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Predictors of Perioperative Complications in Head and Neck Patients
D. Gregory Farwell, MD;
Dominic F. Reilly, MD;
Ernest A. Weymuller, Jr, MD;
Deborah L. Greenberg, MD;
Thomas O. Staiger, MD;
Neal A. Futran, DMD, MD
Arch Otolaryngol Head Neck Surg. 2002;128:505-511.
ABSTRACT
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Background Patients with significant medical problems requiring major otolaryngology
procedures are at high risk for both medical and surgical complications.
Objective To identify risk factors associated with perioperative complications
in medically compromised patients undergoing major otolaryngology procedures.
Methods Ninety-three consecutive patients with significant comorbid medical
illnesses (eg, diabetes, hypertension) undergoing major head and neck surgical
procedures were referred to a medical consultation center for preoperative
assessment and medical management. Patient and surgical characteristics as
well as perioperative complications were identified and recorded. Univariate
and multivariate analyses were performed to determine which characteristics
were associated with complications.
Results Thirty-two patients (34%) had postoperative complications. Twenty-six
patients (28%) had serious medical complications, and 18 (19%) had surgical
complications. No deaths occurred in the study population. On univariate analysis,
the factors associated with all complications included history of hepatitis,
flap reconstruction, oncologic surgery, preoperative radiation therapy, preoperative
gastrostomy placement, intraoperative transfusion, anesthesia time ( 8
hours), and those with greater intraoperative fluid replacement and estimated
blood losses. Only anesthesia time (8 hours) remained independently significant
on multivariate analysis. A history of hepatitis and prolonged anesthesia
time were the only independent predictors of medical complications. The only
independent predictor of surgical complications was the volume of intraoperative
fluid administered.
Conclusions Prolonged anesthesia times of 8 hours or more, a history of hepatitis,
and large-volume intraoperative fluid resuscitations predicted adverse outcomes.
Special care must be taken in counseling these patients preoperatively and
in caring for them during their operative and postoperative course.
INTRODUCTION
MAJOR otolaryngology procedures are often complicated by challenging
anatomy, complex reconstructions, and long surgical procedures. Additionally,
many patients undergoing these procedures have comorbid medical conditions
that complicate their care and may predispose them to perioperative complications.
These patients may frequently have a history of tobacco and/or alcohol abuse.
As such, they may be at risk for significant cardiac and pulmonary disease.
Proper assessment of the risk of perioperative complications is an important
part of the preoperative planning and counseling, as these comorbidities often
have significant impact on the perioperative course.
Different authors have evaluated a variety of patient and surgical factors
associated with adverse perioperative events.1-5
Within the head and neck literature, several authors have evaluated complications
and noted the importance of comorbidities in predicting postoperative complications.6-7 These have included radiation exposure,
operative time, hypertension, alcohol abuse, and the Charlson comorbidity
score.6-12
Piccirillo13 and Singh et al14
recently demonstrated that medical comorbidities are an independent predictor
of survival in patients with head and neck cancer. However, the specific risk
of complications in patients with significant medical comorbidities undergoing
major otolaryngology procedures remains incompletely explored. The aim of
this study was to examine this issue more completely, ultimately allowing
us to better predict which patients will develop perioperative complications.
PARTICIPANTS AND METHODS
The study was performed at the University of Washington Medical Center,
Seattle. All otolaryngology–head and neck surgery patients 18 years
and older with significant medical problems were referred to the medical consultation
service for preoperative evaluation. Study participants provided written informed
consent and the project was approved by our institutional review committee.
PATIENTS
One hundred forty-one consecutive patients considered at risk for perioperative
complications were referred preoperatively to the medical consultation center
for evaluation prior to otolaryngology–head and neck surgery from October
17, 1995, to June 9, 1997. These patients represented approximately 6% of
the otolaryngology–head and neck surgery patients undergoing surgical
procedures. Patients were referred for preoperative evaluation by the surgical
team or anesthesiologists when there were concerns about medical comorbidities.
These concerns included active or presumed cardiovascular, respiratory, or
endocrine diseases; significant deconditioning; and advanced age. Of those
patients, 134 (95%) consented to participate in a study designed to examine
the impact of self-reported exercise tolerance on the risk of serious postoperative
complications. Our study population is a subgroup of the otolaryngology patients
in that study.3
Of the eligible patients, 26 (19%) were determined to have minor procedures
and were excluded from the study. Minor procedures were associated with minimal
risk and included biopsies, panendoscopy, vocal cord medializations, and nasal
reconstructions. Of the remaining 108 patients having major procedures, 15
patients (14%) had their procedure canceled, leaving 93 patients to form our
study population. Patients whose procedures were canceled generally opted
for alternative therapy (chemotherapy/radiation therapy) or no treatment.
DATA COLLECTION
Each patient was evaluated and managed preoperatively and postoperatively
by a team of physicians that included an attending otolaryngologist and internist.
Outside records were sought and preoperative testing was ordered as clinically
indicated. There was no additional testing specifically performed as part
of this study.
The patient's medical problems, habits, and exercise tolerance were
prospectively recorded by the internal medicine team and cataloged in a computer
database. Information about the nature of the surgical procedure, reconstruction
technique used, estimated intraoperative blood loss, intraoperative transfusions,
and preoperative radiation or chemotherapy was collected retrospectively by
review of the medical record. The American Society of Anesthesiologists (ASA)
classification was assigned by the attending anesthesiologist on the day of
surgery. The duration of anesthesia and ASA classification were obtained from
the department of anesthesia's existing quality improvement database or the
anesthesia record.
PERIOPERATIVE COMPLICATIONS
Prior to beginning the study, a list of 26 serious perioperative medical
complications and their definitions was established.3
They included those of a cardiovascular, pulmonary, neurologic, infectious,
and miscellaneous nature. Only events that caused the patient to require additional
therapy, placed the patient at increased risk, or prolonged the length of
stay were included. Minor complications, such as urinary tract infections
and atelectasis, were excluded. Medical complications were recorded from entry
into the preanesthesia area until the time of discharge from the hospital.
Two attending internists blinded to the study design and results of the preoperative
evaluation reviewed each record to assure that it met the predefined criteria.
In instances when the 2 internists disagreed on the diagnosis, a third physician
adjudicated the case. A second category of surgical complications was devised
after the surgical procedures had been completed. These included wound breakdown,
fistula formation, flap donor and recipient site complications, flap failure,
wound hematomas, and the need for additional (unexpected) procedures. These
complications were identified by review of the medical record by one of us
(D.G.F.). Both immediate and delayed surgical complications were recorded.
Delayed complications, such as wound breakdown, were often not identified
until patients' outpatient otolaryngology clinic visits. Follow-up data were
available for all patients.
STATISTICAL ANALYSIS
Statistical analysis was performed with SAS, version 6.12, statistical
software (SAS Institute Inc, Cary, NC). Values are reported as mean ±
SD. We considered P .05 to be significant. The  2 tests, including test for trend for ordinal data, or the Fisher exact
test was used to compare categorical variables between groups. All P values shown are for 2 tests, unless otherwise specified.
The Wilcoxon rank sum test was used to compare continuous variables between
groups. Odds ratios estimating the risk of any perioperative complication
were calculated using logistic regression for each variable found to be significant
on univariate analysis. To determine if these variables predicted perioperative
complications independent of one another, we also added them to a multivariable
logistic regression model in a stepwise manner.
RESULTS
PATIENT CHARACTERISTICS
Ninety-three patients, referred to the medical consultation service
for their comorbid diseases, underwent major otolaryngology procedures. The
vast majority (84%) of these cases were oncology related (Table 1). The mean ± SD age of the study population was 65.8
± 13.0 years. The majority of patients were male (66%) and white (91%).
Most had smoked at least 20 pack-years (65%) and 13% had a history of active
alcohol abuse. The majority of patients (55%) were ASA class III.
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Table 1. Patient and Surgical Characteristics in Patients With and
Without All Complications*
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SURGICAL CHARACTERISTICS
Of the 78 oncology-related cases, nearly half received a flap reconstruction
as part of their surgical procedure (n = 36) (Table 1). There were 12 radial forearm, 6 fibula, 5 iliac crest,
3 rectus, 1 scapula, 1 jejunum, and 1 latissimus free flaps used. An additional
13 pectoralis rotational flaps were used in this study population. Completing
the data set were patients undergoing sinus and endoscopic skull-base procedures
(n = 9), otologic procedures (n = 3), uvulopalatopharyngoplasty (n = 2), and
a cricopharyngeal myotomy (n = 1). The majority of patients undergoing sinus
and endoscopic skull-base procedures had significant pulmonary problems (Samter
triad) prompting the preoperative involvement of the medical consult service.
PERIOPERATIVE COMPLICATIONS
Medical Complications
Medical complications occurred in 26 patients (Table 2). These included 7 cardiac, 17 pulmonary, 13 neurologic,
5 serious infections (defined as deep surgical site infection, wound abscess,
bacteremia, or sepsis), and 8 miscellaneous events. Fifteen patients had more
than 1 medical complication. There were no deaths in the study population.
Thirteen patients were unexpectedly transferred to the intensive care unit
or the cardiac telemetry ward. One patient required activation of the hospital
emergency response system (code blue).
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Table 2. Medical Complications
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Surgical Complications
Eighteen patients (19%) had a surgical complication. These included
12 patients with wound breakdowns, 4 with oral cutaneous fistulas, 4 hematomas,
4 donor and 4 flap recipient site complications, and 12 patients who required
an additional unanticipated procedure.
PREDICTORS OF PERIOPERATIVE COMPLICATIONS
All Complications
On univariate analysis (2), the risk for a patient to
develop any complication (medical and surgical combined) was correlated with
a history of hepatitis, oncologic surgery, undergoing a flap reconstruction,
preoperative radiation therapy, preoperative gastrostomy placement, intraoperative
transfusion, smoking within the previous 6 weeks, and an anesthesia time of
8 hours or more (P = .05, 2) (Table 1). Using univariate regression analysis,
those same factors, with the exception of preoperative radiation therapy,
were found to be significantly associated with all complications (Table 3). All patients who had a gastrostomy
tube placed preoperatively had a complication, making regression analysis
of that group (n = 3) impossible. Upon multivariate analysis, only an anesthesia
time of 8 hours or more was an independent predictor of all complications.
(Table 3). After 8 hours of anesthesia,
the complication rate increased dramatically and rose to 100% after 16 hours
of anesthesia (Figure 1).
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Table 3. Outcomes for Patients With All Complications (Medical and
Surgical)*
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Duration of anesthesia vs risk of any postoperative complication.
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Patients with any complication received more intraoperative fluid and
more intraoperative units of blood, had a greater estimated blood loss, and
had longer procedures (Table 1).
However, after correction for the duration of surgery, none of these factors
was significantly associated with all complications.
Patients with any complication had longer lengths of stay (14.2 ±
11.2 vs 4.7 ± 3.9 days; Wilcoxon rank sum, P<.001),
had longer stays in the intensive care unit (6.1 ± 8.5 vs 0.7 ±
1.1 days; Wilcoxon rank sum, P<.001), required
more days of ventilator support (3.0 ± 7.9 vs 0.07 ± 0.3 days;
Wilcoxon rank sum, P<.001), and had a longer period
until tracheostomy decannulation (15.5 ± 25.3 vs 3.1 ± 13.3
days; Wilcoxon rank sum, P<.001).
Advanced age, ASA classification, poor exercise tolerance, history of
smoking 20 pack-years, alcohol abuse, preoperative chemotherapy, weight, and
the other patient and surgical characteristics were not associated with an
increased risk for all complications.
Medical Complications
When evaluating medical complications, a history of hepatitis, undergoing
a flap reconstruction, preoperative gastrostomy placement, intraoperative
transfusion, and a prolonged anesthesia time (8 hours) were significant
by univariate analysis (P<.05, 2)
(Table 4). Patients with medical
complications received a greater amount of intraoperative fluid (5.7 ±
2.6 vs 3.4 ± 2.6 L; Wilcoxon rank sum, P<.001),
received more units of blood intraoperatively (0.61 ± 0.92 vs 0.16
± 0.59 U; Wilcoxon rank sum, P = .006), and
had greater estimated intraoperative blood loss (0.50 ± 0.42 vs 0.32
± 0.38 L; Wilcoxon rank sum, P = .012). Upon
multivariate analysis a history of hepatitis and a prolonged anesthesia time
of 8 hours or more were the only independent predictors of medical complications
(Table 4).
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Table 4. Outcomes for Patients With Medical Complications*
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A history of hepatitis was an independently significant predictor of
adverse outcomes despite the fact that only 5 patients had a medical diagnosis
of a history of hepatitis. Three of these patients had a history of remote
active hepatitis and jaundice; 1 patient had evidence of cirrhosis. The exact
etiology of hepatitis was not confirmed by serologic testing in these patients.
Of those 5 patients, 4 had complications including myocardial ischemia, delirium
(2 patients), acute renal insufficiency, wound infections (2 patients), pneumonia,
alcohol withdrawal, prolonged postoperative ventilation, hypoxia, and a fall.
On subgroup analysis (data not shown), alcohol use (>150 mL per week)
was associated with both alcohol withdrawal and infectious complications (P<.05), but otherwise not associated with any specific
medical complications. Smoking was nearly significant in its association with
an adverse medical complication (Fisher exact test, P
= .056). Additionally, congestive heart failure, advanced age, and diabetes
were not associated with medical complications.
Surgical Complications
Factors associated with surgical complications on univariate analysis
included oncologic surgery, preoperative radiation therapy, performance of
a flap, smoking within the last 6 weeks, intraoperative transfusion, and anesthesia
time of 8 hours or more (P.05) (Table 5). Additionally, patients with surgical complications received
more intraoperative fluid (6.6 ± 2.5 vs 3.4 ± 2.5 L; Wilcoxon
rank sum, P<.001), had greater estimated intraoperative
blood loss (0.57 ± 0.35 vs 0.32 ± 0.39 L; Wilcoxon rank sum, P<.001), and received more units of blood intraoperatively
(0.61 ± 0.92 vs 0.16 ± 0.59 U; Wilcoxon rank sum, P<.001). However, after multivariable analysis, greater intraoperative
fluid administration was the only independent predictor of surgical complications
(Table 5).
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Table 5. Outcomes for Patients With Surgical Complications*
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COMMENT
Patients undergoing major head and neck surgical procedures frequently
have significant comorbidities that increase their risk for perioperative
complications. It is imperative to accurately counsel these patients preoperatively
on the risks inherent to the procedure and the risks associated with their
medical comorbidities. In our study population we have identified a number
of factors that are associated with an increased risk for both medical and
surgical complications. In particular, patients undergoing prolonged procedures
(8 hours), patients with a history of hepatitis, and those who received
greater volumes of fluid intraoperatively were at higher risk for postoperative
complications. Interestingly, several factors commonly believed to predict
adverse outcomes, such as advanced age and diabetes, did not prove significant
in our evaluation. It is possible that the highly select nature of our referred
population may have contributed to advanced age not being significant. These
patients were approximately 20 years older than the nonreferred patients.
However, when controlling for other comorbidities associated with advanced
age, age itself did not prove significant.
The ASA classification system, considered by many to be one of the best
methods for assessing patient risk, did not perform well in our patient population.
As such, our findings are in agreement with Arriaga et al.5
However, this more likely reflects the fact that the majority of our patients
had medical comorbidities making them ASA class II or III. This skewed the
data, making it difficult to establish significance.
Our finding of an independent risk of medical complications in patients
with a history of hepatitis is useful information that was not readily available
in the head and neck surgery literature. While there were few patients in
our study population who had a diagnosis of hepatitis, our data are compelling
in that those patients need to be carefully counseled as to their increased
risk. Given the small numbers of patients in our study with hepatitis, further
evaluation of this risk factor in other populations should be considered.
The relationship between the duration of the procedure and risk has
been long debated. Haljamae15 has shown that
the duration of anesthesia influences the incidence of postoperative complications
but suggests that this incidence might reflect the severity of the underlying
disease and the extent of the surgery performed instead of some unique characteristic
of a prolonged exposure to anesthetics. Likewise, longer operations are associated
with more extensive disease, which might be the cause of the higher complication
rate in long anesthesia times. Schusterman and Horndeski16
performed subgroup analysis on their retrospective evaluation of flap reconstructions
and were not able to show anesthesia time as a predictor of complications.
However, the Singh et al6 study and our data
clearly show that the duration of the anesthesia time is a powerful predictor
of adverse events after correcting for other patient and surgical factors.
For procedures lasting less than 8 hours, the risk of complications remains
low at our institution.
When trying to predict which patients are at higher risk for surgical
complications, we have shown that greater estimated blood loss, oncologic
surgery, preoperative radiation therapy, performance of a flap, recent smoking,
intraoperative transfusions, excessive fluid administration, and prolonged
procedures are all significant on univariate analysis. On multivariate analysis,
surgical complications were associated only with the volume of intraoperative
fluid replacement. This is in contrast to all complications and medical complications,
where the duration of anesthesia proved independently significant but the
volume of fluid administered did not.
Evaluating the interactions between prolonged anesthesia times, blood
loss, intraoperative transfusion, and fluid replacement is challenging. While
it is clear that intravenous fluid replacement and anesthesia time are closely
linked, it is important to coordinate a plan with the anesthesiologist for
judicious fluid replacement. The mechanism of overhydration causing surgical
complications is not immediately clear. In previous retrospective studies
at our institution, prolonged anesthesia was associated with complications
while fluid replacement was not.2 While there
has been little published in head and neck surgery literature on the effect
of fluid replacement and complications, Nishi et al17
have suggested that fluid restriction may reduce the risk of complications
in esophagectomy patients. One could hypothesize that tissue edema increases
wound tension and compromises healing. This is an area that will require future
research to fully understand the effect of fluid replacement on surgical complications.
Undergoing a flap reconstruction was also associated with complications
of both medical and surgical types. When controlling for other predictors,
however, a flap reconstruction did not prove to be an independent predictor
on multivariate analysis. It is likely that the true causes of increased complications
are the additional time required to perform the flap and the observation that
larger tumors, which require the flap reconstructions, tend to present in
sicker patients.
In an effort to reduce the complication rate from flap reconstructions,
efforts should be undertaken to efficiently perform the surgery to minimize
the surgical time. Utilizing 2 teams to perform the oncologic resection and
the flap harvest can dramatically reduce operative time and potentially the
need for excessive fluid administration. Having a coordinated operative team
with anesthesiologists and nurses committed to efficiently starting and proceeding
through the case is also important in minimizing anesthesia times. To help
achieve that goal, we have created a task force to improve on-time starts
and to shorten operative times.
Despite the high complication rate in our study (34%), it is important
to note that we had no deaths. We have coordinated the care of these patients
with a team of attending internists who assist us in the preoperative workup
and through the perioperative treatment. It is our opinion that involving
them in the patient's care has dramatically improved our outcomes. With these
new data on perioperative predictors, we hope to be able to more accurately
counsel patients and improve our ability to plan treatments and prevent these
complications.
AUTHOR INFORMATION
Accepted for publication October 26, 2001.
This work was presented at the Fifth International Conference on Head
and Neck Cancer, San Francisco, Calif, July 30, 2000.
Corresponding author and reprints: D. Gregory Farwell, MD, University
of Washington, Department of Otolaryngology–Head and Neck Surgery, Box
356515, Seattle, WA 98195-6515.
From the Departments of Otolaryngology–Head and Neck Surgery,
(Drs Farwell, Weymuller, and Futran), and Internal Medicine (Drs Reilly, Greenberg,
and Staiger), University of Washington Medical Center, Seattle.
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