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Heft Neal ME, Haring CT, Bellile E, Jaffe CC, Shuman AG, Chinn SB, Stucken CL, Malloy KM, Casper KA, Prince MEP, Chepeha DB, Rosko AJ, Spector ME. Phase II Clinical Trial of Intravenous Levothyroxine to Mitigate Pharyngocutaneous Fistula in Euthyroid Patients Undergoing Salvage Laryngectomy. Clin Cancer Res 2024; 30:2910-2916. [PMID: 38723280 DOI: 10.1158/1078-0432.ccr-24-0782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/01/2024] [Accepted: 05/07/2024] [Indexed: 07/16/2024]
Abstract
PURPOSE Patients undergoing head and neck cancer surgery after prior radiation or chemoradiation are at high risk for wound complications. Hypothyroidism is a known risk factor for wound complications, especially fistulae after salvage total laryngectomy. The purpose of this phase II clinical trial is to investigate the effect of perioperative intravenous levothyroxine supplementation on wound complications in patients undergoing salvage total laryngectomy. PATIENTS AND METHODS Euthyroid patients previously treated with radiation/chemoradiation undergoing total laryngectomy were prospectively recruited (n = 72). Postoperatively, intravenous levothyroxine was administered at a weight-based dose (1.3 mcg/kg/d) and transitioned to enteral dosing on day 7. Free T3, T4, and thyroid-stimulating hormones were collected, and dosing was adjusted accordingly. The primary endpoints were rates of fistula formation and fistula requiring reoperation, compared with matched historic controls. All patients were monitored for adverse effects. RESULTS The rate of postoperative hypothyroidism was 21% compared with 49% in a matched historic cohort. The rate of fistula formation was 18.1%, whereas the rate of fistula requiring reoperation was 4.2%, significantly lower than rates in our historic cohort (34.6% and 14.8%, respectively; P = 0.02 and 0.01). Postoperative hypothyroidism and recurrent clinical stage predicted fistula requiring reoperation in multivariate analysis; other acute phase reactants were not predictive. There were no observed adverse events related to levothyroxine supplementation. CONCLUSIONS Postoperative intravenous levothyroxine supplementation reduced rates of acute hypothyroidism, fistula formation, and fistula requiring reoperation in patients undergoing salvage total laryngectomy without adverse effects. Intravenous levothyroxine is a viable strategy to reduce wound complications in this high-risk patient population.
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Affiliation(s)
- Molly E Heft Neal
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Catherine T Haring
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio
| | - Emily Bellile
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Craig C Jaffe
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark E P Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Douglas B Chepeha
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- University of Toledo Medical Center, ProMedica Physicians Ear, Nose and Throat, Sylvania, Ohio
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Waqar U, Tariq J, Chaudhry AA, Iftikhar H, Zafar H, Abbas SA. A Comprehensive Assessment of Blood Transfusions in Elective Thyroidectomy Based on 180,483 Patients. Laryngoscope 2022; 132:2078-2084. [DOI: 10.1002/lary.30098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/12/2022] [Accepted: 02/23/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Usama Waqar
- Medical College Aga Khan University Karachi Pakistan
| | - Javeria Tariq
- Medical College Aga Khan University Karachi Pakistan
| | | | - Haissan Iftikhar
- Department of Otolaryngology University Hospitals Birmingham United Kingdom
| | - Hasnain Zafar
- Patient Safety & Quality Office, Section of General Surgery, Department of Surgery Aga Khan University Hospital Karachi Pakistan
| | - Syed Akbar Abbas
- Section of Otolaryngology, Head and Neck Surgery, Department of Surgery Aga Khan University Hospital Karachi Pakistan
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Goshtasbi K, Abiri A, Lehrich BM, Abouzari M, Lin HW, Djalilian HR, Hsu FPK, Kuan EC. Association between modified frailty index and surgical outcomes in intradural skull base surgery. J Clin Neurosci 2021; 91:255-259. [PMID: 34373037 DOI: 10.1016/j.jocn.2021.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 06/22/2021] [Accepted: 07/18/2021] [Indexed: 12/21/2022]
Abstract
The objective of this study is to evaluate the impact of preoperative frailty on short-term outcomes following intradural resection of skull base lesions. The 2005-2017 ACS-NSQIP database was queried for 30-day post-operative outcomes of patients undergoing intradural resection of the skull base, extracted by CPT codes 61601, 61606, 61608, and 61616. Five-item modified frailty index (mFI) was calculated based on the history of diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, chronic hypertension, and functional status. A total of 701 patients (58.8% female, 72.0% white) were included with a mean age of 51.8 ± 14.7 years. Compared to patients with mFI = 0 (n = 403), patients with mFI ≥ 1 (n = 298) were more likely to have higher rates of reoperation (13.4% vs. 8.7%, p = 0.045), medical complications (20.5% vs. 9.2%, p < 0.001), surgical complications (13.8% vs. 8.4%, p = 0.024), discharge to non-home facility (DNHF) (24.8% vs. 13.3%, p < 0.001), and prolonged length of hospitalization (7.3 ± 6.8 days vs. 5.6 ± 5.0, p = 0.003). Moreover, mFI = 1-3 was also associated with higher BMI, non-white race, high ASA, and older age (all p < 0.05). Upon adjusting for age, BMI, race, ASA score, and surgical site, multivariate regression analysis demonstrated that higher mFI (treated as a continuous variable) was associated with higher odds of medical complications (OR = 1.630, CI = 1.153-2.308, p = 0.006), surgical complications (OR = 1.594, CI = 1.042-2.438, p < 0.031), and LOS ≥ 10 days (OR = 1.609, CI = 1.176-2.208, p = 0.003). In conclusion, the 5-item mFI can be an independent predictor of several important short-term surgical outcomes following intradural resection of skull base lesions, warranting further investigations into its clinical utility.
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Affiliation(s)
- Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Brandon M Lehrich
- Medical Scientist Training Program, University of Pittsburgh and Carnegie Mellon University, Pittsburgh, PA, USA
| | - Mehdi Abouzari
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Harrison W Lin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Hamid R Djalilian
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA; Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA.
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Burton BN, Okwuegbuna O, Jafari A, Califano J, Brumund KT, Gabriel RA. Association of Preoperative Anemia With 30-Day Morbidity and Mortality Among Patients With Thyroid Cancer Who Undergo Thyroidectomy. JAMA Otolaryngol Head Neck Surg 2020; 145:124-131. [PMID: 30489623 DOI: 10.1001/jamaoto.2018.3099] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Despite the ease of preoperative anemia diagnosis and the availability of treatment options, the morbidity and mortality associated with this condition remain unacceptably high, and the literature describing the association of preoperative anemia with postoperative outcomes following thyroid surgery in patients with thyroid cancer remain sparse. Reporting outcomes in this patient population may help to facilitate preoperative optimization. Objective To assess whether an association exists between preoperative anemia and outcomes following thyroid surgery in patients with thyroid cancer. Design, Setting, and Participants This retrospective, cross-sectional, cohort study used the American College of Surgeons National Surgical Quality Improvement Program database to identify 32 166 patients between 2007 and 2016 with Current Procedural Terminology codes for thyroid surgery and with the International Classification of Diseases, Ninth Revision code of malignant thyroid cancer. Exposures Preoperative anemia as defined using the World Health Organization criteria of hematocrit less than 36% in nonpregnant females and less than 39% in males. Main Outcomes and Measures Multivariable logistic regression analysis was conducted to assess the association of preoperative anemia with the following 30-day postoperative outcomes: pulmonary, infectious, and cardiac complications, overall and serious morbidity (surgical site infection and medical complications), prolonged hospital length of stay (≥75th percentile for the cohort), and mortality. Results Among the 24 912 patients with thyroid cancer who underwent thyroidectomy included in the final analysis, the median (interquartile range) age was 51 (40-62) years and the majority were women (18 705 [75.1%]). The prevalence of preoperative anemia was 12.5% (n = 3108). Within the overall study population, hypertension (9242 patients [37.1%]) followed by active smoking (2992 patients [12.0%]) were the most prevalent comorbidities. The unadjusted odds of anemia vs no anemia were significantly higher for every 10-year increase in age (odds ratio [OR], 1.10; 95% CI, 1.08-1.13) and for black vs white patients (OR, 2.82; 95% CI, 2.51-3.17). The adjusted odds of postoperative overall morbidity (OR, 1.68; 95% CI, 1.29-2.17), mortality (OR, 3.36; 95% CI, 1.37-8.28), and pulmonary (OR, 2.36; 95% CI, 1.65-3.34) and infectious (OR, 1.62; 95% CI, 1.12-2.29) complications were higher in patients with preoperative anemia than in those without preoperative anemia. Conclusions and Relevance The findings from this study suggest that preoperative anemia may not only be associated with racial differences and a higher comorbidity burden but may also increase the likelihood of postoperative morbidity and mortality. These results may provide a basis for further risk reduction strategies and preoperative optimization.
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Affiliation(s)
| | | | - Aria Jafari
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, La Jolla
| | - Joseph Califano
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, La Jolla.,Moores Cancer Center, University of California San Diego Health, La Jolla
| | - Kevin T Brumund
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, La Jolla.,Moores Cancer Center, University of California San Diego Health, La Jolla
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, La Jolla.,Division of Biomedical Informatics, University of California, San Diego, La Jolla
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Povolotskiy R, Cerasiello SY, Siddiqui SH, Baredes S, Eloy JA, Hsueh WD. Anemia and blood transfusion requirements in endoscopic sinus surgery: A propensity-matched analysis. Laryngoscope 2019; 130:1377-1382. [PMID: 31418868 DOI: 10.1002/lary.28228] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/15/2019] [Accepted: 07/22/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Massive bleeding requiring blood transfusion is a feared complication of endoscopic sinus surgery (ESS). In an effort to improve healthcare quality and outcomes, research is focused on identifying the risk factors for complications following surgical procedures. Blood transfusions have been linked to increased complication rates, but their role has not been extensively studied in ESS. METHODS The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) participant user files 2005 to 2014 were queried for all cases of ESS. Patients were divided into cohorts based on anemia (hematocrit <39.00 in men and <36.00 in women) and hematocrit levels. Univariate analyses and a propensity score-matching algorithm were employed. RESULTS Of 630 cases of ESS, 117 (18.6%) had preexisting anemia. Anemic patients were more likely to be black (19.8% vs. 6.7%, P ≤ 0.001), undergo longer operation times (117.50 minutes ±155.73 vs. 129.85 minutes ±36.03, P = 0.005), have diabetes (28.2% vs. 10.9%, P ≤ 0.001), and have hypertension (46.2% vs. 33.1%, P = 0.010). Following propensity score matching, 109 cases were selected for each cohort, with no significant differences in demographics, comorbidities, operation time, or outpatient status. The anemic cohort was independently associated with an increase in overall postoperative complications (17.4% vs. 7.3%, P = 0.038). Transfusion use was significantly associated with preoperative hematocrit levels <30 (30.0% vs. 4.5%, P = 0.001) and between 30 and 34.99 (13.9% vs. 2.5%, P = 0.011). CONCLUSION Preoperative anemia is a significant predictor of overall complications and bleeding requiring transfusion for patients undergoing ESS. These results highlight the need for careful preoperative assessment and management of anemia in this population. LEVEL OF EVIDENCE NA Laryngoscope, 130:1377-1382, 2020.
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Affiliation(s)
- Roman Povolotskiy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Samantha Y Cerasiello
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Sana H Siddiqui
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Wayne D Hsueh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
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Hoesli R, Brennan JR, Rosko AJ, Birkeland AC, Malloy KM, Moyer JS, Prince MEP, Shuman AG, Chinn SB, Stucken CL, Casper KA, Spector ME. Intraoperative Fluorescent Angiography Predicts Pharyngocutaneous Fistula After Salvage Laryngectomy. Ann Surg Oncol 2019; 26:1320-1325. [PMID: 30805812 DOI: 10.1245/s10434-019-07262-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Technology to assess tissue perfusion is exciting with translational potential, although data supporting its clinical applications have been lagging. Patients who have undergone radiation are at particular risk of poor tissue perfusion and would benefit from this expanding technology. We designed a prospective clinical trial using intraoperative indocyanine green angiography to evaluate for wound-healing complications in patients undergoing salvage laryngectomy after radiation failure. PATIENTS AND METHODS This prospective trial included patients undergoing salvage laryngectomy at a National Cancer Institute-designated tertiary cancer center between 2016 and 2018. After tumor extirpation and prior to reconstruction, 10 mg indocyanine green dye was infused and the fluorescence (FHYPO) and ingress rate of the pharyngeal mucosa recorded. The primary outcome measure was formation of a pharyngocutaneous fistula (PCF). RESULTS Patients who developed a PCF had significantly lower FHYPO (87 vs 172, p < 0.001) and ingress rates (6.7 vs 15.8, p = 0.043) compared with those who did not develop a fistula. There were no fistulas in patients with FHYPO > 150 (n = 21) or ingress > 15 (n = 15). There was a 50% fistula rate in patients with FHYPO ≤ 103 (n = 10) and ingress rate ≤ 6 (n = 6). CONCLUSIONS Intraoperative indocyanine green angiography can assess hypoperfusion in patients and predict risk of PCFs after salvage laryngectomy, and can thus intraoperatively risk-stratify patients for postoperative wound-healing complications.
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Affiliation(s)
- Rebecca Hoesli
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Julia R Brennan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Andrew C Birkeland
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Jeffrey S Moyer
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Mark E P Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA.
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Salvage laryngectomy and laryngopharyngectomy: Multicenter review of outcomes associated with a reconstructive approach. Head Neck 2018; 41:16-29. [DOI: 10.1002/hed.25192] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 01/03/2018] [Accepted: 03/02/2018] [Indexed: 11/08/2022] Open
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Karsten RT, Timmermans AJ, ten Cate J, Stuiver MM, van den Brekel MWM. Direct complications and routine ICU admission after total laryngectomy. Acta Otolaryngol 2018; 138:1128-1135. [PMID: 30686089 DOI: 10.1080/00016489.2018.1515497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND In the Netherlands Cancer Institute (NCI), patients are admitted to the Intensive Care Unit (ICU) after total laryngectomy (TL). AIMS/OBJECTIVES To assess direct complications and the need for ICU admission after TL. MATERIAL AND METHODS Patients who underwent a TL in the NCI were reviewed on the occurrence of an event requiring ICU treatment within the first 24 hours postoperatively. The predictive value of predetermined risk factors was assessed with multivariable logistic analysis. The optimal threshold of the risk score assigned by the resulting model was determined. RESULTS An event occurred in 25 of the 113 patients (22%) of which 72% included norepinephrine dependence. Risk analysis showed that patients with either CRT prior to TL or a procedure including pharynx reconstruction, or both, should be indicated for ICU stay. Applying the rule on this cohort, 57 patients (50%) would have been sent to the ward postoperatively of which seven (12%) developed an event requiring ICU treatment. CONCLUSIONS A substantial proportion of the patients developed an event within the first 24 hours after TL. Our risk stratification of patients based on the mentioned risk factors is insufficiently accurate. SIGNIFICANCE The study provides an overview of direct postoperative complications after TL.
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Affiliation(s)
- Rebecca Tosca Karsten
- Department of Head and Neck Surgery, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
| | | | - Julia ten Cate
- Department of Head and Neck Surgery, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
| | - Martijn Matthias Stuiver
- Department of Head and Neck Surgery, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
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Fang M, Hume E, Ibrahim S. Race, Bundled Payment Policy, and Discharge Destination After TKA: The Experience of an Urban Academic Hospital. Geriatr Orthop Surg Rehabil 2018; 9:2151459318803222. [PMID: 30370172 PMCID: PMC6201172 DOI: 10.1177/2151459318803222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/22/2018] [Accepted: 09/04/2018] [Indexed: 12/29/2022] Open
Abstract
Background Total knee arthroplasty (TKA) provides good clinical outcomes for the treatment of end-stage osteoarthritis; however, discharge destination after TKA has major implications on postoperative adverse outcomes and readmissions. With the initiation of Bundled Payments for Care Improvement (BPCI), it is unclear how racial disparities in discharge destination after TKA will be affected by the new bundled payment for TKA. Methods Bundled Payments for Care Improvement was implemented in July 01, 2014, at the University of Pennsylvania. We compared differences during early implementation (July 1, 2014, to, March 30, 2016) and during late policy implementation (April 1, 2016, to February 28, 2017) in patient characteristics (including race: African American [AA], white, and other race), discharge destination (skilled nursing facility [SNF], inpatient rehabilitation facility, home, home with home health, or other), and outcomes. Results We identified 2276 patients who underwent TKA (43.8% AA, 48.2% white, and 8.0% other race). African American patients were more likely to be discharged to SNF as opposed to home than white patients both during the early BPCI (AA: 53.0%, n = 320; white: 32.4%, n = 210, P < .05) and late BPCI implementation (AA: 44.4%, n = 169, white: 26.9%, n = 120, P < .05), though all races showed trends to decreasing SNF use during the late BPCI implementation. Discussion There were no significant differences in readmissions, length of stay, mortality, or intensive care unit days during early and late implementation of BPCI or when AA patients were compared to white patients. Conclusion We found no significant changes in racial variations in discharge destination and outcomes after elective TKA. Bundled Payments for Care Improvement has encouraged better preoperative preparation of patients and discharge planning; however, payment reforms alone might not be sufficient to address variation in post-op management following elective surgery.
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Affiliation(s)
- Michele Fang
- Division of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric Hume
- Division of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Said Ibrahim
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
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Helman SN, Brant JA, Kadakia SK, Newman JG, Cannady SB, Chai RL. Factors associated with complications in total laryngectomy without microvascular reconstruction. Head Neck 2018; 40:2409-2415. [PMID: 30307661 DOI: 10.1002/hed.25363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/15/2018] [Accepted: 05/16/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is little population-level data evaluating risk factors for postoperative complications after total laryngectomy. METHODS We conducted a retrospective review of the American College of Surgeons National Quality Improvement Program identifying patients who underwent total laryngectomy as a primary procedure from 2005 to 2014. Multivariate analysis was performed to identify variables that were independently associated with overall and major complications. RESULTS Eight hundred seventy-one cases met inclusion criteria. Three hundred twenty-eight patients (37.7%) had complications, with operative time (hours; P < .0001), class III (P < .001) wound status, and patient age (decade; P = .003) associated with overall complications. Two hundred one patients had major complications that were associated with steroid use (P = .01) and class III (P = .0083) wound classification. Preoperative hematocrit was correlated with a reduction of all and major complications on multivariate analysis (P < .0001 and P = .036). CONCLUSION Identifying and optimizing risk factors may improve outcomes in total laryngectomy.
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Affiliation(s)
- Samuel N Helman
- Department of Otolaryngology - Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Jason A Brant
- Department of Otolaryngology - Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sameep K Kadakia
- Department of Otolaryngology - Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Jason G Newman
- Department of Otolaryngology - Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven B Cannady
- Department of Otolaryngology - Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raymond L Chai
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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11
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Gallo O, Locatello LG, Larotonda G, Napoleone V, Cannavicci A. Nomograms for prediction of postoperative complications in open partial laryngeal surgery. J Surg Oncol 2018; 118:1050-1057. [DOI: 10.1002/jso.25232] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 08/20/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Oreste Gallo
- Department of Surgery and Translational Medicine; Division of Otolaryngology, University of Florence; Firenze Italy
| | - Luca Giovanni Locatello
- Department of Surgery and Translational Medicine; Division of Otolaryngology, University of Florence; Firenze Italy
| | - Guglielmo Larotonda
- Department of Surgery and Translational Medicine; Division of Otolaryngology, University of Florence; Firenze Italy
| | - Vincenzo Napoleone
- Biodigita - Biostatistical Analysis Section, Gorgia Study Institute; Firenze Italy
| | - Angelo Cannavicci
- Department of Surgery and Translational Medicine; Division of Otolaryngology, University of Florence; Firenze Italy
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12
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Rosko AJ, Birkeland AC, Bellile E, Kovatch KJ, Miller AL, Jaffe CC, Shuman AG, Chinn SB, Stucken CL, Malloy KM, Moyer JS, Casper KA, Prince MEP, Bradford CR, Wolf GT, Chepeha DB, Spector ME. Hypothyroidism and Wound Healing After Salvage Laryngectomy. Ann Surg Oncol 2017; 25:1288-1295. [PMID: 29264671 DOI: 10.1245/s10434-017-6278-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients undergoing salvage laryngectomy are predisposed to radiation-induced hypothyroidism and impaired wound healing secondary to the tissue effects of prior treatment. The impact of hypothyroidism on postoperative wound healing is not established. METHODS A single-institution retrospective case series was performed. The inclusion criteria specified preoperatively euthyroid adults who underwent salvage laryngectomy with concurrent neck dissection between 1997 and 2015 for persistent or recurrent laryngeal squamous cell carcinoma after radiation or chemoradiation therapy (n = 182). The principal explanatory variable was postoperative hypothyroidism, defined as thyroid-stimulating hormone (TSH) higher than 5.5 mIU/L. The primary end points of the study were pharyngocutaneous fistulas and wounds requiring reoperation. Multivariate analysis was performed. RESULTS The fistula rate was 47% among hypothyroid patients versus 23% among euthyroid patients. In the multivariate analysis, the patients who experienced hypothyroidism in the postoperative period had a 3.6-fold greater risk of fistula [95% confidence interval (CI) 1.8-7.1; p = 0.0002]. The hypothyroid patients had an 11.4-fold greater risk for a required reoperation (24.4 vs 5.4%) than the euthyroid patients (95% CI 2.6-49.9; p = 0.001). The risk for fistula (p = 0.003) and reoperation (p = 0.001) increased with increasing TSH. This corresponds to an approximate 12.5% incremental increase in the absolute risk for fistula and a 10% increase in the absolute risk for reoperation with each doubling of the TSH. CONCLUSION Postoperative hypothyroidism independently predicts postoperative wound-healing complications. The association of hypothyroidism with fistula formation may yield opportunities to modulate wound healing with thyroid supplementation or to provide a biomarker of wound progression.
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Affiliation(s)
- Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Andrew C Birkeland
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Emily Bellile
- Department of Biostatistics, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Kevin J Kovatch
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Ashley L Miller
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Craig C Jaffe
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Jeffrey S Moyer
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Mark E P Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Carol R Bradford
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Gregory T Wolf
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA
| | - Douglas B Chepeha
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto Health System, Toronto, ON, Canada
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, MI, USA.
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13
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Wachal B, Johnson M, Burchell A, Sayles H, Rieke K, Lindau R, Lydiatt W, Panwar A. Association of Modified Frailty Index Score With Perioperative Risk for Patients Undergoing Total Laryngectomy. JAMA Otolaryngol Head Neck Surg 2017; 143:818-823. [PMID: 28594992 DOI: 10.1001/jamaoto.2017.0412] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Objective preoperative risk assessment tools, such as the Modified Frailty Index (mFI), may inform patient and physician decision making when considering total laryngectomy. Estimation of outcomes may help to set realistic expectations about recovery and outcomes and facilitate optimal resource management. Objective To evaluate the association between the mFI score as a measure of frailty and outcomes following total laryngectomy. Design, Setting, and Participants Retrospective evaluation using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a risk- and case-mix-adjusted national quality assessment program. The ACS NSQIP database identified 595 patients who underwent total laryngectomy between 2006 and 2012. Patients were assessed for demographics and comorbidity and were stratified on the basis of calculated mFI score. Outcomes, including postoperative complications, length of hospitalization, and discharge destination, were evaluated as a function of increasing frailty using multivariable logistic regression and Cox proportional hazards regression models. Main Outcomes and Measures Risk of postoperative complications, length of hospitalization, and discharge disposition. Results After exclusion of patients who experienced significant deviation from standard care protocols and those with missing or incomplete data, 343 individuals were included in the analysis. Of these, 278 (81.0%) were men, and the mean age was 63 years (95% CI, 61.9-64.4 years). Increasing frailty resulted in a nonlinear but progressive rise in incidence of postoperative adverse events. Overall, 96 (28.0%) patients experienced a postoperative complication, and patients with an mFI score of 3 or higher were more likely to develop postoperative complications than were patients with an mFI score of 0 (50.0% vs 16.7%; OR, 3.83; 95% CI, 1.72- 8.51). Patients in the highest frailty group experienced a longer mean duration of hospitalization (14.2 vs 9.5 days; difference, 4.7; 95% CI, 1.3-8.1 days) and were more likely to require skilled care after discharge (33.3% vs 3.2%; difference, 30.1%; 95% CI, 7.4%-52.9%). Conclusions and Relevance An mFI score of 3 or higher is associated with increased risk for postoperative complications, longer hospitalization, and need for postdischarge skilled care following total laryngectomy. The mFI provides a personalized risk assessment to better inform patients, physicians, and payers when planning a total laryngectomy.
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Affiliation(s)
- Brandon Wachal
- Division of Head and Neck Surgery, University of Nebraska Medical Center, Omaha
| | - Matthew Johnson
- Division of Head and Neck Surgery, University of Nebraska Medical Center, Omaha
| | - Alissa Burchell
- Medical Student, College of Medicine, University of Nebraska Medical Center, Omaha
| | - Harlan Sayles
- College of Public Health, University of Nebraska Medical Center, Omaha
| | - Katherine Rieke
- College of Public Health, University of Nebraska Medical Center, Omaha
| | - Robert Lindau
- Department of Head and Neck Surgical Oncology, Nebraska Methodist Hospital, Omaha
| | - William Lydiatt
- Department of Head and Neck Surgical Oncology, Nebraska Methodist Hospital, Omaha
| | - Aru Panwar
- Division of Head and Neck Surgery, University of Nebraska Medical Center, Omaha.,Department of Head and Neck Surgical Oncology, Nebraska Methodist Hospital, Omaha
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14
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Rosko A, Birkeland A, Shuman A, Prince M, Bradford C, Wolf G, Worden F, Eisbruch A, Srinivasan A, Wong KK, Spector ME. Positron emission tomography-CT prediction of occult nodal metastasis in recurrent laryngeal cancer. Head Neck 2017; 39:980-987. [PMID: 28236331 DOI: 10.1002/hed.24719] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 11/30/2016] [Accepted: 12/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the predictive value of positron emission tomography (PET)-CT in identifying occult nodal metastasis in clinically and radiographically N0 patients with recurrent laryngeal cancer undergoing salvage laryngectomy. METHODS Retrospective review of 46 clinically and radiographically N0 patients with recurrent laryngeal cancer who underwent a PET-CT examination before salvage laryngectomy with neck dissection from January 1, 2002, to December 31, 2014, was performed. RESULTS Two patients (16.7%) had true-positive PET-CT results, whereas 10 patients (83.3%) had false-negative scans, 1 patient (2.9%) had a false-positive result and 33 patients (97.1%) had a true-negative PET-CT. The sensitivity of PET-CT was 16.7% (95% confidence interval [CI], 3.5% to 46.0%) with a specificity of 97.1% (95% CI, 83.8% to 99.9%), positive predictive value (PPV) of 66.7% (95% CI, 20.2% to 94.4%), and negative predictive value (NPV) of 76.7% (95% CI, 62.1% to 87.0%). CONCLUSION PET-CT has poor sensitivity and NPV making PET-CT an imperfect predictor of nodal disease in recurrent laryngeal cancer. © 2017 Wiley Periodicals, Inc. Head Neck 39: 980-987, 2017.
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Affiliation(s)
- Andrew Rosko
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, Michigan
| | - Andrew Birkeland
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, Michigan
| | - Andrew Shuman
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, Michigan
| | - Mark Prince
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, Michigan
| | - Carol Bradford
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, Michigan
| | - Gregory Wolf
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, Michigan
| | - Francis Worden
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ashok Srinivasan
- Department of Radiology, Division of Neuroradiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ka Kit Wong
- Department of Radiology, Division of Nuclear Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Matthew E Spector
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health Center, Ann Arbor, Michigan
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15
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Goepfert RP, Hutcheson KA, Lewin JS, Desai NG, Zafereo ME, Hessel AC, Lewis CM, Weber RS, Gross ND. Complications, hospital length of stay, and readmission after total laryngectomy. Cancer 2016; 123:1760-1767. [PMID: 28026864 DOI: 10.1002/cncr.30483] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/11/2016] [Accepted: 11/14/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND The purpose of this study was to describe the 30-day incidence of complications after total laryngectomy (TL) in a high-volume institution and their impact on the hospital length of stay (LOS) and readmission rates. METHODS A retrospective cohort study of all patients who underwent TL at The University of Texas MD Anderson Cancer Center from January 1, 2010 through June 30, 2013 was conducted. The patient demographics, treatment history, LOS, and 30-day post-TL complications and readmissions were extracted from the medical record. Univariate associations were analyzed, and stepwise backward selection methods were used to fit multivariate models. RESULTS Two hundred forty-five patients were included. Complications occurred in 83 patients (33.9%) and included 3 deaths (1.2%). Wound complications occurred in 53 patients (21.6%), and 34 were pharyngocutaneous fistulas (PCFs; 13.9% overall). Thirty-four patients (13.9%) were readmitted within 30 days. A multivariate analysis revealed the following: wound complications were associated with former (odds ratio [OR], 5.1; P = .03) and current smokers (OR, 5.8; P = .02), PCFs were associated with prior wide-field radiation (OR, 3.1; P = .01) but not prior narrow-field (larynx-only) radiation (OR, 1.4; P = .61), LOS was associated with the type of flap (P = .002) and postoperative hematomas (P = .05), and readmissions were associated with preoperative hypoalbuminemia (P = .003) and postoperative wound complications (P < .001). CONCLUSIONS Complications occurred in approximately one-third of TL patients and particularly in patients with poor wound-healing risk factors such as prior smoking and radiation. As expected, LOS was longer among reconstructed patients. Readmission was associated with hypoalbuminemia and postoperative wound complications. These data can inform quality improvement efforts and the counseling of high-risk patients undergoing TL. Cancer 2017;123:1760-1767. © 2016 American Cancer Society.
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Affiliation(s)
- Ryan P Goepfert
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan S Lewin
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Neha G Desai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy C Hessel
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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16
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Helman SN, Brant JA, Moubayed SP, Newman JG, Cannady SB, Chai RL. Predictors of length of stay, reoperation, and readmission following total laryngectomy. Laryngoscope 2016; 127:1339-1344. [DOI: 10.1002/lary.26454] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/04/2016] [Accepted: 11/14/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Samuel N. Helman
- Department of Otolaryngology-Head and Neck Surgery; New York Eye and Ear Infirmary of Mount Sinai; New York New York
| | - Jason A. Brant
- Department of Otorhinolaryngology-Head and Neck Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Sami P. Moubayed
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Beth Israel; New York New York U.S.A
| | - Jason G. Newman
- Department of Otorhinolaryngology-Head and Neck Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Steven B. Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania
| | - Raymond L. Chai
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Beth Israel; New York New York U.S.A
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17
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Shenson JA, Craig JN, Rohde SL. Effect of Preoperative Counseling on Hospital Length of Stay and Readmissions after Total Laryngectomy. Otolaryngol Head Neck Surg 2016; 156:289-298. [DOI: 10.1177/0194599816671695] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jared A. Shenson
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Stanford, California, USA
| | - Jennifer N. Craig
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L. Rohde
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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