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

Otolaryngology–Head and Neck Surgery 158(5)

were treated with chemoradiotherapy before surgery; these are clean contaminated wounds (compared to clean wounds such as those from wide local resection of skin cancers) and are known to have higher wound infection and healing com- plication rates. 7 An interesting finding in our study is the impact of intraoperative crystalloid administration, as each additional liter given increased the odds of wound-healing complica- tions multiplicatively by 1.21 (95% CI, 1.05-1.38). Many studies have summarized the literature regarding the ideal perioperative fluid administration strategy in head and neck oncology patients 10-12 ; however, few have studied this directly, and most of the literature is based on patients with non–head and neck cancer. A well-designed retrospective study of 154 patients demonstrated that intraoperative fluid resuscitation volume of less than 5.5 L was associated with lower postoperative complications (7 L for major complica- tions). 13 However, a study using a pre- and postintervention design using a goal-directed fluid management technique, which was successful at lowering intraoperative fluid volumes (8185 mL vs 6070 mL), did not demonstrate lower complication rates but did improve length of stay (14.0 days vs 11.5 days). 14 Given our findings and these 2 previous studies in the head and neck free flap population, we recom- mend a multi-institutional randomized prospective clinical trial to assess the impact of different fluid administration protocols and their impact on complication rates. Not surprisingly, advanced age, diabetes mellitus, and mal- nutrition were associated with wound infection complications as has been demonstrated previously in the literature. 15 Nonetheless, age alone should not be a contraindication to sur- gery as many groups have demonstrated the safety of recon- structive approaches in the elderly with appropriate patient selection. 16,17 Optimizing nutrition in the presurgical period is recommended, 12,18 and as a result, on rare occasion at our institution, we will delay surgical intervention for nutritional support. Metabolic abnormalities exist in patients with head and neck cancer patients who have significant preoperative weight loss, and these abnormalities can deteriorate when patients are treated with primary radiotherapy or chemora- diotherapy. 19 Preoperative low albumin 20 and prealbumin levels 21 in head and neck reconstruction patients are associated with increased surgical site infections and free flap failure. Unfortunately, this has not been extensively studied, and fur- ther information is required regarding the ideal preoperative albumin levels as a threshold to delay surgical intervention, given that delay in treatment may also worsen outcomes. In our experience, there is typically a short delay between deci- sion to treat and treatment, and this administrative delay could be used to optimize nutrition in high-risk patients. If an ideal preoperative albumin level is identified, initiation of quality improvement techniques can be used to improve preoperative nutrition as this may further decrease wound infection rates. Similarly, tight sugar control can be targeted to assess whether this improves wound infection rates. During this time period, we also implemented a preo- perative alcohol cessation program. We have previously

demonstrated that this program significantly improved outcomes for those who abuse alcohol ( . 7 drinks per day). 8 Even though our multivariable analysis did not identify alcoholism as a significant independent predictor, we attribute this to the intervention already ongoing in this population. These data must be interpreted in the context of the study design. The most important limitation of this study is the retro- spective design. Prospective collection with standardized tools, such as the Clavien-Dindo complication classification system, has been demonstrated to improve capture of complications. 6,22 Fortunately, our EHR documentation is quite thorough, and therefore, we feel that it did indeed capture most complications in our population. Despite not performing prospective compli- cation capture, we had a high complication rate, and it is unlikely that we missed any major complications. Nonetheless, with prospective capture, we may find a higher rate of compli- cations secondary to higher capture of minor complications. Our study also has several strengths. This is the largest study in the literature looking at predictors of wound-healing and wound infection complications in free flap reconstruction of the head and neck. The data are granular and of excellent qual- ity. Furthermore, the collection was performed at a large aca- demic high-volume center of excellence. These data provide valuable benchmark data for quality improvement projects in this population. Furthermore, it can inform an improved informed consent process in our patients. In conclusion, patients receiving free flap reconstruction are at a high risk of developing medical and surgical com- plications in the postoperative period. Operative time, comorbidity index, and subsite of reconstruction are predic- tors of overall complications with volume of crystalloid administration being a further predictor of wound-healing complications. Wound infection complications are predicted by advanced age, DM, and malnutrition. Many of the identi- fied risk factors can be further studied and targeted with quality improvement initiatives to ultimately improve out- comes in this population. Author Contributions Antoine Eskander , analysis and interpretation of the data, drafting of work and revisions; Stephen Kang , project conception, interpre- tation of data, revising manuscript; Ben Tweel , design of the work, acquisition of data, revising manuscript; Jigar Sitapara , design of the work, acquisition of data, revising manuscript; Matthew Old , project conception, interpretation of data, revising manuscript; Enver Ozer , project conception, interpretation of data, revising manuscript; Amit Agrawal , project conception, interpretation of data, revising manuscript; Ricardo Carrau , project conception, interpretation of data, revising manuscript; James W. Rocco , proj- ect conception, interpretation of data, revising manuscript; Theodoros N. Teknos , project conception, analysis and interpreta- tion of data, drafting of work and revisions.

Disclosures Competing interests: None. Sponsorships: None. Funding source: None.

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