Practice patterns in transoral robotic surgery: Results of an American Head and Neck Society survey

Presentation: S006
Topic: Oropharynx / HPV Related Disease
Type: Oral
Date: Friday, July 23, 2021
Session: 1:00 PM - 1:50 PM Skullbase Plus
Authors: Andrew J Holcomb, MD1; Rachael Kammer, CCCSLP1; Allison Holman, CCCSLP1; Tessa Goldsmith, CCCSLP1; Vasu Divi, MD2; Heather M Starmer, CCCSLP2; Joseph Zenga, MD3; Ryan Li, MD4; Urjeet A Patel, MD5; Jeremy D Richmon, MD1
Institution(s): 1Massachusetts Eye and Ear / Harvard Medical School; 2Stanford University; 3Medical College of Wisconsin; 4Oregon Health Sciences University; 5Northwestern University


Importance:

Perioperative protocols are not well-developed for transoral robotic surgery (TORS), and the degree of variability in perioperative practices between institutions is unknown.


Objective:

To understand current perioperative practices for TORS among academic medical centers.


Design:

Cross-sectional survey


Setting:

Multi-institutional


Participants:

Clinical fellows and fellowship directors participating in 49 American Head and Neck Society Advanced Training Council fellowships


Main Outcome(s) and Measure(s):

Operative decisions, medical and swallowing management, and disposition planning were assessed.


Results:

Thirty-eight responses were voluntarily collected (77.6%). Twenty-three centers (60.5%) performed greater than 25 cases annually with the remainder performing fewer. The DaVinci Si was the most commonly used platform (n=28, 73.7%). Most (n=23, 60.5%) centers limited resections to T1-T2 tumors, and the remainder considered operating on T3-T4 tumors. A majority of institutions advocated tailored resection to adequate margins (n=27, 71.1%) over fixed subunit-based resection (n=11, 28.9%). Most surgeons (n=29, 76.3%) performed neck dissection concurrent with primary tumor ablation, and 89.5% (n=34) routinely ligated branches of the external carotid artery. A minority of institutions (n=17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n= 21, 55.3%), and the most common duration being 24 hours or less (n=22, 57.9%). Opiates were the most commonly used pain medication (n=36, 94.7%), and multimodal analgesia was used at 36 centers (94.7%). Steroids were utilized at 31 centers (81.6%). Mechanical VTE prophylaxis was used at all centers, whereas pharmacologic prophylaxis was used at 29 centers (76.3%). Feeding tubes were placed proactively during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed post-operative swallow evaluations at 29 (78.4%) sites. The most common disposition was a floor bed (n=21, 55.3%), the median length of stay reported was two days (range 0-5, mean 2.45).


Conclusions and Relevance:

Practice patterns are variable among institutions performing TORS. While certain surgical practices were quite common, post-operative practices varied, and many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.