Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor.
JAMA Otolaryngol Head Neck Surg. 2023 Nov 1;149(11):1021-1026. doi: 10.1001/jamaoto.2023.3028.
Because microvascular free flap reconstruction is increasingly used to restore function in patients with head and neck cancer, there is a growing need for evidence-based perioperative care.
To assess the association of different team-based surgical approaches with intraoperative and postoperative outcomes for patients undergoing head and neck free flap reconstruction.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study of 733 patients was conducted at an academic tertiary care medical center. Head and neck oncologic procedures involving microvascular free flap reconstruction with available intraoperative data collected from January 1, 2000, to December 31, 2021, were included.
Patient characteristics including demographic characteristics and comorbid conditions, operative variables, length of stay, and postoperative outcomes were measured. Descriptive statistics and effect size measures were performed to compare the 3 intraoperative surgical team approaches, specifically single surgeon, separate 2-team approach, and integrated 2-team approach; 1:1 nearest neighbor matching without caliper was performed to compare single- vs 2-team and separate and integrated 2-team approaches. Effect size measures including Cramer V for dichotomous variables, the Kendall W coefficient of concordance for ordinal variables, and η2 for continuous variables were reported with 95% CIs to describe precision.
Among 733 cases, there were no clinically significant differences in patient demographic characteristics, clinicopathologic characteristics, and choice of free flap reconstruction based on intraoperative surgical team approach. The mean (SD) age was 58.7 (12.4) years, and 514 were male (70.1%). In terms of operative and postoperative variables, there was a difference in operative times and intraoperative fluid requirements among the 3 different techniques, with the integrated 2-team approach demonstrating a mean reduction in operative time of approximately 2 hours (η2 = 0.871; 95% CI, 0.852-0.887; mean [SD] operative time = 541 [191] minutes for the single-surgeon approach, 399 [175] minutes for the integrated 2-team approach, and 537 [200] minutes for the separate 2-team approach) and lower fluid requirements of greater than 1 L (η2 = 0.790; 95% CI, 0.762-0.817). In both unadjusted analyses and propensity score matching, there were no clinically significant differences in terms of ischemia time, use of pressors, postoperative complications (including free flap failure, number of return trips to the operating room, length of stay, or 30-day readmission) based on intraoperative team approach.
Findings suggest that the integrated 2-team surgical approach for complex head and neck microvascular reconstruction can be used to safely decrease operative time, with no difference in postoperative outcomes.
由于微血管游离皮瓣重建术越来越多地用于恢复头颈部癌症患者的功能，因此对循证围手术期护理的需求也在不断增加。
评估不同基于团队的手术方法与头颈部游离皮瓣重建患者的术中及术后结果的关系。
设计、地点和参与者：这是一项回顾性队列研究，共纳入 733 名患者，在一家学术性三级护理医疗中心进行。纳入了涉及微血管游离皮瓣重建的头颈部肿瘤手术，术中数据可从 2000 年 1 月 1 日至 2021 年 12 月 31 日获得。
患者特征包括人口统计学特征和合并症、手术变量、住院时间和术后结果。进行描述性统计和效应量测量，以比较 3 种术中手术团队方法，即单手术医生、单独的 2 个团队方法和综合的 2 个团队方法；进行无卡尺的 1:1 最近邻匹配，以比较单团队与 2 个团队和单独的 2 个团队方法。报告效应量测量值，包括二分类变量的 Cramer V、有序变量的 Kendall W 一致性系数和连续变量的 η2，并报告 95%置信区间以描述精度。
在 733 例病例中，基于术中手术团队方法，患者的人口统计学特征、临床病理特征和游离皮瓣重建选择无明显临床差异。平均（SD）年龄为 58.7（12.4）岁，514 例为男性（70.1%）。在手术和术后变量方面，3 种不同技术的手术时间和术中液体需求存在差异，综合 2 个团队方法的手术时间平均减少约 2 小时（η2=0.871；95%置信区间，0.852-0.887；单手术医生组的平均手术时间[SD]为 541[191]分钟，综合 2 个团队方法为 399[175]分钟，单独的 2 个团队方法为 537[200]分钟），液体需求超过 1 L（η2=0.790；95%置信区间，0.762-0.817）。在未调整分析和倾向评分匹配中，基于术中团队方法，缺血时间、使用升压药、术后并发症（包括游离皮瓣失败、返回手术室的次数、住院时间或 30 天再入院）均无明显差异。
研究结果表明，用于复杂头颈部微血管重建的综合 2 个团队手术方法可安全地缩短手术时间，而术后结果无差异。
