Outcomes in Patients 80 Years or Older Undergoing Major Head and Neck Ablation and Reconstruction

Outcomes in Patients 80 Years or Older Undergoing Major Head and Neck Ablation and Reconstruction: This cohort study examines factors associated with 30-day postoperative complications, 90-day mortality, and 90-day functional decline and creates a preoperative risk stratification system for elderly patients undergoing head and neck ablation and reconstruction.






Tanya Fancy, MD1; Andrew T. Huang, MD2; Jason I. Kass, MD, PhD3; et alEric D. Lamarre, MD4; Patrick Tassone, MD4; Avinash V. Mantravadi, MD5; Mohamedkazim M. Alwani, MD5; Rahul S. Subbarayan, MD6; Andrés M. Bur, MD6; Mitchell L. Worley, MD7; Evan M. Graboyes, MD7; Caitlin P. McMullen, MD8; Ofer Azoulay, MD9; Mark K. Wax, MD10; Taylor B. Cave, BS10; Samer Al-khudari, MD11; Eric H. Abello, BS11; Kevin M. Higgins, MD12; Jesse T. Ryan, MD13; Susannah C. Orzell, MD13; Richard A. Goldman, MD14; Swar Vimawala, BS14; Rui P. Fernandes, MD, DMD15; Michael Abdelmalik, MD15; Karthik Rajasekaran, MD16; Heidi E. L’Esperance, MD17; Dorina Kallogjeri, MD, MPH17; Jason T. Rich, MD17

Author Affiliations

1Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown

2Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, Houston, Texas

3Department of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts

4Department of Otolaryngology–Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio

5Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis

6Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City

7Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston

8Moffitt Cancer Center, Tampa, Florida

9Department of Otolaryngology–Head and Neck Surgery, New York University Health, New York, New York

10Department of Otolaryngology–Head and Neck Surgery, Oregon Health Sciences University, Portland

11Department of Otolaryngology–Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois

12Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada

13Department of Otolaryngology–Head and Neck Surgery, Upstate Medical University, State University of New York, Syracuse

14Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania

15Department of Otolaryngology–Head and Neck Surgery, University of Florida College of Medicine, Jacksonville

16Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia

17Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri

JAMA Otolaryngol Head Neck Surg. 2019;145(12):1150-1157. doi:10.1001/jamaoto.2019.2768

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Key Points

Question  What characteristics are associated with worse outcomes for patients 80 years or older undergoing major head and neck ablative and reconstructive surgery?



Findings  In this multi-institutional cohort study of 376 patients from 17 academic centers, variables associated with worse outcomes were being 85 years or older, moderate or severe comorbidities, body mass index of less than 25, high frailty, duration of surgery, flap failure, additional operations, and surgery of the maxilla, oral cavity, or oropharynx. A novel risk stratification system incorporating preoperative patient factors is presented.



Meaning  Preoperative patient factors can be used to provide risk stratification information during preoperative counseling and treatment planning; the type of flap is not associated with worse outcomes in this population.



Abstract

Importance  Data regarding outcomes after major head and neck ablation and reconstruction in the growing geriatric population (specifically ≥80 years of age) are limited. Such information would be extremely valuable in preoperative discussions with elderly patients about their surgical risks and expected functional outcomes.



Objectives  To identify patient and surgical factors associated with 30-day postoperative complications, 90-day mortality, and 90-day functional decline; to explore whether an association exists between the type of reconstructive procedure and outcome; and to create a preoperative risk stratification system for these outcomes.



Design, Setting, and Participants  This retrospective, multi-institutional cohort study included patients 80 years or older undergoing pedicle or free-flap reconstruction after an ablative head and neck surgery from January 1, 2015, to December 31, 2017, at 17 academic centers. Data were analyzed from February 1 through April 20, 2019.



Main Outcomes and Measures  Thirty-day serious complication rate, 90-day mortality, and 90-day decline in functional status. Preoperative comorbidity and frailty were assessed using the American Society of Anesthesiologists classification, Adult Comorbidity Evaluation–27 score, and Modified Frailty Index. Multivariable clustered logistic regressions were performed. Conjunctive consolidation was used to create a risk stratification system.



Results  Among 376 patients included in the analysis (253 [67.3%] men), 281 (74.7%) underwent free-flap reconstruction. The median age was 83 years (range, 80-98 years). A total of 193 patients (51.3%) had 30-day serious complications, 30 (8.0%) died within 90 days, and 36 of those not dependent at baseline declined to dependent status (11.0%). Type of flap (free vs pedicle, bone vs no bone) was not associated with these outcomes. Variables associated with worse outcomes were age of at least 85 years (odds ratio [OR] for 90-day mortality, 1.19 [95% CI 1.14-1.26]), moderate or severe comorbidities (OR for 30-day complications, 1.80 [95% CI, 1.34-2.41]; OR for 90-day mortality, 3.33 [95% CI, 1.29-8.60]), body mass index (BMI) of less than 25 (OR for 30-day complications, 0.95 [95% CI, 0.91-0.99]), high frailty (OR for 30-day complications, 1.72 [95% CI, 1.10-2.67]), duration of surgery (OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), flap failure (OR for 90-day mortality, 3.56 [95% CI, 1.47-8.62]), additional operations (OR for 30-day complications, 5.40 [95% CI, 3.09-9.43]; OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), and surgery of the maxilla, oral cavity, or oropharynx (OR for 90-day functional decline, 2.51 [95% CI, 1.30-4.85]). Age, BMI, comorbidity, and frailty were consolidated into a novel 3-tier risk classification system.



Conclusions and Relevance  Important demographic, clinical, and surgical characteristics were found to be associated with postoperative complications, mortality, and functional decline in patients 80 years or older undergoing major head and neck surgery. Free flap and bony reconstruction were not independently associated with worse outcomes. A novel risk stratification system is presented.