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Intraoral hirudotherapy is traditionally used for venous congestion following head and neck free flap reconstruction. Many institutions and healthcare teams have been reluctant to use intraoral leech therapy due to risks such as migration into the airway, increased infection from intraoral manipulation, and patient discomfort. Several protocols recommend blocking the path to the oropharynx via gauze or leaving a tracheotomy in place to protect the airway. This report pre-sents a novel technique for intraoral hirudotherapy that is safe and simple for treatment of free flap venous congestion. The base of a clear cup or a plastic lid is utilized, and the leech is attached onto the inside of the lid with 2 sutures near each end. Several cups with leeches attached are made at a time to reduce delay and difficulty of application by less experienced clinical staff. The leech is then applied onto the compromised flap and then simply removed once it has unlatched from the flap. This method allows the leech to be applied with ease by multiple members of the healthcare team, decreases the need for intraoral manipulation, and reduces the risk of migration into the aerodigestive tract. Future prospective studies are warranted to assess the efficacy of this technique.
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Retalhos de Tecido Biológico , Hiperemia , Aplicação de Sanguessugas , Procedimentos de Cirurgia Plástica , Humanos , Hiperemia/etiologia , Hiperemia/cirurgia , Aplicação de Sanguessugas/efeitos adversos , Aplicação de Sanguessugas/métodos , Pescoço , Procedimentos de Cirurgia Plástica/efeitos adversosRESUMO
BACKGROUND: Free flap failure or vascular compromise remains a dreadful complication of microvascular free tissue transfer. Near-infrared spectroscopy (NIRS) is a novel technique for free flap monitoring that has the propensity for early detection of vascular compromise when compared to the current gold standard, clinical monitoring (CM). The objective of this review is to evaluate the efficacy of a NIRS system in the postoperative monitoring of free flaps and its effect on flap salvage. METHODS: A comprehensive literature review was performed including English-language articles evaluating the use of NIRS in free flap monitoring. MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), OVID, and Web of Science were searched upto December 2017. RESULTS: A total of 590 articles were identified, and 10 articles were included for analysis. Overall, flaps with vascular compromise monitored with NIRS had a significantly higher salvage rate of 89% compared with a salvage rate of 50% in the flaps monitored by CM alone (p < .01). Partial loss occurred in 15% of the successful salvages in the NIRS group versus 80% with CM alone (p < .01). Detection of vascular compromise by NIRS preceded clinical signs on average by 82 ± 49 min. NIRS was accurate in detecting compromised flaps with a low false-positive and false-negative rate. CONCLUSION: Despite lack of robust data, NIRS has the potential to be an objective, accurate, and continuous postoperative free flap monitoring technique with a greater flap salvage rate than CM alone.
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Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica , Humanos , Monitorização Fisiológica , Cuidados Pós-Operatórios , Espectroscopia de Luz Próxima ao InfravermelhoRESUMO
Gastric pull-up (GPU) is among the oldest techniques for reconstructing the pharyngoesophageal junction following cancer resection. This review examines morbidity and mortality rates following GPU pharyngoesophageal junction reconstruction from 1959 until present: 77 studies, 2,705 patients. The odds of mortality, anastomotic complications, and other complications decreased by 37.2% (95%CI = 28.0-45.3%; P < 0.0001), 8.0% (95%CI = -2.1 to 17.1%; P = 0.12), 21.0% (95%CI 3.5-35.2%; P = 0.021) per decade respectively. J. Surg. Oncol. 2016;114:907-914. © 2016 Wiley Periodicals, Inc.
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Neoplasias Esofágicas/cirurgia , Esôfago/cirurgia , Neoplasias Faríngeas/cirurgia , Faringe/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/epidemiologia , Estômago/cirurgia , Anastomose Cirúrgica , Esofagectomia , Humanos , Laringectomia , Faringectomia , Procedimentos de Cirurgia Plástica/mortalidade , Resultado do TratamentoAssuntos
Esôfago/cirurgia , Procedimentos Cirúrgicos Otorrinolaringológicos/métodos , Faringe/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Estômago/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The post-operative management of parotidectomies is highly provider dependent. No guidelines are currently available for timing of parotid drain removal. This study aimed to assess: (1) outcomes and complications after early drain removal (< 4 h, post-operative day [POD] 0) versus late drain removal (POD ≥ 1); (2) current Canadian provider practices. METHODS: A single surgeons ten-year parotidectomy practice was reviewed, spanning his practice change from routine POD ≥ 1 drain removal to POD 0 removal, with extraction of patient demographic, disease, and complication variables. An anonymous, cross-sectional survey on parotid drain practices was distributed to Canadian Society of Otolaryngology-Head and Neck Surgery members. Descriptive statistics, Wilcoxon Rank Sum, and unpaired student's t-tests were calculated. RESULTS: In total, 526 patients were included and 44.7% (235/526) had drains removed POD 0. There was no significant difference in hematoma or seroma rates between the POD 0 and POD ≥ 1 drain removal cohorts. The national survey on parotid drain management had 176 responses. The majority (67.9%) reported routinely using drains after parotidectomy and 62.8% reported using a drain output based criteria for removal. The most common cut-off output was 30 ml in 24 h (range 5-70 ml). CONCLUSION: There was no difference in hematoma or seroma rates for patients with parotid drains removed on POD 0 versus POD ≥ 1. Our national survey found significant variation in Canadian parotidectomy drain removal practices, which may be an area that can be further assessed to minimize hospital resources and improve patient care.
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Remoção de Dispositivo , Seroma , Humanos , Estudos Transversais , Seroma/epidemiologia , Seroma/etiologia , Canadá , HematomaRESUMO
Objective: Laryngeal verrucous carcinoma (LVC) comprises 1% to 4% of all laryngeal tumors. Although controversial, surgery has been the mainstay of treatment, due to concern about anaplastic transformation with radiotherapy. We aimed to study LVC patients to identify treatment patterns for primary and recurrent diseases. Study Design: Retrospective cohort study. Setting: Tertiary referral center. Methods: Patients with a pathological diagnosis of LVC treated over a 28-year period were included. Baseline demographics, and treatment outcome measures including 5-year laryngeal preservation rates (LPR), overall survival (OS), and recurrence-free survival (RFS) were included. A literature review of published studies within the same study period was also completed. Results: Thirty-two patients were included in the analysis (median age 61.5 years, 93.8% [30/32] male). Twenty-three patients had T1 disease, and 9 had T2 disease with no evidence of regional or metastatic disease. The most common presenting symptom was hoarseness (93.8%) and the majority within the glottis 81.3% (26/32). Twenty-nine patients underwent primary surgery only (28 local excisions, 1 vertical partial laryngectomy) meanwhile 3 underwent local excision with postoperative radiotherapy. LPR, OS, and RFS at 5 years were 95.8%, 90.1%, and 80.6%, respectively. Our literature review identified 23 previous studies, mostly single-institution retrospective case series. Our study was the largest Canadian study in the literature to date. Conclusion: All LVC patients were treated with primary surgery, consistent with the current literature with excellent 5-year OS and LPR. There was no consensus on the treatment of recurrent disease. Future prospective multicenter studies are warranted to further study this rare disease population.
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BACKGROUND: The scapula free flap is a versatile option in head and neck reconstruction but is less amenable to simultaneous harvest and ablation. METHODS: Retrospective series (2015-2021) of consecutive scapula flaps. Cases categorized as simultaneous versus sequential, compared for operative time, oncological and patient-reported outcomes. RESULTS: Seventy consecutive scapula free flaps were performed (n = 21 simultaneous, n = 49 sequential). Mandible reconstruction was performed in 51.0% and 61.9% of sequential and simultaneous cases, respectively; 49.0% and 38.1% addressed bony maxillary defects. Simultaneous surgery reduced operative time by 37.9% (151 min, p < 0.00001) and there were fewer tracheostomies performed (p < 0.005). Rates of positive margins and free flap compromise were equivalent (n = 1, 4.8% vs. n = 2, 4.1%). There was no difference in patient-reported outcomes. CONCLUSIONS: This series demonstrates feasibility, efficacy, and outcomes of bony scapula reconstruction of maxillofacial defects comparing simultaneous and sequential approaches. Benefits of the two-team approach are highlighted including decreased operative time.
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Retalhos de Tecido Biológico , Neoplasias de Cabeça e Pescoço , Procedimentos de Cirurgia Plástica , Estudos de Viabilidade , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Estudos Retrospectivos , Escápula/cirurgiaRESUMO
BACKGROUND: Oral cancer is a major health problem worldwide. The 5-year survival rate ranges from 30-60%, and has remained unchanged in the past few decades. This is mainly due to late diagnosis and high recurrence of the disease. Of the patients who receive treatment, up to one third suffer from a recurrence or a second primary tumor. It is apparent that one major cause of disease recurrence is clinically unrecognized field changes which extend beyond the visible tumor boundary. We have previously developed an approach using fluorescence visualization (FV) technology to improve the recognition of the field at risk surrounding a visible oral cancer that needs to be removed and preliminary results have shown a significant reduction in recurrence rates. METHOD/DESIGN: This paper describes the study design of a randomized, multi-centre, double blind, controlled surgical trial, the COOLS trial. Nine institutions across Canada will recruit a total of 400 patients with oral severe dysplasia or carcinoma in situ (N = 160) and invasive squamous cell carcinoma (N = 240). Patients will be stratified by participating institution and histology grade and randomized equally into FV-guided surgery (experimental arm) or white light-guided surgery (control arm). The primary endpoint is a composite of recurrence at or 1 cm within the previous surgery site with 1) the same or higher grade histology compared to the initial diagnosis (i.e., the diagnosis used for randomization); or 2) further treatment due to the presence of severe dysplasia or higher degree of change at follow-up. This is the first randomized, multi-centre trial to validate the effectiveness of the FV-guided surgery. DISCUSSION: In this paper we described the strategies, novelty, and challenges of this unique trial involving a surgical approach guided by the FV technology. The success of the trial requires training, coordination, and quality assurance across multiple sites within Canada. The COOLS trial, an example of translational research, may result in reduced recurrence rates following surgical treatment of early-stage oral cancer with significant impacts on survival, morbidity, patients' quality of life and the cost to the health care system. TRIAL REGISTRATION: Clinicaltrials.gov NCT01039298.
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Carcinoma in Situ/cirurgia , Carcinoma de Células Escamosas/cirurgia , Fluorescência , Neoplasias de Cabeça e Pescoço/cirurgia , Neoplasias Bucais/cirurgia , Cirurgia Assistida por Computador/métodos , Canadá , Análise Custo-Benefício , Método Duplo-Cego , Humanos , Recidiva Local de Neoplasia , Anos de Vida Ajustados por Qualidade de Vida , Carcinoma de Células Escamosas de Cabeça e Pescoço , Cirurgia Assistida por Computador/economiaRESUMO
BACKGROUND: Gastric pull-up is a reconstructive option for circumferential defects after resection of advanced laryngopharyngeal malignancy. Voice loss is expected and vocal rehabilitation remains a challenge. Our study objectives were to investigate the feasibility of secondary tracheoesophageal puncture following gastric pull-up and to analyze voice outcomes. METHODS: This was a prospective cohort study of patients with advanced laryngopharyngeal malignancies who underwent gastric pull-up and secondary tracheoesophageal puncture between 1988 and 2017 at a tertiary-care academic institution. Objective acoustic measures included fundamental frequency and vocal intensity. Perceptual analysis was performed using voice recordings ("Rainbow Passage") randomly presented in a blinded fashion to four clinicians using the validated GRBAS scale. Speech intelligibility was assessed in a blinded fashion using a validated 7-point scale. Additionally, the Voice Handicap Index-10 was administered as a validated patient self-reporting tool. RESULTS: Ten patients (7 male, 3 female) were included, all of whom preferentially used tracheoesophageal puncture for communication. These patients had abnormal median fundamental frequency of 250 (interquartile range (IQR) 214-265) Hz and a limited median vocal intensity of 65.8 (IQR 64.1-68.3) dB. Perceptual analysis (GRBAS) revealed a median 'moderate' degree of impairment [grade 2 (IQR 2-3), roughness 2 (IQR 2-3), breathiness 3 (IQR 2-3), asthenia 2 (IQR 1-2), strain 2 (IQR 1-2)] as did median intelligibility scores [median 5 (IQR 4-7)]. Most patients self-reported an abnormal voice handicap-10 [median 26.5 (IQR 22.8-35.0)]. CONCLUSION: Secondary tracheoesophageal puncture is a safe and feasible option for voice rehabilitation after gastric pull-up. Although analyses demonstrated moderate subjective and objective impairment, tracheoesophageal puncture provided patients with a self-reported means of functional verbal communication and was their preferred method of communication.
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Esofagectomia/métodos , Neoplasias Laríngeas/cirurgia , Laringectomia/métodos , Faringectomia/métodos , Inteligibilidade da Fala , Qualidade da Voz , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , PunçõesRESUMO
Active surveillance (AS) in the management of small, low risk papillary thyroid cancer (PTC) as an alternative option to thyroidectomy, is an area of active research. A national Canadian study is proposed to evaluate the long-term outcomes of patients with small, low risk PTC who choose AS or surgery. This letter describes the proceedings of a national investigator meeting to plan the study.
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Vigilância da População/métodos , Sistema de Registros , Neoplasias da Glândula Tireoide/diagnóstico , Conduta Expectante/estatística & dados numéricos , Canadá/epidemiologia , Humanos , Incidência , Neoplasias da Glândula Tireoide/epidemiologiaRESUMO
BACKGROUND: Virtual surgical planning (VSP), via commercial services or developed in-house, has been applied to facilitate head and neck reconstruction. We evaluate a custom, automated planning software. METHODS: Prospectively, VSP of 25 consecutive patients undergoing segmental mandibular reconstruction was performed. Postoperative CT was used to assess structural accuracy of VSP. Operative time, length of stay, and complication rate of the prospective cohort were compared with those of 25 consecutive retrospective historical cases. RESULTS: The deviations between the plan and execution in mandibular width, projection, and volumetric overlap were 2.32 ± 3.91, 2.39 ± 1.72, and 0.59 ± 0.51 mm respectively. Compared with historical data, there was a significant reduction in operative time and length of stay, and no significant difference in complication rates. CONCLUSION: This is the largest prospective series evaluating an in-house VSP workflow for mandibular reconstruction and the first clinical evaluation of an automated planning platform.
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Retalhos de Tecido Biológico , Reconstrução Mandibular , Cirurgia Assistida por Computador , Fíbula , Humanos , Mandíbula/diagnóstico por imagem , Mandíbula/cirurgia , Estudos Prospectivos , Estudos RetrospectivosRESUMO
OBJECTIVES/HYPOTHESIS: Despite consensus that preoperative nutritional assessment is of importance in the head and neck surgical oncology population, it remains unclear how exactly malnutrition is associated with perioperative morbidity especially among those undergoing microvascular surgery. We aimed to study this association to help inform preoperative risk stratification, guide the use of nutritional interventions, and ultimately help prevent malnutrition related morbidity. STUDY DESIGN: Database analysis. METHODS: Retrospective, linked analysis of the 2011 to 2016 National Surgical Quality Improvement Program. After identifying eligible patients and stratifying according to the Nutrition-Related Index, a univariate screen of preoperative demographic and clinical covariates was performed. Subsequently, propensity score matching was utilized to control for differences in baseline covariates. Perioperative complications and mortality were then analyzed using the propensity score-matched cohorts. RESULTS: Among 977 identified patients, 276 (28.2%) were malnourished. Malnourished patients had higher rates of comorbidity, were more likely to actively smoke, and were more likely to have primaries in the oropharynx or hypopharynx/larynx. After propensity score matching to control for confounders, malnourished patients had higher rates of pulmonary complications (21.5% vs. 11.6%, P < .01), higher rates of bleeding or need for transfusion (56.6% vs. 43.0%, P < .01), higher rates of venous thromboembolism (3.7% vs. 0.8%, P = .03), and a higher 30-day mortality rates (3.7% vs. 0.0%, P < .01). CONCLUSIONS: This nationwide analysis finds that 28.2% of patients undergoing surgery for head and neck cancers with free flap reconstruction are malnourished. Malnourishment was found to be independently associated with postoperative pulmonary complications, bleeding or need for transfusion, and 30-day mortality. LEVEL OF EVIDENCE: NA Laryngoscope, 130:375-380, 2020.
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Neoplasias de Cabeça e Pescoço/cirurgia , Desnutrição/complicações , Microcirurgia , Avaliação Nutricional , Complicações Pós-Operatórias/epidemiologia , Feminino , Neoplasias de Cabeça e Pescoço/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
Importance: High local recurrence rates with aggressive disease remain the main concern in oral cancer survival. Use of a translational device using fluorescence visualization (FV) approved by the US Food and Drug Administration and Health Canada, has shown a marked reduction in the 3-year local recurrence rate of high-grade oral lesions in a single-center observational study. Objective: To determine whether FV- guided surgery can improve local control rates in the treatment of in situ or T1 to T2 category oral squamous cell carcinoma (OSCC). Design, Setting, and Participants: A multicenter randomized clinical trial was conducted in a surgical setting. A total of 457 patients were enrolled between January 18, 2010, and April 30, 2015. Data analysis of the intention-to-treat population was performed from April 3, 2019, to March 20, 2020. Patients with histologically confirmed high-grade dysplasia/carcinoma in situ or T1 to T2 category OSCC were randomized to receive traditional peroral surgery or FV-guided surgery. Intervention: Fluorescence visualization during surgery. Main Outcomes and Measures: The primary outcome was local recurrence of OSCC. Secondary outcomes were failure of the first-pass margin, defined as a histologically confirmed positive margin for severe dysplasia or greater histologic change of the main specimen (ie, not the margins taken from the resection bed), regional or distant metastasis, and death due to disease. Results: Of the 457 patients enrolled in the study, 443 patients (264 [59.6%] men; mean [SD] age, 61.5 [13.3] years) completed the randomized treatment: 227 FV-guided and 216 non-FV guided surgery. The median follow-up was 52 (range, 0.29-90.8) months. In total, 45 patients (10.2%) experienced local recurrence. The 3-year local recurrence rate was 9.4% in the FV-guided group and 7.2% in the non-FV group (difference, 2.2%; 95% CI, -3.2% to 7.4%). Other similarities between the FV vs non-FV groups included failure of first-pass margin (68/227 [30.0%]) vs 65/216 [30.1%]), regional failure (39/227 [17.2%] vs 37/216 [17.1%]), disease-specific survival (23/227 [10.1%] vs 19/26 [8.8%]), and overall survival (41/227 [18.1%] vs 38/216 [17.6%]) were also similar between groups. No adverse events were judged to be related to the intervention. Conclusions and Relevance: In this randomized clinical trial, FV-guided surgery did not improve local control rates in the treatment of patients with in situ or T1 to T2 category oral cancer. Under a controlled environment, FV-guided surgery did not have an evident effect in reduction of local recurrence for localized OSCC. This result suggests that attention be directed to strategies other than improving definitions of nonapparent disease at clinical margins to identify the sources of local recurrence. Trial Registration: ClinicalTrial.gov Identifier: NCT01039298.
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Carcinoma in Situ/cirurgia , Carcinoma de Células Escamosas/cirurgia , Neoplasias Bucais/cirurgia , Recidiva Local de Neoplasia/epidemiologia , Imagem Óptica , Cirurgia Assistida por Computador , Idoso , Carcinoma in Situ/mortalidade , Carcinoma in Situ/patologia , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Neoplasias Bucais/mortalidade , Neoplasias Bucais/patologia , Gradação de Tumores , Estadiamento de Neoplasias , Taxa de SobrevidaRESUMO
BACKGROUND: To describe and evaluate a four step systematic approach to dissecting the recurrent laryngeal nerve (RLN) starting at the cricothyroid junction during thyroid surgery (subsequently referred to as the retrograde medial approach). METHODS: All thyroidectomies completed by the senior author between August 2014 and January 2016 were retrospectively reviewed. Patients were excluded if concurrent lateral or central neck dissection was performed. A follow up period of 1 year was included. RESULTS: Surgical photographs and illustrations demonstrate the four steps in the retrograde medial approach to dissection of the RLN in thyroid surgery. Three hundred forty-two consecutive thyroid surgeries were performed in 17 months, including 213 hemithyroidectomies, 91 total thyroidectomies, and 38 completion thyroidectomies. The rate of temporary and permanent hypocalcemia was 13% (95% confidence interval [CI]: 8-20%) and 3% (95% CI: 1-8%) respectively. The rate of temporary and permanent vocal cord palsy was 9% (95% CI: 6-12%) and 0.3% (95%CI: 0.01-2%) respectively. The median surgical times for hemithyroidectomy, total thyroidectomy, and completion thyroidectomy were 39 min (Interquartile range [IQR]: 33-47 min), 48 min (IQR: 40-60 min), and 40 min (IQR: 35-51 min) respectively. 1% of cases required conversion to an alternative surgical approach. CONCLUSION: In a tertiary endocrine head and neck practice, the routine use of the retrograde medial approach to RLN dissection is safe and results in a short operative time, and a low conversion rate to other RLN dissection approaches.
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Complicações Pós-Operatórias/prevenção & controle , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controle , Nervo Laríngeo Recorrente/cirurgia , Tireoidectomia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Nervo Laríngeo Recorrente/anatomia & histologia , Estudos Retrospectivos , Neoplasias da Glândula Tireoide/cirurgia , Adulto JovemRESUMO
BACKGROUND: As transoral robotic surgery (TORS) is being increasingly used to treat patients with oropharyngeal squamous cell carcinoma (OPSCC), there is an interest in determining contributors to readmission. METHODS: We conducted this retrospective multivariate analysis modeling 30-day readmission using the Nationwide Readmissions Database (2012-2014). RESULTS: Of 950 patients, 117 (12.3%) were readmitted. Hemorrhage and diet/aspiration accounted for 32.5% and 19.7% of readmissions, respectively. Of those readmitted, 23.1% required operative bleeding control, 11.1% required transfusion, 1.7% required tracheostomy, and 18.8% required gastrostomies. Those readmitted were older (mean 63.2 years, SD 9.5 vs 60.9 mean years, SD 10.3) and had longer hospitalizations (mean 5.7 days, SD 6.8 vs mean 4.3 days, SD 4.1) and higher rates of aspiration/pneumonia (9.4% vs 2.4%, P < .01) on index admission. Multivariate analysis demonstrated that aspiration/pneumonia on index admission was independently associated with readmission (OR 3.128, 95% CI 1.178-8.302). CONCLUSIONS: Of the patients 12.3% were readmitted within 30 days with hemorrhage and diet complications as significant contributors.
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Carcinoma de Células Escamosas/cirurgia , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Neoplasias Orofaríngeas/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Idoso , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Estudos de Coortes , Bases de Dados Factuais , Intervalo Livre de Doença , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Cirurgia Endoscópica por Orifício Natural/métodos , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Neoplasias Orofaríngeas/mortalidade , Neoplasias Orofaríngeas/patologia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/patologia , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Procedimentos Cirúrgicos Robóticos/métodos , Análise de Sobrevida , Estados UnidosRESUMO
Objectives There are well-established outcome disparities among different demographic groups with head and neck squamous cell carcinoma (HNSCC). We aimed to investigate the potential contribution of patient choice of nonsurgical treatment to these disparities by estimating the rate of this phenomenon, identifying its predictors, and estimating the effect on cancer-specific survival. Study Design Retrospective nationwide analysis. Settings Surveillance, Epidemiology, and End Results Database (2004-2014). Subjects and Methods Patients with HNSCC, who were recommended for primary surgery, were included. Multivariable logistic regression was used to identify demographic and clinical factors associated with patient choice of nonsurgical treatment, and Kaplan Meier/Cox regression was used to analyze survival. Results Of 114,506 patients with HNSCC, 58,816 (51.4%) were recommended for primary surgery, and of those, 1550 (2.7%) chose nonsurgical treatment. Those who chose nonsurgical treatment were more likely to be older (67.1 ± 12.6 vs 63.6 ± 13.1, P < .01), were of Black (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.28-1.74) or Asian (OR = 1.79; 95% CI, 1.46-2.20) ethnicity, were unmarried (OR married, 0.50; 95% CI, 0.44-0.58), had an advanced tumor, and had a hypopharyngeal or laryngeal primary. Choice of nonsurgical treatment imparted a 2.16-fold (95% CI, 2.02-2.30) increased risk of cancer-specific death. Conclusion Of the patients, 2.7% chose nonsurgical treatment despite a provider recommendation that impairs survival. Choice of nonsurgical treatment is associated with older age, having Black or Asian ethnicity, being unmarried, having an advanced stage tumor, and having a primary site in the hypopharynx or larynx. Knowledge of these disparities may help providers counsel patients and help patients make informed decisions.
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Neoplasias de Cabeça e Pescoço/psicologia , Neoplasias de Cabeça e Pescoço/terapia , Preferência do Paciente , Carcinoma de Células Escamosas de Cabeça e Pescoço/psicologia , Carcinoma de Células Escamosas de Cabeça e Pescoço/terapia , Idoso , Demografia , Feminino , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Programa de SEER , Carcinoma de Células Escamosas de Cabeça e Pescoço/mortalidade , Carcinoma de Células Escamosas de Cabeça e Pescoço/patologia , Taxa de Sobrevida , Resultado do Tratamento , Recusa do Paciente ao Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: Post-acute care (PAC) centers, such as skilled nursing facilities, unskilled nursing facilities, lower acuity hospitals, and rehabilitation centers, serve to optimize recovery after acute care hospitalization. We aimed to identify factors associated with PAC utilization among patients undergoing head and neck cancer surgery with microvascular reconstruction because it may be helpful for patient decision making, discharge planning, and resource allocation. METHODS: Retrospective linked analysis of the 2011 to 2015 National Surgical Quality Improvement Program. Eligible patients were identified and stratified by discharge disposition (home or PAC) after their postoperative acute-care hospitalization. After an initial univariate screen of demographic and clinical variables, a multivariable logistic regression analysis was performed modelling discharge to PAC. RESULTS: Of the 1,652 identified patients, 261 (15.8%) were discharged to PAC. Those admitted to PAC were older, had a higher burden of comorbidity, and were more likely to be functionally dependent. They also had longer surgeries, longer hospitalizations, higher rates of reoperation, and higher rates of postoperative complications. After multivariate analysis, factors independently associated with PAC discharge included increasing age (odds ratio [OR] 2.12 per 10-year increase; 95% confidence interval [CI], 1.81-2.48), active smoking status (odds ratio (OR) 1.61; 95% confidence interval (CI), 1.13-2.29), prolonged hospitalization (OR 1.04; 95% CI, 1.02-1.07), and postoperative pulmonary complications (OR 2.02; 95% CI, 1.36-2.99). CONCLUSION: Of the patients undergoing surgery for head and neck cancers with microvascular reconstruction, 15.8% are discharged to PAC. Age, active smoking status, prolonged hospitalization, and postoperative pulmonary complications (vs. comorbidity, functional status, or primary tumor site) are independently associated with discharge to PAC. LEVEL OF EVIDENCE: Level 2c. Laryngoscope, 2532-2538, 2018.
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Neoplasias de Cabeça e Pescoço/cirurgia , Microcirurgia/métodos , Procedimentos de Cirurgia Plástica/métodos , Instituições de Cuidados Especializados de Enfermagem , Cuidados Semi-Intensivos/estatística & dados numéricos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Air travel mostly causes minor ear, nose and throat complaints. We describe a second report in literature of airway obstruction caused by a drop in atmospheric pressure during a routine commercial flight. CASE PRESENTATION: A 54-year-old male was referred to a head and neck surgeon with a 2 cm left submandibular mass that would enlarge during commercial flights. As the plane gained elevation, the mass would grow and cause him to become stridorous and short of breath. The shortness of breath and stridor would only resolve upon landing of the plane. A CT scan showed a large air sac extending from the larynx at the level of the true vocal cords up to the angle of the mandible. Based on the history and the CT findings a diagnosis of a laryngocele was made. The laryngocele was excised using an external approach, resolving the patient's difficulty with flying. CONCLUSION: This article reports a rare case of upper airway obstruction caused by atmospheric pressure changes during air travel. The reported case is of significance as only a few uncomplicated laryngoceles have been reported to cause airway distress in the literature. This report highlights the epidemiology, presentation, complication and management of laryngoceles.