Impact of Goal Directed Therapy in Head and Neck Oncological Surgery with Microsurgical Reconstruction: Free Flap Viability and Complications

Development and validation of a novel nomogram model for identifying risk of prolonged length of stay among patients receiving free vascularized flap reconstruction of head and neck cancer

Background

The aim of the present study was to build and internally validate a nomogram model for predicting prolonged length of stay (PLOS) among patients receiving free vascularized flap reconstruction of head and neck cancer (HNC).

Methods

A retrospective clinical study was performed at a single center, examining patients receiving free vascularized flap reconstruction of HNC from January 2011 to January 2019. The variables were obtained from the electronic information system. The primary outcome measure was PLOS. Univariate and multivariate analyses were used to find risk factors for predicting PLOS. A model was then built according to multivariate results. Internal validation was implemented via 1000 bootstrap samples.

Results

The study included 1047 patients, and the median length of stay (LOS) was 13.00 (11.00, 16.00) days. Multivariate analysis showed that flap types ((radial forearm free flap (odds ratio [OR] = 2.238; 95% CI, 1.403-3.569; P = 0.001), free fibula flap (OR = 3.319; 95% CI, 2.019-4.882; P < 0.001)), duration of surgery (OR = 1.002; 95% CI, 1.001-1.003; P = 0.004), postoperative complications (OR = 0.205; 95% CI, 0.129-0.325; P = P < 0.001) and unplanned reoperation (OR = 0.303; 95% CI, 0.140-0.653; P = 0.002) were associated with PLOS. In addition to these variables, blood transfusion was comprised in the model. The AUC of the model was 0.78 (95% CI, 0.711-0.849) and 0.725 (95% CI, 0.605-0.845) in the primary and internal validation cohorts, respectively. The DCA revealed the clinical utility of the current model when making intervention decisions within the PLOS possibility threshold range of 0.2-0.8.

Conclusions

Our study developed a nomogram that exhibits a commendable level of accuracy, thereby aiding clinicians in assessing the risk of PLOS among patients receiving free vascularized flap reconstruction for HNC.

Effect of machine learning-guided haemodynamic optimization on postoperative free flap perfusion in reconstructive maxillofacial surgery: A study protocol

AIMS

Intraoperative hypotension and liberal fluid haemodynamic therapy are associated with postoperative medical and surgical complications in maxillofacial free flap surgery. The novel haemodynamic parameter hypotension prediction index (HPI) has shown good performance in predicting hypotension by analysing arterial pressure waveform in various types of surgery. HPI-based haemodynamic protocols were able to reduce the duration and depth of hypotension. We will try to determine whether haemodynamic therapy based on HPI can improve postoperative flap perfusion and tissue oxygenation by improving intraoperative mean arterial pressure and reducing fluid infusion.

METHODS

We present here a study protocol for a single centre, randomized, controlled trial (n = 42) in maxillofacial patients undergoing free flap surgery. Patients will be randomized into an intervention or a control group. In the intervention, group haemodynamic optimization will be guided by machine learning algorithm and functional haemodynamic parameters presented by the HemoSphere platform (Edwards Lifesciences, Irvine, CA, USA), most importantly, HPI. Tissue oxygen saturation of the free flap will be monitored noninvasively by near-infrared spectroscopy during the first 24 h postoperatively. The primary outcome will be the average value of tissue oxygen saturation in the first 24 h postoperatively.

Effect of comfort nursing in the perioperative period of free flap transplantation to repair the defects after surgery for malignant head and neck tumors

To explore the effect of comfort nursing in the perioperative period of free flap transplantation to repair defects of malignant head and neck tumors. This retrospective study included 242 patients with postoperative defects of malignant head and neck tumors repaired using free flap transplantation from December 2017 to December 2022. Among them, 113 patients received routine nursing and were included in the control group, and 129 patients received comfort nursing and were included in the observation group. The perioperative indexes of skin flap transplantation, skin flap necrosis, hospital stay, and cortisol levels were compared. Albumin and pre-albumin levels were compared 1 hour before and 24 hours after surgery. The nursing quality, Self-Rating Depression Scale and Self-Rating Anxiety Scale scores, and nursing satisfaction were compared between the 2 groups. The success rate of skin flap transplantation in the observation group was significantly higher than that in the control group, whereas the rates of skin flap necrosis, length of stay, and cortisol levels were significantly lower in the observation group than in the control group. The Albumin and pre-albumin levels in the observation group were significantly higher than those in the control group 24 hours after surgery. The complication rate was significantly lower in the observation group than in the control group. The Self-Rating Depression Scale and Self-Rating Anxiety Scale scores in the observation group were significantly lower than those in the control group 24 hours after surgery. The satisfaction with nursing was significantly higher in the observation group than in the control group. Comfort nursing improved the success rate of free flap transplantation, reduced complications, reduced stress, improved nutritional, and psychological status of patients during the perioperative period, and improved nursing quality and patient satisfaction with nursing.

Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction

It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.

Development of a Machine-Learning Model for Prediction of Extubation Failure in Patients with Difficult Airways after General Anesthesia of Head, Neck, and Maxillofacial Surgeries

(1) Background: Extubation failure after general anesthesia is significantly associated with morbidity and mortality. The risk of a difficult airway after the general anesthesia of head, neck, and maxillofacial surgeries is significantly higher than that after general surgery, increasing the incidence of extubation failure. This study aimed to develop a multivariable prediction model based on a supervised machine-learning algorithm to predict extubation failure in adult patients after head, neck, and maxillofacial surgeries. (2) Methods: A single-center retrospective study was conducted in adult patients who underwent head, neck, and maxillofacial general anesthesia between July 2015 and July 2022 at the Shanghai Ninth People's Hospital. The primary outcome was extubation failure after general anesthesia. The dataset was divided into training (70%) and final test sets (30%). A five-fold cross-validation was conducted in the training set to reduce bias caused by the randomly divided dataset. Clinical data related to extubation failure were collected and a stepwise logistic regression was performed to screen out the key features. Six machine-learning methods were introduced for modeling, including random forest (RF), k-nearest neighbor (KNN), logistic regression (LOG), support vector machine (SVM), extreme gradient boosting (XGB), and optical gradient boosting machine (GBM). The best performance model in the first cross-validation dataset was further optimized and the final performance was assessed using the final test set. (3) Results: In total, 89,279 patients over seven years were reviewed. Extubation failure occurred in 77 patients. Next, 186 patients with a successful extubation were screened as the control group according to the surgery type for patients with extubation failure. Based on the stepwise regression, seven variables were screened for subsequent analysis. After training, SVM and LOG models showed better prediction ability. In the k-fold dataset, the area under the curve using SVM and LOG were 0.74 (95% confidence interval, 0.55-0.93) and 0.71 (95% confidence interval, 0.59-0.82), respectively, in the k-fold dataset. (4) Conclusion: Applying our machine-learning model to predict extubation failure after general anesthesia in clinical practice might help to reduce morbidity and mortality of patients with difficult airways after head, neck, and maxillofacial surgeries.

Infusion management associated with prolonged length of stay following free flap reconstruction of head and neck defects: A propensity score matching study

BACKGROUND

Surgical resection of the primary lesion and reconstruction of the defects with free flaps are common treatments for head and neck cancer (HNC). However, various variables can lead to prolonged length of stay (LOS). The aim of this study is to investigate risk factors correlated with prolonged LOS following free flap reconstruction of head and neck defects.

METHODS

A retrospective study of patients with all types of free flaps reconstruction of HNC between January 2011 and January 2019 at Sun Yat-sen Memorial Hospital was performed. We recorded predictive variables and divided them into: personal and clinical, hemodynamic, anesthetic and surgical. The primary endpoint was prolonged length of stay. Univariate and multivariate analyses were applied to identify risk factors that associated with prolonged LOS. Propensity score matching was performed with the identified risk variables and other perioperative factors that may impact transfusion decision to explore the independent influence of intraoperative blood transfusion on prolonged LOS.

RESULTS

A total of 1047 patients were included in this study. The median LOS was 13.00 (11.00, 16.00) days. Multivariate analysis suggested that blood transfusion, duration of surgery, postoperative complications and unplanned reoperation were associated with prolonged LOS. After propensity score matching, unnecessary blood transfusion and inadequate fluid rate over 24 h, postoperative complications and unplanned reoperation were identified risk factors that led to prolonged LOS.

CONCLUSION

Unnecessary blood transfusion and inadequate fluid infusion rate over 24 h were independent risk factors associated with prolonged LOS in HNC patients who underwent free flap reconstruction. Our results indicated consideration of restrictive blood transfusion and adequate fluid infusion over postoperative 24 h in these patients.

Shedding of the Endothelial Glycocalyx Independent of Systemic Tryptase Release during Oncologic Oral Surgery: An Observational Study

The endothelial glycocalyx and endothelial surface layer are crucial for several functions of the vasculature. Damage to the glycocalyx (“shedding”) occurs during diverse clinical conditions, including major surgery. Mast cell tryptase has been proposed as one possible “sheddase”. During oncologic oral surgery, glycocalyx shedding could be detrimental due to loss of vascular barrier function and consequent oedema in the musculocutaneous flap graft. Concentrations of the glycocalyx components heparan sulphate and syndecan-1, as well as of tryptase in blood serum before and after surgery, were measured in 16 patients undergoing oncologic oral surgery. Secondary measures were the concentrations of these substances on postoperative days 1 and 2. Heparan sulphate rose from 692 (median, interquartile range: 535–845) to 810 (638–963) ng/mL during surgery. Syndecan-1 increased from 35 (22–77) ng/mL to 138 (71–192) ng/mL. Tryptase remained virtually unchanged with 4.2 (3–5.6) before and 4.2 (2.5–5.5) ng/mL after surgery. Concentrations of heparan sulphate and syndecan-1 in serum increased during surgery, indicating glycocalyx shedding. Tryptase concentration remained equal, suggesting other sheddases than systemic tryptase release to be responsible for damage to the glycocalyx. Investigating strategies to protect the glycocalyx during oncologic oral surgery might hold potential to improve flap viability and patient outcome.

Comparison of restrictive fluid therapy with goal-directed fluid therapy for postoperative delirium in patients undergoing spine surgery: a randomized controlled trial

Background

Postoperative delirium (POD) is a common phenomenon after spinal surgery. Intraoperative fluid management may affect POD. The aim of this study was to compare the effects of restrictive fluid therapy (RF) with those of goal-directed fluid therapy (GDT) on POD.

Methods

A total of 195 patients aged ≥ 50 years who underwent spinal surgery were randomly divided into two groups: the RF group and the GDT group. In group RF, a bolus of lactated Ringer’s solution was administered at a dose of 5 mL·kg^-1 before the induction of anesthesia, followed by a dose of 5 mL·kg^-1·h^-1 until the end of surgery. For patients in the GDT group, in addition to the initial administration of lactated Ringer’s solution at 5 mL·kg^-1, the subsequent fluid therapy was adjusted by using a continuous noninvasive arterial pressure (CNAP) monitoring system to maintain pulse pressure variation (PPV) ≤ 14%. The primary endpoint was the incidence of POD, assessed once daily with the Confusion Assessment Method-Chinese Reversion (CAM-CR) scale at 1–3 days postoperatively. The secondary endpoints were intraoperative fluid infusion volume, urine volume, mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), regional cerebral oxygen saturation (rSO₂) value, lactic acid value, and visual analog scale (VAS) pain score at 1–3 days after surgery. Moreover, postoperative complications and the length of hospital stay were recorded.

Results

The incidence of POD was lower in the GDT group than in the RF group (12.4% vs 4.1%; P = 0.035) in the first 3 days after spine surgery. Compared to group RF, group GDT exhibited a significantly increased volume of intraoperative lactated Ringer’s solution [1500 (interquartile range: 1128 to 1775) mL vs 1000 (interquartile range: 765 to 1300) mL, P < 0.001] and urine volume [398 (interquartile range: 288 to 600) mL vs 300 (interquartile range: 200 to 530) mL, P = 0.012]. Intraoperative MAP, CI and rSO₂ values were higher in the GDT group than in the RF group (P < 0.05). Moreover, the length of hospital stay [17.0 (14 to 20) days versus 14.5 (13 to 17.0) days, P = 0.001] was shorter in the GDT group than in the RF group.

Conclusions

GDT reduced the incidence of POD in middle- and old-aged patients undergoing spinal surgery possibly by stabilizing perioperative hemodynamic and improving the supply and demand of oxygen.

Trial registration

ChiCTR2000032603; Registered on May 3, 2020.