Reducing morbidity and complications after major head and neck cancer surgery: the (future) role of enhanced recovery after surgery protocols

Impact of Prehabilitation With Preoperative Swallowing Exercises on Postoperative Swallowing Morbidity in Oral Cavity Cancer: Randomized Controlled Trial

Background and Objective

Oral cancer surgery and the associated reconstructive procedures cause mechanical and neurological impairment of swallowing. Despite postoperative rehabilitation, functional impairment of swallowing remains a concern. This study is to investigate the potential benefits of prehabilitation with preoperative swallowing exercises to patients undergoing composite resections and compartmental tongue resections so that it results in better swallowing outcomes and improved quality of life after surgery.

Materials and Methods

Sixty patients included in the study were randomized into an exercise and control group of 30 each. Patients with squamous cell carcinoma of the oral cavity undergoing composite resection or compartmental tongue resections were included, and patients with severe trismus at presentation were excluded. Patients in the exercise group were instructed on a set of six active exercises to be followed strictly for a period of at least 1 week before surgery. Preoperative swallowing exercises comprised of evidence-based exercises targeting the muscle groups involved in swallowing. Postoperative swallowing rehabilitation was the same as that of the control group. Patients were assessed after 6 months of surgery. Outcomes were assessed both subjectively and objectively. Objective assessment was done by inexpensive, novel clinical methods of repetitive saliva swallow test (RSST), water swallow test (WST) and food swallow test (FST) to and graded using dysphagia severity scale (1-7).

Results

Average oral intake scale (1-Oral solids, 2-Oral semisolids/easy to chew foods, 3-Oral liquids only and 4-Non-oral, orogastric tube dependent) assessed subjectively was significantly lower in exercise arm, and the control arm had a significantly higher OIS score. Exercise arm had higher number of patients in DSS scores of 5, 6 and 7. The control arm had a higher number of patients in DSS scores of 3 and 4. The differences between the two groups were found to be statistically significant taking into consideration the confounding factors of radiation, wound morbidity and tongue resections.

Conclusion

Preoperative swallowing exercises have shown a positive impact on postoperative swallowing ability. This is the first randomized trial to assess the effect of PSE in postoperative oral cancer patients. Our exercise protocol needs standardization, and clinical objective method of dysphagia assessment requires further validation. However, prehabilitation with PSE has the potential to improve the quality of life in oral cancer patients.

Incidence and risk factors of surgical site infection in patients with head and neck cancer: A meta-analysis

We systematically review the incidence and risk factors of surgical site infection (SSI) in patients with head and neck cancer. PubMed, Embase, Cochrane Library, and Web of Science databases were searched to obtain studies on the risk factors for SSI in patients with HNC. The retrieval time was from the establishment of the database to February 2023. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias in included studies. Meta-analysis was performed by using Stata 15.1 software. A total of 32 articles including 128 919 patients with head and neck cancer and 2949 cases of SSI were included in this meta-analysis. The incidence rate of SSI in head and neck cancer ranges from 19% to 29%, and the overall infection rate was 24%. Meta-analysis indicated that BMI < 20 kg/m2 (OR, 2.64; 95% CI, 1.74-4.00; I2 , 0%), diabetes (OR, 3.00; 95% CI, 2.12-4.16; I2 , 60.6%), ASA score (OR, 1.51; 95% CI, 1.29-1.77; I2 , 0%), radiotherapy (OR, 2.27; 95% CI, 1.87-2.77; I2 , 44.8%), chemotherapy (OR, 2.36; 95% CI, 1.64-3.40; I2 , 0%), clindamycin antibiotic (OR, 2.99; 95% CI, 1.82-2.93; I2 , 36.5%), deficit repair (OR, 3.76; 95% CI, 1.22-11.59; I2 , 91.4%), neck dissection (OR, 2.13; 95% CI, 1.63-2.79; I2 , 16.4%), blood transfusion (OR, 2.29; 95% CI, 1.52-3.45; I2 , 66.2%), mandibular (OR, 3.17; 95% CI, 1.85-5.42; I2 , 73%), tracheostomy (OR, 2.51; 95% CI, 1.74-3.62; I2 , 86.4%), operation time (OR, 1.42; 95% CI, 1.16-1.74; I2 , 86.4%), ALB (OR, 2.48; 95% CI, 1.95-3.15; I2 , 5.3%) were risk factors of surgical site infection in patients with head and neck cancer (p < 0.05). The results of the sensitivity analysis showed good agreement in all risk factors and the results had stability. The present meta-analysis suggests that BMI < 20 kg/m2 , diabetes, ASA score, radiotherapy, chemotherapy, clindamycin antibiotic, deficit repair, neck dissection, blood transfusion, mandibular, tracheostomy, operation time, and ALB were significant risk factors for SSI.

Enhanced Recovery After Surgery Protocols for Head and Neck Cancer: Systematic Review and Meta-analysis

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols aim to optimize the pre-, intra-, and postoperative care of patients to improve surgery outcomes, reduce complications, decrease length of stay, and more. We aim to perform a systematic review and meta-analysis of ERAS protocols for head and neck cancer surgery with or without microvascular reconstruction.

DATA SOURCES

PubMed, Embase, and Web of Science databases were queried, and abstracts were screened independently by 2 investigators.

REVIEW METHODS

This review was conducted in accordance with the PRISMA guidelines. We included comparative observational studies but excluded animal studies, case reports, and case series.

RESULTS

Of 557 articles initially reviewed by title and/or abstract, we identified 30 for full-text screening, and 9 met the criteria for qualitative synthesis. Meta-analysis of length of stay revealed a mean decrease of 1.37 days (95% CI, 0.77-1.96; I2 = 0%; P < .00001) with the ERAS group as compared with non-ERAS controls. The standardized mean difference of the morphine milligram equivalent was 0.72 lower (95% CI, 0.26-1.18; I2 = 82%; P = .002) in the ERAS group vs controls. The quality of studies was moderate with a median MINORS score of 18.5 (range, 13.5-21.5).

CONCLUSION

Implementation of ERAS protocols can lead to decreases in length of stay and opioid drug utilization. However, further high-quality prospective studies of ERAS protocols are needed, especially with stratified analysis of outcomes based on the type of head and neck cancer surgery.

Emerging Concepts Impacting Head and Neck Cancer Surgery Morbidity

All treatment modalities for head and neck cancer carry with them a risk of adverse events. Head and neck surgeons are faced with significant challenges to minimize associated morbidity and manage its sequelae. Recognizing situations in which a surgical complication is an adverse event inherent to the procedure can alleviate the psychologic impact a complication might have on the treatment team and minimize external and internal pressures. Focusing on the complications that can be effectively modified, future complications can be avoided. Also, some surgical morbidities may not be preventable, necessitating the option to reconsider whether the incidents should be labeled toxic reactions rather than a complication. This discussion highlights some of the areas in which additional research is needed to achieve the goal of minimizing the impact of surgical morbidity.

Effect of a Personalized Enteral Nutrition Protocol on the Postoperative Nutritional Status in Patients Who Underwent Oral Cancer Surgery

Differences in the implementation of the perioperative nutrition guidelines and pathways by caregivers lead to differences in enteral nutrition provided to the patients. This study investigated the effect of a personalized enteral nutrition protocol on the postoperative nutritional status of patients who underwent oral cancer surgery at Zhejiang Ningbo NO. 2 Hospital. Those who underwent surgery between July 2017 and October 2018 received routine enteral nutrition based on the Nutritional Risk Screening 2002 (routine group), while those between November 2018 and August 2021 received personalized enteral nutrition based on the Patient-Generated Subjective Global Assessment tool (personalized group). Seventy patients completed the study (routine group, n = 34; personalized group, n = 36). After surgery, the personalized group exhibited significantly greater improvements in serum albumin levels (P < 0.01) (on the 7th and 10th day) and hand grip strength (P < 0.01), higher self-care ability (P < 0.01), lower incidence of gastrointestinal reactions during enteral feeding (P < 0.05), and shorter hospital stay (P < 0.05) than the routine group. Therefore, a personalized enteral nutrition program might improve the postoperative nutritional status, shorten the hospital stay, and accelerate postoperative recovery in patients who underwent oral cancer surgery.

Enhanced recovery after laryngectomy: A feasibility study in 25 patients

PURPOSE

To describe the development and implementation of an enhanced recovery programme for patients undergoing total laryngectomy.

METHODS

A feasibility study set in a tertiary head and neck unit in London, United Kingdom. The programme was developed based on Enhanced Recovery After Surgery (ERAS) Society guidelines for head and neck cancer surgery and local expert group consensus. An ERAS 'booklet' was devised which accompanied all laryngectomy patients during their inpatient stay. Contributors included otolaryngologists, anaesthetists, dieticians, physiotherapists, speech and language therapists and nurses. A 12-month pilot study was undertaken. The main outcome measures were feasibility and adherence.

RESULTS

An enhanced recovery programme for 25 people undergoing total laryngectomy was successfully piloted in a tertiary referral head and neck unit. Median length of stay was reduced in the post-ERAS group by 1.5 days. No statistically significant difference in length of stay, time to first gastrografin swallow, rate of fistula nor postoperative normalcy of eating between the pre and post-ERAS patients who underwent laryngectomy was observed. Clavien-Dindo-grouped complication rates were significantly higher in the post-ERAS group.

CONCLUSION

This enhanced recovery programme for patients undergoing laryngectomy is the first of its kind in the literature. Implementation has been demonstrated feasible. Further longitudinal studies are required to reliably inform us on ERAS programmes' effects on laryngectomy outcomes.

Integration of an enhanced recovery after surgery program for patients undergoing pituitary surgery

Evidence-based enhanced recovery after surgery (ERAS) programs aim to improve patient outcomes and shorten hospital stays. The objective of this study is to describe the development, implementation, and evolution of an ERAS protocol to optimize the perioperative management for patients undergoing endoscopic skull base surgery for pituitary tumors. A systematic review of the literature was performed, best practices were discussed with stakeholders, and institutional guidelines were established and implemented. Key performance indicators (KPI) were measured and patient-reported outcome surveys were collected. The ERAS protocol was introduced successfully at our institution. We describe the process of initiation of the program and the perioperative management of our patients. We demonstrated the feasibility of integration of ERAS protocols for pituitary tumors with multidisciplinary engagement, with a particular emphasis on the use of data informatics and metrics to monitor outcomes. We expect that this approach will translate to improved quality of care for these often-complex patients.

The Use of Dissemination and Implementation to Improve Multimodal Analgesia in Head and Neck Surgery

OBJECTIVES

To optimize the delivery of multimodal analgesia to patients undergoing major head and neck oncologic surgeries.

METHODS

Pilot study included patients enrolled to receive either scheduled acetaminophen and as-needed opioids (control group) or scheduled acetaminophen, gabapentin, ketorolac, and as-needed opioids (experimental group). RCT, a hybrid type 1 effectiveness-implementation pragmatic trial, was designed to test the effectiveness of the intervention. Arm A received scheduled acetaminophen and as-needed opioids. Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the free tissue donor site, scheduled acetaminophen and as-needed opioids.

RESULTS

Pilot: Thirty-one patients undergoing major head and neck surgery were enrolled. Mean MMEs administered in control group (n = 15) was 251.60 mg (SD = 224.57 mg); mean MMEs in Experimental group (n = 16) was 195.78 mg (SD = 131.08 mg), p = 0.401. LOS was 8.0 days in control versus 7.0 days in experimental group (p = 0.054). RCT: Interim analysis for safety and futility was planned during trial's design after 30 patients (n = 14 Arm A, and n = 16 Arm B). Mean MMEs administered were 135.1 mg in Arm A, (SD = 86.0 mg) versus mean MME of 51.3 mg in Arm B (SD = 43.3 mg, (p < 0.05)). Given clear superiority results, the trial was prematurely terminated. Functional pain scores, LOS, and complications were similar between the arms (p > 0.05). Variability of mean MME was compared before and after implementation of the management protocols: SD in RCT#1 was 181.46 mg versus 124.6 mg in RCT#2.

CONCLUSION

Multimodal analgesia significantly reduced the need for opioids in patients undergoing major head and neck surgery.

LEVEL OF EVIDENCE

1, Randomized Clinical Trial Laryngoscope, 133:S1-S11, 2023.

The feasibility of patient-reported outcomes, physical function, and mobilization in the care pathway for head and neck cancer surgical patients

BACKGROUND

Head and neck cancer (HNC) patients are an understudied population whose treatment often includes surgery, causing a wide range of side effects. Exercise prehabilitation is a promising tool to optimize patient outcomes and may confer additional benefits as a prehabilitation tool. The primary objective of this study was to assess the feasibility of measuring patient-reported outcomes (PROs), physical function, and in-hospital mobilization across the HNC surgical timeline in advance of a future prehabilitation trial. The secondary objective was to examine potential changes in these outcomes across the surgical timeline.

METHODS

HNC patients scheduled to undergo oncologic resection with free-flap reconstruction completed assessments of PROs and physical function at three timepoints across the surgical timeline (baseline, in-hospital, and postsurgical/outpatient). Mobilization was measured during the in-hospital period. The feasibility of recruitment and measurement completion was tracked, as were changes in both PROs and physical function.

RESULTS

Of 48 eligible patients, 16 enrolled (recruitment rate of 33%). The baseline and in-hospital PROs were completed by 88% of participants, while the outpatient assessments were completed by 81% of participants. The baseline and in-hospital assessment of physical function were completed by 56% of participants, and 38% completed the outpatient assessment. Measuring in-hospital mobilization was completed for 63% of participants.

CONCLUSION

Measuring PROs and in-hospital mobilization is feasible across the surgical timeline in HNC; however, the in-person assessment of physical function prior to surgery was not feasible. A multidisciplinary collaboration between exercise specialists and clinicians supported the development of new clinical workflows in HNC surgical care that will aid in the implementation of a future prehabilitation trial for this patient population.

Perioperative Symptom Burden and Its Influencing Factors in Patients with Oral Cancer: A Longitudinal Study

Objective

The aim of this study was to identify the symptom burden of perioperative oral cancer patients, its trajectory, and the factors influencing it.

Methods

A longitudinal, repeated measures design with consecutively identified sampling was used to recruit oral cancer patients scheduled for surgical treatment. Data collected included sociodemographic and clinical information, nutritional risk by the Nutritional Risk Screening 2002, and symptom burden by M. D. Anderson Symptom Inventory-Head and Neck Module (MDASI-HN) at preoperation, 7 days postsurgery, and 1 month postsurgery.

Results

Perioperative patients with oral cancer had multiple symptoms. Pain, difficulty swallowing/chewing, and mouth/throat sores (61.9%–76.1%) were the most prevalent symptoms before surgery. The symptom burden was the highest at 7 days after surgery, with the most prevalent symptoms, including difficulty swallowing/chewing, difficulty with voice/speech, and problems with mucus (87.8%–95.4%). At 1 month postsurgery, the 3 main symptoms were numbness or tingling, difficulty swallowing/chewing, and difficulty with voice/speech (all 87.8%). Treatment stage, job, comorbidity, cancer stage, adjuvant therapy, and Nutritional Risk Screening 2002 score were correlated with symptom burdens.

Conclusions

Our study illustrates that perioperative oral cancer patients have multiple symptoms and high symptom burdens, especially at 7 days postsurgery, with prominent symptoms and symptom burdens varying with the treatment stage.

Where Enhanced Recovery after Surgery (ERAS) Protocols Meet the Three Major Current Pandemics: COVID-19, Obesity and Malignancy

Simple Summary

The SARS-CoV-2 (COVID-19) pandemic has significantly modified the medical services provided for patients that receive care either for COVID-19 or for those that need care for benign diseases, including obesity, or for malignant ones, such as gynecological cancer. We sought to investigate the association among three major worldwide health issues (COVID-19, obesity, and malignancy) and how ERAS protocols can potentially provide optimal management of patients with obesity and malignancy during the COVID-19 pandemic, with special attention to patients who required surgery for gynecologic oncology. We strongly believe that the application of ERAS protocols could play a key role during these unprecedented COVID-19 times.

Abstract

The outbreak of the SARS-CoV-2 (COVID-19) pandemic has transformed the provision of medical services for both patients that receive care for COVID-19 and for those that need care either for benign diseases, including obesity, or for malignancies, such as gynecological cancer. In this perspective article, we focus on the association among three major worldwide health issues and how ERAS protocols can potentially provide optimal management of patients with obesity and malignancy during the COVID-19 pandemic, with special attention to patients who required surgery for gynecologic oncology. A thorough search of the literature on the respective topics was performed. Patients with malignancy and obesity presented with increased vulnerability to COVID-19 infection. However, the management of their disease should not be withheld. Protective measures should be established to reduce exposure of patients with oncological diseases to SARS-CoV-2 while simultaneously enabling their access to vaccination. Since ERAS protocols have proved to be efficient in many surgical fields, including gynecologic oncology, general surgery, and orthopedics, we strongly believe that ERAS protocols may play a significant role in this effort. The end of the COVID-19 pandemic cannot be accurately predicted. Nevertheless, we have to ensure the appropriate and efficient management of certain groups of patients.

Acute Pain Management Following Head and Neck Surgery

Acute pain management following major head and neck (HN) surgery is complex. Multimodal analgesia (MMA) regimens including acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, and locoregional anesthetics are safe and effective in this population (including patients undergoing HN free flap surgery). Special considerations for patients undergoing HN free flap surgery include judicious use of steroids and attention to donor site pain. Evidence for specific analgesic regimens following transoral robotic surgery is limited but should include MMA and perioperative dexamethasone. Further study is required to optimize combinations, dosages, and duration of perioperative analgesia medications, opioid and nonopioid, for patients undergoing major HN surgery.

Enhanced recovery after surgery (ERAS) pathway for microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion

OBJECTIVES

Enhanced recovery after surgery (ERAS) principle and minimally invasive surgery allow patients to recover faster and better postoperatively. Due to a paucity of their integration, this retrospective study aims to assess clinical outcomes of ERAS pathway in microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

PATIENTS AND METHODS

A total of 72 consecutive cases were enrolled. According to their inclusion order, the former 21 cases received microendoscopy-assisted MIS-TLIF without any ERAS approach (control group), while the latter 51 participants underwent the same surgery with ERAS protocol (observation group). Perioperative parameters, including operative duration, intraoperative estimated blood loss (EBL), length of stay, postoperative analgesic usage and ambulatory time, were recorded. Visual analogue scale (VAS, back and leg), Barthel index were obtained before and at three days, one month, six months postoperatively. Modified MacNab criteria and Bridwell grading were used to assess surgical outcome and interbody fusion at one week and two years after surgery, respectively.

RESULTS

Observation group had statistically improved perioperative parameters (operative duration, intraoperative EBL, length of stay, postoperative analgesic usage and ambulatory time) in comparison with control group. Remarkable decreases in VAS (back and leg) were observed continuously at three days, one month and six months post-surgery in both groups when compared with scores prior to the surgery. More significant improvement of VAS (back and leg) was found in observation group at both three days and one month postoperatively. Regarding Barthel index, despite its transient decrease at three days after surgery in control group, it showed statistical increase at postoperative one month when compared with preoperative values in both groups; moreover, its inter-groups comparison revealed much more improvement in patients receiving ERAS recommendations; while at final follow-up, it continued further increase in either group. Marginally higher proportion of patients in observation group showed perfect or good clinical outcome, as well as solid interbody fusion.

CONCLUSIONS

ERAS pathway in microendoscopy-assisted MIS-TLIF has advantages of decreased operative time, reduced intraoperative haemorrhage, increased initial back pain relief, decreased length of stay, lowered analgesic usage and earlier daily activity recovery and thus, benefit postoperative rehabilitation further.

Evaluation of a novel database for quality assurance at a head and neck service in New Zealand: an audit of free flap head and neck reconstruction

BACKGROUND

Clinical audit is a critical quality improvement exercise, yet efficient audit tools are lacking. The main objective of this study was to evaluate a recently deployed database in facilitating the process of clinical audit, and the secondary objective was to evaluate the outcomes of free flap reconstruction of the head and neck at our centre.

METHODS

A head and neck cancer-specific database was customized to suit the needs of our head and neck multidisciplinary team. Data has been entered prospectively into this database since March of 2018. An audit of free flap reconstruction of the head and neck over a 12-month period was performed using the database and analysed as a case study to examine its efficacy as a clinical audit tool. Additionally, the outcomes of free flap reconstruction at our centre were compared to those reported in the international literature.

RESULTS

The database allows flexible and specific queries, analysis and export of data, and can provide immediate results. However, issues with data quality and completeness were identified. In this audit, the overall 30-day complication rate and 30-day mortality in patients undergoing free flap reconstruction of the head and neck were 58% and 3%, respectively.

CONCLUSION

The database is fit for its intended purpose as an audit tool. Outcomes of free flap reconstruction of the head and neck at our centre are comparable to those of institutions overseas.

Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction

Importance

An increase in narcotic prescription patterns has contributed to the current opioid epidemic in the United States. Opioid-sparing perioperative analgesia represents a means of mitigating the risk of opioid dependence while providing superior perioperative analgesia.

Objective

To assess whether multimodal analgesia (MMA) is associated with reduced narcotic use and improved pain control compared with traditional narcotic-based analgesics at discharge and in the immediate postoperative period after free flap reconstructive surgery.

Design, Setting, and Participants

This retrospective cohort study assessed a consecutive sample of 65 patients (28 MMA, 37 controls) undergoing free flap reconstruction of a through-and-through mucosal defect within the head and neck region at a tertiary academic referral center from June 1, 2017, to November 30, 2018. Patients and physicians were not blinded to the patients' analgesic regimen. Patients' clinical courses were followed up for 30 days postoperatively.

Interventions

Patients were administered a preoperative, intraoperative, and postoperative analgesia regimen consisting of scheduled and as-needed neuromodulating and anti-inflammatory medications, with narcotic medications reserved for refractory cases. Control patients were administered traditional narcotic-based analgesics as needed.

Main Outcomes and Measures

Narcotic doses administered during the perioperative period and at discharge were converted to morphine-equivalent doses (MEDs) for comparison. Postoperative Defense and Veterans Pain Rating Scale pain scores (ranging from 0 [no pain] to 10 [worst pain imaginable]) were collected for the first 72 hours postoperatively as a patient-reported means of analyzing effectiveness of analgesia.

Results

A total of 28 patients (mean [SD] age, 64.1 [12.3] years; 17 [61%] male) were included in the MMA group and 37 (mean [SD] age, 65.0 [11.0] years; 22 [59%] male) in the control group. The number of MEDs administered postoperatively was 10.0 (interquartile range [IQR], 2.7-23.1) in the MMA cohort and 89.6 (IQR, 60.0-104.5) in the control cohort (P < .001). Mean (SD) Defense and Veterans Pain Rating Scale pain scores postoperatively were 2.05 (1.41) in the MMA cohort and 3.66 (1.99) in the control cohort (P = .001). Median number of MEDs prescribed at discharge were 0 (IQR, 0-18.8) in the MMA cohort and 300.0 (IQR, 262.5-412.5) in the control cohort (P < .001).

Conclusions and Relevance

The findings suggest that after free flap reconstruction, MMA is associated with reduced narcotic use at discharge and in the immediate postoperative period and with superior analgesia as measured by patient-reported pain scores. Patients receiving MMA achieved improved pain control, and the number of narcotic prescriptions in circulation were reduced.

Level of Evidence

3.

Postoperative management in the Intensive Care Unit of head and neck surgery patients

Patient care after major head and neck surgery has changed in recent years. Tumors are the most common reasons for this type of surgery, though it is also used to treat benign conditions. Recent advances in equipment and surgical techniques have improved the postoperative course in this field, allowing early recovery, less pain and infection, a shorter hospital stay, and even better aesthetic results. This is due to the use of minimally invasive techniques, which are gaining relevance. Such techniques allow complex procedures in the head and neck region, through natural orifices or small incisions, with minimal damage and sequelae for the patients. Despite these advances, however, the complexity of the treatment intervention requires multidisciplinary patient management, mostly in the Intensive Care Unit, in order to monitor the possible occurrence of complications. Potential risk factors include previous comorbidity, the type of surgery involved (e.g., bilateral cervical lymphadenectomy), multiple transfusions, and the appearance of early complications requiring repeat surgery. Despite the existence of several studies, there are no standardized protocols for the postoperative period in surgeries of this kind. This causes many specialists to resort to accelerated recovery protocols (ERAS: "Enhanced Recovery After Surgery") that have already been established in other surgical specialties.

Associations between pre-, post-, and peri-operative variables and health resource use following surgery for head and neck cancer

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.