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Li Y, Li Z, Lv Q, Gu Y, Qi Y, Li J, Liu Y, Ma G. Prevalence and risk factors of postoperative delirium in tumor patients after free flap reconstruction: A systematic review and meta-analysis of case-control studies. Surgery 2024; 176:906-917. [PMID: 38910046 DOI: 10.1016/j.surg.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/12/2024] [Accepted: 05/06/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Postoperative delirium is a severe complication of flap transplantation surgery, adversely affecting surgical prognoses. The intricate pathophysiology of postoperative delirium renders the elucidation of its risk factors challenging. This research aims to delineate the prevalence and the specific risk factors of postoperative delirium in patients with cancer undergoing free flap reconstruction through a systematic review and meta-analysis to enlighten proactive prevention measures. METHODS The researchers systematically queried both the international and Chinese databases. Searches were performed for publications from inception until September 14, 2023, using the terms "free tissue flaps," "delirium," "neoplasms," and "risk factors." Data synthesis and statistical analysis were conducted using Stata SE (version 15.0) to calculate the combined effect size for identified risk factors. Reported outcomes included weighted mean differences or odds ratios with their respective 95% confidence intervals. RESULTS Twelve case-control studies were included (ntotal = 3,256). Among them, 515 patients developed postoperative delirium after free flap surgery, compared with 2,741 patients who did not. The outcomes suggest that the risk factors include but are not limited to age, male, late neoplasm staging, use of hypnotic or antipsychotic, history of background diseases, psychiatric review, tracheotomy, and impaired wound healing. In contrast, early neoplasm staging and others are the protective factors with statistical significance. Multivariate analysis further identified significant correlations between preoperative albumin, perioperative blood transfusion, sleep disturbance, postoperative visual analog scale, postoperative albumin, smoking, and the appearance of postoperative delirium. CONCLUSION The determined risk factors were grouped into preoperative, intraoperative, and postoperative categories substantiated by current data to present instructions for postoperative delirium prevention.
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Affiliation(s)
- Yifei Li
- Department of General Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Peoples Republic of China
| | - Zhifeng Li
- First Department of Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, Peoples Republic of China
| | - Qianwen Lv
- Department of Fat Grafting, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Peoples Republic of China
| | - Yunpeng Gu
- Department of Fat Grafting, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Peoples Republic of China
| | - Yue Qi
- Department of Fat Grafting, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Peoples Republic of China
| | - Jiyang Li
- Department of Fat Grafting, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Peoples Republic of China
| | - Yicheng Liu
- Department of General Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Peoples Republic of China
| | - Guie Ma
- Department of General Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Peoples Republic of China.
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2
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Khan U, Hathi K, MacKay C, Corsten M. The Complications of Osseous Reconstruction in the Head and Neck: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024; 171:631-641. [PMID: 38881407 DOI: 10.1002/ohn.793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/11/2024] [Accepted: 04/06/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE To compare the postoperative complications of the fibular free flap (FFF), scapula free flap (SFF), and osteocutaneous radial forearm free flap (OCRFFF) following osseous reconstruction in the head and neck. DATA SOURCES PUBMED, EMBASE, Cochrane. REVIEW METHODS A literature search and systematic review were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A meta-analysis of proportions was conducted using a random effects model to compare operative time and postoperative complications. RESULTS The systematic review identified 26 studies comparing at least 1 variable of interest. The odds ratio estimates favored reduced rates of flap failure with the OCRFFF when compared to FFF (0.7, confidence interval [CI]: 0.29-1.11, P < .001), while FFF and SFF were similar. The mean difference estimates for operative time significantly favored FFF over SFF (-51.04 minutes, CI: -92.73 to -9.35, P = .016) and OCRFFF over FFF (66.77 minutes, CI: 52.74-80.8, P < .001). The FFF was more prone to hardware exposure, longer hospital stays, and donor site complications. Recipient wound complications and fistula rates were similar for all flap types. CONCLUSION Depending on the clinical context, the OCRFFF, FFF, and SFF are all robust options for reconstruction in the head and neck. The OCRFFF is associated with a reduced rate of flap failure and shorter operative times. The SFF requires longer operative times, although significant variation was observed between institutions. The FFF has broad reconstructive indications but is associated with more perioperative and long-term complications.
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Affiliation(s)
- Usman Khan
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kalpesh Hathi
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Colin MacKay
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Martin Corsten
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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3
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Ha Y, Park SO, Park JA, Kim SY, Shim HS, Kim YH. Analysis of Operation Duration in Thoracodorsal Artery Perforator Free-Flap Surgery of the Lower Extremities. Ann Plast Surg 2024; 92:405-411. [PMID: 38527347 DOI: 10.1097/sap.0000000000003901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
PURPOSE This retrospective study aimed to identify the factors that affect the duration of thoracodorsal artery perforator (TDAP) free-flap surgery and to offer strategies for optimizing the surgical procedure. METHODS We analyzed 80 TDAP flap surgeries performed by a single surgeon between January 2020 and December 2022, specifically focusing on free flaps used for lower-extremity defects with single-artery and single-vein anastomosis. The operation duration was defined as the time between the surgeon's initial incision and completion of reconstruction. Linear regression analyses were conducted to identify the factors affecting operation duration. RESULTS The average operative duration was 149 minutes (range, 80-245 minutes). All flaps survived, although 8 patients experienced partial flap loss. The operative duration decreased with increasing patient age and when end-to-end arterial anastomosis was performed. However, the risk increased with larger flap sizes and in patients with end-stage renal disease. CONCLUSIONS Our study identified several factors and methods that could accelerate TDAP free-flap procedures. These findings offer valuable insights for optimizing surgical processes and improving overall surgical outcomes. Although further research is needed to confirm and expand upon these findings, our study provides important guidance for surgeons in developing effective strategies for TDAP flap surgery.
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Affiliation(s)
- Yooseok Ha
- From the Department of Plastic and Reconstructive Surgery, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Seong Oh Park
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Ji Ah Park
- Design Lab of Technology Commercialization Center, Industry-University Cooperation, Foundation of Hanyang University, Seoul, Republic of Korea
| | - Si Yeon Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Hyung-Sup Shim
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
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4
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Gulati A, Heaton CM, Park AM, Seth R, Knott PD. Outcomes Associated with Multiple Free Tissue Transfers Performed in a Single Day. Facial Plast Surg Aesthet Med 2023; 25:472-477. [PMID: 36848581 DOI: 10.1089/fpsam.2022.0392] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Background: Although microvascular free tissue transfer (MFTT) remains technically challenging, surgeons may need to perform >1 MFTT operations in a given day. Objective: To compare MFTT outcomes in cases where surgeons completed one versus two flaps per day by measuring flap viability and complication rates. Methods: A retrospective review was conducted of MFTT cases from January 2011 to February 2022 with >30-day follow-up. Outcomes, including flap survival and operating room takeback, were compared using multivariate logistic regression analysis. Results: Of 1096 patients meeting inclusion criteria (1105 flaps), there was a male predominance (n = 721, 66%). Mean age was 63.0 ± 14.4 years. Complications requiring takeback were identified in 108 flaps (9.8%) and were greatest for double flaps in the same patient (SP) (27.8%, p = 0.06). Flap failure occurred in 23 (2.1%) cases and was also greatest for double flaps in the SP (16.7%, p = 0.001). Takeback (p = 0.06) and failure (p = 0.70) rates were not different between days with one versus two unique patient flaps. Conclusions: Among patients undergoing MFTT, those treated on days in which surgeons perform two unique cases compared with single cases will demonstrate no difference in outcomes, as measured by flap survival and takeback, whereas patients with defects requiring multiple flaps will experience greater takeback and failure rates.
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Affiliation(s)
- Arushi Gulati
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Chase M Heaton
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Andrea M Park
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rahul Seth
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - P Daniel Knott
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
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5
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Tomic J, Starke V, Wallner J, Zemann W, Gary T, Pau M. Heparin regimes in head and neck cancer flap surgery: A retrospective cohort study of free flap complications graded by Clavien-Dindo. J Craniomaxillofac Surg 2023; 51:629-634. [PMID: 37845093 DOI: 10.1016/j.jcms.2023.09.015] [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: 07/11/2023] [Revised: 08/17/2023] [Accepted: 09/30/2023] [Indexed: 10/18/2023] Open
Abstract
The purpose of the current study was to compare two different antithrombotic protocols for free flap reconstruction in head and neck squamous cell carcinoma (HNSCC) patients. Postoperative complications were graded using the Clavien-Dindo (CD) classification and compared between the two groups: the low-molecular-weight heparin (LMWH) group (n = 57) and the unfractionated heparin (UFH) group (n = 59). Patients with HNSCC from January 2010 to January 2022 were included. A total of 116 patients with a mean age of 60.46 years (range 43-83 years) were included in this study. In all, 81 were male (69.8%), and 35 were female (30.2%). Most patients (48.3%) had only grade 1 or 2 complications. CD grades (1-5) were similar between the two groups. Flap loss occurred in 2 patients (1.7%) in the LMWH group (p = 239). Prognostic factors of flap loss were high BMI, hypertension, high T stage, and high N stage. No differences were found between the groups in regard to age, sex, operating times, flap source, recipient vessels and overall complications. The results of this study demonstrate that UFH was as safe and effective as LMWH regarding postoperative complications. Free flap surgery is safe and effective for head and neck reconstruction.
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Affiliation(s)
- Josip Tomic
- Department of Oral and Maxillofacial Surgery, Medical University of Graz, Graz, Austria.
| | - Vasco Starke
- Department of Oral and Maxillofacial Surgery, Medical University of Graz, Graz, Austria
| | - Jürgen Wallner
- Department of Oral and Maxillofacial Surgery, Medical University of Graz, Graz, Austria
| | - Wolfgang Zemann
- Department of Oral and Maxillofacial Surgery, Medical University of Graz, Graz, Austria
| | - Thomas Gary
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Mauro Pau
- Department of Oral and Maxillofacial Surgery, Medical University of Graz, Graz, Austria
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6
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Lee DY, Lim S, Eo S, Yoon JS. Free flap reconstruction of scalp in a case of advanced lung cancer with brain metastasis: A case report. Medicine (Baltimore) 2023; 102:e35097. [PMID: 37682134 PMCID: PMC10489508 DOI: 10.1097/md.0000000000035097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/16/2023] [Indexed: 09/09/2023] Open
Abstract
RATIONALE Reconstruction of wound complications in patients with advanced cancer with distant metastases is challenging for plastic surgeons. This may be due to the cancer patients' hypercoagulability and potential intolerance to general anesthesia. This article aimed to discuss the risk of free-flap reconstruction in such cases. PATIENT CONCERNS The patient was a 58-year-old female with advanced non-small cell lung cancer and brain metastasis. The patient underwent brain radiotherapy and chemotherapy through the Ommaya Reservoir. DIAGNOSES A year ago, she underwent several local flap closures for recurrent wound healing failure due to wound complications, including infection, wound dehiscence, and subsequent device removal. INTERVENTIONS A radial forearm free flap was created under general anesthesia. The patient was discharged in the third postoperative week since the flap remained stable. OUTCOMES At follow-up a month thereafter, the patient exhibited signs of recovery without any complications even while continuing her chemotherapeutic regimen. LESSONS Free flap placement is not an absolute contraindication in cancer patients with distant metastases. Nevertheless, it is associated with clinical challenges and operator hesitancy. This is a case of a successful free flap in a cancer patient with hypercoagulability and suspected floating tumor cells. Postoperative management, in this case, is appropriate.
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Affiliation(s)
- Dong Yun Lee
- Department of Plastic and Reconstructive Surgery, DongGuk University Medical Center, GoYang, South Korea
| | - SooA Lim
- Department of Plastic and Reconstructive Surgery, DongGuk University Medical Center, GoYang, South Korea
| | - SuRak Eo
- Department of Plastic and Reconstructive Surgery, DongGuk University Medical Center, GoYang, South Korea
| | - Jung Soo Yoon
- Department of Plastic and Reconstructive Surgery, DongGuk University Medical Center, GoYang, South Korea
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7
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Iamaguchi RB, Macedo LS, Cho AB, Rezende MRD, Mattar R, Wei TH. Reconstrução microcirúrgica em um hospital ortopédico: Indicações e desfechos em adultos. Rev Bras Ortop 2022; 57:772-780. [PMID: 36226202 PMCID: PMC9550366 DOI: 10.1055/s-0041-1735946] [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: 02/23/2021] [Accepted: 05/18/2021] [Indexed: 11/05/2022] Open
Abstract
Objective
Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications.
Methods
Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis.
Results
We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours (
p
= 0.032) and obesity (
p
= 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count (
p
= 0.001).
Conclusion
The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.
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Affiliation(s)
- Raquel Bernardelli Iamaguchi
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Lucas Sousa Macedo
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Alvaro Baik Cho
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Marcelo Rosa de Rezende
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Rames Mattar
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Teng Hsiang Wei
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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8
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Deane EC, Liu AQ, Nguyen S, Anderson DW, Durham JS, Prisman E. Synchrony in head and neck surgery: Feasibility and outcomes of simultaneous scapular free flap reconstruction. Head Neck 2021; 44:760-769. [PMID: 34936161 DOI: 10.1002/hed.26963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/15/2021] [Accepted: 12/10/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The scapula free flap is a versatile option in head and neck reconstruction but is less amenable to simultaneous harvest and ablation. METHODS Retrospective series (2015-2021) of consecutive scapula flaps. Cases categorized as simultaneous versus sequential, compared for operative time, oncological and patient-reported outcomes. RESULTS Seventy consecutive scapula free flaps were performed (n = 21 simultaneous, n = 49 sequential). Mandible reconstruction was performed in 51.0% and 61.9% of sequential and simultaneous cases, respectively; 49.0% and 38.1% addressed bony maxillary defects. Simultaneous surgery reduced operative time by 37.9% (151 min, p < 0.00001) and there were fewer tracheostomies performed (p < 0.005). Rates of positive margins and free flap compromise were equivalent (n = 1, 4.8% vs. n = 2, 4.1%). There was no difference in patient-reported outcomes. CONCLUSIONS This series demonstrates feasibility, efficacy, and outcomes of bony scapula reconstruction of maxillofacial defects comparing simultaneous and sequential approaches. Benefits of the two-team approach are highlighted including decreased operative time.
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Affiliation(s)
- Emily C Deane
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alice Q Liu
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sally Nguyen
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald W Anderson
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - James Scott Durham
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eitan Prisman
- Department of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Hakim SG, Steller D, Falougy M, Tharun L, Sieg P, Ciocan-Pendefunda C. The sub-fascial pattern of the myocutaneous platysma flap - The anatomical basis and preliminary cases for oral reconstruction. J Craniomaxillofac Surg 2021; 50:267-273. [PMID: 34879974 DOI: 10.1016/j.jcms.2021.11.014] [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: 08/10/2021] [Revised: 10/07/2021] [Accepted: 11/28/2021] [Indexed: 10/19/2022] Open
Abstract
To verify the feasibility of the SF-MPF for oral reconstruction, the anatomic, sonographic and histologic features of the SF-MPF were investigated and the outcome in a series of patients was evaluated. The sonographic and histologic results showed a supra-fascial arterio-venous vascular blood supply to the sub-fascial design of the MPF. The clinical course of 12 consecutive patients who underwent oral reconstruction using the SF-MPF along with ipsi- or lateral neck dissection for treatment of oral cancer showed sufficient pedicle length and reliable blood supply. The SF-MPF is a reliable and safe pedicled myocutaneous flap. Therefore, it should be considered being an additional option when a pedicled flap has to be selected.
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Affiliation(s)
- Samer G Hakim
- Dept. Maxillofacial Surgery, Head and Neck Cancer Centre, University and University Hospital of Lübeck, Lübeck, Germany.
| | - Daniel Steller
- Dept. Maxillofacial Surgery, Head and Neck Cancer Centre, University and University Hospital of Lübeck, Lübeck, Germany
| | - Mohamed Falougy
- Dept. Maxillofacial Surgery, Head and Neck Cancer Centre, University and University Hospital of Lübeck, Lübeck, Germany
| | - Lars Tharun
- Dept. of Pathology, University and University Hospital of Lübeck, Lübeck, Germany
| | - Peter Sieg
- Dept. Maxillofacial Surgery, Head and Neck Cancer Centre, University and University Hospital of Lübeck, Lübeck, Germany
| | - Constantin Ciocan-Pendefunda
- Dept. Maxillofacial Surgery, Head and Neck Cancer Centre, University and University Hospital of Lübeck, Lübeck, Germany
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10
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Miller H, Bush K, Delancy M, Leo ND, Joshi H, Saracco B, Adams A, Gaughan J, Bonawitz S. Effect of preoperative radiation on free flap outcomes for head and neck reconstruction: An updated systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021; 75:743-752. [PMID: 34810143 DOI: 10.1016/j.bjps.2021.09.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 09/17/2021] [Accepted: 09/26/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is an ongoing debate about whether neoadjuvant radiation therapy is associated with higher rates of postoperative complications after head and neck reconstruction. Herle et al. conducted a systematic review in 2014 of 24 studies, finding higher complication rates in irradiated fields. We sought to perform an exhaustive updated systematic review and meta-analysis. METHODS We conducted an updated systematic review of the literature, as outlined in our protocol, which was registered on PROSPERO. Databases included Medline, Embase, Cochrane Central, and Web of Science. There were no limits placed on the date range, place of publication, or origin. Exclusion criteria included patients less than 18 years of age, studies with less than 20 participants (n < 20), case studies, skull base reconstructions, and local tissue rearrangements. The combined results of the studies and relative risks (RR) were calculated. RESULTS 53 studies were included for analysis, including 5,086 free flaps in an irradiated field, and 9,110 free flaps in a non-irradiated field. Of the 53 studies, 21 studies overlapped with those discussed in Herle et al.'s study, with a total of 32 additional studies. Neoadjuvant radiation was found to be a statistically significant risk factor for postoperative complications (RR 1.579, P < 0.001), total flap failure (RR, 1.565; P < 0.001), and fistula (RR, 1.810; P < 0.001). Our work reaffirmed the findings of the Herle et al. STUDY CONCLUSION Preoperative radiation was associated with a statistically significant increase in the risk of total flap failure, fistula, and total complications but not partial flap failure. These high-morbidity complications must be taken into consideration when determining which patients should receive neoadjuvant radiation therapy.
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Affiliation(s)
- Henry Miller
- Department of Surgery, Cooper University Hospital, Camden NJ, United States.
| | - Kathryn Bush
- Cooper Medical School of Rowan University, Camden NJ, United States
| | - Matthew Delancy
- Cooper Medical School of Rowan University, Camden NJ, United States
| | - Nicholas De Leo
- Department of Surgery, Cooper University Hospital, Camden NJ, United States
| | - Hansa Joshi
- Cooper Medical School of Rowan University, Camden NJ, United States
| | - Benjamin Saracco
- Cooper Medical School of Rowan University, Camden NJ, United States
| | - Amanda Adams
- Cooper Medical School of Rowan University, Camden NJ, United States
| | - John Gaughan
- Cooper Research Institute, Cooper University Hospital, Camden NJ, United States
| | - Steven Bonawitz
- Department of Surgery, Cooper University Hospital, Camden NJ, United States
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11
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Molitor M, Mestak O, Pink R, Foltan R, Sukop A, Lucchina S. The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part II: Clinical application. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 165:131-138. [PMID: 33821845 DOI: 10.5507/bp.2021.017] [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: 11/10/2020] [Accepted: 02/26/2021] [Indexed: 11/23/2022] Open
Abstract
Despite the high success rate of micro-vascular flaps, anastomosis compromise occurs in 5-10% and that can lead to flap failure. Reliable monitoring of the flap is therefore of similar importance to that of the precise surgical procedure itself. Multiple methods have been reported for monitoring of the flap vitality, the first one being direct visual monitoring. In buried flaps direct visualisation is not feasible or is unreliable. In these cases we can extend the buried flap to expose a segment of it to act as a monitoring sentinel. For the purpose of this review we used our clinical experience as a starting point, and for the extended information and expertise we conducted a search of the PubMed database. Over 40 monitoring techniques have been reported to-date. Direct visual monitoring is still generally used method with a reliability of up to 100% and an overall success rate of up to 99%. Direct visualisation remains as the simplest, cheapest and yet a very reliable method of flap monitoring. In this review we provide a description of various possible techniques for externalising part of a buried flap, define the tissues that can be used for this purpose and we summarise the procedures that should be followed to achieve the best reliability and validity of monitoring the skin island.
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Affiliation(s)
- Martin Molitor
- Department of Plastic Surgery, First Faculty of Medicine Charles University and Na Bulovce Hospital, Prague, Czech Republic
| | - Ondrej Mestak
- Department of Plastic Surgery, First Faculty of Medicine Charles University and Na Bulovce Hospital, Prague, Czech Republic
| | - Richard Pink
- Department of Maxillofacial Surgery, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Rene Foltan
- Department of Maxillofacial Surgery, General University Hospital and 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Andrej Sukop
- Department of Plastic Surgery, University Hospital Kralovske Vinohrady and 3rd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Stefano Lucchina
- Hand Unit, General Surgery Department, Locarno's Regional Hospital, Via Ospedale 1, 6600 Locarno, Switzerland
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Complex Mandibular Reconstruction for Head and Neck Squamous Cell Carcinoma-The Ongoing Challenge in Reconstruction and Rehabilitation. Cancers (Basel) 2020; 12:cancers12113198. [PMID: 33143098 PMCID: PMC7693398 DOI: 10.3390/cancers12113198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/17/2020] [Accepted: 10/23/2020] [Indexed: 11/21/2022] Open
Abstract
Simple Summary Cancer therapy includes a broad range of microvascular free flaps that may restore defects and improve patients’ quality of life. This is particularly important for head and neck squamous cell carcinoma (HNSCC) and composite mandibular reconstructions, containing tissues of bone, muscle, and skin, which may be problematic due to their magnitude and sensitive location. The subscapular system offers a highly valuable donor site with the most versatility and the potential for rapid rehabilitation. Interestingly, other donor sites are more commonly used internationally. Therefore, we evaluated the use of the subscapular system free flap (SFF), which is the most commonly used free flap at our department. To our knowledge, this retrospective study represents the largest number of SFF cases reported to date in the literature. Furthermore, we examined the quality of life in a subgroup of patients, combining prospective occurrences to provide insight into overall rehabilitation from the patients’ viewpoints. Abstract Large head and neck squamous cell carcinoma (HNSCC) tumors affecting the mandible require a versatile reconstruction to maintain form, function, and quality of life. Large defect reconstruction of soft and hard tissue in the head and neck necessitates, at best, one vascular system including various tissues by large dimensions. The subscapular flap system seems to meet these standards. A retrospective study was conducted focusing on clinical data, including an analysis of the quality of life with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires, (QLQ-C30 and QLQ-H&N43). A total of 154 patients (122 males, 32 females; age range: 31–71 years, mean: 54.5 years) treated at our department from 1983 through to 2019 were included. Of the subscapular system free flaps (SFFs), 147 were based on the angular artery branch of the thoracodorsal pedicle (95.45%), and the remaining seven cases (4.55%) were lateral scapular border flaps. Mean mandible defect length was 7.3 cm. The mean skin paddle dimension was 86.8 cm2. The most common recipient artery was the thyroid superior artery (79.22%). Major postoperative complications occurred in 13 patients (8.44%). This study confirms that SFFs offer excellent soft and hard tissue quality, component independence, a large arc of rotation length, and a large gauge of pedicle, making them the gold standard for the reconstruction of large composite defects of mandibular HNSCC tumors.
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Shinomiya R, Sunagawa T, Nakashima Y, Kodama A, Hayashi Y, Tokumoto M, Adachi N. Monitoring Vascular Compromise Using Ultrasound After Free Tissue Transfer. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1213-1222. [PMID: 31880342 DOI: 10.1002/jum.15210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 12/08/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To report the clinical utility of high-resolution ultrasound (US) for monitoring vascular compromise after free tissue transfer. METHODS Fifty-two tissue transfers in the extremities were included in this study. Blood flow around the anastomotic pedicle and subcutaneous tissue of the grafted flap was monitored with pulsed color and power Doppler US whenever the conventional monitoring method, comprising the bedside assessment of the temperature, capillary refill, and flap color, showed abnormalities until 1 week after reconstruction. RESULTS All flaps were indicated for US monitoring, with 44 flaps showing Doppler signals in each position, even though conventional flap monitoring showed an abnormality. Forty of the 44 flaps showed no flap failure, whereas the remaining 4 flaps developed partial necrosis. Abnormal US findings were noted in 8 of the 52 flaps. Ultrasound revealed interruption of venous blood flow around the anastomotic pedicle in 6 of 8 flaps. Emergent exploration revealed venous occlusion at the anastomotic pedicle, similar to the US finding. In 2 of the 8 flaps, US showed no blood flow to either the anastomotic pedicle or subcutaneous tissue. Emergent exploration revealed arterial occlusion at the anastomotic pedicle. Seven of the 8 reexplored flaps were salvaged after revision surgery with complete flap survival. Partial flap survival was noted in 1 case, but complete flap failure was avoided. CONCLUSIONS Ultrasound is a useful adjunct that enables a direct assessment of perfusion in grafted tissues, which may reduce unnecessary exploration when conventional flap monitoring shows an abnormality.
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Affiliation(s)
- Rikuo Shinomiya
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toru Sunagawa
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuko Nakashima
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akira Kodama
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuta Hayashi
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Maya Tokumoto
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Raguse JD, Trampuz A, Boehm MS, Nahles S, Beck-Broichsitter B, Heiland M, Neckel N. Replacing one evil with another: Is the fibula really a dispensable spare part available for transfer in patients with medication-related osteonecrosis of the jaws? Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 129:e257-e263. [PMID: 32102764 DOI: 10.1016/j.oooo.2019.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/18/2019] [Accepted: 10/15/2019] [Indexed: 11/26/2022]
Abstract
Because of the long-term and consecutive use of different causative agents, clinicians are increasingly encountering patients needing restoration of the stomatognathic system after surgical resection of highly advanced necroses of the jaw. For plastic restoration in these cases, microvascular reconstruction seems to represent the most viable option. According to the limited data available, the risks of this operation are considered comparable with those faced by other patient cohorts. We report here the case of a patient who suffered 2 successive pathologic fractures of the tibia after microsurgical reconstruction of the mandible with a free fibula flap. This exemplifies a general problem, especially because the patient also suffered from a treatment-refractory infection of the transplanted bone. Although the present literature indicates otherwise, fibula transplants might not be the gold standard in these cases. Therefore, alternatives to transplants from the weight-bearing parts of the body need to be considered until more data are available.
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Affiliation(s)
- Jan-Dirk Raguse
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectiology and Septic Surgery, Germany
| | | | - Susanne Nahles
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany
| | - Benedicta Beck-Broichsitter
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany
| | - Max Heiland
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany
| | - Norbert Neckel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Germany.
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15
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Guo Z, Cui W, Hu M, Yu B, Han B, Li Y, Tang X, Li C, Li L. Comparison of hand-sewn versus modified coupled arterial anastomoses in head and neck reconstruction: a single operator's experience. Int J Oral Maxillofac Surg 2020; 49:1162-1168. [PMID: 32035906 DOI: 10.1016/j.ijom.2020.01.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 12/06/2019] [Accepted: 01/23/2020] [Indexed: 02/08/2023]
Abstract
Microvascular coupler devices have gained wide acceptance as an alternative to the traditional hand-sewn technique in reconstructive surgery. However, no study has directly compared the efficacy of the coupler and hand-sewn techniques in arterial anastomosis during head and neck reconstruction surgery. A total of 123 patients who underwent surgery performed by a single surgeon between 2016 and 2018 were included in this retrospective study. The patients were divided into the coupler group and the hand-sewn group according to the technique of arterial anastomosis used. Patients in the coupler group underwent a special procedure including arterial bifurcation to enlarge the recipient artery diameter. Of the 123 free flap surgeries performed, 56 were done using a coupler and 67 with the standard suture technique. One flap in the coupler group failed due to simultaneous arterial and venous thromboses. One flap in the hand-sewn group was lost due to venous compromise. The overall flap survival rate was 98.4% (n=121). There was a significant decrease in anastomotic time when a coupler was used (P<0.001). The complication and flap loss rates were similar in the coupler and hand-sewn groups. The application of the coupler helped to decrease the anastomotic time and achieved satisfactory vessel patency.
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Affiliation(s)
- Z Guo
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - W Cui
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - M Hu
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - B Yu
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - B Han
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Y Li
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - X Tang
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - C Li
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
| | - L Li
- State Key Laboratory of Oral Diseases, National Clinical Research Centre for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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The establishment of a microvascular free flap service in a medium-sized hospital (500 beds)—an eight-year experience. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-019-01548-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The Anterolateral Thigh Perforator Flap in an Innovative Microsurgery Training Method. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 6:e1974. [PMID: 30881788 PMCID: PMC6414106 DOI: 10.1097/gox.0000000000001974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/31/2018] [Indexed: 11/26/2022]
Abstract
The road to becoming a good and confident microsurgeon requires love for your work, patience, and good training facilities. Safe and effective training procedures for young microsurgeons during their plastic surgery residency are necessary and should be applied under standardized conditions. We present an innovative microsurgical training method for plastic surgery residents in the operation theater concerning the anterolateral thigh perforator flap (ALT). In a 2-team approach, the ALT flap harvesting begins parallel to tumor resection. Although the tumor excision team still works in the tumor region, and after the reconstructive team has successfully completed the ALT dissection, residents can work distally to the origin of the perforator vessel (which supplies the flap). Their training involves dissection and anastomosis of the continuation of the descending branch, distally to the perforator supplying the flap. Since 2015, eight operations have been performed with this innovative method with the participation of upcoming microsurgeons. A written informed consent is given to all patients. Our study resulted in the improvement of microsurgical skills of the young microsurgeons. There is no impact to the ALT perforator flap or to the operative time. This training procedure can be safely applied as a training method during plastic surgery residency under standardized conditions. We have the joy of seeing our resident's progress through their high success rates in microsurgery. We recommend this innovative procedure as an adequate teaching method during residency to promote the future of our specialty, and we hope that our students will become even better than their teachers.
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Vascular architecture in free flaps: Analysis of vessel morphology and morphometry in murine free flaps. Microvasc Res 2018; 118:128-136. [PMID: 29577940 DOI: 10.1016/j.mvr.2018.03.006] [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: 08/19/2017] [Revised: 03/16/2018] [Accepted: 03/16/2018] [Indexed: 11/21/2022]
Abstract
The aim of this study was to analyze the development of vascular architecture as well as vascular morphometry and morphology of anastomosed microvascular free flaps. Free pectoral skin flaps were raised in 25 rats and anastomosed to the femoral vessels in the groin region. CD31 immunohistology was performed after 3, 7 and 12 d (each 5 animals each) to analyze microvessel density (MVD), microvessel area (MVA) and microvessel size (MVS). Microvascular corrosion casting was performed after 7 and 12 d (5 animals each) to analyze vessel diameter (VD), intervascular distance (IVD), interbranching distance (IBD), and branching angle (BA). Further on, sprout and pillar density as hallmarks of sprouting and intussusceptive angiogenesis were analyzed. Pectoral skin isles from the contralateral side served as controls. A significantly increased MVD was found after 7 and 12 d (p each <0.001). MVA was significantly increased after 3, 7 and 12 d (p each <0.001) and a significantly increased MVS was analyzed after 3 and 7 d (p each <0.001). VD and IVD were significantly increased after 7 and 12 d (p each <0.001). For IBD, a significantly increase was measured after 7 d (p < 0.001). For IBA, sprout and pillar density, no significant differences were found (p each ≥0.05). Significant changes in the vascular architecture of free flaps after successful microvascular anastomosis were seen. Since there was no evidence for sprout and pillar formation within the free flaps, the increased MVD and flap revascularization might be induced by the receiving site.
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19
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Outcomes Comparison for Microsurgical Breast Reconstruction in Specialty Surgery Hospitals Versus Tertiary Care Facilities. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1514. [PMID: 29184730 PMCID: PMC5682166 DOI: 10.1097/gox.0000000000001514] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/11/2017] [Indexed: 11/28/2022]
Abstract
Background: Postoperative monitoring is crucial in the care of free flap breast reconstruction patients. Tertiary care facilities (TCFs) provide postoperative monitoring in an ICU after surgery. Specialty surgery hospitals (SSHs) do not have ICUs, but these facilities perform free flap breast reconstruction as well. Are outcomes comparable between the 2 facilities in terms of flap reexploration times and overall success? Methods: Retrospective study including 163 SSH and 157 TCF patients. Primary predictor was facility in which the procedure was performed. Secondary predictors included operative, demographic, and comorbidity data. Primary outcomes were flap take back rate and flap failures. Secondary outcomes were total time from adverse event noticed in the flap to returning to the operating room (OR) and total time from decision made to return to the OR to returning to the OR (decision made). Tertiary outcomes were length of stay, operative times, and blood loss. Results: Patients at the TCF were generally less healthy than SSH patients. Salvage rates and failure rates were similar between the 2 institutions. Adverse event noticed and decision made times did not differ between the 2 facilities. Overall flap success rate was 98.22% at SSH and 98.81% at TCF. No primary or secondary predictors had a significant correlation with increased odds for flap failure. Conclusion: SSHs can offer similar outcomes in free flap breast reconstruction with just as effective clinical response times to endangered flaps as found in a TCF. However, surgery at an SSH may best be reserved for healthier patients.
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Associations of Surgeon and Hospital Volumes with Outcome for Free Tissue Transfer by Using the National Taiwan Population Health Care Data from 2001 to 2012. Plast Reconstr Surg 2017; 140:455e-465e. [PMID: 28841623 DOI: 10.1097/prs.0000000000003593] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Greater hospital case volumes are associated with improved outcomes for high-risk procedures. The hospital-outcome association for complex but low-mortality procedures and the association between surgeon versus hospital case volume and surgical outcomes have been less explored. The authors examined the association between surgeon and hospital volume and the success for free tissue transfer (free flap) surgery. The authors hypothesized that there would be positive associations between hospital and surgeon volume and the success of free flap surgery. METHODS The study design was a cross-sectional analysis of adults aged 18 to 64 years who underwent free flap surgery. The authors used 100 percent of all free flap operations between 2001 and 2012 using Taiwan's national data that cover the entire population of 23 million in the country. The authors applied hierarchical regression modeling to analyze volume-outcome associations. RESULTS The association between hospital volume and free flap success was small but positive (OR, 1.007; 95 percent CI, 1.00 to 1.01). For surgeons, their years of experience had a positive association with success of the operation (OR, 1.04; 95 percent CI, 1.02 to 1.06) rather than their annual case volume. Compared with low-volume surgeons (<11 annual cases) working in low-volume hospitals (<95 annual cases), high-volume surgeons (>25 annual cases) working in high-volume hospitals (>156 annual cases) showed greater odds of operation success (OR, 2.97; 95 percent CI, 1.21 to 7.29). CONCLUSIONS Higher volume hospitals and more experienced surgeons, regardless of their annual volume, showed better outcomes. Increasing demand for high-quality care and Taiwan's national policies toward centralization of complex surgical procedures have increased competition among hospitals. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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21
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Safety and Suitability of Finger Replantations as a Residency Training Procedure. Ann Plast Surg 2017; 78:431-435. [DOI: 10.1097/sap.0000000000000945] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Implantable Doppler Probes for Postoperatively Monitoring Free Flaps: Efficacy. A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e1099. [PMID: 27975015 PMCID: PMC5142481 DOI: 10.1097/gox.0000000000001099] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/02/2016] [Indexed: 11/25/2022]
Abstract
Background: Although clinical assessment remains the gold standard for monitoring the circulation of free flaps, several adjunct techniques promote timely salvage by detecting circulation compromise early. The objective of this systematic review was to evaluate the efficacy of an implantable Doppler probe for postoperatively monitoring free flaps. Materials and Methods: English-language articles evaluating the efficacy of implantable Doppler probes compared with clinical assessment for postoperatively monitoring free flaps were analyzed. The outcome measures were total flap failure rates, salvage rates, sensitivity, false-positive rates, and positive likelihood ratios. Results: Of the 504 citations identified, 6 comparative studies were included for meta-analysis. An implantable Doppler probe significantly lowered the flap failure rate (risk ratio: 0.40; 95% confidence interval: 0.21–0.75) and raised the successful salvage rate (risk ratio: 1.73; 95% confidence interval: 1.16–2.59). Pooled sensitivity was higher (1.00 vs 0.98), the positive likelihood ratio was lower (72.16 vs 220.48), and the false-positive rate was higher (0.01 vs 0) in the implantable Doppler probe group than in the clinical assessment group. Conclusion: An implantable Doppler probe is significantly more efficacious than clinical assessment for postoperatively monitoring free flaps.
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Perioperative factors that influence the outcome of microsurgical reconstructions in craniomaxillofacial surgery. Br J Oral Maxillofac Surg 2015; 53:533-7. [DOI: 10.1016/j.bjoms.2015.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 03/14/2015] [Indexed: 11/17/2022]
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Wikner J, Beck-Broichsitter BE, Schlesinger S, Schön G, Heiland M, Assaf AT, Rashad A, Riecke B, Heckel K. Thromboelastometry: A contribution to perioperative free-flap management. J Craniomaxillofac Surg 2015; 43:1065-71. [PMID: 26130612 DOI: 10.1016/j.jcms.2015.05.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 05/23/2015] [Accepted: 05/26/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Microvascular tissue transfer is a fundamental part of reconstructive surgery. Different perioperative anticoagulation regimens exist, influencing hemostatic parameters. Since bleeding and thrombosis are major reasons for revision procedures and flap loss, current practice regarding anticoagulative treatment needs further refinement. Thromboelastometry has been demonstrated as worthwhile in the determination of alterations of the anticoagulation cascade. We evaluated this aspect of thromboelastometry for free flap surgery. METHODS Thirty-five patients undergoing free-flap surgery were enrolled in this study. Blood samples were obtained at three time points: at the beginning of surgery, at time of anastomosis and after 24 h. At each time point, thromboelastometry with special regard to clotting times for the intrinsic and extrinsic paths of coagulation was immediately performed. Global coagulation markers and clinical parameters were collected simultaneously. RESULTS Hemostatic changes were deducible using thromboelastometry perioperatively. Measured parameters differed significantly over time (p < 0.05). Heparin therapy showed a significant effect on the measured slope of INTEM-clotting times (p < 0.001). Altered values of thromboelastometry suggested non-inferiority to standard testing. Neither standard testing nor thromboelastometry were capable of predicting adverse events such as thrombosis, bleeding or flap loss (p > 0.05). CONCLUSIONS Thromboelastometry monitors hemostatic effects almost in real-time and could serve as a supplementary tool in microvascular tissue transfer once its use has been standardized. The utilization of thromboelastometry allows for assessment of the anticoagulation needs of individual patients undergoing free flap surgery, which is frequently accompanied by hemostatic changes in the perioperative setting. Our findings implicate further validation of thromboelastometry in free-flap surgery.
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Affiliation(s)
- Johannes Wikner
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Germany.
| | | | - Saskia Schlesinger
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical CenterHamburg-Eppendorf, Germany
| | - Gerhard Schön
- Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Germany
| | - Alexandre Thomas Assaf
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Germany
| | - Ashkan Rashad
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Germany
| | - Björn Riecke
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Germany
| | - Kai Heckel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical CenterHamburg-Eppendorf, Germany
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Vargas CR, Nguyen JT, Ashitate Y, Silvestre J, Venugopal V, Neacsu F, Kettenring F, Frangioni JV, Gioux S, Lee BT. Near-infrared imaging for the assessment of anastomotic patency, thrombosis, and reperfusion in microsurgery: a pilot study in a porcine model. Microsurgery 2015; 35:309-14. [PMID: 25571855 DOI: 10.1002/micr.22376] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/13/2014] [Accepted: 12/19/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Advances in microsurgical techniques have increased the use of free tissue transfer. Methods of intraoperative flap perfusion assessment, however, still rely primarily on subjective evaluation of traditional clinical parameters. Anastomotic thrombosis, if not expeditiously identified and revised, can result in flap loss with significant associated morbidity. This study aims to evaluate the use of near-infrared (NIR) fluorescence imaging in the assessment of microsurgical anastomotic patency, thrombosis, and vascular revision. MATERIALS AND METHODS A model of pedicle thrombosis was created using bilateral abdominal flaps isolated on deep superior epigastric vascular pedicles in four Yorkshire pigs. Following flap elevation, microvascular arterial and venous anastomoses were performed unilaterally, preserving an intact contralateral control flap. Thrombosis was induced at the arterial anastomosis site using ferric chloride, and both flaps imaged using NIR fluorescence angiography. The thrombosed vascular segments were subsequently excised and new anastomoses performed to restore flow. Follow-up imaging of both flaps was then obtained to confirm patency using fluorescence imaging technology. RESULTS Pedicled abdominal flaps were created and successful anastomotic thrombosis was induced unilaterally in each pig. Fluorescence imaging technology identified large decreases in tissue perfusion of the thrombosed flap within 2 minutes. After successful revision anastomosis, NIR imaging demonstrated dramatic increase in flow to the reconstructed flap, but intensity did not return to pre-thrombosis levels. CONCLUSIONS Early identification of anastomotic thrombosis is important in successful free tissue transfer. Real-time, intraoperative evaluation of flap perfusion, anastomotic thrombosis, and successful revision can be performed using NIR fluorescence imaging.
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Affiliation(s)
- Christina R Vargas
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John T Nguyen
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Yoshitomo Ashitate
- Division of Cancer Diagnostics and Therapeutics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Jason Silvestre
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vivek Venugopal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Florin Neacsu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Frank Kettenring
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John V Frangioni
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Curadel, LLC, Worcester, MA
| | - Sylvain Gioux
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Bernard T Lee
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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