There are 3 global reoperation categories: infection management, flap reoperation urgently or delayed closure; and adjunctive procedures. Numbers of cases for each code are shown parenthetically.
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Thomas WW, Brant J, Chen J, et al. Clinical Factors Associated With Reoperation and Prolonged Length of Stay in Free Tissue Transfer to Oncologic Head and Neck Defects. JAMA Facial Plast Surg. 2018;20(2):154–159. doi:10.1001/jamafacial.2017.1771
What are the clinical factors associated with reoperation and prolonged hospitalization in patients undergoing free tissue transfer for reconstruction of detects related to head and neck malignant neoplasms?
In this review of the American College of Surgeons National Surgical Quality Improvement Program, reoperation, smoking, a clean-contaminated wound class, patient age, a bone-containing flap, and prolonged operative time were associated with prolonged hospital stay. Similar factors were associated with reoperation, and an independent reconstructive team was protective against reoperation.
Surgical teams should focus on wound complication prevention and collaborate with dedicated reconstructive teams to improve rates of reoperation and prevent prolonged hospital stays in this patient population.
Prolonged hospitalization and reoperation after free tissue transfer may be associated with certain clinical factors.
To determine patient and surgical factors associated with length of stay (LOS) and reoperation following surgical procedures for malignant neoplasm of the head and neck involving microvascular free tissue transfer reconstruction.
Design, Setting, and Participants
This was a retrospective review of American College of Surgeons National Surgical Quality Improvement Program data from 2012 to 2014 using International Classification of Diseases, Ninth Revision (ICD-9), codes for malignant neoplasms of the head and neck. Multivariable logistic regression modeling was used to examine correlation of patient and surgical variables with reoperation and LOS. The national retrospective database included outcomes from community and academic participant hospitals (517 member institutions in 2014). A total of 1115 cases of head and neck malignant neoplasm ablation with microvascular free tissue transfer flap were reviewed retrospectively.
Main Outcomes and Measures
Incidence of reoperation within 30 days of index operation and hospitalization equal to or longer than 13.0 days, which is equal to being in the top quartile for duration of stay.
Of the 1115 patients, 370 (33.2) were female, and the mean (SD) age was 66.8 (3.9) years. Predictors of prolonged length of stay included return to the operating room (odds ratio [OR], 4.8; 95% CI, 3.3-6.9), smoking (OR, 2.1; 95% CI, 1.5-3.1), clean-contaminated wound (OR, 2.2; 95% CI, 1.3-4.0), bony flap (OR, 1.8; 95% CI, 1.2-2.8), age (OR, 1.5; 95% CI, 1.2-1.7), and operative time (OR, 1.2; 95% CI, 1.1-1.3). Reoperation occurred 298 times for 225 patients (20.2%). Mean (SD) time to reoperation was 8.0 (7.7) days, with 180 (80%) occurring before discharge from the primary operation. The most common indications for reoperation were neck exploration (37 [12.4%]) or incision and drainage of neck (35 [11.7%]).
Conclusions and Relevance
American College of Surgeons National Surgical Quality Improvement Program data allow for large database analysis of free flap transfer to the head and neck. The data herein provide information to help guide surgeons on which patients will require longer stay in hospital and the most common reasons for return to the operating room. Wound class of index operation, subsequent wound-related complications, and long duration of the index operation were the primary drivers of increased risk for reoperation and, therefore, prolonged hospitalization. These same factors were also associated with prolonged hospitalization without reoperation.
Level of Evidence
Microvascular free tissue transfer is currently the gold standard for reconstructing complex and large volume defects of the head and neck. These flaps provide many functional and aesthetic benefits in the reconstruction of these complex defects, which local and regional reconstruction cannot match.1 In the current era of cost containment and value-based care, free tissue transfer flaps have been shown to increase surgical time, hospital resource utilization, and adverse events, such as venous thromboembolism.2 However, there is evidence supporting a lower cost to benefit ratio for free tissue reconstruction of the head and neck.3 To maximize benefits and minimize complications, preoperative decision-making can be optimized through the use of preoperative risk scores, such as the Caprini Risk Assessment or the American College of Surgeons (ACS) risk calculator for serious complications (https://riskcalculator.facs.org/RiskCalculator/).
Reoperation and prolonged hospitalization significantly increase costs and are 2 key metrics included in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data set. Previous studies have evaluated these outcomes using NSQIP data4,5; however, in 2012 the ACS-NSQIP began including more detailed information regarding readmission and reoperation, allowing for more in-depth analysis than was previously possible; specifically, time to reoperation and details regarding indications for reoperation were added. Previously, the NSQIP data had been used to analyze cases related to malignant neoplasm of the head and neck not requiring free tissue transfer with validated methods.6 In this study, we analyze NSQIP data from 2012 to 2014 to assess for patient characteristics and perioperative variables associated with reoperation and prolonged hospitalization in patients undergoing reconstruction of head and neck defects with microvascular free tissue.
This study was determined to be exempt from review by the institutional review board of the Hospital of the University of Pennsylvania. The ACS-NSQIP data set was queried for cases performed between 2012 and 2014 with primary International Classification of Diseases, Ninth Revision (ICD-9), diagnosis codes for head and neck oncologic cases (excluding thyroid malignant neoplasms). The oncologic codes included are identical to the NSQIP analysis by Bur et al.7Current Procedural Terminology (CPT) codes were used to identify cases, including free tissue transfer reconstruction with more than 2 utilizations in the data set (Table 1).
The NSQIP data set is a deidentified sampling of surgical cases from across North America, and in 2014, there were 517 institutions participating. Each case is abstracted by a trained nurse who is independent of the treatment team and who assesses for 323 variables for each case. Audits are performed regularly to ensure accuracy and standardization. Thirty-day follow-up is assessed through phone and mail surveys. The variables collected and their definitions can be found at the ACS-NSQIP website (http://www. acsnsqip.org/). Specific to this analysis of the NSQIP, operative time was defined into 1-hour cohorts and age was segmented into decade cohorts.
The primary outcomes of interest were prolonged hospitalization and reoperation within 30 days following the index operation. Patient and operative factors included in the initial model for each outcome included age (decade), sex, race, body mass index, preoperative laboratory values, operative time (hours), diabetes, renal failure, congestive heart failure, chronic obstructive pulmonary disease, smoking, dyspnea, functional status, steroid use, hypertension requiring medication, bleeding disorder, wound class, American Society of Anesthesiologists class, flap type, separate operative team for flap. Flap types were considered to be bony or soft tissue based on CPT code (Table 1). A flap was considered to be performed by a second surgical team if the CPT code for the reconstruction was included as a “concurrent” procedure. Furthermore, reoperations were assessed for etiology of reoperation via CPT code of the subsequent operation. Logistic regression was performed to determine the association of the patient and surgical factors with the outcomes of interest. Length of stay was defined as days from operation to discharge, and “long length of stay” was defined as any stay longer than the 75th percentile for the cohort of interest.
Univariate comparison for each variable was initially performed using Pearson χ2 for categorical variables, or Mann-Whitney tests for continuous variables. Variables with P > .20 on univariate analysis or that were missing 10% or more of their values were rejected from the multivariable logistic model. A bidirectional stepwise selection algorithm to optimize the Akaike information criterion was used to select the final multivariable logistic regression model. P < .05 on the final multivariable logistic model was considered significant.
Of the 1115 patients, 370 (33.2%) were female, and the mean age was 66.8 (3.9) years. The query of the ACS-NSQIP for all head and neck oncology cases, excluding thyroid malignant neoplasms, yielded 8609 cases from 2012 to 2014. Of these cases, 1115 (13.0%) received free tissue transfer reconstruction. Demographic, clinical, and perioperative details are presented in Table 2.
Complications were common in this cohort as 604 (54.0%) of the 1115 patients had at least 1 complication. The median time from operation to discharge was 9 days. The mean length of stay was 11.16 days, and the 75th percentile was 13.00 days or greater. Factors associated with a long length of stay on multivariable regression are found in Table 3.
A total of 225 patients had 1 reoperation within 30 days of the index operation, 58 had 2, and 15 patients had 3. Multivariable regression analyses of patient factors associated with reoperations are also presented in Table 3. The Figure presents the CPT codes associated with each initial reoperation. Table 4 presents the number of reoperations associated with CPT codes involving more than 1 occurrence as well as a definition of that CPT code. The mean time to initial reoperation was 8 days, and the median was 6 days. A total of 217 reoperations (94.0%) were related to the index procedure (as defined by ACS-NSQIP), and 80% initial reoperations occurred prior to discharge.
Delivering high-quality care with few complications is the goal of modern reconstructive head and neck surgery; this is also an important metric in today’s health care, and it is increasingly being tied to medical reimbursement. The ACS-NSQIP database provides a large data set of patients with head and neck cancer undergoing microvascular free tissue transfer reconstruction to assess for patient-specific and perioperative factors that are associated with long length of stay and reoperation in an effort to assess for patient factors and perioperative factors associated with these undesirable outcomes. These factors are tightly intertwined in patient care as reoperation, in this analysis, has the strongest association with long length of hospital stay and complications such as flap failure, surgical site infection, and wound dehiscence and others commonly require return to the operating room.4
The laryngeal, hypopharyngeal, and cervical esophageal subsites highlight weaknesses of the NSQIP data set. Diagnosis is listed as a single ICD-9 code, which does not reveal important tumor-specific information such as specific subsite and extension to adjacent subsites. In addition, information regarding prior chemoradiation is not available. Salvage surgical therapy is associated with increased complications, particularly wound healing in the head and neck.8 Knowledge of prior therapy would allow a more refined regression analysis and improved patient counseling.
Active smoking was found to be more common in this cohort than in the general population of US adults (501 [30.5%]),9 and it was a clinical factor associated with a long length of stay. In a prior NSQIP study,10 active smoking was associated with overall complications, and the literature supports its negative effect on wound healing.11 Increased wound complications, but not reoperations, were further confirmed to be associated with smoking by Brands et al,12 and similarly, this review found that smoking was not associated with reoperation. Poor wound healing in smoking patients requires more wound care to stabilize the patient postoperatively for discharge. This mechanism of prolonged hospital stay is further supported in nonmicrovascular head and neck surgery as reported by Helman et al.6
Patient age was found to be a risk factor for a long length of stay. Increasing age was also found by Cannady et al10 to be associated with overall complications. Long length of stay, for which elderly patients are at greater risk, and the increased complications contribute to the increased cost of care for these patients, and Blackwell et al13 estimated the increased cost at approximately $24 000 per patient (in 1998 dollars). Given that patient age was a weak risk factor for a long length of stay and complications,9 age should not be the sole deterrent in the decision to or not to reconstruct a head and neck malignant neoplasm with a free flap.
Operative time was associated with both reoperation and length of hospitalization. Operative time was associated with medical complications in the recent NSQIP study by Cannady et al,10 and this conclusion is supported in the head and neck literature as well as the general surgery literature at large.14,15 Both medical complications, such as sepsis, urinary tract infection, pneumonia, and prolonged ventilation, and complications requiring reoperation, such as early flap failure, wound dehiscence, and organ-space surgical site infection, were associated with increased operative time in the cited studies. It is reasonable that these increased complications drive the prolonged hospitalization and increased reoperations seen in this current study. Furthermore, the protective effect of a second reconstructive team, and the increased operative speed which this allows, further speaks to the negative effect of prolonged operations.16
An evaluation of the CPT codes associated with initial reoperation indicates that complications from wound issues are the primary reason for reoperation. Free flap anastomosis issues are also a large component of early reoperations; successful salvage of anastomotic issues is supported in the literature with rates approaching 100% intraoperatively and 70% in the first 48 hours.17 One consideration for the large group of secondary flap closures is due to wound dehiscent, fistula, or infectious concerns as opposed to loss of the initial free flap. These operations occurred within 30 days of the initial operation but not necessarily during the same admission. The state of the free flap on reoperation is unknown, but late failure of free flaps is very rare. Only 8 of 1310 free flaps were noted to have failed in the series by Yu et al,18 and it is presumed that 5 of these 8 actually failed in the early postoperative period (<7 days) but were not discovered until later owing to the presence of an intact Doppler signal. One conclusion to draw from this information is that improved technical skill in the initial operation is unlikely to produce large gains in decreasing reoperations and thus long length of stay, but improved wound care and wound analysis will greatly improve patient outcomes. Resident physician and physician-extending mid-level wound staff benefit from formal wound care training and wound analysis because they can note and intervene on wound complications earlier.
Patients and hospitals both benefit greatly from reduced complications, reoperations, and readmissions; hospitals initiating quality improvement programs in conjunction with the NSQIP have led to an average of 250 to 500 fewer complications per year. This number of fewer complications on average translates into saving 12 to 36 lives annually and a cost savings of approximately $11 000 per major surgical complication.19,20 Using this NSQIP analysis, surgeons can assess and counsel patients with improved confidence in reporting rates of reoperation and prolonged hospitalization. Furthermore, the rates of reoperation and time to discharge postoperatively can serve as a benchmark against which surgeons can judge their own practice and seek improvement. This analysis of NSQIP is further evidence for advocating for the 2-team head and neck ablation and reconstruction approach because both shorter operating time and a second reconstructive team were associated with fewer reoperations. The cost savings of an NSQIP-driven quality improvement program can be presented to hospital administrators as evidence for the necessity of having a reconstructive head and neck partner for individual physicians in the community. Even with these constraints, we believe this analysis adds significantly to our current understanding of the outcomes associated with these cases.
The limitations of this study are based on the knowledge that the data queried herein are derived from a large, deidentified national database. This database is not specifically tailored to assess complications from otolaryngologic or microvascular surgery. Furthermore, the data regarding reoperation indications are nonspecific in nature and could be influenced by third-party payer behavior regionally. In addition, CPT code usage is not strictly standardized between surgeons. It should be stated that while the NSQIP data set includes a sampling of cases from contributing institutions, and not all institutions include cases from all subspecialties, it is possible that the data analyzed contain an unforeseen selection bias. Additional multi-institutional studies specifically designed to assess free tissue reconstruction in the head and neck would add significantly to our understanding.
Long length of hospital stay and reoperation within 30 days are key patient outcomes that are interrelated and strongly dependent on a patient’s risk for complications. Similar risk factors are noted among these 3 outcomes, with wound contamination status and operative time having a significant effect on long hospitalization and reoperation rates. The lack of concrete NSQIP information regarding extent of subsites proximal to malignant neoplasms makes it difficult to stratify risk in patients with these malignant lesions. It is likely that patients requiring free tissue transfer at the laryngeal and cervical esophagus subsites presented with advanced tumors, and thus their risk for complication, incomplete resection, prolonged hospitalization, and reoperation would be higher, although no concrete data are given for these conclusions. This study provides a useful analysis of reoperation and prolonged hospitalization and identifies excellent wound care as a potential target to improve patient outcomes.
Corresponding Author: Steven B. Cannady, MD, University of Pennsylvania, Otorhinolaryngology, 800 Walnut St, 18th Floor, Philadelphia, PA 19017 (email@example.com).
Accepted for Publication: August 1, 2017.
Published Online: November 30, 2017. doi:10.1001/jamafacial.2017.1771
Author Contributions: Dr Cannady had full access to all the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Thomas, Brant, Coblens, Newman, Chalian, Cannady.
Acquisition, analysis, or interpretation of data: Thomas, Brant, Chen, Coblens, Fischer, Chalian, Shanti, Cannady.
Drafting of the manuscript: Thomas, Brant, Chen, Coblens, Shanti, Cannady.
Critical revision of the manuscript for important intellectual content: Thomas, Brant, Fischer, Newman, Chalian, Cannady.
Statistical analysis: Brant, Chen, Cannady.
Administrative, technical, or material support: Thomas, Coblens, Chalian.
Study supervision: Brant, Fischer, Newman, Chalian, Shanti, Cannady.
Conflict of Interest Disclosures: None reported.
Meeting Presentation: This work was given as an oral presentation by the Corresponding Author at the Triological Combined Sections Meeting; January 20, 2017; New Orleans, Louisiana.
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