Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction

Abstract

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.

Interobserver agreement of skeletal muscle mass measurement on head and neck CT imaging at the level of the third cervical vertebra

“…In the future, HNC patients at high risk of adverse outcomes related to low SMM or sarcopenia might benefit from additional supportive treatment or individualized primary treatment. Several possible interventions may be considered, such as altered chemotherapy dosing [32], prehabilitation before surgery [33], enhanced recovery after surgery [34], intensive physiotherapy [35], and additional nutritional support [36]. A measurement of SMM at the level of C3 might be used as a screening tool for low SMM in HNC cancer patients at diagnosis.…”

How Sweet Is This? A Review and Evaluation of Preoperative Carbohydrate Loading in the Enhanced Recovery After Surgery Model

“…The data supporting preoperative carbohydrate loading in this population is also limited; no high‐quality studies evaluating its benefits have been conducted, and any recommendations would be based on extrapolations from other literature . In the United Kingdom, the practice has become commonplace for head and neck cancer surgery, describing it as “safe and well tolerated.”…”

Best Practice in Surgical Treatment of Malignant Head and Neck Tumors

“…This society develops guidelines for perioperative patient care. Such guidelines have been published for head and neck free tissue transfer (8). ERAS protocols have been evaluated previously and demonstrated to improve quality of care, patient-reported and operative outcomes, and patient safety.…”