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October 13, 2016

Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap ReconstructionA Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society

Author Affiliations
  • 1Section of Otolaryngology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta
  • 2Cancer Strategic Clinical Network, Alberta Health Services, Calgary, Alberta
  • 3Department of Otolaryngology, Division of Head and Neck Surgery, University of California Davis, Sacramento
  • 4Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown NSW, Australia
  • 5ENT Clinic, University Hospital Zurich, Switzerland
  • 6Department of Otolaryngology, Winnipeg, Manitoba
  • 7Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta
  • 8Department of Otolaryngology, Head and Neck Surgery, CHUV, University of Lausanne, Switzerland
  • 9University of California, Davis Health System, Sacramento
  • 10Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
  • 11Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
  • 12Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta
JAMA Otolaryngol Head Neck Surg. Published online October 13, 2016. doi:10.1001/jamaoto.2016.2981

Importance  Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking.

Objective  To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction.

Evidence Review  Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent key words for each topic included “head and neck surgery,” “pharyngectomy,” “laryngectomy,” “laryngopharyngectomy,” “neck dissection,” “parotid lymphadenectomy,” “thyroidectomy,” “oral cavity resection,” “glossectomy,” and “head and neck.” The final selection of literature included meta-analyses and systematic reviews as well as randomized controlled trials where available. In the absence of high-level data, case series and nonrandomized studies in head and neck cancer surgery patients or randomized controlled trials and systematic reviews in non–head and neck cancer surgery patients, were considered. An international panel of experts in major head and neck cancer surgery and enhanced recovery after surgery reviewed and assessed the literature for quality and developed recommendations for each topic based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations were graded following a consensus discussion among the expert panel.

Findings  The literature search, including a hand search of reference lists, identified 215 relevant publications that were considered to be the best evidence for the topic areas. A total of 17 topic areas were identified for inclusion in the protocol for the perioperative care of patients undergoing major head and neck cancer surgery with free flap reconstruction. Best practice includes several elements of perioperative care. Among these elements are the provision of preoperative carbohydrate treatment, pharmacologic thromboprophylaxis, perioperative antibiotics in clean-contaminated procedures, corticosteroid and antiemetic medications, short acting anxiolytics, goal-directed fluid management, opioid-sparing multimodal analgesia, frequent flap monitoring, early mobilization, and the avoidance of preoperative fasting.

Conclusions and Relevance  The evidence base for specific perioperative care elements in head and neck cancer surgery is variable and in many cases information from different surgerical procedures form the basis for these recommendations. Clinical evaluation of these recommendations is a logical next step and further research in this patient population is warranted.