Oral cavity obliteration is a novel predictor of functional outcomes after glossectomy reconstruction.

OBJECTIVES: The primary goal for reconstruction of oral tongue defects is to improve speech and swallowing. The purpose of this study is to present a new reconstructive metric that uses volume displacement to measure oral cavity obliteration and correlate this metric to outcomes of speech and swallowing. METHODS: 47 patients underwent resection and primary closure or free-tissue reconstruction of oral tongue defects. Oral cavity obliteration was measured using a novel oral volume assessment test (OVAT). Briefly, a latex balloon filled with pudding was placed on the patient's tongue and patients performed mouth closure to expel the pudding. Residual volumes represented dead space in the oral cavity and was measured by water displacement. These results were correlated with the Speech and Swallowing Assessment and Assessment of Intelligibility of Dysarthric Speech (AIDS) instruments. RESULTS: The mean residual volume was 7.4 cc (range 3 - 20 cc; sd 4.5 cc). There was a correlation with lower residual volumes (better obliteration) with increasing AIDS efficiency ratio (R = 0.72, p < 0.001). A receiver operator curve was used to identify 10 cc of residual volume as the optimal cutoff point. Binary logistic regression using this cut point showed that residual volume significantly predicts normal nutritional mode (p < 0.001), ability to tolerate all liquids (p = 0.007), range of solids (p = 0.004), eating in public (p = 0.007), understandability (p < 0.001), and speaking in public (p = 0.01). CONCLUSIONS: Oral volume assessment test (OVAT) is a novel measure of residual volume (obliteration) that correlates with improved speech efficiency, intelligibility, speaking in public and swallowing outcomes.

Bivalirudin for unsalvageable venous congestion or obstruction in head and neck free flap reconstruction.

Microvascular free flap surgery permits single-stage reconstruction of complex head and neck ablative defects. Venous congestion can occur in the early postoperative period, risking partial or total flap loss. While prompt surgical re-exploration is often required, a number of adjunct medical treatments have been explored. Recently, there has been an anecdotal rise in the use of the anticoagulant bivalirudin, a recombinant derivative of hirudin. However, there has only been one case series report on the use of bivalirudin in head and neck free flap venous congestion. Here, we describe our team's experience with bivalirudin through a series of 7 patients.

Endoscope-Assisted Transcervical Resection of Parapharyngeal Space Tumors.

OBJECTIVE: We describe a novel technique for endoscope-assisted (EA) transcervical (TC) approach for resection of parapharyngeal space (PPS) tumors and compare perioperative outcomes of this approach to standard TC approaches. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care center. METHODS: This was a single-institution, retrospective analysis of all patients undergoing TC approach for resection of PPS tumors over a 10-year period. We describe unique advantages of our surgical approach utilizing a 0° endoscope for improved surgical access, visualization, and efficiency. χ2 and Student's t test were used to compare perioperative outcomes between cases in which an endoscope was utilized EA for resection versus standard TC approach. RESULTS: Our cohort included 77 patients (n = 40 EA, n = 37 TC). There was no difference in patient age, sex, tumor laterality, tumor size, or tumor location between groups. The EA approach was associated with significantly shorter operative times (median [range] for EA 73 [33-270] minutes vs TC 112 [56-362] minutes, P < .01) and reduced rates of immediate postoperative marginal mandibular nerve paresis (EA: n = 5 [12.5%] vs TC: n = 16 [43.2%], P < 0.01). CONCLUSION: EA TC approach for resection of PPS tumors offers improved surgical access and is associated with reduced surgical time and rates of marginal mandibular nerve paresis compared to standard transcervical approaches.

Retrospective Exploration of Botulinum Toxin Injection for Pharyngoesophageal Segment Dysfunction Post-laryngectomy.

Objective: To assess our institution's experience with botulinum toxin A injection management of pharyngoesophageal (PE) segment dysfunction after laryngectomy in tracheoesophageal voice and swallowing restoration. Study Design: A retrospective review of 43 patients who had Botox as treatment for PE dysfunction. Setting: Tertiary academic center with fellowship-trained otolaryngologists. Methods: Pre- and post-injection outcomes were evaluated using chart review, and the severity of symptoms was recorded based on the subjective assessment by the patient, speech language pathologists, and the treating surgeon. Results: Forty-three patients were treated for PE dysfunction with botulinum toxin A injection. Most patients were male (n = 35, 81.4%), underwent primary cricopharnygeal myotomy (n = 36, 83.7%), and 37 (86%) had both dysphagia and speech concerns. Our injection methods included percutaneous injection by videofluoroscopy (n = 19, 44.2%), transnasal esophagoscopy (17, 40.5%), electromyography (n = 3, 7%), ultrasound (n = 1, 2.3%), or in the operating room (n = 3,7%). We found that 37 (86%) patients had subjective improvement in their symptoms, with 16 (38.1%) improving in both swallow and voice. There were no significant complications, or subjective difference in speech and swallowing outcomes by method of injection. Conclusion: Botulinum toxin A injection appears to be safe and effective for treating difficulty with speech and swallowing due to PE dysfunction after laryngectomy. Institutions should develop standard protocols for treatment and assessment.

Association of prealbumin with complications after total laryngectomy with free flap reconstruction.

OBJECTIVE: Malnutrition is an important risk factor for patient surgical outcomes. This is especially true for head and neck cancer (HNC) patients receiving a total laryngectomy with free flap reconstruction (TLwFFR). Preoperative prealbumin and albumin values have both been used to indicate poor nutrition. This study aims to identify the prognostic value of preoperative prealbumin and albumin levels with wound healing complications in HNC patients after TLwFFR. METHODS: A retrospective review was conducted in all HNC patients who underwent TLwFFR from 2016 to 2022 at a tertiary-care institution. Patients with either preoperative (within 1 month of surgery) prealbumin or albumin lab values were included. Low preoperative prealbumin (low prealbumin) levels and low preoperative albumin (low albumin) levels were defined as ≤20 mg/dL and <3.4 g/dL, respectively. Outcomes collected included all wound healing complications (infection, wound dehiscence, pharyngocutaneous fistula). The association between prealbumin and albumin with outcomes were analyzed using multivariable logistic regression. RESULTS: A total of 83 patients met the inclusion criteria. The mean age at surgery was 61.6 ± 9.3. The overall wound healing complication rate was 33.7 %. There was an association between low prealbumin levels and any wound healing complication. On multivariate analysis, low prealbumin levels were associated with postoperative wound healing complications (OR, 4.7; CI 1.3-17.0. P = 0.02) after controlling for low albumin level, age, smoking, and preoperative radiation. CONCLUSIONS: Low prealbumin levels were associated with wound healing complications in TLwFFR patients. Consideration of consistent prealbumin testing with nutritional intervention may reduce wound healing complications.

A Scoping Review of Pain Management After Transoral Robotic Surgery.

OBJECTIVE: Pain following transoral robotic surgery (TORS) is a driver of adverse outcomes and can lead to readmission and treatment delays. A scoping review was conducted to characterize TORS-related pain and identify key management strategies utilized in the literature. DATA SOURCES: OVID Medline, CINAHL, Cochrane, Pubmed, and Embase databases were queried. REVIEW METHODS: Two team members independently screened titles and abstracts and completed full-text reviews. Studies examining TORS for OPSCC with quantitative pain data were included. The study followed the PRISMA guidelines. RESULTS: A total of 1467 studies were imported for screening and 25 studies were ultimately included. The average study sample size was 89 participants. 68% were conducted in a single-center academic setting. Pain was assessed on varying timelines up to 3 years using 13 different metrics. Pain peaks days-weeks postoperatively and returns to baseline thereafter. Postoperative pain is a significant cause of morbidity and limited data exist about optimal management. CONCLUSION: Prospective studies are needed to characterize and address TORS-related pain.

Postoperative Radiotherapy in Advanced Stage Squamous Cell Carcinoma Requiring Maxillectomy.

OBJECTIVE: To evaluate whether postoperative radiotherapy (PORT) improves survival among patients who received maxillectomy for pT4aN0 maxillary gingival or hard palate squamous cell carcinoma (SCC) with respect to tumor size. STUDY DESIGN: Retrospective analysis. SETTING: National Cancer Database from 2004 to 2019. METHODS: Included adult patients who received maxillectomy (partial, subtotal, or total) and neck dissection for treatment-naive margin negative pT4aN0 SCC of the maxillary gingiva or hard palate. Adjusted for age, gender, race, insurance status, income, education, urban/rural, facility type, region, comorbidity index, tumor grade, and tumor extension. Inverse probability weights were incorporated into a multivariable Cox proportional hazards model. A priori post hoc subgroup analysis was performed according to tumor size. RESULTS: We included 416 patients who underwent maxillectomy for pT4aN0 SCC of the maxillary gingiva or hard palate (mean [standard deviation] age, 71.5 [11.3] years; male, 190 [45.7%]; tumor size 2 cm, 362 [87%]). Overall, 49.3% of patients received PORT (205 patients). PORT was associated with a 50% improvement in survival compared to surgery alone (adjusted hazard ratio [aHR], 0.50; 95% confidence interval [95% CI], 0.32-0.81). On subgroup analysis, PORT was associated with improved survival for tumors 2 cm (aHR, 0.47; 95% CI, 0.29-0.77), but not for tumors < 2 cm (aHR, 1.15; 95% CI, 0.33-4.08). CONCLUSION: The vast majority of patients with pT4aN0 bone-invading SCC of the maxillary gingiva and hard palate benefit from PORT. Patients with tumors < 2 cm did not demonstrate a survival benefit from adjuvant treatment, suggesting that bony invasion alone may not be sufficient criteria for treatment escalation.

3D modeling of anterior 2/3rds glossectomy reconstruction: A volume based donor site evaluation.

OBJECTIVE: Anterior 2/3rds glossectomy results in significant patient morbidity due to speech and swallowing impairment. Microvascular free flap reconstruction compensates for large volume defects. Flap volume is based on the adipose content of the donor site and varies by patient body mass index (BMI) and donor site location. We sought to correlate flap thickness at different donor sites with patient BMI to determine optimal donor site selection. METHODS: Patients with CT scans of the oral cavity, thorax and lower extremity were identified and included. The volumes of the anterior 2/3rds of the tongue were measured and recorded using computed tomography-generated modeling. Pre-muscular tissue thicknesses at anterolateral thigh (ALT), deep inferior epigastric artery (DIEP), latissimus dorsi, and parascapular donor sites were measured. The donor site adequency was defined as reconstructing the tongue volume within 10% of the ideal volume required and stratified based on patient BMI. RESULTS: In 144 patients, the average anterior 2/3rds glossectomy defect was 100.3 cm3. Glossectomy defect size was highly correlated with BMI (p < 0.001). The DIEP flap had the largest volume (155.4 cm3), followed by latissimus (105.6 cm3), parascapula (97.8 cm3), and ALT (60.5 cm3). For patients with BMI ≤ 30, the DIEP flap best reconstructed native tongue volume (up to 113 % of native tongue volume). In patients with BMI > 30.1, native tongue volumes were approximated by the latissimus flap (89-92 % of native tongue) and parascapular flap (85-95 % of native tongue volume). In BMI > 30.1 the DIEP flap provided excess tissue bulk (129-135 % of native tongue volume). CONCLUSION: The DIEP flap more closely approximates the volume needed to reconstruct anterior two-thirds tongue defects for BMIs ≤ 30. The subscapular system flaps provided the best volume match for BMIs > 30 and the DIEP flap provided excess tissue bulk which could be adjusted in the reconstruction process.

Pharyngeal Mucosal Margin Vessel Counts Predict Pharyngocutaneous Fistula in Salvage Laryngectomy.

OBJECTIVE: We evaluated vessel counts in the pharyngeal mucosal margins of patients who underwent salvage laryngectomy to establish whether mucosal vascularity might predict fistula risk. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary Medical Center. METHODS: Patients who underwent salvage total laryngectomy at our institution between 1999 and 2015 were identified. Pharyngeal mucosal margins from laryngectomy specimens were evaluated histologically for each patient, and vessel counts were performed on 5 ×10 images. The primary outcome measure was fistula within 30 days of surgery and mean vessel counts were assessed as the principle explanatory variable. RESULTS: Seventy patients were included and 40% developed a postoperative fistula. There was a large difference in the mean vessel count in patients who did develop fistula (48.6 vessels/×10 field) compared to those who did not (34.7 vessels/×10 field). A receiver operative characteristic curve found that a cutoff value of 33.9 vessels/×10 field provided a sensitivity of 75% and specificity of 62% to predict the likelihood of fistula occurrence (area under the curve = 0.71, 95% confidence interval [CI]: 0.59-0.83). In a binary logistic regression, patients with vessel counts greater than 33.9 had a 5-fold increased risk of developing fistula (95% CI: 1.8-16.45). Histologically, vessels in the pharyngeal mucosa of patients who developed fistulas were more disorganized. CONCLUSION: After salvage laryngectomy, patients with higher mean mucosal margin vessel counts are at increased risk of fistula. The mechanism is unknown, but the disorganization of the vasculature may contribute to poor wound healing. Vessel counting may allow for fistula risk stratification and guide postoperative care.

Utility of bioselection with neoadjuvant chemotherapy for organ preservation in patients with T4 laryngeal cancer.

BACKGROUND: Neoadjuvant chemotherapy for induction selection of definitive treatment (IS) protocols have shown excellent outcomes for organ preservation and survival in patients with T3 laryngeal squamous cell carcinoma (LSCC). We seek to evaluate survival and organ preservation outcomes in T4 LSCC patients treated with IS protocols. METHODS: Retrospective cohort of advanced T3 and T4 LSCC patients who underwent IS protocols based upon potential for preserving a functional larynx. Patients received one neoadjuvant cycle of platinum-based chemotherapy with either 5-fluorouracil or docetaxel or with two cycles of platinum-based chemotherapy with docetaxel and a Bcl-2 inhibitor. Patients who achieved ≥ 50 % response as determined by radiographic review and/or endoscopic evaluation received definitive chemoradiation. Patients who had < 50 % response after IS underwent total laryngectomy (TL) followed by post-operative radiation +/- chemotherapy. RESULTS: Amongst T4 patients, 114 met inclusion criteria including 89 who underwent IS protocols and 25 who received an upfront TL. In total, 76.0 % of T3 patients and 71.9 % of T4 patients responded to IS and underwent definitive chemoradiation. There was no significant difference in hazard of death between T4 IS and T4 TL patients (HR: 0.9, p = 0.86). Among responders, there was no significant difference in 5-year laryngectomy-free survival (T3 - 59.6 %, T4 44.3 %, p = 0.15) or laryngeal preservation by T stage (T3 - 72.8 %, T4 - 73.0 %, p = 0.84). CONCLUSIONS: Select T4 patients may benefit from organ preservation using IS protocols with similar response rates to patients with T3 tumors, without compromising survival when compared to upfront TL.

Acinic cell Carcinoma with high-grade Squamoglandular and Chondrosarcomatous Transformation Mimicking 'Carcinosarcoma ex-pleomorphic Adenoma': A Wrinkle in the Proposed Nomenclature Revision for Sarcomatoid Salivary Gland Neoplasms.

While acinic cell carcinoma (AciCC) can undergo high-grade transformation (HGT) to high-grade adenocarcinoma or poorly differentiated carcinoma, other morphologies such as spindle cell/sarcomatoid carcinoma are rare and not well-characterized. We herein report a novel case of AciCC with squamoglandular and chondrosarcomatous HGT mimicking a so-called 'carcinosarcoma ex-pleomorphic adenoma'. The patient is an 81-year-old male with a two-month history of neck swelling and referred otalgia who presented with a left parapharyngeal space mass extending into retropharyngeal space and pterygoid muscles. On resection, the tumor showed considerable morphologic diversity with high-grade serous and mucous acinar components as well as cribriform to solid apocrine-like components with comedonecrosis and squamous differentiation, all of which were embedded in a chondromyxoid background ranging from paucicellular and bland to a high-grade chondrosarcoma/pleomorphic sarcoma-like appearance. Only a minor conventional AciCC component was noted. Immunostains were negative for AR and only focally positive for GCDFP-15 arguing against a true apocrine phenotype, while PLAG1 and HMGA2 were negative arguing against an antecedent pleomorphic adenoma. On the other hand, SOX-10, DOG-1 and PAS after diastase highlighted serous acinar differentiation, and mucicarmine, and NKX3.1 highlighted mucous acinar differentiation. NR4A3 immunohistochemical staining and NR4A3 fluorescence in situ hybridization were positive in the carcinomatous and sarcomatoid components while sequencing analysis of both components revealed identical alterations involving TP53, PIK3CB, ARID1A, and STK11. This unique case warrants caution in designating all salivary sarcomatoid carcinomas with heterologous elements as part of the 'carcinoma ex-pleomorphic adenoma' family.

Phase II Clinical Trial of Intravenous Levothyroxine to Mitigate Pharyngocutaneous Fistula in Euthyroid Patients Undergoing Salvage Laryngectomy.

PURPOSE: Patients undergoing head and neck cancer surgery after prior radiation or chemoradiation are at high risk for wound complications. Hypothyroidism is a known risk factor for wound complications, especially fistulae after salvage total laryngectomy. The purpose of this phase II clinical trial is to investigate the effect of perioperative intravenous levothyroxine supplementation on wound complications in patients undergoing salvage total laryngectomy. PATIENTS AND METHODS: Euthyroid patients previously treated with radiation/chemoradiation undergoing total laryngectomy were prospectively recruited (n = 72). Postoperatively, intravenous levothyroxine was administered at a weight-based dose (1.3 mcg/kg/d) and transitioned to enteral dosing on day 7. Free T3, T4, and thyroid-stimulating hormones were collected, and dosing was adjusted accordingly. The primary endpoints were rates of fistula formation and fistula requiring reoperation, compared with matched historic controls. All patients were monitored for adverse effects. RESULTS: The rate of postoperative hypothyroidism was 21% compared with 49% in a matched historic cohort. The rate of fistula formation was 18.1%, whereas the rate of fistula requiring reoperation was 4.2%, significantly lower than rates in our historic cohort (34.6% and 14.8%, respectively; P = 0.02 and 0.01). Postoperative hypothyroidism and recurrent clinical stage predicted fistula requiring reoperation in multivariate analysis; other acute phase reactants were not predictive. There were no observed adverse events related to levothyroxine supplementation. CONCLUSIONS: Postoperative intravenous levothyroxine supplementation reduced rates of acute hypothyroidism, fistula formation, and fistula requiring reoperation in patients undergoing salvage total laryngectomy without adverse effects. Intravenous levothyroxine is a viable strategy to reduce wound complications in this high-risk patient population.

Application of Time-Driven Activity-Based Costing for Head and Neck Microvascular Free Flap Reconstruction.

OBJECTIVE: Traditional hospital accounting fails to provide an accurate cost of complex surgical care. Here we describe the application of time-driven activity-based costing (TDABC) to characterize costs of head and neck oncologic procedures involving free tissue transfer. STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary academic medical center. METHODS: An analysis of head and neck oncologic procedures involving microvascular free flap reconstruction from 2018 to 2020 (n = 485) was performed using TDABC methodology to measure cost across operative case and postoperative admission, using quantity of time and cost per unit of each resource to characterize resource utilization. Univariate and generalized linear mixed models were used to examine associations between patient and hospital characteristics and cost of care delivery. RESULTS: The total cost of care delivery was $41,905.77 ± 21,870.27 with operating room (OR) supplies accounting for only 10% of the total cost. Multivariable analyses identified significant cost drivers including operative time, postoperative length of stay, number of return trips to the OR, postoperative complication, number of free flaps performed, and patient transfer from another hospital or via emergency department admission (P < .05). CONCLUSION: Operative time and postoperative length of stay, but not operative supplies, were primary drivers of cost of care for head and neck oncology cases involving free tissue transfer. TDABC offers granular cost characterization to inform cost optimization through unused capacity identification and postoperative admission efficiencies.

Telemedicine-enabled biofeedback electropalatography rehabilitation (TEBER): A pilot study for patients treated with surgery for oral cavity carcinoma.

BACKGROUND: To address the rehabilitative barriers to frequency and precision of care, we conducted a pilot study of a biofeedback electropalatography (EPG) device paired with telemedicine for patients who underwent primary surgery +/- adjuvant radiation for oral cavity carcinoma. We hypothesized that lingual optimization followed by telemedicine-enabled biofeedback electropalatography rehabilitation (TEBER) would further improve speech and swallowing outcomes after "standard-of-care" SOC rehabilitation. METHOD: Pilot prospective 8-week (TEBER) program following 8 weeks of (SOC) rehabilitation. RESULTS: Twenty-seven patients were included and 11 completed the protocol. When examining the benefit of TEBER independent of standard of care, "range-of-liquids" improved by +0.36 [95% CI, 0.02-0.70, p = 0.05] and "range-of-solids" improved by +0.73 [95% CI, 0.12-1.34, p = 0.03]. There was a positive trend toward better oral cavity obliteration; residual volume decreased by -1.2 [95% CI, -2.45 to 0.053, p = 0.06], and "nutritional-mode" increased by +0.55 [95% CI, -0.15 to 1.24, p = 0.08]. CONCLUSION: This pilot suggests that TEBER bolsters oral rehabilitation after 8 weeks of SOC lingual range of motion.

Upfront Neck Dissection for Treatment Selection and Improvement in Quality of Life as a Novel Treatment Paradigm for Deintensification in HPV+ OPSCC.

PURPOSE: Locoregionally advanced HPV+ oropharyngeal squamous cell carcinoma (OPSCC) has excellent cure rates, although current treatment regimens are accompanied by acute and long-term toxicities. We designed a phase II deescalation trial for patients with HPV+ OPSCC to evaluate the feasibility of an upfront neck dissection to individualize definitive treatment selection to improve the quality of life without compromising survival. PATIENTS AND METHODS: Patients with T1-3, N0-2 HPV+ OPSCC underwent an upfront neck dissection with primary tumor biopsy. Arm A included patients with a single lymph node less than six centimeters, with no extracapsular spread (ECS) and no primary site adverse features underwent transoral surgery. Arm B included patients who had two or more positive lymph nodes with no ECS, or those with primary site adverse features were treated with radiation alone. Arm C included patients who had ECS in any lymph node and were treated with chemoradiation. The primary endpoint was quality of life at 1 year compared with a matched historical control. RESULTS: Thirty-four patients were enrolled and underwent selective neck dissection. On the basis of pathologic characteristics, 14 patients were assigned to arm A, 10 patients to arm B, and 9 to arm C. A significant improvement was observed in Head and Neck Quality of Life (HNQOL) compared with historical controls (-2.6 vs. -11.9, P = 0.034). With a median follow-up of 37 months, the 3-year overall survival was 100% and estimated 3-year estimated progression-free survival was 96% [95% confidence interval (CI), 76%-99%]. CONCLUSIONS: A neck dissection-driven treatment paradigm warrants further research as a deintensification strategy.

Use of the spider limb positioner for fibular free flap reconstruction of head and neck bony defects.

BACKGROUND: Osseous and osteocutaneous fibular free flaps are the workhorse of maxillomandibular reconstruction over 30 years after the initial description. Since 2019, we have routinely used the Spider Limb Positioner, adapted from its use in shoulder orthopedic procedures, for fibular free flap harvest. Herein, we describe this novel technique in our cohort. METHODS: We describe our intraoperative setup and endorse the versatility and utility of this technique in comparison to other reported fibular free flap harvest techniques. RESULTS: The Spider Limb Positioner was used 61 times in 60 different patients to harvest osseous or osteocutaneous fibular free flaps. Median (range) tourniquet time for flap harvest was 90 (40-124) minutes. No iatrogenic nerve compression injuries or complications related to lower extremity positioning occurred. CONCLUSION: We describe a novel approach to fibular free flap harvest utilizing the Spider Limb Positioner, which affords optimal ergonomics, visibility, and patient repositioning. There were no nerve injuries or complications related to positioning in our series.

Evaluation of the safety and effectiveness of robot-assisted neck dissections.

BACKGROUND: Robot-assisted neck dissection (RAND) for the management of the regional lymphatic basin offers the potential for improved cosmesis and reduced lymphedema. While RAND has been previously described, functional outcome and oncologic control rates need further elucidation. METHODS: A retrospective, matched cohort study of neck dissections completed at UPMC from 2017 to 2021 was conducted. RAND was identified and matched to open neck dissections (open) in a 1:2 ratio. Matching characteristics included primary cancer site, pre-operative clinical N-stage, age at time of surgery, HPV status, and previous chemoradiation treatment (salvage vs. nonsalvage procedure). Additional information was collected on patient demographics, surgery characteristics, and outcomes. Comparisons were made using t-test, chi-square test, Fisher's exact test, and Kaplan-Meier Wilcoxon (KMW) test with p < 0.05 indicating significance. RESULTS: Overall, RAND and open groups had similar distributions of age, gender, BMI, primary site of cancer, HPV status, clinical N-stage, clinical T-stage, known neck disease prior to procedure, prior chemoradiation therapy, and level(s) of neck dissection. Surgically, RAND procedures yielded less drainage on average (124 mL in RAND vs. 220 mL in open approaches; p = 0.01). There was no difference in the rates of complications, estimated blood loss, or number of lymph nodes obtained. There were also no differences in the rates of adjuvant therapy. Long term, there were no differences in the rates of local, locoregional, and distant recurrence of primary disease between RAND and open procedures. There were also no differences in postprocedure disease-free survival time (KMW p-value = 0.32; HR [of RAND compared with open] = 0.62). Similarly, there were no statistical differences in the overall survival of RAND patients when compared with the open group (75 vs. 58.9 months; HR = 0.11, p = 0.87). CONCLUSION: This study is the first to report the long-term effectiveness of robot-assisted surgery compared with the traditional, open approach. In addition to well-known cosmetic benefits, robot-assisted surgery may also offer patients a reduction in uncomfortable drains and improved effects from lymphedema. Overall, this study provides initial data that the RAND may be considered as an alternative approach to open surgery.

Association of preoperative thyroid hormone replacement with perioperative complications after major abdominal surgery.

OBJECTIVE: To determine the association between preoperative thyroid hormone replacement and complications following major abdominal surgery. METHODS: A retrospective case series was performed of patients enrolled in the Michigan Surgical Quality Collaborative (MSQC) who underwent major abdominal surgery at an academic institution over a 10-year period. The principal explanatory variable was preoperative thyroid hormone replacement. Primary outcomes were morbidity, mortality and length of stay. RESULTS: 2700 patients were identified. On multivariate analysis correcting for established predictors of operative morbidity, patients on preoperative thyroid replacement had a 1.5- fold increased risk of serious morbidity(p â€‹= â€‹0.01), and a 1.7- fold greater risk for serious sepsis(p â€‹= â€‹0.04). Thyroid replacement was associated with longer length of stay(p â€‹< â€‹0.001). While there was a high degree of missing data for surgical approach (31.1 â€‹% missing data), results suggest that patients on thyroid hormone replacement were more likely to undergo an open rather than minimally invasive surgery(p â€‹< â€‹0.01). Open surgery was associated with greater risk of serious morbidity(p â€‹= â€‹0.003) and longer length of stay(p â€‹< â€‹0.001). CONCLUSIONS: Preoperative thyroid hormone replacement independently predicts operative morbidity and length of stay following major abdominal surgery.