Radioactive suture in the treatment of head an neck cancer

Prevention and treatment of postsurgical head and neck infections

Postoperative wound infection is an important cause of postsurgical morbidity. Efforts to reduce the incidence of wound infection are enhanced through appropriate preoperative preparation, adherence to excellent surgical technique, and the provision of outstanding postoperative care. Many head and neck surgical procedures are undertaken in an environment contaminated by saliva containing a large inoculum of potentially pathogenic bacteria. Prospective randomized clinical trials have demonstrated that perioperative antibiotic prophylaxis reduces the risk for postoperative wound infection. Effective antibiotic prophylaxis requires that the antibiotic be effective against normal oral flora. Antibiotics should be administered before wound contamination. The dose of the antibiotic should exceed the minimal inhibitory concentration needed for the normal flora. The antibiotic administration can cease within 24 hours of surgery.

The role of topical antibiotic prophylaxis in patients undergoing contaminated head and neck surgery with flap reconstruction

OBJECTIVES/HYPOTHESIS

Patients undergoing contaminated head and neck surgery with flap reconstruction have wound infection rates of 20% to 25% with parenteral antibiotic prophylaxis. Studies suggest that perioperative antimicrobial mouthwash reduces oropharyngeal flora and may prevent wound infections. We hypothesized that the addition of topical antibiotics to a parenteral prophylactic regimen would reduce the incidence of wound infection in these high-risk patients.

STUDY DESIGN

We performed a randomized, prospective clinical trial.

METHODS

Patients received either 1) parenteral piperacillin/tazobactam (3.375 g every 6 hours for 48 h) or 2) parenteral piperacillin/tazobactam plus topical piperacillin/tazobactam administered as a mouthwash immediately before surgery and once a day for 2 days postoperatively, with piperacillin/tazobactam added to the intraoperative irrigation solution. The wounds of all patients were evaluated daily using predefined objective criteria.

RESULTS

Sixty-two patients met inclusion criteria and were enrolled in the study. The overall wound infection rate was 8.1% (95% confidence interval [CI], 2.7%-17.8%). Two of 31 patients (6.4%) who received parenteral antibiotics alone developed a wound infection compared with 3 of 31 patients (9.7%) randomly assigned to receive topical plus parenteral antibiotics. This difference was not statistically significant (P = >.05). Infection rate was not associated with flap type (rotational vs. free tissue transfer), mandibular reconstruction, age, gender, tumor site, stage, surgical duration, or blood loss.

CONCLUSIONS

These results suggest that piperacillin/tazobactam is a highly effective antibiotic for prevention of wound infection in patients undergoing flap reconstruction following contaminated head and neck surgery. However, the addition of topical piperacillin/tazobactam does not appear to enhance the prophylactic benefit of parenteral antibiotics alone.

Factors affecting wound infection rates in head and neck surgery

PURPOSE

This study was planned with 2 goals in mind: to evaluate the efficacy of prolonged and 1-day antibiotic regimens for prophylaxis and to evaluate the effect of various factors such as neck dissection, localization and stage of tumor, type of laryngectomy, and history of prior radiotherapy, tracheotomy, and diabetes mellitus on postoperative wound infection rates.

METHODS AND MATERIAL

In this study, 408 head and neck procedures (201 clean and 207 clean-contaminated) performed at our institution were retrospectively reviewed.

RESULTS

Prolonged and 1-day antibiotic regimens for both clean and clean-contaminated procedures were similar in efficacy (7% vs 3% for clean procedures [P = 0.165] and 30% vs 28% for clean-contaminated procedures [P = 0.777]). The wound infection rate was higher (13%) after clean radical neck dissections versus other clean procedures (1%) (P = 0.001). For clean-contaminated procedures, factors affecting postoperative wound infection rates were performance of bilateral neck dissections (P = 0.014), disease stage (P = 0.002), type of laryngectomy (P = 0.002), and history of prior tracheotomy (P = 0.006).

Comparison of ampicillin/sulbactam versus clindamycin in the prevention of infection in patients undergoing head and neck surgery

BACKGROUND

Patients requiring major oncologic head and neck surgery are at high risk for postoperative wound infection when the surgical site is contaminated by secretions from the upper aerodigestive tract. Studies to identify agents active in the prevention of postoperative wound infection may serve to reduce patient morbidity.

METHODS

Patients scheduled for a major contaminated head and neck surgical procedure were randomly assigned to receive either ampicillin/sulbactam or clindamycin. Medication was administered 1 to 2 hours prior to surgery and every 6 hours, for a total of five doses. Postoperatively, patients were followed daily for the development of wound infection or other septic complication.

RESULTS

A total of 242 patients were enrolled in the study; 119 received ampicillin/sulbactam, and 123 received clindamycin. A total of 169 patients were considered evaluable. Of the evaluable patients, 14% in each group developed a postoperative wound infection. There were no statistically significant differences between the number of days to onset of wound infection, nor was there a statistically significant difference in the rate of non-wound infections in the two groups. There were no statistically significant differences between the intent to treat group and the evaluable group of patients.

CONCLUSION

It is concluded that ampicillin/sulbactam is as safe and effective as clindamycin in preventing postoperative wound infection following major head and neck surgery.

Chest infection following head and neck surgery: a pilot study

This paper reports the results of a pilot study which examined factors associated with chest infection following head and neck surgery. The overall rate of chest infection was 11%, but was 20% in those patients having a tracheotomy. No infection developed in patients with an intact airway. Other factors which emerged as possibly important were the duration of surgery and heavy regular alcohol intake. We recommend that prophylactic antibiotics be continued for at least 48 h in patients requiring a tracheotomy as part of their head and neck surgery. This is against the trend of shorter antibiotic regimens recommended for prevention of wound infections.

Role of aerobic gram-negative rods, anaerobes, and fungi in wound infection after head and neck surgery: implications for antibiotic prophylaxis

The prevention of wound infection after major contaminated head and neck surgery is a critical issue for the head and neck surgeon. The proper interpretation of cultures taken from wounds is uncertain. Multiple organisms are invariably isolated from this nonsterile site including indigenous aerobic and anaerobic flora, aerobic gram-negative rods, and fungi. We present evidence from controlled antibiotic trials that demonstrate the pathogenicity of oropharyngeal anaerobic flora. The presence of aerobic gram-negative rods and fungi generally represent colonization and antibiotic coverage need not routinely be directed at these organisms. On the other hand, the antibacterial spectrum of an agent used for head and neck would prophylaxis should include coverage for pathogenic oral flora, namely the gram-positive aerobic cocci (especially streptococci) and anaerobic bacteria.

Intraoperative adjuvant radiotherapy for advanced cancers of the head and neck. Preliminary report

We have reported the early local control and survival results of treatment of recurrent or metastatic head and neck tumors with intraoperative brachytherapy. All six patients were locally free of disease after curative surgery and intraoperative brachytherapy for 4 months to 1 year, whereas two of eight patients were alive at last follow-up at 7 and 8 months with some complications after palliative surgery and intraoperative brachytherapy. We advocate such a technique not only in hopelessly advanced tumors but also in less advanced tumors, as well as a definitively integrated plan of management. Doses of iodine-125 of up to 15,000 rads are safe and well tolerated, even in the presence of a past history of radiotherapy.

125I vicryl suture implants as a surgical adjuvant in cancer of the head and neck

Sixty-four intraoperative 125I seed implants using absorbable suture (Vicryl) carriers were performed in 53 patients with head and neck cancers at Stanford between 1975 and 1980. In previously untreated patients, local control in the implanted volume or in all head and neck sites was obtained in 79 and 71%, respectively. Five of these patients (40%) remained NED. Of 34 patients with recurrent carcinomas, local control was obtained in the implant volume in 20 (59%), while 38% had no recurrence post-implantation in any head and neck site. The incidence of complications is correlated with 125I radiation doses, total millicuries inserted, seed strength used, and tissue volume implanted for both untreated patients and those with local recurrences. Guidelines for the optimal use of the above 4 parameters are also presented. We conclude that 125I seed Vicryl intraoperative suture implants are an effective surgical adjuvant in the treatment of advanced, previously untreated or recurrent head and neck cancers.

Cost-effectiveness of prophylactic antibiotics in head and neck surgery

Studies undertaken at the Eye and Ear Hospital of Pittsburgh indicate that antibiotic prophylaxis can reduce the incidence of patient morbidity. In this article we will demonstrate the effect of antibiotic prophylaxis on the economics of major head and neck surgery. One hundred and one patients were assigned to one of four treatment protocols, three of which entailed 1 day of a perioperative prophylactic antibiotic and the fourth a placebo. The study was conducted in a double-blind, randomized fashion. Patients receiving a placebo experienced an infection rate of 78%. Patients receiving cefazolin experienced an infection rate of 33%. Ten percent of patients treated with cefoperazone or cefotaxime developed postoperative wound infection. Postoperative hospitalization averaged 17.9 days for patients who did not develop postoperative wound infection, in contrast to an average of 32.6 days for patients with postoperative would infection. The added cost of postoperative infection justifies the added use of the newer, more expensive antibiotics in view of the reduced postoperative morbidity and postoperative hospitalization.

Pretreatment airway management in obstructing carcinoma of the larynx

Partial endoscopic excision of obstructing laryngeal carcinoma with the CO2 laser is an alternative to emergency tracheotomy or emergency laryngectomy whenever the airway control can be initially ensured by endotracheal intubation. The practical advantages of this approach are elimination of the septic complications of tracheotomy, the opportunity for planned preoperative chemotherapy or radiation therapy, and better nutritional and psychologic preparation of the patient for surgery.