# Metabolic Predictors in Risk Stratification for Oral Cavity and Oropharyngeal Cancer Patients Undergoing Free Flap Tissue Transfer: A Retrospective Study

## TL;DR

This study identifies metabolic and surgical factors that predict complications in cancer patients undergoing free flap surgery, proposing a new risk stratification system.

## Contribution

The novel PRISM scoring system is introduced to predict surgical complications based on metabolic and clinical parameters in head and neck cancer patients.

## Key findings

- Underweight or overweight patients had higher complication rates (p = 0.019).
- Lower albumin and protein levels correlated with increased complications (p = 0.001 and 0.010).
- The PRISM score effectively stratified patients into low-, moderate-, and high-risk groups.

## Abstract

This study aimed to evaluate the clinical, anthropometric, nutritional, and biochemical parameters that influence the outcome of free flap reconstruction in patients with oral cavity and oropharyngeal carcinomas. A retrospective analysis was performed on patients operated on between 2021 and 2024. The included variables were operative duration, flap ischemia time, presence of systemic inflammatory response syndrome (SIRS), body mass index (BMI), serum albumin, total protein, calcium levels, and length of hospitalization. The findings demonstrated a significant correlation between SIRS, operative duration, and ischemia time. Furthermore, deviations in nutritional and biochemical parameters (albumin, calcium, proteins, BMI) were associated with a higher incidence of complications. A PRISM scoring system was suggested based on the findings. In conclusion, these findings provide a foundation for the development of a predictive model and clinical guidelines to support individualized patient optimization before surgery, aiming to improve outcomes in microvascular head and neck reconstruction.

Background/Objectives: Oral and oropharyngeal cancers are highly prevalent and associated with a high mortality. The primary treatment modality is surgery with free flap reconstruction becoming the gold standard. Our study aimed to assess the anthropometric and metabolic predictors of the occurrence of postoperative complications after free flap reconstruction, and to present a PRISM (Predictive Reconstructive Index for Soft-tissue Microflaps) scoring system. Methods: This retrospective cohort study included 92 patients with advanced oral and oropharyngeal squamous cell carcinoma who underwent primary surgical treatment with microvascular free flap reconstruction between 2020 and 2024. Clinical, surgical, and biochemical parameters (operative and flap ischemia time, BMI; serum albumin, total protein, and calcium) were analyzed in relation to postoperative complications. Associations were assessed using correlation analyses and binary logistic regression. Based on the key predictive variables, the PRISM scoring system was developed to estimate perioperative risk. Results: Underweight or overweight patients showed higher complication rates (Kruskal–Wallis, p = 0.019). Longer surgeries were associated with a higher incidence of SIRS, which in turn correlated with increased flap ischemia (Man-Whitney, p = 0.032 and 0.039). Lower albumin and total protein levels on the second postoperative day were linked to more complications (Kruskal–Wallis, p = 0.001 and 0.010), as were lower calcium levels on the first postoperative day (p = 0.033). Additionally, longer hospitalization was significantly associated with complication severity (p = 0.031). The PRISM score stratified patients into low-, moderate-, and high-risk groups. Conclusions: Free flap outcomes in oral and oropharyngeal cancer are influenced by SIRS, nutritional status, and surgical factors. Longer surgeries, flap ischemia, low albumin, protein, calcium, and abnormal BMI increased the complication risk. Careful preoperative assessment, optimization of patient condition, and strategies to minimize operative time and ischemia are essential. The PRISM score may help stratify patients and guide clinical decisions.