Meghan M. Crippen

Association of Anesthesia Duration With Complications After Microvascular Reconstruction of the Head and Neck

Importance Prolonged anesthesia and operative times have deleterious effects on surgical outcomes in a variety of procedures. However, data regarding the influence of anesthesia duration on microvascular reconstruction of the head and neck are lacking. Objective To examine the association of anesthesia duration with complications after microvascular reconstruction of the head and neck. Design, Setting, and Participants The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to collect data. In total, 630 patients who underwent head and neck microvascular reconstruction were recorded in the NSQIP registry from January 1, 2005, through December 31, 2013. Patients who underwent microvascular reconstructive surgery performed by otolaryngologists or plastic surgeons were included in this study. Data analysis was performed from October 15, 2015, to January 15, 2016. Exposures Microvascular reconstructive surgery of the head and neck. Main Outcomes and Measures Patients were stratified into 5 quintiles based on mean anesthesia duration and analyzed for patient characteristics and operative variables (mean [SD] anesthesia time: group 1, 358.1 [175.6] minutes; group 2, 563.2 [27.3] minutes; group 3, 648.9 [24.0] minutes; group 4, 736.5 [26.3] minutes; and group 5, 922.1 [128.1] minutes). Main outcomes include rates of postoperative medical and surgical complications and mortality. Results A total of 630 patients undergoing head and neck free flap surgery had available data on anesthesia duration and were included (mean [SD] age, 61.6 [13.8] years; 436 [69.3%] male). Bivariate analysis revealed that increasing anesthesia duration was associated with increased 30-day complications overall (55 [43.7%] in group 1 vs 80 [63.5%] in group 5, P = .006), increased 30-day postoperative surgical complications overall (45 [35.7%] in group 1 vs 78 [61.9%] in group 5, P < .001), increased rates of postoperative transfusion (32 [25.4%] in group 1 vs 70 [55.6%] in group 5, P < .001), and increased rates of wound disruption (0 in group 1 vs 10 [7.9%] in group 5, P = .02). No specific medical complications and no overall medical complication rate (24 [19.0%] in group 1 vs 22 [17.5%] in group 5, P = .80) or mortality (1 [0.8%] in group 1 vs 1 [0.8%] in group 5, P = .75) were associated with increased anesthesia duration. On multivariate analysis accounting for demographics and significant preoperative factors including free flap type, overall complications (group 5: odds ratio [OR], 1.98; 95% CI, 1.10-3.58; P = .02), surgical complications (group 5: OR, 2.46; 95% CI, 1.35-4.46; P = .003), and postoperative transfusion (group 5: OR, 2.31; 95% CI, 1.27-4.20; P = .006) remained significantly associated with increased anesthesia duration; the association of wound disruption and increased anasthesia duration was nonsignificant (group 5: OR, 2.0; 95% CI, 0.75-5.31; P = .16). Conclusions and Relevance Increasing anesthesia duration was associated with significantly increased rates of surgical complications, especially the requirement for postoperative transfusion. Rates of medical complications were not significantly altered, and overall mortality remained unaffected. Avoidance of excessive blood loss and prolonged anesthesia time should be the goal when performing head and neck free flap surgery. Level of Evidence 3.

The effect of training level on complications after free flap surgery of the head and neck

OBJECTIVES Analyze postoperative complications after free flap surgery based on PGY training level. METHODS Data on free flap surgeries of the head and neck performed from 2005 to 2013 was collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Cases identifying the status of resident participation in the surgery and the PGY level were included. RESULTS There were 582 cases with primary surgeon data available. 63 cases were performed with a junior resident, 211 were performed with the assistance of a senior resident, 279 cases were performed with a fellow, and 29 cases were performed by an attending alone without resident involvement. The overall complication rate was 55.2%. There was no statistically significant difference in the rate of complications between groups (47.6%, 59.7%, 53.0%, 58.6%, p=0.277). After controlling for all confounding variables using multivariate analysis there was no significant difference in morbidity, mortality, readmissions, and reoperation amongst the groups. Furthermore, when comparing resident versus fellow involvement using multivariate analysis there were no significant differences in morbidity (OR=0.768[0.522-1.129]), mortality (OR=1.489[0.341-6.499]), readmissions (OR=1.018[0.458-2.262]), and reoperation (OR=0.863[0.446-1.670]). CONCLUSION Resident and fellow participation in microvascular reconstructive cases does not appear to increase 30-day rates of medical, surgical, or overall complications.

Laryngectomy and smoking: An analysis of postoperative risk

To investigate the impact of smoking on complication rates following total laryngectomy.

Impact of Body Mass Index on Operative Outcomes in Head and Neck Free Flap Surgery

Objective Analyze the risk for perioperative complications associated with body mass index (BMI) class in patients undergoing head and neck free flap reconstruction. Study Design and Setting Retrospective cohort study. Subjects and Methods The National Surgical Quality Improvement Program (NSQIP) database was queried for all cases of head and neck free flaps between 2005 and 2014 (N = 2187). This population was stratified into underweight, normal-weight, overweight, and obese BMI cohorts. Groups were compared for demographics, comorbidities, and procedure-related variables. Rates of postoperative complications were compared between groups using χ2 and binary logistic regression analyses. Results Underweight patients (n = 160) had significantly higher rates of numerous comorbidities, including disseminated cancer, preoperative chemotherapy, and anemia, while obese patients (n = 447) had higher rates of diabetes and hypertension. Rates of overall surgical complications, medical complications, and flap loss were insignificantly different between BMI groups. Following regression, obese BMI was protective for perioperative transfusion requirement (odds ratio [OR] = 0.63, P = .001), while underweight status conferred increased risk (OR = 2.43, P < .001). Recent weight loss was found to be an independent predictor of perioperative cardiac arrest (OR = 3.16, P = .006) while underweight BMI was not (OR = 1.21, P = .763). However, both weight loss and underweight status were associated with significantly increased risk for 30-day mortality (OR = 4.48, P = .032; OR = 4.02, P = .010, respectively). Conclusion Obesity does not increase the risk for postoperative complications in head and neck free flap surgery and may be protective in some cases. When assessing a patient’s fitness for surgery, underweight status or recent weight loss may suggest a reduced ability to tolerate extensive free flap reconstruction.

Impact of diabetes on free flap surgery of the head and neck: A NSQIP analysis

Diabetes is associated with microvascular pathology and may predispose patients undergoing microvascular surgery to complications. This study assesses diabetes as a risk factor for complications following free flap surgery of the head and neck.

Refusal of Cancer-Directed Surgery in Head and Neck Squamous Cell Carcinoma Patients: Surgery Refusal in Head and Neck Cancer

To investigate the risk factors for refusal of recommended surgery in head and neck squamous cell carcinoma (HNSCC) treatment

The Impact of Duty-Hour Restrictions on Complication Rates Following Major Head and Neck Procedures: Head and Neck Surgery Duty-Hour Restrictions

To assess the impact of resident duty‐hour restrictions (DHR) in otolaryngology via comparison of postoperative outcomes between otolaryngology teaching hospitals (Oto‐TH) and nonteaching hospitals (NTH) before and after complete implementation.

Association of Smoking Tobacco With Complications in Head and Neck Microvascular Reconstructive Surgery

Importance Smoking is a highly prevalent risk factor among patients with head and neck cancer. However, few studies have examined the association of this modifiable risk factor on postoperative outcomes following microvascular reconstruction of the head and neck. Objective To analyze the risk associated with smoking in patients undergoing free flap surgery of the head and neck. Design, Setting, and Participants In this retrospective, population, database study, the National Quality Improvement Program data sets from 2005 to 2014 were queried for all cases of head and neck surgery involving free flap reconstruction in the United States. The 2193 cases identified were stratified into smoking and nonsmoking cohorts and compared using &khgr;2 and binary logistic regression analyses. Pack-years of smoking data were used to assess the degree of risk associated with a prolonged history of smoking. All analyses were conducted between January 2018 and June 2018. Main Outcomes and Measures Smoking and nonsmoking cohorts were compared for rates of demographic characteristics, comorbidities, and complications. Following correction for differences in patient demographics and comorbidities, smoking and nonsmoking cohorts were compared for rates of postoperative complications. Complication rates were further assessed within the smoking cohort by number of pack years smoked. Results Of the 2193 patients identified as having undergone free flap reconstruction of the head and neck, 624 (28.5%) had a history of recent smoking. After accounting for differences in demographic variables and patient comorbidities using regression analyses, smoking status was found to be independently associated with wound disruption (odds ratio, 1.74; 95% CI, 1.17-2.59; P = .006) and unplanned reoperation (odds ratio, 1.50; 95% CI, 1.15-1.95; P = .003). An analysis by pack-years of smoking showed that a longer smoking history was significantly associated with higher rates of numerous comorbidities but not with a corresponding increase in rates of complications. Conclusions and Relevance Smokers undergoing free flap reconstruction of the head and neck may be at significantly higher risk of postoperative wound disruption and subsequent reoperation. These risks were independent of pack-years of smoking history, suggesting that both risks were associated with perioperative smoke exposure, and preoperative smoking cessation may be of benefit. Level of Evidence NA.

Predictors of clinical-pathologic stage discrepancy in oral cavity squamous cell carcinoma: A National Cancer Database study

Few studies have examined the frequency and survival implications of clinicopathologic stage discrepancy in oral cavity squamous cell carcinoma (SCC).

Updates in the management of sinonasal mucosal melanoma.

Purpose of review Sinonasal mucosal melanoma (SNMM) is an aggressive cancer with a poor prognosis. Although there is significant study surrounding the treatment of sinonasal malignancies and cutaneous melanomas, the rarity of this tumor has largely precluded robust outcomes analyses. The authors of this review seek to provide an overview of the recent literature related to the treatment of SNMM with added context from our institutional experience with this disease. Recent findings In the surgical management of sinonasal malignancies and SNMM specifically, resection via endoscopic endonasal technique appears to offer comparable oncologic outcomes versus an open approach. The role of adjuvant therapy continues to be debated, but there is strong evidence for improved rates of local control with radiotherapy after complete resection. In the last few years, significant developments have been made in the study of systemic therapies for cutaneous melanoma. The identification of genetic mutations common to mucosal melanoma has allowed for early trials of targeted therapies, but study is ongoing. Summary Although the study of SNMM is largely limited to small retrospective case series, treatment continues to evolve. Until effective systemic therapies can be identified, endoscopic resection with adjuvant radiotherapy may offer the best disease-free survival with acceptably low morbidity.