Skip to main content

Advertisement

SpringerLink
Log in

The risk of free flap revision and subsequent medical costs in patients with hypopharyngeal cancer

  • Head and Neck
  • Published:
European Archives of Oto-Rhino-Laryngology Aims and scope Submit manuscript

Abstract

Background

Few studies have examined the preoperative risks and healthcare costs related to free flap revision in hypopharyngeal cancer (HPC) patients.

Methods

A 20-year retrospective case–control study was conducted using the Chang Gung Research Database, focusing on HPC patients who underwent tumor excision and free flap reconstruction from January 1, 2001, to December 31, 2019. The impacts of clinical variables on the need for re-exploration due to free flap complications were assessed using logistic regression. The direct and indirect effects of these complications on medical costs were evaluated by causal mediation analysis.

Results

Among 348 patients studied, 43 (12.4%) developed complications requiring re-exploration. Lower preoperative albumin levels significantly increased the risk of complications (OR 2.45, 95% CI 1.12–5.35), especially in older and previously irradiated patients. Causal mediation analysis revealed that these complications explained 11.4% of the effect on increased hospitalization costs, after controlling for confounders.

Conclusions

Lower preoperative albumin levels in HPC patients are associated with a higher risk of microvascular free flap complications and elevated healthcare costs, underscoring the need for enhanced nutritional support before surgery in this population.

Level of evidence

3.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

The data cannot be shared publicly because it is owned by Chang Gung Medical Branches, and the authors do not have permission to share it. Data are available from the Department of Medical Research and Development for researchers who meet the criteria for access to confidential data. Interested researchers can request the data by applying through the following contact information: E-mail: taytay@cgmh.org.tw.

References

  1. Bradley PJ (2019) Epidemiology of hypopharyngeal cancer. Adv Otorhinolaryngol 83:1–14. https://doi.org/10.1159/000492299

    Article  PubMed  Google Scholar 

  2. Kwon DI, Miles BA (2019) Hypopharyngeal carcinoma: do you know your guidelines? Head Neck 41(3):569–576. https://doi.org/10.1002/hed.24752

    Article  PubMed  Google Scholar 

  3. Bozec A, Poissonnet G, Dassonville O, Culié D (2023) Current therapeutic strategies for patients with hypopharyngeal carcinoma: oncologic and functional outcomes. J Clin Med. https://doi.org/10.3390/jcm12031237

    Article  PubMed  PubMed Central  Google Scholar 

  4. Chang CS, Chu MW, Nelson JA, Basta M, Gerety P, Kanchwala SK, Wu LC (2017) Complications and cost analysis of intraoperative arterial complications in head and neck free flap reconstruction. J Reconstr Microsurg 33(5):318–327. https://doi.org/10.1055/s-0037-1598618

    Article  PubMed  Google Scholar 

  5. Lin Y, He JF, Zhang X, Wang HM (2019) Intraoperative factors associated with free flap failure in the head and neck region: a four-year retrospective study of 216 patients and review of the literature. Int J Oral Maxillofac Surg 48(4):447–451. https://doi.org/10.1016/j.ijom.2018.08.009

    Article  CAS  PubMed  Google Scholar 

  6. Wang KY, Lin YS, Chen LW, Yang KC, Huang WC, Liu WC (2020) Risk of free flap failure in head and neck reconstruction: analysis of 21,548 cases from a nationwide database. Ann Plast Surg. 84(1S Suppl1):S3-s6. https://doi.org/10.1097/sap.0000000000002180

    Article  CAS  PubMed  Google Scholar 

  7. Eckardt A, Meyer A, Laas U, Hausamen JE (2007) Reconstruction of defects in the head and neck with free flaps: 20 years experience. Br J Oral Maxillofac Surg 45(1):11–15. https://doi.org/10.1016/j.bjoms.2005.12.012

    Article  CAS  PubMed  Google Scholar 

  8. Xu H, Han Z, Ma W, Zhu X, Shi J, Lin D (2021) Perioperative albumin supplementation is associated with decreased risk of complications following microvascular head and neck reconstruction. J Oral Maxillofac Surg 79(10):2155–2161. https://doi.org/10.1016/j.joms.2021.04.030

    Article  PubMed  Google Scholar 

  9. Sweeny L, Rosenthal EL, Light T et al (2019) Outcomes and cost implications of microvascular reconstructions of the head and neck. Head Neck 41(4):930–939. https://doi.org/10.1002/hed.25424

    Article  PubMed  Google Scholar 

  10. Chao CY, Luo SD, Chen WC et al (2022) Effect of glycated hemoglobin A1c on the survival of patients with oral squamous cell carcinoma: a multi-institutional database cohort study. Front Oncol 12:952616. https://doi.org/10.3389/fonc.2022.952616

    Article  PubMed  PubMed Central  Google Scholar 

  11. Shao SC, Chan YY, Kao Yang YH et al (2019) The Chang Gung research database-a multi-institutional electronic medical records database for real-world epidemiological studies in Taiwan. Pharmacoepidemiol Drug Saf 28(5):593–600. https://doi.org/10.1002/pds.4713

    Article  PubMed  Google Scholar 

  12. Lin CC, Lai MS, Syu CY, Chang SC, Tseng FY (2005) Accuracy of diabetes diagnosis in health insurance claims data in Taiwan. J Formos Med Assoc 104(3):157–163

    PubMed  Google Scholar 

  13. Wu CN, Wu SC, Chen WC et al (2021) Angiotensin II receptor blockers and oral squamous cell carcinoma survival: a propensity-score-matched cohort study. PLoS ONE 16(12):e0260772. https://doi.org/10.1371/journal.pone.0260772

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Tingley D, Yamamoto T, Hirose K, Keele L, Imai K (2014) mediation: R package for causal mediation analysis. J Statist Softw. 59(5):1–38. https://doi.org/10.18637/jss.v059.i05

    Article  Google Scholar 

  15. Forner D, Williams BA, Makki FM, Trites JR, Taylor SM, Hart RD (2018) Late free flap failure in head and neck reconstruction: a systematic review. Ear Nose Throat J 97(7):213–216. https://doi.org/10.1177/014556131809700712

    Article  PubMed  Google Scholar 

  16. Crawley MB, Sweeny L, Ravipati P et al (2019) Factors associated with free flap failures in head and neck reconstruction. Otolaryngol Head Neck Surg 161(4):598–604. https://doi.org/10.1177/0194599819860809

    Article  PubMed  Google Scholar 

  17. Mijiti A, Kuerbantayi N, Zhang ZQ, Su MY, Zhang XH, Huojia M (2020) Influence of preoperative radiotherapy on head and neck free-flap reconstruction: systematic review and meta-analysis. Head Neck 42(8):2165–2180. https://doi.org/10.1002/hed.26136

    Article  PubMed  Google Scholar 

  18. Herle P, Shukla L, Morrison WA, Shayan R (2015) Preoperative radiation and free flap outcomes for head and neck reconstruction: a systematic review and meta-analysis. ANZ J Surg 85(3):121–127. https://doi.org/10.1111/ans.12888

    Article  PubMed  Google Scholar 

  19. Chen WF, Chang KP, Chen CH, Shyu VB, Kao HK (2013) Outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy for hypopharyngeal cancer after concurrent chemoradiotherapy. PLoS ONE 8(1):e53985. https://doi.org/10.1371/journal.pone.0053985

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Tan NC, Lin PY, Kuo PJ, Tsai YT, Chen YC, Nguyen KT, Kuo YR (2015) An objective comparison regarding rate of fistula and stricture among anterolateral thigh, radial forearm, and jejunal free tissue transfers in circumferential pharyngo-esophageal reconstruction. Microsurgery 35(5):345–349. https://doi.org/10.1002/micr.22359

    Article  PubMed  Google Scholar 

  21. Danan D, Shonka DC Jr, Selman Y, Chow Z, Smolkin ME, Jameson MJ (2016) Prognostic value of albumin in patients with head and neck cancer. Laryngoscope 126(7):1567–1571. https://doi.org/10.1002/lary.25877

    Article  CAS  PubMed  Google Scholar 

  22. Yen YH, Luo SD, Chen WC et al (2024) The value of the nutritional indicators in predicting free flap failure from a multicentre database. Otolaryngol Head Neck Surg. https://doi.org/10.1002/ohn.706

    Article  PubMed  Google Scholar 

  23. Bye A, Sandmael JA, Stene GB et al (2020) Exercise and nutrition interventions in patients with head and neck cancer during curative treatment: a systematic review and meta-analysis. Nutrients. https://doi.org/10.3390/nu12113233

    Article  PubMed  PubMed Central  Google Scholar 

  24. Yu J, Hong JP, Suh HP et al (2020) Prognostic nutritional index is a predictor of free flap failure in extremity reconstruction. Nutrients. https://doi.org/10.3390/nu12020562

    Article  PubMed  PubMed Central  Google Scholar 

  25. Takahara M, Iida O, Soga Y, Azuma N, Nanto S (2018) Length and cost of hospital stay in poor-risk patients with critical limb ischemia undergoing revascularization. Circ J 82(10):2634–2639. https://doi.org/10.1253/circj.CJ-18-0289

    Article  PubMed  Google Scholar 

  26. Koh HK, Tan NC, Tan BK, Ooi ASH (2019) Comparison of outcomes of fasciocutaneous free flaps and jejunal free flaps in pharyngolaryngoesophageal reconstruction: a systematic review and meta-analysis. Ann Plast Surg 82(6):646–652. https://doi.org/10.1097/sap.0000000000001776

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We appreciate the Biostatistics Center at Kaohsiung Chang Gung Memorial Hospital and the Health Information and Epidemiology Laboratory at the Chiayi Chang Gung Memorial Hospital for helping with the study design and statistics work.

Funding

The project of Kaohsiung Chang Gung Memorial Hospital, Taiwan, CORPG8L0481, supported this work. However, the funders had no role in the study design, data collection, analysis, publication decision, or manuscript preparation.

Author information

Authors and Affiliations

  1. Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong District, Kaohsiung, 83301, Taiwan

    Chun-Hsien Ho, Sheng-Dean Luo, Wei-Chih Chen & Ching-Nung Wu

  2. Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan

    Sheng-Dean Luo & Tai-Jan Chiu

  3. School of Traditional Chinese Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan

    Sheng-Dean Luo & Yao-Hsu Yang

  4. Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

    Tai-Jan Chiu & Shau-Hsuan Li

  5. Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

    Yu-Ming Wang

  6. Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

    Shao-Chun Wu

  7. Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan

    Yao-Hsu Yang

  8. Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan

    Yao-Hsu Yang

  9. Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

    Spencer Chia-Hao Kuo

  10. Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Ching-Nung Wu

  11. School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan

    Sheng-Dean Luo

Authors
  1. Chun-Hsien Ho
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sheng-Dean Luo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Wei-Chih Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tai-Jan Chiu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yu-Ming Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Shao-Chun Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yao-Hsu Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shau-Hsuan Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Spencer Chia-Hao Kuo
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ching-Nung Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization, Writing—Original Draft: C-H, H; Writing—Review and Editing, Supervision: S-D, L; Validation: W–C, C; Software, Formal analysis: S-C, W; Investigation: T-J, C; Visualization: Y-M, W; Formal analysis: Y,-H, Y; Resources: S,-H, L; Methodology: C-H, K; Project administration, Funding acquisition, Conceptualization: C,-N, W.

Corresponding author

Correspondence to Ching-Nung Wu.

Ethics declarations

Conflicts of interests

The authors declare that they have no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

405_2024_8727_MOESM1_ESM.docx

Supplementary file 1. Table S1. Reimbursement codes utilized in this study as per the National Health Insurance (NHI) in Taiwan.

405_2024_8727_MOESM2_ESM.docx

Supplementary file 2. Table S2. Comorbidity categories and corresponding ICD (International Classification of Diseases) Codes.

405_2024_8727_MOESM3_ESM.docx

Supplementary file 3. Table S3. Stratified analysis of the association between preoperative albumin level (classified by continuous value or roc cutoff) and free flap complications, based on age, primary tumor stage, and prior radiotherapy status.

405_2024_8727_MOESM4_ESM.docx

Supplementary file 4. Table S4. Unadjusted impact of various factors on hospitalization-related medical expenses (in USD) for patients with hypopharyngeal cancer undergoing free flap reconstruction post-ablation surgery.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ho, CH., Luo, SD., Chen, WC. et al. The risk of free flap revision and subsequent medical costs in patients with hypopharyngeal cancer. Eur Arch Otorhinolaryngol (2024). https://doi.org/10.1007/s00405-024-08727-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00405-024-08727-5

Keywords

Search

Navigation