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Ferraro T, Ahmed AK, Lee E, Lee SM, Debbaneh PM, Thakkar P, Joshi A, Tummala N. Race and Ethnicity Independently Predict Adverse Outcomes Following Head and Neck Autograft Surgery. Laryngoscope 2024. [PMID: 38407481 DOI: 10.1002/lary.31367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE There is growing attention toward the implications of race and ethnicity on health disparities within otolaryngology. While race is an established predictor of adverse head and neck oncologic outcomes, there is paucity in the literature on studies employing national, multi-institutional data to assess the impact of race and ethnicity on head and neck autograft surgery. METHODS Using the National Surgical Quality Improvement Program (NSQIP) database, trends in 30 days outcomes were assessed. Patients with ICD-10 codes for malignant head and neck neoplasms were isolated. Autograft surgeries were selected using Current Procedural Terminology (CPT) codes for free flap and pedicled flap reconstruction. Primary outcomes included surgical complications, reoperation, readmission, extended length of stay and operation time. Each binary categorical variable was compared to racial/ethnic identity via binary logistic regression. RESULTS The study cohort consisted of 2447 patients who underwent head and neck autograft surgery (80.71% free flap reconstruction and 19.39% pedicled flap reconstruction). Black patients had significantly higher odds of overall surgical complications (odds ratio [OR] 1.583, 95% confidence interval [CI] 1.091, 2.298, p = 0.016) with much higher odds of perioperative blood transfusions (OR 2.291, 95% CI 1.532, 3.426, p = <.001). Hispanic patients were more likely to undergo reoperation within 30 days after surgery and were more likely to be hospitalized for more than 30 days post-operatively (OR 1.566, 95% CI 1.015, 2.418, p = 0.043 and OR 12.224, 95% CI 2.698, 55.377, p = 0.001, respectively). CONCLUSIONS Race and ethnicity serve as independent predictors of complications in the post-operative period following head and neck autograft surgery. LEVEL OF EVIDENCE III Laryngoscope, 2024.
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Affiliation(s)
- Tatiana Ferraro
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
- Drexel University College of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Abdulla K Ahmed
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Esther Lee
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Sean M Lee
- Office of Clinical Research, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Peter M Debbaneh
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente East Bay, Oakland, California, U.S.A
| | - Punam Thakkar
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Arjun Joshi
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
| | - Neelima Tummala
- Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, U.S.A
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Lee JJ, Chibueze S, Walia A, Yaeger LH, Zenga J, Puram SV, Jackson RS, Pipkorn P. Infection Control With Topical Antimicrobial Prophylaxis for Mucosal Head and Neck Surgery: A Meta-analysis. Otolaryngol Head Neck Surg 2023; 168:261-268. [PMID: 35608917 DOI: 10.1177/01945998221100801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/12/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess for differences in surgical site infection (SSI) rates and bacterial load after major mucosal head and neck surgery between patients who received topical antimicrobial prophylaxis and those who did not. DATA SOURCES Ovid Medline, Embase, SCOPUS, Cochrane Library, and ClinicalTrials.gov from inception to May 20, 2021, with cross-referencing of retrieved studies per PRISMA guidelines. REVIEW METHODS Inclusion criteria captured clinical trials, cohort studies, and case-control studies with infectious outcomes of adults who underwent major mucosal head and neck surgery and received perioperative topical antimicrobial therapy to the oral cavity and/or pharynx. Studies of dental procedures were excluded. The primary outcome was SSI rate, and the secondary outcome was bacterial load. Two blinded investigators screened each text. RESULTS Of 265 unique citations, 9 studies of 470 total patients were included. Topical treatments included numerous antibiotics and antiseptics directly applied over mucosa. Pooled SSI rates of 252 patients in the intervention cohort and 218 in the control cohort were 8% (95% CI, 3%-14%; I 2 = 61.2%) and 29% (95% CI, 16%-43%; I 2 = 79.5%), respectively. A meta-analysis of 7 comparative studies totaling 192 patients receiving topical therapy and 218 control patients revealed a pooled relative risk of 0.44 (95% CI, 0.28-0.68; I 2 = 0.0%) in favor of the treatment group. The studies demonstrated a short-term decrease in bacterial counts after topical antimicrobial prophylaxis. CONCLUSION Patients who underwent prophylactic topical antimicrobial therapy had less than half the risk of developing SSI after mucosal head and neck surgery when compared with those who received no topical prophylaxis.
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Affiliation(s)
- Jake J Lee
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Stanley Chibueze
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Amit Walia
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Lauren H Yaeger
- Becker Medical Library, Washington University School of Medicine, St Louis, Missouri, USA
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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Balagopal PG, Suresh S, Nath SR, Sagila SG, George NA. Pattern of Post-Operative Infections Among Oral Cavity Cancer Patients in a Tertiary Care Cancer Centre: A Prospective Study. Indian J Otolaryngol Head Neck Surg 2022; 74:2002-2007. [PMID: 36452549 PMCID: PMC9701943 DOI: 10.1007/s12070-020-01963-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/10/2020] [Indexed: 10/23/2022] Open
Abstract
Surgical site infections (SSIs) constitute a major problem among patients who undergo surgery for oral cancer and remain a substantial cause of morbidity, prolonged hospitalization and death. The aim of this study was to assess the microbial spectrum of post-operative wound infections and to assess the outcome of appropriate antibiotic usage in patients who underwent surgery for oral cancer. This was a prospective observational study done in a tertiary care cancer hospital. Patients who underwent surgery for cancers of the oral cavity during the period January 2014 to December 2016 were included in the study. The spectrum of infections, risk factors, microbial profile, antibiotic susceptibility pattern, treatment given and outcome were assessed. A total of 1431 patients who underwent surgery for cancers of the oral cavity during the study period were followed up. SSIs were noticed in 118 (8%) post-operative cases. This included 55 (76.4%) incisional SSIs and 17 (23.6%) organ/space SSIs. Culture of the surgical site in 72 infected patients yielded a total of 122 isolates. Thirty patients (41.6%) had polymicrobial infections. Gram-negative bacterial isolates (70.5%) outnumbered gram-positive bacterial isolates (27%). Majority of the patients (48 patients-66.6%) were in stage IV disease. Successful management of patients with bacterial infections depends on early identification of bacterial pathogens and selection of an effective antibiotic against the organism. Judicial use of antibiotics is also very essential to prevent the development of drug resistance.
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Affiliation(s)
- P. G. Balagopal
- Department of Head and Neck Surgery, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011 India
| | - Sandeep Suresh
- Department of Head and Neck Surgery, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011 India
| | - Swapna R. Nath
- Department of Microbiology, Regional Cancer Centre, Thiruvananthapuram, Kerala India
| | - S. G. Sagila
- Department of Microbiology, Regional Cancer Centre, Thiruvananthapuram, Kerala India
| | - Nebu Abraham George
- Department of Head and Neck Surgery, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011 India
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Zenga J, Atkinson S, Yen T, Massey B, Stadler M, Bruening J, Peppard W, Reuben M, Hayward M, Mesich B, Buchan B, Ledeboer N, Sanchez JL, Fraser R, Lin CW, Holtz ML, Awan M, Wong SJ, Puram SV, Salzman N. A phase 2 trial of a topical antiseptic bundle in head and neck cancer surgery: Effects on surgical site infection and the oral microbiome. EBioMedicine 2022; 81:104099. [PMID: 35671624 PMCID: PMC9168040 DOI: 10.1016/j.ebiom.2022.104099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 11/27/2022] Open
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Javaux C, Daveau C, Bettinger C, Daurade M, Dupieux-Chabert C, Craighero F, Fuchsmann C, Céruse P, Gleizal A, Sigaux N, Ferry T, Valour F. Osteocutaneous-flap-related osteomyelitis following mandibular reconstruction: a cohort study of an emerging and complex bone infection. J Bone Jt Infect 2022; 7:127-136. [PMID: 35855050 PMCID: PMC9285487 DOI: 10.5194/jbji-7-127-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/23/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract. Osteocutaneous flap (OCF) mandible reconstruction is at
high risk for surgical site infection. This study aimed to describe
diagnosis, management, and outcome of OCF-related osteomyelitis. All
patients managed at our institution for an OCF-related osteomyelitis
following mandible reconstruction were included in a retrospective cohort
study (2012–2019). Microbiology was described according to gold-standard
surgical samples, considering all virulent pathogens, and potential
contaminants if present on at least two samples. Determinants of treatment
failure were assessed by logistic regression and Kaplan–Meier curve
analysis. The 48 included patients (median age 60.5 (IQR, 52.4–66.6) years)
benefited from OCF mandible reconstruction mostly for carcinoma (n=27/48;
56.3 %) or osteoradionecrosis (n=12/48; 25.0 %). OCF-related
osteomyelitis was mostly early (≤3 months post-surgery; n=43/48;
89.6 %), presenting with local inflammation (n=28/47; 59.6 %), nonunion (wound dehiscence)
or sinus tract (n=28/47; 59.6 %), and/or bone or device exposure
(n=21/47; 44.7 %). Main implicated pathogens were Enterobacteriaceae (n=25/41; 61.0 %),
streptococci (n=22/41; 53.7 %), Staphylococcus aureus (n=10/41; 24.4 %), enterococci
(n=9/41; 22.0 %), non-fermenting Gram-negative bacilli (n=8/41;
19.5 %), and anaerobes (n=8/41; 19.5 %). Thirty-nine patients (81.3 %)
benefited from surgery, consisting of debridement with implant retention
(DAIR) in 25/39 (64.1 %) cases, associated with 93 (IQR, 64–128) days of
antimicrobial therapy. After a follow-up of 18 (IQR, 11–31) months, 24/48
(50.0 %) treatment failures were observed. Determinants of treatment
outcomes were DAIR (OR, 3.333; 95 % CI, 1.020–10.898) and an early
infectious disease specialist referral (OR, 0.236 if ≤2 weeks;
95 % CI, 0.062–0.933). OCF-related osteomyelitis following mandibular reconstruction represents
difficult-to-treat infections. Our results advocate for a multidisciplinary
management, including an early infectious-disease-specialist referral to
manage the antimicrobial therapy driven by complex microbiological
documentation.
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Tamagawa S, Iyo T, Kono M, Sugita G, Takeda S, Kumashiro N, Murakami D, Enomoto K, Ohtani M, Hotomi M. Impact of the practical guideline on appropriate usage of antimicrobial treatments for surgical site infections in reconstructive surgery of head and neck cancer. J Infect Chemother 2021; 28:401-405. [PMID: 34887177 DOI: 10.1016/j.jiac.2021.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/23/2021] [Accepted: 11/21/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVES In 2016, Japanese Society of Chemotherapy and Japan Society for Surgical Infection presented the practical guideline for appropriate usage of antimicrobial agents to prevent postoperative infections. This study aims to exhibit the validity of the guideline as a series of effective strategies for prevention of surgical site infections (SSIs) during reconstructive surgery of the head and neck cancer. METHODS We retrospectively evaluated patients who underwent head and neck reconstructive surgery with free or pedicle flaps in a single institute in Japan between July 2010 and July 2020. We evaluated the incidence of SSIs, patient backgrounds, and microbiological characteristics on the basis of antimicrobial prophylaxis recommended by the guideline. RESULTS Enrolled in this study were 102 patients in our institution who underwent head and neck reconstructive surgery with free or pedicle flaps between July 2010 and July 2020. In the period between January 2018 to July 2020 after the SSI guideline was advocated (SSI guideline period), the ratio of administration of sulbactam/ampicillin (SBT/ABPC) was significantly higher (P < 0.001) and the duration of prophylactic antimicrobial treatment was significantly shorter than in the period between July 2010 to December 2017 before the SSI guideline was advocated (Pre-SSI guideline period) (P < 0.001). Incidence of SSIs were similar, even when antibiotic use was changed to be short-term single-agent administration in accordance with the practical guideline. CONCLUSIONS Adherence to the current Japanese practical guideline on appropriate antimicrobial prophylaxis for SSIs can shorten the duration of usage of antimicrobial treatment without increasing the risk for occurrence of SSIs.
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Affiliation(s)
- Shunji Tamagawa
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan
| | - Takuro Iyo
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan
| | - Masamitsu Kono
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan
| | - Gen Sugita
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan
| | - Saori Takeda
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan
| | - Naoko Kumashiro
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan
| | - Daichi Murakami
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan
| | - Keisuke Enomoto
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan
| | - Makiko Ohtani
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan
| | - Muneki Hotomi
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan.
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7
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Gan C, Wang Y, Tang Y, Wang K, Sun B, Wang M, Zhu F. Risk factors for surgical site infection in head and neck cancer. Support Care Cancer 2021; 30:2735-2743. [PMID: 34825984 DOI: 10.1007/s00520-021-06687-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/07/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE Surgical site infection (SSI) frequently occurs in patients with head and neck cancer (HNC) after tumor resection and can lead to death in severe cases. Moreover, there is no definitive conclusion about the risk factors of SSI. Therefore, it is of great clinical significance to study the factors affecting the SSI. METHODS The HNC patients included in this study were all from the Department of Oral and Maxillofacial Surgery of the Second Xiangya Hospital of Central South University (CSU), and these patients received surgical treatment in the department from January 2018 to December 2019. The cross tabulation with chi-squared testing and multivariate regression analysis were applied to determine the risk factors of SSI. To identify the key risk factors of SSI, the caret package was used to construct three different machine learning models to investigate important features involving 26 SSI-related risk factors. RESULTS Participants were 632 HNC patients who underwent surgery in our department from January 2018 to December 2019. During the postoperative period, 82 patients suffered from SSI, and surgical site infection rate (SSIR) was about 12.97%. Multivariate logistic regression analysis shows that diabetes mellitus, primary tumor site (floor of mouth), preoperative radiotherapy, flap failure, and neck dissection (bilateral) are risk factors for SSI of HNC. Machine learning indicated that diabetes mellitus, primary tumor site (floor of mouth), and flap failure were consistently ranked the top three in the 26 SSI-related risk factors. CONCLUSION Diabetes mellitus, primary tumor site (floor of mouth), flap failure, preoperative radiotherapy, and neck dissection (bilateral) are risk factors for SSI of HNC.
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Affiliation(s)
- Chengwen Gan
- Department of Oral and Maxillofacial Surgery, Hainan Provincial People's Hospital, Haikou, Hainan, China
| | - Yannan Wang
- Department of Plastic Surgery, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yan Tang
- Department of Nursing, The Second Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Kai Wang
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, China
| | - Bincan Sun
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, China
| | - Mengxue Wang
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, China
| | - Feiya Zhu
- Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, China.
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Surgical and remote site infections after reconstructive surgery of the head and neck: A risk factor analysis. J Craniomaxillofac Surg 2021; 50:178-187. [PMID: 34802884 DOI: 10.1016/j.jcms.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 09/27/2021] [Accepted: 11/10/2021] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to identify risk factors for surgical (SSI) and remote site (RSI) infections, pathogens and antibiotic resistances in patients after pedicled and free flap reconstruction in the head and neck area. SSI criteria implicated infections affecting superficial or deep tissue in the flap area with purulent discharge, fistula, abscess formation and local infections signs. RSI criteria were defined as infections remote from the surgical site presenting with systemic symptoms like fever, leucocytosis, increase in C-reactive protein, purulent tracheobronchial secretion or deterioration of blood gases. Focus adequate specimen sampling and aerobic and anaerobic incubation and cultivation was performed. Epidemiological data, factors directly related to surgery or reconstruction, perioperative antibiotic regimen, length of stay, autologous blood transfusion and microbiological aspects were retrospectively analysed in 157 patients. 10.8% of patients presented SSI, 12.7% RSI. Cultivated bacteria were sampled from flap sites, blood cultures, central catheters and sputum including mainly gram-negative bacteria (70.3%) being frequently resistant against penicillin (85%) and third generation cephalosporine derivates (48%). Autologous blood transfusion (p = 0.018) and perioperative clindamycin use (p = 0.002) were independent risk factors for overall (SSI and RSI combined) infections. Prior radiation (p = 0.05), autologous blood transfusion (p = 0.034) and perioperative clindamycin use (p = 0.004) were predictors for SSIs. ASA >2 (p = 0.05) was a risk factor for remote site infections and prolonged ICU stay (p = 0.002) was associated with overall infections, especially in irradiated patients. Efforts need to be made in improving patient blood management, antibiotic stewardship and accurate postoperative care to avoid postoperative infections after head and neck reconstructive surgery.
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Tjoa T, Rathi VK, Goyal N, Yarlagadda BB, Barshak MB, Rich DL, Emerick KS, Lin DT, Deschler DG, Durand ML. Pneumonia, urinary tract infection, bacteremia, and Clostridioides difficile infection following major head and neck free and pedicled flap surgeries. Oral Oncol 2021; 122:105541. [PMID: 34564017 DOI: 10.1016/j.oraloncology.2021.105541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/21/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Medical postoperative infections (MPIs) are important causes of morbidity following major head and neck free and pedicled flap reconstruction, but the incidence, time of onset, and microbiology are not well characterized. MATERIALS AND METHODS Medical records were reviewed of all head and neck flap surgeries performed 2009-2014 at an academic medical center. Postoperative pneumonia, urinary tract infection (UTI), bloodstream infection (BSI), Clostridioides difficile (CDI), and surgical site infections (SSI) were noted. Catheter-associated UTI (CAUTI), central line-associated BSI (CLABSI), and methicillin-resistant Staphylococcus aureus (MRSA) BSI were also evaluated. RESULTS Following 715 free (540) or pedicled (175) flap surgeries, 14.1% of patients developed ≥one MPI including pneumonia (10.6%), UTI (2.1%), BSI (0.7%), and CDI (2.4%). Onset was ≤7 days in 77%. The MPI incidence in free vs pedicled flaps was similar. By multivariate analysis, age ≥65 and clindamycin perioperative prophylaxis were associated with increased MPI risk, clean class surgery with decreased risk. The incidence of CAUTI (<1.0%), CLABSI (0.1%), and hospital-onset MRSA BSI (0.1%) was low. SSI rate (7.8% overall) was higher in patients who developed pneumonia (18.4 vs 6.6, p = 0.004). MPI cultures grew gram-negative bacilli or S. aureus in 75%. The length of stay was longer in patients who developed a MPI than those who did not (17.4 vs 10.4 days, p < 0.0001). CONCLUSIONS One-seventh of major head and neck flap surgeries were complicated by MPIs, three-quarters of infections developed within 1 week postoperatively. Gram-negative bacilli and S. aureus were the predominant pathogens.
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Affiliation(s)
- Tjoson Tjoa
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Vinay K Rathi
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Neerav Goyal
- Department of Otolaryngology, Penn State Milton S. Hershey Medical Center, 200 Campus Drive, Hershey, PA 17033, United States.
| | - Bharat B Yarlagadda
- Department of Otolaryngology, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, MA 01805, United States.
| | - Miriam B Barshak
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States.
| | - Debbie L Rich
- Department of Nursing, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States
| | - Kevin S Emerick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Derrick T Lin
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Daniel G Deschler
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States.
| | - Marlene L Durand
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States.
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Ricciardi C, Orabona GD, Picone I, Latessa I, Fiorillo A, Sorrentino A, Triassi M, Improta G. A Health Technology Assessment in Maxillofacial Cancer Surgery by Using the Six Sigma Methodology. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:9846. [PMID: 34574768 PMCID: PMC8469470 DOI: 10.3390/ijerph18189846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/06/2021] [Accepted: 09/15/2021] [Indexed: 12/15/2022]
Abstract
Squamous cell carcinoma represents the most common cancer affecting the oral cavity. At the University of Naples "Federico II", two different antibiotic protocols were used in patients undergoing oral mucosa cancer surgery from 2006 to 2018. From 2011, there was a shift; the combination of Cefazolin plus Clindamycin as a postoperative prophylactic protocol was chosen. In this paper, a health technology assessment (HTA) is performed by using the Six Sigma and DMAIC (Define, Measure, Analyse, Improve, Control) cycle in order to compare the performance of the antibiotic protocols according to the length of hospital stay (LOS). The data (13 variables) of two groups were collected and analysed; overall, 136 patients were involved. The American Society of Anaesthesiologist score, use of lymphadenectomy or tracheotomy and the presence of infections influenced LOS significantly (p-value < 0.05) in both groups. Then, the groups were compared: the overall difference between LOS of the groups was not statistically significant, but some insights were provided by comparing the LOS of the groups according to each variable. In conclusion, in light of the insights provided by this study regarding the comparison of two antibiotic protocols, the utilization of DMAIC cycle and Six Sigma tools to perform HTA studies could be considered in future research.
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Affiliation(s)
- Carlo Ricciardi
- Department of Electrical Engineering and Information Technology, University of Naples “Federico II”, 80125 Naples, Italy;
- Bioengineering Unit, Institute of Care and Scientific Research Maugeri, 27100 Pavia, Italy
| | - Giovanni Dell’Aversana Orabona
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Hospital of Naples “Federico II”, 80131 Napoli, Italy; (G.D.O.); (A.S.)
| | - Ilaria Picone
- Department of Advanced Biomedical Sciences, University Hospital of Naples “Federico II”, 80131 Naples, Italy; (I.P.); (A.F.)
| | - Imma Latessa
- Department of Public Health, University Hospital of Naples “Federico II”, 80131 Naples, Italy; (I.L.); (M.T.)
| | - Antonella Fiorillo
- Department of Advanced Biomedical Sciences, University Hospital of Naples “Federico II”, 80131 Naples, Italy; (I.P.); (A.F.)
| | - Alfonso Sorrentino
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Hospital of Naples “Federico II”, 80131 Napoli, Italy; (G.D.O.); (A.S.)
| | - Maria Triassi
- Department of Public Health, University Hospital of Naples “Federico II”, 80131 Naples, Italy; (I.L.); (M.T.)
- Interdepartmental Center for Research in Healthcare Management and Innovation in Healthcare (CIRMIS), University of Naples “Federico II”, 80131 Naples, Italy
| | - Giovanni Improta
- Department of Public Health, University Hospital of Naples “Federico II”, 80131 Naples, Italy; (I.L.); (M.T.)
- Interdepartmental Center for Research in Healthcare Management and Innovation in Healthcare (CIRMIS), University of Naples “Federico II”, 80131 Naples, Italy
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11
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Stabenau KA, Akakpo KE, Richmon JD, McMullen C, Holcomb AJ, Graboyes EM, Gross J, Pipkorn P, Puram SV, Zenga J. Postoperative wound infections in head and neck surgery: The current state of antiseptic and antibiotic practices. Oral Oncol 2021; 118:105361. [PMID: 34083128 DOI: 10.1016/j.oraloncology.2021.105361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Kaleigh A Stabenau
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Kenneth E Akakpo
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jeremy D Richmon
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
| | - Caitlin McMullen
- Department of Otolaryngology-Head and Neck Surgery, Moffitt Cancer Center, Tampa, FL, United States
| | - Andrew J Holcomb
- Department of Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Omaha, NE, United States
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, United States; Department Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Jennifer Gross
- Department of Otolaryngology-Head and Neck Surgery, Emory School of Medicine, Atlanta, GA, United States
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, Saint Louis, MO, United States
| | - Sidharth V Puram
- Department of Genetics, Washington University School of Medicine, Saint Louis, MO, United States
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States.
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12
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Cheng OT, Stein AP, Babajanian E, Hoppe KR, Li S, Jung H, Abrol A, Akkus A, Younesi M, Altawallbeh G, Ghannoum MA, Bonfield T, Akkus O, Zender CA. Heparin-mediated antibiotic delivery from an electrochemically-aligned collagen sheet. Biomed Mater Eng 2021; 32:159-170. [PMID: 33780355 DOI: 10.3233/bme-201133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Implantable medical devices and hardware are prolific in medicine, but hardware associated infections remain a major issue. OBJECTIVE To develop and evaluate a novel, biologic antimicrobial coating for medical implants. METHODS Electrochemically compacted collagen sheets with and without crosslinked heparin were synthesized per a protocol developed by our group. Sheets were incubated in antibiotic solution (gentamicin or moxifloxacin) overnight, and in vitro activity was assessed with five-day diffusion assays against Pseudomonas aeruginosa. Antibiotic release over time from gentamicin-infused sheets was determined using in vitro elution and high performance liquid chromatography (HPLC). RESULTS Collagen-heparin-antibiotic sheets demonstrated larger growth inhibition zones against P. aeruginosa compared to collagen-antibiotic alone sheets. This activity persisted for five days and was not impacted by rinsing sheets prior to evaluation. Rinsed collagen-antibiotic sheets did not produce any inhibition zones. Elution of gentamicin from collagen-heparin-gentamicin sheets was gradual and remained above the minimal inhibitory concentration for gentamicin-sensitive organisms for 29 days. Conversely, collagen-gentamicin sheets eluted their antibiotic load within 24 hours. Overall, heparin-associated sheets demonstrated larger inhibition zones against P. aeruginosa and prolonged elution profile via HPLC. CONCLUSION We developed a novel, local antibiotic delivery system that could be used to coat medical implants/hardware in the future and reduce post-operative infections.
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Affiliation(s)
- Olivia T Cheng
- Case Western Reserve University (CWRU) School of Medicine, Cleveland, OH, USA
| | - Andrew P Stein
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Eric Babajanian
- Case Western Reserve University (CWRU) School of Medicine, Cleveland, OH, USA
| | - Kathryn R Hoppe
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Shawn Li
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Hyungjin Jung
- Department of Biomedical Engineering, CWRU, Cleveland, OH, USA
| | - Anish Abrol
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Anna Akkus
- Department of Macromolecular Science & Engineering, CWRU, Cleveland, OH, USA
| | - Mousa Younesi
- Department of Biomedical Engineering, CWRU, Cleveland, OH, USA
| | | | - Mahmoud A Ghannoum
- Center for Medical Mycology, CWRU and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Ozan Akkus
- Department of Biomedical Engineering, CWRU, Cleveland, OH, USA
| | - Chad A Zender
- Department of Otolaryngology, University of Cincinnati, Cincinnati, OH, USA
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13
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Ponsiglione AM, Ricciardi C, Improta G, Orabona GD, Sorrentino A, Amato F, Romano M. A Six Sigma DMAIC methodology as a support tool for Health Technology Assessment of two antibiotics. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2021; 18:3469-3490. [PMID: 34198396 DOI: 10.3934/mbe.2021174] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Health Technology Assessment (HTA) and Six Sigma (SS) have largely proved their reliability in the healthcare context. The former focuses on the assessment of health technologies to be introduced in a healthcare system. The latter deals with the improvement of the quality of services, reducing errors and variability in the healthcare processes. Both the approaches demand a detailed analysis, evidence-based decisions, and efficient control plans. In this paper, the SS is applied as a support tool for HTA of two antibiotics with the final aim of assessing their clinical and organizational impact in terms of postoperative Length Of Stay (LOS) for patients undergoing tongue cancer surgery. More specifically, the SS has been implemented through its main tool, namely the DMAIC (Define, Measure, Analyse, Improve, Control) cycle. Moreover, within the DMAIC cycle, a modelling approach based on a multiple linear regression analysis technique is introduced, in the Control phase, to add complementary information and confirm the results obtained by the statistical analysis performed within the other phases of the SS DMAIC. The obtained results show that the proposed methodology is effective to determine the clinical and organizational impact of each of the examined antibiotics, when LOS is taken as a measure of performance, and guide the decision-making process. Furthermore, our study provides a systematic procedure which, properly combining different and well-assessed tools available in the literature, demonstrated to be a useful guidance for choosing the right treatment based on the available data in the specific circumstance.
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Affiliation(s)
- Alfonso Maria Ponsiglione
- Department of Electrical Engineering and Information Technology (DIETI), University of Naples "Federico II", Naples, Italy
| | - Carlo Ricciardi
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Giovanni Improta
- Department of Public Health, University of Naples "Federico II", Naples, Italy
- Interdepartmental Center for Research in Healthcare Management and Innovation in Healthcare (CIRMIS), University of Naples "Federico II", Naples, Italy
| | - Giovanni Dell'Aversana Orabona
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Hospital of Naples "Federico II", Naples, Italy
| | - Alfonso Sorrentino
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Hospital of Naples "Federico II", Naples, Italy
| | - Francesco Amato
- Department of Electrical Engineering and Information Technology (DIETI), University of Naples "Federico II", Naples, Italy
- Interdepartmental Center for Research in Healthcare Management and Innovation in Healthcare (CIRMIS), University of Naples "Federico II", Naples, Italy
| | - Maria Romano
- Department of Electrical Engineering and Information Technology (DIETI), University of Naples "Federico II", Naples, Italy
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14
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Harris BN, Patel R, Kejner A, Russell B, Ramadan J, Bewley A. Thrombocytosis Predicts Surgical Site Infection in Head and Neck Microvascular Surgery- A Pilot Study. Laryngoscope 2021; 131:1542-1547. [PMID: 33443771 DOI: 10.1002/lary.29386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/07/2020] [Accepted: 01/03/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE/HYPOTHESIS Early and objective prediction of complications in head and neck reconstructive surgery could decrease morbidity and prolonged hospital stays but unfortunately most complications are not identified until their effect is fully realized. There are limited data regarding the association of platelet levels and post-operative complications. Post-operative thrombocytosis (POTCT) is proposed as a possible indicator for complications following free-flap reconstruction. STUDY DESIGN Retrospective review. METHODS A multisite retrospective chart review of patients undergoing free tissue transfer between 2013 and 2018 was undertaken. POTCT was recorded and data normalized between institutions. Data were compared between groups using t-tests and logistic regression (P < .05). A lag-1 difference was used to compare the rate of change in platelet values. RESULTS A total of 398 patients were included. POTCT and a rate of change of 30 K between POD5 and POD6 was significantly associated with the presence of post-operative complication (P = .007). Additionally, lag-1 difference demonstrated a significant association of change in daily platelet counts and complication rates. CONCLUSIONS Isolated POTCT may be an early predictor of complications in HNC patients undergoing free-flap reconstruction. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1542-1547, 2021.
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Affiliation(s)
- Brianna N Harris
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Rusha Patel
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Alexandra Kejner
- Department of Otolaryngology, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Benjamin Russell
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Jad Ramadan
- Department of Statistics, West Virginia University, Morgantown, West Virginia, U.S.A
| | - Arnaud Bewley
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
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15
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Hamill CS, Snyder V, Sykes KJ, O'Toole T. Prevalence of Multidrug-Resistant Organisms in Patients Undergoing Free Flap Reconstruction. Laryngoscope 2020; 131:E1881-E1887. [PMID: 33179795 DOI: 10.1002/lary.29268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/05/2020] [Accepted: 11/01/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVES/HYPOTHESIS The purpose of this study is to evaluate the relationship between antibiotic prophylaxis and prevalence of multidrug-resistant organisms (MDRO) in patients undergoing head and neck cancer reconstruction. STUDY DESIGN Retrospective Chart Review. METHODS Retrospective review of patients who underwent head and neck free flap reconstruction at our institution between 2009 to 2016. RESULTS Of the 145 patients that underwent head and neck tumor removal surgery using free tissue flaps to cover the defect and therafter received antibiotic prophylaxis, 30 (20.7%) developed postoperative surgical site (n = 17, 55.7%) or distant (n = 13, 43.4%) infections. Seven had a multidrug-resistant infection, the most common with Methicillin-Resistant Staphylococcus aureus (MRSA). There was no significant relationship between antibiotic spectrum or duration to the development of postoperative infections or MDRO. Pseudomonas and MRSA infections were low overall with only one multidrug-resistant Pseudomonas infection. CONCLUSIONS The choice of antibiotic prophylaxis should cover organisms these patients are at highest risk for including anaerobes and Gram-negative organisms. A shorter duration of antibiotic prophylaxis should be considered given no increased risk of postoperative infection nor MDRO. Finally, one must be aware of the potential threat of multidrug-resistant Pseudomonas and MRSA amongst this vulnerable population and identity these with culture driven treatment. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1881-E1887, 2021.
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Affiliation(s)
- Chelsea S Hamill
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center/Case Western Reserve, Cleveland, Ohio, U.S.A
| | - Vusala Snyder
- Department of Otolaryngology- Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Kevin J Sykes
- Department of Otolaryngology- Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, U.S.A
| | - Thomas O'Toole
- Department of Otolaryngology, Head and Neck Surgery, Spectrum Health Medical Group, Grand Rapids, Michigan, U.S.A
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16
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Unplanned 30-day readmission rates after plastic and reconstructive surgery procedures: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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A health technology assessment between two pharmacological therapies through Six Sigma: the case study of bone cancer. TQM JOURNAL 2020. [DOI: 10.1108/tqm-01-2020-0013] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeHead and neck cancers are multi-factorial diseases that can affect many sides of people's life and are due to a lot of risk factors. According to their characteristics, the treatment can be surgical, use of radiation or chemotherapy. The use of a surgical treatment can lead to surgical infections that are a main theme in medicine. At the University hospital of Naples “Federico II”, two antibiotics were employed to tackle the issue of the infections and they are compared in this paper to find which one implies the lowest length of hospital stay (LOS) and the reduction of infections.Design/methodology/approachThe Six Sigma methodology and its problem-solving strategy DMAIC (define, measure, analyse, improve, control), already employed in the healthcare sector, were used as a tool of a health technology assessment between two drugs. In this paper the DMAIC roadmap is used to compare the Ceftriaxone (administered to a group of 48 patients) and the association of Cefazolin plus Clindamycin (administered to a group of 45 patients).FindingsThe results show that the LOS of patients treated with Ceftriaxone is lower than those who were treated with the association of Cefazolin plus Clindamycin, the difference is about 41%. Moreover, a lower number of complications and infections was found in patients who received Ceftriaxone. Finally, a greater number of antibiotic shifts was needed by patients treated with Cefazolin plus Clindamycin.Research limitations/implicationsWhile the paper enhances clearly the advantages for patients' outcomes regarding the LOS and the number of complications, it did not analyse the costs of the two antibiotics.Practical implicationsEmploying the Ceftriaxone would allow the Department of Maxillofacial Surgery to obtain lower LOS and a limited number of complications/infections for recovered patients, consequently reducing the hospitalization costs.Originality/valueThere is a double value in this paper: first of all, the comparison between the two antibiotics gives an answer to one of the main issues in medicine that is the reduction of hospital-acquired infections; secondly, the Six Sigma through its DMAIC cycle can be employed also to compare two biomedical technologies as a tool of health technology assessment studies.
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18
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Marinone Lares SG, Clark S, Mathy JA, Chaplin J, McIvor N. Evaluation of a novel database for quality assurance at a head and neck service in New Zealand: an audit of free flap head and neck reconstruction. ANZ J Surg 2020; 90:1386-1390. [PMID: 32436238 DOI: 10.1111/ans.15974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical audit is a critical quality improvement exercise, yet efficient audit tools are lacking. The main objective of this study was to evaluate a recently deployed database in facilitating the process of clinical audit, and the secondary objective was to evaluate the outcomes of free flap reconstruction of the head and neck at our centre. METHODS A head and neck cancer-specific database was customized to suit the needs of our head and neck multidisciplinary team. Data has been entered prospectively into this database since March of 2018. An audit of free flap reconstruction of the head and neck over a 12-month period was performed using the database and analysed as a case study to examine its efficacy as a clinical audit tool. Additionally, the outcomes of free flap reconstruction at our centre were compared to those reported in the international literature. RESULTS The database allows flexible and specific queries, analysis and export of data, and can provide immediate results. However, issues with data quality and completeness were identified. In this audit, the overall 30-day complication rate and 30-day mortality in patients undergoing free flap reconstruction of the head and neck were 58% and 3%, respectively. CONCLUSION The database is fit for its intended purpose as an audit tool. Outcomes of free flap reconstruction of the head and neck at our centre are comparable to those of institutions overseas.
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Affiliation(s)
| | - Sita Clark
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Jon A Mathy
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand.,Auckland Regional Plastic Surgery Unit, Auckland, New Zealand
| | - John Chaplin
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Nick McIvor
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
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19
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The effect of preventive oral care on postoperative infections after head and neck cancer surgery. Auris Nasus Larynx 2020; 47:643-649. [PMID: 32037040 DOI: 10.1016/j.anl.2020.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/23/2019] [Accepted: 01/14/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to investigate the incidence of postoperative pneumonia (PP) and surgical site infection (SSI) in head and neck cancer (HNC) patients and clarify the relationship between oral care and postoperative infection. METHODS We conducted a retrospective observation survey based on the medical records of 209 HNC surgery patients managed at a University Hospital in 2016-2018. The incidence of PP and SSI were assessed in patients who underwent operations of the nose and paranasal sinuses to the larynx. Factors associated with PP and SSI in a univariate analysis were included in a multiple logistic regression analysis. A Cox proportional hazards model was used analyze the incidence of PP according to time after surgery. The present study was approved by the ethical review board of our Institute. RESULTS The rates of PP and SSI in our study population were 20.5% and 23.0%. Operative time (P < 0.01), blood loss (P = 0.004), tracheostomy (P < 0.01), reconstruction (P < 0.01), and preoperative plaque control record (PCR) (P < 0.01) were significantly associated with PP. The PCR depicted the oral hygiene based on the percentage of plaque attached to the tooth neck. A multiple logistic regression analysis indicated that the incidence of PP was significantly higher in patients with PCR values of ≥50% after preoperative oral care (OR=10.174, 95% CI 2.14-48.32, P = 0.004). Tracheostomy (P < 0.01), reconstruction (P = 0.044), a lower preoperative albumin level (P = 0.019), and a lower preoperative hemoglobin level (P < 0.01) were significantly associated with SSI. CONCLUSIONS The incidence of PP among patients who received oral care was high in those patients with high PCR values, indicating the importance of increasing compliance to preoperative oral care.
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20
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Goel AN, Raghavan G, St John MA, Long JL. Risk Factors, Causes, and Costs of Hospital Readmission After Head and Neck Cancer Surgery Reconstruction. JAMA FACIAL PLAST SU 2020; 21:137-145. [PMID: 30418467 DOI: 10.1001/jamafacial.2018.1197] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Thirty-day hospital readmissions have substantial direct costs and are increasingly used as a measure of quality care. However, data regarding the risk factors and reasons for readmissions in head and neck cancer surgery reconstruction are lacking. Objective To describe the rate, risk factors, and causes of 30-day readmission in patients with head and neck cancer following free or pedicled flap reconstruction. Design, Setting, and Participants This retrospective, population-based cohort study analyzed medical records from the Nationwide Readmissions Database of 9487 patients undergoing pedicled or free flap reconstruction of head and neck oncologic defects between January 1, 2010, and December 31, 2014. Data analysis was performed in October 2017. Exposures Pedicled or free flap reconstruction of an oncologic head and neck defect. Main Outcomes and Measures The primary outcome was 30-day all-cause readmissions. Secondary outcomes included risk factors, causes, and costs of readmission. Multivariate regression analyses were conducted to determine factors independently associated with 30-day readmissions. Results Among 9487 patients included in the study (6798 male; 71.7%), the median age was 63 years (interquartile range, 55-71 years), and the 30-day readmission rate was 19.4% (n = 1839), with a mean cost per readmission of $15 916 (standard error of the mean, $785). The most common indication for readmission was wound complication (26.5%, n = 487). On multivariate regression, significant risk factors for 30-day readmission were median household income in the lowest quartile (vs highest quartile: odds ratio [OR], 1.58; 95% CI, 1.18-2.11), congestive heart failure (OR, 1.68; 95% CI, 1.14-2.47), liver disease (OR, 2.02; 95% CI, 1.22- 3.33), total laryngectomy (OR, 1.40; 95% CI, 1.12-1.75), pharyngectomy (OR, 1.47; 95% CI, 1.08-2.01), blood transfusion (OR, 1.30; 95% CI, 1.04-1.64), discharge to home with home health care (vs routine: OR, 1.32; 95% CI, 1.04-1.67), and discharge to a nursing facility (vs routine: OR, 1.77; 95% CI, 1.30-2.40). Conclusions and Relevance Using the Nationwide Readmissions Database, we demonstrate that approximately 1 in 5 patients undergoing head and neck cancer surgery reconstruction is readmitted within 30 days of surgery. Readmissions are most commonly associated with wound complications. Socioeconomic status, complex ablative procedures, and patient comorbidities are independent risk factors for readmission. These findings may be useful to clinicians in developing perioperative interventions aimed to reduce hospital readmissions and improve quality of patient care.
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Affiliation(s)
- Alexander N Goel
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA)
| | - Govind Raghavan
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA)
| | - Maie A St John
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).,Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, California.,UCLA Head and Neck Cancer Program, UCLA Medical Center, Los Angeles, California
| | - Jennifer L Long
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).,Research Service, Department of Veterans Affairs, Los Angeles, California
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21
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Zirk M, Zalesski A, Peters F, Kreppel M, Zinser M, Zöller JE. Oral recipient site infections in reconstructive surgery - impact of the graft itself and the perioperative antibiosis. Clin Oral Investig 2019; 24:1599-1605. [PMID: 31643002 DOI: 10.1007/s00784-019-03078-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 09/15/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study was designed to assess the influence of peri/post-operative antibiotic prophylaxis (POABP) and the reconstructive graft itself on recipient sites infections in head and neck surgery. MATERIALS AND METHODS In this retrospective cohort study, 322 consecutive patients with reconstructive surgery were investigated. The primary objective was to analyze the differences of commonly applied reconstructive grafts on the occurrence of oral recipient site infections. Moreover, differences of POABP regimes (namely: ampicillin/sulbactam, 2nd generation cephalosporins, clindamycin) and antibiotic alternatives were investigated. In addition, patients' length of in-hospital stay was analyzed in regard to reconstructive graft and POABP regime. RESULTS The free radial forearm flap and split-thickness skin graft presented significantly less recipient site infections and shorter length of in-hospital stays (LOS) in comparison to further six reconstructive technique with pedicled tissue transfer or bone transfers. LOS was significantly shorter for patients with ampicillin/sulbactam than with 2nd generation cephalosporins as POABP. 91% of the harvested pathogens (n=193) were susceptible to the combination of 2nd and 3rd generation cephalosporins. Secondly, 92 out 113 (81%) harvested pathogens presented susceptibility to moxifloxacin. CONCLUSION Smaller tissue transfers are less prone to infections of the recipient site and present low LOS. For an POABP regime, the combination of 2nd and 3rd generation cephalosporins presents substantial results in recipient site infections. In cases of allergy, potential pathogens show adequate susceptibility to moxifloxacin. CLINICAL RELEVANCE A combination of 2nd and 3rd generation cephalosporins may be used to prevent recipient sites in head and neck surgery.
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Affiliation(s)
- Matthias Zirk
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany.
| | - Artjom Zalesski
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Franziska Peters
- Department of Dermatology, University of Cologne, Cologne, Germany.,Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, Cologne, Germany
| | - Matthias Kreppel
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Max Zinser
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Joachim E Zöller
- Department for Oral and Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
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22
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Oral recipient site infections in reconstructive surgery - impact of the graft itself and the perioperative antibiosis. Clin Oral Investig 2019. [PMID: 31643002 DOI: 10.1007/s00784‐019‐03078‐6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES This study was designed to assess the influence of peri/post-operative antibiotic prophylaxis (POABP) and the reconstructive graft itself on recipient sites infections in head and neck surgery. MATERIALS AND METHODS In this retrospective cohort study, 322 consecutive patients with reconstructive surgery were investigated. The primary objective was to analyze the differences of commonly applied reconstructive grafts on the occurrence of oral recipient site infections. Moreover, differences of POABP regimes (namely: ampicillin/sulbactam, 2nd generation cephalosporins, clindamycin) and antibiotic alternatives were investigated. In addition, patients' length of in-hospital stay was analyzed in regard to reconstructive graft and POABP regime. RESULTS The free radial forearm flap and split-thickness skin graft presented significantly less recipient site infections and shorter length of in-hospital stays (LOS) in comparison to further six reconstructive technique with pedicled tissue transfer or bone transfers. LOS was significantly shorter for patients with ampicillin/sulbactam than with 2nd generation cephalosporins as POABP. 91% of the harvested pathogens (n=193) were susceptible to the combination of 2nd and 3rd generation cephalosporins. Secondly, 92 out 113 (81%) harvested pathogens presented susceptibility to moxifloxacin. CONCLUSION Smaller tissue transfers are less prone to infections of the recipient site and present low LOS. For an POABP regime, the combination of 2nd and 3rd generation cephalosporins presents substantial results in recipient site infections. In cases of allergy, potential pathogens show adequate susceptibility to moxifloxacin. CLINICAL RELEVANCE A combination of 2nd and 3rd generation cephalosporins may be used to prevent recipient sites in head and neck surgery.
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Chiesa-Estomba CM, Lechien JR, Fakhry N, Melkane A, Calvo-Henriquez C, de Siati D, Gonzalez-Garcia JA, Fagan JJ, Ayad T. Systematic review of international guidelines for perioperative antibiotic prophylaxis in Head & Neck Surgery. A YO-IFOS Head & Neck Study Group Position Paper. Head Neck 2019; 41:3434-3456. [PMID: 31282061 DOI: 10.1002/hed.25856] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/10/2019] [Accepted: 06/12/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Surgical site infection (SSI) is defined as an infection that occurs after a surgical incision or organ manipulation during surgery. The frequency reported for clean head and neck surgical procedures without antimicrobial prophylaxis is <1%. In contrast, infection rates in patients undergoing complicated cancer surgery are high, ranging from 24% to 87% of patients without antimicrobial prophylaxis. METHODS Guidelines and recommendations about the use of antibiotics in head and neck surgery from 2004 to 2019 were reviewed. RESULTS Four guidelines from Oceania, 5 from South America, 5 from North America, 2 from the United Kingdom, 11 from Europe, 1 from Africa, 1 from the Middle East, and 3 from Asia were included. A total of 118 papers were included for analysis and recommendation. CONCLUSION Antibiotic prophylaxis can decrease the incidence of SSI. However, the risks associated with antibiotic exposure and the risk of antibiotic resistance need to be taken into consideration.
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Affiliation(s)
| | - Jérome R Lechien
- Department of Human Anatomy & Experimental Oncology, University of Mons, Mons, Belgium
| | - Nicolas Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Universitary Hospital of la Conception, Marseille, France
| | - Antoine Melkane
- Department of Otolaryngology-Head and Neck Surgery, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Christian Calvo-Henriquez
- Department of otolaryngology-Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Daniele de Siati
- Department of Otorhinolaryngology-Centre d'AudioPhonologie des Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Jose Angel Gonzalez-Garcia
- Department of Otorhinolaryngology-Head & Neck Surgery, Hospital Universitario Donostia, San Sebastian, Spain
| | | | - Tareck Ayad
- Division of Otolaryngology-Head & Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
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Usubuchi M, Matsuura K, Goto T, Asada Y, Imai T, Ogawa T, Kato K, Saijo S. Professional Oral Health Care at General Dental Clinic Reduces Postoperative Complications of Head and Neck Free-Flap Reconstruction Surgery. J Cancer 2019; 10:205-210. [PMID: 30662541 PMCID: PMC6329870 DOI: 10.7150/jca.26298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 10/23/2018] [Indexed: 12/19/2022] Open
Abstract
Background: Extensive resection and free-flap reconstruction surgery has become the standard treatment for locally advanced head and neck cancer. Surgical site infection (SSI) is one of the serious complications of this treatment. This study aimed to investigate the risk factor for onset of SSI, particularly focusing on whether preoperative professional oral health care in cooperation with general dental clinics is effective in reducing the occurrence of SSI. Methods: From March 2003 to August 2011, 183 patients who underwent head and neck free-flap reconstructive surgery by the same plastic surgeon at Miyagi Cancer Center for Head and Neck Surgery were investigated retrospectively. Results: Of the 183 patients, 135 and 48 were men and women, respectively, with a mean age of 62 (range, 29-82) years. The tumor was located in the oral cavity (n = 76), hypopharynx (n = 55), oropharynx (n = 28), and others (n = 24). Clinical stages were stage I/II in 18, stage III/IV in 164 patients, and benign tumor in one patient, based on UICC classification. SSI occurred in 66 patients (36.1%). Based on multivariate analysis, professional oral health care [P = 0.0076, odds ratio (OR) = 0.39] and radiation therapy history (P = 0.0214, OR = 2.820) were shown as factors that are significantly related to SSI. Conclusion: This study identified history of radiation therapy as a significant risk factor for SSI from univariate and multivariate analysis and revealed that patients receiving preoperative professional oral health care at general dental clinics reduce the risk of SSI. Preoperative professional oral health care in cooperation with general dental clinics has been shown to reduce SSI of head and neck free-flap reconstructive surgery.
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Affiliation(s)
| | | | - Takahiro Goto
- Department of Plastic and Reconstructive Surgery, Miyagi Cancer Center
| | - Yukinori Asada
- Department of Head and Neck Surgery, Miyagi Cancer Center
| | - Takayuki Imai
- Department of Head and Neck Surgery, Miyagi Cancer Center
| | - Takenori Ogawa
- Department of Otolaryngology-Head and Neck Surgery, Tohoku University Graduate School of Medicine
| | - Kengo Kato
- Department of Otolaryngology-Head and Neck Surgery, Tohoku University Graduate School of Medicine
| | - Shigeru Saijo
- Department of Head and Neck Surgery, Miyagi Cancer Center
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Current practice trends in microvascular free flap reconstruction by fellowship-trained otolaryngologists. J Craniomaxillofac Surg 2018; 46:2120-2126. [DOI: 10.1016/j.jcms.2018.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 07/18/2018] [Accepted: 08/23/2018] [Indexed: 11/23/2022] Open
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Haque M, McKimm J, Godman B, Abu Bakar M, Sartelli M. Initiatives to reduce postoperative surgical site infections of the head and neck cancer surgery with a special emphasis on developing countries. Expert Rev Anticancer Ther 2018; 19:81-92. [DOI: 10.1080/14737140.2019.1544497] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Mainul Haque
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, Malaysia
| | - Judy McKimm
- Swansea University School of Medicine, Grove Building, Swansea University, Swansea, Wales, UK
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, United Kingdom
- Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sasako Makgatho Health Sciences University, Garankuwa, South Africa
| | - Muhamad Abu Bakar
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, Malaysia
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
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Incorporating a continuous suction system as a preventive measure against fistula-related complications in head and neck reconstructive surgery. Arch Plast Surg 2018; 45:449-457. [PMID: 30282416 PMCID: PMC6177638 DOI: 10.5999/aps.2018.00094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/22/2018] [Indexed: 11/09/2022] Open
Abstract
Background Although previous studies have focused on determining prognostic and causative variables associated with fistula-related complications after head and neck reconstructive surgery, only a few studies have addressed preventive measures. Noting that pooled saliva complicates wound healing and precipitates fistula-related complications, we devised a continuous suction system to remove saliva during early postoperative recovery. Methods A continuous suction system was implemented in 20 patients after head and neck reconstructive surgery between January 2012 and October 2017. This group was compared to a control group of 16 patients at the same institution. The system was placed orally when the lesion was on the anterior side of the retromolar trigone area, and when glossectomy or resection of the mouth floor was performed. When the orohypopharynx and/or larynx were eradicated, the irrigation system was placed in the pharyngeal area. Results The mean follow-up period was 9.2±2.4 months. The Hemovac system was applied for an average of 7.5 days. On average, 6.5 days were needed for the net drain output to fall below 10 mL. Complications were analyzed according to their causes and rates. A fistula occurred in two cases in the suction group. Compared to the control group, a significant difference was noted in the surgical site infection rate (P<0.031). Conclusions Clinical observations showed reduced saliva pooling and a reduction in the infection rate. This resulted in improved wound healing through the application of a continuous suction system.
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Veve MP, Greene JB, Williams AM, Davis SL, Lu N, Shnayder Y, Li DX, Noureldine SI, Richmon JD, Lin LO, Hanasono MM, Pipkorn P, Jackson RS, Hornig JD, Light T, Wax MK, Yiu Y, Bekeny J, Old M, Hernandez D, Patel UA, Ghanem TA. Multicenter Assessment of Antibiotic Prophylaxis Spectrum on Surgical Infections in Head and Neck Cancer Microvascular Reconstruction. Otolaryngol Head Neck Surg 2018. [DOI: 10.1177/0194599818756299] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Objective To characterize and identify risk factors for 30-day surgical site infections (SSIs) in patients with head and neck cancer who underwent microvascular reconstruction. Study Design Cross-sectional study with nested case-control design. Setting Nine American tertiary care centers. Subjects and Methods Hospitalized patients were included if they underwent head and neck cancer microvascular reconstruction from January 2003 to March 2016. Cases were defined as patients who developed 30-day SSI; controls were patients without SSI at 30 days. Postoperative antibiotic prophylaxis (POABP) regimens were categorized by Gram-negative (GN) spectrum: no GN coverage, enteric GN coverage, and enteric with antipseudomonal GN coverage. All POABP regimens retained activity against anaerobes and Gram-positive bacteria. Thirty-day prevalence of and risk factors for SSI were evaluated. Results A total of 1307 patients were included. Thirty-day SSI occurred in 189 (15%) patients; median time to SSI was 11.5 days (interquartile range, 7-17). Organisms were isolated in 59% of SSI; methicillin-resistant Staphylococcus aureus (6%) and Pseudomonas aeruginosa (9%) were uncommon. A total of 1003 (77%) patients had POABP data: no GN (17%), enteric GN (52%), and antipseudomonal GN (31%). Variables independently associated with 30-day SSI were as follows: female sex (adjusted odds ratio [aOR], 1.6; 95% CI, 1.1-2.2), no GN POABP (aOR, 2.2; 95% CI, 1.5-3.3), and surgical duration ≥11.8 hours (aOR, 1.9; 95% CI, 1.3-2.7). Longer POABP durations (≥6 days) or antipseudomonal POABP had no association with SSI. Conclusions POABP without GN coverage was significantly associated with SSI and should be avoided. Antipseudomonal POABP or longer prophylaxis durations (≥6 days) were not protective against SSI. Antimicrobial stewardship interventions should be made to limit unnecessary antibiotic exposures, prevent the emergence of resistant organisms, and improve patient outcomes.
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Affiliation(s)
- Michael P. Veve
- Wayne State University, Detroit, Michigan, USA
- Henry Ford Health System, Detroit, Michigan, USA
| | | | | | - Susan L. Davis
- Wayne State University, Detroit, Michigan, USA
- Henry Ford Health System, Detroit, Michigan, USA
| | - Nina Lu
- Department of Otolaryngology, School of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Yelizaveta Shnayder
- Department of Otolaryngology, School of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - David X. Li
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Lawrence O. Lin
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Patrik Pipkorn
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Ryan S. Jackson
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Joshua D. Hornig
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tyler Light
- Oregon Health Sciences University, Portland, Oregon, USA
| | - Mark K. Wax
- Oregon Health Sciences University, Portland, Oregon, USA
| | - Yin Yiu
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James Bekeny
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew Old
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | | | - Tamer A. Ghanem
- Wayne State University, Detroit, Michigan, USA
- Henry Ford Health System, Detroit, Michigan, USA
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Kuo PJ, Wu SC, Chien PC, Chang SS, Rau CS, Tai HL, Peng SH, Lin YC, Chen YC, Hsieh HY, Hsieh CH. Artificial neural network approach to predict surgical site infection after free-flap reconstruction in patients receiving surgery for head and neck cancer. Oncotarget 2018; 9:13768-13782. [PMID: 29568393 PMCID: PMC5862614 DOI: 10.18632/oncotarget.24468] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 02/03/2018] [Indexed: 12/22/2022] Open
Abstract
Background The aim of this study was to develop an effective surgical site infection (SSI) prediction model in patients receiving free-flap reconstruction after surgery for head and neck cancer using artificial neural network (ANN), and to compare its predictive power with that of conventional logistic regression (LR). Materials and methods There were 1,836 patients with 1,854 free-flap reconstructions and 438 postoperative SSIs in the dataset for analysis. They were randomly assigned tin ratio of 7:3 into a training set and a test set. Based on comprehensive characteristics of patients and diseases in the absence or presence of operative data, prediction of SSI was performed at two time points (pre-operatively and post-operatively) with a feed-forward ANN and the LR models. In addition to the calculated accuracy, sensitivity, and specificity, the predictive performance of ANN and LR were assessed based on area under the curve (AUC) measures of receiver operator characteristic curves and Brier score. Results ANN had a significantly higher AUC (0.892) of post-operative prediction and AUC (0.808) of pre-operative prediction than LR (both P<0.0001). In addition, there was significant higher AUC of post-operative prediction than pre-operative prediction by ANN (p<0.0001). With the highest AUC and the lowest Brier score (0.090), the post-operative prediction by ANN had the highest overall predictive performance. Conclusion The post-operative prediction by ANN had the highest overall performance in predicting SSI after free-flap reconstruction in patients receiving surgery for head and neck cancer.
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Affiliation(s)
- Pao-Jen Kuo
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Peng-Chen Chien
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shu-Shya Chang
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsueh-Ling Tai
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shu-Hui Peng
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chun Lin
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chun Chen
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsiao-Yun Hsieh
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Ren Y, Deschler DG, Sajed D, Durand ML. Case of late-onset, relapsing surgical site infection related to a venous coupler placed during free flap reconstruction for major head and neck cancer. Head Neck 2018; 40:E29-E32. [PMID: 29328540 DOI: 10.1002/hed.25043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 11/07/2017] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Venous coupling devices are widely used during reconstructive surgery involving microvascular anastomosis but have not served as foreign bodies in head and neck surgical site infections. METHODS We conducted a case report. RESULTS A patient underwent resection and free flap reconstruction for recurrent tongue squamous cell carcinoma. She developed a neck abscess due to Streptococcus intermedius 7 weeks postoperatively, days after starting chemoradiotherapy. The surgical site infection healed with drainage and antibiotics. Two surgical site infection relapses due to S. intermedius occurred 3 and 8 weeks after completing radiation, the second relapse after a prolonged course of i.v. antibiotics. Surgical exploration revealed a venous coupler within granulation tissue. The device was removed and no further surgical site infection relapses occurred. CONCLUSION To the best of our knowledge, this is the first report of a delayed-onset head and neck surgical site infection in which a venous coupler served as a foreign body. An infected foreign body should be suspected in relapsing surgical site infections due to a single organism.
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Affiliation(s)
- Yin Ren
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Daniel G Deschler
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Dipti Sajed
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Marlene L Durand
- Department of Medicine, Infectious Disease Unit, Massachusetts General Hospital, and Infectious Disease Service, Massachusetts Eye and Ear, Boston, Massachusetts
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Haidar YM, Tripathi PB, Tjoa T, Walia S, Zhang L, Chen Y, Nguyen DV, Mahboubi H, Armstrong WB, Goddard JA. Antibiotic prophylaxis in clean-contaminated head and neck cases with microvascular free flap reconstruction: A systematic review and meta-analysis. Head Neck 2017; 40:417-427. [PMID: 29083525 DOI: 10.1002/hed.24988] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 05/08/2017] [Accepted: 09/15/2017] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Optimal antibiotic prophylaxis duration in head and neck clean-contaminated free-flap cases is unknown. METHODS A systematic review/meta-analysis was conducted using PubMed/MEDLINE, Cochrane Library, Web-of-Science, and Scopus databases. RESULTS Of the 3755 searched articles, 5 articles were included for a total of 861 patients. The recipient surgical site infection risk was significantly higher in patients receiving prophylactic antibiotics for ≤24 hours compared to >24 hours (relative risk [RR] 1.56; 95% confidence interval [CI] 1.13-2.14). In the post hoc multivariate analysis based on available individual-level data on 697 patients from 3 studies, the risk of surgical site infection for ≤24 hours versus >24 hours was not significant after adjusting for antibiotic type (RR 1.09; 95% CI 0.78-1.55). When compared to ampicillin-sulbactam, patients who received clindamycin prophylaxis had an increased likelihood of recipient surgical site infection (RR 2.85; 95% CI 1.95-4.17). CONCLUSION Less than or equal to 24 hours of antibiotic prophylaxis in head and neck clean-contaminated free-flap is likely sufficient but a strong conclusion remains elusive. Clindamycin prophylaxis increases the risk of recipient surgical site infection. Further prospective trials are necessary to clarify.
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Affiliation(s)
- Yarah M Haidar
- Department of Otolaryngology - Head and Neck Surgery, University of California - Irvine, Irvine, California
| | - Prem B Tripathi
- Department of Otolaryngology - Head and Neck Surgery, University of California - Irvine, Irvine, California
| | - Tjoson Tjoa
- Department of Otolaryngology - Head and Neck Surgery, University of California - Irvine, Irvine, California
| | - Sartaaj Walia
- Department of Otolaryngology - Head and Neck Surgery, University of California - Irvine, Irvine, California
| | - Lishi Zhang
- Institute for Clinical and Translational Science, University of California, Irvine, Irvine, California
| | - Yanjun Chen
- Institute for Clinical and Translational Science, University of California, Irvine, Irvine, California
| | - Danh V Nguyen
- Department of Medicine, University of California - Irvine School of Medicine, Irvine, California
| | - Hossein Mahboubi
- Department of Otolaryngology - Head and Neck Surgery, University of California - Irvine, Irvine, California
| | - William B Armstrong
- Department of Otolaryngology - Head and Neck Surgery, University of California - Irvine, Irvine, California
| | - Julie A Goddard
- Department of Otolaryngology - Head and Neck Surgery, University of Colorado, Boulder, Colorado
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Surgical Site Infections in Patients Receiving Osteomyocutaneous Free Flaps to the Head and Neck. Does Choice of Antibiotic Prophylaxis Matter? J Oral Maxillofac Surg 2017; 75:2223-2229. [DOI: 10.1016/j.joms.2017.02.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/04/2017] [Accepted: 02/06/2017] [Indexed: 11/23/2022]
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Veve MP, Davis SL, Williams AM, McKinnon JE, Ghanem TA. Considerations for antibiotic prophylaxis in head and neck cancer surgery. Oral Oncol 2017; 74:181-187. [PMID: 28943204 DOI: 10.1016/j.oraloncology.2017.09.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023]
Abstract
Peri/post-operative antibiotic prophylaxis (POABP) has become standard practice for preventing surgical site infections (SSI) in head and neck cancer patients undergoing microvascular reconstruction, but few data exist on optimal POABP regimens. Current surgical prophylaxis guideline recommendations fail to account for the complexity of microvascular reconstruction relative to other head and neck procedures, specifically regarding wound classification and antibiotic duration. Selection of POABP spectrum is also controversial, and must balance the choice between too narrow, risking subsequent infection, or too broad, and possible unwanted effects (e.g. antibiotic resistance, Clostridium difficile-associated diarrhea). POABP regimens should retain activity against bacteria expected to colonize the upper respiratory/salivary tracts, which include Gram-positive organisms and facultative anaerobes. However, Gram-negative bacilli also contribute to SSI in this setting. POABP doses should be optimized in order to achieve therapeutic tissue concentrations at the surgical site. Antibiotics targeted towards methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa are not warranted for all patients. Prolonged POABP durations have shown no differences in SSI when compared to short POABP durations, but prolonged durations provide unnecessarily antibiotic exposure and risk for adverse effects. Given the lack of standardization behind antibiotic POABP in this setting and the potential for poor patient outcomes, this practice necessitates an additional focus of surgeons and antimicrobial stewardship programs. The purpose of this review is to provide an overview of POABP evidence and discuss pertinent clinical implications of appropriate use.
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Affiliation(s)
- Michael P Veve
- University of Tennessee Health Science Center, College of Pharmacy, Knoxville, TN, USA; University of Tennessee Medical Center, Knoxville, TN, USA.
| | - Susan L Davis
- Wayne State University, Detroit, MI, USA; Henry Ford Health System, Detroit, MI, USA
| | | | | | - Tamer A Ghanem
- Wayne State University, Detroit, MI, USA; Henry Ford Health System, Detroit, MI, USA
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Cannon RB, Houlton JJ, Mendez E, Futran ND. Methods to reduce postoperative surgical site infections after head and neck oncology surgery. Lancet Oncol 2017; 18:e405-e413. [PMID: 28677576 DOI: 10.1016/s1470-2045(17)30375-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/11/2017] [Accepted: 03/27/2017] [Indexed: 12/30/2022]
Abstract
Head and neck cancer surgery is often a complex multi-step procedure that includes major resections, vascularised tissue reconstruction, and extensive neck dissection. The upper aerodigestive tract mucosal lining is often disrupted during surgery, which requires the management of a clean-contaminated field and the need to reconstruct the mucosal lining. With bacterial contamination, surgical site infections (SSI) are a serious complication that can result in delayed wound healing, wound breakdown, fistula formation, and compromised tissue reconstruction. Methods to reduce SSI in patients with head and neck cancer have been intensely researched, yielding evolving and varied practice patterns. In this Review, we outline the data supporting perioperative antibiotic prophylaxis for clean-contaminated surgeries, which suggest that clindamycin is an inadequate prophylactic antibiotic therapy in the reduction of SSI, and that prolonged antibiotic courses have no established benefit. For salvage laryngectomy after radiotherapy with or without chemotherapy, reconstruction with vascularised tissue reduces the frequency and severity of pharyngocutaneous fistula formation. These evidence-based recommendations have been shown to reduce the chance of SSI after head and neck surgery.
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Affiliation(s)
- Richard B Cannon
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Jeffrey J Houlton
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Eduardo Mendez
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Neal D Futran
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA.
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Akashi M, Kusumoto J, Sakakibara A, Hashikawa K, Furudoi S, Komori T. Literature Review of Criteria for Defining Recipient-Site Infection after Oral Oncologic Surgery with Simultaneous Reconstruction. Surg Infect (Larchmt) 2017; 18:755-764. [PMID: 28792850 DOI: 10.1089/sur.2017.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The lack of uniformity of criteria for defining recipient-site infection after oral oncologic surgery with simultaneous reconstruction is problematic despite numerous studies on this issue. This study aimed to investigate the difference in the criteria for defining recipient-site infection after oral oncologic surgery with reconstruction. METHODS A Medline search was performed via PUBMED using the following combinations of key terms that were tagged in the title, abstract, or both: "surgical site infection-head neck," "surgical site infection-oral cancer," "antibiotic prophylaxis-head neck," and "surgical site infection-oral carcinoma." Search results were filtered between 2005 and 2017. Articles in which there was no mention of the criteria for definition of surgical-site infection were excluded. RESULTS The number of articles that met the inclusion criteria was 24. The lack of uniformity in the criteria for defining recipient-site infection in each article appeared to be attributable mainly to differences in whether an orocutaneous fistula and superficial incisional infection were regarded as recipient-site infection. CONCLUSION Reconsideration of the categorization of orocutaneous fistula as infection, regardless of the etiology, and differentiation of superficial and deep incisional infections are necessary for correct assessment of recipient-site infection in oral oncologic surgery.
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Affiliation(s)
- Masaya Akashi
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Junya Kusumoto
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Akiko Sakakibara
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Kazunobu Hashikawa
- 2 Department of Plastic Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Shungo Furudoi
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Takahide Komori
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
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Lin S, Melki S, Lisgaris MV, Ahadizadeh EN, Zender CA. Post-operative MRSA infections in head and neck surgery. Am J Otolaryngol 2017; 38:417-421. [PMID: 28478091 DOI: 10.1016/j.amjoto.2017.03.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 03/31/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE Surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus (MRSA) is a serious post-operative complication, with head and neck cancer patients at greater risk due to the nature of their disease. Infection with MRSA has been shown to be costly and impart worse outcomes on patients who are affected. This study investigates incidence and risks for MRSA SSIs at a tertiary medical institution. MATERIALS AND METHODS This study reviewed 577 head and neck procedures from 2008 to 2013. Twenty-one variables (i.e. tumor characteristics, patient demographics, operative course, cultures) were analyzed with SPSS to identify trends. A multivariate analysis controlled for confounders (age, BMI, ASA class, length of stay) was completed. RESULTS We identified 113 SSIs of 577 procedures, 24 (21.23%) of which were MRSA. Of all analyzed variables, hospital exposure within the preceding year was a significant risk factor for MRSA SSI development (OR 2.665, 95% CI: 1.06-6.69, z statistic 2.086, p=0.0369). Immunosuppressed patients were more prone to MRSA infections (OR 14.1250, 95%CI: 3.8133-52.3217, p<0.001), and patients with a history of chemotherapy (OR 3.0268, 95% CI: 1.1750-7.7968, p=0.0218). Furthermore, MRSA SSI resulted in extended post-operative hospital stays (20.8±4.72days, p=0.031). CONCLUSIONS Patients who have a history of chemotherapy, immunosuppression, or recent hospital exposure prior to their surgery are at higher risk of developing MRSA-specific SSI and may benefit from prophylactic antibiotic therapy with appropriate coverage. Additionally, patients who develop MRSA SSIs are likely to have an extended postoperative inpatient stay.
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Affiliation(s)
- Sharon Lin
- Ear, Nose, and Throat Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Sami Melki
- Ear, Nose, and Throat Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Michelle V Lisgaris
- Department of Medicine - Infectious Diseases, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Emily N Ahadizadeh
- Ear, Nose, and Throat Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States; Case Western Reserve University, School of Medicine, 10900 Euclid Avenue, Cleveland, OH, United States
| | - Chad A Zender
- Ear, Nose, and Throat Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.
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Hernaiz-Leonardo JC, Golzarri MF, Cornejo-Juárez P, Volkow P, Velázquez C, Ostrosky-Frid M, Vilar-Compte D. Microbiology of surgical site infections in patients with cancer: A 7-year review. Am J Infect Control 2017; 45:761-766. [PMID: 28385464 DOI: 10.1016/j.ajic.2017.02.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Health care-associated infections (HAIs) have arisen as major sources of multidrug-resistant bacteria. Surgical site infections (SSIs) are the most frequent HAIs in many countries, with high antimicrobial-resistant prevalence. METHODS A 7-year retrospective review (2008-2014) of microbiologic data within a prospective surveillance program on patients with SSI at a cancer hospital in Mexico. RESULTS There were 23,421 surgeries performed during the study period. The SSI rate was 7.9%. Gram-negative bacilli (GNB) were found in 56.5% of samples. Escherichia coli was the most frequent microorganism (27.5%), followed by Staphylococcus aureus (16.3%). SSI caused by S aureus showed a decreasing trend (P = .04). Extended-spectrum β-lactamase (ESBL)-producing E coli increased from 39.5% in 2008 to 72.5% in 2014 (P < .001). Fluoroquinolone resistance also increased in all members of the Enterobacteriaceae. Methicillin-resistant S aureus (MRSA) was isolated in 32% of cases with no significant increase (P value is not significant). CONCLUSIONS GNB caused most SSIs, with an increase of ESBL E coli strains. In breast and thoracic surgery, S aureus remained the most frequent isolate. MRSA remained stable throughout the study period. We observed a decreasing trend in S aureus. These findings show the differences in the microbiology of SSIs in a middle-income country and the increasing trend of ESBL enterobacteria and other multidrug-resistant organisms, such as Enterococcus faecium.
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Affiliation(s)
| | | | | | - Patricia Volkow
- Department of Infectious Diseases, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Consuelo Velázquez
- Microbiology Laboratory, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Mauricio Ostrosky-Frid
- Programa de estudios combinados en medicina, Faculty of Medicine, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Diana Vilar-Compte
- Department of Infectious Diseases, Instituto Nacional de Cancerología, Mexico City, Mexico.
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Yao CM, Ziai H, Tsang G, Copeland A, Brown D, Irish JC, Gilbert RW, Goldstein DP, Gullane PJ, de Almeida JR. Surgical site infections following oral cavity cancer resection and reconstruction is a risk factor for plate exposure. J Otolaryngol Head Neck Surg 2017; 46:30. [PMID: 28390434 PMCID: PMC5385089 DOI: 10.1186/s40463-017-0206-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/27/2017] [Indexed: 01/01/2023] Open
Abstract
Background Plate-related complications following head and neck cancer ablation and reconstruction remains a challenging problem often requiring further management and reconstructive surgeries. We aim to identify an association between surgical site infections (SSI) and plate exposure. Methods A retrospective study between 1997 and 2014 was performed to study the association between postoperative SSI and plate exposures. Eligible patients included those with a history of oral squamous cell carcinoma who underwent surgical resection, neck dissection, and free tissue reconstruction. Demographic and treatment related information was collected. SSI were classified based on CDC definition and previously published literature. Univariable analysis on demographic factors, smoking history, diabetes, radiation, surgical and hardware related factors; while multivariable analysis on SSI, plate height, segmental mandibulectomy defects and radiation were conducted such as using cox proportional hazard models. Results Three hundred sixty-five patients were identified and included in our study. The mean age of the study group was 59.2 (+/−13.8), with a predominance of male patients (61.9%). 10.7% of our patient cohort had diabetes, and another 63.8% had post-operative radiation therapy. Patients with SSI were more likely to have plate exposure (25 vs. 6.4%, p <0.001). Post-operative SSI, mandibulectomy defects, and plate profile/thickness were associated with plate exposure on univariable analysis (OR = 5.72, p < 0.001; OR = 2.56, p = 0.014; OR = 1.44, p = 0.003 respectively) and multivariable analysis (OR = 5.13, p < 0.001; OR = 1.36, p = 0.017; OR = 2.58, p = 0.02 respectively). Conclusion Surgical site infections are associated with higher rates of plate exposure. Plate exposure may require multiple procedures to manage and occasionally free flap reconstruction.
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Affiliation(s)
- Christopher M Yao
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada
| | - Hedyeh Ziai
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada
| | - Gordon Tsang
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada
| | - Andrea Copeland
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada
| | - Dale Brown
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada
| | - Ralph W Gilbert
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada
| | - Patrick J Gullane
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 3-955, Toronto, ON, M5G 2 M9, Canada.
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Saunders S, Reese S, Lam J, Wulu J, Jalisi S, Ezzat W. Extended use of perioperative antibiotics in head and neck microvascular reconstruction. Am J Otolaryngol 2017; 38:204-207. [PMID: 28139320 DOI: 10.1016/j.amjoto.2017.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/17/2017] [Indexed: 11/17/2022]
Abstract
PURPOSE Many head and neck surgical procedures are considered clean-contaminated wounds and antibiotic prophylaxis is recommended. Despite prophylaxis, the incidence of surgical site infections remains significant - especially in the setting of free tissue transfer. The antibiotic course is often of a longer duration after free tissue transfer than the recommended 24hour post-operatively. Currently, there is no consensus on appropriate antibiotic regimen or duration at this time. This study investigates the outcomes of a 7-day perioperative antibiotic regimen after microvascular reconstruction of the head and neck at our institution. MATERIALS AND METHODS A retrospective review was performed of 72 patients undergoing microvascular free tissue at our institution between 09/2011 and 03/2014. The antibiotic regimen, post-operative surgical (including surgical site infections) and medical complications were noted. Our rates of complications and adverse events were compared to all surgical patients, as well as all inpatients hospital-wide with use of the University Health System Consortium database. RESULTS Seventy-two subjects met inclusion criteria for this study. The majority of subjects received cefazolin/metronidazole (69.4%). Subjects with beta-lactam allergy received clindamycin (12.5%). The remainder received an alternative regimen (18.1%). All received at least 7days of antibiotics. The rate of hospital acquired C. difficile diarrhea was 0.57% hospital-wide, 1.13% in Otolaryngology patients, and 1.4% in this study. There were no instances of a multi-drug resistant infection or any adverse reactions to the administration of antibiotics. When compared with other antibiotic regimens, clindamycin was associated with a significantly increased rate of either medical or surgical infections (OR 14.38, p=0.02) and longer hospital stay (average=18days, p<0.05). CONCLUSION The use of a 7-day prophylactic antibiotic regimen is not associated with an increased risk of antibiotic-associated infections, multi-drug resistant infections, or antibiotic-associated complications. The use of clindamycin is associated with increased risk of medical and surgical infections post-operatively and should be avoided in the prophylactic perioperative phase after free tissue transfer of the head and neck.
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Affiliation(s)
- Stefanie Saunders
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Stephen Reese
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Jimmy Lam
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Jacqueline Wulu
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Scharkuh Jalisi
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Waleed Ezzat
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA.
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Khan MN, Perez E, Goljo E, Iloreta A, Park RCW, Genden EM, Miles BA. The price of free tissue transfer after tongue reconstruction: quantifying the risks. Laryngoscope 2017; 127:1551-1557. [DOI: 10.1002/lary.26461] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 10/01/2016] [Accepted: 11/14/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Mohemmed N. Khan
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York New York U.S.A
| | - Enrique Perez
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York New York U.S.A
| | - Erden Goljo
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York New York U.S.A
| | - Alfred Iloreta
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York New York U.S.A
| | - Richard Chan Woo Park
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York New York U.S.A
| | - Eric M. Genden
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York New York U.S.A
- Department of Otolaryngology-Head and Neck Surgery; Rutgers University; Newark New Jersey U.S.A
| | - Brett A. Miles
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York New York U.S.A
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Aureden K, Barnes S, Myers F. Looking Forward--Infection Prevention in 2016. AORN J 2016; 102:596-601. [PMID: 26616320 DOI: 10.1016/j.aorn.2015.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
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Goyal N, Yarlagadda BB, Deschler DG, Emerick KS, Lin DT, Rich DL, Rocco JW, Durand ML. Surgical Site Infections in Major Head and Neck Surgeries Involving Pedicled Flap Reconstruction. Ann Otol Rhinol Laryngol 2016; 126:20-28. [PMID: 27913719 DOI: 10.1177/0003489416672871] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate surgical site infections (SSI) after pedicled reconstruction in head and neck surgery. METHODS Records of patients with pedicled flap reconstructions between 2009 and 2014 at Massachusetts Eye and Ear were reviewed. Onset of SSI or fistula ≤30 days postoperatively was noted. A free flap cohort was reviewed for comparison. RESULTS Two hundred and eight pedicled reconstructions were performed for cancer (83%), osteoradionecrosis (7%), and other reasons (10%). Most (72%) cases were clean-contaminated and American Society of Anesthesiologists classification 3 or higher (73%); 63% of patients had prior radiation. The SSIs occurred in 9.1% and were associated with a longer length of stay (P = .004) but no particular risk factors. Seventeen patients developed a fistula (11 without SSI). The SSI rates were not significantly different between pedicled and free flaps, but pedicled flap patients were older, more likely to have had prior surgery and/or radiation, and be methicillin-resistant Staphylococcus aureus positive. In the combined population, multivariate analysis demonstrated clean-contaminated wound classification (P = .03), longer operating time (P = .03), and clindamycin prophylaxis (P = .009) as SSI risk factors. CONCLUSIONS The SSI rate following pedicled flap surgeries was low and similar to free flap surgeries despite a significantly different population. No specific risk factors were associated with developing a pedicled flap SSI.
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Affiliation(s)
- Neerav Goyal
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA .,Department of Surgery, Division of Otolaryngology Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Bharat B Yarlagadda
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Lahey Hospital & Medical Center, Department of Otolaryngology, Burlington, Massachusetts, USA
| | - Daniel G Deschler
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Kevin S Emerick
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Derrick T Lin
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Debbie L Rich
- Department of Nursing, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - James W Rocco
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Marlene L Durand
- Massachusetts General Hospital, Department of Medicine, Infectious Disease Unit, and Massachusetts Eye and Ear, Infectious Disease Service, Boston, Massachusetts, USA
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Yaembut N, Ampornaramveth RS, Pisarnturakit PP, Subbalekha K. Dental Student Hand Hygiene Decreased With Increased Clinical Experience. JOURNAL OF SURGICAL EDUCATION 2016; 73:400-408. [PMID: 26861583 DOI: 10.1016/j.jsurg.2015.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/22/2015] [Accepted: 12/28/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To investigate the effectiveness, related knowledge, attitudes, and practices of hand hygiene (HH) among dental students with different levels of clinical experience. DESIGN This was a cross-sectional analytical study. Bacterial samples on the participants' hands were obtained using a swab technique before and after handwashing, for oral surgical procedures. After culturing, the colony-forming units were counted. Self-reported questionnaires reflecting the knowledge, attitudes, and practices related to HH were completed by the participants. SETTING This study was performed in a primary oral health care institution, Faculty of Dentistry, Chulalongkorn University (Bangkok, Thailand). Bacterial samples and self-reported questionnaires were collected in the Department of Oral and Maxillofacial Surgery. Bacterial culture was performed in the Department of Microbiology. PARTICIPANTS The 120 participants comprised first, second, third-year clinical training students (CTs), and postgraduate dental students (PGs) (32, 34, 30, and 24 participants, respectively). RESULTS More than 99% of the bacteria were eliminated from the participants' hands after handwashing. Significantly higher numbers of bacteria were recovered from the hands of the PGs compared with those of the CTs, and the hands of the third-year CTs compared with those of the first-year CTs (p < 0.001), after HH. The first-year CTs had the highest attitude scores, whereas the PGs had the lowest practice scores. The knowledge scores were similar in all groups. CONCLUSION HH effectiveness, attitudes, and practices of dental students decreased as students gained more clinical experience, whereas knowledge did not. Our results suggest that HH instruction should be given throughout the duration of dental students' education.
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Affiliation(s)
- Nanmanas Yaembut
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | | | - Pagaporn P Pisarnturakit
- Department of Community Dentistry, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Keskanya Subbalekha
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand.
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Goyal N, Emerick KS, Deschler DG, Lin DT, Yarlagadda BB, Rich DL, Durand ML. Risk factors for surgical site infection after supraclavicular flap reconstruction in patients undergoing major head and neck surgery. Head Neck 2016; 38:1615-1620. [PMID: 27098679 DOI: 10.1002/hed.24480] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/03/2016] [Accepted: 03/16/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Surgical site infections can adversely affect flaps in head and neck reconstruction. The purpose of this study was to evaluate the risk factors of surgical site infections in supraclavicular artery island flap reconstructions. METHODS Records of patients undergoing head and neck surgery from 2011 to 2014 with supraclavicular artery island flap reconstruction at a single specialty hospital were reviewed; surgical site infections ≤30 days postoperatively were noted. RESULTS Of 64 patients, 86% underwent resection for malignancy, 55% previously received radiation. Sixty-three percent of surgeries were clean-contaminated. Seven patients (11%) developed recipient site surgical site infections, all in patients who underwent clean-contaminated surgery for malignancy. There was no complete flap loss. No significant differences in demographics or perioperative factors were noted. Oral cavity and laryngeal reconstructions (p = .014) and clean-contaminated surgery (p = .04) were factors associated with increased surgical site infection risk on univariate but not multivariate analysis. Patients with surgical site infections had longer hospitalizations (p = .003). CONCLUSION The supraclavicular artery island flap can be used for head and neck reconstruction with a low rate of surgical site infection. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.
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Affiliation(s)
- Neerav Goyal
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. .,Penn State Milton S. Hershey Medical Center, Division of Otolaryngology Head and Neck Surgery, Hershey, Pennsylvania.
| | - Kevin S Emerick
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Daniel G Deschler
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Derrick T Lin
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Bharat B Yarlagadda
- Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Lahey Hospital and Medical Center, Department of Otolaryngology, Burlington, Massachusetts
| | - Debbie L Rich
- Department of Nursing, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Marlene L Durand
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, Massachusetts
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Kubo T, Matsuda K, Kiya K, Hosokawa K. Behavior of anastomozed vessels and transferred flaps after anastomosed site infection in head and neck microsurgical reconstruction. Microsurgery 2016; 36:658-663. [PMID: 26790991 DOI: 10.1002/micr.30025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 11/23/2015] [Accepted: 12/31/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This report evaluates the behavior of anastomosed vessels and transferred flaps after anastomosed site infection in head and neck reconstruction. PATIENTS AND METHODS Eleven free-flap cases after infection at the vascular pedicle site were included, the patency of which was observed macroscopically after re-exploration and pus drainage. Location was in the tongue (5 cases), oropharynx (3 cases), mouth floor (1 case), mandible (1 case), and hypopharynx (1 case). Transferred flaps originated from rectus abdominis (3 cases), anterolateral thigh (3 cases), radial forearm (3 cases), jejunum (1 case), and latissimus dorsi (1 case). Days for infection found were ranged 3-14 days postoperatively. Causes of infection were the salivary fistula formation in 5 cases, and precise etiology was not defined in the other 6 cases. RESULTS Disruption of the vascular pedicles occurred with high frequency after infection. Disruption of vein occurred most frequently (5 cases), followed by both artery and vein (2 cases) and artery only (1 case). Of the eight flaps, two flaps failed, but the other six flaps survived despite pedicle disruption, indicating overall survival of nine flaps after pedicle site infection. Five of the nine survived cases were healed with simple washing and ointment application. However, the other four patients, whose cause of infection was a salivary fistula, needed second flap transfer to treat those fistulas. CONCLUSION Disruption of anastomosed vessels can occur with high frequency after infection, causing subsequent flap loss. Therefore, surgeons need to deal with pedicle site infection to save the flap. © 2015 Wiley Periodicals, Inc. Microsurgery 36:658-663, 2016.
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Affiliation(s)
- Tateki Kubo
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ken Matsuda
- Division of Plastic and Reconstructive Surgery, Niigata University Graduate School of Medicine, Niigata, Japan
| | - Koichiro Kiya
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ko Hosokawa
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Khanh NT, Iyer NG. Management of post-operative fistula in head and neck surgery: Sweeping it under the carpet? World J Otorhinolaryngol 2015; 5:93-104. [DOI: 10.5319/wjo.v5.i4.93] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/19/2015] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
The most dreaded complication in head and neck surgery is the development of fistula. Fistulas are common and devastating. The prevalence and the risk factors that contribute to fistula formation after head and neck procedures were discussed briefly. The main goal of this manuscript is to discuss current management of head and neck fistula. We believed that the best management strategy for head and neck fistulas is prevention. We recommend a holistic preventive approach during the perioperative period. The roles of different types of wound products and hyperbaric oxygen therapy were also discussed and highlighted. We also discussed the operative repair of fistulas, which relies on the tenet of providing well-vascularized tissue to an area of poor wound healing. Most often, the surgeon’s preference and range of operative skills dictate the timing and the type of repair. We highlighted the use of the pectoralis major, a well-known flap, as well as a novel technique in the surgical repair of complex, difficult-to-heal head and neck fistula.
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47
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Pool C, Kass J, Spivack J, Nahumi N, Khan M, Babus L, Teng MS, Genden EM, Miles BA. Increased Surgical Site Infection Rates following Clindamycin Use in Head and Neck Free Tissue Transfer. Otolaryngol Head Neck Surg 2015; 154:272-8. [DOI: 10.1177/0194599815617129] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 10/23/2015] [Indexed: 11/15/2022]
Abstract
Objective The development of surgical site infections (SSIs) can put the viability of free tissue transfer reconstructions at risk, often resulting in considerable postoperative morbidity and prolonged hospitalization. Current antibiotic prophylactic guidelines suggest a first- or second-generation cephalosporin with metronidazole for clean-contaminated cases and recommend clindamycin as an alternative choice in penicillin-allergic patients. This study was designed to examine the rates of postoperative infection associated with prophylactic antibiotic regimens, including patients receiving clindamycin as an alternative due to penicillin allergy. Study Design Case series with chart review. Setting Tertiary academic medical center. Subjects Patients undergoing major ablative head and neck resection involving the pharynx and oral cavity reconstructed via free tissue transfer. Methods The sample included patients (n = 266) who underwent free tissue transfer involving the oral cavity and pharynx from 2009 to 2014. Data included demographic data, medical comorbidities, anatomic tumor subsite and surgical procedure, and prophylactic antibiotic regimen. SSI data were examined up to 30 days after the initial surgical procedure. Multivariate logistic regression analysis was performed to determine the overall risk for SSI. Culture data were also reviewed. Results The data indicated that clindamycin was associated with an approximate 4-fold increased risk for SSI (odds ratio, 3.784; 95% confidence interval: 1.367-10.470 [ P = .010]) after controlling for possible confounding factors. Conclusion For patients with a true penicillin allergy, we recommend broader gram-negative coverage with alternative antibiotics, such as cefuroxime, when undergoing free tissue transfer in the head and neck.
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Affiliation(s)
- Christopher Pool
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason Kass
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Spivack
- Department of Population Health Science and Policy, Icahn Medical Institute, New York, New York, USA
| | - Nadav Nahumi
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohemmed Khan
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lenard Babus
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marita S. Teng
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric M. Genden
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brett A. Miles
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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