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

Otolaryngology–Head and Neck Surgery 158(5)

wound-healing complications, and wound infection complica- tions as well as their predictors in a high-volume head and neck ablative and reconstructive practice.

history assessment, including Charlson comorbidity index (CCI) and specific assessment of diabetes mellitus (DM), coronary artery disease (CAD), peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), hepatic disease, obesity, hypothyroidism, and malnutrition. Also captured was smok- ing and alcoholism history, which was operationalized as never, current smoker, or previous smoker and alcoholism at the time of surgery, respectively. Alcoholism at the time of surgery was defined by 2 or more drinks per day or a listed diagnosis of alcohol abuse. Flap and wound factors included type of flap, defect type, prior radiation or chemoradiation, recurrent tumor status, and tumor pathologic and operative features. Specifically, defect type was categorized as (1) oral cavity (including maxillary defects), (2) oropharyngeal/laryngeal/hypopharyngeal, and (3) others (which encompasses clean defects in which there was not mucosal breach [neck cutaneous defects, parotidectomy defects, scalp defects, etc]). We designated this categorization to compare defect contamination and complexity while main- taining granularity even within mucosal wounds from those that are less complicated (such as a maxillary or tongue defect) and those that are at a higher risk of pharyngeal leak with subsequent complications (such as pharyngeal and laryn- geal defects). Intraoperative factors assessed included flap ischemia time, total OR time, estimated blood loss, and amount of crystalloid, colloid, packed red blood cells, and fresh frozen plasma used. Patient complications (medical or surgical) prior to discharge such as wound infection (cellulitis or abscess) or healing concerns (dehiscence or fistula), flap loss, hematoma, and any medical complications such as myo- cardial infarction, pulmonary embolus, stroke, and Clostridium difficile colitis were measured. Outcomes Charts were thoroughly reviewed by 2 independent reviewers independent of the attending surgeon for any complications that could be gathered from any of the notes, including the daily progress notes, notes about consulting services, radio- graphy reports, and discharge summaries. Our primary out- come included any complication, which includes both medical and surgical complications. Secondary outcomes include (1) wound-healing complications (ie, fistula or dehis- cence) and (2) wound infection complications (ie, cellulitis or abscess). Further to this, we also report but do not specifi- cally analyze medical complication rates such as myocardial infarction (MI), cerebrovascular accident (CVA), pneumonia, delirium tremens (DTs), C difficile colitis, and flap loss. Statistical Analysis Covariates were compared for each outcome using a uni- variable logistic regression model (given the binary out- comes) and were considered for the multivariable analysis using a backward selection algorithm if the univariable P value was less than or equal to .10. Colinearity of variables was assessed using variance inflation factor prior to simulta- neously entering them into our multivariable analysis to

Methods Study Population

This was a retrospective review of patients undergoing free flap reconstruction of defects caused by ablative head and neck oncologic surgery or complications of treatment, specifi- cally pharyngocutaneous fistula or osteoradionecrosis, at the James Cancer Hospital, The Ohio State University (OSU) Wexner Medical Center, from 2006 to 2012. Therefore, it includes the assessment of outcomes for all reconstruction pro- cedures (including patients who required secondary reconstruc- tion for osteoradionecrosis, fistula, etc) performed by our head and neck oncologic reconstructive surgeons. Electronic health records (EHRs) were used to abstract most relevant data points, which were well documented given that the EHR was the primary system for charting at our institution during the study years in question, while the remaining data were col- lected via review of archived paper records. This allowed us to assess all admission records, operative reports, orders, and clinic progress notes. Chart abstraction was performed by 2 independent reviewers independent of the attending surgeon. Surgeons were blinded to their individual outcomes. The study protocol was approved by the Institutional Review Board and Office of Responsible Research Practices at The James Cancer Hospital and Solove Research Institute of The Ohio State University Comprehensive Cancer Center. Postoperative Course Prior to February 17, 2009, all patients were admitted to the intensive care unit (ICU) after surgery. After this date, most head and neck free flap patients were transferred directly to the ‘‘specialty-specific floor’’ after surgery unless they received a craniotomy or thoracotomy. The specialty-specific floor has a nurse to free flap patient ratio of 1:2, and we have previ- ously described the safety and cost savings related to this transition of structure of care. 9 At our institution, the usual postoperative flap protocol includes flap checks every hour for the first 24 hours followed by every 2 hours for the next 24 hours and then every 4 hours for the remainder of the inpatient stay. Tracheostomy tube change and downsize occurs on postoperative day 5, followed by capping and decannulation when appropriate. In patients with mucosal reconstruction, on postoperative day 6, a speech-language pathology assessment is performed for potential oral intake if appropriate on postoperative day 7. This is often delayed to 10 to 14 days in patients who have previously received radio- therapy with or without chemotherapy, and in some cases, patients are sent home with a nasogastric tube or gastrostomy tube for a delayed oral trial in clinic at 2 to 3 weeks. Covariates Patient covariates included age, sex, OSU preoperative assessment clinic (OPAC) consult, and thorough medical

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