Impact of Prior Oncologic Treatment on Complications and Functional Outcomes in 1751 Head and Neck Free Flap Reconstruction Patients: An Institutional Analysis Using American College of Surgeons National Surgical Quality Improvement Program Methodology

Abstract

PURPOSE: Patients with head and neck squamous cell carcinoma (HN-SCC) frequently present with locally advanced disease, and many develop locoregional recurrence. Treatment of locally advanced or recurrent HN-SCC often involves neoadjuvant chemotherapy and/or radiation. However, a knowledge gap exists regarding the interplay of toxicities from prior oncologic treatments on successful reconstruction. The aim of this study was to evaluate the effect of prior oncologic treatment, including chemotherapy, radiation, and/or surgery, on long-term outcomes and functional status after head and neck free flap reconstruction utilizing a prospectively maintained database modeled on the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). METHODS AND MATERIALS: This is a retrospective review of all head and neck free flap reconstructions at our institution from 2012 to 2019. Data were retrieved from our database, which utilizes NSQIP methodology modified to track major head and neck oncologic reconstructive outcomes. In contrast to the NSQIP, which limits prior treatment to 3 months before the index procedure, our database includes any prior oncologic treatment. RESULTS: One thousand seven hundred fifty-one patients were identified, 1093 of whom received prior oncologic treatment before the principal operative procedure for tumor extirpation and immediate free flap reconstruction. Patients without prior treatment were more likely to be active smokers (25% versus 18%; P < 0.0001) and have body mass index ≥25 (67% versus 53%; P <0.0001), hypertension (55% versus 47%; P < 0.0001), and diabetes (18% versus 12%; P < 0.001). Patients receiving prior treatment had higher rates of steroid use (8% versus 5%; P = 0.019) and preoperative G-tube placement (15% versus 3%; P < 0.0001). On multivariate analysis, prior treatment did not increase the risk of postoperative complications including: flap loss, fistula, infection, hematoma, seroma, reoperation, or readmission (P > 0.05). However, there was a significant increase in the risk of transfusion (odds ratio [OR], 2.01; 95% CI, 1.60–2.53), death within 12 months (OR 1.43; 95% CI, 1.05–1.95), G-tube dependency at 3 months postoperative (OR, 1.42; 95% CI, 1.11–1.81), and poor speech scores (OR, 1.40; 95% CI, 1.01–1.95). When comparing prior surgery versus chemotherapy versus radiation, multivariate analysis indicated that chemotherapy was associated with the highest risk of: transfusion (OR, 2.51; 95% CI, 1.96–3.22), death within 12 months (OR, 1.67; 95% CI, 1.20–2.33), and G-tube dependency at 3 months postoperative (OR, 1.78; 95% CI, 1.37–2.32). Prior radiation as associated with the highest risk of poor postoperative speech scores at 3 months (OR, 1.82; 95% CI, 1.27–2.61). CONCLUSIONS: The goals of HN-SCC treatment and reconstruction include disease stabilization, prolonging survival, and improving quality of life. This study demonstrates prior oncologic treatment is not associated with flap loss or postoperative wound-healing complications, after controlling for confounding factors. It is associated with higher mortality and worse functional outcomes, which may reflect disease burden. Our results demonstrate that free flap head and neck reconstruction is a reasonable choice for well-selected patients with advanced and recurrent HN-SCC, even in the setting of multiple prior treatments, and has the potential to improve quality of life and reduce functional deficits.