Impact of Early Mobilization on Recovery after Major Head and Neck Surgery with Free Flap Reconstruction

Abstract

Surgery with free flap reconstruction is a standard treatment for head and neck cancer (HNC). Because of the complexity of HNC surgery, recovery can be challenging, and complications are common. One of the foundations of enhanced recovery after surgery (ERAS) is early postoperative mobilization. The ERAS guidelines for HNC surgery with free flap reconstruction recommend mobilization within 24 h. This is based mainly on evidence from other surgical disciplines, and the extent to which mobilization within 24 h improves recovery after HNC surgery has not been explored. This retrospective analysis included 445 patients from the Calgary Head and Neck Enhanced Recovery Program. Mobilization after 24 h was associated with more complications of any type (OR = 1.73, 95% CI [confidence interval] = 1.16–2.57) and more major complications (OR = 1.76; 95% CI = 1.00–3.16). When accounting for patient and clinical factors, mobilization after 48 h was a significant predictor of major complications (OR = 2.61; 95% CI = 1.10–6.21) and prolonged length of stay (>10 days; OR = 2.85, 95% CI = 1.41–5.76). This comprehensive analysis of the impact of early mobilization on postoperative complications and length of stay in a large HNC cohort provides novel evidence supporting adherence to the ERAS early mobilization recommendations. Early mobilization should be a priority for patients undergoing HNC surgery with free flap reconstruction.

From Pathways to Practice: Impact of Implementing Mobilization Recommendations in Head and Neck Cancer Surgery with Free Flap Reconstruction

“…Postoperative mobilization data were missing in 11% (n = 55) of cases. It is believed the missing data were missing at random either due to failure to flag a case for data collection or a failure to record mobilization milestones in the chart [18].…”

“…In HNC surgery with free flap reconstruction, ERAS strongly recommends that patients are mobilized within 24 h [12], based on data from one HNC-specific cohort study [16] and evidence from other types of surgeries [17]. In our companion paper, we found that mobilization delayed beyond 24 h was associated with more complications, providing novel HNC-specific evidence for the ERAS recommended timeframe [18]. However, compliance with early mobilization recommendations can be low, particularly in the early adoption of an enhanced recovery pathway [19].…”

“…We also explored whether recommendation compliance (yes/no) was a significant predictor of major postoperative complications and a prolonged LOS using multivariable models presented in our companion paper. Procedures for variable selection for our previous logistic regression models to identify predictors of postoperative complications and LOS are described in detail in our companion paper [18].…”

“…We also explored whether compliance with the recommendation (yes/no) was a significant predictor within our multivariable models of major postoperative complications and LOS (presented in our companion paper). Taking other important covariates into consideration (including alcohol status), we previously found that mobilization after 48 h was associated with having a major postoperative complication and a prolonged LOS 18 . Here, we found that compliance with the mobilization recommendation was not itself a predictor within these models (when substituting mobilization within 48 h for compliance, considering the overlap in these variables; Tables S3 and S4).…”

Framework, component, and implementation of enhanced recovery pathways

“…These interventions have been linked with shorter hospitalization duration and improved postoperative mobilization [ 84 , 85 ]. Furthermore, these devices enable objective quantification of postoperative mobilization (e.g., step count) which facilitates monitoring of recovery, and also provide high quality data for research [ 86 ].…”