Resource utilization and patient morbidity in head and neck reconstruction

Outcomes Associated with Multiple Free Tissue Transfers Performed in a Single Day

Background: Although microvascular free tissue transfer (MFTT) remains technically challenging, surgeons may need to perform >1 MFTT operations in a given day. Objective: To compare MFTT outcomes in cases where surgeons completed one versus two flaps per day by measuring flap viability and complication rates. Methods: A retrospective review was conducted of MFTT cases from January 2011 to February 2022 with >30-day follow-up. Outcomes, including flap survival and operating room takeback, were compared using multivariate logistic regression analysis. Results: Of 1096 patients meeting inclusion criteria (1105 flaps), there was a male predominance (n = 721, 66%). Mean age was 63.0 ± 14.4 years. Complications requiring takeback were identified in 108 flaps (9.8%) and were greatest for double flaps in the same patient (SP) (27.8%, p = 0.06). Flap failure occurred in 23 (2.1%) cases and was also greatest for double flaps in the SP (16.7%, p = 0.001). Takeback (p = 0.06) and failure (p = 0.70) rates were not different between days with one versus two unique patient flaps. Conclusions: Among patients undergoing MFTT, those treated on days in which surgeons perform two unique cases compared with single cases will demonstrate no difference in outcomes, as measured by flap survival and takeback, whereas patients with defects requiring multiple flaps will experience greater takeback and failure rates.

The submental flap for head and neck reconstruction: Comparison of outcomes to the radial forearm free flap

OBJECTIVES

To compare intraoperative, postoperative, functional, and oncologic outcomes of the submental island pedicled flap (SIPF) to the radial forearm free flap (RFFF).

STUDY DESIGN

Retrospective review; comparison with statistical analysis.

METHODS

A retrospective review was performed on patients at two tertiary care academic hospitals by a single surgeon. Consecutive patients who underwent cancer resection and reconstruction with SIPF or RFFF between 2004 and 2016 were included. Cancer staging, surgical procedure, hospital stay, complications, and functional and oncologic results were extracted.

RESULTS

The study included 146 patients (57 SIPF; 89 RFFF). The most prevalent primary site was oral cavity, with a minority in the oropharynx, paranasal sinuses, or external face. Mean area of the SIPF was smaller at 28 cm² compared to 48 cm² for the RFFF. Operative time for SIPF was shorter at 6.5 hours compared to 9 hours for RFFF. Hospital stay was 8.0 days for SIPF patients and 10.0 days for RFFF patients. Multivariate analysis confirmed these differences were significant. Functional outcomes of speech quality and gastrostomy feeding tube dependence were similar between the SIPF and RFFF groups. There was no difference in local recurrence rate for SIPF (16%) and RFFF (19%), and there was no difference in overall recurrence. Kaplan-Meier curves showed no difference in recurrence between both groups, and multivariate logistic regression demonstrated no association between SIPF and local recurrence.

CONCLUSION

Operative time and hospital stay are both significantly reduced with the SIPF. Functional and oncologic results are similar with no contraindication to the SIPF. The SIPF is a good first-line choice for head and neck reconstruction.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:S1-S10, 2020.

Free Tissue Transfer versus Pedicled Flap Cost in Head and Neck Cancer

OBJECTIVE: We sought to compare the overall 1-year management costs for patients receiving a free tissue transfer with those of patients receiving a pedicled flap reconstruction as a component of their primary head and neck cancer treatment.

STUDY DESIGN AND SETTING: Case-control, cost identification analysis of 21 matched pairs of patients and multivariate analysis of variables associated with treatment costs was conducted in a tertiary referral academic institution.

RESULTS: No significant difference in total 1-year charges between the pedicled and free tissue transfer groups was found. A structured measure of patient comorbidity was the only variable significantly associated with total 1-year charges.

CONCLUSIONS: Total 1-year treatment costs of primary upper aerodigestive tract cancers are similar for patients reconstructed with free tissue transfer or a pedicled flap.

SIGNIFICANCE: Within the context of overall 1-year management costs, the primary determinants of health care expense for these patients are comorbidity and extent of disease, not reconstructive technique.

Reimbursement for reconstruction by tissue transfer-a European comparison

Background

Case payment mechanisms have become the principal means of remunerating hospitals in most developed countries. Our purpose was to analyse the reimbursement for different types of tissue transfer in five European countries.

Methods

We looked at common surgical options for pedicled and free flaps. The recipient site of a flap and the principal diagnosis were systematically modified and processed with national grouper software in order to identify Diagnosis-Related Groups from which the proceeds were derived. The primary data originated from the database of the German Institute for the Hospital Remuneration System as aggregate information. We conducted eight specialist interviews to transfer the available data into clinical practice. Data of real patients were not available and we rather simulated standard patients to avoid dilution of results.

Results

Altogether, payment for pedicled flaps averaged 5933€ and was 8517€ for free flaps. The comparison of both flap types within a country revealed significant differences in Germany, Austria and Sweden only (p < 0.001). Italy has the highest mean proceeds for pedicled flaps, followed by Sweden, Germany, Austria and the UK. This relationship changes for free flaps with Sweden achieving the highest payments. Overall, reimbursement conformity is higher for free flaps.

Conclusions

Most countries have procedure-driven payment systems for flap surgery, which additionally can strongly depend on the diagnosis. Nevertheless the latter does not always justify existing price differences. For the first time, clinical cases in tissue transfer were compared internationally. In today`s dynamic world of health care, we should observe other countries` compensation systems to identify ways of improving our own.

Major surgery in elderly head and neck cancer patients: immediate and long-term surgical results and complication rates

BACKGROUND

Evaluation of immediate and long-term surgical results in major surgery for the head and neck tumours in elderly patients and identification of tumour and patient related factors that affect the incidence and severity of surgical and medical complications.

METHODS

Retrospective analysis of a series of 24 consecutive patients aged 70 and over with head and neck tumours undergoing extensive surgical resections with reconstruction with/without osseous and/or soft tissue transfer. Patients' demographics and surgery and tumour related data were extracted from appropriate charts and recorded. Pre-existent comorbid conditions, immediate and long-term surgical and medical complications were analysed. Pre-existing comorbidities were graded and staged using the Comorbidity Data Collection Form. Postoperative surgical and medical complications were scored according to their severity.

RESULTS

Overall complication rate in present study was 63% and 54% of patients experienced clinically important surgical and/or medical complications. However, medium admission time remained at 16 days. Presence of advanced comorbidity, longer operative times and advanced stage of disease seemed to influence the development of surgical or medical complications.

CONCLUSIONS

Major surgery for head and neck tumours is of great value even in elderly patients providing very good surgical results with acceptable complication rates. The choice of treatment modality should be based on all factors affecting the treatment outcomes. In particular, the presence of the co-existent underlying diseases should be assessed meticulously and in cases with clinically important comorbidities the surgical treatment stress should be reduced to minimum.

Comorbid condition as a prognostic factor for complications in major surgery of the oral cavity and oropharynx with microvascular soft tissue reconstruction

BACKGROUND

Identification of factors, especially comorbidity, that affect the incidence and severity of complications in head and neck cancer patients.

METHODS

One hundred patients with an oral/oropharynx carcinoma undergoing composite resection and microvascular soft tissue transfer were analyzed. Patient data and tumor and treatment factors were recorded. Comorbidity was graded by an Adult Comorbidity Evaluation 27 (ACE-27) test. Postoperative complications were scored according to their severity.

RESULTS

Comorbidity score ACE-27 grade 2 or higher was present in 47% of patients, whereas 33% had a clinically important complication develop. A comorbidity score of ACE-27 grade > or =2 was a strong predictor for complications (p <.001). There were no other predictors for postoperative complications.

CONCLUSIONS

Comorbidity is of great importance for prediction of postoperative complications in head and neck cancer patients, especially an ACE-27 grade > or =2. It may be concluded from these results that prevention of complications should focus on comorbidities.

Free tissue transfer versus pedicled flap in head and neck reconstruction

OBJECTIVES

Free flaps are often criticized as being medically risky for the patient, expensive, and too time-consuming when compared with the traditional rotational flap repair. Perhaps the costs do not outweigh the benefits. The study analyzes many aspects of resource utilization and patient outcome to determine whether these criticisms hold true.

STUDY DESIGN

Retrospective patient review.

METHODS

Sixty-five patient charts were reviewed. The following data were abstracted: flap type, tumor location and stage, preoperative American Society of Anesthesiologists score, preoperative irradiation, postoperative medical complications, flap outcome, length of hospital stay, date of first intake by mouth, and date of decannulation. The data were analyzed for free flaps and rotational flaps. Then data were analyzed again for free and rotational flaps performed for only patients who underwent a composite resection, to further standardize the results.

RESULTS

For all defect types, free flap operative time was statistically greater (9 h 35 min for free flaps vs. 4 h 58 min for rotational flaps). Regarding hospital charges, only patients who had a free flap after composite resection differed in amount charged when free versus rotational flaps were compared (53,585 dollars for free flaps vs. 32,984 dollars for rotational flaps). Length of intensive care unit stay differed between patients having composite resection of the two flap types (0.1 d after rotational flap vs. 1.4 d after free flap).

CONCLUSIONS

The differences between the two reconstruction methods are only a few. We do not think that longer operative time, longer length of intensive care unit stay, and increased hospital charges are significant enough to deny a patient a superior repair. We also think that as surgeons' experience increases, these differences may one day no longer hold true.

Octogenarian free flap reconstruction: complications and cost of therapy

OBJECTIVE

The study goal was to document the reliability, incidence of complications, and cost of therapy for patients older than 80 years who undergo microvascular head and neck reconstruction.

PATIENTS AND METHODS

Thirteen octogenarians underwent free flap reconstruction of defects resulting from the treatment of head and neck cancer at an academic tertiary care medical center. The incidence of medical and reconstructive complications and the cost of hospitalization were compared with those for 99 younger patients who were treated during the same time period.

RESULTS

There were no cases of free flap failure or significant reconstructive complications in the octogenarians. The incidence of medical complications was 62% in the octogenarians and 15% in the younger patients. The average cost of therapy was $54,702 per octogenarian patient compared with $30,397 per younger patient. The increased incidence of medical complications and increased cost arose primarily from an increased severity of preoperative systemic illness in the octogenarians. However, controlling for comorbidity did not eliminate the discrepancy in medical complications between the octogenarians and the younger patients.

CONCLUSIONS

Although microvascular head and neck reconstruction in the elderly is very reliable, the incidence of medical complications and the cost of therapy are significantly increased in octogenarians.

The outcome of failed free flaps in head and neck and extremity reconstruction: what is next in the reconstructive ladder?

The indications for free flaps have been more or less clarified; however, the course of reconstruction after the failure of a free flap remains undetermined. Is it better to insist on one's initial choice, or should surgeons downgrade their reconstructive goals? To establish a preliminary guideline, this study was designed to retrospectively analyze the outcome of failed free-tissue transfers performed in the authors hospital. Over the past 8 years (1990 through 1997), 3361 head and neck and extremity reconstructions were performed by free-tissue transfers, excluding toe transplantations. Among these reconstructions, 1235 flaps (36.7 percent) were transferred to the head and neck region, and 2126 flaps (63.3 percent) to the extremities. A total of 101 failures (3.0 percent total plus the partial failure rate) were encountered. Forty-two failures occurred in the head and neck region, and 59 in the extremities. Evaluation of the cases revealed that one of three following approaches to handling the failure was taken: (1) a second free-tissue transfer; (2) a regional flap transfer; or (3) conservative management with debridement, wound care, and subsequent closure by secondary intention, whether by local flaps or skin grafting. In the head and neck region, 17 second free flaps (40 percent) and 15 regional flaps (36 percent) were transferred to salvage the reconstruction, whereas conservative management was undertaken in the remaining 10 cases (24 percent). In the extremities, 37 failures were treated conservatively (63 percent) in addition to 17 second free flaps (29 percent) and three regional flaps (5 percent) used to salvage the failed reconstruction. Two cases underwent amputation (3 percent). The average time elapsed between the failure and second free-tissue transfer was 12 days (range, 2 to 60 days) in the head and neck region and 18 days (range, 2 to 56 days) in the extremities. In a total of 34 second free-tissue transfers at both localizations, there were only three failures (9 percent). However, in the head and neck region, seven of the regional flaps transferred (47 percent) and four cases that were conservatively treated (40 percent) either failed or developed complications that lengthened the reconstruction period because of additional procedures. Six other free-tissue transfers had to be performed to manage these complicated cases. Conservative management was quite successful in the extremities; most patients' wounds healed, although more than one skin-graft procedure was required in 10 patients (27 percent). In conclusion, a second free-tissue transfer is, in general, a relatively more reliable and more effective procedure for the treatment of flap failure in the head and neck region, as well as failed vascularized bone flaps in the reconstruction of the extremities. Conservative treatment may be a simple and valid alternative to second (free) flaps for soft-tissue coverage in extremities with partial and even total losses.

Length of stay after free flap reconstruction of the head and neck

OBJECTIVES

To analyze the incidence and timing of postoperative complications after free tissue transfer (FTT) and relate that to length of stay (LOS.)

STUDY DESIGN

We reviewed one surgeon's experience with 97 patients undergoing 100 head and neck reconstructions via FTT for a variety of traumatic and ablative defects

METHODS

Charts were reviewed for demographic data, type of defect and flap, complications, LOS, length of intensive care unit (ICU) stay, date of decannulation, and first oral intake, any readmission to the hospital, and preoperative radiation status.

RESULTS

Using strict guidelines, 31% of patients had some form of complication, including a 9% flap failure rate. Average postoperative LOS for all patients was 11 days. Average LOS for uncomplicated cases was 9 and for complicated cases was 16 days. For cases with flap-related complications the average LOS rose to 20 days. All reconstructive failures (defined as patients requiring subsequent surgical procedures after a flap-related complication, regardless of outcome) occurred within the first 7 postoperative days. Three patients were readmitted for various reasons: a partial flap dehiscence (postoperative day [POD] 9), meningitis (POD 24), and orocutaneous fistula (POD 22), for a 3.2% readmission rate. Fourteen percent of patients were on a regimen of oral intake, and 13% had decannulation by the time of discharge. Resumption of oral intake and tracheostomy decannulation were accomplished on an outpatient basis in the remainder of patients.

CONCLUSIONS

There were no preventable complications associated with early hospital discharge, nor was there evidence of adverse patient outcome. We conclude that early hospital discharge is feasible after FTT reconstruction and is consistent with quality care.

Need for intensive care after operations for head and neck cancer surgery

We compared the postoperative morbidity of 44 patients who had had major head and neck oncological resections and who were nursed postoperatively on a general ward with that of 33 who were nursed on an intensive care unit at North Manchester General Hospital and Withington Hospital, South Manchester, respectively. There was no difference in the general morbidity (9/44, 20% compared with 9/33, 27%, 95%, CI of difference -0.26 to 0.13). We conclude that it is safe to nurse the patients on a general ward provided that certain conditions are fulfilled.