Head and Neck Reconstructive Surgery: Characterization of the One-Team and Two-Team Approaches

SURGICAL ONCOLOGY AND RECONSTRUCTION

Head and Neck Reconstructive Surgery: Characterization of the One-Team and Two-Team Approaches Sina J. Torabi, BA,* Fouad Chouairi, BS,y Jacob Dinis, BS,z and Michael Alperovich, MDx Purpose:

To the best of our knowledge, no studies have compared the patient profiles for 1- versus 2-team surgery within head and neck oncosurgery.

Patients and Methods:

A retrospective study of the data from 2968 patients who had undergone concurrent head and neck extirpative and reconstructive surgery in the National Surgical Quality Improvement Program (2010 to 2017) was conducted. Patients were stratified into 1- and 2-team surgery groups, and the demographic data were compared. Univariate analyses of the outcomes before and after propensity score matching were conducted.

Results:

Most ablative and reconstructive head and neck procedures (68.5%) were performed using a 1-team approach. The patients who had undergone 2-team surgery were more likely to have a higher American Society of Anesthesiologists classification (P < .001), to require mandibulectomy (P < .001) or glossectomy (P < .001), and to receive a microvascular free flap (P < .001) but were less likely to require parotidectomy (P < .001) or to receive a rotational flap (P < .001). Before propensity score matching, the patients undergoing 2-team surgery had longer operative times (P < .001), longer postoperative stays (P < .001), greater rates of a return to the operating room (P = .001), and an increased rate of complications (P < .001). After propensity score matching, the 2-team approach continued to have longer operative times (P < .001) and an increased incidence of complications (P < .001) but no significant differences in the length of stay or rate of return to the operating room after Bonferroni’s correction.

Conclusions: Nationally, most head and neck ablative and reconstructive surgeries were completed by 1 team. More complicated reconstructive procedures involving microvascular free flaps have been more commonly performed by 2 teams, resulting in slightly longer operative times and greater associated complication rates. Ó 2019 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-10, 2019

Reconstruction after ablative head and neck surgery requires restoration of both form and function. The integrity of the alimentary tract, speech, deglutition, mastication, and oral and oronasal competence and prevention of salivary contamination of the surround-

ing structures are among the many goals of restorative surgery. Advances in microvascular techniques and surgical planning have enabled single-stage, highly accurate reconstructions.1 Surgical approaches can include a single team that performs both the

*Medical Student, Department of Surgery, Yale University School

Address correspondence and reprint requests to Dr Alperovich:

of Medicine, New Haven, CT.

Section of Plastic and Reconstructive Surgery, Department of Sur-

yMedical Student, Department of Surgery, Yale University School

gery, Yale University School of Medicine, 330 Cedar St, Boardman

of Medicine, New Haven, CT.

Bldg, Third Fl, New Haven, CT 06510; e-mail: Michael.alperovich@

zMedical Student, Department of Surgery, Yale University School

yale.edu

of Medicine, New Haven, CT; and Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT.

Received March 14 2019 Accepted September 10 2019

xAssistant Professor, Section of Plastic and Reconstructive

Ó 2019 American Association of Oral and Maxillofacial Surgeons

Surgery Department of Surgery, Yale University School of

0278-2391/19/31084-5

Medicine, New Haven, CT.

https://doi.org/10.1016/j.joms.2019.09.011

Conflict of Interest Disclosures: None of the authors have any relevant financial relationship(s) with a commercial interest.

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2

HEAD AND NECK TEAM SURGERY

extirpative and the reconstructive procedures or a 2team approach involving separate oncologic and reconstructive teams.2 The theoretical benefits of 2 teams include simultaneous surgeries, reduced surgeon fatigue, and negation of the need for a single surgical team to balance the competing goals of oncologic fidelity against the final reconstructive outcome. This allows the ablative team to err on slightly wider margins, even when the reconstructive team would benefit from a less extensive resection.2 One criticism of the 2-team approach relates to surgeon–surgeon familiarity with the outcomes and the greater incidence of adverse events. In breast reconstruction, a 2-team approach was associated with higher infection rates among teams that had partnered together less frequently,3 although a competing study disputed this finding.4 Breast reconstruction occurs in a generally healthier patient population with less surgical procedural morbidity but, similarly, includes extirpative and reconstructive teams. Another potential variable includes the potential insights that the ablative surgeon would have regarding the defect that could aid in planning the reconstructive surgery. Surgical teams unfamiliar with each other or teams from different surgical specialties might not realize optimized transfers of information from the ablation when determining the reconstruction plan. Simultaneous procedures can theoretically reduce the operative and anesthesia time, 2 variables associated with surgical and flap complications.5,6 In a 2-team approach, reconstruction—in particular, microvascular flap harvest—can often start during the extirpative procedure, although some surgeons

have preferred a sequential approach after first defining the ablative defect.2 To date, only limited-outcome studies have compared the efficacy of the 1-team versus 2-team approach. By comprehensively comparing all head and neck ablative procedures in a national database for an 8-year period and by rigorous statistically matching of the available patient characteristics, we evaluated the 1-team and 2-team approaches to assess the 30-day outcomes.

Patients and Methods DATA SOURCE

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use data file was reviewed from 2008 to 2016. The ACS-NSQIP uses a stringent auditing mechanism, involving 8-day systematic sampling cycling and certified clinical reviewers to ensure accuracy of the data. The data are derived from 680 sites and collects information on more than 150 surgical variables.7 PATIENT POPULATION AND DEFINITIONS OF ONEAND TWO-TEAM APPROACH

All cases that included both a head and neck ablative procedure and reconstruction during a single anesthetic event were included. The ablative and reconstructive codes used are listed in Table 1. The ACSNSQIP contains 21 separate variables for Common Procedural Terminology (CPT) codes: 1 principal, 10 other, and 10 concurrent CPT codes. The principle CPT code was considered the main operative procedure. The other CPT codes represented other surgeries

Table 1. PROCEDURES AND RELEVANT COMMON PROCEDURAL TERMINOLOGY CODES

Procedures Ablative procedures Maxillectomy and/or orbitectomy Parotidectomy Auriculectomy Mandibulectomy Glossectomy Laryngopharyngectomy Soft tissue excision Concurrent procedures Neck dissection Tracheotomy Reconstructive procedures Soft tissue free flap Bone flap Local flap

CPT Codes Variable location in NSQIP: principal and/or other only 21030, 21034, 21048, 21049, 31225, 31230, 65110 42420, 42425, 42426 69120, 69155, 69150 21044, 21045, 21046, 21047, 210125, 21040 41116, 41120, 41130, 41135, 41140, 41145, 41150, 41153, 41155 31365, 31368, 31390, 31395 21014, 21013, 21012, 21011, 21016, 21015 Variable location in NSQIP: principal and/or other only 38720, 38724 31600, 31603, 31610 Variable location in NSQIP: either principal/other or concurrent 15756, 15757, 15758, 15842 20955, 20956, 20957, 20962, 20969, 20970, 20972, 20973 15732, 15740, 15750

Abbreviations: CPT, Common Procedural Terminology; NSQIP, National Surgical Quality Improvement Program. Torabi et al. Head and Neck Team Surgery. J Oral Maxillofac Surg 2019.

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performed by the principal surgical team. The concurrent CPT codes represent other surgeries performed by a separate surgical team. The inclusion criteria for the study required the ablation code as the principal or other procedure. Any case with an ablation code or neck dissection code in the concurrent CPT position was excluded to eliminate ablative procedures performed by more than 1 team. Furthermore, any reconstructive code that was in both the principal/other and the concurrent CPT sections was excluded to eliminate reconstructive procedures performed by more than 1 team. Finally, cases with missing data were excluded (Fig 1).

propensity score itself. All analyses of the outcomes were performed again within the matched cohort. Statistical significance was defined as P #.05 for all tests. Bonferroni’s correction was applied to all univariate c2 analyses according to the largest family of comparisons (13 comparisons in the medical complications category), setting statistical significance at P < .0038. Data were analyzed using SPSS, version 25.0 (IBM Corp, Armonk, NY). The study was exempt from review by the institutional human research protection program because it used data from a pre-existing, de-identified public database.

Results OTHER VARIABLE DEFINITIONS

The body mass index (BMI) was calculated from the height and weight. A numeric value for the number of comorbidities was calculated from a list, which included smoking status, diabetes mellitus, dyspnea, functional health status, ventilator dependence, a history of severe chronic obstructive pulmonary disease, ascites, congestive heart failure, hypertension requiring medication, dialysis use, acute renal failure, disseminated cancer, open wounds, dirty or infected wounds, steroid use for chronic conditions, more than 10% loss in body weight in the previous 6 months, bleeding disorder, the use of transfusions before surgery, and preoperative sepsis or systemic inflammatory response syndrome. The complications were divided into surgical complications, medical complications, or any complication. A new variable termed ‘‘30 days or longer postoperative stay’’ was calculated from the variable, the number of days from surgery to discharge. All other ACS-NSQIP variable definitions can be found in the NSQIP data dictionary.7 STATISTICAL ANALYSIS

The variables analyzed included the demographic data, comorbidities, procedure types, and outcomes. The c2 test, t test, and Fisher exact test were used for categories with 10 or fewer cases. Propensity scores were obtained for the likelihood of a 2-team approach and were derived from a binary logistic regression adjusting for the demographic factors, procedures, and comorbidities with P < .200 on univariate analysis (Table 2). The number of comorbidities, ablations, or flaps was excluded from the regression to prevent collinearity. The cases were matched in a 1:1 ratio via the propensity scores and using a 0.005 caliper without replacement, which gave priority to exact matches. The propensity score matching accuracy was confirmed on univariate analysis for all demographic, comorbid, and procedure variables and the

COMPARING ONE-TEAM AND TWO-TEAM PATIENT CHARACTERISTICS

A total of 2968 patients who had undergone a concurrent head and neck ablative and reconstruction procedure was identified. Of the 2968 procedures, 2032 (68.5%) had been performed by a single team and 936 (31.5%) using a 2-team ablative and reconstructive approach. No differences were noted in age, gender, BMI, or the number of comorbidities between the 1-team and 2-team procedures after Bonferroni’s correction. Patients with a 2-team surgical approach were more likely to have lost more than 10% of their body weight (P < .001) and to have a dirty or infected wound (P = .006), although the latter was not significant after Bonferroni’s correction. Patients who had undergone procedures with 2 teams were more likely to have an American Society of Anesthesiologists (ASA) classification of 3 or greater (83.6 vs 72.0%; P < .001). With respect to ablative procedures, the 2-team cases were less likely to undergo parotidectomy (9.6 vs 15.9%; P < .001) but more likely to have undergone glossectomy (56.6 vs 49.2%; P < .001), mandibulectomy (22.2 vs 14.2%; P < .001), neck dissection (58.2 vs 8.7%; P < .001), and tracheotomy (55.8 vs 37.1%; P < .001). They were also more likely to have undergone multiple ablative procedures at one setting (12.6 vs 8.7%; P = .001). Regarding the reconstruction, the 2-team approach was more likely to have used a soft tissue free flap (62.0 vs 52.7%; P < .001), a bone free flap (31.6 vs 15.6%; P < .001), or more than 1 type of flap (5.1 vs 2.4%; P < .001). In contrast, the 1-team approach was more likely to have used local rotational flaps (34.1 vs 11.6%; P < .001). Propensity score matching eliminated differences in the available preoperative variables or procedure type to control for differences in the ablative and reconstructive patterns, yielding 864 single-team surgeries and 864 matching 2team surgeries.

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HEAD AND NECK TEAM SURGERY

FIGURE 1. CONSORT (consolidated standards for reporting trials) diagram of inclusion and exclusion criteria. Torabi et al. Head and Neck Team Surgery. J Oral Maxillofac Surg 2019.

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TORABI ET AL

Table 2. ANALYSIS OF DEMOGRAPHIC DATA AND COMORBIDITIES STRATIFIED BY APPROACH BEFORE AND AFTER PROPENSITY SCORE MATCHING

Before 1:1 Matching

Variable Age* (yr) 18-40 41-60 61-80 >81 Gender* Male Female BMI* (kg/m2) Underweight (#18.5) Normal (18.51-24.99) Overweight (25-29.99) Obese ($30) ASA classification* No disturbance, Class 1 Mild disturbance, Class 2 Severe disturbance, Class 3 Life threatening, Class 4 Comorbidities (n) 0 1 $2 Specific comorbidities Diabetes mellitus Smoker Dyspnea* Impaired functional status Ventilator dependent COPD Ascites CHF* Hypertension Dialysis Disseminated cancer Open wound Dirty/infected wound* Steroid use >10% Body weight loss* Bleeding disorder Preoperative transfusion Systemic sepsis Primary ablative procedure Maxillectomy and/or orbitectomy* Parotidectomy* Auriculectomy* Mandibulectomy* Glossectomy* Laryngopharyngectomy* Soft tissue excision* >1 Type of ablation Concurrent procedure Neck dissection* Tracheotomy*

One-Team (n = 2032)

Two-Team (n = 936)

137 (6.7) 739 (36.4) 966 (47.5) 190 (9.4)

59 (6.3) 350 (37.4) 462 (49.4) 65 (6.9)

1320 (65.0) 712 (35.0)

643 (68.7) 293 (31.3)

142 (7.0) 792 (39.0) 594 (29.2) 504 (24.8)

65 (6.9) 383 (40.9) 286 (30.6) 202 (21.6)

37 (1.8) 531 (26.1) 1285 (63.2) 179 (8.8)

8 (0.9) 146 (15.6) 716 (76.5) 66 (7.1)

498 (24.5) 736 (36.2) 798 (39.3)

224 (23.9) 307 (32.8) 405 (43.3)

271 (13.3) 652 (32.1) 157 (7.7) 42 (2.1) 4 (0.2) 144 (7.1) 3 (0.1) 17 (0.8) 968 (47.6) 6 (0.3) 146 (7.2) 99 (4.9) 13 (0.6) 81 (4.0) 152 (7.5) 54 (2.7) 10 (0.5) 20 (1.0)

112 (12.0) 313 (33.4) 91 (9.7) 23 (2.5) 1 (0.1) 61 (6.5) 0 (0.0) 3 (0.3) 459 (49.0) 2 (0.2) 64 (6.8) 45 (4.8) 16 (1.7) 41 (4.4) 107 (11.4) 25 (2.7) 3 (0.3) 13 (1.4)

215 (10.6) 323 (15.9) 45 (2.2) 288 (14.2) 999 (49.2) 198 (9.7) 154 (7.6) 177 (8.7) 990 (48.7) 753 (37.1)

After 1:1 Matching (Caliper, 0.005) One-Team (n = 864)

Two-Team (n = 864)

41 (4.7) 332 (38.4) 435 (50.3) 56 (6.5)

54 (6.3) 328 (38.0) 420 (48.6) 62 (7.2)

578 (66.9) 286 (33.1)

579 (67.0) 285 (33.0)

60 (6.9) 344 (39.8) 253 (29.3) 207 (24.0)

63 (7.3) 370 (42.8) 246 (28.5) 185 (21.4)

3 (0.3) 153 (17.7) 665 (77.0) 43 (5.0)

8 (0.9) 143 (16.6) 651 (75.3) 62 (7.2)

204 (23.6) 301 (34.8) 359 (41.6)

211 (24.4) 288 (33.3) 365 (42.2)

.301 .464 .068 .500 1.000 .570 .556 .147 .478 1.000 .732 .940 .006 .615 <.001y .983 .766 .329

110 (12.7) 294 (34.0) 63 (7.3) 14 (1.6) 0 (0.0) 61 (7.1) 1 (0.1) 3 (0.3) 409 (47.3) 3 (0.3) 60 (6.9) 38 (4.4) 8 (0.9) 19 (2.7) 78 (9.0) 20 (2.3) 7 (0.8) 8 (0.9)

101 (11.7) 289 (33.4) 82 (9.5) 21 (2.4) 1 (0.1) 58 (6.7) 0 (0.0) 3 (0.3) 417 (48.3) 2 (0.2) 56 (6.5) 38 (4.4) 9 (1.0) 31 (4.5) 92 (10.6) 21 (2.4) 2 (0.2) 11 (1.3)

.508 .799 .099 .232 1.000 .776 1.000 1.000 .700 1.000 .701 1.000 1.000 .084 .258 .874 .179 .646

81 (8.7) 90 (9.6) 12 (1.3) 208 (22.2) 530 (56.6) 92 (9.8) 50 (5.3) 118 (12.6)

.104 <.001y .085 <.001y <.001y .942 .025 .001y

67 (7.8) 88 (10.2) 10 (1.2) 157 (18.2) 510 (59.0) 86 (10.0) 31 (3.6) 77 (8.9)

78 (9.0) 89 (10.3) 12 (1.4) 169 (19.6) 491 (56.8) 90 (10.4) 46 (5.3) 103 (11.9)

.340 .937 .831 .461 .355 .750 .080 .041

545 (58.2) 522 (55.8)

<.001y <.001y

482 (55.8) 486 (56.3)

494 (57.2) 459 (53.1)

.560 .192

P Value .163

.499

.046

.959

.285

<.001y

P Value

.502

.103

.093

.797

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HEAD AND NECK TEAM SURGERY

Table 2. Cont’d

Before 1:1 Matching

Variable Reconstructive procedure Soft tissue free flap* Bone free flap* Local flap* >1 Type of flap Propensity scores

After 1:1 Matching (Caliper, 0.005)

One-Team (n = 2032)

Two-Team (n = 936)

P Value

One-Team (n = 864)

Two-Team (n = 864)

P Value

1071 (52.7) 317 (15.6) 692 (34.1) 48 (2.4) 0.281  0.147

580 (62.0) 296 (31.6) 109 (11.6) 48 (5.1) 0.390  0.141

<.001y <.001y <.001y <.001y <.001y

567 (65.6) 224 (25.9) 102 (11.8) 29 (3.4) 0.372  0.129

555 (64.2) 233 (27.0) 108 (12.5) 32 (3.7) 0.372  0.129

.545 .624 .659 .696 .993

Data presented as mean  standard deviation or n (%). Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease. * Propensity matched for this variable. y Statistically significant. Torabi et al. Head and Neck Team Surgery. J Oral Maxillofac Surg 2019.

VARIABLES FAVORING A 2-TEAM APPROACH

After binary logistic regression analysis (Table 3), few factors were independently associated with an increased likelihood of a 2-team approach. Patients with a wound classified as dirty were more likely to have a 2-team approach (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 1.1 to 5.5; P = .027), as were those with dyspnea (aOR, 1.4; 95% CI, 1.0 to 1.9; P = .024) and those who had experienced weight loss (aOR, 1.3; 95% CI, 1.0 to 1.8; P = .043). Among the ablative procedures, laryngopharyngectomy (aOR, 1.8; 95% CI, 1.2 to 2.7; P = .002) and parotidectomy (aOR, 1.5; 95% CI, 1.1 to 2.1; P = .016) were more likely to have had a 2team approach. Within the reconstruction procedures, microvascular bone and composite flaps (aOR, 3.4; 95% CI, 2.1 to 5.4; P < .001) and microvascular soft tissue flaps (aOR, 2.1; 95% CI, 1.3 to 3.3; P = .002) were associated with the use of 2 teams. Finally, tracheotomy had an increased likelihood for a 2-team approach (aOR, 1.6; 95% CI, 1.3 to 1.9; P < .001). OUTCOME PROFILES BETWEEN ONE- AND TWOTEAM SURGERIES

The complication rates were high across both cohorts—37.0% with the 1-team approach and 52.5% for the 2-team approach. The intra- and postoperative transfusion rates were also high in both groups (1team, 22.5%; 2-team, 32.6%). The common complications included superficial surgical site infections (SSIs) (1-team, 6.7%; 2-team, 6.6%), deep incisional SSIs (1-team, 3.4%; 2-team, 6.3%), wound disruption or dehiscence (1-team, 3.7%; 2-team, 8.1%), and pneumonia (1-team, 4.5%; 2-team, 9.2%). Before matching to account for the greater complexity of cases typically

completed by 2 teams, as demonstrated by the demographics analysis, patients who had undergone a 2team approach experienced longer operative times (P < .001), longer hospital stays (P < .001), and a greater rate of reoperation (P = .002). The patients who had undergone 2-team surgeries also had a greater incidence of any complication (P < .001), including both medical (P < .001) and surgical (P < .001) complications. The surgical complications, including increased deep incisional SSIs (P < .001), wound dehiscence (P < .001), and transfusion (P < .001), were greater in the 2-team approach. A full list of outcome comparisons is presented in Table 4. Given the preoperative differences between the 2 groups, the analysis was repeated with data from the propensity matched cohorts. The operative time for the 2-team surgeries remained longer (574.4 vs 532.0 minutes; P < .001), and they had a greater incidence of any complications (51.5 vs 42.1%; P < .001). The 2-team approach also had a greater incidence of wound dehiscence (8.0 vs 3.8%; P < .001), although no differences were noted in the overall surgical complications after Bonferroni correction (P = .004). The incidence of medical complications was also greater with the 2-team approach (20.1 vs 14.4%; P = .0018), resulting mostly from prolonged ventilator use (7.2 vs 2.8%; P < .001) and greater rates of pneumonia (9.1 vs 5.2%; P = .0015).

Discussion Head and neck surgical practice and training include both extirpative and reconstructive procedures.1,8-11 Although some surgical centers have a practice model in which a single surgeon performs both portions, others work in teams, dividing the ablative and reconstructive procedures. A recent

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Table 3. BINARY LOGISTIC REGRESSION TO PREDICT TEAM SIZE

Event: Two-Team Surgery Variable Age (yr) 18-40 41-60 61-80 >81 Gender Male Female BMI (kg/m2) Underweight (#18.5) Normal (18.51-24.99) Overweight (25-29.99) Obese ($30) ASA classification No disturbance, Class 1 Mild disturbance, Class 2 Severe disturbance, Class 3 Life threatening, Class 4 Comorbidities* Dyspnea CHF Dirty/infected wound >10% Body weight loss Primary ablative procedure* Maxillectomy and/or orbitectomy Parotidectomy Auriculectomy Mandibulectomy Glossectomy Laryngopharyngectomy Soft tissue excision Concurrent procedures* Neck dissection Tracheotomy Reconstructive procedure* Soft tissue free flap Bone free flap Local flap

OR (95% CI)

P Value

1.000 0.921 (0.643-1.320) 0.968 (0.678-1.384) 0.885 (0.560-1.398)

Reference .654 .860 .600

1.000 0.890 (0.743-1.066)

Reference .205

0.802 (0.568-1.131) 1.000 1.065 (0.871-1.303) 0.930 (0.746-1.160)

.207 Reference .537 .521

1.000 1.135 (0.501-2.573) 2.031 (0.905-4.558) 1.281 (0.540-3.036)

Reference .761 .086 .574

1.415 (1.047-1.912) 0.335 (0.092-1.217) 2.469 (1.109-5.497) 1.346 (1.009-1.797)

.024y .096 .027y .043y

0.919 (0.645-1.309) 1.518 (1.080-2.135) 1.108 (0.549-2.239) 1.298 (0.962-1.751) 1.258 (0.936-1.691) 1.826 (1.243-2.683) 1.410 (0.938-2.119)

.639 .016y .775 .088 .128 .002y .098

1.152 (0.973-1.364) 1.615 (1.339-1.948)

.101 <.001y

2.103 (1.326-3.337) 3.372 (2.122-5.359) 0.664 (0.412-1.071)

.002y <.001y .093

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; CHF, congestive heart failure; CI, confidence interval; OR, odds ratio. * The reference was either the lack of the comorbidity or when procedure had not been performed, as appropriate. y Statistically significant. Torabi et al. Head and Neck Team Surgery. J Oral Maxillofac Surg 2019.

survey identified the use of 2 surgical teams for 98.5% of microvascular flap reconstructions, with more than three quarters (76.3%) using otolaryngologists for both teams.12 Advocates of the 2-team approach believe it reduces surgeon fatigue, maximizes efficiency, and preserves the checks and balances between the competing goals of resection and reconstruction.2 With the increasing comfort and predictability with

microsurgery, microvascular free flaps have become the standard for reconstructing composite, 3dimensional head and neck defects but often require longer procedures.13,14 The opportunity for both teams to work simultaneously can shorten the total procedure time and enable the ablative surgeon to focus on obtaining adequate margins without having to optimize the area for subsequent reconstruction.2

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Table 4. ANALYSIS OF SURGICAL OUTCOMES STRATIFIED BY APPROACH BEFORE AND AFTER PROPENSITY SCORE MATCHING

Before 1:1 Matching

Variable Total operative time (min) Operation to discharge (days) Death within 30 days 30-Day return to OR Still in hospital $30 daysz Any readmissionk Any complication Surgical complications Superficial SSI Deep incisional SSI Organ space SSI Wound dehiscence/ disruption Transfusion intra-/ postoperative (ie, because of severe bleeding) Medical complication Pneumonia Unplanned intubations Urinary tract infection DVT/thrombophlebitis Pulmonary embolism Ventilator >48 hr CVA/stroke with neurologic deficit Cardiac arrest requiring CPR Myocardial infarction Sepsis Septic shock Progressive renal failure Acute renal failure

After 1:1 Matching (Caliper, 0.005)

One-Team (n = 2032)

Two-Team (n = 936)

P Value

One-Team (n = 864)

Two-Team (n = 864)

P Value

470.81  206.64 9.62  7.93z

584.33  189.34*

<.001y

574.38  185.12*

<.001y

<.001y

532.07  186.55 10.98  7.71x

12.21  9.89*

12.05  9.52*

.011

26 (1.3) 303 (14.9) 51/2025 (2.5) 143/1726 (8.3) 751 (37.0) 644 (31.7) 137 (6.7) 69 (3.4) 41 (2.0) 76 (3.7)

12 (1.3) 184 (19.7) 46/935 (4.9) 68/795 (8.6) 491 (52.5) 416 (44.4) 62 (6.6) 59 (6.3) 28 (3.0) 76 (8.1)

.995 .001y .001y .821 <.001y <.001y .905 <.001y .102 <.001y

12 (1.4) 159 (18.4) 24/861 (2.8) 78/747 (10.4) 364 (42.1) 316 (36.6) 65 (7.5) 28 (3.2) 18 (2.1) 33 (3.8)

11 (1.3) 167 (19.3) 41/863 (4.8) 62/734 (8.4) 445 (51.5) 374 (43.3) 57 (6.6) 56 (6.5) 23 (2.7) 69 (8.0)

.834 .623 .032 .190 <.001y .004 .452 .0017y .429 <.001y

458 (22.5)

305 (32.6)

<.001y

240 (27.8)

269 (31.1)

.126

250 (12.3) 92 (4.5) 45 (2.2) 19 (0.9) 23 (1.1) 13 (0.6) 63 (3.1) 6 (0.3)

192 (20.5) 86 (9.2) 29 (3.1) 13 (1.4) 9 (1.0) 9 (1.0) 71 (7.6) 2 (0.2)

<.001y <.001y .151 .266 .849 .361 <.001y 1.000

125 (14.5) 45 (5.2) 18 (2.1) 12 (1.4) 13 (1.5) 7 (0.8) 24 (2.8) 3 (0.3)

174 (20.1) 79 (9.1) 25 (2.9) 13 (1.5) 9 (1.0) 9 (1.0) 62 (7.2) 1 (0.1)

.0018y .0015y .280 .840 .521 .803 <.001y .625

18 (0.9)

9 (1.0)

.837

8 (0.9)

8 (0.9)

1.000

27 (1.3) 57 (2.8) 10 (0.5) 3 (0.1) 3 (0.1)

10 (1.1) 39 (4.2) 5 (0.5) 4 (0.4) 3 (0.3)

.599 .051 1.000 .217 .387

8 (0.9) 26 (3.0) 2 (0.2) 1 (0.1) 0 (0.0)

7 (0.8) 33 (3.8) 5 (0.6) 3 (0.3) 3 (0.3)

1.000 .354 .452 .625 .250

Data presented as mean  standard deviation or n (%). Abbreviations: CPR, cardiopulmonary resuscitation; CVA, cerebrovascular accident; DVT, deep vein thrombosis; OR, odds ratio; SSI, surgical site infection. * One sample excluded from analysis because of missing data. y Statistically significant. z Seven samples excluded from analysis because of missing data. x Three samples excluded from analysis because of missing data. k Missing data. Torabi et al. Head and Neck Team Surgery. J Oral Maxillofac Surg 2019.

We have presented an analysis that evaluated patient profiles and outcomes for simultaneous ablation and reconstruction for both 1- and 2-team approaches. The finding that a 2-team approach has been favored for more complex ablative15 and reconstructive14 procedures and that a 1-team approach has predominated

in reconstructions using local flaps was consistent with expectations. Two-team surgeries were predominantly used for the more involved ablative procedures (ie, glossectomy, mandibulectomy, and composite resection). The 2-team approach was also favored in patients who were more ill, as evidenced by the higher

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TORABI ET AL

preoperative ASA classification and greater rates of weight loss. Furthermore, the 2-team approach tended to use more complex free flap reconstructions with a greater use of multiple flaps within the same procedure. Given the selection bias favoring the 2-team approach for more complex ablative and reconstructive procedures, the increased operative length and hospital stay for the 2-team approach was not unexpected. Regarding the complications, the overall complication rates were high, more than 40% for the entire sample. Given the differences in certain preoperative risk factors, the greater rate of complications in the 2-team cohort was not surprising. Previous data of head and neck resection and reconstruction have shown that a greater ASA classification was associated with an increased hospital length of stay16 and major complications such as fistula or flap loss.17 In an attempt to discern the true surgical and complication differences between the approaches, we used propensity score matching to neutralize the preoperative and procedural differences between the 1- and 2-team approach according to the data available in the database. Rather than shortening the total operative time, the 2-team approach was still associated with significantly longer surgery. This finding might 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 the 2-team approach to allow for flap harvest during ablation. It is also possible that another confounding variable, not accounted for in the database, such as a history of alcohol dependence or postoperative alcohol withdrawal, could have accounted for this finding.18 The propensity matched cohort also showed a greater complication rate with the 2-team approach. Longer surgeries, such as were seen with the 2-team approach, are a known risk factor for increased perioperative complications with many surgeries,19,20 including head and neck surgeries16,21 and plastic reconstructive procedures.22 However, our results might also reflect imperfect matching as a result of inherent limitations in the NSQIP data set, including a lack of oncologicspecific variables, such as TNM staging, might have skewed the reported results. Furthermore, the ablative and reconstructive CPT codes might not reflect the variability in procedural difficulty both between and within the codes. For example, more total glossectomy procedures might have been performed using the 2team approach and more hemiglossectomy procedures using the 1-team approach. However, the total number of glossectomies was equivalent. It is possible that patients undergoing 2-team surgeries might have had disproportionally larger defects, influencing the operative time and outcomes, such as wound complications. The limitations inherent to the present study included unknown oncologic outcomes, pathologic

margins, and >30-day survival between the 2 cohorts. Because the present study explored the perioperative outcomes and complications, this was a significant limitation to our ability to frame our comparison conclusions. It is likely that the patients who had undergone 2-team surgery were those with more advanced diseases requiring more invasive ablation and more extensive reconstruction, even after controlling for NSQIP-reported variables. Furthermore, individual surgeon experience, surgical volume, and hospital setting were not available from the data set. The surgeon–surgeon working relationship and familiarity—both possibly influencing outcomes—were not available.4 Our data-driven definition of the team approach could have led to mischaracterization in cases in which trainee functions as a de facto second team performing either the ablative or reconstructive surgery simultaneously with the primary surgery. Nevertheless, although caution should be used in interpreting the outcomes of the present study, the limitations were partially outweighed by the large power of the validated database. One strength of the present study was the profiling of the types of patients who had undergone specific surgical approaches, which could help inform surgeon choices and future studies. In conclusion, to the best of our knowledge, we have presented the first and largest profile analysis and comparison of perioperative outcomes between the 1-team and 2-team head and neck oncologic and reconstructive surgery. The trends revealed a preference for a 2-team approach for more complex ablative and reconstructive procedures. Propensity matching comparing the 1-team and 2-team approach revealed persistently longer operative times and higher complications rates with the 2-team cohort; however, the oncologic factors were unknown. Acknowledgments The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the hospitals participating in the ACS-NSQIP were the source of the data used. They have not verified and are not responsible for the statistical validity of the data analysis or the conclusions we have derived.

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HEAD AND NECK TEAM SURGERY 14. McCrory AL, Magnuson JS: Free tissue transfer versus pedicled flap in head and neck reconstruction. Laryngoscope 112:2161, 2002 15. Houlton JJ, Bevans SE, Futran ND: Unfavorable results after free tissue transfer to head and neck: Lessons learned at the University of Washington. Clin Plast Surg 43:683, 2016 16. Tadiparthi S, Enache A, Kalidindi K, et al: Hospital stay following complex major head and neck resection: What factors play a role? Clin Otolaryngol 39:156, 2014 17. Broome M, Juilland N, Litzistorf Y, et al: Factors influencing the incidence of severe complications in head and neck free flap reconstructions. Plast Reconstr Surg Global Open 4:e1013, 2016 18. Genther DJ, Gourin CG: The effect of alcohol abuse and alcohol withdrawal on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 122:1739, 2012 19. Kim JY, Khavanin N, Rambachan A, et al: Surgical duration and risk of venous thromboembolism. JAMA Surg 150:110, 2015 20. Karhade AV, Fandino L, Gupta S, et al: Impact of operative length on post-operative complications in meningioma surgery: A NSQIP analysis. J Neurooncol 131:59, 2017 21. Goyal N, Yarlagadda BB, Deschler DG, et al: Surgical site infections in major head and neck surgeries involving pedicled flap reconstruction. Ann Otol Rhinol Laryngol 126:20, 2017 22. Hardy KL, Davis KE, Constantine RS, et al: The impact of operative time on complications after plastic surgery: a multivariate regression analysis of 1753 cases. Aesthet Surg J 34: 614, 2014