1
|
Anagnos VJ, Brody RM, Carey RM, De Ravin E, Tasche KK, Newman JG, Shanti RM, Chalian AA, Rassekh CH, Weinstein GS, O'Malley BW, Cannady Md SB. Post-operative Monitoring for Head and Neck Microvascular Reconstruction in the Era of Resident Duty Hour Restrictions: A Retrospective Cohort Study Comparing 2 Monitoring Protocols. Ann Otol Rhinol Laryngol 2023; 132:310-316. [PMID: 35473389 DOI: 10.1177/00034894221088176] [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: 11/16/2022]
Abstract
OBJECTIVES To determine whether 2 different methods of post-operative head and neck free flap monitoring affect flap failure and complication rates. METHODS A retrospective chart review of 803 free flaps performed for head and neck reconstruction by the same microvascular surgeon between July 2013 and July 2020 at 2 separate hospitals within the same healthcare system. Four-hundred ten free flaps (51%) were performed at Hospital A, a medical center where flap checks were performed at frequent, scheduled intervals by in-house resident physicians and nurses; 393 free flaps (49%) were performed at Hospital B, a medical center where flap checks were performed regularly by nursing staff with resident physician evaluation as needed. Total free flap failure, partial free flap failure, and complications (consisting of wound infection, fistula, and reoperation within 1 month) were assessed. RESULTS There were no significant differences between Hospitals A and B when comparing rates of total free flap failure, partial free flap failure, complication, or re-operation (P = .27, P = .66, P = .65, P = .29, respectively). There were no significant differences in urgent re-operation rates for flap compromise secondary to thrombosis and hematoma (P = .54). CONCLUSIONS In our series, free flap outcomes did not vary based on the degree of flap monitoring by resident physicians. This data supports the ability of a high-volume, well-trained, nursing-led flap monitoring program to detect flap compromise in an efficient fashion while limiting resident physician obligations in the age of resident duty hour restrictions.
Collapse
Affiliation(s)
- Vincent J Anagnos
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Brody
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan M Carey
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Emma De Ravin
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kendall K Tasche
- Department of Otorhinolaryngology: Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jason G Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Rabie M Shanti
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Oral and Maxillofacial Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ara A Chalian
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher H Rassekh
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory S Weinstein
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Bert W O'Malley
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven B Cannady Md
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
2
|
Guo B, Fang X, Shan Y, Li J, Shen Y, Ma C. Salvage mandibular reconstruction: multi-institutional analysis of 17 patients. Int J Oral Maxillofac Surg 2021; 51:191-199. [PMID: 34384647 DOI: 10.1016/j.ijom.2021.07.014] [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: 10/26/2020] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
Unsuccessful mandibular reconstruction occasionally occurs, leaving the patient with undesirable function and contours. In such cases, second- or third-time corrective operations are challenging. However, published studies on the complicated retreatment of such patients are scarce. A retrospective analysis covering the years 2015-2019 was conducted in three centers. All 17 patients included had undergone prior failed mandibular reconstructions in other institutions. Salvage secondary or tertiary reconstructive surgeries were attempted and the results are presented. Major factors for these failed reconstructions included exposed non-vascularized bone grafts (n = 7, 41.2%), flap loss (n = 4, 23.5%), exposed artificial joint (n = 3, 17.6%), skewed occlusion with deformity (n = 1, 5.9%), non-union (n = 1, 5.9%), and recurrence (n = 1, 5.9%). Fibula flaps were transferred in 15 patients, while iliac flaps were used in two patients for mandibular re-do reconstructions. Virtual surgical designs were conducted in nine (52.9%) patients, with navigation-guided approaches performed in three cases. Postoperative functions were relatively favorable in these complicated mandibular re-do reconstruction cases. Mandibular symmetry (mandibular length and height; P = 0.002) and condylar position (P < 0.001) were regained after these re-do attempts. Secondary or tertiary mandibular re-do reconstruction can still achieve good functional outcomes with appropriate preoperative selection and well-conceived designs, especially with the aid of virtual surgery and navigation.
Collapse
Affiliation(s)
- B Guo
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - X Fang
- Department of Oral and Maxillofacial Surgery, Xiangya Stomatological Hospital, Central South University, Changsha, Hunan, China
| | - Y Shan
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - J Li
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Y Shen
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - C Ma
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China.
| |
Collapse
|
3
|
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: 11] [Impact Index Per Article: 2.2] [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.
Collapse
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.
| |
Collapse
|
4
|
Polacco MA, Hou H, Kuppusamy P, Chen EY. Measuring Flap Oxygen Using Electron Paramagnetic Resonance Oximetry. Laryngoscope 2019; 129:E415-E419. [PMID: 31034638 DOI: 10.1002/lary.28043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/03/2019] [Accepted: 04/15/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine if electron paramagnetic resonance (EPR) oximetry is a viable technology to aid in flap monitoring. STUDY DESIGN Prospective cohort. METHODS This was a cohort study assessing accuracy and speed of EPR oximetry in detecting ischemia of a saphenous artery-based flap in a rat model, using transcutaneous oximetry as a control. Measurements were obtained under both resting and ischemic conditions for nine Sprague Dawley rats (18 flaps), for 3 postoperative days following flap elevation. RESULTS The mean partial pressure of oxygen prior to tourniquet application was 66.9 ± 8.9 mm Hg with EPR oximetry and 64.7 ± 5.2 mm Hg with transcutaneous oximetry (P = .45). Mean partial pressures of oxygen during tourniquet application were 8.9 ± 3.2 mm Hg and 8.5 ± 2.9 mm Hg for EPR oximetry and transcutaneous oximetry, respectively (P = .48), and 67.2 ± 6.9 mm Hg and 65.3 ± 6.1 mm Hg after tourniquet release for EPR oximetry and transcutaneous oximetry, respectively (P = .44). The mean ischemia detection time of EPR oximetry was 49 ± 21 seconds. CONCLUSIONS Offering timely, accurate, and noninvasive tissue oxygen measurements, EPR oximetry is a promising adjunct in flap monitoring. LEVEL OF EVIDENCE NA Laryngoscope, 129:E415-E419, 2019.
Collapse
Affiliation(s)
- Marc A Polacco
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Huagang Hou
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Eunice Y Chen
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
5
|
Patel SY, Meram AT, Kim DD. Soft Tissue Reconstruction for Head and Neck Ablative Defects. Oral Maxillofac Surg Clin North Am 2019; 31:39-68. [PMID: 30449526 DOI: 10.1016/j.coms.2018.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Soft tissue reconstruction of head and neck ablative defects is a broad, challenging, and subjective topic. The authors outline goals to keep in mind when deciding on a primary reconstructive option for defects created by oncologic resection. Factors considered in local, regional, and distant flap selection are discussed. Based on the goals of reconstruction and factors involved in flap selection, a defect-based reconstructive algorithm is developed to help choose the ideal reconstructive option. The authors also discuss indications, pearls, pitfalls, and challenges in the harvest and inset of commonly used soft tissue flaps for head and neck reconstructive surgery.
Collapse
Affiliation(s)
- Stavan Y Patel
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA.
| | - Andrew T Meram
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA
| | - Dongsoo D Kim
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA
| |
Collapse
|