From Pathways to Practice: Impact of Implementing Mobilization Recommendations in Head and Neck Cancer Surgery with Free Flap Reconstruction.
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ABSTRACT:
SUBMITTER: Twomey R
PROVIDER: S-EPMC8228478 | biostudies-literature | 2021 Jun
REPOSITORIES: biostudies-literature
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From Pathways to Practice: Impact of Implementing Mobilization Recommendations in Head and Neck Cancer Surgery with Free Flap Reconstruction.
Twomey Rosie R Matthews T Wayne TW Nakoneshny Steven C SC Schrag Christiaan C Chandarana Shamir P SP Matthews Jennifer J McKenzie David D Hart Robert D RD Li Na N Dort Joseph C JC Sauro Khara M KM
Cancers 20210609 12
One of the foundational elements of enhanced recovery after surgery (ERAS) guidelines is early postoperative mobilization. For patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction, the ERAS guideline recommends patients be mobilized within 24 h postoperatively. The objective of this study was to evaluate compliance with the ERAS recommendation for early postoperative mobilization in 445 consecutive patients who underwent HNC surgery in the Calgary Head and Neck En ...[more]
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Project description:Surgery with free flap reconstruction is a standard treatment for head and neck cancer (HNC). Because of the complexity of HNC surgery, recovery can be challenging, and complications are common. One of the foundations of enhanced recovery after surgery (ERAS) is early postoperative mobilization. The ERAS guidelines for HNC surgery with free flap reconstruction recommend mobilization within 24 h. This is based mainly on evidence from other surgical disciplines, and the extent to which mobilization within 24 h improves recovery after HNC surgery has not been explored. This retrospective analysis included 445 patients from the Calgary Head and Neck Enhanced Recovery Program. Mobilization after 24 h was associated with more complications of any type (OR = 1.73, 95% CI [confidence interval] = 1.16-2.57) and more major complications (OR = 1.76; 95% CI = 1.00-3.16). When accounting for patient and clinical factors, mobilization after 48 h was a significant predictor of major complications (OR = 2.61; 95% CI = 1.10-6.21) and prolonged length of stay (>10 days; OR = 2.85, 95% CI = 1.41-5.76). This comprehensive analysis of the impact of early mobilization on postoperative complications and length of stay in a large HNC cohort provides novel evidence supporting adherence to the ERAS early mobilization recommendations. Early mobilization should be a priority for patients undergoing HNC surgery with free flap reconstruction.
| S-EPMC8227616 | biostudies-literature
Project description:ImportanceMajor head and neck surgery with microvascular free tissue transfer reconstruction is complex, with considerable risk of morbidity. Little is known about patients' experiences, including decision-making prior to, and regret following, free flap surgery.ObjectiveTo characterize patient experiences and decision regret of patients undergoing head and neck reconstructive free flap surgery.Design, setting, and participantsThis mixed-methods cohort study comprising semistructured interviews was conducted June to August 2021 at a single tertiary academic cancer center. Participants underwent head and neck reconstructive surgery with microvascular free tissue transfer (flap) more than 3 months before recruitment (range, 3 months to 4 years). Interview transcripts were qualitatively analyzed for themes. Participants also completed a Decision Regret Scale questionnaire.ExposureMicrovascular free flap surgery for head and neck reconstruction.Main outcomes and measuresThematic analysis of interviews, decision regret score.ResultsSeventeen participants were interviewed. Median (IQR) age was 61 (52-70) years. Overall, 7 participants were women (49%), and 10 of 17 were men (59%). The most common free flap was fibula (8/17, 47%). Three major themes with 9 subthemes were identified: theme 1 was the tremendous effect of preoperative counseling on surgical decision-making and satisfaction, with subthemes including (1) importance of clinical care team counseling on decision to have surgery; (2) emotional context colors preoperative understanding and retention of information; (3) expectation-setting affects satisfaction with preoperative counseling; and (4) desire for diversified delivery of preoperative information. Theme 2 was coexisting and often conflicting priorities, including (1) desire to survive above all else, and (2) desire for quality of life. Theme 3 was perception of surgery as momentous and distressing, including (1) surgery as a traumatic event; (2) centrality of mental health, emotional resolve, and gratitude to enduring surgery and recovery; and (3) sense of accomplishment in recovery. On the Decision Regret Scale, most participants had no regret (n = 8, 47%) or mild regret (n = 5, 29%); 4 had moderate-to-severe regret (24%).Conclusions and relevanceIn this mixed-methods cohort study, patient experiences surrounding major head and neck reconstructive free flap surgery were described. Opportunities to improve support for this complex and vulnerable population, and to mitigate decision regret, were identified.
| S-EPMC10884946 | biostudies-literature
Project description:BackgroundAdherence to guidelines for antibiotic prophylaxis is often poor and is an important target for antimicrobial stewardship programs. Prescribing audits that suggested poor adherence to guidelines in a plastic surgery department led to a targeted education program to bring antibiotic prescriptions in line with hospital guidelines. We reviewed whether this intervention was associated with changed perioperative prescribing and altered surgical outcomes, including the rate of surgical site infections, specifically looking at clean-contaminated head and neck tumor resections with free flap reconstruction.MethodsA retrospective cohort study was performed on 325 patients who underwent clean-contaminated head and neck tumor resection and free flap reconstruction from January 1, 2013, to February 19, 2019. Patients were divided into 2 groups, those before (pre-intervention) and after (postintervention) the education campaign. We analyzed patient demographic and disease characteristics, intraoperative and postoperative factors, and surgical outcomes.ResultsPatients pre-intervention were prescribed longer courses of prophylactic antibiotics (median [interquartile range], 9 [8] vs 1 [1]; P < .001), more topical chloramphenicol ointment (21.82% vs 0%; P < .001), and more oral nystatin (36.9% vs 12.2%; P < .001). Patients postintervention had higher rates of recipient infections (36.11% vs 17.06%; P < .001) and donor site infections (6.94% vs 1.19%; P = .006).ConclusionsFollowing the education campaign, patients were prescribed shorter courses of prophylactic antibiotics, more of the recommended cefazolin-metronidazole regimen, and fewer topical antibiotics. However, patients also had a higher rate of surgical site infections.
| S-EPMC8743122 | biostudies-literature
Project description:IntroductionHistorically, there were concerns vasopressors impair free flap outcomes, but recent studies suggest vasopressors are safe. Here we investigate this controversy by (1) evaluating vasopressors' effect on head and neck free-flap survival and surgical complications, and (2) performing soft tissue and bony subset analysis.Patients and methodsPost hoc analysis was performed of a single-blinded, prospective, randomized clinical trial at a tertiary care academic medical center involving patients ≥18 years old undergoing head and neck free flap reconstruction over a 16-month period. Patients were excluded if factors prevented accurate FloTrac™ use. Patients were randomized to traditional volume-based support, or goal-directed support including vasopressor use. Primary data was obtained by study personnel through intraoperative data recording and postoperative medical record review.ResultsForty-one and 38 patients were randomized to traditional and pressor-based algorithms, respectively. Flap survival was 95% (75/79). There was no significant difference between the pressor-based and traditional protocols' flap failure (1/38 [3%] vs. 3/41 [7%], RR 0.36, 95% CI of RR 0.04-3.31, p = .63) or flap-related complications (12/38 [32%] vs. 18/41 [44%], RR 0.72, 95% CI 0.40-1.29, p = .36) Soft tissue flaps had surgical complication rates of 12/30 (40%) and 9/27 (33%) for traditional and pressor-based protocols, respectively. Bony flaps had surgical complication rates of 6/11 (55%), and 3/11 (27%) for traditional and pressor-based protocols, respectively.ConclusionsIntraoperative goal-directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures.
| S-EPMC8396078 | biostudies-literature
Project description:ObjectivesTo establish the implications of frailty as a predictor of outcome in patients with head and neck cancer requiring flap repair.DesignRetrospective cohort.Data sourceWe captured data from patients above 60 years old undergoing head and neck tumour resection and free flap reconstruction surgery between June 2019 and June 2020 at the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University. The data contain all treatment information.Outcome variablesSurgery repeated in 30 days, postoperative complications, hospital length of stay, postoperative main biochemical standards.Exposure variablesAge, sex, smoking history, alcoholism history, American Society of Anesthesiologists score, National Nosocomial Infection Surveillance score and Clinical T staging were exposure variables. The frailty index is the main variable.ResultA total of 254 patients were included in this study. Among them, 124 patients were classified as frail, while 130 patients were classified as non-frail. We found that frail patients stayed in the hospital longer than non-frail patients after surgery (p=0.018). According to the data of 26 frail patients who directly entered the intensive care unit (ICU), we found that these patients had a lower leucocyte count (p=0.005).ConclusionsFrailty is a useful predictor of outcomes in patients undergoing head and neck cancer surgery with flap reconstruction. Frailty can be a clinical tool used to identify high-risk patients and guide perioperative care to optimise patient outcomes. Frail patients have better outcomes if they directly enter the ICU.
| S-EPMC9743268 | biostudies-literature
Project description:The 2019 novel coronavirus disease (COVID-19) is a highly contagious zoonosis produced by SARS-CoV-2 that is spread human-to-human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities. There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists, and otolaryngologists. Health workers represent between 3.8% and 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter). All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55 to 65?years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases, and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Health care facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case-by-case basis for patients with cancer. For those who are working with COVID-19 infected patients' isolation is compulsory in the following settings: (a) unprotected close contact with COVID-19 pneumonia patients; (b) onset of fever, cough, shortness of breath, and other symptoms (gastrointestinal complaints, anosmia, and dysgeusia have been reported in a minority of cases). For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (eg, rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia), it is strongly recommended that all health care personnel wear personal protective equipment such as N95, gown, cap, eye protection, and gloves. The procedures described are essential in trying to maintain safety of health care workers during COVID-19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID-19 positive subjects, and their protection should be considered a priority in the present circumstances.
| S-EPMC7262203 | biostudies-literature
Project description:ImportanceHead and neck oncological resection and reconstruction is a complex process that requires multidisciplinary collaboration and prolonged operative time. Numerous factors are associated with operative time, including a surgeon's experience, team familiarity, and the use of new technologies. It is paramount to evaluate the contribution of these factors and modalities on operative time to facilitate broad adoption of the most effective modalities and reduce complications associated with prolonged operative time.ObjectiveTo examine the association of head and neck cancer resection and reconstruction interventions with operative time.Design, setting, and participantsThis large cohort study included all patients who underwent head and neck oncologic resection and free flap-based reconstruction in Calgary (Alberta, Canada) between January 1, 2007, and March 31, 2020. Data were analyzed between November 2021 and May2022.InterventionsThe interventions that were implemented in the program were classified into team-based strategies and the introduction of new technology. Team-based strategies included introducing a standardized operative team, treatment centralization in a single institution, and introducing a microsurgery fellowship program. New technologies included use of venous coupler anastomosis and virtual surgical planning.Main outcomes and measuresThe primary outcome was mean operative time difference before and after the implementation of each modality. Secondary outcomes included returns to the operating room within 30 days, reasons for reoperation, returns to the emergency department or readmissions to hospital within 30 days, and 2-year and 5-year disease-specific survival. Multivariate regression analyses were performed to examine the association of each modality with operative time.ResultsA total of 578 patients (179 women [30.9%]; mean [SD] age, 60.8 [12.9] years) undergoing 590 procedures met inclusion criteria. During the study period, operative time progressively decreased and reached a 32% reduction during the final years of the study. A significant reduction was observed in mean operative time following the introduction of each intervention. However, a multivariate analysis revealed that team-based strategies, including the use of a standardized nursing team, treatment centralization, and a fellowship program, were significantly associated with a reduction in operative time.ConclusionsThe results of this cohort study suggest that among patients with head and neck cancer, use of team-based strategies was associated with significant decreases in operative time without an increase in complications.
| S-EPMC10360003 | biostudies-literature
Project description:ImportanceBecause microvascular free flap reconstruction is increasingly used to restore function in patients with head and neck cancer, there is a growing need for evidence-based perioperative care.ObjectiveTo assess the association of different team-based surgical approaches with intraoperative and postoperative outcomes for patients undergoing head and neck free flap reconstruction.Design, setting, and participantsThis retrospective cohort study of 733 patients was conducted at an academic tertiary care medical center. Head and neck oncologic procedures involving microvascular free flap reconstruction with available intraoperative data collected from January 1, 2000, to December 31, 2021, were included.Main outcomes and measuresPatient characteristics including demographic characteristics and comorbid conditions, operative variables, length of stay, and postoperative outcomes were measured. Descriptive statistics and effect size measures were performed to compare the 3 intraoperative surgical team approaches, specifically single surgeon, separate 2-team approach, and integrated 2-team approach; 1:1 nearest neighbor matching without caliper was performed to compare single- vs 2-team and separate and integrated 2-team approaches. Effect size measures including Cramer V for dichotomous variables, the Kendall W coefficient of concordance for ordinal variables, and η2 for continuous variables were reported with 95% CIs to describe precision.ResultsAmong 733 cases, there were no clinically significant differences in patient demographic characteristics, clinicopathologic characteristics, and choice of free flap reconstruction based on intraoperative surgical team approach. The mean (SD) age was 58.7 (12.4) years, and 514 were male (70.1%). In terms of operative and postoperative variables, there was a difference in operative times and intraoperative fluid requirements among the 3 different techniques, with the integrated 2-team approach demonstrating a mean reduction in operative time of approximately 2 hours (η2 = 0.871; 95% CI, 0.852-0.887; mean [SD] operative time = 541 [191] minutes for the single-surgeon approach, 399 [175] minutes for the integrated 2-team approach, and 537 [200] minutes for the separate 2-team approach) and lower fluid requirements of greater than 1 L (η2 = 0.790; 95% CI, 0.762-0.817). In both unadjusted analyses and propensity score matching, there were no clinically significant differences in terms of ischemia time, use of pressors, postoperative complications (including free flap failure, number of return trips to the operating room, length of stay, or 30-day readmission) based on intraoperative team approach.Conclusions and relevanceFindings suggest that the integrated 2-team surgical approach for complex head and neck microvascular reconstruction can be used to safely decrease operative time, with no difference in postoperative outcomes.
| S-EPMC10557027 | biostudies-literature
Project description:BackgroundAfter head and neck cancer surgery with free flap reconstruction, the use of glucocorticoids is often required to alleviate inflammation and edema. However, the impact of glucocorticoid on postoperative complications and cancer progression remains unclear.MethodsThis retrospective cohort study included 711 elderly patients who underwent head and neck cancer surgery with free flap reconstruction at Shanghai Ninth People's Hospital from January 1, 2014, to December 31, 2022. Patients were categorized based on postoperative glucocorticoid usage into a high-dose steroid group (n = 307) and a control group (n = 404). The study focused on the impact of postoperative GC use on postoperative complications and long-term oncological outcomes.ResultsMultivariate analysis indicated that compared to the control group, the high-dose steroid group had a significant increase in postoperative complications, including atelectasis (OR: 3.83, 95% CI: 1.27-14.11, P = 0.025), postoperative hyperglycemia (OR: 1.54, 95% CI: 1.14-2.08, P = 0.006), and flap complications (OR: 4.61, 95% CI: 3.31-6.47, P < 0.001). These complications often required extended hospital stays (β: 1.656, 95% CI: 1.075-2.236, P < 0.001). Additionally, the high-dose steroid group had a higher rate of unplanned readmissions within one year (OR: 5.61, 95% CI: 3.87-8.25, P < 0.001). The increased readmission rates were notably due to difficulties swallowing requiring percutaneous gastrostomy (OR: 3.62, 95% CI: 1.97-6.98, P < 0.001), recurrence (OR: 9.34, 95% CI: 5.02-19.05, P < 0.001), and metastasis (OR: 4.78, 95% CI: 2.58-9.44, P < 0.001).ConclusionThe use of high-dose postoperative glucocorticoids is associated with increased postoperative complications, higher readmission rates, and poorer oncological outcomes in patients. The results advocate for cautious use and dosage management of perioperative glucocorticoids in head and neck surgeries to optimize patient outcomes.
| S-EPMC11896068 | biostudies-literature
Project description:Advances in head and neck reconstruction have resulted in improved outcomes with single-stage repair of defects ranging from intraoral to pharyngoesophageal to skull base defects. Key to success of surgery is choosing an appropriate reconstructive option based on the patient's wishes and fitness for major surgery. Where possible, free tissue transfer provides the best functional and aesthetic outcomes for the vast majority of defects. In this article, we present an algorithm to guide choice of flap selection and review principles of reconstruction and secondary surgery for head and neck defects.
| S-EPMC3324247 | biostudies-other