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Philips R, Best KA, Agarwal A, Sagheer H, Selman Y, Sweeney L, Wax M, Krein H, Heffelfinger R, Luginbuhl A, Curry J. A Survey of Microvascular Technique Preferences Among American Head Neck Society Members. Laryngoscope 2024; 134:1265-1277. [PMID: 37610286 DOI: 10.1002/lary.30995] [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: 01/27/2023] [Revised: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE To identify practices in microvascular techniques in routine and challenging scenarios. STUDY DESIGN Cross-sectional study. METHODS A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021. RESULTS The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2-13) and median flaps per year was 35 (22-50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029). CONCLUSIONS This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length. LEVEL OF EVIDENCE 5 Laryngoscope, 134:1265-1277, 2024.
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Affiliation(s)
- Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Keisha A Best
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Aarti Agarwal
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Hamad Sagheer
- Department of Anesthesiology, University of Florida, Gainesville, Florida, U.S.A
| | - Yamil Selman
- Head and Neck Surgical Oncology, Memorial Healthcare System, Hollywood, Florida, U.S.A
| | - Larissa Sweeney
- Department of Otolaryngology-Head and Neck Surgery, University of Miami, Miami, Florida, U.S.A
| | - Mark Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
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Shimbo K, Kawamoto H, Koshima I. Combined Revascularization and Free Flap Reconstruction for Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2023; 39:581-588. [PMID: 36577499 DOI: 10.1055/a-2003-9004] [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: 12/30/2022]
Abstract
BACKGROUND Combined revascularization and free flap reconstruction is one treatment method for chronic limb-threatening ischemia (CLTI) with complex wounds. The purpose of this systematic review and meta-analysis was to investigate the characteristics of this combined procedure and to assess postoperative outcomes. METHODS A systematic search was performed across PubMed, Scopus, and the Web of Science for studies between January 2000 and February 2022. A random-effects meta-analysis for postoperative outcome was conducted. RESULTS Fifteen articles encompassing 1,176 patients with 1,194 free flaps were ultimately included in the qualitative and quantitative assessment. Our meta-analysis showed the following complication rates for short-term postoperative outcomes: 37% (95% confidence interval [CI], 18-53%; I 2 = 74%) for reoperation, 13% (95% CI, 2-24%; I 2 = 0%) for vascular thrombosis, 9% (95% CI, 0-17%; I 2 = 0%) for total flap failure, 8% (95% CI, 0-17%; I 2 = 0%) for partial flap failure, 4% (95% CI, 0-10%; I 2 = 0%) for amputation, and 3% (95% CI, 0-9%; I 2 = 0%) for 30-day mortality. The 1-, 3-, and 5-year limb salvage rates were 86% (95% CI, 78-92%), 81% (95% CI, 68-88%), and 71% (95% CI, 53-83%), respectively. The 1-, 3-, and 5-year patient survival rates were 93% (95% CI, 90-96%), 92% (95% CI, 77-97%), and 75% (95% CI, 50-88%), respectively. CONCLUSION Combined revascularization and free flap reconstruction for CLTI with complex wounds was clearly effective for the long-term outcomes. However, this combined procedure should be considered on the assumption that the reoperation rate is high and that flap-related complications rate may be higher than lower extremity reconstruction of other etiologies.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
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Shimbo K, Kawamoto H, Koshima I. Venous end-to-side anastomosis for free-flap reconstruction in the extremities: A case series and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 83:4-11. [PMID: 37263077 DOI: 10.1016/j.bjps.2023.05.004] [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: 01/20/2023] [Revised: 04/10/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023]
Abstract
This case series aimed to investigate the result of venous end-to-side (ETS) anastomosis in the extremities to contribute to a meta-analysis to evaluate the postoperative complications of venous ETS anastomosis in the extremities. This was a single-center case series and meta-analysis of patients who underwent venous ETS anastomosis for free-flap reconstruction of the extremities. We reviewed the records of 41 free flaps in 40 patients and performed a comprehensive search of PubMed, Scopus, and Web of Science for studies published from inception to December 2022. Primary outcomes were venous thrombosis, takebacks, and total and partial flap failures. Complication rates and confidence intervals were calculated using a random-effects model. In our case series, four (12.2%) patients with five flaps were taken back to the operating room, three (7.3%) flaps were due to venous thrombosis, and three (7.3%) flaps ultimately resulted in total flap failure. Our meta-analysis demonstrated the following complication rates: 4.0% (95% confidence interval [CI], 0-18.1%; I2 = 0%) for venous thrombosis, 8.5% (95% CI, 0-21.8%; I2 = 0%) for takebacks, 5.8% (95% CI, 0-18.3%; I2 = 0%) for total flap failure, and 8.8% (95% CI, 0-28.4%; I2 = 0%) for partial flap failure. Our case series and meta-analysis showed that the result of venous ETS anastomosis in the extremities was positive, and this technique was effective for addressing venous size discrepancy; although, its superiority to end-to-end anastomosis could not be established.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan; International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan.
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Lee SH, Lee KT, Park BY. Association of Dual Venous Anastomosis with Reduced Risks for Flap Congestion in Microsurgical Lower Extremity Reconstruction: A Multicenter Study. J Reconstr Microsurg 2022. [PMID: 36580972 DOI: 10.1055/s-0042-1760109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Flap congestion related with venous thrombosis is a major cause for microsurgical lower extremity reconstruction failure. Conducting dual venous anastomosis has been suggested to reduce risks for the adverse outcomes; however, its efficacy remains controversial. This study evaluated a potential association of dual venous anastomosis with the development of flap congestion in diverse clinical situations. METHODS This multicenter study included patients who underwent microsurgical lower extremity reconstruction at two institutions. They were divided into two groups based on the number of venous anastomoses-single and dual groups. Their perfusion-related complications (PRCs), including total/partial flap loss, arterial or venous insufficiency, and emergent reoperation, were compared. Independent association of the number of venous anastomoses with the outcomes was evaluated. Further analyses were conducted using propensity score matching. RESULTS In total, 225 cases were analyzed, of which 92 were included in the single group and the other 133 in the dual group. The two groups had generally similar baseline characteristics. The dual group presented significantly lower rates of PRC, including total/partial flap loss, flap congestion, and emergent reoperation. Multivariable analyses showed that conducting dual venous anastomoses was associated with reduced risks for the development of overall PRC and flap congestion. These associations were more prominent when restricting analyses for cases with chronic wound and trauma (vs. oncologic defects). Similar associations were observed in the propensity score matching analysis. CONCLUSION Conducting dual venous anastomosis seems associated with reduced risks for flap congestion in microsurgical lower extremity reconstruction, especially for cases with unfavorable conditions.
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Affiliation(s)
- Sang-Hun Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Bo Young Park
- Department of Plastic and Reconstructive Surgery, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
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Shimbo K, Kawamoto H, Koshima I. Selection of deep or superficial recipient vein in lower extremity reconstruction using free flap: A systematic review and meta-analysis. Microsurgery 2022; 42:732-739. [PMID: 35930261 DOI: 10.1002/micr.30946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/11/2022] [Accepted: 07/22/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Free flap surgeries are useful procedures for lower-extremity reconstruction. Recipient vein selection for anastomosis is important to avoid venous congestion and thrombosis. Although deep or superficial venous system can be used as a recipient vein site, there is a lack of consensus on which system would be superior to avoid postoperative complications. This systematic review and meta-analysis aimed to assess the differences in outcomes between deep and superficial vein anastomosis for lower-extremity free flap reconstruction. METHODS The PubMed, Scopus, Web of Science, and Cochrane Library medical databases were systematically searched from inception to April 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comparative meta-analysis was conducted on studies of deep and superficial venous system anastomosis outcomes, comprising vascular thrombosis, reoperation, complete flap necrosis, and any flap necrosis. The fixed-effects meta-analysis model was used when low heterogeneity (I2 < 50%) was present. RESULTS Six studies with 789 flaps were included in the analysis and qualitative and quantitative syntheses. The rate of vascular thrombosis (8.2% vs. 15.1%; p = .005) was significantly lower for flaps involving deep vein anastomosis than for those involving superficial vein anastomosis. The rate of reoperation after deep vein anastomosis was lower than that after superficial vein anastomosis, with no statistically significant difference (9.0% vs. 14.7%; p = .06). There were no significant differences in the rates of complete (2.5% vs. 2.0%; p = .90) or any flap necrosis (7.0% vs. 9.8%; p = .20). CONCLUSION Deep vein anastomosis might be recommended for avoiding vascular thrombosis.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Haruka Kawamoto
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan.,International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
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Free versus Pedicled Flaps for Lower Limb Reconstruction: A Meta-Analysis of Comparative Studies. J Clin Med 2022; 11:jcm11133672. [PMID: 35806957 PMCID: PMC9267676 DOI: 10.3390/jcm11133672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Free and pedicled flaps are both valuable surgical strategies for lower limb reconstruction. Evidence that compares both techniques is scarce. Our aim is to synthetise all the comparative studies by conducting a meta-analysis to identify post-operative outcomes. Method: A systematic review of pubmed, EMBASE, Cochrane library, and Web of Science was conducted, aiming at articles comparing the outcomes of free versus pedicled flaps in lower limb reconstruction. A pooled analysis with the Mantel and Haenszel methods and random effect analysis provided results as a risk ratio with a 95% confidence interval. Results: 10 retrospective studies were selected. While the flap necrosis rate did not differ significantly between techniques (RR 1.35, 95%CI 0.76–2.39, p = 0.31), the partial flap necrosis rate was significantly lower in free flaps (RR 0.45, 95%CI 0.22–0.91, p = 0.03). The overall complication rate (RR 0.83, 95%CI 0.64–1.07, p = 0.16) and revision surgery rate (RR 1.38, 95%CI 0.55–3.50, p = 0.49) did not differ significantly. No significant difference was found in the high aesthetic satisfaction rate (RR 1.76, 95%CI 0.57–5.41, p = 0.32) and post-operative infection rate (RR 0.85, 95%CI 0.55–1.33, p = 0.48). Conclusion: Despite important variability in the choice of flaps and outcomes reported among studies, free and pedicled flaps appear to be reliable surgical strategies for lower limb reconstruction with similar surgical outcomes.
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Zhang W, Zhu H, Ye P, Wu M. Unplanned reoperation after radical surgery for oral cancer: an analysis of risk factors and outcomes. BMC Oral Health 2022; 22:204. [PMID: 35614416 PMCID: PMC9131687 DOI: 10.1186/s12903-022-02238-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/17/2022] [Indexed: 12/04/2022] Open
Abstract
Background Unplanned reoperation (UR) after radical surgery for oral cancer (OC) is a health threat for the patients. The aim of the study was to identify the incidence of and risk factors for unplanned reoperation following oral cancer radical surgery, and to explore a potential role for long-term survival. Methods The present study followed a retrospective study design. Univariate and multivariate analyses were used to identify risk factors for demographic and clinical characteristics of patients. Survival analysis was performed by the Kaplan–Meier method. The data was analyzed statistically between November and December 2021. Results The incidence of UR was 15.7%. The primary cause of UR was reconstructed flap complications. Multivariate logistic regression analyses revealed that diabetes, tumor size, type of reconstruction, and nodal metastasis were independent risk factors for UR. Patients undergoing UR had a longer hospitalization, more post-operative complications, and a higher mortality compared with the non-UR group. UR is negatively correlated with the cancer-specific survival rate of patients (Log-rank test, P = 0.024). Conclusion Diabetes, tumor size, pedicled flap reconstruction and cervical nodal metastasis (N2) as independent risk factors for UR was discovered. UR was positively correlated with perioperative complications prolong hospital stay, and increased early mortality, but negatively correlated with the cancer-specific survival rate survival rate.
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Affiliation(s)
- Wei Zhang
- Department of Oral and Maxillofacial Surgery, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, 223300, Jiangsu Province, China
| | - Hong Zhu
- Department of Pharmacy, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, 223300, Jiangsu Province, China
| | - Pu Ye
- Department of Oral and Maxillofacial Surgery, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, 223300, Jiangsu Province, China
| | - Meng Wu
- Department of Oral and Maxillofacial Surgery, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, 223300, Jiangsu Province, China.
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