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Tuncali D, Yilmaz N, Aslan G. AN UNUSUAL COMPLICATION FOLLOWING FREE-TISSUE TRANSFER: PULSE RATE PERCEPTION. Plast Reconstr Surg 2004; 114:1010. [PMID: 15468419 DOI: 10.1097/01.prs.0000138704.01533.8e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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252
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Brüner S, Bickert B, Sauerbier M, Germann G. Concept of arteriovenous loupes in high-risk free-tissue transfer: history and clinical experiences. Microsurgery 2004; 24:104-13. [PMID: 15038014 DOI: 10.1002/micr.20006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The present study describes the concepts of arteriovenous (A-V) loupes prior to microsurgical free flap transfer in a selected high-risk group of patients. A one-stage concept was employed in 26 patients; 5 patients underwent two-stage flap transfer. Seven thrombotic occlusions of the A-V fistula or flap vessels were recorded; 6 patients underwent successful revision. Overall flap survival was 96.8% and compared favorably to reports in the literature. Defect coverage could be achieved in all but one case. It can be concluded from the data that in selected high-risk patient groups, i.e., following radiation, compound trauma, chronic infection, or multiple comorbidities, the creation of an A-V fistula prior to flap transfer may facilitate innovative reconstructive solutions.
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Affiliation(s)
- Simone Brüner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, University of Heidelberg, Ludwigshafen, Germany.
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253
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Ross DA, Hundal JS, Son YH, Ariyan S, Shin J, Lowlicht R, Sasaki CT. Microsurgical Free Flap Reconstruction Outcomes in Head and Neck Cancer Patients after Surgical Extirpation and Intraoperative Brachytherapy. Laryngoscope 2004; 114:1170-6. [PMID: 15235342 DOI: 10.1097/00005537-200407000-00007] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The management of recurrent or persistent head and neck cancer poses a challenging problem. Salvage surgery for these individuals consists of ablative surgery, interstitial brachytherapy, and microsurgical free flap reconstruction. This study reviews complications after such reconstruction. METHODS We reviewed 139 consecutive head and neck cancer patients undergoing free flap reconstruction from January 1994 to May 2002. These included 66 patients with recurrent head and neck cancer undergoing intraoperative brachytherapy (IOBT) and free flap reconstruction and 73 undergoing free flap reconstructions only. A total of 142 reconstructions were performed, with three patients in IOBT group receiving two free flap reconstructions per patient, giving us a total of 69 reconstructions in the IOBT group versus 73 in the non-IOBT group. Nine patients were excluded from the IOBT group because of nonsynchronous use of brachytherapy and reconstruction, and 10 patients were excluded from the other group because they had prior radiotherapy or surgical treatment, leaving us with a total of 123 reconstructions, 60 in the IOBT group and 63 in the non-IOBT group. The IOBT group patients received iodine Vicryl seed implants, palladium seed implants, or both, to deliver an average dose of 79.3 +/- 31.8 Gy (mean +/- 1SD) to the surgical bed. RESULTS All patients were followed for evidence of local wound complications. The IOBT group showed multiple complications in 23 (38.33%) of 60 reconstructions, the most common being wound dehiscence in 11. This, when compared with the non-IOBT group complications (15.87%), was found to be statistically significant (chi test, P <.01). CONCLUSION IOBT increases the rate of complications in patients undergoing microvascular free tissue transfer. This, however, should not deter or alter the aggressiveness of cancer therapy used for managing recurrent head and neck cancer.
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Affiliation(s)
- Douglas A Ross
- Section of Otolaryngology, Yale University School of Medicine, New Haven, CT 06520-8041, USA.
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254
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Setälä LP, Korvenoja EML, Härmä MA, Alhava EM, Uusaro AV, Tenhunen JJ. Glucose, lactate, and pyruvate response in an experimental model of microvascular flap ischemia and reperfusion: A microdialysis study. Microsurgery 2004; 24:223-31. [PMID: 15160382 DOI: 10.1002/micr.20045] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Early diagnosis of postoperative perfusion failure is essential in microsurgical tissue transfer. In order to determine if microdialysis could be used in diagnosing flap ischemia, we tested this method in an experimental pig model. Sixty-six flaps (34 myocutaneous and 29 cutaneous) were created in 18 anesthetized pigs. During the experiment, secondary ischemia was induced for 5 h by selective clamping of the artery (20 flaps) or vein (21 flaps). Glucose, lactate, and pyruvate concentrations were measured hourly from the muscular and dermal layers. We found that decreasing glucose levels and increasing lactate concentrations were associated with arterial and venous occlusions from the first hour of ischemia. In venous ischemia, lactate concentrations remained lower than those in arterial ischemia. The increase in lactate-to-pyruvate and lactate-to-glucose ratios was related to ischemia and also discriminated arterial occlusion from venous occlusion. In conclusion, microdialysis can be used to facilitate early detection of ischemia.
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Affiliation(s)
- Leena P Setälä
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland.
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255
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Copcu E, Metin K, Aktas A, Sivrioglu NS, Öztan Y. Cervicopectoral flap in head and neck cancer surgery. World J Surg Oncol 2003; 1:29. [PMID: 14690542 PMCID: PMC317373 DOI: 10.1186/1477-7819-1-29] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2003] [Accepted: 12/22/2003] [Indexed: 11/18/2022] Open
Abstract
Background Reconstruction of the head and neck after adequate resection of primary tumor and neck dissection is a challenge. It should be performed at one sitting in advanced tumors. Defects caused by the resection should be closed with flaps which match in color, texture and hair bearing characteristics with the face. Cervicopectoral flap is a one such flap from chest and neck skin mainly used to cover the cheek defects. Methods This study included twelve patients presenting with cancer of the head and neck to Izmir Ataturk Training Hospital and Adnan Menderes University Hospital. Tumor resection and neck dissection was performed in one session by the same surgeon. A single incision was made and a medially based cervicopectoral fascio-cutaneous flap was used for surgical exposure in neck dissection and for closure of defects after tumor resection. Results There was no major complication. Two flaps had partial superficial epidermolysis at the suture line. Good aesthetic and functional results were achieved. Conclusion The cervicopectoral flap is an excellent alternative for the reconstruction of head and neck. Harvesting and application of the flap is rapid and safe. Only a single incision is sufficient for dissection and flap elevation. This flap achieves perfect surgical exposure, makes neck dissection easy and allows one to perform both tumor resection and neck dissection in one session.
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Affiliation(s)
- Eray Copcu
- Department of Plastic and Reconstructive Surgery, Medical Faculty, Adnan Menderes, University, Aydin, Turkey
| | - Kubilay Metin
- Department of E.N.T, Medical Faculty, Adnan Menderes University, Aydin, Turkey
| | - Alper Aktas
- Department of Plastic and Reconstructive Surgery, Ataturk Training Hospital, Izmir, Turkey
| | - Nazan S Sivrioglu
- Department of Plastic and Reconstructive Surgery, Medical Faculty, Adnan Menderes, University, Aydin, Turkey
| | - Yücel Öztan
- Department of Plastic and Reconstructive Surgery, Ataturk Training Hospital, Izmir, Turkey
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256
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Borggreven PA, Kuik DJ, Quak JJ, de Bree R, Snow GB, Leemans CR. Comorbid condition as a prognostic factor for complications in major surgery of the oral cavity and oropharynx with microvascular soft tissue reconstruction. Head Neck 2003; 25:808-15. [PMID: 12966504 DOI: 10.1002/hed.10291] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Identification of factors, especially comorbidity, that affect the incidence and severity of complications in head and neck cancer patients. METHODS One hundred patients with an oral/oropharynx carcinoma undergoing composite resection and microvascular soft tissue transfer were analyzed. Patient data and tumor and treatment factors were recorded. Comorbidity was graded by an Adult Comorbidity Evaluation 27 (ACE-27) test. Postoperative complications were scored according to their severity. RESULTS Comorbidity score ACE-27 grade 2 or higher was present in 47% of patients, whereas 33% had a clinically important complication develop. A comorbidity score of ACE-27 grade > or =2 was a strong predictor for complications (p <.001). There were no other predictors for postoperative complications. CONCLUSIONS Comorbidity is of great importance for prediction of postoperative complications in head and neck cancer patients, especially an ACE-27 grade > or =2. It may be concluded from these results that prevention of complications should focus on comorbidities.
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Affiliation(s)
- Pepijn A Borggreven
- Department of Otolaryngology-Head and Neck Surgery, VU Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
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257
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Eckardt A, Fokas K. Microsurgical reconstruction in the head and neck region: an 18-year experience with 500 consecutive cases. J Craniomaxillofac Surg 2003; 31:197-201. [PMID: 12914703 DOI: 10.1016/s1010-5182(03)00039-8] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Microvascular free tissue transfer has become a significant factor in the reconstruction of head and neck cancer patients. Various donor sites are available to enable anatomical and functional repair of a defect. METHODS All free vascularized tissue transfers performed during the period from March 1982 to September 2000 were retrieved from this hospital's database and analysed with regard to the surgical defect, chosen donor site and complications. RESULTS During the 18-year period a total of 1,164 patients with head and neck cancer were treated in this institution. A total of 500 free-flap reconstructions were performed for 479 patients. In the majority of patients (n = 451) reconstruction was indicated following ablative tumour surgery. With regard to donor site selection, the first choice of free jejunum was used in 181 patients, followed by the radial forearm flap in 140 patients. Among the 500 free-flap reconstructions, a total flap loss rate of 6% was observed. Patient age (p = 0.004) and tobacco use (p = 0.043) were significant risk factors for complications overall, whereas patient age (p = 0.021) and operating time (p = 0.043) were significantly correlated with local complications. CONCLUSION Immediate repair of head and neck defects using free tissue transfer is a successful and reliable method and is becoming the gold standard at many institutions. The complication rate is low once experience with these techniques has been acquired.
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Affiliation(s)
- André Eckardt
- Department of Oral and Maxillofacial Surgery, Hannover Medical University, Carl-Neuberg-Strasse 1, Hannover 30625, Germany.
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258
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Yeow KM, Liao CT, Tsay PK, Chen IH, Cheng MH, Chen HC, Wei FC. US-guided catheter drainage of postoperative head and neck fluid collections. J Vasc Interv Radiol 2003; 14:589-95. [PMID: 12761312 DOI: 10.1097/01.rvi.0000071091.76348.f5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To analyze results of percutaneous catheter drainage of large fluid collections in the head and neck region noted in the immediate postoperative period. MATERIALS AND METHODS Thirty-four consecutive patients with 41 large fluid collections in the head and neck detected 7-10 days after oncologic surgery underwent percutaneous catheter drainage. There were 29 men and five women, with a mean age of 52.2 years (95% CI: 47.8-56.7). Each patient had a surgical drain placed in the posterior neck triangle; three patients had low-grade fever and six had diabetes at the time of percutaneous catheter drainage. Conventional management consisting of serial needle aspirations at bedside followed by pressure dressing failed in 15 of 34 patients (44%). Ultrasound-guided drainage was performed and catheters were connected to vacuum balls for continuous suction drainage. RESULTS The average fluid volume estimated by sonographic measurement was 84 cm(3) (95% CI: 57-112 cm(3)). The fluid content was serosanguinous in 46% (19 of 41), uncoagulated blood in 32% (13 of 41), pus in 15% (six of 41), and saliva in 7% (three of 41). The mean duration of catheter drainage was nine days (95% CI: 7-10 d) and mean fluid drainage was 287 mL (95% CI: 188-387 mL). Ninety-one percent of patients (31 of 34) were successfully treated with initial catheter drainage. Three patients had recurrent fluid collections at the same locations: two were treated with repeated catheter insertions and one required a limited open drainage. No complication related to catheter drainage was noted at 6-month follow-up. CONCLUSION Percutaneous catheter drainage is effective for large fluid collections in the head and neck region noted in the immediate postoperative period irrespective of contents.
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Affiliation(s)
- Kee-Min Yeow
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Chang Gung University, Tao Yuan, Taiwan, R.O.C.
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259
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Abstract
The occurrence of pharyngocutaneous fistula after oncologic head and neck surgery is a serious complication. It is the most common complication after major hypopharyngeal and laryngeal ablative surgery. The cause and management guidelines are still controversial. Contributing risk factors of impaired wound healing should be recognized in preoperative planning. Perioperative technical issues and preventive postoperative care play a major role in the prevention of fistulae, limiting the severity of the fistula and minimizing secondary complications. Surgical salvage of cancers treated with organ preservation approaches is associated with higher rates of postoperative complications, particularly in cases in which mucosal membranes are transgressed and surgically closed. Patients who require surgical repair are best treated by the use of regional myocutaneous flaps or free tissue transfers. This subset of patients is likely best treated in regional centers of excellence with well developed multidisciplinary programs for ablative and reconstructive head and neck surgery.
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Affiliation(s)
- Antti A Mäkitie
- Toronto General Hospital, Eaton North 7-242, 200 Elizabeth Street, Toronto, ON, M5G 2C4 Canada.
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260
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Stavrianos SD, McLean NR, Fellows S, Hodgkinson PD, Kostaki A, Kelly CG, Soames JV. Microvascular histopathology in head and neck oncology. BRITISH JOURNAL OF PLASTIC SURGERY 2003; 56:140-4. [PMID: 12791358 DOI: 10.1016/s0007-1226(03)00024-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A histological study of both recipient and flap vessels was performed in 30 patients with head and neck cancer, and relevant preoperative risk factors were assessed. A total of 35 free flaps were transferred in 30 patients; 16 patients had preoperative radiotherapy, 13 were smokers, eight had hypertension and six had peripheral vascular disease. No significant venous pathology was found in either the flap or the neck veins. However, over two-thirds of the neck arteries and one-half of the flap arteries were found to have microscopic arterial pathology. The only pre-existing factor significantly influencing vessel pathology was hypertension (P=0.007). All flaps survived, although in two there was some loss of the skin paddle. This study reveals that the majority of patients undergoing microsurgery in the head and neck region have pre-existing arterial damage in both the flap and the recipient arteries, but this does not have a significant effect on the overall patency of the microvascular anastomoses.
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Affiliation(s)
- S D Stavrianos
- The Northern Head and Neck Cancer Unit, The Freeman Hospital, Newcastle-upon-Tyne, UK
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261
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Chiang S, Azizzadeh B, Buga G, Ignarro L, Calcaterra T, Blackwell K. Local administration of nitric oxide donor significantly impacts microvascular thrombosis. Laryngoscope 2003; 113:406-9. [PMID: 12616187 DOI: 10.1097/00005537-200303000-00003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES/HYPOTHESIS Clinical pharmacotherapy has demonstrated a role in preventing microvascular thrombosis in both experimental and clinical settings. Previous studies in the rabbit model have noted an increased rate of thrombosis with intravenous infusion of nitric oxide antagonists. The study assessed the effects of local application of nitric oxide agonists and antagonists on microvascular anastomotic patency rates. STUDY DESIGN A randomized, prospective analysis. METHODS An arterial inversion graft microvascular thrombosis model was used in New Zealand white rabbits. The rabbits were randomly assigned to nitric oxide agonist, antagonist, and control groups. In each rabbit, the common femoral artery was surgically exposed and a 2-mm arterial inversion graft was harvested. The anastomosis of the graft to the common femoral artery was performed in solutions of either 100 micromol/L spermine NONOate (nitric oxide donor), 100 micromol/L nitro-L-arginine-methyl ester (L-NAME) (nitric oxide synthase inhibitor), or 0.9% sodium chloride (control) solution. The contralateral common femoral artery also underwent arterial inversion graft testing with the use of the same solution. Arterial patency was assessed 1 hour after anastomosis. RESULTS Sixteen of 22 arterial inversion grafts performed in the spermine NONOate solution remained patent, and 6 of 22 clotted. Eleven of 21 arterial inversion grafts performed in the control solution remained patent, and 10 clotted. Seven of 21 arterial inversion grafts performed in the L-NAME solution remained patent, and 14 clotted. These results were found to be statistically significant using the chi test with a value of less than.05. CONCLUSIONS In the rabbit model, local application of nitric oxide agonists and antagonists can significantly impact anastomotic patency rates. Further studies may demonstrate a role for the clinical use of nitric oxide in microvascular surgery.
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Affiliation(s)
- Scott Chiang
- Department of Surgery, School of Medicine, University of California-Los Angeles, 10833 Le Conte Avenue, Room 16-155, Los Angeles, CA 90095-1705, USA.
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262
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Li S, Frassica D, DeWeese T, Lee DJ, Geng J, Nag S. A real-time image-guided intraoperative high-dose-rate brachytherapy system. Brachytherapy 2003; 2:5-16. [PMID: 15062158 DOI: 10.1016/s1538-4721(03)00006-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2002] [Revised: 10/29/2002] [Accepted: 11/17/2002] [Indexed: 11/21/2022]
Abstract
PURPOSE To develop a real-time, image-guided intraoperative high-dose-rate brachytherapy system. METHODS AND MATERIALS The surface applicator, a catheter array on a 1-mm-thick soft and semitransparent silicone rubber sheet, was directly sutured on the surgical bed. A three-dimensional video camera was then used to instantly capture images of the catheters and the surgical surface. Tracing the catheters on the images allowed us to automatically determine the dwell source positions. Dwell times in the dwell positions were optimized to minimize the dose variation and deviation from the treatment prescription. A dose-texture plot was created to quantify the dose distribution. RESULTS Treatment planning time was reduced from hours to a few minutes. Phantom tests have shown that the new source localization is accurate with sigma<1.5 mm. All hot spots and cold spots had been eliminated after the dwell-time optimization. CONCLUSIONS This real-time, image-guided planning system can provide optimal image-guided intraoperative high-dose-rate brachytherapy with geometric and dosimetric improvements and a short planning time.
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Affiliation(s)
- Shidong Li
- Department of Radiation Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21231, USA.
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263
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Abstract
The patient with head and neck disease has several peculiarities that need to be recognized for the treating team to offer optimal care. These arise from the primary disorders (eg, head and neck cancer or injuries) and the morbidity they might cause, the associated comorbidities, and the possible complications of treatment. A team approach involving the surgeon, the intensivist, and other caretaking personnel is essential to achieve high-quality care and ensure the best results possible.
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Affiliation(s)
- Stavros Garantziotis
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, 275 Medical Sciences Research Building, Box 2629, Durham, NC 27710, USA.
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264
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Hall SF, Rochon PA, Streiner DL, Paszat LF, Groome PA, Rohland SL. Measuring comorbidity in patients with head and neck cancer. Laryngoscope 2002; 112:1988-96. [PMID: 12439168 DOI: 10.1097/00005537-200211000-00015] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Comorbidities are diseases or conditions that coexist with a disease of interest. The importance of comorbidities is that they can alter treatment decisions, change resource utilization, and confound the results of survival analysis. OBJECTIVE The objective of this study was to determine the best comorbidity index to use in survival analysis of patients with squamous cell carcinoma of the head and neck. METHOD Four validated indexes, with very different methodologies (i.e., the Charlson Index, the Cumulative Illness Rating Scale, the Kaplan-Feinstein Classification, the Index of Co-existent Disease), were tested using data from 379 unselected consecutive patients with complete 3-year follow-up from the Kingston Regional Cancer Center. Kaplan-Meier analysis and Cox Proportional Hazards Regression were used to stratify patients into three levels of increasing severity of comorbidity for each index. The Proportion of Variance Explained and Receiver Operating Characteristics curves were used to compare the performance of the indexes. CONCLUSION The Kaplan-Feinstein Classification was the most successful in stratifying patients in this population.
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Affiliation(s)
- Stephen F Hall
- Department of Otolaryngology, Queen's University, Kingston, Ontario, Canada.
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265
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Chiang S, Cohen B, Blackwell K. Myocardial infarction after microvascular head and neck reconstruction. Laryngoscope 2002; 112:1849-52. [PMID: 12368628 DOI: 10.1097/00005537-200210000-00027] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE/HYPOTHESIS Microvascular flap transfer is a popular method for immediate reconstruction of defects in the head and neck resulting after the treatment of head and neck cancer. Head and neck cancer occurs most commonly in elderly patients with a high prevalence of heavy smoking. Surgery in this patient population is frequently prolonged and is associated with significant intraoperative blood loss. The present study seeks to identify factors contributing to perioperative myocardial infarction and to determine the best course of management. STUDY DESIGN Retrospective analysis of 193 consecutive free flap surgeries. METHODS A series of 193 microvascular free flaps performed over a 5-year period for reconstruction of defects in the head and neck was retrospectively analyzed to identify the incidence, management, and outcome of perioperative myocardial infarction in this patient population. RESULTS Myocardial infarctions occurred in seven patients, for an overall incidence of 3.6%. Statistical analysis using logistic regression failed to demonstrate any significant relationship between age, sex, total operative time, operative blood loss, net intraoperative fluid shifts, tumor stage, American Society of Anesthesiology (ASA) preoperative classification, type of free flap, and the occurrence of perioperative myocardial infarction. Hemodynamic instability manifested by hypotension occurred in four patients who had perioperative myocardial infarction. Three of these patients underwent urgent coronary artery bypass surgery, whereas one patient underwent urgent endovascular therapy with subsequent stabilization of the hemodynamic instability. All free flaps survived despite myocardial infarction and hemodynamic instability. Two patients (29%) died after postoperative intervals of 74 and 99 days, never having left the hospital. CONCLUSIONS Systemic hypotension is a well-recognized risk factor for free flap failure. Our experience suggests that aggressive intervention to reverse coronary ischemia associated with hemodynamic instability has a favorable outcome on free flap survival, and free flap thrombosis is not an inevitable outcome of the low-flow state associated with perioperative cardiopulmonary bypass. Although the overall incidence of perioperative myocardial infarction in patients undergoing microvascular head and neck reconstruction is low, patient mortality is high, so emphasis should be placed on preoperative identification of patients with coronary artery disease.
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Affiliation(s)
- Scott Chiang
- Division of Head and Neck Surgery, Department of Surgery, University of California Los Angeles School of Medicine, Los Angeles, California 90095, USA.
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266
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Blackwell KE, Azizzadeh B, Ayala C, Rawnsley JD. Octogenarian free flap reconstruction: complications and cost of therapy. Otolaryngol Head Neck Surg 2002; 126:301-6. [PMID: 11956539 DOI: 10.1067/mhn.2002.122704] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The study goal was to document the reliability, incidence of complications, and cost of therapy for patients older than 80 years who undergo microvascular head and neck reconstruction. PATIENTS AND METHODS Thirteen octogenarians underwent free flap reconstruction of defects resulting from the treatment of head and neck cancer at an academic tertiary care medical center. The incidence of medical and reconstructive complications and the cost of hospitalization were compared with those for 99 younger patients who were treated during the same time period. RESULTS There were no cases of free flap failure or significant reconstructive complications in the octogenarians. The incidence of medical complications was 62% in the octogenarians and 15% in the younger patients. The average cost of therapy was $54,702 per octogenarian patient compared with $30,397 per younger patient. The increased incidence of medical complications and increased cost arose primarily from an increased severity of preoperative systemic illness in the octogenarians. However, controlling for comorbidity did not eliminate the discrepancy in medical complications between the octogenarians and the younger patients. CONCLUSIONS Although microvascular head and neck reconstruction in the elderly is very reliable, the incidence of medical complications and the cost of therapy are significantly increased in octogenarians.
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Affiliation(s)
- Keith E Blackwell
- Division of Head and Neck Surgery, Department of Surgery, University of California Los Angeles School of Medicine, USA.
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267
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Disa JJ, Pusic AL, Hidalgo DH, Cordeiro PG. Simplifying microvascular head and neck reconstruction: a rational approach to donor site selection. Ann Plast Surg 2001; 47:385-9. [PMID: 11601572 DOI: 10.1097/00000637-200110000-00004] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to review the authors' 13-year experience with free tissue transfer for head and neck oncology patients. This study was a retrospective review of 728 free flaps performed in 698 patients. Recipient sites were subdivided by region into the mandible (N = 253), mid face/orbit (N = 190), hypopharynx (N = 134), oral cavity (N = 104), skull base (N = 36), and scalp (N = 11). The overall free flap success rate was 98.6%. Seventy-nine flaps (10.9%) were reexplored for vascular compromise. Ten flaps (1.4%) were lost in their entirety. The overall complication rate was 17.5%. Four donor sites (forearm, fibula, rectus, and jejunum) were used for 92% of the patients. The results of the study confirm the efficacy of free tissue transfer in the reconstruction of oncological head and neck defects. In this series the free forearm, fibula, rectus, and jejunum flaps have become the workhorse donor sites for the vast majority of defects.
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Affiliation(s)
- J J Disa
- Division of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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268
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Haughey BH, Wilson E, Kluwe L, Piccirillo J, Fredrickson J, Sessions D, Spector G. Free flap reconstruction of the head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg 2001; 125:10-7. [PMID: 11458207 DOI: 10.1067/mhn.2001.116788] [Citation(s) in RCA: 248] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We undertook this study of free flap reconstruction of the head and neck to stratify patients and procedures, to determine how donor site preference changed over time, to assess medical and surgical outcomes, and to identify variables associated with complications. METHODS We analyzed computerized medical records from 236 patients who underwent a total of 241 reconstructions at a tertiary academic medical center in St. Louis between 1989 and 1998. We created a more detailed retrospective database of 141 of those patients by using 48 perioperative variables and 7 adverse outcome measures. Multivariate statistical models were used to analyze associations between variables and outcomes. RESULTS The fibula became the preferred donor site for mandibular reconstruction, and the radial forearm became the preferred donor site for pharyngoesophageal reconstruction. For the 241 procedures, the mortality rate was 2.1%, the median length of stay was 11 days, and the flap survival rate was 95%. Administration of more than 7 L of crystalloid during surgery and age over 55 were associated with major medical complications. Blood transfusion, prognostic comorbidity, and number of surgeons correlated with length of stay. Cigarette smoking and receipt of more than 7 L of crystalloid during surgery were associated with overall flap complications, and weight loss of more than 10% before surgery, more than one operating surgeon, and cigarette smoking were associated with major flap complications. CONCLUSIONS Risk to patients and transferred tissue is low in free flap head and neck reconstruction. Age, smoking history, and weight loss should be considered during patient selection. Fluid balance should be considered during and after surgery. Division of labor for patient care should be carefully delineated among surgeons in a teaching setting.
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Affiliation(s)
- B H Haughey
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
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269
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Abstract
Microvascular surgery has become the preferred method for mandible reconstruction. Whenever possible, immediate reconstruction at the time of segmental mandible resection will provide the best aesthetic and functional result. Four donor sites (fibula, iliac crest, radial forearm, and scapula) have become the primary sources of vascularized bone and soft tissue for the reconstruction. The fibula has multiple advantages, including bone length and thickness, donor site location permitting flap harvest simultaneously with tumor resection, and minimal donor site morbidity. The fibula donor site should be the first choice for most defects, particularly those with anterior or large bony defects requiring multiple osteotomies. Use of an alternative donor site is best reserved for cases with large soft tissue and minimal bone requirements. Dental rehabilitation through the use of prostheses and osseointegrated dental implants is an important part of the reconstructive process to optimize aesthetics and function. An algorithm for mandible reconstruction with microvascular osseous flaps is presented. Semin. Surg. Oncol. 19:226-234, 2000.
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Affiliation(s)
- J J Disa
- Plastic Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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270
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Abstract
As the world population ages, oncologists are increasingly confronted with the problem of comorbidity in cancer patients. This has stemmed an increasing interest into approaching comorbidity in a systematic way, in order to integrate it in treatment decisions. So far, data on the subject have been widely scattered through the medical literature. This article is aimed at reviewing the available data on the interaction of comorbidity and prognosis. This overview should provide an accessible source of references for oncological investigators developing research in the field. Various methods have been used to sum comorbidity. However, a major effort remains to be done to analyze how various diseases combine in influencing prognosis. The main end-point explored so far is mortality, with which comorbidity globally is reliably correlated. A largely open challenge remains to correlate comorbidity with treatment tolerance, and functional and quality of life outcomes, as well as to integrate it in clinical decision-making.
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Affiliation(s)
- M Extermann
- H. Lee Moffitt Cancer Center at the University of South Florida, 12902 Magnolia Drive, Tampa, FL 33612, USA.
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271
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Update on microvascular free tissue transfer: new trends and applications. Curr Opin Otolaryngol Head Neck Surg 2000. [DOI: 10.1097/00020840-200008000-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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