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Hernandez Alvarez A, Lee D, Kim EJ, Schuster K, Taritsa I, Foppiani J, Valentine L, Weidman AA, Comer C, Lee BT, Lin SJ. An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures. J Reconstr Microsurg 2024. [PMID: 38889744 DOI: 10.1055/s-0044-1787776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage. METHODS A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed. RESULTS From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique. CONCLUSION Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.
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Affiliation(s)
| | - Daniela Lee
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Erin J Kim
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kirsten Schuster
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Iulianna Taritsa
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jose Foppiani
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Lauren Valentine
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Allan A Weidman
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Carly Comer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Berger LE, Huffman SS, Bovill JD, Spoer DL, Shin S, Truong BN, Gupta N, Attinger CE, Akbari CM, Evans KK. Free Tissue Transfer to the Lower Extremity in the Setting of Thrombocytosis and the Role of Antiplatelet Therapy: A Propensity Score-Matched Analysis. J Reconstr Microsurg 2024; 40:40-49. [PMID: 36928902 DOI: 10.1055/a-2056-1561] [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: 03/18/2023]
Abstract
BACKGROUND Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes. METHODS A retrospective review of thrombocytotic patients who underwent LE FTT between 2011 and 2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score matched for comorbidity burden and postoperative risk stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage, and ambulatory status. RESULTS Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n = 51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p = 0.949 and 0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p = 0.020 and 0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n = 43) and 79.2% (n = 42), respectively, with no differences between cohorts. CONCLUSION Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements.
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Affiliation(s)
- Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - John D Bovill
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Stephanie Shin
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Brian N Truong
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Nisha Gupta
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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Fisher AH, Jones I, Malta K, Arnold A, Nelson ZJ, Bonawitz S. Reevaluating Thrombocytosis as a Risk Factor in Free Flap Surgery: Does Timing Matter? Ann Plast Surg 2023; 91:740-744. [PMID: 37962259 DOI: 10.1097/sap.0000000000003710] [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: 11/15/2023]
Abstract
INTRODUCTION Thrombocytosis, defined as a platelet count >400,000, has been implicated as a risk factor in free flap failure. Despite proposed mechanisms of pedicle thrombosis, recent studies have suggested that thrombocytosis has no effect on free tissue transfer viability. Risk factors that may compromise successful free tissue transfer should be understood and elucidated, with particular attention to thrombocytosis and its conflicting evidence in the literature. We hypothesize that thrombocytosis has no bearing on free flap success or the rates of pedicle thrombosis. METHODS Our institution performed a retrospective chart review on all patients who underwent free flap reconstruction over the past 6 years. Patient demographics, medical history, type and location of free tissue transfer, preoperative platelets, postoperative platelets, and flap outcomes and complications (wound dehiscence, infection, hematoma, seroma, and need for blood transfusion) were recorded. Independent t test, Mann-Whitney U tests, χ2 test, and Fisher exact tests were used to determine P values to compare flap outcomes in patients with thrombocytosis (platelet count >400,000) and those with platelet counts less than 400,000. RESULTS In our 502-patient cohort, 71 were found to have a platelet count >400,000 (35 preoperatively and 36 postoperatively) and 431 patients had platelet counts <400,000. There were 42 reconstructive failures (flap success rate of 91.6%) and 111 returns to the operating room (OR). For patients with postoperative thrombocytosis, 24 flaps returned to the OR (44.4%), whereas in patients without thrombocytosis, 87 flaps returned to the OR (19.4%; P < 0.001). In patients with postoperative thrombocytosis, 10 OR returns were due to pedicle venous thrombosis (18.5%), in comparison to 10 returns for venous thrombosis in those with normal platelets (2.2%; P < 0.001). There was a small difference in free flap success rates between those with postoperative thrombocytosis and normal platelets, 88.7% versus 92.11%; however, this was not statistically significant ( P = 0.71). The thrombocytosis group had a higher incidence of overall postoperative complications ( P = 0.002). CONCLUSIONS Thrombocytosis has historically been cited as a risk factor for free flap reconstruction failure with recent conflicting evidence in the literature. In patients with postoperative thrombocytosis, we found an increased risk of venous thrombosis; however, this did not result in increased flap failure. There was an increase in postoperative complications, which corresponds with National Surgical Quality Improvement Program data reported in the literature. We suspect that thrombocytosis is not a harbinger of free flap failure but rather a marker for overall inflammation, which may confer a higher rate of venous thrombosis requiring reoperation and postoperative complications.
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Affiliation(s)
- Alec Hayes Fisher
- From the Division of Plastic and Reconstructive Surgery, Cooper University Hospital
| | - India Jones
- From the Division of Plastic and Reconstructive Surgery, Cooper University Hospital
| | - Kiana Malta
- Cooper Medical School Rowan University, Camden, NJ
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Tarle M, Čvrljević I, Raguž M, Lukšić I. Hemoglobin-Albumin-Lymphocyte-Platelet (HALP) Score as a Predictive Model for the Success of Reconstruction of Head and Neck Defects with Free Microvascular Flaps. J Clin Med 2023; 12:5314. [PMID: 37629355 PMCID: PMC10455496 DOI: 10.3390/jcm12165314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Significant advances in reconstructive head and neck surgery with free microvascular flaps have had a positive impact on esthetic outcomes and quality of life. However, complications still occur in some patients. This study investigated the influence of the Hemoglobin, Albumin, Lymphocyte, and Platelet Score (HALP score), an immunonutritive marker, on complications and flap success. The retrospective analysis included 194 patients who underwent reconstruction of head and neck defects with free microvascular flaps. The HALP score correlated strongly with overall complications, including flap necrosis, infection, fistula, and hematoma. Hemoglobin, albumin, lymphocytes, and platelets individually showed associations with specific complications. HALP score was an extremely strong predictor of complications (AUC = 0.85). HALP score may be valuable for assessing patient status and predicting complications in microvascular free-flap reconstruction to allow timely interventions and improve outcomes. Further research is needed to investigate additional predictors and improve postoperative care.
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Affiliation(s)
- Marko Tarle
- Department of Maxillofacial Surgery, Dubrava University Hospital, 10000 Zagreb, Croatia; (M.T.); (I.Č.)
- School of Dental Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Igor Čvrljević
- Department of Maxillofacial Surgery, Dubrava University Hospital, 10000 Zagreb, Croatia; (M.T.); (I.Č.)
| | - Marina Raguž
- Department of Neurosurgery, Dubrava University Hospital, 10000 Zagreb, Croatia;
- School of Medicine, Catholic University of Croatia, 10000 Zagreb, Croatia
| | - Ivica Lukšić
- Department of Maxillofacial Surgery, Dubrava University Hospital, 10000 Zagreb, Croatia; (M.T.); (I.Č.)
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
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Pu LLQ, Song P. Reoperative Microsurgical Free Flap Surgery: Lessons Learned. Ann Plast Surg 2023; 90:S187-S194. [PMID: 36752558 DOI: 10.1097/sap.0000000000003370] [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: 02/09/2023]
Abstract
ABSTRACT Microsurgical free flap surgery has revolutionized reconstructive surgery at most academic centers worldwide. However, free flap failures still occur even in the hands of the most experienced microsurgeon. Although we have achieved a great deal of success performing microsurgical free flap reconstruction for various indications, complications from initial free flap surgery that result in reoperation remain a small, but steady percentage. Venous flap congestion is one of the most challenging conditions that result in free flap failure if not resolved promptly. It can be caused by several conditions, and salvage for venous congestion is often difficult and time consuming. Over 20 years, the senior author has encountered 2 unique situations that resulted in venous congestion of the flap requiring reoperative surgery for flap salvage or a second free flap. Several medical conditions can compromise free flap surgery and result in total flap loss. The senior author has also encountered 2 medical conditions resulting in total flap loss. However, both patients received successful second free tissue transfers when combined with unique perioperative management strategies. It is our hope that this review will highlight some unique management strategies for reoperative microsurgical free tissue transfer and serve as "lessons learned" for initial salvage procedures and a second free tissue transfer. We also hope our reoperative approach demonstrated in this review will help the future generation of microsurgeons to avoid such complications altogether so that overall outcome after microsurgical free flap surgery can further be improved.
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Affiliation(s)
- Lee L Q Pu
- From the Division of Plastic Surgery, University of California, Davis, Sacramento, CA
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Mirzamohammadi F, Nnamani Silva ON, Leaf RK, Eberlin KR, Valerio IL. Chemoprophylaxis and Management of Venous Thromboembolism in Microvascular Surgery. Semin Plast Surg 2023; 37:57-72. [PMID: 36776808 PMCID: PMC9911223 DOI: 10.1055/s-0042-1760381] [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: 02/11/2023]
Abstract
This review aims to highlight the common pharmacological and nonpharmacological interventions utilized for thromboprophylaxis as well as flap salvage in microsurgery. A literature review was conducted in PubMed/National Center for Biotechnology Information, Scopus, Web of Science, and MEDLINE databases. Articles with a focus on thromboprophylaxis in microsurgical procedures spanning head and neck surgery, breast and extremity microvascular reconstruction, deep venous thrombosis/pulmonary embolus in microvascular surgery, and flap thrombosis and salvage were included in this review. The majority of available evidence supports mechanical venous thromboembolism (VTE) prophylaxis in all patients undergoing microsurgery given the presence of multiple risk factors for VTE within this particular patient population. Based on the literature review, addition of VTE chemoprophylactic agents is beneficial and an algorithmic approach to thromboprophylaxis in microsurgery patients and management of patients with thrombosis based on literature review and senior authors' experience is recommended and outlined.
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Affiliation(s)
- Fatemeh Mirzamohammadi
- Wright State University Plastic Surgery Residency Program, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | | | - Rebecca K. Leaf
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kyle R. Eberlin
- Division of Plastic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ian L. Valerio
- Division of Plastic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Dang S, Mady LJ, Tarfa R, Li JC, Bontempo F, Chibisov I, Kubik MW, Solari MG, Sridharan S. Head and Neck Reconstruction in Patients with Polycythemia Vera: Case Series and Literature Review. J Hand Microsurg 2023; 15:67-74. [PMID: 36761055 PMCID: PMC9904977 DOI: 10.1055/s-0041-1734398] [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: 10/20/2022] Open
Abstract
Background Polycythemia vera (PV) is a myeloproliferative disease with overproduction of erythrocytes, leukocytes, and platelets causing an increased risk of both thrombosis and hemorrhage. There are limited reports and no established guidelines for managing such patients undergoing reconstructive surgery. Methods We present four patients with PV and head and neck cancer who required reconstruction after resection and provide a review of the current literature. Results Preoperatively, patients on cytoreductive therapy continued with their treatment throughout their hospital course and had hematologic parameters normalized with phlebotomy or transfusions if needed. Two patients who underwent free flap surgery (cases 1 and 2) had postoperative courses complicated by hematoma formation and persistent anemia, requiring multiple transfusions. Cases 3 and 4 (JAK2+ PV and JAK2- PV, respectively) underwent locoregional flap without postoperative complications. Conclusion Concomitant presentation of PV and head and neck cancer is uncommon and presents unique challenges for the reconstructive surgeon. Overall, we recommend that patients should have hematologic parameters optimized prior to surgery, continue ruxolitinib or hydroxyurea, and hold antiplatelet/anticoagulation per established department protocols. It is essential to engage a multidisciplinary team involving hematology, head and neck and reconstructive surgery, anesthesia, and critical care to develop a standardized approach for managing this unique subset of patients.
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Affiliation(s)
- Sophia Dang
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Leila J. Mady
- Department of Otorhinolaryngology Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Rahilla Tarfa
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Jonathan C. Li
- Combined Internal Medicine–Pediatrics Residency Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Frank Bontempo
- Department of Internal Medicine, The Institute of Transfusion Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Irina Chibisov
- Department of Internal Medicine, The Institute of Transfusion Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Mark W. Kubik
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Mario G. Solari
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Shaum Sridharan
- Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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Stevens MN, Freeman MH, Shinn JR, Kloosterman N, Carr S, Mannion K, Rohde SL. Preoperative Predictors of Free Flap Failure. Otolaryngol Head Neck Surg 2023; 168:180-187. [PMID: 35412879 DOI: 10.1177/01945998221091908] [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: 11/02/2021] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure. STUDY DESIGN Retrospective cohort study of 1070 patients. SETTING Head and neck surgical oncology service at a tertiary care center from 2005 to 2019. METHODS Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (<8 days from surgery). RESULTS In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure. CONCLUSION Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.
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Affiliation(s)
- Madelyn N Stevens
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael H Freeman
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Austin, Texas, USA
| | | | - Shane Carr
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Levin LS. From replantation to transplantation: The evolution of orthoplastic extremity reconstruction. J Orthop Res 2022. [PMID: 36413095 DOI: 10.1002/jor.25488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/20/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.
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Affiliation(s)
- L Scott Levin
- Department of Orthopaedic Surgery, Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Levin LS. CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes. Clin Orthop Relat Res 2021; 479:2397-2399. [PMID: 34570743 PMCID: PMC8509994 DOI: 10.1097/corr.0000000000001994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 01/31/2023]
Affiliation(s)
- L Scott Levin
- Chair, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
- USA, MC, Retired
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11
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Patel H, Srinivasa DR, Volod O, Wang ED, Kim EA. Rotational Thromboelastometry Derivative Fibrinogen-Platelet Ratio Predicts Thrombosis in Microsurgery. J Reconstr Microsurg 2021; 37:774-782. [PMID: 34010965 DOI: 10.1055/s-0041-1727190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Early detection of thrombotic events is of paramount importance for microsurgical procedures. Here, we present findings that underscore the value of rotational thromboelastometry (ROTEM) to aid in decision-making for pre- and postoperative anticoagulation, as well for patients with suspected hypercoagulability. METHODS We prospectively collected pre- and postoperative ROTEM values on all free flap cases at the University of California, San Francisco, from 2015 to 2016. Patient age, body mass index, comorbidities, operative reports, risk factors, thrombotic complications, and outcomes were collected from electronic medical records. Two-sample t-tests were used to compare ROTEM values between cohorts. Modeling for sensitivity, specificity, and accuracy was done for threshold fibrinogen-to-platelet ratio (FPR). RESULTS Of 52 patients who underwent free-tissue transfer, 15 had a thrombotic event either intraoperatively or postoperatively that required revision of the vascular anastomosis. Eight patients were clinically hypercoagulable preoperatively, seven of which had a thrombotic event. Several pre- and postoperative ROTEM values differed significantly between thrombotic and nonthrombotic cases. Preoperative (p = 0.027) and postoperative (p = 0.013) FPR were statistically significant when comparing the thrombotic to the nonthrombotic cohort. Threshold FPR ≥ 30 was the most sensitive and FPR ≥ 40 was the most specific. CONCLUSION Our study affirms other studies that established ROTEM as an effective predictive tool for thrombotic events during free-tissue transfer. However, a lower threshold for FPR improves catchment of thrombotic events and flap failure with acceptable sensitivity. Our results support the routine use of ROTEM for detecting hypercoagulability in patients who would potentially benefit from intervention to prevent thrombotic complications.
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Affiliation(s)
- Harsh Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dhivya R Srinivasa
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Oksana Volod
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric D Wang
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California
| | - Esther A Kim
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California
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12
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Wickramasinghe D, Adegbola S, Sahnan K, Morar P, Carvello M, Di Candido F, Maroli A, Spinelli A, Warusavitarne J. A scoring system to predict a prolonged length of stay after surgery for Crohn's disease. Colorectal Dis 2021; 23:1205-1212. [PMID: 33539619 DOI: 10.1111/codi.15567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/13/2022]
Abstract
AIM Many factors influence the postoperative length of stay (LOS) in Crohn's disease (CD). This study aims to identify the factors associated with a prolonged LOS after ileocolic resection (ICR) for CD and to develop a scoring system to predict the postoperative LOS in CD. METHOD Patient data were collected from St Marks Hospital, London, UK, and the Humanitas Clinical and Research Center Milan, Italy, for all patients who underwent an ICR for CD from 2005 to 2017. Logistic regression was used for multivariate analysis. The scoring system was developed from the logistic regression model. The performance of the scoring system was evaluated using the area under the receiver operating characteristic curve (AUROC). RESULTS A total of 628 surgeries were included in the analysis. Eighty eight surgeries were excluded due to missing data. The remaining 543 were divided into two cohorts for the development (n = 418) and validation (n = 125) of the scoring system. The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included the time since diagnosis, American Society of Anesthesiologists (ASA) grade, perioperative use of steroids, surgical access, strictureplasty and platelet count. The AUROCs for the development and validation cohorts were 0.732 and 0.7, respectively (p < 0.0001). The cut-off score suggested by Youden's index was 50, with a sensitivity of 65.6% and a specificity of 73.3%. CONCLUSION The time since diagnosis, ASA grade, steroid use, surgical access, strictureplasty and platelet count were associated with a prolonged LOS and were used to develop a scoring system. The calculator is available online at https://rebrand.ly/Crohnscal.
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Affiliation(s)
- Dakshitha Wickramasinghe
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.,St Mark's Hospital, London, UK
| | | | | | | | - Michele Carvello
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Francesca Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Milan, Italy
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Milan, Italy
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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13
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Parham CS, Shen C, Pennock MM, Henderson SR, Kulaylat AS, Johnson TS. Correlation between Venous Thromboembolism Risk and Venous Congestion in Microvascular Reconstruction of the Lower Extremity. Plast Reconstr Surg 2020; 146:1177-1185. [PMID: 33136965 DOI: 10.1097/prs.0000000000007273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Risk for venous thromboembolism formation and the relationship to postoperative free flap venous congestion and flap failure have not been adequately evaluated in a trauma population. The authors aim to use the Caprini Risk Assessment Model to evaluate the association between venous thromboembolism risk and postoperative flap venous congestion following lower extremity free tissue transfer. METHODS A retrospective analysis was conducted of all patients who underwent lower extremity free flap reconstruction of traumatic defects at a single institution between 2007 and 2016. A Wilcoxon rank sum test was used for nonparametric analysis of aggregate Caprini Risk Assessment Model scores and flap outcomes. Flap venous congestion and failure rates as associated with the categorical variables underlying the Caprini Risk Assessment Model were further studied. Logistic regression was used to evaluate each of these outcomes and other flap-related covariates relative to the Caprini Risk Assessment Model categorical variables that had the greatest effect on our patient sample. RESULTS One hundred twelve patients underwent lower extremity free flap reconstruction. One hundred eight free flaps were analyzed. Eight patients were excluded. The majority of patients were male (75.9 percent) and required reconstruction because of acute trauma (68.1 percent versus 31.9 percent for chronic wounds). There was no statistically significant association found between age, body mass index, or timing of trauma versus venous congestion, flap failure, or other flap-related covariates. CONCLUSION In patients with significantly elevated Caprini Risk Assessment Model scores, there was no significant association between venous thromboembolism risk and flap failure following free tissue reconstruction of lower extremities. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
| | - Chan Shen
- From the Penn State Health Milton S. Hershey Medical Center
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14
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Vanags I, Stepanovs J, Ozolina A, Mukans M, Bjertnaes LJ, Mamaja B. Thromboelastometry for Assessing Risks of Free Flap Thrombosis in Patients Undergoing Microvascular Surgery. Front Med (Lausanne) 2020; 7:289. [PMID: 32656219 PMCID: PMC7324680 DOI: 10.3389/fmed.2020.00289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/22/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Coagulation assessment is often missing in microvascular surgery. We aimed at evaluating the predictive value of thromboelastometry for free flap thrombosis in microvascular surgery patients. Materials and Methods: We enrolled 103 adult patients with traumatic injuries scheduled for microvascular free flap surgery into a prospective observational study. Thirty-six patients with recent trauma underwent surgery within 30 days (ES group), and were compared with 67 trauma patients who underwent surgery later than 30 days (late surgery, LS group) after the injury. Rotational thromboelastometry (RTE) was performed before surgery. Functional fibrinogen to platelet ratio (FPR) ≥ 42 was selected as the main hypercoagulability index. Free flap thrombosis was set as primary outcome. Thrombotic risk factors and duration of surgery related to free flap thrombosis were secondary outcomes. Statistical significance p < 0.05; not significant NS. Results: Six patients (16.7%) in the ES group and 10 (14.9%) in the LS group had free flap thrombosis (NS). In the entire cohort, free flap thrombosis rate increased in the presence of thrombogenic comorbidities (OR 4.059, CI 1.33-12.37; p = 0.014) and prolonged surgery times (OR 1.007, CI 1 - 1.012; p = 0.05). Although hypercoagulability occurred more frequently in the ES group (44.4%) than in the LS group (11.9%; p < 0.001), it was not associated with higher free flap thrombosis rate. In ES group patients with surgery times > 240 min, the risk of free flap thrombosis increased (OR 3.5, CI 1.16-10.6; p = 0.026) with 93.3% sensitivity and 86.7% specificity (AUC 0.85; p = 0.007). In contrast, in LS patients hypercoagulability increased the odds of free flap thrombosis (OR 8.83, CI 1.74-44.76; p = 0.009). Moreover, a positive correlation was found between FPR ≥ 42 and free flap thrombosis rate (r = 0.362; p = 0.003). In the LS group, the presence of thrombogenic comorbidities correlated with free flap thrombosis rate (OR 7, CI 1.591-30.8; p = 0.01). Conclusions: In LS patients with thrombogenic comorbidities, thromboelastometry supports the detection of hypercoagulability and predicts free flap thrombosis risk. In ES patients, postoperative hypercoagulability did not predict free flap thrombosis. Prolonged surgery time should be considered as a risk factor.
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Affiliation(s)
- Indulis Vanags
- Department of Anaesthesiology and Reanimatology, Riga Stradinš University, Riga, Latvia.,Department of Anaesthesiology and Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Jevgenijs Stepanovs
- Department of Anaesthesiology, Riga East Clinical University Hospital, Riga, Latvia
| | - Agnese Ozolina
- Department of Anaesthesiology and Reanimatology, Riga Stradinš University, Riga, Latvia.,Department of Anaesthesiology, Riga East Clinical University Hospital, Riga, Latvia
| | - Maksims Mukans
- Statistical Unit, Riga Stradinš University, Riga, Latvia
| | - Lars J Bjertnaes
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Biruta Mamaja
- Department of Anaesthesiology and Reanimatology, Riga Stradinš University, Riga, Latvia.,Department of Anaesthesiology, Riga East Clinical University Hospital, Riga, Latvia
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15
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Tarabishy SP, Inglesby D, Tapp M, Corral GD, Herrera FA. Thrombocytosis is associated with complications after microvascular surgery: An NSQIP data analysis. Microsurgery 2019; 40:288-297. [DOI: 10.1002/micr.30530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/27/2019] [Accepted: 10/04/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Sami P. Tarabishy
- Division of Plastic Surgery Medical University of South Carolina Charleston South Carolina
| | - Dani Inglesby
- College of Medicine Medical University of South Carolina Charleston South Carolina
| | - Marion Tapp
- College of Medicine Medical University of South Carolina Charleston South Carolina
| | - Gabriel Del Corral
- Department of Plastic Surgery Medstar Georgetown University Hospital Washington District of Columbia
| | - Fernando A. Herrera
- Division of Plastic Surgery Medical University of South Carolina Charleston South Carolina
- Department of Surgery, Ralph H Johnson Veterans Affairs Medical Center Charleston South Carolina
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16
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Reoperation of Lower Extremity Microsurgical Reconstruction When Facing Postsplenectomy Thrombocytosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2492. [PMID: 31942291 PMCID: PMC6908350 DOI: 10.1097/gox.0000000000002492] [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: 04/10/2019] [Accepted: 08/26/2019] [Indexed: 11/26/2022]
Abstract
Patients who sustain high-energy polytrauma are a unique population in that their mechanism of injury may induce multiorgan damage requiring immediate interventions such as splenectomy and bony fixation for mangled extremities. This results in the intersection of certain conditions, such as postsplenectomy thrombocytosis with the need for soft tissue reconstruction, often with free tissue transfer, for limb salvage after severe trauma to the lower extremity. However, there are no treatment guidelines in the management of postsplenectomy thrombocytosis in the setting of a lower extremity free flap reconstruction. We present a patient who had initial free tissue transfer to the lower extremity complicated by delayed microvascular thrombosis at postoperative day 4, during which time his platelet count exceeded more than 1,000,000/mm3. However, a successful second lower extremity free tissue transfer was achieved after platelet-reductive treatment with platelet apheresis during the perioperative period. Our patient went on to heal from his second free flap without further complications. Thus, thrombocytosis in the setting of free tissue transfer requires perioperative intervention to correct this hematologic condition. An innovative utilization of platelet apheresis may ensure the success of free tissue transfer by addressing the thrombocytosis in microsurgical patients after splenectomy.
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17
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Drizlionoka K, Zariņš J, Ozoliņa A, Ņikitina-Zaķe L, Mamaja B. Polymorphism rs2066865 in the Fibrinogen Gamma Chain ( FGG) Gene Increases Plasma Fibrinogen Concentration and Is Associated with an Increased Microvascular Thrombosis Rate. ACTA ACUST UNITED AC 2019; 55:medicina55090563. [PMID: 31484330 PMCID: PMC6780972 DOI: 10.3390/medicina55090563] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/21/2019] [Accepted: 08/30/2019] [Indexed: 11/17/2022]
Abstract
Background and Objective: Thrombosis due to inherited hypercoagulability is an issue that has been raised in microvascular flap surgery previously. We analyzed the association of a single nucleotide polymorphism (SNP) in rs2066865 in the fibrinogen gamma chain (FGG) gene, alteration in plasma fibrinogen concentration, and presence of microvascular flap thrombosis. Materials and Methods: A total of 104 adult patients with microvascular flap surgery were subjected to an analysis of the presence of SNP rs2066865 in the FGG gene. Alterations in plasma fibrinogen concentration according to genotype were determined as a primary outcome, and flap thrombosis was defined as a secondary outcome. Results: Flap thrombosis was detected in 11.5% of patients (n = 12). Successful revision of anastomosis was performed in four patients, resulting in a microvascular flap survival rate of 92.3%. We observed an increase in plasma fibrinogen concentration in genotype G/A and A/A carriers (G/G, 3.9 (IQR 4.76-3.04); G/A, 4.28 (IQR 5.38-3.18); A/A, 6.87 (IQR 8.25-5.49) (A/A vs. G/A, p = 0.003 and A/A vs. G/G, p = 0.001). Within group differences in microvascular flap thrombosis incidence rates were observed—G/G 6/79 (7.59%); G/A 5/22 (22.7%); A/A 1/3 (33.3%) (OR 0.30 95%; CI 0.044 to 0.57), p = 0.016; RR 3.2—when G/G versus G/A and A/A were analyzed respectively. Conclusions: A/A and G/A genotype carriers of a single nucleotide polymorphism in rs2066865 in the fibrinogen gamma chain gene had a higher plasma fibrinogen concentration, and this might be associated with an increased microvascular flap thrombosis incidence rate. Determined polymorphism could be considered as a genetic marker associated with microvascular flap thrombosis development. To confirm the results of this study, the data should be replicated in a greater sample size.
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Affiliation(s)
- Karina Drizlionoka
- Department of Anaesthesiology, Riga East Clinical University Hospital, LV-1024 Riga, Latvia.
| | - Jānis Zariņš
- Centre of Plastic and Reconstructive Microsurgery of Latvia, LV-1024 Riga, Latvia
| | - Agnese Ozoliņa
- Department of Anaesthesiology and Critical Care, Riga Stradins University, LV-1007 Riga, Latvia
| | | | - Biruta Mamaja
- Department of Anaesthesiology, Riga East Clinical University Hospital, LV-1024 Riga, Latvia
- Department of Anaesthesiology and Critical Care, Riga Stradins University, LV-1007 Riga, Latvia
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18
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Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis. Plast Reconstr Surg 2018; 141:191-199. [PMID: 28938362 DOI: 10.1097/prs.0000000000003927] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical indications are expanding for the use of fasciocutaneous free flaps in lower extremity traumatic reconstruction. The authors assessed the impact of muscle versus fasciocutaneous free flap coverage on reconstructive and functional outcomes. METHODS A multicenter retrospective review was conducted on all lower extremity traumatic free flaps performed at Duke University (1997 to 2013) and the University of Pennsylvania (2002 to 2013). Muscle and fasciocutaneous flaps were compared in two subgroups (acute trauma and chronic traumatic sequelae), according to limb salvage, ambulation time, and flap outcomes. RESULTS A total of 518 lower extremity free flaps were performed for acute traumatic injuries (n = 238) or chronic traumatic sequelae (n = 280). Muscle (n = 307) and fasciocutaneous (n = 211) flaps achieved similar cumulative limb salvage rates in acute trauma (90 percent versus 94 percent; p = 0.56) and chronic trauma subgroups (90 percent versus 88 percent; p = 0.51). Additionally, flap choice did not impact functional recovery (p = 0.83 for acute trauma; p = 0.49 for chronic trauma). Flap groups did not differ in the rates of flap thrombosis, flap salvage, flap loss, or tibial nonunion requiring bone grafting. Fasciocutaneous flaps were more commonly reelevated for subsequent orthopedic procedures (p < 0.01) and required fewer secondary skin-grafting procedures (p = 0.01). Reconstructive and functional outcomes remained heavily influenced by injury severity. CONCLUSIONS Muscle and fasciocutaneous free flaps achieved comparable rates of limb salvage and functional recovery. Flap selection should be guided by defect characteristics and reconstructive needs. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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19
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Barton BM, Riley CA, Fitzpatrick JC, Hasney CP, Moore BA, McCoul ED. Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review. Laryngoscope 2017; 128:412-421. [PMID: 28581030 DOI: 10.1002/lary.26703] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Postoperative use of anticoagulation after free tissue transfer in head and neck ablative procedures is common practice, but a clear protocol has not been well established. The outcome measures including total flap failure, thrombosis, and hematoma formation for different anticoagulation regimens in free tissue transfer in the head and neck were reviewed. DATA SOURCES PubMed, Ovid, and Cochrane databases were examined for patients who underwent free tissue transfer following head and neck ablative procedures. REVIEW METHODS Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting anticoagulation regimens following free tissue transfer in head and neck ablative procedures. Outcomes included total flap failure, thrombosis, and hematoma formation. Two independent reviewers assessed the quality of the articles by using the Methodological Index for Non-Randomized Studies. RESULTS A total of 368 articles were identified. An additional 36 articles were identified through screening of reference lists. Twenty-one of these studies met final inclusion criteria for qualitative analysis. Outcome data on total flap failure, thrombosis, and hematoma formation were extracted and analyzed for comparison against all anticoagulation regimens. Total flap failure, thrombosis, and hematoma formation rates were 4.4%, 4.5%, and 2.2%, respectively. Individual study rates ranged from 0.0% to 10.7%, 0.0% to 10.4%, and 0.6% to 7.2%, respectively. CONCLUSIONS There is not adequate evidence to develop a standardized anticoagulation protocol for head and neck free flap procedures. Comparable flap complications were reported between all the employed anticoagulation methods studied, though significant variability in study design among articles existed. Prospective, randomized studies are warranted to determine the optimal postoperative anticoagulation regimen following free tissue transfer of the head and neck. Laryngoscope, 128:412-421, 2018.
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Affiliation(s)
- Blair M Barton
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Christian P Hasney
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
| | - Brian A Moore
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
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