Head and Neck Oncologic and Reconstructive Surgery: Is a One Team or Two Team Approach Better?
Sina J. Torabi, Fouad Chouairi, BS, Jacob Dinis, BS, John Persing, MD, Michael Alperovich, MD.
Yale School of Medicine, New Haven, CT, USA.
PURPOSE: Reconstruction following ablative head and neck surgery requires restoration of both form and function. Surgical approaches can include a single team that performs both the extirpative and reconstructive procedure or a two-team approach involving separate oncologic and reconstructive teams. The theoretical benefits of two teams include simultaneous surgeries, reduced surgeon fatigue, and balancing the competing goals of oncologic fidelity against the final reconstructive outcome. A criticism of a two-team approach relates to surgeon-surgeon familiarity with outcomes and higher adverse events. For instance, in breast reconstruction, a two-team approach has been associated with increased infection rates. No studies comparing the efficacy of one- vs. two-team surgeries within head and neck oncosurgery exist.
METHODS: A retrospective study of 2,388 patients undergoing concurrent head and neck extirpative and reconstructive surgery in the National Surgical Quality Improvement Program (2008-2016) was conducted (Figure 1). Patients were stratified into one- and two-team surgery groups. Univariate analyses on outcomes before and after propensity score matching were conducted. A Bonferroni correction was applied to all univariate chi-square analyses according to the largest family of comparisons (13 comparisons in "medical complications"), setting statistical significance at p<0.0038.
Figure 1) CONSORT Diagram of Inclusion and Exclusion Criteria
RESULTS: The majority of ablative and reconstructive head and neck procedures, 67.9%, were performed with a one-team approach. Patients who underwent two-team surgeries were more likely to have higher ASA classes (p<0.001) and undergo a microvascular free flap (p<0.001), but less likely to have a rotational flap (p<0.001). Before propensity score matching, patients undergoing two-team surgeries had longer operation times (p<0.001), longer post-operative stays (p<0.001), higher rates of return to the operating room (p=0.002), and increased complications (p<0.001). Following propensity score matching, the two-team approach continued to have longer operative times (p<0.001) and increased complications (p<0.001), but no significant differences in length of stay or rate of return to the operating room.
CONCLUSION: To the best of our knowledge, we present the first and largest comparison of peri-operative outcomes between one-team versus two-team head and neck oncologic and reconstructive surgery. Nationally, the majority of head and neck ablative and reconstructive surgeries are completed by one team. More complicated reconstructive procedures involving microvascular free flaps are more commonly performed by two teams. Rather than shortening total operative time, the two-team approach was associated with significantly longer surgeries. This finding may reveal a pattern of working in sequence rather than in parallel during these combined surgeries. The finding is in contrast to the often cited theoretical advantages of a two-team approach to allow flap harvest during the ablation. Furthermore, the propensity matched cohort also demonstrated higher complications in a two-team approach. Longer surgeries, as was seen with the two-team approach, are a known risk factor for increased peri-operative complications. It is also possible that another variable such as variability in surgeon experience or hospital setting could be impacting on complications.
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