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Hernandez Alvarez A, Lee D, Kim EJ, Schuster K, Taritsa I, Foppiani J, Valentine L, Weidman AA, Comer C, Lee BT, Lin SJ. An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures. J Reconstr Microsurg 2024. [PMID: 38889744 DOI: 10.1055/s-0044-1787776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage. METHODS A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed. RESULTS From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique. CONCLUSION Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.
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Affiliation(s)
| | - Daniela Lee
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Erin J Kim
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kirsten Schuster
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Iulianna Taritsa
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jose Foppiani
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Lauren Valentine
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Allan A Weidman
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Carly Comer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Impacts of vascular comorbidities on free flap perfusion in microvascular head and neck reconstruction. Eur Arch Otorhinolaryngol 2023; 280:3375-3382. [PMID: 36897365 DOI: 10.1007/s00405-023-07913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/04/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE Arterial hypertension (AHTN), type 2 diabetes mellitus (DM), and atherosclerotic vascular disease (ASVD) are common vascular comorbidities in patients undergoing reconstruction of the head and neck region with a microvascular free flap. These conditions may affect flap perfusion (microvascular blood flow and tissue oxygenation), which is a prerequisite for flap survival and thus reconstruction success. This study aimed to investigate the impacts of AHTN, DM, and ASVD on flap perfusion. METHODS Data from 308 patients who underwent successful reconstruction of the head and neck region with radial free forearm flaps, anterolateral thigh flaps, or fibula free flaps between 2011 and 2020 were retrospectively analyzed. Flap perfusion was measured intraoperatively and postoperatively with the O2C tissue oxygen analysis system. Flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation were compared between patients with and without AHTN, DM, and ASVD. RESULTS Intraoperative hemoglobin oxygen saturation and postoperative blood flow were lower in patients with ASVD than in patients without ASVD (63.3% vs. 69.5%, p = 0.046; 67.5 arbitrary units [AU] vs. 85.0 AU, p = 0.036; respectively). These differences did not persist in the multivariable analysis (all p > 0.05). No difference was found in intraoperative or postoperative blood flow or hemoglobin oxygen saturation between patients with and without AHTN or DM (all p > 0.05). CONCLUSION Perfusion of microvascular free flaps used for head and neck reconstruction is not impaired in patients with AHTN, DM, or ASVD. Unrestricted flap perfusion may contribute to the observed successful use of microvascular free flaps in patients with these comorbidities.
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Ronen O, Robbins KT, Shaha AR, Kowalski LP, Mäkitie AA, Florek E, Ferlito A. Emerging Concepts Impacting Head and Neck Cancer Surgery Morbidity. Oncol Ther 2023; 11:1-13. [PMID: 36565427 PMCID: PMC9935772 DOI: 10.1007/s40487-022-00217-0] [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] [Accepted: 12/01/2022] [Indexed: 12/25/2022] Open
Abstract
All treatment modalities for head and neck cancer carry with them a risk of adverse events. Head and neck surgeons are faced with significant challenges to minimize associated morbidity and manage its sequelae. Recognizing situations in which a surgical complication is an adverse event inherent to the procedure can alleviate the psychologic impact a complication might have on the treatment team and minimize external and internal pressures. Focusing on the complications that can be effectively modified, future complications can be avoided. Also, some surgical morbidities may not be preventable, necessitating the option to reconsider whether the incidents should be labeled toxic reactions rather than a complication. This discussion highlights some of the areas in which additional research is needed to achieve the goal of minimizing the impact of surgical morbidity.
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Affiliation(s)
- Ohad Ronen
- Head and Neck Surgery Unit, Department of Otolaryngology-Head and Neck Surgery, Affiliated With Azrieli Faculty of Medicine, Galilee Medical Center, Bar-Ilan University, POB 21, Nahariya, Safed, 2210001, Israel.
| | - K Thomas Robbins
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Ashok R Shaha
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Luiz P Kowalski
- Department of Otorhinolaryngology-Head and Neck Surgery, A.C. Camargo Cancer Center, São Paulo, Brazil
- Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Antti A Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ewa Florek
- Laboratory of Environmental Research, Department of Toxicology, Poznan University of Medical Sciences, Poznan, Poland
| | - Alfio Ferlito
- Coordinator of International Head and Neck Scientific Group, Padua, Italy
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Allen BN, Wang Q, Filali Y, Worthington KS, Kacmarynski DSF. Full-Thickness Oral Mucoperiosteal Defects: Challenges and Opportunities. TISSUE ENGINEERING. PART B, REVIEWS 2022; 28:813-829. [PMID: 34409870 PMCID: PMC9469748 DOI: 10.1089/ten.teb.2021.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/10/2021] [Indexed: 11/12/2022]
Abstract
Regenerative engineering strategies for the oral mucoperiosteum, as may be needed following surgeries, such as cleft palate repair and tumor resection, are underdeveloped compared with those for maxillofacial bone. However, critical-size tissue defects left to heal by secondary intention can lead to complications, such as infection, fistula formation, scarring, and midface hypoplasia. This review describes current clinical practice for replacing mucoperiosteal tissue, including autografts and allografts. Potentially paradigm-shifting experimental regenerative engineering strategies for mucoperiosteal wound healing, such as hybrid grafts and engineered matrices, are also discussed. Throughout the review, the advantages and disadvantages of each replacement or regeneration strategy are outlined in the context of clinical outcomes, quality of life for the patient, availability of materials, and cost of care. Finally, future directions for research and development in the area of mucoperiosteum repair are proposed, with an emphasis on identifying globally available and affordable solutions for promoting mucoperiosteal regeneration. Impact statement Unassisted oral mucoperiosteal wound healing can lead to severe complications such as infection, fistulae, scarring, and developmental abnormalities. Thus, strategies for promoting wound healing must be considered when mucoperiosteal defects are incident to oral surgery, as in palatoplasty or tumor resection. Emerging mucoperiosteal tissue engineering strategies, described in this study, have the potential to overcome the limitations of current standard-of-care donor tissue grafts. For example, the use of engineered mucoperiosteal biomaterials could circumvent concerns about tissue availability and immunogenicity. Moreover, employment of tissue engineering strategies may improve the equity of oral wound care by increasing global affordability and accessibility of materials.
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Affiliation(s)
- Brittany N Allen
- Roy J. Carver Department of Biomedical Engineering, College of Engineering, The University of Iowa, Iowa City, Iowa, USA
| | - Qi Wang
- Roy J. Carver Department of Biomedical Engineering, College of Engineering, The University of Iowa, Iowa City, Iowa, USA
| | - Yassine Filali
- Roy J. Carver Department of Biomedical Engineering, College of Engineering, The University of Iowa, Iowa City, Iowa, USA
| | - Kristan S Worthington
- Roy J. Carver Department of Biomedical Engineering, College of Engineering, The University of Iowa, Iowa City, Iowa, USA
| | - Deborah S F Kacmarynski
- Department of Otolaryngology - Head and Neck Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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Politano SF, Balchander D, Cabrera CI, Thuener JE, Teknos TN, Rezaee RP, Li S, Fowler N, Tamaki A. Impact of intraoperative ischemia time on acute complications of head and neck microvascular free tissue transfer: A systematic review and meta-analysis. Am J Otolaryngol 2022; 43:103467. [PMID: 35429849 DOI: 10.1016/j.amjoto.2022.103467] [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: 03/27/2022] [Accepted: 04/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND To evaluate the relationship between intraoperative ischemia time with acute microvascular free tissue transfer (MFTT) complications in head and neck reconstruction. METHODS A systematic review using PRISMA guidelines was performed. Inclusion encompassed all available studies published and indexed using PubMed, Medline, and Embase. Meta-analyses were performed using the Cochrane Review Manager tool. Methodological Index for Non-Randomized Studies (MINORS), the Revised Cochrane risk-of-bias tool for randomized trials, and the NIH Study Quality Assessment Tool for non-randomized prospective studies. RESULTS A total of 430 citations were reviewed. 25 were included in our overall qualitative analysis, and 14 for meta-analysis. When comparing ischemia times for flaps with and without complications, no significant difference was observed (p = 0.98). Additionally, in a separate cohort, no significant effect was realized when correlating ischemia time to overall rates and total complications. CONCLUSION Ischemia time was not significantly different between those with and without acute flap complications.
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Affiliation(s)
- Stephen F Politano
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | - Claudia I Cabrera
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jason E Thuener
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Theodoros N Teknos
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rod P Rezaee
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Shawn Li
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nicole Fowler
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Akina Tamaki
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Lewcun J, Massand S, Trangucci J, Shen C, Johnson TS. Head and Neck Free Flap Reconstruction in an Academic versus a Community Setting. J Reconstr Microsurg 2021; 38:466-471. [PMID: 34583394 DOI: 10.1055/s-0041-1735835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Head and neck free flap reconstructions are complex procedures requiring extensive resources, and have the potential to be highly morbid. As such, it is imperative that they should be performed in an appropriate setting, optimizing outcomes while limiting morbidity. The aim of this study is to identify any disparities in the treatment outcomes of patients undergoing head and neck free flap reconstruction by a single surgeon in an academic versus a community hospital setting. METHODS A retrospective review of all patients who underwent head and neck free flap reconstruction for any indication by a single surgeon from 2009 to 2019 was conducted. All surgeries were performed at one of two hospitals: one academic medical center and one community hospital. Demographics and rates of partial or complete flap failure, medical complications, surgical complications, mortality, and other secondary outcomes were compared between the two settings. RESULTS Ninety-two patients who underwent head and neck free flap reconstruction were included. Fifty-seven (62%) of free flap reconstructions were performed in the academic medical center, while 35 (38%) were performed in the community hospital. There were no significant differences in complete flap loss, either intraoperative or postoperative (p = 0.5060), partial flap loss (p = 0.5827), postoperative surgical complications (p = 0.2930), or medical complications (p = 0.7960) between groups. The in-hospital mortality rate was 0% (n = 0) at the university hospital as compared with 5.7% at the community hospital (p = 0.0681). The mean operative time was 702.3 minutes at the university hospital and 606.3 minutes at the community hospital (p = 0.0080). CONCLUSION Head and neck free flap surgery can be performed safely in either an academic or a community setting, with no difference in primary outcomes of surgery. Preferential selection of either treatment setting should be based on consideration of patient needs and availability of auxiliary specialty services.
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Affiliation(s)
- Joseph Lewcun
- Division of Plastic Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Sameer Massand
- Division of Plastic Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - John Trangucci
- Department of Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, Pennsylvania
| | - Chan Shen
- Division of Plastic Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Timothy S Johnson
- Division of Plastic Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania
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7
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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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8
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Clinical consequences of head and neck free-flap reconstructions in the DM population. Sci Rep 2021; 11:6034. [PMID: 33727645 PMCID: PMC7966812 DOI: 10.1038/s41598-021-85410-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/01/2021] [Indexed: 01/13/2023] Open
Abstract
Diabetes mellitus (DM) is a common comorbidity and risk factor for postoperative complications in head and neck (H&N) microsurgical reconstructions. Our study focused on the association between DM and individual complications regarding both surgical and medical aspects. A meta-analysis of English-language articles comparing a series of complications between DM and non-DM H&N free-flap recipients was performed by comprehensive meta-analysis (CMA). Twenty-seven articles presented 14,233 H&N free-flap reconstructions, and a subset of 2329 analyses including diabetic cases was included for final analysis. Total postoperative (RR = 1.194, p < 0.001; OR = 1.506, p = 0.030) and surgical (RR = 1.550, p = 0.001; OR = 3.362, p < 0.001) complications were increased in DM subjects. Free-flap failure/necrosis (RR = 1.577, p = 0.001; OR = 1.999, p = 0.001) and surgical site infections (OR = 2.414, p < 0.001) were also increased in diabetic recipients. However, return to the operating room, dehiscence, fistulas, plate exposures, readmissions, and mortalities were not increased in DM patients. DM increased various complications in H&N free-flap reconstructions. Surgical indications should be cautiously evaluated, and aggressive treatments should be implemented for high-risk recipients.
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9
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Mamidi IS, Li L, Jones JW, Lee R, Rana MS, Reilly BK. Impact of Diabetes Mellitus Following Tonsillectomy in Adults: A National Surgical Quality Improvement Program Analysis. Ann Otol Rhinol Laryngol 2020; 130:682-688. [PMID: 33094637 DOI: 10.1177/0003489420967041] [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: 11/15/2022]
Abstract
OBJECTIVES To identify 30-day complication rates specific to patients with diabetes mellitus following tonsillectomy. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing tonsillectomy between 2005 and 2018. Patients were stratified into 3 cohorts: insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM), and non-diabetes mellitus (NODM). Coarsened-exact-matching was utilized to account for baseline differences between cohorts. Outcomes studied included post-operate complications, prolonged hospitalization, and unplanned readmissions. RESULTS A total of 986 DM and 26 774 NODM patients were included, and the mean age of patients undergoing tonsillectomy was 29.5 ± 11.6 and 28.7 ± 11.0 years, respectively. The majority of patients were female (70.5% for both DM and NODM cohorts) and White/Caucasian (89.2% vs 89.3%). Among patients undergoing tonsillectomy, a greater proportion of DM patients experienced an operative time greater than or equal to the 75th percentile (35 minutes; 25.9% vs 22.8%, P = .024), overall morbidity (12.6% vs 5.4%, P < .001), pneumonia (0.6% vs 0.2%, P = .036), and reoperation (10.2% vs 3.5% P < .001) in comparison to NODM patients. In an analysis between IDDM (n = 379) and NIDDM (n = 211) patients, IDDM patients were at an increased risk for prolonged hospitalization (1.4% vs 0.0%, P = .045), pneumonia (5.2% vs 0.5%, P < .001), urinary tract infections (3.3% vs 0.3% P = .004), major complications (15.6% vs 7.7%, P = .002), minor complications (19.9% vs 8.2%, P < .001), and overall complications (10.0% vs 1.3%, P < .001). CONCLUSION DM patients are at a heightened risk for complications following tonsillectomy. Standardized protocols, careful pre-operative planning, and stringent glycemic management may help optimize patient outcomes.
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Affiliation(s)
- Ishwarya S Mamidi
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Lilun Li
- Division of Otolaryngology, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Joel W Jones
- Department of Otolaryngology, Louisiana State University, New Orleans, Louisiana, USA
| | - Ryan Lee
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Md Sohel Rana
- Center for Surgical Care, Children's National Health System, Washington, District of Columbia, USA
| | - Brian K Reilly
- Department of Otolaryngology, The Children's National Medical Center, Washington, District of Columbia, USA
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10
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Makiguchi T, Yamaguchi T, Nakamura H, Yamatsu Y, Hirai Y, Shoda K, Kurozumi S, Ibaragi S, Harimoto N, Motegi SI, Shirabe K, Yokoo S. Evaluation of overall and disease-free survival in patients with free flaps for oral cancer resection. Microsurgery 2020; 40:859-867. [PMID: 33085115 DOI: 10.1002/micr.30668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/27/2020] [Accepted: 09/18/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE Sarcopenia is characterized by depletion of skeletal muscle mass (SMM) and can cause increased postoperative complication in free flap procedure. One of the most important considerations while deciding the indication of the procedure is patients' survival. This study aimed to verify the relationship between low SMM and survival in patients who undergo oral cancer resection using free flap. METHODS SMM was evaluated using the skeletal muscle index (SMI cm2 /m2 ), which was defined using cross-sectional areas of skeletal muscles on computed tomography at the level of the third lumbar vertebrae normalized for height. Overall, 111 patients who underwent primary oral cancer resection and free flaps were included. Multivariate Cox regression analyses were used to evaluate the prognostic factors for survival. RESULTS A total of 25 patients (22.5%) were diagnosed with low SMM. The mean SMI was 42.2 cm2 /m2 . Multivariable analyses showed that increased age (hazard ratio [HR]; 4.98, p = .004), infiltrative growth pattern INF-c (HR; 3.83, p = .037), and low SMM (HR; 2.59, p = .034) were significant negative prognostic factors for overall survival. Increased age (HR; 3.18, p = .005), extra-nodal extension (HR; 3.30, p = .001), and low SMM (HR; 2.42, p = .017) were significant negative prognostic factors for disease-free survival. CONCLUSIONS Low SMM is a significant negative prognostic factor for overall and disease-free survival in oral cancer patients undergoing free flap. Future prospective studies are warranted to identify effective preoperative exercise and nutrition programs to improve low skeletal muscle and survival rate in patients undergoing free flap procedures.
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Affiliation(s)
- Takaya Makiguchi
- Department of Oral and Maxillofacial Surgery, and Plastic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Takahiro Yamaguchi
- Department of Oral and Maxillofacial Surgery, and Plastic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hideharu Nakamura
- Department of Oral and Maxillofacial Surgery, and Plastic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yukie Yamatsu
- Department of Oral and Maxillofacial Surgery, and Plastic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yuki Hirai
- Department of Oral and Maxillofacial Surgery, and Plastic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Koki Shoda
- Department of Oral and Maxillofacial Surgery, and Plastic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Sasagu Kurozumi
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Soichiro Ibaragi
- Department of Oral and Maxillofacial Surgery, and Plastic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Norifumi Harimoto
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Ken Shirabe
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Satoshi Yokoo
- Department of Oral and Maxillofacial Surgery, and Plastic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
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11
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Goshtasbi K, Verma SP. Early Adverse Events Following Transcervical Hypopharyngeal Diverticulum Surgery. Ann Otol Rhinol Laryngol 2020; 130:497-503. [DOI: 10.1177/0003489420962136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective: To describe rates of short-term morbidity following transcervical surgical treatment of hypopharyngeal diverticulum (HD) and analyze predictors of adverse events. Methods: The 2005 to 2017 National Surgical Quality Improvement Program database was queried to identify patients diagnosed with HD undergoing open transcervical diverticulectomy. Results: A total of 597 patients with a mean age of 71.4 ± 12.3 years were included. Thirty-day adverse events were experienced by 63 (10.6%) subjects, including 6.5% unplanned reoperations, 4.2% surgical complications, 4.4% medical complications, 2.7% readmissions, and 0.7% deaths. Medical complications notably included pneumonia (2.0%), reintubation (1.2%), sepsis (1.2%), intubation >48 hours (0.5%), urinary tract infection (0.5%), or deep vein thrombosis (0.5%), while surgical complications included organ/space infection (2.0%) and superficial (1.3%) or deep (1.0%) surgical site infection. Gender, race, functional status, diabetes, dyspnea, hypertension, steroid use, and recent weight loss were not associated with adverse events. Length of operation and hospitalization were both higher among those with adverse events (127.4 ± 107.9 vs 95.7 ± 59.8 minutes, P = 0.027, and 7.4 ± 7.4 vs 2.8 ± 3.6 days, P < 0.001). On multivariable logistic regression, high American Society of Anesthesiologists (ASA) class (OR = 2.02, P = 0.017), smoking (OR = 2.10, P = 0.044), and operation time (OR = 1.01; P = 0.005) were independent predictors of adverse events. Obesity was not associated with length of stay, readmission/reoperation, or complications. However, increased age was associated with shorter operations ( P = 0.020), higher length of hospitalization ( P < 0.001), and higher mortality ( P = 0.027) and readmission rates ( P = 0.023). Conclusion: Understanding clinical factors associated with complications following open surgery for HD such as ASA score, smoking status, length of operation, and age can help optimize surgical outcomes for at-risk patients.
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Affiliation(s)
- Khodayar Goshtasbi
- Department of Otolaryngology—Head and Neck Surgery, University of California Irvine, Orange, CA, USA
| | - Sunil P. Verma
- Department of Otolaryngology—Head and Neck Surgery, University of California Irvine, Orange, CA, USA
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12
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Huang GJ, Kong XY. Diabetes mellitus in major head and neck cancer surgery. Head Neck 2020; 42:3799-3801. [PMID: 32965731 DOI: 10.1002/hed.26451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/18/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
- Guan-Jiang Huang
- Department of Otorhinolaryngology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiao-Yang Kong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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13
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Caputo MP, Shabani S, Mhaskar R, McMullen C, Padhya TA, Mifsud MJ. Diabetes mellitus in major head and neck cancer surgery: Systematic review and
meta‐analysis. Head Neck 2020; 42:3031-3040. [DOI: 10.1002/hed.26349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/10/2020] [Accepted: 06/09/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- Mathew P. Caputo
- Department of Otolaryngology—Head & Neck Surgery University of South Florida Morsani College of Medicine Tampa Florida USA
| | - Sepehr Shabani
- Department of Otolaryngology—Head & Neck Surgery University of South Florida Morsani College of Medicine Tampa Florida USA
| | - Rahul Mhaskar
- Department of Internal Medicine University of South Florida Morsani College of Medicine Tampa Florida USA
| | - Caitlin McMullen
- Department of Head and Neck and Endocrine Oncology H. Lee Moffitt Cancer Center & Research Institute Tampa Florida USA
| | - Tapan A. Padhya
- Department of Otolaryngology—Head & Neck Surgery University of South Florida Morsani College of Medicine Tampa Florida USA
- Department of Head and Neck and Endocrine Oncology H. Lee Moffitt Cancer Center & Research Institute Tampa Florida USA
| | - Matthew J. Mifsud
- Department of Otolaryngology—Head & Neck Surgery University of South Florida Morsani College of Medicine Tampa Florida USA
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14
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Salvage Free Tissue Transfer for Clival Osteoradionecrosis After Repeat Proton Beam Therapy. World Neurosurg 2020; 138:485-490. [DOI: 10.1016/j.wneu.2020.03.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 11/30/2022]
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15
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Grammatica A, Piazza C, Pellini R, Montalto N, Lancini D, Vural A, Barbara F, Ferrari M, Nicolai P. Free Flaps for Advanced Oral Cancer in the "Older Old" and "Oldest Old": A Retrospective Multi-Institutional Study. Front Oncol 2019; 9:604. [PMID: 31334124 PMCID: PMC6617546 DOI: 10.3389/fonc.2019.00604] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/19/2019] [Indexed: 12/14/2022] Open
Abstract
Introduction: Surgery followed by adjuvant therapy represents the most adequate treatment for advanced oral squamous cell carcinoma (OSCC). Free flaps are considered the best reconstructive option after major oral surgery. In the last decades, OSCC has increased in the elderly due to an augmented life span. The aim of this work is to evaluate the feasibility of microvascular surgery in patients older than 75 years, focusing on clinical and surgical prognosticators. Methods: “Older old” (aged ≥ 75) and “oldest old” (>85) patients who underwent microvascular reconstruction for OSCC from 2002 to 2018 were retrospectively evaluated in three referral Head and Neck Departments. Demographic, clinical, and surgical data were collected and analyzed. Pre-operative assessment was performed by ASA and ACE-27 scores. Complications were grouped as medical or surgical, and major or minor according to the Clavien-Dindo scale. Results: Eighty-four patients (72 “older old” and 12 “oldest old”) were treated with a free flap success rate of 94.1%. Thirty-seven (44.7%) and nine (10.7%) patients had minor and major medical complications, respectively; 18 (21.4%) and 17 (20.2%) had minor and major surgical complications, respectively. Twenty-one (25%) patients had both medical and surgical complications (with a statistically significant association, p = 0.018). Overall, 52 (61.9%) patients had at least one complication: ASA score, diabetes mellitus, and duration of general anesthesia (DGA) significantly impacted the complication rate at multivariate analysis. Conclusion: Our data confirm the feasibility of free flaps for OSCC reconstruction in appropriately selected elderly patients. Pre-operative assessment and aggressive management of glycemia in patients with diabetes is mandatory. DGA should be reduced as much as possible to prevent post-surgical complications. Comprehensive geriatric assessment is of paramount importance in this subset of patients.
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Affiliation(s)
- Alberto Grammatica
- Department of Otorhinolaryngology-Head Neck Surgery, University of Brescia, Brescia, Italy
| | - Cesare Piazza
- Department of Otorhinolaryngology, Maxillofacial and Thyroid Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy
| | - Raul Pellini
- Department of Otolaryngology and Head and Neck Surgery, IRCCS National Cancer Institute, Rome, Italy
| | - Nausica Montalto
- Department of Otorhinolaryngology-Head Neck Surgery, University of Brescia, Brescia, Italy
| | - Davide Lancini
- Department of Otorhinolaryngology-Head Neck Surgery, University of Brescia, Brescia, Italy
| | - Alperen Vural
- Department of Otorhinolaryngology-Head Neck Surgery, University of Brescia, Brescia, Italy
| | - Francesco Barbara
- Department of Otorhinolaryngology-Head Neck Surgery, University of Bari, Bari, Italy
| | - Marco Ferrari
- Department of Otorhinolaryngology-Head Neck Surgery, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Department of Otorhinolaryngology-Head Neck Surgery, University of Brescia, Brescia, Italy
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Scaglioni MT, Giovanoli P, Scaglioni MF, Yang JCS. Microsurgical head and neck reconstruction in patients with coronary artery disease: A perioperative assessment algorithm. Microsurgery 2019; 39:290-296. [PMID: 30648284 DOI: 10.1002/micr.30429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/24/2018] [Accepted: 12/27/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND With the rising number of patients in advanced age receiving microsurgical procedures, coronary artery disease (CAD) and its challenging management is of increasing importance. Evidence based data concerning morbidity and mortality are rare. We present our experiences with this highly selected patient population and propose a preoperative assessment algorithm. PATIENTS AND METHODS Between January 2006 and May 2016, a total of 57 patients with CAD received 58 free flaps. Median age of our patients was 64 years (interquartile range 57.5-70.0). Squamous cell carcinoma was the reason for reconstruction in all cases. Defect of the buccal, gum, tongue, lip, trigone, palatal, and hypopharyngeal regions were reconstructed. Patient characteristics and comorbidities were recorded. We especially focused on the preoperative cardiac assessment and treatment of patients who were scheduled for microsurgical free tissue transfer such as medical history, cardiac risk assessment, and further cardiac testing such as Doppler-echocardiography and myocardial perfusion assessment. Intraoperative course as well as postoperative morbidity and mortality was described. RESULTS About 54.4% of the selected cohort received cardiac catheterization due to a clinical preoperative cardiac assessment performed individually by the cardiologist on duty. In total, 52 fasciocutaneous anterolateral thigh flaps, four osteocutaneous fibula flaps, and two radial forearm flaps were performed. The flap survival rate was 96.6%. The overall surgical complication rate was 28.1% (16 patients), mostly due to wound infections (seven cases) and partial flap necrosis (four cases). Three patients died, resulting in a mortality rate of 5.2%. CONCLUSION CAD patients receiving head and neck microsurgical reconstructions are still at high risk for adverse consequences due to surgery. The microsurgical community is requested to share the experience of those cases in order to develop reliable and evidence based statements of the perioperative risks and prognosis for these patients. We additionally introduce a standardized perioperative cardiac assessment and treatment algorithm for head and neck surgery patients with CAD.
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Affiliation(s)
- Marie-Therese Scaglioni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland.,Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Mario F Scaglioni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland.,Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Johnson Chia-Shen Yang
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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