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Risk Factors for Postoperative Complications in Oral Cancer and Their Prognostic Implications
Giulianno Molina de Melo, MD;
Karina de Cássia Braga Ribeiro, DDS, MSc;
Luiz P. Kowalski, MD, PhD;
Daniel Deheinzelin, MD, PhD
Arch Otolaryngol Head Neck Surg. 2001;127:828-833.
ABSTRACT
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Background The surgical treatment of head and neck cancer can be limited by the
risk of postoperative complications. Early identification of risk factors
based on clinical characteristics may assist therapeutic planning.
Objectives To identify risk factors for these complications and to evaluate their
prognostic significance.
Methods The medical records of 110 patients with oral squamous cell carcinoma
admitted from January 1, 1990, to December 31, 1994, who underwent radical
surgery were reviewed. Data collected included demographic information, comorbidities,
extended clinical severity stage, treatment, complications, and survival.
The  2 test was used to verify the association between the
variables. Survival analysis was performed with the Kaplan-Meier method. Logistic
and Cox proportional hazards regression were used to build models with independent
predictive factors for the risk of complications and death, respectively.
Results The overall complication rate was 50%. Dehiscence and infection rates
were 20.9% and 22.7%, respectively. The death rate was 3.6%. Forty-seven patients
(42.7%) were electively referred to the intensive care unit (ICU). The occurrence
of postoperative complications was associated with extended clinical severity
stage (P = .02), type of surgery (P = .03), ICU
(P = .03), type of reconstruction (P = .02), Functional
Severity Index (P = .03), neck dissection (P = .002),
and APACHE II (Acute Physiology and Chronic Health Evaluation II) (P = .008). The number of complications was significantly correlated
with the length of hospital stay (r = 0.24, P =
.01) and with the Functional Severity Index (r = 0.19, P = .04). Five-year overall survival was affected by the type of complications
(none, 41.7%; local, 34.1%; and local plus systemic, 0% [P<.001]),
ICU (no, 46.3%; yes, 20.7% [P = .001]), and extended clinical
severity stage (stage 1, 75.6%; stage 2, 50%; stage 3, 28.6%; and stage 4,
10.2% [P<.001]). In a multivariate analysis bilateral neck
dissection (relative risk = 3.57, P = .01) and an APACHE II score
greater than 10 (relative risk = 3.86, P = .02) were independent
risk factors for complications. The predictive prognostic model consisted
of the following: staying in the ICU (hazard ratio = 1.83), local plus systemic
complications (hazard ratio = 6.27), and extended clinical severity stage
(stage 3, hazard ratio = 3.57; stage 4, hazard ratio = 6.34).
Conclusions Bilateral neck dissection and the APACHE II score were identified as
risk factors for postoperative complications in oral cancer, which also increase
the length of hospital stay. The occurrence of systemic complications, advanced
extended clinical severity stage, and staying in an ICU adversely affect the
prognosis. Therefore, the prompt recognition of the adverse risk factors for
postoperative complications may guide proactive interventions that may improve
survival and achieve cost-effectiveness.
INTRODUCTION
APPROXIMATELY 30 000 new cases of oral cavity and pharyngeal cancer
are diagnosed annually in the United States, with almost 58% being located
in the tongue and other parts of mouth.1 In
Brazil 10 980 new cases of mouth cancer were estimated for the year 2000.2 The main goal of the treatment is the eradication
of the cancer through control of the primary lesion and regional metastasis,
with restoration of form and function.3 The
anatomical extension of the disease, evaluated by the TNM system, is the most
important prognostic factor.4 However, the
unpredictable clinical evolution of some patients has led to the searching
of other prognostic markers such as surgical margins,5
histopathological features,6-7
molecular abnormalities,8 and comorbidities.9-12 Recent
advances in the anesthetic and cancer ablative techniques, as well as microvascular
reconstruction of the resultant defect allowed more radical oncological procedures
for advanced head and neck cancer.13 Nevertheless,
the curative intent can be limited by the hazard of life-threatening postoperative
complications. The prompt recognition of risk factors for complications based
on preoperative clinical characteristics of the patient with oral cancerplus
the identification of the risks associated with the surgical procedure itself
can help determine the appropriate therapeutic planning to prevent severe
complications.10 The objectives of this article
are to identify the risk factors associated with the development of postoperative
complications and to establish their prognostic significance on the survival
of patients with oral cancer.
PATIENTS AND METHODS
We reviewed 247 medical records of patients with squamous cell carcinoma
of the oral tongue or floor of the mouth, admitted to the Centro de Tratamento
e Pesquisa Hospital do Câncer A. C. Camargo, São Paulo, Brazil,
from January 1, 1990, to December 31, 1994. The following criteria were used
for inclusion in the study: a histologically confirmed diagnosis; absence
of previous oncological treatment for this primary tumor; complete clinical
evaluation allowing APACHE II (Acute Physiology and Chronic Health Evaluation
II), American Society of Anesthesiologists, National Cancer Institute, and
Functional Severity Index (FSI) classifications; absence of distant metastasis
at diagnosis; and surgical treatment with a curative purpose, exclusive or
as part of a multidisciplinary approach. A total of 110 patients met the criteria
for inclusion in the study.
Data collection from the medical records was performed using a specially
designed form. These data included demographic information, smoking status,
alcoholism status, TNM staging (Union Internationale Contre le Cancer or American
Joint Committee on Cancer classification),4
tumor site, surgical risk (American Society of Anesthesiology Scale), type
of surgery and neck dissection, type of reconstruction, comorbidities according
to National Cancer Institute classification,14
FSI,12 extended clinical severity stage (ECSS),12 APACHE II score,15
length of stay in an intensive care unit (ICU), and nosocomial and postoperative
complications. Outcome measures included development of complications in the
immediate postoperative period (until 30 days) and 5-year overall survival.
Patients were followed up from the date of diagnosis to the date of last objective
evaluation or death. Only 4.5% of the patients were lost to follow-up.
The FSI was created through the identification of 9 variables that influenced
prognosis based on the following Cox proportional hazards regression model:
daily alcohol consumption, neck lump, dysphagia, weight loss, hematocrit of
0.35 or lower, age older than 50 years, National Cancer Institute comorbidity
index level 2 (>3 comorbidities), earache, and oral cavity bleeding. The FSI
was built through the multiplication of the values of the hazard ratio (HR)
for each patient. When the condition was absent, we gave the value of 1 for
that category. The score ranged from 1 to 258.23, and the results allowed
for grouping patients into 3 categories, based on the percentiles 30 and 60:
high (score  8.7), intermediate (score >3.8 and <8.7), and low (score  3.8)
grade of functional commitment. Consolidation of the FSI categories with the
TNM system created the extended clinical severity staging system (ECSS), consisting
of 4 stages (1 [best] to 4 [worst]).12
The APACHE II classification is a revised version of the APACHE prototype
system. It includes 12 physiologic measures (temperature; mean arterial pressure;
heart rate; respiratory rate; oxygenation; levels of arterial sodium, serum
potassium, and serum creatinine; hematocrit, white blood cell count, and Glasgow
Coma Scale score), age, and severe chronic health problems. The physiologic
score is determined from the worst value, eg, the lowest hematocrit or the
highest respiratory rate, during the initial 24 hours after admission to the
ICU.15 In our study we also applied APACHE
II for patients not referred to the ICU, based on findings of the first 24
hours of the postoperative period.
Patients were electively referred to the ICU based on 1 of the following
criteria: expected operative time longer than 6 hours and/or the presence
of a comorbidity diagnosed preoperatively, such as coronary insufficiency
or advanced chronic obstructive pulmonary disease, requiring strict cardiopulmonary
monitoring.
Wound infection was recorded only for patients who present suppurative
drainage and/or who developed a mucocutaneous fistula.16
Wounds noted to have erythema or erythema and edema may be considered infected
in the presence of fever, based on an evaluation performed by the surgeon.
The information on the forms was entered in a database (DBase for Windows;
Borland International, Scotts Valley, Calif). Periodically, revisions were
made to verify the internal consistency of the data. For statistical analysis,
commercially available software (Statistical Product and Service Solutions
for Windows, release 7.5; SPSS Inc, Chicago, Ill) was used. Descriptive statistics
were used as a preliminary analysis of the relationship between the baseline
variables and outcome events. The t test was used
to compare means. The Pearson coefficient was used to confirm correlation
between the continuous variables; the 2 test was used to verify
the association between categorical variables. Survival analysis was performed
using the Kaplan-Meier method (with the log rank test value being used to
compare groups). Logistic regression was used to find risk factors for postoperative
complications and the Cox proportional hazards regression model was chosen
to identify independent prognostic factors. For all statistical tests 
= .05.
RESULTS
The cohort of 110 patients included 93 men (84.5%) and 17 women (15.5%);
93 patients were white and 17 belonged to other ethnic groups. The patients'
ages ranged from 31 to 80 years (mean age, 57.5 years). Fifty-nine patients
had tumors in the tongue; 51 had tumors in the floor of the mouth. Eighty-two
patients (75.6%) were daily drinkers of alcohol, while there was an equal
division between patients who never drank alcohol and social drinkers (12.7%
in each group). One hundred patients (90.9%) were tobacco users and 10 (9.1%)
had never smoked. Pain was the most frequently reported symptom (affecting
69 patients [62.7%]) followed by weight loss (affecting 46 patients [41.8%]).
Earache, odynophagia, and oral cavity bleeding affected only 19 patients (17.3%)
who had symptoms. According to the comorbidity National Cancer Institute index,12 64 patients (58.1%) were classified as being at level
1 (0-3 comorbidities) and the remaining 46 patients (41.9%) were classifed
as being at level 2 (>3 comorbidities). Patients' distribution according to
FSI, ECSS, and TNM is given in Table 1.
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Table 1. Patients' Distribution According to TNM, FSI, and ECSS*
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Sixty-four patients (58.2%) did not have lymph node involvement (N0).
Clinical neck metastasis was detected in 46 patients (41.8%) with the following
distribution: N1, 11 patients (36.7%); N2a, 1 patient (0.9%); N2b, 12 patients
(10.9%); N2c, 10 patients (9.1%); and N3, 3 patients (2.7%). Among patients
classified as having TNM stage IV, 13 (11.8%) had bilateral neck involvement.
All patients underwent surgery as the primary treatment; 69 received irradiation
as adjuvant therapy. They underwent the following types of surgery: partial
glossectomy or pelvectomy (17 patients), pelviglossectomy or pelviglossomandibulectomy
(80 patients), and hemiglossectomy or total glossectomy (13 patients). Forty-four
patients (40%) underwent marginal or sectional mandibulectomy. Neck dissection
was performed in 97 patients (88.2%), with 57 (51.8%) unilateral surgical
procedures and 40 (36.4%) bilateral surgical procedures. Supraomohyoid, classic
radical, or a modified radical neck dissection was performed unilaterally
in 22 patients (20%), 20 (18.2%), and 15 (13.6%), respectively. Among those
who had bilateral neck dissections, the combination of radical neck dissection
and contralateral supraomohyoid was performed in 19 patients (17.3%) and bilateral
supraomohyoid neck dissection was the therapy used in 12 patients (10.9%).
Simultaneous bilateral comprehensive neck dissection or bilateral modified
radical neck dissection was performed in 5 (4.5%) and 4 (3.6%) patients, respectively.
The surgical defect was closed primarily in 50 patients (45.5%). A tongue
flap was used in 29 patients (26.3%), pectoralis major myocutaneous flap in
24 (21.8%), a microvascular flap in 4 (3.6%), and other myocutaneous flaps
in 3 (2.7%).
Surgical procedure included a tracheostomy in 96 patients (87.3%). No
significant statistical association was noted between tracheostomy and chest
infection (P = .49).
Operative time varied from 25 to 810 minutes (mean ± SD = 334.8
± 164.2 minutes). Twenty-nine (67.4%) of 43 patients with operative
times longer than 6 hours developed postoperative complications in contrast
to 26 (39.4%) of 66 patients with operative times shorter than 6 hours (P = .004). A higher rate of systemic complications (14%)
between patients with operative times longer than 6 hours (P = .03) as well as more frequent occurrence of wound infection (39.5%)
(P = .001) were observed.
All but 1 patient received prophylactic antibiotic agents starting in
the operating room, immediately before surgery, for a period that varied from
24 to 288 hours (median time, 72 hours). Fifty-four patients (49.1%) received
a combination of 4 g/d of cephalothin sodium plus 4 g/d of chloramphenicol
succinate, 45 patients received 1.8 g/d of clindamycin phosphate (40.9%),
and 10 patients (9.1%) received other types of antibiotic agents. There was
no association between the type of antibiotic used and postoperative complications
(P = .63). We also could not observe a statistically
significant difference between the mean period of antibiotic therapy in the
group that had postoperative complications (97.3 hours) and the group without
postoperative complications (95.1 hours) (P = .86).
There was no difference in the frequency of postoperative complications comparing
patients receiving antibiotic therapy up to 24 hours and patients receiving
antibiotic therapy for longer than 24 hours (P =
.82).
Forty-seven patients (42.7%) were electively referred to the ICU. The
length of stay in the ICU varied from 1 to 13 days (mean length of ICU stay,
2 days). The APACHE II score was 10 or fewer in 76 patients (69.1%) and higher
than 10 in 34 patients. The length of hospital stay ranged from 2 to 54 days
(mean length of hospital stay, 9 days).
The overall complication rate was 50%. Postoperative complications are
listed in Table 2.
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Table 2. Frequency of Postoperative Complications According to Type
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The occurrence of postoperative complications was associated with neck
dissection (P = .002), APACHE II score (P = .008), type of reconstruction (P = .02),
ECSS (P = .02), type of surgery (P = .03), FSI (P = .03), tracheostomy (P = .004), operative time (P =
.004), and staying in the ICU (P = .03). The number
of complications was significantly correlated with the length of hospital
stay (r = 0.24, P = .01)
and FSI (r = 0.19, P = .04).
In a multivariate analysis bilateral neck dissection (relative risk [RR] =
3.57, P = .01) and an APACHE II score higher than
10 (RR = 3.86, P = .02) were independent risk factors
for complications.
Five-year overall survival was affected by the type of complications
(none, 41.7%; local, 34.1%; and local plus systemic, 0%; P<.001) (Figure 1), staying
in the ICU (no, 46.3%; yes, 20.7%; P = .001) (Figure 2), and ECSS (stage 1, 75.6%; stage
2, 50%; stage 3, 28.6%; and stage 4, 10.2%; P<.001).
The predictive prognostic model was composed by staying in the ICU (HR = 1.83),
local plus systemic complications (HR = 6.27), and ECSS (stage 3, HR = 3.57;
and stage 4, HR = 6.34).
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Figure 1. Five-year overall survival according
to the type of complications.
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Figure 2. Five-year overall survival according
to the stay in the intensive care unit.
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COMMENT
A surgical complication has been defined as a development, which is
generally to the patient's detriment, arising at the time of operation or
during the postoperative period.17 Complications
after major surgery for patients with oral cancer increase treatment costs,
delay adjuvant treatment, augment late sequelae, affect quality of life, and
also can cause a patient's death if not diagnosed and promptly treated.18 During the last few years, advances in surgical techniques,
the introduction of new antibiotic agents, a better understanding of fluid
balance physiology, improved methods for blood transfusions, developments
in anesthetic techniques, and the establishment of ICUs improved the safety
of major head and neck oncological surgery decreasing the risk and severity
of complications.19 Although the indications
of surgical treatment are standardized in most institutions, the rates of
complications are still high and the identification of risk factors associated
with them can reduce morbidity and possibly improve survival in patients with
oral cancer, thus achieving cost-effectiveness.20-22
In our study the overall complication rate was 50%, similar to other
reports in the literature.19, 22
Infection was also the most frequent (22.7%) among local and systemic complications,
again in agreement with the literature.16, 22-23
Many recent studies24-26
have addressed the issue of identifying patients at high risk for developing
a wound infection following head and neck oncological surgery. Advanced stage
of tumor,16 type of reconstruction,16 preoperative radiotherapy,21
nutritional status,16 comorbidities,16 duration of surgery,16
classification of procedure,16 antibiotic prophylaxis,16 and alcohol consumption16
have been significantly related to the probability of postoperative wound
infection. Robbins et al16 also noted that
the use of blood replacement, surgical drains, and nasogastric tubes were
significant predictors of wound infection even when it was hypothesized that
this finding was essentially related to the extent and duration of surgery.
The prognostic significance of postoperative wound infection on head and neck
cancer is still controversial.
The variations in type and duration of antibiotic agents that were noted
in our study can be explained by the lack of a standardized regimen in the
study period. The benefit of prophylactic antibiotic therapy has been clearly
proven, whereas the best regimen and length of time the antibiotic agents
are administered remain controversial.24, 26-28
Some authors reported that there was no statistically significant difference
in the rate of wound infection noted in patients receiving distinct types
of antibiotic agents29 that was also noted
in our study. However, another study showed that the rate of wound infection
was significantly lower in patients receiving prophylaxis with a combined
regimen of metronidazole and cefazolin vs cefazolin alone.16
Our incidence of chylous fistula is similar to other series.21, 30-32 Our
rate of hematoma (3.7%) is higher than the 1% and 1.9% incidence reported
by Gall et al33 and Yoder et al,21
respectively, but is lower than the 4.2% rate described by Johnson and Cummings.34
In our series, a low rate of pneumonia was detected, whereas in other
studies it ranged from 7% to 15%.20, 35-37
Several aspects of head and neck surgery make pneumonia a frequent complication
irrespective of the underlying functional class or medical condition. Probably,
the intensive pulmonary care and the few patients who underwent hemiglossectomy
or total glossectomy with risk for aspiration have contributed to the low
rate of pneumonia in our patients.
Reported postoperative complication rates associated with tracheostomy
vary considerably,38 and the chest infection
is the most common problem detected, achieving rates up to 20%.39
Although tracheostomy was associated with postoperative complications in our
study, this correlation with chest infection was unconfirmed.
The mortality rate (3.6%) in our study is comparable to other studies.19-20,33, 40 The
causes of postoperative death in our study were arterial rupture, hypovolemic
shock, respiratory distress, and sudden death.
To our knowledge, no report analyzed the influence of the number of
complications on the length of hospital stay for head and neck cancer until
this article. However, some authors reported a strong correlation between
wound infection and prolonged hospital stay.20
Clinical conditions can adversely affect the rate of complications in
head and neck cancer surgery.16, 20-21,36, 41
Such factors have been studied recently,10, 13, 37
with predictive value in determining the risk of complications in surgically
treated patients with oral cancer.
The choice of a neck dissection is based on the primary site as well
as the number, size, and location of positive lymph nodes. In addition, the
results and morbidity associated with each type of neck dissection must be
considered. A selective neck dissection is often recommended for patients
with cancer of the oral tongue who have a clinically N0 neck. Comprehensive
neck dissection is required in the presence of palpable cervical metastases.
Bilateral radical neck dissection has been used for many years for the treatment
of proved or suspected bilateral metastatic disease, carrying significant
morbidity and mortality rates.42 Our mortality
rate for patients who underwent this procedure (7.5%) is similar to other
rates described in the literature,42-43
but it is higher than 2.1% reported in a series of 193 bilateral radical neck
dissections from our institution.44
The APACHE II scoring system is primarily intended for patients in ICUs,
but attempts have been made to use this score in patients with severe trauma,45 abdominal sepsis,46
postoperative enterocutaneous fistulas,47 and
acute pancreatitis.48 The prognostic value
of APACHE II has been shown in patients having major general surgery with
indications that included lymphoma, colorectal cancer, breast cancer, gastric
cancer, ovarian cancer, and pancreatic cancer,49
but we could not find in the literature any study emphasizing the relation
between the APACHE II score and postoperative complications in patients with
head and neck cancer.
There is little information available about the level of utilization
of the ICU by patients with head and neck cancer.50-51
Some centers prefer not admitting patients with cancer to an ICU52
while other centers admit all patients to an ICU after head and neck procedures.53 Ryan and Hochman54
could not find complications associated with early hospital discharge. Inversely
to the expected, staying in an ICU for at least 3 days is encouraged for better
monitoring of the patient's condition. In a retrospective study, 37 (1.5%)
of 2346 patients undergoing head and neck surgery required admission to the
ICU, since this access is extraordinary and reserved for patients requiring
cardiopulmonary assistance or monitoring.50
Another study comparing patients who had had major head and neck oncological
resections and who were nursed postoperatively on a general ward with those
who were referred to an ICU contrasts with the findings in our study that
did not find differences in general morbidity (20% vs 27%).51
This observation is in partial agreement with our findings, since it was noted
that a statistically significantly higher rate of postoperative complications
were found in patients referred to the ICU. In this series, the advanced ECSS
(stages 3 and 4), the type of surgery, and the surgical reconstruction (microvascular
or myocutaneous flap) determined the necessity of the ICU. Characteristically,
the patients who required ICU monitoring were those at high risk for complications
(local and local plus systemic). Therefore, the use of this variable as a
prognostic marker could not be reliable because it would be just a reflex
of the severity of the disease. Moreover, excluding ICU from the predictive
model of death, type of reconstruction emerges as a prognostic factor. This
finding is in accord with the extension of surgery criteria used for ICU referral.
The indication for admittance to the ICU for patients with oral cancer in
our study was adequate and was supported by the lower inpatient postoperative
death rates.
Some authors9-11
reported the negative influence of advanced comorbidities on survival of patients
with head and neck cancer corroborating our findings, probably by alterations
on biological interaction between tumor and host. Prediction of outcome is
important in disease stratification and subsequent decision-making process.49 The identification of risk factors for postoperative
complications may assist the surgeon in classifying patients into groups with
distinct probabilities of postoperative morbidity and mortality, and the prevention
of complications can turn to a better prognosis.
AUTHOR INFORMATION
Accepted for publication March 27, 2001.
Presented as a poster at the annual meeting of the American Head and
Neck Society, Fifth International Conference on Head and Neck Cancer, San
Francisco, Calif, July 29-August 2, 2000.
Corresponding author: Luiz P. Kowalski, MD, PhD, Department of Head
and Neck Surgery, Centro de Tratamento e Pesquisa Hospital do Câncer
A. C. Camargo, R. Professor Antônio Pudente, 211CEP 01509-010 São
Paulo-SP, Brazil (e-mail: lp_kowalski{at}uol.com.br).
From the School of Medicine, University of São Paulo (Dr de
Melo), and the Hospital Cancer Registry (Dr Ribeiro), Department of Head and
Neck Surgery and Otorhinolaryngology (Dr Kowalski), and the Intensive Care
Unit (Dr Deheinzelin), Centro de Tratamento e Pesquisa Hospital do Câncer
A. C. Camargo, São Paulo, Brazil.
REFERENCES
| |
1. Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin. 2000;50:7-33.
ABSTRACT
2. Ministério da Saúde. Estimativa da incidência e mortalidade por
câncer no Brasil para 2000. Rio de Janeiro, Instituto Nacional de Câncer, 2000.
3. Cunningham MJ, Johnson JT, Myers EN, Schramm VL Jr, Thearle PB. Cervical lymph node metastasis after local excision of early squamous
cell carcinoma of the oral cavity. Am J Surg. 1986;152:361-366.
FULL TEXT
|
ISI
| PUBMED
4. Hermanek P, ed, Sobin LH, ed. UICC TNM Classification of Malignant Tumors. 4th ed. 2nd version. Berlin, Germany: Springer-Verlag; 1992.
5. Loree TR, Strong EW. Significance of positive margins in oral cavity squamous carcinoma. Am J Surg. 1990;160:410-414.
FULL TEXT
|
ISI
| PUBMED
6. Asakage T, Yokose T, Mukai K, et al. Tumor thickness predicts cervical metastasis in patients with stage
I/II carcinoma of the tongue. Cancer. 1998;82:1443-1448.
FULL TEXT
|
ISI
| PUBMED
7. Woolgar JA, Scott J. Prediction of cervical lymph node metastasis in squamous cell carcinoma
of the tongue/floor of mouth. Head Neck. 1995;17:463-472.
ISI
| PUBMED
8. Shin DM, Lippman SM, Lee J, et al. p53 Expression: predicting recurrence and second primary tumors in
head and neck squamous cell carcinoma. J Natl Cancer Inst. 1996;88:519-529.
FREE FULL TEXT
9. Pugliano FA, Piccirillo JF, Zequeira MR, et al. Clinical-severity staging system for oropharyngeal cancer. Arch Otolaryngol Head Neck Surg. 1997;123:1118-1124.
FREE FULL TEXT
10. Singh B, Bhaya M, Zimbler M, et al. Impact of comorbidity on outcome of young patients with head and neck
squamous cell carcinoma. Head Neck. 1998;20:1-7.
FULL TEXT
|
ISI
| PUBMED
11. Pugliano FA, Piccirillo JF, Zequeira MR, Fredrickson JM, Perez CA, Simpson JR. Clinical-severity staging system for oral cavity cancer: five-year
survival rates. Otolaryngol Head Neck Surg. 1999;120:38-45.
FULL TEXT
| PUBMED
12. Ribeiro KC, Kowalski LP, Latorre MR. Impact of comorbidity, symptoms, and patients' characteristics on the
prognosis of patients with oral carcinomas. Arch Otolaryngol Head Neck Surg. 2000;126:1079-1085.
FREE FULL TEXT
13. Singh B, Cordeiro PG, Santamaria E, Shaha AR, Pfister DG, Shah JP. Factors associated with complications in microvascular reconstruction
of head and neck defects. Plast Reconstr Surg. 1999;103:403-411.
ISI
| PUBMED
14. Yancik R, Wesley MN, Ries LA, et al. Comorbidity and age as predictors of risk for early mortality of male
and female colon carcinoma patients: a population-based study. Cancer. 1998;82:2123-2134.
FULL TEXT
|
ISI
| PUBMED
15. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818-829.
ISI
| PUBMED
16. Robbins KT, Favrot S, Hanna D, Cole R. Risk of wound infection in patients with head and neck cancer. Head Neck. 1990;12:143-148.
ISI
| PUBMED
17. Shaheen OH. Problems in Head and Neck Surgery. London, England: Balliere Tindall; 1984:ix.
18. Evans PHR. Complications in head and neck surgery and how to avoid trouble. J Laryngol Otol. 1989;103:926-929.
ISI
| PUBMED
19. Kowalski LP, Alcantara PSM, Magrin J, Parise O Jr. A case control study on complications and survival in elderly patients
undergoing major head and neck surgery. Am J Surg. 1994;168:485-490.
FULL TEXT
|
ISI
| PUBMED
20. Pelczar BT, Weed HG, Schuller DE, Young DC, Reilley TE. Identifying high-risk patients before head and neck oncology surgery. Arch Otolaryngol Head Neck Surg. 1993;119:861-864.
FREE FULL TEXT
21. Yoder MG, Krause CJ, Kwyer TA. Infectious and noninfectious complications in major head and neck surgery. Otolaryngol Head Neck Surg. 1979;87:797-806.
ISI
| PUBMED
22. Girod DA, McCulloch TM, Tsue TT, Weymuller EA Jr. Risk factors for complications in clean-contaminated head and neck
surgical procedures. Head Neck. 1995;17:7-13.
ISI
| PUBMED
23. Grandis JR, Snyderman CH, Johnson JT, Yu VL, D'Amico F. Postoperative wound infection: a poor prognostic sign for patients
with head and neck cancer. Cancer. 1992;70:2166-2170.
FULL TEXT
|
ISI
| PUBMED
24. Becker GD. Identification and management of the patients at high risk for wound
infection. Head Neck Surg. 1986;8:205-210.
ISI
| PUBMED
25. Brown BM, Johnson JT, Wagner RL. Etiologic factors in head and neck wound infections. Laryngoscope. 1987;97:587-590.
ISI
| PUBMED
26. Cole RR, Robbins KT, Cohen JI, Wolf PF. A predictive model for wound sepsis in oncologic surgery of the head
and neck. Otolaryngol Head Neck Surg. 1987;96:165-171.
ISI
| PUBMED
27. Fee WE, Glenn M, Handen C, Hopp ML. One day vs. two days of prophylactic antibiotics in patients undergoing
major head and neck surgery. Laryngoscope. 1984;94:612-614.
ISI
| PUBMED
28. Brand B, Johnson JT, Myers EN, Thearle B, Sigler BA. Prophylactic perioperative antibiotics in contaminated head and neck
surgery. Otolaryngol Head Neck Surg. 1982;90:315-318.
ISI
| PUBMED
29. Johnson JT, Wagner RL, Schuller DE, Gluckman J, Suen JY, Snyderman NL. Prophylactic antibiotics for head and neck surgery with flap reconstruction. Arch Otolaryngol Head Neck Surg. 1992;118:488-490.
FREE FULL TEXT
30. Smits G, Krause CJ, McCabe BF. Complications associated with combined therapy of oral and pharyngeal
neoplasms. Ann Otol Rhinol Laryngol. 1972;81:496-500.
ISI
| PUBMED
31. Myers EN, Dinerman WS. Management of chylous fistulas. Laryngoscope. 1975;85:835-840.
FULL TEXT
|
ISI
| PUBMED
32. Crumley RL, Smith JD. Postoperative chylous fistula: prevention and management. Laryngoscope. 1976;86:804-813.
FULL TEXT
|
ISI
| PUBMED
33. Gall AM, Sessions DG, Ogura JH. Complications following surgery for cancer of the larynx and hypopharynx. Cancer. 1977;39:624-631.
FULL TEXT
|
ISI
| PUBMED
34. Johnson JT, Cummings CW. Hematoma after head and neck surgery: a major complication? Otolaryngology. 1978;86:ORL171-ORL175.
35. Joyce LD, McQuarrie DG. Applications of contemporary reconstructive techniques in head and
neck surgery for anterior oral-facial cancers. Surgery. 1976;80:373-378.
ISI
| PUBMED
36. Weber RS, Hankins P, Rosenbaum B, Raad I. Nonwound infections following head and neck oncologic surgery. Laryngoscope. 1993;103:22-27.
ISI
| PUBMED
37. McCulloch TM, Jensen NF, Girod DA, Tsue TT, Weymuller EA Jr. Risk factors for pulmonary complications in the postoperative head
and neck surgery patient. Head Neck. 1997;19:372-377.
FULL TEXT
|
ISI
| PUBMED
38. Chew JY, Cantrell RW. Tracheostomy complications and their management. Arch Otolaryngol. 1972;96:538-545.
FREE FULL TEXT
39. Castling B, Telfer M, Avery BS. Complications of tracheostomy in major head and neck surgery: a retrospective
study of 60 consecutive cases. Br J Oral Maxillofac Surg. 1994;32:3-5.
FULL TEXT
|
ISI
| PUBMED
40. Cummings CW, Johnson J, Chung CK, et al. Complications of laryngectomy and neck dissection following planned
preoperative radiotherapy. Ann Otol Rhinol Laryngol. 1977;86:745-750.
ISI
| PUBMED
41. van Bokhorst-de van der Schueren MA, Leeuwen PA, Sauerwein HP, Kuik DJ, Snow GB, Quak JJ. Assessment of malnutrition parameters in head and neck cancer and their
relation to postoperative complications. Head Neck. 1997;19:419-425.
FULL TEXT
|
ISI
| PUBMED
42. Ballantyne AJ, Jackson GJ. Synchronous bilateral neck dissection. Am J Surg. 1982;144:452-455.
FULL TEXT
|
ISI
| PUBMED
43. Razack SM, Sako K, Baffi R, et al. Simultaneous bilateral neck dissection. J Surg Oncol. 1980;15:387-392.
ISI
| PUBMED
44. Magrin J, Kowalski LP. Bilateral radical neck dissection: results in 193 cases. J Surg Oncol. 2000;75:232-240.
FULL TEXT
|
ISI
| PUBMED
45. Rutledge R, Fakhry S, Rutherford E, Muakkassa F, Meyer A. Comparison of APACHE II, Trauma Score, and Injury Severity Score as
predictors of outcome in critically injured trauma patients. Am J Surg. 1993;166:244-247.
FULL TEXT
|
ISI
| PUBMED
46. Bohnen JM, Mustard RA, Schouten BD. Steroids, APACHE II score, and the outcome of abdominal infection. Arch Surg. 1994;129:33-37.
FREE FULL TEXT
47. Altomare DF, Serio G, Pannarale OC, et al. Prediction of mortality by logistic regression analysis in patients
with postoperative enterocutaneous fistulae. Br J Surg. 1990;77:450-453.
ISI
| PUBMED
48. Fan ST, Lai EC, Mok FP, Lo CM, Zheng SS, Wong J. Prediction of the severity of acute pancreatitis. Am J Surg. 1993;166:262-268.
FULL TEXT
|
ISI
| PUBMED
49. Goffi L, Saba V, Ghiselli R, Necozione S, Mattei A, Carle F. Preoperative APACHE II and ASA score in patients having major general
surgical operations: prognostic value and potential clinical applications. Eur J Surg. 1999;165:730-735.
FULL TEXT
|
ISI
| PUBMED
50. Downey RJ, Friedlander P, Groeger J, et al. Critical care for the severely ill head and neck patient. Crit Care Med. 1999;27:95-97.
FULL TEXT
|
ISI
| PUBMED
51. Godden DR, Patel M, Baldwin A, Woodwards RT. Need for intensive care after operations for head and neck surgery. Br J Oral Maxillofac Surg. 1999;37:502-505.
FULL TEXT
|
ISI
| PUBMED
52. Sculier JP, Markiewicz E. Intensive care in anticancer centers: an international inquiry. Support Care Cancer. 1995;3:130-134.
FULL TEXT
|
ISI
| PUBMED
53. Muakkassa FF, Fakhry SM, Rutledge R, et al. Cost-effective use of microcomputers for quality assurance and resource
utilization in the surgical intensive care unit. Crit Care Med. 1990;18:1243-1247.
ISI
| PUBMED
54. Ryan MW, Hochman M. Length of stay after free flap reconstruction of the head and neck. Laryngoscope. 2000;110:210-216.
FULL TEXT
|
ISI
| PUBMED
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