Complications of long and intermediate term venous catheters in cystic fibrosis patients: A multicenter study

Background

Totally implantable venous access devices (TIVADs) or peripherally inserted central venous catheters (PICCs) are commonly used in the care of patients with cystic fibrosis (CF), but they are associated with various complications, including thrombosis, infection, and insertion site symptoms.

The blind pushing technique for peripherally inserted central catheter placement through brachial vein puncture

Objective

The objective of this study was to conduct a prospective clinical trial evaluating the technical feasibility and short-term clinical outcome of the blind pushing technique for placement of pretrimmed peripherally inserted central catheters (PICCs) through brachial vein access.

The impact of antibiotic impregnated PICC lines on the incidence of bacteremia in a regional burn center

Introduction

Peripherally inserted central catheters (PICCs) have been used increasingly in burn patients who often have decreased intravascular volumes and obtaining intravascular access for resuscitative efforts can be difficult. A potentially serious complication is bloodstream infection. The purpose of our study is to examine the impact of antibiotic impregnated PICC lines on the bacteremia rate in a regional burn center.

Methods

Consecutive patients admitted to the burn unit and receiving an antibiotic impregnated PICC line were included in the study. Baseline demographics and bacteremia rate was recorded. A retrospective chart review was then undertaken of the 30 consecutive patients admitted to the burn unit and receiving a PICC line prior to the study period.

Results

Nineteen patients were enrolled over the two-year period. The bacteremia rate for the study group was 0% compared to the 50% bacteremia rate of the retrospective control group (p = <0.001).

Conclusion

Antibiotic impregnated PICC lines decrease the bacteremia rate in our burn population. This has potential benefits for both patient morbidity and mortality as well as potential cost savings for the healthcare system.     

The Management of Cervical Lymph Nodes in Patients with Cutaneous Melanoma

Background

The aim of this study was to review the management of cervical lymph nodes in patients with cutaneous melanoma and to analyze factors influencing prognosis.

Methods

This was a retrospective cohort study of patients who had cervical node surgery at the Sydney Melanoma Unit from 1990 to 2004.

Results

Of 716 patients who met the study criteria, 339 had a sentinel node biopsy (SNB) and 396 had a neck dissection. Locoregional recurrence occurred in 27.6?% of those undergoing therapeutic neck dissection and 60?% eventually developed distant metastases. Radiotherapy was given as adjuvant treatment in 110 of the patients who had a therapeutic neck dissection (41?%), but this was not associated with improved regional control (p?=?.322). Multivariate analysis showed that nodal positivity (p?<?.001) and primary tumor ulceration (p?=?<?.027) were the most important predictors of locoregional recurrence and that primary tumor Breslow thickness (p?=?.009) and node positivity (p?=?.046) were the most important factors predicting survival. SNB-positive patients who underwent immediate completion lymphadenectomy had a 5-year survival advantage over those who had a therapeutic neck dissection for macroscopic disease (54?% vs 47?%, p?=?.028).

Conclusions

Nodal status was the most important factor predicting disease-free and overall survival in patients with melanoma of the head and neck. Adjuvant radiotherapy was not associated with better locoregional control in the non-randomized cohorts of patients in this study.     

Accidental insertion of a percutaneous venovenous cannula into the persistent left superior vena cava of a patient undergoing liver transplantation

Purpose

Persistent left superior vena cava (PLSVC) is a rare congenital vascular abnormality found in 0.3% of the general population. We report herein a rare complication involving the accidental insertion of a large bore cannula into the PLSVC during liver transplantation (LT).

Clinical features

A 63-yr-old man with primary sclerosing cholangitis presented for LT. Given the existence of a tunnelled dialysis catheter in the right internal jugular vein (IJV) and a triple lumen catheter via the left IJV, insertion of an 18 French cannula for venovenous bypass (VVB) was performed via the left IJV using the existing triple lumen cannula as a conduit for a guidewire. Upon initiation of VVB, profound systemic hypotension occurred, and liver transplantation was completed without the further use of VVB. A chest x-ray confirmed a malposition of the VVB cannula with a large left hemothorax. A mini-sternotomy was performed for removal of the VVB cannula, which was found to be inserted in the PLSVC. Retrospectively, the presence of PLSVC was not anticipated due to a normal superior vena cava and a left innominate vein, as revealed by the course of a pre-existing left internal jugular vein triple lumen catheter on a preoperative chest x-ray, and due to a normal-sized coronary sinus on preoperative echocardiography.

Conclusion

Malpositioning of a venous cannula in a PLSVC should be anticipated as one of the potential complications of vascular access via the left internal jugular vein.     

Outcome of peripherally inserted central venous catheters in surgical and medical neonates

Background/Purpose

Peripherally inserted central venous catheters (PICCs) are commonly used for neonatal vascular access. The aim of this study was to look at PICC line complication rates and possible predictors of PICC infection in a neonatal intensive care unit.

Method

This was a prospective study of 226 neonates who had PICCs on our neonatal intensive care unit between January 2006 and June 2009. Complete data was available on 218 neonates who had 294 PICC lines. Criteria for catheter-related sepsis was positive blood cultures (peripheral/central) and/or a positive catheter tip culture after removal in the presence of a clinical suspicion of line sepsis.

Results

Of 218 neonates, 132 (169 lines) were medical, and 86 (125 lines) were surgical. Our PICC line infection rate was 17 infections per 1000 catheter-days. Surgical neonates had infection rates of 24.8% compared with 18.3% of medical neonates (P < .18). The odds ratio for a PICC infection was 3.1 (95% confidence interval, 1.64-5.87) if the catheter was in situ for 9 days or more, P < .01. Coagulase-negative staphylococcus was isolated from 55 (89%) of 62 blood cultures.

Conclusions

Our PICC infection rate was 17 per 1000 catheter-days. The length of catheter stay was the only predictor of PICC infection.     

Revision rates and cumulative financial burden in patients treated with hemiarthroplasty compared to cannulated screws after femoral neck fractures

Introduction

This study compares re-operation rates and financial burden following the treatment of femoral neck fractures treated with hemiarthroplasty compared to non-displaced femoral neck fractures treated with cannulated screws.

Methods

Data was retrospectively analyzed from a prospective database at a university hospital setting on patients undergoing hemiarthroplasty after femoral neck fractures and those with non-displaced femoral neck fractures treated with cannulated screws over a 7-year period. Re-operation rates were determined and financial data was analyzed. Charges refer to amounts billed by the hospital to insurance carriers, while costs refer to financial burden carried by the hospital during treatment.

Results

There were 491 femoral neck fractures (475 patients) that underwent hemiarthroplasty (HA) and 120 non-displaced fractures (119 patients) treated with cannulated screw (CannS) fixation. Both groups had similar age, sex, Charlson co-morbidity scores, pre-operative Parker mobility scores, and 12-month mortality. There were 29 (5.9 %) reoperations in the HA group and 16 (13.3 %) in the CannS group (P = 0.007). The majority of re-operations occurred within 12 months for both groups [21/29 (72 %) HA group; 15/16 (94 %) CannS group; P = 0.13]. Average hospital charges per patient for the index procedure were higher in the HA group ($17,880 ± 745) compared to the CannS group ($14,104 ± 5,047; P < 0.001). After accounting for additional procedures related to their initial surgical fixation, average hospital charges and costs remained higher in the HA group.

Conclusion

Patients treated with hemiarthroplasty for femoral neck fractures have lower re-operation rates than patients treated with cannulated screws for non-displaced femoral neck fractures, with 80 % of re-operations occurring in the first 12 months. Hospital charges and costs to the hospital for treating patients undergoing hemiarthroplasty were higher than patients treated with cannulated screws for the index procedure alone, and after accounting for re-operations.     

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

Background

The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC).

Methods

Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score–matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness.

Results

We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P < 0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P < 0.001), and have a reencounter (17.5% versus 11.4%, P < 0.001) within 30 d of discharge. However, in the PSM cohort (n = 4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio = 3.95, 95% confidence interval: 1.45, 10.71).

Conclusions

After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.     

The McCoy levering laryngoscope in patients with limited neck extension

Purpose

The McCoy levenng laryngoscope is a modified Macintosh laryngoscope, which has a hinged tip controlled by a lever on the handle. The purpose of this study was to investigate whether the tip elevation of this laryngoscope results in better laryngeal visualization than using the Macintosh laryngoscope when the patient’s neck is fixed in the neutral position.

Methods

Fifty female patients (ASA physical status I–II) undergoing elective surgery during general anaesthesia were investigated. The patient’s neck was manually fixed in the neutral position by an assistant, and laryngeal visualization was attempted first with a size #3 Macintosh laryngoscope (Macintosh trial), and then with a size #3 McCoy levering laryngoscope with blade tip elevation (McCoy trial), and tracheal intubation was attempted. Trials of laryngeal visualization were evaluated with the Cormadc score.

Results

In the Macintosh trial, 36 of 50 (72%) patients were evaluated grade 3, and two grade 4. In most of the patients graded 2 and 3 in the Macintosh trial (70% of the grade 2 and 83% of the grade 3 cases), the laryngeal view was improved by using the McCoy levering laryngoscope. The Cormack grade in the McCoy trial was less than that in the Macintosh tnal (P < 0.01). No complications were observed during the study.

Conclusion

The McCoy levenng laryngoscope improved laryngeal visualization in patients whose neck cannot be extended.     

The use of lateral X-ray view for the diagnosis and management plan of fractured neck of femurs

Background

Fractured neck of femur is a condition where classifications, diagnosis and treatments are frequently debatable. Lateral X-ray is routinely requested but their quality is often suboptimal and they are not always clinically useful for the management plan. We assess the role of the lateral view in the management plan of fractured neck of femur.

Method

Eight orthopaedic surgeons reviewed 24 AP views of fractured neck of femur. The classification of the fracture and the proposed management plan were noted. A few days later, the lateral view of the same patients was added to the AP view and the classification/management plan was noted. Both series of results (AP only vs AP and Lat) were compared for treatment plan and classification of fracture.

Results

Lateral view does not change significantly the classification of the fracture (P = 0.0001) or the treatment plan (P = 0.007).

Conclusion

We recommend that lateral projection X-rays are requested only in cases where it is felt that the AP view is not providing enough information for the diagnosis and management plan of the fracture.     

Posterior Approach for Laparoscopic Pancreaticoduodenectomy to Prevent Replaced Hepatic Artery Injury

Background

Laparoscopic pancreaticoduodenectomy (PD) has become more popular despite its complexity and tendency for higher morbidity.1 Replaced right hepatic artery (RRHA) and replaced common hepatic artery (RCHA), both originating from the superior mesenteric artery (SMA), are the most significant and relatively common vascular anomalies in patients undergoing PD, occurring in 8.6–21 and 0.4–4.5 % of cases, respectively.2 ^, 3 An inadvertent injury to theses arteries may result in an intra- or postoperative bleeding, hepatic or bile duct ischemia, and consequent leakage or delayed stricture in the bilioenteric anastomosis.2 ^– 4 Therefore, preservation of these aberrant hepatic arteries is essential unless their resection is oncologically indicated.2 We describe a posterior approach that can be advantageous in laparoscopic PD for patients with a RRHA or RCHA.

Methods

The posterior approach was used in 81 laparoscopic PDs at the Institute Mutualiste Montsouris between 1994 and 2012.5 In brief, retropancreatic dissection is performed to complete kocherization and expose the posterolateral aspect of the SMA. The origin of the RRHA or RCHA can then be identified and dissected. After division of the pancreatic neck, the portal vein and RRHA or RCHA are separated off the pancreatic neck. In case of the RCHA, the gastroduodenal artery originating from the RCHA is divided during this dissection.

Results

The video shows a secure procedure to preserve a RCHA in laparoscopic PD by early identification and dissection of the aberrant artery via the posterior approach.

Conclusions

The posterior approach can help to prevent inadvertent RRHA or RCHA injury in laparoscopic PD.     

Morbidity of central neck dissection: primary surgery vs reoperation. Results of a case–control study

Purpose

Complication rate in reoperative central neck node surgery is one of the main arguments to favor prophylactic central neck dissection at first operation in patients with papillary thyroid carcinoma. We evaluated if reoperative central neck dissection implies an increased postoperative morbidity. Secondarily, we aimed also to verify the effectiveness of the surgical resection of reoperative central neck dissection.

Methods

Forty-one patients who underwent reoperative central neck dissection after initial thyroidectomy for papillary thyroid carcinoma between January 2008 and May 2012 were compared to 41 controls who underwent central neck dissection at initial operation.

Results

The two groups were well matched for age, sex, and pN stage (P?=?0.296, 0.199, and 1.000, respectively). Three patients had distant metastases at presentation. No significant difference was found concerning mean number of removed nodes (P?=?0.064). No significant difference was found between the reoperative and the control groups concerning transient hypocalcemia (17 vs 19, respectively) (P?=?0.901) and transient recurrent nerve palsy (2 vs 2) (P?=?0.608). Follow-up was completed in 69 out of all the included patients (85.2 %). At a mean follow-up of 33 months, two patients (2.9 %) experienced nodal recurrence.

Conclusions

Morbidity of central neck dissection is similar for primary surgery and reoperation. In high-volume centers, reoperative central neck dissection can be safely accomplished when needed, allowing to achieve locoregional control in most of patients.     

Undertreatment of Thick Head and Neck Melanomas: An Age-based Analysis

Purpose

To determine U.S. treatment patterns for pathologic staging practices in patients with thick head and neck melanomas (HNM).

Methods

Patients with thick HNM without clinical evidence of in-transit, regional, or distant metastatic spread at presentation were identified from the Surveillance Epidemiology and End Results database. Treatment trends for patients were summarized, and univariate and multivariate analyses were performed to identify associations between varying practice patterns.

Results

A total of 1,230 patients with HNM meeting the inclusion criteria were identified. Surgical staging procedures were utilized in 53.5 %, including both sentinel lymph node biopsy (37 %) and elective neck dissection (16 %). Patients undergoing a surgical staging procedure were younger (64 vs. 77 years, p < 0.001) with smaller tumors (6.3 vs. 6.6 mm, p = 0.008). The rate of occult nodal disease was 22 % in patients undergoing a surgical staging procedure. The presence of a positive regional node in this subgroup of patients was associated with a significant reduction in disease-specific (44 vs. 59 months, p < 0.001) and overall survival (40 vs. 53 months, p < 0.001) on univariate analysis. On multivariate analysis, the presence of a positive node was the most significant factor for reduced overall survival (hazard ratio 2.36, 95 % confidence interval 1.71–3.23) and disease-specific survival (hazard ratio 2.84, 95 % confidence interval 1.99–4.06).

Conclusions

Pathologic staging procedures provide independent prognostic information for patients with thick HNM. Despite this, current practice patterns demonstrate underutilization, particularly in elderly patients. Further work is needed to address the barriers to pathologic staging implementation in patients with thick HNM.     

The impact of bladder neck mucosal eversion during open radical prostatectomy on bladder neck stricture and urinary extravasation

Purpose

To determine whether the bladder neck mucosal eversion (BNM-eversion) during radical retropubic prostatectomy (RRP) reduces the risk of bladder neck stricture (BNS) and of peri-anastomotic extravasation (PAE) in postoperative cystography.

Methods

Two hundred and eleven patients with clinically localized prostate cancer underwent RRP and were prospectively randomized into patients with BNM-eversion (group I) and without BNM-eversion (group II). All patients underwent an evaluation of PAE by retrograde cystography on postoperative day?8. We assessed BNS after 6?months.

Results

Ninety-two patients with and 113 patients without BNM-eversion were included. There was no significant difference in baseline characteristics, including age, TNM-classification, Gleason score, PSA, prostate volume, and blood loss in both groups. A complete follow-up of 6?months for BNS was available for 188 patients (89.1?%). Sixteen BNS out of 188 patients were recorded, 4.7?% (n?=?4) in group I and 11.7?% (n?=?12) in group II (p?=?0.09). Data from 205 out of 211 patients were available for the evaluation of the extravasation by cystography. Peri-anastomotic extravasation was detectable in 11.96?%, (11/205) in group I and in 21.24?% (24/205) in group II (p?=?0.08).

Conclusion

BNM-eversion does not have a positive influence on the prevention of bladder neck strictures. Peri-anastomotic extravasation detected by cystography does not correlate with a formation of bladder neck stricture.     

Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL

Purpose

Interscalene brachial plexus block (interscalene block) complications usually depend on the dose administered. The objective of this study was to determine whether ultrasound-guided interscalene block with a 5-mL dose of 0.75% ropivacaine would have sufficient analgesic efficacy after shoulder arthroscopic surgery when compared with a 10-mL dose.

Methods

Patients undergoing arthroscopic rotator cuff repair surgery (n = 60) were assigned randomly to one of two groups receiving 5 mL (Group 5) or 10 mL (Group 10) of 0.75% ropivacaine. Ultrasound-guided interscalene block was performed using the in-plane technique, and general anesthesia was administered. Time to first analgesic request was recorded, and the following issues were assessed in the postanesthesia care unit at six, 12, 24, and 48 hr postoperatively: postoperative pain as determined by a visual analogue scale (VAS), patient satisfaction, hemidiaphragmatic paralysis, other block-related complications, and postoperative nausea and vomiting (PONV).

Results

There was no significant difference between groups in time to first analgesic requirement (median [interquartile range] for Group 5: 16 [12-48] hr, Group 10: 18 [12-48] hr; P = 0.907). The postoperative pain VAS score was similar in both groups. The incidence of hemidiaphragmatic paralysis on postoperative chest x-ray was 33% in Group 5 and 60% in Group 10 (P = 0.035). However, the incidences of other block-related complications, PONV, and patient satisfaction were not significantly different between groups.

Conclusion

Interscalene block performed under ultrasound guidance with 0.75% ropivacaine 5 mL showed analgesic efficacy similar to that with 0.75% ropivacaine 10 mL, but with a lower incidence of hemidiaphragmatic paralysis.     

Liver Injury Due to Chemotherapy-induced Sinusoidal Obstruction Syndrome Is Associated with Sinusoidal Capillarization

Background

Indocyanine green (ICG) retention is a validated test of hepatic function in patients with chronic liver disease. The underlying mechanism for the impairment of ICG retention in patients undergoing chemotherapy for colorectal liver metastases (CLM) remains unclear. We sought to elucidate the mechanism for impairment of ICG retention in patients with CLM.

Methods

Clinicopathologic data of 98 patients with CLM undergoing hepatectomy were analyzed. The archived nontumoral liver parenchyma bearing no CLM were immunostained with CD34 antibody to determine the sinusoidal capillarization.

Results

Of 98 patients, 80 received preoperative chemotherapy. Sinusoidal obstruction syndrome (SOS) occurred in 39 patients (39.8%). The development of SOS in patients receiving oxaliplatin-based chemotherapy was significantly higher compared to those receiving non-oxaliplatin-based chemotherapy (P?=?0.003). SOS was independently associated with abnormal ICG retention rate at 15 minutes (ICG-R15) (odds ratio 3.45, 95% confidence interval 1.31?C9.04, P?=?0.012) and CD 34 overexpression (odds ratio 18.76, 95% confidence interval 4.58?C76.81, P?r?=?0.707, P?r?=?0.423, P?r?=?0.629, P?r?=?0.522, P?Conclusions These results suggest that the deterioration of hepatic functional reserve due to SOS is associated with sinusoidal capillarization, indicated by CD34 overexpression within nontumoral liver parenchyma adjacent to SOS.     

Treatment for T1-2 Oral Squamous Cell Carcinoma with or Without Perineural Invasion: Neck Dissection and Postoperative Adjuvant Therapy

Background

Although perineural invasion (PNI) has been a poor prognostic factor for head and neck cancers, few studies have focused on oral squamous cell carcinoma (OSCC). The independent significance of PNI in early T1-2 OSCC and the benefit of treatment modification based on PNI status have not been assessed. This study investigated the role of PNI in T1-2 OSCC patients, with focus on the controversial issues of neck management and postoperative adjuvant therapy.

Methods

PNI status was re-reviewed under hematoxylin and eosin staining in tumors of 307 consecutive T1-2 OSCC patients. Oncologic and survival outcomes were analyzed by univariate and multivariate analyses.

Results

PNI was identified in 84 (27.4%) patients, correlating with several established poor prognostic factors. In multivariate analysis, PNI remained an independent predictor for neck metastasis, neck recurrence, and a worse 5-year disease-specific survival. Elective neck dissection contributed to a significantly better 5-year disease-specific survival only in cN0 patients with PNI-positive tumors (P?=?0.0071) but not in those with PNI-negative tumors (P?=?0.3566). In low-risk patients who were treated by surgery alone, including neck dissection, the 5-year disease-specific survival rates were almost the same in those with PNI-positive tumors and those with PNI-negative tumors (92.0 vs. 92.9%; P?=?0.9104).

Conclusions

Elective neck dissection is indicated for cN0 patients with PNI-positive tumors for the efficacy of improving disease-specific survival as well as neck control. However, low-risk PNI-positive patients who undergo neck dissection do not need postoperative adjuvant therapy, because the residual risk from PNI is minimal.     

The utility of transthoracic echocardiography to confirm central line placement: An observational study

Background

Ultrasound visualization of neck vessels is the standard method used to assist with internal jugular vein (IJV) central line placement. Nevertheless, this practice has not eliminated the risk of carotid puncture and/or inadvertent arterial cannulation. Transesophageal echocardiography (TEE) effectively verifies wire placement within the heart but is invasive and not always available. We examined the feasibility and potential utility of using transthoracic echocardiography (TTE) to verify the distal wire in the right atrium (RA) before dilation and cannulation of the IJV.

Methods

Following institutional Research Ethics Board approval and signed consent, 100 patients scheduled for elective cardiac surgery were recruited. As per standard practice at our institution, all patients were to have a central line inserted under general anesthesia with TEE visualization of the guidewire. Transesophageal echocardiography (apical or subcostal four-chamber images) was performed by one of four operators while another anesthesiologist performed central line placement. Following IJV puncture, blood was rapidly aspirated and reinjected to produce microbubbles. Subsequently, a 0.035-inch j-tipped flexible guidewire was inserted and visualized with TEE. The wire was then reinserted into the RA under TTE visualization.

Results

Overall, the RA was viewed 94% (95% confidence interval [CI] 87 to 98) of the time with TTE, and both the microbubbles and guidewire were detected 91% (95% CI 84 to 96) of the time. The subjects in whom the guidewire could not be well visualized had a higher mean body mass index (33.6 vs 28.8; P = 0.01).

Conclusions

Transesophageal echocardiography is a feasible, noninvasive, and potentially useful method to confirm appropriate placement of the guidewire before dilation and cannulation of the IJV.     

Feasibility of Preservation of the Submandibular Gland During Neck Dissection in Patients With Early-Stage Oral Cancer

Background

The impact of submandibular gland (SMG) preservation during neck dissection on the survival of patients with early-stage oral squamous-cell carcinoma (OSCC) remains undocumented.

Methods

The medical records of all patients with early-stage OSCC (stage I and II) who underwent wide excision of the primary tumor and simultaneous neck dissection between 1999 and 2006 at our facility were retrospectively reviewed.

Results

We analyzed 408 patients, including 33 patients with and 375 patients without SMG preservation. The 5-year disease-free and overall survival rates were 78.8% and 90.9% for the patients with SMG preservation and 75.4% and 90.4% for the patients without SMG preservation, and these differences were not statistically significant (P = 0.79, P = 0.99, respectively). Similar survival rates between patients with and without SMG preservation were observed in those with oral tongue squamous-cell carcinoma (SCC) and with buccal SCC. Patients with T2 OSCC with SMG preservation had significantly lower 5-year disease-free survival rate than those without SMG preservation (P = 0.02), but overall survival rates were similar between these two groups.

Conclusions

Preservation of the SMG during neck dissection may be oncologically safe in patients with T1 OSCC, but the feasibility of SMG preservation seems less clear for T2 OSCC.     

Minimum Nodal Yield in Oral Squamous Cell Carcinoma: Defining the Standard of Care in a Multicenter International Pooled Validation Study

Purpose

There is evidence to suggest that a nodal yield <18 is an independent prognostic factor in patients with clinically node negative (cN0) oral squamous cell carcinoma (SCC) treated with elective neck dissection (END). We sought to evaluate this hypothesis with external validation and to investigate for heterogeneity between institutions.

Patients and Methods

We analyzed pooled individual data from 1,567 patients treated at nine comprehensive cancer centers worldwide between 1970 and 2011. Nodal yield was assessed with Cox proportional hazard models, stratified by study center, and adjusted for age, sex, pathological T and N stage, margin status, extracapsular nodal spread, time period of primary treatment, and adjuvant therapy. Two-stage random-effects meta-analyses were used to investigate for heterogeneity between institutions.

Results

In multivariable analyses of patients undergoing selective neck dissection, nodal yield <18 was associated with reduced overall survival [hazard ratio (HR) 1.69; 95 % confidence interval (CI) 1.22–2.34; p = 0.002] and disease-specific survival (HR 1.88; 95 % CI 1.21–2.91; p = 0.005), and increased risk of locoregional recurrence (HR 1.53; 95 % CI 1.04–2.26; p = 0.032). Despite significant differences between institutions in terms of patient clinicopathological factors, nodal yield, and outcomes, random-effects meta-analysis demonstrated no evidence of heterogeneity between centers in regards to the impact of nodal yield on disease-specific survival (p = 0.663; I ² statistic = 0).

Conclusion

Our data confirm that nodal yield is a robust independent prognostic factor in patients undergoing END for cN0 oral SCC, and may be applied irrespective of the underlying patient population and treating institution. A minimum adequate lymphadenectomy in this setting should include at least 18 nodes.