A Multi-institutional Analysis of Late Complications in Scapula, Fibula, and Osteocutaneous Radial Forearm Free Flaps.

OBJECTIVES: (1) Evaluate the association of flap type with late complications in patients undergoing osseous head and neck reconstruction with the fibula free flap (FFF), osteocutaneous radial forearm free flap (OCRFFF), and scapula free flap (SFF). (2) Compare the prevalence of late complications based on minimum duration of follow-up. STUDY DESIGN: Retrospective cohort study. SETTING: Multiple academic medical centers. METHODS: Patients undergoing FFF, OCRFFF, or SFF with ≥6-month follow-up were stratified by type of flap performed. The association of flap type with late complications was analyzed via univariable and multivariable logistic regression, controlling for relevant clinical risk factors. Additionally, the frequency of late complications by minimum duration of follow-up was assessed. RESULTS: A total of 617 patients were analyzed: 312 (50.6%) FFF, 230 (37.3%) OCRFFFF, and 75 (12.2%) SFF. As compared with the SFF, the FFF (adjusted odds ratio [aOR], 3.05; 95% CI, 1.61-5.80) and OCRFFF (aOR, 2.17; 95% CI, 1.12-4.22) were independently associated with greater odds of overall late recipient site wound complications. The SFF was independently associated with the lowest odds of hardware exposure when compared with the FFF (aOR, 2.61; 95% CI, 1.27-5.41) and OCRFFF (aOR, 2.38; 95% CI, 1.11-5.12). The frequency of late complications rose as minimum duration of follow-up increased until plateauing at 36 months. CONCLUSIONS: This multi-institutional study suggests that the long-term complication profile of the SFF and OCRFFF compares favorably to the FFF. The SFF may be associated with the fewest overall late recipient site complications and hardware exposure, while the FFF may be associated with the most of these 3 options.

Association of comorbidity score with perioperative outcomes following transoral robotic surgery: National analysis.

BACKGROUND: The association of comorbidities with perioperative outcomes after transoral robotic surgery (TORS) is not well-defined in the literature. METHODS: Using the National Cancer Database, 4004 patients with T1-T2 oropharyngeal cancer between 2010 and 2017 were stratified based on their Charlson-Deyo Comorbidity Class (CDCC). Thirty-day unplanned readmissions, 30-day mortality, and 90-day mortality were compared using chi-square test and logistic regression. Hospital length of stay (LOS) was compared using the Kruskal-Wallis test. RESULTS: LOS was greater for patients with CDCC 2 or 3 compared to CDCC 0 or 1 (p < 0.001). Increasing age and CDCC ≥3 were associated with 30-day mortality (CDCC ≥3: odds ratio [OR] 5.55, 95% confidence interval [CI] 1.59-19.45). CDCC ≥3 (OR 2.61, 95%CI 1.09-6.27) was significantly associated with 30-day readmissions. CONCLUSION: This national analysis demonstrates greater rates of unplanned 30-day readmissions, longer hospitalizations, and increased 30- and 90-day mortality after TORS in patients with CDCC ≥3.

Implications of Treatment Modality on Chronic Opioid Use Following Treatment for Head and Neck Cancer.

OBJECTIVE: To investigate the relationship between treatment modality and chronic opioid use in a large cohort of patients with head and neck cancer. STUDY DESIGN: Retrospective cohort study. SETTING: Single academic center. METHODS: There were 388 patients with head and neck cancer treated between January 2011 and December 2017 who met inclusion criteria. Clinical risk factors for opioid use at 3 and 6 months were determined with univariate and multivariate analyses. RESULTS: The prevalence of opioid use was 43.0% at 3 months and 33.2% at 6 months. On multivariate analysis, primary chemoradiation (odds ratio [OR], 4.04; 95% CI, 1.91-8.55) and surgery with adjuvant chemoradiation (OR, 2.39; 95% CI, 1.09-5.26) were associated with opioid use at 3 months. Additional risk factors at that time point included pretreatment opioid use (OR, 7.63; 95% CI, 4.09-14.21) and decreasing age (OR, 1.03; 95% CI, 1.01-1.06). At 6 months, primary chemoradiation (OR, 2.40; 95% CI, 1.34-4.28), pretreatment opioid use (OR, 5.86; 95% CI, 3.30-10.38), current tobacco use (OR, 2.00; 95% CI, 1.18-3.40), and psychiatric disorder (OR, 1.79; 95% CI, 1.02-3.14) were associated with opioid use. CONCLUSION: Of the patients who receive different treatment modalities, those receiving primary chemoradiation are independently at highest risk for chronic opioid use. Other risk factors include pretreatment opioid use, tobacco use, and a psychiatric disorder. In an effort to reduce their risk of chronic opioid use, preventative strategies should be especially directed to these patients.

Prognostic Impact of Metastatic Site and Pattern in Patients with Metastatic Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: Investigate the relationship between site and pattern of distant metastasis (DM) and overall survival (OS) in a multi-institutional cohort of patients with DM head and neck cancer (HNC). STUDY DESIGN: Retrospective review. METHODS: 283 patients treated at 4 academic centers in the Midwest HNC Consortium between 2000 and 2015 were retrospectively reviewed. Disease patterns were divided between solitary metastatic versus polymetastatic (≥2 sites) disease. Survival functions for clinically relevant variables were estimated using Kaplan-Meier and Cox proportional hazards models. RESULTS: Median OS for all patients was 9.0 months (95% confidence interval [CI]: 7.4-10.6). Lung (n = 220, 77.7%) was the most common site of DM, followed by bone (n = 90, 31.8%), mediastinal lymph nodes (n = 55, 19.4%), liver (n = 41, 14.5%), and brain (n = 17, 6.0%). Bone metastases were independently associated with the worst prognosis (hazard ratio [HR] = 1.6, 95% CI: 1.3-2.1). On univariate analysis, brain metastases were associated with improved prognosis (HR = 0.5, 95% CI: 0.3-0.9), although this was not statistically significant on the multivariate analysis. Polymetastatic disease was present in the majority of patients (n = 230, 81.3%) and was associated with a worse prognosis compared to solitary metastatic disease (HR = 1.4, 95% CI: 1.0-2.0). CONCLUSION: Our large, multi-institutional review indicates that both the metastatic pattern and site of DM impact OS. Polymetastatic disease and bone metastasis are associated with worse prognosis, independent of treatment received. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1838-E1846, 2021.

Prophylactic arterial ligation following transoral robotic surgery: A systematic review and meta-analysis.

Prophylactic arterial ligation has been proposed to reduce the severity of postoperative hemorrhage following transoral robotic surgery (TORS). Previous studies have shown a trend toward a reduction in major and severe bleeding. Search strategies were implemented in multiple databases and completed in August 2018. Inclusion and exclusion criteria were designed to capture studies examining adults undergoing TORS for oropharyngeal cancer. Four retrospective studies were selected appropriate for analysis by two reviewers who independently extracted data. PRISMA guidelines were followed. A random-effects model was used for meta-analysis. Meta-analysis of 619 patients in four retrospective reviews showed that the pooled RR of major and severe bleeding events was significantly lower in prophylactically ligated patients (RR, 0.28; 95% CI, 0.08-0.92; I2 = 0). Prophylactic arterial ligation of external carotid artery branches is associated with a decreased risk of major and severe bleeding events, although confounding factors remain incompletely analyzed.

Effect of treatment modality on chronic opioid use in patients with T1/T2 oropharyngeal cancer.

BACKGROUND: The effect of treatment modality on long-term opioid dependence in patients with oropharyngeal cancer has not been reported. METHODS: A retrospective cohort of 122 patients with T1/T2 oropharyngeal cancer undergoing treatment was generated. Risk factors associated with chronic opioid use were investigated by univariate and multivariate analyses. RESULTS: The prevalence of chronic opioid use was 45.9%. On multivariate analysis, primary nonsurgical treatment (odds ratio [OR] 4.5, 95% confidence interval [CI]: 1.7-11.4), pretreatment opioid use (OR 14.9, 95% CI: 3.5-62.5), psychiatric disorder (OR 4.3, 95% CI: 1.03-18.5), alcohol use (OR 2.6, 95% CI: 1.03-6.5), and younger age (OR 1.1, 95% CI: 1.02-1.11) were significantly associated with chronic opioid use. CONCLUSION: Primary nonsurgical treatment, younger age, pretreatment opioid use, alcohol use, and psychiatric disorder were independently associated with an increased risk of chronic opioid use. Preventative strategies should be especially focused toward these patients to reduce their risk of long-term opioid use.

Mandibular Invasion by Oral Squamous Cell Carcinoma: Clinicopathologic Features of 74 Cases.

OBJECTIVES: (1) For patients with oral squamous cell carcinoma (OSCC) and mandibular invasion, to determine whether prior radiation to the head and neck region (PXRTHN) affects the density of osteoblasts, osteoclasts, or fibroblasts along the tumor interface invading the mandible and whether this is significantly associated with overall survival. (2) To identify clinicopathologic features that are associated with overall survival. STUDY DESIGN: Case series with chart review. SETTING: University of Missouri hospital. SUBJECTS AND METHODS: Retrospective review of 74 cases with pathologically confirmed mandible invasion by OSCC and surgical treatment between January 1, 2005, and December 31, 2015. A board-certified anatomic pathologist reviewed the slides from all mandibulectomy cases. RESULTS: The mean density of osteoclasts was 2.0 per linear mm among the patients with PXRTHN and 7.1 among those without PXRTHN ( P < .001). Positive soft tissue frozen section margin was significantly associated with overall survival on univariate analysis ( P < .001; hazard ratio [HR], 0.34; 95% CI, 0.19-0.62) and multivariate analysis ( P = .026; HR, 0.41; 95% CI, 0.19-0.90). Maximum tumor dimension was significantly associated with overall survival on univariate analysis ( P = .021; HR, 1.19; 95% CI, 1.03-1.38) and multivariate analysis ( P = .002; HR, 1.49; 95% CI, 1.16-1.93). Osteoclast, osteoblast, and fibroblast density were not associated with overall survival. CONCLUSIONS: (1) Osteoclast density along the tumor front is significantly lower among patients with PXRTHN. Stromal cell density was not associated with overall survival. (2) Positive soft tissue frozen section margin and maximum tumor dimension are significantly associated with overall survival among patients with mandibular invasion by OSCC.

Utility of Intraoperative Frozen Section in Large Thyroid Nodules.

OBJECTIVE: To determine if the routine use of intraoperative frozen section (iFS) results in cost savings among patients with nodules >4 cm with nonmalignant cytology undergoing a thyroid lobectomy. STUDY DESIGN: Case series with chart review; cost minimization analysis. SETTING: Single academic center. SUBJECTS AND METHODS: Records were reviewed on a consecutive sample of 48 patients with thyroid nodules >4 cm and nonmalignant cytology who were undergoing thyroid lobectomy in which iFS was performed between 2010 and 2015. A decision tree model of thyroid lobectomy with iFS was created. Comparative parameters were obtained from the literature. A cost minimization analysis was performed comparing lobectomy with and without iFS and the need for completion thyroidectomy with costs estimated according to 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample. RESULTS: The overall malignancy rate was 25%, and 33% of these malignancies were identified intraoperatively. When the malignancy rates obtained from our cohort were applied, performing routine iFS was the less costly scenario, resulting in a savings of $486 per case. When the rate of malignancy identified on iFS was adjusted, obtaining iFS remained the less costly scenario as long as the rate of malignancies identified on iFS exceeded 12%. If patients with follicular lesions on cytology were excluded, 50% of malignancies were identified intraoperatively, resulting in a savings of $768 per case. CONCLUSIONS: For patients with nodules >4 cm who are undergoing a diagnostic lobectomy, the routine use of iFS may result in decreased health care utilization. Additional cost savings could be obtained if iFS is avoided among patients with follicular lesions.

Impact of perioperative hyperglycemia in patients undergoing microvascular reconstruction.

BACKGROUND: The effects of perioperative hyperglycemia on complications and outcomes in microvascular reconstruction have not been reported in the literature. METHODS: A retrospective cohort of 203 patients undergoing microvascular reconstruction was generated. Perioperative glucose levels and clinical factors were tested for associations with complications using simple and multivariate analyses. RESULTS: Hyperglycemia (blood glucose ≥ 180 mg/dL) occurred in 91 patients (44.8%) perioperatively, and was associated with increased rates of surgical complications, medical complications, surgical site infections, fistulas, and wound dehiscence. On univariate analysis, a more strict definition of hyperglycemia (blood glucose ≥ 165 mg/dL) was significantly associated with greater rates of venous thrombosis, although this lost statistical significance on multivariate analysis. CONCLUSION: Perioperative hyperglycemia occurs commonly in patients undergoing microvascular reconstruction and is associated with higher rates of complications, independent of a preexisting diagnosis of diabetes mellitus. Further research is needed to define the ideal glycemic target in this population.

Economic Impact of Frozen Section for Thyroid Nodules with "Suspicious for Malignancy" Cytology.

Objective To perform a cost analysis of the routine use of intraoperative frozen section (iFS) among patients undergoing a thyroid lobectomy with "suspicious for malignancy" (SUSP) cytology in the context of the 2015 American Thyroid Association guidelines. Study Design Case series with chart review; cost minimization analysis. Setting Academic. Subjects and Methods Records were reviewed for patients with SUSP cytology who underwent thyroid surgery between 2010 and 2015 in which iFS was utilized. The diagnostic test performance of iFS and the frequency of indicated completion/total thyroidectomies based on the 2015 guidelines were calculated. A cost minimization analysis was performed comparing lobectomy, with and without iFS, and the need for completion thyroidectomy according to costs estimated from 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Results Sixty-five patients met inclusion criteria. The malignancy rate was 61.5%, 45% of which was identified intraoperatively. The specificity and positive predictive value were 100%. The negative predictive value and sensitivity were 83% and 95%, respectively. Completion/total thyroidectomy was indicated for 9% of patients; 83% of these individuals had findings on iFS that would have changed management intraoperatively. Application of the new guidelines would have resulted in a significant reduction in the frequency of conversion to a total thyroidectomy when compared with the actual management (26.1% vs 7.7%, P = .005). Performing routine iFS was the less costly scenario, resulting in a savings of $474 per case. Conclusion For patients with SUSP cytology undergoing lobectomy, routine use of iFS would result in decreased health care utilization.

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

BACKGROUND: 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/m(2) undergoing free flap reconstruction. METHODS: A multi-institutional retrospective cohort was created. Medical complications, surgical complications, and procedural variables were recorded. Logistic regression was used to investigate univariate and multivariate associations between outcomes and predictors. RESULTS: Of 582 cases, 128 patients (22%) had BMI >30. Surgical complications occurred in 153 cases (26.3%), with an adjusted odds ratio (OR) for association of surgical complications with BMI >30 of 0.92 (p = .71). Medical complications occurred in 178 cases (30.6%), with an adjusted OR of 0.78 (p = .26). Age and advanced comorbidity status (Adult Comorbidity Evaluation-27 [ACE-27] 2 or 3) were associated with medical complications (p < .0001). CONCLUSION: BMI >30 does not predict medical or surgical complications in patients undergoing head and neck free flap surgery. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1188-E1191, 2016.

Use of fluorescent angiography to assess donor site perfusion prior to free tissue transfer.

OBJECTIVE: To describe a novel use of fluorescent angiography in assessing donor limb perfusion prior to free tissue harvest in microvascular free tissue transfer. STUDY DESIGN: Retrospective case series. METHODS: From January 2012 to June 2013, 59 patients underwent head-and-neck microvascular free tissue reconstruction. Evaluation of donor site perfusion via indocyanine green (ICG) fluorescent angiography was utilized in 12 patients and 13 free flaps. Eleven cases were radial forearm free flaps (RFFF) and two were fibula free flaps (FFF). Preoperatively, RFFF patients were evaluated with Allen's testing, Doppler ultrasound, or both. FFF patients underwent magnetic resonance angiography. ICG was used intraoperatively to evaluate donor limb perfusion prior to free flap harvest. Intraoperative and postoperative complications of the donor limb were evaluated with cost analysis. RESULTS: Average follow-up was 5.3 months. Preoperative Allen's testing was normal in six patients and ultrasound was performed in eight patients. One patient had a normal ultrasound, three showed minimal dampening, and four exhibited severe waveform flattening. There were no intraoperative complications using ICG. All 12 patients displayed adequate donor limb perfusion via fluorescent angiography. No digital or acute ischemic events were identified intraoperatively or postoperatively. There was no significant decrease in functionality or mobility of the donor limb. One patient noted mild arm pain with use. CONCLUSION: Fluorescent angiography is another method to evaluate donor site perfusion prior to free tissue harvest. Larger prospective analysis would be helpful to more thoroughly evaluate safety, although this is limited by the overall low risk of ischemic complications. LEVEL OF EVIDENCE: 4.

Stretch of the minimally invasive incision during thyroid and parathyroid surgery.

OBJECTIVE: Identify and quantify changes in length of the skin incision following minimally invasive thyroid and parathyroid surgery and determine whether these changes persist postoperatively. STUDY DESIGN: Cohort study. SETTING: Tertiary care teaching hospital. SUBJECTS AND METHODS: Between July 2012 and June 2013, a prospective, nonrandomized study was performed on 44 consecutive patients undergoing open cervical minimally invasive thyroidectomy (incision approximately 6 cm or less) or minimally invasive parathyroidectomy (incision approximately 3 cm or less). Incision length was measured following initial incision, immediately after wound closure, and on postoperative follow-up at 2-week and 14-week visits. RESULTS: Thirty-one patients underwent minimally invasive thyroidectomy or parathyroidectomy with initial incision lengths ranging from 20 mm to 60 mm. Seven patients (21%) underwent total thyroidectomy with a mean length of 45 ± 8 mm, 15 patients (44%) underwent unilateral thyroid lobectomy with a mean length of 37 ± 5 mm, and 9 patients (26%) underwent parathyroidectomy with a mean length of 28 ± 2 mm. On average, the skin incision lengthened by 3.0 ± 0.9 mm during surgery representing an intraoperative stretch of 8.0% (P < .0001). Incision lengths decreased by an average of 0.3 mm at 2-week postoperative follow-up (ns) and 6.3 mm at 14-week postoperative follow-up (P < .0001). CONCLUSION: Significant intraoperative incision stretch is likely to occur during minimally invasive thyroid and parathyroid surgery. Postoperative follow-up data suggest that the increase in incision length is not permanent and resolves upon postoperative follow-up.

Ultrasound for localization in primary hyperparathyroidism.

OBJECTIVE: To evaluate the capability of ultrasound for preoperative localization in primary hyperparathyroidism. STUDY DESIGN: Prospective study. SETTING: Multi-institutional Midwest Head and Neck Cancer Consortium. SUBJECTS AND METHODS: Two hundred twenty patients who underwent preoperative localization and had parathyroid surgery were evaluated. The findings of preoperative localization studies were correlated with surgical findings. RESULTS: Preoperative ultrasonography, sestamibi scintigraphy, or both were obtained in 77%, 93%, and 69% of the patients, respectively. Preoperative ultrasonography and sestamibi scintigraphy localized an abnormality in 71% and 79% of patients, respectively. At the time of surgery, the localization by ultrasound was accurate in 82%. The accuracy of localization was similar for sestamibi scintigraphy (85%). In patients with inaccurate ultrasound localization, the sestamibi scintigraphy correctly identified the site of disease in only 45%. In patients with a nonlocalizing ultrasound, sestamibi scintigraphy was able to localize disease in only 47%, with 2 being in the mediastinum. CONCLUSIONS: Ultrasonography is an acceptable initial localization study for patients with primary hyperparathyroidism. In patients with nonlocalizing ultrasound, sestamibi scintigraphy should be obtained, but can be expected to detect an abnormality in less than 50% of patients.