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Schuman AD, Bindal M, Amadio G, Turney AM, Hernandez DJ, Sandulache VC, Liou NE, Wang R, Huang AT. Safety of An Enhanced Recovery After Surgery Protocol After Head and Neck Free Tissue Transfer. Laryngoscope 2024. [PMID: 38895890 DOI: 10.1002/lary.31564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/01/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVES Implementing enhanced recovery after surgery (ERAS) protocols and decreasing length of stay (LOS) have become a priority for major surgeries, including microvascular free tissue transfer (MVFTT) reconstruction of the head and neck. We describe an ERAS protocol with the goal to further reduce length of stay beyond national medians. METHODS Retrospective chart review between August 2016 and February 2023, including all patients who underwent MVFTT after oral cavity, skull base, salivary gland, and cutaneous ablative surgery. An ERAS protocol was implemented in March 2020. RESULTS A total of 383 patients were included. Approximately 59.8% underwent oral cavity MVFTT, 34.5% cutaneous and lateral skull base, and 5.8% maxillary and anterior skull base. A total of 209 (54.7%) patients had surgery prior to implementation of the ERAS protocol and 174 (45.3%) after. Median LOS decreased from 9 days (interquartile interval [IQR] 8-11) to 6 (IQR 5-7.5, p < 0.0001) following oral cavity MVFTT. For cutaneous and lateral skull base reconstruction, median LOS decreased from 6 days (IQR 5-8) to 3 (IQR 3-7, p < 0.0001). For anterior skull base and sinonasal MVFTT, median LOS decreased from 8 (IQR 7-9) to 5 days (IQR 4.5-7, p = 0.0005). Rate of discharge to skilled nursing or subacute rehabilitation facilities decreased (24% before ERAS, 9.2% after, p < 0.0001). Thirty-day readmission rate was similar before and after implementation (10.5% vs. 10.3, p = 0.954). Discharge to facility was associated with readmission (OR 2.34, 95% CI 1.12-4.89, p = 0.024). CONCLUSION AND RELEVANCE Implementation of the ERAS protocol was associated with decreased LOS. There was no increase in rate of readmission. LEVEL OF EVIDENCE N/A Laryngoscope, 2024.
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Affiliation(s)
- Ari D Schuman
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Mohini Bindal
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Grace Amadio
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Anne M Turney
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - David J Hernandez
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Vlad C Sandulache
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - N Eddie Liou
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Ray Wang
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Andrew T Huang
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
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Forster C, Jacques V, Abdelnour-Berchtold E, Krueger T, Perentes JY, Zellweger M, Gonzalez M. Enhanced recovery after chest wall resection and reconstruction: a clinical practice review. J Thorac Dis 2024; 16:2604-2612. [PMID: 38738262 PMCID: PMC11087605 DOI: 10.21037/jtd-23-911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/29/2024] [Indexed: 05/14/2024]
Abstract
Since the late 1990s, and Henrik Kehlet's hypothesis that a reduction of the body's stress response to major surgeries could decrease postoperative morbidity, "Enhanced Recovery After Surgery" (ERAS) care pathways have been streamlined. They are now well accepted and considered standard in many surgical disciplines. Yet, to this day, there is no specific ERAS protocol for chest wall resections (CWRs), the removal of a full-thickness portion of the chest wall, including muscle, bone and possibly skin. This is most unfortunate because these are high-risk surgeries, which carry high morbidity rates. In this review, we propose an overview of the current key elements of the ERAS guidelines for thoracic surgery that might apply to CWRs. A successful ERAS pathway for CWR patients would entail, as is the standard approach, three parts: pre-, peri- and postoperative elements. Preoperative items would include specific information, targeted patient education, involvement of all members of the team, including the plastic surgeons, smoking cessation, dedicated nutrition and carbohydrate loading. Perioperative items would likely be standard for thoracotomy patients, namely carefully selective pre-anesthesia sedative medication only in some rare instances, low-molecular-weight heparin throughout, antibiotic prophylaxis, minimization of postoperative nausea and vomiting, avoidance of fluid overload and of urinary drainage. Postoperative elements would include early mobilization and feeding, swift discontinuation of intravenous fluid supply and chest tube removal as soon as safe. Optimal pain management throughout also appears to be critical to minimize the risk of respiratory complications. Together, all these items are achievable and may hold the key to successful introduction of ERAS pathways to the benefit of CWR patients.
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Affiliation(s)
- Céline Forster
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Valentin Jacques
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Thorsten Krueger
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Jean Yannis Perentes
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Matthieu Zellweger
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Michel Gonzalez
- Service of Thoracic Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
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Nieminen T, Tapiovaara L, Bäck L, Lindford A, Lassus P, Lehtonen L, Mäkitie A, Keski-Säntti H. Enhanced recovery after surgery (ERAS) protocol improves patient outcomes in free flap surgery for head and neck cancer. Eur Arch Otorhinolaryngol 2024; 281:907-914. [PMID: 37938375 PMCID: PMC10796721 DOI: 10.1007/s00405-023-08292-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND In recent years, enhanced recovery after surgery (ERAS) guidelines have been developed to optimize pre-, intra-, and postoperative care of surgical oncology patients. The aim of this study was to compare management outcome of patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction at our institution before and after the implementation of the ERAS guidelines. METHODS This retrospective study comprised 283 patients undergoing HNC surgery with free flap reconstruction between 2013 and 2020. Patients operated before and after the implementation of the ERAS protocol in October 2017 formed the pre-ERAS group (n = 169), and ERAS group (n = 114), respectively. RESULTS In the pre-ERAS group the mean length of stay (LOS) and intensive care unit length of the stay (ICU-LOS) were 20 days (range 7-79) and 6 days (range 1-32), and in the ERAS group 13 days (range 3-70) and 5 days (range 1-24), respectively. Both LOS (p < 0.001) and ICU-LOS (p = 0.042) were significantly reduced in the ERAS group compared to the pre-ERAS group. There were significantly fewer medical complications in the ERAS group (p < 0.003). No difference was found between the study groups in the surgical complication rate or in the 30-day or 6-month mortality rate after surgery. CONCLUSIONS We found reduced LOS, ICU-LOS, and medical complication rate, but no effect on the surgical complication rate after implementation of the ERAS guidelines, which supports their use in major HNC surgery.
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Affiliation(s)
- Teija Nieminen
- Department of Perioperative and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029 HUS, Helsinki, Finland.
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
| | - Laura Tapiovaara
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leif Bäck
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andrew Lindford
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Patrik Lassus
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lasse Lehtonen
- HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Mäkitie
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Harri Keski-Säntti
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Govil N, Tripathi M, Parag K, Agrawal SP, Kumar M, Varshney S. Role of protocol-guided perioperative care to enhance recovery after head and neck neoplasm surgery: An institutional experience. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:491-500. [PMID: 37678465 DOI: 10.1016/j.redare.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 10/30/2022] [Indexed: 09/09/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) improve recovery after surgery. This study aimed to determine whether ERAS leads to a decrease in stay in the hospital and improves global and functional recovery after head and neck neoplasms surgery. METHODS We performed a prospective case and historical control study after the ERAS application. The hospital database selected 50 confirmed eligible patients in control non-ERAS group. Prospectively 54 patients were included in the ERAS group. The primary outcome was time to readiness for discharge (TRD); secondary outcomes were the length of stay (LOS), readmission rate of up to 30 days and Quality of recovery score QoR-15. Data were compared with appropriate parametric and nonparametric tests. RESULTS Baseline demographic data of patients were comparable between the two groups. Patients in ERAS group had significantly shorter TRD compared to the non-ERAS group 8 (6-10) vs 11 (8-16); p-value = 0.002. LOS was also significantly shorter in the ERAS group compared to the non-ERAS group [8 (7-11) vs 12 (9-17); p-value = 0.002]. Readmission at 30-days was no different, with six patients in each group. QoR-15 score was statistically better in ERAS group (94.88 ± 12.50) compared to non-ERAS group (85.44 ± 12.68) [p value < 0.001]. CONCLUSION Implementing the ERAS programme decreased TRD and LOS and improved patient-reported recovery outcome QoR-15 in head and neck neoplasms surgery.
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Affiliation(s)
- N Govil
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India.
| | - M Tripathi
- Institute of Medical Sciences Mangalagiri, Mangalagiri, India
| | - K Parag
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
| | - S P Agrawal
- Department of Otorhinolaryngology-Head & Neck Surgery, AIIMS Rishikesh, Rishikesh, India
| | - M Kumar
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
| | - S Varshney
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
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Ferreira PRC, De Oliveira RIP, Vaz MD, Bentes C, Costa H. Opioid-Free Anaesthesia Reduces Complications in Head and Neck Microvascular Free-Flap Reconstruction. J Clin Med 2023; 12:6445. [PMID: 37892584 PMCID: PMC10607324 DOI: 10.3390/jcm12206445] [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: 08/24/2023] [Revised: 09/29/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
Head and neck free-flap microvascular surgeries are complex and resource-intensive procedures where proper conduct of anaesthesia plays a crucial role in the outcome. Flap failure and postoperative complications can be attributed to multiple factors, whether surgical- or anaesthesia-related. The anesthesiologist should ensure optimised physiological conditions to guarantee the survival of the flap and simultaneously decrease perioperative morbidity. Institutions employ different anaesthetic techniques and results vary across centres. In our institution, two different total intravenous approaches have been in use: a remifentanil-based approach and a multimodal opioid-sparing approach, which is further divided into an opioid-free anaesthesia (OFA) subgroup. We studied every consecutive case performed between 2015 and 2022, including 107 patients. Our results show a significant reduction in overall complications (53.3 vs. 78.9%, p = 0.012), length of stay in the intensive care unit (3.43 ± 5.51 vs. 5.16 ± 4.23 days, p = 0.046), duration of postoperative mechanical ventilation (67 ± 107 vs. 9 ± 38 h, p = 0.029), and the need for postoperative vasopressors (10% vs. 46.6%, p = 0.001) in the OFA group (vs. all other patients). The multimodal and OFA strategies have multiple differences regarding the fluid therapy, intraoperative type of vasopressor used, perioperative pathways, and various drug choices compared to the opioid-based technique. Due to the small number of cases in our study, we could not isolate any attitude, as an independent factor, from the success of the OFA strategy as a whole. Large randomised controlled trials are needed to improve knowledge and help define the ideal anaesthetic management of these patients.
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Affiliation(s)
- Paulo-Roberto Cardoso Ferreira
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
- Medical Sciences Department, University of Aveiro, 3810-193 Aveiro, Portugal
| | | | - Marta Dias Vaz
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
| | - Carla Bentes
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
| | - Horácio Costa
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
- Medical Sciences Department, University of Aveiro, 3810-193 Aveiro, Portugal
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List MA, Knackstedt M, Liu L, Kasabali A, Mansour J, Pang J, Asarkar AA, Nathan C. Enhanced recovery after surgery, current, and future considerations in head and neck cancer. Laryngoscope Investig Otolaryngol 2023; 8:1240-1256. [PMID: 37899849 PMCID: PMC10601592 DOI: 10.1002/lio2.1126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/15/2022] [Indexed: 10/31/2023] Open
Abstract
Objectives Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence 2a.
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Affiliation(s)
- Marna A. List
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Mark Knackstedt
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Lucy Liu
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ahmad Kasabali
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- College of MedicineLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Jobran Mansour
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - John Pang
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ameya A. Asarkar
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Cherie‐Ann Nathan
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- Feist‐Weiller Cancer CenterShreveportLouisianaUSA
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Shinozaki T, Imai T, Kobayashi K, Yoshimoto S, Zenda S, Yamaguchi T, Eguchi K, Okano T, Mashiko T, Kurosaki M, Miyaji T, Matsuura K. Preoperative steroid for enhancing patients' recovery after head and neck cancer surgery with free tissue transfer reconstruction: protocol for a phase III, placebo-controlled, randomised, double-blind study (J-SUPPORT 2022, PreSte-HN Study). BMJ Open 2023; 13:e069303. [PMID: 37258074 DOI: 10.1136/bmjopen-2022-069303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION There is no established methodology for the perioperative management of head and neck cancer surgery and free tissue transfer reconstruction (HNS-FTR). A single dose of corticosteroid administered immediately before surgery has been shown to reduce postoperative pain and nausea/vomiting after some types of surgery. However, the efficacy of this strategy has not been demonstrated in HNS-FTR, and the increased risk of infectious complications associated with its use cannot be ruled out. This phase III, placebo-controlled, randomised, double-blind, comparative, multicentre study seeks to determine if preoperative administration of corticosteroid hormone has an adjunctive effect in terms of reducing pain and nausea/vomiting after surgery and improving the quality of postoperative recovery. METHODS AND ANALYSIS Using the minimisation method, patients undergoing HNS-FTR are currently being recruited and randomly assigned to a study arm at a 1:1 allocation rate. The study treatment arm consists of 8.0 mg of dexamethasone phosphate dissolved in 100 mL of saline administered as a single dose by intravenous infusion. These treatments will be administered in a double-blind fashion. All patients will receive perioperative care according to the common multicentre enhanced recovery after surgery programme. The primary endpoint is the quality of postoperative recovery, as determined by the area under the curve (AUC) for total score on the Japanese version of the Quality of Recovery Score (QOR-40J) on postoperative days 2 and 4. The point estimate and CI for the difference in the AUC between the groups on postoperative days 2 and 4 will be calculated. ETHICS AND DISSEMINATION The study will be performed in accordance with the Declaration of Helsinki and Japan's Clinical Trials Act. The study protocol was approved by the Certified Review Board of National Cancer Center Hospital East (Reference K2021004). TRIAL REGISTRATION NUMBER The study was registered in the Japan Registry of Clinical Trials (jRCTs031210593; V.3.0, November 2021, available at https://jrct.niph.go.jp/en-latest-detail/jRCTs031210593).
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Affiliation(s)
- Takeshi Shinozaki
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takayuki Imai
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Japan
| | - Kenya Kobayashi
- Department of Head and Neck Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Seiichi Yoshimoto
- Department of Head and Neck Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Sadamoto Zenda
- Department of Radiation Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kohtaro Eguchi
- Department of Head and Neck Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoka Okano
- Department of Pharmacy, National Cancer Center-Hospital East, Kashiwa, Japan
| | - Tomoe Mashiko
- Division of Supportive Care, Survivorship and Translational Research, National Cancer Center, Tokyo, Japan
| | - Miyuki Kurosaki
- Division of Supportive Care, Survivorship and Translational Research, National Cancer Center, Tokyo, Japan
| | - Tempei Miyaji
- Division of Supportive Care, Survivorship and Translational Research, National Cancer Center, Tokyo, Japan
| | - Kazuto Matsuura
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Chiang SH, Ho MH, Wu SH, Lin CC. Postoperative recovery among head and neck cancer patients receiving microvascular free flap surgery with implementing nurse-protocolized targeted sedation: relationship of use of sedatives and mechanical ventilation to length of ICU stay. Support Care Cancer 2023; 31:317. [PMID: 37133641 DOI: 10.1007/s00520-023-07730-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/04/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE Patients receiving microvascular free flap surgery are usually admitted to a high-dependency adult intensive care unit (ICU). Research is limited to investigate postoperative recovery among head and neck cancer patients in the ICU. This study aimed to evaluate a nursing-protocolized targeted sedation on postoperative recovery and to examine the relationship of demographic characteristics, use of sedation, mechanical ventilator to length of ICU stay in patients receiving microvascular free flap surgery for head and neck reconstruction. METHODS This retrospective study involves 125 ICU patients at a medical centre in Taiwan. Medical records were reviewed between 1 January 2015 and 31 December 2018 including surgery-related data, medications and sedations used, and ICU-related outcomes. RESULTS The mean length of ICU stay was 6.2 days (SD = 2.6), and the mean duration of mechanical ventilation was 4.7 days (SD = 2.3). The daily dosage of sedation used in patients who received microvascular free flap surgery was dramatically reduced since the postoperative day (POD) 7. Over 50% of patients switched to PS + SIMV ventilator mode on POD 4. Duration of sedation used (r = 0.331, p < 0.001), total dosage of sedation (r = 0.901, p < 0.001), clear consciousness (r = - 0.517, p < 0.001), and duration on mechanical ventilator (r = 0.378, p < 0.001) are correlated with the length of ICU stay. CONCLUSION This study provides an understanding of the use of sedation, mechanical ventilator, and length of ICU stay to inform the continued education for clinicians.
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Affiliation(s)
- Su-Hua Chiang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
| | - Mu-Hsing Ho
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Szu-Hsien Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Chin Lin
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong.
- Alice Ho Miu Ling Nethersole Charity Foundation Professor in Nursing, Pokfulam, Hong Kong.
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Enhanced Recovery After Surgery. Otolaryngol Clin North Am 2022; 55:1271-1285. [DOI: 10.1016/j.otc.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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10
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Bertazzoni G, Testa G, Tomasoni M, Mattavelli D, Del Bon F, Montalto N, Ferrari M, Andreoli M, Morello R, Sbalzer N, Vecchiati D, Piazza C, Nicolai P, Deganello A. The Enhanced Recovery After Surgery (ERAS) protocol in head and neck cancer: a matched-pair analysis. ACTA OTORHINOLARYNGOLOGICA ITALICA 2022; 42:325-333. [PMID: 36254650 PMCID: PMC9577693 DOI: 10.14639/0392-100x-n2072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022]
Abstract
Objective In this study, we aimed to describe the prospective implementation of the Enhanced Recovery after Surgery (ERAS) protocol in an Italian tertiary academic centre. Methods Adult patients receiving surgery for primary or recurrent clinical stage III/IV squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx were enrolled. The primary objective was to evaluate the impact of the ERAS protocol on length of hospital stay (LOS). The secondary objective was to assess its impact on complications. To evaluate the results of the ERAS protocol, a matched-pair analysis was conducted, comparing ERAS patients with comparable cases treated before 2018. Results Forty ERAS and 40 non-ERAS patients were analysed. There were no significant differences between the cohorts regarding age, gender, stage of disease, comorbidity, ASA score, and duration of surgery. A significantly shorter LOS for the ERAS group (median, 14 days; range, 10-19) than for non-ERAS patients (median, 17.5 days; range, 13-21) was observed (p = 0.0128). The incidence of complications was not significantly different (p = 0.140). Conclusions Our study demonstrates that the introduction of an ERAS protocol in the daily practice is feasible, and can result in significant reduction in LOS.
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Affiliation(s)
- Giacomo Bertazzoni
- Department of Otorhinolaryngology, Azienda Socio-Sanitaria Territoriale di Cremona, Cremona, Italy,Correspondence Giacomo Bertazzoni Department of Otorhinolaryngology Azienda Socio-Sanitaria Territoriale di Cremona, viale Concordia 1, 26100 Cremona, Italy Tel. +39 0372 405282 E-mail:
| | - Gabriele Testa
- Unit of Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Michele Tomasoni
- Unit of Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy, Unit of Otorhinolaryngology, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Francesca Del Bon
- Unit of Otorhinolaryngology, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Nausica Montalto
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, Azienda Ospedale Università Padua, Padua, Italy
| | - Marco Ferrari
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, Azienda Ospedale Università Padua, Padua, Italy
| | - Marco Andreoli
- Clinical Nutrition, Azienda Socio-Sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Riccardo Morello
- Department of Otorhinolaryngology, Azienda Socio-Sanitaria Territoriale di Cremona, Cremona, Italy
| | - Nicola Sbalzer
- Department of Anaesthesia and Intensive Care, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Daniela Vecchiati
- Department of Anaesthesia and Intensive Care, Azienda Socio-sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | | | - Piero Nicolai
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padova, Azienda Ospedale Università Padua, Padua, Italy
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11
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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.
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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
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12
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Prasad A, Chorath K, Barrette L, Go B, Deng J, Moreira A, Rajasekaran K. Implementation of an enhanced recovery after surgery protocol for head and neck cancer patients: Considerations and best practices. World J Otorhinolaryngol Head Neck Surg 2022; 8:91-95. [PMID: 35782405 PMCID: PMC9242413 DOI: 10.1002/wjo2.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/03/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Aman Prasad
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Kevin Chorath
- Department of Otorhinolaryngology‐Head and Neck Surgery University of Pennsylvania Philadelphia Pennsylvania USA
| | - Louis‐Xavier Barrette
- Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Beatrice Go
- Department of Otorhinolaryngology‐Head and Neck Surgery University of Pennsylvania Philadelphia Pennsylvania USA
| | - Jie Deng
- School of Nursing, Laboratory of Innovative & Translational Nursing Research University of Pennsylvania Philadelphia Pennsylvania USA
| | - Alvaro Moreira
- Department of Pediatrics University of Texas Health San Antonio San Antonio Texas USA
| | - Karthik Rajasekaran
- 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
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13
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Liu DH, Yu AJ, Ding L, Swanson MS. Association Between Insurance Type and Outcomes of Reconstructive Head and Neck Cancer Surgery. Laryngoscope 2021; 132:1946-1952. [PMID: 34846071 DOI: 10.1002/lary.29966] [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: 07/19/2021] [Revised: 09/23/2021] [Accepted: 11/19/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES/HYPOTHESIS Although the benefits of expanding health insurance coverage are clear, there are limited studies comparing the different types of insurance. This study aims to determine the association between insurance type and outcomes in patients with head and neck cancer undergoing reconstructive surgery in the United States. METHODS Population-based cross-sectional study of the 2012-2014 National Inpatient Sample. We identified 1,314 patients with head and neck cancers undergoing tumor ablative surgery followed by pedicled or free flap reconstruction of oncologic defects. Insurance type was classified as private, Medicare, Medicaid, self-pay, or other. The primary outcome was extended length of stay (LOS), defined as greater than 14 days, which represented the 75th percentile of the study sample. Secondary outcomes included acute medical complications, surgical complications, morbidities, and costs. Analyses were adjusted for gender, geographic location, and various medical comorbidities. RESULTS In univariate analysis, insurance type was associated with extended LOS (P = .001), medical complications (P = <.001), and mortalities (P = .020). After controlling for other covariates in the multivariate analysis, compared to private insurance, Medicare and Medicaid were both associated with significantly higher odds of extended LOS (adjusted odds ratio [OR] [95% confidence interval (CI)] = 1.73 [1.09-2.76] and 2.22 [1.38-3.58], respectively). Medicare was associated with significantly higher odds of medical complications, but Medicaid was not (adjusted OR [95% CI] = 1.53 [1.02-2.31] and 1.64 [0.97-2.78], respectively). CONCLUSIONS Medicaid and Medicare were independently associated with extended LOS after reconstructive head and neck cancer surgery. Medicare was associated with higher rates of medical complications. Efforts to address LOS should target care planning and coordination. LEVEL OF EVIDENCE NA Laryngoscope, 2021.
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Affiliation(s)
- Derek H Liu
- Keck School of Medicine of the University of Southern California, Los Angeles, California, U.S.A.,Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, U.S.A
| | - Alison J Yu
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, U.S.A
| | - Li Ding
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, U.S.A
| | - Mark S Swanson
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, U.S.A
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14
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Saraswathula A, Gourin CG, Vosler PS. Guide to Enhanced Recovery for Cancer Patients Undergoing Surgery: Head and Neck Cancer. Ann Surg Oncol 2021; 28:6932-6935. [PMID: 33891196 DOI: 10.1245/s10434-021-10029-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/03/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter S Vosler
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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15
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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.
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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.
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