Head & Neck Team Studies Usefulness of SRC for Certain Surgery Patients

Janki Shah, MD, and Eric Lamarre, MD

Microvascular free flaps are frequently used for reconstruction following ablation of head and neck tumors and are one of the most common and complex procedures performed by reconstructive surgeons in the Cleveland Clinic Head & Neck Institute.

Prior to performing the surgery, our physicians do all they can to assess risk to the patient. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator (SRC) has been found to be a useful tool for counseling patients during the preoperative process.

Developed in 2013, the SRC has been available as a universal risk estimation tool for more than 1,500 unique surgical procedures across multiple subspecialties. It contains patient data on more than 1.4 million operations and associated preoperative characteristics and postoperative complications.

This surgical risk stratification tool looks at a patient’s preoperative risk factors, existing comorbidities, the type of surgery being performed and other factors. It then generates patient-specific estimates for risk of postoperative complications and length of hospital stay.
This validated, risk adjusted and outcome-based tool is designed to guide preoperative discussion and the informed consent process as we counsel patients on the risks of the surgery and any perioperative complications.

Associated with improved quality of surgical care, use of the ACS NSQIP surgical risk calculator has been shown to decrease morbidity and mortality, improve resource allocation, and limit healthcare costs on a national level. The accuracy of the calculator has been evaluated in multiple surgical subspecialties with several publications in the head and neck surgery literature.

Cleveland Clinic study takes a closer look

The purpose of our study was to assess the validity of the ACS NSQIP surgical risk calculator in predicting postoperative complications in patients undergoing microvascular head and neck reconstruction. These patients typically have many comorbidities and risk factors, such as advanced age, history of alcohol and tobacco use, and/or prior chemoradiation that is useful in the clinical decision-making process.

We performed a retrospective chart review and reviewed medical records for 320 patients who underwent head and neck reconstruction with anterolateral thigh, fibula, and radial forearm free flaps from 2012 to 2015 at Cleveland Clinic. We documented the preoperative risk factors as well as the postoperative morbidities, including pneumonia, cardiac complications, surgical site infection, venous thromboembolism, length of hospital stay, and 30-day return to operating room as tracked by NSQIP for each patient.

Once all the required preoperative variables were gathered, the ACS NSQIP SRC was used to calculate the risk of perioperative complications for all patients. The predicted outcomes for length of stay and postoperative complications were compared with the observed rates for our data. The differences in observed vs. predicted outcomes for each of the outcomes, including pneumonia, cardiac complication, venous thromboembolism, return to OR, and discharge to nursing facility, were statistically significant. This suggests that the ACS NSQIP surgical risk calculator is overall a poor predictor of risk of postoperative complications for patients undergoing head and neck free flap reconstruction.

To our knowledge, this study represents one of the largest single institution investigation assessing the accuracy of the ACS NSQIP SRC in predicting the risk of perioperative complications for head and neck microvascular reconstruction. Given that it does not account for the intrinsic complexity of microvascular surgery and for the many risk factors unique to the head and neck cancer population, it was not surprising that we found that the SRC had limited efficacy in evaluating risk of most perioperative complications for these surgical patients.

Further studies should focus on the various risk factors specific to the head and neck cancer population and development of a specialty-specific surgical risk calculator that more accurately predicts outcomes in these complex head and neck surgery patients.

Dr. Lamarre is a surgeon in the Head & Neck Institute. Dr. Shah is a fellow in the Head & Neck Institute.

References

1. American College of Surgeons National Surgical Quality Improvement Program. ACS NSQIP Surgical Risk Calculator. 2014. http://www.riskcalculator.facs .org/RiskCalculator/.

2. Arce, K., Moore, E.J., Lohse, C.M. et al, The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator does not accurately predict risk of 30-day complications among patients undergoing microvascular head and neck reconstruction. J Oral Maxillofac Surg. 2016;74:1850–1858.

3. Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013; 217(5):833-842.e3.

4. Lewis CM, Aloia TA, Shi W, et al. Development and feasibility of a specialty-specific National Surgical Quality Improvement Program (NSQIP): the head and neck-reconstructive surgery NSQIP. JAMA Otolaryngol Head Neck Surg. 2016;142:321-327.
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6. Prasad KG, Nelson BG, Deig CR, Schneider AL, Moore MG. ACS NSQIP risk calculator: an accurate predictor of complications in major head and neck surgery? Otolaryngol Head Neck Surg. 2016;155:740-742.

7. Schneider, A.L., Deig, C.R., Prasad, K.G. et al, Ability of the National Surgical Quality Improvement program risk calculator to predict complications following total laryngectomy. JAMA Otolaryngol Head Neck Surg. 2016;142:972–979.

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