National Surgical Quality Improvement Program risk calculator validity in South Australian laryngectomy patients

A NSQIP study comparing surgical outcomes between primary and non-primary TEPs after total laryngectomy

OBJECTIVE

Tracheoesophageal puncture with voice prosthesis (TEP) is considered the gold standard for voice rehabilitation after total laryngectomy; however, there is debate as to whether it should be inserted concurrently with removal of the larynx (primary TEP), or as a separate, additional procedure at a later date (secondary TEP). We utilized the National Surgical Quality Improvement Program Database (NSQIP) to compare postoperative complications, readmission rates, and reoperation rates among individuals who underwent total laryngectomy with or without concurrent TEP placement.

METHODS

We conducted a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP) from 2012 to 2019. Patients were categorized into primary and non-primary TEP groups using a variation of CPT codes for total laryngectomy, tracheoesophageal prosthesis, and type of reconstruction. Univariate analyses were performed and significance was determined at p < 0.05.

RESULTS

A total of 1974 patients who underwent total laryngectomy were identified from the database: 1505 (77.3 %) in the non-primary TEP group and 442 (22.7 %) in the primary TEP group. Patients in the non-primary TEP group were more likely to have an ASA class greater than or equal to three (91.2 % primary vs. 84.6 % non-primary, p < 0.001). Patients in the non-primary TEP group were also more likely to require intraoperative or postoperative blood transfusions within the first 72 h of surgery (20.5 % non-primary vs. 15.3 % primary, p = 0.016). Both groups had similar rates of wound breakdown and dehiscence. There remained no significant difference based on type of reconstruction.

CONCLUSIONS

This study suggests that patients receiving primary TEPs are not at a greater risk of developing wound complications such as pharyngocutaneous fistulas in the 30-day postoperative period. This remained true when patients were stratified by type of flap reconstruction. Patients in the non-primary TEP group were more likely to have an ASA category of 3 or greater, which may explain why they experienced higher rates of complications such as blood transfusions intra-operatively or post-operatively.

Validation of a risk prediction calculator in Australian patients undergoing head and neck microsurgery reconstruction

BACKGROUND

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) surgical risk calculator (SRC) is an open access calculator predicting patients' risk of postoperative complications. This study aims to assess the validity of the SRC in patients undergoing microsurgical free flap reconstruction at an Australian tertiary referral centre.

METHODS

This is a retrospective cohort study of 200 consecutive patients treated up to November 2020. SRC-predicted rates of postoperative complications and hospital length of stay (LOS) were compared to those observed for the ablative and reconstructive components of the procedure. The performance of the SRC was assessed using Brier scores, area under the receiver operating characteristic (ROC) curve (AUC), and the Hosmer-Lemeshow test.

RESULTS

For both ablative and reconstructive components, the SRC discriminates well for pneumonia and urinary tract infection, and it is calibrated well for readmission and sepsis, but it does not discriminate and calibrate well for any single outcome. SRC-predicted hospital LOS and actual LOS did not correlate well for the reconstructive component, but they correlated strongly for the ablative component.

CONCLUSIONS

The SRC is a poor predictor of postoperative complication rates and hospital LOS in patients undergoing head and neck microsurgical reconstruction.