ABSTRACT
OBJECTIVES: Standards of care for total laryngectomy (TL) patients in the postoperative period have not been established. Perioperative care remains highly variable and perhaps primarily anecdotally based. The aim of this study was to survey members of the American Head and Neck Society to capture management practices in the perioperative care of TL patients. METHODS: In this survey study, an electronic survey was distributed to the international attending physician body of the American Head and Neck Society. Forty-five-question electronic surveys were distributed. A total of 777 members were invited to respond, of whom 177 (22.8%) fully completed the survey. The survey elicited information on management preferences in the perioperative care of TL patients. Differences in management on the basis of irradiation status and pharyngeal repair (primary closure vs regional or free flap reconstruction) were ascertained. Main outcomes and measures were time to initiate oral feeding, perioperative antibiotic selection and duration, and estimated pharyngocutaneous fistula rates. These measures were stratified by patient type. RESULTS: Most respondents completed head and neck fellowships (77.0%) and practice at academic tertiary centers (72.3%). Ampicillin/sulbactam was the most preferred perioperative antibiotic (43.2%-49.1% depending on patient type), followed by cefazolin and metronidazole in combination (32.0%-33.7%) and then clindamycin (10.8%-12.6%). Compared with nonirradiated patients, irradiated patients were significantly more likely to have longer durations of antibiotics ( P < .05), longer postoperative times to initiate oral feeding ( P < .05), and higher estimated fistula rates ( P < .05). Additionally, in nonirradiated patients, flap-repaired patients (vs primary repair) were significantly more likely to have longer durations of antibiotics (odds ratio, 1.29; 95% confidence interval, 1.13-1.48) and postoperative times to initiate oral feeding (odds ratio, 2.24; 95% confidence interval, 1.76-2.84). CONCLUSIONS: Perioperative management of TL patients is highly variable. Management of antibiotics and oral feeding are significantly affected by irradiation status and scope of pharyngeal repair. Further studies are needed to standardize perioperative care for this unique patient population.
Subject(s)
Laryngeal Neoplasms/surgery , Laryngectomy , Perioperative Care , Practice Patterns, Physicians' , Surgical Oncology , Anti-Bacterial Agents/therapeutic use , Cutaneous Fistula/etiology , Eating , Humans , Laryngectomy/adverse effects , Laryngectomy/methods , Pharyngeal Diseases/etiology , Pharynx/surgery , Postoperative Complications/therapy , Practice Guidelines as Topic , Radiotherapy, Adjuvant , Respiratory Tract Fistula/etiology , Standard of Care , Time Factors , United StatesABSTRACT
OBJECTIVES: We sought to investigate the postoperative complications of vestibular schwannoma excision and determine their significant clinical predictors. STUDY DESIGN: Cross-sectional. SETTING: California Hospital Inpatient Discharge Datasets 1997-2011. SUBJECTS AND METHODS: Data for vestibular schwannoma excisions performed in California were extracted using the ICD-9-CM code "04.01 excision of acoustic neuroma." Demographics, principal payer, state of residence, comorbidities, as well as hospital case volume were examined as possible predictors. Postoperative complications and patient disposition were examined as outcome variables. Comorbidities and complications were identified using ICD-9-CM diagnoses and procedures codes. RESULTS: Overall, 6553 cases were examined. Comorbidities were present in 2539 (38.7%) patients. Postoperative complications occurred in 1846 (28.2%) patients; 1714 (26.2%) neurological and 337 (5.1%) medical complications. Patients' admission ended with death or further care (ie, skilled nursing facilities) in 260 (4.0%) cases. Mortality rate was 0.2%. No significant changes were observed over time. Multivariate analysis revealed that the odds of neurological complications were greater in the 2007-2011 period (OR = 1.51; 95% CI, 1.12-2.04), in patients with comorbidities (OR = 1.48; 95% CI, 1.16-1.88), and in hospitals with low case volume (OR = 1.69; 95% CI. 1.31-2.18). The odds of medical complications were also greater in the 2007-2011 period (OR = 1.69; 95%, CI 1.02-2.80). Female gender, non-Caucasian ethnicity, presence of comorbidities, and low hospital case volume were associated with greater odds of patients requiring further care. CONCLUSION: Comorbidities and low hospital case volume were major risk factors for complications. No significant changes in rates of complications from vestibular schwannoma surgery were observed over the 15-year period.
