Objectives: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.Methods: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.Results: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.Conclusions: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.

Microscopic tumor cut-through revised to negative margins is a powerful prognosticator that is observed only when regional disease is also present. The value of adjuvant therapeutic regimens is questionable in patients with microscopic tumor cut-through, revised to negative margins, and with no regional disease.

Surgical salvage for oropharyngeal SCC after failure of radiotherapy (+/- chemotherapy) is feasible. Patients who may benefit from surgery include those without regional recurrence and/or those in whom negative margins can be obtained. However, patients may be tracheotomy or gastrostomy tube dependent. The p16 status did not seem to have prognostic impact in the salvage setting; however, larger series are required to assess this relationship. © 2015 Wiley Periodicals, Inc. Head Neck 38: E658-E664, 2016.

Programmed death ligand-1 (PD-L1) immunohistochemistry is used to guide treatment decisions regarding the use of checkpoint immunotherapy in the management of urothelial carcinoma of the bladder and hypopharyngeal (HP) squamous cell carcinoma. With increasing PD-L1 testing options, a need has arisen to assess the analytical comparability of diagnostic assays in order to develop a more sustainable testing strategy. Using tissue microarrays, PD-L1 expression in tumor cells (TCs) and immune cells (ICs) was manually scored in 197 cases and 27 cases of bladder and HP cancer, respectively. Three commercial kits (Ventana SP263, Ventana SP142, Dako 22C3) and 1 platform-independent test (Cell Signalling Technologies E1L3N) were utilized. Across the 3 commercially available clones, 14% and 74% of urothelial carcinomas were positive and negative, respectively, whereas 7% and 78% of HP carcinomas were positive and negative, respectively. Twelve percent of bladder and 15% HP cases showed discrepant PD-L1 classification results. Regardless of the scoring algorithm used, E1L3N provided comparable PD-L1 staining results. Fleiss' kappa and intraclass correlation coefficient (ICC) analyses demonstrated substantial agreement among all antibody clones (k=0.639 to 0.791) and excellent reliability among SP263, 22C3, and E1L3N antibodies (ICC, 0.929 to 0.949) in TC staining. Compared with the other 3 clones, SP142 TC staining was lower with only moderate correlation (ICC, 0.500 to 0.619). Generally, the reliability of immune cell staining was lower compared with TC staining (ICC, 0.519 to 0.866). Our results demonstrate good analytic comparability of all 4 antibodies. The results are encouraging and support growing optimism in the pathology and oncology communities concerning strategies in PD-L1 assay use.

T he transfer of autogenous, vascularized free-tissue is a cornerstone of modern reconstructive surgery, particularly when dealing with extensive oncological ablations and large post-traumatic defects. A half-century after Jacobson and Suarez (1) described the first sutured microvascular anastomosis, the cumulative efforts of surgeons and researchers have refined free tissue transfer (FTT) into a reliable modality that often provides excellent cosmetic and functional results.In addition to adequate presurgical planning and meticulous dissection technique, the microvascular anastomosis is critically important for successful reconstruction. The reported success rate of FTT ranges from 91% to 99%, with the majority of failures being due to technical errors with vessel anastomosis (2). Indeed, a hand-sewn anastomosis is a technically demanding procedure, particularly when dealing with veins, which prompted investigation into alternative strategies to suture. One example is the microvascular anastomotic coupling device (MACD), an interlocking ring-pin design that is becoming more widely used in FTT. Initial animal studies demonstrated favourable tensile characteristics and healing of coupled vessels (3), and subsequent case series in head and neck, breast and limb reconstructive surgery have reported favourably on MACD utilization. These case series have been limited by smaller numbers and variability in reconstructive subsites; however, recently, several larger series have been published. We sought to systematically review the literature to examine the utility of MACD use in FTT with regard to success rates and optimal applications of this device. MethodsA search of PubMed, Ovid MEDLINE, and EMBASE databases (inception to January 2011) was performed using major search terms including "microvascular anastomotic coupler", "anastomotic device", "venous coupler", "Nakayama ring pin" and "free tissue transfer". Two independent reviewers performed the title and abstract review, identifying relevant articles for retrieval. Inclusion criteria were MACD utilization and FTT reconstruction. There was no limitation placed on BACKGrouNd:The microvascular anastomosis remains a technically sensitive and critical determinant of success in free tissue transfer. The microvascular anastomotic coupling device is an elegant, friction-fit ring pin device that is becoming more widely used. oBJeCtive: To systematically review the literature to examine the utility of the microvascular coupler in free tissue transfer. Methods: A comprehensive database search was performed to identify eligible publications. Inclusion criteria were anastomotic coupler utilization and free-tissue transfer. Recorded information from eligible studies included patient age, follow-up, radiation history, number of free-flaps and failure rates, reconstruction subsites, number of coupled venous and arterial anastomoses, coupling time, conversion to sutured anastomosis, coupler size and thrombosis rates. results: Twenty-five studies reporting on 3207 patients were inc...

Objectives: To evaluate whether frailty and functional measures are predictors of perioperative complications and length of hospital stay (LOS) in patients undergoing head and neck cancer surgery.Study Design: Prospective study. Methods: Patients 50 years and older undergoing major head and neck cancer surgery between 2011 and 2015 preoperatively completed Fried's Frailty Index, Barthel Index, Lawton-Brody questionnaire and Vulnerable Elders Survey-13. Primary outcome measures were postoperative complications and LOS, which were analyzed using multivariable logistic and linear regression models.Results: There were 274 patients recruited (105 aged 50-64 and 169 aged 65 and older). Of these, 119, 132, and 23 were defined as non-frail, pre-frail, and frail, respectively. Frailty score and functional measures were not predictors of overall complications. In multivariable models, frailty score (odds ratio [OR] = 1.36; 95% confidence interval [CI], 1.04-1.78, P = .025) was a predictor of medical complications and Clavien-Dindo Grade III and higher complications independent of age and comorbidity. Higher frailty score (β = 1.07; 95% CI, 1.02-1.12, P = .0025) and less independence on the Lawton Brody (β = −0.08; 95% CI, −0.11 to −0.05, P < .001) and Barthel Index (β = −0.12; 95% CI, −0.19 to −0.06, P < .001) were predictors of increased LOS.Conclusions: Frailty was a predictor of type and severity of complications. Both frailty and measures of independence in activities of daily living were independent predictors of LOS. Frailty and functional assessment can help surgeons identify patients at risk of adverse postoperative outcomes and thus aid in counselling patients as well as identifying patients that may benefit from comprehensive geriatric assessment and targeted interventions.

With proper patient selection, endoscopic resection of juvenile nasopharyngeal angiofibroma is feasible and may be preferable to traditional open approaches. Results suggest that after endonasal resection, disease recurrence is low. Most larger lesions, especially those with intracranial spread, continue to require open approaches for complete resection.

N/A.