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Transcervical arterial ligation for prevention of postoperative hemorrhage in transoral oropharyngectomy: Systematic review and meta-analysis
Abstract
Background:
Transcervical arterial ligation has been studied as a useful procedure to prevent bleeding events after transoral robotic surgery (TORS).
Methods:
A systematic review of English-language literature on arterial ligation in TORS from 2005 to 2019 was conducted using Cochrane, PubMed, Web of Science (WoS), and ScienceDirect databases. Studies evaluating ligation and rates of postoperative hemorrhage were included. Meta-analysis of included studies was performed to assess impact of ligation on postoperative hemorrhage.
Results:
Five studies with 2008 patients were included. History of radiation (odds ratio [OR] = 2.26, P = .02) and advanced tumor stage (OR = 1.93, P = .02) were found to predispose patients to postoperative hemorrhage. Arterial ligation was protective against severe hemorrhage in the mixed primary surgical modality cohort (OR = 0.33, P = .03) and in the TORS-only subgroup (OR = 0.21, P = .02), but did not significantly impact overall odds of postoperative hemorrhage.
Conclusion:
Transcervical arterial ligation offers protection against major/severe postoperative hemorrhage in patients undergoing TORS.
Level of evidence:
II.
... Post-operative haemorrhage is one of the most common complications following TORS, with an overall rate of approximately 6.5% [13]. Although the rate of haemorrhage is marginally higher than that of traditional tonsillectomy, there is a higher risk of catastrophic bleeding resulting in tracheostomy or death [14]. Elective ligation of branches of the external carotid artery has been widely adopted by head and neck surgeons to reduce the risk of post-operative bleeding after it was shown to reduce the incidence of major or severe haemorrhage in a systematic review of 2008 patients [14]. ...
... Although the rate of haemorrhage is marginally higher than that of traditional tonsillectomy, there is a higher risk of catastrophic bleeding resulting in tracheostomy or death [14]. Elective ligation of branches of the external carotid artery has been widely adopted by head and neck surgeons to reduce the risk of post-operative bleeding after it was shown to reduce the incidence of major or severe haemorrhage in a systematic review of 2008 patients [14]. ...
... Our study results are in keeping with reported outcomes of haemorrhage rates in patients having received prophylactic arterial ligation, with a post-operative haemorrhage rate of 6% including one major haemorrhage and no instances of severe haemorrhage in this case series. It has been suggested that the benefit of vessel ligation may decrease over time due to tumour neovascularisation [14], however, our results demonstrate that an interval of 1-2 weeks between vessel ligation and subsequent TORS resection does not appear to negatively impact the rate of haemorrhage. On the contrary, it has been proposed that staging vessel ligation prior to TORS may reduce intraoperative bleeding and improve surgical conditions when performing a robotic oropharyngeal resection [10], although it must be noted that evidence to support this proposal is anecdotal and may prove difficult to verify due to the exceedingly small estimated blood loss that is usually recorded during TORS procedures. ...
Purpose
Transoral robotic surgery (TORS) has become increasingly recognised as a safe and effective treatment for early oropharyngeal squamous cell carcinoma, often performed in conjunction with neck dissection (ND) and vessel ligation. It has been proposed that performing the neck dissection in a staged fashion prior to TORS results in low rates of transoral haemorrhage and pharyngocutaneous fistula, and may aid in TORS patient selection by eliminating patients who would require multi-modality treatment based on nodal pathology. This study aims to assess the effect of staged neck dissection with TORS in mitigating pharyngocutaneous fistulae and post-operative haemorrhage as well as the impact of staged ND on TORS patient selection.
Methods
A retrospective cohort analysis was performed of patients undergoing staged ND with intent to proceed to TORS at two Australian hospitals between 2014 and 2022. Incidence of post-operative haemorrhage and pharyngocutaneous fistula and length of inpatient stay was identified. The number of patients who did not proceed to TORS was recorded.
Results
One hundred and four patients were identified who underwent staged neck dissection with an intention to proceed to TORS. Six patients did not proceed to TORS following pathological assessment of the neck dissection specimen and ninety-eight patients (91 primary, 7 salvage) underwent TORS. There were six cases of secondary haemorrhage (one major, two intermediate and three minor). There were no cases of pharyngocutaneous fistula.
Conclusion
Staged neck dissection prior to TORS results in low rates of haemorrhage and pharyngocutaneous fistula and can improve TORS patient selection.
... Adequate control over vascular structures during robotic surgery is of paramount importance. In order to avoid catastrophic bleeding after TORS often ligation of the external carotid artery is recommended, 31 which however in the radiated neck would require an additional transcervical procedure. RESA for radiated patients performed through a submental incision provides readily access to Lesser's triangle at the level of the hypoglossal nerve. ...
We report on the first clinical experience with the robotic‐assisted extended “Sistrunk” approach (RESA) for access to constrained spaces of the upper aerodigestive tract. This prospective case cohort study include six patients that underwent RESA if transoral exposure could not be achieved. Three patients received previous radiation. Patients were postoperatively followed until week 16 for perioperative complications, surgical margins, and functional outcomes. In all patients RESA allowed adequate exposure and resection with negative margins. Three patients who underwent salvage surgery experienced a minor or intermediate grade postoperative bleeding. No patient developed a pharyngocutaneous fistula. Three patients recovered their swallowing to their preoperative status and the remaining three experienced an improvement. All patients experienced complete recovery of their voice. RESA has the potential to provide a new organ preservation approach for head and neck cancer (HNC) not amenable to transoral exposure and thus warrants further prospective clinical studies.
... 19 More recently, prophylactic arterial ligation has been shown in multiple systematic reviews to be associated with a reduced risk of major and severe bleeding after TORS. 20,21 Our study included a number of limitations. As with all studies involving national databases, selection bias, incomplete data, and coding errors limit its use. ...
Background:
The association of comorbidities with perioperative outcomes after transoral robotic surgery (TORS) is not well-defined in the literature.
Methods:
Using the National Cancer Database, 4004 patients with T1-T2 oropharyngeal cancer between 2010 and 2017 were stratified based on their Charlson-Deyo Comorbidity Class (CDCC). Thirty-day unplanned readmissions, 30-day mortality, and 90-day mortality were compared using chi-square test and logistic regression. Hospital length of stay (LOS) was compared using the Kruskal-Wallis test.
Results:
LOS was greater for patients with CDCC 2 or 3 compared to CDCC 0 or 1 (p < 0.001). Increasing age and CDCC ≥3 were associated with 30-day mortality (CDCC ≥3: odds ratio [OR] 5.55, 95% confidence interval [CI] 1.59-19.45). CDCC ≥3 (OR 2.61, 95%CI 1.09-6.27) was significantly associated with 30-day readmissions.
Conclusion:
This national analysis demonstrates greater rates of unplanned 30-day readmissions, longer hospitalizations, and increased 30- and 90-day mortality after TORS in patients with CDCC ≥3.
... TAL has been associated with a clinically important reduction in the rate of major postoperative hemorrhage events of the oropharynx and has become a standard practice to prevent major hemorrhage in clinical trials such as ECOG 3311(NCT01898494). [44][45][46] This practice, however, is not standard in TORS-SGL, which has overall major and minor hemorrhage rates of 2.28% and 0.15%. As demonstrated by this review, the use of TAL was only reported in three series and performed on a total of 49 patients undergoing TORS-SGL (9.74%) in the literature. ...
Introduction: Our umbrella review aimed to summarize and revisit the evidence from all of the meta-analyses and systematic reviews regarding the treatments of oropharyngeal squamous cell carci-noma (OPSCC). Materials and Methods: Major medical databases such as PubMed, Scopus, Embase, Web of Science, Google Scholar, Cochrane Library, BIOSIS, and EBSCO were searched. The overall search process was conducted in 3 stages. Results: Finally, a total of 28 studies met the inclusion criteria and were included in this study. Out of those 28 meta-analyses, a total of 315 primary studies were screened in order to extract the data and perform the statistical analysis. In total, data from 22,619 patients was analyzed. Conclusion: The main objective of the present umbrella review was to summarize and analyze all of the evidence-based data provided by numerous meta-analyses and systematic reviews regarding the treatment of OPSCC. Our study delivers the most up-to-date and evidence-based results regarding the different therapeutic modalities of this malignancy in one concise review, making it the ultimate tool for physicians treating OPSCC.
Background:
Transoral robotic surgery (TORS) has been used in the salvage setting for head and neck cancers both with and without reconstruction. The complications of salvage TORS and the effect of reconstruction on complications has not been studied.
Objective:
To study the complications of salvage TORS and examine the effect of reconstruction on complication rates.
Method:
An electronic search of the English- language literature using PubMed, Medline, and the Cochrane database was conducted and a systematic review performed in accordance with PRISMA guidelines (CRD42020181057).
Results:
A total of 23 studies including 533 patients have been published on salvage TORS.The average patient age was 61.2 years.Prior treatment was described for 420 patients.205 (48.8%) underwent prior definitive radiotherapy (RT).160 (38.1%) underwent definitive chemoradiotherapy (CRT).Only 55 (13.1%) had prior surgery.Overall, there were 158 complications with a pooled rate of 33.6% (95%CI: 25.4-42.3%).77 were major complications requiring surgical intervention with a pooled rate of 18.9% (95% CI: 14.8-23.3%).The number of patients undergoing reconstruction among salvage cases in the literature is 59 (9.19%), with 24 local flaps and 25 microvascular free flaps.Reconstruction was associated with lower overall hemorrhage rates but had no impact on major hemorrhage rates.
Conclusions:
The pooled incidence rates of major complications, major POH and emergency tracheostomy following salvage TORS are 18.9%, 10.5%, and 4.4%.The rate of death following salvage TORS is 3.6%. Reconstruction was associated with lower overall hemorrhage rate after salvage TORS but had no impact on major postoperative hemorrhage rates.
Objective:
Dose de-escalation of adjuvant therapy (DART) in patients with HPV(+)OPSCC was investigated in two prospective Phase II and III clinical trials (MC1273 and MC1675). We report the 30-day morbidity and mortality associated with primary TORS resection in patients enrolled in these trials.
Materials and methods:
Patients with HPV(+)OPSCC, who underwent TORS resection between 2013 and 2020 were considered in this analysis. The severity of postoperative transoral bleeding was graded using both the Hinni Grade (HG) transoral surgery bleeding scale and the Common Terminology for Adverse Events (CTCAE) v5.0. Post-surgical complications within 30 days of surgery, as well as rates of tracheostomy, PEG and nasogastric tube placement.
Results:
219 patients were included. A total of 7 (3.2 %) patients had a tracheostomy placed at the time of surgery, and all were decannulated within 26 days (median: 5, range: 2-26). There were 33 (15.1 %) returns to the emergency department (ED) with 10 (4.6 %) patients requiring readmission. Using the HG scale, 10 (4.6 %) patients experienced ≥ Grade 3 bleeding with no Grade 5 or 6 bleeds. In contrast, using the CTCAE scale, 15 patients (6.8 %) experienced ≥ Grade 3 bleeding with no Grade 5 bleeds. There was one post-operative death in a patient withdrawn from the trial, and no deaths related to hemorrhage.
Conclusion and relevance:
TORS for HPV(+)OPSCC in carefully selected patients at a high volume center was associated with low morbidity and mortality.
Introduction: Transoral laser microsurgery and transoral robotic surgery have become common approaches to treating oropharyngeal squamous cell carcinoma. Early stage cancers are the best candidates for transoral resection.Technique: Transoral oropharyngectomy of the tonsil or base of tongue requires adequate exposure and access, which may be limited by patient- and tumor-specific characteristics. Multiple robotic systems are available, each with their own advantages and disadvantages.Outcomes: Oncologic outcomes of transoral surgery for oropharyngeal cancer are comparable to radiation or chemoradiotherapy based on available data. Functional outcomes from transoral surgery are consistently better than standard of care chemoradiotherapy when the patient is spared adjuvant radiation. Patients who receive transoral surgery with radiation may still achieve a functional benefit compared to definitive chemoradiotherapy, but the benefit is diminished.Trials: Many ongoing trials are investigating the role of transoral resection in treatment de-escalation for human papillomavirus-associated oropharyngeal squamous cell carcinoma. The few trials that have been complete to date demonstrate very promising survival and functional outcomes using transoral surgery as a component of treatment de-escalation. Ongoing clinical trials will continue to elucidate the optimal role and efficacy of transoral surgery in treatment de-escalation.Conclusion: Transoral surgery using laser microsurgery or robotic surgery is increasing in popularity for the treatment of early stage oropharyngeal squamous cell carcinoma. The use of these minimally invasive surgical approaches may expand as ongoing clinical trials are completed.KeywordsOropharyngeal cancerHead and neck cancerSquamous cell carcinomaHuman papillomavirusTransoral robotic surgeryTransoral laser microsurgery
Over time, the primary treatment modality of oropharyngeal squamous cell cancers (OPSCC) is intensity-modulated radiation therapy (IMRT), eventually associated with chemotherapy (CHT). This treatment modality is preferred for reduced impact on the quality of life rather than aggressive open surgical approaches. The advent of TransOral Robotic Surgery (TORS) has rediscovered the role of surgery in the treatment of OPSCC. Although the primary chemoradiation therapy (CRT) and transoral robotic surgery (TORS) are competing for similar oncologic results, CRT may result in significant functional complaints such as severe dysphagia and feeding tube dependence and, on the other hand, TORS might result in surgical defects depending on the size of the resection and anatomic location. Nevertheless, TORS may intercept the locoregionally advanced population through pathologic downstaging as well as the potential for improvement in oncologic outcomes. The available reconstructive options allow an expanding role of this minimally invasive surgery, even in locally advanced tumours. Finally, the surgical management of OPSCC with TORS identifies areas of opportunity in shortening the overall treatment package time compared to traditional surgery.
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2015, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2016, were collected by the National Center for Health Statistics. In 2019, 1,762,450 new cancer cases and 606,880 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2006‐2015) was stable in women and declined by approximately 2% per year in men, whereas the cancer death rate (2007‐2016) declined annually by 1.4% and 1.8%, respectively. The overall cancer death rate dropped continuously from 1991 to 2016 by a total of 27%, translating into approximately 2,629,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the racial gap in cancer mortality is slowly narrowing, socioeconomic inequalities are widening, with the most notable gaps for the most preventable cancers. For example, compared with the most affluent counties, mortality rates in the poorest counties were 2‐fold higher for cervical cancer and 40% higher for male lung and liver cancers during 2012‐2016. Some states are home to both the wealthiest and the poorest counties, suggesting the opportunity for more equitable dissemination of effective cancer prevention, early detection, and treatment strategies. A broader application of existing cancer control knowledge with an emphasis on disadvantaged groups would undoubtedly accelerate progress against cancer.
There is an increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) in the western world due to human papillomavirus (HPV). According to the Danish Head and Neck Cancer Group guidelines, the current recommended treatment of patients with OPSCC in Denmark is primary radiation therapy (RT) with or without concomitant chemotherapy. This is the first study in Scandinavia from a head and neck cancer centre that aims to demonstrate the feasibility of performing primary transoral robotic surgery (TORS) and concurrent neck dissection for patients with early stage OPSCC. Between September 2014 and January 2016, 30 consecutive patients with clinical T1-T2, N0-N1 OPSCC underwent primary TORS and concurrent neck dissection. The patients were offered postoperative adjuvant therapy according to pathological risk parameters: pT >2, T-site margin <2 mm, pN >1 or extracapsular extension (ECE). Concomitant chemotherapy was offered to patients with the presence of ECE or involved margins. Twenty-nine patients had negative margins on T-site after primary resection. Only one patient had a close margin of 1 mm. Unilateral neck dissection was performed in 21 patients while nine patients underwent bilateral neck dissection. Due to an upstaging following surgery, 13 patients were referred to adjuvant therapy. Four of these patients received RT and two patients received concomitant chemo-radiation (CCR) therapy. Seven patients declined the recommended adjuvant therapy one of whom later developed an N-site recurrence and received salvage surgery with postoperative RT. In summary, 43% of the patients were referred to adjuvant therapy following primary surgery which was mainly due to N-site stage migration and ECE. Primary TORS and concurrent neck dissection is a safe and feasible procedure that may be an alternative to primary RT and CCR in a selected group of patients with early stage OPSCC.
Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
Background: Intensity-modulated radiation therapy (IMRT) with or without concurrent chemotherapy is widely utilized for the treatment of oropharyngeal squamous cell carcinoma (OPSCC). However, due to significant acute and late toxicities there has been increasing interest in minimally invasive surgical approaches, particularly transoral robotic surgery (TORS) in an attempt to preserve patient quality of life while maintaining oncologic outcomes. The aim of this study was to review the current literature in order to compare primary IMRT versus TORS in the management of OPSCC. Methods: A MEDLINE search was conducted to identify studies reporting on the outcomes of TORS or IMRT in the treatment of OPSCC. Reference lists were also reviewed for relevant articles. Oncologic, functional, and quality of life data is summarized and discussed. Results: One hundred-ninety papers were identified through the MEDLINE search. An additional 52 papers were retrieved by hand searching the reference lists. Ultimately, 44 papers were identified that discussed outcomes after IMRT or TORS for OPSCC. No outcomes from randomized trials were identified. Conclusion: No randomized trials comparing TORS versus IMRT to each other were identified. Uncontrolled reports from the current literature suggest comparable oncologic outcomes with TORS compared to IMRT and functional outcomes may be superior. However, the median follow-up was relatively short and the TORS studies included patients with earlier stage OPSCC on average compared to IMRT studies. Prospective, randomized controlled trials and direct, well-matched comparisons are needed to further elucidate the role for TORS in the treatment of oropharyngeal squamous cell carcinoma.
Objectives/hypothesis:
To develop a technique for computer enhanced robotic transoral supraglottic partial laryngectomy in the canine model.
Study design:
Surgical procedure on the larynx in a canine model with a commercially available surgical robot.
Methods:
With use of the da Vinci Surgical Robot (Intuitive Surgical, Inc., Sunnyvale, CA), the supraglottic partial laryngectomy was performed on a mongrel dog that had been orotracheally intubated using general anesthesia. The videoscope and the 8 mm end-effectors of the robotic system were introduced through three ports, transorally. The surgical procedure was performed remotely from the robotic system console. The procedure was documented with still and video photography.
Results:
Supraglottic partial laryngectomy was successfully performed using the da Vinci Surgical Robot, with 8 mm instrumentation. The robotic system allowed for celerity and accuracy secondary to findings specific to the surgical approach, including excellent hemostasis, superb visualization of the operative field with expeditious identification of laryngeal submucosal soft tissue and skeletal landmarks, and multiplanar transection of tissues. In addition, the use of the robotic system also was found to have technical advantages inherent in robotic surgery, including the use of "wristed" instrumentation, tremor abolition, motion scaling, and three-dimensional vision.
Conclusions:
The da Vinci Surgical Robot allowed for successful robotic transoral supraglottic partial laryngectomy in the canine model.
Recent increases in incidence and survival of oropharyngeal cancers in the United States have been attributed to human papillomavirus (HPV) infection, but empirical evidence is lacking.
HPV status was determined for all 271 oropharyngeal cancers (1984-2004) collected by the three population-based cancer registries in the Surveillance, Epidemiology, and End Results (SEER) Residual Tissue Repositories Program by using polymerase chain reaction and genotyping (Inno-LiPA), HPV16 viral load, and HPV16 mRNA expression. Trends in HPV prevalence across four calendar periods were estimated by using logistic regression. Observed HPV prevalence was reweighted to all oropharyngeal cancers within the cancer registries to account for nonrandom selection and to calculate incidence trends. Survival of HPV-positive and HPV-negative patients was compared by using Kaplan-Meier and multivariable Cox regression analyses.
HPV prevalence in oropharyngeal cancers significantly increased over calendar time regardless of HPV detection assay (P trend < .05). For example, HPV prevalence by Inno-LiPA increased from 16.3% during 1984 to 1989 to 71.7% during 2000 to 2004. Median survival was significantly longer for HPV-positive than for HPV-negative patients (131 v 20 months; log-rank P < .001; adjusted hazard ratio, 0.31; 95% CI, 0.21 to 0.46). Survival significantly increased across calendar periods for HPV-positive (P = .003) but not for HPV-negative patients (P = .18). Population-level incidence of HPV-positive oropharyngeal cancers increased by 225% (95% CI, 208% to 242%) from 1988 to 2004 (from 0.8 per 100,000 to 2.6 per 100,000), and incidence for HPV-negative cancers declined by 50% (95% CI, 47% to 53%; from 2.0 per 100,000 to 1.0 per 100,000). If recent incidence trends continue, the annual number of HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical cancers by the year 2020.
Increases in the population-level incidence and survival of oropharyngeal cancers in the United States since 1984 are caused by HPV infection.
Background:
To report our experience of postoperative hemorrhage in patients following transoral robotic surgery (TORS).
Methods:
Data was collected on patients having TORS. Postoperative hemorrhage within 30 days was graded using the Mayo clinic grading system.
Results:
TORS operations were performed on 122 patients. There were 23 bleeding events classified as minor to severe following 19 operations (16%). Hemorrhage requiring a return to the operating room occurred after 7 operations (6%). The odds of an emergent hemorrhage was 5.19 times greater in patients that had a staged neck dissection after TORS (p= 0.05). The odds of a postoperative bleeding event were 2.6 times greater in patients receiving a larger resection (p=0.107). There were no hemorrhage events in the 36 patients who received a synchronous neck dissection with transcervical ligation of the external carotid artery.
Conclusions:
Surgical intervention for TORS hemorrhage occurred in 6% patients. No haemorrhage occurred in patients who had ligation of the external carotid artery. This article is protected by copyright. All rights reserved.
Objective:
To assess the incidence of first bite syndrome (FBS) in transoral robotic surgical (TORS) patients undergoing transcervical arterial ligation.
Methods:
Retrospective case series of all patients diagnosed with FBS following prophylactic transcervical arterial ligation of branches of the external carotid system between March 2010 and December 2016 at a single academic center.
Results:
Six patients with FBS after TORS with transcervical arterial ligation were evaluated, representing 7% of all patients who underwent neck dissection with concomitant transcervical arterial ligation (6 of 83). Median presentation of FBS was 63 days, with an average duration of 66 days. Treatment ranged from observation to botulinum toxin injection.
Conclusion:
Patients who undergo transcervical arterial ligation to minimize bleeding complications following TORS are at risk of developing first bite syndrome.
Level of evidence:
4. Laryngoscope, 2017.
Background:
The value of transcervical arterial ligation during transoral robotic surgery (TORS) as a measure to decrease postoperative bleeding incidence or severity is unclear.
Methods:
A retrospective single institution study was performed to identify risk factors for hemorrhage after TORS for oropharyngeal squamous cell carcinoma (SCC).
Results:
Overall, 13.2% of patients (35/265) experience postoperative hemorrhage. T classification, perioperative use of anticoagulants, surgeon experience >50 cases, and tumor subsite were not predictors of postoperative hemorrhage. Of this cohort, 28% underwent prophylactic arterial ligation. The overall incidence of bleeding was not significantly decreased in patients who underwent arterial ligation (12.1% vs 13.6%; p = .84). However, arterial ligation significantly reduced the incidence of major and severe bleeding events (1.3% vs 7.8%; p = .04). Radiation before TORS was a risk factor for major and severe postoperative hemorrhage (p < .02).
Conclusion:
Transcervical arterial ligation during TORS may reduce the severity of postoperative hemorrhagic events. © 2017 Wiley Periodicals, Inc. Head Neck, 2017.
Background
Transoral robotic-assisted surgery (TORS) is increasingly utilized in the treatment of oropharyngeal squamous cell carcinoma (OPSCC). Postoperative bleeding is a significant and potentially fatal complication of TORS. Prophylactic ligation of ipsilateral external carotid artery (ECA) branches is a recognized strategy to reduce postoperative bleeding risk. We examined the incidence and sequelae of postoperative oropharyngeal bleeding with and without routine ECA ligation.
Methods
OPSCC patients treated with TORS between 2010 and 2015 with minimum 30 days follow up were included. Clinicopathological data, operative details, and postoperative course were abstracted for analysis. Cases of postoperative bleeding were classified as Minor, Intermediate, Major, and Severe. The incidence and severity of bleeding was compared between patients treated with and without prophylactic ECA ligation.
Results
Bleeding after TORS was documented in 13/201 (6.5%) patients. The majority of bleeding episodes were observed among anticoagulated or previously radiated patients. By surgeon preference, 52 patients had prophylactic ECA ligation during neck dissection while the remaining 149 patients did not. There was no significant difference in overall incidence of postoperative bleeding between patients with prophylactic ECA ligation (3/52, 5.8%) and patients without (10/149, 6.7%) [p = 0.53]. However, severe bleeding complications (4, 2.0%) were only observed in patients without prophylactic ligation.
Conclusion
A small but meaningful risk of bleeding after TORS for OPSCC exists, particularly among anticoagulated or previously radiated patients. Prophylactic ECA ligation did not significantly impact the overall incidence of postoperative bleeding but may reduce the risk of severe (life-threatening) bleeding.
Objective
Outcomes of concurrent versus staged neck dissection with transoral robotic surgery have not been studied. This study compares outcomes of concurrent versus staged transoral robotic surgery and neck dissection.
Design
Retrospective administrative database analysis.
Setting
Article 28 licensed inpatient and outpatient care facilities in New York State.
Subjects/Methods
Adults undergoing transoral robotic surgery with staged or concurrent neck dissection from 2008 to 2014 were identified in the New York Statewide Planning and Research Collaborative System database. We compared complications, readmissions, subsequent procedures, and length of stay for concurrent versus staged procedures with multivariable logistic regression and multiple linear regression models.
Results
Of the 425 patients undergoing transoral robotic surgery and neck dissection, 333 had concurrent procedures, and 92 had staged. Risk-adjusted length of stay for concurrent procedures was 42.3% less than that of staged procedures ( P < .0001). Neck dissection timing was not associated with postoperative complications ( P = .41), readmissions ( P = .67), or additional procedures, including reconstruction, tracheostomy, or gastrostomy ( P = .17, .84, .82, respectively). Bleeding (7.8%) was the most common complication, and the majority (78.8%) required reoperation. Bleeding or surgical error was not associated with either concurrent or staged surgery (concurrent vs staged: adjusted odds ratio, 0.68; 95% CI, 0.35-1.37; P = .26).
Conclusions
Concurrent and staged procedures are equivalent with respect to adverse events, but length of stay is shorter for concurrent procedures. Cost and clinical benefits associated with length of stay are unknown, and it is reasonable to allow operator preference and patient factors to determine surgical logistics.
Surgery with transoral robotic surgery (TORS) offers significant advantages compared with traditional open surgical approaches and potentially minimizes the long-term side effects of organ preservation therapy with chemoradiation. Angled telescopes and wristed instruments allow visualization and access to areas of the pharynx that are difficult to reach with line-of-sight instrumentation. Although the application of TORS in head and neck surgery has expanded considerably, there are still only limited data available on the postoperative complications and their management. As further data become available, it is likely that further risk factors and treatment strategies will become available.
Objective:
With the emergence of transoral robotic approaches, head and neck surgeons are faced with an unfamiliar inside-out head and neck anatomy. This study was performed to describe key anatomic landmarks and surgical considerations of transoral robotic resection of the lateral oropharyngeal wall, the parapharyngeal space, and the base of the tongue.
Study design:
Descriptive transoral anatomic study.
Setting:
Academic anatomy laboratory and tertiary academic hospital.
Subjects and methods:
Transoral dissections of the lateral pharyngeal wall, base of tongue, and parapharyngeal space were performed in 5 vascular silicone-injected cadavers to illustrate anatomic landmarks from the inside-out perspective. Lateral neck dissections were also performed to better appreciate the anatomic structures and to be more familiar with intraoperative anatomy.
Results:
The neurovascular and muscular structures located in parapharyngeal space, lateral oropharyngeal wall, and base of tongue were described. Surgical significance of key anatomic landmarks was emphasized with high-quality illustrations.
Conclusion:
A thorough understanding of transoral anatomy is crucial to perform transoral robotic surgery safely and efficiently. To understand inside-out anatomy of base of tongue, lateral oropharyngeal wall, and parapharyngeal space, cadaveric dissection is highly beneficial and may help to shorten the learning curve for transoral robotic dissections.
Background Transoral robotic-assisted surgery (TORS) carries a small, but not insignificant, risk of life-threatening post-surgical hemorrhage. The aim of this study was to analyze all post-TORS hemorrhagic events at our institution to establish preventative recommendations. Methods Retrospective review of 224 consecutive patients who underwent TORS for any indication at a single tertiary care institution. Results Twenty-two patients (n=22, 9.82%) had varying degrees of post-operative bleeding. An impaired ability to protect the airway at the time of hemorrhage increased the rate of severe complications. Prophylactic transcervical arterial ligation did not significantly decrease overall post-operative bleeding rates (9.1% vs. 9.9%, p=1.00); however, there was a trend towards decreased hemorrhage severity in prophylactically ligated patients (3.0% vs. 7.3%, p=.7040). Conclusion Prophylactic transcervical arterial ligation may reduce the incidence of severe bleeding following TORS. Post-TORS patients displaying an inability to protect the airway should be strongly considered for prophylactic tracheostomy to assist airway protection. This article is protected by copyright. All rights reserved.
© 2015 Wiley Periodicals, Inc.
The literature is scarce regarding transoral robotic surgery (TORS) with simultaneous neck dissection. This study evaluates the safety and efficacy of concurrent neck dissection in oropharyngeal squamous cell carcinoma (SCC) treated with TORS.
Analysis of 113 patients with oropharyngeal SCC treated with TORS and concurrent neck dissection.
Six intraoperative communications between pharynx and neck region were recognized. After pharyngeal mucosal flap advancement, one defect was closed primarily and another one was reinforced with acellular dermal matrix. In one case, submandibular gland was transposed posteriorly over the sutured defect as a support. One omohyoid and two digastric muscular pedicle rotation flaps were used in the remaining 3 patients for the reconstruction of pharyngeal communications. None of the patients developed postoperative pharyngocutaneous fistula.
Advantage of TORS oropharyngectomy, when compared to open approaches, is the avoidance of pharyngocutaneous fistula even in the presence of concurrent neck dissection. This article is protected by copyright. All rights reserved.
© 2015 Wiley Periodicals, Inc.
Objective:
Assessment of incidence, risk factors, management, and outcome of postoperative hemorrhage after transoral oropharyngectomy for cancer of the lateral oropharynx.
Methods:
Retrospective review of a cohort of 514 cancers of the lateral oropharynx consecutively resected.
Results:
Incidence of postoperative hemorrhage was 3.6%. In 31.5% of cases, onset was after hospital discharge. No hemorrhages occurred after the end of the fourth postoperative week. Variables associated with increased risk of hemorrhage were advanced age (P=.004), antithrombotic treatment (P=.012), and robotic assistance (P=.009). When the source of hemorrhage could be identified, hemostasis, performed transorally in most cases, was highly effective; no patients in this subgroup showed recurrence. In spontaneously resolved hemorrhage under observation or when no active site of bleeding was found on exploration under general anesthesia, the recurrence rate was 18.1%. Overall, hemorrhage resulted in death in 2 patients.
Conclusion:
Exploration under general anesthesia in case of active bleeding and observation with discussion of arterial exploration of the ipsilateral external carotid system in patients in whom no source of bleeding can be identified are the keys to successful management of this potentially lethal complication.
Background:
This is a single-institution prospective study in a tertiary care center to evaluate feasibility, completeness of resection, and functional outcomes for oropharyngeal squamous cell carcinoma (SCC) treated primarily with transoral robotic-assisted resection.
Methods:
Thirty-five patients with T1 and T2 squamous cell carcinoma of the oropharynx were included. They underwent transoral robotic surgery (TORS) between September 2011 and April 2013, with a median follow-up time of 13 months.
Results:
Main outcome measures were completeness of resection, disease-free survival, and cancer recurrence for the preliminary oncologic outcome; postoperative bleeding, number of days intubated, rate of elective tracheotomy, duration of intensive care and/or intermediate care, speech and swallowing function, and length of nasogastric and/or gastrostomy tube dependency for the functional results.
Conclusion:
Our 1-year (median) functional and early oncologic results of 35 patients with oropharyngeal cancer treated primarily with TORS are encouraging to continue gaining further experiences with this surgical modality on a select subgroup of patients. © 2014 Wiley Periodicals, Inc. Head Neck, 2014.
Objectives/hypothesis:
Determine revisits and reasons for revisits after adult tonsillectomy.
Study design:
Cross-sectional analysis of multistate ambulatory surgery and hospital databases.
Methods:
Ambulatory adult tonsillectomies performed as the sole procedure were extracted from the State Ambulatory Surgery databases for New York, Florida, Iowa, and California for 2010. Cases were linked to the State Emergency Department databases and the State Inpatient databases for visit encounters occurring 0 to 14 days after tonsillectomy. The number of revisits (including readmissions) was determined as well as the reason for revisit categorized as post-tonsillectomy bleeding, acute pain, or fever/dehydration. The overall rate of occurrence of and intervention rate for post-tonsillectomy bleeding was determined.
Results:
A total of 7,748 adult tonsillectomies were examined (mean age, 29.2 years; 64.4% female). Overall, 11.6% of patients had a revisit after tonsillectomy (9.6% revisited the ambulatory surgery center, 78.8% the emergency department, and 11.6% to inpatient admission). The primary diagnoses at the first revisit were bleeding (41.3%), acute pain (22.1%), and fever/dehydration (13.2%). Overall, 2.1% of patients incurred a second revisit after adult tonsillectomy (10.7% of these to inpatient admission). Among all tonsillectomies, 4.8% of adult tonsillectomies presented with a bleeding diagnosis at a first revisit. Overall, 2.2% underwent a procedure to control bleeding at a first revisit.
Conclusions:
The current data quantify at a multistate level revisits, revisit diagnoses, and procedural rates for post-tonsillectomy bleeding in the adult population. Interventions to offset revisits for acute pain and fever/dehydration should be explored to decrease adult tonsillectomy morbidity.
Level of evidence:
2b.
Importance
With an increasing incidence of oropharyngeal carcinoma and prevalence of transoral surgical techniques, postoperative bleeding, with its associated risk factors, deserves evaluation.
Objective
To classify and review postoropharyngectomy hemorrhage rates and associated risk factors.
Design, Setting, and Participants
Single-institution, multicenter retrospective medical chart review analyzing surgical procedures in 906 patients treated with transoral surgery for oropharyngeal carcinoma at a tertiary care, academic referral center from 1994 to 2012. Tumor stage, previous treatment, resection method, and transcervical external carotid branch ligation were analyzed in relationship to postoperative hemorrhage rate, and severity. A novel classification system was created, grading bleeding episodes as minor, intermediate, major, or severe based on management method and related sequelae.
Results
Postoperative bleeding occurred in 5.4% of patients (49 of 906) with 67.3% of these (33 of 49) requiring operative intervention. Severe bleeding episodes were very rare (1.1% of patients). Transcervical external carotid system vessel ligation was performed with the primary resection in 15.6% of patients with no overall difference in bleeding rate or severity of bleeding in patients who underwent ligation vs those who did not (P = .21 and P = .66, respectively). Vessel ligation was performed more frequently in patients with a higher T stage (P = .002). In previously treated patients, severity of bleeding was decreased if vessels were ligated (P > .05). Higher T-stage tumors had a higher bleeding rate (P = .02). Bleeding rates were similar between those treated with laser (5.6%) and robotic (5.9%) oropharyngectomy (P = .80); however, patients with significantly higher T-stage tumors were treated with laser vs robot techniques (P < .001).
Conclusions and Relevance
Transoral resection of oropharyngeal carcinoma is safe, and severe life-threatening hemorrhage is rare. Although transcervical vessel ligation did not result in an overall decrease in bleeding rate, there is a trend toward reduced postoropharyngectomy bleeding severity with ligation. We recommend ligation for higher T-stage tumors, primary tonsil tumors, and patients undergoing revision surgery.
Objective
To investigate surgeon preferences for perioperative management of transoral robotic surgery (TORS) and explore the frequency of postoperative complications.Study DesignRetrospective survey.SettingMulti-institutional.Subjects and Methods
An electronic survey was sent to over 300 TORS-trained surgeons in the United States identified by Intuitive Surgical, Inc. Participation was voluntary and solicited by email invitations to participate 3 times over a 1-month period.ResultsA total of 2015 procedures were reported by 45 respondent TORS-trained surgeons: 67% academic, 33% nonacademic. A minority of TORS procedures (n = 214, 10.6%) were performed on previously irradiated patients. Neck dissections were performed concurrently (58%) or staged (42%). Fewer than 6% of TORS procedures required tracheotomy or reconstruction. Most surgeons (62%) initiated oral intake on postoperative day 0-1. Of the patients who required readmission, bleeding (n = 62, 3.1%) was the most common cause followed by dehydration (n = 26, 1.3%). Other complications of surgery included tooth injury (n = 29, 1.4%), percutaneous endoscopic gastrostomy (PEG) dependency >6 months (n = 21, 1.0%), temporary hypoglossal nerve injury (n = 18, 0.9%), and lingual nerve injury (n = 11, 0.6%). A total of 6 deaths (0.3%) were reported within 30 days of TORS. All reported deaths were due to postoperative hemorrhage. The complication rate decreased significantly with higher surgeon case volume (>50 cases).ConclusionsTORS is associated with a low major complication rate, early initiation of oral intake, and a low rate of long-term PEG dependency. Postoperative hemorrhage was the most common cause of hospital readmission and postoperative mortality.
Importance
Because treatment for oropharyngeal squamous cell carcinoma (OPSCC), especially in patients of older age, is associated with decreased patient quality of life (QOL) after surgery, demonstration of a less QOL-impairing treatment technique would improve patient satisfaction substantially.Objective
To determine swallowing, speech, and QOL outcomes following transoral robotic surgery (TORS) for OPSCC.Design, Participants, and Setting
This prospective cohort study of 81 patients with previously untreated OPSCC was conducted at a tertiary care academic comprehensive cancer center.Interventions
Primary surgical resection via TORS and neck dissection as indicated.Main Outcomes and Measures
Patients were asked to complete the Head and Neck Cancer Inventory (HNCI) preoperatively and at 3 weeks as well as 3, 6, and 12 months postoperatively. Swallowing ability was assessed by independence from a gastrostomy tube (G-tube). Clinicopathologic and follow-up data were also collected.Results
Mean follow-up time was 22.7 months. The HNCI response rates at 3 weeks and 3, 6, and 12 months were 79%, 60%, 63%, and 67% respectively. There were overall declines in speech, eating, aesthetic, social, and overall QOL domains in the early postoperative periods. However, at 1 year post TORS, scores for aesthetic, social, and overall QOL remained high. Radiation therapy was negatively correlated with multiple QOL domains (P < .05 for all comparisons), while age older than 55 years correlated with lower speech and aesthetic scores (P < .05 for both). Human papillomavirus status did not correlate with any QOL domain. G-tube rates at 6 and 12 months were 24% and 9%, respectively. Greater extent of TORS (>1 oropharyngeal site resected) and age older than 55 years predicted the need for a G-tube at any point after TORS (P < .05 for both).Conclusions and Relevance
Patients with OPSCC treated with TORS maintain a high QOL at 1 year after surgery. Adjuvant treatment and older age tend to decrease QOL. Patients meeting these criteria should be counseled appropriately.
Objective
An increasing number of head and neck surgeons have begun using transoral robotic-assisted surgery. Our objective was to examine the postoperative bleeding complications we have encountered to determine risk factors and to discuss the topic of hemorrhage control.Study DesignCase series with chart review.Methods
Medical records were reviewed in 147 consecutive patients undergoing transoral robotic-assisted surgery for any indication at one tertiary academic medical center between March 2007 and September 2011.ResultsEleven of 147 (7.5%) patients undergoing transoral robotic-assisted surgery experienced some degree of postoperative hemorrhage, with 9 patients requiring reoperation for examination and/or control of bleeding. Bleeding occurred at a mean of 11.1 ± 9.2 days after initial operation. Eight of 11 (72%) patients who bled were on antithrombotic medication (anticoagulants or antiplatelet agents) for other medical comorbidities. The postoperative hemorrhage rate in patients taking antithrombotic medication (8/48 patients = 17%) was significantly higher than in those not taking antithrombotics (3/99 patients = 3%), P = .0057. While the bleeding rate in salvage surgery (3/29 = 10.3%) was slightly higher than in primary surgery (8/118 = 6.8%), this difference did not reach statistical significance.Conclusion
Potential for postoperative bleeding in association with antithrombotic medications in patients undergoing transoral robotic-assisted surgery should be recognized. Various effective techniques for management of these patients without robotic assistance were demonstrated.
Human papillomavirus (HPV)-associated oropharyngeal carcinoma has become the predominate cause of oropharyngeal carcinoma in the United States and Europe. Management of this disease is controversial. Traditional open surgical techniques gave way to concurrent chemoradiotherapy following several American and European organ-preservation trials suggesting that both modalities were equally efficacious. More recently, minimally invasive surgical techniques have gained popularity. These techniques provide an opportunity to achieve a complete surgical resection without the treatment-related morbidity associated with open surgery. Proponents of this technique contend that transoral surgical techniques provide a means to analyze the tumor tissue, prognosticate, and personally direct therapy. Skeptics suggest that HPV-associated oropharyngeal carcinoma responds well to chemoradiotherapy and that surgery may not provide a treatment advantage. Both approaches provide a unique perspective and both are currently being studied under trial.
Our objective was to determine the safety, feasibility, and the adequacy of surgical margins for transoral robotic surgery (TORS), by reviewing the early results from independent institutional review board-approved clinical trials in three separate institutions.
Pooled Data from Independent Prospective Clinical Trials.
One hundred ninety-two patients were initially screened, but inadequate exposure did not permit TORS in 13 (6.7%). For two additional patients, TORS was begun but intraoperatively converted to an open procedure. Thus, the intent-to-treat population was 177 patients (average age, 59 years; 81% male), predominantly comprised of tumors arising in the oropharynx (139, 78%) and larynx (26, 15%). TORS was performed for 161 (91%) patients with malignant disease: 153 (95%) with squamous cell carcinoma (T1 [50, 32.7%], T2 [74, 48.4%], T3 [21, 13.7%], T4 [8, 5.2%]), six patients (3.72%) with salivary gland tumors, and two patients with carcinoma in situ. The average follow-up was 345 days.
There was no intraoperative mortality or death in the immediate postoperative period. Average estimated blood loss was 83 mL; no patient required transfusion. The rate of positive margins was 4.3%. Twenty-nine patients (16%) experienced 34 serious adverse events that required hospitalization or intervention (grade 3) or were considered life threatening (grade 4, 2.3%). Tracheostomy was performed in 12.4% of all patients (22/177), but only 2.3% had a tracheostomy at last follow-up. For all patients undergoing TORS without previous therapy, the percutaneous endoscopic gastrostomy dependency rate was 5.0%. The average hospital stay was 4.2 days.
Based on this multicenter study, TORS appears to be safe, feasible, and as such play an important role in the multidisciplinary management of head and neck cancer.
Transoral robotic surgery provides a mechanism to approach tumors of the upper aerodigestive tract through a natural body orifice--the mouth. The technique has been applied most often to malignant tumors of the oropharynx. The use of this technique, however, forces the surgeon to view the anatomy from a different vantage point. Head and neck surgeons are accustomed to the oropharynx from lateral to medial. The transoral approach forces surgeons to consider the anatomy from the oral cavity and oropharynx medial perspective. This article will discuss the relevant anatomy, operative goals, robotic technique, and clinical considerations of transoral robotic surgery of the oropharynx.
1) Determine the incidence of pharyngocutaneous fistula associated with transoral robotic oropharyngectomy with concurrent neck dissection. 2) Discuss prevention and treatment of pharyngocutaneous fistulization as a consequence of transoral oropharyngeal surgery with concurrent neck dissection.
Retrospective, single-institution chart review of 148 consecutive patients who underwent transoral robotic surgery with synchronous neck dissection for oropharyngeal neoplasia April 2007 to February 2010.
Forty-two of 148 (29%) patients were identified as having an orocervical communication intraoperatively. All were managed with some combination of primary closure, local tissue advancement, fibrin glue application, and cervical drain placement. Of these, six (4%) developed a subcutaneous pharyngeal fluid accumulation requiring postoperative management via controlled incision and drainage with daily packing placement. All the patients had aesthetic and functional results comparable to those patients who did not have/develop an orocervical communication. No patients experienced a delay from their operative treatment that prevented them from initiating recommended adjuvant therapy on schedule.
Transoral robotic surgery is emerging as a primary treatment modality for oropharyngeal malignancies. Neck dissection is a required portion of operative therapy in many of these patients, and many surgeons delay neck dissection to prevent pharyngocutaneous fistula. Pharyngeal communication with the neck is a common occurrence during transoral surgery when it is combined concurrently with neck dissection, but persistent fistula formation is an uncommon, preventable, but potentially problematic, complication resulting from this operative technique. Prompt recognition and intervention are of paramount importance in preventing acute, long-term functional impairment.
To assess toxicities, functional outcomes, and health-related quality of life associated with concurrent chemoradiation therapy (CRT) in patients with head and neck cancer.
Prospective and retrospective outcomes study.
Tertiary care institution.
Participants in the longitudinal Outcomes Assessment Project whose head and neck cancer was treated with CRT between February 1, 2000, and March 1, 2007 (n = 104).
Patients prospectively provided functional and health-related quality of life information, including data from the 1-year and most current follow-up visits. Medical records were reviewed to determine toxicity and survival rates.
Well-defined acute and late toxicities; functional outcomes (diet, dentition, tracheostomies); head and neck cancer-specific, general health, and depression outcomes; and survival rates.
Most patients had oropharyngeal or laryngeal tumors (87.5%) and advanced-stage disease (75.0%). Approximately one-half had hematologic toxicities and toxicity-related treatment delays. Approximately one-quarter had neurotoxicities and/or ototoxicites, moist desquamation, pneumonia, nausea and vomiting requiring hospitalization or intravenous fluids, dehydration or malnutrition requiring hospitalization, and mild or moderate fever. Although patients receiving the current intensity-modulated radiation therapy (IMRT) protocol using the Pinnacle(3) planning system had more toxicity-related treatment delays, they had fewer toxicities and better functional and health-related quality of life outcomes compared with those receiving conventional lateral opposing-field radiation or the initial IMRT protocol using the Best nomos PEACOCK planning system.
Patients receiving CRT experience a substantial number of treatment-related adverse events, primarily affecting oropharyngeal and laryngeal function, with improvement noted for the current IMRT protocol. Improving dental prosthetic rehabilitation and including evaluations with speech and swallowing pathologists before and during treatment may enhance patient outcomes.
The Surveillance Research Program of the American Cancer Society's Department of Epidemiology and Surveillance Research reports its 33rd annual compilation of cancer frequency, incidence, mortality, and survival data for the United States.
Concurrent chemoradiotherapy (CCRT) for squamous cell carcinoma of the head and neck (SCCHN) increases both local tumor control and toxicity. This study evaluates clinical factors that are associated with and might predict severe late toxicity after CCRT.
Patients were analyzed from a subset of three previously reported Radiation Therapy Oncology Group (RTOG) trials of CCRT for locally advanced SCCHN (RTOG 91-11, 97-03, and 99-14). Severe late toxicity was defined in this secondary analysis as chronic grade 3 to 4 pharyngeal/laryngeal toxicity (RTOG/European Organisation for the Research and Treatment of Cancer late toxicity scoring system) and/or requirement for a feeding tube >or= 2 years after registration and/or potential treatment-related death (eg, pneumonia) within 3 years. Case-control analysis was performed, with a multivariable logistic regression model that included pretreatment and treatment potential factors.
A total of 230 patients were assessable for this analysis: 99 patients with severe late toxicities and 131 controls; thus, 43% of assessable patients had a severe late toxicity. On multivariable analysis, significant variables correlated with the development of severe late toxicity were older age (odds ratio 1.05 per year; P = .001); advanced T stage (odds ratio, 3.07; P = .0036); larynx/hypopharynx primary site (odds ratio, 4.17; P = .0041); and neck dissection after CRT (odds ratio, 2.39; P = .018).
Severe late toxicity after CCRT is common. Older age, advanced T-stage, and larynx/hypopharynx primary site were strong independent risk factors. Neck dissection after CCRT was associated with an increased risk of these complications.
The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses
- Wellsga Sheab
- O' Connelld