Implementation and Outcomes of <scp>ERAS</scp> Protocol for Major Oncologic Head and Neck Surgery

Murr, Alexander T.; Sweeney, Craig; Lenze, Nicholas R.; Farquhar, Douglas R.; Hackman, Trevor

doi:10.1002/lary.30904

Cited by 6 publications

(6 citation statements)

References 22 publications

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“…Blood laboratory tests including values of C-reactive protein, albumin, prealbumin, and thyroid-stimulating hormone are assessed at least twice before the surgery date. Its extensive measures have shown significant reduction in hospital LOS in numerous studies, which is in alignment with our study's findings 32,34,35 …”

Section: Discussionsupporting

confidence: 92%

“…Its extensive measures have shown significant reduction in hospital LOS in numerous studies, which is in alignment with our study's findings. 32,34,35 Limitations of this study are consistent with those of a retrospective review. As the NSQIP database only includes select information from participating hospitals, it may not be representative of the general population and introduce selection bias.…”

Section: Discussionsupporting

confidence: 68%

“…The protocol, which includes optimization of nutritional status, is implemented in many different surgical fields, including H&N cancer patients. 32 Enhanced Recovery After Surgery implements nutritional protocol with multiple strategies. 33 First, a dedicated H&N dietician is assigned to each patient who plans to undergo H&N surgery.…”

Section: Discussionmentioning

confidence: 99%

“…Enhanced Recovery After Surgery programs offer evidence-based, interdisciplinary care to facilitate recovery. The protocol, which includes optimization of nutritional status, is implemented in many different surgical fields, including H&N cancer patients 32 . Enhanced Recovery After Surgery implements nutritional protocol with multiple strategies 33 .…”

Section: Discussionmentioning

confidence: 99%

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Malnutrition in Head and Neck Free Flap Reconstruction as a Predictor of Adverse Outcomes

Herzog,

Panchal,

Sikder

et al. 2024

Ann Plast Surg

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Introduction Malnutrition is associated with increased mortality in patients with head and neck (H&N) cancer. Because albumin levels are used as a surrogate for nutritional status, the purpose of this study is to assess whether malnutrition is associated with adverse postoperative outcomes in H&N free flap reconstruction. Materials and Methods The 2006–2018 National Surgical Quality Improvement Program Database was queried for patients undergoing flap procedures of the H&N based on Current Procedure Terminology codes. Patients were included if they were operated on by an otolaryngologist or when the primary surgical site was H&N. Nutritional status was categorized as malnourished (preoperative albumin level <3.5 g/dL) or normal (preoperative albumin level ≥3.5 g/dL). Major complications included pulmonary complications, cardiac complications, deep vein thrombosis/pulmonary embolism, and sepsis/septic shock. Minor complications included surgical infection, urinary tract infection, bleeding, and dehiscence. Data were analyzed via univariate chi-square and multivariate regression analyses. Results Of the patients, 2532 (83.3%) had normal albumin and 506 (16.7%) had hypoalbuminemia. Patients with hypoalbuminemia were more likely to have smoking history (P = 0.008), pulmonary comorbidity (P < 0.001), renal comorbidity (P = 0.018), disseminated cancer (P < 0.001), steroid use (P < 0.001), recent weight loss (P < 0.001), bleeding disorder (P = 0.023), and preoperative transfusion (P < 0.001). After adjustment for preoperative variance, malnourished patients were more likely to experience death (P < 0.001), return to operating room (P < 0.001), free flap failure (P = 0.008), pulmonary complication (P < 0.001), deep vein thrombosis/pulmonary embolism (P = 0.019), wound disruption (P = 0.042), intraoperative transfusion (P < 0.001), minor complication (P < 0.001), major complication (P < 0.001), and extended length of stay (P < 0.001). Of the patients with normal albumin, 2.1% experienced flap failure compared with 6.3% of patients with hypoalbuminemia. It should be noted that malnourished patients were 3.370 times more likely to experience flap failure (95% confidence interval, 1.383–8.212; P = 0.008) and 3.975 times more likely to experience death (95% confidence interval, 1.700–9.626; P = 0.001) than those with normal albumin. Conclusion Malnutrition is associated with death, flap failure, minor complications, and other major complications following H&N free flap surgery, even after controlling for preoperative variance. Optimizing preoperative nutrition status before free flap procedures may ameliorate morbidity and mortality in H&N patients.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 68%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Malnutrition in Head and Neck Free Flap Reconstruction as a Predictor of Adverse Outcomes

Herzog,

Panchal,

Sikder

et al. 2024

Ann Plast Surg

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“…1 Initially developed in the colorectal surgery population, ERAS has now been shown to improve patient outcomes across a wide array of operations. [2][3][4][5][6] Several thoracic ERAS protocols have been described, and while they consist of similar themes and strategies, [7][8][9] the interpretation of specifics and subsequent execution of thoracic ERAS has been inconsistent and varied from hospital to hospital. Furthermore, most thoracic ERAS protocols described in the literature have been implemented at individual hospitals.…”

mentioning

confidence: 99%

Anatomic Lung Resection Outcomes After Implementation of a Universal Thoracic ERAS Protocol Across a Diverse Healthcare System

Dyas,

Stuart,

Bronsert

et al. 2024

Annals of Surgery

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Objective: We sought to evaluate how implementing a thoracic Enhanced Recovery After Surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection. Summary Background Data: The effect of implementing the ERAS Society/European Society of Thoracic Surgery (ESTS) thoracic ERAS protocol on postoperative outcomes throughout an entire healthcare system has not yet been reported. Methods: This was a prospective cohort study within one healthcare system (1/2019-3/2023). A thoracic ERAS protocol was implemented on 5/1/2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay (LOS), opioid use, chest tube duration, and total cost. Patients were grouped into pre- and post-ERAS cohorts. Bivariable comparisons were performed using independent t-test, chi-square, or Fisher’s exact tests, and multivariable logistic regression was performed to control for confounders. Results: There were 1,007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a BMI between 18.5-29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the post-implementation group had lower risk-adjusted rates of any morbidity, any respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative LOS (all P<0.05). Conclusions: Postoperative outcomes were improved after implementation of an evidence-based thoracic ERAS protocol throughout the healthcare system. This study validates the ERAS Society/ESTS guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective.

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Safety of An Enhanced Recovery After Surgery Protocol After Head and Neck Free Tissue Transfer

Schuman,

Bindal,

Amadio

et al. 2024

The Laryngoscope

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ObjectivesImplementing enhanced recovery after surgery (ERAS) protocols and decreasing length of stay (LOS) have become a priority for major surgeries, including microvascular free tissue transfer (MVFTT) reconstruction of the head and neck. We describe an ERAS protocol with the goal to further reduce length of stay beyond national medians.MethodsRetrospective chart review between August 2016 and February 2023, including all patients who underwent MVFTT after oral cavity, skull base, salivary gland, and cutaneous ablative surgery. An ERAS protocol was implemented in March 2020.ResultsA total of 383 patients were included. Approximately 59.8% underwent oral cavity MVFTT, 34.5% cutaneous and lateral skull base, and 5.8% maxillary and anterior skull base. A total of 209 (54.7%) patients had surgery prior to implementation of the ERAS protocol and 174 (45.3%) after. Median LOS decreased from 9 days (interquartile interval [IQR] 8–11) to 6 (IQR 5–7.5, p < 0.0001) following oral cavity MVFTT. For cutaneous and lateral skull base reconstruction, median LOS decreased from 6 days (IQR 5–8) to 3 (IQR 3–7, p < 0.0001). For anterior skull base and sinonasal MVFTT, median LOS decreased from 8 (IQR 7–9) to 5 days (IQR 4.5–7, p = 0.0005). Rate of discharge to skilled nursing or subacute rehabilitation facilities decreased (24% before ERAS, 9.2% after, p < 0.0001). Thirty‐day readmission rate was similar before and after implementation (10.5% vs. 10.3, p = 0.954). Discharge to facility was associated with readmission (OR 2.34, 95% CI 1.12–4.89, p = 0.024).Conclusion and RelevanceImplementation of the ERAS protocol was associated with decreased LOS. There was no increase in rate of readmission.Level of EvidenceN/A Laryngoscope, 2024

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Implementation and Outcomes of ERAS Protocol for Major Oncologic Head and Neck Surgery

Cited by 6 publications

References 22 publications

Malnutrition in Head and Neck Free Flap Reconstruction as a Predictor of Adverse Outcomes

Malnutrition in Head and Neck Free Flap Reconstruction as a Predictor of Adverse Outcomes

Anatomic Lung Resection Outcomes After Implementation of a Universal Thoracic ERAS Protocol Across a Diverse Healthcare System

Safety of An Enhanced Recovery After Surgery Protocol After Head and Neck Free Tissue Transfer

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