1
|
Namavarian A, Gabinet-Equihua A, Deng Y, Khalid S, Ziai H, Deutsch K, Huang J, Gilbert RW, Goldstein DP, Yao CMKL, Irish JC, Enepekides DJ, Higgins KM, Rudzicz F, Eskander A, Xu W, de Almeida JR. Length of Stay Prediction Models for Oral Cancer Surgery: Machine Learning, Statistical and ACS-NSQIP. Laryngoscope 2024; 134:3664-3672. [PMID: 38651539 DOI: 10.1002/lary.31443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/17/2024] [Accepted: 03/27/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Accurate prediction of hospital length of stay (LOS) following surgical management of oral cavity cancer (OCC) may be associated with improved patient counseling, hospital resource utilization and cost. The objective of this study was to compare the performance of statistical models, a machine learning (ML) model, and The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) calculator in predicting LOS following surgery for OCC. MATERIALS AND METHODS A retrospective multicenter database study was performed at two major academic head and neck cancer centers. Patients with OCC who underwent major free flap reconstructive surgery between January 2008 and June 2019 surgery were selected. Data were pooled and split into training and validation datasets. Statistical and ML models were developed, and performance was evaluated by comparing predicted and actual LOS using correlation coefficient values and percent accuracy. RESULTS Totally 837 patients were selected with mean patient age being 62.5 ± 11.7 [SD] years and 67% being male. The ML model demonstrated the best accuracy (validation correlation 0.48, 4-day accuracy 70%), compared with the statistical models: multivariate analysis (0.45, 67%) and least absolute shrinkage and selection operator (0.42, 70%). All were superior to the ACS-NSQIP calculator's performance (0.23, 59%). CONCLUSION We developed statistical and ML models that predicted LOS following major free flap reconstructive surgery for OCC. Our models demonstrated superior predictive performance to the ACS-NSQIP calculator. The ML model identified several novel predictors of LOS. These models must be validated in other institutions before being used in clinical practice. LEVEL OF EVIDENCE 3 Laryngoscope, 134:3664-3672, 2024.
Collapse
Affiliation(s)
- Amirpouyan Namavarian
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Yangqing Deng
- Department of Biostatistics, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Shuja Khalid
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
| | - Hedyeh Ziai
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Konrado Deutsch
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jingyue Huang
- Department of Biostatistics, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Ralph W Gilbert
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Christopher M K L Yao
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Danny J Enepekides
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Kevin M Higgins
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Vector Institute for Artificial Intelligence, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
- Department of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sinai Health System, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Li W, Li X, Chen Y, Li Y, Chen R, Kang Z, Huang Z, Zhao Y. Effects of acute normovolemic hemodilution and allogeneic blood transfusion on postoperative complications of oral and maxillofacial flap reconstruction: a retrospective study. BMC Oral Health 2024; 24:606. [PMID: 38789959 PMCID: PMC11127284 DOI: 10.1186/s12903-024-04302-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
OBJECTIVE Patients undergoing oral and maxillofacial flap reconstruction often need blood transfusions due to massive blood loss. With the increasing limitations of allogeneic blood transfusion (ABT), doctors are considering acute normovolemic hemodilution (ANH) because of its advantages. By comparing the differences in the (Δ) blood indices and postoperative complications of patients receiving ABT or ANH during the reconstruction and repair of oral and maxillofacial tumor flaps, this study's purpose was to provide a reference for the clinical application of ANH. METHODS The clinical data of 276 patients who underwent oral and maxillofacial flap reconstruction from September 25, 2017, to October 11, 2021, in the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, were retrospectively analyzed. According to the intraoperative blood transfusion mode, the patients were divided into two groups: ABT and ANH. The differences in the (Δ) blood indices and the incidence of postoperative complications between the groups were analyzed. RESULTS Among the 276 patients who had ANH (124/276) and ABT (152/276), there were no differences in (Δ) Hb, (Δ) PT, or (Δ) FIB (P > 0.05), while (Δ) WBC, (Δ) PLT, (Δ) APTT and (Δ) D-dimer were significantly different (P < 0.05). The blood transfusion method was not an independent factor for flap crisis (P > 0.05). The wound infection probability in patients with high post-PTs was 1.953 times greater than that in patients with low post-PTs (OR = 1.953, 95% CI: 1.232 ∼ 3.095, P = 0.004). A normal or overweight BMI was a protective factor for pulmonary infection, and the incidence of pulmonary infection in these patients was only 0.089 times that of patients with a low BMI (OR = 0.089, 95% CI: 0.017 ∼ 0.462). Moreover, a high ASA grade promoted the occurrence of pulmonary infection (OR = 6.373, 95% CI: 1.681 ∼ 24.163). The blood transfusion mode (B = 0.310, β = 0.360, P < 0.001; ANH: ln hospital stay = 2.20 ± 0.37; ABT: ln hospital stay = 2.54 ± 0.42) improved the length of hospital stay. CONCLUSION Preoperative and postoperative blood transfusion (Δ) Hb, (Δ) PT, and (Δ) FIB did not differ; (Δ) WBC, (Δ) PLT, (Δ) APTT, and (Δ) D-dimer did differ. There was no difference in the effects of the two blood transfusion methods on flap crisis, incision infection or lung infection after flap reconstruction, but ANH resulted in a 3.65 day shorter average hospital stay than did ABT.
Collapse
Affiliation(s)
- Wenhao Li
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Xueer Li
- Department of Maxillofacial Surgery, The First Affiliated Hospital of Guangdong Pharmaceutical University, 19th Nonglinxia Road, Guangzhou, Guangdong, 510080, China
| | - Yanhong Chen
- Department of Transfusion Medicine, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Yanling Li
- Department of Transfusion Medicine, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Rui Chen
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Ziqin Kang
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Zhiquan Huang
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China.
| | - Yili Zhao
- Department of Transfusion Medicine, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China.
| |
Collapse
|
3
|
Blache A, Carsuzaa F, Beddok A, Deneuve S, Marcy PY, James D, Dejean C, Dapké S, Devauchelle B, Thariat J. [Issues and implementation of postoperative radiotherapy after flap reconstructive surgery in head and neck cancers]. Bull Cancer 2024; 111:496-504. [PMID: 38553286 DOI: 10.1016/j.bulcan.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 05/13/2024]
Abstract
The management of head and neck cancers is multidisciplinary, often relying on the use of combined treatments to maximize the chances of cure. Combined treatments are however also responsible for cumulative side effects. The aim of reconstructive surgery with a flap is to restore a function lost with the loss of substance from the tumor resection. However, changes in reconstructive surgery have impact of postoperative radiotherapy planning. The optimization of imaging protocols for radiotherapy planning should make it possible to identify postoperative changes and to distinguish flaps from surrounding native tissues to delineate the flaps and document the spontaneous evolution of these flaps or dose-effect relationships in case of radiotherapy. Such changes include atrophy, fibrosis of soft tissue flaps and osteoradionecrosis of bone flaps. Radiotherapy optimization also involves standardization of the definition of target volumes in situations where a flap is present, a situation that is increasingly common in routine care. This evolution of practice, beyond the essential multidisciplinary consultation meetings defining treatment indications, requires a close radio surgical collaboration with respect to technical aspects of the two disciplines. Doing so, anticipation of relapse and toxicity profiles could possibly lead to propose strategies for personalized de-escalation of multimodal treatments through interdisciplinary trials.
Collapse
Affiliation(s)
- Alice Blache
- Département de radiothérapie, centre hospitalier universitaire Amiens-Picardie, 80000 Amiens, France.
| | - Florent Carsuzaa
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | | | - Sophie Deneuve
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital of Rouen, Poitiers, France
| | - Pierre-Yves Marcy
- Polyclinics ELSAN Group, Department of Radiodiagnostics and Interventional Imaging, PolyClinics Les Fleurs, Quartier Quiez, 83189 Ollioules, France
| | - Dylan James
- Radiotherapy Department, University Hospital of Brest, Brest, France
| | | | - Stéphanie Dapké
- Departement of Maxillofacial Surgery, Research Unit, UR7516 CHIMERE, University of Picardy Jules-Verne, Institut Faire Faces, University Hospital of Amiens Picardy, Amiens Picardy, France
| | - Bernard Devauchelle
- Departement of Maxillofacial Surgery, Research Unit, UR7516 CHIMERE, University of Picardy Jules-Verne, Institut Faire Faces, University Hospital of Amiens Picardy, Amiens Picardy, France
| | - Juliette Thariat
- Department of radiotherapy, Centre François-Baclesse, Corpuscular Physics Laboratory, IN2P3, Ensicaen, CNRS UMR 6534, Université de Normandie, GORTEC, Caen, France
| |
Collapse
|
4
|
Ghaffar WB, Shamim F, Khalil M, Abdul Ghaffar MB, Munir T. Impact of intraoperative fluid administration and complications in head and neck cancer free flap surgery at a tertiary care hospital of a low and middle-income country. J Perioper Pract 2024:17504589241232507. [PMID: 38634434 DOI: 10.1177/17504589241232507] [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: 04/19/2024]
Abstract
Perioperative fluid administration plays an essential role in head and neck cancer free flap surgery. The impact of intraoperative fluid administration on postoperative complications in head and neck cancer free flap surgery remains ill-defined. All adult patients who underwent a free flap surgery for head and neck cancer between January 2014 and December 2018 were included in the study. A total of 224 patients met the inclusion criteria. The mean age of patients was 45.0 years, and the majority were male (85.7%). Buccal mucosa squamous cell carcinoma (83%) was the most common diagnosis, and anterolateral thigh flap (46.4%) was the most routinely performed procedure. Perioperatively, ringer's lactate was used most abundantly (68.3%). A total of 101 complications were reported in the postoperative period, consisting of 67 medical complications and 34 surgical complications. In conclusion, there is no statistically significant association between the quantity of fluid administration and postoperative complications.
Collapse
Affiliation(s)
- Waleed Bin Ghaffar
- Department of Anaesthesiology, The Aga Khan University, Karachi, Pakistan
| | - Faisal Shamim
- Department of Anaesthesiology, The Aga Khan University, Karachi, Pakistan
| | - Mujtaba Khalil
- Dean's Clinical Research Fellowship, The Aga Khan University, Karachi, Pakistan
| | - Moeed Bin Abdul Ghaffar
- Department of Otolaryngology, Head and Neck Surgery, The Aga Khan University, Karachi, Pakistan
| | - Tahir Munir
- Department of Anaesthesiology, The Aga Khan University, Karachi, Pakistan
| |
Collapse
|
5
|
Thariat J, Carsuzaa F, Beddok A, Deneuve S, Marcy PY, Merlotti A, Dejean C, Devauchelle B. Reconstructive flap surgery in head and neck cancer patients: an interdisciplinary view of the challenges encountered by radiation oncologists in postoperative radiotherapy. Front Oncol 2024; 14:1379861. [PMID: 38665951 PMCID: PMC11043495 DOI: 10.3389/fonc.2024.1379861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Background Major advances have been made in reconstructive surgery in the last decades to reduce morbidity in head and neck cancer. Flaps are now present in 80% of patients with oral cavity cancer to cover anatomic, functional, and cosmetic needs. However, gaps in interdisciplinary innovation transfer from surgery to postoperative radiotherapy (poRT) remain challenging. We aimed to provide an interdisciplinary view of the challenges encountered by radiation oncologists in planning head and neck postoperative radiotherapy. Methods A systematic and critical review was conducted to address areas of optimization in surgery and radiology that may be relevant to poRT. Results Despite extensive surgical literature on flap techniques and salvage surgery, 13 retrospective series were identified, where flap outcomes were indirectly compared between surgery alone or poRT. These low-evidence studies suggest that radiotherapy accelerates flap atrophy, fibrosis, and osteoradionecrosis and deteriorates functional outcomes. Preliminary evidence suggests that tumor spread occurs at the flap-tissue junction rather than in the flaps. One prospective 15-patient study showed 31.3% vs. 39.2% flap volume reduction without or with poRT. In an international consensus, experts recognized the needs for optimized flap-sparing poRT against flap-related functional deterioration and bone damage. CT, MRI, and PET-CT modalities show potential for the delineation of the junction area between native tissues and flap for flap segmentation and to characterize flap-specific changes quantitatively and correlate them with patterns of relapse or complications. Conclusion Flap management in poRT is insufficiently documented, but poRT seems to damage flaps. Current gaps in knowledge underscore the need for prospective flap assessment and interdisciplinary trials investigating flap morbidity minimization by flap-sparing poRT planning.
Collapse
Affiliation(s)
- Juliette Thariat
- Department of Radiotherapy, Centre François-Baclesse, Caen, France
- Corpuscular Physics Laboratory, IN2P3, Ensicaen, CNRS UMR 6534, Caen, France
- Faculté de Médecine de Caen, Université de Normandie, Caen, France
| | - Florent Carsuzaa
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Arnaud Beddok
- Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Orsay, France
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sophie Deneuve
- Surgical Oncology Department, Centre Léon Bérard, UNICANCER, Lyon, France
- Inserm, U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon Bérard, Lyon, France
| | - Pierre-Yves Marcy
- Polyclinics ELSAN Group, Department of Radiodiagnostics and Interventional Imaging, PolyClinics Les Fleurs, Ollioules, France
| | - Anna Merlotti
- Radiotherapy Department, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | | | - Bernard Devauchelle
- Departement of Maxillofacial Surgery, University Hospital of Amiens Picardy, Research Unit, UR7516 CHIMERE, University of Picardy Jules Verne, Institut Faire Faces, Amiens, France
| |
Collapse
|
6
|
Gugliotta Y, Rubattino S, Fasolis M, Ramieri G, Copelli C. Postoperative infections associated with microvascular free flaps in head and neck reconstruction: Analysis of risk factors and results with a standardized prophylaxis protocol. J Plast Reconstr Aesthet Surg 2023; 87:61-68. [PMID: 37812845 DOI: 10.1016/j.bjps.2023.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 08/23/2023] [Accepted: 09/12/2023] [Indexed: 10/11/2023]
Abstract
Currently, large defects of the head and neck regions are mainly reconstructed using microvascular free flap. Postoperative infections, including surgical site infections (SSIs) and medical postoperative infections (MPI), are important causes of morbidity and worsening of surgical outcomes. The authors aimed to analyze the results obtained using a standardized prophylaxis protocol in a series of 100 consecutive patients who underwent microvascular reconstruction surgery between 2016 and 2021 at a single institution, to identify the risk factors, which could be overcome, to minimize the incidence of infectious complications. In this study, 24 patients developed infectious complications. Higher American Society of Anesthesiologists (ASA) score was statistically associated with higher risk of infectious complications (p = 0.01), need for postoperative transfusions (p = 0.01), and higher T and N stage (p = 0.03 and p = 0.02, respectively) in patients with cancer. We also found a correlation between the increase in surgery duration, hospitalization, and intensive care unit (ICU) stay with higher risk of infection (p = 0.03, p = 0.01, and p = 0.001, respectively). Nine patients reported partial or total flap necrosis and in this group of patients, a higher incidence of infectious complication was recorded (p = 0.001). Our experience shows that SSIs and MPIs affect the global and surgical outcomes of patients and both their incidences can be reduced by correcting potential risk factors preoperatively (e.g., anemia), intraoperatively (amount of blood loss and duration of surgery), and postoperatively (duration of hospitalization and ICU stay and early elimination of potential sources of infection).
Collapse
Affiliation(s)
- Y Gugliotta
- Department of Surgical Sciences, Maxillo-Facial Surgery Unit, AOU Città della Salute e della Scienza, University of Turin, Italy
| | - S Rubattino
- Department of Surgical Sciences, Maxillo-Facial Surgery Unit, AOU Città della Salute e della Scienza, University of Turin, Italy.
| | - M Fasolis
- Department of Surgical Sciences, Maxillo-Facial Surgery Unit, AOU Città della Salute e della Scienza, University of Turin, Italy
| | - G Ramieri
- Department of Surgical Sciences, Maxillo-Facial Surgery Unit, AOU Città della Salute e della Scienza, University of Turin, Italy
| | - C Copelli
- Maxillo-Facial Surgery, Interdisciplinary Department of Medicine, University of Bari, Italy
| |
Collapse
|
7
|
Denis B, Gourbeix C, Coninckx M, Foy JP, Bertolus C, Constantin JM, Degos V. Maxillofacial free flap surgery outcomes in critical care: a single-center investigation looking for clues to improvement. Perioper Med (Lond) 2022; 11:11. [PMID: 35264210 PMCID: PMC8908562 DOI: 10.1186/s13741-022-00244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Maxillofacial surgery for free flap reconstructions is associated with many complications due to technical complexity and comorbidity of patients. With a focus on critical care, the authors studied the impact of complications to highlight predictors of poor postoperative outcomes in order to implement optimization protocols. Methods This case-control study analyzed the relationship between perioperative variables and postoperative medical and surgical complications of patients who underwent head and neck surgery using fibular and forearm free flaps. The primary objective was the incidence of prolonged intensive care unit (ICU) length of stay (LOS). Secondary objectives were the incidence of ICU readmissions, postoperative infections, and 1-year mortality. A univariable logistic regression model was used. A study of mortality was performed with survival analysis. Regarding our primary objective, we performed a Benjamini-Hochberg procedure and a multivariable Poisson regression with defined variables of interest. Results The data of 118 hospital stays were included. Prolonged ICU LOS was observed in 47% of cases and was associated with chronic obstructive pulmonary disease, pneumopathies, intraoperative blood transfusion, and surgical duration. Medical and surgical complications were associated with prolonged ICU LOS. After the Benjamini-Hochberg procedure, infectious complications, complications, major complications, total number of pneumopathies, and operative time remained significant. At least one complication was experienced by 71% of patients during the hospitalization, and 33% of patients suffered from major complications. Infectious complications were the most common (40% of patients) and were mainly caused by pneumonia (25% of patients); these complications were associated with low preoperative hemoglobin level, intraoperative blood transfusion, accumulation of reversible cardiovascular risk factors, chronic alcohol consumption, and duration of surgery. Pneumonia was specifically associated with chronic obstructive pulmonary disease. The ICU readmission rate was 10% and was associated with lower preoperative hemoglobin level, pneumopathies, surgical duration, and use of a fibular flap. The 1-year mortality was 12%, and the survival analysis showed no association with prolonged ICU LOS. Poisson regression showed that ICU LOS was prolonged by smoking history, lower preoperative hemoglobin level, intraoperative blood transfusion, major complication, and pneumopathies. Conclusions Practices such as blood management and respiratory prehabilitation could be beneficial and should be evaluated as a part of global improvement strategies.
Collapse
Affiliation(s)
- Bruno Denis
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France. .,Intensive Care Unit, Saint-Luc Hospital, Université Catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Claire Gourbeix
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Marine Coninckx
- Maxillofacial Surgery Unit, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Jean-Philippe Foy
- Maxillofacial Surgery Unit, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Chloé Bertolus
- Maxillofacial Surgery Unit, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Jean-Michel Constantin
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Vincent Degos
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| |
Collapse
|
8
|
Pai K, Baaklini C, Cabrera CI, Tamaki A, Fowler N, Maronian N. The Utility of Comorbidity Indices in Assessing Head and Neck Surgery Outcomes: A Systematic Review. Laryngoscope 2021; 132:1388-1402. [PMID: 34661923 DOI: 10.1002/lary.29905] [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: 04/19/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the utility of comorbidity index (CI) scores in predicting outcomes in head and neck surgery (HNS). The CIs evaluated were the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Kaplan-Feinstein Index (KFI), American Society of Anesthesiologists Physical Status (ASA-PS), Adult Comorbidity Evaluation-27 (ACE-27), National Cancer Institute Comorbidity Index (NCI-CI), and the Washington University Head and Neck Comorbidity Index (WUHNCI). METHODS We report a systematic review according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases (PubMed, Cochrane, and Embase) and manual search of bibliographies identified manuscripts addressing how CI scores related to HNS outcomes. RESULTS A total of 116 studies associated CI scores with HNS outcomes. CIs were represented in the literature as follows: ASA-PS (70/116), CCI (39/116), ACE-27 (24/116), KFI (7/116), NCI-CI (3/116), ECI (2/116), and WUHNCI (1/116). The most frequently cited justification for calculating each CI (if provided) was: CCI for its validation in other studies, ACE-27 for its utility in cancer patients, and ECI for its comprehensive design. In general, the CCI and ACE-27 were predictive of mortality in HNS. The ECI was most consistent in predicting >1-year mortality. The ACE-27 and KFI were most consistent in predicting medical complications. CONCLUSION Despite inconsistencies in the literature, CIs provide insights into the impact of comorbidities on outcomes in HNS. These scores should be employed as an adjunct in the preoperative assessment of HNS patients. Comparative studies are needed to identify indices that are most reliable in predicting HNS outcomes. LEVEL OF EVIDENCE NA Laryngoscope, 2021.
Collapse
Affiliation(s)
- Kavya Pai
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, U.S.A
| | - Carla Baaklini
- Northeast Ohio Medical University, Rootstown, Ohio, U.S.A
| | - Claudia I Cabrera
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Akina Tamaki
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Nicole Fowler
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Nicole Maronian
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| |
Collapse
|
9
|
Mady LJ, Poonia SK, Baddour K, Snyder V, Kurukulasuriya C, Frost AS, Cannady SB, Chinn SB, Fancy T, Futran N, Hanasono MM, Lewis CM, Miles BA, Patel U, Richmon JD, Wax MK, Yu P, Solari MG, Sridharan S. Consensus of free flap complications: Using a nomenclature paradigm in microvascular head and neck reconstruction. Head Neck 2021; 43:3032-3041. [PMID: 34145676 DOI: 10.1002/hed.26789] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/10/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We aim to define a set of terms for common free flap complications with evidence-based descriptions. METHODS Clinical consensus surveys were conducted among a panel of head and neck/reconstructive surgeons (N = 11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of "good" or "fair") were eliminated. RESULTS Five out of nineteen terms scored K < 0.74. Eliminated terms included "vascular compromise"; "cellulitis"; "surgical site abscess"; "malocclusion"; and "non- or mal-union." Terms that achieved consensus were "total/partial free flap failure"; "free flap takeback"; "arterial thrombosis"; "venous thrombosis"; "revision of microvascular anastomosis"; "fistula"; "wound dehiscence"; "hematoma"; "seroma"; "partial skin graft failure"; "total skin graft failure"; "exposed hardware or bone"; and "hardware failure." CONCLUSION Standardized reporting would encourage multi-institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk-adjusted benchmarks, and enhance education and communication.
Collapse
Affiliation(s)
- Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Seerat K Poonia
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vusala Snyder
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Ariel S Frost
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Tanya Fancy
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Neal Futran
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brett A Miles
- Department of Otolaryngology, Northwell Health, New York, New York, USA
| | - Urjeet Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mario G Solari
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
10
|
Jones AJ, Campiti VJ, Alwani M, Novinger LJ, Tucker BJ, Bonetto A, Yesensky JA, Sim MW, Moore MG, Mantravadi AV. Sarcopenia is associated with blood transfusions in head and neck cancer free flap surgery. Laryngoscope Investig Otolaryngol 2021; 6:200-210. [PMID: 33869752 PMCID: PMC8035950 DOI: 10.1002/lio2.530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/29/2020] [Accepted: 01/20/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To determine if sarcopenia is a predictor of blood transfusion requirements in head and neck cancer free flap reconstruction (HNCFFR). METHODS A single-institution, retrospective review was performed of HNCFFR patients with preoperative abdominal imaging from 2014 to 2019. Demographics, comorbidities (modified Charlson Comorbidity Index [mCCI]), skeletal muscle index (cm2/m2), oncologic history, intraoperative data, and 30-day postoperative complications (Clavien-Dindo score [CD]) were collected. Binary logistic regression was performed to determine predictors of transfusion. RESULTS Eighty (33.5%), 66 (27.6%), and 110 (46.0%) of n = 239 total patients received an intraoperative, postoperative, or any perioperative blood transfusion, respectively. Sixty-two (25.9%) patients had sarcopenia. Patients receiving intraoperative transfusions had older age (P = .035), more frequent alcoholism (P = .028) and sarcopenia (P < .001), greater mCCI (P < .001), lower preoperative hemoglobin (P < .001), reconstruction with flaps other than forearm (P = .003), and greater operative times (P = .001), intravenous fluids (P < .001), and estimated blood loss (EBL, P < .001). Postoperative transfusions were associated with major complications (CD ≥ 3; P < .001). Multivariate regression determined sarcopenia (P = .023), mCCI (P = .013), preoperative hemoglobin (P = .002), operative time (P = .036), and EBL (P < .001) as independent predictors of intraoperative transfusion requirements. Postoperative transfusions were predicted by preoperative hemoglobin (P = .007), osseous flap (P = .036), and CD ≥ 3 (P < .001). A perioperative transfusion was predicted by sarcopenia (P = .021), preoperative hemoglobin (P < .001), operative time (P = .008), and CD ≥ 3 (P = .018). CONCLUSION Sarcopenia is associated with increased blood transfusions in HNCFFR. Patients should be counseled preoperatively on the associated risks, and the increased blood product requirement should be accounted in resource-limited scenarios. LEVEL OF EVIDENCE 4.
Collapse
Affiliation(s)
- Alexander Joseph Jones
- Department of Otolaryngology–Head and Neck SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Vincent J. Campiti
- Department of Otolaryngology–Head and Neck SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Mohamedkazim Alwani
- Department of Otolaryngology–Head and Neck SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Leah J. Novinger
- Department of Otolaryngology–Head and Neck SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Brady Jay Tucker
- Department of Otolaryngology–Head and Neck SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Andrea Bonetto
- Department of SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Jessica A. Yesensky
- Department of Otolaryngology–Head and Neck SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Michael W. Sim
- Department of Otolaryngology–Head and Neck SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Michael G. Moore
- Department of Otolaryngology–Head and Neck SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Avinash V. Mantravadi
- Department of Otolaryngology–Head and Neck SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| |
Collapse
|
11
|
Clinical consequences of head and neck free-flap reconstructions in the DM population. Sci Rep 2021; 11:6034. [PMID: 33727645 PMCID: PMC7966812 DOI: 10.1038/s41598-021-85410-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/01/2021] [Indexed: 01/13/2023] Open
Abstract
Diabetes mellitus (DM) is a common comorbidity and risk factor for postoperative complications in head and neck (H&N) microsurgical reconstructions. Our study focused on the association between DM and individual complications regarding both surgical and medical aspects. A meta-analysis of English-language articles comparing a series of complications between DM and non-DM H&N free-flap recipients was performed by comprehensive meta-analysis (CMA). Twenty-seven articles presented 14,233 H&N free-flap reconstructions, and a subset of 2329 analyses including diabetic cases was included for final analysis. Total postoperative (RR = 1.194, p < 0.001; OR = 1.506, p = 0.030) and surgical (RR = 1.550, p = 0.001; OR = 3.362, p < 0.001) complications were increased in DM subjects. Free-flap failure/necrosis (RR = 1.577, p = 0.001; OR = 1.999, p = 0.001) and surgical site infections (OR = 2.414, p < 0.001) were also increased in diabetic recipients. However, return to the operating room, dehiscence, fistulas, plate exposures, readmissions, and mortalities were not increased in DM patients. DM increased various complications in H&N free-flap reconstructions. Surgical indications should be cautiously evaluated, and aggressive treatments should be implemented for high-risk recipients.
Collapse
|
12
|
Harris BN, Patel R, Kejner A, Russell B, Ramadan J, Bewley A. Thrombocytosis Predicts Surgical Site Infection in Head and Neck Microvascular Surgery- A Pilot Study. Laryngoscope 2021; 131:1542-1547. [PMID: 33443771 DOI: 10.1002/lary.29386] [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: 09/01/2020] [Revised: 12/07/2020] [Accepted: 01/03/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE/HYPOTHESIS Early and objective prediction of complications in head and neck reconstructive surgery could decrease morbidity and prolonged hospital stays but unfortunately most complications are not identified until their effect is fully realized. There are limited data regarding the association of platelet levels and post-operative complications. Post-operative thrombocytosis (POTCT) is proposed as a possible indicator for complications following free-flap reconstruction. STUDY DESIGN Retrospective review. METHODS A multisite retrospective chart review of patients undergoing free tissue transfer between 2013 and 2018 was undertaken. POTCT was recorded and data normalized between institutions. Data were compared between groups using t-tests and logistic regression (P < .05). A lag-1 difference was used to compare the rate of change in platelet values. RESULTS A total of 398 patients were included. POTCT and a rate of change of 30 K between POD5 and POD6 was significantly associated with the presence of post-operative complication (P = .007). Additionally, lag-1 difference demonstrated a significant association of change in daily platelet counts and complication rates. CONCLUSIONS Isolated POTCT may be an early predictor of complications in HNC patients undergoing free-flap reconstruction. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1542-1547, 2021.
Collapse
Affiliation(s)
- Brianna N Harris
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Rusha Patel
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Alexandra Kejner
- Department of Otolaryngology, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Benjamin Russell
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Jad Ramadan
- Department of Statistics, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Arnaud Bewley
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| |
Collapse
|
13
|
Chorath K, Go B, Shinn JR, Mady LJ, Poonia S, Newman J, Cannady S, Revenaugh PC, Moreira A, Rajasekaran K. Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis. Oral Oncol 2020; 113:105117. [PMID: 33360446 DOI: 10.1016/j.oraloncology.2020.105117] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined. OBJECTIVE To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction. METHODS We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes. RESULTS 18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]). CONCLUSION There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.
Collapse
Affiliation(s)
- Kevin Chorath
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Beatrice Go
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Justin R Shinn
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Seerat Poonia
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Jason Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Steven Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter C Revenaugh
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Alvaro Moreira
- Department of Pediatrics, University of Texas Health-San Antonio, San Antonio, TX, United States
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
| |
Collapse
|
14
|
Jones AJ, Campiti VJ, Alwani M, Novinger LJ, Bonetto A, Sim MW, Yesensky JA, Moore MG, Mantravadi AV. Skeletal Muscle Index's Impact on Discharge Disposition After Head and Neck Cancer Free Flap Reconstruction. Otolaryngol Head Neck Surg 2020; 165:59-68. [PMID: 33290190 DOI: 10.1177/0194599820973232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the role of skeletal muscle index (SMI) in the assessment of frailty and determination of discharge to post-acute care facilities (PACF) after head and neck cancer free flap reconstruction (HNCFFR). STUDY DESIGN Retrospective cohort. SETTING Single-institution, academic tertiary referral center. METHODS Adult patients undergoing HNCFFR from 2014 to 2019 with preoperative abdominal computed tomography imaging were retrospectively analyzed. Patient demographics, 5-factor modified frailty index (5-mFI), body mass index (BMI), SMI at the third lumbar vertebra, oncologic history, perioperative data, and Clavien-Dindo (CD) complications were collected. Binary logistic regression was used to identify independent predictors of discharge disposition. RESULTS The cohort consisted of 206 patients, 62 (30.1%) of whom were discharged to PACF. Patients discharged to PACF were of older age (65.4 vs 57.1 years, P < .0001) and had a lower SMI (38.8 vs 46.8 cm2/m2, P < .0001), higher 5-mFI (≥3; 25.8% vs 4.2%, P < .0001), and greater incidence of stage IV (80.6% vs 64.1%, P = .0211) aerodigestive cancer (80.6% vs 66.7%, P = .0462). Patients discharged to PACF experienced more blood transfusions (74.2% vs 35.4%, P < .0001), major postoperative complications (CD ≥3, 40.3% vs 12.9%, P < .0001), and delirium (33.9% vs 4.2%, P < .0001). After adjusting for pre- and postoperative factors, multivariate binary logistic regression identified age (P = .0255), 5-mFI (P < .0042), SMI (P = .0199), stage IV cancer (P = .0250), aerodigestive tumor (P = .0366), delirium (P < .0001), and perioperative blood transfusion (P = .0144) as independent predictors of discharge to PACF. CONCLUSIONS SMI and 5-mFI are independently associated with discharge to PACF after HNCFFR and should be considered in preoperative planning and assessment of frailty.
Collapse
Affiliation(s)
- Alexander Joseph Jones
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Mohamedkazim Alwani
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Leah J Novinger
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrea Bonetto
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael W Sim
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jessica A Yesensky
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael G Moore
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Avinash V Mantravadi
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
15
|
Lebo NL, Quimby AE, Caulley L, Thavorn K, Kekre N, Brode S, Johnson-Obaseki S. Surgical Site Infection Affects Length of Stay After Complex Head and Neck Procedures. Laryngoscope 2020; 130:E837-E842. [PMID: 31977071 DOI: 10.1002/lary.28512] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 02/23/2024]
Abstract
OBJECTIVES/HYPOTHESIS Quality improvement (QI) initiatives emphasize a need for reduction in hospital length of stay (LOS). We sought to determine the impact of surgical site infections (SSIs) on LOS after complex head and neck surgery (HNS). STUDY DESIGN Retrospective cohort analysis. METHODS An analysis of the American College of Surgeons National Surgical Quality Improvement Program was undertaken. All adult patients undergoing complex HNS from 2005 to 2016 were included in the analysis. Our main outcomes were SSI incidence and increase in hospital LOS attributable to SSI. RESULTS Of 4,014 patients identified, 16.5% developed SSI. History of smoking, diabetes, preoperative wound infection, contaminated or dirty wound classes, and prolonged operative time were found to significantly predict postoperative SSI. Adjusting for significant pre- and postoperative factors, SSI was associated with significantly increased LOS (hazard ratio = 0.486, 95% confidence interval: 0.419-0.522). CONCLUSIONS SSI following complex HNS is associated with significantly increased hospital LOS. This result supports the need for institutional QI strategies that target SSIs after head and neck procedures in an effort to provide the highest quality care at the lowest possible cost. Our analysis identifies risk factors that can allow identification of patients at high risk of SSI and prolonged hospitalization. LEVEL OF EVIDENCE 2b Laryngoscope, 2020.
Collapse
Affiliation(s)
- Nicole L Lebo
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Alexandra E Quimby
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Caulley
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology, Erasmus Medical Centre, Rotterdam, the Netherlands
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Institute for Clinical and Evaluative Sciences, Toronto, Ontario, Canada
| | - Natasha Kekre
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Brode
- Department of Medicine, Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | | |
Collapse
|
16
|
Noel CW, Forner D, Wu V, Enepekides D, Irish JC, Husain Z, Chan KKW, Hallet J, Coburn N, Eskander A. Predictors of surgical readmission, unplanned hospitalization and emergency department use in head and neck oncology: A systematic review. Oral Oncol 2020; 111:105039. [PMID: 33141060 DOI: 10.1016/j.oraloncology.2020.105039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/18/2020] [Accepted: 10/04/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To identify predictors of unplanned hospitalization and emergency department (ED) use among head and neck oncology patients. METHODS Peer reviewed publications were identified through a systematic search of MEDLINE, Embase and Cochrane CENTRAL. Studies describing a cohort of HNC patients that detailed predictors of unplanned hospitalization or ED use in risk-adjusted models were eligible for inclusion. The methodologic quality of included studies was assessed using the Quality In Prognostic Studies (QUIPS) tool and an adapted version of the GRADE framework. RESULTS Of the 932 articles identified, 39 studies met our inclusion criteria with 31/39 describing predictors of surgical readmission and 10/39 describing predictors of ED use or unplanned hospitalization during radiation/chemoradiation treatment. Risk factors were classified into either 'patient-related', 'cancer severity' or 'process' factors. In the subset of studies looking at readmission following surgery wound complications (10/14 studies), presence of comorbidity (16/28 studies), low socioeconomic status (8/17 studies), cancer stage (9/14 studies), and prolonged hospital stay (7/18 studies) were the variables most frequently associated with readmission on multivariable analysis. Presence of comorbidity (6/10) and chemotherapy use (4/10) were more frequently associated with ED use and unplanned hospitalization. CONCLUSIONS Several consistent predictors have been identified across a variety of studies. This work is a critical first step towards the development of readmission and ED prediction models. It also enables meaningful comparison of hospital readmission rates with risk adjustment in HNC patients.
Collapse
Affiliation(s)
- Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David Forner
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vincent Wu
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Danny Enepekides
- Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Natalie Coburn
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| |
Collapse
|
17
|
Unplanned 30-day readmission rates after plastic and reconstructive surgery procedures: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
18
|
Unscheduled return to the operating theatre after head and neck surgery with free flap repair. Br J Oral Maxillofac Surg 2020. [DOI: 10.1016/j.bjoms.2020.08.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
19
|
Giovacchini F, Bensi C, Paradiso D, Docimo R, Tullio A. Association between blood transfusions and complications in head and neck reconstruction: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2020; 278:2171-2185. [PMID: 32870364 DOI: 10.1007/s00405-020-06286-z] [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: 06/12/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this meta-analysis is to assess the correlation between blood transfusions and the medical/surgical complications after head and neck reconstructive surgery. METHODS The PRISMA protocol was used and the literature search was performed on Pubmed, Scopus, Cochrane Library and Web of Science up to March 13, 2020. The risk of bias in individual studies was assessed through the Newcastle Ottawa Scale. RESULTS A total of 1219 records were screened after the electronic search, 22 of which were included in the qualitative analysis. Of there 22 scores, 18 articles were included in the meta-analysis. The OR for medical and surgical complications of transfused patients was 1,64 (95% CI 1.23-2.21); while, the OR for hospital readmission was 1.53 (95% CI 1.29-1.81). CONCLUSIONS The results of this meta-analysis suggested that blood transfusions are associated with both an increased risk of surgical and medical complications of head and neck flaps and with the hospital readmission.
Collapse
Affiliation(s)
- Francesco Giovacchini
- Maxillo-Facial Surgery Unit, Santa Maria Della Misericordia Hospital, Piazza Menghini 1, San Sisto, Perugia, Italy
| | - Caterina Bensi
- Paediatric Dentistry Post-Graduate School, University of Rome "Tor Vergata", Via Montpellier 1, Rome, Italy.
| | - Daniele Paradiso
- S.S.D. of Oral Surgery and Ambulatory, Santa Maria Della Misericordia Hospital, Piazza Menghini 1, San Sisto, Perugia, Italy
| | - Raffaella Docimo
- Paediatric Dentistry, Department of Surgical Sciences, University of Rome "Tor Vergata", Via Montpellier 1, Rome, Italy
| | - Antonio Tullio
- Maxillo-Facial Surgery, University of Perugia, Perugia, Italy
| |
Collapse
|
20
|
Crystal DT, Curiel DA, Abdul-Hamed S, Blankensteijn LL, Ibrahim AMS, Lee BT, Lin SJ. Outcomes of microvascular bone flaps versus osteocutaneous flaps in head and neck reconstruction. Microsurgery 2020; 40:731-740. [PMID: 32729977 DOI: 10.1002/micr.30634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 04/14/2020] [Accepted: 06/29/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Surgical resection of head and neck (H&N) neoplasms requiring osseous reconstruction have underdefined complication profiles. This study aimed to characterize postoperative outcomes of patients with H&N neoplasia undergoing osteocutaneous flap (OCF) or bare bone flap (BBF) reconstructions. MATERIALS AND METHODS Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) 2005-2017 databases. Queried for diagnosis and procedural codes extracted patients with H&N neoplasms undergoing BBF or OCF reconstruction. Postoperative complications were evaluated. Multivariable regression generated adjusted odds ratios. RESULTS A cohort of 746 patients were identified. Of reconstructions, 24.9% (n = 186/746) were BBFs while 75.1% (n = 560/746) were OCFs. 58.1% of the BBF cohort and 59.9% of the OCF cohort experienced an all-cause complication (p = .654). Sub-stratified, 24.2% of BBF and 17.5% of OCF patients experienced a wound complication (p = .045). Regression analysis demonstrated no difference in risk for medical complications between cohorts. However, patients receiving OCFs had a decreased likelihood of developing a wound complication (OR 0.652; 95%CI 0.430-0.989; p = .044) compared to patients receiving BBFs. CONCLUSION The incidence of complications following osseous reconstruction of the H&N is considerable. Although several complication outcomes do not seem to differ between BBF or OCF reconstructions, OCFs is associated with a decreased likelihood of wound complications.
Collapse
Affiliation(s)
- Dustin T Crystal
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel A Curiel
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Senan Abdul-Hamed
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Louise L Blankensteijn
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmed M S Ibrahim
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bernard T Lee
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
21
|
Weyh A, Nocella R, Abdelmalik M, Pucci R, Quimby A, Bunnell A, Fernandes R. An analysis of unplanned readmissions after head and neck microvascular reconstructive surgery. Int J Oral Maxillofac Surg 2020; 49:1559-1565. [PMID: 32475708 DOI: 10.1016/j.ijom.2020.04.017] [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: 12/20/2019] [Revised: 03/08/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
The 30-day readmission rate is a highly scrutinized metric of quality surgical care, because readmission is costly and perceived to be avoidable with planning and patient education. Head and neck surgery patients generally have multiple risk factors for readmission, as readmitted patients are generally older, with more co-morbidities, lower socio-economic status, and a history of multiple emergency department visits and readmissions. A retrospective cohort study was implemented to determine the incidence and etiology of 30-day readmission after microvascular head and neck reconstructive surgery, focusing on social risk factors. Data were analyzed by χ2 test, analysis of variance, t-test, and logistic regression, with statistical significance set at P<0.05. Of 209 patients included in this study, 35 (16.7%) had a 30-day readmission. Increased needs at discharge were associated with increased readmission, while other social risk factors were less significant for a readmission in this study.
Collapse
Affiliation(s)
- A Weyh
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| | - R Nocella
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| | - M Abdelmalik
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| | - R Pucci
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Italy.
| | - A Quimby
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| | - A Bunnell
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| | - R Fernandes
- Department of Oral and Maxillofacial Surgery, University of Florida Jacksonville, Jacksonville, FL, USA.
| |
Collapse
|
22
|
Marinone Lares SG, Clark S, Mathy JA, Chaplin J, McIvor N. Evaluation of a novel database for quality assurance at a head and neck service in New Zealand: an audit of free flap head and neck reconstruction. ANZ J Surg 2020; 90:1386-1390. [PMID: 32436238 DOI: 10.1111/ans.15974] [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: 03/01/2020] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical audit is a critical quality improvement exercise, yet efficient audit tools are lacking. The main objective of this study was to evaluate a recently deployed database in facilitating the process of clinical audit, and the secondary objective was to evaluate the outcomes of free flap reconstruction of the head and neck at our centre. METHODS A head and neck cancer-specific database was customized to suit the needs of our head and neck multidisciplinary team. Data has been entered prospectively into this database since March of 2018. An audit of free flap reconstruction of the head and neck over a 12-month period was performed using the database and analysed as a case study to examine its efficacy as a clinical audit tool. Additionally, the outcomes of free flap reconstruction at our centre were compared to those reported in the international literature. RESULTS The database allows flexible and specific queries, analysis and export of data, and can provide immediate results. However, issues with data quality and completeness were identified. In this audit, the overall 30-day complication rate and 30-day mortality in patients undergoing free flap reconstruction of the head and neck were 58% and 3%, respectively. CONCLUSION The database is fit for its intended purpose as an audit tool. Outcomes of free flap reconstruction of the head and neck at our centre are comparable to those of institutions overseas.
Collapse
Affiliation(s)
| | - Sita Clark
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Jon A Mathy
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand.,Auckland Regional Plastic Surgery Unit, Auckland, New Zealand
| | - John Chaplin
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Nick McIvor
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
23
|
Kastenberg ZJ, Wall N, Malhotra N, Zobell S, Mammen L, Short SS, Rollins MD. The effect of multidisciplinary colorectal center development on short-term hospital readmissions for patients with anorectal malformations or Hirschsprung disease. J Pediatr Surg 2020; 55:541-544. [PMID: 31859042 DOI: 10.1016/j.jpedsurg.2019.10.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/30/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Hospital readmissions have become a quality metric for both hospital systems and individual surgeons. The medical literature is replete with studies describing readmission rates and factors contributing to readmissions following surgical procedures. Relatively little, however, has been done to define potential solutions to these problems. Over the past decade there has been a movement toward the development of multidisciplinary colorectal centers at high volume children's hospitals. We hypothesized that the development of a colorectal center at our children's hospital decreased readmissions in our colorectal surgery population. MATERIALS AND METHODS A retrospective review was performed including all patients with the diagnosis of anorectal malformation (ARM) or Hirschsprung disease (HD) at our institution between the years of 2005-2017. Patient level outcomes were compared between the cohort treated prior to (2005-2010) and the cohort treated after the development of the colorectal center (2012-2017). RESULTS A total of 354 patients were identified. One hundred seventy-eight patients (113 ARM, 65 HD) were treated prior to and 176 patients (110 ARM, 66 HD) were treated after the development of the colorectal center. Forty-five (25.3%) patients underwent neonatal repair prior to development of the center compared to 15 (8.5%) after. 111 (62.4%) patients underwent colostomy prior to the colorectal center comparted to 95 (54%) after. The rate of readmission within 120 days of discharge in the early group was 63% compared to 52% in those managed in the multidisciplinary colorectal center (p = 0.04). Conversely, the rate of emergency room visits increased from 8.4% to 27.3% (p = 0.01). The decrease in readmission rates was more pronounced in the ARM group, while the HD cohort had similar readmission rates before and after the establishment of the center. Multivariate logistic regression revealed an odds ratio of 0.59 (95% CI 0.37-0.92) for readmission following the development of the multidisciplinary colorectal center. DISCUSSION The development of a multidisciplinary colorectal center at our institution was associated with decreased hospital readmissions, but an increase in emergency department resource utilization. These findings suggest improved efficiency in patient care with the implementation of a multispecialty, patient centered approach while also identifying areas of focus for future quality improvement initiatives. LEVEL OF EVIDENCE Level III, retrospective comparative study.
Collapse
Affiliation(s)
- Zachary J Kastenberg
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT.
| | - Natalie Wall
- University of Utah School of Medicine, Salt Lake City, UT
| | - Neha Malhotra
- Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, UT
| | - Sarah Zobell
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT
| | - Lija Mammen
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT
| | - Scott S Short
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT
| | - Michael D Rollins
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT
| |
Collapse
|
24
|
Densky J, Eskander A, Kang S, Chan J, Tweel B, Sitapara J, Ozer E, Agrawal A, Carrau R, Rocco J, Teknos TN, Old M. Risk Factors Associated With Postoperative Delirium in Patients Undergoing Head and Neck Free Flap Reconstruction. JAMA Otolaryngol Head Neck Surg 2020; 145:216-221. [PMID: 30605208 DOI: 10.1001/jamaoto.2018.3820] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Importance Postoperative delirium (POD) is associated with an increased rate of adverse events, higher health care costs, and longer hospital stays. At present, limited data are available regarding the risk factors for developing POD in patients undergoing head and neck free flap reconstruction. Identification of patients at high risk of developing POD will allow implementation of risk-mitigation strategies. Objective To determine the frequency of and risk factors associated with POD in patients undergoing free flap reconstruction secondary to head and neck disease. Design, Setting, and Participants This retrospective cohort study included 515 patients undergoing free flap reconstruction from January 1, 2006, through December 31, 2012, at the James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Care Center, a tertiary care cancer hospital. Preoperative, intraoperative, and postoperative data were collected retrospectively. Data from January 1, 2006, through December 31, 2012, were analyzed, and the final date of data analysis was January 8, 2018. Interventions Head and neck free flap reconstruction. Main Outcomes and Measures The primary outcome was the development of POD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Univariable and multivariable logistic regression were used to identify risk factors associated with POD. Results Five hundred fifteen patients underwent free flap reconstruction during the study period (66.2% male; mean [SD] age, 60.1 [12.8] years). Of these, 56 patients (10.9%) developed POD. On multivariable analysis, risk factors associated with POD included increased age (odds ratio [OR], 1.06; 95% CI, 1.02-1.11), male sex (OR, 5.02; 95% CI, 1.47-17.20), increased operative time (OR for each 1-minute increase, 1.004 [95% CI, 1.001-1.006]; OR for each 1-hour increase, 1.26 [95% CI, 1.08-1.46]), advanced nodal disease (OR, 3.00; 95% CI, 1.39-6.46), and tobacco use (OR, 7.23; 95% CI, 1.43-36.60). Preoperative abstinence from alcohol was identified as a protective factor (OR, 0.24; 95% CI, 0.12-0.51). Conclusions and Relevance This study identified variables associated with a higher risk of developing POD. Although many of these risk factors are nonmodifiable, they provide a target population for quality improvement initiatives. Furthermore, preoperative alcohol abstinence may be useful in preventing POD.
Collapse
Affiliation(s)
- Jaron Densky
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus
| | - Antoine Eskander
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital, Toronto, Ontario, Canada
| | - Stephen Kang
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus
| | - Jon Chan
- Department of Otolaryngology-Head & Neck Surgery, Virginia Commonwealth University, Richmond
| | - Ben Tweel
- Department of Otolaryngology-Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jigar Sitapara
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus
| | - Enver Ozer
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus
| | - Amit Agrawal
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus
| | - Ricardo Carrau
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus
| | - James Rocco
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus
| | - Ted N Teknos
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus
| | - Matthew Old
- Department of Otolaryngology-Head & Neck Surgery, Division of Head & Neck Oncology, The Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus
| |
Collapse
|
25
|
Optimizing value in head and neck cancer free flap surgery. Curr Opin Otolaryngol Head Neck Surg 2019; 27:413-419. [DOI: 10.1097/moo.0000000000000570] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
26
|
Ebner JJ, Mehra T, Gander T, Schumann P, Essig H, Zweifel D, Rücker M, Slankamenac K, Lanzer M. Novel application of the Clavien-Dindo classification system and the comprehensive complications index® in microvascular free tissue transfer to the head and neck. Oral Oncol 2019; 94:21-25. [PMID: 31178208 DOI: 10.1016/j.oraloncology.2019.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 03/11/2019] [Accepted: 05/05/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Julian Jakob Ebner
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland.
| | - Tarun Mehra
- Medical Office, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Thomas Gander
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Paul Schumann
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Harald Essig
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Daniel Zweifel
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Martin Rücker
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Ksenjia Slankamenac
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Martin Lanzer
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| |
Collapse
|
27
|
Old M. Failure to Report Related Studies. JAMA Otolaryngol Head Neck Surg 2019; 145:293-294. [PMID: 30816922 DOI: 10.1001/jamaoto.2019.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Matthew Old
- The James Cancer Hospital and Solove Research Institute, Wexner Medical Center, Division of Head & Neck Oncology, Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus
| |
Collapse
|
28
|
Balakrishnan K, Brereton J, Cohen ST, Kokoska MS, Brenner MJ. Optimizing Value in Otolaryngology Through Patient Safety and Quality Improvements. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0216-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|