Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
INTRODUCTION: Reconstruction with microvascular free tissue transfer (MFTT) is commonly performed following complex head and neck cancer (HNC) resections and allows for improved functional and aesthetic outcomes. Most postoperative complications related to flap perfusion arise from thrombotic events and impose a great burden on the patient and healthcare system. Thrombocytosis, defined as having a platelet count above 450,000 platelets/mm3, is an easy-to-measure value that may serve as a surrogate for thrombophilia. A prior analysis of the ACS-NSQIP database associated preoperative thrombocytosis with complications following MFFT procedures across various surgical subspecialties. Here, we seek to further define this risk specific to MFFT for HNC and characterize the utility of preoperative thrombocytosis as a prognostic factor for postoperative complications in this population.
METHODS: We performed a retrospective query of the 2010-2022 ACS-NSQIP database for patients who underwent MFTT reconstruction for HNC. Patients with available preoperative platelet counts were stratified into two cohorts: those with >450,000 platelets/mm3 and those with a platelet level within normal range (***– <450,000 platelets/mm3). The primary endpoints were postoperative surgical complications (superficial surgical site infection (SSI), deep SSI, organ space SSI, wound dehiscence, bleeding), medical complications, prolonged operative time (=90th percentile), prolonged length of stay (LOS) (=90th percentile), unplanned readmission, re-operation, non-home discharge, and Clavien-Dindo grade IV (CDIV) ICU-level complications. Multivariable binary logistic regression models were performed to calculate adjusted odds ratio and confidence intervals to evaluate the association between preoperative thrombocytosis and post-operative complications. R Studio Version 2023.03.1 was used to conduct all statistical analyses.
RESULTS: Of 7,365 patients (mean age 62.7 years, 68% male) who met inclusion criteria, 294 (4.0%) had documented preoperative thrombocytosis. Patients with preoperative thrombocytosis were younger (60.6 vs 62.8 years, p<0.001), more likely to be Black or African American (15% vs 8.6%, p<0.001), and more likely to have preoperative hypoalbuminemia, dyspnea on exertion, chronic obstructive pulmonary disease, wound infection, significant weight loss in the last 6 months, and congestive heart failure (p<0.05). Upon adjustment for any demographics and comorbidities significantly associated with thrombocytosis on univariable analysis, multivariable analysis found preoperative thrombocytosis to be independently associated with any surgical complication (OR 1.54, 95% CI 1.02-2.36, p=0.042) and reoperation within 30 days (OR 1.68, 95% CI 1.08-2.59, p=0.020).
CONCLUSION: Based on our large national cohort review, preoperative thrombocytosis may be a poor prognostic factor associated with surgical complications and re-operation among patients with HNC undergoing MFFT. These findings are consistent with other studies identifying elevated platelet count as a prognostic marker for adverse outcomes following microvascular reconstruction. Evaluation of this marker in the preoperative setting can help identify patients who may require additional preoperative workup, intraoperative monitoring, and careful postoperative surveillance to prevent potential complications. Further studies are needed to validate the utility of preoperative thrombocytosis as a significant preoperative risk factor and potential pharmacological, nutritional, preoperative rehabilitation methods to potentially modify this metric to mitigate postoperative risk following MFFT for HNC.