Risk factors associated with the development of sepsis after reconstructive flap surgery. J Plast Surg Hand Surg 2019;53:328-334. [PMID: 31204583 DOI: 10.1080/2000656x.2019.1626738]

Race and Ethnicity Independently Predict Adverse Outcomes Following Head and Neck Autograft Surgery

OBJECTIVE

There is growing attention toward the implications of race and ethnicity on health disparities within otolaryngology. While race is an established predictor of adverse head and neck oncologic outcomes, there is paucity in the literature on studies employing national, multi-institutional data to assess the impact of race and ethnicity on head and neck autograft surgery.

METHODS

Using the National Surgical Quality Improvement Program (NSQIP) database, trends in 30 days outcomes were assessed. Patients with ICD-10 codes for malignant head and neck neoplasms were isolated. Autograft surgeries were selected using Current Procedural Terminology (CPT) codes for free flap and pedicled flap reconstruction. Primary outcomes included surgical complications, reoperation, readmission, extended length of stay and operation time. Each binary categorical variable was compared to racial/ethnic identity via binary logistic regression.

RESULTS

The study cohort consisted of 2447 patients who underwent head and neck autograft surgery (80.71% free flap reconstruction and 19.39% pedicled flap reconstruction). Black patients had significantly higher odds of overall surgical complications (odds ratio [OR] 1.583, 95% confidence interval [CI] 1.091, 2.298, p = 0.016) with much higher odds of perioperative blood transfusions (OR 2.291, 95% CI 1.532, 3.426, p = <.001). Hispanic patients were more likely to undergo reoperation within 30 days after surgery and were more likely to be hospitalized for more than 30 days post-operatively (OR 1.566, 95% CI 1.015, 2.418, p = 0.043 and OR 12.224, 95% CI 2.698, 55.377, p = 0.001, respectively).

CONCLUSIONS

Race and ethnicity serve as independent predictors of complications in the post-operative period following head and neck autograft surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3595-3603, 2024.

Racial Disparities Following Reconstructive Flap Procedures

BACKGROUND

Prior reports have highlighted disparities in healthcare access, environmental conditions, and food insecurity between Black and White populations in the United States. However, limited studies have explored racial disparities in postoperative complications, particularly reconstructive flap surgeries.

METHODS

Cases of flap reconstruction based on named vascular pedicles were identified in the American College of Surgeons National Surgical Quality Improvement Program database and grouped into 3 time periods: 2005 to 2009, 2010 to 2014, and 2015 to 2019. Logistic regression was used to compare rates of postoperative complications between White and Black patients within each time period while controlling for comorbidities. Data for flap failure was only available from 2005 to 2010.

RESULTS

A total of 56,116 patients were included in the study, and 6293 (11.2%) were Black. Black patients were significantly younger than White patients and had increased rates of hypertension, smoking, and diabetes across all years ( P <0.01). Black patients had significantly higher rates of sepsis compared to White patients in all time periods. From 2005 to 2009, Black patients had a significantly higher incidence of flap failure (aOR=2.58, P <0.01), return to the operating room (aOR=1.53, P =0.01), and having any complication (aOR=1.48, P <0.01). From 2010 to 2019, White patients had a higher incidence of superficial surgical site infection.

CONCLUSIONS

Surgical complication rates following flap reconstruction based on a named vascular pedicle were higher for Black patients. Limited data on this topic currently exists, indicating that additional research on the drivers of racial disparities is warranted to improve plastic surgery outcomes in Black patients.

Healthcare Disparities in Otolaryngology

Purpose of Review

The purpose of this review is to summarize some of the recent research studies on healthcare disparities across various subspecialties within otolaryngology. This review also highlights the impact of COVID-19 pandemic on disparities and proposes potential interventions to mitigate disparities.

Recent Findings

Significant healthcare disparities in care and treatment outcomes have been reported across all areas of otolaryngology. Notable differences in survival, disease recurrence, and overall mortality have been noted based on race, ethnicity, socioeconomic status (SES), insurance status, etc. This is most well-researched in head and neck cancer (HNC) within otolaryngology.

Summary

Healthcare disparities have been identified by numerous research studies within otolaryngology for many vulnerable groups that include racial and ethnic minority groups, low-income populations, and individuals from rural areas among many others. These populations continue to experience suboptimal access to timely, quality otolaryngologic care that exacerbate disparities in health outcomes.

Development and validation of a patient-specific model to predict postoperative SIRS in older patients: A two-center study

Introduction

Postoperative systemic inflammatory response syndrome (SIRS) is common in surgical patients especially in older patients, and the geriatric population with SIRS is more susceptible to sepsis, MODS, and even death. We aimed to develop and validate a model for predicting postoperative SIRS in older patients.

Methods

Patients aged ≥65 years who underwent general anesthesia in two centers of Third Affiliated Hospital of Sun Yat-sen University from January 2015 to September 2020 were included. The cohort was divided into training and validation cohorts. A simple nomogram was developed to predict the postoperative SIRS in the training cohort using two logistic regression models and the brute force algorithm. The discriminative performance of this model was determined by area under the receiver operating characteristics curve (AUC). The external validity of the nomogram was assessed in the validation cohort.

Results

A total of 5,904 patients spanning from January 2015 to December 2019 were enrolled in the training cohort and 1,105 patients from January 2020 to September 2020 comprised the temporal validation cohort, in which incidence rates of postoperative SIRS were 24.6 and 20.2%, respectively. Six feature variables were identified as valuable predictors to construct the nomogram, with high AUCs (0.800 [0.787, 0.813] and 0.822 [0.790, 0.854]) and relatively balanced sensitivity (0.718 and 0.739) as well as specificity (0.718 and 0.729) in both training and validation cohorts. An online risk calculator was established for clinical application.

Conclusion

We developed a patient-specific model that may assist in predicting postoperative SIRS among the aged patients.

The Impact of Metabolic Syndrome on Microvascular Head and Neck Reconstruction: An ACS-NSQIP data analysis

BACKGROUND

Metabolic syndrome (MetS) can predispose patients to poorer surgical outcomes. In this study, we sought to evaluate the impact of MetS on the postoperative outcomes of head and neck microvascular reconstruction.

METHODS

Review of the 2015-2019 NSQIP database identified 5,323 cases of microvascular reconstruction, of which 3,809 were head and neck cases. Of the included patients, 184 had MetS and 3625 did not. The groups were compared in terms of demographics and comorbidities. Postoperative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and nonhome discharge.

RESULTS

The MetS group had higher rates of medical complications (p<0.0001), sepsis (p=0.02), septic shock (p=0.01), and skilled care-discharge (p=0.0004). Analysis by flap type revealed that MetS patients receiving free skin flaps experienced higher rates of organ space infection (p=0.02), sepsis (p<0.0001), and lower home-discharge (p=0.01). In the free muscle group, superficial incisional infection (p=0.04), UTI (p=0.02), and septic shock (p=0.01) were higher in MetS patients. Stratification by surgical site showed that the occurrence of sepsis was significantly higher in the patients receiving microvascular flap reconstruction of the larynx (p=0.04) or tongue(p=0.03). Stratification of the MetS patients according to treatment for diabetes showed that patients receiving insulin experienced a higher rate of superficial incisional infection (p=0.04). A multivariate analysis verified significantly higher rates of medical complications (p<0.0001), sepsis (p=0.03) and septic shock (p=0.01) in the MetS group.

CONCLUSION

Patients with MetS undergoing head and neck microvascular reconstruction are at increased risk of postoperative medical complications, including sepsis and septic shock, and are more likely to be discharged to a skilled care facility. Surgical outcomes were found to depend on the type of flap and site of surgery.