Enhanced recovery after surgery in head and neck surgery: Reduced opioid use and length of stay

Postoperative Implementation of Virtual Reality and Wearable Devices: Opportunities and Challenges

OBJECTIVE

To examine implementation of virtual reality (VR) and Fitbit wearable activity devices in postoperative recovery.

METHODS

This was a prospective, 4-arm, randomized controlled trial of patients undergoing inpatient head and neck surgery at a tertiary academic center from November 2021 to July 2022. Patients were randomized to Control, VR, Fitbit, or combined VR + Fitbit groups. Patients in the VR groups were brought VR headsets to use throughout each day, and patients in the Fitbit groups wore Fitbit devices and were encouraged to achieve 2,000 daily steps. The primary outcome was average daily opioid use, measured as milligram morphine equivalents (MME).

RESULTS

There were 80 patients included. The majority of patients were male (68.8%), and mean age was 58.8 ± 14.4 years. Only the combined VR + Fitbit cohort was associated with reduced average daily opioid use (VR + Fitbit: 8.8 [20.6] MME vs. Control: 26.4 [37.4] MME, p = 0.02). Patients in intervention groups also had higher hospital satisfaction (p = 0.02). VR was utilized 26% of the time it was provided, with mean use time of 23.8 ± 7.8 min. Mean post-VR subjective pain reduction was 1.0 ± 1.3, and there were three mild adverse events of neck or nasal discomfort. Among the Fitbit groups, there were no adverse events and daily step counts ≥2,000 steps were achieved 45% of the time.

CONCLUSION

Implementation of VR and wearable activity devices in postoperative recovery appears well tolerated and may facilitate further development of Enhanced Recovery After Surgery (ERAS) protocols, though there are challenges to maximizing device usage.

LEVEL OF EVIDENCE

2 Laryngoscope, 135:2044-2050, 2025.

Unveiling Prescribing Patterns: A Systematic Review of Chronic Opioid Prescriptions After Head and Neck Cancer Surgeries

OBJECTIVE

This study aims to review opioid prescribing changes for pain management in head and neck cancer (HNC) surgery patients, given the recent focus on Enhanced Recovery After Surgery protocols.

DATA SOURCES

MEDLINE, Embase, and CENTRAL, covering 1998 to 2023.

REVIEW METHODS

We selected studies that evaluated opioid prescribing patterns post-major HNC surgery in various settings, including tertiary care hospitals and community hospitals. Primary outcomes considered were prevalence and patterns of opioid use post-surgery, as well as related outcomes such as chronic use and side effects.

RESULTS

Of 1278 abstracts, 24 studies involving 17,027 patients from the United States, China, and Canada met inclusion criteria. Quality was assessed using the MINORS scale, with an average score of 9.9 for non-comparative studies and 20.0 for comparative studies. Persistent opioid use post-surgery, defined as ongoing prescriptions 90 days after treatment, was noted in 15.4% to 64% of patients. Two studies reported adverse events, with up to 16% of patients experiencing side effects. Risk factors for chronic use included preoperative opioid use, tobacco use, higher cancer stage, adjuvant treatment, and demographic factors. Correlations were found between larger opioid prescriptions and shorter survival in advanced cancers. There was notable variability in patient-reported pain control.

CONCLUSION

Persistent opioid use post-HNC surgery is common, with variable efficacy and risk of adverse effects. Tailoring pain management to individual risk factors and focusing on multimodal analgesia could reduce the risks of continued opioid use. Future prospective studies are required to identify optimal pain management strategies.

Implementation of an Enhanced Recovery Pathway for Pediatric Single Lobe Thyroidectomy

INTRODUCTION

Enhanced Recovery Pathways (ERP) have gained popularity for optimizing perioperative care, improving patient outcomes, and reducing hospital stays. While extensively studied in adult populations, ERPs in pediatric patients, especially for thyroid surgeries, are uncommon. The aim of this study was to determine the feasibility and effectiveness of implementing an ERP designed for pediatric patients undergoing single-lobe thyroidectomy.

METHODS

This prospective study was conducted at Nationwide Children's Hospital from January 2023 to December 2024 and involved children 8 years of age or older undergoing single lobe thyroidectomy. Patients with significant comorbid conditions or undergoing total thyroidectomy were excluded. The ERP incorporated standardized preoperative, intraoperative, and postoperative care. Outcome measures were postoperative pain, incidence of postoperative nausea, time to discharge, and patient/parent satisfaction. Data were analyzed using descriptive statistics.

RESULTS

16 patients were included, predominantly female (81.3 %, n = 13), ranging in age from 8 to 17 years. The median surgical time was 63 min (Interquartile Range [IQR]: 56.5, 75). Following surgery, patients spent a median of 60 min (IQR: 43, 63.5) in the post-anesthesia care unit (PACU) and 217 min (IQR: 189, 260) in the transitional care unit (TCU) before discharge. Adherence to the ERP was high, with 100 % compliance to the order set. 81 % of patients experienced no nausea or vomiting in the PACU/TCU. A single patient required an extended stay due to postoperative nausea, for same-day discharge success rate of 93.8 %. Post-discharge, 93.8 % of patients reported no nausea, and pain was effectively managed without opioid use in 68.8 % of patients. There were no intraoperative or postoperative complications. No patients required readmission, and all reported high satisfaction with the care received on post-operative satisfaction survey (mean score = 5/5).

DISCUSSION

Implementation of a pediatric ERP for single-lobe thyroidectomy was successful in promoting same-day discharge, effective pain control without opioids, healthcare utilization management, high patient satisfaction. These findings suggest that ERPs can be safely and effectively adapted for select pediatric thyroid surgery, potentially setting a new standard for perioperative care in this population.

LEVEL OF EVIDENCE

III.

Decreased Postoperative Emesis and Opioid Use After Implementation of ERAS Protocol for Free Flap Surgery

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols are designed to improve postoperative outcomes. In this study, we compare outcomes for patients undergoing head and neck free flap surgery at a quaternary care institution before and after an ERAS protocol was implemented.

STUDY DESIGN

Retrospective study.

SETTING

Single quaternary care center.

METHODS

Retrospective evaluation of outcomes from patients who underwent head and neck surgery with free flap reconstruction prior to ERAS (January 2018 to May 2022, baseline) with patient outcomes after implementation (June 2022 to September 2023, ERAS). Outcomes studied included length of stay (LOS), opioid utilization, postoperative emesis, readmission, and mortality.

RESULTS

Patients in the ERAS group had significantly lower opioid utilization (206.84 ± 217 morphine milligram equivalent vs 415.53 ± 431, P < .01) and significantly lower rates of postoperative emesis (1.74% vs 28.27%, P < .01). This difference in emesis remained significant in the subgroup of patients who underwent total laryngectomy. The decreases in opioid use and emesis remained significant in multivariate analyses controlling for demographic factors and surgery type. We found no significant decrease in LOS or mortality.

CONCLUSION

In the year after implementing an ERAS protocol for head and neck free flap surgery, we found significantly lower opioid utilization and the unique finding of lower postoperative emesis overall, including in the laryngectomy subgroup for whom emesis-induced fistula is most impactful. No difference was noted in LOS or mortality. To our knowledge, this is the first study of an ERAS protocol for head and neck surgery to show a decrease in postoperative emesis.

Enhanced recovery after endoscopic sinus surgery: Establishing comprehensive protocols for improvement of perioperative patient care

Objectives

Enhanced recovery after surgery (ERAS) protocols for endoscopic sinus surgery (ESS) have not been widely implemented, and a critical review of ERAS recommendations and a comprehensive analysis of the supporting literature has not been undertaken. We describe an ESS ERAS protocol including key perioperative interventions for patients undergoing ESS and assess the available evidence.

Data Sources

A search was conducted of all relevant ERAS literature in otorhinolaryngology, anesthesia, and surgery using Medline (via PubMed), and Scopus. Keywords included "endoscopic sinus surgery," "sinus surgery," "FESS," and "ESS" for each area of intervention. Where applicable, the authors considered high-level evidence for recommendations devised for patient cohorts in otorhinolaryngology not undergoing ESS, as well as cohorts undergoing surgical procedures for which ERAS protocols have been extensively evaluated.

Methods

Studies received grades of "low," "moderate," or "high" quality evidence based on the Oxford Centre for Evidence-Based Medicine criteria. Each intervention was subsequently assigned a grade of "strong," "weak," or "conditional" based on the available evidence.

Results

Strong recommendations include comprehensive patient education and counseling, minimization of preoperative fasting, application of topical/local anesthetics and vasoconstrictors, use of total intravenous anesthesia, avoidance of pharyngeal packing, and use of postoperative nasal irrigation and multimodal analgesia. Conditional recommendations include antibiotic prophylaxis. Weak recommendations include perioperative venous thromboembolism prophylaxis, controlled hypotension, and use of postoperative nasal packing/dressing.

Conclusion

A comprehensive ERAS protocol for ESS can include a variety of high yield, evidence-based interventions that would likely improve surgical outcomes and patient satisfaction.

Enhanced Recovery After Surgery Compliance and Outcomes for Head and Neck Reconstructive Surgery

Importance

Few studies have examined the association between enhanced recovery after surgery (ERAS) compliance and postoperative outcomes within head and neck (HN) free flap reconstructive surgery. Doing so may inform future interventions to improve ERAS adoption and improve postoperative outcomes.

Objective

To assess overall compliance with ERAS guidelines and its association with postoperative outcomes among individuals undergoing HN free flap reconstructive surgery.

Design, Setting, and Participants

This retrospective cohort study included patients who underwent ERAS-guided HN major reconstructive surgery in Alberta, Canada between January 2017 and September 2021. Data analysis occurred from May 2024 until August 2024.

Main Outcomes and Measures

ERAS compliance was assessed for 17 ERAS care elements, and the total compliance score for each patient was a sum of the compliance for each ERAS care element. Compliance was categorized as low compliance (<53%), moderate compliance (53%-72%), and high compliance (>72%). Postoperative outcomes included hospital length of stay and hospital readmission and emergency department admissions within 30 days, intensive care unit readmission, complications, and severe complications. Unadjusted and adjusted models (using backward stepwise regression) assessed associations between ERAS compliance (exposure) and postoperative outcomes.

Results

Of 257 patients, 90 (35.0%) were female, and the mean (SD) age was 62.4 (13.3) years. Overall, 196 (76.3%) had moderate compliance, 50 (19.5%) had low ERAS compliance, and 11 (4.3%) had high compliance. Preoperative (86%) and intraoperative (73%) ERAS compliance exceeded postoperative compliance (38%). Compliance for ERAS care elements varied widely, with the highest compliance observed for preincision antibiotic prophylaxis (99.6%) and the lowest compliance observed for postoperative early mobilization (10.2%). Postoperative hospital length of stay decreased by 0.71 days (95% CI, -1.34 to -0.08), and the odds of experiencing complications decreased by 28% (odds ratio, 0.72; 95% CI, 0.56-0.90) for each 1-unit increase in the total ERAS compliance score.

Conclusions and Relevance

This results of this cohort study suggest that higher overall compliance with ERAS guidelines was associated with improved postoperative outcomes for individuals undergoing major HN free flap reconstructive surgery. There also appeared to be discrepancies in compliance between preoperative and postoperative phases, suggesting areas for interventions designed to improve adherence to ERAS protocols and underscoring the need for proactive compliance monitoring for optimizing patient outcomes in major HN surgery.

Disparities in Postoperative Pain Management: A Scoping Review of Prescription Practices and Social Determinants of Health

Background: Opioid analgesic therapy has been traditionally used for pain management; however, the variability in patient characteristics, complexity in evaluating pain, availability of treatment within facilities, and U.S. physicians overprescribing opioids have contributed to the current opioid epidemic. Despite large research efforts investigating the patterns of postsurgical pain management and influencing factors, it remains unclear how these overall trends vary across the varying sizes and available resources of academic hospitals, community hospitals, and outpatient surgery centers. The primary aim of this scoping review was to examine the patterns of contemporary postoperative pain management across healthcare settings, including academic medical centers, community hospitals, and outpatient surgery centers. Specifically, this study investigates how prescription practices for opioids, NSAIDs, and acetaminophen are influenced by patient demographics, including sex, race, gender, insurance status, and other social determinants of health (SDoH), to inform equitable and patient-centered pain management strategies. Methods: This study utilized The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and was used as a reference checklist. The Arksey and O'Malley methodological framework was used to guide the review process. To ensure comprehensive coverage, searches were conducted across three major databases: PubMed, Embase, and Cochrane Library. Results: A total of 43 eligible studies were retained for analysis. The highest reported Healthy People 2030 category was Social and community context (n = 39), while the highest reported category of SDoH was age (n = 36). A total of 34 articles listed sex and age as SDoH. Additional SDoH examined were race/ethnicity (n = 17), insurance (n = 7), employment (n = 1), education (n = 4), and income (n = 1). This review suggests that there are significant gaps in the implementation of institution-specific, patient-centered, and equitable pain management strategies, particularly in academic hospitals, which our findings show have the highest rates of opioid and NSAID prescriptions (n = 26) compared to outpatient surgical centers (n = 8). Findings from our review of the literature demonstrated that while academic hospitals often adopt enhanced recovery protocols aimed at reducing opioid dependence, these protocols can fail to address the diverse needs of at-risk populations, such as those with chronic substance use, low socioeconomic status, or racial and ethnic minorities. Conclusions: Findings from this review are expected to have implications for informing both organizational-specific and nationwide policy recommendations, potentially leading to more personalized and equitable pain management strategies across different healthcare settings. These include guidelines for clinicians on addressing various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care.

Enhanced recovery after surgery (ERAS) protocol improves patient outcomes in free flap surgery for head and neck cancer

BACKGROUND

In recent years, enhanced recovery after surgery (ERAS) guidelines have been developed to optimize pre-, intra-, and postoperative care of surgical oncology patients. The aim of this study was to compare management outcome of patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction at our institution before and after the implementation of the ERAS guidelines.

METHODS

This retrospective study comprised 283 patients undergoing HNC surgery with free flap reconstruction between 2013 and 2020. Patients operated before and after the implementation of the ERAS protocol in October 2017 formed the pre-ERAS group (n = 169), and ERAS group (n = 114), respectively.

RESULTS

In the pre-ERAS group the mean length of stay (LOS) and intensive care unit length of the stay (ICU-LOS) were 20 days (range 7-79) and 6 days (range 1-32), and in the ERAS group 13 days (range 3-70) and 5 days (range 1-24), respectively. Both LOS (p < 0.001) and ICU-LOS (p = 0.042) were significantly reduced in the ERAS group compared to the pre-ERAS group. There were significantly fewer medical complications in the ERAS group (p < 0.003). No difference was found between the study groups in the surgical complication rate or in the 30-day or 6-month mortality rate after surgery.

CONCLUSIONS

We found reduced LOS, ICU-LOS, and medical complication rate, but no effect on the surgical complication rate after implementation of the ERAS guidelines, which supports their use in major HNC surgery.

Patient Safety/Quality Improvement Primer, Part IV: How to Measure and Track Improvements

Patient safety and quality improvement (PS/QI) has become an integral part of the health care system, and the ability to effectively use data to track, understand, and communicate performance is essential to designing and implementing quality initiatives, as well as assessing their impact. Though many otolaryngologists are proficient in the methodologies of traditional research pursuits, educational gaps remain in the foundational principles of PS/QI measurement strategies. Part IV of this PS/QI primer discusses the fundamentals of measurement design and data analysis methods specific to PS/QI. Consideration is given to the selection of appropriate measures when designing a PS/QI project, as well as the method and frequency for collecting these measures. In addition, this primer reviews key aspects of tracking and analyzing data, providing an overview of statistical process control methods while highlighting the construction and utility of run and control charts. Lastly, this article discusses strategies to successfully develop and execute PS/QI initiatives in a way that facilitates the ability to appropriately measure their effectiveness and sustainability.

Efficacy of an enhanced recovery after surgery pathway to manage pain, nausea and vomiting after head and neck surgeries with free tissue transfer reconstruction

BACKGROUND

Pain and post-operative nausea and vomiting are the main factors that impair the quality of recovery after surgery. Very few reports have analyzed patient-reported outcomes to investigate the efficacy of an enhanced recovery after surgery protocol to alleviate these symptoms after head and neck surgeries with free tissue transfer reconstruction.

METHODS

We investigated post-operative pain and post-operative nausea and vomiting in 47 patients who underwent head and neck surgeries with free tissue transfer reconstruction with enhanced recovery after surgery support between February 2021 and August 2022. Patient-reported outcomes were assessed using the visual analog scale and Japanese version of the Quality of Recovery-40.

RESULTS

Significant increases in the mean visual analog scale scores for pain and post-operative nausea and vomiting were observed only on post-operative Day 1 compared with preoperative values (pain: 3.19 ± 2.78 vs. 1.96 ± 2.42, P = 0.0408; post-operative nausea and vomiting: 1.52 ± 2.09 vs. 0.54 ± 1.37, P = 0.0194). From post-operative Day 2, there were no significant differences between the pre- and post-operative visual analog scale scores, and no significant increases in the incidences of moderate or severe pain and post-operative nausea and vomiting compared with preoperatively. The Japanese version of the Quality of Recovery-40 score for post-operative pain showed no significant deterioration compared with preoperatively, while the Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting showed significant deterioration compared with the preoperative value on post-operative Days 2, 4 and 7.

CONCLUSIONS

The visual analog scale and Japanese version of the Quality of Recovery-40 scores for post-operative pain and visual analog scale score for post-operative nausea and vomiting suggested that the enhanced recovery after surgery strategy favorably controlled pain and post-operative nausea and vomiting after head and neck surgeries with free tissue transfer reconstruction. However, as the post-operative Japanese version of the Quality of Recovery-40 score for post-operative nausea and vomiting was lower than the preoperative value, there is still a need for further improvement of the enhanced recovery after surgery pathway.

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

Objectives

Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients.

Methods

Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion.

Results

A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation.

Conclusion

Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol.

Level of Evidence

2a.

Supply of opioids and information provided to patients after surgery in an Australian hospital: A cross-sectional study

Opioids are commonly prescribed to manage pain after surgery. However, excessive supply on discharge can increase patients' risk of persistent opioid use and contribute to the reservoir of unused opioids in the community that may be misused. This study aimed to evaluate the use of opioids in Australian surgical patients after discharge and patient satisfaction with the provision of opioid information after discharge. This prospective cohort study was conducted at a tertiary referral and teaching hospital. Surgical patients were called 7-28 days after discharge to identify their opioid use and the information that they received after discharge. In total, 66 patients responded. Most patients underwent orthopaedic surgery (45.5%; 30/66). The median days of opioids supplied on discharge was 5 (IQR 3-5). In total, 40.9% (27/66) of patients had >50% of their opioids remaining. Patients undergoing orthopaedic surgery were less likely to have >50% of their opioids remaining (P = 0.045), whilst patients undergoing urological or renal surgeries were significantly more likely (P = 0.009). Most patients recalled receiving information about their opioids (89.4%; 59/66). However, the majority (51.5%; 34/66) did not recall receiving any information about the signs of opioid toxicity and interactions between opioids and alcohol. In conclusion, around 40% of patients had more than half of their opioid supply remaining after they ceased taking their opioid. Although most patients recalled receiving information about their opioids, more than half did not recall receiving any information about the signs of opioid toxicity or interactions between opioids and alcohol.

Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery

OBJECTIVE

To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery.

METHODS

The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed.

RESULTS

The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population.

CONCLUSION

Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.

Opioid Sparing Multimodal Analgesia for Transoral Robotic Surgery: Improved Analgesia and Narcotic Use Reduction

Objective

To compare postoperative pain scores and opioid consumption in patients after transoral robotic surgery (TORS).

Study Design

Single institution retrospective cohort study.

Setting

TORS was performed at a single academic tertiary care center.

Methods

This study compared traditional opioid-based and opioid-sparing multimodal analgesia (MMA) regimens in patients with oropharyngeal and supraglottic malignancy after TORS. Data were obtained from the electronic health records from August 2016 to December 2021. The average postoperative pain scores and total opioid consumption in morphine milligram equivalents were calculated for postoperative days (PODs) 0 to 3. The secondary objectives were to quantify and characterize opioid prescriptions upon hospital discharge.

Results

A total of 114 patients were identified for this study, 58 patients in the non-MMA cohort and 56 in the MMA cohort. Postoperative pain levels in the MMA cohort were statistically lower on POD 0 (p = 0.001), POD 1 (p = 0.001), and POD 3 (p = 0.004). Postoperative opioid consumption decreased significantly in the MMA cohort from 37.7 to 10.8 mg on POD 0 (p = 0.002), 65.9 to 19.9 mg on POD 1 (p < 0.001), 36.0 to 19.3 mg on POD 2 (p = 0.02), and 45.4 to 13.8 mg on POD 3 (p = 0.02). The number of patients discharged from the hospital with a prescription for narcotics was significantly lower in the MMA cohort (71.4%) compared with the non-MMA cohort (98.3%) (p < 0.001).

Conclusion

Implementation of our MMA pain protocol reduced pain levels and narcotic consumption in the immediate postoperative period.

Postoperative protocols following endoscopic skull base surgery: An evidence-based review with recommendations

BACKGROUND

Postoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence-based guidance.

METHODS

The PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated.

RESULTS

A total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction.

CONCLUSION

The evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high-quality studies are needed in order to devise optimal postoperative ESBS protocols.

Acute Swallowing Outcomes After Surgical Resection of Oral Cavity and Oropharyngeal Cancers With the Mandibular Lingual Release Approach

OBJECTIVE

To investigate the incidence, nature, severity, and recovery of early dysphagia in patients following surgical resection of oral and/or oropharyngeal squamous cell carcinoma with a mandibular lingual release approach (MLRA).

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary head and neck cancer center.

METHODS

Inclusion of patients' after surgical resection of oral cavity and/or oropharyngeal squamous cell carcinoma via an MLRA between 2012 and 2017. Data collection included acute medical care, enteral feeding, and swallowing outcomes derived from clinical swallow examination and videofluoroscopic swallowing study assessments at baseline, after surgery, and prior to discharge.

RESULTS

Twenty-eight patients were eligible for participation (23 males; mean age, 63 years). Baseline clinical swallow examination findings revealed that 32% (n = 9) were tolerating normal diet and fluids preoperatively (Functional Oral Intake Scale [FOIS] = 7). Following surgery, the majority (n = 21, 75%) experienced severe dysphagia (FOIS ≤4), of which 15 were nil by mouth. Twelve patients received a postoperative videofluoroscopic swallowing study, with silent aspiration observed in 9 cases. At discharge, 12 (43%) patients had persistent severe functional dysphagia (FOIS ≤4) with ongoing enteral feeding requirements, of which 7 were nil by mouth. Eleven (39%) were managing diets of modified fluid/diet consistencies (FOIS = 5), and 5 (18%) had mild dysphagia (FOIS ≥6) at discharge. None were able to manage a normal diet. The average length of hospital stay was 27.9 days.

CONCLUSIONS

Early dysphagia post-MLRA is a common and often severe complication of surgery. Patients require extended hospital admission with prolonged enteral feeding, which may persist postdischarge. This cohort requires early intervention by speech-language pathology services to aid swallow rehabilitation.

Monitoring postoperative ambulation and sleep after head and neck surgery: A feasibility and utility study using wearable devices

BACKGROUND

To evaluate use of wearable activity devices to monitor trends in ambulation and sleep after head and neck surgery.

METHODS

Patients utilized Fitbit devices after surgery. Daily activity and sleep scores, step counts, and total sleep time (TST) were obtained.

RESULTS

There were 30 patients within the final cohort. Trends in step counts after specific procedures were identified, and higher subjective activity level correlated with step counts (r = 0.25, 95% CI = 0.07-0.41). Among patients with complete step data (n = 24), POD1 steps ≥200 were associated with reduced length of stay (4.5 ± 1.7 days vs. 7.2 ± 4.0 days, 95% CI = 0.33-5.0). Mean TST was 5.4 ± 2.5 h, TST correlated with subjective sleep scores (r = 0.25, 95% CI = 0.03-0.044), and clinical events associated with sleep-wake transitions on Fitbit devices were identified.

CONCLUSIONS

Wearable activity devices appear feasible for monitoring trends in postoperative ambulation and sleep. Use of these devices may facilitate postoperative recovery.

The Enhanced Recovery After Surgery (ERAS) protocol in head and neck cancer: a matched-pair analysis

Objective

In this study, we aimed to describe the prospective implementation of the Enhanced Recovery after Surgery (ERAS) protocol in an Italian tertiary academic centre.

Methods

Adult patients receiving surgery for primary or recurrent clinical stage III/IV squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx were enrolled. The primary objective was to evaluate the impact of the ERAS protocol on length of hospital stay (LOS). The secondary objective was to assess its impact on complications. To evaluate the results of the ERAS protocol, a matched-pair analysis was conducted, comparing ERAS patients with comparable cases treated before 2018.

Results

Forty ERAS and 40 non-ERAS patients were analysed. There were no significant differences between the cohorts regarding age, gender, stage of disease, comorbidity, ASA score, and duration of surgery. A significantly shorter LOS for the ERAS group (median, 14 days; range, 10-19) than for non-ERAS patients (median, 17.5 days; range, 13-21) was observed (p = 0.0128). The incidence of complications was not significantly different (p = 0.140).

Conclusions

Our study demonstrates that the introduction of an ERAS protocol in the daily practice is feasible, and can result in significant reduction in LOS.

Enhanced recovery after microvascular reconstruction in head and neck cancer – A prospective study

Objectives

Patients undergoing microvascular reconstruction after head and neck cancer typically have several comorbidities, and the procedures are often followed by complications and prolonged hospitalization. Consequently, the application of enhanced recovery after surgery (ERAS) for these patients undergoing microvascular reconstruction has gained attention in recent years. ERAS is a peri- and postoperative care concept that has repeatedly shown beneficial results for a wide variety of surgical procedures, including microvascular reconstruction. This study presents the results after the introduction of our ERAS protocol for head and neck cancer reconstruction.

Methods

We prospectively treated 30 consecutive patients according to our ERAS protocol from June 2019 to December 2020 and compared the results of the treated patients with those of patients treated with our traditional recovery after surgery (TRAS) protocol. We are based on our ERAS protocol on the following core elements of recovery: improved patient information, goal-directed fluid therapy, minimally invasive surgery, opioid-sparing multimodal analgesia, early ambulation, and pre-defined functional discharge criteria.

Results

The baseline characteristics of the groups were comparable. The ERAS group had a significantly shorter length of stay (13.1 vs. 20.3 days, p < 0.001), significantly shorter time to ambulation (3.0 days vs. 6.4 days, p < 0.001), shorter time to removal of nasogastric tube (13.3 days vs. 22.7 days, p = 0.05), and fewer tracheostomies performed (10% vs. 90%, p < 0.001). There were no differences in complications, flap survival, or 30-day re-admissions between the two groups.

Conclusion

The introduction of ERAS in patients with head and neck cancer undergoing microvascular reconstruction seems safe and results in improved recovery.

Level of evidence

3

Enhanced recovery after surgery (ERAS) in head and neck oncologic surgery: Impact on return to intended oncologic therapy (RIOT) and survival

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways in head and neck cancer (HNC) have shown to improve perioperative outcomes and reduce complications. The longer term implications on adjuvant treatment and survival have not been studied. We hereby report the first study on the impact of an ERAS pathway on return to intended oncologic treatment (RIOT) and overall survival (OS) in HNC.

METHODS

200 patients undergoing head and neck oncologic surgery on an ERAS pathway between March 1, 2016 and March 31, 2019 were matched to controls over the same interval. Demographic, tumor and adjuvant therapy-related data were collected, including time to adjuvant therapy(TAT) and treatment package time(TPT). Risk factors for TAT > 42 days and TPT ≥ 85 days were assessed. OS was compared and risk factors for inferior OS determined.

RESULTS

Baseline characteristics including co-morbidities and tumor stage were similar. Of 179 patients planned for adjuvant treatment, there was no difference in RIOT rate (89.0% vs 87.5%, p = 0.753), proportion of TAT > 42 days of surgery (55.6% vs 59.7%, p = 0.642), or TPT ≥ 85 days (48.1% vs 57.1, p = 0.258), for the ERAS and control groups, respectively. On multivariate analysis, alcohol use (OR 3.58; 95 %CI 1.11-11.52) and recurrent disease status (OR 2.88; 95 %CI 1.40-5.93) were independently associated with prolonged TAT. Three-year OS was similar between the ERAS and control groups (73% vs 76%, p = 0.521).

CONCLUSION

ERAS has not shown to improve RIOT or OS in the current study. However, its benefit for perioperative outcomes is undeniable and further studies are required on longer term quality and survival outcomes.

Designing an evidence-based free-flap pathway in head and neck reconstruction

Background

The use of autologous free-tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer. This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free-flap care.

Data Sources

This article examines English literature from PubMed and offers expert opinion on perioperative free-flap care for head and neck oncology.

Conclusion

Free-flap reconstruction for head and neck cancer is a process that, while individualized for each patient, is best supported by a comprehensive and standardized care pathway. Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence-based practice is rewarded with improved outcomes.

Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review

Objective

Management of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesic properties and side effects. The objective of this review is to discuss the efficacy and safety of multimodal analgesia (MMA) for these patients.

Methods

Pubmed, Cochrane, Embase, Scopus, and clinicaltrials.gov were systematically searched for all comparative studies of patients receiving MMA (nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, anticonvulsants, local anesthetics, and corticosteroids) for head and neck cancer surgeries. The primary outcome was additional postoperative opioid usage, and secondary outcomes included subjective pain scores, complications, adverse effects, and 30-day outcomes.

Results

A total of five studies representing 592 patients (MMA, n = 275; non-MMA, n = 317) met inclusion criteria. The most commonly used agents were gabapentin, NSAIDs, and acetaminophen (n = 221), NSAIDs (n = 221), followed by corticosteroids (n = 35), dextromethorphan (n = 40), and local nerve block (n = 19). Four studies described a significant decrease in overall postoperative narcotic usage with two studies reporting a significant decrease in hospital time. Subjective pain scores widely varied with two studies reporting reduced pain at postoperative day 3. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates.

Conclusion

MMA is an increasingly popular strategy that may reduce dependence on opioids for the treatment of postoperative pain. A variety of regimens and protocols are available for providers to utilize in the appropriate head and neck cancer patient.

Anaesthesia for reconstructive free flap surgery for head and neck cancer

Head and neck cancer surgery presents significant challenges for the anaesthetist. A thorough multidisciplinary preoperative assessment and optimisation of the patient is essential, including nutritional and psychological evaluation. The incidence of a difficult airway is high, and the anaesthetist must be skilled in advanced airway techniques. Surgery is extensive, often requiring reconstructive surgery with either a pedicled or free flap. Detailed knowledge of flap physiology and anatomy is needed, and anaesthesia comprises careful management of mean arterial pressure, fluid administration, temperature control and oxygenation. The Enhanced Recovery after Surgery Society and the Society for Head and Neck Anaesthesia consensus recommendations provide guidance on current best practice. Despite continued debate, it now appears that this constitutes goal-directed fluid therapy, coupled with judicious vasopressor therapy sufficient to achieve an adequate mean arterial pressure. Emerging techniques such as prehabilitation and postoperative near-infrared spectroscopy flap monitoring provide hope of improved outcomes going forward.

Enhanced recovery after posterior deep infiltrating endometriosis surgery: a national study

OBJECTIVE

To evaluate the impact of the implementation of a national enhanced recovery after surgery (ERAS) program for posterior deep infiltrating endometriosis (DIE) surgery on the length of hospital stay, the rate of postoperative complications, and readmission within 30 days.

DESIGN

Comparative exposed/nonexposed observational study.

SETTING

Study based on the French national medicoeconomic database of the Program of Medicalization of Information System.

PATIENTS

Seven hundred and sixty-four women who underwent DIE surgery were involved and matched (1:3 ratio) into two groups: ERAS group for the year 2019 and non-ERAS group for the year 2015.

INTERVENTIONS

Surgical management for posterior DIE.

MAIN OUTCOME MEASURES

The length of hospital stay, the rate of postoperative complications during the initial hospital stay, and readmission within 30 days.

RESULTS

The ERAS group included 191 women, and the non-ERAS group included 573 women. The mean length of hospital stay was shorter in the ERAS group than in the non-ERAS group (4.28 ± 3.80 days vs. 5.42 ± 4.04 days, respectively). The rate of postoperative abdominal or pelvic pain syndromes was lower in the ERAS group than in the non-ERAS group (5/191 (2.62%) vs. 48/573 (8.38%), respectively; relative risk, 0.31 [0.125-0.7969]). The rate of postoperative complication and the rate of readmission within 30 days were not different between the two groups.

CONCLUSIONS

The implementation of ERAS has a significant positive impact on patient outcomes after DIE surgery. The length of hospital stay and abdominal or pelvic pain syndromes were reduced without increasing complications or readmission within 30 days.

Association Between Insurance Type and Outcomes of Reconstructive Head and Neck Cancer Surgery

OBJECTIVES/HYPOTHESIS

Although the benefits of expanding health insurance coverage are clear, there are limited studies comparing the different types of insurance. This study aims to determine the association between insurance type and outcomes in patients with head and neck cancer undergoing reconstructive surgery in the United States.

METHODS

Population-based cross-sectional study of the 2012-2014 National Inpatient Sample. We identified 1,314 patients with head and neck cancers undergoing tumor ablative surgery followed by pedicled or free flap reconstruction of oncologic defects. Insurance type was classified as private, Medicare, Medicaid, self-pay, or other. The primary outcome was extended length of stay (LOS), defined as greater than 14 days, which represented the 75th percentile of the study sample. Secondary outcomes included acute medical complications, surgical complications, morbidities, and costs. Analyses were adjusted for gender, geographic location, and various medical comorbidities.

RESULTS

In univariate analysis, insurance type was associated with extended LOS (P = .001), medical complications (P = <.001), and mortalities (P = .020). After controlling for other covariates in the multivariate analysis, compared to private insurance, Medicare and Medicaid were both associated with significantly higher odds of extended LOS (adjusted odds ratio [OR] [95% confidence interval (CI)] = 1.73 [1.09-2.76] and 2.22 [1.38-3.58], respectively). Medicare was associated with significantly higher odds of medical complications, but Medicaid was not (adjusted OR [95% CI] = 1.53 [1.02-2.31] and 1.64 [0.97-2.78], respectively).

CONCLUSIONS

Medicaid and Medicare were independently associated with extended LOS after reconstructive head and neck cancer surgery. Medicare was associated with higher rates of medical complications. Efforts to address LOS should target care planning and coordination.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Sustained reduction of discharge opioid prescriptions in an enhanced recovery after thoracic surgery program: A multilevel generalized linear model

BACKGROUND

Enhanced Recovery After Surgery programs have been shown to effectively reduce opioid prescriptions at discharge after their implementation in several institutions, but little is known regarding the sustainability of this effect. Understanding opioid prescribing patterns after long-term implementation of Enhanced Recovery After Surgery initiatives may help guide further opioid prescription reduction and improvements. Our group aimed to determine whether reductions in opioid prescriptions at discharge are sustained in an Enhanced Recovery After Surgery program for thoracic surgery.

METHODS

This retrospective cohort included 2,081 patients undergoing thoracic surgery within a 4-year Enhanced Recovery After Surgery program from March 2016 through April 2020. Our Enhanced Recovery After Surgery protocol included a standardized multimodal analgesic regimen (ie, preoperative gabapentin, tramadol, intercostal nerve block with liposomal bupivacaine, and intraoperative acetaminophen, and ketorolac) and the rest of the interventions recommended by the Enhanced Recovery After Surgery society guidelines. Our primary outcomes were the presence of opioid prescriptions at discharge (hydrocodone, hydromorphone, and oxycodone) and the total opioid amount prescribed (morphine equivalent daily dose). Multilevel generalized linear models were used to account for surgeon variabilities and types of thoracic resection.

RESULTS

Over the study period, the rate of opioid prescriptions at discharge reduced from 35% (Mar 2016) to 25% (Apr 2020), and the amount of opioid prescribed declined from 184 ± 321 morphine equivalent daily dose to 94 ± 251 morphine equivalent daily dose. In multilevel generalized linear models, there was a sustained downward trend in opioid prescriptions over the study period (β -11.8 morphine equivalent daily dose per year, P = .048), which was also directly correlated with the use of minimally invasive surgery (β -84.9 morphine equivalent daily dose for video-assisted thoracoscopic surgery, P < .001; β -139.2 morphine equivalent daily dose for robotic-assisted thoracic surgery, P < .001), intraoperative opioid administration (β -1.4 morphine equivalent daily dose per 1 morphine equivalent dose, P = .026), and the amount of postoperative acetaminophen (β -18.2 morphine equivalent daily dose per 1 g, P = .026). The sustained reduction of opioid prescriptions at discharge did not impact hospital readmission rates within 30 days (odds ratio 1.17, 95% confidence interval 0.86-1.59, P = .306). Subgroup analysis showed a significant, sustained decrease in hydromorphone (β -10.9 morphine equivalent daily dose per year, P = .004), but not for hydrocodone prescriptions (β -5.7 morphine equivalent daily dose per year, P = .168) or oxycodone (β +4.78 morphine equivalent daily dose per year, P = .183).

CONCLUSION

Our Enhanced Recovery After Surgery program for thoracic surgery contributed to a sustained reduction of opioid prescriptions at discharge, which positively correlated with the duration of its implementation and the use of minimally invasive surgical techniques but was negatively impacted by the amount of intraoperative opioid administration.

Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

OBJECTIVE

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

PURPOSE

The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

ACTION STATEMENTS

The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

From Pathways to Practice: Impact of Implementing Mobilization Recommendations in Head and Neck Cancer Surgery with Free Flap Reconstruction

One of the foundational elements of enhanced recovery after surgery (ERAS) guidelines is early postoperative mobilization. For patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction, the ERAS guideline recommends patients be mobilized within 24 h postoperatively. The objective of this study was to evaluate compliance with the ERAS recommendation for early postoperative mobilization in 445 consecutive patients who underwent HNC surgery in the Calgary Head and Neck Enhanced Recovery Program. This retrospective analysis found that recommendation compliance increased by 10% despite a more aggressive target for mobilization (from 48 to 24 h). This resulted in a decrease in postoperative mobilization time and a stark increase in the proportion of patients mobilized within 24 h (from 10% to 64%). There was a significant relationship between compliance with recommended care and time to postoperative mobilization (Spearman's rho = -0.80; p < 0.001). Hospital length of stay was reduced by a median of 2 days, from 12 (1QR = 9-16) to 10 (1QR = 8-14) days (z = 3.82; p < 0.001) in patients who received guideline-concordant care. Engaging the clinical team and changing the order set to support clinical decision-making resulted in increased adherence to guideline-recommended care for patients undergoing major HNC surgery with free flap reconstruction.

Impact of Early Mobilization on Recovery after Major Head and Neck Surgery with Free Flap Reconstruction

Simple Summary

For patients diagnosed with head and neck cancer (HNC), surgery to remove the tumour is a standard treatment. The surgery is complex-in most cases, the mouth and throat need to be rebuilt using tissue from another area of the body to restore appearance and function. Recovery from HNC surgery is challenging, and complications occur frequently. It is recommended that patients get out of bed and move (are “mobilized”) as early as possible after surgery (within 24 h) to improve recovery. However, evidence for this recommendation mainly comes from other types of cancer. Therefore, this study investigated whether early mobilization impacts recovery in patients undergoing HNC surgery. We found that delaying mobilization (after 24 h) was linked with more complications and a longer stay in the hospital. Helping patients mobilize within 24 h after HNC surgery should be a priority for healthcare teams.

Abstract

Surgery with free flap reconstruction is a standard treatment for head and neck cancer (HNC). Because of the complexity of HNC surgery, recovery can be challenging, and complications are common. One of the foundations of enhanced recovery after surgery (ERAS) is early postoperative mobilization. The ERAS guidelines for HNC surgery with free flap reconstruction recommend mobilization within 24 h. This is based mainly on evidence from other surgical disciplines, and the extent to which mobilization within 24 h improves recovery after HNC surgery has not been explored. This retrospective analysis included 445 patients from the Calgary Head and Neck Enhanced Recovery Program. Mobilization after 24 h was associated with more complications of any type (OR = 1.73, 95% CI [confidence interval] = 1.16–2.57) and more major complications (OR = 1.76; 95% CI = 1.00–3.16). When accounting for patient and clinical factors, mobilization after 48 h was a significant predictor of major complications (OR = 2.61; 95% CI = 1.10–6.21) and prolonged length of stay (>10 days; OR = 2.85, 95% CI = 1.41–5.76). This comprehensive analysis of the impact of early mobilization on postoperative complications and length of stay in a large HNC cohort provides novel evidence supporting adherence to the ERAS early mobilization recommendations. Early mobilization should be a priority for patients undergoing HNC surgery with free flap reconstruction.

Association Between Multimodal Analgesia Administration and Perioperative Opioid Requirements in Patients Undergoing Head and Neck Surgery With Free Flap Reconstruction

Importance

The opioid epidemic has reignited interest in opioid-sparing strategies in managing pain. However, few studies have focused on opioid use during perioperative care in patients undergoing head and neck surgery with free flap reconstruction.

Objectives

To examine the association between multimodal analgesia (MMA) administration and perioperative opioid requirements in patients undergoing head and neck surgery with free flap reconstruction and to investigate whether MMA alters the duration of stay in the postanesthesia care unit (PACU).

Design, Setting, and Participants

In this retrospective case-control study, data were collected between April 1, 2016, and December 31, 2017. The study was conducted at a single cancer center in the United States. Participants were 357 patients 18 years or older scheduled for head and neck surgery with free flap reconstruction.

Exposures

Patients in the treatment group received oral celecoxib, gabapentin, and/or tramadol hydrochloride before surgery. Control group patients did not receive any of these medications.

Main Outcomes and Measures

The amount of opioid administered in the operating room and in the PACU was converted to morphine equivalent daily dose (MEDD) for comparison between the 2 groups. The duration of stay in the PACU was based on the start time and end time of PACU care recorded by nurses in the PACU.

Results

In total, 149 patients (mean [SD] age, 60.3 [13.7] years; 104 [69.8%] men) were included in the treatment group, and 208 patients (mean [SD] age, 64.2 [13.6] years; 146 [70.2%] men) were included in the control group. The mean (SD) MEDD of opioid given during surgery was 51.7 (19.8) in the treatment group and 67.9 (24.7) in the control group, for a difference in the means (treatment vs control) of -16.17 (95% CI, -20.81 to -11.52). In the PACU, the mean (SD) MEDD of opioid given was 11.7 (13.3) in the treatment group and 14.9 (15.7) in the control group, for a difference in the means (treatment vs control) of -3.22 (95% CI, -6.40 to -0.03). The MMA treatment remained largely associated with reduced amount of opioid given during surgery, in the PACU, and both combined after controlling for other important factors.

Conclusions and Relevance

This case-control study found that the patients who received MMA before head and neck surgery with free flap reconstruction required less opioid medication. The treatment group also had shorter duration of stay in the PACU compared with the control group.

Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis

INTRODUCTION

Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined.

OBJECTIVE

To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction.

METHODS

We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes.

RESULTS

18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]).

CONCLUSION

There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.

Enhanced recovery protocol for transoral robotic surgery demonstrates improved analgesia and narcotic use reduction

BACKGROUND

No study has evaluated the impact of the Enhanced Recovery After Surgery (ERAS) protocol on opioid usage among patients undergoing transoral robotic surgery (TORS).

METHODS

In this retrospective study, patients undergoing TORS were enrolled in an ERAS protocol and compared to control patients. Primary outcome measures included postoperative mean morphine equivalent dose (MED), Defense and Veterans Pain Rating Scale (DVPRS) pain scores, and opioid prescriptions on discharge.

RESULTS

The mean MED administered postoperatively was lower in the ERAS group (17.6 mg) than in the control group (65.0 mg) (p < .001). Average postoperative DVPRS scores were 2.9 in the ERAS group vs. 4.2 in the control group (p = .042). Fewer patients in the ERAS group received opioid prescriptions on discharge (31.6%) than controls (96.2%) (p < .001).

CONCLUSION

The TORS ERAS protocol is associated with reduced postoperative opioid usage, lower pain scores, and reduced opioid requirements on discharge.

An enhanced recovery programme improves the comfort and outcomes in children with obstructive sleep apnoea undergoing adenotonsillectomy: A retrospective historical control study

OBJECTIVE

To explore the effects of an enhanced recovery after surgery (ERAS) programme on postoperative rehabilitation in children with obstructive sleep apnoea (OSA) during the perioperative period of adenotonsillectomy.

DESIGN

A retrospective historical control study.

SETTING

Service improvement project.

PARTICIPANTS

The study included 394 children with OSA (207 males, 187 females; age range, 2.5 years to 14 years) who underwent adenotonsillectomy.

MAIN OUTCOME MEASURES

The children who had undergone adenoidal ablation and bilateral tonsillectomy were divided into an ERAS group (208 patients) treated with the combined optimisation measures and a control group (186 patients) treated with traditional measures during the perioperative period. The postoperative incidence of complications, pain scores, anxiety scores and postoperative diets in the two groups were assessed.

RESULTS

Patients in the ERAS group had significantly a lower overall complication rate and incidence of fever for 2 weeks of follow-up when compared to patients in the control group through the application of perioperative optimisation measures. Furthermore, patients in the ERAS group had less post-surgical pain, had better dietary intake at days 1, 3 and 7 after surgery and had lower preoperative anxiety scores after admission education and while waiting in the operation room.

CONCLUSION

The ERAS programme consisting of combined optimisation measures can reduce physical and psychological trauma during the perioperative period of adenotonsillectomy performed for children with OSA.

Opioid Prescribing in Patients Undergoing Neck Dissections With Short Hospitalizations

Objective

To evaluate postoperative opioid prescribing in patients undergoing neck dissections with short hospitalizations.

Study Design

Retrospective cohort study.

Setting

Tertiary academic hospital.

Methods

The study population included patients who underwent lateral neck dissections with or without an associated head and neck procedure and required hospitalization for ≤3 days from 2012 to 2019. Interventions to decrease opioid utilization, including preoperative counseling, multimodality pain management, and multidisciplinary collaboration, were implemented in September 2016. Patients were divided into 2 groups: preintervention (group 1) and postintervention (group 2). The mean quantity of opioids prescribed during hospitalization, at discharge, and in refills was calculated in morphine milligram equivalents (MME).

Results

A total of 407 patients were included in the analysis: 223 patients in group 1 and 184 patients in group 2 (42.3% female, 89.4% white; average age, 55.2 years [95% CI, 53.6-56.9]). The mean opioid quantity prescribed in unilateral neck dissection alone decreased from 353.9 MME (95% CI, 266.7-441.2) in group 1 to 113.3 MME (95% CI, 87.8-138.7) in group 2 ( P < .001; effect size, 1.0). Statistically significant decreases in mean opioid quantity prescribed were also observed in unilateral neck dissection in combination with thyroidectomy, parotidectomy, glossectomy, or tonsillectomy. The percentage of patients requiring opioid prescription refills was not statistically different between the groups.

Conclusion

This study demonstrates that the quantity of opioids prescribed in patients undergoing neck dissections and associated head and neck procedures with short hospitalizations can be reduced to as low as 100 to 125 MME with preoperative counseling, multimodality pain management, and multidisciplinary collaboration.

ERAS for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization

OBJECTIVES

We implement a novel enhanced recovery after surgery (ERAS) protocol with pre-operative non-opioid loading, total intravenous anesthesia, multimodal peri-operative analgesia, and restricted red blood cell (pRBC) transfusions. 1) Compare differences in mean postoperative peak pain scores, opioid usage, and pRBC transfusions. 2) Examine changes in overall length of stay (LOS), intensive care unit LOS, complications, and 30-day readmissions.

METHODS

Retrospective cohort study comparing 132 ERAS vs. 66 non-ERAS patients after HNC tissue transfer reconstruction. Data was collected in a double-blind fashion by two teams.

RESULTS

Mean postoperative peak pain scores were lower in the ERAS group up to postoperative day (POD) 2. POD0: 4.6 ± 3.6 vs. 6.5 ± 3.5; P = .004) (POD1: 5.2 ± 3.5 vs. 7.3 ± 2.3; P = .002) (POD2: 4.1 ± 3.5 vs. 6.6 ± 2.8; P = .000). Opioid utilization, converted into morphine milligram equivalents, was decreased in the ERAS group (POD0: 6.0 ± 9.8 vs. 10.3 ± 10.8; P = .010) (POD1: 14.1 ± 22.1 vs. 34.2 ± 23.2; P = .000) (POD2: 11.4 ± 19.7 vs. 37.6 ± 31.7; P = .000) (POD3: 13.7 ± 20.5 vs. 37.9 ± 42.3; P = .000) (POD4: 11.7 ± 17.9 vs. 36.2 ± 39.2; P = .000) (POD5: 10.3 ± 17.9 vs. 35.4 ± 45.6; P = .000). Mean pRBC transfusion rate was lower in ERAS patients (2.1 vs. 3.1 units, P = .017). There were no differences between ERAS and non-ERAS patients in hospital LOS, ICU LOS, complication rates, and 30-day readmissions.

CONCLUSION

Our ERAS pathway reduced postoperative pain, opioid usage, and pRBC transfusions after HNC reconstruction. These benefits were obtained without an increase in hospital or ICU LOS, complications, or readmission rates.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E792-E799, 2021.

Age Is Associated With Pain Experience and Opioid Use After Head and Neck Free Flap Reconstruction

OBJECTIVES

To describe pain experience and opioid use after major head and neck reconstructive surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients undergoing major head and neck surgery with microvascular free tissue transfer (free flaps) at a tertiary academic center were included. Pain scores (0-10) and demographic and clinical data were ascertained from medical records. Discharge opioid prescriptions and refills obtained within 30 days were recorded. Patient characteristics were compared with pain scores using nonparametric rank-sum tests and with likelihood of refill using logistic regression models to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

The study population comprised 445 patients. Median age was 60 years (interquartile range 50-68). Most patients had cancer (N = 350, 78%). The majority of free flaps were fibula (N = 153, 34%) or radial forearm (N = 159, 36%). Older patients reported significantly lower pain scores, whereas patients with opioid tolerance, anxiety, current smokers, and those undergoing larger volume resections or boney free flaps reported significantly higher pain scores. One-quarter (N = 115, 26%) of patients obtained opioid refills. Patients aged ≥ 60 years had one-half the odds of obtaining a refill compared with patients aged < 60 years (adjusted odds ratio [aOR] = 0.52, 95% confidence interval [CI] = 0.33-0.84), whereas surgical defect volume ≥ 100 cm³ (aOR = 1.92, 95% CI = 1.21-3.07) and higher pain score (aOR = 1.19, 95% CI = 1.07-1.32 per 1 point increase) increased the odds of refill.

CONCLUSION

Continued opioid use after discharge is common among patients undergoing major head and neck reconstruction, particularly for younger patients and after more extensive surgery. Older patients reported lower pain intensity and were less likely to obtain opioid refills, highlighting the wisdom of judicious opioid use for this vulnerable population.

LEVEL OF EVIDENCE

IV Laryngoscope, 130: E469-E478, 2020.