RESUMEN
PURPOSE: Head and neck paragangliomas are slow growing tumors where observation has become more widely accepted. Tumor growth rate as well as predictors of increased tumor growth were analyzed with the goal to identify factors to better predict disease progression and counsel patients. MATERIALS AND METHODS: Multi-institutional retrospective cohort study from 2011 to 2020. RESULTS: 130 head and neck paragangliomas in 125 patients were analyzed. 38 were observed (30.4%), 16 radiated (12.8%), and 71 underwent surgery (56.8%). Surgical patients were significantly younger (p = 0.038) and with more genetically mediated paragangliomas (p = 0.026). Significantly more patients were asymptomatic in the observation group (p = 0.005). Of the 39 observed tumors, 43.6% (n = 17) grew with a tumor doubling time of 5.67 years. More than half of the observed paragangliomas had no growth. When examining symptoms postoperatively and at follow-up, the surgical cohort had significantly more worsening symptoms (p = 0.007) and new cranial neuropathies (p = 0.031). CONCLUSIONS: Head and neck paragangliomas have slow growth rates if they grow at all. Patients in the surgical cohort had more clinical symptoms at presentation and worsening postoperative symptoms.
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Enfermedades de los Nervios Craneales , Neoplasias de Cabeza y Cuello , Paraganglioma , Progresión de la Enfermedad , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Paraganglioma/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: During the last two decades, significant advancements in the treatment of laryngeal cancer have occurred. Although survival of head and neck cancer patients has improved over time, the temporal trend of laryngeal cancer survival is an area of controversy. METHODS: From 2004 to 2016, 77,527 patients who had laryngeal cancer treated with curative intent in the United States were identified in the National Cancer Database. Relative and observed survival rates were assessed for temporal trends. Multinomial logistic regression investigated the relationship between American Joint Committee on Cancer (AJCC) stage and increasing calendar year. RESULTS: No significant improvement in 2- or 5-year observed survival (OS) or relative survival (RS) was observed. The 5-year RS ranged from 61.72 to 63.97%, and the 5-year OS ranged from 54.26 to 56.52%. With each increasing year, the proportion of stage 4 disease increased, with risk for stage 4 disease at the time of diagnosis increasing 2.2% annually (adjusted odds ratio [aOR], 1.022; 95% confidence interval [CI], 1.017-1.028; p < 0.001). This increase was driven by a 4.7% yearly increase in N2 disease (aOR, 1.047; 95% CI, 1.041-1.053; p < 0.001), with an annual 1.2% increase in T3 disease (aOR, 1.012; 95% CI, 1.007-1.018; p < 0.001) and a 1.2% increase in T4 disease (aOR, 1.012; 95% CI, 1.005-1.018; p < 0.001). CONCLUSION: Despite advances in the field, laryngeal cancer survival in the United States is not improving over time. This may be due to an increase in the proportion of stage 4 disease, driven primarily by increasing nodal disease. To achieve survival improvement commensurate with scientific and technologic advances, efforts should be made to diagnose and treat laryngeal cancer at earlier stages to prevent further stage migration.
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Neoplasias de Cabeza y Cuello , Neoplasias Laríngeas , Humanos , Neoplasias Laríngeas/patología , Neoplasias Laríngeas/terapia , Estadificación de Neoplasias , Estudios Retrospectivos , Tasa de Supervivencia , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: The COVID-19 pandemic has required triage and delays in surgical care throughout the world. The impact of these surgical delays on survival for patients with head and neck squamous cell carcinoma (HNSCC) remains unknown. METHODS: A retrospective cohort study of 37 730 patients in the National Cancer Database with HNSCC who underwent primary surgical management from 2004 to 2016 was performed. Uni- and multivariate analyses were used to identify predictors of overall survival. Bootstrapping methods were used to identify optimal time-to-surgery (TTS) thresholds at which overall survival differences were greatest. Cox proportional hazard models with or without restricted cubic splines were used to determine the association between TTS and survival. RESULTS: The study identified TTS as an independent predictor of overall survival (OS). Bootstrapping the data to dichotomize the cohort identified the largest rise in hazard ratio (HR) at day 67, which was used as the optimal TTS cut-point in survival analysis. The patients who underwent surgical treatment longer than 67 days after diagnosis had a significantly increased risk of death (HR, 1.189; 95% confidence interval [CI], 1.122-1.261; P < 0.0001). For every 30-day delay in TTS, the hazard of death increased by 4.6%. Subsite analysis showed that the oropharynx subsite was most affected by surgical delays, followed by the oral cavity. CONCLUSIONS: Increasing TTS is an independent predictor of survival for patients with HNSCC and should be performed within 67 days after diagnosis to achieve optimal survival outcomes.
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Neoplasias Hipofaríngeas/cirugía , Neoplasias Laríngeas/cirugía , Neoplasias de la Boca/cirugía , Neoplasias Orofaríngeas/cirugía , Procedimientos Quirúrgicos Otorrinolaringológicos/estadística & datos numéricos , Carcinoma de Células Escamosas de Cabeza y Cuello/cirugía , Tiempo de Tratamiento/estadística & datos numéricos , Anciano , COVID-19 , Estudios de Cohortes , Atención a la Salud , Femenino , Humanos , Neoplasias Hipofaríngeas/mortalidad , Neoplasias Laríngeas/mortalidad , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/mortalidad , Neoplasias Orofaríngeas/mortalidad , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , SARS-CoV-2 , Carcinoma de Células Escamosas de Cabeza y Cuello/mortalidad , Oncología QuirúrgicaRESUMEN
BACKGROUND: Human papillomavirus (HPV)-mediated oropharyngeal cancer (OPC) is associated with dramatically improved survival in comparison with HPV-negative OPC and can be successfully treated with surgical and nonsurgical approaches. National treatment trends for OPC were investigated with the National Cancer Data Base (NCDB). METHODS: The NCDB was reviewed for primary HPV-mediated OPC in 2010-2014. Multivariable regression was used to identify predictors of both nonsurgical therapy and receipt of adjuvant chemoradiation (CRT). RESULTS: There were 13,363 patients identified with a median age at diagnosis of 58 years. The incidence of triple-modality treatment (surgery with adjuvant chemotherapy) decreased from 23.7% in 2010 to 16.9% in 2014 (R2 = 0.96), whereas the incidence of nonsurgical treatment increased from 63.9% to 68.7% (R2 = 0.89). Hospitals in the top treatment volume quartile (quartile 1 [Q1]; n = 29) had a lower rate of positive margins (16.3%) than bottom-quartile centers (n = 741; rate of positive margins, 36.4%; P < .001); Q1 hospitals used surgical therapy significantly more. Independent predictors of nonsurgical therapy included older age, advanced disease, lower hospital volume, and living closer to the hospital or outside the Pacific United States. In surgically treated patients, younger age, lower hospital volume, nodal disease, positive surgical margins, and extranodal extension (ENE) also predicted more adjuvant CRT use. CONCLUSIONS: The use of upfront surgical treatment decreased from 2010 to 2014. Hospital volume shows a strong, inverse correlation with the rate of positive surgical margins. The upfront treatment strategy is predicted not only by staging but also by patient-, geographic-, and hospital-specific factors. Lower hospital volume remains independently associated with increased triple-modality therapy after adjustments for positive margins, ENE, and pathologic staging.
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Carcinoma de Células Escamosas/terapia , Neoplasias Orofaríngeas/terapia , Infecciones por Papillomavirus/complicaciones , Factores de Edad , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/virología , Quimioradioterapia Adyuvante/estadística & datos numéricos , Distribución de Chi-Cuadrado , Terapia Combinada/tendencias , Femenino , Accesibilidad a los Servicios de Salud , Hospitales de Alto Volumen/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Humanos , Masculino , Márgenes de Escisión , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Orofaríngeas/patología , Neoplasias Orofaríngeas/virología , Faringectomía , Análisis de Regresión , Estudios Retrospectivos , Estadísticas no Paramétricas , Estados UnidosRESUMEN
Resection and reconstruction of midface involve complex ablative and reconstructive tools in head and oncology and maxillofacial prosthodontics. This region is extraordinarily important for long-term aesthetic and functional performance. From a reconstructive standpoint, this region has always been known to present challenges to a reconstructive surgeon due to the complex three-dimensional anatomy, the variable defects created, combination of the medical and dental functionalities, and the distance from reliable donor vessels for free tissue transfer. Another challenge one faces is the unique features of each individual resection defect as well as individual patient factors making each preoperative planning session and reconstruction unique. Understanding the long-term effects on speech, swallowing, and vision, one should routinely utilize a multidisciplinary approach to resection and reconstruction, including head and neck reconstructive surgeons, prosthodontists, speech language pathologists, oculoplastic surgeons, dentists, and/or craniofacial teams as indicated and with each practice pattern. With this in mind, we present our planning and reconstructive algorithm in midface reconstruction, including a dedicated focus on dental rehabilitation via custom presurgical planning.
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Procedimientos de Cirugía Plástica , Colgajos Quirúrgicos , Estética Dental , Cara/cirugía , Humanos , Periodo PreoperatorioRESUMEN
BACKGROUND: The status of surgical margins is the most important prognosticator for patients undergoing surgical resection of head and neck squamous cell carcinoma (HNSCC). Despite this, analysis of surgical margins is fraught with inconsistencies, including the ways in which margins are sampled and interpreted. Fundamentally, even the definition what constitutes a "clear" (or negative) margin may vary between institutions, surgeons, and pathologists. METHODS: The PubMed database was queried for articles relevant to the topic, and experts in the field were consulted regarding key articles for inclusion. Abstracts were reviewed and the full text was accessed for articles of particular interest. RESULTS: Data regarding various approaches to traditional margin analysis have been published without consensus. Several next-generation technologies have emerged in recent years that hold promise. CONCLUSION: An overview and appraisal of traditional margin analysis techniques are provided. Additionally, we explore novel technologies that may assist in more accurate margin assessment, guide the extent of surgical resections intraoperatively, and inform decisions regarding adjuvant treatment postoperatively.
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Neoplasias de Cabeza y Cuello/patología , Márgenes de Escisión , Carcinoma de Células Escamosas de Cabeza y Cuello/patología , Neoplasias de Cabeza y Cuello/cirugía , Humanos , Pronóstico , Carcinoma de Células Escamosas de Cabeza y Cuello/cirugíaRESUMEN
BACKGROUND: Exome and targeted sequencing studies have identified potential driver mutations for a variety of tumor types. Cutaneous squamous cell carcinoma (cSCC) is one of the most highly mutated cancers but typically is associated with low rates of metastasis and high survival rates. Nevertheless, metastatic cSCC is a significant health threat; up to 8800 individuals die each year of this disease. METHODS: Because it is difficult to predict which cSCCs are more likely to metastasize, and because to the best of the authors' knowledge there are no targeted therapies specifically designated for patients with metastatic cSCC, exome and/or targeted sequencing of 18 metastatic and 10 primary cSCCs was performed to identify mutations that were more frequent in metastatic tumors and might be targeted for therapeutic benefit. The authors compared their results with published sequencing results of an additional 223 primary tumors and 68 metastatic cSCCs. RESULTS: The authors identified genes demonstrating higher mutation frequencies in metastatic cSCC compared with primary tumors, including the chromatin remodeling gene lysine methyltransferase 2D (KMT2D) and the classic skin tumor suppressor tumor protein p53 (TP53), which was found to be mutated in 54% of primary tumors compared with 85% of metastatic tumors (P<.0001). CONCLUSIONS: These studies appear to uncover potential pathways that are important in metastatic cSCC and that broaden understanding of the biology contributing to aggressive tumor behavior. These results may lead to new therapeutic strategies. Cancer 2017;123:1184-1193. © 2016 American Cancer Society.
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Carcinoma de Células Escamosas/genética , Carcinoma de Células Escamosas/patología , Mutación , Neoplasias Cutáneas/genética , Neoplasias Cutáneas/patología , Anciano , Anciano de 80 o más Años , Biomarcadores de Tumor , Análisis Mutacional de ADN , Femenino , Regulación Neoplásica de la Expresión Génica , Secuenciación de Nucleótidos de Alto Rendimiento , Humanos , Masculino , Persona de Mediana Edad , Tasa de Mutación , Clasificación del Tumor , Metástasis de la Neoplasia , Estadificación de NeoplasiasRESUMEN
Inattention to differences between animal strains is a potential cause of irreproducibility of basic science investigations. Accordingly, the authors' laboratory sought to ensure that cross-comparisons of results generated from studies of mandibular physiology utilizing the Sprague Dawley and Lewis rat strains are valid. The authors specifically investigated baseline histomorphometrics, bone mineral density, and biomechanical strength of the unaltered endogenous mandibles of the inbred, isogenic Lewis rat, and the outbred, nonisogenic Sprague Dawley rat to determine if they are indeed equal. The authors hypothesized that little difference would be found within these metrics.The authors' study utilized 20 male Lewis and Sprague Dawley rats, which underwent no manipulation other than final dissection and analysis. Ten rats from each strain underwent bone mineral density and biomechanical strength analysis. The remaining rats underwent histological analysis. Descriptive and bivariate statistics were computed and the P value was set at 0.05.Lewis rats had a significantly greater number of empty lacunae. Sprague Dawley rats exhibited a significantly greater ratio of bone volume-to-total volume, bone mineral density, tissue mineral density, bone volume fraction, and total mineral content. No differences were found during biomechanical testing.This study demonstrates that differences exist between the Lewis and Sprague Dawley rat within unaltered baseline mandibular tissue. However, these differences appear to have limited functional impact, as demonstrated by similar biomechanical strength metrics. Other specific differences not addressed in this manuscript may exist. However, the authors believe that researchers may confidently cross-compare results between the 2 strains, while taking into account the differences found within this study.
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Mandíbula/anatomía & histología , Mandíbula/fisiología , Animales , Fenómenos Biomecánicos , Densidad Ósea , Masculino , Ratas , Ratas Endogámicas Lew , Ratas Sprague-Dawley , Reproducibilidad de los ResultadosRESUMEN
The purpose of this study is to determine if intraoperatively placed bone marrow stem cells (BMSCs) will permit successful osteocyte and mature bone regeneration in an isogenic murine model of distraction osteogenesis (DO) following radiation therapy (XRT). Lewis rats were split into three groups, DO only (Control), XRT followed by DO (xDO) and XRT followed by DO with intraoperatively placed BMSCs (xDO-BMSC). Coronal sections from the distraction site were obtained, stained and analyzed via statistical analysis with analysis of variance (ANOVA) and subsequent Tukey or Games-Howell post-hoc tests. Comparison of the xDO-BMSC and xDO groups demonstrated significantly improved osteocyte count (87.15 ± 10.19 vs. 67.88 ± 15.38, P = 0.00), and empty lacunae number (2.18 ± 0.79 vs 12.34 ± 6.61, P = 0.00). Quantitative analysis revealed a significant decrease in immature osteoid volume relative to total volume (P = 0.00) and improved the ratio of mature woven bone to immature osteoid (P = 0.02) in the xDO-BMSC compared with the xDO group. No significant differences were found between the Control and xDO-BMSC groups. In an isogenic murine model of DO, BMSC therapy assuaged XRT-induced cellular depletion, resulting in a significant improvement in histological and histomorphometric outcomes.
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Regeneración Ósea/fisiología , Tratamiento Basado en Trasplante de Células y Tejidos/métodos , Mandíbula/crecimiento & desarrollo , Trasplante de Células Madre Mesenquimatosas , Osteocitos/citología , Osteogénesis por Distracción/métodos , Animales , Células de la Médula Ósea/citología , Células Cultivadas , Modelos Animales de Enfermedad , Mandíbula/efectos de la radiación , Células Madre Mesenquimatosas/citología , Ratones , Ratas , Ratas Endogámicas LewRESUMEN
PURPOSE: The vascularity, bone mineral density distribution, and histomorphometric data between the inbred, isogenic Lewis rat and the outbred, nonisogenic Sprague Dawley rat within mandibular distraction osteogenesis (MDO) were evaluated to allow future researchers to compare the results generated from these 2 animals. We hypothesized that little difference would be found between the 2 strains within these metrics. MATERIALS AND METHODS: We implemented a comparative study between the Lewis and Sprague Dawley rat strains within MDO. The sample was composed of 17 male Lewis and 17 male Sprague Dawley rats that underwent surgical external fixation and distraction. The rats' hemimandibles were distracted to a total distance of 5.1 mm. After 28 days of consolidation, 9 rats from each group underwent bone mineral density distribution analysis. The remaining rats from each group were analyzed for the vascular and histologic metrics. Descriptive and bivariate statistics were computed, and the P value was set at .05. RESULTS: We demonstrated successful MDO in all the rats, with no significant difference found in the histologic or bone mineral density distribution metrics. No significant differences were found in any of the vascular metrics, with the exception of vascular separation, which was not normalized to the mandibular volume (P = .048). CONCLUSIONS: The results of the present study have demonstrated that little dissimilarity exists between the isogenic Lewis and outbred Sprague Dawley models of MDO. Thus, researchers can confidently compare the gross results between the 2 strains, with consideration of the very small differences between the 2 models. For studies that require an isogenic strain, the Lewis rat is an apt surrogate for the Sprague Dawley strain.
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Densidad Ósea , Mandíbula/cirugía , Osteogénesis por Distracción/métodos , Animales , Modelos Animales de Enfermedad , Masculino , Mandíbula/diagnóstico por imagen , Ratones , Osteotomía/métodos , Ratas Endogámicas Lew , Ratas Sprague-Dawley , Microtomografía por Rayos XRESUMEN
Transoral robotic surgery (TORS) is increasingly used in laryngeal/hypopharyngeal cancer surgery. Ablative procedures described in these anatomical sites include: (i) supraglottic laryngectomy, (ii) total laryngectomy, (iii) glottic cordectomy, and (iv) partial pharyngectomy. TORS supraglottic laryngectomy remains the most commonly performed of these procedures. Initial oncologic and functional outcomes with these procedures are promising and comparable to other treatment options. As robotic instrumentation technology advances a rise in TORS laryngeal/hypopharyngeal surgery is anticipated.
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Carcinoma de Células Escamosas/cirugía , Neoplasias de Cabeza y Cuello/cirugía , Neoplasias Hipofaríngeas/cirugía , Neoplasias Laríngeas/cirugía , Laringectomía/métodos , Faringectomía/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Ergonomía , Humanos , Laringectomía/instrumentación , Curva de Aprendizaje , Destreza Motora , Boca , Selección de Paciente , Faringectomía/instrumentación , Carcinoma de Células Escamosas de Cabeza y Cuello , Resultado del TratamientoRESUMEN
Multiple diagnostic and treatment paradigms exist for the management of carcinoma of unknown primary (CUP) metastatic to cervical lymph nodes. Transoral robotic surgery (TORS) has emerged as a modality for diagnosis and treatment of CUP, optimizing identification and resection of the primary tumor, although also preventing chemotherapy in a subset of patients. This article presents the authors' treatment paradigm and reviews the literature supporting the use of TORS in the management of CUP.
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Carcinoma de Células Escamosas/cirugía , Neoplasias de Cabeza y Cuello/cirugía , Ganglios Linfáticos/cirugía , Disección del Cuello/métodos , Neoplasias Primarias Desconocidas/diagnóstico , Procedimientos Quirúrgicos Robotizados/métodos , Tonsilectomía , Quimioterapia Adyuvante , Neoplasias de Cabeza y Cuello/patología , Humanos , Ganglios Linfáticos/patología , Metástasis Linfática , Boca , Disección del Cuello/instrumentación , Radioterapia Adyuvante , Recuperación de la Función , Procedimientos Quirúrgicos Robotizados/instrumentación , Tonsilectomía/instrumentación , Tonsilectomía/métodos , Resultado del TratamientoRESUMEN
INTRODUCTION: Head and neck cancer is a debilitating and disfiguring disease. Although numerous treatment options exist, an array of debilitating side effects accompany them, causing physiological and social problems. Distraction osteogenesis (DO) can avoid many of the pathologies of current reconstructive strategies; however, due to the deleterious effects of radiation on bone vascularity, DO is generally ineffective. This makes investigating the effects of radiation on neovasculature during DO and creating quantifiable metrics to gauge the success of future therapies vital. The purpose of this study was to develop a novel isogenic rat model of impaired vasculogenesis of the regenerate mandible in order to determine quantifiable metrics of vascular injury and associated damage. METHODS: Male Lewis rats were divided into two groups: DO only (n=5) AND Radiation Therapy (XRT)+DO (n=7). Afterwards, a distraction device was surgically implanted into the mandible. Finally, they were distracted a total of 5.1mm. Animals were perfused with a radiopaque casting agent concomitant with euthanasia, and subsequently demineralization, microcomputed tomography, and vascular analysis were performed. RESULTS: Vessel volume fraction, vessel thickness, vessel number, and degree of anisotropy were diminished by radiation. Vessel separation was increased by radiation. CONCLUSION: The DO group experienced vigorous vessel formation during distraction and neovascularization with a clear, directional progression, while the XRT/DO group saw weak vessel formation during distraction and neovascularization. Further studies are warranted to more deeply examine the impairments in osteogenic mechanotransductive pathways following radiation in the murine mandible. This isogenic model provides quantifiable metrics for future studies requiring a controlled approach to immunogenicity.
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Vasos Sanguíneos/efectos de la radiación , Irradiación Craneana , Mandíbula/irrigación sanguínea , Mandíbula/efectos de la radiación , Mandíbula/cirugía , Mecanotransducción Celular/efectos de la radiación , Neovascularización Fisiológica/efectos de la radiación , Osteogénesis por Distracción/métodos , Animales , Vasos Sanguíneos/fisiopatología , Irradiación Craneana/efectos adversos , Masculino , Mandíbula/diagnóstico por imagen , Modelos Animales , Osteogénesis por Distracción/efectos adversos , Radioterapia Adyuvante , Ratas Endogámicas Lew , Factores de Tiempo , Microtomografía por Rayos XRESUMEN
OBJECTIVE: To identify factors influencing volume change in non-osseous oral free flap reconstruction using postoperative cross-sectional imaging and 3-dimensional segmentation of the free flap's muscular and adipose tissue content. METHODS: Oral tongue free flap reconstruction cases (2014-2019) were reviewed with inclusion of patients with 3 postoperative, cross-sectional imaging studies with 1 within 6 months, 1 within 1 year, and 1 that spanned 2 years post-reconstruction. Exclusion criteria included recurrence, significant dental artifact, bony reconstruction, and flap failure. Demographics, risk factors, and surgical/clinical treatments were identified. Flap volumes were measured using Materialise MIMICS. RESULTS: Twenty-two patients met strict inclusion criteria. Four flaps were anterolateral thighs and 18 radial forearms. Median percent volume loss greater than 2 years post-reconstruction was 53.2% overall, 58.1% for radial forearms, and 45.4% for ALTs (21.4% for adipose tissue and 57.4% for muscular tissue). Univariate analysis revealed glossectomy amount was associated with percent volume loss (P = .0417). Each successive postoperative month, the flap decreased by 1.54% (P < .0001). Checking for the interaction effect, the percent of flap loss across time was different for glossectomy amount (P = .0093), obesity status (P = .0431), and base of tongue involvement (P = .0472). CONCLUSION: Glossectomy type, and thus flap size, is a positive predictor for flap atrophy. Obesity and base of tongue involvement are negative predictors for flap atrophy. The amount of tissue loss may differ from classical teachings with median atrophy 53.2% greater than 2 years post-reconstruction.
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Colgajos Tisulares Libres , Neoplasias de la Lengua , Humanos , Proyectos Piloto , Neoplasias de la Lengua/cirugía , Lengua/cirugía , Glosectomía/métodos , ObesidadRESUMEN
The osteocutaneous radial forearm free flap (OCRFFF) is a versatile flap with the ability to reconstruct complex defects. We detail the techniques necessary to harvest an OCRFFF, including an outline on making 90-degree osteotomies to maximize bone harvest. In this pictorial essay, we provide illustrations of the anatomy and surgical techniques necessary for OCRFFF harvest. Detailed discussion is provided on how to protect the perforators to the bone and the approach to making osteotomies in a 90-degree fashion. The approach for prophylactic plating of the radius to prevent radius fractures is outlined. A case presentation on the real-life utilization of this flap is included. The OCRFFF is an excellent head and neck reconstructive option. While there are limitations to its use for patients requiring dental rehabilitation or long/anterior mandibular defects, for the right patient and indication it has shown great success in reconstructive efforts.
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Antebrazo , Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Femenino , Humanos , Trasplante Óseo/métodos , Carcinoma de Células Escamosas/cirugía , Antebrazo/cirugía , Neoplasias de Cabeza y Cuello/cirugía , Osteotomía/métodos , Procedimientos de Cirugía Plástica/métodos , Radio (Anatomía)/cirugía , Recolección de Tejidos y Órganos/métodos , Anciano de 80 o más AñosRESUMEN
The osteocutaneous radial forearm (OCRFF) is a versatile free flap option for bony defects of the head and neck, given the thinness and pliability of the forearm cutaneous paddle, pedicle length, reliability, lack of atherosclerosis, and functional concerns common to other osseous donor sites. The OCRFF was once associated with a high risk of radial fracture, in addition to concerns about the quality and durability of bone stock for osseous reconstruction, particularly for the mandible. Following the introduction of prophylactic plating of the radius, the incidence of symptomatic radial fracture has drastically decreased. Furthermore, modifications of the bony osteotomies and other evolutions of this flap harvest have increased the use of the OCRFF throughout the head and neck. Despite these advantages, the OCRFF is not widely utilized by microvascular reconstructive surgeons due to perceived limitations and risks. Herein, we present a multidisciplinary, contemporary review of the harvest technique, outcomes, and perioperative management for the OCRFF.
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Antebrazo , Colgajos Tisulares Libres , Humanos , Antebrazo/cirugía , Procedimientos de Cirugía Plástica/métodos , Radio (Anatomía)/cirugía , Neoplasias de Cabeza y Cuello/cirugíaRESUMEN
Importance: As the incidence of oropharyngeal squamous cell carcinoma (OPSCC) continues to rise in the US, an increasing number of patients are being treated with transoral robotic surgery (TORS). Readmission following surgery can potentially delay initiation of adjuvant treatment and affect survival outcomes. Objective: To identify risk factors for 30-day postoperative readmission in patients undergoing TORS for OPSCC. Design, Setting, and Participants: This retrospective, population-based cohort study used data from the Nationwide Readmissions Database from 2010 to 2017. All patients undergoing TORS for OPSCC were identified using International Classification of Diseases codes and included. Exclusion criteria were age younger than 18 years or incomplete information regarding index admission or readmission. The analysis was performed from April to October 2023. Exposure: TORS for OPSCC. Main Outcomes and Measures: Univariate and multivariate analyses were performed to determine factors associated with 30-day readmission. Covariates included demographics and medical comorbidities, socioeconomic factors, hospital characteristics, and surgical details. Trends in readmission over time, reasons for readmission, and characteristics of the readmission were also examined. Results: A weighted total of 5544 patients (mean [SD] age, 60.7 [0.25] years; 4475 [80.7%] male) underwent TORS for OPSCC. The overall readmission rate was 17.5% (n = 971), and these rates decreased over the study period (50 of 211 patients [23.7%] in 2010 vs 58 of 633 patients [9.1%] in 2017). Risk factors associated with readmission included male sex (adjusted odds ratio [AOR], 1.54; 95% CI, 1.07-2.20) and a diagnosis of congestive heart failure (AOR, 2.42; 95% CI, 1.28-4.58). Factors associated with decreased rate of readmission included undergoing concurrent selective neck dissection (AOR, 0.30; 95% CI, 0.22-0.41). Among the 971 readmissions, the most common readmission diagnoses were bleeding (151 [15.6%]), electrolyte and digestive problems (44 [4.5%]), pneumonia (44 [4.5%]), and sepsis (26 [2.7%]). Conclusions and Relevance: In this cohort study, readmission rates following TORS for oropharynx cancer decreased over time; however, a subset of patients required readmission most commonly related to bleeding, infection, and electrolyte imbalance. Concurrent neck dissection may be protective against readmission. Elucidation of risk factors for readmission after TORS for OPSCC offers opportunities for evidence-based shared decision-making, quality improvement initiatives, and improved patient counseling.