A National Comparison of Postoperative Head and Neck Reconstructive Surgery Outcomes in Patients with and Without Immunosuppression

Purpose/Objective(s) To characterize and assess the effects of immunosuppression on non–head-and-neck-specific postoperative complications following head and neck free flap reconstructive surgery. Materials/Methods A 2005-2016 retrospective analysis of adults undergoing head and neck reconstructive procedures was performed using the National Surgical Quality Improvement Program (NSQIP) database. Patients with immunosuppression (n=3,222) were compared with patients with no immunosuppression (n=130). Immunosuppression was defined as steroid use for a chronic condition. Categorical variables were assessed with Fisher's exact test and continuous variables were assessed with Student's t-test. Primary outcomes were 30-day postoperative variables, including return to the operating room, re-intubation, surgical site infection (SSI), and readmission. Multivariable logistic regression analysis was used to evaluate preoperative factors that were noted to be significantly associated with the primary outcomes of interest on univariate analysis. Significance was set at alpha <0.05. Results Patients on immunosuppression were more likely to be older, have higher American Society of Anesthesiology (ASA) class, have worse functional status, and have higher rates of hypertension. The 30-day mortality rate was 2.3% for immunosuppressed patients and 0.9% for non-immunosuppressed patients (P > 0.05). Overall, immunosuppressed patients were more likely to experience at least 1 complication (53.8% vs 32.9%, P < 0.001) and almost twice as likely to have a postoperative surgical complication (50.0% vs 28.1%, P < 0.001). The immunosuppressed cohort had higher rates of superficial SSI (11.5% vs 5.9%, P = 0.014) and organ space SSI (4.6% vs 1.7%, P = 0.029). On multivariable analysis, immunosuppression was not associated with increased risk of return to the operating room within 30 days. However, ASA class 3 or 4, dependent functional status, hypertension, inpatient status, and malignant final pathology were all risk factors for re-operation (P < 0.05). Patients with a BMI > 30 were significantly less likely to return to the operating room (OR, 0.726; 95% CI, 0.569, 0.926; P = 0.010). Conclusion National data suggest that head and neck reconstructive procedures in both immunosuppressed and non-immunosuppressed populations are relatively safe. However, immunosuppression is associated with higher rates of postoperative complications and postoperative surgical complications, with superficial and organ space surgical site infections being the largest contributors. These findings may play a role in determining treatment plans for patients and optimizing risk reduction.