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Englisch C, Vladic N, Ay C. Bleeding Risk in Patients with Cancer. Hamostaseologie 2024. [PMID: 39227022 DOI: 10.1055/a-2347-6507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024] Open
Abstract
The hemostatic system and cancer display a tight interconnection, and hemostatic imbalance frequently occurs in patients with cancer. While extensive knowledge about thrombotic risk has been generated, less is known about bleeding risk and associated risk factors. However, bleeding risk is of high significance as patients with cancer frequently receive therapeutic anticoagulation for various indications and/or are candidates for primary thromboprophylaxis. The risk of bleeding in patients with cancer is variable and difficult to assess in clinical practice. Certain clinical settings such as hospitalization, specific underlying risk factors (e.g., tumor type), and medications (e.g., anticoagulation) can contribute to the individual bleeding risk of a patient with cancer. In addition, some dynamic factors such as platelet count or kidney function have an impact. Particularly, data on baseline risk of bleeding are lacking to allow for risk assessment in cancer patients without anticoagulation. In contrast, risk assessment models for the prediction of bleeding events in cancer patients receiving anticoagulation have been developed; however, these have yet to be validated. The recognition of the importance of bleeding risk in cancer patients is growing, leading to an increasing number of studies investigating and reporting bleeding complications. As study designs and reporting of bleeding events vary, it is challenging to offer a clear synthesis of evidence. In this narrative review, we provide an overview of currently available data about incidence, risk factors, and clinical impact of bleeding events in patients with cancer, and critically review risk assessment models for bleeding in cancer patients during anticoagulant therapy.
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Affiliation(s)
- Cornelia Englisch
- Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna; Vienna, Austria
| | - Nikola Vladic
- Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna; Vienna, Austria
| | - Cihan Ay
- Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna; Vienna, Austria
- Department of Obstetrics, Gynecology and Perinatal Medicine, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Dietz A, Pirlich M, Stöhr M, Zebralla V, Wiegand S. [Surgical Treatment of Oropharyngeal Cancer - Recommendations of the Current German S3 Guideline, Part I]. Laryngorhinootologie 2024; 103:599-612. [PMID: 39089244 DOI: 10.1055/a-2223-4083] [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: 08/03/2024]
Abstract
In general, a trend towards transoral resection (as opposed to classic open approaches) + neck dissection + adjuvant radio- (chemo-) therapy has been observed for oropharyngeal carcinoma over the last 20 years. Techniques of transoral surgery (TOS), including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) have been propagated in retrospective comparisons with conventional surgery or primary radiochemotherapy as gentle, minimally invasive procedures with good late functional results. Meta-analyses of mostly uncontrolled retrospective analyses suggest that TORS may have better disease-free survival (DFS) and a reduced risk of free flap reconstruction compared with open surgery. TORS (TOS) was associated with fewer tumor-positive resection margins (R1), a lower number of recurrences, fewer intraoperative tracheostomies, a shorter inpatient stay and a shorter duration of postoperative nasal tube feeding compared to open surgery. In principle, based on the best evidence currently available from registry studies, stage I-II oropharyngeal carcinomas can be treated either with primary surgery or radiochemotherapy with a comparable chance of survival. With comparable evidence for stage III and IVa, p16neg. oropharyngeal carcinomas, the majority of authors advocate primary surgery followed by adjuvant radiotherapy or radiochemotherapy as the treatment of first choice. For p16pos. patients the results of registry studies are inconsistent, although the largest registry study on 450 HPV-positive stage III patients shows a significant superiority of primary surgery + adjuvant radiochemotherapy. Since all registry studies did not adjust for smoking status, among other factors, the current data situation should be evaluated with the necessary caution.
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Affiliation(s)
| | | | | | - Veit Zebralla
- Klinik und Poliklinik für Hals-, Nasen-, Ohrenheilkunde, Universitätsklinikum Leipzig AöR, Leipzig, Germany
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Laccourreye O, Garcia D, Rahman A, Holsinger FC. Ten-Year Efficacy of Transoral Surgery for Squamous Carcinoma of the Lateral Oropharynx. Laryngoscope 2024. [PMID: 38932658 DOI: 10.1002/lary.31574] [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: 01/19/2024] [Revised: 05/10/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES To document the 10-year results of transoral mandibular preservation surgery for patients with T1-2 squamous cell carcinoma (SCC) arising from the lateral oropharynx. METHODS This was a retrospective 30-year review using STROBE guidelines at an academic, tertiary referral center. A total of 294 patients with T1-2 SCC of the lateral oropharynx were reviewed. Only 19% of patients were never-smokers, suggesting a predominantly HPV-negative population. All patients had transoral mandibular preservation surgery. Follow-up therapy included neck dissection (76.5%), induction chemotherapy (57.8%), and postoperative radiation therapy (31.6%) Local control, survival, and functional endpoints, as well as the consequences of local recurrence, were analyzed. RESULTS The 10-year local disease control was 88.3%. Local recurrence was salvaged in 50% of cases, resulting in an overall 94.5% local control rate. The overall 10-year survival was 50%. Mortality was related to metachronous second primary cancer (MSPC) (29.2%), medical comorbidities (25.7%), uncontrolled local recurrence (10%), and complications following transoral resection (4.2%). In multivariate analysis, the development of an MSPC significantly increased (p < 0.005) the risk of death. Overall, 95.2% of patients achieved mandibular preservation. However, gastrostomy and tracheostomy dependence occurred in 1% and 0.3% of cases, respectively. CONCLUSIONS For a patient population with a significant percentage of tobacco-associated oropharyngeal cancer (OPC), transoral surgery was associated with long-term minimal postoperative complications and a high rate of local control. MSPC was the main cause of death during the first 10 postoperative years. Such long-term figures support transoral surgery as an effective first-line treatment for early-stage predominantly tobacco-related OPC. LEVEL OF EVIDENCE 4 Laryngoscope, 2024.
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Affiliation(s)
- Ollivier Laccourreye
- Université Paris Cité, Service d'Otorhinolaryngologie et de Chirurgie Cervico-Faciale, HEGP, AP-HP, Paris, France
| | - Dominique Garcia
- Université Paris Cité, Service d'Otorhinolaryngologie et de Chirurgie Cervico-Faciale, HEGP, AP-HP, Paris, France
| | - Arifeen Rahman
- Division of Head & Neck Surgery, Department of Otolaryngology, Stanford University, Palo Alto, California, U.S.A
| | - F C Holsinger
- Division of Head & Neck Surgery, Department of Otolaryngology, Stanford University, Palo Alto, California, U.S.A
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Maza G, Sharma A. Topical Hemostatic Agents and Risk of Postoperative Hemorrhage After Transoral Robotic Surgery. EAR, NOSE & THROAT JOURNAL 2024:1455613241233097. [PMID: 38380626 DOI: 10.1177/01455613241233097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Objective: Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS). The available research literature on topical hemostatic agents is deficient, despite their wide use. This study aims to evaluate the frequency and severity of hemorrhagic events after TORS procedures, performed with various topical hemostatic agents. Methods: This study was planned as a retrospective review to identify postoperative hemorrhage events in a database of all consecutive adult patients who required TORS from January 1, 2015, to April 1, 2020. All procedures were performed in one single institution by the same surgeon. In 2017, bovine gelatin matrix with thrombin (BgMT) was replaced by the porcine gelatin matrix with thrombin (PgMT) for all procedures. Postoperative hemorrhage was identified, along with hemostatic agents employed and other variables. Results: A cohort of 80 TORS procedures was obtained from a population of 78 individuals (60 males:18 females). BgMT was used in 28 procedures (35%), and five cases of postoperative hemorrhage were identified (17.8%), two of them were severe. PgMT was used in 52 procedures (65%) just observing one minor hemorrhagic event (1.92%). Although a significant difference was observed for total events between groups (P = .0183), there was no difference between major or severe hemorrhagic events (P = .1196). The overall rate of major and severe postoperative hemorrhage in the study population was 2.5% (n = 80). Conclusions: This is the first study to evaluate topical hemostatic agents during TORS procedures. The PgMT group had a reduced incidence of total postoperative hemorrhages, although there was no difference in the number of severe hemorrhagic events. The overall simplicity and cost-effectiveness of these agents would support their use, particularly considering the potential risk associated with airway hemorrhage.
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Affiliation(s)
- Guillermo Maza
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Arun Sharma
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
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Cannavicci A, Cioccoloni E, Moretti F, Cammaroto G, Iannella G, De Vito A, Sgarzani R, Gessaroli M, Ciorba A, Bianchini C, Corazzi V, Capaccio P, Vicini C, Meccariello G. Single centre analysis of perioperative complications in trans-oral robotic surgery for oropharyngeal carcinomas. Indian J Otolaryngol Head Neck Surg 2023; 75:842-847. [PMID: 37275059 PMCID: PMC10235366 DOI: 10.1007/s12070-023-03518-6] [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: 12/01/2022] [Accepted: 01/19/2023] [Indexed: 02/07/2023] Open
Abstract
Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was conducted to show the rates of peri-operative complications after TORS for OPSCC in our experience. Single centre retrospective analysis of consecutive OPSCC treated with TORS. The surgical complication severity was recorded according to Clavien-Dindo criteria (CDC). Eighty-seven OPSCC were operated with TORS. According to CDC, grade I, grade II and IIIb were registered in 8%, 4.6% and 11.5% of cases, respectively. The postoperative pain, registered with visual-analogue scale (VAS) score, was 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions (p < 0.01). The impact on swallowing function was not significant between secondary healing and flap reconstructions(p = 0.96). Any major or life-threatening intraoperative complications have not been recorded. Only one patient had postoperative bleeding into the neck whilst 13.3% of patients had postoperative bleeding from the primary tumor. No total local or free flap failure were registered. The mean duration of tracheostomy use was 7.4 ± 2.6 days, and nasogastric tube 14.3 ± 6.9 days. Only one patient, who had also reconstruction with flap, experienced a postoperative severe dysphagia with severe aspiration, needing a permanent tracheostomy tube and percutaneous endoscopic gastrostomy feeding. TORS for OPSCC showed less morbidity, lower risk of severe complication and mortality. Thus, this treatment modality could be offered as first line treatment in selected cases.
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Affiliation(s)
- Angelo Cannavicci
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
| | - Eleonora Cioccoloni
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
| | | | - Giovanni Cammaroto
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
| | | | - Andrea De Vito
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Santa Maria Delle Croci Hospital, Azienda USL Della Romagna, Ravenna, Italy
| | - Rossella Sgarzani
- Burn Unit, Department of Surgery, Bufalini Hospital, Azienda USL Della Romagna, Cesena, Italy
| | - Manlio Gessaroli
- Maxillo-Facial Surgery Unit, Department of Surgery, Bufalini Hospital, Azienda USL Della Romagna, Cesena, Italy
| | - Andrea Ciorba
- Otolaryngology Unit, University of Ferrara, Ferrara, Italy
| | | | | | - Pasquale Capaccio
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Claudio Vicini
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
- Otolaryngology Unit, University of Ferrara, Ferrara, Italy
| | - Giuseppe Meccariello
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Azienda USL Della Romagna, Viale Forlanini 34, 47100 Forlì, Italy
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Hussain T. Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery. Laryngorhinootologie 2022; 101:S160-S185. [PMID: 35605618 DOI: 10.1055/a-1647-8650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.
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Affiliation(s)
- Timon Hussain
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen
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Young A, Bigcas JL, Yang A, Reeve N, Kim Y, Wang RC. Transoral robotic submandibular gland transposition to reconstruct radical tonsillar resection defects. Head Neck 2021; 43:1695-1698. [PMID: 33506547 DOI: 10.1002/hed.26622] [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: 08/13/2020] [Revised: 12/30/2020] [Accepted: 01/15/2021] [Indexed: 11/08/2022] Open
Abstract
Significant dysphagia, pain, and risk of bleeding occur after transoral robotic surgery (TORS) radical tonsillectomy. We present a novel surgical technique utilizing robotically assisted submandibular gland transposition (SMGT) to reconstruct the radical tonsillar defect. A 48-year-old male with p16+ tonsillar squamous cell carcinoma underwent deep TORS radical tonsillectomy, contralateral tonsillectomy, ipsilateral neck dissection, and TORS-assisted reconstruction of the radical defect with ipsilateral SMGT. Postoperatively, the patient experienced minimal pain and was discharged on postoperative day (POD) 3 tolerating a soft diet. There were no episodes of postoperative bleeding. This procedure was performed in five other cases as well. Transoral robotic SMGT can be used successfully to repair deep TORS radical tonsillectomy defects and may theoretically reduce dysphagia, pain, and the risk of hemorrhage.
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Affiliation(s)
- Allen Young
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Jo-Lawrence Bigcas
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Albert Yang
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Nathaniel Reeve
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Yuna Kim
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Robert C Wang
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA
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Sethi RK, Chen MM, Malloy KM. Complications of Transoral Robotic Surgery. Otolaryngol Clin North Am 2020; 53:1109-1115. [DOI: 10.1016/j.otc.2020.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Sharbel DD, Abkemeier M, Sullivan J, Zimmerman Z, Albergotti WG, Duvvuri U, Byrd JK. Transcervical arterial ligation for prevention of postoperative hemorrhage in transoral oropharyngectomy: Systematic review and meta-analysis. Head Neck 2020; 43:334-344. [PMID: 32974970 DOI: 10.1002/hed.26480] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/23/2020] [Accepted: 09/11/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Transcervical arterial ligation has been studied as a useful procedure to prevent bleeding events after transoral robotic surgery (TORS). METHODS A systematic review of English-language literature on arterial ligation in TORS from 2005 to 2019 was conducted using Cochrane, PubMed, Web of Science (WoS), and ScienceDirect databases. Studies evaluating ligation and rates of postoperative hemorrhage were included. Meta-analysis of included studies was performed to assess impact of ligation on postoperative hemorrhage. RESULTS Five studies with 2008 patients were included. History of radiation (odds ratio [OR] = 2.26, P = .02) and advanced tumor stage (OR = 1.93, P = .02) were found to predispose patients to postoperative hemorrhage. Arterial ligation was protective against severe hemorrhage in the mixed primary surgical modality cohort (OR = 0.33, P = .03) and in the TORS-only subgroup (OR = 0.21, P = .02), but did not significantly impact overall odds of postoperative hemorrhage. CONCLUSION Transcervical arterial ligation offers protection against major/severe postoperative hemorrhage in patients undergoing TORS. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Daniel D Sharbel
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Mary Abkemeier
- Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - James Sullivan
- Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Zach Zimmerman
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - William G Albergotti
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Umamaheswar Duvvuri
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James Kenneth Byrd
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
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Parhar HS, Brody RM, Shimunov D, Rajasekaran K, Rassekh CH, Basu D, O'Malley BW, Chalian AA, Newman JG, Loevner L, Lazor JW, Weinstein GS, Cannady SB. Retropharyngeal Internal Carotid Artery Management in TORS Using Microvascular Reconstruction. Laryngoscope 2020; 131:E821-E827. [PMID: 32621638 DOI: 10.1002/lary.28876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/16/2020] [Accepted: 05/27/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Guidelines for transoral robotic surgery (TORS) have generally regarded patients with retropharyngeal carotid arteries as contraindicated for surgery due to a theoretical risk of intraoperative vascular injury and/or perioperative cerebrovascular accident. We aimed to demonstrate that careful TORS-assisted resection and free flap coverage could not only avoid intraoperative injury and provide a physical barrier for vessel coverage but also achieve adequate margin control. STUDY DESIGN Retrospective cohort analysis. METHODS Retrospective review of patients with oropharyngeal malignancies and radiologically confirmed retropharyngeal carotid arteries who underwent TORS, concurrent neck dissection, and free flap reconstruction between 2015 and 2019. RESULTS Twenty patients were included, 19 (95.0%) with tonsillar tumors and one (5.0%) with a tongue base tumor with significant tonsillar extension. Eighteen patients (90.0%) received a radial artery forearm flap, one (5.0%) an ulnar artery forearm flap, and one (5.0%) an anteromedial thigh flap. All 20 (100%) flaps were inset through combined transcervical and transoral approaches without mandibulotomy. There were no perioperative mortalities, carotid injuries, oropharyngeal bleeds, cervical hematomas, or cerebrovascular accidents. One patient (5.0%) had a free flap failure requiring explant. All patients underwent decannulation and resumed a full oral diet. The mean length of hospitalization was 6.8 (standard deviation 1.2) days. One (5.0%) patient had a positive margin. CONCLUSION In this analysis, 20 patients with oropharyngeal malignancy and retropharyngeal carotid arteries underwent TORS, neck dissection, and microvascular reconstruction without serious complication (perioperative mortality, vascular injury, or neurologic sequalae) with an acceptable negative margin rate. These results may lead to a reconsideration of a commonly held contraindication to TORS. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E821-E827, 2021.
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Affiliation(s)
- Harman S Parhar
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Robert M Brody
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - David Shimunov
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Devraj Basu
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Laurie Loevner
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jillian W Lazor
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Gregory S Weinstein
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Steven B Cannady
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Janik S, Brkic FF, Grasl S, Königswieser M, Franz P, Erovic BM. Tracheostomy in bilateral neck dissection: Comparison of three tracheostomy scoring systems. Laryngoscope 2019; 130:E580-E586. [PMID: 31747469 DOI: 10.1002/lary.28413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/11/2019] [Accepted: 10/27/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To evaluate whether elective tracheostomy is justified after tumor resection and bilateral neck dissection (ND) and whether application of tracheostomy scoring systems is reliable for planning of postoperative airway management. STUDY DESIGN Retrospective cohort study. METHODS We retrospectively assessed airway management in 160 patients with head and neck squamous cell carcinomas. Additionally, we applied and analyzed the 1) Cameron, 2) TRACHY, and 3) CASST tracheostomy scoring systems on the tracheostomy recommendations. RESULTS Elective tracheostomies were performed in 51.3% of our patients, particularly in T3 to T4 tumors, cases with free flap reconstruction, and concurrent procedures. Among patients undergoing concurrent procedures, those who received tracheostomy showed significantly longer inpatient stays (27.8 ± 30.0 days vs. 13.3 ± 6.6 days; P < 0.001). Tracheostomy recommendation coincides with the performance of bilateral ND in 28.6% (CASST), 60.0% (Cameron), and 75.0% (TRACHY) of the cases, respectively. By applying corresponding criteria, tracheostomy would be recommended in 2.5% (CASST), 76.9% (Cameron), and 84.4% (TRACHY) of our cases. Bleeding episodes were the most common complication occurring in 10 patients (6.3%), but tracheostomy scores did not significantly differ between bleeders and nonbleeders. CONCLUSION Bilateral ND on its own is not a reliable predictor for elective tracheostomy. Furthermore, given the significant heterogeneity of currently available scoring systems, they prove inadequate for decision making and predictive modeling of tracheostomy placement. LEVEL OF EVIDENCE 4 Laryngoscope, 130:E580-E586, 2020.
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Affiliation(s)
- Stefan Janik
- Department of Otolaryngology, Head and Neck Surgery, Medical University Vienna, Austria
| | - Faris F Brkic
- Department of Otolaryngology, Head and Neck Surgery, Medical University Vienna, Austria
| | - Stefan Grasl
- Department of Otolaryngology, Head and Neck Surgery, Medical University Vienna, Austria
| | - Meinhard Königswieser
- Department of Otorhinolaryngology, Tertiary Teaching Hospital Rudolfstiftung, Vienna, Austria
| | - Peter Franz
- Department of Otorhinolaryngology, Tertiary Teaching Hospital Rudolfstiftung, Vienna, Austria
| | - Boban M Erovic
- Institute of Head and Neck Diseases, Evangelical Hospital Vienna, Vienna, Austria
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Parhar HS, Gausden E, Patel J, Prisman E, Anderson DW, Durham JS, Rush B. Analysis of readmissions after transoral robotic surgery for oropharyngeal squamous cell carcinoma. Head Neck 2018; 40:2416-2423. [PMID: 30102813 DOI: 10.1002/hed.25362] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 03/03/2018] [Accepted: 05/16/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND As transoral robotic surgery (TORS) is being increasingly used to treat patients with oropharyngeal squamous cell carcinoma (OPSCC), there is an interest in determining contributors to readmission. METHODS We conducted this retrospective multivariate analysis modeling 30-day readmission using the Nationwide Readmissions Database (2012-2014). RESULTS Of 950 patients, 117 (12.3%) were readmitted. Hemorrhage and diet/aspiration accounted for 32.5% and 19.7% of readmissions, respectively. Of those readmitted, 23.1% required operative bleeding control, 11.1% required transfusion, 1.7% required tracheostomy, and 18.8% required gastrostomies. Those readmitted were older (mean 63.2 years, SD 9.5 vs 60.9 mean years, SD 10.3) and had longer hospitalizations (mean 5.7 days, SD 6.8 vs mean 4.3 days, SD 4.1) and higher rates of aspiration/pneumonia (9.4% vs 2.4%, P < .01) on index admission. Multivariate analysis demonstrated that aspiration/pneumonia on index admission was independently associated with readmission (OR 3.128, 95% CI 1.178-8.302). CONCLUSIONS Of the patients 12.3% were readmitted within 30 days with hemorrhage and diet complications as significant contributors.
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Affiliation(s)
- Harman S Parhar
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, Canada.,T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Elizabeth Gausden
- T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jayendrakumar Patel
- T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Eitan Prisman
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Donald W Anderson
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - J Scott Durham
- Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Barret Rush
- T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts.,Division of Critical Care Medicine, University of British Columbia, Vancouver, Canada
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Abstract
In the head and neck region, great potential is seen in robot-assisted surgery (RAS). Mainly in cancer surgery, the use of robotic systems seems to be of interest. Until today, two robotic systems (DaVinci® und FLEX®) have gained approval for clinical use in the head and neck region, and multiple other systems are currently in pre-clinical testing. Although, certain groups of patients may benefit from RAS, no unbiased randomized clinical studies are available. Until today, it was not possible to satisfactorily prove any advantage of RAS as compared to standard procedures. The limited clinical benefit and the additional financial burden seem to be the main reasons, why the comprehensive application of RAS has not been realized so far.This review article describes the large variety of clinical applications for RAS in the head and neck region. In addition, the financial and technical challenges, as well as ongoing developments of RAS are highlighted. Special focus is put on risks associated with RAS and current clinical studies. We believe, that RAS will find its way into clinical routine during the next years. Therefore, medical staff will have to increasingly face the technical, scientific and ethical features of RAS.
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Affiliation(s)
- Patrick J Schuler
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm
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14
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Determinants of re-operation for bleeding in head and neck cancer surgery. The Journal of Laryngology & Otology 2018. [PMID: 29517474 DOI: 10.1017/s0022215118000294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Post-operative bleeding in the head and neck area is potentially fatal. This 'real world' study sought to assess factors that increase the risk of re-operation for post-operative bleeding in head and neck cancer surgery. METHODS A total of 456 patients underwent surgery for head and neck cancer (591 operations). The primary endpoint was re-operation for bleeding. RESULTS The rate of re-operation for bleeding was 5 per cent of all operations. Re-operation for bleeding was an independent risk factor for 30-day mortality (odds ratio = 5.27, p = 0.014). Risk factors for re-operation because of bleeding included excessive (more than 4000 ml) fluid administration (over 24 hours) (p < 0.001), heavy alcohol consumption (p = 0.014), pre-operative oncological treatment (p = 0.017), advanced disease stage (p = 0.020) and higher tumour (T) classification (p = 0.034). Operations with more excessive bleeding (700 ml or more) were associated with an increased risk (p = 0.001) of re-operation for post-operative bleeding. Moreover, the risk of re-operation was significantly higher in patients undergoing microvascular surgery compared to those who had no oncological treatment pre-operatively (18 vs 6 per cent, p = 0.001). CONCLUSION The 30-day mortality risk increased over 5-fold in patients undergoing re-operation for bleeding.
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16
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Kishimoto Y, Sogami T, Uozumi R, Funakoshi M, Miyamoto SI, Kitamura M, Suzuki C, Muto M, Tateya I, Omori K. Complications After Endoscopic Laryngopharyngeal Surgery. Laryngoscope 2017; 128:1546-1550. [DOI: 10.1002/lary.26953] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/09/2017] [Accepted: 09/10/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Yo Kishimoto
- Department of Otolaryngology-Head and Neck Surgery
| | - Tohru Sogami
- Department of Otolaryngology-Head and Neck Surgery
| | - Ryuji Uozumi
- Department of Biomedical Statistics and Bioinformatics
| | | | - Shin-ichi Miyamoto
- Department of Gastroenterology and Hepatology; Graduate School of Medicine, Kyoto University; Kyoto Japan
| | | | | | | | | | - Koichi Omori
- Department of Otolaryngology-Head and Neck Surgery
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17
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The keys to conservative treatment of early-stage squamous cell carcinoma of the tonsillar region. Eur Ann Otorhinolaryngol Head Neck Dis 2017; 134:259-264. [DOI: 10.1016/j.anorl.2017.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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18
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Old M. Reduction of severe oropharyngeal hemorrhage following transoral robotic surgery. Oral Oncol 2017; 72:190-191. [PMID: 28669748 DOI: 10.1016/j.oraloncology.2017.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Matthew Old
- The James Cancer Hospital and Solove Research Institute, Wexner Medical Center at The Ohio State University, Department of Otolaryngology-Head and Neck Surgery, Starling Loving Hall, B217, 320 West 10th Ave, Columbus, OH 43210, United States.
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Kubik M, Mandal R, Albergotti W, Duvvuri U, Ferris RL, Kim S. Effect of transcervical arterial ligation on the severity of postoperative hemorrhage after transoral robotic surgery. Head Neck 2017; 39:1510-1515. [PMID: 28570011 DOI: 10.1002/hed.24677] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 08/19/2016] [Accepted: 11/08/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The value of transcervical arterial ligation during transoral robotic surgery (TORS) as a measure to decrease postoperative bleeding incidence or severity is unclear. METHODS A retrospective single institution study was performed to identify risk factors for hemorrhage after TORS for oropharyngeal squamous cell carcinoma (SCC). RESULTS Overall, 13.2% of patients (35/265) experience postoperative hemorrhage. T classification, perioperative use of anticoagulants, surgeon experience >50 cases, and tumor subsite were not predictors of postoperative hemorrhage. Of this cohort, 28% underwent prophylactic arterial ligation. The overall incidence of bleeding was not significantly decreased in patients who underwent arterial ligation (12.1% vs 13.6%; p = .84). However, arterial ligation significantly reduced the incidence of major and severe bleeding events (1.3% vs 7.8%; p = .04). Radiation before TORS was a risk factor for major and severe postoperative hemorrhage (p < .02). CONCLUSION Transcervical arterial ligation during TORS may reduce the severity of postoperative hemorrhagic events. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1510-1515, 2017.
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Affiliation(s)
- Mark Kubik
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rajarsi Mandal
- Department of Surgery, Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William Albergotti
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Seungwon Kim
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Zenga J, Suko J, Kallogjeri D, Pipkorn P, Nussenbaum B, Jackson RS. Postoperative hemorrhage and hospital revisit after transoral robotic surgery. Laryngoscope 2017; 127:2287-2292. [PMID: 28425577 DOI: 10.1002/lary.26626] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/16/2017] [Accepted: 03/21/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate the incidence and complications related to postoperative hemorrhage (POH) after transoral robotic surgery (TORS). STUDY DESIGN Retrospective review of the State Inpatient Database (SID), the State Ambulatory Surgery Database (SASD), and the State Emergency Department Database (SEDD) from the Healthcare Cost and Utilization Project. METHODS Patients were identified from the SID, SASD, and SEDD for the states of Florida, New York, and California from 2005 to 2013 who had an International Classification of Diseases, Ninth Edition code for a surgical procedure on the upper aerodigestive tract associated with a code for robotic-assisted surgery. Univariate logistic regression was used to explore factors associated with POH. RESULTS Five hundred nine patients underwent TORS. Indications for surgery included neoplastic disease in 376 (74%) and sleep apnea in 74 (15%). Forty-one (8%) had an episode of POH at a median of 9 days postoperatively (range = 0-21 days). Twenty-four (5%) required an intervention related to their POH. Sixteen (3%) required return to the operating room for control of hemorrhage; 11 (2%) had a severe complication that required embolization or tracheostomy. Charlson Comorbidity Score of ≥3 (odds ratio [OR] = 3.02, 95% confidence interval [CI] = 1.45-6.30) and a tonsillar neoplasm (OR = 1.96, 95% CI = 1.03-3.74) were significantly associated with POH. CONCLUSIONS The incidence of POH after TORS was low, and few of these patients had a severe complication related to this event. Medical comorbidity and tonsillar subsite may be independent risk factors for POH. These data provide a benchmark for informed decision making in TORS and a basis for further study. LEVEL OF EVIDENCE 4. Laryngoscope, 127:2287-2292, 2017.
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Affiliation(s)
- Joseph Zenga
- Department of Otolaryngology-Head and Neck Surgery, Washington University, Saint Louis, Missouri, U.S.A
| | - Jasmina Suko
- Department of Otolaryngology-Head and Neck Surgery, Washington University, Saint Louis, Missouri, U.S.A
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University, Saint Louis, Missouri, U.S.A
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University, Saint Louis, Missouri, U.S.A
| | - Brian Nussenbaum
- Department of Otolaryngology-Head and Neck Surgery, Washington University, Saint Louis, Missouri, U.S.A
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University, Saint Louis, Missouri, U.S.A
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