Free Flap Reconstructive Surgery Research Articles

Length of Stay Prediction Models for Oral Cancer Surgery: Machine Learning, Statistical and ACS-NSQIP.

Accurate prediction of hospital length of stay (LOS) following surgical management of oral cavity cancer (OCC) may be associated with improved patient counseling, hospital resource utilization and cost. The objective of this study was to compare the performance of statistical models, a machine learning (ML) model, and The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) calculator in predicting LOS following surgery for OCC. A retrospective multicenter database study was performed at two major academic head and neck cancer centers. Patients with OCC who underwent major free flap reconstructive surgery between January 2008 and June 2019 surgery were selected. Data were pooled and split into training and validation datasets. Statistical and ML models were developed, and performance was evaluated by comparing predicted and actual LOS using correlation coefficient values and percent accuracy. Totally 837 patients were selected with mean patient age being 62.5 ± 11.7 [SD] years and 67% being male. The ML model demonstrated the best accuracy (validation correlation 0.48, 4-day accuracy 70%), compared with the statistical models: multivariate analysis (0.45, 67%) and least absolute shrinkage and selection operator (0.42, 70%). All were superior to the ACS-NSQIP calculator's performance (0.23, 59%). We developed statistical and ML models that predicted LOS following major free flap reconstructive surgery for OCC. Our models demonstrated superior predictive performance to the ACS-NSQIP calculator. The ML model identified several novel predictors of LOS. These models must be validated in other institutions before being used in clinical practice. Level 3 Laryngoscope, 2024.

Early oral feeding and its impact on postoperative outcomes in head and neck cancer surgery: a meta-analysis

BackgroundEarly oral feeding has been previously postulated to contribute to developing postoperative complications following head and neck reconstructive surgeries using free flaps. This study assessed the association between the timing of oral feeding (early vs. late) and postoperative complications and length of hospital stay among these patients.MethodPubMed, Scopus, Cochrane, and Web of Science were searched using terms such as “oral feeding” and “head or neck cancer.” We utilized RevMan software version 5.4 for the analysis. The study defined early oral feeding as feeding within 5-day post-operation, while late oral feeding was defined as feeding after the fifth postoperative day. Five papers that met the inclusion criteria were included in the analysis, with 1097 patients.ResultsThe results showed that early feeding was not significantly associated with postoperative fistulas (RR 0.49, 95% CI 0.23 to 1.05, p-value = 0.07), hematoma/seroma (RR 0.71, 95% CI 0.33 to 1.51, p-value = 0.38), or flap failure (RR 0.84, 95% CI = 0.38 to 1.87, p-value = 0.67). However, early oral feeding was significantly associated with shorter hospital stays than late oral feeding (MD −3.18, 95% CI −4.90 to −1.46, p-value = 0.0003).ConclusionNo significant difference exists between early and late oral feeding regarding the risk of postoperative complications in head and neck cancer (HNC) patients who underwent free flap reconstruction surgery. However, early oral feeding is significantly associated with a shorter hospital stay than late oral feeding. Thus, surgeons should consider implementing early oral feeding after free flap reconstruction in HNC patients.

Impact of goal directed therapy in free flap reconstructive surgery of the head and neck

Impact of goal directed therapy in free flap reconstructive surgery of the head and neck

Influence of sarcopenia on postoperative complications in patients undergoing autologous microsurgical breast reconstruction: an inverse probability of treatment weighting analysis.

Sarcopenia is characterized by the loss of skeletal muscle mass and power. Preoperative sarcopenia may be associated with an increased risk of postoperative complications after autologous free-flap breast reconstruction surgery; however, this relationship is controversial. This study aimed to determine whether preoperative sarcopenia is associated with a high complication rate in patients undergoing autologous free-flap breast reconstruction. Patients who underwent autologous free-flap breast reconstruction at our hospital between 2019 and 2021 were included in the study. Data on significant complications requiring surgical intervention were retrospectively collected from the medical records. Sarcopenia was defined as having a skeletal muscle index value <41 cm2/m2. The skeletal muscle index was calculated by dividing the sum of the psoas and iliopsoas muscle areas at the level of the third lumbar vertebra by the patient's height in meters squared. The relationship between preoperative sarcopenia and postoperative complications was investigated using an inverse probability of treatment weighting (IPTW) analysis. Among the 203 participants, 90 (44.33%) had preoperative sarcopenia. The general patient characteristics were similar between the sarcopenia and non-sarcopenia groups after IPTW adjustment. Sarcopenia did not significantly increase the risk of flap failure or emergency surgery related to breast reconstruction before IPTW adjustment. However, after IPTW adjustment, the rates of recipient site infection and hematoma were significantly higher in participants with sarcopenia than in those without sarcopenia (p < 0.001 and p = 0.014, respectively). Preoperative sarcopenia may influence certain complications of autologous free-flap breast reconstruction surgery.

Effect of preoperative programmed death-1 or programmed death ligand-1 immune check point inhibition on complications after surgery for primary head and neck cancer.

There is sparse literature on the effect of preoperative immunotherapy on complications after surgery for primary head and neck squamous cell carcinoma (HNSCC). The objectives are to compare complication rates in patients receiving surgery with and without neoadjuvant immune checkpoint inhibitors (nICI) for primary HNSCC and to evaluate factors associated with increased odds of surgical complications. A retrospective review of patients who underwent ablation and free flap reconstruction or transoral robotic surgery (TORS) for primary HNSCC between 2017-2021 was conducted. Complications were compared between patients who underwent surgery with or without nICI before and after propensity score matching. Regression analysis to estimate odds ratios was performed. A total of 463 patients met inclusion criteria. Free flap reconstruction constituted 28.9% of patients and TORS constituted 71.1% of patients. nICI was administered in 83 of 463 (17.9%) patients. There was no statistically significant difference in surgical, medical, or overall complications between patients receiving surgery with or without nICI. In the unmatched cohort, multivariable model identified non-White race, former/current smoking history, free flap surgery, and perineural invasion as factors significantly associated with increased complications. In the matched cohort, multivariable model identified advanced age and free flap surgery as factors significantly associated with increased complications. It is safe to give immunotherapy before major surgery in patients who have head and neck cancer. Advanced age, non-White race, current/former smoking, free flap surgery, and perineural invasion may be associated with increased the odds of surgical complications.

544 Effect of Tranexamic Acid on Microvascular Thrombosis in Autologous Free Tissue Transfer

Abstract Aim The use of Tranexamic Acid (TXA) has been shown to be effective in reducing haemorrhage and mortality in numerous surgical settings and has a wide range of proposed benefits linked to anti-inflammatory effects which promotes healing and reduces pain and discomfort. However, the surgical community has been reluctant to incorporate TXA use into mainstream practices in microvascular surgery due to possible risk of thromboembolic events. Hence, we aim to report our experience with the use of TXA in microsurgical reconstruction. Method We performed a retrospective single-centre cohort study including any patients who underwent autologous free flap tissue transfer at a district general hospital, from 1 January 2016 to 20 April 2022. The Chi-squared test was used to determine if there were any significant differences between the proportion of patients who developed any evidence of microvascular thrombosis, flap failure, or return to theatre. Univariate logistic regression was used to calculate odds ratio. Results The treatment group (N = 160) received TXA (1g intravenous) at the time of general anaesthetic induction as per the senior author’s routine practice, while the control group (N = 80) did not receive TXA at any point of the hospital admission, according to the normal practice of other surgeons. No differences were found between the proportion of patients who developed flap failure, venous congestion or were returned to theatre between the TXA and control group. Conclusions Our study shows that TXA administration did not increase microvascular thrombosis in free flap reconstructive surgery, contributing evidence that TXA is safe to use in microvascular surgery.

Development and validation of a novel craniofacial statistical shape model for the virtual reconstruction of bilateral maxillary defects

Bilateral maxillary defects are a challenge for fibula free flap reconstruction (FFFR) surgery due to limitations in virtual surgical planning (VSP) workflows. While meshes of unilateral defects can be mirrored to virtually reconstruct missing anatomy, Brown class c and d defects lack a contralateral reference and associated anatomical landmarks. This often results in poor placement of osteotomized fibula segments. This study was performed to improve the VSP workflow for FFFR using statistical shape modeling (SSM) – a form of unsupervised machine learning – to virtually reconstruct premorbid anatomy in an automated, reproducible, and patient-specific manner. A training set of 112 computed tomography scans was sourced from an imaging database by stratified random sampling. The craniofacial skeletons were segmented, aligned, and processed via principal component analysis. Reconstruction performance was validated on a set of 45 unseen skulls containing various digitally generated defects (Brown class IIa–d). Validation metrics demonstrated promising accuracy: mean 95th percentile Hausdorff distance of 5.47 ± 2.39 mm, mean volumetric Dice coefficient of 48.8 ± 14.5%, compactness of 7.28 × 105 mm2, specificity of 1.18 mm, and generality of 8.12 × 10−6 mm. SSM-guided VSP will allow surgeons to create patient-centric treatment plans, increasing FFFR accuracy, reducing complications, and improving postoperative outcomes.

Percutaneous tracheostomy in head and neck oncology surgery: How Covid-19 changed our practice

Enhanced experience in performing percutaneous tracheostomies during the COVID-19 pandemic resulted in changes to airway management protocol for patients undergoing major head and neck reconstructive surgery within our department. Most patients now receive a percutaneous tracheostomy over the previously favoured surgical tracheostomy. The aim of this study was to review our experience in performing percutaneous tracheostomies, whilst comparing complication rates with surgical tracheostomies performed in similar settings. All consecutive patients undergoing free flap reconstructive surgery for head and neck cancer between June 2020 and November 2021 were included, with 56 patients receiving a percutaneous tracheostomy. Data across a range of variables including age, BMI, comorbidities and complications was compared with 56 surgical tracheostomies performed for the same group of patients before the COVID-19 pandemic and resultant protocol changes. In the percutaneous group, a marginally lower complication rate was observed over the surgical tracheostomy group; 28.57% and 30.35% respectively. Analysis of the 16 patients who experienced complications in the percutaneous group led to development of selection criteria to identify appropriate patients to receive a percutaneous tracheostomy in future, based on factors such as BMI, bleeding risk and positioning deformities. The COVID-19 pandemic has offered a multitude of learning experiences for healthcare professionals to change our practice. In our unit, this has involved modifying the routine tracheostomy procedure used for airway management intra- and post-operatively in major head and neck reconstruction surgery.

Effects of frailty on patients undergoing head and neck cancer surgery with flap reconstruction: a retrospective analysis

ObjectivesTo establish the implications of frailty as a predictor of outcome in patients with head and neck cancer requiring flap repair.DesignRetrospective cohort.Data sourceWe captured data from patients above 60 years...

Psychological impact on patients with oral cancer before undergoing resection and free flap reconstruction surgery

The psychological state of patients with advanced oral cancer should be evaluated as the disease and its treatment are considered to impose immense psychological burden. This study aimed to clarify the psychological state of patients with oral cancer immediately prior to their surgery. This study included patients with oral cancer scheduled for a free flap reconstruction surgery between February 2017 and October 2020. The Japanese version of the Impact of Event Scale-Revised (IES-R), a self-administered assessment used to screen post-traumatic stress disorder (PTSD) symptoms, was used to investigate their psychological status. The self-administered IES-R questionnaire was completed by 34 patients. The median IES-R score was 19 points (8–38), and the scores did not differ by background characteristics. Of the 34 patients, 14 (41.2%) had a cutoff value score of 25 points or higher. PTSD symptoms may occur in some patients with advanced oral cancer prior to surgery. Support is required to alleviate anxiety regarding the patient's treatment, subsequent life, and prognosis. • Limited studies examined mental stress in patients with oral cancer pre-treatment. • Impact of Event Scale-Revised scores did not differ by background characteristics. • Some patients with oral cancer may experience some PTSD symptoms before surgery.

Assessment of Operative Time for Lip and Oral Cancers: A Tool to Improve Operative Room Efficiency.

Operation theatre (OT) time utilisation rates can be improved with an assessment of the procedure time that will result in effective scheduling of cases. Our study is the first of its kind to audit the amount of OT time required for a particular surgery in lip and oral cavity cancers, depending on the various components of this complex procedure. This prospective cross-sectional study, based on an operative room database of 323 OT sessions, was conducted in the Department of Surgical Oncology at a tertiary care centre on lip and oral cancer patients from January 1st, 2019 to December 31st, 2020. Various components of the surgery, like the primary site, operating surgeon, type of neck dissection, bone resection, and reconstructive procedure, were noted. The time of entry and exit of the patient from the OT was noted. Operative time and OT time utilisation rates were calculated. SPSS 21.0 statistical tool; Students 'T', ANOVA and Games-Howell tests were applied. In 323 OT sessions, while 303 surgeries were done for primary cases (93.8%), the remaining 20 cases were for recurrent cases (6.2%). Buccal mucosa and the floor of the mouth were the most and least common sites, respectively. The mean OT time was 212.42 ± 73.83min, the maximum being the primary at alveolus. The mean OT late start time was 70.03 ± 23.41min and the mean OT runover time was 37.62 ± 43.53min. The mean time varied significantly with the type of neck dissection, bone resection, and reconstructive surgery done and the operating surgeon. The mean OT time was highest for free flap reconstructive surgery (328.71 ± 62.02min), but it didn't vary with its type. Considering only the lip and oral cancer surgeries, the OT time utilisation rate was 57.1%. Assessment and quantification of the operative duration of lip and oral cancer surgeries will help in accurate prediction of surgical duration, better OT list planning, and thus improved OT time utilisation rate. Our research not only provides data on the historical mean of procedures, but it may also encourage other centres to adopt our quantitative approach to OT scheduling.

P-67686931-185 - A craniofacial statistical shape model for the virtual reconstruction of bilateral maxillary defects.

<h3>Purpose</h3> Bilateral maxillary defects (whether traumatic, surgical, or congenital in origin) challenge fibula free flap (FFF) reconstruction surgery due to limitations in virtual surgery planning (VSP) workflows. While segmented 3D meshes of unilateral maxillary defects can be mirrored to virtually reconstruct missing anatomy, bilateral defects (Brown class c and d) lack a contralateral reference and associated anatomical landmarks. This often results in poor placement of osteotomized fibula segments. The current study improves the VSP workflow for FFF reconstructions using statistical shape modelling (SSM) – a form of unsupervised machine learning – to virtually reconstruct premorbid anatomy in an automated, reproducible, and patient-specific manner. <h3>Methods</h3> The SSM training set was sourced from the New Mexico Decedent Image Database via stratified random sampling to ensure even age and sex distributions. Skulls from 104 computed tomography scans were segmented and rigidly aligned, after which principal component (PC) analysis was applied to construct a discrete Gaussian process (GP). Defect reconstruction was accomplished on a validation set of 8 skulls via an iterative closest point algorithm with GP regression. <h3>Results</h3> Preliminary analysis shows that Brown class 2c maxillectomy defects can be virtually reconstructed with promising accuracy [Hausdorff distance=7.89±1.63mm, volumetric Dice coefficient=99.1±0.01%, compactness=7.22×105 mm2 (over the first 97 PC), specificity=1.18mm, and generality=1.06×10−5mm]. <h3>Conclusion</h3> SSM-guided VSP will allow surgeons to create patient-centric treatment plans, increasing reconstruction accuracy and reducing the risk of complications. This is expected to improve post-operative outcomes.

Influence of biological sex on intra- and postoperative course of microvascular free flap reconstructive surgery in the head and neck region: A retrospective analysis involving 215 patients

This retrospective study investigates differences in peri-/postoperative complications/outcomes of head and neck microvascular free flap reconstructions between female (FFP) and male flap patients (MFP).Evaluated variables: biological sex, age, ASA status, tumor type, preoperative radiation/chemotherapy, medical comorbidities; flap type, reconstruction (primary/secondary), operative time; length of stay on ICU, prolonged stay on ICU and its reasons, length of hospitalization, prolonged hospitalization and its reasons; flap success, revisions, overall complications, mortality.N = 215 patients (86 FFP; 129 MFP) were included. MFP exhibited higher nicotine abuse (P < .001), received more large-volume flaps (P < .001), and operative time was longer (P = .013). Sex had no influence on postoperative and outcome variables.Biological sex has no influence on the postoperative course following head and neck microsurgical free flap reconstructions.

Effects of ischemic conditioning on head and neck free flap oxygenation: a randomized controlled trial

Flap failure after microvascular reconstructive surgery is a rare but devastating complication caused by reperfusion injury and tissue hypoperfusion. Remote ischemic conditioning (RIC) provides protection against ischemia/reperfusion injury and reduces tissue infarction. We hypothesized that RIC would enhance flap oxygenation and exert organ-protective effects during head and neck free flap reconstructive surgery. Adult patients undergoing free flap transfer surgery for head and neck cancer were randomized to receive either RIC or sham-RIC during surgery. RIC consisted of four cycles of 5-min ischemia and 5-min reperfusion applied to the upper or lower extremity. The primary endpoint, tissue oxygen saturation of the flap, was measured by near-infrared spectroscopy on the first postoperative day. Organ-protective effects of RIC were evaluated with infarct size of rat hearts perfused with plasma dialysate from patients received RIC or sham-RIC. Between April 2018 and July 2019, 50 patients were randomized (each n = 25) and 46 were analyzed in the RIC (n = 23) or sham-RIC (n = 23) groups. Tissue oxygen saturation of the flap was similar between the groups (85 ± 12% vs 83 ± 9% in the RIC vs sham-RIC groups; P = 0.471). Myocardial infarct size after treatment of plasma dialysate was significantly reduced in the RIC group (44 ± 7% to 26 ± 6%; P = 0.018) compared to the sham-RIC group (42 ± 6% to 37 ± 7%; P = 0.388). RIC did not improve tissue oxygenation of the transferred free flap in head and neck cancer reconstructive surgery. However, there was evidence of organ-protective effects of RIC in experimental models.Trial registration: Registry number of ClinicalTrials.gov: NCT03474952.

Short-term and long-term outcomes of free flap reconstruction versus amputation for diabetic foot reconstruction in patients with end-stage renal disease

In Taiwan, the prevalence of diabetes mellitus complicated by end-stage renal disease (ESRD) has been increasing and diabetes-related foot amputation is commonplace. In recent years, limb salvage has become top priority. The long-term outcomes of patients on hemodialysis undergoing diabetic foot reconstruction using free flaps remain unknown. Data from the National Health Insurance Research Database on hemodialysis patients with type 2 diabetes who received amputation or free flap reconstruction surgery for diabetic foot ulcer were analyzed from 2000 to 2013 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. After 1:4 propensity score matching, 86 and 344 patients were assigned to the free flap reconstruction and amputation groups, respectively. The 5-year survival rate was significantly higher in patients who received free flap compared to the amputated group (1-year survival rate=80.0% vs. 67.6%, p=0.030; 3-year survival rate=49.7% vs. 35.5%, p=0.024; 5-year rate=30.1% vs. 19.9%, p=0.018; however, after 5 years, the overall long-term survival rate was similar in both groups (p=0.064). Patients who had lower limb amputation after flap reconstruction were susceptible to mortality (adjusted HR=1.39; p=0.069). Peripheral arterial disease was a dependent risk factor (HR=1.45; p=0.037) for long-term survival, whereas old age (> 75 years; HR=1.65; p=0.004), cerebrovascular disease (adjusted HR=1.36; p=0.011), and sepsis (adjusted HR=1.85; p=0.035) served as independent risk factors. Hemodialysis patients with diabetic foot ulcer who had limb salvaged showed a higher 5-year survival rate as compared to the amputated group.

Head and neck reconstruction with free vascularized flaps; our experience

Objectives The available data of the use of free vascularized flaps in head and neck reconstruction in a single centre is presented. Materials and Methods All patients who received a free vascularized flap in our department in the past 5 years (2017-2021) were recorded. Results 21 patients were included, 20 oncologic patients and self-inflicted gunshot injury patient. As far as the oncologic patients are concerned, 10 patients received a free flap in the same stage as tumour resection, 4 received a free flap after disease recurrence, and 6 received a free flap after a disease-free period, either for a post-surgical correction of a deformity or to manage post-therapy complications, such as osteoradionecrosis or trismus. In total the survival rate of the oncologic patients is 60%. No major post-surgical complications were observed as far as the flap survival was concerned. The anterolateral thigh flap and fibula flap were the most preferred for reconstruction in 8 and 8 cases respectively. The radial forearm free flap was used in 3 patients and the gracilis flap in 2 patients. Conclusion The contribution of our Department in the use of free vascularized flaps, despite small, indicates that they can be effectively used in patients either as immediate reconstruction or a reconstruction in a 2-step approach. Mortality rates are associated with disease recurrence or other major comorbidities of the patients. This experience can be the basis for further expansion of the free flap reconstruction surgery in our Department. ​

Perioperative Myocardial Infarction in Free Flap for Head and Neck Reconstruction.

Acute myocardial infarction (AMI) is a postoperative complication of major surgical procedures, including free flap surgery. It is the most common cause of postoperative morbidity and mortality. Moreover, patients receiving free flap reconstruction for the head and neck have significant risk factors such as coexisting coronary artery disease (CAD). Our primary aim was to ascertain predictors of perioperative AMI to enable early detection and consequently early treatment of perioperative AMI. Our secondary aim was to determine the group of patients who would be at a high risk for perioperative AMI after free flap surgery. This retrospective study enrolled patients who underwent free flap reconstruction surgery at the Division of Plastic and Reconstructive Surgery of Taipei Veterans General Hospital between 2013-01 and 2017-12. This study included 444 patients and 481 free flap head and neck reconstruction surgeries. Fifteen (3.1%) patients were diagnosed with perioperative AMI. Statistical analysis of the variables revealed that patients with underlying CAD or cerebrovascular accident (CVA) were at a high risk of developing perioperative AMI (odds ratio: 6.89 and 11.11, respectively). The flap failure rate was also higher in patients with perioperative AMI compared with those without perioperative AMI (P = 0.015). Patients with underlying diseases, such as CAD or CVA, constituted high-risk groups for perioperative AMI.

A case of tongue cancer that underwent free flap reconstruction surgery during pregnancy

A case of tongue cancer that underwent free flap reconstruction surgery during pregnancy

1318 Peri and Post-operative Fluid Management in Relation to Outcomes in Free Flap Reconstructive Surgery - A Systematic Review

Abstract Aim Free tissue transfer is one of the options available in the armamentarium of the reconstructive surgeon. Being a highly demanding and skilled procedure, success is dependent not only on the technical aspect of the anastomosis, but also on other variables including a patient’s fluid status. In order to address the controversy surrounding optimal fluid balance in free flap reconstruction, a systematic review of studies investigating the influence of peri and post- operative fluid balance on free flap reconstruction outcomes was carried out. Method We searched the Medline database from 1970 to 2020 and manually searched the bibliographies of relevant studies. The articles were graded according to the level of evidence set out by the Centre for Evidenced-Based Medicine and followed the PRISMA guidelines. Results Of the 62 abstracts screened, we identified 14 studies that met the inclusion criteria. Of the 14 studies, 12 studies concluded that excessive fluid therapy led to either medical or surgical complications (including free flap complications) or increased length of hospital stay. One study concluded that restricted fluid therapy led to a higher complication rate of delayed thrombotic events. One study reported no difference between volume of fluid administered with respect to pulmonary complications. Conclusions An important aspect of successful microvascular reconstruction involves determining a patient’s fluid status and targeted optimal resuscitation. This is best achieved with goal directed fluid therapy using tools such as an oesophageal doppler or other arterial waveform- based systems. Further good quality trials are required to determine which system is superior.

Factors Associated With Postoperative Delirium in Patients Undergoing Complex Head and Neck Flap Surgery

Postoperative delirium (PD) is a common and severe complication, following extensive surgery and prolonged stays in intensive care units (ICU). The study aimed to estimate the frequency of and identify risk factors for PD in a unified sample of head and neck surgery patients. The investigators implemented a retrospective cohort study composing of patients undergoing free flap reconstructive surgery over 1 year. The predictor variables were identified as 146 general and periprocedural parameters. The primary outcome variable was PD (+ or -). Descriptive and bivariate statistics were performed to identify existing correlations between the predictive factors and PD and the P-value was set at .05. A logistic regression model (LRM) was created to adjust for possible confounding factors and reveal possible independent prognostic factors for the onset of PD. Hundred patients (group 1, 18 with PD+, group 2, 82 without PD) undergoing microvascular free flap (65 males, 35 females, mean age = 65 [range 18 to 84 years]) surgery were recruited. The investigators identified 15 variables that were statistically associated with PD. In the LRM, after adjusting for age, diabetes status, and preoperative TSH, free fibula transplants (FT) as type of surgery was associated with an increased risk for PD (FT, Odds Ratio (OR) 6.3 (1.6 to 25.7, P = .01). The investigators identified 15 variables associated with an increased risk of developing PD, one of which had a statistically significant association after adjusting for other variables in a LRM. Future research efforts should be devoted to assessing the use of these variables for predicting PD further. Since the use of FT showed to be an independent prognostic parameter for the development of PD in this study, patients receiving FT should get special attention in the first days after surgery to prevent PD and associated complications such as increased mortality and prolonged hospital stays.