Oleg Militsakh

Impact of Pharyngeal Closure Technique on Fistula After Salvage Laryngectomy

IMPORTANCEnNo consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy. We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post-radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge.nnnOBJECTIVEnTo determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx.nnnDESIGNnMulti-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers.nnnSETTINGnAcademic, tertiary referral centers.nnnPATIENTSnThe study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up.nnnMAIN OUTCOMES AND MEASURESnFistula incidence, severity, and predictors of fistula.nnnRESULTSnOf the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P < .001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P < .001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25% (P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15% (P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks).nnnCONCLUSIONS AND RELEVANCEnPharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.

Current Strategies in Reconstruction of Maxillectomy Defects

OBJECTIVEnTo outline a contemporary review of defect classification and reconstructive options.nnnDESIGNnReview article.nnnSETTINGnTertiary care referral centers.nnnRESULTSnAlthough prosthetic rehabilitation remains the standard of care in many institutions, the discomfort of wearing, removing, and cleaning a prosthesis; the inability to retain a prosthesis in large defects; and the frequent need for readjustments often limit the value of this cost-effective and successful method of restoring speech and mastication. However, flap reconstruction offers an option for many, although there is no agreement as to which techniques should be used for optimal reconstruction. Flap reconstruction also involves a longer recovery time with increased risk of surgical complications, has higher costs associated with the procedure, and requires access to a highly experienced surgeon.nnnCONCLUSIONnThe surgeon and reconstructive team must make individualized decisions based on the extent of the maxillectomy defect (eg, the resection of the infraorbital rim, the extent of palate excision, skin compromise) and the need for radiation therapy.

Outcomes of the Osteocutaneous Radial Forearm Free Flap for Mandibular Reconstruction

IMPORTANCEnLimited donor and recipient site complications support the osteocutaneous radial forearm free flap (OCRFFF) for mandibular reconstruction as a useful option for single-stage mandibular reconstruction.nnnOBJECTIVEnTo examine and report long-term outcomes and complications at the donor and recipient sites for patients undergoing the OCRFFF for mandibular reconstruction.nnnDESIGNnRetrospective review.nnnSETTINGnAcademic, tertiary care medical center.nnnPATIENTSnThe study population comprised 167 consecutive patients who underwent single-staged mandibular reconstruction with an OCRFFF.nnnMEAN OUTCOME MEASURESnRates of complications at the donor and recipient sites.nnnRESULTSnThe mean patient age was 61 years (range, 20-93 years). Men compromised 68% of the population. Follow-up interval ranged from 2 to 99 months (mean, 25.9 months). The median length of bone harvested was 7 cm (range, 2.5-12.0 cm). Prophylactic plating was completed for each of the radii at the time of harvest. Donor site complications included radial fracture (1 patient [0.5%]), tendon exposure (47 patients [28%]), and donor hand weakness or numbness (13 patients [9%]). Recipient site complications included mandible hardware exposure (29 patients [17%]), mandible nonunion or malunion (4 patients [2%]), and mandible bone or hardware fracture (4 patients [2%]). Using regression analysis, we found that patients were 1.3 times more likely to have plate exposure for every increase of 1 cm of bone harvest length; this was statistically significant (P = .04).nnnCONCLUSIONS AND RELEVANCEnThis is the largest single study reporting outcomes and complications for patients undergoing OCRFFF for mandibular reconstruction. Prophylactic plating of the donor radius has nearly eliminated the risk of pathologic radial bone fractures. Limited long-term donor and recipient site complications support the use of this flap for single-stage mandibular reconstruction.

Mandibulectomy and free flap reconstruction for bisphosphonate-related osteonecrosis of the jaws

IMPORTANCEnBisphosphonate-related osteonecrosis of the jaws is an increasingly recognized complication of intravenous and oral bisphosphonate therapy. Our experience suggests that mandibulectomy and free flap reconstruction is an effective treatment for patients with stage 3 and recalcitrant stage 2 disease.nnnOBJECTIVEnTo analyze indications for segmental mandibulectomy and microvascular free flap reconstruction for bisphosphonate-related osteonecrosis of the jaws and surgical outcomes following this procedure.nnnDESIGN, SETTING, AND PARTICIPANTSnIn a multi-institutional case series study conducted in academic tertiary care centers, 13 patients underwent segmental mandibulectomy and microvascular free flap reconstruction, including 8 patients with stage 3 disease and 5 patients with recalcitrant stage 2 disease. All patients had persistent or progressive disease despite conservative oral care and antibiotic treatment.nnnINTERVENTIONSnSegmental mandibulectomy and microvascular free flap reconstruction.nnnMAIN OUTCOMES AND MEASURESnTreatment efficacy and postoperative complications. RESULTS There was 1 total flap loss due to infection. The patient with a flap loss ultimately underwent a successful fibula osteocutaneous free flap reconstruction after serial irrigation and debridement. The overall complication rate was 46% (n = 6). All complications occurred in patients with stage 3 disease. Ultimately, all patients achieved a successful reconstruction, with no recurrences. All patients tolerated a soft or regular diet postoperatively.nnnCONCLUSIONS AND RELEVANCEnBisphosphonate-related osteonecrosis of the jaws is an increasingly recognized complication of intravenous and oral bisphosphonate therapy that can occasionally progress to involve full-thickness mandibular destruction, pathologic fracture, and fistulization, as well as chronic pain and infection. Mandibulectomy and free flap reconstruction is an effective treatment for patients with stage 3 and recalcitrant stage 2 bisphosphonate-related osteonecrosis of the jaws. High rates of chronic infection and underlying medical comorbidities may predispose to a substantial perioperative complication rate.

Vascularized tissue transfer in head and neck surgery: Is intensive care unit–based management necessary?

To study the impact of a non–intensive care unit (ICU)–based postoperative management strategy on patient outcomes following vascularized free tissue transfer for head and neck surgical defects.

Obesity and perioperative complications in head and neck free tissue reconstruction.

Free tissue transfer is a mainstay in reconstruction of complex head and neck defects. The purpose of this study was to determine if perioperative complications were more common in patients with body mass index (BMI) >30 kg/m2 undergoing free flap reconstruction.

Rehabilitation of a parotidectomy patient—A systematic approach

Parotidectomy is a common surgical procedure. Resultant contour defect, Freys syndrome, and facial nerve rehabilitation deserve special consideration. Microsurgical techniques provide unparallel advantage for reconstruction of large‐volume defects. Same‐stage reconstruction of the defect is advocated and often beneficial to the patient. The importance of full communication between the extirpative and reconstructive surgeon cannot be underscored. Often, institutional and personal biases must be overcome to provide best quality care for the patient. This article provides a comprehensive review of the medical literature on the subject and contrives a systematic approach to the use of various reconstructive techniques.

Multimodal Analgesia in Outpatient Head and Neck Surgery: A Feasibility and Safety Study

Importance Perioperative analgesia strategies that rely solely on narcotics may contribute to adverse effects and concerns about opioid abuse or dependence. Multimodal analgesia protocols incorporating nonnarcotic agents may reduce the need for postoperative narcotic use. Objective To evaluate the feasibility and safety of a multimodal analgesia protocol for outpatient head and neck surgical procedures and to identify the association of the multimodal analgesia protocol with postoperative pain perception scores and patient satisfaction. Design, Setting, and Participants Retrospective evaluation of prospectively collected data on adults who underwent outpatient thyroid, parathyroid, and parotid surgery between July 2016 and February 2017 at the head and neck surgery service of a tertiary care hospital using a multimodal analgesia strategy with use of immediate preoperative acetaminophen and gabapentin, and intention to treat with a nonnarcotic postoperative outpatient analgesia strategy. Main Outcomes and Measures Overall patient satisfaction scores, Overall Benefit of Analgesia Score (OBAS), and median resting and peak pain scores were recorded. Incidence of reliance on a narcotic-based postoperative outpatient analgesia strategy and adverse events related to altered analgesia strategy were identified. Results Sixty-four patients (48 [75%] female; mean [SD] age, 54.6 [14.3] years) underwent outpatient thyroid, parathyroid, or parotid surgery with use of a multimodal analgesia protocol. On a 10-point rating scale, patients reported low resting pain perception scores (median, 2 [range, 0-8]) and peak pain scores (median, 4 [range, 0-9]). The OBAS assessment for composite effectiveness of analgesia indicated a favorable median score of 1 (range, 0-10; permissible range, 0-28, with lower scores better). Thirty-nine (61%) patients were able to avoid postoperative narcotic use on discharge. Fifty-six (88%) patients reported “high” or “very high” satisfaction with the multimodal analgesia strategy. No complications related to bleeding, hematoma, significant adverse events, or readmissions were observed. Conclusion and Relevance A multimodal analgesia strategy was feasible and safe in patients undergoing outpatient head and neck surgery and may reduce the need for narcotic use. It was associated with low pain perception scores, favorable OBAS, and overall satisfaction scores. The role of multimodal analgesia needs additional evaluation through comparative effectiveness assessment vs conventional pain management strategies.

Impact of Primary Tracheoesophageal Puncture on Outcomes after Total Laryngectomy

Objectives To identify differences in postoperative wound complications associated with a primary tracheoesophageal puncture (TEP) at the time of laryngectomy versus no TEP. Study Design Retrospective review of large national data set. Setting Academic and nonacademic health care facilities in United States, contributing de-identified, risk-adjusted clinical data to the American College of Surgeons National Surgical Quality Improvement Program. Subjects and Methods The National Surgical Quality Improvement Program data set for years 2006 to 2012 identified 430 patients who underwent total laryngectomy with or without a primary TEP. Patients who underwent a TEP at the time of laryngectomy (n = 68) were compared with patients who underwent laryngectomy without a TEP (n = 362). Postoperative wound complications and secondary outcomes, including medical complications and length of hospitalization, were compared between the groups. Results The incidence of “superficial” and “deep or organ space” surgical site infection, medical complications, return to the operating room, and length of hospitalization were similar between the groups. Patients in the TEP group had a higher overall wound complication rate (relative risk, 2.02; 95% CI = 1.06-3.84; attributable risk, 8.17%; number needed to harm, 12). Conclusions Performance of a primary TEP concurrent to total laryngectomy contributed to a small increase in attributable risk for overall wound complications but did not add substantial risk for “superficial” or “deep or organ space” surgical site infection, medical complications, or increased burden for resource utilization. These data may help inform patient choice and physician recommendations for primary alaryngeal speech rehabilitation.

Impact of PET/CT on Staging and Treatment of Advanced Head and Neck Squamous Cell Carcinoma

Objective To understand the effects of positron emission tomography/computed tomography (PET/CT) evaluation on patients with previously untreated head and neck squamous cell carcinoma (HNSCC) with clinical evidence of regional lymph node involvement. Study Design Prospective blinded study. Setting Tertiary care cancer center. Subjects and Methods Informed consent was obtained and data collected from 52 consecutive previously untreated patients with HNSCC and clinical evidence of cervical metastasis. All patients underwent conventional evaluation for HNSCC and whole body PET/CT. Data were evaluated by 5 independent reviewers, who performed TNM staging per the American Joint Committee on Cancer (seventh edition) manual and proposed a treatment plan prior to viewing, and after reviewing, PET/CT. Cases where at least 3 of 5 reviewers agreed were considered significant. Results There were 0 patients for whom review of the PET/CT altered the T-class assessment (95% CI, 0-6.8), 12 (23.1%) for whom PET/CT altered N classification (95% CI, 12.5-34.5), and 2 (3.8%) for whom PET/CT altered the M classification (95% CI, 0.5-13.2). For 5 patients (9.6%), overall stage was altered per PET/CT review (95% CI, 3.2-21). For 3 patients (5.8%), PET/CT findings prompted reviewers to alter treatment recommendations (95% CI, 1.2-15.9). Conclusion When added to more conventional patient evaluation, PET/CT results in changes to the TNM categories, but overall staging and treatment were less frequently affected. Whether PET/CT should be used routinely for patients with stage III and IV HNSCC is still subjective and merits further study.