Abstract
Management of the oral cancer, involves surgical intervention and the associated complications are quite prevalent after oral cancer surgery. This article aims to provide a comprehensive review of all the possible complications associated with surgical management of oral cancer to apprise about adequate management of such complications if they manifest. An internet based literature review was performed in PubMed, Embase and Cochrane Central Register electronic databases using keywords “oral cancer,” “oral surgical procedures,” “post operative complications,” “intra operative complications,” which resulted in 19 articles. After screening only relevant English language articles from 2000–2022 were considered. A working classification, described in our study, provides an easier understanding of the possible complications associated with surgical management of the oral cancer. It has been based depending upon their time of occurrence. A learned surgeon thus can provide adequate surgical care and minimize the occurrence of such complications that may occur even with adequate precautions. If such complications do occur, there is always a management protocol.
Keywords: Oral cancer, potential complications, surgical complications, surgical management
INTRODUCTION
Oral and oropharyngeal cancer remains among the top ten most common malignancies in the world.[1] Surgical intervention is required not only for diagnosis like incisional biopsies but also as en-mass excision for treatment in majority of cases. The oral cancer surgery is associated with various complications that might occur during intra-operative, early, and late post-operative period.[2] Adequate and timely management of these complications will not only enhance the survival, but also improve the quality of life postoperatively. As per the available literature, many of the complications are preventable, while others are manageable by adequate knowledge and clinical experience. In this article, we intend to provide a working classification and comprehensive review of all the possible complications associated with surgical treatment of oral cancer based on their time of occurrences and provide an insight on methods of their prevention and management.
METHOD OF DATA COLLECTION
A literature search in PubMed, Embase and Cochrane Central Register electronic databases using keywords “oral cancer,” “oral surgical procedure,” “post-operative complications,” “intra-operative complications” was conducted. The search was restricted to English language articles, and books published from January 2000 to December 2022. The included 19 publications were relevant to the long-term surgical complications associated with surgical treatment of the oral cancer.
PROPOSED WORKING CLASSIFICATION OF POTENTIAL COMPLICATIONS DURING ORAL CANCER SURGERY
During surgery for oral cancer, surgeons encounter various common, as well as rare complications. A simple working classification has been proposed here based on their time of occurrence [refer to Table 1].
Table 1.
Classification of potential complications during oral cancer surgery
| Category of complication | Types |
|---|---|
| Intraoperative/Immediate Complications | Bleeding and Blood Loss |
| Airway Compromise | |
| Circulatory Disturbance | |
| Early Post-Operative Complications | Flap failure |
| Tracheostomy Complications | |
| Chyle Leakage | |
| Post-Operative Pyschosis | |
| Baroreflex Dysfunction | |
| Surgical Site Infections | |
| Late Post-Operative Complications | Cancer Resection Complications •Failure to cure disease •Speech and swallowing difficulties •Mastication and nutrition difficulties and Trismus •Neurologic complication •Disfigurements |
| Chronic Fistulas | |
| Failure of Hardware | |
| Donor Site Morbidity |
It is notable that some of the complications may fall under more than one category as they can occur at different points of intervention. The potential complications are described in detail below.
Intraoperative/immediate complications
Complications can occur during intraoperative period and can be associated with any type of surgery.
Bleeding and blood loss
Blood loss is one of the most common complications in a surgically treated case of the oral cancer.[3,4,5] Causes of intra-operative bleeding includes failure to diagnose or rule out any history of systemic bleeding disorders, multiple iatrogenic damage to blood vessels, raised blood pressures etc., Causes of post-operative bleeding includes hematoma and seroma formation, jugular vein rupture, and carotid blowout syndrome.[6] Methods to minimize bleeding intra-operatively, involves the use of pressure packing [refer Figure 1], electro-coagulation [refer Figure 2], and ligation with sutures [refer Figures 3 a-c].
Figure 1.
Pressure pack being applied to arrest bleeding during neck dissection. Black arrow indicates a bleeding vessel (courtesy - Department of Oral and Maxillofacial Surgery, KGMU, Lucknow)
Figure 2.
Photograph showing Electro-coagulation method employed for controlling bleeding intraoperatively (courtesy-Department of Oral and Maxillofacial Surgery, KGMU, Lucknow)
Figure 3.
Photograph showing ligation artery or vein with sutures for controlling bleeding intraoperatively in Modified Radical Neck Dissection (courtesy -Department of Oral and Maxillofacial Surgery, KGMU, Lucknow) (a) Two hemostat being used to clamp the vessel. (b) Blood vessel tied with 3-0 vicryl. c) Suture ligation completed
Rupture of the carotid artery and its branches are referred to as carotid blowout and when it presents with signs and symptoms, it is called carotid blowout syndrome. Blowout causes blood loss, airway compromise, neurologic deficits and even death. In patients with head and neck disease, carotid blowout accounts for 11% of all deaths.[7]
Cardiac blowout can be classified into three types depending upon its clinical severity, Type 1 (Threatened Blowout) when exposed Carotid artery vessel is due to tumor invasion, type 2 (Impending Blowout) is the sentinel bleeding that occur before occurrence of actual carotid blowout and type 3 (Acute Blowout) is acute bleeding from vessel.
Primary management of carotid blowout includes airway establishment, pressure packing to the bleeding site, minimal neck manipulations, fluid management and blood transfusions. Definitive management of carotid blowout syndrome includes coverage with vascularized flaps such as supraclavicular flap [Figure 4], pectoralis major flap [Figure 5] or the delta-pectoral flap. For Type 2, the carotid vessels are studied bilaterally with aid of interventional radiology. If it is ruled out then internal jugular vein is the probable cause for sentinel bleeds and hence need to be managed by ligation. For Type 3, ligation of the carotid artery is conducted. The steps are mentioned in Figure 6.
Figure 4.
The Supraclavicular flap is based on the supraclavicular artery and was first described by Lamberty in 1979. It can be used as a rotational, tunneled flap, or even free flap for carotid wall repairs
Figure 5.
Pectoralis major flap. Arrow indicates direction of flap transfer to the carotid vessel
Figure 6.
Emergency ligation of Carotid artery.[7] Steps - Incision along the anterior border of the SCM is placed. The SCM is then retracted posteriorly and the carotid sheath and great vessels are exposed. The carotid sheath is opened and the internal jugular vein is retracted laterally. Common carotid artery mobilization is done from the vagus nerve and suture ligation is done. After ligation it is covered with a vascularized flap and sutured
Pectoralis major flap is very versatile flap for reconstructive purposes. As shown in Figure 5a small island of pectoralis major flap can be harvested and passed into the neck for repair of the injured carotid vessel.
Airway compromise
Airway compromise is both an immediate and a late complication in oral cancer patient.
Management involves surgical exploration for developing hematoma and ligation of the bleeding vessels. Often tracheostomy may be done as a life-saving procedure.
Circulatory disturbance
Prolonged surgeries in the oral cancer surgeries causes significant blood loss. This is monitored intraoperatively by measuring arterial blood gas levels, fluid input and urine output. Patient often need blood transfusion hence patient should always have blood in hand or donor arranged before undergoing cancer surgery. Blood transfusion should be conducted to maintain hemoglobin levels between 6 gm/dl to 10 gm/dl. It has also been seen that blood transfusion causes immunosuppression and often lead to cancer recurrence. A hemoglobin level of <6 mg/dl is always an indication for blood transfusion.
Early post-operative complications
Early post-operative complications are the ones that occur following surgery. Here we have included the complications that occur between 3–4 weeks, post-surgery.
Flap failure
Microvascular free flaps or pedicle flaps are often necessary in the reconstruction of the extensive defects after reception of the primary tumor. Flap failure is a common complication caused due to the vascular occlusion. Venous thrombosis is more common that arterial thrombosis. It occurs within 48 hours of surgery. If it occurs after 48 hours of surgery then it is probably due to the infection and mechanical stress around the sutures. Flap monitoring is performed by color, turgor, capillary refill, and temperature. Flap failure is diagnosed by pin prick test, temperature of flap, random blood glucose monitoring, surface doppler and implantable doppler. Management can be non-surgical when conducted by leech therapy (hydrotherapy), but it is not practiced anymore. Surgical management of flap is described in flowchart below [Figure 7].[8]
Figure 7.
Flowchart describing surgical algorithm for management of thrombus
Partial flap loss is often managed by debridement and secondary healing followed by re-suturing. Hyperbaric oxygen [Figure 8] therapy in flap failure is used as well, to improve vascularity, viability, and tissue stability. Hyperbaric oxygen therapy is usually started after 48 hours of first evidence of flap failure. Salvage flaps [refer to Figure 9] may be used to reconstruct the defect resulting from flap loss. Most commonly pectoralis myocutaneous major flap, forehead flap, delto-pectoral, or latissimus dorsi flap are used.
Figure 8.
Hyperbaric oxygen therapy showed improvement in a thrombosed pectoralis major mountainous flap (courtesy-Department of Oral and Maxillofacial Surgery, KGMU, Lucknow)
Figure 9.
Failure of pectoralis major myocutaneous flap salvaged with forehead flap (courtesy -Department of Oral and Maxillofacial Surgery, KGMU, Lucknow)
Tracheostomy complications and care
Complications associated with tracheostomy that occur intraoperatively includes hemorrhage, injury to trachea, carotid artery rupture or damage to esophagus. Those occurring during early post-operative period include apnoea, heamorrahge, subcutaneous emphysema, pneumo-mediastinum, pneumothorax, accidental extubating, infections, and difficulty in swallowing. Late post-operative complications include difficult de-cannulation, tracheo-cutaneous fistula, tracheo-oesophageal fistula, and tracheal stenosis [refer Table 2].[9]
Table 2.
Various complications of tracheostomy (source Bailey and Love’s Short Practice of Surgery)
| Intra-operative complication | Bleeding |
|---|---|
| Injury to trachea, carotid artery, Oesophagus | |
| Early post-operative complications | Apnoea |
| Bleeding | |
| Subcutaneous emphysema, Pneumo-mediastinum, pneumothorax | |
| Accidental extubating | |
| Infection | |
| Swallowing difficulties | |
| Late post-operative complication | Difficult to de-cannulate |
| Tracheo-cutaneous fistula, Tracheo-oesophageal fistula | |
| Tracheal stenosis |
Tracheostomy Daily Care in the Postoperative setting includes.[10]
Oxygen therapy and humidification
It consists of mobilization and physiotherapy, humidification circuit, nebulized saline, mucolytics such as hypertonic saline, N-acetyl cysteine, bronchodilators such as Levo-salbutamol, Ipratropium bromide and Budesonide and heat moist exchange filters all are used depending on the extent needed.
Care of the cannula
The cannula must be cleaned everyday as respiratory secretions tend to block the tube lumen. Cleaning and air drying of the cannula is conducted. Spare cannula should always be kept bedside.
Suctioning
Pre-oxygenation and sterile protocols should be followed. In-line suctioning is conducted for mechanically ventilated patients in the ICU. Catheter size calculation should be conducted using the formula - (Tube size in mm/2) *3. Normal saline and Sodium bicarbonate can be used during suctioning. If patient can cough then we should encourage coughing, which brings secretions near tracheostomy tube better. Only 1/3rd of suction catheter should be inserted. Care must be taken to not suction more than three times in a row and not more than 10 sec duration each
Tracheostomy dressing and ties
Stoma should be cleaned with a sterile gauze and patted dry. Often Betadine gauze pack is placed over the stoma below the tracheostomy tube. If redness and pus discharge is seen then empirical antibiotic therapy must be started.
Ties: Ties should be changed daily. It should not be very tight and there should be about two finger width gaps presents below the tie.
Chyle leakage
Chyle leakage is both an intra-operative and post-operative complication. It occurs in 2%–8% head and neck dissection.[11] Intraoperative chyle leak management includes[12]- Ligation of thoracic duct, cyanoacrylate adhesives, vicryl mesh or fibrin glue. Local flaps such as clavicular head of sternocleidomastoid or anterior scalene flap may be used for repair. Distant flaps such as pectoralis myocutaneous major flap has also been used. Postoperative chyle leak management depends upon the output of chyle leakage. If there is low output (<500 ml/day), conservative methods are used that includes: a) Bed rest with head end elevated to 30 to 40 degrees to reduce intrathoracic pressures, b) Diet – IV fluids, protein rich diet, low or non- fat diet and medium chain fatty acid diet (as it bypasses the GI lymphatics). Nil-per-oral (NPO) method is an old method and itis not used anymore. Total parenteral nutrition is a newer and an advanced method, but must be used cautiously as it often causes hypoglycemic shock, c) Wound care- controversial method as it often compresses the flap pedicle, d) Drugs – Somatostatin and its analogues namely Octreotide and Orlistat, and e) Topical agents – OK-432 and Tetracycline as sclerosing agents injected at site or into the surgical drain.
In cases of high output (>500 ml/day)—Surgical exploration is the treatment of choice.
Due to the chyle leak there occurs, local inflammation at the site that makes identification of thoracic duct orifice difficult intraoperatively. To overcome this, we use pre-operative fatty diet and anti-Trendelenburg positioning. If chyle leakage do not stop with surgical exploration it is advisable to go for interventional radiology procedures.
Post operative psychosis
It is a rare complication that occurs in the operated patient. It has been observed in our center in three patients in year 2022. Probable causes include increased length of ICU stay, advanced age, long surgeries, and diabetes.[13] It is managed by sedative drugs and psychiatric counselling depending upon the grade of post-operative psychosis.
Baroreflex dysfunction
Baroreflex failure is the inability of the body’s ability to regulate the blood pressures. Post-surgical cancer and irradiated patients are prone to such dysfunctions as the baroreceptor sensors get damaged leading to complications such as hypertensive and hypotensive crisis as well as orthostatic hypotension. Management involves education of the patient, stress reduction protocols after cancer surgery and blood pressure medications.
Surgical site infections
Surgical site infection is infection in a surgical wound occurring within 30 days after the procedure. Clinical symptoms include tenderness, fever, pus, and wound dehiscence. Prevention includes pre-operative antimicrobial prophylaxis and proper sterilization protocols to prevent such infections. Management involves wound debridement to freshen the wound margins and methods to promote secondary healing and re-suturing following debridement procedures [refer to Figure 10].
Figure 10.
Surgical site infection (courtesy-Department of Oral and Maxillofacial Surgery, KGMU, Lucknow)
Late post-operative complications
Complications that occur after months to years after surgery are considered as late post operative complications. These are described in detail below.
Cancer resection complications
Failure to cure disease
Failure to cure cancer is the most devastating outcome of the disease.[1] Occurs due to persistent disease, local or regional recurrence, secondary primaries, distant metastasis. Prevention methods involve use of frozen section intraoperatively (accuracy of 96%–98%). Adequate neck dissection minimizes the chances of recurrence. Proper follow-up protocols such as computed tomography (CT) and magenetic resonance imaging (MRI) are indicated. Positron emission tomography (PET) scanning is the diagnostic aid of choice because it helps allows to differentiate between post-surgical/post-radiation scarring from recurrences.[14]
Here we have two scenarios:
Non-irradiated patients with recurrence: Surgery [Figure 11] + Chemotherapy + Radiotherapy
Figure 11.
(a) pre-operative photograph showing intial presentation of the lesion. (b) post-operative photographs after hemi-maxillectomy of left side. (c) post-operative photographs of 1 week showing recurrence in the left side. Hemimaxillectomy of the right side was performed as well. This was followed by reconstruction of intraoral defect with temporalis flap from the left side
Irradiated patients with recurrence: Only surgery should be done as repeat radiotherapy carries high risk of complications.
Figures 11a-c shows the management of recurrence of Ductal carcinoma of maxilla.
Speech and swallowing difficulties
Difficulties in speech and swallowing may prevail as a complication of cancer resection. Speech defects can be understood via flowchart described below [refer Figure 12].
Figure 12.
Flowchart describing chronology for speech defects in oral cavity following cancer resection
Prevention methods include, Pre-treatment counselling and teaching of swallowing manoeuvres pre-operatively.
Management includes a programmed of compensations, speech articulations and intelligibility speaking methods. It can be started once the suture lines have been healed.
Swallowing difficulties can be improved post-operatively by head turn and chin tuck postures. Manoeuvres such as supra-glottic swallow and Mendelsohn method can be used and therapeutic exercises, such as thermal tactile stimulation. Intra-oral prosthesis [Figure 13] have shown to improve swallowing and speech function as well.[15]
Figure 13.
Intra oral prosthesis used after cancer resection for rehabilitation of patient (courtesy Department of Oral and Maxillofacial Surgery, KGMU, Lucknow) (a) occlusal view of prosthesis, (b) intaglio view showing obturator of prosthesis, (c) prosthesis placed intraorally
Mastication and nutrition difficulties and trismus
Maxillary and mandibular resections affect mastication because of loss of tooth-to-tooth contacts and reduction mastication forces. Nutrition is also affected because of loss of soft tissue bulk and nerve stimulation to the site. Trismus is limited mouth opening that is a common complaint after cancer surgery. Fibrosis and scarring causes this either due to the surgery or radiotherapy and hence this is usually seen in the late post-operative period. Trismus is relieved by using muscle relaxants, physiotherapy, hyperbaric oxygen therapy, rubber plugs, spatulas, TheraBite device etc.
Neurological complications
It has been observed that various cranial nerves are at risk of damage after cancer surgery. Of importance is the spinal accessory, facial and phrenic nerve.
Damage to Spinal Accessory Nerve: Associated with shoulder syndrome. Management includes- Careful dissection around the vicinity of nerve, limited use of electrocautery, Anastomosis of spinal accessory nerve and physiotherapy for shoulder syndrome.
Damage to Facial Nerve- Careful planning of the incisions and taking into consideration the route of the nerves and identification during flap elevation, is the best way of preventing iatrogenic injury to branches of the facial nerve.
Damage to Phrenic Nerve: Causes pulmonary complication. One should limit the surgical dissection to a layer superficial to the pre-vertebral fascia and careful identification, may assist surgeons in preventing this complication.[16]
Disfigurements
Oral Cancer surgery causes severe disfigurement. After, radiotherapy this is even more severe and evident. Prevention methods, include the use of various incisions and flap. We should always go for tension free closure of the surgical defect. There should be gentle and careful handling of soft tissues and protection of skin from electrocautery burns and traction. Elevation of thick flaps with good blood supply reduces scarring and contractures [refer to Figure 14].[17]
Figure 14.
Post surgical scarring and contracture in an operated oral cancer patient. (courtesy -Department of Oral and Maxillofacial Surgery, KGMU, Lucknow)
Management includes
(a) Maxillectomy: The lower lid extension of Weber-Fergusson incision causes un-aesthetic scarring. Modification to reduce such scars have been developed [Figure 15].
Figure 15.
Modified incision for maxillectomy procedures the first figure shows omitting the infraorbital extension and the second photograph shows supraorbital rim extension
(b) Mandibulectomy: Lip split incision has been used since 1900s and recently many incision modifications have been given to reduce disfigurement [refer to Figures 16 and 17].
Figure 16.
Modified Lip split incisions
Figure 17.
Robson incision showing minimal scarring compared to the standard Lip-Split incision (courtesy-Department of Oral and Maxillofacial Surgery, KGMU, Lucknow)
Chronic fistulas
Salivary fistulas can occur as early as 1 week, to late as 3–4 weeks, after cancer surgery.
Fistulas that are present at 1 month after surgery are considered chronic fistulas. Management includes surgical exploration to direct salivary seepage away from vital structures. If tail of parotid is cut suturing of the tail of parotid is done intraoperatively. The patient should be prescribed empirical antimicrobial therapy and nutritional support should be given.
If drainage is persistent for more than 4 weeks, then excision of the fistulous tract is conducted with primary closure of the defect. Anticholinergics like glycopyrrolate are used along with surgery. Finally, use of various local, regional, and free flaps to reconstruct the defect after fistula excision is also advocated.
Failure of hardware
Plate exposures, fracture of plates, screw loosening are commonly seen after a long time in the operated squamous cell carcinoma patient.
Management includes: Removal of plates and screws. If patient is planned for post-operative radiotherapy, hyperbaric oxygen therapy is an effective treatment option before hardware removal.
Donor site morbidity
Scarring and surgical site exposure [refer to Figure 18] may occur in the site of flap harvest. There may also be difficulty in mobility of limbs and gait disturbances. It is managed by physiotherapy and scar revisions.
Figure 18.
Surgical site exposure of bone in a case where Free fibula flap was harvested (courtesy-Department of Oral and Maxillofacial Surgery, KGMU, Lucknow)
CONCLUSION
Management of oral cancer includes a combination of surgery, chemotherapy, and radiotherapy wherein surgical management of respectable tumors is considered the most ideal and effective treatment of choice. Though various guidelines exist in literature to have a good surgical outcome, cancer surgery always carries with it, various complications both intraoperatively and postoperatively. Any surgical complications should be prevented first to the best of our abilities and then managed accordingly.
Pre-operative planning before surgery is of paramount importance. Of importance is pre-operative patient fitness, risk assessment, risk to benefit ratio, pre-operative anesthetic evaluation, pre-operative treatment planning with accurate clinical and radiographic evaluation in the cancer patient. Important factors that make a surgery successful includes daily monitoring of patients’ vitals, his/her general health conditions, presence of any systemic diseases etc., Tumor board discussion and multi-disciplinary approach should always be considered for a favorable outcome.
Intraoperative complications are mostly the same complications associated with any kind of surgical procedures. The intraoperative complications such as blood loss and airway disturbances can be life threatening and even lead to death of the patient. Hence the protocol for management of the patient must be strictly followed.
Early post-operative complications are not life threatening but if not managed can lead to increased morbidity and mortality of the cancer patient. Flap loss causes loss of structure and function and heavy scarring that causes aesthetic deformity in the patient of oral cancer. Chyle leak is more of a nuisance rather than a complication but it is very troublesome for the patient and mostly can be manage conservatively. Tracheostomy care guidelines must be strictly followed to prevent any adverse complications.
For late postoperative complications. Intraoperatively adequate clearance of tumor is important otherwise it leads to cancer recurrence and secondary primaries which reduces the survival rate of the individual. Other complications like post-operative organ loss and surgical site morbidity and disfigurements can be easily managed by careful planning during the intraoperative period.
Hence, the complications following oral cancer surgery from life threatening to late complications might require emergent intervention to improve the post-surgical care of the operated oral cancer patient.
Patient consent and approval
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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