Advertisement

Comprehensive complication index: A new reporting standard for postoperative complications of free-flap reconstruction in head and neck cancer patients

      Objective

      We aimed to validate and evaluate the comprehensive complication index (CCI) as a measure of postoperative complications (POCs) in the patients with head and neck squamous cell carcinoma (HNSCC) who had undergone free-flap reconstruction.

      Study Design

      A single-center, prospective cohort study was conducted on the patients with primary HNSCC treated between 2015 and 2020.

      Results

      Of 443 patients, 177 experienced POCs (40.0%). According to the new CCI, 93 patients had severe POCs (score ≥26.2; 21.0%), and only 76 patients were classified as having severe POCs (grade ≥III; 17.2%) according to the traditional Clavien-Dindo classification (CDC). The patients with CCI scores ≥26.2 had a higher rate of major adverse short-term outcomes, such as prolonged length of the hospital stay after surgery, excessive medical costs, and the need for transfusion. Importantly, the Kaplan-Meier analysis revealed a lower overall survival rate for patients with severe complications (CCI score ≥26.2, P = .038). However, no statistically significant differences were observed between CDC grades III or above and overall survival (P = .100).

      Conclusions

      The CCI can be used to evaluate POCs of free-flap reconstruction in patients with HNSCC. It performed more accurately than the CDC in short- and long-term outcome prediction and risk factor identification.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      References

        • Chow LQM.
        Head and neck cancer.
        New Engl J Med. 2020; 382: 60-72
        • Cramer JD
        • Burtness B
        • Le QT
        • Ferris RL.
        The changing therapeutic landscape of head and neck cancer.
        Nat Rev Clin Oncol. 2019; 16: 669-683
        • Pfister DG
        • Spencer S
        • Adelstein D
        • et al.
        Head and neck cancers, version 2.2020, NCCN clinical practice guidelines in oncology.
        J Natl Compr Canc Netw. 2020; 18: 873-898
        • Dort JC
        • Farwell DG
        • Findlay M
        • et al.
        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.
        JAMA Otolaryngol Head Neck Surg. 2017; 143: 292-303
        • Dooley BJ
        • Karassawa ZD
        • Mcgill MR
        • et al.
        Intraoperative and postanesthesia care unit fluid administration as risk factors for postoperative complications in patients with head and neck cancer undergoing free tissue transfer.
        Head Neck. 2020; 42: 14-24
        • Artiles-Armas M
        • Roque-Castellano C
        • Conde-Martel A
        • Marchena-Gómez J.
        The comprehensive complication index is related to frailty in elderly surgical patients.
        J Surg Res. 2019; 244: 218-224
        • Haden TD
        • Prunty MC
        • Jones AB
        • Deroche CB
        • Murray KS
        • Pokala N.
        Comparative perioperative outcomes in septuagenarians and octogenarians undergoing radical cystectomy for bladder cancer—do outcomes differ?.
        Eur Urol Focus. 2018; 4: 895-899
        • Choi N
        • Park SI
        • Kim H
        • Sohn I
        • Jeong HS.
        The impact of unplanned reoperations in head and neck cancer surgery on survival.
        Oral Oncol. 2018; 83: 38-45
        • Clavien PA
        • Barkun J
        • de Oliveira ML
        • et al.
        The Clavien-Dindo classification of surgical complications: five-year experience.
        Ann Surg. 2009; 250: 187-196
        • Dindo D
        • Demartines N
        • Clavien PA.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Monteiro E
        • Sklar MC
        • Eskander A
        • et al.
        Assessment of the Clavien-Dindo classification system for complications in head and neck surgery.
        Laryngoscope. 2014; 124: 2726-2731
        • Slankamenac K
        • Graf R
        • Barkun J
        • Puhan MA
        • Clavien PA.
        The comprehensive complication index: a novel continuous scale to measure surgical morbidity.
        Ann Surg. 2013; 258: 1-7
        • Yamashita S
        • Sheth RA
        • Niekamp AS
        • et al.
        Comprehensive complication index predicts cancer-specific survival after resection of colorectal metastases independent of RAS mutational status.
        Ann Surg. 2017; 266: 1045-1054
        • Zaheer S
        • Pimentel SD
        • Simmons KD
        • et al.
        Comparing international and United States undergraduate medical education and surgical outcomes using a refined balance matching methodology.
        Ann Surg. 2017; 265: 916-922
        • Awad MI
        • Shuman AG
        • Montero PH
        • Palmer FL
        • Shah JP
        • Patel SG.
        Accuracy of administrative and clinical registry data in reporting postoperative complications after surgery for oral cavity squamous cell carcinoma.
        Head Neck. 2015; 37: 851-861
        • Mentula PJ
        • Leppaniemi AK.
        Applicability of the Clavien-Dindo classification to emergency surgical procedures: a retrospective cohort study on 444 consecutive patients.
        Patient Saf Surg. 2014; 8: 31
        • Kim T
        • Suh Y
        • Huh Y
        • et al.
        The comprehensive complication index (CCI) is a more sensitive complication index than the conventional Clavien-Dindo classification in radical gastric cancer surgery.
        Gastric Cancer. 2018; 21: 171-181
        • Kowalewski KF
        • Müller D
        • Mühlbauer J
        • et al.
        The comprehensive complication index (CCI): proposal of a new reporting standard for complications in major urological surgery.
        World J Urol. 2021; 39: 1631-1639
        • Clavien PA
        • Vetter D
        • Staiger RD
        • et al.
        The comprehensive complication index (CCI(R)): added value and clinical perspectives 3 years “down the line.
        Ann Surg. 2017; 265: 1045-1050
        • Slaman AE
        • Lagarde SM
        • Gisbertz SS
        • van Berge Henegouwen MI.
        A quantified scoring system for postoperative complication severity compared to the Clavien-Dindo classification.
        Digest Surg. 2015; 32: 361-366
        • Kiong KL
        • Lin FY
        • Yao C
        • et al.
        Impact of neoadjuvant chemotherapy on perioperative morbidity after major surgery for head and neck cancer.
        Cancer. 2020; 126: 4304-4314
        • Choudry MHA
        • Shuai Y
        • Jones HL
        • et al.
        Postoperative complications independently predict cancer-related survival in peritoneal malignancies.
        Ann Surg Oncol. 2018; 25: 3950-3959
        • Schimansky S
        • Lang S
        • Beynon R
        • et al.
        Association between comorbidity and survival in head and neck cancer: results from Head and Neck 5000.
        Head Neck. 2019; 41: 1053-1062
        • Nathan H
        • Yin H
        • Wong SL.
        Postoperative complications and long-term survival after complex cancer resection.
        Ann Surg Oncol. 2017; 24: 638-644
        • Pai K
        • Baaklini C
        • Cabrera CI
        • Tamaki A
        • Fowler N
        • Maronian N.
        The utility of comorbidity indices in assessing head and neck surgery outcomes: a systematic review.
        Laryngoscope. 2022; 132: 1388-1402
        • Slankamenac K
        • Nederlof N
        • Pessaux P
        • et al.
        The comprehensive complication index: a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials.
        Ann Surg. 2014; 260: 757-763