RESUMEN
The British Association of Oral and Maxillofacial Surgery is soon to implement the Quality Outcomes in Oral in Maxillofacial Surgery (QOMS) to provide a platform for quality management across the specialty in the UK. The initial oncology and reconstruction audits for QOMS involves data collection on specific procedures and metrics. The aim of this report is to determine their appropriateness using extant audit datasets in our institution that overlap substantially with the QOMS audits. Pre-existing datasets comprising information on patients treated for oral cavity SCC with curative intent were analysed. Data on surgical margins, lymphadenectomy lymph node yield, delay between surgery and adjuvant radiotherapy, duration of hospital stay, and complications including flap failures were analysed. All statistical analyses were performed with SPSS 25. Run charts describing longitudinal data were generated using SPC for Excel version 6. Twenty three patients (3.1%) of 701 resections had a positive surgical margin reported. Seventeen (4.3%) of patients had less than 18 LNs in the ND specimen analysed. Mean time to start date of adjuvant therapy was 62 days. Only 9% of patients commenced adjuvant therapy within 6 weeks. The median duration of stay was 18 days. In 1153 free flaps a failure rate of 4.3% was identified. A total of 1349 complications (CD I-V) were recorded in the 1111 patients undergoing major surgery with free flap reconstruction. The QOMS selected metrics for oncology and reconstruction are clinically relevant, readily measurable, and likely to be actionable by the surgical team.
Asunto(s)
Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Benchmarking , Humanos , Cirujanos Oromaxilofaciales , Estudios Retrospectivos , Reino UnidoRESUMEN
Complete tumour resection (R0 margin) is an axiom of surgical oncology. Oral cancer ablation is challenging, due to anatomical, functional, and aesthetic considerations. R0 margin is strongly linked to better survival outcomes with great variation in the R0 % across units. This is commonly attributed to disease biology. Without disputing the importance of biological characteristics, we contend that image-based anatomical surgical planning has an important role to play in achieving complete resection. Here, we present our approach utilising cross-sectional imaging, anatomical characteristics and spatial awareness in planning resections for floor of mouth (FOM) and oral tongue cancers. We highlight the challenge of controlling the deep tumour margin lingual to mandible due to anterior vector constraints and emphasise the importance of resecting the genial muscles in a planned fashion and that any rim resection should be obliquely sagittal. In resecting lateral FOM tumours, assessing extension to the parapharyngeal fat is crucial; and mandibular rim resection at a sagittal plane below the mylohyoid line is often required. Assessing the proximity of the contralateral neurovascular pedicle, pre-epiglottic space and hyoid bone are crucial parameters to determine the extent of tongue tumour resection. Our cohort included 173 patients with FOM SCC and 299 patients with tongue SCC. Six patients (3.5%) from the FOM group and eight patients (3%) from the tongue group had involved (R1) margins following surgery. This was associated with local relapse (p<0.05). In conclusion, we demonstrate that image-based planning can aid achieving R0 resections and reduce disease relapse.
Asunto(s)
Neoplasias de Cabeza y Cuello , Neoplasias de la Lengua , Estética Dental , Humanos , Suelo de la Boca/diagnóstico por imagen , Suelo de la Boca/patología , Suelo de la Boca/cirugía , Recurrencia Local de Neoplasia/patología , Estadificación de Neoplasias , Lengua/diagnóstico por imagen , Lengua/patología , Lengua/cirugía , Neoplasias de la Lengua/diagnóstico por imagen , Neoplasias de la Lengua/patología , Neoplasias de la Lengua/cirugíaRESUMEN
Our aims were to determine the prevalence and association of postoperative delirium (POD) in head and neck (H&N) cancer patients undergoing free flap reconstruction at the oral and maxillofacial surgery (OMFS) unit, Queen Elizabeth University Hospital (QEUH) Glasgow, and to assess whether these determinants can be modified to optimise patient care and reduce the occurrence of POD. Delirium remains an important problem in the postoperative care of patients undergoing major H&N surgery, and early detection and management improve overall outcomes. The patient database containing details of the preoperative physical status (including alcohol misuse, chronic comorbidity, and physiological status) of 1006 patients who underwent major H&N surgery with free-flap repair at the QEUH from 2009-2019, was analysed. Factors associated with delirium were studied, identifying univariate associations as well as multivariate models to determine independent risk factors. The incidence of POD was 7.5% (75/1006; 53 male:22 female; mean (SD) age 65.41 (13.16) years). POD was strongly associated with pre-existing medical comorbidities, excess alcohol, smoking, a prolonged surgical operating time (more than 700 minutes), tracheostomy, blood transfusion, and bony free flaps. Those with POD were at an increased risk of postoperative wound and lung complications, and were more likely to require a hospital stay of more than 21 days. Presurgical assessment should identify risk factors to optimise the diagnosis and treatment of POD, and will enhance patient care by reducing further medical and surgical complications, and overall hospital stay.
Asunto(s)
Delirio , Colgajos Tisulares Libres , Neoplasias de la Boca , Anciano , Delirio/epidemiología , Delirio/etiología , Femenino , Humanos , Masculino , Neoplasias de la Boca/epidemiología , Neoplasias de la Boca/cirugía , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Escocia/epidemiologíaRESUMEN
Postoperative prognostic stratification using the Union for International Cancer Control (UICC) TNM 8th edition staging rules (UICC 8) may identify additional groups of patients who could benefit from adjuvant radiotherapy. Currently, selection for such treatment is not based on all known prognostic factors, and their relative importance may vary depending on the overall risk category. The objective of this study therefore was to evaluate these possibilities. We retrospectively studied 644 patients who had surgery with curative intent for oral squamous cell carcinoma (OSCC) between March 2006 and February 2017. The outcomes of interest were disease-specific survival (DSS) and locoregional recurrence (LRR). Patients were re-staged according to the UICC 8 staging rules. Putative clinical and pathological prognostic variables were evaluated and hazard ratios estimated. Regression analysis was done to identify independent prognostic factors, and iterative analyses identified clinically-relevant risk categories with a minimum of residual prognostic variables. The significance of recognised pathological prognostic factors differed according to the overall risk category. An intermediate risk group comprising patients with pN1 disease as well those with pT3 disease solely on the basis of a depth of invasion (DOI) of more than 10 mm, was identified. A trial to evaluate the benefit or otherwise of adjuvant radiotherapy in this group is now required. Individual prognostic risk factors should be considered within the context of the overall risk category in patients with OSCC.
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Carcinoma de Células Escamosas , Neoplasias de la Boca , Carcinoma de Células Escamosas/cirugía , Humanos , Neoplasias de la Boca/cirugía , Recurrencia Local de Neoplasia , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Medición de RiesgoRESUMEN
Depth of invasion is an important predictor of survival. A study by the International Consortium (ICOR) for Outcome Research proposed incorporation of it (together with the greatest surface dimension, or the anatomical criteria, or both) into the T stage. This has been adopted in part by the 8th edition of the Union for International Cancer Control (UICC) TNM 8 classification of malignant tumours for oral squamous cell carcinoma (SCC). Our aim was to verify depth of invasion as an independent prognostic factor, and to validate the staging by comparing it with that specified in the 7th edition (TNM 7) and the T-staging model proposed by the International Consortium. We retrospectively studied 449 patients who had had operations for a previously untreated primary oral cancer between 2006 and 2014 at a single centre, and analysed the independent predictive value of depth of invasion for both disease-specific and overall survival. It was an independent predictor of disease-specific survival as were sex, perineural invasion, and N stage. It was also an independent predictor of overall survival together with sex and N status. Staging in TNM 8 gave a better balance of distribution than that in TNM 7, but did not discriminate between prognosis in patients with T3 and T4 disease. The proposed International Consortium rules for T-staging gave an improved balance in distribution and hazard discrimination. The incorporation of depth of invasion into the T-staging rules for oral SCC improved prognostic accuracy and is likely to influence the selection of patients for adjuvant treatment. Our findings suggest that the TNM 8 staging lacks hazard discrimination in patients with locally-advanced disease because its T4 staging is restricted to anatomical criteria.
Asunto(s)
Carcinoma de Células Escamosas/patología , Neoplasias de la Boca/patología , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/clasificación , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/clasificación , Neoplasias de la Boca/diagnóstico , Neoplasias de la Boca/mortalidad , Invasividad Neoplásica/patología , Estadificación de Neoplasias/normas , Pronóstico , Análisis de Supervivencia , Adulto JovenRESUMEN
To understand and reduce the impact of postoperative complications, we studied 568 patients who had had operations over 72 months in our hospital. Multivariate analysis indicated that factors indicative of coexisting conditions (including activated systemic inflammation) and the complexity of the operation are primary determinants of postoperative complications. The enhanced recovery after surgery (ERAS) care pathway did not have an effect on their occurrence or severity. Systematic study of patients' toleration of major head and neck operations is required, as optimal perioperative care pathways remain elusive.
Asunto(s)
Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello/cirugía , Complicaciones Posoperatorias/epidemiología , Humanos , Estudios ProspectivosRESUMEN
INTRODUCTION: Bacterial resistance against antibiotics has become an increasing challenge in the treatment of cutaneous infections. Consequences can be severe, especially in infected wounds following previous local radiotherapy. Certain endogenous peptide antibiotics, the host defence peptides (HDPs), exhibit broad-spectrum antimicrobial activity and promote wound healing. Their use as supplements to conventional antibiotics is a current topic of discussion; however, knowledge of their quantities in healthy and compromised tissue is a prerequisite for such discussion. To date, no data concerning HDP quantities in irradiated skin are available. METHODS: Expression profiles of the genes encoding HDPs, namely human beta-defensin-1 (DEFB1, hBD-1), beta-defensin-2 (DEFB4A, hBD-2), beta-defensin-3 (DEFB103, hBD-3) and S100A7, were assessed in samples of non-irradiated and irradiated neck. RESULTS: A reduction in the expression of all of the examined genes was observed in irradiated skin when compared with non-irradiated skin (statistically significant in the case of S100A7, P = 0.013). Immunohistochemistry revealed differences in HDP distribution with respect to the epithelial layers. CONCLUSION: The study demonstrates a significant reduction in HDP gene expression in neck skin as a result of radiotherapy. These findings might represent a starting point for novel treatments of cutaneous infections in irradiated patients, such as topical supplementation of synthetic HDP.
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Neoplasias de la Boca/radioterapia , Proteínas S100/biosíntesis , Piel/metabolismo , beta-Defensinas/biosíntesis , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Expresión Génica , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/metabolismo , Neoplasias de la Boca/patología , ARN Mensajero/biosíntesis , ARN Mensajero/genética , Radioterapia/efectos adversos , Proteína A7 de Unión a Calcio de la Familia S100 , Proteínas S100/genética , beta-Defensinas/genéticaRESUMEN
The aim of this pilot study was to evaluate the feasibility of measuring the change in magnitude, speed, and motion similarity of facial animations in head and neck oncology patients, before and after lip split mandibulotomy. Seven subjects (four males, three females) aged 42-80 years were recruited. The subjects were asked to perform four facial animations (maximal smile, lip purse, cheek puff, and grimace) from rest to maximal position. The animations were captured using a Di4D motion capture system, which recorded 60 frames/s. Nine facial soft tissue landmarks were manually digitized on the first frame of the three-dimensional image of each animation by the same operator and were tracked automatically for the sequential frames. The intra-operator digitization error was within 0.4mm. Lip purse and maximal smile animations showed the least amount of change in magnitude (0.2mm) following surgery; speed difference was least for smile animation (-0.1mm/s). Motion similarity was found to be highest for lip purse animation (0.78). This pilot study confirmed that surgery did influence the dynamics of facial animations, and the Di4D capture system can be regarded as a feasible objective tool for assessing the impact of surgical interventions on facial soft tissue movements.
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Expresión Facial , Neoplasias de Cabeza y Cuello/fisiopatología , Imagenología Tridimensional/métodos , Fotogrametría/instrumentación , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Factibilidad , Femenino , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios ProspectivosAsunto(s)
Colgajos Tisulares Libres/trasplante , Laringoscopios , Faringe/cirugía , Procedimientos de Cirugía Plástica/instrumentación , Humanos , Fibras Ópticas , Procedimientos de Cirugía Plástica/métodos , Succión/instrumentación , Succión/métodos , Cirugía Asistida por Video/instrumentación , Cirugía Asistida por Video/métodosRESUMEN
Patients with head and neck cancer who have resection, radiotherapy, chemoradiotherapy, or a combination of these require nutritional support to be implemented before treatment, and this may involve insertion of a prophylactic gastrostomy feeding tube. The aim of this study was to compare the use and complication rates of percutaneous endoscopic gastrostomy (PEG) and radiologically inserted gastrostomy (RIG) in these patients at a tertiary referral centre. We retrospectively reviewed gastrostomy data forms completed by nutritional support nursing staff over a recent 34-month period, which included information on method of insertion, 30-day postoperative serious and minor complications, and mortality. A total of 110 patients had prophylactic insertion of a gastrostomy (21 PEG, 89 RIG) over the study period. In the first 12 months 13 (31%) PEG feeding tubes were placed but in the last 12 months none were inserted using an endoscopic approach. Serious complications occurred with 2 (10%) PEG and 12 (13%) RIG; the most common cause was accidental removal of the tube (n=13, 12%). Minor complications of peristomal infection, leakage, or blockage of the tube occurred in 6 (5%) gastrostomies. No patients died during the study period. In recent years, and in the absence of recommended guidelines, there has been an increase in the elective insertion of RIG in patients with head and neck cancer. Serious complications for both methods of insertion in this study are comparable with similar reports. However, with RIG there is a high rate of tubes becoming dislodged with the potential for serious consequences. The most appropriate method to insert a gastrostomy tube in patients with head and neck cancer remains unclear.
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Gastrostomía/métodos , Neoplasias de Cabeza y Cuello/terapia , Apoyo Nutricional , Accidentes , Fuga Anastomótica/etiología , Remoción de Dispositivos , Nutrición Enteral/instrumentación , Nutrición Enteral/métodos , Falla de Equipo , Estudios de Seguimiento , Gastroscopía/métodos , Gastrostomía/efectos adversos , Humanos , Complicaciones Posoperatorias , Radiología Intervencionista/métodos , Estudios Retrospectivos , Infección de la Herida Quirúrgica/etiologíaAsunto(s)
Fisura del Paladar/diagnóstico , Músculos Palatinos/anomalías , Anciano , Fisura del Paladar/patología , Diagnóstico Diferencial , Enfermedades del Oído/diagnóstico , Oído Medio/patología , Humanos , Masculino , Paladar Duro/anomalías , Paladar Blando/anomalías , Pólipos/diagnóstico , Trastornos del Habla/diagnóstico , Úvula/anomalíasRESUMEN
Liposarcomas account for up to 20% of all soft tissue tumours. They are uncommon in the head and neck. Sarcomas of the oral region (excluding lymphoma) account for 5% of all oral cancers, of which 10% are liposarcomas. Fewer than 80 cases have been reported in the world literature, most of which presented as expansile masses. The prognosis of liposarcoma is dependant on the histopathologic type, location, and adequacy of surgical treatment. Well-differentiated types have a good prognosis and minimal metastatic potential. We report a case of well-differentiated liposarcoma (lipoma-like subtype), that presented as a gingival polyp.
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Neoplasias Gingivales/patología , Liposarcoma/patología , Pólipos/patología , Adipocitos/patología , Diagnóstico Diferencial , Humanos , Liposarcoma/clasificación , Masculino , Persona de Mediana EdadAsunto(s)
Angioplastia Coronaria con Balón/métodos , Reestenosis Coronaria/prevención & control , Stents , Reestenosis Coronaria/epidemiología , Estenosis Coronaria/terapia , Diabetes Mellitus/terapia , Implantes de Medicamentos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Stents/estadística & datos numéricosRESUMEN
A policy of selective implantation of drug eluting stents, in a minority of lesions most likely to benefit, seems to be a rational way to employ this new and currently costly technology.
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Reestenosis Coronaria/prevención & control , Stents , Reestenosis Coronaria/economía , Ahorro de Costo , Costos y Análisis de Costo , Toma de Decisiones , Implantes de Medicamentos/efectos adversos , Implantes de Medicamentos/economía , Diseño de Equipo , Humanos , Medición de Riesgo , Factores de Riesgo , Stents/efectos adversos , Stents/economíaRESUMEN
OBJECTIVE: To investigate a population of elderly people for atrial fibrillation and to determine how many of the cases identified might benefit from treatment with anticoagulants. METHODS: From a practice of four primary care physicians, 1422 patients aged 65 years and over were identified, of whom 1207 (85% of the total population) underwent electrocardiographic screening to detect the presence of atrial fibrillation. Patients with the arrhythmia were further evaluated by echocardiography and interview, to stratify their risk of stroke based on echocardiographic and clinical risk factors, their perceived risk from anticoagulation, and their attitude towards this treatment. Their primary care physician was also interviewed to determine the factors influencing the prescription of anticoagulants. RESULTS: The arrhythmia occurred in 65 patients (5.4% overall), its prevalence increasing markedly with age (2.3% in 65 to 69 years age group; 8.1% in those over 85). Warfarin was being prescribed to 21.4% of these patients, although the findings of the study indicate that a further 20% were eligible for this treatment. Symptoms suggestive of cardiac failure were common (32.1%) and coexisting pathology was often identified by cardiac ultrasound in these patients (left ventricular hypertrophy, 32.1%; impaired left ventricular contractility, 21.4%; left atrial dilation, 80.4%; mitral annular calcification, 42.9%; mitral stenosis, 7.1%; mitral regurgitation, 48.2%; aortic stenosis, 8.9%). In all but one case, the decision to anticoagulate was based on the clinical rather than the echocardiographic findings. CONCLUSIONS: Individual risk-benefit assessment in elderly patients with atrial fibrillation suggests that almost half (41.4%) are eligible for full anticoagulation with warfarin, whereas presently only one fifth are receiving this treatment. The decision to anticoagulate can be made on clinical grounds in most cases. If these results are confirmed, a doubling of the current number of patients taking anticoagulants can be anticipated.