TY - JOUR
AU - Matsuura,, Kazuto
AB - Abstract Background Head and neck (H&N) cancer patients are often malnourished and have diminished immunity. H&N surgery with free tissue transfer reconstruction (HNS-FTTR) is associated with a relatively high incidence of postoperative complications. Methods Associations between possible risk factors and postoperative Clavien–Dindo (C–D) grades ≥ II and ≥ IIIa wound healing- or infection-related complications, postoperative overall complications and prolonged hospital stay were investigated in 188 patients who underwent HNS-FTTR during 2014–2018. The preoperative prognostic nutritional index (PNI) was calculated using the serum albumin level and total lymphocyte count. Results C–D ≥ II and ≥ IIIa complications were seen in 66 (35.1%) and 37 (19.7%) patients, respectively. Multivariate analysis showed that (i) previous irradiation was significantly associated with C–D ≥ II wound healing- or infection-related complications and prolonged hospital stays [odds ratio (OR) 3.096 and 3.328; P = 0.007 and 0.008, respectively]; and (ii) operation time of ≥9 h 20 min was a significant risk factor for C–D ≥ IIIa wound healing- or infection-related complications, and C–D ≥ IIIa overall complications (OR 2.987 and 2.257; P = 0.021 and 0.047, respectively). (3) Only preoperative PNI ≤ 40 was associated with all occurrences of C–D ≥ II and ≥ IIIa wound healing- or infection-related complications, C–D ≥ II and ≥ IIIa overall complications, and prolonged hospital stays (OR 3.078, 2.918, 2.627, 3.132 and 3.116; P = 0.020, 0.046, 0.036, 0.023 and 0.025, respectively). Conclusions PNI, easily calculated, was the lone risk factor significantly predicting all C–D ≥ II and ≥ IIIa postoperative wound healing- or infection-related complications, C–D ≥ II and ≥ IIIa postoperative overall complications and prolonged hospital stay after HNS-FTTR. head and neck neoplasms, postoperative complications, risk factors, prognostic nutritional index Introduction Major head and neck (H&N) surgery with free tissue transfer reconstruction (HNS-FTTR) is a reliable, frequently performed surgical technique (1). Although the overall success rate of this surgical procedure is high (95–97%) (2), subsequent postoperative flap necrosis or a major fistula is a devastating development. In addition, because HNS-FTTR is a prolonged endeavor, the estimated incidence of overall postoperative complications—not restricted to major complications such as flap necrosis, major fistula, and wound infection—is reportedly 48–57% (3). Hence, if we could identify risk factors to predict such postoperative complications, a new strategy could be elucidated to reduce the number of complications associated with HNS-FTTR. H&N cancers sometimes originate from the route of food intake and other times from carcinogenesis due to excessive alcohol consumption. Therefore, H&N cancer patients are often malnourished and have already experienced significant weight loss at the start of their treatment (4). Poor nutritional status and its accompanying decreased immune function are associated with a delayed wound healing process, major postoperative complications and eventually a poor prognosis. The prognostic nutritional index (PNI) is a simple indicator of patients’ nutritional status and immune function. PNI was initially developed as an indicator of preoperative nutritional status of patients with a gastric or colorectal malignancy (5). It is calculated based on the concentration of serum albumin and the number of total lymphocytes. One study reported that patients with PNI ≤ 40 had a high complication rate and a poor prognosis. Thus, PNI ≤ 40 was reported as a contraindication to creating an anastomosis (5). A pretreatment low PNI was also reported to be associated with a poor prognosis in H&N cancer patients treated with chemoradiotherapy (6), those with nasopharyngeal cancer (7, 8) and patients with hypopharyngeal cancer treated surgically (9). However, its value for predicting postoperative complications in patients with an H&N cancer, especially those undergoing HNS-FTTR, is still unknown. We, therefore, conducted a retrospective analysis of HNS-FTTR cases at the Miyagi Cancer Center to evaluate the role of PNI in predicting postoperative complications, along with other risk factors such as a low body mass index (BMI), older age, radiotherapy history, surgery duration and bleeding volume. Patients and methods The institutional review board of the Miyagi Cancer Center approved the study protocol, which was conducted in accordance with the Helsinki Declaration. This retrospective study focused on patients with H&N cancer who underwent HNS-FTTR at Miyagi Cancer Center between January 2014 and December 2018. Among the patients in whom HNS-FTTR was performed, 188 were evaluated for the relation between possible risk factors for postoperative complications, including patients’ characteristics, PNI and duration of hospitalization. We investigated the following individual factors: sex, age, body weight, height, primary site of the cancer, operation time, blood loss volume, H&N irradiation history, albumin (g/dl), total lymphocyte count (count/mm3), postoperative hospitalization period and postoperative complications. The blood data used were those obtained at a time as close as possible to just prior to the surgery. Our records show that these data were obtained 0–48 days preoperatively (average 8 days, median 1 day). The PNI was calculated using the following formula (5). $$\begin{eqnarray*} &&10\times \mathrm{serum}\kern0.17em \mathrm{albumin}\kern0.17em \mathrm{level}\;\left(\mathrm{g}/\mathrm{dl}\right)+0.005\\ &&\,\times\ \mathrm{total}\kern0.17em \mathrm{lymphocyte}\kern0.17em \mathrm{count}\;(\mathrm{counts}/{\mathrm{mm}}^3) \end{eqnarray*}$$ The BMI was calculated as the patient’s weight (in kilograms) divided by his or her height (in meters squared). Postoperative complications were investigated according to the Clavien–Dindo (C–D) classification (10). C–D grade ≥ II was defined as the appearance of any complications and C–D grade ≥ IIIa as the appearance of severe complications. We assumed that age ≥ 70 and BMI < 18.5 kg/m2 were risk factors for postoperative complications because they were included in the Nutritional Risk Screening system (NRS2002) as described previously (11). Regarding the operation time and blood loss volume, patients with values above the overall median for each parameter were considered at high risk and those below the median at low risk. A history of preoperative irradiation—known to be the major risk factor predicting fistula formation after H&N surgery (12, 13)—was also evaluated to confirm the significance of the PNI as a comparison parameter. We then combined the negative sequelae related to wound healing (e.g. wound dehiscence, leakage, skin necrosis, reconstructed flap necrosis) and the complications related to infection (e.g. wound infection, postoperative pneumonia, sepsis). Hereafter, those combined items are referred to, as wound healing- or infection-related complications. Statistical analysis Fisher’s exact test was used for comparisons between two independent groups for each variable, and the t-test was used to compare the mean values of the two groups. Logistic regression analysis was adopted for the multivariate analysis of covariance for event occurrence. For all tests, P < 0.05 indicated significance. Results This study included 188 patients with H&N cancer who underwent HNS-FTTR during the period from January 2014 to December 2018 at our institution. The characteristics of patients are shown in Table 1. Regarding the postoperative hospital stay, it should be noted that eight patients remained hospitalized until their adjuvant postoperative radiotherapy with or without chemotherapy was completed. Table 1 Patients’ characteristics Sex .  Male 147 (78.2)  Female 41 (21.8) Age (years)  Average 64.3  Median 65 Primary site  Oral cavity 74 (39.4)  Oropharynx 37 (19.7)  Hypopharynx and cervical esophagus 60 (31.9)  Larynx 5 (2.7)  Nasal cavity and paranasal sinus 10 (5.3)  Salivary gland 2 (1.1) Operation time (h:min)  Average 9:28  Median 9:20 Blood loss (ml)  Average 263  Median 220 History of H&N irradiation  Yes 32 (17.0)  No 156 (83.0) Occurrence of C–D grade ≥ 2 complications  Yes 66 (35.1)  No 122 (64.9) Length of hospital stay after surgery (days)  Average 35  Median 24.5 Sex .  Male 147 (78.2)  Female 41 (21.8) Age (years)  Average 64.3  Median 65 Primary site  Oral cavity 74 (39.4)  Oropharynx 37 (19.7)  Hypopharynx and cervical esophagus 60 (31.9)  Larynx 5 (2.7)  Nasal cavity and paranasal sinus 10 (5.3)  Salivary gland 2 (1.1) Operation time (h:min)  Average 9:28  Median 9:20 Blood loss (ml)  Average 263  Median 220 History of H&N irradiation  Yes 32 (17.0)  No 156 (83.0) Occurrence of C–D grade ≥ 2 complications  Yes 66 (35.1)  No 122 (64.9) Length of hospital stay after surgery (days)  Average 35  Median 24.5 Results are numbers (%) of patients unless otherwise indicated. H&N, head and neck; C–D, Clavien–Dindo. Open in new tab Table 1 Patients’ characteristics Sex .  Male 147 (78.2)  Female 41 (21.8) Age (years)  Average 64.3  Median 65 Primary site  Oral cavity 74 (39.4)  Oropharynx 37 (19.7)  Hypopharynx and cervical esophagus 60 (31.9)  Larynx 5 (2.7)  Nasal cavity and paranasal sinus 10 (5.3)  Salivary gland 2 (1.1) Operation time (h:min)  Average 9:28  Median 9:20 Blood loss (ml)  Average 263  Median 220 History of H&N irradiation  Yes 32 (17.0)  No 156 (83.0) Occurrence of C–D grade ≥ 2 complications  Yes 66 (35.1)  No 122 (64.9) Length of hospital stay after surgery (days)  Average 35  Median 24.5 Sex .  Male 147 (78.2)  Female 41 (21.8) Age (years)  Average 64.3  Median 65 Primary site  Oral cavity 74 (39.4)  Oropharynx 37 (19.7)  Hypopharynx and cervical esophagus 60 (31.9)  Larynx 5 (2.7)  Nasal cavity and paranasal sinus 10 (5.3)  Salivary gland 2 (1.1) Operation time (h:min)  Average 9:28  Median 9:20 Blood loss (ml)  Average 263  Median 220 History of H&N irradiation  Yes 32 (17.0)  No 156 (83.0) Occurrence of C–D grade ≥ 2 complications  Yes 66 (35.1)  No 122 (64.9) Length of hospital stay after surgery (days)  Average 35  Median 24.5 Results are numbers (%) of patients unless otherwise indicated. H&N, head and neck; C–D, Clavien–Dindo. Open in new tab Complications of C–D grade ≥ II (C–D ≥ II) were seen in 66 patients (35.1%) with a total of 79 events. Those of C–D grade ≥ IIIa (C–D ≥ IIIa) were identified in 37 patients (19.7%). The details regarding these complications are shown in Table 2. Using a univariate analysis, we investigated the association between the incidences of C–D ≥ II and ≥ IIIa complications and risk factors such as preoperative H&N irradiation history, age ≥ 70 years, operation time ≥ 9 h 20 min, blood loss ≥ 220 ml, BMI <18.5 kg/m2, and PNI ≤ 40 (Table 3). Patients with a history of H&N irradiation tended to have C–D ≥ II postoperative complications, although without statistical significance. Operation time ≥ 9 h 20 min and PNI ≤ 40 were significantly associated with the incidence of overall C–D ≥ II and ≥ IIIa complications. We then investigated the association between the incidences of C–D ≥ II or ≥ IIIa wound healing- or infection-related complications and the risk factors. A history of H&N irradiation was significantly associated with the incidence of C–D ≥ II wound healing- or infection-related complications. Operation time of ≥9 h 20 min was significantly associated with the incidence of C–D ≥ IIIa wound healing- or infection-related complications. Only PNI ≤ 40 was significantly associated with the incidence of both C–D ≥ II and ≥ IIIa wound healing- or infection-related complications. Table 2 Postoperative complications according to the C–D classification Complications . C–D classification . Total events . Grade II . Grade IIIa . Grade IIIb . Grade IVa . Grade IVb . Grade V . . Supraventricular arrhythmia 11 0 0 0 0 0 11 Bradyarrhythmia 1 1 0 0 0 0 2 Ischemic heart disease 1 0 0 0 0 0 1 Heart failure 0 0 0 1 0 0 1 Deep vein thrombosis 1 0 0 0 0 0 1 Cerebral infarction 1(d) 0 0 0 0 0 1 Obstructive ileus 2 1 3 0 0 0 6 Pleural effusion 4 0 0 0 0 0 4 Chylothorax 0 1 0 0 0 0 1 Lymphorrhea 5 2 0 0 0 0 7 Salivary fistula 0 1 0 0 0 0 1 Postoperative bleeding 0 0 1 0 0 0 1 Wound infection 4 10 2 0 0 0 16 Wound dehiscence 2 3 2 0 0 0 7 Leakage 0 2 2 0 0 0 4 Skin necrosis 0 0 3 0 0 0 3 Reconstructed flap necrosis 0 2 3 0 0 0 5 Pneumonia 5 0 0 1 0 0 6 Sepsis 0 0 0 1 0 0 1 Total events 37 23 16 3 0 0 79 Complications . C–D classification . Total events . Grade II . Grade IIIa . Grade IIIb . Grade IVa . Grade IVb . Grade V . . Supraventricular arrhythmia 11 0 0 0 0 0 11 Bradyarrhythmia 1 1 0 0 0 0 2 Ischemic heart disease 1 0 0 0 0 0 1 Heart failure 0 0 0 1 0 0 1 Deep vein thrombosis 1 0 0 0 0 0 1 Cerebral infarction 1(d) 0 0 0 0 0 1 Obstructive ileus 2 1 3 0 0 0 6 Pleural effusion 4 0 0 0 0 0 4 Chylothorax 0 1 0 0 0 0 1 Lymphorrhea 5 2 0 0 0 0 7 Salivary fistula 0 1 0 0 0 0 1 Postoperative bleeding 0 0 1 0 0 0 1 Wound infection 4 10 2 0 0 0 16 Wound dehiscence 2 3 2 0 0 0 7 Leakage 0 2 2 0 0 0 4 Skin necrosis 0 0 3 0 0 0 3 Reconstructed flap necrosis 0 2 3 0 0 0 5 Pneumonia 5 0 0 1 0 0 6 Sepsis 0 0 0 1 0 0 1 Total events 37 23 16 3 0 0 79 Open in new tab Table 2 Postoperative complications according to the C–D classification Complications . C–D classification . Total events . Grade II . Grade IIIa . Grade IIIb . Grade IVa . Grade IVb . Grade V . . Supraventricular arrhythmia 11 0 0 0 0 0 11 Bradyarrhythmia 1 1 0 0 0 0 2 Ischemic heart disease 1 0 0 0 0 0 1 Heart failure 0 0 0 1 0 0 1 Deep vein thrombosis 1 0 0 0 0 0 1 Cerebral infarction 1(d) 0 0 0 0 0 1 Obstructive ileus 2 1 3 0 0 0 6 Pleural effusion 4 0 0 0 0 0 4 Chylothorax 0 1 0 0 0 0 1 Lymphorrhea 5 2 0 0 0 0 7 Salivary fistula 0 1 0 0 0 0 1 Postoperative bleeding 0 0 1 0 0 0 1 Wound infection 4 10 2 0 0 0 16 Wound dehiscence 2 3 2 0 0 0 7 Leakage 0 2 2 0 0 0 4 Skin necrosis 0 0 3 0 0 0 3 Reconstructed flap necrosis 0 2 3 0 0 0 5 Pneumonia 5 0 0 1 0 0 6 Sepsis 0 0 0 1 0 0 1 Total events 37 23 16 3 0 0 79 Complications . C–D classification . Total events . Grade II . Grade IIIa . Grade IIIb . Grade IVa . Grade IVb . Grade V . . Supraventricular arrhythmia 11 0 0 0 0 0 11 Bradyarrhythmia 1 1 0 0 0 0 2 Ischemic heart disease 1 0 0 0 0 0 1 Heart failure 0 0 0 1 0 0 1 Deep vein thrombosis 1 0 0 0 0 0 1 Cerebral infarction 1(d) 0 0 0 0 0 1 Obstructive ileus 2 1 3 0 0 0 6 Pleural effusion 4 0 0 0 0 0 4 Chylothorax 0 1 0 0 0 0 1 Lymphorrhea 5 2 0 0 0 0 7 Salivary fistula 0 1 0 0 0 0 1 Postoperative bleeding 0 0 1 0 0 0 1 Wound infection 4 10 2 0 0 0 16 Wound dehiscence 2 3 2 0 0 0 7 Leakage 0 2 2 0 0 0 4 Skin necrosis 0 0 3 0 0 0 3 Reconstructed flap necrosis 0 2 3 0 0 0 5 Pneumonia 5 0 0 1 0 0 6 Sepsis 0 0 0 1 0 0 1 Total events 37 23 16 3 0 0 79 Open in new tab Table 3 Univariate analysis for the association between risk factors and postoperative complications Risk factors . C–D grade ≥ 2 . C–D grade ≥ 3a . OR . 95% CI . P value . OR . 95% CI . P value . Occurrence of complications H&N irradiation history 2.120 0.956–4.701 0.067 1.789 0.749–4.073  0.222 Age ≥ 70 years 1.607 0.883–2.907 0.154 1.062 0.516–2.277 >0.999 Operation time ≥ 9 h:20 m 1.874 1.014–3.413 0.048* 2.411 1.115–5.159  0.027* Blood loss ≥ 220 ml 1.455 0.792–2.593 0.285 1.070 0.538–2.134 >0.999 BMI < 18.5 kg/m2 1.346 0.680–2.706 0.464 0.949 0.415–2.261 >0.999 PNI ≤ 40 3.180 1.365–7.404 0.006* 3.126 1.355–7.248  0.011* The occurrence of wound healing- or infection-related complications H&N irradiation history 3.421 1.471–7.449 0.007* 2.661 1.119–6.526  0.055 Age ≥ 70 years 1.441 0.716–2.995 0.353 1.263 0.547–2.910  0.676 Operation time ≥ 9 h:20 m 2.015 0.974–4.207 0.072 3.015 1.248–6.868  0.015* Blood loss ≥ 220 ml 1.384 0.677–2.750 0.472 1.085 0.514–2.330 >0.999 BMI < 18.5 kg/m2 1.763 0.778–3.800 0.194 0.891 0.346–2.278 >0.999 PNI ≤ 40 4.156 1.724–9.604 0.002* 3.128 1.311–7.946  0.022* Risk factors . C–D grade ≥ 2 . C–D grade ≥ 3a . OR . 95% CI . P value . OR . 95% CI . P value . Occurrence of complications H&N irradiation history 2.120 0.956–4.701 0.067 1.789 0.749–4.073  0.222 Age ≥ 70 years 1.607 0.883–2.907 0.154 1.062 0.516–2.277 >0.999 Operation time ≥ 9 h:20 m 1.874 1.014–3.413 0.048* 2.411 1.115–5.159  0.027* Blood loss ≥ 220 ml 1.455 0.792–2.593 0.285 1.070 0.538–2.134 >0.999 BMI < 18.5 kg/m2 1.346 0.680–2.706 0.464 0.949 0.415–2.261 >0.999 PNI ≤ 40 3.180 1.365–7.404 0.006* 3.126 1.355–7.248  0.011* The occurrence of wound healing- or infection-related complications H&N irradiation history 3.421 1.471–7.449 0.007* 2.661 1.119–6.526  0.055 Age ≥ 70 years 1.441 0.716–2.995 0.353 1.263 0.547–2.910  0.676 Operation time ≥ 9 h:20 m 2.015 0.974–4.207 0.072 3.015 1.248–6.868  0.015* Blood loss ≥ 220 ml 1.384 0.677–2.750 0.472 1.085 0.514–2.330 >0.999 BMI < 18.5 kg/m2 1.763 0.778–3.800 0.194 0.891 0.346–2.278 >0.999 PNI ≤ 40 4.156 1.724–9.604 0.002* 3.128 1.311–7.946  0.022* OR, odds ratio. *Statistically significant. Open in new tab Table 3 Univariate analysis for the association between risk factors and postoperative complications Risk factors . C–D grade ≥ 2 . C–D grade ≥ 3a . OR . 95% CI . P value . OR . 95% CI . P value . Occurrence of complications H&N irradiation history 2.120 0.956–4.701 0.067 1.789 0.749–4.073  0.222 Age ≥ 70 years 1.607 0.883–2.907 0.154 1.062 0.516–2.277 >0.999 Operation time ≥ 9 h:20 m 1.874 1.014–3.413 0.048* 2.411 1.115–5.159  0.027* Blood loss ≥ 220 ml 1.455 0.792–2.593 0.285 1.070 0.538–2.134 >0.999 BMI < 18.5 kg/m2 1.346 0.680–2.706 0.464 0.949 0.415–2.261 >0.999 PNI ≤ 40 3.180 1.365–7.404 0.006* 3.126 1.355–7.248  0.011* The occurrence of wound healing- or infection-related complications H&N irradiation history 3.421 1.471–7.449 0.007* 2.661 1.119–6.526  0.055 Age ≥ 70 years 1.441 0.716–2.995 0.353 1.263 0.547–2.910  0.676 Operation time ≥ 9 h:20 m 2.015 0.974–4.207 0.072 3.015 1.248–6.868  0.015* Blood loss ≥ 220 ml 1.384 0.677–2.750 0.472 1.085 0.514–2.330 >0.999 BMI < 18.5 kg/m2 1.763 0.778–3.800 0.194 0.891 0.346–2.278 >0.999 PNI ≤ 40 4.156 1.724–9.604 0.002* 3.128 1.311–7.946  0.022* Risk factors . C–D grade ≥ 2 . C–D grade ≥ 3a . OR . 95% CI . P value . OR . 95% CI . P value . Occurrence of complications H&N irradiation history 2.120 0.956–4.701 0.067 1.789 0.749–4.073  0.222 Age ≥ 70 years 1.607 0.883–2.907 0.154 1.062 0.516–2.277 >0.999 Operation time ≥ 9 h:20 m 1.874 1.014–3.413 0.048* 2.411 1.115–5.159  0.027* Blood loss ≥ 220 ml 1.455 0.792–2.593 0.285 1.070 0.538–2.134 >0.999 BMI < 18.5 kg/m2 1.346 0.680–2.706 0.464 0.949 0.415–2.261 >0.999 PNI ≤ 40 3.180 1.365–7.404 0.006* 3.126 1.355–7.248  0.011* The occurrence of wound healing- or infection-related complications H&N irradiation history 3.421 1.471–7.449 0.007* 2.661 1.119–6.526  0.055 Age ≥ 70 years 1.441 0.716–2.995 0.353 1.263 0.547–2.910  0.676 Operation time ≥ 9 h:20 m 2.015 0.974–4.207 0.072 3.015 1.248–6.868  0.015* Blood loss ≥ 220 ml 1.384 0.677–2.750 0.472 1.085 0.514–2.330 >0.999 BMI < 18.5 kg/m2 1.763 0.778–3.800 0.194 0.891 0.346–2.278 >0.999 PNI ≤ 40 4.156 1.724–9.604 0.002* 3.128 1.311–7.946  0.022* OR, odds ratio. *Statistically significant. Open in new tab Following the univariate analysis, we performed a multivariate analysis using a logistic regression model to examine the relation between the incidences of C–D ≥ II and ≥ IIIa overall postoperative complications or postoperative wound healing- or infection-related complications and the aforementioned risk factors (Table 4). Previous irradiation and PNI ≤ 40 were significantly associated with C–D ≥ II wound healing- or infection-related complications. Operation time of ≥9 h 20 min was significantly associated with the incidence of both C–D ≥ IIIa overall complications and C–D ≥ IIIa wound healing- or infection-related complications. PNI ≤ 40 alone was a significant risk factor for the incidence of all postoperative overall C–D ≥ II and ≥ IIIa complications and for postoperative C–D ≥ II and ≥ IIIa wound healing- or infection-related complications. Table 4 Multivariate analysis for the association between risk factors and postoperative complications Risk factors . C–D grade ≥ 2 . C–D grade ≥ 3a . OR . 95% CI . P value . OR . 95% CI . P value . Occurrence of complications . H&N irradiation history 1.913 0.849–4.309 0.118 1.640 0.646–4.163 0.298 Age ≥ 70 years 1.855 0.951–3.620 0.070 1.028 0.456–2.314 0.947 Operation time ≥ 9 h:20 m 1.707 0.883–3.302 0.112 2.257 1.009–5.049 0.047* Blood loss ≥ 220 mL 1.419 0.740–2.723 0.293 0.892 0.411–1.936 0.773 BMI < 18.5 kg/m2 1.093 0.483–2.472 0.830 0.556 0.198–1.617 0.288 PNI ≤ 40 2.627 1.068–6.462 0.036* 3.132 1.173–8.360 0.023* The occurrence of wound healing- or infection-related complications H&N irradiation history 3.096 1.291–7.427 0.007* 2.631 0.988–7.005 0.053 Age ≥ 70 years 1.766 0.786–3.965 0.169 1.214 0.491–2.999 0.674 Operation time ≥ 9 h:20 m 1.798 0.806–4.008 0.152 2.987 1.182–7.549 0.021* Blood loss ≥ 220 mL 1.409 0.642–3.092 0.392 0.924 0.391–2.183 0.857 BMI < 18.5 kg/m2 1.286 0.497–3.327 0.604 0.507 0.152–1.692 0.269 PNI ≤ 40 3.078 1.197–7.914 0.020* 2.918 1.017–8.371 0.046* Risk factors . C–D grade ≥ 2 . C–D grade ≥ 3a . OR . 95% CI . P value . OR . 95% CI . P value . Occurrence of complications . H&N irradiation history 1.913 0.849–4.309 0.118 1.640 0.646–4.163 0.298 Age ≥ 70 years 1.855 0.951–3.620 0.070 1.028 0.456–2.314 0.947 Operation time ≥ 9 h:20 m 1.707 0.883–3.302 0.112 2.257 1.009–5.049 0.047* Blood loss ≥ 220 mL 1.419 0.740–2.723 0.293 0.892 0.411–1.936 0.773 BMI < 18.5 kg/m2 1.093 0.483–2.472 0.830 0.556 0.198–1.617 0.288 PNI ≤ 40 2.627 1.068–6.462 0.036* 3.132 1.173–8.360 0.023* The occurrence of wound healing- or infection-related complications H&N irradiation history 3.096 1.291–7.427 0.007* 2.631 0.988–7.005 0.053 Age ≥ 70 years 1.766 0.786–3.965 0.169 1.214 0.491–2.999 0.674 Operation time ≥ 9 h:20 m 1.798 0.806–4.008 0.152 2.987 1.182–7.549 0.021* Blood loss ≥ 220 mL 1.409 0.642–3.092 0.392 0.924 0.391–2.183 0.857 BMI < 18.5 kg/m2 1.286 0.497–3.327 0.604 0.507 0.152–1.692 0.269 PNI ≤ 40 3.078 1.197–7.914 0.020* 2.918 1.017–8.371 0.046* *Statistically significant. Open in new tab Table 4 Multivariate analysis for the association between risk factors and postoperative complications Risk factors . C–D grade ≥ 2 . C–D grade ≥ 3a . OR . 95% CI . P value . OR . 95% CI . P value . Occurrence of complications . H&N irradiation history 1.913 0.849–4.309 0.118 1.640 0.646–4.163 0.298 Age ≥ 70 years 1.855 0.951–3.620 0.070 1.028 0.456–2.314 0.947 Operation time ≥ 9 h:20 m 1.707 0.883–3.302 0.112 2.257 1.009–5.049 0.047* Blood loss ≥ 220 mL 1.419 0.740–2.723 0.293 0.892 0.411–1.936 0.773 BMI < 18.5 kg/m2 1.093 0.483–2.472 0.830 0.556 0.198–1.617 0.288 PNI ≤ 40 2.627 1.068–6.462 0.036* 3.132 1.173–8.360 0.023* The occurrence of wound healing- or infection-related complications H&N irradiation history 3.096 1.291–7.427 0.007* 2.631 0.988–7.005 0.053 Age ≥ 70 years 1.766 0.786–3.965 0.169 1.214 0.491–2.999 0.674 Operation time ≥ 9 h:20 m 1.798 0.806–4.008 0.152 2.987 1.182–7.549 0.021* Blood loss ≥ 220 mL 1.409 0.642–3.092 0.392 0.924 0.391–2.183 0.857 BMI < 18.5 kg/m2 1.286 0.497–3.327 0.604 0.507 0.152–1.692 0.269 PNI ≤ 40 3.078 1.197–7.914 0.020* 2.918 1.017–8.371 0.046* Risk factors . C–D grade ≥ 2 . C–D grade ≥ 3a . OR . 95% CI . P value . OR . 95% CI . P value . Occurrence of complications . H&N irradiation history 1.913 0.849–4.309 0.118 1.640 0.646–4.163 0.298 Age ≥ 70 years 1.855 0.951–3.620 0.070 1.028 0.456–2.314 0.947 Operation time ≥ 9 h:20 m 1.707 0.883–3.302 0.112 2.257 1.009–5.049 0.047* Blood loss ≥ 220 mL 1.419 0.740–2.723 0.293 0.892 0.411–1.936 0.773 BMI < 18.5 kg/m2 1.093 0.483–2.472 0.830 0.556 0.198–1.617 0.288 PNI ≤ 40 2.627 1.068–6.462 0.036* 3.132 1.173–8.360 0.023* The occurrence of wound healing- or infection-related complications H&N irradiation history 3.096 1.291–7.427 0.007* 2.631 0.988–7.005 0.053 Age ≥ 70 years 1.766 0.786–3.965 0.169 1.214 0.491–2.999 0.674 Operation time ≥ 9 h:20 m 1.798 0.806–4.008 0.152 2.987 1.182–7.549 0.021* Blood loss ≥ 220 mL 1.409 0.642–3.092 0.392 0.924 0.391–2.183 0.857 BMI < 18.5 kg/m2 1.286 0.497–3.327 0.604 0.507 0.152–1.692 0.269 PNI ≤ 40 3.078 1.197–7.914 0.020* 2.918 1.017–8.371 0.046* *Statistically significant. Open in new tab We then proceeded to examine the associations between the hospitalization periods and those risk factors using a t-test, which found that an H&N irradiation history, the operation time of ≥9 h 20 min, and PNI ≤ 40 were associated with prolonged hospitalization (Table 5). Finally, we performed a multivariate analysis according to the median hospitalization period of 24.5 days using a logistic regression analysis. It revealed that an H&N irradiation history and PNI ≤ 40 were significant risk factors for prolonged hospitalization (Table 6). Table 5 Association between risk factors and hospitalization duration Risk factors . Hospitalization periods (days) . P value . H&N irradiation history 46.03 ± 6.657 0.0157* No irradiation history 32.97 ± 2.011 Age ≥ 70 years 39.65 ± 3.736 0.0964 Age < 70 years 32.61 ± 2.366 Operation time ≥ 9 h:20 m 41.58 ± 3.550 0.0014* Operation time < 9 h:20 m 28.68 ± 1.738 Blood loss ≥ 220 ml 36.26 ± 3.090 0.6051 Blood loss < 220 ml 34.14 ± 2.676 BMI < 18.5 kg/m2 41.83 ± 5.397 0.0809 BMI ≥ 18.5 kg/m2 33.29 ± 2.104 PNI ≤ 40 53.48 ± 7.297 <0.0001* PNI > 40 31.86 ± 1.911 Risk factors . Hospitalization periods (days) . P value . H&N irradiation history 46.03 ± 6.657 0.0157* No irradiation history 32.97 ± 2.011 Age ≥ 70 years 39.65 ± 3.736 0.0964 Age < 70 years 32.61 ± 2.366 Operation time ≥ 9 h:20 m 41.58 ± 3.550 0.0014* Operation time < 9 h:20 m 28.68 ± 1.738 Blood loss ≥ 220 ml 36.26 ± 3.090 0.6051 Blood loss < 220 ml 34.14 ± 2.676 BMI < 18.5 kg/m2 41.83 ± 5.397 0.0809 BMI ≥ 18.5 kg/m2 33.29 ± 2.104 PNI ≤ 40 53.48 ± 7.297 <0.0001* PNI > 40 31.86 ± 1.911 *Statistically significant. Open in new tab Table 5 Association between risk factors and hospitalization duration Risk factors . Hospitalization periods (days) . P value . H&N irradiation history 46.03 ± 6.657 0.0157* No irradiation history 32.97 ± 2.011 Age ≥ 70 years 39.65 ± 3.736 0.0964 Age < 70 years 32.61 ± 2.366 Operation time ≥ 9 h:20 m 41.58 ± 3.550 0.0014* Operation time < 9 h:20 m 28.68 ± 1.738 Blood loss ≥ 220 ml 36.26 ± 3.090 0.6051 Blood loss < 220 ml 34.14 ± 2.676 BMI < 18.5 kg/m2 41.83 ± 5.397 0.0809 BMI ≥ 18.5 kg/m2 33.29 ± 2.104 PNI ≤ 40 53.48 ± 7.297 <0.0001* PNI > 40 31.86 ± 1.911 Risk factors . Hospitalization periods (days) . P value . H&N irradiation history 46.03 ± 6.657 0.0157* No irradiation history 32.97 ± 2.011 Age ≥ 70 years 39.65 ± 3.736 0.0964 Age < 70 years 32.61 ± 2.366 Operation time ≥ 9 h:20 m 41.58 ± 3.550 0.0014* Operation time < 9 h:20 m 28.68 ± 1.738 Blood loss ≥ 220 ml 36.26 ± 3.090 0.6051 Blood loss < 220 ml 34.14 ± 2.676 BMI < 18.5 kg/m2 41.83 ± 5.397 0.0809 BMI ≥ 18.5 kg/m2 33.29 ± 2.104 PNI ≤ 40 53.48 ± 7.297 <0.0001* PNI > 40 31.86 ± 1.911 *Statistically significant. Open in new tab Table 6 Multivariate analysis for the association between risk factors and prolonged hospitalization periods . OR . 95% CI . P value . H&N irradiation history 3.328 1.366–8.106 0.008* Age ≥ 70 years 1.515 0.791–2.898 0.210 Operation time ≥ 9 h:20 m 1.742 0.921–3.296 0.088 Blood loss ≥ 220 ml 1.039 0.554–1.950 0.904 BMI < 18.5 kg/m2 0.910 0.410–2.020 0.816 PNI ≤ 40 3.116 1.152–8.428 0.025* . OR . 95% CI . P value . H&N irradiation history 3.328 1.366–8.106 0.008* Age ≥ 70 years 1.515 0.791–2.898 0.210 Operation time ≥ 9 h:20 m 1.742 0.921–3.296 0.088 Blood loss ≥ 220 ml 1.039 0.554–1.950 0.904 BMI < 18.5 kg/m2 0.910 0.410–2.020 0.816 PNI ≤ 40 3.116 1.152–8.428 0.025* *Statistically significant. Open in new tab Table 6 Multivariate analysis for the association between risk factors and prolonged hospitalization periods . OR . 95% CI . P value . H&N irradiation history 3.328 1.366–8.106 0.008* Age ≥ 70 years 1.515 0.791–2.898 0.210 Operation time ≥ 9 h:20 m 1.742 0.921–3.296 0.088 Blood loss ≥ 220 ml 1.039 0.554–1.950 0.904 BMI < 18.5 kg/m2 0.910 0.410–2.020 0.816 PNI ≤ 40 3.116 1.152–8.428 0.025* . OR . 95% CI . P value . H&N irradiation history 3.328 1.366–8.106 0.008* Age ≥ 70 years 1.515 0.791–2.898 0.210 Operation time ≥ 9 h:20 m 1.742 0.921–3.296 0.088 Blood loss ≥ 220 ml 1.039 0.554–1.950 0.904 BMI < 18.5 kg/m2 0.910 0.410–2.020 0.816 PNI ≤ 40 3.116 1.152–8.428 0.025* *Statistically significant. Open in new tab Discussion We investigated factors that might predict postoperative complications and prolonged hospitalization after HNS-FTTR. In our multivariate analysis, a prolonged operation time of ≥9 h 20 min was highly correlated with C–D ≥ IIIa (severe) postoperative complications. Although the mechanism has not been elucidated, it could be assumed that the prolonged operation time group included patients with more complex surgery, such as salvage operations after chemoradiotherapy, multiple reconstructive surgical procedures, reoperations and, in some cases, operations lasting as long as 18 h, suggesting that severe surgical invasiveness led to this outcome. It was clear even before the study that there was a consensus among H&N surgeons that a history of H&N irradiation was associated with a high incidence of complications in the vicinity of irradiated fields. A previous meta-analysis proved that H&N radiotherapy was correlated with postoperative flap necrosis, wound dehiscence, and fistula formation following HNS-FTTR (13). Another meta-analysis showed that a history of H&N irradiation was correlated with a high incidence of fistula formation after laryngectomy (12). Similarly, we found that H&N irradiation was highly associated with subsequent C–D ≥ II wound healing-related or infection-related complications and prolonged hospitalization. These results were consistent with the aforementioned reports. In contrast, however, our multivariate analysis indicated that a low PNI score prior to HNS-FTTR was associated with both C–D ≥ II and ≥ IIIa postoperative overall complications, wound healing- or infection-related complications, and prolonged hospitalization. However, there were no significant associations with C–D ≥ II or C–D ≥ IIIa postoperative overall complications or C–D ≥ IIIa wound healing- or infection-related complications in the histories of the H&N irradiation group. Hence, the significance of a low PNI as a risk factor for complications after HNS-FTTR was similar to or greater than that of prior H&N irradiation. There have been several reports that a low PNI is correlated with a poor prognosis in patients with various cancers (14–18). It was also reported that pretreatment of a low PNI was correlated with a poor prognosis in patients with H&N cancers treated with chemoradiotherapy (6), those with nasopharyngeal cancers (7, 8) and patients with hypopharyngeal cancer that had been treated surgically (9). Regarding the association between PNI and treatment-related complications, low PNI levels were correlated with the occurrence of serious complications in H&N cancer patients treated with chemoradiotherapy (19, 20). Nevertheless, the value of PNI as a predictor of postoperative complications after H&N cancer surgery is not well understood. The PNI was originally introduced to estimate the status of postoperative complications after gastrointestinal surgery (5) followed by several reports on how a low PNI is a predictor of postoperative complications in the presence of various types of cancer (14, 15, 21–24). As H&N cancers originate in the oral cavity, pharynx and cervical esophagus, they sometimes interfere with passage of food intake. Little food intake combined with excessive alcohol consumption and smoking are major risk factors encouraging the development of H&N cancers, which, in turn, further deteriorate patients’ nutritional status. Approximately 35–60% of all H&N cancer patients are reported to be malnourished at the time of diagnosis (25). Weight loss of >10% during the 6 months before surgery was reported to place the patient at great risk for major complications after H&N surgery (26). Thus, not only is malnutrition apparent in many H&N cancer patients at admission, it constitutes a risk factor postoperatively. Furthermore, treatment-induced toxicities would further impair the nutritional status of H&N cancer patients. In one study, malnourished patients who underwent HNS-FTTR were at greater risk of postoperative pulmonary complications, bleeding, venous thromboembolism and other postoperative complications, and they had higher 30-day mortality rates (27). Low BMI was reported to be associated with postoperative complications after H&N surgery (28, 29). BMI <18.5 kg/m2 was also included in a Nutrition Risk Screening system (NRS2002) as indicating severe status (11). In the present analysis, however, there was no significant correlation between BMI <18.5 kg/m2 and postoperative complications or prolonged hospitalization after HNS-FTTR. PNI, one of the indicators of malnutrition, is calculated based on the concentration of serum albumin and the total lymphocyte count (5). In our analysis, because a low PNI was significantly associated with the occurrence of postoperative complications and prolonged hospitalization, we once again recognized the influence of the preoperative nutritional status and immune function on the postoperative outcome. There is currently no definitive indicator of malnutrition. Preoperative weight loss of >10% during the past 6 months has been reported to be a significant risk factor (26, 30), although body weight 6 months previously as a parameter is sometimes uncertain, and it seems unlikely to be the definitive indicator. PNI, which we adopted in this study, is simply calculated from the results of routine blood tests (i.e. serum albumin and total lymphocyte count). Therefore, PNI would be a suitable surrogate for malnutrition status because of its low cost, simplicity and usefulness. We set the cutoff value of PNI at 40 in this study. PNI was originally established as the most reliable factor for predicting postoperative complications. The initial original report by Onodera et al. (5) showed that patients with PNI ≤ 40 had a high mean complication rate and that PNI ≤ 40 was a contraindication for performing anastomosis in patients with gastric or colorectal cancer. Some research on the relation between the PNI and prognosis attempted to establish a PNI cutoff value. As already noted, two reports evaluated the relation between H&N cancer treatment-related complications and PNI values, focusing not on surgery-related but chemoradiotherapy-related toxicities (19, 20). In one report, a cutoff value of 36, derived from the median value, was established (19), although PNI ≤ 36 seems unusually low. In another report (20), a cutoff value of 40, derived from the initial original report (5), was adopted. We similarly examined the risk factors of treatment-related complications, and a PNI ≤ 40 cutoff was considered appropriate in this analysis. In fact, among the 188 patients who underwent HNS-FTTR in our study, 29 (15.4%) had a PNI of ≤40, which represented the proportion of patients who were at extremely high risk postoperatively. Setting the PNI cutoff value may still be controversial, so we should properly deal with it as a future task. Malnutrition is closely associated with decreased immune function. Reduced immune function portends a worse outcome—represented by infection and fistula formation—after HNS-FTTR because of the suppressed capacity to fight postoperative infection. What should we do to improve preoperative nutritional status and hence bolster the immunity of H&N cancer patients? Introducing nutritional therapy preoperatively is essential. For that purpose, proper nutritional assessment and nutritional guidance should be conducted as early as possible during outpatient visits. Treatment-related toxicities were reduced in a reported nutritional intervention group of patients with H&N cancer (31). For enteral nutrition, immune-strengthening nutrients should be considered. Perioperative administration of a specific formula containing immune-building nutrients (composed of arginine, omega-3-fatty acids and ribonucleotides) has been recommended for malnourished patients who are to undergo major H&N surgery (30). In a systematic review of randomized control trials, reducing the duration of the postoperative hospital stay was recognized in some trials by adding immune-enhancing nutrients to the diet. The postoperative complications were reduced in that arginine-enhanced group (32). Nevertheless, at present, the superiority of immune-enhancing nutrients over standard formulas has not been determined (30, 32) and so requires in-depth studies. We also had conducted a randomized study on the effectiveness of immune-enhancing nutrients against H&N cancer patients’ treatment-related toxicities (33) and confirmed their positive effects. Therefore, we have a positive view on immune-enhancing nutrients. We believe that, as recommended by the guideline for severe risk cases (30), 10–14 days of nutritional therapy would be beneficial for patients with PNI ≤ 40 as well, and enhanced immune-enhanced nutritional therapy would be especially proper for those patients. In conclusion, we examined 188 patients retrospectively and found that preoperative PNI ≤ 40 was a significant risk factor for the occurrence of overall C–D ≥ II and ≥ IIIa postoperative complications, wound healing- or infection-related complications, and a prolonged hospital stay after HNS-FTTR. PNI is an indicator that can be easily calculated based on the results of routine blood tests. The study has the limitations of being a retrospective study with a limited number of cases, and establishing the PNI cutoff value might be controversial. We believe that our report has value, however, because there have been no reports that examined in detail the correlation between postoperative complications of HNS-FTTR and preoperative PNI. A further large-scale prospective study to reconfirm the value of PNI and a large-scale trial of immunonutritional therapy are required in the future to reduce the number of complications after HNS-FTTR. Funding No specific funding was received in support of this study. Conflict of interest statement None declared. References 1. Tanaka K , Sakuraba M , Miyamoto S , et al. Analysis of operative mortality and post-operative lethal complications after head and neck reconstruction with free tissue transfer . Jpn J Clin Oncol 2011 ; 41 : 758 – 63 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Genden EM , Rinaldo A , Suarez C , et al. Complications of free flap transfers for head and neck reconstruction following cancer resection . Oral Oncol 2004 ; 40 : 979 – 84 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Shaari CM , Buchbinder D , Costantino PD , et al. Complications of microvascular head and neck surgery in the elderly . Arch Otolaryngol Head Neck Surg 1998 ; 124 : 407 – 11 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Lees J . Incidence of weight loss in head and neck cancer patients on commencing radiotherapy treatment at a regional oncology centre . Eur J Cancer Care 1999 ; 8 : 133 – 6 . Google Scholar Crossref Search ADS WorldCat 5. Onodera T , Goseki N , Kosaki G . Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients . Nihon Geka Gakkai Zasshi 1984 ; 85 : 1001 – 5 (in Japanese) . Google Scholar PubMed OpenURL Placeholder Text WorldCat 6. Bruixola G , Caballero J , Papaccio F , et al. Prognostic nutritional index as an independent prognostic factor in locoregionally advanced squamous cell head and neck cancer . ESMO Open 2018 ; 3 : e000425 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Yang L , Xia L , Wang Y , et al. Low prognostic nutritional index (PNI) predicts Unfavorable distant metastasis-free survival in nasopharyngeal carcinoma: A propensity score-matched analysis . PLoS One 2016 ; 11 :e0158853. OpenURL Placeholder Text WorldCat 8. Du XJ , Tang LL , Mao YP , et al. Value of the prognostic nutritional index and weight loss in predicting metastasis and long-term mortality in nasopharyngeal carcinoma . J Transl Med 2015 ; 13 : 364 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Ye LL , Oei RW , Kong FF , et al. The prognostic value of preoperative prognostic nutritional index in patients with hypopharyngeal squamous cell carcinoma: a retrospective study . J Transl Med 2018 ; 16 : 12 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Clavien PA , Barkun J , de Oliveira ML , et al. The Clavien-Dindo classification of surgical complications: five-year experience . Ann Surg 2009 ; 250 : 187 – 96 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Kondrup J , Rasmussen HH , Hamberg O , Stanga Z , Ad Hoc EWG . Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials . Clin Nutr 2003 ; 22 : 321 – 36 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Paydarfar JA , Birkmeyer NJ . Complications in head and neck surgery: a meta-analysis of postlaryngectomy pharyngocutaneous fistula . Arch Otolaryngol Head Neck Surg 2006 ; 132 : 67 – 72 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Herle P , Shukla L , Morrison WA , Shayan R . Preoperative radiation and free flap outcomes for head and neck reconstruction: a systematic review and meta-analysis . ANZ J Surg 2015 ; 85 : 121 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 14. Jiang N , Deng JY , Ding XW , et al. Prognostic nutritional index predicts postoperative complications and long-term outcomes of gastric cancer . World J Gastroenterol 2014 ; 20 : 10537 – 44 . Google Scholar Crossref Search ADS PubMed WorldCat 15. Mohri Y , Inoue Y , Tanaka K , et al. Prognostic nutritional index predicts postoperative outcome in colorectal cancer . World J Surg 2013 ; 37 : 2688 – 92 . Google Scholar Crossref Search ADS PubMed WorldCat 16. Hirahara N , Tajima Y , Fujii Y , et al. Preoperative prognostic nutritional index predicts long-term surgical outcomes in patients with esophageal squamous cell carcinoma . World J Surg 2018 ; 42 : 2199 – 208 . Google Scholar Crossref Search ADS PubMed WorldCat 17. Jeon HG , Choi DK , Sung HH , et al. Preoperative prognostic nutritional index is a significant predictor of survival in renal cell carcinoma patients undergoing nephrectomy . Ann Surg Oncol 2016 ; 23 : 321 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 18. Broggi MS , Patil D , Baum Y , et al. Onodera's prognostic nutritional index as an independent prognostic factor in clear cell renal cell carcinoma . Urology 2016 ; 96 : 99 – 105 . Google Scholar Crossref Search ADS PubMed WorldCat 19. Chang PH , Hsieh JC , Yeh KY , et al. Prognostic nutritional index relevance in chemoradiotherapy for advanced oral cavity, oropharyngeal and hypopharyngeal cancer . Asia Pac J Clin Nutr 2018 ; 27 : 996 – 1001 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 20. Kono T , Sakamoto K , Shinden S , Ogawa K . Pre-therapeutic nutritional assessment for predicting severe adverse events in patients with head and neck cancer treated by radiotherapy . Clin Nutr 2017 ; 36 : 1681 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 21. Rungsakulkij N , Tangtawee P , Suragul W , et al. Correlation of serum albumin and prognostic nutritional index with outcomes following pancreaticoduodenectomy . World J Clin Cases 2019 ; 7 : 28 – 38 . Google Scholar Crossref Search ADS PubMed WorldCat 22. Ke M , Xu T , Li N , et al. Prognostic nutritional index predicts short-term outcomes after liver resection for hepatocellular carcinoma within the Milan criteria . Oncotarget 2016 ; 7 : 81611 – 20 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 23. Nozoe T , Kimura Y , Ishida M , et al. Correlation of pre-operative nutritional condition with post-operative complications in surgical treatment for oesophageal carcinoma . Eur J Surg Oncol 2002 ; 28 : 396 – 400 . Google Scholar Crossref Search ADS PubMed WorldCat 24. Bailon-Cuadrado M , Perez-Saborido B , Sanchez-Gonzalez J , et al. Prognostic nutritional index predicts morbidity after curative surgery for colorectal cancer . Cir Esp 2019 ; 97 : 71 – 80 . Google Scholar Crossref Search ADS PubMed WorldCat 25. Alshadwi A , Nadershah M , Carlson ER , et al. Nutritional considerations for head and neck cancer patients: a review of the literature . J Oral Maxillofac Surg 2013 ; 71 : 1853 – 60 . Google Scholar Crossref Search ADS PubMed WorldCat 26. van Bokhorst-de van der Schueren MA , van Leeuwen PA , Sauerwein HP , et al. Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications . Head Neck 1997 ; 19 : 419 – 25 . Google Scholar Crossref Search ADS PubMed WorldCat 27. Parhar HS , Durham JS , Anderson DW , Rush B , Prisman E . The association between the nutrition-related index and morbidity following head and neck microsurgery . Laryngoscope 2019 ; doi: 10.1002/lary.27912 . OpenURL Placeholder Text WorldCat Crossref 28. Heo YH , Yagi S , Toriyama K , et al. Relationship between BMI and postoperative complications with free flap in anterolateral craniofacial reconstruction . Plast Reconstr Surg Glob Open 2016 ; 4 : e636 . Google Scholar Crossref Search ADS PubMed WorldCat 29. Lo SL , Yen YH , Lee PJ , Liu CC , Pu CM . Factors influencing postoperative complications in reconstructive microsurgery for head and neck cancer . J Oral Maxillofac Surg 2017 ; 75 : 867 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 30. Weimann A , Braga M , Carli F , et al. ESPEN guideline: clinical nutrition in surgery . Clin Nutr 2017 ; 36 : 623 – 50 . Google Scholar Crossref Search ADS PubMed WorldCat 31. Paccagnella A , Morello M , Da Mosto MC , et al. Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy . Support Care Cancer 2010 ; 18 : 837 – 45 . Google Scholar Crossref Search ADS PubMed WorldCat 32. Casas Rodera P , de Luis DA , Gomez Candela C , Culebras JM . Immunoenhanced enteral nutrition formulas in head and neck cancer surgery: a systematic review . Nutr Hosp 2012 ; 27 : 681 – 90 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 33. Imai T , Matsuura K , Asada Y , Sagai S , Katagiri K , Ishida E , et al. Effect of HMB/Arg/Gln on the prevention of radiation dermatitis in head and neck cancer patients treated with concurrent chemoradiotherapy . Jpn J Clin Oncol 2014 ; 44 : 422 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Preoperative prognostic nutritional index as a method to predict postoperative complications after major head and neck surgery with free tissue transfer reconstruction
JO - Japanese Journal of Clinical Oncology
DO - 10.1093/jjco/hyz133
DA - 2020-01-24
UR - https://www.deepdyve.com/lp/oxford-university-press/preoperative-prognostic-nutritional-index-as-a-method-to-predict-V77LND8Ylt
SP - 29
VL - 50
IS - 1
DP - DeepDyve
ER -