Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Enhanced Recovery After Surgery (ERAS) aims to reduce perioperative stress for patients primarily by improving nutrition status, fluid management, and pain control. ERAS has been shown to reduce morbidity, shorten hospital stay, and reduce postoperative opioid use in head and neck surgery. Studies are beginning to demonstrate the association between ERAS and shorter time to adjuvant treatment (TAT) following major head and neck surgery.
Objectives: To implement ERAS protocol at our institution for patients undergoing head and neck free flap reconstruction and to analyze its efficacy in improving postoperative outcomes and reducing postoperative opioid use, hospital length of stay, and TAT.
Methods: This is a single center prospective observational quality improvement study for adults undergoing head and neck free flap reconstruction for oncologic and non-oncologic indications. Implementation of ERAS included optimizing pathways for preoperative nutrition consultation, intraoperative fluid and anesthetic management, and postoperative pain regimen. Patients in the ERAS cohort (January to December 2023) were categorized into mucosal or non-mucosal for reconstruction and compared to a historical control of patients undergoing free flap surgery in the 24 months preceding implementation of the protocol (January 2021 to December 2022). Analysis included variables such as demographics, comorbidities, disease- and surgery-specific data, postoperative outcomes including hospital length of stay, 72 hour morphine milligram equivalent opioid requirement, adjuvant therapy timing, and rates of wound complications, reoperation, emergency room visit, readmission, and mortality.
Results: In total, 426 free flaps, 181 of which in ERAS group, were included. Mean age was 66 years (range: 20-92) and 296 (69%) were male. No significant differences were found between ERAS and control for comorbidities, history of radiation, chemotherapy, or prior head and neck surgery, smoking, or alcohol use. The ERAS group had significantly higher rates of preoperative opioid use (p=0.021). For both mucosal and non-mucosal subgroups, there were no significant differences in hospital length of stay, reoperation, wound or medical complication, acute kidney injury requiring nephrology consult, return to emergency room, readmission, or mortality. ERAS patients with mucosal reconstruction required fewer opioids postoperatively (p=0.002), experienced significantly shorter TAT (mean 51 vs. 62 days; p<0.001), and had shorter treatment package time for their oncologic care (96 vs 110 days; p<0.001) compared with the historical control.
Conclusion: We demonstrate the safety of ERAS to improve pain control and the association with shorter TAT in patients with mucosal reconstruction.