Publications by authors named "Alexander Langerman"

77 Publications

Socioeconomic Influences on Short-term Postoperative Outcomes in Patients With Oral Cavity Cancer Undergoing Free Flap Reconstruction.

Otolaryngol Head Neck Surg 2021 May 25:1945998211012954. Epub 2021 May 25.

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objective: To evaluate the associations between median household income (MHI) and area deprivation index (ADI) on postoperative outcomes in oral cavity cancer.

Study Design: Retrospective review (2000-2019).

Setting: Single-institution tertiary medical center.

Methods: MHI and ADI were matched from home zip codes. Main postoperative outcomes of interest were length of tracheostomy use, length of hospital stay, return to oral intake, discharge disposition, and 60-day readmissions. Linear and logistic regression controlled for age, sex, race, body mass index, tobacco and alcohol use history, primary tumor location, disease staging at presentation, and length of surgery. A secondary outcome was clinical disease staging (I-IV) at time of presentation.

Results: The cohort (N = 681) was 91.3% White and 38.0% female, and 51.7% presented with stage IV disease. The median age at the time of surgery was 62 years (interquartile range [IQR], 53-71). The median MHI was $47,659 (IQR, $39,324-$58,917), and the median ADI was 67 (IQR, 48-79). ADI and MHI were independently associated with time to return of oral intake (β = 0.130, P = .022; β = -0.092, P = .045, respectively). Neither was associated with length of tracheostomy, hospital stay, discharge disposition, or readmissions. MHI quartiles were associated with a lower risk of presenting with more advanced disease (Q3 vs Q1: adjusted odds ratio, 0.56 [95% CI, 0.32-0.97]).

Conclusion: MHI is associated with oral cavity cancer staging at the time of presentation. MHI and ADI are independently associated with postoperative return to oral intake following intraoral tumor resection and free flap reconstruction.
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http://dx.doi.org/10.1177/01945998211012954DOI Listing
May 2021

A Survey of Overlapping Surgery Policies at U.S. Hospitals.

J Law Med Ethics 2021 ;49(1):64-73

The authors surveyed hospitals across the country on their policies regarding overlapping surgery, and found large variation between hospitals in how this practice is regulated. Specifically, institutions chose to define "critical portions" in a variety of ways, ultimately affecting not only surgical efficiency but also the autonomy of surgical trainees and patient experiences at these different hospitals.
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http://dx.doi.org/10.1017/jme.2021.11DOI Listing
July 2021

Diagnostic approaches to carcinoma of unknown primary of the head and neck.

Eur J Cancer Care (Engl) 2021 May 1:e13459. Epub 2021 May 1.

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Squamous cell carcinoma in cervical lymph nodes arising from an undetected primary tumour, termed carcinoma of unknown primary (SCCUP), is a well-recognized clinical presentation within head and neck oncology. SCCUP is a common presentation for patients with human papillomavirus-mediated oropharyngeal cancer (HPV + OPSCC), as patients with HPV + OPSCC often present with smaller primary tumours and early nodal metastasis. Meticulous work-up of the SCCUP patient is central to the management of these patients as identification of the primary site improves overall survival and allows for definitive oncologic resection or more focused radiation when indicated. This review summarizes the comprehensive diagnostic approach to the SCCUP patient, including history and physical examination, methods of biopsy of the cervical lymph node, imaging modalities and intraoperative methods to localize the unknown primary. Novel techniques such as transcervical ultrasound of the oropharynx, narrow band imaging and diagnostic transoral robotic surgery are also discussed.
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http://dx.doi.org/10.1111/ecc.13459DOI Listing
May 2021

Novel Technologies in Airway Diseases: With Greater Power Comes Greater Responsibility.

J Bronchology Interv Pulmonol 2021 Apr;28(2):95-97

Center for Biomedical Ethics and Society.

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http://dx.doi.org/10.1097/LBR.0000000000000760DOI Listing
April 2021

Neuroendocrine carcinomas of the head and neck: A small case series.

Am J Otolaryngol 2021 Jul-Aug;42(4):102992. Epub 2021 Feb 17.

Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, Nashville, TN 37232, United States of America. Electronic address:

Introduction: Neuroendocrine tumors of the head and neck are rare and arise either from epithelial or neuronal origin. Debate continues over the classification systems and appropriate management of these pathologies.

Objective: By investigating a small set of cases of high grade epithelial-derived neuroendocrine tumors of the head and neck (neuroendocrine carcinomas or NEC) from one institution, we compare survival rates of NEC of the head and neck to pulmonary NEC.

Methods: We identified patients from pathology records with neuroendocrine carcinomas of the head and neck and retrospectively collected clinical data as well as immunohistochemical (IHC) staining data.

Results: We identified 14 patients with NEC, arising from the parotid (n = 5), nasal cavity (n = 4), larynx (n = 2), and other regions (n = 2). One additional patient had NEC arising in two sites simultaneously (parotid and nasal). Staining patterns using IHC were relatively consistent across specimens, showing reactivity to chromogranin and synaptophysin in 73% and 100% of specimens, respectively. Treatment courses varied across patients and included combinations of surgery, chemotherapy, and/or radiation. The overall survival rate at 1, 2, and 5 years of these patients was 56%, 56%, and 43% with a mean follow-up time of 2.12 years.

Conclusion: Compared to NEC arising in the lung, this subset of patients had better survival rates, but worse survival rates than the more common squamous cell carcinoma of the head and neck.
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http://dx.doi.org/10.1016/j.amjoto.2021.102992DOI Listing
February 2021

Patient Perceptions of Audio and Video Recording in the Operating Room.

Ann Surg 2021 Jan 15. Epub 2021 Jan 15.

*Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN †Program on Surgical Ethics, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN ‡International Center for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Ontario, Canada.

Background Data: Continuous audio-video recording of the operating room (OR), akin to the aviation industry's black box, has been proposed as a means to enhance training, supplement the medical record, and allow large-scale analysis of surgical performance and safety. These recordings would include patients' bodies; yet, understanding of patient perceptions regarding such technology is limited.

Objective: The goal of this study was to determine surgical patients' perceptions of hypothetical continuous audio-video OR recording (ORR).

Methods: Semi-structured interviews were conducted during elective surgery pre-operative appointments during a two-week period in August 2018 at a quaternary care center. Deidentified transcripts were analyzed using thematic analysis.

Results: Forty-nine subjects were interviewed. Subjects recognized the potential for recording to improve surgical quality, safety and training. Subjects also desired access to an objective record of their own surgery, for the purposes of future care, medical-legal evidence, and to satisfy their own curiosity and understanding. Subjects had mixed perceptions regarding OR decorum and thus, differing views on the potential effect of ORR on OR behavior; some imagined that ORR would discourage bad behavior and others worried that it would cause unnecessary anxiety to the surgical team.

Conclusions: Patients have a diverse set of views about the potential benefits, risks, and uses for OR data and consider themselves to be important stakeholders. Our study identifies pathways and potential challenges to implementation of continuous audio/video recording in operating rooms.
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http://dx.doi.org/10.1097/SLA.0000000000004759DOI Listing
January 2021

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

Ann Otol Rhinol Laryngol 2021 Feb 25:3489421995283. Epub 2021 Feb 25.

Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, CA, USA.

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients.

Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence.

Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression.

Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.
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http://dx.doi.org/10.1177/0003489421995283DOI Listing
February 2021

Improving Mortality Attribution in Otolaryngology - Head and Neck Surgery.

Laryngoscope 2021 06 10;131(6):E1805-E1810. Epub 2021 Feb 10.

Department of Otolaryngology Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.

Objective/hypothesis: Mortality attribution can have significant implications for reimbursement, hospital/department rankings, and perceptions of safety. This work seeks to compare the accuracy of externally assigned diagnosis-related group (DRG)-based service line mortality attribution in otolaryngology to an internal review process that assigns mortality to the teams that cared for a patient during hospitalization.

Study Design: Retrospective case series.

Methods: Mortality events at Vanderbilt University Medical Center (VUMC) from 2012 to 2018 were compared. Included events were assigned to the otolaryngology service line (OSL) via the following methods: an external agency (Vizient) using DRG, utilization management assignment based on the service that provided care at admission (admission service), discharge (discharge service), or throughout hospitalization (major service line), or through the internal VUMC mortality review committee. Internal review was considered the standard for comparison.

Results: Of the 28 mortality events assigned to OSL by the DRG-based external method, nine (32%) were actually attributable to OSL. Of the 23 total mortality events attributable to OSL at our institution, external DRG-based review captured nine (39%). The designation of major service during hospitalization was correct 95% of the time and captured 87% of mortality events. Differences between external and internal attribution methods were statistically significant (P < .001).

Conclusions: DRG-based models are frequently utilized but can be inaccurate when attributing mortality for an individual otolaryngology department. Otolaryngology mortalities appear to be captured and assigned more accurately by assigning deaths to the service that renders the majority of care during hospitalization.

Level Of Evidence: 4 Laryngoscope, 131:E1805-E1810, 2021.
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http://dx.doi.org/10.1002/lary.29418DOI Listing
June 2021

Institution-Specific Strategies for Head and Neck Oncology Triage During the COVID-19 Pandemic.

Ear Nose Throat J 2020 Dec 4:145561320975509. Epub 2020 Dec 4.

Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: This work seeks to better understand the triage strategies employed by head and neck oncologic surgical divisions during the initial phases of the coronavirus 2019 (COVID-19) outbreak.

Methods: Thirty-six American head and neck surgical oncology practices responded to questions regarding the triage strategies employed from March to May 2020.

Results: Of the programs surveyed, 11 (31%) had official department or hospital-specific guidelines for mitigating care delays and determining which surgical cases could proceed. Seventeen (47%) programs left the decision to proceed with surgery to individual surgeon discretion. Five (14%) programs employed committee review, and 7 (19%) used chairman review systems to grant permission for surgery. Every program surveyed, including multiple in COVID-19 outbreak epicenters, continued to perform complex head and neck cancer resections with free flap reconstruction.

Conclusions: During the initial phases of the COVID-19 pandemic experience in the United States, head and neck surgical oncology divisions largely eschewed formal triage policies and favored practices that allowed individual surgeons discretion in the decision whether or not to operate. Better understanding the shortcomings of such an approach could help mitigate care delays and improve oncologic outcomes during future outbreaks of COVID-19 and other resource-limiting events.

Level Of Evidence: 4.
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http://dx.doi.org/10.1177/0145561320975509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720027PMC
December 2020

Not All Conflicts Are Bad: Why Some Conflicts of Interests Advance Patients' Interests.

Am J Bioeth 2020 10;20(10):92-94

Vanderbilt University Medical Center.

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http://dx.doi.org/10.1080/15265161.2020.1806626DOI Listing
October 2020

Using Surgical Video to Classify Intraoperative Events.

Ann Surg 2020 08;272(2):227-228

Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN.

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http://dx.doi.org/10.1097/SLA.0000000000003934DOI Listing
August 2020

The Value of the Surgeon Informatician.

J Surg Res 2020 08 10;252:264-271. Epub 2020 May 10.

IBM Watson Health, Cambridge, Massachusetts; Departments of Pediatric Surgery, Pediatrics, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.

Clinical informatics is an interdisciplinary specialty that leverages big data, health information technologies, and the science of biomedical informatics within clinical environments to improve quality and outcomes in the increasingly complex and often siloed health care systems. Core competencies of clinical informatics primarily focus on clinical decision making and care process improvement, health information systems, and leadership and change management. Although the broad relevance of clinical informatics is apparent, this review focuses on its application and pertinence to the discipline of surgery, which is less well defined. In doing so, we hope to highlight the importance of the surgeon informatician. Topics covered include electronic health records, clinical decision support systems, computerized order entry, data analytics, clinical documentation, information architectures, implementation science, quality improvement, simulation, education, and telemedicine. The formal pathway for surgeons to become clinical informaticians is also discussed.
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http://dx.doi.org/10.1016/j.jss.2020.04.003DOI Listing
August 2020

Embedding Ethics Education in Clinical Clerkships by Identifying Clinical Ethics Competencies: The Vanderbilt Experience.

HEC Forum 2020 Jun;32(2):163-174

Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA.

The clinical clerkships in medical school are the first formal opportunity for trainees to apply bioethics concepts to clinical encounters. These clerkships are also typically trainees' first sustained exposure to the "reality" of working in clinical teams and the full force of the challenges and ethical tensions of clinical care. We have developed a specialized, embedded ethics curriculum for Vanderbilt University medical students during their second (clerkship) year to address the unique experience of trainees' first exposure to clinical care. Our embedded curriculum is centered around core "ethics competencies" specific to the clerkship: for Medicine, advanced planning and end-of-life discussions; for Surgery, informed consent; for Pediatrics, the patient-family-provider triad; for Obstetrics and Gynecology, women's autonomy, unborn child's interests, and partner's rights; and for Neurology/Psychiatry, decision-making capacity. In this paper, we present the rationale for these competencies, how we integrated them into the clerkships, and how we assessed these competencies. We also review the additional ethical issues that have been identified by rotating students in each clerkship and discuss our strategies for continued evolution of our ethics curriculum.
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http://dx.doi.org/10.1007/s10730-020-09410-yDOI Listing
June 2020

Should I Buy This? A Decision-Making Tool for Surgical Value-Based Purchasing.

Otolaryngol Head Neck Surg 2020 09 14;163(3):397-399. Epub 2020 Apr 14.

Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Many considerations affect the value that a new instrument or product may generate in a surgical practice. This review serves as a guide for surgeons considering new purchases and/or wishing to advocate for hospital acquisition of new items. A summary of data from academic and industry practices is presented, with pertinent examples using relevant surgical devices such as disposable devices, laparoscopic trocars, and otologic endoscopes. Surgeons considering incorporating a new instrument or technology within their practice should weigh the following factors before decision making: patient and clinical care factors, surgeon and care team factors, and hospital factors such as cost, revenue, and sourcing. A surgeon well-versed in stakeholder interests who is involved in the purchase of a new instrument may have significant influence in value-based decision making that not only affects his or her practice but ultimately maximizes value for the patient.
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http://dx.doi.org/10.1177/0194599820915194DOI Listing
September 2020

Surgeon Perspectives on Benefits and Downsides of Overlapping Surgery: In-depth, Qualitative Interviews.

Ann Surg 2020 Apr 8. Epub 2020 Apr 8.

Program in Surgical Ethics, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN.

Objective: The aim of the study was to characterize surgeon perspectives regarding the benefits and downsides of conducting overlapping surgery.

Background: Although surgeons are key stakeholders in current discussions surrounding overlapping surgery, little has been published regarding their opinions on the practice. Further characterization of surgeon perspectives is needed to guide future studies and policy development regarding overlapping surgery.

Methods: Study information was sent to all members of 3 professional surgical societies. Interested individuals were eligible to participate if they identified as attending surgeons in an academic setting who work with trainees. Purposive selection was used to diversify surgeons interviewed across multiple dimensions, including subspecialty and opinion regarding appropriateness of overlapping surgery. In-depth, qualitative interviews were conducted with participants regarding their opinions on overlapping surgery.

Results: The 51 surgeons interviewed identified a wide array of potential benefits and disadvantages of overlapping surgery, some of which have not previously been measured, including downsides to surgeon wellness and patient experience, less surgeon control over procedures, and difficulty in scheduling cases. Interviewees often disagreed as to whether overlapping surgery negatively or positively affects each dimension discussed, particularly regarding the impact on resident training.

Conclusions: The utilization of the novel perspectives presented here will allow for targeted assessment of physician perspectives in future quantitative studies and increase the likelihood that variables measured encompass the range of factors that surgeons find meaningful and relevant. Priority areas of future research should include examining effects of overlapping surgery on surgical training and surgeon wellness.
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http://dx.doi.org/10.1097/SLA.0000000000003722DOI Listing
April 2020

Transcervical sonography and human papillomavirus 16 E6 antibodies are sensitive for the detection of oropharyngeal cancer.

Cancer 2020 06 4;126(11):2658-2665. Epub 2020 Mar 4.

Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Human papillomavirus 16 (HPV-16) E6 seropositivity is a promising early marker of human papillomavirus-driven oropharyngeal cancer (HPV-OPC), yet more sensitive imaging modalities are needed before screening is considered. The objective of this study was to determine the sensitivity of transcervical sonography (TCS) for detecting clinically apparent HPV-OPC in comparison with computed tomography (CT) and positron emission tomography (PET)/CT.

Methods: Fifty-one patients with known or suspected HPV-OPC without prior treatment underwent oropharyngeal TCS and blood collection (for HPV multiplex serology testing). Eight standard sonographic images were collected; primary-site tumors were measured in 3 dimensions if identified. Each patient underwent a full diagnostic workup as part of standard clinical care. The pathologic details, HPV status, final staging, and imaging findings were abstracted from the medical record. The sensitivity of each imaging modality was compared with the final clinical diagnosis (the gold standard).

Results: Twenty-four base of tongue cancers (47%), 22 tonsillar cancers (43%), and 2 unknown primary cancers (4%) were diagnosed; 3 patients (6%) had no tumors. All p16-tested patients were positive (n = 47). Primary-site tumors were correctly identified in 90.2% (95% confidence interval [CI], 78.6%-96.7%) with TCS, in 69.4% (95% CI, 54.6%-81.7%) with CT, and in 83.3% (95% CI, 68.6%-93.0%) with PET/CT. TCS identified tumors in 10 of 14 cases missed by CT and recognized the absence of tumors in 3 cases for which CT or PET/CT was falsely positive. The smallest sonographically identified primary-site tumor was 0.5 cm in its greatest dimension; the average size was 2.3 cm. Among p16-positive patients, 76.1% (95% CI, 61.2%-87.4%) were seropositive for HPV-16 E6.

Conclusions: TCS and HPV-16 E6 antibodies are sensitive for the diagnosis of HPV-OPC.
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http://dx.doi.org/10.1002/cncr.32799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7829679PMC
June 2020

Trust as a Predictor of Patient Perceptions Regarding Overlapping Surgery and Trainee Independence.

Laryngoscope 2020 11 17;130(11):2728-2735. Epub 2020 Feb 17.

Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A.

Objectives: To examine opinions on trainee independence and attending presence among a cross-section of the general population and explore how perceptions of trust, past experiences, and demographics interacted with comfort consenting to these surgical scenarios.

Study Design: Mixed-methods METHODS: Based on prior qualitative analysis, we designed a survey of patient preferences and values that focused on trust in healthcare practitioners and processes, which also included comfort ratings of three surgical scenarios (including overlapping surgery). The survey was administered to a sample from the general public using Mechanical Turk. We identified discreet domains of trust and examined the association of responses to these domains with comfort ratings, prior healthcare experiences, and demographics.

Results: We analyzed 225 surveys and identified four patient subgroups based on responses to the surgical scenarios. Subjects that were more comfortable with overlapping surgery were more trusting of trainees and delegation by the attending. Past experiences in healthcare (positive and negative) were associated with multiple domains of trust (in trainees, surgeons, and the healthcare system). Demographics were not predictive of trust responses or comfort ratings.

Conclusion: Patients express varying degrees of comfort with overlapping surgery, and this is not associated with demographics. Past negative experiences have an impact on trust in the healthcare system overall, and trust in trainees specifically predicts comfort with attending absence from the operating room. Efforts to increase patient comfort with overlapping surgery and surgical training should include strategies to address past negative experiences and foster trust in trainees and the delegation process.

Level Of Evidence: IV Laryngoscope, 130:2728-2735, 2020.
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http://dx.doi.org/10.1002/lary.28557DOI Listing
November 2020

Patient values regarding overlapping surgery: Identification of distinct patient subgroups.

Laryngoscope 2020 12 20;130(12):2779-2784. Epub 2019 Nov 20.

Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.

Objectives/hypothesis: To explore patient values associated with their comfort level with surgical trainees and attending surgeon absence from the operating room.

Study Design: Qualitative interviews with general medical patients.

Methods: We analyzed data from qualitative interviews with patients that included a quantitative rating on a visual analog scale (VAS) of comfort consenting to three surgical scenarios, including overlapping surgery, to identify subgroups of patients based on comfort level. After identifying subgroups, we compared qualitative responses from participants who were generally comfortable with overlapping surgery to those who were uncomfortable to identify themes associated with these perceptions.

Results: We identified three subgroups of patients based on the patterns of VAS responses. Participants who were comfortable with overlapping surgery expressed trust in the surgeon and delegation process. Those who were most uncomfortable expressed a strong desire to know who was operating on them, and a desire for control over their surgical process. Subjects uncomfortable with overlapping surgery were also generally not sensitive to tradeoffs (cost, timing).

Conclusions: We identified distinct subgroups of patients based on their comfort level with trainee independence and primary attending availability. By examining the predominant values in these subgroups, we identified potential explanations for patient discomfort with attending absence. Strategies to enhance patients' knowledge about the process of surgery and a sense of control over their own care may improve comfort with trainee participation and overlapping surgery.

Level Of Evidence: 6 Laryngoscope, 2019.
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http://dx.doi.org/10.1002/lary.28405DOI Listing
December 2020

Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality.

JAMA Surg 2020 01 15;155(1):e194620. Epub 2020 Jan 15.

Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.

Importance: Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood.

Objective: To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study.

Design, Setting, And Participants: This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress.

Exposures: Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score.

Main Outcomes And Measures: Postoperative mortality at 30, 90, and 180 days.

Results: Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures.

Conclusions And Relevance: We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.
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http://dx.doi.org/10.1001/jamasurg.2019.4620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6865246PMC
January 2020

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

JAMA Otolaryngol Head Neck Surg 2020 01;146(1):20-29

Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research.

Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease.

Design, Setting, And Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook.

Main Outcomes And Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications.

Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk.

Conclusions And Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.
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http://dx.doi.org/10.1001/jamaoto.2019.3022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824232PMC
January 2020

Resident Perspectives on Teaching During Awake Surgical Procedures.

J Surg Educ 2019 Nov - Dec;76(6):1492-1499. Epub 2019 May 3.

University of Chicago, Department of Surgery, Chicago, Illinois; NorthShore University HealthSystem, Department of Surgery, Evanston, Illinois. Electronic address:

Introduction: Residents learn technical and communication skills during training and practice both concurrently during awake surgical procedures. Patients have expressed mixed views on resident involvement in their surgical care, making this context challenging for residents to navigate. We sought to qualitatively explore resident perspectives on teaching during awake surgical procedures.

Methods: Residents in Urology, Obstetrics and Gynecology, and General Surgery who had been exposed to 10 or more awake surgical procedures were recruited for recorded focus groups at the University of Chicago. Recordings were transcribed, coded, and reviewed by 3 researchers using the constant comparative method until thematic saturation was reached.

Results: Twenty-five residents participated in 5 focus groups. Residents identified positive educational techniques during awake surgery including preprocedural communication, explaining teaching and the resident role, whispering/nonverbal communication, involving the patient in education, and confident educator. Residents described challenges and failures in education, including hesitating to ask questions, hesitating to correct a learner, whispering/nonverbal communication, and taking over. In discussing informed consent during awake procedures, some residents described that the consent process should or did change during awake procedures, for example, to include more information about the resident role.

Conclusions: Residents participating in awake surgical procedures offer new insights on successful techniques for teaching during awake surgery, emphasizing that good communication in the procedure room starts beforehand. They also identify challenges with teaching in this context, often related to a lack of open and clear communication.
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http://dx.doi.org/10.1016/j.jsurg.2019.04.007DOI Listing
October 2020

Early onset oral tongue squamous cell carcinoma: Associated factors and patient outcomes.

Head Neck 2019 06 11;41(6):1952-1960. Epub 2019 Jan 11.

Vanderbilt University Medical Center, Department of Otolaryngology, Nashville, Tennessee, USA.

Background: Incidence of oral tongue squamous cell carcinoma (OTC) is rising among those under age 50 years. The etiology is unknown.

Methods: A total of 395 cases of OTC diagnosed and/or treated at Vanderbilt University Medical Center between 2000 and 2017 were identified. Of those, 113 (28.6%) were early onset (age < 50 years). Logistic regression was used to identify factors associated with early onset OTC. Cox proportional hazards models evaluated survival and recurrence.

Results: Compared to typical onset patients, patients with early onset OTC were more likely to receive multimodality treatment (surgery and radiation; adjusted odds ratio [aOR], 2.7; 95% confidence interval [CI], 1.2-6.3) and report a history of snuff use (aOR, 5.4; 95% CI, 1.8-15.8) and were less likely to report a history of cigarette use (aOR, 0.5; 95% CI, 0.2-0.9). Early onset patients had better overall survival (adjusted hazard ratio, 0.6).

Conclusions: This is the largest study to evaluate factors associated with early onset OTC and the first to report an association with snuff.
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http://dx.doi.org/10.1002/hed.25650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7010313PMC
June 2019

Patient opinions regarding surgeon presence, trainee participation, and overlapping surgery.

Laryngoscope 2019 06 24;129(6):1337-1346. Epub 2018 Dec 24.

Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.

Objectives: To explore patient opinions and underlying values regarding overlapping surgery (OS) scenarios, specifically evaluating the effect of attending surgeon presence and availability, as well as trainee participation on patient comfort level and willingness to consent.

Study Design: Mixed methods.

Methods: Forty adults participated in semi-structured interviews. Interviews included vignettes involving three scenarios of OS (1: attending present; 2: attending absent for wound closure; 3: attending absent and unavailable for wound closure, with covering attending), visual analog scale ratings of participants' comfort with scenarios, and cognitive debriefing. Themes and subthemes were identified using hierarchical coding of transcripts, and quantitative and qualitative analyses were conducted.

Results: Quantitative analysis revealed anticipated decreases in comfort with decreasing attending presence/availability (mean comfort level 94% vs. 78% vs. 63% for scenarios 1 vs. 2 vs. 3, P < 0.005), although many patients reported improved comfort with scenario 3 if meeting the covering attending. Participants demonstrated a preference for less trainee involvement (P < 0.005, scenario 1) and greater trainee experience (P < 0.05, all scenarios). However, not all individuals were uncomfortable with attending absence or trainee independence. Themes important for decision making included trust in the surgeon, surgeon experience, trainee involvement, disease severity, cost, and wait time.

Conclusion: Patients varied highly in their willingness to consent to OS scenarios. In settings of trainee independence and covering surgeons, many patients desired meeting these members of the treatment team, which improved comfort for some. For some patients, tradeoffs and incentives of timeliness, cost, and convenience modified their willingness to have OS.

Level Of Evidence: 4 Laryngoscope, 129:1337-1346, 2019.
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http://dx.doi.org/10.1002/lary.27541DOI Listing
June 2019

Early onset oral tongue cancer in the United States: A literature review.

Oral Oncol 2018 12 14;87:1-7. Epub 2018 Oct 14.

Vanderbilt University Medical Center, Department of Otolaryngology, 1215 21st Ave S, Nashville, TN 37232, USA; Vanderbilt University Medical Center, 2525 West End Ave, Suite 300, Nashville, TN, 37203, USA. Electronic address:

The incidence of early onset oral tongue squamous cell carcinoma (OTC) has been increasing in the United States, and no clear etiology has been identified. Studies on this topic have generally been small and presented varied results. The goal of this review is to analyze and synthesize the literature regarding early onset OTC risk factors, outcomes, and molecular analyses within the US. To date, studies suggest that early onset OTC patients tend to have less heavy cigarette use than typical onset patients, but there may be an association between early onset OTC and smokeless tobacco (chewing tobacco and snuff) use. Early onset OTC is associated with similar or possibly improved survival compared to typical onset OTC. There has been no evidence to support a significant role for human papillomavirus in development of early onset OTC. Further research with larger cohorts of these patients is needed to better characterize this disease entity.
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http://dx.doi.org/10.1016/j.oraloncology.2018.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7039330PMC
December 2018

Papillary-Type Carcinoma of the Thyroglossal Duct Cyst: The Case for Conservative Management.

Ann Otol Rhinol Laryngol 2018 Oct 9;127(10):710-716. Epub 2018 Aug 9.

1 Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objectives: Thyroglossal duct cyst (TGDC) is the most common congenital neck mass, presenting in up to 7% of the population. TGDC carcinoma is much less common, occurring in roughly 1% of patients diagnosed with TGDC. The vast majority of these tumors are papillary-type thyroid cancer. Given its rarity, there is wide variation in management recommendations for this disease. Extent of surgical management and need for adjuvant therapy including radioactive iodine ablation (RAI) are particularly debated, with some authors arguing aggressive therapy including RAI for any patients who undergo concurrent thyroidectomy with the Sistrunk procedure for TGDC carcinoma. We present a series of patients treated for TGDC carcinoma at our institutions and discuss our management algorithm.

Methods: This is a retrospective chart review of patients with TGDC treated at 2 separate institutions. Factors reviewed included patient age, sex, preoperative diagnosis, preoperative work-up, extent of therapy, and use of adjuvant therapy.

Results: Six patients who were treated for TGDC carcinoma at our institutions were identified. One patient was excluded because the patient had been treated at an outside facility prior to referral. All patients had papillary-type thyroid cancer. One patient underwent the Sistrunk procedure alone, and the remaining 4 underwent the Sistrunk procedure plus total thyroidectomy. Two of 4 patients were noted to have malignancy in the thyroid. Two of 4 patients who underwent thyroidectomy additionally received adjuvant RAI.

Conclusion: Thyroglossal duct cyst carcinoma is uncommon and management is controversial. In low-risk patients (single tumor focus, negative margins, normal preoperative neck/thyroid imaging, no extension of TGDC carcinoma beyond the cyst wall), the Sistrunk procedure alone with observation of the thyroid may be sufficient. In this patient population, RAI is unlikely to be of any substantial benefit.
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http://dx.doi.org/10.1177/0003489418791892DOI Listing
October 2018

Head and Neck Cancer Patients: Rates, Reasons, and Risk Factors for 30-Day Unplanned Readmission.

Otolaryngol Head Neck Surg 2018 07 22;159(1):149-157. Epub 2018 May 22.

2 Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Objective To analyze rates, risk factors, and complications for 30-day readmission among head and neck cancer (HNC) patients. Methods Retrospective review of administrative records from Vizient (Irving, Texas) Clinical Data Base/Resource Manager on HNC patients who underwent a head and neck surgical procedure from January 2013 through September 2015 at 176 academic and community medical centers. Results Of the 18,121 patients included in the study, 2502 patients were readmitted within 30 days (13.8%). Mean time to readmission was 11 ± 8.2 days. Cancer of the hypopharynx, oropharynx, pharynx, and larynx all had higher odds of readmission compared to oral cavity (odds ratio [OR], 1.8, 1.7, 1.6, and 1.5; 95% confidence interval [CI], 1.4-2.2, 1.4-1.9, 1.2-2.3, and 1.3-1.7, respectively). Consistent with this, flap procedures and laryngectomy had the highest odds of readmission (OR, 1.4 and 1.3; 95% CI, 1.3-1.6 and 1.0-1.5 vs glossectomy, respectively). The most common surgical causes for readmission were postoperative infection (17.6%) and surgical wound dehiscence (16.8%), which most commonly presented on postdischarge days 4 to 5. Acute cardiac events occurred in up to 15.4% of patients depending on complexity of surgery. Dysphagia and electrolyte disturbances were common (15.8% and 15.4%, respectively); patients with these complications typically presented earlier, between days 3 and 4. Discussion Patients with HNC are at high risk of readmission. The cancer subsite and procedure significantly influenced the risk, rate, and reason for readmission. Implications for Practice Findings from this study can help quality improvement and patient safety administrators develop interventions that uniquely target HNC populations.
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http://dx.doi.org/10.1177/0194599818776633DOI Listing
July 2018

How Should Trainee Autonomy and Oversight Be Managed in the Setting of Overlapping Surgery?

AMA J Ethics 2018 Apr 1;20(4):342-348. Epub 2018 Apr 1.

A head and neck surgeon and ethicist at Vanderbilt University Medical Center in Nashville, Tennessee.

This case highlights an attending surgeon's conflicts between duty to care for individual patients, train independent surgeons, and serve a patient population in an efficient manner. Although oversight of surgical residents and multiple operating room scenarios can be conducted in an ethical manner, patients might not understand the realities of surgical training and clinical logistics without explicit disclosure. Central to the ethical concerns of the case are the attending surgeon's obfuscation of resident involvement and her insufficient oversight of two concurrent procedures. Full and proper informed consent, increased transparency, better planning, and improved communication could have prevented this difficult situation.
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http://dx.doi.org/10.1001/journalofethics.2018.20.4.ecas3-1804DOI Listing
April 2018

Nuanced Reporting of Fistulas in Laryngectomy Studies.

Otolaryngol Head Neck Surg 2018 08 17;159(2):213-214. Epub 2018 Apr 17.

2 School of Medicine, Vanderbilt University, Nashville, Tennessee, USA.

Pharyngocutaneous fistula is an important complication of laryngectomy and can vary significantly in severity. Many authors have advocated for the use of vascularized flaps (eg, pectoralis major) to reduce the risk of fistula. Prevention of small, self-limited fistulas may not be worth the morbidity of a vascularized flap in some cases. More nuanced analysis of fistula outcomes, stratified by severity, may enable better surgeon-patient decision making regarding the use of vascularized flaps in laryngectomy.
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http://dx.doi.org/10.1177/0194599818770617DOI Listing
August 2018

Are We Ready for Our Close-up?: Why and How We Must Embrace Video in the OR.

Ann Surg 2017 Dec;266(6):934-936

*Department of Otolaryngology and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN †Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1097/SLA.0000000000002232DOI Listing
December 2017

Operating Room Inefficiencies Attributable to Errors in Surgical Case Scheduling and Surgeon Procedure Heterogeneity.

Am J Med Qual 2016 11 22;31(6):584-588. Epub 2015 Sep 22.

University of Chicago, Chicago, IL.

This study examined effects of scheduling errors on operating room efficiency and surgeon procedure heterogeneity on the rate of incorrectly scheduled cases. Operative cases in an academic center over 11 months were categorized as correctly or incorrectly scheduled. Surgeon heterogeneity was the number of unique procedures performed. Delays were greater for misbooked first cases (median 9 minutes late (interquartile range [IQR] 2-24) vs 4 (IQR 0-13), P < .01). For subsequent cases, turnover time was longer if misbooked (47 minutes (IQR 33-69) vs 39 (IQR 28-55), P < .01). Overall, the difference between actual and scheduled length was greater for misbooked cases (26 minutes (IQR -15 to +79) vs 6 (IQR -17 to +38), P < .01). Highest heterogeneity surgeons had higher risk of incorrect scheduling compared with the lowest (odds ratio = 1.97, 95% confidence interval [1.34-2.98], P < .01). Scheduling errors led to delays in first starts, unexpectedly longer cases, and prolonged turnovers. Highest heterogeneity surgeons were at greatest risk for misbooking.
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http://dx.doi.org/10.1177/1062860615606517DOI Listing
November 2016
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