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.

National analysis of positive surgical margins in oropharyngeal salivary gland malignancies.

OBJECTIVE: Positive surgical margins (PSM) are associated with worse survival in oropharyngeal salivary gland malignancies (OPSGM), but existing literature is limited to small series. Our objective was to identify risk factors for PSM using the national cancer database (NCDB), including a transoral robotic surgical (TORS) approach. METHODS: NCDB was queried for patients with T1-T4a OPSGM undergoing resection between 2010 and 2017. Risk factors for PSM were determined using logistic regression. Overall survival (OS) was analyzed using Kaplan-Meier and Cox proportional hazards models. RESULTS: Of 785 patients, 165 (21.0 %) had PSM. Age, stage T4a tumors (OR 2.00, 95 % Confidence Interval [CI]: 1.03-3.88), adenoid cystic carcinoma (OR 2.02, 95 % CI: 1.29-3.18), and treatment at lower volume institutions (OR 1.68, 95 % CI: 1.09-2.59) were all independently associated with PSM. TORS versus a non-robotic approach was not associated with PSM (23.9 % vs 20.4 %, p 0.358), respectively. Positive margins were independently associated with a worse OS than negative margins (HR 1.63, 95 % CI: 1.03-2.59). Adjuvant radiation therapy was associated with improved survival in high grade tumors with positive margins. CONCLUSION: This study represents the largest review assessing risk factors for positive margins in OPSGM. Histologic type (adenoid cystic carcinoma), age, T4a tumor stage and treatment at a lower volume institution were all predictive of positive margins. With increasing use of TORS over the last decade, there does not appear to be a greater risk of positive margins using this modality in select patients. LEVEL OF EVIDENCE: N/A.

National Analysis of Oropharyngeal Salivary Gland Malignancies Treated With Transoral Robotic Surgery.

OBJECTIVES: (1) To compare perioperative outcomes and overall survival of patients with oropharyngeal salivary gland malignancies (OPSGMs) treated with transoral robotic surgery (TORS) versus other approaches. (2) To identify clinical factors associated with a robotic surgical approach. STUDY DESIGN: Retrospective analysis of the National Cancer Database (NCDB). SETTING: NCDB. METHODS: Data obtained from the NCDB were analyzed between 2010 and 2017 for patients with T1-T4a OPSGMs without distant metastases treated surgically. Patients were stratified by surgical approach (TORS vs nonrobotic), and clinicopathologic factors were compared with the t test or chi-square test for continuous or categorical variables, respectively. Overall survival was analyzed by patient demographics and clinical factors according to Kaplan-Meier and Cox proportional hazards models. Factors associated with TORS were assessed with logistic regression. RESULTS: A total of 785 patients were analyzed. A non-soft palate primary site (odds ratio, 12.9; 95% CI, 6.6-25.2) and treatment at an academic facility (odds ratio, 2.0; 95% CI, 1.2-3.5) were independently associated with TORS. There were no significant differences in the positive margin rate, 30-day mortality, or overall survival between the groups. The 30-day unplanned readmission rate was higher in patients treated with TORS versus nonrobotic resections (5.8% vs 1.7%, P = .0004). When stratified by tumor subsite, there was a significant decrease in hospital length of stay in patients with tongue base tumors undergoing TORS versus nonrobotic resections (P = .029). CONCLUSION: This study suggests that TORS may be a viable treatment modality for appropriately selected patients with OPSGM.