The impact of a post-operative clinical care pathway on head and neck microvascular free tissue transfer outcomes

The effect of transfusion on survival in head and neck cancer after free tissue reconstruction

Objective

To examine if perioperative blood transfusion affects overall survival (OS) and recurrence-free survival (RFS) in head and neck cancer patients who undergo free tissue reconstruction.

Design

Retrospective cohort study.

Methods

The medical records of free tissue flaps between 2007 and 2010 were reviewed. Differences in demographics and clinical factors based on the level of transfused packed red blood cells (PRBC) were examined using chi-squared tests, Kruskal-Wallis tests, and/or ANOVA tests. Survival time was compared using a Cox proportional hazard model.

Results

Data were available for 183 patients. Patients who had PRBC transfusion significantly differed from the non-transfused group by flap type, flap with bone, Charlson Comorbidity Index (CCI), and hemoglobin and hematocrit. When stratified into three groups based on units of PRBC; flap type, flap with bone, CCI, preoperative hemoglobin, and hematocrit were found to differ significantly. The 2-year Kaplan-Meier plot demonstrated improved OS for those who did not receive any PRBC transfusion. The use of more than 3 units of blood decreased 2-year OS significantly when compared to the non-transfused group. Finally, after adjusting for CCI using a Cox proportional hazard model, survival was significantly affected by CCI.

Conclusion

After controlling for patient age, oncologic stage, cancer subsite, histology, type of free flap, vascularized bone-containing flap, recurrence type, CCI, and preoperative hemoglobin and hematocrit, patients who received 3 or more units of PRBC in the perioperative period had significantly decreased OS. RFS did not differ between the transfused versus non-transfused groups.

Level of Evidence

Level 4.

Creating a social media strategy for an international cardiothoracic research network: a scoping review

AIMS

A cardiac surgery international nursing and allied professional research network titled CONNECT was created to strengthen collaborative cardiac surgery research through shared initiatives including supervision, mentorship, workplace exchange programs, and multi-site clinical research. As with any new initiative, there is a need to build brand awareness to enhance user familiarity, grow membership, and promote various opportunities offered. Social media has been used across various surgical disciplines; however, their effectiveness in promoting scholarly and academic-based initiatives has not been examined. The aim of this scoping review was to examine the different types of social media platforms and strategies used to promote cardiac research initiatives for CONNECT.

METHODS AND RESULTS

A scoping review was undertaken in which a comprehensive and thorough review of the literature was performed. Fifteen articles were included in the review. Twitter appeared to be the most common form of social media used to promote cardiac initiatives, with daily posts being the most frequent type of engagement. Frequency of views, number of impressions and engagement, link clicks, and content analysis were the most common types of evaluation metrics that were identified.

CONCLUSION

Findings from this review will inform the design and evaluation of a targeted Twitter campaign aimed at increasing brand awareness of CONNECT, which will include the use of @CONNECTcardiac Twitter handle, hashtags, and CONNECT-driven journal clubs. In addition, the use of Twitter to disseminate information and brand initiatives related to CONNECT will be evaluated using the Twitter Analytics function.

REGISTRATION

Open Science Framework: osf.io/q54es.

Role of protocol-guided perioperative care to enhance recovery after head and neck neoplasm surgery: An institutional experience

BACKGROUND

Enhanced recovery after surgery (ERAS) improve recovery after surgery. This study aimed to determine whether ERAS leads to a decrease in stay in the hospital and improves global and functional recovery after head and neck neoplasms surgery.

METHODS

We performed a prospective case and historical control study after the ERAS application. The hospital database selected 50 confirmed eligible patients in control non-ERAS group. Prospectively 54 patients were included in the ERAS group. The primary outcome was time to readiness for discharge (TRD); secondary outcomes were the length of stay (LOS), readmission rate of up to 30 days and Quality of recovery score QoR-15. Data were compared with appropriate parametric and nonparametric tests.

RESULTS

Baseline demographic data of patients were comparable between the two groups. Patients in ERAS group had significantly shorter TRD compared to the non-ERAS group 8 (6-10) vs 11 (8-16); p-value = 0.002. LOS was also significantly shorter in the ERAS group compared to the non-ERAS group [8 (7-11) vs 12 (9-17); p-value = 0.002]. Readmission at 30-days was no different, with six patients in each group. QoR-15 score was statistically better in ERAS group (94.88 ± 12.50) compared to non-ERAS group (85.44 ± 12.68) [p value < 0.001].

CONCLUSION

Implementing the ERAS programme decreased TRD and LOS and improved patient-reported recovery outcome QoR-15 in head and neck neoplasms surgery.

Barriers and Facilitators in Implementation of an Esophagectomy Care Pathway: a Qualitative Analysis

INTRODUCTION

A new postoperative esophagectomy care pathway was recently implemented at our institution. Practice pattern change among provider teams can prove challenging; therefore, we sought to study the barriers and facilitators toward pathway implementation at the provider level.

METHODS

This qualitative study was guided by the Theoretical Domains Framework (TDF) to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen in-depth interviews were conducted with providers involved with the pathway. Matrix analysis was used to analyze the data.

RESULTS

Providers included attending surgeons (n = 6), advanced practice providers (n = 8), registered dietitian (n = 1), and clinic staff (n = 1). TDF domains that were salient across our findings included knowledge, beliefs about consequences, social influences, and environmental context and resources. Identified facilitators included were electronic health record tools, such as note templates including pathway components and a pathway-specific order set, patient satisfaction, and preliminary data indicating clinical benefits such as a reduced anastomotic leak rate. The major barrier reported was a hesitance to abandon previous practice patterns, most prevalent at the attending surgeon level.

CONCLUSION

The TDF enabled us to identify and understand the individuals' perceived barriers and facilitators toward adoption and implementation of a postoperative esophagectomy pathway. This analysis can help guide and improve adoption of surgical patient care pathways among providers.

Outpatient Parotidectomy, a Safety and Financial Review

OBJECTIVE

The objective of this study is to investigate the safety, efficacy, and potential cost-savings of the outpatient parotidectomy procedure.

METHODS

This is a retrospective chart review of all patients who underwent a parotidectomy at a large academic center from 2015 through 2019 including demographic data, postoperative complications, drain placement, readmission, and financial cost. A comparison was performed between patients who underwent an outpatient vs inpatient parotidectomy.

RESULTS

A total of 335 patients underwent parotidectomy (136 outpatient; 199 inpatient). Comparison of patient demographics, common comorbidities, tumor size, tumor type, postoperative complications, and readmission rate was similar between the inpatient and outpatient cohorts. The overall mean cost difference between inpatient parotidectomy and outpatient parotidectomy for all years was $1528.58 (95%CI: $1139-$1916).

CONCLUSION

The outpatient parotidectomy procedure has a comparable safety profile to the inpatient procedure while providing a significant cost-savings benefit.

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.

Evidence-Based Guidelines for Management of Head and Neck Mucosal Malignancies during the COVID-19 Pandemic

OBJECTIVE

Due to the current coronavirus disease 2019 (COVID-19) pandemic, otolaryngologists face novel challenges when treating patients with head and neck cancer. The purpose of this review is to evaluate the current evidence surrounding the treatment of these patients during this pandemic and to provide evidence-based recommendations with attention to increased risk in this setting.

DATA SOURCES

A review of the literature was performed with PubMed. Because recently published articles on this topic may not yet be indexed into PubMed, otolaryngology journals were hand searched for relevant articles. Guidelines from national organizations were reviewed to identify additional relevant sources of information.

REVIEW METHODS

Two groups of search terms were created: one with terms related to COVID-19 and another with terms related to head and neck cancer and its management. Searches were performed of all terms in each group as well as combinations of terms between groups. Searches and subsequent exclusion of articles were performed in accordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Additional articles were identified after relevant journals and guidelines from national organizations were reviewed.

CONCLUSIONS

Patients with head and neck mucosal malignancy require continued treatment despite the current pandemic state. Care must be taken at all stages of treatment to minimize the risk to patients and health care workers while maintaining focus on minimizing use of limited resources.

IMPLICATIONS FOR PRACTICE

Patient care plans should be guided by best available evidence to optimize outcomes while maintaining a safe environment in the setting of this pandemic.