IN REFERENCE TO POSTOPERATIVE COMPLICATIONS IN ELDERLY PATIENTS UNDERGOING NECK DISSECTION FOR HEAD AND NECK CANCER
2Ankara Yıldırım Beyazıt Üniversitesi Tıp Fakültesi Kulak Burun Boğaz Anabilim Dalı, Ankara Türkiye
Introduction
Dear Editor,First of all, I would like to congratulate the authors for addressing such an important issue as postoperative complications in elderly patients undergoing neck dissection for head and neck cancer1. The increasing prevalence of elderly patients in clinical practice makes studies of this kind highly valuable.
At the outset, I would also like to underline the institutional context. Ankara Bilkent City Hospital is one of the most important healthcare institutions in Turkey and serves as a pioneering example, similar to several models abroad, but unique in our country as the first of its kind. The hospital provides high-quality healthcare services within a structure that brings together three separate institutions under the same roof: Ankara Yıldırım Beyazıt University Faculty of Medicine, Health Sciences University Faculty of Medicine, and the Ministry of Health. This unique composition, in line with the 2007 Bologna Process principles, allows the transfer of accumulated knowledge across institutions, fosters healthy academic competition, and creates an environment where service delivery and academic standards are continuously improved. Although collaboration and mutual support are evident, it should be emphasized that individual academic teams carry out clinical service delivery.
Having carefully reviewed the article and considering the critical comments shared within our professional community, I would like to provide the following observations:
1. Title?Content Consistency
Although the article focuses on "elderly" patients, 61% of the cases included were under the age of 65. This discrepancy raises questions about the alignment between the article title and the study population.
2. Primary Tumor Classification
The grouping of "lip?oral cavity" and "larynx?hypopharynx" tumors together is problematic, as these subsites differ significantly in lymphatic spread, treatment modalities, and complication risks. A more refined classification would strengthen the validity of the findings.
3. Additional Comment on Authorship and Case Origin
At first glance, the high number of authors may create the impression that this is a multicenter study. However, the corresponding author has not specified the individual contributions of each co-author, nor has it been clarified whether the presented cases belong solely to the corresponding author, to specific co-authors, or to multiple institutions. This lack of transparency raises concerns regarding both the authorship criteria and the origin of the cases. Clear statements on these issues would increase the scientific reliability and academic integrity of the study.
4. Additional Comment on Surgical Classification and Documentation
Given that this study could have been designed as an epidemiological and clinical investigation, it would have been highly valuable if the neck dissections performed had been reported in detail according to the established classifications: radical, modified radical, functional, supraomohyoid, anterior, posterolateral, and anterolateral neck dissections. Such stratification would allow a more precise assessment of complication risks and comparability with other published series.
To the best of my knowledge, the Neck Dissection Impairment Index has not yet been applied in our context. Moreover, there is no explicit statement confirming that the operative notes of all reported cases were systematically reviewed, which raises further concerns regarding the completeness and reliability of complication data. Providing these details would significantly enhance the study"s methodological rigor and clinical relevance.
5. Details of Complications
Complications were reported in broad categories (e.g., "local complications"), without sufficient detail on critical nerve (marginal mandibular, spinal accessory) or vascular injuries, which are both well-known and clinically significant in neck dissection.
6. Comment on Complication Reporting Standards
Neck dissection complications are well documented in the classical surgical literature and are typically categorized into intraoperative, immediate postoperative, and delayed postoperative events.
• Intraoperative complications include vascular injuries (e.g., internal jugular vein), lymphatic injuries (e.g., thoracic duct), and nerve injuries (e.g., marginal mandibular nerve, spinal accessory nerve).
• Immediate postoperative complications (within the first 24 hours) include hemorrhage, airway obstruction, and increased intracranial pressure.
• Delayed complications include marginal mandibular or spinal accessory nerve dysfunction, chylorrhea, wound dehiscence, flap necrosis, pneumothorax, bronchopneumonia, deep vein thrombosis, pharyngocutaneous fistula, recurrence, and metastasis.
It would have been highly valuable if the authors had presented their complication data according to this standard classification, preferably in tabular form. Such a structured presentation would provide greater clarity, allow comparison with the existing literature, and enhance the educational value of the article.
7. Impact of COVID-19 Period
As three of the six study years coincide with the COVID-19 pandemic, variations in surgical practice and patient selection may have influenced the results, yet this was not discussed.
8. Comment on Pulmonary Complications and Study Population
The reported pulmonary complication rates and some other parameters are notably higher than those documented in the literature, which the authors referenced mainly with a single study from Brazil dating back to 2011. This reliance on outdated data weakens the scientific grounding of the discussion.
Furthermore, as noted earlier, 61% of patients in the cohort were under 65 years of age, despite the title focusing on "elderly" patients. Had the study been restricted to patients ?65 years, in line with its title, the complication rates?particularly pulmonary complications?might have been even higher. This discrepancy raises concerns both about the study design and the interpretation of results.
9. References and Literature Update
Some cited references are outdated (e.g., from 2004). Incorporating more recent large-scale studies and indices such as the Neck Dissection Impairment Index would have strengthened the discussion.
10. Institutional Context and Generalization
Ankara Bilkent City Hospital hosts more than one otorhinolaryngology (ENT) group, each affiliated with different institutions (AYBÜ, SBÜ, and the Ministry of Health). The current study reflects the experience of only one group, but the way it is presented may create the impression that it represents all ENT groups in the hospital. Such generalization does not accurately reflect the institutional reality.