1. The POMR of HNC patients was about 1‰
From January 2010 to December 2019, a total of 6972 HNC (4560 were male and 2412 were female) patients admitted to our hospital who were ready to accept or had undergone surgery, with an average age of(48.32 ± 4.34) years. 7 patients (6 males and 1 female) died during perioperative period and the POMR was about 1‰, aged from 46 to 76 years, with an average age of༈60.71 ± 8.12) years. Among them, 5 cases had comorbidities, including 3 cases of hypertension, 1 case of diabetes, 1 case of hypertension, hypertensive heart disease and Hypercholesterolemia. In addition, 1 case had previous head and neck tumor-related surgery, and 3 case had received radiotherapy before surgery. For the 7 deaths, 3 patients died of cervical artery rupture and hemorrhage. 1 patient died of acute heart failure, cardiac arrest, severe pneumonia, and ischemic hypoxic encephalopathy. The demographics and comorbidities details of the 7 deaths see Table 1.
Table 1
Demographics, comorbidities and preoperative parameters of the 7 perioperative deaths
Patient
ID
|
Sex
|
Age
|
Smoking
|
Drinking
|
Tumor recurrence
|
Previous operation
|
Previous radiotherapy
|
Previous chemotherapy
|
comorbidities
|
1
|
Male
|
68
|
Yes
|
Yes
|
No
|
No
|
No
|
No
|
No
|
2
|
Male
|
63
|
Yes
|
Yes
|
No
|
No
|
Yes
|
Yes
|
Hypertension
|
3
|
Male
|
51
|
Yes
|
Yes
|
No
|
No
|
Yes
|
No
|
Hypertension
|
4
|
Female
|
76
|
No
|
No
|
No
|
No
|
No
|
No
|
No
|
5
|
Male
|
61
|
No
|
Yes
|
No
|
No
|
No
|
No
|
Diabetes
|
6
|
Male
|
46
|
Yes
|
Yes
|
No
|
No
|
No
|
No
|
Hypertension, hypertensive heart disease, hypercholesterolemia
|
7
|
Male
|
60
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Hypertension
|
Case presentation
Patient 1: Male, 68 years old, admitted to hospital on March 18, 2013, pathologically diagnosed as "Left soft palate squamous cell carcinoma". 4 days after admission, “Extended tumor resection combined with cervical lymph node clearance + left anterolateral femoral myocutaneous flap transfer repair + tracheotomy” was performed under general anesthesia. On the 4th day after the operation, the patient developed active bleeding in the mouth and nose, and dark red liquid could be drawn from the gastric tube. The patient died after 2 hours’ rescue. The causes of death were: 1. Respiratory obstruction. 2. Hemorrhagic shock.
Patient 2: Male, 63 years old, admitted to hospital on December 9, 2013, diagnosed as "Left soft palate squamous cell carcinoma", had a history of hypertension for more than 10 years. 4 days after admission, “Extended tumor resection + left anterolateral femoral myocutaneous flap transfer repair + tracheotomy” was performed under general anesthesia. On the 2nd day after the operation, the patient developed "loss of consciousness, cyanosis of the lips, no spontaneous breathing, no heart beat and disappearance of carotid artery beats", and died 1.5 hours’ after rescue. Cause of death: Cardiac respiratory arrest.
Patient 3
Male, 51 years old, admitted to hospital on September 16, 2014, diagnosed as “Left Tonsil Squamous Cell Carcinoma”, had a history of hypertension for more than 13 years, and
had received radiotherapy and chemotherapy before the admission. 9 days after admission, “Extended tumor resection combined with cervical lymph node clearance + left anterolateral thigh muscle skin flap transfer repair + tracheotomy” was performed under general anesthesia. A flap crisis occurred on the 4th day after surgery, and the “pectoralis major myocutaneous flap transplantation” was performed again. On the 3rd day after the second operation, pus exuded from the right neck wound, which gradually increased. Bacterial culture of wound secretions showed: Enterobacter aeruginosa, Pseudomonas aeruginosa infection. On the 12th day after the second operation, the patient had massive bleeding from the neck wound, mouth and nose, and died 1.5 hours later. The cause of death: bleeding from large blood vessels in the neck leads to respiratory and circulatory failure.
Patient 4: Female, 76 years old, admitted to the hospital on October 6, 2015, diagnosed as “Left Tongue Cell Carcinoma”. Magnetic resonance imaging (MRI) showed the tumor invaded the internal carotid artery. Considering that the internal carotid artery may need to be ligated during the operation, a “ballon occlusion test (BOT)” was performed before the operation. 9 days after admission, “Extended tumor resection combined with left anterolateral thigh musculocutaneous flap transfer repair + tracheotomy” was performed under general anesthesia. 5 days after the operation, the patient had bleeding from the neck wound. Emergency surgery indicated internal carotid artery rupture, and the rupture was located where the balloon was placed. After the comprehensive consideration of the advantages and disadvantages of the two treatment options of vascular anastomosis and internal carotid artery ligation, internal carotid artery anastomosis was selected after consultation with the patient’ families. On the 2nd day after the emergency operation, the patient developed neck bleeding again and died after half an hour. The cause of death: hemorrhage of large blood vessels in the neck.
Patient 5: Male, 61 years old, admitted to hospital on February 5, 2017, diagnosed as “Left oropharyngeal squamous cell carcinoma", had a history of diabetes for more than 9 years. 4 days after admission, “Extended tumor resection combined with left anterolateral thigh musculocutaneous flap transfer repair + tracheotomy” was performed under general anesthesia. Pulmonary infection occurred on the 11th day after surgery. On the 12th day after surgery, the patient developed symptoms of loss of consciousness and shortness of breath, heart rate increased to 178 beats/min, blood oxygen saturation was 74%, and blood pressure was 115/67 mmHg. The patient died 1 hour despite all treatments. The cause of death: heart failure.
Patient 6: Male, 46 years old, admitted to the hospital on March 1, 2018, diagnosed as “Left tongue squamous cell carcinoma". 8 days after admission, “Extended tumor resection combined with left anterolateral thigh musculocutaneous flap transfer repair” was performed under general anesthesia. 3 days after the operation, the patient developed neck wound infection. On the 6th day after the operation, the patient developed irritability, poor breathing, dark red blood flowing out of the mouth, obvious swelling of the neck wound, and bleeding from the incision. After opening the neck wound at the bedside, "dark red blood clots and active bleeding" were found. An emergency tracheotomy was performed immediately. During the tracheotomy, a cardiac arrest occurred and chest compressions were performed. The heartbeat recovered 36 minutes later. The patient underwent “debridement and hemostasis” of neck wound under general anesthesia, and was sent to ICU for further sub-hibernation treatment after the operation. The patient developed brain death 12 days later. The cause of death: ischemic hypoxic encephalopathy
Patients 7: Male, 60 years old, admitted to the hospital on December 24, 2018, diagnosed as “Postoperative recurrence of left oropharyngeal squamous cell carcinoma”. The patient had a history of 13 years of hypertension, and received 3 months of radiotherapy before admission. The physical examination indicated the patient had cachexia, electrolyte imbalance, and hypoproteinemia. 2 days after admission, the patient developed dyspnea with a blood oxygen saturation of 85%, and was transferred to ICU for further treatment. 4 days after admission, the patient developed lung infection (severe pneumonia) and type I respiratory failure. 12 days after admission, the patient’s families gave up treatment, and the patient died 2 hours after removing the ventilator. The causes of death: severe pneumonia and type I respiratory failure.
The summary of intraoperative and postoperative parameters of the 7 perioperative deaths see Table 2.
Table 2
Intraoperative and postoperative parameters of the 7 perioperative deaths
Patient
ID
|
Stage
|
Tumor site
|
ASA grade
|
Operation time(min)
|
Neck dissection
|
Airway management
|
Local wound infection
|
Etiology of perioperative mortality
|
1
|
Ⅲ
|
Left soft palate
|
Ⅲ
|
850
|
Unilateral
|
Tracheotomy
|
Yes
|
Cervical artery rupture and bleeding, airway obstruction
|
2
|
Ⅲ
|
Left soft palate
|
Ⅲ
|
350
|
Unilateral
|
Tracheotomy
|
No
|
Cardiac arrest
|
3
|
Ⅳ
|
Right tonsil
|
Ⅲ
|
760
|
Bilateral
|
Tracheotomy
|
Yes
|
Cervical artery rupture and bleeding
|
4
|
Ⅳ
|
Left tongue
|
Ⅲ
|
585
|
Bilateral
|
Tracheotomy
|
Yes
|
Cervical artery rupture and bleeding
|
5
|
Ⅲ
|
Left mouth pharynx
|
Ⅱ
|
580
|
Unilateral
|
Tracheotomy
|
No
|
Acute heart failure, lung infection
|
6
|
Ⅲ
|
Left tongue
|
Ⅱ
|
410
|
Unilateral
|
No
|
Yes
|
Ischemic hypoxic encephalopathy (brain death), lung infection
|
7
|
Ⅳ
|
Left neck lymph node
|
Ⅲ
|
No
|
No
|
No
|
No
|
Severe pneumonia, type I respiratory failure
|
3. Preoperative radiotherapy, hypertension, diabetes and postoperative infection are risk factors for perioperative death of HNC
In order to further evaluate the risk factors of perioperative death, we screened out 1695 patients with complete data from 6972 patients. Further univariate and multivariate logistic regression analysis showed that prior radiotherapy, postoperative infection, diabetes and hypertension are risk factors for perioperative death (Figure. 1A, B).
4. Hypertension and postoperative infection are significantly related to poor OS in HNC patients.
To further evaluate the relationship between the prognosis of HNC and preoperative radiotherapy, wound infection, diabetes, or hypertension, we selected patients from 1295 patients who underwent surgery from January 2010 to December 2014, and evaluated their five-year survival rate. It was found that hypertension and postoperative infection were significantly related to poor OS (Figure. 2A, B).