Use of Cervical Fascia to Prevent Pharyngocutaneus Fistula After Total Laryngectomy

OBJECTIVE

This study aimed to compare the pharyngocutaneous fistula (PCF) between patients who underwent reconstruction using cervical fascia after total laryngectomy and those who did not and to investigate the factors affecting PCF rates.

METHODS

We retrospectively compared 22 patients operated between February 2021 and March 2023 who received cervical fascia flap as the study group and 21 patients operated between January 2018 and March 2023 who did not receive fascia flap as the control group. The study included patients who underwent total laryngectomy for Stage 3 and 4 squamous cell laryngeal cancer.

RESULTS

We included 43 patients, with 22 (51.2%) and 21 patients (48.8%) in the study and control groups, respectively. The age and sex were not different between the two groups (p = 0.471, p = 0.176, respectively). The distribution of patients as per sex, smoking, alcohol use, chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, and multiple comorbidities was similar in both groups (p > 0.05). PCF was observed in one patient (4.5%) and seven patients (33.3%) in the study and control groups, respectively. The PCF rate was significantly lower in the study group (p = 0.021). When the relationship between flap use and risk factors was compared by correlation analysis, a moderate negative relationship was found between flap use and PCF (p = 0.015, r = -0.370).

CONCLUSION

The use of a cervical fascia flap is effective in reducing fistula rates after total laryngectomy. Its main advantages include being technically simpler than alternative techniques, locally available, cost-effective.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:4964-4970, 2024.

Improving Head and Neck Microvascular Reconstructive Care with a Novel Perioperative Checklist

OBJECTIVE/HYPOTHESIS

To appraise the utility of a novel EMR-based checklist for complex head and neck microvascular free-tissue reconstruction.

STUDY DESIGN

A prospectively collected retrospective matched cohort study from a single tertiary care academic institution.

METHODS

A retrospective matched cohort study from an academic tertiary care center with 76 total patients analyzed for disease-specific and quality outcomes before and after implementation of an EMR-based checklist tailored to complex head and neck care. The intervention group consisted of 38 consecutive patients undergoing microvascular free tissue reconstruction after implementation of the EMR-based checklist strategy. A historic cohort of 38 patients was derived by matching patients meticulously for disease-specific and surgical characteristics. Primary outcomes included post-operative medical and surgical complications, intensive care requirements, 30-day reoperation rates, hospital length of stay, and completion of preoperative metastatic evaluations. Secondary outcomes included patterns of antibiotic administration, ultimate discharge dispositions, flap survival, and recognition of preoperative hypothyroidism in previously radiated patients.

RESULTS

Implementation of the perioperative checklist yielded an overall reduction in major medical complications (10.5% vs. 29.0%, P < .05*), post-operative antibiotic administration (17.4% vs. 44.7%, P < .05*), hospital length of stay (median (IQR) days 6 (1) versus 7 (3.25), P < .05*), and improved metastatic evaluation completion (92.1% vs. 63.2%, P < .05*). There was an improved discharge disposition (92.1% vs. 73.7%, P < .05*). No difference was observed in major wound complications (50.0% vs. 57.9%, P = .49), 30-day re-operation rates (31.5% vs. 34.2%, P = .81), 30-day readmission rates (21.1% vs. 21.1%, P > .99), escalations to intensive-care (13.2% vs. 21.1%, P = .36), or flap survival (97.4% vs. 89.5%, P = .17).

CONCLUSIONS

Use of our EMR-based perioperative checklist reduced major medical complications, post-operative antibiotic administration, hospital length of stay, and improved discharge outcomes for patients undergoing microvascular free-tissue reconstruction.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2251-E2256, 2021.

Critical Care and Postoperative Management of the Head and Neck Patient

Head and neck surgical patients, at times, can represent a challenging population to manage in the intensive care unit postoperatively. Close interaction between the critical care and surgical teams, awareness of potential surgery-specific complications, and utilization of protocol-driven care can reduce risk of morbidity significantly in this population and enhance outcomes. Given the relative complexity of otolaryngologic surgery and the unique risk that head and neck pathologies can pose to patient airway, breathing, and circulation, these collective circumstances warrant detailed discussion in the interest of minimizing patient morbidity and mortality.

Effects of a Comprehensive Performance Improvement Strategy on Postoperative Adverse Events in Head and Neck Surgery

Objectives

We aimed to demonstrate the efficacy of a multifaceted performance improvement regimen to reduce the incidence of adverse events following a spectrum of head and neck surgical procedures.

Methods

We conducted a chart review of patients who underwent a head and neck procedure between January 1, 2013, and October 30, 2015, at our institution, including 392 patients (450 procedures) before the quality improvement regimen was implemented (October 1, 2013) and 942 patients (1136 procedures) after implementation. Multivariate statistical models were used to investigate the association of clinical parameters and the intervention with postoperative adverse event rate.

Results

The incidence of adverse events decreased from 12.9% to 7.2% (95% CI, 2.46%-9.38%) after the intervention. Male sex (adjusted odds ratio [ORadj] = 1.57; 95% CI, 1.06-2.31) and the intervention (ORadj = 0.51; 95% CI, 0.35-0.74) were predictive of overall adverse event incidence by univariate and multivariate analyses. Although patient comorbid status, quantified with the Charlson Comorbidity Index, was not found to affect overall adverse event risk, each 1-point increase in index score was associated with a 17% relative increase (ORadj = 1.17; 95% CI, 1.03-1.33) in the odds of a high-grade adverse event.

Discussion

Comprehensive performance improvement programs can improve perioperative adverse event risk in head and neck surgery. Patient comorbid status and sex are considerations during assessment of the likelihood of high-grade and overall adverse event risk, respectively.

Implications for Practice

Given the cost of surgical complications, a comprehensive approach to perioperative risk mitigation is warranted.

Nuanced Reporting of Fistulas in Laryngectomy Studies

Pharyngocutaneous fistula is an important complication of laryngectomy and can vary significantly in severity. Many authors have advocated for the use of vascularized flaps (eg, pectoralis major) to reduce the risk of fistula. Prevention of small, self-limited fistulas may not be worth the morbidity of a vascularized flap in some cases. More nuanced analysis of fistula outcomes, stratified by severity, may enable better surgeon-patient decision making regarding the use of vascularized flaps in laryngectomy.