Perioperative factors associated with adverse outcomes in head and neck cancer surgery with free flap reconstruction: A sub-analysis of the HANCOS trial.

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Background: Head and neck cancer surgeries with free flap reconstruction carry high morbidity, with complication rates of 30–40%. This sub-analysis of the HANCOS prospective study evaluates perioperative factors influencing outcomes, aiming to identify modifiable risk factors and improve surgical benchmarks in this high-risk population. Methods: This prospective observational cohort sub-analysis single-center observational study after institutional ethics committee approval and CTRI reg. CTRI/2025/10/096289 [Registered on: 22/10/2025] Trial Registered Prospectively. Current data consists of 100 adult patients undergoing major HNC surgery with free flap reconstruction. Data collection spanned preoperative, intraoperative, and postoperative phases, focusing on three key outcomes: re-exploration, flap failure, and pulmonary complications. Predictors were analysed using univariate and multivariate logistic regression models to identify independent risk factors. Results: The observed incidence rates were 7.0% for re-exploration, 5.0% for flap failure, and 9.0% for pulmonary complications. Multivariate analysis revealed that longer operative duration was independently associated with re-exploration (OR 1.5 per 60 min; p=0.04). For flap failure, significant independent predictors included hypoalbuminemia (OR 3.1 per 1 g/dL decrease; p=0.03) and greater intraoperative blood loss (OR 1.3 per 100 mL; p=0.04). Pulmonary complications were strongly predicted by higher ARISCAT scores (OR 2.2 per 10 points; p=0.002), pre-existing COPD/asthma (OR 3.8; p=0.03). Conclusion: Adverse outcomes following free flap reconstruction in head and neck cancer surgery are significantly influenced by modifiable perioperative factors. Poor nutritional status, prolonged operative duration, and increased intraoperative blood loss are key determinants of complications, while elevated ARISCAT scores and respiratory comorbidities strongly predict pulmonary events. Targeted preoperative optimization and vigilant intraoperative management may reduce complications and enhance both short-term recovery and long-term outcomes. Conflict of Interest: None declared. Funding: Investigator-initiated study with no external funding.