2018-19 Section 7-Neoplastic and Inflammatory Diseases of the Head and Neck eBook

Reprinted by permission of Otolaryngol Head Neck Surg. 2018; 158(5):839-847.

Original Research—Facial Plastic and Reconstructive Surgery

Otolaryngology– Head and Neck Surgery 2018, Vol. 158(5) 839–847 American Academy of Otolaryngology–Head and Neck

Predictors of Complications in Patients Receiving Head and Neck Free Flap Reconstructive Procedures Antoine Eskander, MD, ScM, FRCSC 1 , Stephen Kang, MD 2 , Ben Tweel, MD 3 , Jigar Sitapara, MD 2 , Matthew Old, MD 2 , Enver Ozer, MD 2 , Amit Agrawal, MD 2 , Ricardo Carrau, MD 2 , James W. Rocco, MD, PhD 2 , and Theodoros N. Teknos, MD 2

Surgery Foundation 2018 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599818757949 http://otojournal.org

T here has been an increased application of microvas- cular reconstruction in the management of head and neck cancers to functionally and aesthetically rehabi- litate patients. 1,2 There are a growing number of training programs with varying levels of experience and comfort with these techniques. In the era of organ preservation with concurrent chemoradiotherapy, free flap reconstruction has demonstrated decreased fistula rates and has also proven to be useful in the management of long-term sequelae such as osteoradionecrosis. 2 Although there is an abundance of stud- ies assessing free flap failure rates, 3-5 there is a paucity of studies looking at overall medical and surgical complication rates and their predictors. 6 Our previous work has demonstrated that the most important predictor of increased length of stay, readmission, and unplanned return to the operating room (OR) is any medical or surgical complication. 7 A more granular under- standing of the rate, type, and cause for these complications can better inform the consent process. Furthermore, certain subpopulations can be targeted to prevent and treat these complications early. Last, quality improvement techniques can be used to help decrease such complications when they are associated with modifiable risk factors such as the alco- hol cessation protocol. 8 The objective of this study is to study the true overall com- plication rate, including medical and surgical complications, 1 Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital, Toronto, Ontario, Canada 2 Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA 3 Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA This article was presented at the 2017 AAO-HNSF Annual Meeting and OTO Experience; September 10-13, 2017; Chicago, Illinois. Corresponding Author: Theodoros N. Teknos, MD, Department of Otolaryngology–Head & Neck Surgery, James Cancer Hospital and Solove Research Institute, 456 West 10th Avenue, Rm #4a, Columbus, OH 43210, USA. Email: ted.teknos@osumc.edu

No sponsorships or competing interests have been disclosed for this article.

Abstract Objective. To (1) determine the overall complication rate, wound healing, and wound infection complications and (2) identify preoperative, intraoperative, and postoperative pre- dictors of these complications.

Study Design. Case series with chart review.

Setting. Tertiary academic cancer hospital.

Subjects and Methods. All head and neck free flap patients at The Ohio State University (2006-2012) were assessed. Multivariable logistic regression assessed the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes. Results. Of the 515 patients identified, 54% had a complication predicted by longer operating room (OR) time, higher comorbid- ity index, and oral cavity and pharyngeal tumor sites. Predictors of wound-healing complications (15%) were longer OR time, volume of crystalloid given intraoperatively, and oral cavity and pharyngeal tumor sites. Predictors of wound infection (12%) were younger age, diabetes mellitus, and malnutrition. Conclusions. Wound healing and infectious complications account for most complications in patients with head and neck cancer undergoing free flap reconstruction. Clean con- taminated wounds are a significant predictor of wound com- plications. Advanced OR time, advanced age, and comorbidity status, including diabetes mellitus and malnutri- tion, are other important predictors. Crystalloid administra- tion is also an important predictor of wound-healing complications, and this warrants further study.

Keywords head and neck surgery, free flap, reconstructive surgery, complications, head and neck cancer

Received October 22, 2017; revised December 19, 2017; accepted January 18, 2018.

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