The association of frailty with morbidity and mortality following major mucosal head and neck surgery

OBJECTIVES

Frailty refers to a state of reduced physiological reserve and functional decline. We sought to analyse whether frailty, assessed using the 5-item modified frailty index (5mFI), was associated with increased morbidity and mortality following major mucosal head and neck surgery.

MATERIALS AND METHODS

We performed a retrospective study of patients undergoing major mucosal head and neck surgical resection over a 2-year period. Potential confounding variables were controlled by way of multivariable regression analysis.

RESULTS

There were 310 patients included with 77 (24.8 %) classified as frail. Most patients were male (219/310, 70.7 %), had a history of smoking (246/310, 79.4 %) and 151 patients (48.7 %) were older than 65 at time of surgery. Most surgeries related to oral cavity or oropharyngeal subsites (227/310, 73.2 %) and 150 patients (48.4 %) underwent microvascular free tissue reconstruction. On multivariable analysis, frail patients were more likely to suffer adverse outcomes such as a return to theatre (OR 3.47, 95 % CI 1.82-6.62, p < 0.001), a Clavien-Dindo grade IV complication (OR 6.23, 95 % CI 2.55-15.20, p < 0.001) or medical complications, such as respiratory complications (OR 2.61, 95 % CI 1.45-4.69; p = 0.001) or delirium (OR 5.05, 95 % CI 2.46-10.33; p < 0.001). Additionally, hospital length of stay was increased among frail patients (ß 16.46 days, 95 % CI 9.85-23.07 days; p < 0.001). Neither 90-day nor 1-year post-operative mortality was increased in frail patients.

CONCLUSION

Frailty assessed using the 5mFI was associated with greater post-operative morbidity, but not mortality following major mucosal head and neck surgery.

Enhanced recovery after surgery (ERAS) in head and neck oncologic surgery: Impact on return to intended oncologic therapy (RIOT) and survival

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways in head and neck cancer (HNC) have shown to improve perioperative outcomes and reduce complications. The longer term implications on adjuvant treatment and survival have not been studied. We hereby report the first study on the impact of an ERAS pathway on return to intended oncologic treatment (RIOT) and overall survival (OS) in HNC.

METHODS

200 patients undergoing head and neck oncologic surgery on an ERAS pathway between March 1, 2016 and March 31, 2019 were matched to controls over the same interval. Demographic, tumor and adjuvant therapy-related data were collected, including time to adjuvant therapy(TAT) and treatment package time(TPT). Risk factors for TAT > 42 days and TPT ≥ 85 days were assessed. OS was compared and risk factors for inferior OS determined.

RESULTS

Baseline characteristics including co-morbidities and tumor stage were similar. Of 179 patients planned for adjuvant treatment, there was no difference in RIOT rate (89.0% vs 87.5%, p = 0.753), proportion of TAT > 42 days of surgery (55.6% vs 59.7%, p = 0.642), or TPT ≥ 85 days (48.1% vs 57.1, p = 0.258), for the ERAS and control groups, respectively. On multivariate analysis, alcohol use (OR 3.58; 95 %CI 1.11-11.52) and recurrent disease status (OR 2.88; 95 %CI 1.40-5.93) were independently associated with prolonged TAT. Three-year OS was similar between the ERAS and control groups (73% vs 76%, p = 0.521).

CONCLUSION

ERAS has not shown to improve RIOT or OS in the current study. However, its benefit for perioperative outcomes is undeniable and further studies are required on longer term quality and survival outcomes.

Association of Multiprofessional Preoperative Assessment and Information for Patients With Head and Neck Cancer With Postoperative Outcomes

IMPORTANCE

Multidisciplinary perioperative assessment for patients undergoing complex oncologic head and neck cancer (HNC) surgery is widely implemented. However, to our knowledge, the association of multiprofessional preoperative assessment, information, and briefing with postoperative outcomes has not been evaluated.

OBJECTIVE

To compare postoperative complications, length of hospital stay (LOS), readmissions, mortality, and costs per case among patients undergoing complex oncologic HNC surgery before and after the implementation of a comprehensive preoperative multiprofessional assessment and information day (MUPAID).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, single-center case-control study was conducted at a tertiary referral head and neck anticancer center/university cancer institute and compared patients with HNC who were undergoing complex oncological surgeries between January 2012 and July 2018 before (control group) and after (intervention group) implementation of the institutional MUPAID. Data analysis was conducted between 2019 and 2020. The intervention group comprised patients who participated in the MUPAID beginning in February 2015. These patients were assessed by a multiprofessional team and provided with structured and comprehensive information on the surgical procedure and its functional, social, financial, and psychological effects, as well as the postoperative care, rehabilitation, and follow-up period. Patients in the control group had also undergone complex oncologic HNC surgery and were selected through surgical procedure codes.

MAIN OUTCOMES AND MEASURES

The end points were postoperative rate and severity of complications, LOS, readmissions, mortality, and costs per case.

RESULTS

The study included 161 patients, 81 in the intervention (25 women [30.9%]) and 80 in the control group (18 women [22.5%]). The groups showed no relevant differences in sociodemographic, disease, and procedural characteristics. The intervention cohort presented with fewer major local and systemic complications (Clavien-Dindo score, III-V: 34.6% vs 52.5%; difference proportion, -0.179; 95% CI, -0.33 to -0.03), shorter median LOS (12 days [IQR, 10-16 days] vs 16 days [IQR, 11-20] days; effect size, 0.482; 95% CI Cohen d, 0.152-0.812) and decreased median charge per case ($50 848 [IQR, $42 510-$63 479] vs $69 602 [IQR, $45 631-$96 280]; effect size, 0.534; 95% CI Cohen d, 0.22-0.85).

CONCLUSIONS AND RELEVANCE

The results of this case-control study suggest that MUPAID for patients who are undergoing complex oncologic HNC surgery is associated with shortened LOS and costs per case as well as decreased complications severity. These results are promising on a patient level in the potential to minimize individual treatment burden, as well as on an institutional and health care system level in the potential significant optimization of surgical outcomes and financial aspects.

Risk Factors for 30-Day Mortality After Head and Neck Microsurgical Reconstruction for Cancer: NSQIP Analysis

OBJECTIVE

To identify the incidence and risk factors for 30-day postoperative mortality after microsurgical head and neck reconstruction following oncological resection.

STUDY DESIGN

Retrospective case-control study.

SETTING

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

METHODS

Microsurgical head and neck reconstructive cases were identified from 2005 to 2018 using Current Procedural Terminology codes and oncologic procedures using the International Classification of Disease 9 and 10 codes. The outcome of interest was 30-day mortality.

RESULTS

The 30-day postoperative mortality rate was 1.2%. Univariate logistic regression analysis identified the following associations: age >80 years, hypertension, poor functional status, preoperative wound infection, renal insufficiency, malnutrition, anemia, and prolonged operating time. Multivariable logistic regression models were used to stratify further by the degree of malnutrition and anemia. Hematocrit <30% was found to be an independent risk factor for 30-day postoperative mortality (odds ratio [OR] = 9.59, confidence interval [CI] 2.32-39.65, P < .1) with albumin <3.5 g/dL. This association was even stronger with albumin <2.5 g/dL (OR = 11.64, CI 3.06-44.25, P < .01). One-third of patients (36.6%) had preoperative anemia, of which less than 1% required preoperative transfusion, although one-quarter (24.6%) required intraoperative or 72 hours postoperative transfusion.

CONCLUSIONS

Preoperative anemia is a risk factor for 30-day postoperative mortality. This association seems to get stronger with worsening anemia. Identification and optimization of such patients preoperatively may mitigate the incidence of 30-day postoperative mortality.

Association of Preoperative Anemia With 30-Day Morbidity and Mortality Among Patients With Thyroid Cancer Who Undergo Thyroidectomy

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.

The high stakes of head and neck surgery following radiation and chemotherapy - An assessment of complications and survival

OBJECTIVES

To investigate variables that predict medical and surgical complications in patients undergoing salvage surgery after primary organ-preserving therapy for head and neck cancer and to investigate the effect of complications on 5-year overall survival.

MATERIALS AND METHODS

A retrospective study was conducted on patients undergoing salvage surgery after primary organ-preserving therapy for head and neck cancer at a tertiary institution from 2006 to 2011. Multivariable regression analysis was used to assess association between independent variables and medical and surgical complications. A Kaplan-Meier survival curve was plotted to assess effect of surgical and medical complications on 5-year overall survival.

RESULTS

One hundred thirty-six patients undergoing salvage surgery after primary organ-preservation surgery met inclusion criteria. Surgical complications occurred in 68/136 (50.0%) of patients. After adjusting for confounders, young age and history of hypothyroidism were significant predictors of surgical complications (p < 0.05). Medical complications occurred in 37/136 (27.2%) of patients. After adjusting for confounders, older age and history of hepatic disease were significant predictors of having a medical complication (p < 0.05). Patients with no complications had better overall survival than patients with medical complications (p = 0.009). There was no difference in overall survival between patients without complications and patients with surgical complications only (p = 0.259).

CONCLUSION

Risk factors for medical and surgical complications include history of hypothyroidism, liver disease, and age. Survival outcomes are not affected by surgical complications but are significantly affected by medical complications highlighting the importance of personalized patient care and medical co-management.

Impact of a hospital-wide sepsis pathway on improved quality of care and clinical outcomes in surgical patients at a comprehensive cancer centre

PURPOSE

Sepsis is a significant complication following cancer surgery. Although standardised care bundles improve sepsis outcomes in other populations, the benefits in cancer patients are unclear. The objectives of this study were to describe the epidemiology of sepsis in cancer patients post-surgery, and to evaluate the impact of a clinical sepsis pathway on management and clinical outcomes.

METHODS

A standardised hospital-wide sepsis pathway was developed in 2013, and all cases of sepsis at the Peter MacCallum Cancer Centre in 2014 were retrospectively evaluated. Inclusion criteria were sepsis onset during the 100-day period following a surgical procedure for cancer diagnosis. Patients were identified using ICD-10-AM sepsis discharge codes, audit documentation and the hospital's antimicrobial approval system. Sepsis episodes were classified as managed on- or off-pathway.

RESULTS

A total of 119 sepsis episodes were identified. Of these, 71 (59.7%) were managed on the sepsis pathway. Episodes managed on-pathway resulted more frequently in administration of appropriate antibiotics compared to those off-pathway (94.4% vs. 66.7%, p < 0.001), and had shorter time to first-dose antibiotics (median 85 vs. 315 min, p < 0.001). Pathway utilisation was associated with significant reductions in need for inotropes (7% vs. 13%, p = 0.023), ventilation (3% vs. 10%, p = 0.006) and length of hospitalisation (median 15 vs. 30 days, p = 0.008). The most frequent source of infection was organ-space surgical site infection (24.4% of instances).

CONCLUSIONS

A dedicated hospital-wide sepsis pathway had significant impact on the quality of care and clinical outcomes of sepsis in cancer surgery patients. Cost-benefit analysis of sepsis pathways for cancer patients is required.

Factors associated with complications in total laryngectomy without microvascular reconstruction

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.

Early (90-day) mortality after radical radiotherapy for head and neck squamous cell carcinoma: A population-based analysis

BACKGROUND

A retrospective, population-based analysis of 90-day mortality in patients with squamous cell carcinoma of the head and neck treated with radiotherapy was performed to determine the early mortality rate and associated risk factors.

METHODS

Data were abstracted for all consecutive patients with cancer of the head and neck treated from 1998 to 2014 at the BC Cancer Agency with curative intent radiotherapy (n = 5658). Logistic regression analysis was used to determine factors associated with early mortality.

RESULTS

The median age at diagnosis was 63 years. The mortality rate at 90 days after starting radiotherapy (RT) was 3.6% (n = 203/5658). The cause of death was attributed to head and neck cancer for 81% of patients. Multivariate analysis demonstrated that increasing age, oral cavity subsite, and advanced T and N classification were associated with an increased risk of early mortality (p < .05).

CONCLUSIONS

The risk of early mortality was 3.6%. Elderly patients with advanced T and N classification had the highest risk of early mortality.

Preoperative assessment of the risk of postoperative death in patients with oral squamous cell carcinoma: a consideration beyond age, sex, and stage of cancer

Despite improvements in the management of patients in critical care, about 3% patients who have an operation with curative intent for oral squamous cell carcinoma (SCC) do not survive their stay in hospital. Our aim was to assess the risk factors for postoperative death that were independent of the stage of the cancer, or the age and sex of the patients. We screened 4760 consecutive inpatients at a maxillofacial tertiary care centre from 2011 to 2016, and 34 of them had died within the first three months after operation. We matched them with a further 34 patients with the same TNM stage, age, and sex. General personal and clinical data and preoperative laboratory values were screened, and we applied a Charlson Comorbidity Score (for anaesthetic risk) for each group. Patients' mean (SD) age was 66 (12) years old. There was no significant difference in sex (p=1), age (p=0.718), or TNM classification. Those who died after operation had significantly more renal (p=0.027) and gastrointestinal (p=0.006) diseases, but cardiac diseases (p=0.468) and diabetes mellitus (p=1) were not significant risk factors in themselves. Patients who died postoperatively had significantly worse risk scores (p=0.001) overall. The most common causes of death were septic shock (n=10) and acute cardiac (n=9) or respiratory failure (n=7). Our findings suggested that general diseases were not intrinsically a contraindication for operation with curative intent. The Charlson Comorbidity Score helped to detect potentially fatal courses and could be useful in the preoperative assessment of patients whose general health is not good.

Sequelae of Index Complications following Inpatient Head and Neck Surgery: Characterizing Secondary Complications

Objective To characterize patterns of secondary complications after inpatient head and neck surgery. Study Design Retrospective cohort study. Setting National Surgical Quality Improvement Program (2005-2015). Subjects and Methods We identified 18,584 patients who underwent inpatient otolaryngologic surgery. Four index complications were studied: pneumonia, bleeding or transfusion event (BTE), deep/organ space surgical site infection (SSI), and myocardial infarction (MI). Each patient with an index complication was matched to a control patient based on propensity for the index event and event-free days. Rates of 30-day secondary complications and mortality were compared. Results Index pneumonia (n = 254) was associated with several complications, including reintubation (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.2-26.4), sepsis (OR, 8.8; 95% CI, 4.5-17.2), and death (OR, 5.3; 95% CI, 1.9-14.9). Index MI (n = 50) was associated with increased odds of reintubation (OR, 17.2; 95% CI, 3.5-84.1), ventilatory failure (OR, 5.8; 95% CI, 1.8-19.1), and death (OR, 24.8; 95% CI, 2.9-211.4). Index deep/organ space SSI (n = 271) was associated with dehiscence (OR, 7.2; 95% CI, 3.6-14.2) and sepsis (OR, 38.3; 95% CI, 11.6-126.4). Index BTE (n = 1009) increased the odds of cardiac arrest (OR, 3.9; 95% CI, 1.8-8.5) and death (OR, 2.9; 95% CI, 1.6-5.1). Conclusions Our study is the first to quantify the effect of index complications on the risk of specific secondary complications following inpatient head and neck surgery. These associations may be used to identify patients most at risk postoperatively and target specific interventions aimed to prevent or interrupt further complications.