Factors Impacting Discharge Destination Following Head and Neck Microvascular Reconstruction

OBJECTIVE

Determine which variables impact postoperative discharge destination following head and neck microvascular free flap reconstruction.

STUDY DESIGN

Retrospective review of prospectively collected databases.

METHODS

Consecutive patients undergoing head and neck microvascular free flap reconstruction between January 2010 and December 2019 (n = 1972) were included. Preoperative, operative and postoperative variables were correlated with discharge destination (home, skilled nursing facility [SNF], rehabilitation facility, death).

RESULTS

The mean age of patients discharged home was lower (60 SD ± 13, n = 1450) compared to those discharged to an SNF (68 SD ± 14, n = 168) or a rehabilitation facility (71 SD ± 14, n = 200; p < 0.0001). Operative duration greater than 10 h correlated with a higher percentage of patients being discharged to a rehabilitation or SNF (25% vs. 15%; p < 0.001). Patients were less likely to be discharged home if they had a known history of cardiac disease (71% vs. 82%; p < 0.0001). Patients were less likely to be discharged home if they experienced alcohol withdrawal (67% vs. 80%; p = 0.006), thromboembolism (59% vs. 80%; p = 0.001), a pulmonary complication (46% vs. 81%; p < 0.0001), a cardiac complication (46% vs. 80%; p < 0.0001), or a cerebral vascular event (25% vs. 80%; p < 0.0001). There was no correlation between discharge destination and occurrence of postoperative wound infection, salivary fistula, partial tissue necrosis or free flap failure. Thirty-day readmission rates were similar when stratified by discharge destination.

CONCLUSION

There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination. Patient age, operative duration and occurrence of a medical complication postoperatively did correlate with discharge destination.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:95-104, 2023.

Impact of preoperative and intraoperative management on outcomes in osteoradionecrosis requiring free flap reconstruction

BACKGROUND

Perioperative management of advanced osteoradionecrosis of the head and neck requiring free flap (FF) reconstruction varies. Our objectives included assessment of practice patterns and outcomes.

METHODS

Multi-institutional, retrospective review of FF reconstruction for head and neck osteoradionecrosis (n = 260).

RESULTS

Administration of preoperative antibiotics did not correlate with reduction in postoperative complications. Preoperative alcohol use correlated with higher rates of hardware exposure (p = 0.03) and 30-day readmission (p = 0.04). Patients with FF compromise had higher TSH (p = 0.04) and lower albumin levels (p = 0.005). Prealbumin levels were lower in patients who required neck washouts (p = 0.02) or a second FF (p = 0.03). TSH levels were higher in patients undergoing postoperative debridement (p = 0.03) or local flap procedures (p = 0.04).

CONCLUSION

Malnutrition, hypothyroidism, and substance abuse correlated with a higher incidence of postoperative wound complications in patients undergoing FF reconstruction for advanced osteoradionecrosis. Preoperative antibiotics use did not correlate with a reduction in postoperative wound complications.

Age and Comorbidities Impact Medical Complications and Mortality Following Free Flap Reconstruction

OBJECTIVE

Determine if age correlated with surgical or medical complications following head and neck free flap reconstruction.

STUDY DESIGN

Retrospective review of prospectively collected databases.

METHODS

Patients undergoing head and neck free flap reconstruction at three tertiary care institutions were included (n = 1972). Cohorts were based on age (<65, 65-75, 75-85, and >85). Outcomes reviewed operative duration, length of stay, surgical complications (free flap failure, fistula, hematoma, dehiscence, and infection), and medical complications (thromboembolism, stroke, cardiac, and pulmonary).

RESULTS

Anatomic site (P < .0001) and donor site varied by age (P < .0001). There was no difference in operative duration (P = .3) or length of hospitalization (P = .8) by age. The incidence of medical complications increased with increasing age. Pulmonary complication rates: <65 (3.9%), 65 to 75 (4.8%), 75 to 85 (7.1%), and >85 (11%) (P = .02). Cardiac complication rates: <65 (2.0%), 65 to 75 (7.3%), 75 to 85 (6.1%), and >85 (16.4%) (P < .0001). Mortality increased with age: <65 (0.4%), 65 to 75 (0.8%), 75 to 85 (1.1%), and >85 (4.1%) (P < .003). Medical complications correlated with mortality rates: pulmonary (3.5% vs. 0.6%; OR: 5.5; 95% CI: 1.5-20.0; P = .004); cardiac (3.3% vs. 0.6%; OR: 6.0; 95% CI: 1.6-21.8; P = .002); thromboembolism (4.6% vs. 0.7%; OR: 7.3; 95% CI: 1.6-33.6; P = .003); stroke (42% vs. 0.5%; OR: 149; 95% CI: 40-558; P < .0001); and sepsis (5% vs. 0.7%; OR 7.5; 95% CI: 1.0-60.5; P = .03). Age did not correlate with free flap success (P = .5), surgical complications (hematoma, P = .33; fistula, P = .23; infection, P = .07; and dehiscence, P = .37), or thirty-day readmission (P = .3).

CONCLUSION

Following free flap reconstruction, patient age did not correlate with development of a surgical complication. Patient age did correlate with development of a medical complication. Postoperative medical complications were found to correlate with perioperative mortality.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Microvascular Reconstruction of Osteonecrosis: Assessment of Long-term Quality of Life

OBJECTIVE

Review long-term clinical and quality-of-life outcomes following free flap reconstruction for osteonecrosis.

STUDY DESIGN

Retrospective multi-institutional review.

SETTING

Tertiary care centers.

METHODS

Patients included those undergoing free flap reconstructions for osteonecrosis of the head and neck (N = 232). Data included demographics, defect, donor site, radiation history, perioperative management, diet status, recurrence rates, and long-term quality-of-life outcomes. Quality-of-life outcomes were measured using the University of Washington Quality of Life (UW-QOL) survey.

RESULTS

Overall flap success rate was 91% (n = 212). Relative to preoperative diet, 15% reported improved diet function at 3 months following reconstruction and 26% at 5 years. Osteonecrosis recurred in 14% of patients (32/232); median time to onset was 11 months. Cancer recurrence occurred in 13% of patients (29/232); median time to onset was 34 months. Results from the UW-QOL questionnaire were as follows: no pain (45%), minor or no change in appearance (69%), return to baseline endurance level (37%), no limitations in recreation (40%), no changes in swallowing following reconstruction (28%), minor or no limitations in mastication (29%), minor or no speech difficulties (93%), no changes in shoulder function (84%), normal taste function (19%), normal saliva production (27%), generally excellent mood (44%), and no or minimal anxiety about cancer (94%).

CONCLUSION

The majority of patients maintained or had advancement in diet following reconstruction, with low rates of osteonecrosis or cancer recurrence and above-average scores on UW-QOL survey suggesting good return of function and quality of life.

Robotic-assisted transoral removal of a bilateral floor of mouth ranulas

Objective

To describe the management of bilateral oral ranulas with the use of the da Vinci Si Surgical System and discuss advantages and disadvantages over traditional transoral resection.

Study Design

Case Report and Review of Literature.

Results

A 47 year old woman presented to our service with an obvious right floor of mouth swelling. Clinical evaluation and computerized tomography scan confirmed a large floor of mouth ranula on the right and an incidental asymptomatic early ranula of the left sublingual gland. After obtaining an informed consent, the patient underwent a right transoral robotic-assisted transoral excision of the ranula and sublingual gland with identification and dissection of the submandibular duct and lingual nerve. The patient had an excellent outcome with no evidence of lingual nerve paresis and a return to oral intake on the first postoperative day. Subsequently, the patient underwent an elective transoral robotic-assisted excision of the incidental ranula on the left sublingual gland.

Conclusion

We describe the first robotic-assisted excision of bilateral oral ranulas in current literature. The use of the da Vinci system provides excellent visualization, magnification, and dexterity for transoral surgical management of ranulas with preservation of the lingual nerve and Wharton's duct with good functional outcomes. However, the use of the robotic system for anterior floor of mouth surgery in terms of improved surgical outcomes as compared to traditional transoral surgery, long-term recurrence rates, and cost effectiveness needs further validation.

Ultrafiltration in the treatment of refractory congestive heart failure

Artificial subtraction of fluids and solutes was evaluated in the course of acute and chronic heart failure when it became refractory to standard intensive medical treatment. A group of 19 patients (mean age 57 years), 9 with ischemic, 2 amyloidotic, 4 valvular, and 4 idiopathic cardiomyopathy, were treated. In 17 patients extracorporeal ultrafiltration (UF) by means of a polysulfonate ultrafilter was adopted along 125 sessions (105 assisted by a roller pump and 20 as a slow continuous ultrafiltrate). In two patients continuous peritoneal dialysis was adopted. In every case UF was well tolerated. Ultrafiltrate volumes ranged from 1680 to 3500 ml for every session with corresponding Na losses ranging from 194 to 434 mEq/session. Improved clinical and functional status with reduction of edema was observed in 17 of 19 patients. In 12 patients UF could be discontinued due to restored response to diuretics; 5 of these patients could subsequently undergo heart surgery (1 transplant, 3 valve replacement, 1 coronary bypass). The remaining 7 patients survived on medical therapy alone for an average of 228 days. In 7 of 19 cases, UF could not be discontinued, and these patients died after an average of 23 days of treatment. In conclusion, UF proved to be effective in eliminating salt-fluid overload and restoring response to medical treatment. Patients who are potential surgical candidates seem to be the most suitable for UF.