Neck Dissection Technique Commonality and Variance: A Survey on Neck Dissection Technique Preferences among Head and Neck Oncologic Surgeons in the American Head and Neck Society

Impact of Drain Removal Timing and Prophylactic Antibiotic Agents on Surgical Site Infections in Head and Neck Reconstruction

Background: Regarding drain removal timing in head and neck reconstruction, each institution applies its criteria, and a clear consensus has not been established. This pre-post study aims to identify risk factors for surgical site infection (SSI) after reconstructive surgical procedure for head and neck cancer, specifically examining the influence of drain removal timing. Patients and Methods: A cohort of 220 patients undergoing reconstructive surgical procedure was analyzed. Patients had closed suction drains removed on post-operative day (POD) 2 or POD3. The primary endpoint was SSI incidence within 30 days after operation. Secondary endpoints included the incidence of hematoma and lymphorrhea within 30 days after operation and drain tip culture results. Statistical analyses were performed using Fisher exact test and logistic regression models. Results: SSIs occurred in 14.5% of patients, with no significant difference between the POD2 (14.6%) and POD3 (14.5%) groups. No substantial differences were found for hematoma and lymphorrhea. The positive rate of drain tip cultures was significantly greater in the POD3 group (38.2%) compared with the POD2 group (18.0%). Multi-variable analysis showed no correlation between SSI and POD3 drain removal (odds ratio [OR], 0.728; p = 0.471). However, significant SSI risk factors included oral cavity lesions (OR, 3.510; p = 0.003) and ampicillin prophylaxis (OR, 5.266; p < 0.001). Conclusions: Oral cavity lesions and ampicillin prophylaxis were substantial SSI risk factors in reconstructive surgical procedure for head and neck cancer. However, drain removal timing did not significantly affect SSI incidence or other complications. Considering benefits such as shorter hospital stays and less chance of retrograde bacterial invasion, removing drains on POD2 is preferable compared with removal on POD3. Further research is needed to refine prophylactic protocols and enhance patient outcomes.

Submandibular Gland Preservation in Oral Cavity Squamous Cell Carcinomas: Our Analysis at A Tertiary Care Hospital

Introduction

Surgical excision forms the principal treatment of oral cavity squamous cell carcinomas. The comprehensive surgical management consists of Wide Local Excision of the tumor and Neck Dissection with removal of Submandibular gland. The submandibular gland accounts for 70-90 % of unstimulated salivary volume. Its excision as a part of neck dissection has been found to cause high Incidence (21% vs 7%) of postoperative xerostomia. Recent studies have highlighted that the preservation of the SMG is possible and oncologically safe in early-grade OCSCC with N0 neck as the involvement of SMG in such cases is low and its preservation decreases the chances of xerostomia.

Materials and Methods

80 subjects were included in the study to estimate the prevalence of metastatic submandibular gland involvement in oral cavity squamous cell carcinomas. The presence of metastasis into the salivary gland was studied and the mechanism/route of involvement was analysed. The comparison was made between the early and advanced tumors for SMG metastasis irrespective of the primary subsite involvement.

Results

In the current study low prevalence (6.2 %) of metastasis to SMG was seen. It was seen in high-grade tumors only. None of the early-grade tumors showed any evidence of SMG metastasis. The most common pattern (80%) of glandular involvement was a direct extension from the primary tumor.

Conclusions

Our study concludes that SMG preservation neck dissections can be carried out in early-grade OCSCC irrespective of primary tumor site involvement. The advantages of preserving the SMG are multiple. Furthermore, the morbidity is markedly decreased with its preservation without any compromise on oncological safety.

Risk stratification of submandibular salivary gland involvement in oral squamous cell carcinoma based on histopathological parameters: A 15-year retrospective study

Objective

Squamous cell carcinoma (SCC) represents about 90% of all oral malignancies. The study aimed to assess the involvement of the submandibular salivary gland (SMG) in oral SCC (OSCC) patients and the need for SMG excision.

Materials and Methods

Demographics, clinical information and staging of the 210 patients undergoing surgery for OSCC were obtained from the department records. The histopathological slides were retrospectively reviewed. The nodal status was also verified with the histopathology reports. Frequency distribution, Chi-square association, ordinal logistic regression analysis and Kaplan-Meier analysis were performed.

Results

SMG was excised in 171 patients. Five patients had SMG involvement. Buccal mucosa (BM) and gingivobuccal sulcus had a greater risk of level IB metastases (P < 0.01). Pattern 3 and pattern 4 of invasion had a higher risk of level IB metastases (P = 0.04). Depth of invasion (DOI) >4 mm was associated with level IB lymph node (LN) involvement (P = 0.0001). DOI >4 mm to 8 mm had 3.7 times the risk and a DOI >8 mm to 12 mm had 5 times the risk of level IB metastases. Pattern of invasion (POI), tumour budding and DOI >4 mm were significant prognosticators for patient survival.

Conclusion

Histologically, patients may be categorised as 'high risk': those with an increased risk of level IB LN involvement and 'low risk': those at low risk for level IB involvement with the help of POI, tumour budding and DOI as risk factors. In low-risk patients, SMG may be spared and the level IB LNs are dissected. High-risk patients may be chosen as candidates for SMG transfer or excision based on the extent of LN involvement.

Outcomes and complications of postoperative seroma cavities following soft-tissue sarcoma resection

Introduction

Seroma development is a known complication following extremity and trunk soft-tissue sarcoma (STS) resection. The purpose of this study is to evaluate and characterize seroma outcomes and the development of associated complications.

Methods

A retrospective review of 123 patients who developed postoperative seromas following STS resection at a single institution was performed. Various patient and surgical factors were analyzed to determine their effect on overall seroma outcomes.

Results

77/123 seromas (62.6%) were uncomplicated, 30/123 (24.4%) developed infection, and 16/123 (13.0%) were symptomatic and required aspiration or drainage for symptom relief at an average of 12.2 months postoperatively. 65/123 (52.8%) seromas resolved spontaneously at an average time of 12.41 months. Seromas in the lower extremity (p=0.028), surgical resection volume >864 cm3, (p=<0.001) and initial seroma volume >42 cm3 (p=<0.001) increased the likelihood of infection. 90% of infected seromas developed the infection within the first three months following initial resection. No seromas which were aspirated or drained ultimately developed an infection following these procedures, though 50% recurred.

Discussion

Most seromas following STS resection are uncomplicated and do not require intervention, though a large resection cavity >864 cm3 and a large seroma volume >42 cm3 are risk factors for complications.

Effect of Drain Output on the Timing of Closed Suction Drain (CSD) Removal After Head and Neck Surgery

Background: A closed suction drain (CSD) is often utilized in head and neck surgical procedures to obliterate dead space. CSDs reduce seroma and hematoma formation, thereby improving skin apposition and wound healing. The use of drains for prolonged periods of time, however, may increase the risk of wound infection. Interestingly, the evidence regarding the need for, and management of, post-operative CSDs after head and neck surgery is scarce. The current criterion of drain removal when output is less than 30 cubic centimeters (cm³) within a 24-hour period and/or on the third post-operative day (POD) is widely utilized. The aforementioned criterion is based on anecdotal evidence from small studies with specific surgical procedures. In this study, we aim to evaluate the criteria for drain removal and to lay the groundwork for an updated paradigm for drain management in head and neck oncologic surgery.

Study Design: Retrospective cohort study

Setting: Academic tertiary care hospital

Methods: A retrospective study was performed. Patients were included if they underwent head and neck surgery at the University of Miami Hospital between January 1, 2019 and July 1, 2020 and had at least one CSD. Volume of drain output on each POD was recorded until the day of drain removal. The development of post-operative wound complications (i.e., seroma, hematoma, infection/abscess, and dehiscence) was also recorded.

Results: From our initial cohort of 302 patients, 145 patients met inclusion criteria. A total of 10 patients developed a post-operative wound complication. Patients had a mean age of 58.3 ± 15.0 years. The median inter-quartile range (IQR) drain output (cm³) on the day of CSD removal from patients who developed a wound complication was similar (15; IQR, 5-37.5) when compared to those who did not develop a wound complication (25; IQR, 10-30). This difference was not statistically significant (p = 0.60). Additionally, the cohort who developed a post-operative wound complication had their drain removed on an earlier POD (1; IQR, 1-1 (Mean 1.2)) when compared to the cohort who did not develop any complications (1; IQR, 1-1 (Mean 1.5)). This difference was also not statistically significant (p = 0.48) .

Conclusion: There is no association between drain output (cm³) or day of CSD removal with the development of wound complications. These results warrant further studies to prospectively evaluate earlier CSD removal in head and neck surgery.

Surgical drainage after limb salvage surgery and endoprosthetic reconstruction: is 30 mL/day critical?

Background

Periprosthetic infection is a major cause of failure after segmental endoprosthetic reconstruction. The purpose of this study is to determine whether certain aspects of drain output affect infection risk, particularly the 30 mL/day criterion for removal.

Methods

Two hundred and ninety-five patients underwent segmental bone resection and lower limb endoprosthetic reconstruction at one institution. Data on surgical drain management and occurrence of infection were obtained from a retrospective review of patients’ charts and radiographs. Univariate and multivariate Cox regression analyses were performed to identify factors associated with infection.

Results

Thirty-one of 295 patients (10.5%) developed infection at a median time of 13 months (range 1–108 months). Staphylococcus aureus was the most common organism and was responsible for the majority of cases developing within 1 year of surgery. Mean output at the time of drain removal was 72 mL/day. Ten of 88 patients (11.3%) with ≤ 30 mL/day drainage and 21 of 207 patients (10.1%) with > 30 mL/day drainage developed infection (p = 0.84). In multivariate analysis, independent predictive factors for infection included sarcoma diagnosis (HR 4.13, 95% CI 1.4–12.2, p = 0.01) and preoperative chemotherapy (HR 3.29, 95% CI 1.1–9.6, p = 0.03).

Conclusion

Waiting until drain output is < 30 mL/day before drain removal is not associated with decreased risk of infection for segmental endoprostheses of the lower limb after tumor resection. Sarcoma diagnosis and preoperative chemotherapy were independent predictors of infection.

Comparing human and mouse salivary glands: A practice guide for salivary researchers

Mice are a widely utilized in vivo model for translational salivary gland research but must be used with caution. Specifically, mouse salivary glands are similar in many ways to human salivary glands (i.e., in terms of their anatomy, histology, and physiology) and are both readily available and relatively easy and affordable to maintain. However, there are some significant differences between the two organisms, and by extension, the salivary glands derived from them must be taken into account for translational studies. The current review details pertinent similarities and differences between human and mouse salivary glands and offers practical guidelines for using both for research purposes.