title: Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society.
abstract: Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking.
  
  
  
  To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction.
  
  
  
  Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent key words for each topic included "head and neck surgery," "pharyngectomy," "laryngectomy," "laryngopharyngectomy," "neck dissection," "parotid lymphadenectomy," "thyroidectomy," "oral cavity resection," "glossectomy," and "head and neck." The final selection of literature included meta-analyses and systematic reviews as well as randomized controlled trials where available. In the absence of high-level data, case series and nonrandomized studies in head and neck cancer surgery patients or randomized controlled trials and systematic reviews in non-head and neck cancer surgery patients, were considered. An international panel of experts in major head and neck cancer surgery and enhanced recovery after surgery reviewed and assessed the literature for quality and developed recommendations for each topic based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations were graded following a consensus discussion among the expert panel.
  
  
  
  The literature search, including a hand search of reference lists, identified 215 relevant publications that were considered to be the best evidence for the topic areas. A total of 17 topic areas were identified for inclusion in the protocol for the perioperative care of patients undergoing major head and neck cancer surgery with free flap reconstruction. Best practice includes several elements of perioperative care. Among these elements are the provision of preoperative carbohydrate treatment, pharmacologic thromboprophylaxis, perioperative antibiotics in clean-contaminated procedures, corticosteroid and antiemetic medications, short acting anxiolytics, goal-directed fluid management, opioid-sparing multimodal analgesia, frequent flap monitoring, early mobilization, and the avoidance of preoperative fasting.
  
  
  
  The evidence base for specific perioperative care elements in head and neck cancer surgery is variable and in many cases information from different surgerical procedures form the basis for these recommendations. Clinical evaluation of these recommendations is a logical next step and further research in this patient population is warranted.
authors.affiliation: Section of Otolaryngology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta2Cancer Strategic Clinical Network, Alberta Health Services, Calgary, Alberta.
authors.forename: Joseph C
authors.initials: JC
authors.lastname: Dort
authors.affiliation: Department of Otolaryngology, Division of Head and Neck Surgery, University of California Davis, Sacramento.
authors.forename: D Gregory
authors.initials: DG
authors.lastname: Farwell
authors.affiliation: Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown NSW, Australia.
authors.forename: Merran
authors.initials: M
authors.lastname: Findlay
authors.affiliation: ENT Clinic, University Hospital Zurich, Switzerland.
authors.forename: Gerhard F
authors.initials: GF
authors.lastname: Huber
authors.affiliation: Department of Otolaryngology, Winnipeg, Manitoba.
authors.forename: Paul
authors.initials: P
authors.lastname: Kerr
authors.affiliation: Cancer Strategic Clinical Network, Alberta Health Services, Calgary, Alberta7Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta.
authors.forename: Melissa A
authors.initials: MA
authors.lastname: Shea-Budgell
authors.affiliation: Department of Otolaryngology, Head and Neck Surgery, CHUV, University of Lausanne, Switzerland.
authors.forename: Christian
authors.initials: C
authors.lastname: Simon
authors.affiliation: University of California, Davis Health System, Sacramento.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Uppington
authors.affiliation: Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta.
authors.forename: David
authors.initials: D
authors.lastname: Zygun
authors.affiliation: Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
authors.forename: Olle
authors.initials: O
authors.lastname: Ljungqvist
authors.affiliation: Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Harris
mesh_terms: D058752:Free Tissue Flaps; D006258:Head and Neck Neoplasms / Q000601:surgery*; D006801:Humans; D018529:Nutritional Support; D010353:Patient Education as Topic; D019990:Perioperative Care; D019651:Plastic Surgery Procedures