Risk factors of recipient site infection in head and neck cancer patients undergoing pectoralis major myocutaneous flap reconstruction

The pectoralis major myocutaneous pedicled flap-Its past and current practice in a dedicated microsurgery service. Review of the literature, and debunking controversies

BACKGROUND

The pectoralis major myocutaneous pedicled (PMMP) flap is still considered by many a workhorse flap in head and neck (H&N) reconstruction, despite free flap surgery advancing. The authors aimed to examine this claim and associated myths and controversies by analyzing literature trends and revealing the role of the PMMP flap in a well-established microsurgery center.

METHODS

The senior author's reconstructive H&N practice between 1995 and 2022 was reviewed to describe and critically judge primary and secondary PMMP flap decisions to provide invaluable lessons learned and debunk common controversies related to complex H&N reconstruction. A literature review from 1978 to 2022 evaluated PMMP flap articles from plastic surgery and allied H&N specialties, with a deeper analysis on publications from 2010 onward.

RESULTS

In 27 years of practice, the senior author performed 2871 major H&N reconstructions, including 27 PMMP flaps. Both primary (13/27) and secondary (14/27) PMMP flaps decreased over time. Indications shifted from external skin compromise (fistulae/metastases) to complex medical morbidity and high-risk neck status. Neck status was increasingly evaluated based on any previous violation, surgical or irradiative, rather than simply number of remaining vessels. A literature review revealed an ongoingly abundant and primary PMMP flap use, largely by non-plastic surgeons.

CONCLUSION

The PMMP flap can and should be reserved for complex, high-risk or free flap-exhausted cases. Thus, current indications deserve redefinition. Multidisciplinary collaboration in specialized centers with plastic surgeons is imperative to ensure appropriate reconstructive rational and protect patient outcomes, as changing reconstructive hands and starting anew risks reconstructive regression.

Incidence and risk factors of surgical site infection in patients with head and neck cancer: A meta-analysis

We systematically review the incidence and risk factors of surgical site infection (SSI) in patients with head and neck cancer. PubMed, Embase, Cochrane Library, and Web of Science databases were searched to obtain studies on the risk factors for SSI in patients with HNC. The retrieval time was from the establishment of the database to February 2023. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias in included studies. Meta-analysis was performed by using Stata 15.1 software. A total of 32 articles including 128 919 patients with head and neck cancer and 2949 cases of SSI were included in this meta-analysis. The incidence rate of SSI in head and neck cancer ranges from 19% to 29%, and the overall infection rate was 24%. Meta-analysis indicated that BMI < 20 kg/m2 (OR, 2.64; 95% CI, 1.74-4.00; I2 , 0%), diabetes (OR, 3.00; 95% CI, 2.12-4.16; I2 , 60.6%), ASA score (OR, 1.51; 95% CI, 1.29-1.77; I2 , 0%), radiotherapy (OR, 2.27; 95% CI, 1.87-2.77; I2 , 44.8%), chemotherapy (OR, 2.36; 95% CI, 1.64-3.40; I2 , 0%), clindamycin antibiotic (OR, 2.99; 95% CI, 1.82-2.93; I2 , 36.5%), deficit repair (OR, 3.76; 95% CI, 1.22-11.59; I2 , 91.4%), neck dissection (OR, 2.13; 95% CI, 1.63-2.79; I2 , 16.4%), blood transfusion (OR, 2.29; 95% CI, 1.52-3.45; I2 , 66.2%), mandibular (OR, 3.17; 95% CI, 1.85-5.42; I2 , 73%), tracheostomy (OR, 2.51; 95% CI, 1.74-3.62; I2 , 86.4%), operation time (OR, 1.42; 95% CI, 1.16-1.74; I2 , 86.4%), ALB (OR, 2.48; 95% CI, 1.95-3.15; I2 , 5.3%) were risk factors of surgical site infection in patients with head and neck cancer (p < 0.05). The results of the sensitivity analysis showed good agreement in all risk factors and the results had stability. The present meta-analysis suggests that BMI < 20 kg/m2 , diabetes, ASA score, radiotherapy, chemotherapy, clindamycin antibiotic, deficit repair, neck dissection, blood transfusion, mandibular, tracheostomy, operation time, and ALB were significant risk factors for SSI.

Has the Pectoralis Major flap Really Become Obsolete?

Aim

To evaluate the current role of pectoralis major (PM) flap including the reasons for selecting it over free flaps.

Materials and methods

All patients who underwent PM flap at Apollo Hospitals Ahmedabad during the 3-year period from January 2020 to December 2022 were included. Patient demographics, tumour characteristics and complications were studied and reasons for selecting pectoralis major flap were analyzed. Data was entered in Microsoft excel spreadsheet and analyzed using online statistical calculators. The p value of < 0.05 was considered statistically significant.

Results

57 patients underwent reconstruction with PM flap while 154 patients underwent free flap reconstruction. 54 were male and 3 were female. Median age was 51 years. PM flap was used for intraoral lining in 25 patients, and it was bilobed in 26 patients with full thickness cheek defect. Most common complication was wound infection seen in 10 patients. 5 patients developed marginal necrosis of the flap and 5 had donor site wound dehiscence. No complete flap loss was seen. During the same period, 15/154 (9.74%) patients with free flaps developed complete flap necrosis and this was statistically significant (p = 0.012). Reasons for choosing PM flap were also analyzed. 14 patients had major comorbidities, 18 had extensive disease, in 5 patients it was used for salvage post free flap failure, while 10 previously treated patients had unavailability of suitable vessels for anastomosis. 12 patients underwent PM flap due to financial constraints.

Conclusion

Thus, PM flap is not obsolete and continues to maintain its place in head and neck reconstruction.

Post-Operative Infections in Head and Neck Cancer Surgery: Risk Factors for Different Infection Sites

Background: Post-operative infections in head and neck cancer (HNC) surgery represent a major problem and are associated with an important increase in mortality, morbidity, and burden on the healthcare system. The aim of this retrospective observational study was to evaluate post-operative infections in HNC surgery and to analyze risk factors, with a specific focus on different sites of infection. Methods: Clinical data about 488 HNC patients who underwent surgery were recorded. Univariate and multivariate analyses were performed to identify risk factors for post-operative infections. Results: Post-operative infections were observed in 22.7% of cases. Respiratory and surgical site infections were the most common. Multiple site infections were observed in 3.9% of cases. Considering all infection sites, advanced stage, tracheotomy, and higher duration of surgery were risk factors at multivariate analysis. Median hospital stay was significantly longer in patients who had post-operative infection (38 vs. 9 days). Conclusions: Post-operative infections may negatively affect surgical outcomes. A correct identification of risk factors may help the physicians to prevent post-operative infections in HNC surgery.

Association between blood transfusions and complications in head and neck reconstruction: a systematic review and meta-analysis

PURPOSE

The aim of this meta-analysis is to assess the correlation between blood transfusions and the medical/surgical complications after head and neck reconstructive surgery.

METHODS

The PRISMA protocol was used and the literature search was performed on Pubmed, Scopus, Cochrane Library and Web of Science up to March 13, 2020. The risk of bias in individual studies was assessed through the Newcastle Ottawa Scale.

RESULTS

A total of 1219 records were screened after the electronic search, 22 of which were included in the qualitative analysis. Of there 22 scores, 18 articles were included in the meta-analysis. The OR for medical and surgical complications of transfused patients was 1,64 (95% CI 1.23-2.21); while, the OR for hospital readmission was 1.53 (95% CI 1.29-1.81).

CONCLUSIONS

The results of this meta-analysis suggested that blood transfusions are associated with both an increased risk of surgical and medical complications of head and neck flaps and with the hospital readmission.

Pectoralis major myocutaneous flap in salvage reconstruction following free flap failure in head and neck cancer surgery

Objective

This study aimed to compare the results of the pectoralis major myocutaneous (PMM) flap in primary and salvage head and neck cancer surgery.

Methods

A total of 160 patients were enrolled in this study. The salvage group consisted of 30 patients who received immediate PMM flap surgery following free flap failure. In the primary group, the PMM flap was primarily chosen for 130 patients. Related information was collected and analysed. The University of Washington (UW)-Quality of Life questionnaire, version 4, was mailed to every patient.

Results

Partial necrosis was significantly lower in the primary group (n = 13, 10.0%) than in the salvage group (n = 7, 23.3%). Surgical site infection was found in 10 (7.8%) patients in the primary group and in six (20.0%) patients in the salvage group. The mean composite quality of life scores were 66.8 ± 20.5 and 66.2 ± 22.1 in the two groups, respectively. Differences in scores for domains of activity, mood, and anxiety were significant. Disease-specific survival and recurrence-free survival rates were not different between the two groups.

Conclusion

PMM flap salvage reconstruction has a higher complication rate and poorer functional results, but similar survival prognosis, compared with primary surgery.

Literature Review of Criteria for Defining Recipient-Site Infection after Oral Oncologic Surgery with Simultaneous Reconstruction

BACKGROUND

The lack of uniformity of criteria for defining recipient-site infection after oral oncologic surgery with simultaneous reconstruction is problematic despite numerous studies on this issue. This study aimed to investigate the difference in the criteria for defining recipient-site infection after oral oncologic surgery with reconstruction.

METHODS

A Medline search was performed via PUBMED using the following combinations of key terms that were tagged in the title, abstract, or both: "surgical site infection-head neck," "surgical site infection-oral cancer," "antibiotic prophylaxis-head neck," and "surgical site infection-oral carcinoma." Search results were filtered between 2005 and 2017. Articles in which there was no mention of the criteria for definition of surgical-site infection were excluded.

RESULTS

The number of articles that met the inclusion criteria was 24. The lack of uniformity in the criteria for defining recipient-site infection in each article appeared to be attributable mainly to differences in whether an orocutaneous fistula and superficial incisional infection were regarded as recipient-site infection.

CONCLUSION

Reconsideration of the categorization of orocutaneous fistula as infection, regardless of the etiology, and differentiation of superficial and deep incisional infections are necessary for correct assessment of recipient-site infection in oral oncologic surgery.

Surgical Site Infections in Major Head and Neck Surgeries Involving Pedicled Flap Reconstruction

OBJECTIVE

To evaluate surgical site infections (SSI) after pedicled reconstruction in head and neck surgery.

METHODS

Records of patients with pedicled flap reconstructions between 2009 and 2014 at Massachusetts Eye and Ear were reviewed. Onset of SSI or fistula ≤30 days postoperatively was noted. A free flap cohort was reviewed for comparison.

RESULTS

Two hundred and eight pedicled reconstructions were performed for cancer (83%), osteoradionecrosis (7%), and other reasons (10%). Most (72%) cases were clean-contaminated and American Society of Anesthesiologists classification 3 or higher (73%); 63% of patients had prior radiation. The SSIs occurred in 9.1% and were associated with a longer length of stay (P = .004) but no particular risk factors. Seventeen patients developed a fistula (11 without SSI). The SSI rates were not significantly different between pedicled and free flaps, but pedicled flap patients were older, more likely to have had prior surgery and/or radiation, and be methicillin-resistant Staphylococcus aureus positive. In the combined population, multivariate analysis demonstrated clean-contaminated wound classification (P = .03), longer operating time (P = .03), and clindamycin prophylaxis (P = .009) as SSI risk factors.

CONCLUSIONS

The SSI rate following pedicled flap surgeries was low and similar to free flap surgeries despite a significantly different population. No specific risk factors were associated with developing a pedicled flap SSI.

Reliability of the pectoralis major myocutaneous flap in reconstructive oral cancer surgery in developing countries: Our experience

BACKGROUND

Although free flaps are nowadays considered 'Gold standard' of head and neck reconstruction, pectoralis major myocutaneous (PMMC) flap is still popular among many reconstructive cancer surgeons in developing countries for its many advantages and also due to lack of resources for free flaps in most of the centers, large number of cancer patients with poor nutritional status and economic condition. However, many studies have reported high complication rate in PMMC flap. So, the purpose of our study was to evaluate the reliability of PMMC flap.

METHODS

Within a span of 2 years, 20 reconstructions were done with PMMC flaps in patients with oral cancer and they were followed for a period of 1 year. Documentation was done for patient demographics, site of lesion, duration for reconstruction, occurrence of complications, etc.

RESULT

Among 17 males and 3 female patients, complications developed in 4 males and all female patients (total 7 patients, overall 35%). Flap-related complications were - one major (5%) and six minor (30%), which were comprised of three orocutaneous fistula (15%), three partial flap loss (15%), two marginal necrosis (10%), and one donor site necrosis (5%). Total necrosis was nil in our study. All the complications were managed conservatively except the patient with major complication which required intervention. Final cosmetic and functional outcome was acceptable in majority of patients.

CONCLUSION

PMMC flap is still 'workhorse' of reconstruction in head neck cancer patients in developing countries and can be used effectively with acceptable morbidity.

Risk factors for surgical site infection after supraclavicular flap reconstruction in patients undergoing major head and neck surgery

BACKGROUND

Surgical site infections can adversely affect flaps in head and neck reconstruction. The purpose of this study was to evaluate the risk factors of surgical site infections in supraclavicular artery island flap reconstructions.

METHODS

Records of patients undergoing head and neck surgery from 2011 to 2014 with supraclavicular artery island flap reconstruction at a single specialty hospital were reviewed; surgical site infections ≤30 days postoperatively were noted.

RESULTS

Of 64 patients, 86% underwent resection for malignancy, 55% previously received radiation. Sixty-three percent of surgeries were clean-contaminated. Seven patients (11%) developed recipient site surgical site infections, all in patients who underwent clean-contaminated surgery for malignancy. There was no complete flap loss. No significant differences in demographics or perioperative factors were noted. Oral cavity and laryngeal reconstructions (p = .014) and clean-contaminated surgery (p = .04) were factors associated with increased surgical site infection risk on univariate but not multivariate analysis. Patients with surgical site infections had longer hospitalizations (p = .003).

CONCLUSION

The supraclavicular artery island flap can be used for head and neck reconstruction with a low rate of surgical site infection. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.