Perioperative Nutrition in Head and Neck Free Flap Reconstruction - 12

Nutritional optimization is a key but often overlooked aspect of the management of head and neck cancer (HNC) patients undergoing surgical resection and free flap reconstruction. Due to various physical factors, comorbidities, and metabolic perturbations, these patients are at substantial risk for malnourishment prior to, during, and after treatment. As perioperative malnutrition is associated with adverse operative outcomes, it is an important target for improved interventions. In this chapter, the pathophysiology of malnutrition in HNC patients, the effects of malnutrition on surgical outcomes, and the available tools for assessing nutritional status are reviewed. We also examine evidence-based interventions to address malnutrition throughout the perioperative period, particularly within the context of enhanced recovery after surgery (ERAS) protocols. Based on this evidence, we propose a comprehensive nutrition management pathway to be implemented into existing clinical frameworks to improve perioperative nutrition in HNC patients. While larger prospective, randomized trials are necessary to better assess specific new nutrition interventions such as immunonutrition and early feeding in HNC patients undergoing free flap reconstruction, it is critical that malnutrition is identified and intervened upon prior to surgery and that nutrition monitoring and appropriate nutritional support are continued throughout the perioperative period

Update on anterior skull base reconstruction

Anterior skull base reconstruction has rapidly evolved over the past few years as endoscopic approaches to resect tumors in this region have become more established. The present review evaluates the robust amount of new literature on this topic over the past year with particular attention to minimally invasive methods for reconstruction. Although vascularized local flaps remain the mainstay reconstructive choice when available for the anterior skull base, innovative techniques for all types of reconstruction, ranging from free grafts to free flaps continue to emerge. Because of the unique challenges and wide variety of options available to repair the anterior skull base with the goal to prevent or treat cerebrospinal fluid leaks, surgical expertise and experience in this field is of utmost importance

Flap Monitoring - 9

Free tissue transfer, a complex surgical procedure, carries a considerable risk of complications and morbidity when flap failure occurs. However, by promptly identifying signs and symptoms indicating problems with the microvascular anastomosis, potential issues can be addressed early on, potentially preventing the need for further extensive surgeries and ensuring successful salvage of the flap. In this chapter, various techniques and devices designed to monitor the viability of the flap during the early postoperative period are thoroughly examined. These methods aid in the assessment of flap perfusion, oxygenation, and overall viability. Examples include Doppler ultrasound, near-infrared spectroscopy, and clinical observation. By employing these monitoring tools, surgeons can detect potential complications at an early stage, enabling timely intervention and improving the overall outcomes of free tissue transfer procedures. The chapter sheds light on the importance of vigilance in postoperative care and highlights the value of monitoring techniques in preventing flap failure and minimizing associated morbidity

Lymphoepithelial carcinoma of the major salivary glands: Predictors of survival in a non-endemic region

Lymphoepithelial carcinoma (LEC) of the salivary glands is extremely rare worldwide, with studies limited to small case reports and case series from endemic areas (Southern China, Arctic Inuits) and strong association to Epstein Barr Virus (EBV). Studies on non-endemic regions are even more limited given the reality of only sporadic cases in these areas. Using the National Cancer Database (NCDB), we present the largest study on salivary LEC from a non-endemic region, the United States. A retrospective review of the NCDB from 1998-2012 for LEC of the major salivary glands was performed. Demographic and clinical variables were extracted for analysis. Multivariate COX regression was used to assess predictors of survival. Two hundred and thirty-eight cases were identified (0.66% of all salivary cancers). Median age at diagnosis was 62 with peak incidence in ages 50-70. Most patients were Caucasian (81.2%), without gender preference. Regional metastasis was common (45.1%) and did not significantly impact survival. Distant metastasis was rare (2%). Overall survival (OS) at 5- and 10 years was 77% and 56%. Surgery and radiotherapy significantly showed better survival outcomes than surgery alone (p62, advanced stage, and dual modality therapy were significant predictors of survival in multivariate analysis. Lymphoepithelial carcinoma in the US mostly affects an older, Caucasian demographic. Regional metastasis is common and survival is fair at 5- and 10 years. Surgery and radiation are recommended for early and advanced disease stages. Age, stage, and therapy are significant predictors of survival outcomes

Use of Sleeve Neurrorhaphy at the Brainstem for Facial Nerve Reconstruction

Introduction: Neurorrhaphy at the brainstem for reconstruction of the facial nerve remains a technical challenge. Traditional suture techniques prove increasingly difficult with the tendency toward approaches with more limited dissection and when resection of the nerve extends proximally close to the brainstem. A method for secure approximation of the proximal end of the remaining nerve and the graft not requiring the placement of suture would be beneficial in these difficult cases. Methods: Case report. Results: A 30 year old man was found to have a facial nerve schwannoma upon workup for asymmetric sensorineural hearing loss and elected for surgical resection. Following removal of the tumor via translabyrinthine approach the nerve was deficient several millimeters from the brainstem to the second genu in the mastoid. Devitalized cadaveric allograph (Avance Nerve Graft, AloGen, Inc., Alachua, FL, USA) was placed and sutured to the distal end of the nerve. Given the limited remaining proximal portion at the brainstem and the anatomical constraints it was elected to perform a sleeve neurorrhaphy to secure the graft to the remaining nerve. The graft and remaining nerve were approximated and wrapped with commercially available porcine submucosa extracellular matrix (AxoGuard Nerve Protector, AloGen, Inc., Alachua, FL, USA). Gelfilm was then placed between the repair and the brainstem, the dura was closed around the graft and the mastoid defect filled with fat. Discussion: Suture neurorrhaphy remains a technical challenge especially at the brainstem and the cerebellopontine angle. The depth of repair, anatomical constraints of the craniotomy, and generally limited length of proximal remaining nerve add to the difficulty of placing sutures using traditional techniques. The use of a wrap to secure the ends of the nerve and graft to each other also acts to protect the microenvironment which may promote growth of the axons. This case report describes the use of such a wrap to approximate and secure the residual stump of facial nerve at the brainstem with devitalized cadaveric nerve graft. Conclusion: The use of sleeve neurorrhaphy provides an alternative to traditional sutures for reconstruction of the facial nerve at the brainstem. This report serves as a technical description and long term follow up of a larger cohort of patients will be required to adequately compare this technique with the current suture technique

High-Risk Cutaneous Squamous Cell Cancer of the Head and Neck: Risk Factors for Recurrence and Impact of Adjuvant Treatment

The behavior of advanced cutaneous squamous cell carcinoma of the head and neck (HNcSCC) remains poorly understood, with highly variable risk factors and a paucity of data for adjuvant treatment. The objective of our study was to review the oncologic outcomes of patients with high-risk HNcSCC treated with surgery and to identify risk factors for treatment failure. Retrospective cohort study. Retrospective review of patients treated for HNcSCC with definitive surgery involving at least parotidectomy and neck dissection at a tertiary care academic center from 2011 to 2017 was conducted. The primary outcome was disease-free survival (DFS). One-hundred four patients with a median age of 68 years (range = 42-91 years) were reviewed. Twenty-one patients were treated with surgery alone, 45 patients underwent adjuvant radiotherapy (RT), and 38 patients underwent adjuvant chemoradiotherapy (CRT). The 2-year DFS for patients treated with surgery, surgery + RT, and surgery + CRT were 71%, 65%, and 58%, respectively, with no significant difference between the groups (P = .70). On multivariate analyses, tumor size (P = .006) and perineural invasion (PNI, P = .04) independently predicted recurrence. The addition of chemotherapy did not appear to improve DFS, neither for those patients with extranodal extension and/or positive margins (P = .93) nor for the entire cohort (P = .43). Advanced HNcSCC has a high recurrence rate despite adjuvant treatment. Tumor size >2 cm was a strong independent risk factor for recurrence. Out of the traditional mucosal HNcSCC risk factors, PNI was most strongly associated with worse DFS. There was no observed survival benefit to the addition of chemotherapy. 4. Laryngoscope, 131:E136-E143, 2021

Abnormal Microvasculature in Laryngectomy Mucosal Margins may be Associated with Increased Risk of Fistula

Pharyngocutaneous fistula after laryngectomy is common and significantly increases the morbidity of the procedure. Intraoperative, objective variables that can reliably predict fistula formation would be useful to surgeons deciding how to reconstruct the laryngectomy defect. Retrospective chart review of 50 radiated patients and 10 non-radiated patients who underwent total laryngectomy at a single tertiary care institution. Patients with pharyngocutaneous fistula were selected to ensure a representative sample were available for comparison. All patients had pathology slides available for re-review by a single, blinded pathologist. Margins of both radiated (n = 50) and non-radiated (n = 10) larynges were examined for 7 histologic features, and odds ratios were calculated to assess whether these features were associated with fistula. When evaluating all 60 patients, both telangiectatic capillaries and hyalinized arterioles were associated with fistula (OR 3.72 and 9.21, respectively). Collinearity between the variables was evaluated; findings indicated a high likelihood of having hyalinized arterioles if telangiectatic capillaries were also present (OR 31.67 [3.13, 320.06]). Microvascular changes in radiated tissue have previously been described in other anatomic subsites, but the larynx and pharynx have not been specifically evaluated. Laryngectomy mucosal margins appear to display similar changes, and evidence of this damage may be associated with fistula formation. These features could potentially guide the surgeon to alter the reconstructive technique

IL-1 Receptor Antagonist Inhibits Early Granulation Formation

Using a functional model of airway granulation tissue in laryngotracheal stenosis, we investigated changes in histopathology and inflammatory markers within granulation tissue in response to an interleukin-1 receptor antagonist (IL-1Ra). This study allows us to further delineate the immune response to wound healing and potentially identify treatment markers. Laryngotracheal complexes (LTCs) of donor mice underwent direct airway injury. The LTCs were transplanted into subcutaneous tissue of recipient mice in 2 groups: IL-1Ra treated and untreated. The IL-1Ra-treated arm received daily intraperitoneal injections of IL-1Ra for 3 weeks. The LTCs were then harvested. Granulation formation was measured. The mRNA expression of transforming growth factor (TGF) beta and IL-1 was quantified using real-time reverse transcript polymerase chain reaction. There were statistically significant differences in lamina propria thickness. There were no statistically significant changes in mRNA expression of TGF-β and IL-1β between the treated and untreated specimens. Using a previously described murine model, we delineate inflammatory markers that can be targeted for potential therapy. While the levels of inflammatory markers do not change significantly, the lamina propria thickness shows that the effects of IL-1 have been inhibited. The early use of the IL-1Ra will inhibit the efficacy of IL-1 in the inflammatory cascade and can prevent early granulation formation

The Impact of Obesity on Hospital Length of Stay and Post-operative Complications after Transsphenoidal Pituitary Surgery: an Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database

Background: The transsphenoidal approach to the pituitary, using endoscopic or microscopic techniques, is associated with decreased morbidity compared with traditional craniotomies. Most published series demonstrate that serious complications are rare and that mortality rates are less than 1 percent. Obesity and its associated comorbidities can adversely affect perioperative outcomes and may predispose patients to increased risk of complications. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a nationally validated, risk-adjusted database that tracks surgical outcomes with the goal of improving patient outcomes and safety. The objective of this study was to evaluate the impact of obesity on hospital length of stay, return to operating room and post-operative medical complications using the NSQIP database. Methods: The NSQIP database was queried for all patients that underwent transsphenoidal pituitary surgery by searching for current procedural terminology (CPT) codes 61548 or 62165. Patient demographic data obtained included age, gender and body mass index (BMI). Patient outcome data analyzed included hospital length of stay and major post-operative complications including pneumonia, unplanned reintubation, return to operating room, venous thromboembolism, myocardial infarction, cardiac arrest, stroke and death. Patients were categorized as either obese (BMI < 30 kg/m2) or non-obese (BMI ≥ 30 kg/m2). Hospital length of stay and the incidence of major post-operative complications were compared between obese and non-obese patients (Wilcoxon rank-sum and χ2 test, respectively). P-values <0.05 were considered statistically significant. Results: A total of 844 transsphenoidal surgeries were reported in NSQIP between 2006 and 2013. Mean patient age was 39.2 ± 0.5 years. Patients were evenly balanced by gender (427 female (50.7%), 415 male (49.3%)) and average BMI was 31.1 ± 0.2. kg/m2. Average hospital length of stay was 4.8 ± 0.3 days. Serious post-operative complications were rare. Eight patients developed pneumonia (0.9%) and twenty (2.4%) patients required unplanned reintubation. Thromboembolic complications were uncommon with 8 (0.9%) deep vein thromboses and 4 (0.5%) pulmonary emboli. Cardiovascular complications were rare with only 1 (0.1%) myocardial infarction and 6 (0.7%) cardiac arrests. Nine patients (1.0%) developed stroke and there were 7 deaths (0.8%). Non-obese patients had significantly shorter average length of hospitalization compared with obese patients (4.5 ± 0.5 versus 5.0 ± 0.4 days, p  = 0.01). Obese patients also had a higher post-operative complication rate compared with non-obese patients (2.6% versus 5.3%, p  = 0.04). In total, 34 patients (4.0%) required reoperation, with the most common indication being repair of cerebrospinal fluid leak. There was no significant correlation between BMI and need for reoperation ( p  = 0.97). Conclusions: Transsphenoidal surgery is a safe approach to the sella for the resection of pituitary lesions. We report a series of 844 patients that underwent transsphenoidal surgery using the NSQIP database, a large national surgical patient database that was developed to improve patient outcomes and safety. Our data suggest that obesity is associated with increased hospital length of stay and may increase the risk of post-operative complications following transsphenoidal pituitary surgery

Changes in head and neck oncologic practice during the COVID

Introduction The COVID-19 pandemic has raised controversies regarding safe and effective care of patients with head and neck cancer. It is unknown how much the pandemic has changed surgeon practice. Methods A questionnaire was distributed to head and neck surgeons assessing opinions related to treatment and concerns for the safety of patients, self, family, and staff. Results A total of 88 head and neck surgeons responded during the study period. Surgeons continued to recommend primary surgical treatment for oral cavity cancers. Respondents were more likely to consider nonsurgical therapy for patients with early glottic cancers and HPV-mediated oropharynx cancer. Surgeons were least likely to be concerned for their own health and safety and had the greatest concern for their resident trainees. Conclusions This study highlights differences in the willingness of head and neck surgeons to delay surgery or alter plans during times when hospital resources are scarce and risk is high