supplementation. Health care provider compliance obtaining preoperative laboratory values was 56%. There was a strong negative correlation between modified Nutrition-Related Index (mNRI) and number of complications (P = .01), specifically, fistula rate (P = .04) and unplanned reoperation (P = .04). Enrolled patient average length of stay was 7 ± 4.4 days.

Discussion

Our patients demonstrated compliance with implementation of an ERAS nutrition protocol likely facilitated by dietitian engagement. mNRI potentially reflects risk for head and neck surgery complications.

Implications for Practice

QI processes demand reassessment and modification to ensure efficient and targeted approaches to improving patient care.

Preoperative Serum Albumin Predicts Wound Dehiscence but Not Infection After Surgery for Oral Squamous Cell Carcinoma

PURPOSE

Inadequate nutrition is common in individuals diagnosed with cancer. The present study evaluated the association between preoperative albumin and postoperative complications in otherwise healthy patients presenting with newly diagnosed squamous cell carcinoma of the oral cavity primarily managed with ablative surgery.

PATIENTS AND METHODS

A retrospective cohort study of patients with newly diagnosed oral squamous cell carcinoma from 2005 to 2019 was performed. Patients referred to and managed by a single surgeon (ERC) and who had not received any nutritional support in the preoperative period were included in the study. The primary predictor variable was preoperative albumin level. Other studied variables were patient demographic data and TNM stage. Complications related to primary ablative surgery represented the primary outcome variable. χ² analysis was completed to assess for significant associations between independent albumin groups (4+, 3.5 to 3.9, and 3.0 to 3.4 g/dL) in relation to postoperative complications. Multivariate logistic regression analysis was completed to control for clinical variables and medical comorbidities when testing the association between albumin and dehiscence.

RESULTS

The patient cohort included 268 individuals; of whom, 154 were men. The average age of the patients at surgery was 63 years. When controlling for all other variables, albumin was the only statistically significant predictor of postoperative dehiscence, P = .005. Patients with albumin of 3.5 to 3.9 g/dL had 3.24 times higher odds of dehiscence (95% confidence interval 1.42 to 7.38) in comparison with participants in the 4+ g/dL group. There was no difference of odds between the 3.0 to 3.4 group and the 4+ reference group.

CONCLUSIONS

Our study demonstrated that among those individuals meeting the inclusion criteria, there is a statistically significant association between lower albumin levels and postoperative complication rates, specifically dehiscence.

Preoperative Prognostic Nutritional Index Value is Related to Postoperative Delirium in Elderly Patients After Noncardiac Surgery: A Retrospective Cohort Study

Purpose

Malnutrition has been considered as a risk factor for postoperative delirium (POD). The Prognostic Nutritional Index (PNI) is a validated tool for assessing nutritional status. This study aimed to investigate the association between preoperative PNI values and the occurrence of POD in elderly surgical patients.

Methods

The retrospective cohort study included 361 elderly individuals who underwent noncardiac surgery between 2018 and 2019. Perioperative data were collected from the patients’ medical records. PNI was used to evaluate preoperative nutritional status. The primary outcome was the occurrence of POD. Univariate and multivariate logistic regression analyses were used to identify key factors associated with POD and assess the relationship between PNI values and the occurrence of POD. Receiver operating characteristic (ROC) curve analysis was used to assess the predictive value of PNI for POD.

Results

Seventy-two (19.9%) individuals developed postoperative delirium after surgery. Compared with patients of normal nutrition status (PNI ≥ 50), mild malnutrition (PNI 45–50) did not increase the risk of POD, while patients with moderate to severe malnutrition (PNI 40–45) (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.31–6.50) and serious malnutrition (PNI < 40) (OR, 3.15; 95% CI, 1.12–8.83) were more likely to develop POD. The cut-off value of PNI was 46.05 by ROC curve analysis, the area under the curve (AUC) was 0.69 (95% CI 0.62–0.77).

Conclusion

Preoperative PNI value is related to postoperative delirium in elderly patients after noncardiac surgery.

Preoperative Fasting Abbreviation With Whey Protein Reduces the Occurrence of Postoperative Complications in Patients With Head and Neck Cancer: A Randomized Clinical Trial

BACKGROUND

Surgery has become the treatment of choice for head and neck cancer (HNC) in most cases. Preoperative fasting abbreviation and nutrition screening have been suggested to reduce the occurrence of postoperative complications. This study aimed to evaluate the addition of whey protein in the preoperative fasting abbreviation and to analyze the association of nutrition status on postoperative complications in patients with HNC.

METHODS

A randomized, single-blind clinical trial was performed. Patients recruited from March to November 2018 at a national cancer reference center in Brazil were divided into 2 groups: intervention group (clear fluids with carbohydrate plus whey protein [CHO-P]) and control group (clear fluids with carbohydrate only [CHO]). All patients were evaluated by the Patient-Generated Subjective Global Assessment (PG-SGA) and body mass index. Logistic regression analyses were performed to assess associations between the studied variables, generating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 49 patients met the eligibility criteria and enrolled in the study. A PG-SGA score of 4-8, indicating moderate malnutrition (OR, 10.91; 95% CI, 1.05-112.91), was an independent factor that increased the risk of postoperative complication, whereas the CHO-P group (OR, 0.04; 95% CI, 0.01-0.26) was found to be an independent factor in reducing such risk.

CONCLUSION

The addition of whey protein to clear fluids (CHO-P group) was associated with a reduced risk of postoperative complications compared with the CHO group. Furthermore, moderate malnourishment was associated with an increased risk of postoperative complications for patients with HNC.

Nutritional status in patients of mandibular osteoradionecrosis: A single-institution experience

BACKGROUND

Mandibular osteoradionecrosis (ORN) is a devastating complication secondary to the radiotherapy of head and neck cancer. The nutritional status of ORN patients is compromised, but remains rarely studied. We aimed to evaluate the overall nutritional status of patients with ORN and explore the risk factors behind poor nutrition.

METHODS

This is a single-institution cross-sectional study. Patients diagnosed with ORN were consecutively recruited in a tertiary teaching hospital from July 2017 to August 2019. Multiple laboratory markers and physical indicators were examined to profile their nutritional status. The potential risk factors of poor nutrition were explored by logistic regression.

RESULTS

A total of 107 patients with ORN were recruited. Among them, almost all patients (95.3%) had at least one laboratory marker lower than the normal physiological range. A total of 40 (37.5%) patients were categorized as undernutrition, who had lower serum albumin (mean difference: 1.8 ± 0.8 g/L; p = .02), prealbumin (mean difference: 26.8 ± 10.8 mg/L; p = .02), and BMI (3.8 ± 0.4 kg/m² ; p < .0001) compared to patients of normal nutrition. Notably, the multivariate logistic regression indicated that patients with semi-liquid diet had 14.41 (95% CI: 3.03-68.54, p = .001) times; patients with liquid diet had 5.70 (95% CI: 1.55-20.98, p = .009) times more likely to be in undernutrition, as compared to patients with regular diets.

CONCLUSIONS

This is the first study characterizing the poor nutritional status in ORN patients. Patients having semi-liquid or liquid diets tended to have poorer nutritional status. The nutritional status of ORN patients should be underlined for professional nutritional supports so as to enhance their quality of life. More studies are warranted.

A novel nutritional risk score and prognosis of oral cancer patients: A prospective study

OBJECTIVES

To evaluate the prognostic performance of a novel nutritional risk score based on serum iron, hemoglobin, and body mass index (BMI) in oral cancer patients, and to predict the response to chemotherapy in patients with different nutritional status.

METHODS

X-tile analysis was performed to determine the optimal cutoff values of serum iron, hemoglobin, and BMI. A nutritional risk score was established by using the HR values of serum iron, hemoglobin, and BMI. Kaplan-Meier curve and multivariable Cox proportional hazards models were used to evaluate the prognostic value of the nutritional risk score in overall survival (OS) and oral cancer-specific survival (OCSS).

RESULTS

Serum iron, hemoglobin, and body mass index were all inversely related to the prognosis of oral cancer. The adjusted HR of serum iron, hemoglobin, and BMI were 1.562, 1.886, and 1.465 for OS, and 1.653, 1.865, and 1.443 for OCSS. Patients with higher nutritional risk score had a poorer OS and OCSS. Additionally, chemotherapy was only associated with improved OCSS in patients with the lowest nutritional risk score, but not in patients with higher one.

CONCLUSIONS

Nutritional risk score is of prognostic value in oral cancer patients. Favorable response to chemotherapy may only be observed in well-nourished oral cancer patients with lower nutritional risk score.

Preoperative underweight is associated with adverse postoperative events in patients undergoing microvascular reconstruction surgery for oral and maxillofacial cancer

We aimed to describe the prevalence of postoperative complications and evaluate its relationship with underweight, obesity, preoperative nutritional status, and systemic inflammation status in patients undergoing microvascular reconstruction for oral and maxillofacial cancer. Patients who were ≥20 years old and underwent microvascular reconstruction surgery between January 2009 to June 2019 were investigated. Patient demographics including body mass index, prognostic nutritional status, and neutrophil-lymphocyte ratio were collected. Logistic regression analysis was applied to evaluate these impacts on postoperative complications. A postoperative complication was defined as a Clavien-Dindo classification more than or equal to II. Of the 145 patients included in the analysis, 83 patients (57.2%) experienced postoperative complications, belonging to a Clavien-Dindo classification Ⅱ (n=71), Ⅲb (n=11), and Ⅳa (n=1). Multiple logistic regression revealed that a body mass index less than 18.5 kg/m² (odds ratio 6.19, 95% confidential interval 1.34-28.6, P=0.02) was related to postoperative complications. Another multiple logistic regression model including all explanatory factors found that underweight (P=0.03) was related to postoperative complications. This retrospective study showed that preoperative underweight was associated with postoperative complications as evaluated by the Clavien-Dindo classification.

Sarcopenia as an early complication of patients with head and neck cancer with dysphagia

OBJECTIVE

To evaluate the relationship between dysphagia and sarcopenia in patients with head and neck cancer (HNC).

METHODS

A cross-sectional, prospective study, sample by convenience, including men with HNC during their initial oncologic evaluation. Patients answered questionnaires (demographic data, lifestyle habits, disease characteristics and the Short International Physical Activity Questionnaire). Swallowing capacity, bioelectrical impedance (BIA), handgrip strength (HGS) and physical performance test (Timed Up and Go test) were evaluated. Sarcopenia was diagnosed following the European Working Group on Sarcopenia and Foundation for the National Institute of Health criterion.

RESULTS

71 men, elderly (66.9 ± 6.25 years) and adults (53.17 ± 3.66 years), were divided into the dysphagic group (DG, 44) and the non-dysphagic group (NDG, 27). The DG presented lower body mass index (BMI), lower skeletal muscle mass and a higher number of sarcopenic individuals than the NDG (p < 0.05). The degree of dysphagia was associated with weight loss (p = 0.006) but not with sarcopenia (p = 0.084) in the DG. The multivariate analysis showed that age, percentage of weight loss and BMI interfered with pre-sarcopenia, and only age influenced sarcopenia (p < 0.005).

CONCLUSION

Patients with dysphagia had a high prevalence of sarcopenia in the pre-treatment phase, related to age.

Association of Bolster Duration With Uptake Rates of Fibula Donor Site Skin Grafts

Importance

The fibula free flap donor site is associated with both short-term and long-term morbidity. Split-thickness skin graft (STSG) loss can lead to long delays in donor site healing and is associated with significant adverse sequelae. Patients may experience initial good STSG uptake after bolster removal but may have subsequent partial or total loss related to contact pressure or shearing.

Objective

To determine if increased duration of bolster use is associated with increased STSG uptake rates following fibula free flap reconstruction.

Design, Setting, and Participants

This retrospective cohort study included patients 18 years and older undergoing fibula free flap reconstruction following head and neck extirpative surgery at a tertiary care academic medical center from May 2013 to March 2019. The donor sites were photographed 4 weeks postoperatively, and areas of graft uptake were measured using image processing software. The baseline demographic, comorbidity, and operative characteristics were also collected.

Interventions

A fine mesh gauze with 3% bismuth tribromophenate and petrolatum blend bolster was sutured over leg STSGs placed on fibula free flap donor sites intraoperatively, and the ankle and lower leg were immobilized for 5 days in a plaster splint. Bolsters were either removed on postoperative day 5 or 14. Thereafter, the STSGs were covered with a petroleum and bismuth gauze and a cotton dressing.

Main Outcomes and Measures

Rates of donor site infection and STSG percentage uptake at 4 weeks.

Results

Of the 42 included patients, 31 (74%) were male, and the mean (SD) age was 62.1 (13.1) years. A total of 20 patients were included in the 5-day group, and 22 were included in the 14-day group. The 14-day bolster group had a higher mean percentage skin graft uptake rate compared with the 5-day bolster duration group (77.5% vs 59.9%), with an effect size of -0.632 (95% CI, -1.260 to -0.004). Patients with Adult Comorbidity Evalution-27 scores of 3 had poorer rates of STSG uptake compared with patients with Adult Comorbidity Evalution-27 scores of 0 to 2 (65.9% vs 82.9%), with an effect size of 0.599 (95% CI, -0.191 to 1.389). No donor site infections were noted in either group.

Conclusions and Relevance

Fourteen-day bolster application to the fibula free flap donor site was associated with better STSG uptake rates than 5-day bolster application.

New techniques and recommendations in the management of free flap surgery for head and neck defects in cancer patients

Free flap surgery is the gold standard surgical treatment for head and neck defects in cancer patients. Outcomes have improved considerably, probably due to recent advances in surgical techniques. In this article, we review improvements in the parameters traditionally used to optimize hematocrit levels and body temperature and to prevent vasoconstriction, and describe the use of cardiac output-guided fluid management, a technique that has proved useful in other procedures. Finally, we review other parameters used in free flap surgery, such as clotting/platelet management and nutritional optimization.

Role of Albumin as a Nutritional and Prognostic Marker in Elective Intestinal Surgery

BACKGROUND

The aim of this study was to investigate albumin, nutritional status, and inflammation in the perioperative course of patients undergoing elective intestinal surgery.

METHODS

A retrospective analysis of patients with preoperative measurements of nutritional parameters who underwent intestinal surgery between April 2017 and August 2018 at our institution was performed. Preoperatively, the correlation of albumin levels with markers for inflammation and nutritional status was investigated. Postoperatively, albumin levels were assessed with regard to high-grade morbidity and inflammation.

RESULTS

A total of 105 patients were included. Preoperatively, albumin levels were correlated with both markers for nutritional status and inflammation, with phase angle (PA) (p=0.004) and C-reactive protein (CRP) (p < 0.001) as independent factors predicting the albumin levels in multivariable analysis. Postoperatively, the reduction in serum albumin (∆-albumin) on postoperative day (POD) 1/2 (p=0.025) and POD 4/5 (p=0.003) was significantly associated with Clavien-Dindo complications ≥grade III. A cut-off value of 27.3% for ∆-albumin on POD 1/2 predicted postoperative high-grade morbidity (sensitivity 75% and specificity 69%). The product of ∆-albumin and CRP on POD 4/5 identified patients with major complications more reliably than ∆-albumin or CRP alone (sensitivity 91% and specificity 72%).

CONCLUSION

Preoperatively, albumin was a marker for nutritional status even if an inflammatory component was present. Postoperatively, ∆-albumin on POD 1/2 predicted high-grade morbidity. A new marker to identify patients with major complications on POD 4/5 is presented.

Nutritional assessment and prognosis of oral cancer patients: a large-scale prospective study

Background

To evaluate and compare the prognostic performance of four nutritional indicators body mass index (BMI), serum albumin (ALB), prognostic nutritional index (PNI) and nutritional risk index (NRI) in oral cancer patients, and to predict the response to chemotherapy in patients with different nutritional status.

Methods

This prospective study which involved 1395 oral cancer patients was conducted in Fujian, China from September 2007 to November 2018. The BMI, PNI and NRI were calculated according to the following formulas: BMI = weight / height² (kg/m²), PNI = albumin (g/l) + 0.005 × lymphocyte (count/μl) and NRI = (1.519 × albumin, g/l) + (41.7× present/ideal body weight), respectively. The univariate and multivariate Cox proportional hazards models were used to compare the prognostic value of BMI, ALB, PNI and NRI in overall survival (OS) in oral cancer.

Results

Patients with BMI < 18.5 kg/m² (VS 18.5 kg/m² ≤ BMI < 24 kg/m²) had a poor survival outcome (HR = 1.585; 95% CI: 1.207–2.082 ). ALB, PNI, NRI were inversely correlated with OS of oral cancer (HR = 0.716; 95% CI: 0.575–0.891; HR = 0.793; 95% CI: 0.633–0.992; HR = 0.588; 95% CI: 0.469–0.738, respectively). In addition, the prognostic predictive performance of NRI was superior to BMI or ALB or PNI. Interestingly, compared with patients with better nutritional status, chemotherapy was significantly associated with poorer OS in malnourished oral cancer patients.

Conclusions

BMI, ALB, PNI and NRI are of prognostic value in patients with oral cancer and the prognostic performance of NRI was superior to BMI or ALB or PNI. Malnutrition (BMI < 18.5 kg/m² or ALB< 40 g/l or PNI < 49.3 or NRI < 97.5) could predict an unfavorable response to chemotherapy in oral cancer patients.

Impact of nutritional status at the outset of assessment on postoperative complications in head and neck cancer

OBJECTIVES

Half of the patients presenting with head and neck tumor are malnourished at the outset of treatment. Muscle mass loss (sarcopenia) seems to be critical. The aim of the present study was to assess the impact of nutritional status and sarcopenia on postoperative complications in head and neck cancer.

MATERIALS AND METHODS

A retrospective study for the period November 2014 to May 2016 included 92 patients operated on for head and neck squamous cell carcinoma. Complications at 30 days were graded on the 5-level Clavien-Dindo classification. Nutritional status was assessed anthropometrically (weight), biologically (albuminemia and Nutrition Risk Index (NRI)), on CT (muscle mass index at 3rd lumbar vertebra) and functionally (Short Physical Performance Battery). Assessment was made at the outset of management, and nutritional treatment was initiated as appropriate. Potential risk factors for postoperative complications were assessed: performance status, prior radiation therapy, smoking and alcohol abuse.

RESULTS

54% of patients were malnourished on the NRI. 41% had grade≥2 complications. The most frequent complications were infection and healing disorder. The risk of complications was higher in case of malnutrition (62% vs. 17%; P<0.001) and sarcopenia (56% vs. 22%; P<0.01), with 50% longer hospital stay (P=0.04).

CONCLUSION

Malnutrition and sarcopenia are independent risk factors for postoperative complications.

Significance of Anthropometric and Nutritive Factors in Oral and Oropharyngeal Cancer Patients Undergoing Free Flap Reconstruction

PURPOSE

This study analyzed associations between preoperative nutritional status and the incidence of early postoperative complications as a primary outcome in patients with oral and oropharyngeal cancer undergoing free flap reconstruction. We hypothesized that preoperative nutritional status may be linked with specific complications, allowing for better preoperative risk assessment.

PATIENTS AND METHODS

This longitudinal, retrospective cohort study encompassed 113 patients, all treated surgically for oral and oropharyngeal cancer in the period from March 2013 up to March 2018 in a tertiary referral center. Variables considered were preoperative and postoperative serum albumin and protein values; body mass index; waist-to-hip ratio; circumference of the neck, waist, hip, and thigh; number of cigarettes smoked per day during the 10-year period before surgery; average alcohol consumption; operative time; and postoperative albumin administration.

RESULTS

Our study identified preoperative protein serum concentration (≤62 g/L), postoperative albumin administration (≥200 mL), number of cigarettes smoked per day (>20), and prolonged operative time (≥450 minutes) to be associated with postoperative complications.

CONCLUSIONS

This is the first study reporting cutoff values of clinical significance in assessing patient preoperative nutritional status in light of reducing postoperative complications after free flap reconstruction.

Prognostic significance of albumin levels prior to treatment in patients with head and neck squamous cell carcinoma

INTRODUCTION AND OBJECTIVES

Pre-treatment albumin levels have been shown to have prognostic capacity in oncological patients. The aim of this study is to analyse the relationship between albumin levels and prognosis in patients with head and neck squamous cell carcinoma (HNSCC).

METHODS

We performed a retrospective study in a cohort of 741 patients with HNSCC and a plasmatic albumin testing within the 4weeks prior to the start of treatment. The relationship between disease-specific survival and plasma albumin levels was analysed by a recursive partitioning analysis.

RESULTS

Albumin levels showed a directly proportional and statistically significant association with disease-specific survival. According to the results of the recursive partitioning analysis, the cut-off points with a higher prognostic capacity were 37.5g/L and 46.1g/L. Taking patients with albumin levels >46.1g/L as the benchmark, patients with albumin levels between 37.5-46.1g/L had a 1.44 times higher risk of disease-specific death (95%CI: .95-2.19, P=.081), and patients with levels <37.5g/L had a 3.19 times higher risk (95%CI: 2.01-5.04, P=.0001). The differences in survival based on albumin levels were only seen in patients with advanced stage tumours (stagesIII-IV).

CONCLUSION

Pre-treatment plasmatic albumin is an independent prognostic factor for patients with advanced stage HNSCC (III-IV), 37.5g/L being the cut-off point with the highest prognostic capacity.

Perioperative Care of Free Flap Patients

Microvascular free tissue transfer is an indispensable reconstructive option in head and neck reconstruction. Flap failure is relatively rare, but it is nonetheless very morbid and psychologically devastating to patients when it does occur. Further, complications after free tissue transfer to the head and neck remain common. There are numerous ongoing debates about various facets of preoperative, intraoperative, and postoperative care of patients undergoing free flap reconstruction of the head and neck, all ultimately searching for the optimal treatment algorithm to further improve flap success, minimize complications, and maximize patient outcomes. Herein, the authors review current literature surrounding optimal preoperative nutritional support, intraoperative vasopressor use, perioperative fluid management, use of antithrombotic agents, antibiotic use, and other facets of the care of head and neck free flap patients to provide a guide to surgeons.

Nutritional status in patients with head and neck cancer undergoing radiotherapy: a longitudinal study

PURPOSE

Patients with head and neck cancers are susceptible to malnutrition during radiotherapy. This study aimed to determine the changes in the nutritional status and its determinants in patients with head and neck cancer during radiotherapy.

METHODS

This prospective observational study was performed in an outpatient Radiation Oncology clinic with a sample of 54 patients. An interview form (including anthropometric and laboratory parameters), the Patient-Generated Subjective Global Assessment to assess nutritional status, quality of life scales, and toxicity criteria were used for data collection at the baseline, the end of radiotherapy and 1 and 3 months after radiotherapy.

RESULTS

While the majority of the patients (90%) were well nourished at baseline, most of the patients (74%) were malnourished at the end of radiotherapy (p < 0.001). During radiotherapy, patients developed malnutrition, reflected in a decrease in food intake, approximately 5% loss of body weight, a reduction in mid-arm upper circumference and mid-arm muscle mass, and reduced serum protein and albumin levels. The nutritional status was worse in oropharyngeal cancers (p = 0.021), advanced stage (p = 0.004), use of concomitant chemotherapy (p = 0.041), and worse toxicity (p < 0.001). Furthermore, the nutritional status was strongly associated with the quality of life.

CONCLUSIONS

This study demonstrated negative impact of radiotherapy on the nutritional status of patients with head and neck cancer. The study also showed the association of the nutritional status and the quality of life. The nutritional status should be assessed during different periods in the trajectory of treatment due to its significant contribution to the quality of life.

Infectious complications in head and neck surgery: Porto Oncology Centre retrospective analysis

OBJECTIVE

To analyze the impact of infectious complications and microbiology in the postoperative period after major oncologic neck surgeries.

METHODS

A retrospective study conducted in an oncology center, including all the consecutive patients who developed infectious complications after major neck cancer surgery, from October 2012 to May 2016 (44 months). Among other data, we collected TNM stage, ASA score, body mass index, comorbidities and habits, pre and postoperative hemoglobin levels, albumin serum levels, pre-surgical treatments, length of inpatient stay, isolated microbiological agents and the recorded complications and mortality rate.

RESULTS

In the studied period, 761 major neck surgeries were performed. Of these, 96 patients had complications (12.6%). Pharyngocutaneous fistula (PCF) was the most frequent complication (56%) and nosocomial pneumonia was the most common systemic complication (23%). Pseudomonas aeruginosa was the principal microorganism of the 26 species isolated (15%). 12 deaths were registered. Using multiple linear regression we concluded that flap/cutaneous necrosis and PCF were complications with statistical significance that prolonged inpatient stay. The same complications had significant relative risk for more than 30 days of hospitalization.

CONCLUSION

The postoperative period is critical for the successful treatment of head and neck oncology patients. PCF and flap/cutaneous necrosis were the principal complications which worsened the outcomes during this critical period. The early recognition and treatment of these complications is crucial.

Risk Factors for Adverse Outcome for Elderly Patients undergoing Curative Oncological Resection for Gastrointestinal Malignancies

BACKGROUND

The incidence of gastrointestinal cancer increases with age, with approximately 20% of these cases in people over 80 years of age. Due to pre-existing comorbidities, this onco-geriatric population often presents diagnostic and therapeutic challenges.

METHODS

A systematic review of articles on PubMed was performed to determine the predictive ability of screening tools and their components regarding the occurrence of adverse outcomes in elderly onco-surgical patients with gastrointestinal malignancies.

RESULTS

Surgical procedures in this patient cohort, particularly complex resections, may result in increased morbidity and mortality. The decision to treat an elderly patient with curative intent requires sound clinical judgment based on knowledge, consideration of objective parameters, and experience. These patients could potentially be optimized for surgery with the improvement of nutritional and overall performance status as well as with stabilizing comorbidities.

CONCLUSION

Various geriatric assessment and screening tools have been developed to identify risk factors to assist the surgeon and the interdisciplinary team in treatment planning, including the Frailty Assessment Score, Timed Up and Go test, nutritional status, and Activities of Daily Living test. It is important to emphasize that transparent and open communication between the treating surgeon and the patient is crucial in that the patient fully understands the implications of the treatment plan.