Abstract
Background/Aim: Handgrip strength has been used to evaluate the potential of elderly patients to survive different medical conditions or procedures, or to predict the nutritional status and length of hospitalization. The aim of this study was to evaluate the use of handgrip strength as a predictor of the length of hospitalization and need for prolonged intensive care in patients with oral malignancies requiring surgical resection and simultaneous primary reconstruction with microvascular free flap. Patients and Methods: This is a retrospective study of 37 head and neck carcinoma patients operated between 2012 and 2014 who had undergone a handgrip force test. The microvascular free flaps used were: radial forearm flap (n=23), anterolateral thigh flap (n=10), and iliac crest free flap (n=4). Results: Average stay at the hospital was 13.3 days after the operation and there was a 2.9-days need for intensive care. Handgrip strength did not predict susceptibility to complications, duration of hospitalization, or 12-month survival in the study population. Conclusion: Other anamnestic and medical factors and not handgrip strength should be considered when evaluating operability of the patient or their individual risks for microvascular reconstruction.
Handgrip strength (HGS), or handgrip force, has been used as a tool to evaluate the potential of elderly patients to survive different medical conditions and procedures or to predict the nutritional status or length of hospitalization (1-4). Zhuang et al. reported low HGS to be associated with a poorer outcome for several cancers; especially breast, lung, and colorectal cancers (5). In oral and head and neck carcinomas, HGS has been more rarely used as a predictor of surgery-related complications. Interestingly, in head and neck cancer patients undergoing curative targeted radiation therapy, HGS seemed not to correlate with the nutritional status of patients (6). However, general sarcopenia has been associated with poorer survival rates in patients with multimodal therapy (7). Surgical resection of oral carcinoma can be performed with direct closure or partial closure and secondary healing, if the tumor is small. Pedicled flaps or more often microvascular free flaps are often required for functional reconstruction if larger resections are required for reliable cancer curation. However, microvascular free flaps commonly require longer hospitalization and have more severe complication potential. Therefore, it is important to evaluate each patients’ physical status and select a suitable flap type for each individual to obtain the best outcome (8). There is no general or widely adapted protocol for preoperative evaluation of head and neck cancer patient’s frailty. Since HGS has been shown to be a reliable predictor of survival in patients with cancers in various other sites, it was also thought as an interesting option in oral cancer patients due to its fast clinical feasibility and quantitative nature. The aim of this study was to evaluate HGS as a predictor for long hospitalization and need for prolonged intensive care in patients with oral malignancies requiring surgical resection and primary reconstruction with microvascular free flap.
Patients and Methods
This is a retrospective study of oral carcinoma patients operated between October 1, 2012, and October 31, 2014, at the Department of Maxillofacial Surgery, Helsinki University Hospital, Finland. The trial has been registered in the Helsinki University Central Hospital, Helsinki, Finland, Clinical Trials Register with the trial number 356. Patients with malignancy operated with surgical resection and primary microvascular reconstruction and an available handgrip strength test were included in the study. This cohort is a subpopulation of a larger cohort (9), published earlier, of which subjects with available HGS data are here analyzed. Clinical and socio-economic data as well as follow-up survival data were collected from the Hospital District medical records. Collected data included primary and post-operatively confirmed histopathological diagnosis, evaluated by the multidisciplinary head and neck tumor board of Helsinki University Hospital, as well as TNM classification, all clinical patient records, imaging data, social and economic data available in hospital social workers records, and date of death. Surgical complications were classified according to the Clavien-Dindo classification (10, 11) and all patients with major complications needed second surgery within three weeks. Current or former working history was also collected from social workers’ notes and patients were recorded either as white-collar or blue-collar workers to evaluate potential bias in HGF data. In our unit, HGS data are collected by measuring the handgrip force with a Saehan hydraulic hand dynamometer, model SH5001, with adjustable handle (Yangdeok-Dong, Republic of Korea) (12). Three measures were performed on a sitting position arm, resting torso, and an elbow angle of 90 degrees. Both sides were tested three times per side and highest score was recorded for left and right individually. Body mass index was calculated for each patient; however, no additional muscle mass assessments were performed. Written informed consent was obtained from all patients. The data were collected and arranged using Microsoft Excel version 2016 and analyzed by using SPSS software version 26 (IBM, NY, USA) for statistical analysis. Statistical significance was evaluated using one way ANOVA and Mann-Whitney and Wilcoxon W tests (13).
Results
The study population consisted of 37 oral cancer patients. Overall patient characteristics and type of surgery can be seen in detail in Table I. Briefly, of 37 patients 15 were female and 22 male and the microvascular free flaps used were the radial forearm flap (RFF, n=23), anterolateral thigh flap (ALT, n=10), and deep circumflex iliac artery and bone free flap (ICFF, n=4). Average hospital stay was 13.3 days after the operation, and the need for intensive care unit (ICU) was 2.9 days. Of the 37 patients, 28 returned home after hospitalization, whereas 9 needed further therapy and supportive therapy in secondary medical institutions. Average preoperative HGS was 33 kg (right 34.2 kg, left 31.8 kg) for the patients. Effect of HGS on duration of hospitalization, susceptibility to postoperative complications, 3-month survival, or 12-month survival were not statistically significant. Female and male patients were also analyzed individually with similar results. Since physical discrepancy explained by patient work history could be a potential confounding factor for HGS its effect was also analyzed. The study population was further divided into subgroups of white-collar and blue-collar workers, and the effect of work history and HGS was evaluated by multivariate analysis. However, the results were not statistically significant. Charlson comorbidity index seemed to slightly correlate with one-year survival; however, the effect was not statistically significant (p=0.073). We also analyzed the effects of smoking, body mass index (BMI), alcohol consumption, age, and American Society of Anesthesiologists class (ASA-class), all of which were statistically insignificant. We also further analyzed the effect of microvascular flap type on the factors evaluated. ICFF flap was associated with poorer 12-month survival (p=0.013); however, subpopulations consisted of only four patients, all having widely infiltrating disease, which more probably explains the outcome. Neck dissection was performed on the majority of the patients and its width had no effect on outcome. The complications were divided into major and minor complications. Major complications observed (n=8) were partial flap loss (n=1), heart event requiring ICU (n=3), vena stasis requiring reoperation (n=2), hematoma, and need for emergency tracheostoma. No correlations between HGS and complications was observed.
Patient data and surgical outcome.
Discussion
The first purpose of the present study was to evaluate the use of HGS as a predictor for hospitalization and need for intensive care in patients with oral malignancies requiring surgical resection and primary reconstruction with microvascular free flap. Low HGS has been earlier demonstrated to poorly correlate with the nutritional status of the head and neck cancer patients during radiotherapy. This seems to be in line with our present data on HGS on duration of patient hospitalization or one-year survival. This is an interesting finding since low HGS has been associated with poorer outcome in other surgical managements of elderly or nutritionally compromised patients, such as those with hip fracture (14). The nutritional status of the patients in this study was rather good based on BMI (average 24.6), which suggests that despite the malignancies being located in the oral cavity, they had little effect on mastication and/or nutrition. In our study, no other quantitative muscle mass metrics or systematic evaluation of sarcopenia was performed. This would have helped to better evaluate the physical status of the patients. However, the aim of the study was to refer fast and easily feasible HGS evaluation for the clinicians to evaluate preoperative risks for the operation. Since it is possible that patients’ work history can affect HGS especially in physical workers, we also analyzed its effect on multivariate analysis. Interestingly, subgroups of blue-collar and white-collar workers did not differ regarding HGS, duration of hospitalization, complication rate, or patient survival. Similarly, female and male patients were evaluated together, as well as individually, and no statistical correlations on patient outcome were detected. However, larger registry-based studies have previously demonstrated that work history can affect head and neck cancer incidence and behavior (15, 16) but most probably the effects can be explained by other factors than patient physical status.
The secondary aim of the study was to evaluate the effects of patient demographics, smoking, alcohol consumption, CCI, and ASA, or flap type on complications and/or to the duration of hospitalization. None of the anamnestic factors studied affected the outcome of the patients. However, the ICFF flap associated with poorer survival of the patients. Only four patients with ICFF were included in the cohort, as it is commonly used in larger resections, when needing composite reconstructions of both the bone and soft tissue, which naturally affects the prognosis. Suh et al. have previously reported head and neck microvascular reconstructions to be rather reliable with only 0.8% flap failure rate; however, complications do exist (36%) and they can even be fatal (1.3%) (17). Our study population also revealed a rather high complication rate of microvascular reconstruction; only 40% of the patients managed to be discharged without complications. No fatal complications existed. We have previously demonstrated similar results with ICFF reconstruction (18).
In general, it can be said that microvascular reconstructions are rather reliable and even severe complications can be resolved for the benefit of the patient (19-22). It is known that large resections in the oral cavity can lead to severe problems in nutrition and microvascular resections can prevent this adverse effect; however, patient physical status-related factors may sometime be more significant than the type of reconstruction used (23, 24). Our results suggest that HGS poorly correlates with the clinical outcome or patient’s susceptibility to complications when treating oral cancers with surgical resection and primary microvascular reconstructions. Clinical examination and surgical experience play an important role in the design of surgery. In addition, careful examination, clinical intuition, and flap type selection play an important role when evaluating risk for complication rates. The search for new, fast, and feasible preoperative tools for patient risk evaluation is also warranted.
Acknowledgements
The Authors would like to thank Emil Aaltonen Foundation (Tampere, Finland), Päivikki and Sakari Sohlberg Foundation (Helsinki, Finland), The Finnish Medical Foundation (Helsinki, Finland), Paulo Foundation (Helsinki, Finland), Helsinki University Hospital District Funds (Helsinki, Finland), and Finnish Dental Society Apollonia (Helsinki, Finland) for the research grants.
Footnotes
Authors’ Contributions
Authors JS, LT, and SK collected patient data and drafted the manuscript. JT was responsible for the original study design as well as manuscript preparation. TW was responsible for statistical analysis and manuscript preparation.
Conflicts of Interest
The Authors confirm that no conflicts of interest exist in relation to this study.
- Received March 15, 2022.
- Revision received March 29, 2022.
- Accepted March 31, 2022.
- Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
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