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Wang H, Wang Q, Li Z. Middle Meningeal Arterial Embolization Combined With Drilling in the Treatment of Acute Epidural Hematoma. J Craniofac Surg 2024:00001665-990000000-01658. [PMID: 38829986 DOI: 10.1097/scs.0000000000010384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 06/05/2024] Open
Abstract
OBJECTIVE The purpose of this study was to determine the technical feasibility and safety of middle meningeal arterial (MMA) embolization combined with drilling drainage in the treatment of acute epidural hematoma (AEDH) by comparing it with traditional craniotomy in the treatment. METHODS One hundred seventeen patients with AEDH treated for MMA embolization combined with drilling and drainage or craniotomy hematoma removal from January 2017 to September 2020 were retrospectively analyzed and divided into a craniotomy group (n=85) and a minimally invasive group (n=32). Hematoma removal was performed in the craniotomy group, and MMA embolization combined with drilling and drainage was performed in the minimally invasive group. The general clinical data, imaging data, surgery, and follow-up of the 2 groups were compared and analyzed. RESULTS Compared with the craniotomy group, the residual hematoma volume in the minimally invasive group was higher than in the craniotomy group. The average postoperative drainage duration in the minimally invasive group was longer than in the craniotomy group. Compared with the craniotomy group, the minimally invasive group was associated with shorter operative time, less intraoperative bleeding, and lower rates of postoperative rebleeding. In addition, the incidence of postoperative complications and length of hospitalization in the minimally invasive group were significantly shortened. CONCLUSION Middle meningeal arterial embolization combined with drilling and drainage in the treatment of AEDH caused by MMA active bleeding is safe, effective, and more minimally invasive, and can be promoted and applied.
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Affiliation(s)
- Henglu Wang
- Departments of Interventional Vascular Surgery
| | - Qingbo Wang
- Neurosurgery, Binzhou Medical University Hospital, , Binzhou, Shandong, People's Republic of China
| | - Zefu Li
- Neurosurgery, Binzhou Medical University Hospital, , Binzhou, Shandong, People's Republic of China
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2
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Lenkeit CP, Fritz CG, Choi JS, Schutt CA, Hong RS, Babu SC, Bojrab DI. Quantifying the effect of shoulder size on operation duration: an analysis of stapes surgery outcomes. J Laryngol Otol 2024; 138:258-264. [PMID: 37203445 DOI: 10.1017/s0022215123000890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To investigate the effect of body mass index on hearing outcomes, operative time and complication rates following stapes surgery. METHOD This is a five-year retrospective review of 402 charts from a single tertiary otology referral centre from 2015 to 2020. RESULTS When the patient's shoulder was adjacent to the surgeon's dominant hand, the average operative time of 40 minutes increased to 70 minutes because of a significant positive association between higher body mass index and longer operative times (normal body mass index group (<25 kg/m2) r = 0.273, p = 0.032; overweight body mass index group (25-30 kg/m2) r = 0.265, p = 0.019). Operative times were not significantly longer upon comparison of low and high body mass index groups without stratification by laterality (54.9 ± 19.6 minutes vs 57.8 ± 19.2 minutes, p = 0.127). CONCLUSION There is a clinically significant relationship between body mass index and operating times. This may be due to access limitations imposed by shoulder size.
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Affiliation(s)
- Christopher P Lenkeit
- Michigan Ear Institute, Farmington Hills, Michigan, USA
- Department of Otolaryngology - Head and Neck Surgery, McLaren Oakland, Pontiac, Michigan, USA
| | - Christian G Fritz
- Michigan Ear Institute, Farmington Hills, Michigan, USA
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Christopher A Schutt
- Michigan Ear Institute, Farmington Hills, Michigan, USA
- Neurotology Division, St John Providence Health System, Novi, Michigan, USA
- Department of Surgery, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Robert S Hong
- Michigan Ear Institute, Farmington Hills, Michigan, USA
- Neurotology Division, St John Providence Health System, Novi, Michigan, USA
- Department of Surgery, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University, Detroit, Michigan, USA
| | - Seilesh C Babu
- Michigan Ear Institute, Farmington Hills, Michigan, USA
- Neurotology Division, St John Providence Health System, Novi, Michigan, USA
- Department of Surgery, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University, Detroit, Michigan, USA
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Gulati A, Heaton CM, Park AM, Seth R, Knott PD. Outcomes Associated with Multiple Free Tissue Transfers Performed in a Single Day. Facial Plast Surg Aesthet Med 2023; 25:472-477. [PMID: 36848581 DOI: 10.1089/fpsam.2022.0392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Background: Although microvascular free tissue transfer (MFTT) remains technically challenging, surgeons may need to perform >1 MFTT operations in a given day. Objective: To compare MFTT outcomes in cases where surgeons completed one versus two flaps per day by measuring flap viability and complication rates. Methods: A retrospective review was conducted of MFTT cases from January 2011 to February 2022 with >30-day follow-up. Outcomes, including flap survival and operating room takeback, were compared using multivariate logistic regression analysis. Results: Of 1096 patients meeting inclusion criteria (1105 flaps), there was a male predominance (n = 721, 66%). Mean age was 63.0 ± 14.4 years. Complications requiring takeback were identified in 108 flaps (9.8%) and were greatest for double flaps in the same patient (SP) (27.8%, p = 0.06). Flap failure occurred in 23 (2.1%) cases and was also greatest for double flaps in the SP (16.7%, p = 0.001). Takeback (p = 0.06) and failure (p = 0.70) rates were not different between days with one versus two unique patient flaps. Conclusions: Among patients undergoing MFTT, those treated on days in which surgeons perform two unique cases compared with single cases will demonstrate no difference in outcomes, as measured by flap survival and takeback, whereas patients with defects requiring multiple flaps will experience greater takeback and failure rates.
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Affiliation(s)
- Arushi Gulati
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Chase M Heaton
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Andrea M Park
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rahul Seth
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - P Daniel Knott
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
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Shaikh N, Noor K, Jafary H, Chung J, Fancy T, Stokes W. Effect of 2 Teams and Operative Time on Complications After Oral Cavity Free Flap Reconstruction. Ann Otol Rhinol Laryngol 2023; 132:1430-1437. [PMID: 37012707 DOI: 10.1177/00034894231164802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
OBJECTIVE Evaluate the effects of operative time and 2 team approach on complications after soft tissue free flap reconstruction for oral tongue cancer. METHODS Patients with oncologic glossectomy with myocutaneous or fasciocutaneous free flap reconstruction were included from the 2015 to 2018 American College of Surgery National Surgical Quality Improvement Program. The primary predictive variables assessed were operative time and 2 team approach; control variables included age, sex, body mass index (BMI), 5-question-modified frailty index (mFI-5), American Society of Anesthesiologists (ASA) class, and total work relative value units (wRVU). Outcomes assessed included 30-day mortality, 30-day reoperation, hospital length of stay beyond 30 days, readmission, medical and surgical complications, and non-home discharge. Multivariable logistic/linear regression models were used to predict surgical outcomes. RESULTS Microvascular soft tissue free flap reconstruction of the oral cavity after glossectomy was performed on 839 patients. Operative time was independently associated with readmission, prolonged length of stay, surgical complications, medical complications, and non-home discharge. A 2-team approach was independently associated with prolonged length of stay and medical complications. The mean operative time of the 1-team and 2-team approach was 8.73 and 9.13 hours. The 1-team approach did not significantly increase operative time (P = .16). CONCLUSIONS In the largest study to date of operative time on post-surgical outcomes after glossectomy and soft tissue free flap reconstruction, we found longer operative times increased rates of postoperative complications and non-home discharge. The 1-team approach is non-inferior to the 2-team approach with respect to operating time and complications.
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Affiliation(s)
- Noah Shaikh
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| | - Kinza Noor
- School of Medicine, West Virginia, Morgantown, WV, USA
| | - Haseeb Jafary
- Marshall University School of Medicine, Huntington, WV, USA
| | - Jeffson Chung
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| | - Tanya Fancy
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| | - William Stokes
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
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Yang YC, Chen YS, Liao WC, Yin CH, Lin YS, Chen MW, Chen JS. Significant perioperative parameters affecting postoperative complications within 30 days following craniotomy for primary malignant brain tumors. Perioper Med (Lond) 2023; 12:54. [PMID: 37872604 PMCID: PMC10594926 DOI: 10.1186/s13741-023-00343-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 10/02/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The occurrence of postoperative complications within 30 days (PC1M) of a craniotomy for the removal of a primary malignant brain tumor has been associated with a poor prognosis. However, it is still unclear to early predict the occurrence of PC1M. This study aimed to identify the potential perioperative predictors of PC1M from its preoperative, intraoperative, and 24-h postoperative parameters. METHODS Patients who had undergone craniotomy for primary malignant brain tumor (World Health Organization grades III and IV) from January 2011 to December 2020 were enrolled from a databank of Kaohsiung Veterans General Hospital, Taiwan. The patients were classified into PC1M and nonPC1M groups. PC1M was defined according to the classification by Landriel et al. as any deviation from an uneventful 30-day postoperative course. In both groups, data regarding the baseline characteristics and perioperative parameters of the patients, including a new marker-kinetic estimated glomerular filtration rate, were collected. Logistic regression was used to analyze the predictability of the perioperative parameters. RESULTS The PC1M group included 41 of 95 patients. An American Society of Anesthesiologists score of > 2 (aOR, 3.17; 95% confidence interval [CI], 1.19-8.45; p = 0.021), longer anesthesia duration (aOR, 1.16; 95% CI, 0.69-0.88; p < 0.001), 24-h postoperative change in hematocrit by > - 4.8% (aOR, 3.45; 95% CI, 1.22-9.73; p = 0.0019), and 24-h postoperative change in kinetic estimated glomerular filtration rate of < 0 mL/min (aOR, 3.99; 95% CI, 1.52-10.53; p = 0.005) were identified as independent risk factors for PC1M via stepwise logistic regression analysis. When stratified according to the age of ≥ 65 years (OR, 11.55; 95% CI, 1.30-102.79; p = 0.028), the reduction of kinetic estimated glomerular filtration rate was more robustly associated with a higher risk of PC1M. CONCLUSIONS Four parameters were demonstrated to significantly influence the risk of PC1M in patients undergoing primary malignant brain tumor removal. Measuring and verifying these markers, especially kinetic estimated glomerular filtration rate, would help early recognition of PC1M risk in clinical care.
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Affiliation(s)
- Yao-Chung Yang
- Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Yao-Shen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung City, 81362, Taiwan
| | - Wei-Chuan Liao
- Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Institute of Health Care Management, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Yung-Shang Lin
- Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Meng-Wei Chen
- Department of Surgery, Kaohsiung Armed Force General Hospital, Kaohsiung, Taiwan
| | - Jin-Shuen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung City, 81362, Taiwan.
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Hicks MD, Vasudev M, Bishop JL, Garcia N, Chowdhury F, Pham TT, Heslop G, Greene B, Jeyarajan H, Grayson JW, Goddard JA, Tjoa T, Haidar Y, Thomas CM. Effect of Perioperative Antithrombotics on Postoperative Transfusion and Hematoma in Head and Neck Free Flaps. OTO Open 2023; 7:e86. [PMID: 37854346 PMCID: PMC10580001 DOI: 10.1002/oto2.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 07/30/2023] [Accepted: 09/05/2023] [Indexed: 10/20/2023] Open
Abstract
Objective To explore if antiplatelet or anticoagulant therapy increases the risk of transfusion requirement or postoperative hematoma formation in patients undergoing microvascular reconstruction for head and neck defects. Study Design Retrospective cohort study. Setting Departments of Otolaryngology-Head and Neck Surgery at the University of Alabama at Birmingham, the University of Colorado, and the University of California Irvine. Methods A multi-institutional, retrospective review on microvascular reconstruction of the head and neck between August 2013 to July 2021. Perioperative antithrombotic data were collected to examine predictors of postoperative transfusion and hematoma. Results A total of 843 free flaps were performed. Preoperative hemoglobin, hematocrit, operative time, and flap type were positive predictors of postoperative transfusion in both bivariate (P < .0001) and multivariate analyses (P < .0001). However, neither anticoagulation nor antiplatelet therapy were predictive of postoperative transfusion rates and hematoma formation. Conclusion Antithrombotic regimens do not increase the risk of postoperative transfusion or hematoma in head and neck microvascular reconstruction. Based on this limited data, perioperative antithrombotic regimens can be considered in patients who may otherwise be at risk for these postoperative complications.
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Affiliation(s)
- Melanie D. Hicks
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Milind Vasudev
- School of MedicineUniversity of California Irvine School of MedicineIrvineCaliforniaUSA
| | - Jessica L. Bishop
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Natalie Garcia
- School of MedicineUniversity of Alabama at Birmingham Heersink School of MedicineBirminghamAlabamaUSA
| | - Farshad Chowdhury
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Tiffany T. Pham
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Gabriela Heslop
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Benjamin Greene
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Hari Jeyarajan
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jessica W. Grayson
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Julie A. Goddard
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Tjoson Tjoa
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California IrvineIrvineCaliforniaUSA
| | - Yarah Haidar
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California IrvineIrvineCaliforniaUSA
| | - Carissa M. Thomas
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- O'Neal Comprehensive Cancer CenterBirminghamAlabamaUSA
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Sawaf T, Renslo B, Virgen C, Farrokhian N, Yu KM, Gessert TG, Jackson C, O'Neill K, Sperry B, Kakarala K. Team Consistency in Reducing Operative Time in Head and Neck Surgery with Microvascular Free Flap Reconstruction. Laryngoscope 2023; 133:2154-2159. [PMID: 36602097 DOI: 10.1002/lary.30542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/03/2022] [Accepted: 12/15/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE(S) To evaluate the impact of consistent surgical teams on procedure duration in head and neck free tissue transfer, and to evaluate the length of stay and readmission rates with consistent teams. METHODS A retrospective chart review of head and neck microvascular reconstruction by a single surgeon between August 2017 and November 2021 was performed. Procedure duration, wound complications, length of stay, and 30-day readmissions were analyzed. One circulating nurse (CN) and surgical technologist (ST) were considered "consistent" due to their prior work with the primary surgeon. All others were considered "ad hoc." Teams were "Consistent CN + ST," "Consistent ST," "Consistent CN," or "Ad hoc." Procedure duration between groups was compared via analysis of variance. Multivariate linear regression was performed to predict procedure duration. RESULTS A total of 135 patients were included. Age, sex, and American Society of Anesthesiologists status did not significantly differ across groups (p = 0.963; p = 0.467; p = 0.908, respectively). The mean procedure duration was 339.3 min and differed significantly across all groups (p = 0.006, Cohen d = 0.32). Compared to the Ad hoc group, consistent teams demonstrated significant reductions in mean procedure duration (Consistent CN + ST: 58.4 min, p = 0.001, Cohen d = 0.67; Consistent ST: 51.6 min, p = 0.013, Cohen d = 0.61; Consistent CN: 44.5 min, p = 0.031, Cohen d = 0.52). Controlling for other factors, the ad hoc team predicted increased procedure duration on multivariate analysis ( β 57.38, 19.92-94.85, p < 0.003). Wound complications, length of stay, and readmission rates did not differ significantly across groups (p = 0.940; p = 0.174; p = 0.935, respectively). CONCLUSION Consistent CN and ST improve operative efficiency in head and neck-free tissue transfer. Future studies may evaluate the impact of team consistency on complications, physician burnout, and health systems costs. LEVEL OF EVIDENCE 3 Laryngoscope, 133:2154-2159, 2023.
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Affiliation(s)
- Tuleen Sawaf
- Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Bryan Renslo
- Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Celina Virgen
- Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nathan Farrokhian
- Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Katherine M Yu
- Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Thomas G Gessert
- Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Cree Jackson
- Perioperative Services, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Katie O'Neill
- Perioperative Services, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Bethany Sperry
- Perioperative Services, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Kiran Kakarala
- Department of Otolaryngology - Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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Kakarala K, Mifsud M, Dziegielewski P. Improving Quality and Value in Head and Neck Reconstruction. Otolaryngol Clin North Am 2023; 56:853-858. [PMID: 37380327 DOI: 10.1016/j.otc.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Multiple advances in surgical techniques, technology, and perioperative patient care have revolutionized head and neck reconstruction over the last 40 years. Concurrent with these advances, health systems, patients, and payers have become increasingly focused on value and quality, owing in part to rapidly increasing health care costs. However, there is no consensus on how to define value and quality in the realm of head and neck reconstruction. This review focuses on the past, present, and future of quality improvement efforts in head and neck reconstruction.
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Affiliation(s)
- Kiran Kakarala
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
| | - Matthew Mifsud
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida School of Medicine, 13330 USF Laurel Drive, Tampa, FL 33612, USA
| | - Peter Dziegielewski
- Department of Otolaryngology-Head and Neck Surgery, University of Florida School of Medicine, 1600 Southwest Archer Road, D1-121, Gainesville, FL 32608, USA
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Steinbichler TB, Rauchenwald T, Rajsic S, Fischer HT, Wolfram D, Runge A, Dejaco D, Prossliner H, Pierer G, Riechelmann H. Delayed Reconstruction after Major Head and Neck Cancer Resection: An Interdisciplinary Feasibility Study. Cancers (Basel) 2023; 15:2777. [PMID: 37345114 DOI: 10.3390/cancers15102777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/09/2023] [Accepted: 05/13/2023] [Indexed: 06/23/2023] Open
Abstract
A single immediate reconstruction with free tissue transfer is the method of choice after major head and neck cancer (HNC) resection, but this is frequently associated with long operating hours. Considering regulatory working hour constraints, we investigated whether a two-staged reconstructive approach with temporary defect coverage by an artificial tissue substitute would be feasible. HNC patients underwent either immediate or delayed reconstruction after tumor resection. Patients with delayed reconstruction received preliminary reconstruction with an artificial tissue substitute followed by definitive microvascular reconstruction in a separate, second procedure. Of the 33 HNC patients, 13 received delayed reconstruction and 20 received immediate reconstruction. Total anesthesia time (714 vs. 1011 min; p < 0.002) and the total duration of hospital stay (34 ± 13 vs. 25 ± 6 days; p = 0.03) were longer in the delayed reconstruction group. Perioperative morbidity (p = 0.58), functional outcome (p > 0.1) and 5-year postoperative survival rank (p = 0.28) were comparable in both groups. Delayed reconstruction after HNC resection was feasible. Perioperative morbidity, functional outcome and overall survival were comparable to immediate reconstruction.
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Affiliation(s)
- Teresa B Steinbichler
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Tina Rauchenwald
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Sasa Rajsic
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Hannes T Fischer
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Dolores Wolfram
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Annette Runge
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Daniel Dejaco
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Harald Prossliner
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Gerhard Pierer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Herbert Riechelmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
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Ju LS, Zhu J, Brant JO, Morey TE, Gravenstein N, Seubert CN, Vasilopoulos T, Setlow B, Martynyuk AE. Intergenerational Perioperative Neurocognitive Disorder in Young Adult Male Rats with Traumatic Brain Injury. Anesthesiology 2023; 138:388-402. [PMID: 36637480 PMCID: PMC10411496 DOI: 10.1097/aln.0000000000004496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The authors tested the hypothesis that the effects of traumatic brain injury, surgery, and sevoflurane interact to induce neurobehavioral abnormalities in adult male rats and in their offspring (an animal model of intergenerational perioperative neurocognitive disorder). METHODS Sprague-Dawley male rats (assigned generation F0) underwent a traumatic brain injury on postnatal day 60 that involved craniectomy (surgery) under 3% sevoflurane for 40 min followed by 2.1% sevoflurane for 3 h on postnatal days 62, 64, and 66 (injury group). The surgery group had craniectomy without traumatic brain injury, whereas the sevoflurane group had sevoflurane only. On postnatal day 90, F0 males and control females were mated to generate offspring (assigned generation F1). RESULTS Acutely, F0 injury rats exhibited the greatest increases in serum corticosterone and interleukin-1β and -6, and activation of the hippocampal microglia. Long-term, compared to controls, F0 injury rats had the most exacerbated corticosterone levels at rest (mean ± SD, 2.21 ± 0.64 vs. 7.28 ± 1.95 ng/ml, n = 7 - 8; P < 0.001) and 10 min after restraint (133.12 ± 33.98 vs. 232.83 ± 40.71 ng/ml, n = 7 - 8; P < 0.001), increased interleukin-1β and -6, and reduced expression of hippocampal glucocorticoid receptor (Nr3c1; 0.53 ± 0.08 fold change relative to control, P < 0.001, n = 6) and brain-derived neurotrophic factor genes. They also exhibited greater behavioral deficiencies. Similar abnormalities were evident in their male offspring, whereas F1 females were not affected. The reduced Nr3c1 expression in F1 male, but not female, hippocampus was accompanied by corresponding Nr3c1 promoter hypermethylated CpG sites in F0 spermatozoa and F1 male, but not female, hippocampus. CONCLUSIONS These findings in rats suggest that young adult males with traumatic brain injury are at an increased risk of developing perioperative neurocognitive disorder, as are their unexposed male but not female offspring. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Ling-Sha Ju
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Jiepei Zhu
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Jason O Brant
- Department of Biostatistics, University of Florida, College of Medicine, Gainesville, Florida
| | - Timothy E Morey
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Nikolaus Gravenstein
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Christoph N Seubert
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida
| | - Terrie Vasilopoulos
- Departments of Anesthesiology, Orthopedic Surgery and Sports Medicine, University of Florida, College of Medicine, Gainesville, Florida
| | - Barry Setlow
- Department of Psychiatry and the McKnight Brain Institute, University of Florida, College of Medicine, Gainesville, Florida
| | - Anatoly E Martynyuk
- Department of Anesthesiology and the McKnight Brain Institute, University of Florida, College of Medicine, Gainesville, Florida
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11
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Irawati N, Every J, Dawson R, Leinkram D, Elliott M, Ch'ng S, Low H, Palme CE, Clark J, Wykes J. Effect of operative time on complications associated with free flap reconstruction of the head and neck. Clin Otolaryngol 2023; 48:175-181. [PMID: 36321439 DOI: 10.1111/coa.14000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 09/15/2022] [Accepted: 10/23/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate whether prolonged operative time is negatively associated with post-operative complications and length of stay in patients undergoing microvascular free flap reconstruction for complex head and neck defects. METHODS 342 consecutive patients undergoing microvascular reconstruction for head and neck defects between 2017-2019 at a single institution were evaluated. Operative outcomes and operative time were compared whilst controlling for patient and treatment related factors. RESULTS Mean operative time was 551 min and length of stay was 16.2 days. An 11% increase in the risk of a post-operative complication was observed for every additional hour of operative time (OR 1.11, 95% CI 1.03-1.21, p = 0.011) after adjusting for patient and treatment factors. A cut-off of 9 h yielded a 92% increase in complications on either side of this (OR 1.92, 95% CI 1.18-3.13, p = 0.009). Increased operative time was also associated with increased length of stay and return to theatres, but not medical complications. CONCLUSION Prolonged operative time is significantly associated with increased surgical complications, length of stay and return to theatres when performing microvascular reconstructive surgery for head and neck defects.
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Affiliation(s)
- Nina Irawati
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - James Every
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Rebecca Dawson
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - David Leinkram
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Michael Elliott
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Sydney Ch'ng
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Hubert Low
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Carsten E Palme
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jonathan Clark
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - James Wykes
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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12
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Lee J, Lee JE, Ryu JM, Kim SW, Nam SJ, Yu JH. The use of absorbable skin stapler in mastectomy does not increase the rate of surgical site infection. Ann Surg Treat Res 2023; 104:137-143. [PMID: 36910562 PMCID: PMC9998960 DOI: 10.4174/astr.2023.104.3.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/11/2023] [Accepted: 01/26/2023] [Indexed: 03/09/2023] Open
Abstract
Purpose The use of absorbable skin staplers (ASS) for skin closure has been increasing due to their convenience and time-saving effect. In this study, we evaluated the effectiveness of ASS in reducing skin closure time and its safety regarding surgical site infection (SSI), comparing it to conventional hand sewing (HS) in patients who underwent mastectomy. Methods A single-center, retrospective study was conducted. The electronic medical records of patients who underwent mastectomy between July 2015 and June 2020 in Samsung Medical Center were reviewed. The data included previously known risk factors for SSI. We compared the time expended on skin closure and the occurrence rate of SSI between the ASS group and the HS group. Results We included 4,311 patients in the analysis. Among them, 520 patients were treated with ASS and 3,791 patients with HS. The average time for skin closure was 16.2 ± 10.1 minutes in the ASS group and 36.5 ± 29.0 minutes in the HS group (P < 0.001). The SSI rate was 0.38% (2 of 520) in the ASS group and 0.36% (14 of 3,791) in the HS group (P > 0.999). Conclusion The use of ASS in mastectomy reduced the time for skin closure significantly but did not increase the SSI. Therefore, it can be an effective and safe choice to use ASS instead of HS for skin closure in mastectomy.
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Affiliation(s)
- Jin Lee
- Division of Breast, Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Eon Lee
- Division of Breast, Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jai Min Ryu
- Division of Breast, Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Won Kim
- Division of Breast, Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Jin Nam
- Division of Breast, Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Han Yu
- Division of Breast, Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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13
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Din-Lovinescu C, Barinsky GL, Povolotskiy R, Grube JG, Park CW. Percutaneous Endoscopic Gastrostomy Tube Timing in Head and Neck Cancer Surgery. Laryngoscope 2023; 133:109-115. [PMID: 35366010 PMCID: PMC10084390 DOI: 10.1002/lary.30127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/27/2022] [Accepted: 03/21/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine outcomes and complications in patients receiving a percutaneous endoscopic gastrostomy (PEG) tube on the same day of head and neck cancer (HNC) surgery versus later in hospitalization. METHODS The 2003-2014 Nationwide Inpatient Sample was queried for patients undergoing ablative HNC procedures who had a PEG tube placed. Cases were stratified by PEG tube timing into an early (on the same day as ablative procedure) and late (later in hospitalization) group. Demographics and outcomes were compared using univariate analysis and multivariate regression modeling. RESULTS A total of 4,068 cases were included, of which 2,206 (54.23%) underwent early PEG and 1,862 (45.77%) received a late PEG tube. Late PEG tube patients were more likely to have a diagnosis of malnutrition (18.0% vs. 15.3%, p = 0.018) or renal failure (4.7% vs. 3.0%, p = 0.006). On multivariate regression analysis, patients receiving late PEG tubes were more likely to experience aspiration pneumonia, acute pulmonary disease, infectious pneumonia, sepsis, hematoma, wound disruption, surgical site infection, and fistula formation (all p < 0.05). The mean length of stay and hospital charges in the late PEG group were significantly greater (17.1 vs. 12.6 days, p < 0.001) and ($159,993 vs. $125,705, p < 0.001), respectively. CONCLUSIONS Patients undergoing HNC surgery who received a PEG tube on the day of ablative surgery had lower complication rates, shorter length of stay, and decreased hospital costs compared to those who had a PEG tube placed later during hospitalization. Further research is needed to determine the causal relationships behind these findings. LEVEL OF EVIDENCE 3 Laryngoscope, 133:109-115, 2023.
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Affiliation(s)
- Corina Din-Lovinescu
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Gregory L Barinsky
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Roman Povolotskiy
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jordon G Grube
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Chan W Park
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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14
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Runge A, Vales A, Pommer G, Raab H, Prossliner H, Randhawa A, Schennach H, Riechelmann H. Perioperative Blood Transfusion in Head and Neck Cancer Revisited. Laryngoscope 2022. [PMID: 37021734 DOI: 10.1002/lary.30341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To reevaluate the frequency of perioperative blood transfusion, transfusion triggers, and survival impact in patients with incident, surgically treated head and neck cancer (HNC) in restrictive transfusion regimens. METHODS Retrospective analysis of surgically treated patients with incident HNC with and without perioperative blood transfusion between 2008 and 2019 at the Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, according to the department's clinical Head and Neck Tumor Registry. RESULTS Of the 590 patients included, perioperative transfusions were administered in 6.3% (n = 37, transfusion group). Following multivariable logistic regression, likelihood of blood transfusions was increased in patients with poorer general health conditions (ASA score III/IV; OR 3.7; 95% CI 1.9-8.6; p = 0.002), hemoglobin <12.5 g/dL (OR 2.7; 95% CI 1.1-6.4; p = 0.03), longer duration of surgery (OR 1.006 per minute of surgery time; 95% CI 1.003-1.008; p < 0.001), and negative p16 status (OR 5.3; 95% CI = 1.1-25; p = 0.03). Based on 14 matching variables related to survival and perioperative blood transfusion, a control group of 37 matching patients without perioperative transfusion was identified. Using univariate analysis, overall survival in transfusion and control groups did not differ significantly (p = 0.25). After adjusting for four parameters with limited matching accuracy (Chi square p < 0.2) in Cox regression analysis, a transfusion related hazard ratio close to 1 (HR 0.92; 95% CI 0.34-2.51; p = 0.87) was observed. CONCLUSION Considering current restrictive transfusion regimens and general transfusion risks, the administration of blood products in HNC patients during the perioperative period is not associated with additional oncologic hazard. LEVEL OF EVIDENCE III Laryngoscope, 2022.
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Affiliation(s)
- Annette Runge
- Department of Otorhinolaryngology, Head and Neck Surgery Medical University of Innsbruck Innsbruck Austria
| | - Anja Vales
- Institute for Blood Transfusion and Immunological Department Medical University of Innsbruck Innsbruck Austria
| | - Gabriele Pommer
- Department of Otorhinolaryngology, Head and Neck Surgery Medical University of Innsbruck Innsbruck Austria
| | - Helmut Raab
- Department of Anesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Harald Prossliner
- Department of Anesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Avneet Randhawa
- Department of Otolaryngology – Head and Neck Surgery Rutgers New Jersey Medical School Newark New Jersey USA
| | - Harald Schennach
- Institute for Blood Transfusion and Immunological Department Medical University of Innsbruck Innsbruck Austria
| | - Herbert Riechelmann
- Department of Otorhinolaryngology, Head and Neck Surgery Medical University of Innsbruck Innsbruck Austria
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GENCER ERKOC M, ERKİN Y, HANCI V. Postanestezi Bakim Ünitesinde Takip Edilen Major Baş-Boyun Cerrahisi Geçiren Hastaların Değerlendirilmesi: 6 Yillik Retrospektif Analiz. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2022. [DOI: 10.17944/mkutfd.983464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Giriş: Çalışmamızda kliniğimizde son altı yılda major baş boyun cerrahisi geçiren ve post-anestezi yoğun bakım ünitesinde (PABÜ) takip edilen hastaların retrospektif incelenerek postoperatif sonuçlara etki eden faktörleri belirlenmesini amaçladık.
Gereç ve Yöntem: Major baş boyun cerrahisi geçiren ve PABÜ’de postoperatif yoğun bakım takibi yapılan hastalarının Hastaların demografik özellikleri, komorbiditeleri, preoperatif laboratuvar bulguları, hastalığın evreleri, cerrahi özellikleri, intraoperatif özellikleri, postoperatif takip bulguları, komplikasyonları, yatış süreleri, morbiditeleri probel sistemi ve hasta dosyaları incelenerek kayıt ve analiz edildi.
Bulgular: Çalışmamıza toplam 74 major baş boyun cerrahisi olgusu dahil edildi. Hastaların Charlson komorbidite indeksleri (CCI) ile ASA skoru ve yaş arasında istatistiksel olarak anlamlı fark saptanmıştır. Operasyon süresi; KOAH, serbest flep ile rekonstrüksiyon ve trakeostomi ihtiyacı olan hastalarda artmaktaydı. Preoperatif sodyum düzeyleri ve intraoperatif kan transfüzyonu ile mekanik ventilasyon (MV) süresi arasında istatistiksel anlamlı ilişki saptanmıştır. PABÜ yatış süresi ile 60 yaş üzeri olma, preoperatif albumin seviyesi ve preoperatif sodyum değerleri, nötrofil-lenfosit oranları, kan transfüzyonu ve MV süresi arasında ilişki olduğu belirlenmiştir. Yoğun bakım ihtiyacı gelişmesi ile preoperatif serum sodyum düzeyleri, operasyon süresi, kan transfüzyonu, MV süresi, PABÜ yatış süresi arasında istatistiksel anlamlı ilişki saptanmıştır. Çalışmamızda incelediğimiz hastaların 19 (%25,7)’unda komplikasyon izlenmiştir. Mortalite ile PABÜ yatış süresi ve yoğun bakım ihtiyacı arasında istatistiksel olarak anlamlı ilişki gözlenmektedir. N evresi ile komplikasyon, hastane yatışı süresince yoğun bakım ithiyacı gelişmesi ve mortalite arasında istatistiksel olarak anlamlı ilişki görülmüştür.
Sonuç: Çalışmamızda major baş boyun cerrahisi hastalarında postoperatif sonuçlar üzerine, preoperatif elektrolit bozuklukları, nötrofil-lenfosit oranları, operasyon süresi, intraoperatif kan transfüzyonu, mekanik ventilasyon süresi ile N evresinin etkili faktörler arasında olduğu belirlenmiştir.
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Mark M, Eggerstedt M, Urban MJ, Al‐Khudari S, Smith R, Revenaugh P. Designing an evidence‐based free‐flap pathway in head and neck reconstruction. World J Otorhinolaryngol Head Neck Surg 2022; 8:126-132. [PMID: 35782403 PMCID: PMC9242419 DOI: 10.1002/wjo2.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022] Open
Abstract
Background The use of autologous free‐tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer. This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free‐flap care. Data Sources This article examines English literature from PubMed and offers expert opinion on perioperative free‐flap care for head and neck oncology. Conclusion Free‐flap reconstruction for head and neck cancer is a process that, while individualized for each patient, is best supported by a comprehensive and standardized care pathway. Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence‐based practice is rewarded with improved outcomes.
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Affiliation(s)
- Michelle Mark
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Michael Eggerstedt
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Matthew J. Urban
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Samer Al‐Khudari
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Ryan Smith
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
| | - Peter Revenaugh
- Department of Otorhinolaryngology‐Head and Neck Surgery, Section of Facial Plastic and Reconstructive Surgery Rush University Medical Center Chicago Illinois USA
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Ganor O, Jolly D, Wu CA, Boskey ER. Can gender-affirming surgeries be safely combined? An NSQIP analysis of 30-day outcomes and case planning factors. J Plast Reconstr Aesthet Surg 2022; 75:2664-2670. [PMID: 35597710 DOI: 10.1016/j.bjps.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 03/07/2022] [Accepted: 04/12/2022] [Indexed: 11/18/2022]
Abstract
As gender-affirming surgeries are being performed, new techniques have been developed to meet patient desires, including recent reports of several gender-affirming procedures being combined into a single operative encounter. Such a development may provide several advantages to both patients and providers. However, it is less clear whether combining these procedures affects patient safety and surgical case planning factors. To address this, we compared the complication rates and the length of hospital stay and operative time for standalone and combined gender-affirming procedures (e.g., hysterectomy and bilateral mastectomy, breast augmentation, and vaginoplasty) performed between 2005 and 2019 in the National Surgical Quality Improvement Program database. There were 1857 standalone mastectomies, 826 standalone hysterectomies, and 30 cases where they were combined. There were 379 vaginoplasties, 648 breast augmentations, and 31 cases where they were combined. There was no evidence of differences in overall health status between those undergoing combined and standalone procedures. Two-sample proportion testing did not find significant differences in any of the complications experienced between standalone and combined procedures. Similarly, two-sample t-tests did not find significant differences in the length of the hospital stays nor in the length of the operative encounter between standalone and combined masculinizing surgeries. Combining breast augmentation and vaginoplasty, however, saved an average of 97.86 min (p = .000) of operating time. These results suggest that combining gender-affirming procedures may be a safe and viable option for individuals who desire multiple gender-affirming procedures and may even be an advantageous option for patients and practitioners alike.
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Affiliation(s)
- Oren Ganor
- Center for Gender Surgery, Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States; Department of Surgery, Harvard Medical School, Boston, MA, United States
| | - Divya Jolly
- Center for Gender Surgery, Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States.
| | - Catherine A Wu
- Student, Harvard Medical School, Boston, MA, United States
| | - Elizabeth R Boskey
- Center for Gender Surgery, Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, United States; Department of Surgery, Harvard Medical School, Boston, MA, United States; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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18
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Brauer PR, Byrne PJ, Prendes BL, Ku JA, Ciolek PJ, Jia X, Lamarre ED. Association between hypertension requiring medication and 30-day outcomes in head and neck microvascular surgery. Head Neck 2021; 44:168-176. [PMID: 34704643 DOI: 10.1002/hed.26907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/02/2021] [Accepted: 10/15/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hypertension has been shown to be both a protective factor and a risk factor for complications in head and neck reconstructive surgery. METHODS Retrospective analysis of microvascular free tissue transfer patients using the National Surgical Quality Improvement Program database. RESULTS Hypertensive patients (n = 1598; 46.9%) had a significantly higher rate of complications, including pneumonia (p < 0.001), myocardial infarction (p = 0.003), and intra/post-operative transfusion (p < 0.001). In a multivariable model, hypertension was associated with returning to the operating room (OR = 1.45 [95% CI 1.20, 1.76], p < 0.001), post-operative medical complications (OR = 1.53 [95% CI 1.24, 1.90], p < 0.001), and surgical complications (OR = 1.17 [95% CI 1.00, 1.37], p = 0.047). However, no difference in 30-day readmission was found (p > 0.05). CONCLUSIONS Hypertension is a modifiable risk factor for post-operative complications in head and neck free tissue transfer, in which prospective studies are required to establish causation. This study may serve as an impetus for proactive recommendations to manage hypertension before undergoing head and neck microvascular surgery.
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Affiliation(s)
- Philip R Brauer
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick J Byrne
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jamie A Ku
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peter J Ciolek
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xuefei Jia
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric D Lamarre
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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19
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Ali B, Choi EE, Barlas V, Petersen TR, Menon NG, Morrell NT. Risk Factors for 30-Day Mortality After Head and Neck Microsurgical Reconstruction for Cancer: NSQIP Analysis. OTO Open 2021; 5:2473974X211037257. [PMID: 34616994 PMCID: PMC8489772 DOI: 10.1177/2473974x211037257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 12/14/2022] Open
Abstract
Objective To identify the incidence and risk factors for 30-day postoperative mortality after microsurgical head and neck reconstruction following oncological resection. Study Design Retrospective case-control study. Setting American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Methods Microsurgical head and neck reconstructive cases were identified from 2005 to 2018 using Current Procedural Terminology codes and oncologic procedures using the International Classification of Disease 9 and 10 codes. The outcome of interest was 30-day mortality. Results The 30-day postoperative mortality rate was 1.2%. Univariate logistic regression analysis identified the following associations: age >80 years, hypertension, poor functional status, preoperative wound infection, renal insufficiency, malnutrition, anemia, and prolonged operating time. Multivariable logistic regression models were used to stratify further by the degree of malnutrition and anemia. Hematocrit <30% was found to be an independent risk factor for 30-day postoperative mortality (odds ratio [OR] = 9.59, confidence interval [CI] 2.32-39.65, P < .1) with albumin <3.5 g/dL. This association was even stronger with albumin <2.5 g/dL (OR = 11.64, CI 3.06-44.25, P < .01). One-third of patients (36.6%) had preoperative anemia, of which less than 1% required preoperative transfusion, although one-quarter (24.6%) required intraoperative or 72 hours postoperative transfusion. Conclusions Preoperative anemia is a risk factor for 30-day postoperative mortality. This association seems to get stronger with worsening anemia. Identification and optimization of such patients preoperatively may mitigate the incidence of 30-day postoperative mortality.
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Affiliation(s)
- Barkat Ali
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - EunHo Eunice Choi
- Biostatistics, Epidemiology, and Research Designs, Clinical and Translational Science Center, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Venus Barlas
- University of New Mexico, School of Medicine, Albuquerque, New Mexico, USA
| | - Timothy R Petersen
- Department of Anesthesia and Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Nathan G Menon
- Department of Orthopedics, Hand, and Microsurgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Nathan T Morrell
- Department of Orthopedics, Hand, and Microsurgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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20
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Intraoperative Fluid Management Implies Insignificant Influence to Surgical Outcomes in Head and Neck Microvascular Reconstruction Cases. Plast Reconstr Surg 2021; 147:627e-633e. [PMID: 33776038 DOI: 10.1097/prs.0000000000007777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Deliberate fluid administration has been used to maintain a hyperdynamic systemic circulation in free tissue transfer operations. The effects of intraoperative volume loading on postoperative complications have been controversial. The authors hypothesized that increasing intraoperative fluid administration was associated with increased postoperative surgical complications. METHODS Free flap operations for head and neck reconstruction between 2004 and 2014 were reviewed. A generalized estimating equation model was used to estimate the effect of intraoperative fluid administration on surgical outcomes. The optimized thresholds of anesthetic time were tested by the Youden index for flap compromise and major complications. RESULTS A total of 2983 consecutive cases were included in the study. The incidences of flap compromise and total loss were 1.5 and 3.3 percent, respectively. Intraoperative fluid administration was not associated with surgical complications (p = 0.195). However, a 1-hour increase in anesthesia time was associated with a 19 percent increased risk of flap compromise (adjusted OR, 1.19; 95 percent CI, 1.10 to 1.29; p < 0.001). CONCLUSION Prolonged anesthetic time, but not fluid administration, was associated with adverse surgical outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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21
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Katsnelson JY, Tyrell R, Karadsheh MJ, Manstein E, Egleston B, Deng M, Baltodano PA, Shafqat MS, Patel SA. Postoperative Complications Associated with the Choice of Reconstruction in Head and Neck Cancer: An Outcome Analysis of 4,712 Patients from the ACS-NSQIP Database. J Reconstr Microsurg 2021; 38:343-360. [PMID: 34404103 DOI: 10.1055/s-0041-1733922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Microsurgical free flaps have largely supplanted pedicled flaps as the gold standard for head and neck cancer reconstruction. However, incidence of postoperative complications after accounting for patient comorbidities based on choice of reconstruction has not been well-defined in the literature in recent years. METHODS Patients undergoing head and neck reconstruction were identified in the 2011-2016 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database and stratified into groups by free flap, myocutaneous pedicled flap, and other reconstruction. Demographics were analyzed and covariates balanced using overlap propensity score-based weighting. Logistic regression was used for binary outcomes and Gamma generalized linear model was used for length of stay. RESULTS A total of 4,712 patients met inclusion criteria out of which 1,297 patients (28%) underwent free flap, 208 patients (4%) pedicled flap, and 3,207 patients (68%) had other, or no reconstruction performed. After adjusting for patient and disease-specific factors, pedicled flap reconstruction was associated with a higher risk of deep vein thrombosis (odds ratio [OR] = 2.64, confidence interval [CI] 1.02-6.85, p = 0.045), sepsis (OR = 2.95, CI 1.52-5.71, p = 0.001), and infection (OR = 2.03, CI 1.39-2.96, p <0.001) compared with free flap reconstruction. Free flaps had the longest mean operative time compared with the other two groups (unadjusted 578 vs. 440 vs. 326, p <0.001). Pedicled flaps had a lower incidence of bleeding requiring transfusion (adjusted OR = 0.65, CI 0.50-0.85, p = 0.002), and lower incidence of prolonged mechanical ventilation (adjusted OR = 0.33, CI 0.12-0.92, p = 0.034) compared with free flaps. There was no difference in rates of reoperation, hospital readmission, or hospital length-of-stay between pedicled and free flaps. CONCLUSION Myocutaneous pedicled flaps are associated with higher overall short-term postoperative complications compared with free flaps in head and neck reconstruction, which demonstrate a more favorable morbidity profile without significantly impacting hospital readmission, reoperation, or length-of-stay.
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Affiliation(s)
- Jacob Y Katsnelson
- Department of Surgery, Abington-Jefferson Health, Abington, Pennsylvania
| | - Richard Tyrell
- Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Murad J Karadsheh
- Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Ely Manstein
- Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Brian Egleston
- Biostatistics and Bioinformatics Facility, Temple University Health System, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Mengying Deng
- Biostatistics and Bioinformatics Facility, Temple University Health System, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Pablo A Baltodano
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - M Shuja Shafqat
- Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.,Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania.,Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Sameer A Patel
- Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.,Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania.,Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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22
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Farooqi AS, Detchou DKE, Glauser G, Strouz K, McClintock SD, Malhotra NR. Overlapping single-level lumbar fusion and adverse short-term outcomes. J Neurosurg Spine 2021; 35:571-582. [PMID: 34359028 DOI: 10.3171/2020.12.spine201861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is a paucity of research on the safety of overlapping surgery. The purpose of this study was to evaluate the impact of overlapping surgery on a homogenous population of exactly matched patients undergoing single-level, posterior-only lumbar fusion. METHODS The authors retrospectively analyzed case data of 3799 consecutive adult patients who underwent single-level, posterior-only lumbar fusion during a 6-year period (June 7, 2013, to April 29, 2019) at a multihospital university health system. Outcomes included 30-day emergency department (ED) visit, readmission, reoperation, and morbidity and mortality following surgery. Thereafter, coarsened exact matching was used to match patients with and without overlap on key demographic factors, including American Society of Anesthesiologists (ASA) class, Charlson Comorbidity Index (CCI) score, sex, and body mass index (BMI), among others. Patients were subsequently matched by both demographic data and by the specific surgeon performing the operation. Univariate analysis was carried out on the whole population, the demographically matched cohort, and the surgeon-matched cohort, with significance set at a p value < 0.05. RESULTS There was no significant difference in morbidity or any short-term outcome, including readmission, reoperation, ED evaluation, and mortality. Among the demographically matched cohort and surgeon-matched cohort, there was no significant difference in age, sex, history of prior surgery, ASA class, or CCI score. Overlapping surgery patients in both the demographically matched cohort and the matched cohort limited by surgeon had longer durations of surgery (p < 0.01), but no increased morbidity or mortality was noted. Patients selected for overlap had fewer prior surgeries and lower ASA class and CCI score (p < 0.01). Patients with overlap also had a longer duration of surgery (p < 0.01) but not duration of closure. CONCLUSIONS Exactly matched patients undergoing overlapping single-level lumbar fusion procedures had no increased short-term morbidity or mortality; however, duration of surgery was 20 minutes longer on average for overlapping operations. Further studies should assess long-term patient outcomes and the impact of overlap in this and other surgical procedures.
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Affiliation(s)
- Ali S Farooqi
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, and
| | - Donald K E Detchou
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, and
| | - Gregory Glauser
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, and
| | - Krista Strouz
- 2McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia; and
- 3West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, Pennsylvania
| | - Scott D McClintock
- 3West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, Pennsylvania
| | - Neil R Malhotra
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, and
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23
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Miller H, Bush KM, Betances A, Kota R, Wu S, De Leo N, Gaughan J, Bonawitz S. Effect of Daily Dosage of Morphine Milligram Equivalents on Free Flap Complications: A Single-Institution Retrospective Study. J Plast Reconstr Aesthet Surg 2021; 74:2486-2494. [PMID: 33935007 DOI: 10.1016/j.bjps.2021.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/16/2021] [Accepted: 03/11/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There appears to be an association between preoperative opioid use and postoperative complications. We sought to determine whether patients with a history of chronic opiate use (defined as 3 months or more of sustained use) prior to undergoing free flap surgery have higher rates of 30-day complications. METHODS A retrospective review of patients undergoing free flaps from 2015 to 2020 was performed. Patient characteristics were analyzed, including daily preoperative dose of opiates, which were then converted to morphine milligram equivalents; intra-operative variables such as estimated blood loss and operating room time; and 30-day outcomes, including wound and flap complications, return to the operating room, and readmissions. RESULTS One hundred fifty-five patients received 160 free flaps. Of these flaps, 50/160 (31%) were performed on patients with an opiate prescription for at least three months prior to surgery. Using multivariable analysis, morphine milligram equivalents, a surrogate for opioid dose, were significantly associated with flap complications (odds ratio (OR) 1.011, 95% confidence interval (CI) 1.003-1.020, p<0.01), partial flap loss (OR 1.010, 95% CI 1.003-1.019, p<0.01), and surgical site infections (OR 1.017, 95% CI 1.007-1.027, p<0.01). Additionally, estimated blood loss was associated with partial flap loss (OR 4.838, 95% CI 1.589-14.728, p<0.006), and operating room time was also associated with flap complications (OR 1.337, 95% CI 1.152-1.150, p<0.01). CONCLUSION Chronic preoperative opioid use is common for free flap surgery, and according to our single-center experience, higher daily doses are a risk factor for flap complications and surgical site infections. These findings add to the growing body of evidence that opioid use is a modifiable risk factor that may increase surgical morbidity.
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Affiliation(s)
- Henry Miller
- Department of Surgery, Cooper University Hospital, Camden NJ.
| | | | | | - Rasagnya Kota
- Cooper Medical School of Rowan University, Camden NJ
| | - Samantha Wu
- Cooper Medical School of Rowan University, Camden NJ
| | - Nicholas De Leo
- Department of Surgery, Cooper University Hospital, Camden NJ
| | - John Gaughan
- Cooper Research Institute, Cooper University Hospital, Camden NJ
| | - Steven Bonawitz
- Department of Surgery, Cooper University Hospital, Camden NJ
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González-García JA, Chiesa Estomba CM, Sistiaga-Suarez JA, Larruscain E, Urazan-Murcia JD, Altuna X. Pedicled Supraclavicular Artery Island Flap Versus Free Radial Forearm Flap: Perioperative Outcomes in Head and Neck Reconstruction. Cureus 2021; 13:e13213. [PMID: 33717750 PMCID: PMC7944373 DOI: 10.7759/cureus.13213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Radial forearm free flap (RFFF) and supraclavicular artery island flap (SCAIF) are some of the most common fasciocutaneous flaps used for head and neck (H&N) reconstruction. MATERIAL AND METHODS A retrospective analysis of clinical data and outcomes of 31 consecutive patients who underwent H&N reconstruction using either SCAIF or RFFF over a three-year period, aiming to compare the surgical outcomes of the SCAIF and the RFFF in H&N reconstruction. RESULTS Thirty-two flaps were performed in 31 patients (17 SCAIFs and 15 RFFFs). There was no difference in patient demographics between both groups. Hospital stay was longer in the SCAIF group (30.7 ± 18.2 days (min: 9/max: 60) versus 19.2 ± 15.8 days (min: 7/max: 72). Patients who underwent reconstruction with a SCAIF had shorter reconstructive procedure time; 74.4 min (min: 60/max: 93) versus 147.8 min (min: 140/max: 187). Overall morbidity was not significantly different (SCAIF 52.7% vs RFFF 39.9%, p = NS). Global flap survival was higher without statistical significance in the RFFF group (100%) versus the SCAIF group (70.7%). CONCLUSION Despite the advantages related to the use of SCAIF like regarding the time spent in the reconstructive procedure. In our experience, the RFFF continues to be the most successful technique with similar perioperative outcomes and fewer complication rates. In this vein, both techniques can be reasonably used to reconstruct post-ablative H&N defects. However, in our experience, the use of SCAIF may lengthen hospital length of stay probably due to the augmented risk of flap failure.
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Affiliation(s)
| | | | | | - Ekhiñe Larruscain
- ENT - Head and Neck Surgery, Hospital Universitario Donostia, Donostia, ESP
| | - Juan D Urazan-Murcia
- ENT - Head and Neck Surgery, Hospital Universitario Donostia, San Sebastian, ESP
| | - Xabier Altuna
- ENT - Head and Neck Surgery, Hospital Universitario Donostia, San Sebastian, ESP
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25
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Wang W, Ong A, Vincent AG, Shokri T, Scott B, Ducic Y. Flap Failure and Salvage in Head and Neck Reconstruction. Semin Plast Surg 2020; 34:314-320. [PMID: 33380919 DOI: 10.1055/s-0040-1721766] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
With advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.
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Affiliation(s)
- Weitao Wang
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Adrian Ong
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Aurora G Vincent
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Tom Shokri
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Britney Scott
- Department of Otolaryngology - Head and Neck Surgery, Kettering Health Network, Dayton, Ohio
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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26
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Lebo NL, Quimby AE, Caulley L, Thavorn K, Kekre N, Brode S, Johnson-Obaseki S. Surgical Site Infection Affects Length of Stay After Complex Head and Neck Procedures. Laryngoscope 2020; 130:E837-E842. [PMID: 31977071 DOI: 10.1002/lary.28512] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 02/23/2024]
Abstract
OBJECTIVES/HYPOTHESIS Quality improvement (QI) initiatives emphasize a need for reduction in hospital length of stay (LOS). We sought to determine the impact of surgical site infections (SSIs) on LOS after complex head and neck surgery (HNS). STUDY DESIGN Retrospective cohort analysis. METHODS An analysis of the American College of Surgeons National Surgical Quality Improvement Program was undertaken. All adult patients undergoing complex HNS from 2005 to 2016 were included in the analysis. Our main outcomes were SSI incidence and increase in hospital LOS attributable to SSI. RESULTS Of 4,014 patients identified, 16.5% developed SSI. History of smoking, diabetes, preoperative wound infection, contaminated or dirty wound classes, and prolonged operative time were found to significantly predict postoperative SSI. Adjusting for significant pre- and postoperative factors, SSI was associated with significantly increased LOS (hazard ratio = 0.486, 95% confidence interval: 0.419-0.522). CONCLUSIONS SSI following complex HNS is associated with significantly increased hospital LOS. This result supports the need for institutional QI strategies that target SSIs after head and neck procedures in an effort to provide the highest quality care at the lowest possible cost. Our analysis identifies risk factors that can allow identification of patients at high risk of SSI and prolonged hospitalization. LEVEL OF EVIDENCE 2b Laryngoscope, 2020.
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Affiliation(s)
- Nicole L Lebo
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Alexandra E Quimby
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Caulley
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology, Erasmus Medical Centre, Rotterdam, the Netherlands
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Institute for Clinical and Evaluative Sciences, Toronto, Ontario, Canada
| | - Natasha Kekre
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Brode
- Department of Medicine, Division of Respirology, University Health Network, Toronto, Ontario, Canada
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27
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Unnecessary Blood Transfusion Prolongs Length of Hospital Stay of Patients Who Undergo Free Fibular Flap Reconstruction of Mandibulofacial Defects: A Propensity Score-Matched Study. J Oral Maxillofac Surg 2020; 78:2316-2327. [PMID: 32866482 DOI: 10.1016/j.joms.2020.07.213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/25/2020] [Accepted: 07/22/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Blood transfusion is usually a common clinical practice in flap transfer surgery because of its invasive hemorrhagic nature. Although intraoperative restrictive transfusion policy was suggested in vascularized fibular flap reconstruction, its clinical evidence was still insufficient. Therefore, our study aimed to investigate the influence of intraoperative blood transfusion on length of stay (LOS) after vascularized fibular flap reconstruction. PATIENTS AND METHODS Patients who underwent vascularized fibular flap reconstruction of mandibulofacial defects between 2012 and 2018 were reviewed. Univariate and multivariate analyses were performed to identify factors that influenced LOS. The identified factors and other perioperative factors that may influence transfusion decision were included in propensity score matching to explore the independent impact of intraoperative blood transfusion on LOS. RESULTS About 375 patients were included, and the median LOS was 14.00 (12.00, 19.00) days in our study. Multivariate analysis suggested that duration of surgery, fluid infusion speed for more than 24 hours on operative day, intraoperative blood transfusion, and postoperative complication were associated with prolonged LOS (P < .05). Propensity score matching was performed, and the difference of LOS between the matched transfused and nontransfused group was statistically significant (15.00 [12.75, 20.00] vs 14.00 [11.75, 16.25]; P < .001). The comparison between the matched and unmatched transfused patients indicated that the former has less radiotherapy history, blood loss, and higher preoperative hemoglobin (P ≤ .001). CONCLUSIONS Intraoperative blood transfusion is independently associated with prolonged LOS in patients without preoperative anemia, radiotherapy history, or intraoperative massive hemorrhage who undergo vascularized fibular flap reconstruction. Efforts should be made to avoid unnecessary intraoperative blood transfusion, and our results support consideration of a restrictive transfusion policy in these patients.
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28
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Kim S, Lee DH, Ahn KM. Microvascular reconstruction for maxillofacial defects: a retrospective analysis of outcomes and complications in 121 consecutive cases. Maxillofac Plast Reconstr Surg 2020; 42:29. [PMID: 32884927 PMCID: PMC7447709 DOI: 10.1186/s40902-020-00273-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/12/2020] [Indexed: 12/15/2022] Open
Abstract
Background Microvascular reconstruction is the treatment of choice after oral cancer ablation surgery. There are few published studies of free flap survival among Korean populations. This study aimed to determine the survival rate after 121 consecutive cases of maxillofacial microvascular reconstruction and to analyze the complications associated with microsurgery. Methods This study included consecutive patients who underwent microsurgical reconstruction with free flaps, from January 2006 through September 2019, performed by a single surgeon at the oral and maxillofacial surgery department of a tertiary medical center. A total of 121 cases were reviewed retrospectively. The flap survival rate, flap type, radiotherapy history, complications, and treatment results were analyzed. Results Four different flap types were used for microvascular reconstruction: radial forearm (n = 65), fibula (n = 34), latissimus dorsi (n = 21), and serratus anterior muscle with rib bone free flap (n = 1). Total necrosis of the flap was found in four cases (two latissimus dorsi flaps and two fibular flaps). The free flap survival rate was 97.5%. Nineteen patients received radiotherapy before surgery, and none of them experienced flap failure. The mean operation time was 334 ± 83.1 min, and the mean ischemic time was 48.9 ± 12.7 min. Conclusions The success rate was reliable and comparable with previous studies. The success rate was not affected by radiation therapy. Free flaps can be safely used even after radiation treatment.
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Affiliation(s)
- SeongRyoung Kim
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Dong-Hun Lee
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Kang-Min Ahn
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505 Korea
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29
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Crystal DT, Curiel DA, Abdul-Hamed S, Blankensteijn LL, Ibrahim AMS, Lee BT, Lin SJ. Outcomes of microvascular bone flaps versus osteocutaneous flaps in head and neck reconstruction. Microsurgery 2020; 40:731-740. [PMID: 32729977 DOI: 10.1002/micr.30634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 04/14/2020] [Accepted: 06/29/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Surgical resection of head and neck (H&N) neoplasms requiring osseous reconstruction have underdefined complication profiles. This study aimed to characterize postoperative outcomes of patients with H&N neoplasia undergoing osteocutaneous flap (OCF) or bare bone flap (BBF) reconstructions. MATERIALS AND METHODS Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) 2005-2017 databases. Queried for diagnosis and procedural codes extracted patients with H&N neoplasms undergoing BBF or OCF reconstruction. Postoperative complications were evaluated. Multivariable regression generated adjusted odds ratios. RESULTS A cohort of 746 patients were identified. Of reconstructions, 24.9% (n = 186/746) were BBFs while 75.1% (n = 560/746) were OCFs. 58.1% of the BBF cohort and 59.9% of the OCF cohort experienced an all-cause complication (p = .654). Sub-stratified, 24.2% of BBF and 17.5% of OCF patients experienced a wound complication (p = .045). Regression analysis demonstrated no difference in risk for medical complications between cohorts. However, patients receiving OCFs had a decreased likelihood of developing a wound complication (OR 0.652; 95%CI 0.430-0.989; p = .044) compared to patients receiving BBFs. CONCLUSION The incidence of complications following osseous reconstruction of the H&N is considerable. Although several complication outcomes do not seem to differ between BBF or OCF reconstructions, OCFs is associated with a decreased likelihood of wound complications.
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Affiliation(s)
- Dustin T Crystal
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel A Curiel
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Senan Abdul-Hamed
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Louise L Blankensteijn
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmed M S Ibrahim
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bernard T Lee
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Vanags I, Stepanovs J, Ozolina A, Mukans M, Bjertnaes LJ, Mamaja B. Thromboelastometry for Assessing Risks of Free Flap Thrombosis in Patients Undergoing Microvascular Surgery. Front Med (Lausanne) 2020; 7:289. [PMID: 32656219 PMCID: PMC7324680 DOI: 10.3389/fmed.2020.00289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/22/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Coagulation assessment is often missing in microvascular surgery. We aimed at evaluating the predictive value of thromboelastometry for free flap thrombosis in microvascular surgery patients. Materials and Methods: We enrolled 103 adult patients with traumatic injuries scheduled for microvascular free flap surgery into a prospective observational study. Thirty-six patients with recent trauma underwent surgery within 30 days (ES group), and were compared with 67 trauma patients who underwent surgery later than 30 days (late surgery, LS group) after the injury. Rotational thromboelastometry (RTE) was performed before surgery. Functional fibrinogen to platelet ratio (FPR) ≥ 42 was selected as the main hypercoagulability index. Free flap thrombosis was set as primary outcome. Thrombotic risk factors and duration of surgery related to free flap thrombosis were secondary outcomes. Statistical significance p < 0.05; not significant NS. Results: Six patients (16.7%) in the ES group and 10 (14.9%) in the LS group had free flap thrombosis (NS). In the entire cohort, free flap thrombosis rate increased in the presence of thrombogenic comorbidities (OR 4.059, CI 1.33-12.37; p = 0.014) and prolonged surgery times (OR 1.007, CI 1 - 1.012; p = 0.05). Although hypercoagulability occurred more frequently in the ES group (44.4%) than in the LS group (11.9%; p < 0.001), it was not associated with higher free flap thrombosis rate. In ES group patients with surgery times > 240 min, the risk of free flap thrombosis increased (OR 3.5, CI 1.16-10.6; p = 0.026) with 93.3% sensitivity and 86.7% specificity (AUC 0.85; p = 0.007). In contrast, in LS patients hypercoagulability increased the odds of free flap thrombosis (OR 8.83, CI 1.74-44.76; p = 0.009). Moreover, a positive correlation was found between FPR ≥ 42 and free flap thrombosis rate (r = 0.362; p = 0.003). In the LS group, the presence of thrombogenic comorbidities correlated with free flap thrombosis rate (OR 7, CI 1.591-30.8; p = 0.01). Conclusions: In LS patients with thrombogenic comorbidities, thromboelastometry supports the detection of hypercoagulability and predicts free flap thrombosis risk. In ES patients, postoperative hypercoagulability did not predict free flap thrombosis. Prolonged surgery time should be considered as a risk factor.
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Affiliation(s)
- Indulis Vanags
- Department of Anaesthesiology and Reanimatology, Riga Stradinš University, Riga, Latvia.,Department of Anaesthesiology and Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Jevgenijs Stepanovs
- Department of Anaesthesiology, Riga East Clinical University Hospital, Riga, Latvia
| | - Agnese Ozolina
- Department of Anaesthesiology and Reanimatology, Riga Stradinš University, Riga, Latvia.,Department of Anaesthesiology, Riga East Clinical University Hospital, Riga, Latvia
| | - Maksims Mukans
- Statistical Unit, Riga Stradinš University, Riga, Latvia
| | - Lars J Bjertnaes
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Biruta Mamaja
- Department of Anaesthesiology and Reanimatology, Riga Stradinš University, Riga, Latvia.,Department of Anaesthesiology, Riga East Clinical University Hospital, Riga, Latvia
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Reply to Comment on "Suprapubic Pedicled Phalloplasty in Transgender Men: a Multicentric Retrospective Cohort Analysis". Int J Impot Res 2020; 33:862-863. [PMID: 32376882 DOI: 10.1038/s41443-020-0274-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 11/08/2022]
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32
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Lindeborg MM, Puram SV, Sethi RK, Abt N, Emerick KS, Lin D, Deschler DG. Predictive factors for prolonged operative time in head and neck patients undergoing free flap reconstruction. Am J Otolaryngol 2020; 41:102392. [PMID: 31918856 DOI: 10.1016/j.amjoto.2020.102392] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 12/28/2019] [Accepted: 01/03/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Defining the predictive factors associated with prolonged operative time may reduce post-operative complications, improve patient outcomes, and decrease cost of care. The aims of this study are to 1) analyze risk factors associated with prolonged operative time in head and neck free flap patients and 2) determine the impact of lengthier operative time on surgical outcomes. METHODS This retrospective cohort study evaluated 282 head and neck free flap reconstruction patients between 2011 and 2013 at a tertiary care center. Perioperative factors investigated by multivariate analyses included gender, age, American Society of Anesthesiologists class, tumor subsite, stage, flap type, preoperative comorbidities, and perioperative hematocrit nadir. Association was explored between operative times and complications including flap take back, flap survival, transfusion requirement, flap site hematoma, and surgical site infection. RESULTS Mean operative time was 418.2 ± 88.4 (185-670) minutes. Multivariate analyses identified that ASA class III (beta coefficient + 24.5, p = .043), stage IV tumors (+34.8, p = .013), fibular free flaps (-44.8, p = .033 for RFFF vs. FFF and - 67.7, p = .023 for ALT vs FFF) and COPD (+36.0, p = .041) were associated with prolonged operative time. History of CAD (-43.5, p = .010) was associated with shorter operative time. There was no statistically significant association between longer operative time and adverse flap outcomes or complications. CONCLUSION As expected, patients who were medically complex, had advanced cancer, or underwent complex flap reconstruction had longer operative times. Surgical planning should pay special attention to certain co-morbidities such as COPD, and explore innovative ways to minimize operative time. Future research is needed to evaluate how these factors can help guide planning algorithms for head and neck patients.
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Matošević M, Pegan A, Sambunjak D, Solter D, Vagić D, Rašić I, Košec A. Significance of Anthropometric and Nutritive Factors in Oral and Oropharyngeal Cancer Patients Undergoing Free Flap Reconstruction. J Oral Maxillofac Surg 2019; 78:644-650. [PMID: 31838094 DOI: 10.1016/j.joms.2019.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/12/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE This study analyzed associations between preoperative nutritional status and the incidence of early postoperative complications as a primary outcome in patients with oral and oropharyngeal cancer undergoing free flap reconstruction. We hypothesized that preoperative nutritional status may be linked with specific complications, allowing for better preoperative risk assessment. PATIENTS AND METHODS This longitudinal, retrospective cohort study encompassed 113 patients, all treated surgically for oral and oropharyngeal cancer in the period from March 2013 up to March 2018 in a tertiary referral center. Variables considered were preoperative and postoperative serum albumin and protein values; body mass index; waist-to-hip ratio; circumference of the neck, waist, hip, and thigh; number of cigarettes smoked per day during the 10-year period before surgery; average alcohol consumption; operative time; and postoperative albumin administration. RESULTS Our study identified preoperative protein serum concentration (≤62 g/L), postoperative albumin administration (≥200 mL), number of cigarettes smoked per day (>20), and prolonged operative time (≥450 minutes) to be associated with postoperative complications. CONCLUSIONS This is the first study reporting cutoff values of clinical significance in assessing patient preoperative nutritional status in light of reducing postoperative complications after free flap reconstruction.
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Affiliation(s)
- Marijana Matošević
- Student, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Alan Pegan
- Assistant Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Dario Sambunjak
- Assistant Professor, Department of Sociology, Catholic University of Croatia, Zagreb, Croatia
| | - Darko Solter
- Assistant Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Davor Vagić
- Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Ivan Rašić
- Assistant Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Andro Košec
- Assistant Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia.
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Liu Z, Wu H, Liufu N, Cheng S, Huang H, Hu C, Cao M. Development and validation of a nomogram incorporating selected systemic inflammation-based prognostic marker for complication prediction after vascularized fibula flap reconstruction. Oral Oncol 2019; 99:104467. [PMID: 31678763 DOI: 10.1016/j.oraloncology.2019.104467] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 09/23/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To develop and validate a nomogram incorporating systemic inflammatory markers (the Albumin/NLR Score [ANS]) to predict postoperative complications after vascularized fibula flap reconstruction. PATIENTS AND METHODS A total of 238 patients who underwent vascularized fibula flap reconstruction between March 2012 and December 2016 were collected as the primary cohort. Univariable and multivariable analysis were performed to identify independent risk factors for postoperative complications. Backward stepwise logistic regression analysis was then applied with and without the ANS; and nomograms were established based on these criteria. Independent validation of these nomograms was carried out in an independent validation cohort including 106 consecutive patients from December 2016 and January 2018. RESULTS Radiotherapy history (odds ratio [OR] = 0.336; 95% CI, 0.157-0.717; P = 0.005), the ANS (OR = 0.248; 95% CI, 0.093-0.661; P = 0.005) and fluid infusion rate over 24 h (OR = 0.671; 95% CI, 0.479-0.94; P = 0.02) were identified as independent risk factors for postoperative complications. A higher C-index was found in both the primary (0.759; 95% CI, 0.719-0.739) and validation cohort (0.704; 95% CI, 0.613-0.659) for the nomogram incorporating the ANS, and NRI was 0.496 (95% CI, 0.072-0.920; P = 0.022) comparing of these nomograms. Furthermore, a wider threshold probability (0.2-0.9) and superior clinical value were observed in the nomogram incorporating the ANS on the decision curve. CONCLUSION The ANS was an independent risk factor for postoperative complications associated with vascularized fibula flap reconstruction. The nomogram incorporating the ANS was established with better accuracy and showed more potential clinical benefit for the estimation of postoperative complications.
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Affiliation(s)
- Zhongqi Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 510120 Guangzhou, PR China
| | - Haixuan Wu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 510120 Guangzhou, PR China
| | - Ning Liufu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 510120 Guangzhou, PR China
| | - Shi Cheng
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 510120 Guangzhou, PR China
| | - Haoquan Huang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 510120 Guangzhou, PR China
| | - Chuwen Hu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 510120 Guangzhou, PR China
| | - Minghui Cao
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 510120 Guangzhou, PR China.
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Torabi SJ, Chouairi F, Dinis J, Alperovich M. Head and Neck Reconstructive Surgery: Characterization of the One-Team and Two-Team Approaches. J Oral Maxillofac Surg 2019; 78:295-304. [PMID: 31622570 DOI: 10.1016/j.joms.2019.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To the best of our knowledge, no studies have compared the patient profiles for 1- versus 2-team surgery within head and neck oncosurgery. PATIENTS AND METHODS A retrospective study of the data from 2968 patients who had undergone concurrent head and neck extirpative and reconstructive surgery in the National Surgical Quality Improvement Program (2010 to 2017) was conducted. Patients were stratified into 1- and 2-team surgery groups, and the demographic data were compared. Univariate analyses of the outcomes before and after propensity score matching were conducted. RESULTS Most ablative and reconstructive head and neck procedures (68.5%) were performed using a 1-team approach. The patients who had undergone 2-team surgery were more likely to have a higher American Society of Anesthesiologists classification (P < .001), to require mandibulectomy (P < .001) or glossectomy (P < .001), and to receive a microvascular free flap (P < .001) but were less likely to require parotidectomy (P < .001) or to receive a rotational flap (P < .001). Before propensity score matching, the patients undergoing 2-team surgery had longer operative times (P < .001), longer postoperative stays (P < .001), greater rates of a return to the operating room (P = .001), and an increased rate of complications (P < .001). After propensity score matching, the 2-team approach continued to have longer operative times (P < .001) and an increased incidence of complications (P < .001) but no significant differences in the length of stay or rate of return to the operating room after Bonferroni's correction. CONCLUSIONS Nationally, most head and neck ablative and reconstructive surgeries were completed by 1 team. More complicated reconstructive procedures involving microvascular free flaps have been more commonly performed by 2 teams, resulting in slightly longer operative times and greater associated complication rates.
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Affiliation(s)
- Sina J Torabi
- Medical Student, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Fouad Chouairi
- Medical Student, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Jacob Dinis
- Medical Student, Department of Surgery, Yale University School of Medicine, New Haven, CT; and Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT
| | - Michael Alperovich
- Assistant Professor, Section of Plastic and Reconstructive Surgery Department of Surgery, Yale University School of Medicine, New Haven, CT.
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Ibrahim A, Ndeti K, Bur A, Sykes K, Shnayder L, Tsue T, Westbrook A, Kakarala K. Association of a Lean Surgical Plan of the Day With Reduced Operating Room Time for Head and Neck Free Flap Reconstruction. JAMA Otolaryngol Head Neck Surg 2019; 145:926-930. [PMID: 31415075 DOI: 10.1001/jamaoto.2019.2250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Inefficiency in the operating room (OR) is detrimental to the patient, the hospital, and the surgeon. Head and neck procedures requiring microvascular reconstruction are complex, lengthy operations in which prolonged operative time is associated with higher complication rates and increased costs. Objective To use Lean methodology to identify potential OR efficiency improvement opportunities for head and neck surgical cases involving free tissue transfer, to implement an intervention, the free flap plan of the day, and to evaluate OR times after implementation. Design, Setting, and Participants Phase 1: In 2015, with the assistance of the Lean Promotion Office at our institution, a tertiary academic medical center, we identified efficiency-improvement opportunities for 10 patients undergoing free flap reconstruction. Phase 2: A single intervention, the free flap plan of the day, was implemented on February 1, 2016. A retrospective medical record review of head and neck free flap reconstructions beginning 2 years before the implementation of the intervention and ending 2 years after the intervention was performed from February 1, 2014 until February 1, 2018 to analyze OR times, cost, and complications. Mean OR times were compared using the t test. Main Outcomes and Measures In-room-to-incision time and total OR time. Results Phase 1: The surgical procedures of 10 patients undergoing free flap reconstruction were observed by Lean specialists, and a time study with a process map was completed. Using this framework, major opportunities for decreasing intraoperative time waste were identified. Multiple communication breakdowns were seen to drive intraoperative time waste; therefore, a free flap plan of the day was created to improve communication between team members. Phase 2: 200 patients were included in the study and were categorized into 2 groups, no plan group (n = 104) and plan group (n = 96), based on whether the plan of the day was used or not. The age and sex distributions of the study participants were not collected. Mean in-room-to-incision time was 54.3 minutes for the no plan group and 47.2 minutes for the plan group (difference, 7.1 minutes; 95% CI, 3.8-10.4 minutes). Mean total OR time was 524.1 minutes for the no plan group and 467.4 minutes for the plan group (difference, 56.7 minutes; 95% CI, 23.6-89.6 minutes). Conclusions and Relevance Lean methodology was used to identify efficiency-improvement opportunities for head and neck free flap reconstruction procedures and to design a focused intervention. A free flap plan of the day was used in this study to improve communication between the OR team and was found to improve efficiency and be associated with reduced OR times.
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Affiliation(s)
- Ahmed Ibrahim
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Kavindu Ndeti
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Andres Bur
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Kevin Sykes
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Lisa Shnayder
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Terence Tsue
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | | | - Kiran Kakarala
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City
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Ebner JJ, Mehra T, Gander T, Schumann P, Essig H, Zweifel D, Rücker M, Slankamenac K, Lanzer M. Novel application of the Clavien-Dindo classification system and the comprehensive complications index® in microvascular free tissue transfer to the head and neck. Oral Oncol 2019; 94:21-25. [PMID: 31178208 DOI: 10.1016/j.oraloncology.2019.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 03/11/2019] [Accepted: 05/05/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Julian Jakob Ebner
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland.
| | - Tarun Mehra
- Medical Office, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Thomas Gander
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Paul Schumann
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Harald Essig
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Daniel Zweifel
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Martin Rücker
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
| | - Ksenjia Slankamenac
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Martin Lanzer
- Department of Oral and Maxillofacial Surgery, University Hospital Zurich (Head of Department Prof. Dr. Med. Dr. Med. Dent. Martin Rücker), Frauenklinikstrasse 24, CH-8091 Zurich, Switzerland
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Glauser G, Agarwal P, Ramayya AG, Chen HI, Lee JYK, Schuster JM, Osiemo B, Goodrich S, Smith LJ, McClintock SD, Malhotra NR. Association of Surgical Overlap during Wound Closure with Patient Outcomes among Neurological Surgery Patients at a Large Academic Medical Center. Neurosurgery 2019; 85:E882-E888. [DOI: 10.1093/neuros/nyz142] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/25/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Several studies have explored the effect of overlapping surgery on patient outcomes, but impact of surgical overlap during wound closure has not been studied.
OBJECTIVE
To examine the association of overlap during wound closure and suture time overlap (STO) with patient outcomes in a heterogeneous neurosurgical population.
METHODS
Over 4 yr (7/2013-7/2017), 1 7689 neurosurgical procedures were retrospectively reviewed at a single, multihospital academic medical center. STO was defined as all surgeries for which an overlapping surgery occurred, exclusively, during wound closure of the index case being studied. We excluded nonelective cases and overlapping surgeries that involved overlap during surgical portions of the case other than wound closure. Tests of independence and Wilcoxon tests were used for statistical analysis.
RESULTS
Patients with STO had a shortened length of hospital stay (100.6 vs 135.1 h; P < .0001), reduced deaths in follow-up (1.59% vs 5.45%; P = .0004), and lower 30- to 90-d readmission rates (3.64% vs 7.47%; P = .0026). Patients with STO had no increase in revision surgery. Patients with STO had longer wound closure times (26.5 vs 23.9 min; P < .0001) but shorter total surgical times (nonclosure surgical time 101.8 vs 133.3 min; P < .0001; and total surgical time 128.3 vs 157.1 min; P < .0001).
CONCLUSION
Surgical overlap during wound closure (STO) is associated with improved or at least noninferior patient outcomes, as it pertains to readmissions and wound revisions.
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Affiliation(s)
- Gregory Glauser
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Philadelphia, Philadelphia, Pennsylvania
| | - Prateek Agarwal
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Philadelphia, Philadelphia, Pennsylvania
| | - Ashwin G Ramayya
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Philadelphia, Philadelphia, Pennsylvania
| | - H Isaac Chen
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Philadelphia, Philadelphia, Pennsylvania
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Philadelphia, Philadelphia, Pennsylvania
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin Osiemo
- McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia, Pennsylvania
- The West Chester Statistical Institute, Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Stephen Goodrich
- McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia, Pennsylvania
- The West Chester Statistical Institute, Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Lachlan J Smith
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Philadelphia, Philadelphia, Pennsylvania
| | - Scott D McClintock
- The West Chester Statistical Institute, Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Neil R Malhotra
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Philadelphia, Philadelphia, Pennsylvania
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Affiliation(s)
- John S Rhee
- Department of Otolaryngology and Communication Services, Medical College of Wisconsin, Milwaukee.,Editor
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40
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Likhterov I, Roche AM, Urken ML. Contemporary Osseous Reconstruction of the Mandible and the Maxilla. Oral Maxillofac Surg Clin North Am 2019; 31:101-116. [DOI: 10.1016/j.coms.2018.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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41
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Pal N, Butterworth J. Anesthesia Duration Does Not Exist in a Surgical Vacuum. JAMA FACIAL PLAST SU 2018; 20:525-526. [PMID: 30178003 DOI: 10.1001/jamafacial.2018.1129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nirvik Pal
- Virginia Commonwealth University, Richmond
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Pivalizza EG. Anesthesia Duration Does Not Exist in a Surgical Vacuum. JAMA FACIAL PLAST SU 2018; 20:525. [PMID: 30178053 DOI: 10.1001/jamafacial.2018.1123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Evan G Pivalizza
- Department of Anesthesiology, University of Texas McGovern Medical School, Houston
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Abt NB, Puram SV, Sinha S, Sethi RKV, Goyal N, Emerick KS, Lin DT, Deschler DG. Transfusion in Head and Neck Cancer Patients Undergoing Pedicled Flap Reconstruction. Laryngoscope 2018; 128:E409-E415. [PMID: 30247764 DOI: 10.1002/lary.27393] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/10/2018] [Accepted: 05/29/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Blood product utilization is monitored to prevent unnecessary transfusions. Head-and-neck pedicled flap reconstruction transfusion-related outcomes were assessed. METHODS One hundred and thirty-six pedicled flap patients were reviewed: 64 supraclavicular artery island flaps (SCAIF), 57 pectoralis major (PM) flaps, and 15 submental (SM) flaps. Outcome parameters included flap-related complications, medical complications, length of stay (LOS), and flap survival. Multivariable logistic regression analyses were performed. Multivariable logistic regression analyses were performed to adjust for relevant pre- and perioperative factors. RESULTS Of all head-and-neck pedicled flap patients included in our analyses (n = 136), 40 (29.4%) received blood transfusions. The average pretransfusion hematocrit (Hct) was 24.3% ± 0.5%, with 2.65 ± 0.33 units transfused and a posttransfusion Hct increase of 5.0% ± 0.6%. Transfusion rates differed with PM (47.4%), SCAIF (17.2%), and SM (13.3%) flaps (P < 0.005). Patients undergoing PM reconstruction trended toward higher transfusion requirements (PM 2.89 ± 0.47 units, SC 2.18 ± 0.28 units, and SM 2.00 ± 0.0 units), with transfusion occurring later in the postoperative course (4.9 ± 1.3 days vs. 2.4 ± 0.1 days for all other flaps; P = 0.08). Infection, dehiscence, fistula, or medical complications were not different. Transfusion thresholds of Hct < 21 versus Hct < 27 exhibited no difference in LOS, flap-survival, or medical/flap-related complications. CONCLUSION Transfusion is not associated with surgical or medical morbidity following head and neck pedicled flap reconstruction. There were no differences in outcomes between transfusion triggers of Hct < 21 versus Hct < 27, suggesting that a more conservative transfusion trigger may not precipitate adverse patient complications. Our data recapitulate findings in free flap patients and warrant further investigation of transfusion practices in head and neck flap reconstruction. LEVEL OF EVIDENCE 4. Laryngoscope, 128:E409-E415, 2018.
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Affiliation(s)
- Nicholas B Abt
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Sidharth V Puram
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Sumi Sinha
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Rosh K V Sethi
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Neerav Goyal
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hersey, Pennsylvania, U.S.A
| | - Kevin S Emerick
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Derrick T Lin
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Daniel G Deschler
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
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Kovatch KJ, Hanks JE, Stevens JR, Stucken CL. Current practices in microvascular reconstruction in otolaryngology-head and neck surgery. Laryngoscope 2018; 129:138-145. [PMID: 30194763 DOI: 10.1002/lary.27257] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES/HYPOTHESIS Despite major advances in the field of head and neck microvascular free tissue transfer (MFTT) over the past several decades, there are no standardized perioperative regimens for the care of patients undergoing free flap reconstructive surgery, and continued variation in practice exists. This study aimed to report current trends in the field of MFTT performed by otolaryngologists, including surgeon training, institutional operative practices, and perioperative management. STUDY DESIGN Cross-sectional survey. METHODS A survey of Accreditation Council for Graduate Medical Education-accredited residency programs and American Head and Neck Society fellowship sites was conducted. RESULTS Seventy-one (62.8%) programs responded, with 67 (94.4%) routinely performing MFTT and 23 (32.4%) having a dedicated microvascular fellowship program. Of institutions performing MFTT, 66 (98.5%) reported the use of a two-surgeon team, most commonly both otolaryngologists (76.3%). Institutional MFTT volumes and donor site frequency are reported. Postoperative care includes routine admission to the intensive care unit (75.2%), step-down unit (15.0%), or general care floor (8.1%). Postoperative flap monitoring practices, including modalities, personnel, and timing/frequency show institutional variation. Despite differences in postoperative monitoring regimen and management (sedation, anticoagulation, antibiotic use), surgeon-reported measures of flap success rate (95.7%, standard deviation [SD] 4.7%) and complication rate (6.8%, SD 2.4%) show little difference across institutions. CONCLUSIONS Many elements of MFTT perioperative care show continued variation at an institutional level. There is a notable shift toward the two-team approach within otolaryngology. Self-reported flap complication and success rates showed no significant differences based on perioperative care and monitoring regimen. Further study of perioperative practices should focus on standardization of care to improve overall outcomes in this complex patient population. LEVEL OF EVIDENCE NA Laryngoscope, 129:138-145, 2019.
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Affiliation(s)
- Kevin J Kovatch
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, U.S.A
| | - John E Hanks
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, U.S.A
| | - Jayne R Stevens
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, U.S.A
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, U.S.A
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Comprehensive approach to reestablishing form and function after radical parotidectomy. Am J Otolaryngol 2018; 39:542-547. [PMID: 29907429 DOI: 10.1016/j.amjoto.2018.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/06/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The reconstructive goals following radical parotidectomy include restoration of symmetry, reanimation of the face, and reestablishment of oral competence. We present our experience utilizing the anterolateral thigh (ALT) free flap, orthodromic temporalis tendon transfer (OTTT), and facial nerve cable grafting to reestablish form and function. MATERIAL AND METHODS From 2010 to 2016, 17 patients underwent radical parotidectomy followed by immediate reconstruction. An ALT was harvested to accommodate the volume and skin defect. Additional fascia lata and motor nerve to vastus lateralis (MNVL) were obtained. Anastomosis of the ALT to recipient vessels was performed, most commonly using the facial artery and internal jugular vein. OTTT was performed by securing the medial tendon of the temporalis to orbicularis oris through a nasolabial incision. Fascia lata was tunneled through the lower lip, then secured laterally to the temporalis tendon. The MNVL was cable grafted from either the proximal facial nerve or masseteric nerve to the distal facial nerve branches. ALT fascia was suspended to the superficial muscular aponeurotic system. RESULTS Average follow up was 19 months. Only one patient failed to achieve symmetry attributed to dehiscence of OTTT. All patients achieved oral competence and dynamic smile with OTTT activation. Facial nerve recovery was seen in 8 patients. 5 reached a House Brackman Score of 3. Two donor site seromas and two wound infections occurred. CONCLUSION Simultaneous ALT, OTTT, and facial nerve cable grafting provides early reestablishment of facial symmetry, facial reanimation, and oral competence with minimal morbidity.
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Zhao EH, Nishimori K, Brady J, Siddiqui SH, Eloy JA, Baredes S, Park RCW. Analysis of Risk Factors for Unplanned Reoperation Following Free Flap Surgery of the Head and Neck. Laryngoscope 2018; 128:2790-2795. [DOI: 10.1002/lary.27417] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 05/03/2018] [Accepted: 06/06/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Eric H. Zhao
- Department of Otolaryngology-Head and Neck Surgery; Newark New Jersey U.S.A
| | - Kalin Nishimori
- Department of Otolaryngology-Head and Neck Surgery; Newark New Jersey U.S.A
| | - Jacob Brady
- Department of Otolaryngology-Head and Neck Surgery; Newark New Jersey U.S.A
| | - Sana H. Siddiqui
- Department of Otolaryngology-Head and Neck Surgery; Newark New Jersey U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery; Newark New Jersey U.S.A
- Department of Neurological Surgery; Newark New Jersey U.S.A
- Department of Ophthalmology and Visual Science; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
- Center for Skull Base and Pituitary Surgery; Neurological Institute of New Jersey, Rutgers New Jersey Medical School; Newark New Jersey U.S.A
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery; Newark New Jersey U.S.A
- Center for Skull Base and Pituitary Surgery; Neurological Institute of New Jersey, Rutgers New Jersey Medical School; Newark New Jersey U.S.A
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Bornemann-Cimenti H, Szilagyi IS. Limitations, Transparency, and Conclusions. JAMA FACIAL PLAST SU 2018; 20:337-338. [DOI: 10.1001/jamafacial.2017.2437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Helmar Bornemann-Cimenti
- Department of Anesthesiology and Intensive Care Medicine, Medical University Graz, Graz, Austria
| | - Istvan S. Szilagyi
- Department of Anesthesiology and Intensive Care Medicine, Medical University Graz, Graz, Austria
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Park RCW, Brady JS, Gubenko Y. Limitations, Transparency, and Conclusions-Reply. JAMA FACIAL PLAST SU 2018; 20:338-339. [PMID: 29879286 DOI: 10.1001/jamafacial.2017.2440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Richard Chan Woo Park
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Jacob S Brady
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Yuiry Gubenko
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Department of Anesthesiology, Rutgers New Jersey Medical School, Newark
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Influence of coupler size on revision rate and timing of revision after free flap tissue transfer in the head and neck. Eur Arch Otorhinolaryngol 2017; 275:199-206. [DOI: 10.1007/s00405-017-4804-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 11/07/2017] [Indexed: 11/27/2022]
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