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Cosset T, Tonnerre D, Gorphe P, Dupret-Bories A, Dufour X, Carsuzaa F. Free-flap reconstruction methods in head-and-neck oncologic surgery: A CROSS practice survey of members of the French GETTEC Head-and-Neck Tumor Study Group. Eur Ann Otorhinolaryngol Head Neck Dis 2024:S1879-7296(24)00053-X. [PMID: 38658260 DOI: 10.1016/j.anorl.2024.04.002] [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: 04/26/2024]
Abstract
OBJECTIVE To survey practices concerning the use of anticoagulants and antiplatelets in microvascular free-flap reconstruction following oncological surgery of the head and neck. METHODS A survey of practices was carried out between September 2022 and March 2023. An online questionnaire was sent to members of the French GETTEC Head-and-Neck Tumor Study Group in all French centers practicing head-and-neck cancer surgery with reconstruction using microvascular free-flaps. The questionnaire asked surgeons about their practices regarding the use of intra- and postoperative anticoagulants and antiplatelets, preoperative management of comorbidities, and prevention of postoperative complications. RESULTS Sixty-one percent of the 38 respondents (23/38) used intraoperative intravenous heparin injection, associated to flap irrigation with heparin for 76% of surgeons (29/38) and/or a heparin solution bath for 37% (14/38). Postoperative anticoagulation was used by 95% of surgeons (36/38), and antiplatelets by 40% (15/38). Postoperatively, 40% (15/38) carried out monitoring using an implantable micro-Doppler probe, associated to analysis of clinical characteristics of the flap. CONCLUSION Reconstructive surgery using microvascular free-flaps involves numerous factors that can influence success. Prospective studies, particularly concerning the management of anticoagulants, could enable a national consensus on methods for free-flap reconstruction.
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Affiliation(s)
- T Cosset
- Service ORL, chirurgie cervicofaciale et audiophonologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
| | - D Tonnerre
- Service ORL, chirurgie cervicofaciale et audiophonologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
| | - P Gorphe
- Département d'ORL et de chirurgie cervicofaciale, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - A Dupret-Bories
- Service ORL et chirurgie cervicofaciale et audiophonologie, IUCT Oncopole, 1, avenue Irène-Joliot-Curie, 31100 Toulouse, France
| | - X Dufour
- Service ORL, chirurgie cervicofaciale et audiophonologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
| | - F Carsuzaa
- Service ORL, chirurgie cervicofaciale et audiophonologie, centre hospitalier universitaire de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France.
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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: 0] [Impact Index Per Article: 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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3
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Flagg CA, Stevens JR, Chinn S. Practice Trends and Evidence-Based Practice in Microvascular Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00071-3. [PMID: 37221115 DOI: 10.1016/j.otc.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Microvascular and free flap reconstruction are important to the otolaryngology-head and neck surgery practice. Herein, the reader will find an up-to-date discussion of various evidence-based practice trends related to microvascular surgery, including surgical techniques, anesthetic and airway considerations, free flap monitoring and troubleshooting, surgical efficiency, and both patient-related and surgeon-related risk factors that may affect outcomes.
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Affiliation(s)
- Candace A Flagg
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, TX, USA.
| | - Jayne R Stevens
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, TX, USA
| | - Steven Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Rogel Cancer Center, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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4
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Laehn SJ, LoGuidice JA, Hettinger PC, Rein LE, Peppard WJ. Postoperative depth of sedation and associated outcomes in free flap transfers to the head and neck. Head Neck 2021; 44:391-398. [PMID: 34799940 DOI: 10.1002/hed.26929] [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: 04/23/2021] [Revised: 09/23/2021] [Accepted: 11/05/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND To evaluate the impact of postoperative depth of sedation in free flap transfers to the head and neck. METHODS A single center, retrospective cohort of 92 patients were stratified by depth of sedation, light sedation (RASS -1 or greater) or deep sedation (RASS less than -1), and analyzed for postoperative flap and medical complications. RESULTS Of the 92 patients 45 were included in the light sedation and 47 in the deep sedation group. Flap complication requiring return to the operating room occurred in 8 (22.2%) patients in light sedation compared to 12 (27.7%) (p = 0.450) patients in deep sedation. A composite outcome of flap and medical complications occurred less frequently in the light sedation group 14 (31.8%) compared to deep sedation 32 (69.6%) (p < 0.001). CONCLUSION There was no difference in return to the operating room between the two groups. Light sedation had reduced incidence of medical complications compared to deep.
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Affiliation(s)
| | - John Anthony LoGuidice
- Department of Plastic Surgery, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Lisa Egner Rein
- Department of Biostatistics, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - William John Peppard
- Division of Trauma and Acute Care Surgery, Department of Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Pharmacy, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Madrigal J, Mukdad L, Han AY, Tran Z, Benharash P, St John MA, Blackwell KE. Impact of Hospital Volume on Outcomes Following Head and Neck Cancer Surgery and Flap Reconstruction. Laryngoscope 2021; 132:1381-1387. [PMID: 34636433 DOI: 10.1002/lary.29903] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/15/2021] [Accepted: 10/05/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE/HYPOTHESIS Utilization of flaps for reconstruction of large head and neck cancer (HNCA) defects has become more prevalent. The present study aimed to assess the impact of center experience as measured by annual hospital caseload on mortality, major complications, resource utilization, and 90-day readmissions following HNCA resection with flap reconstruction. STUDY DESIGN Non-Randomized Controlled Cohort Study. METHODS All adult patients undergoing elective HNCA resection with flap reconstruction were identified utilizing the 2010 to 2018 Nationwide Readmissions Database. Hospitals were subsequently classified as low-, medium-, or high-volume based on annual institutional surgical caseload tertiles. Multivariable regression models were implemented to assess the independent association of hospital volume with the outcomes of interest. RESULTS Over the nine-year study period, the proportion of HNCA resection with flap reconstruction gradually increased (12.8% in 2010 vs. 17.3% in 2018, P < .001). Although increasing hospital volume did not alter the odds of mortality, patients treated at high-volume centers were less likely to experience both surgical (adjusted odds ratio [AOR] 0.81, 95% confidence interval [CI] 0.67-0.97, P = .025) and medical complications (AOR 0.70, 95% CI 0.57-0.85, P < .001). Furthermore, these patients had shorter hospitalizations (-2.1 days, 95% CI -2.7 to -1.4 days, P < .001) and decreased costs (-$8,100, 95% CI -11,400 to -4,700, P < .001) compared to counterparts at low-volume centers. However, hospital volume did not impact 90-day readmissions. CONCLUSION Patients undergoing HNCA resection with flap reconstruction at high-volume centers were less likely to experience surgical and medical complications while incurring shorter hospitalizations and lower costs. Implementation of volume standards may be appropriate to improve outcomes in this surgical population. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Josef Madrigal
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, U.S.A.,Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, U.S.A
| | - Laith Mukdad
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, U.S.A
| | - Albert Y Han
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, U.S.A
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, U.S.A
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, U.S.A
| | - Maie A St John
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, U.S.A
| | - Keith E Blackwell
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, U.S.A
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6
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Aponte-Ortiz JA, Greenberg-Worisek AJ, Marinelli JP, May M, Spears GM, Labott JR, Mecham JC, Moore EJ, Visscher SL, Borah BJ, Janus JR. Cost and clinical outcomes of postoperative intensive care unit versus general floor management in head and neck free flap reconstructive surgery patients. Am J Otolaryngol 2021; 42:103029. [PMID: 33857778 DOI: 10.1016/j.amjoto.2021.103029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/04/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare clinical, surgical, and cost outcomes in patients undergoing head and neck free-flap reconstructive surgery in the setting of postoperative intensive care unit (ICU) against general floor management. METHODS Retrospective analysis of head and neck free-flap reconstructive surgery patients at a single tertiary academic medical center. Clinical data was obtained from medical records. Cost data was obtained via the Mayo Clinic Rochester Cost Data Warehouse, which assigns Medicare reimbursement rates to all professional billed services. RESULTS A total of 502 patients were included, with 82 managed postoperatively in the ICU and 420 on the general floor. Major postoperative outcomes did not differ significantly between groups (Odds Ratio[OR] 1.54; p = 0.41). After covariate adjustments, patients managed in the ICU had a 3.29 day increased average length of hospital stay (Standard Error 0.71; p < 0.0001) and increased need for take-back surgery (OR 2.35; p = 0.02) when compared to the general floor. No significant differences were noted between groups in terms of early free-flap complications (OR 1.38;p = 0.35) or late free-flap complications (Hazard Ratio 0.81; p = 0.61). Short-term cost was $8772 higher in the ICU (range = $5640-$11,903; p < 0.01). Long-term cost did not differ significantly. CONCLUSION Postoperative management of head and neck oncologic free-flap patients in the ICU does not significantly improve major postoperative outcomes or free-flap complications when compared to general floor care, but does increase short-term costs. General floor management may be appropriate when cardiopulmonary compromise is not present.
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Affiliation(s)
- Jaime A Aponte-Ortiz
- Center for Clinical and Translational Science, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; University of Puerto Rico School of Medicine, PO Box 365067, San Juan, PR 00936-5067, USA. http://t.co/JAO_MDMS
| | | | - John P Marinelli
- Mayo Clinic School of Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Matthew May
- Department of Otolaryngology- Head and Neck Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Grant M Spears
- Biomedical Statistics and Informatics, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Joshua R Labott
- Mayo Clinic School of Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Jeffrey C Mecham
- Mayo Clinic School of Medicine, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA. http://t.co/Jffmchm
| | - Eric J Moore
- Department of Otolaryngology- Head and Neck Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA. http://t.co/EricJMooreMayo
| | - Sue L Visscher
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Bijan J Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; Division of Health Care Policy and Research, Department of Health Sciences, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Jeffrey R Janus
- Department of Otolaryngology- Head and Neck Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
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7
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Gearing PF, Daly JF, Tang NSJ, Singh K, Ramakrishnan A. Risk factors for surgical site infection in free-flap reconstructive surgery for head and neck cancer: Retrospective Australian cohort study. Head Neck 2021; 43:3417-3428. [PMID: 34409671 DOI: 10.1002/hed.26837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/30/2021] [Accepted: 07/29/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Surgical site infections (SSI) are common complications of free-flap reconstruction for head and neck cancer defects. This study aimed to identify risk factors for SSI following a significant change in local antibiotic prophylaxis practice. METHODS A retrospective cohort study was conducted of 325 patients receiving free-flap reconstruction for head and neck cancer defects at a tertiary hospital in Melbourne, Australia between 2013 and 2019. Charts were queried for recipient SSI (primary outcome), donor SSI, other infections, antibiotic use, hospital length of stay, and mortality. RESULTS Risk factors for SSI included female sex, T-classification, hardware insertion, clindamycin prophylaxis, and operative duration. There was a trend toward increased SSI with shorter ≤24 h prophylaxis (OR: 0.43). CONCLUSION Antibiotic duration and type were associated with SSI. Complexity of surgery, T-classification, hardware use, and operative duration were also independently associated with SSI. A prospective trial is indicated to elicit optimal prophylactic antibiotic duration.
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Affiliation(s)
- Peter Francis Gearing
- The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - John Frederick Daly
- The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Nicholas Shi Jie Tang
- Department of Plastic & Reconstructive Surgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kasha Singh
- The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Victorian Infectious Diseases Unit, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Anand Ramakrishnan
- Department of Plastic & Reconstructive Surgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
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8
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Healy DW, Cloyd BH, Straker T, Brenner MJ, Damrose EJ, Spector ME, Saxena A, Atkins JH, Ramamurthi RJ, Mehta A, Aziz MF, Cattano D, Levine AI, Schechtman SA, Cavallone LF, Abdelmalak BB. Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia. Anesth Analg 2021; 133:274-283. [PMID: 34127591 DOI: 10.1213/ane.0000000000005564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.
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Affiliation(s)
- David W Healy
- From the Department of Anesthesiology, The University of Michigan Medical School, Ann Arbor, Michigan
| | - Benjamin H Cloyd
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Tracey Straker
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York
| | - Michael J Brenner
- Department of Otolaryngology, Michigan Medicine-University of Michigan, Ann Arbor, Michigan
| | - Edward J Damrose
- Department of Otolaryngology/Head & Neck Surgery & Anesthesiology/Perioperative Medicine (by courtesy)
| | - Matthew E Spector
- Department of Otolaryngology, Michigan Medicine-University of Michigan, Ann Arbor, Michigan
| | - Amit Saxena
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Joshua H Atkins
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Arpan Mehta
- Department of Anesthesiology, Perioperative Medicine & Pain Management, The University of Miami, Miami, Florida
| | - Michael F Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Davide Cattano
- Department of Anesthesiology, McGovern Medical School, UTHealth Houston, Houston, Texas
| | - Adam I Levine
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samuel A Schechtman
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Laura F Cavallone
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Basem B Abdelmalak
- Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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9
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Richardson C, Abrol A, Cabrera CI, Goldstein J, Maronian N, Rodriguez K, D'Anza B. The power of a checklist: Decrease in emergency department epistaxis transfers after clinical care pathway implementation. Am J Otolaryngol 2021; 42:102941. [PMID: 33592555 DOI: 10.1016/j.amjoto.2021.102941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Annually, epistaxis costs US hospitals over $100 million dollars. Many patients visit emergency departments (ED) with variable treatment, thus providing opportunity for improvement. OBJECTIVE To implement an epistaxis clinical care pathway (CCP) in the ED, and analyze its effects on treatment and ED transfers. METHODS An interdisciplinary team developed the CCP to be implemented at a tertiary hospital system with 11 satellite EDs. The analysis included matched eight-month periods prior to pathway implementation and after pathway implementation. Subjects included patients with ICD-10 code diagnosis of epistaxis. Patients under 18 years old, recent surgery or trauma, or bleeding disorders were excluded. There were 309 patients from the pre-implementation cohort, 53 of which were transferred and 37 met inclusion criteria; 322 from the post-implementation cohort, 37 of which were transferred, and 15 met inclusion criteria. Outcome measures included epistaxis intervention by ED providers and otolaryngologists before and after pathway implementation. RESULTS CCP implementation resulted in a 61% reduction in patient transfers (p < 0.001). ED providers showed a 51% increase in documentation of anterior rhinoscopy with proper equipment, 34% increased use of topical vasoconstrictors, 40% increased use of absorbable packing, 7% decrease in use of unilateral non-absorbable packing, and 17% decrease in use of bilateral non-absorbable packing. CONCLUSIONS Prior to CCP implementation, ED treatment of epistaxis varied significantly. CCP resulted in standardized treatment and significant reduction in transfers. A CCP checklist is an effective way to standardize care and prevent unnecessary hospital transfers.
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10
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Guzu M, Rossetti D, Hennet PR. Locoregional Flap Reconstruction Following Oromaxillofacial Oncologic Surgery in Dogs and Cats: A Review and Decisional Algorithm. Front Vet Sci 2021; 8:685036. [PMID: 34095284 PMCID: PMC8175653 DOI: 10.3389/fvets.2021.685036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/21/2021] [Indexed: 11/13/2022] Open
Abstract
Primary treatment of most oromaxillofacial tumors in dogs and cats is resective surgery. Management of malignant tumors may be very challenging as wide/radical free-margin surgical removal must be achieved while preserving vital functions. Removal of orofacial tumors may result in large defects exposing the oral cavity or creating a communication with the nasal, pharyngeal, or orbital cavities. Such defects require orofacial reconstruction in order to restore respiratory and manducatory functions. The veterinary surgeon must be familiar with reconstructive techniques in order to prevent the inability of closing the defect, which could lead to an insufficient resection. Small oral defects exposing the nasal cavity are best closed with local random mucosal flaps. Closure of large oral defects may be better achieved with a facial or major palatine-based axial-pattern flap. Small to moderate facial defects can be closed with local advancement or transposition skin flaps. Reconstruction of large facial defects often requires the use of locoregional axial pattern flaps such as the caudal auricular, the superficial temporal, or the facial (angularis oris) myocutaneous axial pattern flaps. Recent publications have shown that the facial (angularis oris) flap is a very versatile and reliable flap in orofacial reconstructive surgery. A surgical decision algorithm based on the size, nature, and location of the defect is proposed.
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Affiliation(s)
- Michel Guzu
- Dentistry and Oromaxillofacial Surgery Unit, Department of Surgery, ADVETIA Centre Hospitalier Vétérinaire, Vélizy-Villacoublay, France
| | - Diego Rossetti
- Department of Surgery, CHV ADVETIA, Vélizy-Villacoublay, France
| | - Philippe R. Hennet
- Dentistry and Oromaxillofacial Surgery Unit, Department of Surgery, ADVETIA Centre Hospitalier Vétérinaire, Vélizy-Villacoublay, France
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11
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Han M, Ochoa E, Zhu B, Park AM, Heaton CM, Seth R, Knott PD. Risk Factors for and Cost Implications of Free Flap Take-backs: A Single Institution Review. Laryngoscope 2021; 131:E1821-E1829. [PMID: 33438765 DOI: 10.1002/lary.29382] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/06/2020] [Accepted: 01/03/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE/HYPOTHESIS For patients undergoing microvascular free tissue transfer (MFTT), we evaluated risk factors and financial implications of operating room (OR) take-back procedures. STUDY DESIGN Retrospective review at a tertiary care center. METHODS Patients who underwent MFTT for head and neck reconstruction from 2011 to 2018 were identified. We compared hospital length of stay and overall costs associated with OR take-back procedures. Multivariable regression analysis evaluated factors associated with OR take-backs during the same hospitalization. RESULTS A total of 727 free flaps were reviewed, and 70 OR take-backs (9.6%) were identified. Mean total length of stay (LOS) in the ICU was 3.4 days versus 6.7 days for non-take-back and take-back flaps, respectively (P < .001). Mean total LOS on the regular floor was 6.3 days versus 13.1 days, respectively (P < .001). This resulted in a cost differential of $33,507 (94.3% increase relative to non-take-back flaps). The total cost associated with an OR take-back was $39,786. Hematomas were the most common cause of take-backs and wound dehiscence was associated with the highest costs. On multivariable analysis, higher ASA class (OR, 2.06; 95% CI, 1.11-3.99; P = .026) and shorter ischemia times (OR, 0.52; 95% CI, 0.29-0.95; P = .030) were independently associated with increased risk of take-backs. CONCLUSIONS OR take-backs infrequently occur but are associated with a significant increase in financial burden when compared to free flap cases not requiring OR take-back. The large majority of the cost differential lies in a substantial increase of ICU and floor LOS for take-back flaps when compared to non-take-back flaps. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1821-E1829, 2021.
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Affiliation(s)
- Mary Han
- School of Medicine, University of California, San Francisco, California, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Edgar Ochoa
- School of Medicine, University of California, San Francisco, California, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Bovey Zhu
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Andrea M Park
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Chase M Heaton
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Rahul Seth
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - P Daniel Knott
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
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12
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Chorath K, Go B, Shinn JR, Mady LJ, Poonia S, Newman J, Cannady S, Revenaugh PC, Moreira A, Rajasekaran K. Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis. Oral Oncol 2020; 113:105117. [PMID: 33360446 DOI: 10.1016/j.oraloncology.2020.105117] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined. OBJECTIVE To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction. METHODS We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes. RESULTS 18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]). CONCLUSION There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.
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Affiliation(s)
- Kevin Chorath
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Beatrice Go
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Justin R Shinn
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Seerat Poonia
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Jason Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Steven Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter C Revenaugh
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Alvaro Moreira
- Department of Pediatrics, University of Texas Health-San Antonio, San Antonio, TX, United States
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
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13
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Sandelski MM, Rabbani CC, Moore MG, Sim MW. Flap demise reversed after central venous access device removal: A case report. Clin Case Rep 2020; 8:1631-1634. [PMID: 32983465 PMCID: PMC7495769 DOI: 10.1002/ccr3.2970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/24/2020] [Accepted: 05/02/2020] [Indexed: 11/09/2022] Open
Abstract
Patients undergoing head and neck free flap reconstruction should be evaluated for radiation-induced venous stenosis and presence of central venous port as a potential risk for flap failure.
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Affiliation(s)
| | - Cyrus C. Rabbani
- Department of Otolaryngology – Head and Neck SurgeryIndiana University School of MedicineIndianapolisINUSA
| | - Michael G. Moore
- Department of Otolaryngology – Head and Neck SurgeryIndiana University School of MedicineIndianapolisINUSA
| | - Michael W. Sim
- Department of Otolaryngology – Head and Neck SurgeryIndiana University School of MedicineIndianapolisINUSA
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14
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Tapia B, Garrido E, Cebrian JL, Castillo JLD, Alsina E, Gilsanz F. New techniques and recommendations in the management of free flap surgery for head and neck defects in cancer patients. Minerva Anestesiol 2020; 86:861-871. [PMID: 32486605 DOI: 10.23736/s0375-9393.20.13997-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Free flap surgery is the gold standard surgical treatment for head and neck defects in cancer patients. Outcomes have improved considerably, probably due to recent advances in surgical techniques. In this article, we review improvements in the parameters traditionally used to optimize hematocrit levels and body temperature and to prevent vasoconstriction, and describe the use of cardiac output-guided fluid management, a technique that has proved useful in other procedures. Finally, we review other parameters used in free flap surgery, such as clotting/platelet management and nutritional optimization.
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Affiliation(s)
- Blanca Tapia
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain -
| | - Elena Garrido
- Department of Anesthesia an Intensive Care, Wexner Medical Center, Columbus, OH, USA
| | - Jose L Cebrian
- Department of Oral and Maxillofacial Surgery, La Paz University Hospital, Madrid, Spain
| | - Jose L Del Castillo
- Department of Oral and Maxillofacial Surgery, La Paz University Hospital, Madrid, Spain
| | - Estibaliz Alsina
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain
| | - Fernando Gilsanz
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain
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15
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Karamanos E, Walker R, Wang HT, Shah AR. Perioperative Fluid Resuscitation in Free Flap Breast Reconstruction: When Is Enough Enough? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2662. [PMID: 32537330 PMCID: PMC7253255 DOI: 10.1097/gox.0000000000002662] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/06/2019] [Indexed: 02/05/2023]
Abstract
Perioperative liberal fluid resuscitation (LFR) can result in interstitial edema and venous congestion and may be associated with compromised perfusion of free flaps and higher incidence of wound complications. We hypothesized that restrictive intraoperative fluid resuscitation improves flap perfusion and lowers the wound complication rate in free flap breast reconstruction.
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Affiliation(s)
- Efstathios Karamanos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Tex
| | - Rachael Walker
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Tex
| | - Howard T Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Tex
| | - Amita R Shah
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health San Antonio, San Antonio, Tex
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16
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Pota V, Passavanti MB, Aurilio C, Barbarisi M, Giaccari LG, Colella U, Fiore M, Mangoni di Santostefano GSRC, Sansone P, Pace MC. Ketamine Infusion in Post-Surgical Pain Management after Head and Neck Surgery: A Retrospective Observational Study. THE OPEN ANESTHESIA JOURNAL 2019. [DOI: 10.2174/2589645801913010132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Head and neck cancer affects approximately 382,000 new patients per year worldwide with a significant portion undergoing surgical treatment. During postoperative period key elements in the Intensive Care Unit (ICU) are airway management and pain control.
Objective:
We evaluated the average change of inpatient pain control using a Numerical Rating Score (NRS). We also evaluated the time of extubation after ICU admission recording the incidence of desaturation and the necessity of re-intubation. Secondary outcomes were the incidence of postoperative complications, included those narcotics-related, and the use of rescue analgesics.
Methods:
In this retrospective observational study, we analyzed data of registry before and after we have changed our postoperative analgesic protocol from remifentanil infusion to ketamine infusion.
Results:
Medical records of 20 patients were examined. 10 patients received 0.5 mg/kg ketamine bolus at the end of surgery, followed by a continuous infusion of 0.25 mg/kg/h. All patients presented a significant decrease in pain intensity from the 4th to 48th postoperative hour (p < 0.05), but statically not a significant difference in NRS score was recorded between the two groups. Time to extubation was shorter in ketamine group compared to the remifentanil group (112.30 min ± 16.78 vs. 78 min ± 14.17; p < 0.05). Desaturation rate was 10% in the remifentanil group, while no case was recorded in the ketamine group.
Conclusion:
The level of analgesia provided by ketamine and remifentanil was comparable. Ketamine was superior in ventilatory management of the patient with more rapid extubation and with no case of desaturation.
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17
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Sánchez-Sánchez M, Martínez JR, Civantos B, Millán P. Perioperative in Intensive Medicine of reconstructive surgery and burned patients. Med Intensiva 2019; 44:113-121. [PMID: 31387770 DOI: 10.1016/j.medin.2019.07.005] [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: 06/07/2019] [Revised: 07/03/2019] [Accepted: 07/07/2019] [Indexed: 10/26/2022]
Abstract
Burned patients may need prolonged admissions in the Intensive Care Service, both for initial care and for the pre and postoperative treatment of the multiple surgeries they require. The initial resuscitation of critically burned patients requires adequate monitoring to calculate the fluid therapy necessary to replenish the losses and ensure tissue perfusion, but without excesses that increase interstitial edema. In addition, monitoring can evaluate the systemic inflammatory response that can lead to shock and organic dysfunctions. After this initial phase we will find a critical patient who requires multiple reinterventions in non-optimal situations, so he will need special care over a long period of time. In addition, the Intensive Care Service offers specific postoperative care for reconstructive surgery and the transplantation of composite tissues (upper limb and face) in which its success depends on a rigorous control through adequate monitoring and treatment.
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Affiliation(s)
- M Sánchez-Sánchez
- Servicio de Medicina Intensiva, Unidad de Quemados Críticos, Hospital Universitario La Paz-Carlos III-Cantoblanco/IdiPaz, Madrid, España.
| | - J R Martínez
- Servicio de Cirugía Plástica, Estética y Reparadora, Unidad de Quemados Críticos, Hospital Universitario La Paz-Cantoblanco-Carlos III/IdiPaz, Madrid, España
| | - B Civantos
- Servicio de Medicina Intensiva, Unidad de Quemados Críticos, Hospital Universitario La Paz-Carlos III-Cantoblanco/IdiPaz, Madrid, España
| | - P Millán
- Servicio de Medicina Intensiva, Unidad de Quemados Críticos, Hospital Universitario La Paz-Carlos III-Cantoblanco/IdiPaz, Madrid, España
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18
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Abstract
Microvascular free tissue transfer is an indispensable reconstructive option in head and neck reconstruction. Flap failure is relatively rare, but it is nonetheless very morbid and psychologically devastating to patients when it does occur. Further, complications after free tissue transfer to the head and neck remain common. There are numerous ongoing debates about various facets of preoperative, intraoperative, and postoperative care of patients undergoing free flap reconstruction of the head and neck, all ultimately searching for the optimal treatment algorithm to further improve flap success, minimize complications, and maximize patient outcomes. Herein, the authors review current literature surrounding optimal preoperative nutritional support, intraoperative vasopressor use, perioperative fluid management, use of antithrombotic agents, antibiotic use, and other facets of the care of head and neck free flap patients to provide a guide to surgeons.
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Affiliation(s)
- Aurora Vincent
- Otolaryngology, Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Raja Sawhney
- Facial Plastic and Reconstructive Surgery, Otolaryngology Head and Neck Surgery, University of Florida, Gainesville, Florida
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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19
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Kovatch KJ, Hanks JE, Stevens JR, Stucken CL. Current practices in microvascular reconstruction in otolaryngology-head and neck surgery. Laryngoscope 2018; 129:138-145. [PMID: 30194763 DOI: 10.1002/lary.27257] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES/HYPOTHESIS Despite major advances in the field of head and neck microvascular free tissue transfer (MFTT) over the past several decades, there are no standardized perioperative regimens for the care of patients undergoing free flap reconstructive surgery, and continued variation in practice exists. This study aimed to report current trends in the field of MFTT performed by otolaryngologists, including surgeon training, institutional operative practices, and perioperative management. STUDY DESIGN Cross-sectional survey. METHODS A survey of Accreditation Council for Graduate Medical Education-accredited residency programs and American Head and Neck Society fellowship sites was conducted. RESULTS Seventy-one (62.8%) programs responded, with 67 (94.4%) routinely performing MFTT and 23 (32.4%) having a dedicated microvascular fellowship program. Of institutions performing MFTT, 66 (98.5%) reported the use of a two-surgeon team, most commonly both otolaryngologists (76.3%). Institutional MFTT volumes and donor site frequency are reported. Postoperative care includes routine admission to the intensive care unit (75.2%), step-down unit (15.0%), or general care floor (8.1%). Postoperative flap monitoring practices, including modalities, personnel, and timing/frequency show institutional variation. Despite differences in postoperative monitoring regimen and management (sedation, anticoagulation, antibiotic use), surgeon-reported measures of flap success rate (95.7%, standard deviation [SD] 4.7%) and complication rate (6.8%, SD 2.4%) show little difference across institutions. CONCLUSIONS Many elements of MFTT perioperative care show continued variation at an institutional level. There is a notable shift toward the two-team approach within otolaryngology. Self-reported flap complication and success rates showed no significant differences based on perioperative care and monitoring regimen. Further study of perioperative practices should focus on standardization of care to improve overall outcomes in this complex patient population. LEVEL OF EVIDENCE NA Laryngoscope, 129:138-145, 2019.
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Affiliation(s)
- Kevin J Kovatch
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, U.S.A
| | - John E Hanks
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, U.S.A
| | - Jayne R Stevens
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, U.S.A
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, U.S.A
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20
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Eskander A, Kang S, Tweel B, Sitapara J, Old M, Ozer E, Agrawal A, Carrau R, Rocco JW, Teknos TN. Predictors of Complications in Patients Receiving Head and Neck Free Flap Reconstructive Procedures. Otolaryngol Head Neck Surg 2018; 158:839-847. [DOI: 10.1177/0194599818757949] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital, Toronto, Ontario, Canada
| | - Stephen Kang
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Ben Tweel
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jigar Sitapara
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Matthew Old
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Enver Ozer
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Amit Agrawal
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Ricardo Carrau
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - James W. Rocco
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Theodoros N. Teknos
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
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