Submandibular gland involvement in oral cavity squamous cell carcinoma: a retrospective multicenter study

BACKGROUND

The submandibular gland (SMG) is routinely excised during neck dissection. Given the importance of the SMG in saliva production, it is important to understand its involvement rate by cancer tissue and the feasibility of its preservation.

METHODS

Retrospective data were collected from five academic centers in Europe. The study involved adult patients affected by primary oral cavity carcinoma (OCC) undergoing tumor excision and neck dissection. The main outcome analyzed was the SMG involvement rate. A systematic review and a meta-analysis were also conducted to provide an updated synthesis of the topic.

RESULTS

A total of 642 patients were enrolled. The SMG involvement rate was 12/642 (1.9%; 95% CI 1.0-3.2) when considered per patient, and 12/852 (1.4%; 95% CI 0.6-2.1) when considered per gland. All the glands involved were ipsilateral to the tumor. Statistical analysis showed that predictive factors for gland invasion were: advanced pT status, advanced nodal involvement, presence of extracapsular spread and perivascular invasion. The involvement of level I lymph nodes was associated with gland invasion in 9 out of 12 cases. pN0 cases were correlated with a reduced risk of SMG involvement. The review of the literature and the meta-analysis confirmed the rare involvement of the SMG: on the 4458 patients and 5037 glands analyzed, the involvement rate was 1.8% (99% CI 1.1-2.7) and 1.6% (99% CI 1.0-2.4), respectively.

CONCLUSIONS

The incidence of SMG involvement in primary OCC is rare. Therefore, exploring gland preservation as an option in selected cases would be reasonable. Future prospective studies are needed to investigate the oncological safety and the real impact on quality of life of SMG preservation.

1119 Readdressing Consent in Head & Neck Free Flap Surgery: The Nottingham Experience

Aim

The Montgomery vs NHS Lanarkshire case in 2015 led to a paradigm shift in the consent process within surgery. It became incumbent upon clinicians to outline all “material risks” prior to a procedure. Within head and neck surgery, the Enhanced Recovery After Surgery (ERAS) pathway addresses this obligation through a multi-disciplinary approach. The aim of this audit was to assess the effect of the existing ERAS pathway on the consent process.

Method

35 head and neck oncology cases involving free flap reconstruction were identified across two audit cycles. Cases pre- and post-introduction of the ERAS pathway were analysed to assess whether the existing pathway led to improvement in consent quality.

8 key consent elements were identified based on a review of current literature and guidelines. This was our gold standard. A tick-box system was devised, and each case assigned a percentage score based on compliance with these criteria. A consent checklist was introduced within the ERAS pathway file alongside multi-disciplinary documentation which would follow the patient from the pre-operative environment through to discharge.

Results

Prior to the introduction of the ERAS pathway, there was a 58% compliance with the gold standard. Upon implementation of the ERAS protocol, compliance rose to 65%. Following introduction of the checklist, compliance rose further to 85%. This resulted in an overall increase in compliance of 27%.

Conclusions

We recommend the introduction of a focused consent checklist within any unit providing major head and neck reconstruction procedures in order to ensure informed consent, mitigating medico-legal risks post-operatively.

Justification of routine venous thromboembolism prophylaxis in head and neck cancer reconstructive surgery

BACKGROUND

Venous thromboembolism (VTE) is a preventable complication in which early ambulation is expected after head and neck surgery. Thus, the role of VTE prophylaxis is questionable and needs further assessment. The purpose of this study was to specify the relative contributing risk factors for patients who underwent head and neck cancer ablation with immediate reconstruction.

METHODS

A retrospective analysis was conducted of consecutive head and neck cancer ablations with immediate reconstructions between 2008 and 2013. Dextran and prostaglandin E2 (PGE2) were routinely given as flap thromboprophylaxis. Logistic regression was applied to analyze the potentially significant risk factors.

RESULTS

Of 1953 subjects, the incidence of symptomatic VTE was 2.2% with 0.1% mortality rate. Prolonged surgery (>592.5 minutes; P = .048), immobilization (>4 days; P = .019), and subjects without postoperative flap thromboprophylaxis (P = .002) are significant risk factors for VTE development.

CONCLUSION

Our flap thromboprophylaxis regime might have played a crucial role in keeping the incidence of VTE low. Despite prolonged immobilization in fibula flap reconstruction, the incidence of VTE remained low when flap thromboprophylaxis was given.