Team-Based Surgical Approach to Head and Neck Microvascular Free Flap Reconstruction.

Importance: Because microvascular free flap reconstruction is increasingly used to restore function in patients with head and neck cancer, there is a growing need for evidence-based perioperative care. Objective: To assess the association of different team-based surgical approaches with intraoperative and postoperative outcomes for patients undergoing head and neck free flap reconstruction. Design, Setting, and Participants: This retrospective cohort study of 733 patients was conducted at an academic tertiary care medical center. Head and neck oncologic procedures involving microvascular free flap reconstruction with available intraoperative data collected from January 1, 2000, to December 31, 2021, were included. Main Outcomes and Measures: Patient characteristics including demographic characteristics and comorbid conditions, operative variables, length of stay, and postoperative outcomes were measured. Descriptive statistics and effect size measures were performed to compare the 3 intraoperative surgical team approaches, specifically single surgeon, separate 2-team approach, and integrated 2-team approach; 1:1 nearest neighbor matching without caliper was performed to compare single- vs 2-team and separate and integrated 2-team approaches. Effect size measures including Cramer V for dichotomous variables, the Kendall W coefficient of concordance for ordinal variables, and η2 for continuous variables were reported with 95% CIs to describe precision. Results: Among 733 cases, there were no clinically significant differences in patient demographic characteristics, clinicopathologic characteristics, and choice of free flap reconstruction based on intraoperative surgical team approach. The mean (SD) age was 58.7 (12.4) years, and 514 were male (70.1%). In terms of operative and postoperative variables, there was a difference in operative times and intraoperative fluid requirements among the 3 different techniques, with the integrated 2-team approach demonstrating a mean reduction in operative time of approximately 2 hours (η2 = 0.871; 95% CI, 0.852-0.887; mean [SD] operative time = 541 [191] minutes for the single-surgeon approach, 399 [175] minutes for the integrated 2-team approach, and 537 [200] minutes for the separate 2-team approach) and lower fluid requirements of greater than 1 L (η2 = 0.790; 95% CI, 0.762-0.817). In both unadjusted analyses and propensity score matching, there were no clinically significant differences in terms of ischemia time, use of pressors, postoperative complications (including free flap failure, number of return trips to the operating room, length of stay, or 30-day readmission) based on intraoperative team approach. Conclusions and Relevance: Findings suggest that the integrated 2-team surgical approach for complex head and neck microvascular reconstruction can be used to safely decrease operative time, with no difference in postoperative outcomes.

Lymph node level ratio as a predictor of survival in oral cavity squamous cell carcinoma.

OBJECTIVE: To evaluate whether nodal yields and ratios based on level serves as prognostic indicators in patients with oral cavity squamous cell carcinoma undergoing neck dissection. MATERIALS AND METHODS: A retrospective analysis of 342 patients with oral cavity squamous cell carcinoma treated surgically between 1998 and 2017 were included.Demographics and clinicopathologic data were collated. Disease specific survival and overall survival were analyzed via Kaplan-Meier method and log-rank test as well as univariable and multivariable Cox models. RESULTS: Total nodal yield is associated with improved overall and disease specific survival (p < 0.01). Total positive nodal yield (p < 0.01), positive nodal ratio per level (p < 0.001), and identification of <4 lymph nodes/level (p < 0.001) are associated with worse disease specific survival and overall survival. A ratio of at least 4 lymph nodes/level dissected yields the maximal hazard ratio on for both disease specific and overall survival optimizes the Kaplan-Meier split between survival groups. After controlling for sex, age, margin status, disease stage, extranodal extension, perineural invasion, and lymphovascular invasion as fixed covariates in the Cox models, a nodal level ratio of 4 lymph nodes/level provides hazard ratio (95% CI) of 3.59 (1.69, 7.60); p < 0.0006) for disease free survival and 2.90 (1.54, 5.46; p < 0.001) for overall survival. CONCLUSION: Nodal level ratio of < 4 lymph nodes/level is associated with worse disease specific and overall survival in oral cavity squamous cell carcinoma. This level-specific metric may prove useful qualitatively and in predicting survival in oral cavity cancer with broader utility to address variations in levels of neck dissection performed.

The Michigan Action Progress System (MAPS): Enhancing a Culture of Professionalism, Accountability, and Psychological Safety.

OBJECTIVE: To prioritize trainee well-being, promote professionalism, and allow individuals to raise concerns without fear of retribution, one surgical department created an innovative process by which individuals can raise concerns and obtain subsequent support. DESIGN AND SETTING: The University of Michigan Department of Surgery implemented the Michigan Action Progress System (MAPS) in February 2021. PARTICIPANTS: General Surgery residents, faculty, and staff voluntarily participate in MAPS. RESULTS: Since implementation, there have been 26 entries into MAPS. Petitioners included students (10, 38%), residents and fellows (7, 27%), staff (1, 4%), faculty (1, 4%), and anonymous petitioners (7, 27%). Concerns regarding racism (1, 4%), bullying (11, 52%), gender discrimination (1, 4%), and other incidents (8, 38%) were addressed though MAPS. CONCLUSIONS: We have successfully implemented an innovative system that focuses on the needs of the user, consolidates handling of concerns, and emphasizes transparency, documentation, education, and improvement to promote a culture of professionalism and accountability.

Translation of Legislation: Effect Analysis of Michigan Opioid Law on Clinical Practice.

BACKGROUND: To combat almost 450,000 Americans dying of opioid overdose between 1999 and 2018, the Michigan Opioid Laws were implemented on July 1, 2018, to reduce overprescription of opioids. This retrospective study evaluated the effect of this legislation on prescribing patterns after thoracic operations at an academic, tertiary care center. METHOD: Charts of 776 patients undergoing lobectomy, paraesophageal hiatal hernia repair, Nissen fundoplication, or esophagectomy between July 1, 2017, and July 1, 2019, were reviewed. Populations were identified before and after the July 1, 2018 implementation of the Michigan Opioid Laws. Procedure type, analgesic type, total pills, morphine equivalents, and refills and their pill number were independent variables. Patients using opioids for >30 days before operations were excluded. RESULTS: Overall, 629 patients were included in the analysis (324 pre-legislation patients, 305 post-legislation patients). The average number of opioids prescribed to patients at discharge before the legislation was 28.0 pills vs 21.4 pills after (P < .01). Before implementation of the Michigan Opioid Laws, 14.5% of patients received refills, whereas only 5.9% received refills after implementation, reducing the average number of refills per patient from 0.19 to 0.07 (P < .001). Average morphine equivalents and percentage of patients receiving opioids showed no statistical difference. CONCLUSIONS: The implementation of the Michigan Opioid Laws correlated with a change in clinical practice, potentially by reducing the number of pills and refills prescribed per patient, and did not deter providers from prescribing opioids acutely. This suggests that the Michigan Opioid Laws allow prescribing freedom while giving legislative structure encouraging time-conscious tapering. The Michigan Opioid Laws may serve as a model for other states to emulate.