Cumulative Sum Analysis of the Learning Curve of Free Flap Reconstruction in Head and Neck Cancer Patients.

Free flap reconstruction in head and neck cancer patients with prior tumor resection, neck dissection, and irradiation is clinically challenging. The purpose of this study was to investigate the reliability and outcome of using the anterolateral thigh (ALT) flap and transverse cervical recipient vessels for microvascular reconstruction in patients with depleted vessels in the head and neck region caused by previous surgery and irradiation. Between January 2015 and December 2017, microsurgical head and neck reconstruction was performed using the ALT flap and transverse cervical artery (TCA) as the recipient vessel in 15 patients who had undergone previous neck dissections and irradiation for cancer treatment. All patients had a "vessel-depleted neck" resulting from severe scarring and radiation fibrosis. Clinical data of each patient were recorded. All ipsilateral TCAs were found to be damage free. Subsequently, free ALT flaps were revascularized using the TCAs. One patient developed venous thrombosis, and another patient developed arterial thrombosis. They were both salvaged within 6 hours postoperatively. No flap failure or mortalities were reported within the 30-day postoperative period. Two patients developed orocutaneous fistula and were further managed with wound care. The mean follow-up time was 11.9 ± 6.0 months (range, 5-23 months). Five patients died during the follow-up period from cancer progression. The use of the free ALT flap and TCA as the recipient vessel provides favorable microsurgical outcomes in patients with depleted recipient vessels in the head and neck region caused by previous neck dissections and radiation therapy.

Background: One of the most challenging methods is a free flap reconstruction in the third world: wanting in more endeavors. There is an intense requirement in the realm of training and experience in addressing head and neck defect issues. This study is aimed at expressing our experience with the free flap as a useful reconstruction method.Methods: Some patients were included as candidates in a retrospective study for free flap reconstruction, referring to diverse hospitals in different places in Tehran, Iran, from 2013 to 2020. Patients' demographic data, tumor profile, as well as flap results, were under assessment. Means (±Standard Deviation=SD), and median (with an interquartile range =IQR=Q1-Q3) for continuous variables; frequencies, as well as proportions for categorical variables, were reported. The variables' comparison among both groups – death or survival –was conducted employing either X2 tests or Fisher's accurate test for proportions; also, unpaired t-tests for means.Results: 330 individuals of patients undergoing 7 years of free-flap operation were under evaluation. The age ranged from 7 to 96 years, with an average of 51.91 ± 17.87 (Mean ± SD). The tongue (118, 37.6%) was the tumor's most typical origin; radial forearm flap (133, 40.3%), the most employed flap accompanied by anterolateral thigh flap (110, 33.3%). The success rate of free flaps surgery was 94 %, and merely 20 individuals of (6%) patients experienced flap necrosis; 21 individuals of patients (6.4%) died in the hospital after the surgical operation.Conclusion: In spite of the several limitations in our country as there are in other developing countries, the surgery of free flap reconstruction in head and neck defects has experienced an evolution in the last few years. In order to achieve better outcomes, we are supposed to mitigate the related issues to underlying diseases, patients suffering from, and the delay in the realm of detecting flap vascular complications in our setting.

Head and neck cancers are one of the leading causes of morbidity and mortality in Indian population. Reconstruction and restoration of function are also of paramount importance in these patients. The aim of this study was to report outcomes for free flaps and pedicle flaps in patients with oral cavity cancers. A retrospective analysis of 628 patients with oral cavity cancers who underwent reconstruction with either free flaps or pedicle flaps during 2014-2020 was done. The median age of the cohort was 49years. The free flap reconstruction was performed in 481 (76%) and pedicle flap in 147 (24%) patients. Among free and pedicle flaps, 27 (5.6%) and 3 (2.1%) respectively had major flap complications and 25 (5.1%) and 14 (9.9%) respectively had minor complications. CCI score > 4 was associated with higher events (p = 0.02) in free flap group. The outcomes of free flaps are similar in comparison to pedicle flaps in patients with oral cavity cancers. The higher CCI score is significantly associated with increased flap-related complications for the free flap group.

This study aimed to evaluate the presence of subjective post-operative donor site morbidity after fibula free flap reconstruction in head and neck cancer patients, utilising three validated instruments: the 36-item Short Form Health Survey, the Short Musculoskeletal Function Assessment questionnaire and the Lower Limb Core Scale. In this retrospective study, all head and neck cancer patients who underwent fibula free flap reconstruction between January 2009 and July 2014 were identified. All questionnaires and their respective subcomponents were scored. Twenty-one cases were included. Patients were found to have a higher Short Musculoskeletal Function Assessment bothersome index (22.42 vs 13.77, p = 0.03), a lower Short Form 36 Health Survey Physical Component Summary score (42.44 vs 50, p < 0.01) and a decreased Lower Limb Core Scale score (47.08 vs 90.52, p < 0.01), compared to US population norms. The Short Form 36 Health Survey Mental Component Summary scores and Short Musculoskeletal Function Assessment function index failed to demonstrate significant differences. Gender affected overall disability. In this study, significant long-term disability was demonstrated after fibular flap reconstruction, as measured by the Lower Limb Core Scale.

The objectives of this study were to classify and analyze perioperative complications following free flap reconstruction in the head and neck and investigate potential predictors of these complications. A retrospective chart analysis of 304 consecutive free flap reconstructions for defects in the head and neck were examined. Patient and operative characteristics as well as complications were recorded prospectively and analyzed using ordinal logistic regression. The overall complication rate was 32.6% with a perioperative mortality rate of 0.3%. The flap loss rate was 2.0% and the partial flap necrosis rate was 1.0%. Multivariate analysis demonstrated a significant correlation between perioperative complication and tumor stage as well as reconstruction site. The rate and grade of complications with free flap reconstruction in the head and neck were found to be low. Higher tumor stage and pharyngoesophageal reconstruction were found to be associated with increased complication grades, whereas preoperative radiation alone and chemoradiation were not. Smoking and alcohol use, age, diabetes mellitus, peripheral vascular disease, and preoperative myocardial infarction as well as preoperative cerebrovascular accident were not found to be associated with increased complications. No statistically significant difference in complication grades was found with different flap types or indications for reconstruction.

The purpose of the current study was to compare two different antithrombotic protocols for free flap reconstruction in head and neck squamous cell carcinoma (HNSCC) patients. Postoperative complications were graded using the Clavien–Dindo (CD) classification and compared between the two groups: the low-molecular-weight heparin (LMWH) group (n = 57) and the unfractionated heparin (UFH) group (n = 59). Patients with HNSCC from January 2010 to January 2022 were included. A total of 116 patients with a mean age of 60.46 years (range 43–83 years) were included in this study. In all, 81 were male (69.8%), and 35 were female (30.2%). Most patients (48.3%) had only grade 1 or 2 complications. CD grades (1–5) were similar between the two groups. Flap loss occurred in 2 patients (1.7%) in the LMWH group (p = 239). Prognostic factors of flap loss were high BMI, hypertension, high T stage, and high N stage. No differences were found between the groups in regard to age, sex, operating times, flap source, recipient vessels and overall complications. The results of this study demonstrate that UFH was as safe and effective as LMWH regarding postoperative complications. Free flap surgery is safe and effective for head and neck reconstruction.

There is no clear evidence on the number of cases required to master the techniques required in robot-assisted surgery for different surgical fields and techniques. The purpose of this study was to clarify the learning curve of robot-assisted rectal surgery for malignant disease by surgical process. The study retrospectively analyzed robot-assisted rectal surgeries performed between April 2014 and July 2020 for which the operating time per process was measurable. The following learning curves were created using the cumulative sum (CUSUM) method: (1) console time required for total mesorectal excision (CUSUM tTME), (2) time from peritoneal incision to inferior mesenteric artery dissection (CUSUM tIMA), (3) time required to mobilize the descending and sigmoid colon (CUSUM tCM), and (4) time required to mobilize the rectum (CUSUM tRM). Each learning curve was classified into phases 1-3 and evaluated. A fifth learning curve was evaluated for robot-assisted lateral lymph node dissection (CUSUM tLLND). This study included 149 cases. Phase 1 consisted of 32 cases for CUSUM tTME, 30 for CUSUM tIMA, 21 for CUSUM tCM, and 30 for CUSUM tRM; the respective numbers were 54, 48, 45, and 61 in phase 2 and 63, 71, 83, and 58 in phase 3. There was no significant difference in the number of cases in each phase. Lateral lymph node dissection was initiated in the 76th case where robot-assisted rectal surgery was performed. For CUSUM tLLND, there were 12 cases in phase 1, 6 in phase 2, and 7 cases in phase 3. These findings suggest that the learning curve for robot-assisted rectal surgery is the same for all surgical processes. Surgeons who already have adequate experience in robot-assisted surgery may be able to acquire stable technique in a smaller number of cases when they start to learn other techniques.

BackgroundUnilateral biportal endoscopy (UBE) is gaining popularity owing to its versatility as a spinal endoscopic procedure. However, the general value of the learning curve for discectomy by UBE is unknown. This retrospective study aimed to determine the learning curve of UBE for lumbar discectomy using a cumulative summation (CUSUM) method. We examined the learning curves of four surgeons at an institution and factors that shortened the learning curves.MethodsThe study included 200 patients (mean age 44.2 years) who underwent lumbar discectomy by UBE at our hospital and four male orthopedic surgeons who had performed 50 UBE discectomies. An approximate curve using the CUSUM method was created using the mean operative time for each case as the target. All surgeons had performed lumbar discectomy and over 200 spinal surgeries before inducing UBE. Surgeon A received specialized training in shoulder arthroscopic surgery. The surgical times before and after the curve reached its maximum value were compared; a point of significant difference was defined as case to proficiency.ResultsThe mean operative times for surgeons A, B, C, and D were 48, 66, 90, and 87 min, respectively. The approximate curves obtained using the CUSUM method had maxima at x = 22, 20, 27, and 13. The operating times of Surgeons A and B showed significant differences before and after the maxima (59 vs. 39 and 75 vs. 60), whereas those of Surgeons C and D did not (96 vs. 84 and 95 vs. 85).ConclusionsUBE is generally considered to have a steep learning curve; in this study, the learning curve differed depending on the surgeon. The surgeon with the best learning curve was trained as an arthroscopic surgeon. Coordination for endoscopic surgery influenced the learning curve compared to the experience with spine surgery.

A major challenge in head and neck reconstruction in patients with a "frozen neck" is the limited availability of recipient vessels including the carotid artery system. The aim of the present study was to investigate the suitability of the transverse cervical vessels as recipient vessels for free flap reconstruction in head and neck cancer patients. Thirty-three sides of necks in 26 patients requiring free flap reconstruction were explored. The presence, location, and size of the transverse cervical vessels were documented. Two arteries (6 percent) and four veins (12 percent) were unavailable. Eight arteries (24 percent) and two veins (6 percent) had a diameter of less than 2 mm, 23 arteries (70 percent) and 18 veins (55 percent) had a diameter of 2 to 3 mm, and nine veins (27 percent) were larger than 3 mm. The contralateral neck was explored because of the lack of suitable ipsilateral vessels in six patients (23 percent). The transverse cervical vessels were unsuitable on both sides in two patients (8 percent). All the available transverse cervical vessels were found to be free of disease. Moderate scarring in the supraclavicular region was present in two cases. All flaps survived without vascular events. The transverse cervical vessels were thus suitable as recipient vessels in 92 percent of patients and should be the first choice in difficult head and neck reconstructions.

Cumulative sum failure analysis of the learning curve with endovascular abdominal aortic aneurysm repair.

Video-assisted thoracic surgical (VATS) lobectomy is gaining popularity in the treatment of lung cancer. The aim of this study is to investigate the learning curve of VATS lobectomy by using multidimensional methods and to compare the learning curve groups with respect to perioperative clinical outcomes. We retrospectively reviewed a prospective database to identify 67 consecutive patients who underwent VATS lobectomy for lung cancer by a single surgeon. The learning curve was analyzed by using moving average and the cumulative sum (CUSUM) method. With the moving average and CUSUM analyses for the operation time, patients were stratified into two groups, with chronological order defining early and late experiences. Perioperative clinical outcomes were compared between the two learning curve groups. According to the moving average method, the peak point for operation time occurred at the 26th case. The CUSUM method also showed the operation time peak point at the 26th case. When results were compared between early- and late-experience periods, the operation time, duration of chest drainage, and postoperative hospital stay were significantly longer in the early-experience group (cases 1 to 26). The intraoperative estimated blood loss was significantly less in the late-experience group (cases 27 to 67). CUSUM charts showed a decreasing duration of chest drainage after the 36th case and shortening postoperative hospital stay after the 37th case. Multidimensional statistical analyses suggested that the learning curve for VATS lobectomy for lung cancer required ∼26 cases. Favorable intraoperative and postoperative care parameters for VATS lobectomy were observed in the late-experience group.

Use of the cumulative sum method (CUSUM) to assess the learning curves of ultrasound-guided continuous femoral nerve block

Background and Objective: A significant revolution in head and neck reconstruction occurred with advent of free flap transfer. The objective of this study was to review our experience during 14 years in performing 36 free flap for head and neck region. Materials and Methods: A retrospectively hospital chart review of in 35 free flap cases between February 1993 and July 2006 was done. Patient’s sex, age, T stage, type of free flap, flap success rate, post operative complications were evaluated. Results: 34 (94%) of 36 free flap were success. 2 cases partial tissue necrosis happened due to venous congestion, so local free flap was done. Post operative complications were happened 7 cases. 4 cases were seen fistulas, 1 case was seen wound dehiscence, 1 case was seen infection, 1 case was seen hematoma. Conclusion: In review of our experience, free flap reconstruction in head and neck defect has useful procedure in high success outcomes and cosmetics aspect. (J Clinical Otolaryngol 2006;17:223–227)

Robot-assisted partial nephrectomy (RAPN) has become the standard treatment for small renal tumors, offering better perioperative outcomes than open surgery. However, objective evaluations of the RAPN learning curve are limited. While the Trifecta criteria-comprising negative surgical margins, no perioperative complications, and warm ischemia time (WIT) ≤ 25min-are commonly used to assess surgical outcomes, they are inadequate for continuous proficiency assessment. This study aimed to evaluate the RAPN learning curve using the cumulative sum (CUSUM) method based on Trifecta achievement and its components. We retrospectively analyzed 119 RAPN cases performed by three surgeons at a single institution between 2017 and 2022. All surgeons (≥ 30 cases; ≥ 15year experience) were included. CUSUM charts were created using Trifecta achievement rates with thresholds (p₀ = 0.4, p₁ = 0.8), and further analysis was performed on individual components. Distinct learning curve transitions were observed only in Surgeon B, with proficiency achieved at the 9th case for complication rates and the 4th case for overall Trifecta achievement. No clear transitions were seen in WIT or surgical margins, or in any component for Surgeons A and C. These findings suggest that Surgeons A and C may have already attained proficiency before the study period. The CUSUM method offers a practical tool for visualizing and quantifying individual learning curves in RAPN based on clinically relevant criteria. Despite some limitations, CUSUM enables continuous, surgeon-specific assessment. Future studies should integrate additional metrics to develop more comprehensive training programs and improve surgical safety and outcomes.

Background and AimsRobotic-assisted right hemicolectomy (RARH) has many benefits in treating colon cancer, but it is a new technology that needs to be evaluated. This study aims to assess the learning curve (LC) of RARH procedures with the complete mesoscopic exception and D3 lymph node dissection for colon carcinoma.MethodsA retrospective analysis was performed on a consecutive series of 76 patients who underwent RARH from July 2014 to March 2018. The operation time was evaluated using the cumulative sum (CUSUM) method to analyze the LC. The patients were categorized into two groups based on the LC: Phase I and Phase II. Statistical methods were used to compare clinicopathological data on intraoperative and perioperative outcomes at different stages of the study.ResultsThe peak point of the LC was observed in the 27th case. Using the CUSUM method, we divide the LC into two stages. Stage 1 (initial learning stage): Cases 1–27 and Stage 2 (proficiency phase): Cases 28–76. There were no obvious distinctions between the two patients’ essential characteristics (age, sex, body mass index, clinical stage, and ASA score). The mean operation time of each group is 187.37 ± 45.56 min and 161.1 ± 37.74 min (P = 0.009), respectively. The intraoperative blood loss of each group is 170.4 ± 217.2 ml and 95.7 ± 72.8 ml (P = 0.031), respectively.ConclusionBased on the LC with CUSUM analysis, the data suggest that the learning phase of RARH was achieved after 27 cases. The operation time and the intraoperative blood loss decrease with more cases performed.