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Namavarian A, Gabinet-Equihua A, Deng Y, Khalid S, Ziai H, Deutsch K, Huang J, Gilbert RW, Goldstein DP, Yao CMKL, Irish JC, Enepekides DJ, Higgins KM, Rudzicz F, Eskander A, Xu W, de Almeida JR. Length of Stay Prediction Models for Oral Cancer Surgery: Machine Learning, Statistical and ACS-NSQIP. Laryngoscope 2024; 134:3664-3672. [PMID: 38651539 DOI: 10.1002/lary.31443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/17/2024] [Accepted: 03/27/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Accurate prediction of hospital length of stay (LOS) following surgical management of oral cavity cancer (OCC) may be associated with improved patient counseling, hospital resource utilization and cost. The objective of this study was to compare the performance of statistical models, a machine learning (ML) model, and The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) calculator in predicting LOS following surgery for OCC. MATERIALS AND METHODS A retrospective multicenter database study was performed at two major academic head and neck cancer centers. Patients with OCC who underwent major free flap reconstructive surgery between January 2008 and June 2019 surgery were selected. Data were pooled and split into training and validation datasets. Statistical and ML models were developed, and performance was evaluated by comparing predicted and actual LOS using correlation coefficient values and percent accuracy. RESULTS Totally 837 patients were selected with mean patient age being 62.5 ± 11.7 [SD] years and 67% being male. The ML model demonstrated the best accuracy (validation correlation 0.48, 4-day accuracy 70%), compared with the statistical models: multivariate analysis (0.45, 67%) and least absolute shrinkage and selection operator (0.42, 70%). All were superior to the ACS-NSQIP calculator's performance (0.23, 59%). CONCLUSION We developed statistical and ML models that predicted LOS following major free flap reconstructive surgery for OCC. Our models demonstrated superior predictive performance to the ACS-NSQIP calculator. The ML model identified several novel predictors of LOS. These models must be validated in other institutions before being used in clinical practice. LEVEL OF EVIDENCE 3 Laryngoscope, 134:3664-3672, 2024.
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Affiliation(s)
- Amirpouyan Namavarian
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Yangqing Deng
- Department of Biostatistics, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Shuja Khalid
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
| | - Hedyeh Ziai
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Konrado Deutsch
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jingyue Huang
- Department of Biostatistics, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Ralph W Gilbert
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Christopher M K L Yao
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Danny J Enepekides
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Kevin M Higgins
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Vector Institute for Artificial Intelligence, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
- Department of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sinai Health System, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Le JM, Morlandt AB, Patel K, Bourne G, Seri C, Ying YP. Is the Use of Dexmedetomidine Upon Emergence From Anesthesia Associated With Neck Hematoma Formation Following Head and Neck Microvascular Reconstruction? J Oral Maxillofac Surg 2024:S0278-2391(24)00269-6. [PMID: 38718840 DOI: 10.1016/j.joms.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Dexmedetomidine (DEX) is a highly selective alpha-2-receptor agonist, and its use has not been well studied in major microvascular reconstructive surgery of the head and neck. PURPOSE The purpose is to measure the association between DEX and neck hematoma formation in subjects undergoing head and neck microvascular reconstructive surgery. STUDY DESIGN, SETTING, SAMPLE The investigators implemented a retrospective cohort study on subjects undergoing microvascular head and neck reconstruction for benign and malignant pathology at the University of Alabama at Birmingham from 2014 to 2021. Patients with unresectable tumors were excluded. PREDICTOR VARIABLE The predictor variable was the intraoperative use of DEX upon emergence from general anesthesia. Subjects received standard anesthetic drugs and DEX, while control subjects received only standard anesthetic drugs. MAIN OUTCOME VARIABLE(S) The primary outcome was postoperative neck hematoma formation necessitating a return to the operating theater. The secondary outcome was the length of stay (LOS). COVARIATES The covariates were demographic, operative, and oral morphine equivalents of anesthesia drugs. ANALYSES Bivariate analyses were performed using the Student's t-test and the χ2 test for continuous and categorical variables. Multivariate regression analyses were conducted to assess for associations between DEX and the outcomes adjusted for confounding variables when present. P values of < .05 were regarded as statistically significant. RESULTS A total of 297 subjects (mean age, 59.6 years, and standard deviation [SD], 14.9) with 61.6% male received DEX, and 304 subjects (mean age, 58.9 years, and SD, 14.6) with 60.2% male served as controls (P > .5). A total of 11 postoperative neck hematoma occurred in the control group when compared to 2 in the DEX (relative risk = 5.4, 95% confidence interval [CI], 1.2 to 24, P = .02). The mean LOS was 7.7 (SD, 4.3) and 9.4 (SD, 8.1) for the DEX and control groups (95% CI, 0.7 to 2.8, P < .01). After adjusting for tobacco history, tracheostomy, and neck dissection, DEX (Beta coefficient (B) = -1.7, 95% CI -2.7 to -0.7, P < .01) and neck dissection (B = 2.2, 95% CI 1.0 to 3.4, P < .01) were statistically associated with LOS. CONCLUSION AND RELEVANCE The use of intraoperative DEX upon emergence from general anesthesia was associated with lower postoperative neck hematoma formation and a shorter length of stay following microvascular head and neck reconstruction.
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Affiliation(s)
- John M Le
- Resident, Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, AL.
| | - Anthony B Morlandt
- Professor, Section of Oral Oncology, Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Kirav Patel
- Resident, Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Graham Bourne
- Dental student, School of Dentistry, University of Alabama at Birmingham, Birmingham, AL
| | - Chaitra Seri
- Dental student, School of Dentistry, University of California Los Angeles, Los Angeles, CA
| | - Yedeh P Ying
- Associate Professor, Section of Oral Oncology, Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, AL
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Vollmer A, Nagler S, Hörner M, Hartmann S, Brands RC, Breitenbücher N, Straub A, Kübler A, Vollmer M, Gubik S, Lang G, Wollborn J, Saravi B. Performance of artificial intelligence-based algorithms to predict prolonged length of stay after head and neck cancer surgery. Heliyon 2023; 9:e20752. [PMID: 37928044 PMCID: PMC10623164 DOI: 10.1016/j.heliyon.2023.e20752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
Background Medical resource management can be improved by assessing the likelihood of prolonged length of stay (LOS) for head and neck cancer surgery patients. The objective of this study was to develop predictive models that could be used to determine whether a patient's LOS after cancer surgery falls within the normal range of the cohort. Methods We conducted a retrospective analysis of a dataset consisting of 300 consecutive patients who underwent head and neck cancer surgery between 2017 and 2022 at a single university medical center. Prolonged LOS was defined as LOS exceeding the 75th percentile of the cohort. Feature importance analysis was performed to evaluate the most important predictors for prolonged LOS. We then constructed 7 machine learning and deep learning algorithms for the prediction modeling of prolonged LOS. Results The algorithms reached accuracy values of 75.40 (radial basis function neural network) to 97.92 (Random Trees) for the training set and 64.90 (multilayer perceptron neural network) to 84.14 (Random Trees) for the testing set. The leading parameters predicting prolonged LOS were operation time, ischemia time, the graft used, the ASA score, the intensive care stay, and the pathological stages. The results revealed that patients who had a higher number of harvested lymph nodes (LN) had a lower probability of recurrence but also a greater LOS. However, patients with prolonged LOS were also at greater risk of recurrence, particularly when fewer (LN) were extracted. Further, LOS was more strongly correlated with the overall number of extracted lymph nodes than with the number of positive lymph nodes or the ratio of positive to overall extracted lymph nodes, indicating that particularly unnecessary lymph node extraction might be associated with prolonged LOS. Conclusions The results emphasize the need for a closer follow-up of patients who experience prolonged LOS. Prospective trials are warranted to validate the present results.
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Affiliation(s)
- Andreas Vollmer
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070, Würzburg, Germany
| | - Simon Nagler
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070, Würzburg, Germany
| | - Marius Hörner
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070, Würzburg, Germany
| | - Stefan Hartmann
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070, Würzburg, Germany
| | - Roman C. Brands
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070, Würzburg, Germany
| | - Niko Breitenbücher
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070, Würzburg, Germany
| | - Anton Straub
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070, Würzburg, Germany
| | - Alexander Kübler
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070, Würzburg, Germany
| | - Michael Vollmer
- Department of Oral and Maxillofacial Surgery, University Hospital of Tübingen, 72076, Tübingen, Germany
| | - Sebastian Gubik
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070, Würzburg, Germany
| | - Gernot Lang
- Department of Orthopedics and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Babak Saravi
- Department of Orthopedics and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Venous Thromboembolism Rates After Free Flap Reconstruction of the Head and Neck Region. Ann Plast Surg 2023:00000637-990000000-00217. [PMID: 36921331 DOI: 10.1097/sap.0000000000003520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major concern for the postoperative hospitalized patient, especially after long and complex procedures. Cancer itself also contributes to the hypercoagulable state, further complicating the management of patients. Despite prophylaxis, breakthrough events can occur. We aimed to assess our institutional VTE and bleeding rates after free flap reconstruction of the head and neck (H&N) region and the factors associated with VTE events. METHODS A retrospective review of the patients who underwent H&N free flap reconstruction at an academic center from 2012 to 2021 was performed from a prospectively maintained database. Data regarding patient demographics, medical history, surgical details, and overall outcomes were collected. Outcomes studied included postoperative 30-day VTE rates and major bleeding events. Patients who had a VTE event were compared with the rest of the cohort to identify factors associated with VTE. RESULTS Free flap reconstruction of the H&N region was performed in 949 patients. Reconstruction after cancer extirpation for squamous cell carcinoma was the most common etiology (79%). The most common flap was thigh based (50%), followed by the fibula (29%). The most common postoperative VTE chemoprophylaxis regimen was enoxaparin 30 mg twice daily (83%). The VTE and bleeding rates over the 10-year period were 4.6% (n = 44) and 8.7% (n = 83), respectively. Body mass index (28.7 ± 5.8 vs 26.2 ± 6.6, P = 0.013) and pulmonary comorbidities were found to be significantly higher in patients who had a VTE event (43% vs 27%, P = 0.017). Patients with a VTE event had a prolonged hospital stay of 8 more days (19.2 ± 17.4 vs 11 ± 7, P = 0.003) and a higher incidence of bleeding events (27% vs 8%, P < 0.001). CONCLUSIONS Postoperative VTE is a significant complication associated with increased length of hospitalization in patients undergoing free flap reconstruction of the H&N region. Institutional measures should be implemented on an individualized basis based on patient comorbidities to improve the postoperative VTE rates, while balancing the bleeding events.
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Din-Lovinescu C, Barinsky GL, Povolotskiy R, Grube JG, Park CW. Percutaneous Endoscopic Gastrostomy Tube Timing in Head and Neck Cancer Surgery. Laryngoscope 2023; 133:109-115. [PMID: 35366010 PMCID: PMC10084390 DOI: 10.1002/lary.30127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/27/2022] [Accepted: 03/21/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine outcomes and complications in patients receiving a percutaneous endoscopic gastrostomy (PEG) tube on the same day of head and neck cancer (HNC) surgery versus later in hospitalization. METHODS The 2003-2014 Nationwide Inpatient Sample was queried for patients undergoing ablative HNC procedures who had a PEG tube placed. Cases were stratified by PEG tube timing into an early (on the same day as ablative procedure) and late (later in hospitalization) group. Demographics and outcomes were compared using univariate analysis and multivariate regression modeling. RESULTS A total of 4,068 cases were included, of which 2,206 (54.23%) underwent early PEG and 1,862 (45.77%) received a late PEG tube. Late PEG tube patients were more likely to have a diagnosis of malnutrition (18.0% vs. 15.3%, p = 0.018) or renal failure (4.7% vs. 3.0%, p = 0.006). On multivariate regression analysis, patients receiving late PEG tubes were more likely to experience aspiration pneumonia, acute pulmonary disease, infectious pneumonia, sepsis, hematoma, wound disruption, surgical site infection, and fistula formation (all p < 0.05). The mean length of stay and hospital charges in the late PEG group were significantly greater (17.1 vs. 12.6 days, p < 0.001) and ($159,993 vs. $125,705, p < 0.001), respectively. CONCLUSIONS Patients undergoing HNC surgery who received a PEG tube on the day of ablative surgery had lower complication rates, shorter length of stay, and decreased hospital costs compared to those who had a PEG tube placed later during hospitalization. Further research is needed to determine the causal relationships behind these findings. LEVEL OF EVIDENCE 3 Laryngoscope, 133:109-115, 2023.
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Affiliation(s)
- Corina Din-Lovinescu
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Gregory L Barinsky
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Roman Povolotskiy
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jordon G Grube
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Chan W Park
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Bertazzoni G, Testa G, Tomasoni M, Mattavelli D, Del Bon F, Montalto N, Ferrari M, Andreoli M, Morello R, Sbalzer N, Vecchiati D, Piazza C, Nicolai P, Deganello A. The Enhanced Recovery After Surgery (ERAS) protocol in head and neck cancer: a matched-pair analysis. ACTA OTORHINOLARYNGOLOGICA ITALICA 2022; 42:325-333. [PMID: 36254650 PMCID: PMC9577693 DOI: 10.14639/0392-100x-n2072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022]
Abstract
Objective In this study, we aimed to describe the prospective implementation of the Enhanced Recovery after Surgery (ERAS) protocol in an Italian tertiary academic centre. Methods Adult patients receiving surgery for primary or recurrent clinical stage III/IV squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx were enrolled. The primary objective was to evaluate the impact of the ERAS protocol on length of hospital stay (LOS). The secondary objective was to assess its impact on complications. To evaluate the results of the ERAS protocol, a matched-pair analysis was conducted, comparing ERAS patients with comparable cases treated before 2018. Results Forty ERAS and 40 non-ERAS patients were analysed. There were no significant differences between the cohorts regarding age, gender, stage of disease, comorbidity, ASA score, and duration of surgery. A significantly shorter LOS for the ERAS group (median, 14 days; range, 10-19) than for non-ERAS patients (median, 17.5 days; range, 13-21) was observed (p = 0.0128). The incidence of complications was not significantly different (p = 0.140). Conclusions Our study demonstrates that the introduction of an ERAS protocol in the daily practice is feasible, and can result in significant reduction in LOS.
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Affiliation(s)
- Giacomo Bertazzoni
- Department of Otorhinolaryngology, Azienda Socio-Sanitaria Territoriale di Cremona, Cremona, Italy,Correspondence Giacomo Bertazzoni Department of Otorhinolaryngology Azienda Socio-Sanitaria Territoriale di Cremona, viale Concordia 1, 26100 Cremona, Italy Tel. +39 0372 405282 E-mail:
| | - Gabriele Testa
- Unit of Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Michele Tomasoni
- Unit of Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy, Unit of Otorhinolaryngology, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Francesca Del Bon
- Unit of Otorhinolaryngology, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Nausica Montalto
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, Azienda Ospedale Università Padua, Padua, Italy
| | - Marco Ferrari
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, Azienda Ospedale Università Padua, Padua, Italy
| | - Marco Andreoli
- Clinical Nutrition, Azienda Socio-Sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Riccardo Morello
- Department of Otorhinolaryngology, Azienda Socio-Sanitaria Territoriale di Cremona, Cremona, Italy
| | - Nicola Sbalzer
- Department of Anaesthesia and Intensive Care, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Daniela Vecchiati
- Department of Anaesthesia and Intensive Care, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | | | - Piero Nicolai
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, Azienda Ospedale Università Padua, Padua, Italy
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Denholm KA, Steel BJ, Wilson A, Nugent M, Burns A. Factors Determining Post-Operative Length of Stay and Time to Resumption of Feeding Following Free Flap Reconstruction for Oral Cancer. Br J Oral Maxillofac Surg 2022; 60:1240-1245. [DOI: 10.1016/j.bjoms.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/17/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022]
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Chuang CC, Chen MC, Perng CK, Liao WC, Wang TS, Wu SH, Shih YC, Lin CH, Hsiao FY, Feng CJ, Ma H. Postoperative Sedation Duration as an Independent Risk Factor for Postoperative Pneumonia in Head and Neck Cancer Patients Undergoing Free Flap Reconstruction. Ann Plast Surg 2022; 88:S39-S43. [PMID: 35102015 DOI: 10.1097/sap.0000000000003068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patients who had reconstruction for head and neck cancer usually have long duration of postoperative sedation and intensive care. This is due to the complex nature of large-area soft tissue defect surgeries and upper respiratory tract infections associated with them. Postoperative pulmonary complications are common in these patients. In this study, we analyzed the risk factors and the relationship between postoperative complications and the duration of sedation to improve the patients' recovery process after free flap reconstruction for head and neck surgery. MATERIALS AND METHODS This was a retrospective study that included 188 patients who had head and neck surgery with free flap reconstruction in 2011 (traditional recovery group) and 2018 (early recovery group). Postoperative recovery events were compared between the 2 groups. Complications such as pneumonia, wound infection, vascular thrombosis, and bleeding were also analyzed. RESULTS The results showed that the early recovery group had a shorter duration of sedation (P < 0.001), shorter duration of intensive care unit stay (P = 0.05), more rapid ventilator weaning (P < 0.001), and fewer pneumonia events (8.8% vs 39.1%) than the traditional recovery group. Wound- and vessel-related complications were not affected by the duration of sedation. CONCLUSIONS Our study demonstrated that shortening the duration of postoperative sedation can effectively decrease the length of intensive care unit stay and reduce postoperative incidence of pneumonia without increasing wound- and vessel-related complications.
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Affiliation(s)
- Chih-Chao Chuang
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
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Schmid M, Giger R, Nisa L, Mueller SA, Schubert M, Schubert AD. Association of Multiprofessional Preoperative Assessment and Information for Patients With Head and Neck Cancer With Postoperative Outcomes. JAMA Otolaryngol Head Neck Surg 2022; 148:259-267. [PMID: 35050322 PMCID: PMC8778600 DOI: 10.1001/jamaoto.2021.4048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
IMPORTANCE Multidisciplinary perioperative assessment for patients undergoing complex oncologic head and neck cancer (HNC) surgery is widely implemented. However, to our knowledge, the association of multiprofessional preoperative assessment, information, and briefing with postoperative outcomes has not been evaluated. OBJECTIVE To compare postoperative complications, length of hospital stay (LOS), readmissions, mortality, and costs per case among patients undergoing complex oncologic HNC surgery before and after the implementation of a comprehensive preoperative multiprofessional assessment and information day (MUPAID). DESIGN, SETTING, AND PARTICIPANTS This retrospective, single-center case-control study was conducted at a tertiary referral head and neck anticancer center/university cancer institute and compared patients with HNC who were undergoing complex oncological surgeries between January 2012 and July 2018 before (control group) and after (intervention group) implementation of the institutional MUPAID. Data analysis was conducted between 2019 and 2020. The intervention group comprised patients who participated in the MUPAID beginning in February 2015. These patients were assessed by a multiprofessional team and provided with structured and comprehensive information on the surgical procedure and its functional, social, financial, and psychological effects, as well as the postoperative care, rehabilitation, and follow-up period. Patients in the control group had also undergone complex oncologic HNC surgery and were selected through surgical procedure codes. MAIN OUTCOMES AND MEASURES The end points were postoperative rate and severity of complications, LOS, readmissions, mortality, and costs per case. RESULTS The study included 161 patients, 81 in the intervention (25 women [30.9%]) and 80 in the control group (18 women [22.5%]). The groups showed no relevant differences in sociodemographic, disease, and procedural characteristics. The intervention cohort presented with fewer major local and systemic complications (Clavien-Dindo score, III-V: 34.6% vs 52.5%; difference proportion, -0.179; 95% CI, -0.33 to -0.03), shorter median LOS (12 days [IQR, 10-16 days] vs 16 days [IQR, 11-20] days; effect size, 0.482; 95% CI Cohen d, 0.152-0.812) and decreased median charge per case ($50 848 [IQR, $42 510-$63 479] vs $69 602 [IQR, $45 631-$96 280]; effect size, 0.534; 95% CI Cohen d, 0.22-0.85). CONCLUSIONS AND RELEVANCE The results of this case-control study suggest that MUPAID for patients who are undergoing complex oncologic HNC surgery is associated with shortened LOS and costs per case as well as decreased complications severity. These results are promising on a patient level in the potential to minimize individual treatment burden, as well as on an institutional and health care system level in the potential significant optimization of surgical outcomes and financial aspects.
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Affiliation(s)
- Manuela Schmid
- Department of Nursing, Medical-Technical and Medical-Therapeutic Areas, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Roland Giger
- Department of Otorhinolaryngology–Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lluís Nisa
- Department of Otorhinolaryngology–Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Andreas Mueller
- Department of Otorhinolaryngology–Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria Schubert
- School of Health Professions, Zurich University of Applied Science, Winterthur, Switzerland,Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Adrian Daniel Schubert
- Department of Otorhinolaryngology–Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Pai K, Baaklini C, Cabrera CI, Tamaki A, Fowler N, Maronian N. The Utility of Comorbidity Indices in Assessing Head and Neck Surgery Outcomes: A Systematic Review. Laryngoscope 2021; 132:1388-1402. [PMID: 34661923 DOI: 10.1002/lary.29905] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the utility of comorbidity index (CI) scores in predicting outcomes in head and neck surgery (HNS). The CIs evaluated were the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Kaplan-Feinstein Index (KFI), American Society of Anesthesiologists Physical Status (ASA-PS), Adult Comorbidity Evaluation-27 (ACE-27), National Cancer Institute Comorbidity Index (NCI-CI), and the Washington University Head and Neck Comorbidity Index (WUHNCI). METHODS We report a systematic review according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases (PubMed, Cochrane, and Embase) and manual search of bibliographies identified manuscripts addressing how CI scores related to HNS outcomes. RESULTS A total of 116 studies associated CI scores with HNS outcomes. CIs were represented in the literature as follows: ASA-PS (70/116), CCI (39/116), ACE-27 (24/116), KFI (7/116), NCI-CI (3/116), ECI (2/116), and WUHNCI (1/116). The most frequently cited justification for calculating each CI (if provided) was: CCI for its validation in other studies, ACE-27 for its utility in cancer patients, and ECI for its comprehensive design. In general, the CCI and ACE-27 were predictive of mortality in HNS. The ECI was most consistent in predicting >1-year mortality. The ACE-27 and KFI were most consistent in predicting medical complications. CONCLUSION Despite inconsistencies in the literature, CIs provide insights into the impact of comorbidities on outcomes in HNS. These scores should be employed as an adjunct in the preoperative assessment of HNS patients. Comparative studies are needed to identify indices that are most reliable in predicting HNS outcomes. LEVEL OF EVIDENCE NA Laryngoscope, 2021.
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Affiliation(s)
- Kavya Pai
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, U.S.A
| | - Carla Baaklini
- Northeast Ohio Medical University, Rootstown, Ohio, U.S.A
| | - Claudia I Cabrera
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Akina Tamaki
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Nicole Fowler
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Nicole Maronian
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
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11
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LigaSure small jaw versus conventional neck dissection: a systematic review and meta-analysis. J Otolaryngol Head Neck Surg 2021; 50:21. [PMID: 33781344 PMCID: PMC8008542 DOI: 10.1186/s40463-021-00504-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background Neck dissection has a central role in the management of head and neck cancers. This systematic review aimed to compare the intraoperative and postoperative parameters between conventional and LigaSure Small Jaw (LSJ)-assisted neck dissection. Methods PubMed (MEDLINE), Embase, and the Cochrane Library were searched. independently by two authors for relevant articles comparing the outcomes of conventional and LSJ-assisted neck dissection. Data from each study were extracted, and a random-effects model was used in the pooled analysis. Results Compared with conventional techniques, LSJ-assisted neck dissection was associated with a significantly reduced operative time. The rates of postoperative hematoma, infection, amount of intraoperative blood loss, the length of hospital stay and the drainage amount showed no significant intergroup differences. Conclusions The meta-analysis provides evidence that properly using LSJ may reduce the operative time compared with that of conventional techniques. Surgeons may consider using LSJ in neck dissection according to personal experiences. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40463-021-00504-2.
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Ahmed A, Sayed AH, Elkholy J, Elshal S, Badwy A, Abdelhamid B, Ollaek M. Intraoperative MgSO 4 infusion protects oxygenation and lung mechanics in COPD patients during general anesthesia. A randomized clinical trial. Acta Anaesthesiol Scand 2020; 64:1460-1468. [PMID: 32770840 DOI: 10.1111/aas.13684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/21/2020] [Accepted: 07/20/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The purpose of this study was to examine the effects of an intraoperative MgSO4 infusion on arterial oxygenation and lung mechanics in patients with moderate COPD undergoing cancer larynx surgery under general anesthesia (GA). Our primary outcome was arterial oxygenation determined by the PaO2 and PaO2 /FiO2 . The secondary outcomes were lung mechanics (peak airway pressure, airway plateau pressure, dead space, lung compliance, airway resistance) and postoperative complications. METHODS In this randomized controlled double-blinded trial, 40 patients with an ASA classifications II and/or III who were diagnosed with moderate COPD and who were scheduled for cancer larynx surgery under GA were randomly allocated into two equal groups, the target (Mg group) and control group (C group). In the Mg group, 30 mg/kg of 10% MgSO4 solution was administered intravenously for over 20 minutes as the loading dose, followed by the continuous infusion of 10 mg/kg/hr In the C group, the same loading and maintenance infusion rates were administered using 0.9% saline. RESULTS Unlike the C group (baseline "T0" to post-infusion "T1" interval 294 ± 97 vs 238 ± 71 mm Hg, respectively, P = .04 ± SD), the Mg group exhibited preserved intraoperative PaO2 (T0 to T1 interval 271 ± 89 vs 257 ± 53 mm Hg, respectively, P = .54 ± SD) and PaO2 /FiO2 (C group T0 to T1 interval 404 ± 81 vs 349 ± 84, P = .04 and Mg group 394 ± 91 vs 379 ± 95, P = .61, respectively), and these effects were modest. Further, compared to the C group, the Mg group exhibited lower airway resistance, dead space, airway plateau pressure, and peak airway pressure, and higher dynamic compliance. The postoperative PaO2 and PaO2 /FiO2 were higher in the Mg group compared to the C group. CONCLUSIONS Intraoperative infusion of MgSO4 in patients with moderate COPD undergoing laryngectomy surgery under GA produces mild perioperative protective effects on both arterial oxygenation and lung mechanics. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03461328; registration date: 8 March 2018.
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Affiliation(s)
- Abeer Ahmed
- Department of Anesthesiology Surgical ICU and Pain Management Kasr Alainy Faculty of Medicine Cairo University Cairo Egypt
| | - Ahmed H. Sayed
- Department of Anesthesiology Surgical ICU and Pain Management Kasr Alainy Faculty of Medicine Cairo University Cairo Egypt
| | - Jehan Elkholy
- Department of Anesthesiology Surgical ICU and Pain Management Kasr Alainy Faculty of Medicine Cairo University Cairo Egypt
| | - Sahar Elshal
- Department of Anesthesiology Surgical ICU and Pain Management Kasr Alainy Faculty of Medicine Cairo University Cairo Egypt
| | - Abdelrahman Badwy
- Department of Otorhinolaryngology Kasr Alainy Faculty of Medicine Cairo University Cairo Egypt
| | - Bassant Abdelhamid
- Department of Anesthesiology Surgical ICU and Pain Management Kasr Alainy Faculty of Medicine Cairo University Cairo Egypt
| | - Mohamed Ollaek
- Department of Anesthesiology Surgical ICU and Pain Management Kasr Alainy Faculty of Medicine Cairo University Cairo Egypt
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13
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Kiong KL, Lin F, Yao CMKL, Guo T, Ferrarotto R, Weber RS, Lewis CM. Impact of neoadjuvant chemotherapy on perioperative morbidity after major surgery for head and neck cancer. Cancer 2020; 126:4304-4314. [DOI: 10.1002/cncr.33103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/16/2020] [Accepted: 06/20/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Kimberley L. Kiong
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Fang‐Yu Lin
- Department of Symptom Research The University of Texas MD Anderson Cancer Center Houston Texas
| | - Christopher M. K. L. Yao
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Theresa Guo
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Renata Ferrarotto
- Department of Thoracic Head and Neck Medical Oncology The University of Texas MD Anderson Cancer Center Houston Texas
| | - Randal S. Weber
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Carol M. Lewis
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
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14
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Predictors of hospital expenses and hospital stay among patients undergoing total laryngectomy: Cost effectiveness analysis. PLoS One 2020; 15:e0236122. [PMID: 32673371 PMCID: PMC7365401 DOI: 10.1371/journal.pone.0236122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/29/2020] [Indexed: 12/03/2022] Open
Abstract
Objective To determine the predictive factors of postoperative hospital stay and total hospital medical cost among patients who underwent total laryngectomy. Methods A total of 213 patients who underwent total laryngectomy in a tertiary referral center for tumor ablation were enrolled retrospectively between January 2009 and May 2018. Statistical analyses including Pearson's chi-squared test were used to determine whether there was a significant difference between each selected clinical factors and outcomes. The outcomes of interest including postoperative length of hospital stay and inpatient total medical cost. Logistic regression analyses were performed to reveal the relationship between clinical factors and postoperative length of hospital stay or total inpatient medical cost. Results Preoperative radiotherapy (p = 0.007), method of wound closure (p < 0.001), postoperative serum albumin level (p = 0.025), and postoperative serum hemoglobin level (p = 0.04) were significantly associated with postoperative hospital stay in univariate analysis. Postoperative hypoalbuminemia (odds ratio [OR]: 2.477; 95% confidence interval [CI]: 1.189–5.163; p = 0.015) and previous radiotherapy history (OR 2.194; 95% CI: 1.228–3.917; p = 0.008) are independent predictors of a longer postoperative hospital stay in multiple regression analysis. With respect to total inpatient medical cost, method of wound closure (p < 0.001), preoperative serum albumin level (p = 0.04), postoperative serum albumin level (p < 0.001), and history of liver cirrhosis (p = 0.037) were significantly associated with total inpatient medical cost in univariate analysis. Postoperative hypoalbuminemia (OR: 6.671; 95% CI: 1.927–23.093; p = 0.003) and microvascular free flap reconstruction (OR: 5.011; 95% CI: 1.657–15.156; p = 0.004) were independent predictors of a higher total inpatient medical cost in multiple regression analysis. Conclusions Postoperative albumin status is a significant factor in predicting prolonged postoperative hospital stay and higher inpatient medical cost among patients who undergo total laryngectomy. In this cohort, the inpatient medical cost was 48% higher and length of stay after surgery was 35% longer among hypoalbuminemia patients.
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15
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Kao SST, Frauenfelder C, Wong D, Edwards S, Krishnan S, Ooi EH. National Surgical Quality Improvement Program risk calculator validity in South Australian laryngectomy patients. ANZ J Surg 2020; 90:740-745. [PMID: 32159275 DOI: 10.1111/ans.15807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/18/2020] [Accepted: 02/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Assessing an individual patient's post-operative risk profile prior to laryngectomy for cancer is difficult. The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) risk calculator was developed to better inform preoperative decision-making. The calculator uses patient-specific characteristics to estimate the risk of experiencing post-operative complications within 30 days of surgery. We investigated the ACS-NSQIP risk calculator's performance for Australian laryngectomy patients. METHODS The ACS-NSQIP risk calculator was used to retrospectively calculate the 30-day post-operative predicted outcomes in patients who underwent laryngectomy for laryngeal, hypopharyngeal and thyroid cancers (with laryngeal involvement) in two institutions in South Australia. These data were compared against the actual mortality, morbidity, complications and length of stay (LOS) collected from a retrospective chart review. RESULTS A total of 144 patients underwent surgical intervention for malignancies with laryngeal involvement. The median LOS was 25 days (range 13-197) compared to the predicted LOS of 6.5 days (range 3.5-12.5). Overall mortality was 2.78% with post-operative complications occurring in 63% of patients. The most common complication was wound infection, occurring in 33% of patients. Hosmer-Lemeshow plots demonstrated good agreement between predicted and observed rates for complications. CONCLUSION The ACS-NSQIP risk calculator effectively predicted post-operative complication rates in South Australian laryngeal cancer patients undergoing laryngectomy. However, differences in predicted and actual LOS may limit the usefulness of the calculator's LOS predictions for Australian patients.
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Affiliation(s)
- Stephen Shih-Teng Kao
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Claire Frauenfelder
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Department of Otolaryngology, Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Daniel Wong
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Suzanne Edwards
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Suren Krishnan
- Department of Otolaryngology, Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eng Hooi Ooi
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Department of Surgery, Flinders University, Adelaide, South Australia, Australia
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16
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Case-mix adjustment in audit of length of hospital stay in patients operated on for cancer of the head and neck. Br J Oral Maxillofac Surg 2019; 57:866-872. [DOI: 10.1016/j.bjoms.2019.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 07/05/2019] [Indexed: 11/19/2022]
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17
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Tam S, Weber RS, Liu J, Ting J, Hanson S, Lewis CM. Evaluating Unplanned Returns to the Operating Room in Head and Neck Free Flap Patients. Ann Surg Oncol 2019; 27:440-448. [PMID: 31410610 DOI: 10.1245/s10434-019-07675-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Head and neck oncologic surgery with reconstruction represents one of the most complex operations in otolaryngology. Unplanned return to the operating room represents an objective measure of postoperative complications. The purpose of this study was to identify reasons and risk factors for unplanned return to the operating room in patients undergoing head and neck surgery with reconstruction. METHODS This retrospective cohort study of 467 patients undergoing head and neck surgery with free flap reconstruction used a previously-developed Head and Neck-Reconstructive Surgery-specific National Surgical Quality Improvement Program. Disease and site-specific preoperative, intraoperative, and postoperative data were gathered. Comparisons between those with and without an unexpected return to the operating room were completed with univariate and multiple logistic regression models. RESULTS The rate of unexpected return to the operating room was 18.8% (88 patients). Most common reasons for URTOR were flap compromise (24 patients, 5.1%), postoperative infection (21 patients, 4.5%), and hematoma (20 patients, 4.3%). Two risk factors were identified by multivariate analysis: coagulopathy (ORadjusted = 2.83, 95% CI = 1.24-6.19, P = 0.010), and use of alcohol (ORadjusted = 1.9, 95% CI = 1.14-3.33, P = 0.025). CONCLUSIONS Preexisting coagulopathy and increased alcohol consumption were associated with increased risk of unexpected return to the operating room. These findings can aid physicians in preoperative patient counseling and medical optimization and can inform more precise risk stratification of patients undergoing head and neck surgery with reconstruction. Strategies to prevent and mitigate unexpected returns to the operating room will improve patient outcomes, decrease resource utilization, and facilitate successful integration into alternative payment models.
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Affiliation(s)
- Samantha Tam
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randal S Weber
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Liu
- Department of Plastic and Reconstructive Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose Ting
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Summer Hanson
- Department of Plastic and Reconstructive Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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18
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Kuo CY, Chen YT, Sun CK, Hung KC. Ischemic stroke following neck dissection in the elderly. Tzu Chi Med J 2019; 31:177-181. [PMID: 31258294 PMCID: PMC6559032 DOI: 10.4103/tcmj.tcmj_112_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective: Despite the known association of perioperative stroke with perioperative mortality, the prevalence of stroke following neck dissection in elderly patients remains unclear. This study compared the incidence of neck dissection-associated perioperative stroke in elderly and younger patients. Materials and Methods: Totally, 1057 patients receiving neck dissection for head and neck cancers between June 2012 and July 2016 were reviewed at a single center. The patients were divided into elderly (age ≥65 years, n = 177) and younger (age <65 years, n = 880) groups (mean age: 72.3 ± 6.1 and 53.3 ± 7.6, respectively). Patient, anthropometric, and clinical characteristics including diagnoses, comorbidities, length of hospitalization, and incidence of perioperative stroke were compared. Results: Younger patients were more likely to be male (P = 0.001) and to have received radiotherapy (P = 0.013). The prevalence of predisposing factors was higher in the elderly, including history of cerebral vascular accident (P = 0.002), hypertension (P < 0.001), diabetes (P < 0.001), and coronary artery disease (P < 0.001). Elderly patients also had longer hospitalizations (P < 0.001) for which previous radiotherapy was identified as a risk factor (adjusted odds ratio = 3.79, P = 0.0078). Postoperative ischemic stroke was diagnosed in two elderly patients (1.1%), whereas no ischemic strokes occurred in the younger group (P = 0.028). The overall incidence of perioperative stroke was 0.19%. Conclusion: The incidence of perioperative stroke was higher in the elderly than in the younger group. Furthermore, the prevalence of ischemic stroke in elderly patients associated with neck dissection was higher than that previously reported in the aged population after general head and neck operations, highlighting an increased risk of stroke in elderly patients receiving extensive neck surgery.
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Affiliation(s)
- Chuan-Yi Kuo
- Department of Anesthesiology, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan
| | - Yi-Ting Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
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19
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Lang DM, Danan D, Sawhney R, Silver NL, Varadarajan VV, Balamohan S, Bernard SH, Boyce BJ, Dziegielewski PT. Discharge Delay in Head and Neck Free Flap Surgery: Risk Factors and Strategies to Minimize Hospital Days. Otolaryngol Head Neck Surg 2019; 160:829-838. [DOI: 10.1177/0194599819835545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated. Methods Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay. Results In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children ( P < .05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday ( P < .05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay. Discussion DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient’s closest family. Understanding limitations of the patient’s insurance may help plan DC destination. Optimizing hospital resources when available should be a focus. Implications for Practice Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team’s overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized.
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Affiliation(s)
- Dustin M. Lang
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Deepa Danan
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Raja Sawhney
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Natalie L. Silver
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
- University of Florida Health Cancer Center, Gainesville, Florida, USA
| | | | - Sanjeev Balamohan
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Stewart H. Bernard
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Brian J. Boyce
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Peter T. Dziegielewski
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
- University of Florida Health Cancer Center, Gainesville, Florida, USA
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Cohen Atsmoni S, Brener A, Roth Y. Diabetes in the practice of otolaryngology. Diabetes Metab Syndr 2019; 13:1141-1150. [PMID: 31336457 DOI: 10.1016/j.dsx.2019.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 01/14/2019] [Indexed: 02/07/2023]
Abstract
Diabetes mellitus is the most common endocrine disease, characterized by chronic hyperglycemia. The hyperglycemic milieu leads to endothelial injury in blood vessels of variant size, which results in microangiopathy and macroangiopathy (atherosclerosis). Consequential ischemia of nerves and hyperglycemia by itself lead to nerve degeneration and generalized neuropathy, affecting most often the sensory peripheral nerves and the autonomic nervous system. Auditory, vestibular and olfactory sensorium may be compromised by DM. People with DM have an increased susceptibility to infection, as a result of neutrophil dysfunction and impaired humoral immunity. Therefore DM predisposes to certain infectious diseases, such as fungal sinusitis or malignant otitis externa, which are rare in general population. Recovery from infections or from injuries may be compromised by coexisting DM. In this review we discuss complications of DM in the head and neck region. Otolaryngologists and general practitioners should be alert to specific conditions related to DM and be minded of the relevant complications and consequences.
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Affiliation(s)
- Smadar Cohen Atsmoni
- Department of Otolaryngology-Head and Neck Surgery, The Edith Wolsfon Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Avivit Brener
- Pediatric Endocrinology & Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehudah Roth
- Department of Otolaryngology-Head and Neck Surgery, The Edith Wolsfon Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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21
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Badr H, Sobrero M, Chen J, Kotz T, Genden E, Sikora AG, Miles B. Associations between pre-, post-, and peri-operative variables and health resource use following surgery for head and neck cancer. Oral Oncol 2019; 90:102-108. [PMID: 30846167 DOI: 10.1016/j.oraloncology.2019.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE We examined associations between pre-, post-, and peri-operative variables and health resource use in head and neck cancer patients. METHODS Patients (N = 183) who were seen for a pre-surgical consult between January 2012 and December 2014 completed surveys that assessed medical history, a patient-reported outcome measure (PROM) of dysphagia, and quality of life (QOL). After surgery, peri-operative (e.g., tracheostomy, feeding tube) and post-operative (e.g., complications) variables were abstracted from patients' medical records. RESULTS Multivariate regression models using backward elimination showed that pre-surgical University of Washington Quality of Life (UW-QOL) Inventory and M.D. Anderson Dysphagia Inventory (MDADI) composite scores, documented surgical complications, and having a tracheostomy, were all significant predictors of hospital length of stay, explaining 57% of the total variance (F(5, 160) = 18.71, p < .001). Male gender, psychiatric history, and lower pre-surgical MDADI scores significantly predicted thirty-day unplanned readmissions (30dUR). Pre-surgical MDADI composite scores also significantly predicted emergencey department (ED) visits within 30 days of initial hospital discharge (p = .02). CONCLUSIONS Assessment of PROMs and QOL in the pre-surgical setting may assist providers in identifying patients at risk for prolonged LOS and increased health resource use after hospital discharge.
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Affiliation(s)
- Hoda Badr
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA.
| | | | - Joshua Chen
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA; Department of Psychology, University of St Thomas, Houston, TX, USA
| | - Tamar Kotz
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric Genden
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew G Sikora
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Brett Miles
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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22
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Helman SN, Brant JA, Kadakia SK, Newman JG, Cannady SB, Chai RL. Factors associated with complications in total laryngectomy without microvascular reconstruction. Head Neck 2018; 40:2409-2415. [PMID: 30307661 DOI: 10.1002/hed.25363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/15/2018] [Accepted: 05/16/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is little population-level data evaluating risk factors for postoperative complications after total laryngectomy. METHODS We conducted a retrospective review of the American College of Surgeons National Quality Improvement Program identifying patients who underwent total laryngectomy as a primary procedure from 2005 to 2014. Multivariate analysis was performed to identify variables that were independently associated with overall and major complications. RESULTS Eight hundred seventy-one cases met inclusion criteria. Three hundred twenty-eight patients (37.7%) had complications, with operative time (hours; P < .0001), class III (P < .001) wound status, and patient age (decade; P = .003) associated with overall complications. Two hundred one patients had major complications that were associated with steroid use (P = .01) and class III (P = .0083) wound classification. Preoperative hematocrit was correlated with a reduction of all and major complications on multivariate analysis (P < .0001 and P = .036). CONCLUSION Identifying and optimizing risk factors may improve outcomes in total laryngectomy.
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Affiliation(s)
- Samuel N Helman
- Department of Otolaryngology - Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Jason A Brant
- Department of Otolaryngology - Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sameep K Kadakia
- Department of Otolaryngology - Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Jason G Newman
- Department of Otolaryngology - Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven B Cannady
- Department of Otolaryngology - Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raymond L Chai
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Lowery EM, Yong M, Cohen A, Joyce C, Kovacs EJ. Recent alcohol use prolongs hospital length of stay following lung transplant. Clin Transplant 2018; 32:e13250. [PMID: 29620796 PMCID: PMC6023739 DOI: 10.1111/ctr.13250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 11/28/2022]
Abstract
Little is known about the alcohol habits of people with advanced lung disease. Following lung transplantation, patients are asked to abstain from or minimize alcohol use. The aim of this investigation was to assess alcohol use in a cohort of patients with advanced lung disease undergoing evaluation for lung transplant. This is a prospective observational investigation comparing patient self-report of alcohol use with their responses on the Alcohol Use Disorders Identification Test (AUDIT), and alcohol biomarkers collected at the time of transplant. There were 86 included in the cohort, 34% currently using alcohol, 13% had AUDIT scores >3, and 10% had positive results for alcohol biomarkers at the time of transplantation. Patients with evidence of recent alcohol use prior to lung transplant surgery had a 1.5-fold increase in hospital length of stay following lung transplant (P = .028), spent 3 times as long on mechanical ventilation after transplant, and required intensive care unit monitoring nearly 3 times longer than those without recent alcohol use (P = .008). There were no differences in primary graft dysfunction, although several patients with recent alcohol use had post-transplant atrial arrhythmias, acute kidney injury, and acute cellular rejection. Abstaining from alcohol use may optimize outcomes following lung transplant.
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Affiliation(s)
- Erin M Lowery
- Alcohol Research Program, Burn Shock Trauma Research Institute, Loyola University Chicago Health Science Division, Maywood, IL, USA
- Division of Pulmonary and Critical Care, Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Meagan Yong
- Alcohol Research Program, Burn Shock Trauma Research Institute, Loyola University Chicago Health Science Division, Maywood, IL, USA
| | - Arala Cohen
- Alcohol Research Program, Burn Shock Trauma Research Institute, Loyola University Chicago Health Science Division, Maywood, IL, USA
| | - Cara Joyce
- Department of Public Health, Stritch School of Medicine, Loyola University Chicago Health Science Division, Maywood, IL, USA
| | - Elizabeth J Kovacs
- Alcohol Research Program, Division of Gastroenterology, Trauma and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Baskin RM, Zhang J, Dirain C, Lipori P, Fonseca G, Sawhney R, Boyce BJ, Silver NL, Dziegielewski PT. Predictors of returns to the emergency department after head and neck surgery. Head Neck 2017; 40:498-511. [DOI: 10.1002/hed.25019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 07/30/2017] [Accepted: 10/10/2017] [Indexed: 11/10/2022] Open
Affiliation(s)
- R. Michael Baskin
- Department of Otolaryngology; University of Florida; Gainesville Florida
| | - Jingnan Zhang
- Department of Biostatistics; University of Florida; Gainesville Florida
| | - Carolyn Dirain
- Department of Otolaryngology; University of Florida; Gainesville Florida
| | - Paul Lipori
- College of Medicine; University of Florida; Gainesville Florida
| | - Gileno Fonseca
- College of Medicine; University of Florida; Gainesville Florida
| | - Raja Sawhney
- Department of Otolaryngology; University of Florida; Gainesville Florida
| | - Brian J. Boyce
- Department of Otolaryngology; University of Florida; Gainesville Florida
| | - Natalie L. Silver
- Department of Otolaryngology; University of Florida; Gainesville Florida
| | - Peter T. Dziegielewski
- Department of Otolaryngology; University of Florida; Gainesville Florida
- University of Florida Health Cancer Center; Gainesville Florida
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25
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Hong FS, Sieradzki N, Pollock C, Nasra F, Mo A, Willcox A, Churilov L, Ho WK, Smith C. Prevalence and causes of preoperative anaemia in elective major surgery patients. Intern Med J 2017; 47:1400-1404. [DOI: 10.1111/imj.13613] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 08/01/2017] [Accepted: 08/27/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Frank S. Hong
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Nicole Sieradzki
- Department of Anaesthesia; Austin Health; Melbourne Victoria Australia
| | - Claire Pollock
- Department of Anaesthesia; Austin Health; Melbourne Victoria Australia
| | - Faye Nasra
- Department of Anaesthesia; Austin Health; Melbourne Victoria Australia
| | - Allison Mo
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Abbey Willcox
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform; Florey Institute of Neuroscience and Mental Health; Melbourne Victoria Australia
- School of Science; RMIT University; Melbourne Victoria Australia
| | - Wai Khoon Ho
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
| | - Carole Smith
- Department of Laboratory Haematology; Austin Health; Melbourne Victoria Australia
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26
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Bhalla RG, Wang L, Chang SS, Tyson MD. Association between Preoperative Albumin Levels and Length of Stay after Radical Cystectomy. J Urol 2017; 198:1039-1045. [DOI: 10.1016/j.juro.2017.05.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Rohan G. Bhalla
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Nashville, Tennessee
| | - Sam S. Chang
- Department of Urologic Surgery, Nashville, Tennessee
| | - Mark D. Tyson
- Department of Urologic Surgery, Nashville, Tennessee
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27
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Grigor EJ, Ivanovic J, Anstee C, Zhang Z, Gilbert S, Maziak DE, Shamji FM, Sundaresan S, Villeneuve PJ, Ramsay T, Seely AJ. Impact of Adverse Events and Length of Stay on Patient Experience After Lung Cancer Resection. Ann Thorac Surg 2017; 104:382-388. [DOI: 10.1016/j.athoracsur.2017.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/22/2017] [Accepted: 05/08/2017] [Indexed: 11/26/2022]
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Helman SN, Brant JA, Moubayed SP, Newman JG, Cannady SB, Chai RL. Predictors of length of stay, reoperation, and readmission following total laryngectomy. Laryngoscope 2016; 127:1339-1344. [DOI: 10.1002/lary.26454] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/04/2016] [Accepted: 11/14/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Samuel N. Helman
- Department of Otolaryngology-Head and Neck Surgery; New York Eye and Ear Infirmary of Mount Sinai; New York New York
| | - Jason A. Brant
- Department of Otorhinolaryngology-Head and Neck Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Sami P. Moubayed
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Beth Israel; New York New York U.S.A
| | - Jason G. Newman
- Department of Otorhinolaryngology-Head and Neck Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Steven B. Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Raymond L. Chai
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Beth Israel; New York New York U.S.A
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29
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Fritz DK, Matthews TW, Chandarana SP, Nakoneshny SC, Dort JC. Harmonic scalpel impact on blood loss and operating time in major head and neck surgery: a randomized clinical trial. J Otolaryngol Head Neck Surg 2016; 45:58. [PMID: 27821144 PMCID: PMC5100249 DOI: 10.1186/s40463-016-0173-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/01/2016] [Indexed: 12/29/2022] Open
Abstract
Background Long operating time and high blood loss contribute to post-surgical morbidity. Therefore, strategies to reduce these factors should to be tested using robust methods. The purpose of this study was to evaluate the impact of using the harmonic scalpel on operating time and blood loss in patients undergoing resection for advanced oral cancer (OSCC). Methods Thirty-six adult head and neck cancer patients with advanced OSCC requiring primary tumor resection with uni- or bi- lateral selective neck dissection from July 2012 to September 2014 were randomized to either the control group (traditional surgery) or the experimental group (harmonic surgery). Patients older than 18 years who were able to provide informed consent were eligible. Primary outcomes of interest were: intraoperative blood loss (mL) and operative time (minutes) for the ablative part of the surgery. Results Mean blood loss in the experimental group was 260 mL versus 403 mL in the control group (p = 0.08). Mean operative time was 140 min in the experimental group and 159 min in the control group (p = 0.2). Conclusions In this randomized controlled trial, use of the harmonic scalpel did not effect intraoperative blood loss or OR time in patients undergoing surgery for advanced OSCC. Trial registration ClinicalTrials.gov, NCT02017834.
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Affiliation(s)
- Dieter K Fritz
- Department of Surgery, Section of Otolaryngology - Head & Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada
| | - T Wayne Matthews
- Department of Surgery, Section of Otolaryngology - Head & Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada.,Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Shamir P Chandarana
- Department of Surgery, Section of Otolaryngology - Head & Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada.,Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Steven C Nakoneshny
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Joseph C Dort
- Department of Surgery, Section of Otolaryngology - Head & Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada. .,Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada.
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Shenson JA, Craig JN, Rohde SL. Effect of Preoperative Counseling on Hospital Length of Stay and Readmissions after Total Laryngectomy. Otolaryngol Head Neck Surg 2016; 156:289-298. [DOI: 10.1177/0194599816671695] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jared A. Shenson
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Jennifer N. Craig
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L. Rohde
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Tracheostomy and infection prolong length of stay in hospital after surgery for head and neck cancer: a population based study. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 121:22-28.e1. [DOI: 10.1016/j.oooo.2015.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/02/2015] [Accepted: 08/02/2015] [Indexed: 12/13/2022]
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Mays AC, Worley M, Ackall F, D'Agostino R, Waltonen JD. The association between gastrostomy tube placement, poor post-operative outcomes, and hospital re-admissions in head and neck cancer patients. Surg Oncol 2015; 24:248-57. [PMID: 26321115 PMCID: PMC4669044 DOI: 10.1016/j.suronc.2015.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 07/15/2015] [Accepted: 08/09/2015] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Investigate the relationship of G-tube placement timing on post-operative outcomes. PARTICIPANTS 908 patients underwent resection of head and neck upper aerodigestive tract tumors between 2007 and 2013. Patient charts were retrospectively screened for patient demographics, pre-operative nutrition variables, co-morbid conditions, Tumor-Node-Metastasis staging, surgical treatment type, and timing of G-tube placement. Exclusionary criteria included death within the first three months of the resection and resections performed solely for nodal disease. MAIN OUTCOMES Post-surgical outcomes, including wound and medical complications, hospital re-admissions, length of inpatient hospital stay (LOS), intensive care unit (ICU) time. RESULTS 793 surgeries were included: 8% of patients had G-tubes pre-operatively and 25% had G-tubes placed post-operatively. Patients with G-tubes (pre-operative or post-operative) were more likely to have complications and prolonged hospital care as compared to those without G-tubes (p < 0.001). Patients with pre-operative G-tubes had shortened length of stay (p = 0.007), less weight loss (p = 0.03), and fewer wound care needs (p < 0.0001), when compared to those that received G-tubes post-operatively. Those with G-tubes placed post-operatively had worse outcomes in all categories, except pre-operative BMI. CONCLUSIONS Though having enteral access in the form of a G-tube at any point suggests a more high risk patient, having a G-tube placed in the pre-operative period may protect against poor post-operative outcomes. Post-operative outcomes can be predicted based on patient characteristics available to the physician in the pre-operative period.
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Affiliation(s)
- Ashley C Mays
- Department of Otolaryngology, Watlington 4th Floor, Wake Forest Baptist Health, Medical Center Blvd, Winston Salem, NC, 27157, USA.
| | | | - Feras Ackall
- Wake Forest School of Medicine, Winston Salem, NC, USA.
| | - Ralph D'Agostino
- Department of Biostatistical Sciences, Comprehensive Cancer Center, Wake Forest Baptist Health, Winston Salem, NC, USA.
| | - Joshua D Waltonen
- Department of Otolaryngology, Wake Forest Baptist Health, Winston Salem, NC, USA.
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Ren ZH, Xu JL, Fan TF, Ji T, Wu HJ, Zhang CP. The Harmonic Scalpel versus Conventional Hemostasis for Neck Dissection: A Meta-Analysis of the Randomized Controlled Trials. PLoS One 2015; 10:e0132476. [PMID: 26161897 PMCID: PMC4498925 DOI: 10.1371/journal.pone.0132476] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 06/15/2015] [Indexed: 11/18/2022] Open
Abstract
Objective Neck dissection is the most definitive and effective treatment for head and neck cancer. This systematic review aims to compare the efficacy and surgical outcomes of neck dissection between the harmonic scalpel and conventional surgical techniques and conduct a quantitative meta-analysis of the randomized trials. Methods Randomized controlled trials (RCTs) were identified from the major electronic databases (MEDLINE, EMBASE and Cochrane Library) using the keywords ‘‘harmonic scalpel’’ and ‘‘neck dissection,’’ and a quantitative meta-analysis was conducted. The operative time and intraoperative bleeding were the primary outcome measures, and other parameters assessed included the drainage fluid volume and length of hospital stay. Results Seven trials that met the inclusion criteria included 406 neck dissection cases (201 in the harmonic scalpel group). Compared with conventional surgical techniques, the HS group had an operative time that was significantly reduced by 29.3 minutes [mean difference: -29.29; 95% CI = (-44.26, -14.32); P=0.0001], a reduction in intraoperative bleeding by 141.1 milliliters [mean difference: -141.13; 95% CI = (-314.99, 32.73); P=0.11], and a reduction in drainage fluid volume by 64.9 milliliters [mean difference: -64.86; 95% CI = (-110.40, -19.32); P=0.005] , but it is not significant after removal of studies driving heterogeneity. There was no significant difference in the length of the hospital stay [mean difference: -0.21; 95% CI = (-0.48, 0.07); P=0.14]. Conclusion This systematic review showed that using the harmonic scalpel for neck dissection significantly reduces the operative time and drainage fluid volume and that it is not associated with an increased length of hospital stay or perioperative complications. Therefore, the harmonic scalpel method is safe and effective for neck dissection. However, the statistical heterogeneity was high. Further studies are required to substantiate our findings.
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Affiliation(s)
- Zhen-Hu Ren
- Department of Oral and Maxillofacial & Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian-Lin Xu
- Department of Respiratory Medicine, Shanghai chest hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Teng-Fei Fan
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Tong Ji
- Department of Oral and Maxillofacial & Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Han-Jiang Wu
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Chen-Ping Zhang
- Department of Oral and Maxillofacial & Head and Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- * E-mail:
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Gümüş M, Satıcı Ö, Ülger BV, Oğuz A, Taşkesen F, Girgin S. Factors Affecting the Postsurgical Length of Hospital Stay in Patients with Breast Cancer. THE JOURNAL OF BREAST HEALTH 2015; 11:128-131. [PMID: 28331707 DOI: 10.5152/tjbh.2015.2546] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 05/22/2015] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Breast cancer is the most common malignancy and the most common cause of mortality in women worldwide. In addition to the increasing incidence of breast cancer, the length of hospital stay (LOS) after breast cancer surgery has been decreasing. Because LOS is key in determining hospital usage, the decrease in the use of hospital facilities may have implications on healthcare planning. The purpose of this study was to evaluate the factors affecting postoperative LOS in patients with breast cancer. MATERIALS AND METHODS Seventy-six in patients with breast cancer, who had been treated between July 2013 and December 2014 in the General Surgery Clinic of Dicle University, were included in the study. The demographic characteristics of the patients, treatment methods, histopathological features of the tumor, concomitant diseases, whether they underwent neoadjuvant chemotherapy or not, and the length of drain remaining time were retrospectively recorded. RESULTS There was a correlation between drain remaining time, totally removed lymph node, the number of metastatic lymph node, and LOS. LOS of patients treated with neoadjuvant chemotherapy was longer. The patients who underwent breast-conserving surgery had a shorter LOS. Linear regression analysis revealed that the drain remaining time and the number of metastatic lymph nodes were independent risk factors for LOS. CONCLUSION Consideration should be given to cancer screening to diagnose the patients before lymph node metastasis occurs. In addition, drains should be avoided unless required and, if used, they should be removed as early as possible for shortening LOS.
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Affiliation(s)
- Metehan Gümüş
- Department of General Surgery, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Ömer Satıcı
- Department of Biotatistic, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Burak Veli Ülger
- Department of General Surgery, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Abdullah Oğuz
- Department of General Surgery, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Fatih Taşkesen
- Department of General Surgery, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Sadullah Girgin
- Department of General Surgery, Dicle University Faculty of Medicine, Diyarbakır, Turkey
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Akashi M, Furudoi S, Hashikawa K, Sakakibara A, Hasegawa T, Shigeta T, Minamikawa T, Komori T. Postoperative abnormal response of C-reactive protein as an indicator for infectious complications after oral oncologic surgery with primary reconstruction. J Otolaryngol Head Neck Surg 2015; 44:13. [PMID: 25888882 PMCID: PMC4387578 DOI: 10.1186/s40463-015-0066-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 03/20/2015] [Indexed: 11/13/2022] Open
Abstract
Background C-reactive protein (CRP) screening has been reported to be reliable for detection of infectious complications. Postoperative abnormal response of CRP can predict wound infection in colorectal surgery. This study aimed to determine the efficacy of CRP monitoring to detect infectious complications in oral oncologic surgery. Methods One hundred patients who underwent oral cancer resection with primary reconstruction were enrolled. Postoperative kinetics of CRP were classified into a normal or abnormal response. Results A normal CRP response after surgery was observed in 61 patients and an abnormal response was observed in 39. There were postoperative infectious complications in 21 patients, with surgical site infections in 13 patients (early onset in six and late onset in seven). Non-wound infections were found in nine patients. Sensitivity, specificity, the positive predictive value, and the negative predictive value for abnormal CRP response as a predictor for early infectious complications were 100%, 70.1%, 35.9%, and 100%, respectively. Conclusion Postoperative serial CRP screening is a useful test as an indicator of infectious complications in oral oncologic surgery. Normal CRP responses can rule out almost all early infectious complications.
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Affiliation(s)
- Masaya Akashi
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Shungo Furudoi
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Kazunobu Hashikawa
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Akiko Sakakibara
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takumi Hasegawa
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takashi Shigeta
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Tsutomu Minamikawa
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takahide Komori
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
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Kanaan SF, Waitman RL, Yeh HW, Arnold PM, Burton DC, Sharma NK. Structural equation model analysis of the length-of-hospital stay after lumbar spine surgery. Spine J 2015; 15:612-21. [PMID: 25463975 PMCID: PMC4502957 DOI: 10.1016/j.spinee.2014.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 10/22/2014] [Accepted: 11/05/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Length-of-hospital stay (LOS) after lumbar spine surgery (LSS) can be affected by many factors. However, few studies have evaluated predictors of LOS, and all have used limited number of variables as predictors. PURPOSE The purpose of the study was to identify presurgical, surgical, and postsurgical predictors of LOS after LSS. STUDY DESIGN/SETTING Retrospective review of consecutive patients who had LSS at the University of Kansas Hospital from October 2008 to April, 2012. PATIENT SAMPLE Five hundred ninety-three patients underwent LSS consisting of laminotomy, laminectomy, or arthrodesis. DEPENDENT VARIABLE LOS. Multiple presurgical, surgical, and postsurgical variables were extracted from the patients' medical records and considered as possible predictors (independent variables) of LOS. METHODS Potential predictors that were significantly correlated with LOS were used as indicators to construct three latent factors presurgical, surgical, and postsurgical, which were in turn used to predict LOS in a structural equation model. RESULTS The average LOS was 4.01±2.73 days. The presurgical factor was indicated by age (61.97±14.49 years), previous level of function (60.5% were totally independent), previous hemoglobin level (13.70±1.36 mg/dL), and use of assistive devices (60% were assistive device users). The surgical factor was indicated by severity of illness (50.2% had minor disease severity), presence of complications (1.9%), and stay in an intensive care unit (4.0%). The postsurgical factor was indicated by postsurgical walking distance (166.43±175.75 ft), level of assistance during walking (5.18±0.81 out of 7 points), balance scores (6.18±1.82 out of 10 points), and bed mobility and transfer dependency scores (9.81±1.99 out of 14 points). These three latent factors explained 47% of variation in LOS. CONCLUSIONS Postsurgical factors predicted the highest variation in LOS in comparison with presurgical and surgical factors and should be taken into consideration for discharge planning. Postsurgical factors are related to the patient's function, modifiable with rehabilitation, and can be improved to shorten LOS. Inclusion of more reliable and standardized presurgical variables could improve the predictability of the model.
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Affiliation(s)
- Saddam F Kanaan
- Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center
| | | | - Hung-Wen Yeh
- Department of Biostatistics, University of Kansas Medical Center
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center
| | - Neena K Sharma
- Department of Rehabilitation Sciences, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan.
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Reduction of pulmonary complications and hospital length of stay with a clinical care pathway after head and neck reconstruction. Plast Reconstr Surg 2014; 133:1477-1484. [PMID: 24867729 DOI: 10.1097/prs.0000000000000217] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidence-based tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction. METHODS Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups. RESULTS Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days' shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation. CONCLUSIONS A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complications and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Tadiparthi S, Enache A, Kalidindi K, O'Hara J, Paleri V. Hospital stay following complex major head and neck resection: what factors play a role? Clin Otolaryngol 2014; 39:156-63. [DOI: 10.1111/coa.12250] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2014] [Indexed: 11/28/2022]
Affiliation(s)
- S. Tadiparthi
- Department of Plastic Surgery; Newcastle upon Tyne Hospitals; Newcastle-Upon-Tyne UK
| | - A. Enache
- Department of Otolaryngology; Newcastle-Upon-Tyne Hospitals; Newcastle-Upon-Tyne UK
| | | | - J. O'Hara
- Department of Otolaryngology; City Hospitals Sunderland; Sunderland UK
| | - V. Paleri
- Department of Otolaryngology; Newcastle-Upon-Tyne Hospitals; Newcastle-Upon-Tyne UK
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Rutledge JW, Spencer H, Moreno MA. Predictors for Perioperative Outcomes following Total Laryngectomy: A University HealthSystem Consortium Discharge Database Study. Otolaryngol Head Neck Surg 2014; 151:81-6. [PMID: 24690762 DOI: 10.1177/0194599814528451] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 02/27/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The University HealthSystem Consortium (UHC) database collects discharge information on patients treated at academic health centers throughout the United States. We sought to use this database to identify outcome predictors for patients undergoing total laryngectomy. A secondary end point was to assess the validity of the UHC's predictive risk mortality model in this cohort of patients. STUDY DESIGN Retrospective review. SETTING Academic medical centers (tertiary referral centers) and their affiliate hospitals in the United States. SUBJECTS AND METHODS Using the UHC discharge database, we retrieved and analyzed data for 4648 patients undergoing total laryngectomy who were discharged between October 2007 and January 2011 from all of the member institutions. Demographics, comorbidities, institutional data, and outcomes were retrieved. RESULTS The length of stay and overall costs were significantly higher among female patients (P < .0001), while age was a predictor of intensive care unit stay (P = .014). The overall complication rate was higher among Asians (P = .019) and in patients with anemia and diabetes compared with other comorbidities. The average institutional case load was 1.92 cases/mo; we found an inverse correlation (R = -0.47) between the institutional case load and length of stay (P < .0001). The UHC admit mortality risk estimator was found to be an accurate predictor not only of mortality (P < .0002) but also of intensive care unit admission and complication rate (P < .0001). CONCLUSION This study provides an overview of laryngectomy outcomes in a contemporary cohort of patients treated at academic health centers. UHC admit mortality risk is an excellent outcome predictor and a valuable tool for risk stratification in these patients.
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Affiliation(s)
- Jonathan W Rutledge
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Horace Spencer
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mauricio A Moreno
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Wang Y, Stavem K, Dahl FA, Humerfelt S, Haugen T. Factors associated with a prolonged length of stay after acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Int J Chron Obstruct Pulmon Dis 2014; 9:99-105. [PMID: 24477272 PMCID: PMC3901775 DOI: 10.2147/copd.s51467] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Early identification of patients with a prolonged stay due to acute exacerbation of chronic obstructive pulmonary disease (COPD) may reduce risk of adverse event and treatment costs. This study aimed to identify predictors of prolonged stay after acute exacerbation of COPD based on variables on admission; the study also looked to establish a prediction model for length of stay (LOS). Methods We extracted demographic and clinical data from the medical records of 599 patients discharged after an acute exacerbation of COPD between March 2006 and December 2008 at Oslo University Hospital, Aker. We used logistic regression analyses to assess predictors of a length of stay above the 75th percentile and assessed the area under the receiving operating characteristic curve to evaluate the model’s performance. Results We included 590 patients (54% women) aged 73.2±10.8 years (mean ± standard deviation) in the analyses. Median LOS was 6.0 days (interquartile range [IQR] 3.5–11.0). In multivariate analysis, admission between Thursday and Saturday (odds ratio [OR] 2.24 [95% CI 1.60–3.51], P<0.001), heart failure (OR 2.26, 95% CI 1.34–3.80), diabetes (OR 1.90, 95% CI 1.07–3.37), stroke (OR 1.83, 95% CI 1.04–3.21), high arterial PCO2 (OR 1.26 [95% CI 1.13–1.41], P<0.001), and low serum albumin level (OR 0.92 [95% CI 0.87–0.97], P=0.001) were associated with a LOS >11 days. The statistical model had an area under the receiver operating characteristic curve of 0.73. Conclusion Admission between Thursday and Saturday, heart failure, diabetes, stroke, high arterial PCO2, and low serum albumin level were associated with a prolonged LOS. These findings may help physicians to identify patients that will need a prolonged LOS in the early stages of admission. However, the predictive model exhibited suboptimal performance and hence is not ready for clinical use.
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Affiliation(s)
- Ying Wang
- Health Services Research Unit, Lørenskog, Norway ; Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway ; Faculty of Medicine, University of Oslo, Lørenskog, Norway
| | - Knut Stavem
- Health Services Research Unit, Lørenskog, Norway ; Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway ; Faculty of Medicine, University of Oslo, Lørenskog, Norway
| | | | - Sjur Humerfelt
- Department of Pulmonary Medicine, Oslo University Hospital, Aker, Norway
| | - Torbjørn Haugen
- Health Services Research Unit, Lørenskog, Norway ; Clinic for Allergy and Airway Diseases, Oslo, Norway
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Dautremont JF, Rudmik LR, Yeung J, Asante T, Nakoneshny SC, Hoy M, Lui A, Chandarana SP, Matthews TW, Schrag C, Dort JC. Cost-effectiveness analysis of a postoperative clinical care pathway in head and neck surgery with microvascular reconstruction. J Otolaryngol Head Neck Surg 2013; 42:59. [PMID: 24351020 PMCID: PMC3878235 DOI: 10.1186/1916-0216-42-59] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 11/23/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this study is to evaluate the cost-effectiveness of a postoperative clinical care pathway for patients undergoing major head and neck oncologic surgery with microvascular reconstruction. METHODS This is a comparative trial of a prospective treatment group managed on a postoperative clinical care pathway and a historical group managed prior to pathway implementation. Effectiveness outcomes evaluated were total hospital days, return to OR, readmission to ICU and rate of pulmonary complications. Costing perspective was from the government payer. RESULTS 118 patients were included in the study. All outcomes demonstrated that the postoperative pathway group was both more effective and less costly, and is therefore a dominant clinical intervention. The overall mean pre- and post-pathway costs are $22,733 and $16,564 per patient, respectively. The incremental cost reduction associated with the postoperative pathway was $6,169 per patient. CONCLUSION Implementing the postoperative clinical care pathway in patients undergoing head and neck oncologic surgery with reconstruction resulted in improved clinical outcomes and reduced costs.
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Affiliation(s)
- Jonathan F Dautremont
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Luke R Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Justin Yeung
- Division of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Tiffany Asante
- Bachelor of Health Sciences Program, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Steve C Nakoneshny
- Ohlson Research Initiative, Southern Alberta Cancer Research Institute, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Monica Hoy
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Amanda Lui
- Ohlson Research Initiative, Southern Alberta Cancer Research Institute, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shamir P Chandarana
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Thomas W Matthews
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Christiaan Schrag
- Division of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Joseph C Dort
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
- Ohlson Research Initiative, Southern Alberta Cancer Research Institute, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
- HRIC 2A02, 3280 Hospital Dr, Calgary T2N 4Z6, NW, Canada
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Yeung JK, Harrop R, McCreary O, Leung LT, Hirani N, McKenzie D, de Haas V, Matthews TW, Nakoneshny S, Dort JC, Schrag C. Delayed mobilization after microsurgical reconstruction: an independent risk factor for pneumonia. Laryngoscope 2013; 123:2996-3000. [PMID: 23754486 DOI: 10.1002/lary.24241] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/16/2013] [Accepted: 05/16/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVES/HYPOTHESIS Large defects secondary to oral cancer resection are reconstructed with microsurgical free flaps. Pulmonary complications in these patients are common. Postoperative mobilization is recommended to decrease respiratory complications; however, many microsurgeons are reluctant to adopt early mobilization protocols due to the perceived risk of flap compromise. The purpose of this study was to determine the incidence of pneumonia among patients undergoing oral cancer resection and immediate free flap reconstruction and to compare the incidence of this complication between patients mobilized early (<4 days postoperative) versus later. A secondary goal was to determine whether early postoperative mobilization affected microvascular flap outcome. STUDY DESIGN Retrospective cohort study. METHODS Sixty-two consecutive patients treated between 2005 and 2009 with oral carcinoma resection and free flap reconstruction were studied. Information pertaining to comorbidities, postoperative care, and complications were collected. Risk factors for development of pulmonary and flap complications were analyzed. RESULTS The incidence of pneumonia was 30.6%. Longer intensive care unit stay (P = 0.01), tracheostomy decannulation later than 10 days (P = 0.04), and longer operative times (P = 0.04) were significantly associated with pneumonia. Delayed mobilization (after day 4 postoperative) was an independent risk factor for pneumonia (OR = 4.2, 95% CI: 1.1, 17.1). Early mobilization (before day 4 postoperative) was not associated with an increased incidence of secondary flap procedures or flap failure. CONCLUSION Late mobilization of free flap patients is an independent risk factor for developing postoperative pneumonia. Earlier mobilization does not increase flap failure rates, is safe, and should be strongly considered in all free flap patients to reduce pulmonary complications.
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Affiliation(s)
- Justin K Yeung
- Division of Plastic & Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
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Shin YS, Koh YW, Kim SH, Choi EC. The efficacy of the harmonic scalpel in neck dissection: a prospective randomized study. Laryngoscope 2012. [PMID: 23208767 DOI: 10.1002/lary.23704] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS Recently, the Harmonic scalpel (HS) has been used in head and neck surgery as an alternative to conventional hand-tied ligation for hemostasis. Limited data have been published on the evidence of its safety in neck dissection (ND), especially in radical ND. We intended to investigate the safety and efficacy of the HS in ND, while using conventional hand-tied ligation to a minimum. METHOD Fifty-nine patients who underwent ND with primary head and neck cancer resection were enrolled in this study. The group using HS consisted of 29 patients, and the conventional hand-tied ligation technique (CT) group comprised of 30 patients. The following variables were examined: operating time, intraoperative bleeding, incidence of perioperative complications, the number of lymph nodes, total amount of drainage, duration of drain placement, and days of hospital stay. RESULT The use of the HS reduced the operating time of comprehensive ND by an average of 46.5 minutes (P < 0.001), and blood loss was significantly decreased in the HS group than the CT group (163.8 ± 33.8 cc vs. 203.8 ± 36.5 cc, P = 0.002). The number of lymph nodes was not significantly different between the two groups. No significant difference was observed in the total amount of drainage, duration of drain placement, days of hospital stay, and perioperative complications. CONCLUSIONS The HS is a relatively safe and effective alternative method for hand-tie ligation in ND. Moreover, the HS significantly reduced the operating time and amount of blood loss.
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Affiliation(s)
- Yoo Seob Shin
- Department of Otolaryngology, Ajou University School of Medicine, Suwon, Korea
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Marla S, McMillan DC, Stallard S. Factors influencing postoperative length of hospital stay after breast cancer surgery. Breast 2012; 22:289-94. [PMID: 22841480 DOI: 10.1016/j.breast.2012.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 07/08/2012] [Indexed: 10/28/2022] Open
Abstract
As part of a feasibility study to restructure the breast cancer services in Glasgow, factors influencing 'postoperative length of stay' (LOS) and bed utilisation in patients undergoing surgery for breast cancer were examined. Data for patients admitted at five hospitals between March 2007 and February 2008 was collected prospectively. Age, socio-demographic and clinico-pathologic factors were recorded. Independent affects of variables predicting prolonged LOS were assessed using binary logistic regression analysis. Of the 519 women, 252(49%) had screen-detected cancers with a median LOS of 1 day while 267(51%) had symptomatic cancers with a median LOS of 4 days (p < 0.001). On multivariate analysis, axillary procedure performed independently influenced prolonged LOS in both screen-detected and symptomatic cancers. In symptomatic cancers, comorbidities and deprivation also had some influence. While mastectomy with or without axillary surgery utilised 51% of the bed days, a further 20% were utilised by patients having re-operations. This study has helped in the planning of ambulatory surgery services and inpatient bed requirements for patients undergoing breast cancer surgery in Glasgow.
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Affiliation(s)
- Sekhar Marla
- University Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK.
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Rubinsky AD, Sun H, Blough DK, Maynard C, Bryson CL, Harris AH, Hawkins EJ, Beste LA, Henderson WG, Hawn MT, Hughes G, Bishop MJ, Etzioni R, Tønnesen H, Kivlahan DR, Bradley KA. AUDIT-C Alcohol Screening Results and Postoperative Inpatient Health Care Use. J Am Coll Surg 2012; 214:296-305.e1. [DOI: 10.1016/j.jamcollsurg.2011.11.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 11/18/2011] [Accepted: 11/21/2011] [Indexed: 11/27/2022]
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Dedhia RC, Smith KJ, Weissfeld JL, Saul MI, Lee SC, Myers EN, Johnson JT. Cost-identification analysis of total laryngectomy: an itemized approach to hospital costs. Otolaryngol Head Neck Surg 2011; 144:220-4. [PMID: 21493420 DOI: 10.1177/0194599810393117] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To understand the contribution of intraoperative and postoperative hospital costs to total hospital costs, examine the costs associated with specific hospital services in the postoperative period, and recognize the impact of patient factors on hospital costs. STUDY DESIGN Case series with chart review. SETTING Large tertiary care teaching hospital system. SUBJECTS AND METHODS Using the Pittsburgh Head and Neck Organ-Specific Database, 119 patients were identified as having total laryngectomy with bilateral selective neck dissection and primary closure from 1999 to 2009. Cost data were obtained for 112 patients. Costs include fixed and variable costs, adjusted to 2010 US dollars using the Consumer Price Index. RESULTS Mean total hospital costs were $29,563 (range, $10,915 to $120,345). Operating room costs averaged 24% of total hospital costs, whereas room charges, respiratory therapy, laboratory, pharmacy, and radiology accounted for 38%, 14%, 8%, 7%, and 3%, respectively. Median length of stay was 9 days (range, 6-43), and median Charlson comorbidity index score was 8 (2-16). Patients with ≥1 day in the intensive care unit had significantly higher hospital costs ($46,831 vs $24,601, P < .01). The authors found no significant cost differences with stratification based on previous radiation therapy ($27,598 vs $29,915 with no prior radiation, P = .62) or hospital readmission within 30 days ($29,483 vs $29,609 without readmission, P = .97). CONCLUSION This is one of few studies in surgery and the first in otolaryngology to analyze hospital costs for a relatively standardized procedure. Further work will include cost analysis from multiple centers with investigation of global cost drivers.
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Affiliation(s)
- Raj C Dedhia
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Unplanned surgical reoperations in a tertiary hospital: perioperative mortality and associated risk factors. Eur J Anaesthesiol 2011; 28:10-5. [DOI: 10.1097/eja.0b013e32833e33b0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kubrak C, Olson K, Jha N, Jensen L, McCargar L, Seikaly H, Harris J, Scrimger R, Parliament M, Baracos VE. Nutrition impact symptoms: key determinants of reduced dietary intake, weight loss, and reduced functional capacity of patients with head and neck cancer before treatment. Head Neck 2010; 32:290-300. [PMID: 19626639 DOI: 10.1002/hed.21174] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Our aim was to evaluate the prevalence and relationship of symptoms with reduced dietary intake, weight, and functional capacity in patients with head and neck cancer. METHODS Three hundred forty-one patients were prospectively screened with the patient-generated subjective global assessment before treatment. Logistic analysis was used to relate symptoms to reduced dietary intake, weight, and functional capacity. Cumulative hazard analysis was performed to determine the time and risk of weight loss of each symptom. Survival analysis was performed with Cox proportional hazards model. RESULTS Anorexia, dysphagia, mouth sores, and others were significant predictors of reduced dietary intake and weight. Symptom presence accelerated the time and probability of weight loss. Body mass index < or = 18.5 related to overall survival (p value = .001). CONCLUSIONS Symptoms present before treatment may adversely affect the dietary intake, weight, and functional capacity of patients. Symptom treatment and management is critical to weight loss prevention.
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Affiliation(s)
- Catherine Kubrak
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.
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Tsou YA, Hua CH, Lin MH, Tseng HC, Tsai MH, Shaha A. Comparison of pharyngocutaneous fistula between patients followed by primary laryngopharyngectomy and salvage laryngopharyngectomy for advanced hypopharyngeal cancer. Head Neck 2010; 32:1494-500. [DOI: 10.1002/hed.21352] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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