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Evaluating Unplanned Returns to the Operating Room in Head and Neck Free Flap Patients

  • Samantha Tam
  • Randal S. Weber
  • Jun Liu
  • Jose Ting
  • Summer Hanson
  • Carol M. LewisEmail author
Head and Neck Oncology
  • 22 Downloads

Abstract

Background

Head and neck oncologic surgery with reconstruction represents one of the most complex operations in otolaryngology. Unplanned return to the operating room represents an objective measure of postoperative complications. The purpose of this study was to identify reasons and risk factors for unplanned return to the operating room in patients undergoing head and neck surgery with reconstruction.

Methods

This retrospective cohort study of 467 patients undergoing head and neck surgery with free flap reconstruction used a previously-developed Head and Neck-Reconstructive Surgery-specific National Surgical Quality Improvement Program. Disease and site-specific preoperative, intraoperative, and postoperative data were gathered. Comparisons between those with and without an unexpected return to the operating room were completed with univariate and multiple logistic regression models.

Results

The rate of unexpected return to the operating room was 18.8% (88 patients). Most common reasons for URTOR were flap compromise (24 patients, 5.1%), postoperative infection (21 patients, 4.5%), and hematoma (20 patients, 4.3%). Two risk factors were identified by multivariate analysis: coagulopathy (ORadjusted = 2.83, 95% CI = 1.24–6.19, P = 0.010), and use of alcohol (ORadjusted = 1.9, 95% CI = 1.14–3.33, P = 0.025).

Conclusions

Preexisting coagulopathy and increased alcohol consumption were associated with increased risk of unexpected return to the operating room. These findings can aid physicians in preoperative patient counseling and medical optimization and can inform more precise risk stratification of patients undergoing head and neck surgery with reconstruction. Strategies to prevent and mitigate unexpected returns to the operating room will improve patient outcomes, decrease resource utilization, and facilitate successful integration into alternative payment models.

Notes

Funding

None

Disclosures

Samantha Tam, Randal S. Weber, Jun Liu, Jose Ting, Summer Hanson, and Carol M. Lewis declare that they have no conflict of interest.

Supplementary material

10434_2019_7675_MOESM1_ESM.docx (23 kb)
Supplementary material 1 (DOCX 22 kb)

References

  1. 1.
    Weber RS, Lewis CM, Eastman SD, et al. Quality and performance indicators in an academic department of head and neck surgery. Arch Otolaryngol Head Neck Surg. 2010;136(12):1212–1218.CrossRefGoogle Scholar
  2. 2.
    Lewis CM, Monroe MM, Roberts DB, Hessel AC, Lai SY, Weber RS. An audit and feedback system for effective quality improvement in head and neck surgery: can we become better surgeons? Cancer. 2015;121(10):1581–1587.CrossRefGoogle Scholar
  3. 3.
    Khuri SF, Daley J, Henderson W, et al. The national veterans administration surgical risk study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg. 1995;180(5):519–531.Google Scholar
  4. 4.
    Khuri SF, Daley J, Henderson W, et al. The Department of veterans affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA surgical quality improvement program. Ann Surg. 1998;228(4):491–507.CrossRefGoogle Scholar
  5. 5.
    Prasad KG, Nelson BG, Deig CR, et al. ACS NSQIP risk calculator: an accurate predictor of complications in major head and neck surgery? Otolaryngol Head Neck Surg. 2016;155(5):740–742.CrossRefGoogle Scholar
  6. 6.
    Schneider AL, Deig CR, Prasad KG, et al. Ability of the national surgical quality improvement program risk calculator to predict complications following total laryngectomy. JAMA Otolaryngol Head Neck Surg. 2016;142(10):972–979.CrossRefGoogle Scholar
  7. 7.
    Arce K, Moore EJ, Lohse CM, Reiland MD, Yetzer JG, Ettinger KS. The American college of surgeons national surgical quality improvement program surgical risk calculator does not accurately predict risk of 30-day complications among patients undergoing microvascular head and neck reconstruction. J Oral Maxillofac Surg. 2016;74(9):1850–1858.CrossRefGoogle Scholar
  8. 8.
    Bur AM, Brant JA, Mulvey CL, et al. Association of clinical risk factors and postoperative complications with unplanned hospital readmission after head and neck cancer surgery. JAMA Otolaryngol Head Neck Surg. 2016;142(12):1184–1190.CrossRefGoogle Scholar
  9. 9.
    Birkmeyer JD, Shahian DM, Dimick JB, et al. Blueprint for a new American college of surgeons: national surgical quality improvement program. J Am Coll Surg. 2008;207(5):777–782.CrossRefGoogle Scholar
  10. 10.
    Lewis CM, Aloia TA, Shi W, et al. Development and feasibility of a specialty-specific national surgical quality improvement program (NSQIP): the head and neck-reconstructive surgery NSQIP. JAMA Otolaryngol Head Neck Surg. 2016;142(4):321–327.CrossRefGoogle Scholar
  11. 11.
    Halle M, Eriksson BO, Docherty Skogh AC, Sommar P, Hammarstedt L, Gahm C. Improved head and neck free flap outcome-effects of a treatment protocol adjustment from pre- to postoperative radiotherapy. Plast Reconstr Surg Global Open. 2017;5(3):e1253.CrossRefGoogle Scholar
  12. 12.
    Benatar MJ, Dassonville O, Chamorey E, et al. Impact of preoperative radiotherapy on head and neck free flap reconstruction: a report on 429 cases. J Plast Reconstr Aesthet Surg. 2013;66(4):478–482.CrossRefGoogle Scholar
  13. 13.
    Chen Y, Cao W, Gao X, et al. Predicting postoperative complications of head and neck squamous cell carcinoma in elderly patients using random forest algorithm model. BMC Med Inform Decis Mak. 2015;15:44.CrossRefGoogle Scholar
  14. 14.
    Birkmeyer JD, Hamby LS, Birkmeyer CM, Decker MV, Karon NM, Dow RW. Is unplanned return to the operating room a useful quality indicator in general surgery? Arch Surg (Chicago, Ill: 1960). 2001;136(4):405–411.CrossRefGoogle Scholar
  15. 15.
    Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy antithrombotic therapy and prevention of thrombosis, 9th edn: American college of chest physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):e326S–e350S.CrossRefGoogle Scholar
  16. 16.
    Ligh CA, Nelson JA, Wink JD, et al. An analysis of early oncologic head and neck free flap reoperations from the 2005–2012 ACS-NSQIP dataset. J Plast Surg Hand Surg. 2016;50(2):85–92.CrossRefGoogle Scholar
  17. 17.
    Cannady SB, Hatten KM, Bur AM, et al. Use of free tissue transfer in head and neck cancer surgery and risk of overall and serious complication(s): an American College Of Surgeons-National Surgical Quality Improvement Project analysis of free tissue transfer to the head and neck. Head Neck. 2017;39(4):702–707.CrossRefGoogle Scholar
  18. 18.
    Jung MK, Callaci JJ, Lauing KL, et al. Alcohol exposure and mechanisms of tissue injury and repair. Alcohol Clin Exp Res. 2011;35(3):392–399.CrossRefGoogle Scholar
  19. 19.
    Radek KA, Ranzer MJ, DiPietro LA. Brewing complications: the effect of acute ethanol exposure on wound healing. J Leukoc Biol. 2009;86(5):1125–1134.CrossRefGoogle Scholar
  20. 20.
    Trevejo-Nunez G, Kolls JK, de Wit M. Alcohol use as a risk factor in infections and healing: a clinician’s perspective. Alcohol Res 2015;37(2):177–184.Google Scholar
  21. 21.
    Eliasen M, Gronkjaer M, Skov-Ettrup LS, et al. Preoperative alcohol consumption and postoperative complications: a systematic review and meta-analysis. Ann Surg. 2013;258(6):930–942.CrossRefGoogle Scholar
  22. 22.
    Tonnesen H, Petersen KR, Hojgaard L, et al. Postoperative morbidity among symptom-free alcohol misusers. Lancet (London, Engl). 1992;340(8815):334–337.CrossRefGoogle Scholar
  23. 23.
    van Rooijen S, Carli F, Dalton SO, et al. Preoperative modifiable risk factors in colorectal surgery: an observational cohort study identifying the possible value of prehabilitation. Acta Oncol. 2017;56(2):329–334.CrossRefGoogle Scholar
  24. 24.
    Santoro L, Tagliabue M, Massaro MA, et al. Algorithm to predict postoperative complications in oropharyngeal and oral cavity carcinoma. Head Neck. 2015;37(4):548–556.CrossRefGoogle Scholar
  25. 25.
    Shah S, Weed HG, He X, Agrawal A, Ozer E, Schuller DE. Alcohol-related predictors of delirium after major head and neck cancer surgery. Arch Otolaryngol Head Neck Surg. 2012;138(3):266–271.CrossRefGoogle Scholar
  26. 26.
    Gueret G, Bourgain JL, Luboinski B. Sudden death after major head and neck surgery. Current. 2006;14(2):89–94.Google Scholar
  27. 27.
    BuSaba NY, Schaumberg DA. Predictors of prolonged length of stay after major elective head and neck surgery. Laryngoscope. 2007;117(10):1756–1763.CrossRefGoogle Scholar
  28. 28.
    Tonnesen H, Rosenberg J, Nielsen HJ, et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ (Clin Res ed). 1999;318(7194):1311–1316.CrossRefGoogle Scholar
  29. 29.
    Tonnesen H, Nielsen PR, Lauritzen JB, et al. Smoking and alcohol intervention before surgery: evidence for best practice. Br J Anaesth. 2009;102(3):297–306.CrossRefGoogle Scholar
  30. 30.
    Asher SA, White HN, Kejner AE, Rosenthal EL, Carroll WR, Magnuson JS. Hemorrhage after transoral robotic-assisted surgery. Otolaryngol Head Neck Surg. 2013;149(1):112–117.CrossRefGoogle Scholar
  31. 31.
    Kraft CT, Bellile E, Baker SR, et al. Anticoagulant complications in facial plastic and reconstructive surgery. JAMA Facial Plast Surg. 2015;17(2):103–107.CrossRefGoogle Scholar
  32. 32.
    Urken ML, Weinberg H, Buchbinder D, et al. Microvascular free flaps in head and neck reconstruction Report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg. 1994;120(6):633–640.CrossRefGoogle Scholar
  33. 33.
    Blackwell KE. Unsurpassed reliability of free flaps for head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1999;125(3):295–299.CrossRefGoogle Scholar
  34. 34.
    Corbitt C, Skoracki RJ, Yu P, Hanasono MM. Free flap failure in head and neck reconstruction. Head Neck. 2014;36(10):1440–1445.Google Scholar
  35. 35.
    Clemens MW, Hanson SE, Rao S, Truong A, Liu J, Yu P. Rapid awakening protocol in complex head and neck reconstruction. Head Neck. 2015;37(4):464–470.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Samantha Tam
    • 1
  • Randal S. Weber
    • 1
  • Jun Liu
    • 2
  • Jose Ting
    • 1
  • Summer Hanson
    • 2
  • Carol M. Lewis
    • 1
    Email author
  1. 1.Department of Head and Neck Surgery, Division of SurgeryThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of Plastic and Reconstructive Surgery, Division of SurgeryThe University of Texas MD Anderson Cancer CenterHoustonUSA

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