Transoral robotic surgery - time for consensus on pain assessment. A review.

BACKGROUND: In Head and Neck surgery Transoral Robotic Surgery (TORS) is evolving as a key treatment option for benign and malignant lesions in the oropharynx. Even so, postoperative pain is one of the primary early complaints following TORS. Well established evidence-based procedure specific pain treatment guidelines are available for a variety of other surgical specialties. However, there are no guidelines for TORS. AIM: This review describes the available data of early pain intensity following TORS during rest and procedure related activity. METHODS: Literature concerning pain in the immediate postoperative phase following TORS were obtained from two literature databases. RESULTS: Most data on pain intensity following TORS are based upon a numeric rating scale, e.g. the Visual Analogue Scale and/or analgesic demands. Only one randomized clinical trial is available reflecting that the literature is mainly based on retrospective and a few prospective studies. Only one study analyzed pain during relevant functionality, i.e. swallowing. Overall, the studies suffer from a non-standardized approach and there is a need for transparent information concerning the timing of pain ratings and methodology. CONCLUSIONS: The evidence for optimal pain control is limited, particularly during surgical relevant activity. Postoperative pain rating during activity is a fundamental element in pain trials in order to enhance recovery thereby calling for future consensus on assessment methodology.

Why in hospital following transoral robotic lingual tonsillectomy?

BACKGROUND: The reported hospital length of stay (LOS) following transoral robotic surgery lingual tonsillectomy (TORS-L) is variable, with limited understanding of the factors requiring hospitalization and no evidence-based criteria for discharge. AIMS/OBJECTIVES: This observational cohort study investigated factors hindering discharge following TORS-L in a well-defined postoperative care program. METHODS: Patients were included between August 2020 and October 2022. A discharge scheme was filled out twice daily, specifying the factor(s) for hospitalization among patients undergoing TORS-L. This trial was a sub-investigation of a national multicentre randomized clinical trial (RCT) testing the efficiency of high-dose dexamethasone on postoperative pain control. Participation in the RCT demanded admission to the fourth postoperative day as dexamethasone/placebo was given intravenously in repeated dosages till day 4 postoperatively. RESULTS: Eighteen patients were included in the analysis. The main factor for hospitalization was nutritional difficulties, while pain was a limiting factor for discharge only on the first postoperative 1-3 days. More than half of the patients could have potentially been discharged on postoperative day 2 when omitting the RCT treatment plan in the analysis. CONCLUSION: The study estimates that the majority of patients may be discharged on postoperative day 2 following TORS-L.

The effect of dexamethasone on functional pain following Transoral Robotic Surgery: a randomized double blinded clinical trial.

BACKGROUND: Pain is prevalent after most TransOral Robotic Surgery (TORS) procedures and may limit function i.e. swallowing. Currently, there is limited knowledge regarding optimal pain treatment in TORS. AIMS/OBJECTIVES: This clinical trial randomized patients to either a high-dose dexamethasone or low-dose dexamethasone treatment in addition to a multimodal basic analgesic protocol. The aim of the trial was to investigate the pain intensity during rest and swallowing using the Visual Analogue Scale (VAS) after TORS lingual tonsillectomy. Secondary outcomes were acceptable food consistency, nausea, vomiting, opioid rescue usage, length of hospitalization, feeding tube placements, readmissions, blood glucose levels and postoperative complications. METHODS: The trial was conducted between August 2020 and October 2022. Eligible patients were patients scheduled for TORS-L treatment of obstructive sleep apnea syndrome or as part of the diagnostic work-up of head and neck carcinoma of unknown primary. RESULTS: Eighteen patients were and randomized 1:1. There were overall no significant differences between groups in the reported VAS scores during rest or swallowing (p ≥ .05). Overall, there were no differences in the secondary outcomes. CONCLUSION: There were no differences in the pain intensity in the two treatment groups allocated to a basic multimodal analgesic package and either high-dose dexamethasone or low-dose dexamethasone treatment. The trial is the first RCT to include pain measurement during a procedure-relevant activity, thus creating a platform for future recovery studies.

[Transoral robotic surgery for the head and neck].

Transoral robotic surgery (TORS) has been utilized in the head and neck field for more than a decade. It is a minimally invasive technique which ensures flexible instrumentation and 3D visualization of the oropharynx. This has led to a paradigm shift in the treatment of early-stage oropharyngeal cancer and in the diagnostic management of unknown primary of the head and neck. Over time, the indications for TORS have broadened. This review discusses the development, current indications, and future perspectives of TORS within head and neck surgery.

Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study.

BACKGROUND: Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness. METHODS: A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC. RESULTS: Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores. CONCLUSIONS: Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

Human Papillomavirus and Squamous Cell Carcinoma of Unknown Primary in the Head and Neck Region: A Comprehensive Review on Clinical Implications.

Squamous cell carcinoma of unknown primary (SCCUP) is a challenging diagnostic subgroup of oropharyngeal squamous cell carcinoma (OPSCC). The incidence of SCCUP is increasing in parallel with the well-documented increase in OPSCC and is likewise driven by the increase in human papillomavirus (HPV). The SCCUP patient often presents with a cystic lymph node metastasis and undergoes an aggressive diagnostic and treatment program. Detection of HPV in cytologic specimens indicates an oropharyngeal primary tumor origin and can guide the further diagnostic strategy. Advances in diagnostic modalities, e.g., transoral robotic surgery and transoral laser microsurgery, have increased the successful identification of the primary tumor site in HPV-induced SCCUP, and this harbors a potential for de-escalation treatment and increased survival. This review provides an overview of HPV-induced SCCUP, diagnostic modalities, and treatment options.

Long-term survival outcomes after primary transoral robotic surgery (TORS) with concurrent neck dissection for early-stage oropharyngeal squamous cell carcinoma.

BACKGROUND: In 2013, transoral robotic surgery (TORS) was implemented as a protocolled treatment alternative to the traditional radiotherapy (RT) in Denmark for oropharyngeal squamous cell carcinoma (OPSCC). In 2017, we published our first prospective feasibility study, showing that TORS with concurrent neck dissection successfully achieved negative margins in 29 out of 30 patients (97%) with early-stage OPSCC. AIMS/OBJECTIVES: This follow-up study aims to evaluate the five-year overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS). METHODS: Retrospective follow-up study including 30 patients treated with TORS for early-stage OPSCC (T1-T2, N0-N1, M0, UICC 7th edition) from September 2014 to January 2016 at a single head and neck cancer centre in Denmark. The five-year OS, DSS and RFS, including a detailed analysis of the recurrences, were addressed. RESULTS: The five-year OS, DSS and RFS was 90%, 93% and 87%, respectively. Median follow-up was 54.5 months. Four patients developed a recurrence, with one regional, one distant metastatic (M) and two locoregional recurrences. The median time to recurrence was 24 months (range 3-42 months). CONCLUSIONS AND SIGNIFICANCE: This follow-up study demonstrates good five-year OS, DSS and RFS in a prospective cohort of patients undergoing TORS and neck dissection for early-stage OPSCC.

Days alive and out of hospital a validated patient-centred outcome to be used for patients undergoing transoral robotic surgery: protocol and perspectives.

BACKGROUND: Days Alive and Out of Hospital (DAOH) has been validated as a suitable clinical trial outcome. It can be used as a proxy for surgical quality and reflects both procedure specific morbidity and mortality. AIMS/OBJECTIVES: We propose DAOH as a supplement to established patient-related and objective outcomes, since it adds information on health care burden. Two upcoming studies incorporating DAOH are planned and will report DAOH for patients undergoing transoral robotic surgery. METHODS: Firstly, a multicentre national prospective cohort study investigating DAOH with a 1-year follow-up after TORS is planned. Secondly a retrospective study of DAOH with a 1-year follow-up period will be performed using our institute's, the largest TORS center in Scandinavia, transoral robotic surgery (TORS) database. The database consists of more than 250 patients with more than 300 procedures performed between 2013 and 2018. CONCLUSION AND SIGNIFICANCE: The planned studies of DAOH may, when applied to TORS, contribute to a better interpretation of post-treatment morbidity and provide a basis for further interventional studies to enhance recovery, perioperative optimization, and serve as a comparison tool between treatment modalities.