Ann 0101 Rhinal Laryngol99: 1990
MEDICAL COMPLICATIONS IN TOTAL LARYNGECTOMY: INCIDENCE AND RISK FACTORS KEITH
MOISES A. ARRIAGA, MD Los
ANGELES, CALIFORNIA
JONAS
T.
T.
KANEL, MD
PITTSBURGH, PENNSYLVANIA
EUGENE
JOHNSON, MD
N. MYERS, MD
PITTSBURGH, PENNSYLVANIA
PITTSBURGH, PENNSYLVANIA
The prevention and management of medical complications are important components in the surgical treatment of head and neck malignancies. We retrospectively evaluated the postoperative medical complications in 414 patients who underwent total laryngectomy between 1973 and 1987. The mortality rate was 1.2% (five deaths); while major, nonfatal medical complications occurred in 6.3% (24 of 384 patients) - seven strokes, three myocardial infarctions, two pulmonary emboli, and 12 respiratory failures requiring mechanical ventilation. Elderly patients did not experience more frequent or more severe medical complications, and the overall pattern of complications was different from that of other surgical specialties. Only specific cardiovascular and pulmonary risk factors were associated with these complications. We conclude that medical complications are a significant cause of morbidity in total laryngectomy; a focused preanesthetic risk factor analysis by a medical team familiar with head and neck cancer patients assures prompt identification and management of these complications. KEY WORDS -
medical complications, total laryngectomy.
(COPD), liver disease, kidney disease, and diabetes mellitus were recorded as present if the patient was receiving medical therapy for the condition at the time of operation. Severe COPD, congestive heart failure, or stroke was recorded as present if the patient had ever required hospitalization for the condition. Previous myocardial infarction was recorded according to the cardiologist's interpretation of the electrocardiogram (ECG), and significant cardiac murmurs were recorded if a medical consultant had recommended antibiotic prophylaxis for the condition.
INTRODUCTION
The medical complications of surgical procedures are especially important considerations in head and neck surgery because of the high incidence of comorbidity in patients with upper aerodigestive tract tumors. In addition, the socioeconomic pressures of an aging population and cost containment measures implemented by reimbursement agencies make a better understanding of risk factors for surgical morbidity crucial to developing strategies to minimize postoperative complications. This study examines the preanesthetic risk factors and correlates these factors with the incidence and significance of postoperative complications in patients undergoing total laryngectomy. The medical records of patients undergoing total laryngectomy by the University Otolaryngology Group at the Eye and Ear Hospital of the University of Pittsburgh School of Medicine between 1973 and 1987 were reviewed. This included patients undergoing neck dissection or extended pharyngectomy with total laryngectomy. Data were collected on patient age, sex, tumor stage, operations performed, American Society of Anesthesiologists (ASA) physical status category, medical risk factors identified by history and physical examination, operative duration, postoperative surgical complications, medical complications, and duration of hospitalization.
Postoperative Complications. Criteria for the four major medical complications were as follows. 1. Respiratory failure: mechanical ventilation required for more than 24 hours postoperatively or initiated during the postoperative period. 2. Stroke: a new medically documented neurologic deficit of central origin. 3. Myocardial infarction: new ECG changes or elevated creatinine phosphokinase myocardial fraction consistent with myocardial infarction. 4. Pulmonary embolus: diagnostic defects on pulmonary angiography or high probability as indicated by ventilation-perfusion scanning. Medical diagnoses were confirmed by medical specialists, and their clinical diagnoses alone were the criteria for recording minor medical com plications in this study.
Preoperative Conditions. Criteria for recording preoperative comorbidity were as follows. Hypertension, angina, chronic obstructive pulmonary disease
Statistical Evaluation. Statistical evaluation was performed with x2 analysis for discrete variables and Student's t test for continuous variables.
METHODS
From the Departments of Otolaryngology (Arriaga, Johnson, Myers) and Internal Medicine (Kanel), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Dr Arriaga is currently at the House Ear Institute, Los Angeles, California. Presented at the meeting of the American Laryngological Association, Palm Beach, florida, April 28-29, 1990. REPRINTS - Jonas T. Johnson, MD, Dept of Otolaryngology, Eye and Ear Hospital, 203 Lothrop St, Suite 500, Pittsburgh, PA 15213.
611
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Arriaga et al, Medical Complications in Laryngectomy
TABLE 1. AGE DISTRIBUTION OF 414 PATIENTS WITH TOTAL LARYNGECTOMIES ACCORDING TO TUMOR STAGE AND ADDITIONAL PROCEDURES PERFORMED
Tumor stage I II III IV Procedures TL + ND + BND >TL
~65 yr (n=184)* No. %
TL - extended laryngectomy with myocutaneous or free flap reconstruction and unilateral or bilateral neck dissection. 'Nine patients were >80 years; 175 were 65 to 80 years. Staging information was unavailable for 1 patient. tForty-two patients were < 50 years; 188 were 50 to 64 years.
RESULTS
During this interval, 414 patients underwent total laryngectomy; complete chart information was available for 384 patients. Accordingly, the frequency of procedures and complications was recorded on the 414 patients (Tables 1 and 2); however, risk factor analysis was performed on the 384 with complete information. The ages ranged from 28 to 90 years; the mean age was 62 ± 9 years, and 184 patients were 65 years or older (Table 1). The tumor stages and additional operative procedures were similarly distributed among the elderly and younger patients.
The surgical complications of these 384 totallaryngectomies are summarized in Table 4. Major complications occurred in 57 patients (15%). The rate of pharyngocutaneous fistulas was 10 % in totallaryngectomies performed as the sole procedure or with unilateral or bilateral neck dissection (35/350). One patient with a pharyngocutaneous fistula also suffered a carotid erosion that resulted in hemispheric stroke following an emergency carotid ligation. The mean length of hospitalization in this series was 14.5 ± 11 days. Table 5 lists the complications according to the length of hospitalization. Except for pulmonary embolism, major surgical and medical complications were associated with prolonged hospitalization (p < .05). In addition, postoperative pneumonia, pulmonary edema, ECG changes, and postoperative hemorrhage resulted in lengthened hospitalization (p < .05).
Table 2 summarizes the incidence of major postoperative complications and duration of hospitalization according to the operative procedures performed. Pharyngocutaneous fistulas were more frequent in patients undergoing extended laryngectomies with flap reconstructions (p < .05), and postoperative strokes occurred only in patients who underwent neck dissections. Specific operative procedures were not otherwise associated with higher complication rates (p> ,05).
According to the corresponding organ system, significant risk factors were associated with medical complications. Table 6 summarizes the preanesthetic risk factors identified in this series, The predomi-
The overall 3D-day postoperative mortality rate was 1.2% (five deaths), with no operative or peri-
TABLE 2. INCIDENCE OF MAlOR COMPLICATIONS, OPERATING ROOM TIME, PHYSICAL STATUS CATEGORIES, AND LENGTH OF HOSPITALIZATION ACCORDING TO OPERATIVE PROCEDURES IN 414 TOTAL LARYNGECTOMIES Procedure
No.
OR Time (hr)
PS
TL + ND +BND >TL
122 224 34 34
3.5 4.6 5.8 5.7
2.6 2.6 2.7 2.5
Death No. % 1 3 1 0
0.8 1.3 2.9
Fistula No. % 6 29 6 13
4.9 12.9 17.6 38.2
eVA
PE
MI
Vent
Days
0 4 1 2
0 2 0 0
1 0 1 0
1 9 2 0
12.3 15.0 16.9 17.7
OR - operating room, PS - American Society of Anesthesiologists physical status category, Death - mortality from start of operation to 30 days (all occurred as "postoperative," > 48 hours postop and < 30 days postop), Fistula - pharyngocutaneous fistula documented radiographically or diagnosed clinically during hospitalization, eVA - new stroke diagnosed postoperatively, PE - pulmonary embolus, MI - myocardial infarction, Vent - respiratory failure, Days - days hospitalized postoperatively, TL - total laryngectomy alone, + ND - total laryngectomy and unilateral neck dissection, + BND - total laryngectomy and bilateral neck dissection, > TL - extended laryngectomy with myocutaneous or free flap reconstruction and unilateral or bilateral neck dissection.
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Arriaga et al, Medical Complications in Laryngectomy TABLE 3. POSTOPERATIVE MEDICAL COMPLICATIONS IN 384 TOTAL LARYNGECTOMIES
Complications Major Mechanical ventilation Stroke Myocardial infarction Pulmonary embolus Minor Chronic obstructive pulmonary disease exacerbation Pneumonia Pulmonary edema Cardiac arrhythmia requiring therapy Confusion Complications with parenteral hyperalimentation Urinary tract infections Angina Urinary obstruction Hypertension Functional ileus (> 5 d) Drug withdrawal Gastrointestinal bleeding Maxillary sinusitis Hypocalcemia Decubitus ulcers Transfer to nursing home (temporary) Grand mal seizure Suicidal ideation Loss of pacemaker function (temporary) Venous thrombophlebitis Antibiotic allergy
No.
%
12
3.1 1.8 0.8
7
3 2
0.5
33 29 21 17 16
8.6 7.6
13 13 11 9 8
3.4 3.4 2.9
5.5 4.4 4.2
7 5 4 3 3 1 1 1 1 1 1 1
nant preanesthetic risk factors reflect significant alcohol and tobacco abuse, known predisposing factors to upper aerodigestive tract carcinoma. In Table 7, corresponding risk factors are listed according to the complications that occurred more frequently (p < .05) in those patients. Postoperative mortality was associated with a history of stroke or the presence of a significant cardiac murmur; strokes were associated with a history of diabetes mellitus; respiratory failure requiring mechanical ventilation was associated with a history of severe COPD or wheezing on preoperative physical examination. When surgical complications were studied as risk factors, pharyngocutaneous fistulas were associated with postoperative pneumonia (p < .05). This relationship is not surprising in light of the proximity of the fistulous tracts to the tracheostomas. Preanesthetic physical status categories, tumor stage, and operative time did not predict medical complications (p> .05). Table 8 illustrates that the elderly experienced medical complications more frequently than patients younger than 65 years (p< .05); however, maior medical complications (ie, respiratory failure, myocardial infarction, pulmonary embolus, and stroke) were not significantly more frequent in the elderly (p> .05.) Furthermore, although the elderly had more frequent risk factors for complications than younger patients, this trend was not sig-
TABLE 4. SURGICAL COMPLICATIONS IN 384 TOTAL LARYNGECTOMIES
Complications Major Pharyngocutaneous fistulaPostoperative hemorrhage Carotid erosion Chyle fistula Minor Wound infection Facial edema Tracheoesophageal puncture and neoglottis aspiration Intraoperative aspiration Hematoma Corneal abrasion Intraoperative hypotension Seroma Hypoglossal paralysis Phrenic paralysis
No.
%
48
7 1 1
12.5 1.8 0.3 0.3
52 10
13.5 2.6
5 2 2 2 1 1 1 1
1.3
"Incidence in total laryngectomy alone or with unilateral or bilateral neck dissection was 35 of 350 (10 % ).
nificant (p> .05); and the occurrence of complications did not result in longer hospitalizations for the elderly than for younger patients with the same complications (Table 5). The mean length of hospitalization was 14 days for the elderly and 14.9 days for patients less than 65 (Table 8). The extremely poor medical condition of two patients was improved by total laryngectomy. Both patients were 90 years of age, with aspiration pneumonitis, significant cardiac arrhythmias, and mental obtundation; after total laryngectomy, the absence of aspiration resolved the pneumonitis and hypoxia-related arrhythmias. DISCUSSION
The head and neck cancer patients in this series exhibited very similar rates of preanesthetic risk factors as the elderly patients who underwent operations in different surgical specialties in Stephen's' series of 1,000 consecutive patients over age 70. The major distinction is the higher incidence of COPD in our series, 68 % versus 14 % . Yet, despite the similarity of preanesthetic risks, the postoperative mortality in the general surgery patients' was predominantly due to sepsis, acute renal failure, carcinomatosis, and acute respiratory failure. These causes of death were not encountered in the 1.2 % mortality of our series of total laryngectomies. The more frequent occurrence of cardiac death and severe pulmonary complications in the laryngectomy patients may be attributed to the almost universal tobacco abuse among these patients as reflected in the incidence of COPD in head and neck cancer patients. However, since the differences in preanesthetic risks only partially explain the different postoperative complications of these head and neck cancer patients, the systemic stresses of total laryngectomy versus non-head and neck operations must be con-
Downloaded from aor.sagepub.com at DALHOUSIE UNIV on May 17, 2015
614
Arriaga et al, Medical Complications in Laryngectomy TABLE 5. LENGTH OF POSTOPERATIVE HOSPITALIZATION ACCORDING TO POSTOPERATIVE COMPLICATIONS AND AGE IN 384 TOTAL LARYNGECTOMIES
TABLE 6. PREANESTHETIC MEDICAL RISK FACTORS IN 384 TOTAL LARYNGECTOMIES Risk Factors
%
Mean Length Hospitalization d) ~65 yr
MEDICAL COMPLICATIONS IN TOTAL LARYNGECTOMY: INCIDENCE AND RISK FACTORS KEITH
MOISES A. ARRIAGA, MD Los
ANGELES, CALIFORNIA
JONAS
T.
T.
KANEL, MD
PITTSBURGH, PENNSYLVANIA
EUGENE
JOHNSON, MD
N. MYERS, MD
PITTSBURGH, PENNSYLVANIA
PITTSBURGH, PENNSYLVANIA
The prevention and management of medical complications are important components in the surgical treatment of head and neck malignancies. We retrospectively evaluated the postoperative medical complications in 414 patients who underwent total laryngectomy between 1973 and 1987. The mortality rate was 1.2% (five deaths); while major, nonfatal medical complications occurred in 6.3% (24 of 384 patients) - seven strokes, three myocardial infarctions, two pulmonary emboli, and 12 respiratory failures requiring mechanical ventilation. Elderly patients did not experience more frequent or more severe medical complications, and the overall pattern of complications was different from that of other surgical specialties. Only specific cardiovascular and pulmonary risk factors were associated with these complications. We conclude that medical complications are a significant cause of morbidity in total laryngectomy; a focused preanesthetic risk factor analysis by a medical team familiar with head and neck cancer patients assures prompt identification and management of these complications. KEY WORDS -
medical complications, total laryngectomy.
(COPD), liver disease, kidney disease, and diabetes mellitus were recorded as present if the patient was receiving medical therapy for the condition at the time of operation. Severe COPD, congestive heart failure, or stroke was recorded as present if the patient had ever required hospitalization for the condition. Previous myocardial infarction was recorded according to the cardiologist's interpretation of the electrocardiogram (ECG), and significant cardiac murmurs were recorded if a medical consultant had recommended antibiotic prophylaxis for the condition.
INTRODUCTION
The medical complications of surgical procedures are especially important considerations in head and neck surgery because of the high incidence of comorbidity in patients with upper aerodigestive tract tumors. In addition, the socioeconomic pressures of an aging population and cost containment measures implemented by reimbursement agencies make a better understanding of risk factors for surgical morbidity crucial to developing strategies to minimize postoperative complications. This study examines the preanesthetic risk factors and correlates these factors with the incidence and significance of postoperative complications in patients undergoing total laryngectomy. The medical records of patients undergoing total laryngectomy by the University Otolaryngology Group at the Eye and Ear Hospital of the University of Pittsburgh School of Medicine between 1973 and 1987 were reviewed. This included patients undergoing neck dissection or extended pharyngectomy with total laryngectomy. Data were collected on patient age, sex, tumor stage, operations performed, American Society of Anesthesiologists (ASA) physical status category, medical risk factors identified by history and physical examination, operative duration, postoperative surgical complications, medical complications, and duration of hospitalization.
Postoperative Complications. Criteria for the four major medical complications were as follows. 1. Respiratory failure: mechanical ventilation required for more than 24 hours postoperatively or initiated during the postoperative period. 2. Stroke: a new medically documented neurologic deficit of central origin. 3. Myocardial infarction: new ECG changes or elevated creatinine phosphokinase myocardial fraction consistent with myocardial infarction. 4. Pulmonary embolus: diagnostic defects on pulmonary angiography or high probability as indicated by ventilation-perfusion scanning. Medical diagnoses were confirmed by medical specialists, and their clinical diagnoses alone were the criteria for recording minor medical com plications in this study.
Preoperative Conditions. Criteria for recording preoperative comorbidity were as follows. Hypertension, angina, chronic obstructive pulmonary disease
Statistical Evaluation. Statistical evaluation was performed with x2 analysis for discrete variables and Student's t test for continuous variables.
METHODS
From the Departments of Otolaryngology (Arriaga, Johnson, Myers) and Internal Medicine (Kanel), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Dr Arriaga is currently at the House Ear Institute, Los Angeles, California. Presented at the meeting of the American Laryngological Association, Palm Beach, florida, April 28-29, 1990. REPRINTS - Jonas T. Johnson, MD, Dept of Otolaryngology, Eye and Ear Hospital, 203 Lothrop St, Suite 500, Pittsburgh, PA 15213.
611
Downloaded from aor.sagepub.com at DALHOUSIE UNIV on May 17, 2015
612
Arriaga et al, Medical Complications in Laryngectomy
TABLE 1. AGE DISTRIBUTION OF 414 PATIENTS WITH TOTAL LARYNGECTOMIES ACCORDING TO TUMOR STAGE AND ADDITIONAL PROCEDURES PERFORMED
Tumor stage I II III IV Procedures TL + ND + BND >TL
~65 yr (n=184)* No. %
TL - extended laryngectomy with myocutaneous or free flap reconstruction and unilateral or bilateral neck dissection. 'Nine patients were >80 years; 175 were 65 to 80 years. Staging information was unavailable for 1 patient. tForty-two patients were < 50 years; 188 were 50 to 64 years.
RESULTS
During this interval, 414 patients underwent total laryngectomy; complete chart information was available for 384 patients. Accordingly, the frequency of procedures and complications was recorded on the 414 patients (Tables 1 and 2); however, risk factor analysis was performed on the 384 with complete information. The ages ranged from 28 to 90 years; the mean age was 62 ± 9 years, and 184 patients were 65 years or older (Table 1). The tumor stages and additional operative procedures were similarly distributed among the elderly and younger patients.
The surgical complications of these 384 totallaryngectomies are summarized in Table 4. Major complications occurred in 57 patients (15%). The rate of pharyngocutaneous fistulas was 10 % in totallaryngectomies performed as the sole procedure or with unilateral or bilateral neck dissection (35/350). One patient with a pharyngocutaneous fistula also suffered a carotid erosion that resulted in hemispheric stroke following an emergency carotid ligation. The mean length of hospitalization in this series was 14.5 ± 11 days. Table 5 lists the complications according to the length of hospitalization. Except for pulmonary embolism, major surgical and medical complications were associated with prolonged hospitalization (p < .05). In addition, postoperative pneumonia, pulmonary edema, ECG changes, and postoperative hemorrhage resulted in lengthened hospitalization (p < .05).
Table 2 summarizes the incidence of major postoperative complications and duration of hospitalization according to the operative procedures performed. Pharyngocutaneous fistulas were more frequent in patients undergoing extended laryngectomies with flap reconstructions (p < .05), and postoperative strokes occurred only in patients who underwent neck dissections. Specific operative procedures were not otherwise associated with higher complication rates (p> ,05).
According to the corresponding organ system, significant risk factors were associated with medical complications. Table 6 summarizes the preanesthetic risk factors identified in this series, The predomi-
The overall 3D-day postoperative mortality rate was 1.2% (five deaths), with no operative or peri-
TABLE 2. INCIDENCE OF MAlOR COMPLICATIONS, OPERATING ROOM TIME, PHYSICAL STATUS CATEGORIES, AND LENGTH OF HOSPITALIZATION ACCORDING TO OPERATIVE PROCEDURES IN 414 TOTAL LARYNGECTOMIES Procedure
No.
OR Time (hr)
PS
TL + ND +BND >TL
122 224 34 34
3.5 4.6 5.8 5.7
2.6 2.6 2.7 2.5
Death No. % 1 3 1 0
0.8 1.3 2.9
Fistula No. % 6 29 6 13
4.9 12.9 17.6 38.2
eVA
PE
MI
Vent
Days
0 4 1 2
0 2 0 0
1 0 1 0
1 9 2 0
12.3 15.0 16.9 17.7
OR - operating room, PS - American Society of Anesthesiologists physical status category, Death - mortality from start of operation to 30 days (all occurred as "postoperative," > 48 hours postop and < 30 days postop), Fistula - pharyngocutaneous fistula documented radiographically or diagnosed clinically during hospitalization, eVA - new stroke diagnosed postoperatively, PE - pulmonary embolus, MI - myocardial infarction, Vent - respiratory failure, Days - days hospitalized postoperatively, TL - total laryngectomy alone, + ND - total laryngectomy and unilateral neck dissection, + BND - total laryngectomy and bilateral neck dissection, > TL - extended laryngectomy with myocutaneous or free flap reconstruction and unilateral or bilateral neck dissection.
Downloaded from aor.sagepub.com at DALHOUSIE UNIV on May 17, 2015
613
Arriaga et al, Medical Complications in Laryngectomy TABLE 3. POSTOPERATIVE MEDICAL COMPLICATIONS IN 384 TOTAL LARYNGECTOMIES
Complications Major Mechanical ventilation Stroke Myocardial infarction Pulmonary embolus Minor Chronic obstructive pulmonary disease exacerbation Pneumonia Pulmonary edema Cardiac arrhythmia requiring therapy Confusion Complications with parenteral hyperalimentation Urinary tract infections Angina Urinary obstruction Hypertension Functional ileus (> 5 d) Drug withdrawal Gastrointestinal bleeding Maxillary sinusitis Hypocalcemia Decubitus ulcers Transfer to nursing home (temporary) Grand mal seizure Suicidal ideation Loss of pacemaker function (temporary) Venous thrombophlebitis Antibiotic allergy
No.
%
12
3.1 1.8 0.8
7
3 2
0.5
33 29 21 17 16
8.6 7.6
13 13 11 9 8
3.4 3.4 2.9
5.5 4.4 4.2
7 5 4 3 3 1 1 1 1 1 1 1
nant preanesthetic risk factors reflect significant alcohol and tobacco abuse, known predisposing factors to upper aerodigestive tract carcinoma. In Table 7, corresponding risk factors are listed according to the complications that occurred more frequently (p < .05) in those patients. Postoperative mortality was associated with a history of stroke or the presence of a significant cardiac murmur; strokes were associated with a history of diabetes mellitus; respiratory failure requiring mechanical ventilation was associated with a history of severe COPD or wheezing on preoperative physical examination. When surgical complications were studied as risk factors, pharyngocutaneous fistulas were associated with postoperative pneumonia (p < .05). This relationship is not surprising in light of the proximity of the fistulous tracts to the tracheostomas. Preanesthetic physical status categories, tumor stage, and operative time did not predict medical complications (p> .05). Table 8 illustrates that the elderly experienced medical complications more frequently than patients younger than 65 years (p< .05); however, maior medical complications (ie, respiratory failure, myocardial infarction, pulmonary embolus, and stroke) were not significantly more frequent in the elderly (p> .05.) Furthermore, although the elderly had more frequent risk factors for complications than younger patients, this trend was not sig-
TABLE 4. SURGICAL COMPLICATIONS IN 384 TOTAL LARYNGECTOMIES
Complications Major Pharyngocutaneous fistulaPostoperative hemorrhage Carotid erosion Chyle fistula Minor Wound infection Facial edema Tracheoesophageal puncture and neoglottis aspiration Intraoperative aspiration Hematoma Corneal abrasion Intraoperative hypotension Seroma Hypoglossal paralysis Phrenic paralysis
No.
%
48
7 1 1
12.5 1.8 0.3 0.3
52 10
13.5 2.6
5 2 2 2 1 1 1 1
1.3
"Incidence in total laryngectomy alone or with unilateral or bilateral neck dissection was 35 of 350 (10 % ).
nificant (p> .05); and the occurrence of complications did not result in longer hospitalizations for the elderly than for younger patients with the same complications (Table 5). The mean length of hospitalization was 14 days for the elderly and 14.9 days for patients less than 65 (Table 8). The extremely poor medical condition of two patients was improved by total laryngectomy. Both patients were 90 years of age, with aspiration pneumonitis, significant cardiac arrhythmias, and mental obtundation; after total laryngectomy, the absence of aspiration resolved the pneumonitis and hypoxia-related arrhythmias. DISCUSSION
The head and neck cancer patients in this series exhibited very similar rates of preanesthetic risk factors as the elderly patients who underwent operations in different surgical specialties in Stephen's' series of 1,000 consecutive patients over age 70. The major distinction is the higher incidence of COPD in our series, 68 % versus 14 % . Yet, despite the similarity of preanesthetic risks, the postoperative mortality in the general surgery patients' was predominantly due to sepsis, acute renal failure, carcinomatosis, and acute respiratory failure. These causes of death were not encountered in the 1.2 % mortality of our series of total laryngectomies. The more frequent occurrence of cardiac death and severe pulmonary complications in the laryngectomy patients may be attributed to the almost universal tobacco abuse among these patients as reflected in the incidence of COPD in head and neck cancer patients. However, since the differences in preanesthetic risks only partially explain the different postoperative complications of these head and neck cancer patients, the systemic stresses of total laryngectomy versus non-head and neck operations must be con-
Downloaded from aor.sagepub.com at DALHOUSIE UNIV on May 17, 2015
614
Arriaga et al, Medical Complications in Laryngectomy TABLE 5. LENGTH OF POSTOPERATIVE HOSPITALIZATION ACCORDING TO POSTOPERATIVE COMPLICATIONS AND AGE IN 384 TOTAL LARYNGECTOMIES
TABLE 6. PREANESTHETIC MEDICAL RISK FACTORS IN 384 TOTAL LARYNGECTOMIES Risk Factors
%
Mean Length Hospitalization d) ~65 yr
