Single- versus two-stage reconstruction in patients with head and neck cancer: What are the benefits?

In head and neck oncology, surgical treatment frequently results in microvascular reconstruction. Oncologic resection followed by immediate reconstruction is often associated with prolonged working and surgical duration, challenging a surgeon's concentration level and potentially worsening patient outcome. To improve the surgeon's performance and to reduce risk of potential complications, we implemented a two-stage procedure in patients with head and neck cancer. This study critically analyzed the surgical outcomes, organizational benefits, and investigated job satisfaction among affected health care professionals. A retrospective data analysis of patients who had undergone microvascular reconstruction after oncologic head and neck surgery between 2010 and 2021 included 33 patients (n = 33). Twenty patients underwent single-stage reconstruction (group 1, n = 20) and 13 patients underwent two-stage reconstruction (group 2, n = 13) with 12.2 (± 7.4) days between surgeries. The mean surgical duration, and mean start and end time of the reconstructive surgery component differed significantly (p = 0.002). The mean total complication rate (p = 0.58) did not differ significantly, although a trend toward higher demands for blood products was observed in group 1. There was no significant difference in five-year survival (p = 0.28). A questionnaire on subjective work performance was answered by the affected health care professionals (n = 34) and it revealed that 88% preferred long surgeries to be scheduled first and that 97% work most efficiently in the morning. In conclusion, two-stage reconstruction is a suitable option in selected head and neck cancer patients offering the possibility of optimizing preoperative planning and organization. This may result in regular working hours, reduced surgeon fatigue, and improved job satisfaction without compromising patient outcomes or survival.

Perioperative Blood Transfusion in Head and Neck Cancer Revisited.

OBJECTIVE: To reevaluate the frequency of perioperative blood transfusion, transfusion triggers, and survival impact in patients with incident, surgically treated head and neck cancer (HNC) in restrictive transfusion regimens. METHODS: Retrospective analysis of surgically treated patients with incident HNC with and without perioperative blood transfusion between 2008 and 2019 at the Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, according to the department's clinical Head and Neck Tumor Registry. RESULTS: Of the 590 patients included, perioperative transfusions were administered in 6.3% (n = 37, transfusion group). Following multivariable logistic regression, likelihood of blood transfusions was increased in patients with poorer general health conditions (ASA score III/IV; OR 3.7; 95% CI 1.9-8.6; p = 0.002), hemoglobin <12.5 g/dL (OR 2.7; 95% CI 1.1-6.4; p = 0.03), longer duration of surgery (OR 1.006 per minute of surgery time; 95% CI 1.003-1.008; p < 0.001), and negative p16 status (OR 5.3; 95% CI = 1.1-25; p = 0.03). Based on 14 matching variables related to survival and perioperative blood transfusion, a control group of 37 matching patients without perioperative transfusion was identified. Using univariate analysis, overall survival in transfusion and control groups did not differ significantly (p = 0.25). After adjusting for four parameters with limited matching accuracy (Chi square p < 0.2) in Cox regression analysis, a transfusion related hazard ratio close to 1 (HR 0.92; 95% CI 0.34-2.51; p = 0.87) was observed. CONCLUSION: Considering current restrictive transfusion regimens and general transfusion risks, the administration of blood products in HNC patients during the perioperative period is not associated with additional oncologic hazard. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1638-1644, 2023.

Delayed Reconstruction after Major Head and Neck Cancer Resection: An Interdisciplinary Feasibility Study.

A single immediate reconstruction with free tissue transfer is the method of choice after major head and neck cancer (HNC) resection, but this is frequently associated with long operating hours. Considering regulatory working hour constraints, we investigated whether a two-staged reconstructive approach with temporary defect coverage by an artificial tissue substitute would be feasible. HNC patients underwent either immediate or delayed reconstruction after tumor resection. Patients with delayed reconstruction received preliminary reconstruction with an artificial tissue substitute followed by definitive microvascular reconstruction in a separate, second procedure. Of the 33 HNC patients, 13 received delayed reconstruction and 20 received immediate reconstruction. Total anesthesia time (714 vs. 1011 min; p < 0.002) and the total duration of hospital stay (34 ± 13 vs. 25 ± 6 days; p = 0.03) were longer in the delayed reconstruction group. Perioperative morbidity (p = 0.58), functional outcome (p > 0.1) and 5-year postoperative survival rank (p = 0.28) were comparable in both groups. Delayed reconstruction after HNC resection was feasible. Perioperative morbidity, functional outcome and overall survival were comparable to immediate reconstruction.

Accuracy of training blood volume quantification using a visual estimation tool.

BACKGROUND: We investigated whether the use of a specially designed visual estimation tool may improve accuracy in quantifying blood volumes related to surface spreading. METHODS: A prospective, paired-control, single-blinded experimental study was performed at a medical university. Anesthesiologists and emergency medical personnel estimated various blood volumes on surfaces with varying absorptivity (carpet, towel, polyvinyl chloride, wooden flooring) in an experimental setting. We assessed the sensitivity of training blood volume quantification using a self-designed visual estimation tool by comparing the accuracy of visual blood volume estimations before and after practical training with the tool. RESULTS: A total of 352 estimations by 44 participants were evaluated. Accurate estimations improved significantly from pre-training to post-training (P<0.05). The sensitivity of blood volume quantification was 33.0% after training with the visual estimation tool. Estimations did not depend on age, profession, gender or years of the estimator's professional experience. CONCLUSIONS: Training with a visual estimation tool by professional rescuers can improve the estimation accuracy of blood volumes spread on surfaces with varying absorptivity.

Tolerability of inhaled N-chlorotaurine in the pig model.

BACKGROUND: N-chlorotaurine, a long-lived oxidant produced by human leukocytes, can be applied in human medicine as an endogenous antiseptic. Its antimicrobial activity can be enhanced by ammonium chloride. This study was designed to evaluate the tolerability of inhaled N-chlorotaurine (NCT) in the pig model. METHODS: Anesthetized pigs inhaled test solutions of 1% (55 mM) NCT (n = 7), 5% NCT (n = 6), or 1% NCT plus 1% ammonium chloride (NH4Cl) (n = 6), and 0.9% saline solution as a control (n = 7), respectively. Applications with 5 ml each were performed hourly within four hours. Lung function, haemodynamics, and pharmacokinetics were monitored. Bronchial lavage samples for captive bubble surfactometry and lung samples for histology and electron microscopy were removed. RESULTS: Arterial pressure of oxygen (PaO2) decreased significantly over the observation period of 4 hours in all animals. Compared to saline, 1% NCT + 1% NH4Cl led to significantly lower PaO2 values at the endpoint after 4 hours (62 +/- 9.6 mmHg vs. 76 +/- 9.2 mmHg, p = 0.014) with a corresponding increase in alveolo-arterial difference of oxygen partial pressure (AaDO2) (p = 0.004). Interestingly, AaDO2 was lowest with 1% NCT, even lower than with saline (p = 0.016). The increase of pulmonary artery pressure (PAP) over the observation period was smallest with 1% NCT without difference to controls (p = 0.91), and higher with 5% NCT (p = 0.02), and NCT + NH4Cl (p = 0.05).Histological and ultrastructural investigations revealed no differences between the test and control groups. The surfactant function remained intact. There was no systemic resorption of NCT detectable, and its local inactivation took place within 30 min. The concentration of NCT tolerated by A549 lung epithelial cells in vitro was similar to that known from other body cells (0.25-0.5 mM). CONCLUSION: The endogenous antiseptic NCT was well tolerated at a concentration of 1% upon inhalation in the pig model. Addition of ammonium chloride in high concentration provokes a statistically significant impact on blood oxygenation.