Section of Otolaryngology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta2Cancer Strategic Clinical Network, Alberta Health Services, Calgary, Alberta.
Department of Otolaryngology, Division of Head and Neck Surgery, University of California Davis, Sacramento.
JAMA Otolaryngol Head Neck Surg. 2017 Mar 1;143(3):292-303. doi: 10.1001/jamaoto.2016.2981.
Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking.
To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction.
Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent key words for each topic included "head and neck surgery," "pharyngectomy," "laryngectomy," "laryngopharyngectomy," "neck dissection," "parotid lymphadenectomy," "thyroidectomy," "oral cavity resection," "glossectomy," and "head and neck." The final selection of literature included meta-analyses and systematic reviews as well as randomized controlled trials where available. In the absence of high-level data, case series and nonrandomized studies in head and neck cancer surgery patients or randomized controlled trials and systematic reviews in non-head and neck cancer surgery patients, were considered. An international panel of experts in major head and neck cancer surgery and enhanced recovery after surgery reviewed and assessed the literature for quality and developed recommendations for each topic based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations were graded following a consensus discussion among the expert panel.
The literature search, including a hand search of reference lists, identified 215 relevant publications that were considered to be the best evidence for the topic areas. A total of 17 topic areas were identified for inclusion in the protocol for the perioperative care of patients undergoing major head and neck cancer surgery with free flap reconstruction. Best practice includes several elements of perioperative care. Among these elements are the provision of preoperative carbohydrate treatment, pharmacologic thromboprophylaxis, perioperative antibiotics in clean-contaminated procedures, corticosteroid and antiemetic medications, short acting anxiolytics, goal-directed fluid management, opioid-sparing multimodal analgesia, frequent flap monitoring, early mobilization, and the avoidance of preoperative fasting.
The evidence base for specific perioperative care elements in head and neck cancer surgery is variable and in many cases information from different surgerical procedures form the basis for these recommendations. Clinical evaluation of these recommendations is a logical next step and further research in this patient population is warranted.
重要性：头颈部癌症常需施行复杂且劳动密集型的手术，尤其是需要游离皮瓣重建时。在这类患者中，加速康复很重要，但缺乏针对该人群围手术期护理的循证方案。
目的：为头颈部癌症合并游离皮瓣重建患者的围手术期护理提供基于共识的方案。
证据回顾：在获得加速康复外科（enhanced recovery after surgery，ERAS）协会的支持以制定该方案后，对每个主题进行了系统综述。最初在 PubMed 和 Cochrane 数据库中检索了 1965 年至 2015 年 4 月间有关头颈部癌症手术的相关出版物。每个主题的关键一致关键词包括“头颈部手术”、“咽切除术”、“喉切除术”、“喉咽切除术”、“颈部清扫术”、“腮腺淋巴结切除术”、“甲状腺切除术”、“口腔切除术”、“舌切除术”和“头颈部”。文献的最终选择包括荟萃分析和系统评价，以及有随机对照试验时的随机对照试验。在缺乏高级别数据的情况下，纳入了头颈部癌症手术患者的病例系列和非随机研究，或非头颈部癌症手术患者的随机对照试验和系统评价。一个主要的头颈部癌症手术和加速康复后手术方面的国际专家小组审查和评估了文献的质量，并基于推荐评估、制定与评价分级（grading of recommendations, assessment, development and evaluation，GRADE）系统为每个主题制定了推荐意见。所有建议都在专家小组的共识讨论后进行了分级。
发现：文献检索包括对参考文献的手工搜索，共识别出 215 篇与该主题相关的最佳文献。共有 17 个主题被确定纳入头颈部癌症合并游离皮瓣重建患者围手术期护理方案。最佳实践包含了围手术期护理的几个要素。其中包括术前碳水化合物治疗、药物性血栓预防、清洁-污染手术中的围手术期抗生素、皮质类固醇和止吐药、短效镇静剂、目标导向液体管理、阿片类药物节约型多模式镇痛、频繁皮瓣监测、早期活动和避免术前禁食。
结论和相关性：头颈部癌症手术特定围手术期护理要素的证据基础各不相同，在许多情况下，来自不同手术的信息构成了这些建议的基础。对头这些建议进行临床评估是合乎逻辑的下一步，有必要对头颈部癌症患者人群开展进一步研究。
