Importance: Cost savings has become a focus of healthcare reform over recent years with implementation of the Hospital Readmissions Reduction Program. Prolonged postoperative hospital courses can significantly increase healthcare expenditure. While preoperative smoking status is a modifiable risk factor, little is known about the effects of smoking on postoperative complications and length of hospital stay in head and neck cancer patients undergoing free tissue reconstruction. Greater understanding of the impact of smoking on the postoperative course is needed to implement cost-reductive strategies.
Objective: To determine if preoperative smoking increases risk of 30-day complications and prolonged postoperative length of stay after undergoing free tissue reconstruction for head and neck cancer using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.
Methods: ACS-NSQIP data from 2012-2014 was queried for ICD-9 codes of malignancies of the head and neck with associated free tissue reconstruction. Cases with a primary diagnosis of thyroid malignancy were excluded. Complications and length of stay data were analyzed using multivariate regression analysis. Statistical significance was determined using p-value <0.05.
Designs: Cross-sectional retrospective review of ACS-NSQIP from 2006-2010.
Results: A total of 8,609 cases of head and neck malignancy were identified with 1115 cases receiving free tissue reconstruction (13%). 30% of these patients had smoked within 1 year prior to surgery. Prolonged length of stay was defined as greater than 13 days (3rd quartile; 75%). On multivariate analysis, smoking was associated with an increased the risk of prolonged hospital stay (p <0.001, OR 2.14, 95% CI 1.46, 3.13). Overall, there were 1114 complications that occurred in 604 cases. The association between preoperative smoking status and postoperative complications approached significance on univariate (p = 0.053), but was not significant on multivariate analysis.
Conclusions: Tobacco use is prevalent in patients undergoing free tissue reconstruction of the head and neck. The literature shows that smoking may be a risk factor for impaired wound healing, surgical site infections, and flap failure following free tissue reconstruction. However, little was previously known about the effect of smoking on postoperative outcomes including hospital length of stay. Our results indicate that smoking significantly increases hospital length of stay. However, smoking was not associated with increased rate of postoperative complications. Further understanding of the association between smoking and prolonged postoperative hospital course in patients undergoing free tissue transfer for head and neck cancer will allow for improved preoperative teaching with regards to smoking cessation and decrease unnecessarily prolonged hospital stays.