Complications, Mortality, and Functional Decline in Patients 80 Years or Older Undergoing Major Head and Neck Ablation and Reconstruction.

Autor:	Fancy T; Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown., Huang AT; Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas., Kass JI; Department of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts., Lamarre ED; Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio., Tassone P; Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio., Mantravadi AV; Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis., Alwani MM; Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis., Subbarayan RS; Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City., Bur AM; Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City., Worley ML; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston., Graboyes EM; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston., McMullen CP; Moffitt Cancer Center, Tampa, Florida., Azoulay O; Department of Otolaryngology-Head and Neck Surgery, New York University Health, New York, New York., Wax MK; Department of Otolaryngology-Head and Neck Surgery, Oregon Health Sciences University, Portland., Cave TB; Department of Otolaryngology-Head and Neck Surgery, Oregon Health Sciences University, Portland., Al-Khudari S; Department of Otolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois., Abello EH; Department of Otolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois., Higgins KM; Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada., Ryan JT; Department of Otolaryngology-Head and Neck Surgery, Upstate Medical University, State University of New York, Syracuse., Orzell SC; Department of Otolaryngology-Head and Neck Surgery, Upstate Medical University, State University of New York, Syracuse., Goldman RA; Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania., Vimawala S; Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania., Fernandes RP; Department of Otolaryngology-Head and Neck Surgery, University of Florida College of Medicine, Jacksonville., Abdelmalik M; Department of Otolaryngology-Head and Neck Surgery, University of Florida College of Medicine, Jacksonville., Rajasekaran K; Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia., L'Esperance HE; Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri., Kallogjeri D; Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri., Rich JT; Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri.
Jazyk:	angličtina
Zdroj:	JAMA otolaryngology-- head & neck surgery [JAMA Otolaryngol Head Neck Surg] 2019 Dec 01; Vol. 145 (12), pp. 1150-1157.
DOI:	10.1001/jamaoto.2019.2768
Abstrakt:	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.
Databáze:	MEDLINE
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