Postoperative Medical Complications???-Not Microsurgical Complications???-Negatively Influence the Morbidity, Mortality, and True Costs after Microsurgical Reconstruction for Head and Neck Cancer

Division of Plastic and Reconstructive Surgery, University of California Los Angeles School of Medicine, Los Angeles, CA, USA.
Plastic and Reconstructive Surgery (Impact Factor: 2.99). 07/2007; 119(7):2053-60. DOI: 10.1097/01.prs.0000260591.82762.b5
Source: PubMed


Immediate reconstruction of composite head and neck defects using free tissue transfer is an accepted treatment standard. There remains, however, ongoing debate on whether the costs associated with this reconstructive approach merit its selection, especially considering poor patient prognoses and the high cost of care.
A retrospective review of the last 100 consecutive patients undergoing microsurgical reconstruction for head and neck cancer by the two senior surgeons was performed to determine whether microsurgical complications or postoperative medical complications had the more profound influence on morbidity and mortality outcomes and the true costs of these reconstructions.
Two patients required re-exploration of the microsurgical anastomoses, for a re-exploration rate of 2 percent, and one flap failed, for a flap success rate of 99 percent. The major surgical complication rate requiring a second operative procedure was 6 percent. Sixteen percent had minor surgical complications related to the donor site. Major medical complications, defined as a significant risk to the patient's life, occurred in 5 percent of the patients, but there was a 37 percent incidence of "minor" medical complications primarily caused by pulmonary problems and alcohol withdrawal. Postsurgical complications almost doubled the average hospital stay from 13.5 days for those patients without complications to 24 days for patients with complications. Thirty-six percent of the true cost of microsurgical reconstruction of head and neck cancer was due to the intensive care unit and hospital room costs, and 24 percent was due to operating room costs. Postsurgical complications resulted in a 70.7 percent increase in true costs, reflecting a prolonged stay in the intensive care unit and not an increase in operating room costs or regular hospital room costs.
Postoperative medical complications in these elderly, debilitated patients related to pulmonary problems and alcohol withdrawal were statistically far more important in negatively affecting the outcomes and true costs of microsurgical reconstruction.

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    • "In the current review, 20 publications from 19 studies described costs attributable to symptoms and side effects arising directly from the various treatments for HNC [11, 13, 15, 16, 25, 32, 36, 39, 42, 45, 47, 49, 50, 54, 59, 60, 73, 75, 76, 94]. The most commonly reported costs for treatment-related complications were due to infection [15, 16, 39, 45, 49, 59, 73] and surgical reconstruction following tumor resection [11, 36, 60, 75, 94]. Expenses for several other treatment-emergent side effects were noted, including peripheral neuropathy [50], dermatologic adverse drug reactions, acute mucositis [13, 25, 47, 54], osteoradionecrosis [76], and deep vein thrombosis or pulmonary embolism [32]. "
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    ABSTRACT: Background: Head and neck cancer (HNC) and its treatment can affect communication, nutrition, and physical appearance, and the global impact of this disease on patients' quality of life may be substantial. Objective: The aim of this systematic literature review was to describe the impact of HNC and its treatment on the physical, emotional, and social well-being of patients over time, by examining longitudinal studies of patient-reported outcomes (PRO) evaluating these domains. Methods: Databases (MEDLINE and Embase) were searched to identify studies published in English between January 2004 and January 2014 analyzing the humanistic aspects of HNC in adult patients. Additional relevant publications were identified through manual searches of abstracts from recent conference proceedings. Results: Of 1,566 studies initially identified, 130 met the inclusion criteria and were evaluated in the assessment. Investigations using a variety of PRO instruments in heterogeneous patient populations consistently reported that PRO scores decrease significantly from diagnosis through the treatment period, but generally recover to baseline in the first year post-treatment. This trend was observed for many functional domains, although some side effects, such as xerostomia, persisted well beyond 1 year. In addition, considerable evidence exists that baseline PRO scores can predict clinical endpoints such as overall and progression-free survival. Conclusions: Many aspects of HNC, both disease and treatment specific, profoundly affect patients' quality of life. Improved knowledge of these effects on PRO may allow for more informed treatment decisions and can help physicians to better prepare patients for changes they may experience during therapy. Furthermore, the predictive value of baseline PRO data may enable healthcare providers to identify at-risk patients in need of more intensive intervention.
    PharmacoEconomics 05/2014; 32(9). DOI:10.1007/s40273-014-0169-3 · 2.45 Impact Factor
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    • "The resource-intensive nature of the operative procedure itself, along with the often complicated and prolonged inpatient recovery contributes to this burden. The reported rate of complications during inpatient recovery is considerable, and often leads to longer hospital stays, increased cost, and increased mortality [5-9,15]. Postoperative pulmonary complications alone have been shown to increase mortality by 12.8% in these patients [8]. "
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    ABSTRACT: The objective of this study is to evaluate the cost-effectiveness of a postoperative clinical care pathway for patients undergoing major head and neck oncologic surgery with microvascular reconstruction. This is a comparative trial of a prospective treatment group managed on a postoperative clinical care pathway and a historical group managed prior to pathway implementation. Effectiveness outcomes evaluated were total hospital days, return to OR, readmission to ICU and rate of pulmonary complications. Costing perspective was from the government payer. 118 patients were included in the study. All outcomes demonstrated that the postoperative pathway group was both more effective and less costly, and is therefore a dominant clinical intervention. The overall mean pre- and post-pathway costs are $22,733 and $16,564 per patient, respectively. The incremental cost reduction associated with the postoperative pathway was $6,169 per patient. Implementing the postoperative clinical care pathway in patients undergoing head and neck oncologic surgery with reconstruction resulted in improved clinical outcomes and reduced costs.
    Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale 12/2013; 42(1):59. DOI:10.1186/1916-0216-42-59 · 0.89 Impact Factor
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    • "The studies conducted by Schusterman et al. [13], Kroll et al. [14], Hidalgo et al. [15], Nakatsuka et al. [16], Jones et al. [17], Smit et al. [18] and Spiegel and Polat [19] indicate that the free flap technique for tissue reconstruction is very effective, with success rates of about 95% or higher (including salvage procedures). However, a major limitation to this success is the risk of compromised perfusion of the free flap. "
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    ABSTRACT: Objective: The purpose of this paper is to evaluate the efficacy and cost-effectiveness of the implantable Doppler system based on the analysis of the available scientific literature and clinical and cost data available in our hospital. The results of this system are compared to those of conventional free flap monitoring methods. Materials and methods: The literature published between 1991 and 2011 was systematically reviewed. All available cost data were collected and several simulations were performed. A retrospective assessment of the efficacy of conventional methods in our hospital was also conducted. Results and conclusion: The implantable Doppler system is more effective than the conventional methods used to monitor free flap perfusion. The mean flap salvage rate with the implantable Doppler was 21 percentage points higher (81.4 vs. 60.4). The excess cost compared to conventional methods was about CAD 120 per patient (about EUR 94). However, this excess cost can be compensated or even reversed, depending on the initial flap salvage rate in the health facility and the type of free flap (buried vs. non-buried).
    European Annals of Otorhinolaryngology, Head and Neck Diseases 04/2013; 130(2):79-85. DOI:10.1016/j.anorl.2012.07.003 · 0.82 Impact Factor
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