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Schuman AD, Bindal M, Amadio G, Turney AM, Hernandez DJ, Sandulache VC, Liou NE, Wang R, Huang AT. Safety of An Enhanced Recovery After Surgery Protocol After Head and Neck Free Tissue Transfer. Laryngoscope 2024. [PMID: 38895890 DOI: 10.1002/lary.31564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/01/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVES Implementing enhanced recovery after surgery (ERAS) protocols and decreasing length of stay (LOS) have become a priority for major surgeries, including microvascular free tissue transfer (MVFTT) reconstruction of the head and neck. We describe an ERAS protocol with the goal to further reduce length of stay beyond national medians. METHODS Retrospective chart review between August 2016 and February 2023, including all patients who underwent MVFTT after oral cavity, skull base, salivary gland, and cutaneous ablative surgery. An ERAS protocol was implemented in March 2020. RESULTS A total of 383 patients were included. Approximately 59.8% underwent oral cavity MVFTT, 34.5% cutaneous and lateral skull base, and 5.8% maxillary and anterior skull base. A total of 209 (54.7%) patients had surgery prior to implementation of the ERAS protocol and 174 (45.3%) after. Median LOS decreased from 9 days (interquartile interval [IQR] 8-11) to 6 (IQR 5-7.5, p < 0.0001) following oral cavity MVFTT. For cutaneous and lateral skull base reconstruction, median LOS decreased from 6 days (IQR 5-8) to 3 (IQR 3-7, p < 0.0001). For anterior skull base and sinonasal MVFTT, median LOS decreased from 8 (IQR 7-9) to 5 days (IQR 4.5-7, p = 0.0005). Rate of discharge to skilled nursing or subacute rehabilitation facilities decreased (24% before ERAS, 9.2% after, p < 0.0001). Thirty-day readmission rate was similar before and after implementation (10.5% vs. 10.3, p = 0.954). Discharge to facility was associated with readmission (OR 2.34, 95% CI 1.12-4.89, p = 0.024). CONCLUSION AND RELEVANCE Implementation of the ERAS protocol was associated with decreased LOS. There was no increase in rate of readmission. LEVEL OF EVIDENCE N/A Laryngoscope, 2024.
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Affiliation(s)
- Ari D Schuman
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Mohini Bindal
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Grace Amadio
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Anne M Turney
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - David J Hernandez
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Vlad C Sandulache
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - N Eddie Liou
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Ray Wang
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Andrew T Huang
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
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Akita S, Kumamaru H, Motomura H, Mitsukawa N, Morimoto N, Sakuraba M. The volume-outcome relationship in free-flap reconstruction: A nationwide study based on the Clinical Database. J Plast Reconstr Aesthet Surg 2023; 85:500-507. [PMID: 37603985 DOI: 10.1016/j.bjps.2023.07.047] [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: 05/11/2023] [Revised: 06/18/2023] [Accepted: 07/22/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND The association between successful reconstructive surgery with a free flap and hospital volume has not been well established. This study was designed to retrospectively analyze the outcome of free-flap surgery registered in a nationwide surgical registration system in Japan to clarify the relationship between free-flap survival and facilities' average annual number of free-flap surgeries. METHODS We analyzed data from 19,482 free flaps performed during 2017-2020 at 407 facilities throughout Japan. After adjusting for sex, age, and disease classification that differ between the groups, we examined the differences in the flap survival rates among the different facilities in terms of the average number of free-flap surgeries performed annually. RESULTS The total overall necrosis rate was 2.8%. Of all procedures, 14.9%, 12.9%, 33.4%, and 38.8% were performed at facilities with an average number of free-flap procedures <10, 10-19, 20-49, and ≥ 50 per year, respectively, and the respective rates of total necrosis were 6.0%, 3.8%, 2.1%, and 1.7%, respectively. The odds ratios and 95% confidence intervals of flap necrosis for facilities with ≥ 50 cases per year relative to those <10 were 2.70 (1.98-3.68) for nonbreast reconstruction cases and 5.72 (2.77-11.8) for breast reconstruction cases. CONCLUSION This analysis of a nationwide plastic surgery database showed that free-flap surgeries in institutions with a low average annual number of free-flap surgeries had a higher risk of total necrosis. Measures should be taken to either aggregate cases into high-volume centers or improve management at low-volume centers.
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Affiliation(s)
- Shinsuke Akita
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Hisashi Motomura
- Department of Plastic and Reconstructive Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoki Morimoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Minoru Sakuraba
- Department of Plastic and Reconstructive Surgery, Iwate Medical University, Morioka, Japan
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Rehman U, Whiteman E, Sarwar MS, Brennan PA. Reconstruction of head and neck oncological soft tissue defects post-resection using robotic surgery: a systematic review of the current literature. Br J Oral Maxillofac Surg 2023; 61:514-521. [PMID: 37661537 DOI: 10.1016/j.bjoms.2023.07.011] [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: 05/24/2023] [Revised: 07/25/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023]
Abstract
Head and neck cancer (HNC) resection often leaves soft tissue defects and exposure of vital structures. In recent years, there has been an increase in the use of robotic surgery for HNC resections. This allows for achieving smaller defects by using a tissue-sparing approach. However, this poses a challenge for reconstruction with less space available to perform microsurgery. We reviewed the efficacy of robotic surgery in the reconstruction of HNC defects by assessing the impact on flap success and complication rates. A literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE, and COCHRANE databases. A total of 14 articles fulfilled the inclusion criteria with 96 patients aged mean (range) 60.7 (29-87) years, undergoing robotic reconstruction. The radial forearm flap was the most commonly used flap for robot-assisted reconstruction (n = 47). Robotic graft inset was performed in 94 cases and robotic assisted microvascular anastomoses for 25 vessels. One hundred per cent of flaps survived with a total of 25 (26.0%) complications (wound healing (n = 7), fistula formation (n = 2), haematoma (n = 4), dehiscence (n = 10), and wound infection (n = 2). Seven (12.2%) patients required additional surgery for managing complications and revision of the flap. Fewer complications were seen in patients undergoing robotic-assisted microvascular anastomoses compared with open anastomoses (4.0% versus 34.2%, p < 0.05). Robot-assisted reconstruction in HNC defects demonstrates 100% success rate with minor associated complications. Our results also support feasibility in both flap inset and microvascular anastomoses. Our results also demonstrate feasibility in both flap inset and microvascular anastomoses. Significantly fewer complications were seen with robotic-assisted microvascular anastomoses compared with open anastomoses.
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Affiliation(s)
- Umar Rehman
- Core Surgical Trainee, Department of Plastic Surgery, Chelsea and Westminster Hospital, London, United Kingdom.
| | - Elena Whiteman
- Foundation Doctor, Department of Plastic Surgery, Chelsea and Westminster Hospital, London, United Kingdom.
| | - Mohammad Sohaib Sarwar
- Locum Clinical Fellow, Department of Oral and Maxillofacial Surgery, The Queen Victoria Hospital, East Grinstead, United Kingdom.
| | - Peter A Brennan
- Honorary Professor of Surgery, Consultant Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, United Kingdom.
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Mohamed AAS, Mai L, Rao G, Fan S, Mashrah MA, Holkom MAM, Pan C, Lin Z. Perioperative risk factors impact on intensive care unit length of stay (ICU length of stay) in oral squamous cell carcinoma. BMC Oral Health 2023; 23:624. [PMID: 37658335 PMCID: PMC10474623 DOI: 10.1186/s12903-023-03304-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/11/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The trend in postoperative care for free flap patients is to deescalate from routine ICU admission into a specialty recovery unit. This study aims to investigate the predictive parameters in a routine perioperative clinical assessment that are expected to be directly correlated with prolonged ICU length of stay in at-risk patients who received oral reconstructive surgery for squamous cell carcinoma (OSCC). METHODS All patients who underwent ablative surgery for OSCC with free flap reconstruction and were managed in the ICU were included in this study. The primary outcome was ICU-length of stay. Perioperative, operative and postoperative parameters were analyzed using single test ( t-test, ANOVA analysis, correlation coefficients, effect size) and multivariate regression test. The P-value was set as < 0.005 to be considered statically significant. RESULTS The study included 136 homogeneous patients, with a mean ICU length of stay of 4.5 (± 4.43 day). Patients with pre-operative positive renal dysfunction (P = 0.004), peripheral vascular disease (P < 0.001), postoperative complications (P = 0.028) or positive heart failure class III (P < 0.001 ) were recognized as at-risk patients for a significantly longer ICU length of stay. CONCLUSION Patients with perioperative severe renal dysfunction, peripheral vascular disease, postoperative complication or high NYHA class are prone to have a significantly longer ICU length of stay. Several factors were considered as confounders contributing to increased ICU management time in combination with other variables. Additionally, in highly risk patient, the presence of the highly trained medical support, including the appropriate nursing care, is more critical than those patients without these risk factors.
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Affiliation(s)
- Abdo Ahmed Saleh Mohamed
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ibb University, Ibb, Yemen
| | - Lianxi Mai
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Guangxin Rao
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Song Fan
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Mubarak Ahmed Mashrah
- Department of Oral Implant, Guangdong Engineering Research of Oral Restoration and reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Mohamed Ali Mahyoub Holkom
- Department of Oral & Maxillofacial Surgery- head & neck oncology, School of Stomatology, Wuhan University, Wuhan, Hubei, China
| | - Chaobin Pan
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
| | - Zhouyu Lin
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
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Fukuzawa S, Yamagata K, Takaoka S, Uchida F, Ishibashi-Kanno N, Yanagawa T, Bukawa H. Postoperative Deep Sedation after Microvascular Reconstructive Surgery for Oral Cancer Increases the Risk of Early Postoperative Pneumonia. Dent J (Basel) 2023; 11:dj11050137. [PMID: 37232788 DOI: 10.3390/dj11050137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/23/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023] Open
Abstract
This study investigated the effect of postoperative deep sedation after oral cancer reconstructive surgery on the occurrence of early postoperative pneumonia and early postoperative delirium. We obtained medical records of 108 consecutive patients who underwent microvascular reconstructive surgery at Tsukuba University Hospital for oral cancer between January 2013 and December 2021. Forty-six of them woke soon after surgery. Ten of these forty-six patients were restless and required immediate sedation within 3 h after surgery. The comparison between sedation group and no sedation group revealed early postoperative pneumonia in the no sedation group; however, sedation was not related to early postoperative delirium. The preoperative albumin levels of patients with postoperative pneumonia were significantly different (p = 0.03) than those of patients without postoperative pneumonia. The performance status (p = 0.02), preoperative albumin level (p = 0.02), and age 75 years or older (p = 0.02) were significantly associated with postoperative delirium. Restless patients and those who could not be sedated experienced delirium and pneumonia. The risk of pneumonia was increased for patients who were difficult to sedate.
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Affiliation(s)
- Satoshi Fukuzawa
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan
| | - Kenji Yamagata
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan
| | - Shohei Takaoka
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan
| | - Fumihiko Uchida
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan
| | - Naomi Ishibashi-Kanno
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan
| | - Toru Yanagawa
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan
| | - Hiroki Bukawa
- Department of Oral and Maxillofacial Surgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan
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Post-Operative Infections in Head and Neck Cancer Surgery: Risk Factors for Different Infection Sites. J Clin Med 2022; 11:jcm11174969. [PMID: 36078898 PMCID: PMC9456570 DOI: 10.3390/jcm11174969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Post-operative infections in head and neck cancer (HNC) surgery represent a major problem and are associated with an important increase in mortality, morbidity, and burden on the healthcare system. The aim of this retrospective observational study was to evaluate post-operative infections in HNC surgery and to analyze risk factors, with a specific focus on different sites of infection. Methods: Clinical data about 488 HNC patients who underwent surgery were recorded. Univariate and multivariate analyses were performed to identify risk factors for post-operative infections. Results: Post-operative infections were observed in 22.7% of cases. Respiratory and surgical site infections were the most common. Multiple site infections were observed in 3.9% of cases. Considering all infection sites, advanced stage, tracheotomy, and higher duration of surgery were risk factors at multivariate analysis. Median hospital stay was significantly longer in patients who had post-operative infection (38 vs. 9 days). Conclusions: Post-operative infections may negatively affect surgical outcomes. A correct identification of risk factors may help the physicians to prevent post-operative infections in HNC surgery.
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