Celecoxib Decreases Acute Postoperative Opioid Requirements after Head and Neck Reconstruction with Free Tissue Transfer: A Matched-Cohort Study

Presentation: AHNS008
Topic: Quality of Care and Clinical Pathways
Type: Oral
Date: Wednesday, April 18, 2018
Session: 10:30 AM - 11:20 AM Reconstruction and Rehabilitation
Authors: Patrick Carpenter, MD, Hilary McCrary, MD, Vanessa Torrecillas, MD, Amanda Kull, MD, Jason P Hunt, MD, Marcus M Monroe, MD, Luke O Buchmann, MD, Richard B Cannon, MD
Institution(s): University of Utah

Objectives: Head and neck oncology surgery with free tissue reconstruction is associated with significant postoperative pain.  Opioids are classically employed for postoperative analgesia but are associated with significant side effects including respiratory depression, nausea, constipation, and high rates of dependence and addiction.  Celecoxib is a selective COX-2 non-steroidal anti-inflammatory drug (NSAID) and has been shown to achieve analgesia in acute pain settings; however, it is not widely utilized after head and neck free tissue transfer.  The primary aim of this study is to investigate the effect Celecoxib has on opioid requirements in the postoperative setting after head and neck surgery and reconstruction with free tissue transfer. 

Methods: A retrospective matched-cohort study was conducted at the University of Utah evaluating patients who had undergone head and neck oncology surgery with free tissue reconstruction between June 2015 and August 2017.  Utilization of Celecoxib began in Sept 2016 after consultation with the Acute Pain Service and initiation of a quality improvement project.  Since that time it has been administered routinely in a scheduled fashion to all postoperative free flap patients, thus 2 cohorts of consecutive patients were eligible for inclusion.  Patients who received celecoxib in the postoperative setting were matched by stage and site with patients who did not receive celecoxib.  Primary outcomes were oral, intravenous (IV), and total morphine equivalents used in the postoperative setting per day.  Secondary outcomes were complications after surgery.

Results: There were 51 patients in the Celecoxib cohort and 50 patients in the control cohort that met inclusion criteria.  Clinicopathologic data comparing the cohorts is illustrated in Table 1.  Treatment with Celecoxib in the postoperative setting was significantly associated with decreased mean utilization of oral (29.4mg vs. 39.5mg; p=0.04), IV (1.5mg vs. 5.3mg; p<0.001), and total (31.8mg vs. 45mg; p=0.03) opioid morphine equivalents used per day.  Patients who received Celecoxib after head and neck free tissue reconstruction did not have an increased risk of flap dehiscence/surgical site infection (16% vs. 13%; p= 0.44), hematoma (1.9% vs. 4.0%; p= 0.21), or free flap failure rate (4.6% vs. 4.3%; p= 0.51) when compared to controls. 

Conclusion: Utilization of Celecoxib for head and neck oncology patients after reconstruction with free tissue transfer results in a significant decrease in oral, IV, and total opioid requirements without increasing surgery and flap related complications.  Particularly, inclusion of Celecoxib in our new pain management regimen has resulted in a 3.5 fold decrease in IV opioid usage for breakthrough and uncontrolled pain for our patients.

  Controls Celecoxib p value
Table 1. Clinicopathologic factors compared between celecoxib and control cohorts
# Patients 50 51  
Age (mean years) 65 63 0.2
Smoking History 21 23 0.42
Body Mass Index 26.1 28.2 0.73
T4 Lesion 24 25 0.32
Oral Cavity Resection 34 35 0.61