Medical complications in total laryngectomy: incidence and risk factors

A nationwide analysis of salvage surgery for laryngeal cancer in the elderly

BACKGROUND

We aim to describe outcomes of elderly patients undergoing salvage surgery for laryngeal cancer and to characterize the interplay of age with various other factors in this growing population.

METHODS

Using the National Cancer Database, we identified cases of salvage laryngectomy in patients who failed chemoradiation. An age cutoff of 70 years was used to separate subjects into two groups. Various factors were compared.

RESULTS

Of the 825 patients included, 166 (20.1%) were elderly. Elderly patients had worse overall survival (p = 0.001), higher 30-day and 90-day mortality (p = 0.006, p < 0.001), and a longer length of stay (LOS) (p = 0.015). LOS over 1 week was associated with worse survival (p = 0.032).

CONCLUSION

Elderly patients had worse overall perioperative survival than their younger counterparts. LOS and 30-day readmissions were associated with higher risk of mortality in this group. We provide a contemporary set of relevant information for head and neck cancer providers to consider in this growing population.

Deciphering excess healthcare burden in head and neck cancer patients with cardiovascular comorbidity

BACKGROUND

This study aimed to determine the perioperative surgical outcomes for head and neck cancer patients with cardiovascular diseases (CVDs).

METHODS

A cross-sectional analysis was performed using data from the Nationwide Readmissions Database between 2010 and 2014. Logistic regression analysis by enter and backward stepwise methods were used.

RESULTS

A total of 8346 patients met the inclusion criteria. Patients with concomitant CVD had a higher frequency of complications (57.6%) compared with those without (47.4%) (odds ratio [OR] = 1.35, 95% confidence interval [CI] = 1.23-1.48, p < 0.001). Patients with CVD comorbidities were prone to experience in-patient mortality at both admission (OR = 2.4, 95% CI = 1.42-4.05) and readmission (OR = 2.55, 95% CI = 1.10-5.87). CVD patients have prolonged hospital admission (OR = 1.14, 95% CI = 1.02-1.27, p = 0.020) and higher cost (OR = 1.28, 95% CI = 1.15-1.43, p < 0.001). Patients with congestive heart failure were prone to 30 days readmission (OR = 1.67, 95% CI = 1.10-2.53, p = 0.019) and 90 days (OR = 1.65, 95% CI = 1.14-2.39, p = 0.010).

CONCLUSION

This is the first study identifying factors predicting higher risk of perioperative complications of surgical management of head and neck cancer. Those with CVD had higher risk of adverse events.

Perioperative mortality of head and neck cancers

Background

Head and neck cancers are aggressive cancers, most clinical studies focused on the prognosis of patients with head and neck cancer. However, perioperative mortality was rarely mentioned.

Methods

A retrospective analysis was performed using all head and neck cancer patients admitting in the Department of Oral and Maxillofacial Surgery of the Second Xiangya Hospital, Central South University from January 2010 to December 2019. The analysis of overall survival and progression-free survival were performed using the Kaplan–Meier method, and cross tabulation with chi-squared testing was applied to analyze the difference in parameters between groups.

Results

From January 2010 to December 2019, a total of 6576 patients with head and neck cancers were admitted to our department and 7 died in the hospital, all of whom were middle-aged and elderly patients including 6 males and 1 female. The perioperative mortality rate (POMR) was about 1‰. The causes of death included acute heart failure, rupture of large blood vessels in the neck, hypoxic ischemic encephalopathy due to asphyxia, respiratory failure and cardiopulmonary arrest.

Conclusion

Preoperative radiotherapy, previous chemotherapy, hypertension, diabetes, advanced clinical stage and postoperative infection are risk factors for perioperative mortality of head and neck cancer.

Gaps in Training: Misunderstandings of Airway Management in Medical Students and Internal Medicine Residents

Objectives

(1) Evaluate baseline airway knowledge of medical students (MSs) and internal medicine (IM) residents. (2) Improve MS and IM resident understanding of airway anatomy, general tracheostomy and laryngectomy care, and management of airway emergencies.

Methods

A before-and-after survey study was carried out over a single academic year. MS and IM resident knowledge was evaluated before and after an educational, grand rounds–style lecture reviewing airway anatomy, tracheostomy tube components, tracheostomy and laryngectomy care, and clinical vignettes. The primary outcome measure was change in pre- and postlecture survey scores.

Results

Prelecture surveys were completed by 90 participants, and 83 completed a postlecture assessment. Postlecture scores were statistically improved for all questions on the assessment ( P < .001). Level of training did not confer an improved pre- or postlecture survey score.

Discussion

While the majority of participants in our study had previously cared for patients with a tracheostomy or laryngectomy, less than half were able to correctly address basic airway emergencies. Senior IM residents were no more proficient than MSs in addressing airway emergencies. The lack of formal airway training places patients at risk with routine care and in emergencies, demonstrating the need for formal airway education for early medical trainees.

Implications for Practice

Our data demonstrate a serious gap in MS and IM resident knowledge with respect to emergent airway care in patients with tracheostomies and laryngectomies. An interdepartmental collaborative curriculum offers a realistic and potentially life-saving solution for medical trainees.

Venous thromboembolism in head and neck surgery: Risk, outcome, and burden at the national level

BACKGROUND

Venous thromboembolism (VTE) can complicate major surgeries. This study examines the risk and outcomes of VTE in patients who underwent head and neck surgeries.

METHODS

Retrospective cross-sectional analysis utilizing the Nationwide Readmissions Database (2010-2014). Study population included adults (≥18 year) patients who underwent head and neck surgeries.

RESULTS

A total 386 VTE patients and 116 450 controls included. VTE risk was 0.37%, postoperative mortality was 4.87%. Of VTE, 57.02% identified within the initial admission for surgery, while the rest required readmission within 90 days. VTE high-risk surgeries included: major ear/skull base surgeries, major nose/paranasal sinuses surgeries, major mouth/tonsil surgeries, major salivary glands/ducts surgeries, major maxillofacial bones/mandible surgeries, and major and nonmajor pharynx and larynx surgeries (P < .05). Those same surgeries were also associated with a high risk of readmission (P < .05).

CONCLUSIONS

VTE is associated with a significant mortality risk. Surgeries that involve the pharynx and larynx have the highest risk of VTE and readmission.

Total laryngectomy: Surgical morbidity and outcomes - A case series

BACKGROUND

Total laryngectomy (TL) is a well-established procedure for laryngeal and hypopharyngeal cancers. There is an increasing number of TLs done after organ preservation strategies.

AIM

The aim of this study was to report 30-day morbidity and survival outcomes in patients undergoing TL at a tertiary referral center.

SETTING AND DESIGN

This was a retrospective review of a prospective database of TL patients operated during 2012-2013.

MATERIALS AND METHODS

Patient demographics and other data were captured from the database. Surgical complications were graded as per Clavien-Dindo grading system and were also divided into major and minor as per predecided criteria. Recurrence and survival data were computed using Kaplan-Meier survival curves.

RESULTS

A total of 169 patients underwent TL during the study period. About 34% of the patients had received prior radiation therapy. Around 18% of the patients had major complications with a pharyngocutaneous fistula rate of 22.4%. Ninety percent of these were managed conservatively. Though used in a small subset, microvascular reconstruction had the least complication rates. The 3-year disease-free survival and overall survival were 66% and 72%, respectively. There was no difference in survival between per primum and salvage surgery cohorts.

CONCLUSION

TL is a safe and oncologically sound procedure in patients with laryngeal and hypopharyngeal cancers. A large proportion of patients still undergo TL as a de novo procedure. This denotes that patients still present with locally advanced cancers which are not amenable to organ preservation.

Infectious complications in head and neck surgery: Porto Oncology Centre retrospective analysis

OBJECTIVE

To analyze the impact of infectious complications and microbiology in the postoperative period after major oncologic neck surgeries.

METHODS

A retrospective study conducted in an oncology center, including all the consecutive patients who developed infectious complications after major neck cancer surgery, from October 2012 to May 2016 (44 months). Among other data, we collected TNM stage, ASA score, body mass index, comorbidities and habits, pre and postoperative hemoglobin levels, albumin serum levels, pre-surgical treatments, length of inpatient stay, isolated microbiological agents and the recorded complications and mortality rate.

RESULTS

In the studied period, 761 major neck surgeries were performed. Of these, 96 patients had complications (12.6%). Pharyngocutaneous fistula (PCF) was the most frequent complication (56%) and nosocomial pneumonia was the most common systemic complication (23%). Pseudomonas aeruginosa was the principal microorganism of the 26 species isolated (15%). 12 deaths were registered. Using multiple linear regression we concluded that flap/cutaneous necrosis and PCF were complications with statistical significance that prolonged inpatient stay. The same complications had significant relative risk for more than 30 days of hospitalization.

CONCLUSION

The postoperative period is critical for the successful treatment of head and neck oncology patients. PCF and flap/cutaneous necrosis were the principal complications which worsened the outcomes during this critical period. The early recognition and treatment of these complications is crucial.

Antithrombotic Therapy for Venous Thromboembolism and Prevention of Thrombosis in Otolaryngology–Head and Neck Surgery: State of the Art Review

Objective

The aim of this report is to present a cohesive evidence-based approach to reducing venous thromboembolism (VTE) in otolaryngology–head and neck surgery. VTE prevention includes deep venous thrombosis and pulmonary embolism. Despite national efforts in VTE prevention, guidelines do not exist for otolaryngology–head and neck surgery in the United States.

Data Sources

PubMed/MEDLINE.

Review Methods

A comprehensive review of literature pertaining to VTE in otolaryngology–head and neck surgery was performed, identifying data on incidence of thrombotic complications and the outcomes of regimens for thromboprophylaxis. Data were then synthesized and compared with other surgical specialties.

Conclusions

We identified 29 articles: 1 prospective cohort study and 28 retrospective studies. The overall prevalence of VTE in otolaryngology appears lower than that of most other surgical specialties. The Caprini system allows effective individualized risk stratification for VTE prevention in otolaryngology. Mechanical and chemoprophylaxis (“dual thromboprophylaxis”) is recommended for patients with a Caprini score ≥7 or patients with a Caprini score of 5 or 6 who undergo major head and neck surgery, when prolonged hospital stay is anticipated or mobility is limited. For patients with a Caprini score of 5 or 6, we recommend dual thromboprophylaxis or mechanical prophylaxis alone. Patients with a Caprini score ≤4 should receive mechanical prophylaxis alone.

Implications for Practice

Otolaryngologists should consider an individualized and risk-stratified plan for perioperative thromboprophylaxis in every patient. The risk of bleeding must be weighed against the risk of VTE when deciding on chemoprophylaxis.

Pharyngocutaneous Fistula Incidence After PMMC Patch Pharnygoplasty for Post Laryngectomy Defect Reconstruction - Predictive Factors, Our Experience at KMIO

To analyse pharyngocutaneous fistula, post Pectoralis major myocutaneous patch pharnygoplasty, and its association with various tumor, patient and treatment related factors. It is a retrospective study that included 48 patients who underwent laryngectomy and PMMC patch pharyngeal reconstruction from year 2009 to 2013. We studied the previously reported factors that could influence fistula formation such as age, gender, previous radiotherapy, previous tracheostomy, location of tumor, extent of tumor, tumor volume, tumor stage and surgical margins. Pharyngocutaneous fistula was observed in 13(27.1 %) cases. In 84.6 % (n = 11) patients, fistula closure was achieved by conservative measures. No statistically significant association was found between tumor location, extent and size. There was no association between history of previous tracheostomy and postoperative microscopic margin status. Patients with T4 disease showed increased association (36.7 %) compare to T3 stage (11 %) (p value-0.0362). Postoperatively 6 patients presented with dysphagia out of which 4 patients (66.7 %) had history of leak. It also showed significant increase in post operative stay and delay in oral feeding in fistula patients. There is still no consensus regarding the most significant risk factors, our data showed that, most disease and treatment related parameters were not predictive for fistula occurence. Prabably a larger number of patient cohart need to be analysed for additional information.

[Complications of surgical treatment in patients with laryngeal and hypopharyngeal cancer]

INTRODUCTION

Surgical treatment of patients with laryngeal or/and hypopharyngeal cancer is combined with potential risk of complications either local and general. The aim of the study was to evaluate the occurrence of them in the large cohort of patients with mentioned localization of cancer.

MATERIAL AND METHODS

The group of 447 patients, treated between 2000-2005 in Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin were analyzed retrospectively. There were 412 men and 35 women. 426 patients underwent surgical removal of the tumour without any reconstruction procedure. In 21 (4.7%) patients we performed reconstructions of the pharyngeal defect implementing pectoralis major muscle flap. Complications were classified into general and local. Furthermore, according to the time we classified sequel of the treatment into recent (those during the first 7 days after surgery) and late. Statistical analysis of variables was performed using χ² test.

RESULTS

Uncomplicated treatment were accomplished in 78.6% of patients. Local complications occur in 65 (14.5%) and general in 31 (6.9%) individuals. Pharyngo-cutaneous fistula was the most often occurring local sequel which constituted 50.8% of all local complications. Fistula developed in 33 (7.4%) cases. Cardiovascular and pulmonary diseases were the most often among general complications. They occur at the same rate of 25.8% of all general complications cases. Five patients (1.1%) died due to complications developed during the postoperative period.

CONCLUSIONS

We noticed 10.6% local complications in our group of patients whereas only 2.5% of treated persons developed general sequel. The pharyngo-cutaneous fistula was the most often occurring local complication. It has been treated surgically in 15 (45.5%) patients. Whereas cardiovascular and pulmonary diseases were the most often general complications and they occur in above half of all cases with general complications.

Salvage Surgery following Radiation Failure for Laryngeal Cancer in Elderly Patients

Objective. To find the survival rate of patients ≥80 years old who undergo salvage surgery for squamous cell carcinoma of the larynx.

Study Design. National data registry analysis.

Setting. Seventeen population-based registries comprising the National Cancer Institute’s Surveillance, Epidemiology, and End Results database.

Subjects and Methods. Overall, cancer-specific, and relative survival rates were calculated from 1418 patients, stratified into 3 age cohorts, who underwent surgery following radiation therapy for treatment of laryngeal cancer.

Results. The 1-year overall survival of patients ≥80 years old (n = 57) was 76.1%. The cancer-specific survival at 1 year was 86.4%. These survival rates were significantly less than those of patients <65 years old (n = 869), who had a 1-year overall survival of 88.1% ( P = .006) and cancer-specific survival of 90.5% ( P = .029). Patients aged between 65 and 79 years old (n = 492) displayed 1-year overall survival of 80.7% ( P = .426) and cancer-specific survival of 85.1% ( P = .711), which were not significantly different from the ≥80 year cohort. When comparing relative survival at 5 years, the ≥80-year-old cohort’s survival trended the highest (≥80 years, 62.8%; 65-79 years, 51.3%; 20-64 years, 56.2%).

Conclusion. While patients ≥80 years old have a less favorable prognosis than patients <65 years old, the survival rates of patients ≥80 years old are not significantly different from the 65- to 79-year-old cohort. After controlling for non-cancer-related death, patients ≥80 years old appear to have similar 5-year survival outcomes compared with other patients.

Management of chylous fistula as a complication of neck dissection: a 10-year retrospective review

Chylous fistula is a serious complication of neck surgery. The aim of this study was to analyse the incidence, treatment and evolution of chylous fistula in neck dissection. We conducted a retrospective study of 304 patients, 295 (97.03%) men and nine (2.97%) women. Ages ranged from 24 to 80 years (mean = 59.28 years, SD = 6.02) and they had all undergone neck dissection. Chylous fistula occurred in four cases (1.31%). Incidence was 1.83% in laryngeal cancer and 2.7% in oral cavity and oropharyngeal cancer. No statistically significant correlation was found between tumoral stage and fistula occurrence. Radiotherapy prior to surgery was a risk factor although the association was not statistically significant. The incidence rates for radical and functional neck dissection were 3.3% and 0.46%, respectively, statistically significant (P = 0.042). The fistulas were located on the left side in all cases. One of the four patients required surgical intervention and another one died. The occurrence of chylous fistula increased significantly the length of hospital stay (P = 0.01). Chylous fistulas appear on the left side, radiotherapy prior to surgery is a risk factor and there is not correlation with tumoral stage. Chylous fistulas are significantly more common in radical than in functional dissections and increase significantly the length of hospital stay.

Risk factors for surgical-site infections in head and neck cancer surgery

OBJECTIVE

The aim of this study was to identify risk factors for surgical-site infections (SSIs) in patients with head and neck cancer submitted to major clean-contaminated surgery.

STUDY DESIGN

This is a prospective study conducted in a tertiary cancer center hospital.

SUBJECTS AND METHODS

This study includes 258 patients submitted to a major clean-contaminated head and neck oncologic surgery.

RESULTS

The overall SSI rate was 38.8%. The univariate analysis showed the following significant risk factors: race, tobacco consumption, clinical stage, comorbidities, time duration of the surgical procedure, and flap reconstruction. The final model by logistic regression identified the following independent predictors for SSI: tobacco consumption (odds ratio [OR] = 2.96), presence of metastatic lymph nodes (OR = 2.05), flap reconstruction (OR = 2.20), and antimicrobial prophylaxis exceeding 48 hours (OR=1.89).

CONCLUSION

The high-risk patients for SSI in head and neck oncologic surgery were those with cancer at advanced stages, those who were smokers, those presenting comorbidities, those who needed major reconstruction of the surgical wound, or those who were submitted to inadequate antibiotic prophylaxis.

Sudden death after major head and neck surgery

PURPOSE OF REVIEW

This review will discuss the mortality after major ear, nose and throat surgery, particularly sudden death. It will also discuss the postoperative follow-up of patients.

RECENT FINDINGS

Sudden death is a rare event after major ear, nose and throat surgery, and occurs mainly during the first three postoperative days.

SUMMARY

In more recent studies, the mortality rate after neck dissection was below 4%, which is at a lower value than reported in previous studies. Sudden deaths have been described, however, mainly during the first three postoperative days. Alcoholism and perioperative hypotension are two predictive factors for cardiac complications. Careful follow-up of these patients during the early postoperative period should be performed to reduce the mortality by shortening the delay of care.

Thromboprophylaxis in ENT patients: A national survey

The aim of this survey was to establish whether ENT departments in England follow British Medical Journal guidelines on thromboprophylaxis. A telephone survey of doctors in 80 ENT departments was used to present six clinical scenarios. The participants were asked what their local department routinely did. They were also asked whether they were aware of a local or national thromboprophylaxis policy. For patients undergoing procedures other than major head and neck procedures, compliance was poor and ranged between 7.5% and 37.5%. For laryngectomy, the rate was 82.6%. There was no statistical difference in answers given by doctors of different levels of seniority. Where local thromboprophylaxis guidelines exist, compliance is found to be statistically better. These results suggest that most ENT departments do not follow national or local guidelines on thromboprophylaxis. Greater awareness of existing guidelines is required.

Clinical and biochemical outcomes after a randomized trial with a high dose of enteral arginine formula in postsurgical head and neck cancer patients

OBJECTIVE

Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients, using a higher dose of arginine-enhanced diet (17 g/day) than previous studies, could improve nutritional variables as well as clinical outcomes, when compared with a control enteral diet.

DESIGN

Randomized clinical trial.

SETTING

Tertiary care.

SUBJECTS

A population of 72 patients with oral and laryngeal cancer was enrolled.

INTERVENTIONS

At surgery, patients were randomly allocated to two groups: (a) 35 patients receiving an arginine-enhanced formula with arginine (group I) and (b) 37 patients receiving an isocaloric, isonitrogenous enteral formula (group II).

RESULTS

No significant intergroup differences in the trend of the three plasma proteins (albumin, transferrin, prealbumin) and lymphocytes were detected. Episodes of diarrhea rate were equal in both groups (22.8% group I and 21.6% group II: NS). The postoperative infections complications were equal in both groups (5.7% group I and 5.4% group II: NS). Fistula (wound complication) was less frequent in enriched nutrition group (2.8% group I and 18.9% group II: P<0.05), whereas wound infection was similar in both groups. The length of postoperative stay was similar in both (27.9+/-21 vs 28.2+/-12 days; NS).

CONCLUSIONS

At this dose, arginine-enhanced formula improves fistula rates in postoperative head and neck cancer patients without a high rate of diarrhea.

Cardiovascular and respiratory complications after major head and neck surgery

BACKGROUND

Our aim was to gain insight into the incidence rates for, distribution of, and risk factors of postoperative cardiovascular and respiratory complications in major head and neck surgery.

METHODS

We performed a retrospective review of 469 patients who had undergone primary major head and neck surgery. Outcome measures were incidence rates, risk factors, and distribution over time for postoperative cardiovascular and respiratory complications. A multivariate analysis was performed.

RESULTS

The incidence rates for cardiovascular and respiratory complications were 57 of 469 (12%) and 50 of 469 (11%), respectively. The incidence rate for heart failure exceeded that for pneumonia. The peak incidence for cardiovascular complications was on the first postoperative day; for respiratory complications, on the second postoperative day. Risk factors for cardiovascular complications were age, pulmonary disease, alcohol abuse, and tumor location; risk factors for respiratory complications were pulmonary disease, previous myocardial infarction, and American Society of Anesthesiologists (ASA) grade.

CONCLUSION

In this study, the incidence rates for cardiovascular and respiratory complications were very similar. The first postoperative day was crucial with regard to cardiovascular complications. Age and chronic pulmonary diseases were the common risk factors for cardiovascular and respiratory complications.

A Randomized Clinical Trial with Oral Immunonutrition (ω3-Enhanced Formula vs. Arginine-Enhanced Formula) in Ambulatory Head and Neck Cancer Patients

OBJECTIVE

The aim of our study was to investigate whether oral ambulatory nutrition of head and neck cancer patients, using an omega3 fatty acid-enhanced diet (low ratio omega6/omega3 fatty acids) versus an arginine-enhanced diet, could improve nutritional variables as well as clinical outcome, postoperative infectious and wound complications.

RESEARCH METHODS

A population of 73 ambulatory postsurgical patients with oral and laryngeal cancer were enrolled. At discharge from hospital the postsurgical head and neck cancer patients were asked to consume two units per day of either a specially designed omega3 fatty acid-enhanced supplement (group 1) or an arginine-enhanced supplement (group 2) for a 12-week period.

RESULTS

No significant intergroup differences in the trend of the three serum proteins and lymphocytes were detected. Differences were detected in weight (group 1: 65.5 +/- 11.5 kg vs. 70.4 +/- 11.1 kg; p < 0.05) with a significant increase in fat mass in group 1 (15.4 +/- 6.6 vs. 18.1 +/- 8.4 kg; p < 0.05) and in tricipital skinfold. The postoperative infectious complications were similar in both groups (0 in group 1 and 8.57% in group 2; nonsignificant). No local complications were detected in the surgical wound. Gastrointestinal tolerance (diarrhea and vomiting episodes) of both formulas was good.

CONCLUSIONS

At the dose taken, the omega3-enhanced formula improved fat mass and proteins in ambulatory postoperative head and neck cancer patients. The arginine-enhanced formula improved proteins. Further studies are required to examine the potential role of immune-enhanced supplements.

Prognostic significance of wound infections following major head and neck cancer surgery: an open non-comparative prospective study

OBJECTIVE

We evaluated the incidence, risk factors and consequences of wound infection (WI) following major head and neck cancer surgery in an open non-comparative study.

PATIENTS AND METHODS

The study group, comprising 95 patients who underwent clean-contaminated procedures with opening of the upper aerodigestive tract for biopsy-proven squamous cell cancer, were studied over a 1-year period. Antibiotic prophylaxis was amoxicillin and clavulanic acid. More than 20 variables were prospectively recorded for each patient. The mean follow-up was 30 months.

MAIN RESULTS

The overall WI rate was 50.5% (48/95). Most pathogens isolated from samples were gram-negative rods. In univariate analysis, we found three risk factors for WI: alcohol consumption (P = 0.07), a hypopharyngeal location (P = 0.02) and laryngectomy stoma (P = 0.01). WI were associated with postoperative fever (P = l.5 x 10(-11)), postoperative antibiotic therapy (P = 1.5 x 10(-5)) and postoperative death (P = 0.043). Patients without WI had a median postoperative hospital stay of 15 days compared with 29 days for those with WI (P < 0.001). Healing of WI was achieved after a median time of 48 days. WI delayed postoperative radiation therapy in 21 out of 33 evaluable patients. But overall survival, and local and metastatic failures were similar with and without WI.

CONCLUSIONS

WI are associated with a heavy postoperative morbidity, but have no prognostic impact on cancer control.

[Utility of a omega 3 fatty acids oral enhanced formula in biochemical parameters of head and neck cancer patients]

BACKGROUND AND OBJECTIVE

To investigate the influence of a arginine and omega3 fatty acids enhanced supplement in nutritional variables in postsurgical ambulatory patients with head and neck tumors.

PATIENTS AND METHOD

A population of 18 ambulatory postsurgical patients with oral and laryngeal cancer was studied. At hospital discharge, postsurgical head and neck cancer patients were asked to consume two units per day of a specially designed omega3 fatty acid enhanced supplement for a twelve week period.

RESULTS

Eighteen patients were enrolled in the study. The mean age was 62.5 (11.4) years (1 females/17 males). Duration of supplementation was 90.5 (22) days. Significant increases of serum protein levels and lymphocites were detected. PCR levels decreased after supplementation (71.96 [21.7] md/dl vs 25.9 [11.1] mg/dl; p < 0.05). No differences were detected in weight and other anthropometric parameters. A positive correlation between omega3/omega6 ratio and kg of fat mass (r = 0.59; p < 0.05) and midarm circumference (r = 0.62; p < 0.05) were detected. When the population was divided in two groups, group I (ratio omega3/omega6 < 0.51) and group II (ratio omega3/omega6 > 0.51), group II showed higher fat mass than group I (17.32 [5.3] kg vs 13.8 [5.1] kg; p < 0.05).

CONCLUSIONS

This immuno-enhanced formula could improve serum protein levels and PCR in ambulatory postoperative head and neck cancer patients. An increase in fat mass was detected in patients with a high omega3/omega6 intake of polyunsaturated fatty acids.

Randomized clinical trial with an enteral arginine-enhanced formula in early postsurgical head and neck cancer patients

OBJECTIVE

Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients using an arginine-enhanced formula could improve nutritional variables as well as clinical outcomes.

DESIGN

Randomized clinical trial.

SETTING

Tertiary care.

SUBJECTS

A population of 90 patients with oral and laryngeal cancer was enrolled.

INTERVENTIONS

At surgery, patients were randomly allocated to two groups: (a) patients receiving an arginine-enhanced formula with arginine and fiber (group I) and (b) patients receiving an isocaloric, isonitrogenous formula with fiber enteral formula (group II).

RESULTS

No significant intergroup differences in the trend of the three plasma proteins (albumin, transferrin, prealbumin) and lymphocytes were detected. Gastrointestinal tolerance (diarrhea) was better in group II than I (40% group I and 13% group II: P<0.05). The postoperative complications due to infections were similar in both groups (4% group I and 9% group II: ns). Fistula (wound complication) was less frequent in the enriched nutrition group (5% group I and 11% group II: P<0.05); wound infection was similar in both groups. The length of postoperative stay was better in group I than II (25.8+/-15 days vs 35+/-24.6 days; P<0.05).

CONCLUSIONS

In conclusion, arginine-enhanced formula improves fistula rates in postoperative head and neck cancer patients and decreases length of stay.

Otolaryngologic critical care

In this chapter we have reviewed the complicated medical conditions that exist in many head and neck surgical patients. Common surgical procedures that frequently require postoperative monitoring and several infectious disorders requiring intensive care unit admission were also reviewed. Intensivists need to be familiar with these procedures and diseases. Collaboration with the surgical specialist is required to optimize patient care.

Postsurgery enteral nutrition in head and neck cancer patients

OBJECTIVE

Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients, using an arginine-enriched diet, could improve nutritional variables as well as clinical outcomes.

DESIGN

Randomized clinical trial.

SETTING

Tertiary care.

SUBJECTS

A population of 47 patients with oral and laryngeal cancer were enrolled.

INTERVENTIONS

At surgery patients were randomly allocated to two groups: (a) patients receiving an enteral diet supplemented with arginine and fiber (group I); (b) patients receiving an isocaloric, isonitrogenous enteral formula (group II).

RESULTS

No significant intergroup differences in the trend of the three plasma proteins and lymphocytes were detected. Gastrointestinal tolerance (diarrhea) of both formulas was good (17.4% group I and 8.3% group II; NS). During the 3 months after hospital discharge five patients died; no differences were detected between groups (13% group I and 8.3% group II; NS). The incidences postoperative infection complications were similar (nine patients) in both groups (21.7% group I and 16.7% group II; NS). Fistula were less frequent in enriched nutrition group (0% group I and 20.8% group II; P<0.05); wound infection was more frequent in group II, but without statistical difference (4.3% group I and 12.5% group II; NS). The length of postoperative stay was 22.8+/-11.8 days in the enriched group and 31.2+/-19.1 days in the control group (P=0.07).

CONCLUSIONS

In conclusion, enriched formula improves local wound complications in postoperative head and neck cancer patients. Our results suggest that these patients could benefit from an immunonutrient-enhanced enteral formula.

[Comparative study of the use of manual and mechanical suturing in the closure of the mucosal defect in total laryngectomy]

With the present study we try to achieve an objective confirmation of the efficacy given by the mechanical suture in the closing of the pharyngeal defect following a total laryngectomy against the conventional manual suture with absorbable material. Therefore we have studied three random groups of patients: in the first one we include those who had a manual suture (n = 50), in the second one those who had performed a mechanical suture with closed technique (n = 38) and in the third one those who had a mechanical suture with an open technique (n = 12). We have checked that mechanical suture with a closed technique improves significantly the surgical length (212 minutes), the beginning of the oral feeding (10.73 days) and the time of in-hospital stay (13.5 days). Mechanical sutures with a closed technique also reduce the rate of complications such as fistulae (5.26%), infection (0%) and haemorrhage (0%).

Sudden death after neck dissection for cancer

The goal of this study was to analyze the mortality data following neck dissection and determine the risk factors of early death. The hospital mortality records were analyzed from 3,015 consecutive patients who underwent neck dissection. A case control study analyzed risk factors of death during the first 3 postoperative days. The mortality incidences were 0.50% and 1.33%, respectively, during the first 3 and the first 30 postoperative days. Eleven of the 12 unexplained deaths occurred during the first 3 postoperative days, and most of these patients died suddenly. They were more likely to be alcoholic and to have undergone nerve section. In most of the patients who died after the third postoperative day, death was related to a postoperative complication. Although the mechanisms of sudden death remain unclear, careful follow-up of these patients during the early postoperative days should be performed to reduce the mortality risk by shortening the delay of care.

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

BACKGROUND

Malnourished head and neck cancer patients are at increased risk of postoperative complications.

OBJECTIVE

We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss >10% of body weight) head and neck cancer patients undergoing major surgery.

DESIGN

Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding.

RESULTS

Patients in both prefed groups received approximately 9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1, 2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor alpha and P = 0.042 for interleukin 6) at the start of the study than did patients who died.

CONCLUSIONS

Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses.

Complications after Total Laryngectomy in Nonradiated Laryngeal and Hypopharyngeal Carcinomas

To study the complications of total laryngectomy, we evaluated 471 previously untreated patients who underwent total laryngectomy between 1980 and 1997. This series consisted of 358 patients with primary carcinoma of the larynx and 113 with carcinoma of the hypopharynx. Concurrent neck dissection was performed in 85% of patients. Complications were studied in relation to age, T and N stage, previous tracheostomy, neck dissection, margins, reconstruction, tracheoesophageal puncture, and surgeon. Complication treatment and hospitalization were also evaluated. The overall complication rate was 30.7%, with 29.2% major and 6.5% minor complications. The mortality rate was 0.6% (3/471). Pharyngocutaneous fistula was the most frequent wound complication (21%), followed by wound infection (4.2%) and hemorrhage (2.3%). Pneumonia (1.4%) and embolism (0.4%) were the most frequent medical complications. Hypopharyngeal tumors, neck dissection, and extended procedures had a significantly higher rate of complications. Complication causes, prevention, and treatment are discussed.

Radiotherapy in head and neck cancer in the elderly: a challenge

Elderly patients represent the most rapidly growing subgroup of the patient population in France and in the majority of industrialized countries. The effect of age in terms of the prognosis and response to treatment remains unclear. The management strategy (curative versus palliative) for head and neck cancer in the elderly has given vent to divergent opinions and controversies in several respects (the type and quality of treatment, quality of life and economic consequences). This review only focuses on the radiotherapy schedule and head and neck cancers. We compare aged patients with head and neck cancer to younger patients in terms of clinical features, tumor biology, type of treatment, side effects and response. We conclude that if the patient is in a good general condition following a complete evaluation of the cancer, physicians should propose curative treatment with radiotherapy because retrospective trials demonstrate that response in older patients when treated aggressively is comparable to that of younger patients. However, specific trials concerning aged patients with head and neck cancer, quality of life and radiotherapy are warranted.

Salvage treatment for recurrent squamous cell carcinoma of the oral cavity

BACKGROUND

Squamous cell carcinoma (SCCA) of the oral cavity recurs with a frequency of 25%-48%, a fact that usually portends a poor prognosis. Recent studies have reported salvage cure rates as high as 67%. Investigators have also claimed that restaging recurrent tumors provides useful prognostic information, although this has not been demonstrated with tumors of the oral cavity. The purposes of this study were: (1) to report the patterns of recurrent SCCA of the oral cavity; (2) to examine the benefit of restaging oral cavity tumors, and (3) to compare different treatment modalities in the management of recurrent SCCA of the oral cavity. Materials and Methods Thirty-eight patients who developed recurrent SCCA of the oral cavity were reviewed. Salvage treatment consisted of surgery, chemotherapy, radiation therapy, or a combination of these modalities. Survival analysis was based on the stage of the primary and recurrent tumors and the type of salvage treatment received.

RESULTS

The overall recurrence rate was 28%. Local recurrence was most common (58%) followed by locoregional (27%) and regional recurrence (16%). Patients who recurred more than 6 months after completion of their primary treatment had improved survival compared with those who recurred within 6 months of initial treatment. Individuals with stage I-II primary tumors had significantly improved salvage time and total survival time compared with those with stage III-IV primary tumors (p < 0.005 and p < 0.001). Conversely, the stage of the recurrent tumor was not predictive of either improved salvage time or total survival time. Patients who underwent salvage surgery had significantly improved salvage time and total survival time compared with those who received chemotherapy and/or radiation therapy (p < 0.001 and p < 0.002). The overall salvage cure rate was 21%. Neither the stage of the primary or recurrent tumors nor the type of salvage treatment received significantly correlated with an improved cure rate. However, the group of patients who underwent salvage surgery approached a statistically significant improvement in cure rate (p = 0.08).

CONCLUSIONS

Squamous cell carcinoma of the oral cavity is most likely to recur at the primary site. The stage of the primary tumor is significantly correlated with survival even after recurrence, but the stage of the recurrent tumor is not significantly correlated with survival. Patients most likely to benefit from retreatment are those who (1) have primary tumors stage I-II, (2) recur greater than 6 months after their initial treatment, and (3) develop recurrences that are amenable to salvage surgery.

Montgomery salivary bypass tube in the reconstruction of the hypopharynx. Cost-benefit study

This study analyzes the postoperative complications and the functional results in 61 patients who underwent total laryngectomy with partial or total (circumferential) pharyngectomy reconstructed with a pectoralis major myocutaneous flap, in relation to the use of the Montgomery Salivary Bypass Tube (MSBPT). There were no significant differences regarding frequency of postoperative cervical complications in relation to the use of the MSBPT. The median hospital stay for patients without the MSBPT (36 days) was significantly higher than that for patients with the MSBPT (25 days). Although the MSBPT did not modify the rate of complications at the cervical level, it did reduce their severity. A financial study showed the cost-effectiveness of using the MSBPT. Systematic use of the MSBPT is recommended after total laryngectomy with partial or total pharyngectomy reconstructed with a pectoralis major myocutaneous flap.

Postlaryngectomy pharyngocutaneous fistula: incidence, predisposing factors, and therapy

BACKGROUND

Pharyngocutaneous fistula is the most common complication following total laryngectomy. The present study was designed to determine the incidence and predisposing factors and to describe the management of the complication.

METHODS

The records of 246 consecutive patients who underwent total laryngectomy for squamous cell carcinoma were reviewed. We evaluated 23 factors potentially predisposing to fistula formation (age, sex, smoking and drinking habits, hypertension, diabetes, chronic bronchitis, chronic congestive heart failure, anesthesiologic risk, cholinesterase level, pre- and postoperative hemoglobin and albumin levels, previous treatment, previous tracheotomy, site of origin of the tumor, surgical procedure, concurrent neck dissection, suture material, status of surgical margins, clinical stage, and histologic grade) using the chi-squared test and logistic regression analysis.

RESULTS

A pharyngocutaneous fistula developed in 16% of patients within a mean time of 11 days from surgery. Spontaneous closure with local wound care was achieved in 70% of cases. Ten patients required surgical closure by direct suture of the pharyngeal mucosa; a deltopectoral flap and a pectoralis major myocutaneous flap were used in one case each. The mean healing time was 39+/-46 days in the group of patients requiring surgical closure, compared with 19+/-12 days in the group in which spontaneous closure occurred. The definitive model of logistic regression analysis showed that pharyngolaryngectomy, chronic congestive heart failure, and postoperative hemoglobin level lower than 12.5 g/dL carried respectively a two-, five-, and ninefold increase in the risk of fistula development. The model, with a specificity of 81%, is fairly good in identifying patients with a low risk of fistula.

CONCLUSIONS

The results observed in the group of patients under analysis corroborated the relevance of factors such as the extension of laryngectomy and postoperative hemoglobin level on fistula occurrence. However, chronic congestive heart failure, which is an expression of disturbance of the organism, emerged for the first time as an additional statistically significant risk factor for pharyngocutaneous fistula formation. Our experience confirmed that most fistulas can be successfully managed with conservative treatment. Except for the rare cases in which large defects are present, direct suture is appropriate when conservative treatment has failed.

Critical care for the severely ill head and neck patient

OBJECTIVE

To delineate the frequency and causes of admission to a critical care environment for patients undergoing head and neck surgery at Memorial Sloan-Kettering Cancer Center.

DESIGN

Retrospective clinical investigation.

SETTING

Adult intensive care unit of a tertiary referral cancer center.

PATIENTS

All head and neck surgery patients admitted to the special care unit (SCU) of Memorial Sloan-Kettering Cancer Center between January 1, 1994 and December 31, 1995 were included in this study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The data collected included demographic, operative procedures, clinical, laboratory, and physiologic variables at time of SCU admission, at 24 hrs, as well as vital status at the time of discharge from the SCU and hospital. Other data collected were the need for mechanical ventilation and inotropic agents. During the period of January 1, 1994 through December 31, 1995, 37 (1.5%) of 2,346 patients undergoing head and neck surgical procedures required admission to the SCU. During the same period, six patients receiving medical treatment only for head and neck malignant disease were transferred to the SCU. These 43 admissions served as the basis for the study. The causes of admission to the SCU were pulmonary (15/43), cardiac (14/43), wound related (8/43), and other (15/43). The median length of stay in the SCU was 2 days, and the median hospitalization for patients requiring critical care services was 22 days. Seventy-four percent of patients requiring critical care services were eventually discharged to home.

CONCLUSIONS

Current preoperative evaluation, operative and anesthetic techniques, and perioperative care result in a low frequency of utilization of critical care services by patients undergoing head and neck surgery. There is no single identifiable cause of complications for patients after head and neck surgery leading to utilization of critical care services.

Common surgical procedures

This article illustrates some common surgical procedures. Radiologists and other physicians frequently see patients who have had one or more of these operations. We hope to illustrate with drawings and radiographs the basic purpose of the procedures and the relevant anatomy. This is not intended to illustrate or discuss the actual surgical techniques. Our intention is to illustrate one generally accepted way of performing a given type of surgical procedure. For many of these operations, there may be multiple other techniques to accomplish the same result for the patient. Some of the illustrations and text in this monograph were originally published in Radiologic Guide to Medical Devices and Foreign Bodies, edited by T.B. Hunter and D.G. Bragg, St. Louis: Mosby-Year Book, 1994.

Oral health care for the cancer patient

Orofacial complications are common after radiotherapy to the head and neck, and after chemotherapy for malignant disease. Mucositis is the most frequent and often most distressing complication, but adverse reactions can affect all other orofacial tissues. This paper discusses the aetiopathogenesis and current means available for preventing, ameliorating and treating these complications, as well as indicating research directions.

Mortality and morbidity with intraoperative radiotherapy for head and neck cancer

OBJECTIVE

To critically evaluate the morbidity and mortality associated with intraoperative radiation therapy (IORT). IORT allows the delivery of large single-doses of radiation to a visible tumor bed with exclusion (or shielding) of critical normal structures from the treatment field. Morbidity and mortality associated with IORT has been directly studied in abdominal malignancies, but only briefly mentioned in the head and neck literature.

PATIENTS AND METHODS

At the Arthur G. James Cancer Hospital, The Ohio State University Medical Center, 53 patients with advanced head and neck cancer were treated with surgical resection and IORT. Twenty of these patients had intraoperative high-dose-rate (HDR) brachytherapy, whereas the remaining 33 received intraoperative electron beam therapy. All patients received 7.5 to 20 Gy of radiation. Those treated were reviewed evaluating perioperative mortality, major and minor complications, and length of hospital stay. All patients have been followed at least 3 months postoperatively.

RESULTS

There were no perioperative deaths. Additionally, there was no increase in the number of complications or length of hospital stay associated with the use of IORT. The mean length of hospital stay was 13.0 days. The major complication rate was 16.8%. Of the major complications, 9% were medical and not related to the surgical site. The minor complication rate was 8%.

CONCLUSION

As we strive to increase control of advanced head and neck cancer, IORT may play an exciting role for intensifying the therapy. At this institution, IORT did not add to the mortality or morbidity of an aggressive multimodality treatment schema.

Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery

OBJECTIVE

Internists frequently evaluate preoperative cardiopulmonary risk and co-manage cardiac and pulmonary complications, but the comparative incidence and clinical importance of these complications are not clearly delineated. This study evaluated incidence and length of stay for both cardiac and pulmonary complications after elective laparotomy.

DESIGN

Nested case-control.

SETTING

University-affiliated Department of Veterans Affairs Hospital.

PATIENTS

Computerized registry of all 2,291 patients undergoing elective abdominal operations from 1982 to 1991.

MEASUREMENT AND MAIN RESULTS

Strategy for ascertainment and verification of complications was systematic and explicit. The charts of all 116 patients identified by the registry as having complications and 412 (19%) randomly selected from 2,175 remaining patients were reviewed to verify presence or absence of cardiac or pulmonary complications, using explicit criteria and independent abstraction of pre- and postoperative components of charts. From these 528 validated cases and controls (23% of the cohort), 96 cases and 96 controls were matched by operation type and age within ten years. Hospital and intensive care unit stays were significantly longer (p < 0.0001) for the cases than for the controls (24.1 vs 10.3 and 5.6 vs 1.5 days, respectively). All 19 deaths occurred among the cases. Among the cases, pulmonary complications occurred significantly more often than cardiac complications (p < 0.00001) and were associated with significantly longer hospital stays (22.7 vs 10.4 days, p = 0.001). Combined cardiopulmonary complications occurred among 28% of the cases. Misclassification-corrected incidence rates for the entire cohort were 9.6% (95% CI 7.2-12.0) for pulmonary and 5.7% (95% CI 3.6-7.7) for cardiac complications.

CONCLUSIONS

For noncardiac surgery, previous research has focused on cardiac risk. In this study, pulmonary complications were more frequent, were associated with longer hospital stay, and occurred in combination with cardiac complications in a substantial proportion of cases. These results suggest that further research is needed to fully characterize the clinical epidemiology of postoperative cardiac and pulmonary complications and better guide preoperative risk assessment.

Salvage laryngectomy for unsuccessful larynx preservation therapy

From 1983 to 1991, 31 patients underwent salvage laryngectomy for persistent or recurrent squamous carcinoma of the larynx (14), hypopharynx (15), or oropharynx (2) as part of a larynx preservation protocol. Laryngectomy was performed as a consequence of poor response to induction chemotherapy in 13 and for recurrent disease after completion of chemotherapy and irradiation in 18. Postoperative pharyngocutaneous fistula occurred in 39%, resulting in prolonged hospitalization. Local control was achieved in 68%, more often in patients with laryngeal as opposed to nonlaryngeal primaries (86% versus 53%; p = .05). The overall actuarial survival and disease-specific survival at 2 years were 32% and 38%, respectively. Disease-specific survival at 2 years was better in patients with laryngeal as compared to nonlaryngeal primaries (56% versus 24%; p = .02). There were no long-term survivors among the nonlaryngeal primary patients. In selected patients in whom larynx preservation failed, salvage laryngectomy was associated with acceptable local control and survival. Palliation was obtained in patients who were not cured by their laryngectomy. Future investigation will focus on identification of factors predicting complications and strategies to reduce the incidence and severity.

Vascularized free-tissue transfer in head and neck surgery

Microsurgical vascularized free-tissue transfer has had a dramatic impact on the field of head and neck reconstruction. This technique has extended the extirpative limits of resection by facilitating complex reconstruction of head and neck defects in one stage with very high success and minimal patient morbidity. Although its impact on improving cure rates and survival statistics has yet to be determined, it has proven very valuable in the palliation of patients with advanced malignancies. The horizons for future applications are infinite. Neurotization of free-flap transfer may potentially improve the functional outcome for patients. In the future, free flaps may be prefabricated to allow for improved mandibular reconstruction or tracheal reconstruction. These tissue composites may potentially be a vehicle through which adjuvant therapy can be better delivered to the tumor bed. Microsurgical free-tissue transfer will have an expanding role in the treatment of patients with head and neck tumors, and continued refinements in these techniques will open new vistas for the reconstructive surgeons in the future.

Communication status following laryngectomy: the Iowa experience 1984-1987

Data regarding treatment and outcome for a consecutive series of 73 total laryngectomy patients were collected from clinical records with a follow-up period of 30 to 78 months postoperatively. Notable findings were that 27% were women; 75% reported hoarseness or a voice change as an early symptom; and 22% reported combined heavy use of both cigarettes and alcohol. Of the 73 patients, 38 (52%) died during the follow-up period; 18 of the 38 died within 1 year postoperatively. Thirty-nine (53%) of the 73 had received a surgical tracheoesophageal fistula (TEF) for voice restoration, as either a primary or a secondary procedure. Of the 39, 75% were using the TEF at last examination, with no failures attributed to sphincter spasm. Of the total group, the primary communication modality was reported to be use of a TEF by 44% and use of an electrolarynx by 50%. Limitations of the study and directions for future investigations are discussed.