Impact of Post Operative Recovery Pathways on Peri-Operative And Oncologic Outcomes in Head and Neck Squamous Cell Carcinoma Patients

Abstract

Impact of Enhanced Recovery After Surgery protocols on short term outcomes following Laryngectomy with or without pharyngectomy An IPTW Analysis Importance Enhanced Recovery After Surgery (ERAS) protocols have demonstrated improvements in postoperative outcomes following major head and neck surgical procedures. However, their impact on patients undergoing Total Laryngectomy with or without pharyngectomy, with or without neck dissection and reconstruction procedures (TL ± P) remains unclear. Objective To assess the association of ERAS protocol implementation in patients undergoing TL ± P procedures with short-term postoperative outcomes, including length of stay (LoS), incidence of unplanned return to the operating room (RTOR) and readmission in the 30-days following TL ± P, surgical and donor site infections (SSI; DSI), and pharyngocutaneous fistula (PCF) formation, and time to initiation of enteral and oral feeds. Study Design, Participants and Setting This was a retrospective cohort study of 240 adult patients who underwent the TL ± P procedures for any indication between January 2016 and June 2023 at a single academic subspecialty hospital in the United States. Inverse probability weighted regression models were used in the analysis. Exposure This study compared a cohort of patients who underwent surgery under a site-specific Enhanced Recovery After Surgery (ERAS) protocol, implemented in June 2019, with a historical cohort of patients who received the standard Traditional Recovery After Surgery (TRAS) care. Main Outcomes and Measures The primary outcome measures were the postoperative LoS, incidence of readmission and RTOR in the first 30-days following TL ±P. The secondary outcomes were the incidence of SSI, DSI, PCF, and the time to enteral and oral feed initiation. Results Among the 240 patients who underwent TL ± P procedures (83 TRAS,157 ERAS) (Mean age 67 years, 82 % Male). The ERAS cohort did not demonstrate significant differences in LoS (ERAS Median 10 days [IQR 8 – 13] vs TRAS Median 9 days [IQR 8 – 15] ; p = 0.53), and 30-day RTOR incidence(21 % vs. 10 %; p = 0.23). ERAS was associated lower incidence of readmission within the first 30-days of TL ± P (TRAS 35 % vs ERAS 26 %; p = 0.05), fewer incidences of surgical site infections (TRAS 48 % vs ERAS 37 %; p = 0.03), with earlier enteral (TRAS : Mean 1.5 days vs ERAS : Mean 1.25 days; p = 0.002) and oral feed initiation (TRAS : Mean 17 days vs ERAS : Mean 12 days; p = 0.005), with no significant differences in the incidence of donor site infections (TRAS 7 % vs. ERAS 10 %; p = 0.17), or pharyngocutaneous fistula formation (TRAS 21 % vs ERAS 16%; p = 0.12). Conclusion/Relevance Implementation of site-specific ERAS protocols was associated with earlier enteral and oral feed initiation, fewer incidences of 30-day readmissions and SSI, but was not associated with shorter LoS, RTOR incidence, or short-term complications (DSI, and PCF). IMPACT OF ENHANCED RECOVERY AFTER SURGERY PROTOCOLS ON SURVIVAL AND PERI-OPERATIVE OUTCOMES IN HEAD AND NECK CANCER SURGERY AN IPTW WEIGHTED RETROSPECTIVE COHORT STUDY Importance Enhanced Recovery After Surgery (ERAS) protocols are widely adopted for their peri-operative benefits across multiple surgical disciplines. However, their association with long-term oncologic outcomes in head and neck squamous cell carcinoma (HNSCC), remains unexplored, especially considering the heterogeneity of tumor subsites. Objective To evaluate the association between ERAS protocols and long-term oncological outcomes, and peri-operative metrics, in patients undergoing curative-intent surgery for mucosal HNSCC. Study Design, Setting, and Participants This retrospective, single-center cohort study included 389 adult patients with histologically confirmed mucosal HNSCC of the oral cavity, oropharynx, hypopharynx, and larynx who underwent ablative and reconstructive surgery between January 2016 and August 2024 at a tertiary academic medical center. Inverse Probability of Treatment Weighting (IPTW) was use to balance the baseline characteristics between the ERAS and Traditional Recovery After Surgery (TRAS) cohorts. Intervention/Exposure Patients were assigned to either an ERAS-based postoperative care pathway (implemented institutionally in June 2019) or a TRAS pathway, determined by the date of surgery. Outcomes The main outcomes were 60-month overall survival (OS), loco-regional recurrence-free survival (LRFS), metastasis-free survival (MFS), and disease-free survival (DFS). Secondary outcomes included the rate of starting adjuvant therapy within 8 weeks, time to adjuvant treatment, length of hospital stay (LoS), and 30-day rates of readmission and return to the operating room (RTOR), incidence of surgical and donor site infections (SSI, DSI) and time to initiation of per-oral feeds. Results Of 389 patients, 294 received ERAS-based care and 95 received TRAS based care. After IPTW adjustment, baseline characteristics were well-balanced. In the analysis of the entire cohort, no significant association was observed between the ERAS pathway and evaluated survival endpoints (OS : HR 1.09; 95% CI, 0.75,1.56; p = 0.64; LRFS : HR 1.13, 95% CI: 0.76,1.68; p = 0.53; MFS: HR 1.40, 95% CI: 0.83,2.36; p = 0.19 and DFS: HR 1.05, 95% CI: 0.76,1.46; p = 0.75). However, a statistically significant interaction was identified between the recovery pathway and primary tumor site for all survival outcomes (all p 0.001). In site-specific analyses, ERAS was associated with worse survival outcomes for oral cavity cancers (OS HR 1.67; LRFS HR 1.98; MFS HR 2.64 and DFS HR 1.65; all p 0.05). In contrast, an association with improved survival was observed for patients with oropharyngeal and hypopharyngeal cancers (OS HR 0.40; LRFS HR 0.26 and MFS HR 0.30; all p 0.05, and laryngeal cancers(OS HR 0.50; LRFS HR 0.44; MFS HR 0.48 and DFS HR 0.45; all p 0.05. Perioperatively, ERAS implementation was associated with a shorter LoS (median ERAS: 10 vs. TRAS: 12 days; p = 0.05) and lower incidences of RTOR (ERAS: 15 % vs TRAS: 29%; p = 0.003). No statistically significant association was observed between the ERAS and RIOT rate (TRAS: 42% VS ERAS: 45%; p = 0.67), time to initiation of adjuvant treatment (Median - TRAS: 56 days vs ERAS 55 days; p = 0.58), 30- day readmission (TRAS: 29 % vs ERAS: 29%; p = 0.46), post-operative infections [(SSI – TRAS: 58% vs ERAS: 48%; p = 0.37); (DSI - TRAS: 20% vs ERAS: 16%; p = 0.60)] and per-oral feed initiation (Median TRAS: 15 days vs ERAS: 10 days; p = 0.83). Conclusion/Relevance In this cohort, the association between ERAS protocols and long-term oncologic outcomes in HNSCC surgery appears to be dependent on the primary tumor site. The implementation of this protocol was associated with survival benefits for patients with oropharyngeal, hypopharyngeal, and laryngeal tumors but with worse survival outcomes among patients with oral cavity cancers. These findings highlight the potential limitations of a "one-size-fits-all" ERAS approach and suggest that the relationship between recovery pathways and oncologic outcomes in HNSCC is complex and may require the development of site-specific protocols.