1
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Yu S, Wei K, Zhou D, Lin Q, Li T. Predictive factors of postoperative complications related to free flap reconstruction in head and neck cancer patients admitted to intensive care unit: a retrospective cohort study. BMC Anesthesiol 2024; 24:258. [PMID: 39075344 PMCID: PMC11285200 DOI: 10.1186/s12871-024-02649-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 07/19/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND The epidemiology and risk factors for postoperative complications related to free flap reconstruction in head and neck cancer patients admitted to the Intensive Care Unit (ICU) are unknown. METHODS We performed a retrospective cohort study of patients with free flap reconstruction of head and neck cancer between September 2015 and April 2023 admitted to the ICU of Beijing Tongren Hospital. The univariate and multivariate analyses were used to explore the risk factors for postoperative complications related to free flap reconstruction admitted to ICU, including flap necrosis, bleeding, fistula, and infection. RESULTS A total of 239 patients were included in this study, and 38 (15.9%) patients had postoperative complications related to free flap reconstruction. The median length of ICU stay was 1 day (interquartile range, 1-2 days). Multivariate analysis found that low BMI (P < 0.001), high postoperative CRP (P = 0.005), low hemoglobin (P = 0.012), and inadequate fluid intake (P < 0.05) were independent risk factors for complications. CONCLUSIONS Postoperative complications related to free flap reconstruction were common in this ICU population. Careful fluid management and monitoring of CRP and hemoglobin levels may reduce complications.
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Affiliation(s)
- Shujing Yu
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, No. 2, Xihuan South Road, Daxing District, Beijing, China
| | - Kaiyuan Wei
- School of Basic Medicine, Capital Medical University, Beijing, China
| | - Dawei Zhou
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, No. 2, Xihuan South Road, Daxing District, Beijing, China
| | - Qing Lin
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, No. 2, Xihuan South Road, Daxing District, Beijing, China
| | - Tong Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, No. 2, Xihuan South Road, Daxing District, Beijing, China.
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2
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Li W, Li X, Chen Y, Li Y, Chen R, Kang Z, Huang Z, Zhao Y. Effects of acute normovolemic hemodilution and allogeneic blood transfusion on postoperative complications of oral and maxillofacial flap reconstruction: a retrospective study. BMC Oral Health 2024; 24:606. [PMID: 38789959 PMCID: PMC11127284 DOI: 10.1186/s12903-024-04302-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
OBJECTIVE Patients undergoing oral and maxillofacial flap reconstruction often need blood transfusions due to massive blood loss. With the increasing limitations of allogeneic blood transfusion (ABT), doctors are considering acute normovolemic hemodilution (ANH) because of its advantages. By comparing the differences in the (Δ) blood indices and postoperative complications of patients receiving ABT or ANH during the reconstruction and repair of oral and maxillofacial tumor flaps, this study's purpose was to provide a reference for the clinical application of ANH. METHODS The clinical data of 276 patients who underwent oral and maxillofacial flap reconstruction from September 25, 2017, to October 11, 2021, in the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, were retrospectively analyzed. According to the intraoperative blood transfusion mode, the patients were divided into two groups: ABT and ANH. The differences in the (Δ) blood indices and the incidence of postoperative complications between the groups were analyzed. RESULTS Among the 276 patients who had ANH (124/276) and ABT (152/276), there were no differences in (Δ) Hb, (Δ) PT, or (Δ) FIB (P > 0.05), while (Δ) WBC, (Δ) PLT, (Δ) APTT and (Δ) D-dimer were significantly different (P < 0.05). The blood transfusion method was not an independent factor for flap crisis (P > 0.05). The wound infection probability in patients with high post-PTs was 1.953 times greater than that in patients with low post-PTs (OR = 1.953, 95% CI: 1.232 ∼ 3.095, P = 0.004). A normal or overweight BMI was a protective factor for pulmonary infection, and the incidence of pulmonary infection in these patients was only 0.089 times that of patients with a low BMI (OR = 0.089, 95% CI: 0.017 ∼ 0.462). Moreover, a high ASA grade promoted the occurrence of pulmonary infection (OR = 6.373, 95% CI: 1.681 ∼ 24.163). The blood transfusion mode (B = 0.310, β = 0.360, P < 0.001; ANH: ln hospital stay = 2.20 ± 0.37; ABT: ln hospital stay = 2.54 ± 0.42) improved the length of hospital stay. CONCLUSION Preoperative and postoperative blood transfusion (Δ) Hb, (Δ) PT, and (Δ) FIB did not differ; (Δ) WBC, (Δ) PLT, (Δ) APTT, and (Δ) D-dimer did differ. There was no difference in the effects of the two blood transfusion methods on flap crisis, incision infection or lung infection after flap reconstruction, but ANH resulted in a 3.65 day shorter average hospital stay than did ABT.
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Affiliation(s)
- Wenhao Li
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Xueer Li
- Department of Maxillofacial Surgery, The First Affiliated Hospital of Guangdong Pharmaceutical University, 19th Nonglinxia Road, Guangzhou, Guangdong, 510080, China
| | - Yanhong Chen
- Department of Transfusion Medicine, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Yanling Li
- Department of Transfusion Medicine, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Rui Chen
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Ziqin Kang
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China
| | - Zhiquan Huang
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China.
| | - Yili Zhao
- Department of Transfusion Medicine, Sun Yat-sen Memorial Hospital, 107th Yanjiang Xi Road, Guangzhou, Guangdong, 510120, China.
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3
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Topkan E, Somay E, Selek U. RE: Fibular free flap necrosis after mandibular reconstruction surgery with osteoradionecrosis: Establishment and verification of an early warning model. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 125:101745. [PMID: 38141824 DOI: 10.1016/j.jormas.2023.101745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/25/2023]
Affiliation(s)
- Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey; Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Kyrenia University, Girne, Cyprus.
| | - Ugur Selek
- Department of Radiation Oncology, Faculty of Medicine, Koc University, Istanbul, Turkey
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4
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Rondinelli MB, Weltert LP, Ruocco G, Ornelli M, Delle Femmine PF, De Rosa A, Pierelli L, Felici N. Patient Blood Management in Microsurgical Procedures for Reconstructive Surgery. Diagnostics (Basel) 2023; 13:2758. [PMID: 37685296 PMCID: PMC10486619 DOI: 10.3390/diagnostics13172758] [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: 05/30/2023] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 09/10/2023] Open
Abstract
Introduction: The main purpose of reconstructive surgery (RS) is to restore the integrity of soft tissues damaged by trauma, surgery, congenital deformity, burns, or infection. Microsurgical techniques consist of harvesting tissues that are separated from the vascular sources of the donor site and anastomosed to the vessels of the recipient site. In these procedures, there are some preoperative modifiable factors that have the potential to influence the outcome of the flap transfer and its anastomosis. The management of anemia, which is always present in the postoperative period and plays a decisive role in the implantation of the flap, covers significant importance, and is associated with clinical and laboratory settings of chronic inflammation. Methods: Chronic inflammatory anemia (ACD) is a constant condition in patients who have undergone RS and correlates with the perfusion of the free flap. The aim of this treatment protocol is to reduce the transfusion rate by maintaining both a good organ perfusion and correction of the patient's anemic state. From January 2017 to September 2019, we studied 16 patients (16 males, mean age 38 years) who underwent microsurgical procedures for RS. Their hemoglobin (Hb) levels, corpuscular indexes, transferrin saturation (TSAT) ferritin concentrations and creatinine clearance were measured the first day after surgery (T0), after the first week (T1), and after five weeks (T2). At T0, all the patients showed low hemoglobin levels (average 7.4 g/dL, STD 0.71 range 6.2-7.4 g dL-1), with an MCV of 72, MCH of 28, MCHC of 33, RDW of 16, serum iron of 35, ferritin of 28, Ret% of 1.36, TRF of 277, creatinine clearance of 119 and high ferritin levels (range 320-560 ng mL-1) with TSAT less than 20%. All the patients were assessed for their clinical status, medical history and comorbidities before the beginning of the therapy. Results: A collaboration between the two departments (Department of Transfusion Medicine and Department of Reconstructive Surgery) resulted in the application of a therapeutic protocol with erythropoietic stimulating agents (ESAs) (Binocrit 6000 UI/week) and intravenous iron every other day, starting the second day after surgery. Thirteen patients received ESAs and FCM (ferric carboxymaltose, 500-1000 mg per session), three patients received ESAs and iron gluconate (one vial every other day). No patients received blood transfusions. No side effects were observed, and most importantly, no limb or flap rejection occurred. Conclusions: Preliminary data from our protocol show an optimal therapeutic response, notwithstanding the very limited scientific literature and data available in this specific surgical field. The enrollment of further patients will allow us to validate this therapeutic protocol with statistically sound data.
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Affiliation(s)
| | - Luca Paolo Weltert
- Department of Medical Statistics, Saint Camillus International University of Health and Medical Sciences (UniCamillus), 00131 Rome, Italy
| | - Giovanni Ruocco
- Department of Reconstructive Surgery, San Camillo-Forlanini Hospital, 00152 Rome, Italy (N.F.)
| | - Matteo Ornelli
- Department of Reconstructive Surgery, San Camillo-Forlanini Hospital, 00152 Rome, Italy (N.F.)
| | | | - Alessandro De Rosa
- Department of Transfusion Medicine, San Camillo-Forlanini Hospital, 00152 Rome, Italy (L.P.)
| | - Luca Pierelli
- Department of Transfusion Medicine, San Camillo-Forlanini Hospital, 00152 Rome, Italy (L.P.)
- Department of Experimental Medicine, La Sapienza University, 00161 Rome, Italy
| | - Nicola Felici
- Department of Reconstructive Surgery, San Camillo-Forlanini Hospital, 00152 Rome, Italy (N.F.)
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5
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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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6
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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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7
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Sorg H, Sorg CGG, Tilkorn DJ, Thönnes S, Karimo R, Hauser J. Free Flaps for Skin and Soft Tissue Reconstruction in the Elderly Patient: Indication or Contraindication. Med Sci (Basel) 2023; 11:medsci11010012. [PMID: 36810479 PMCID: PMC9944069 DOI: 10.3390/medsci11010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/15/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Increased lifespan and the improvement of medical treatment have given rise to research in reconstructive procedures in elderly patients. Higher postoperative complication rates, longer rehabilitation, and surgical difficulties remain a problem in the elderly. We asked whether a free flap in elderly patients is an indication or a contraindication and performed a retrospective, monocentric study. METHODS Patients were divided into two groups (YOUNG 0-59 years; OLD > 60 years). The endpoint was the survival of flaps and their dependence on patient- and surgery-specific parameters using multivariate analysis. RESULTS A total of 110 patients (OLD n = 59) underwent 129 flaps. The chance of flap loss increased as soon as two flaps were performed in one surgery. Anterior lateral thigh flaps had the highest chance for flap survival. Compared with the lower extremity, the head/neck/trunk group had a significantly increased chance of flap loss. There was a significant increase in the odds of flap loss in linear relation to the administration of erythrocyte concentrates. CONCLUSION The results confirm that free flap surgery can be indicated as a safe method for the elderly. Perioperative parameters such as two flaps in one surgery and transfusion regimens must be considered as risk factors for flap loss.
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Affiliation(s)
- Heiko Sorg
- Department of Plastic and Reconstructive Surgery, Marien Hospital Witten, Marienplatz 2, 58452 Witten, Germany
- Department of Health, University of Witten/Herdecke, Alfred-Herrhausen-Str. 50, 58455 Witten, Germany
- Correspondence:
| | - Christian G. G. Sorg
- Department of Management and Entrepreneurship, Faculty of Management, Economics and Society, University of Witten/Herdecke, 58455 Witten, Germany
| | - Daniel J. Tilkorn
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Alfried Krupp Krankenhaus, Hellweg 100, 45276 Essen, Germany
| | - Simon Thönnes
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Alfried Krupp Krankenhaus, Hellweg 100, 45276 Essen, Germany
| | - Rees Karimo
- Department of Plastic and Reconstructive Surgery, Marien Hospital Witten, Marienplatz 2, 58452 Witten, Germany
| | - Jörg Hauser
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Alfried Krupp Krankenhaus, Hellweg 100, 45276 Essen, Germany
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8
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Tu CH, Hong SF. Preoperative anemia: Predictor of free flap reconstruction complications in head and neck cancer. CHINESE J PHYSIOL 2023; 66:21-27. [PMID: 36814153 DOI: 10.4103/cjop.cjop-d-22-00115] [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] [Indexed: 02/22/2023] Open
Abstract
Free flap reconstruction has been the mainstay among reconstruction surgeries for head and neck cancer. Intraoperative and postoperative hemoglobin (Hb) levels were both possible risk factors of flap failure and had been discussed widely. However, few investigations of preoperative Hb were seen in the previous study with its effect to flap condition remain uncertain and no conclusions in the literature. Patients who underwent free flap reconstruction after head and neck surgery in our institution between May 2014 and May 2019 were enrolled. The postoperative flap condition was observed carefully, and re-exploration was performed if necessary. We then retrospectively collected patient data with several intraoperative and postoperative indices. A total of 598 patients were enrolled in our study. The total major flap complication rate was 10.6%, with an overall success rate of 89.4%. They were predominantly male (95%), and most of them underwent free flap reconstruction for the first time (91%). A total of 81 (13%) patients received radiotherapy before reconstruction. Among all factors, the preoperative Hb level and free flap type showed significance in univariate and multivariate analyses. A previous history of radiotherapy, body mass index, nutrition status, or poorly controlled diabetes mellitus showed no significant results in either univariate or multivariate analysis. Our study showed that a lower preoperative Hb level affects free flap survival. Meanwhile, preoperative radiotherapy history has no significant influence in either univariate or multivariate analysis.
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Affiliation(s)
- Cheng Hung Tu
- Department of ENT Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - San Fu Hong
- Department of ENT Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan
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9
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"Systematic Review and Guidelines for Perioperative Management of Pediatric Patients Undergoing Major Plastic Surgery Procedures, With a Focus on Free Tissue Transfer.". Plast Reconstr Surg 2022; 150:406e-415e. [PMID: 35674517 DOI: 10.1097/prs.0000000000009325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Microsurgical free tissue transfer has been successfully implemented for various reconstructive applications in children. The goal of this study was to identify the best available evidence on perioperative management of pediatric patients undergoing free tissue transfer, and use it to develop evidence-based care guidelines. METHODS A systematic review was conducted in Pubmed, Embase, Scopus, and Cochrane Library databases. Since a preliminary search of the pediatric microsurgical literature yielded scant data with low level of evidence (LOE), pediatric anesthesia guidelines for healthy children undergoing major surgeries were also included. Exclusion criteria included: vague descriptions of perioperative care, case reports, and studies of syndromic or chronically ill children. RESULTS 204 articles were identified, and 53 met inclusion criteria. Management approaches specific to the pediatric population were used to formulate recommendations. High quality data was found for anesthesia, analgesia, fluid administration / blood transfusion, and anticoagulation (LOE 1). Lower quality evidence was identified for patient temperature (LOE 3) and vasodilator use (LOE 4). Key recommendations include: administering sevoflurane for general anesthesia, implementing a multimodal analgesia strategy, limiting preoperative fasting, restricting blood transfusions until hemoglobin < 7 g/dl unless patient is symptomatic, and reserving chemical venous thromboembolism prophylaxis for high risk patients. CONCLUSIONS Pediatric-specific guidelines are important as they acknowledge physiologic differences in children, which may be overlooked when extrapolating from adult studies. These evidence-based recommendations are a key first step toward standardization of perioperative care of pediatric patients undergoing plastic surgical procedures, including free tissue transfer, to improve outcomes and minimize complications.
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10
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Big data analysis of the risk factors and rates of perioperative transfusion in immediate autologous breast reconstruction. Sci Rep 2022; 12:5314. [PMID: 35351949 PMCID: PMC8964768 DOI: 10.1038/s41598-022-09224-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 02/24/2022] [Indexed: 11/08/2022] Open
Abstract
Patients undergoing autologous breast reconstruction (ABR) are more likely to require perioperative transfusions due to the increased intraoperative bleeding. In addition to the mastectomy site, further incisions and muscle dissection are performed at the donor sites, including the back or abdomen, increasing the possibility of transfusion. The purpose of this study was to evaluate perioperative transfusion rates and risk factors according to the type of ABR through analysis of big data. Patients who underwent total mastectomy for breast cancer between 2014 and 2019 were identified. The patients were divided into mastectomy only and immediate ABR groups. The transfusion rate was 14-fold higher in the immediate ABR group (16.1%) compared to the mastectomy only group (1.2%). The transfusion rate was highest with the pedicled transverse rectus abdominis myocutaneous flap (24.2%). Performance of the operation in medical institutions located in the provinces and coronary artery disease (CAD) were significant risk factors for the need for transfusion. The perioperative transfusion risk among patients undergoing immediate ABR was related to the flap type, location of medical institution, and CAD. Based on the higher transfusion rate in this study (16.1%) compared to previous studies, the risk factors for the need for transfusion should be determined and evidence-based guidelines should be developed to reduce the transfusion rates.
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11
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Iamaguchi RB, Macedo LS, Cho AB, Rezende MRD, Mattar R, Wei TH. Reconstrução microcirúrgica em um hospital ortopédico: Indicações e desfechos em adultos. Rev Bras Ortop 2022; 57:772-780. [PMID: 36226202 PMCID: PMC9550366 DOI: 10.1055/s-0041-1735946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/18/2021] [Indexed: 11/05/2022] Open
Abstract
Objective
Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications.
Methods
Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis.
Results
We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours (
p
= 0.032) and obesity (
p
= 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count (
p
= 0.001).
Conclusion
The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.
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Affiliation(s)
- Raquel Bernardelli Iamaguchi
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Lucas Sousa Macedo
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Alvaro Baik Cho
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Marcelo Rosa de Rezende
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Rames Mattar
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Teng Hsiang Wei
- Grupo de Cirurgia da Mão e Microcirurgia Reconstrutiva, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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12
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Skoog H, Chisolm P, Altonji SJ, Moore L, Carroll WR, Richman J, Greene B, Grayson JW. Moving to a more restrictive transfusion protocol: Outcomes in head and neck free flap surgery. Am J Otolaryngol 2022; 43:103268. [PMID: 34695698 DOI: 10.1016/j.amjoto.2021.103268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/14/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine if a more restrictive transfusion protocol results in increased rates of adverse flap outcomes in patients undergoing free tissue transfer. MATERIALS AND METHODS Mixed retrospective and prospective cohort study. Patients who underwent surgery before the protocol change were collected retrospectively. Patients who underwent surgery after the protocol change were collected prospectively. RESULTS Of the 460 patients who underwent free tissue transfer, 116 patients in the pre-change cohort (N = 211) underwent transfusion (54.98%) and 78 in the post-change cohort(N = 249) (31.33%) (p < 0.001). The mean number of units transfused was 1.55 + 2.00 in the pre-change cohort, and 0.78 + 1.51 in the post-change cohort (p < 0.001). When separated temporally, the pre-change cohort received significantly more blood transfusions than the post-change cohort in the operating room (33.65% vs 18.07%) (p < 0.01), within 72 h of surgery (35.55% vs 15.66%) (p < 0.001), and after 72 h after surgery to discharge (16.59% vs 8.03%) (p = 0.018017). The rate of flap failure was 6.70% in the pre-change cohort, and 5.31% in the post-change cohort (p = 0.67). In a logistic regression model controlling for potential confounders, transfusion protocol was not significantly associated with flap failure (OR = 1.1080, 95% CI: 0.48-2.54). There were no significant differences between cohorts for medical morbidity, ICU transfer, or death. CONCLUSION Our data support the conclusion that patients undergoing free tissue transfer to the head and neck can be transfused following the same protocols as other patients, without increasing the rate of flap failure or other morbidities. LEVEL OF EVIDENCE 3 (mixed retrospective, prospective cohort study).
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Affiliation(s)
- Hunter Skoog
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America.
| | - Paul Chisolm
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
| | - Samuel J Altonji
- Duke University, Department of Head and Neck Surgery and Communication Sciences, Durham, NC, United States of America
| | - Lindsay Moore
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
| | - William R Carroll
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
| | - Joshua Richman
- University of Alabama Birmingham, Department of Surgery, Birmingham, AL, United States of America
| | - Benjamin Greene
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
| | - Jessica W Grayson
- University of Alabama at Birmingham, Department of Otolaryngology Head and Neck Surgery, Birmingham, AL, United States of America
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A single-center experience with head-to-toe microsurgical reconstruction in bloodless medicine patients. J Plast Reconstr Aesthet Surg 2021; 75:823-830. [PMID: 34776392 DOI: 10.1016/j.bjps.2021.08.022] [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: 04/30/2020] [Revised: 04/21/2021] [Accepted: 08/26/2021] [Indexed: 11/20/2022]
Abstract
Patients who decline blood transfusions, including members of the Jehovah's Witness faith, often face challenges when they require or desire prolonged operations such as free tissue transfer (FTT). This study aims to outline our institution's experience with treating bloodless medicine patients and offers the first anatomically comprehensive evaluation of FTT in this population. All patients undergoing FTT from 2017 to 2020 at a single institution were retrospectively reviewed. Patients who declined blood products were selected. Outcomes of interest include flap success, operative complications, and changes to hemoglobin measurements. Ten patients undergoing 11 FTT procedures were identified. Average age was 62.4 years (SD 7.6). Most patients were female (n = 9) and Black (n = 8). Average body mass index was 31.3 (SD 5.6), American Society of Anesthesiologists Physical Status was 2.9 (SD 0.5), and Charlson Comorbidity Index was 3.8 (SD 1.1). Sites of FTT reconstruction were breast (6), lower extremity (3), and scalp (2). Average operative time was 390 min (SD 85.1), with an average estimated blood loss of 170 mL (SD 100.4). The difference between preoperative hemoglobin to first postoperative hemoglobin measurement averaged 2.2 g/dL (SD 1.4). Average patient follow-up was 12 months (SD 7.8). Flap success occurred in 10 cases. One patient with flap failure was successfully reconstructed with a second procedure. Despite a small, heterogeneous cohort, our success rate in this highly comorbid population indicates that FTT can be performed effectively for patients who cannot use blood products. Bloodless medicine protocols are beneficial to providers serving patients with transfusion restrictions and systems that strive to limit transfusion volume and risk.
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14
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Torres Fuentes CE, Rodríguez Mantilla IE, Cáceres DNG, Camargo Gonzalez DF. Red Blood Cell Transfusion and its Relationship with Pedicle Thrombosis in Microvascular Free Flaps. J Reconstr Microsurg 2021; 38:402-408. [PMID: 34474496 DOI: 10.1055/s-0041-1733994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Free flaps have become a highly valuable tool for complex reconstructive surgeries. The requirement of red blood cell transfusion (RBCT) during the perioperative period is common and its effect on the free flap survival is debatable. The aim of this study was to determine the relationship between perioperative RBCT and vascular pedicle thrombosis (VPT). METHODS For this study 302 free flaps performed between January 2006 and December 2019 were retrospectively analyzed. It included their characteristics from before, during, and after the surgical procedure. The incidence of VPT and flap survival were calculated based on Kaplan Meier's method and the relationship between VPT and perioperative variables were analyzed by Cox regression models. RESULTS The transfusion group was represented by 62 flaps (20.5%) and no transfusion by 240 flaps. The overall transfusion requirement was 20.5% and the cumulative incidence of VPT was 9.11%. A statistically significant relationship was not demonstrated between flap survival and transfusion status (HR = 1.73 IC 95%: 0.5 to 3.96; p = 0.192) (p = 0.192) independently from the number of units transfused, the preoperative diagnosis of anemia, and the type of flap used and did not establish an increased risk of VPT. CONCLUSIONS This study did not demonstrate an association between RBCT during preoperative period and the risk for VPT or microvascular free flap survival rate on postoperative follow up.
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Affiliation(s)
- Carlos Eduardo Torres Fuentes
- Hand Surgery and Microsurgery Division, Department of Plastic and Reconstructive Surgery, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Iván Enrique Rodríguez Mantilla
- Department of plastic and reconstructive surgery, Hospital de San José. Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Diego Nicolás Guerrero Cáceres
- Department of plastic and reconstructive surgery, Hospital de San José. Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Diego Felipe Camargo Gonzalez
- Department of plastic and reconstructive surgery, Hospital de San José. Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
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15
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Macrophage Migration Inhibitory Factor-An Innovative Indicator for Free Flap Ischemia after Microsurgical Reconstruction. Healthcare (Basel) 2021; 9:healthcare9060616. [PMID: 34063809 PMCID: PMC8223971 DOI: 10.3390/healthcare9060616] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 12/02/2022] Open
Abstract
(1) Background: Nowadays, the use of microsurgical free flaps is a standard operative procedure in reconstructive surgery. Still, thrombosis of the microanastomosis is one of the most fatal postoperative complications. Clinical evaluation, different technical devices and laboratory markers are used to monitor critical flap perfusion. Macrophage migration inhibitory factor (MIF), a structurally unique cytokine with chemokine-like characteristics, could play a role in predicting vascular problems and the failure of flap perfusion. (2) Methods: In this prospective observational study, 26 subjects that underwent microsurgical reconstruction were observed. Besides clinical data, the number of blood leukocytes, CRP and MIF were monitored. (3) Results: Blood levels of MIF, C-reactive protein (CRP) and leukocytes increased directly after surgery. Subjects that needed surgical revision due to thrombosis of the microanastomosis showed significantly higher blood levels of MIF than subjects without revision. (4) Conclusion: We conclude that MIF is a potential and innovative indicator for thrombosis of the microanastomosis after free flap surgery. Since it is easy to obtain diagnostically, MIF could be an additional tool to monitor flap perfusion besides clinical and technical assessments.
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16
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Sanchez-Porro Gil L, Leon Vintro X, Lopez Fernandez S, Vega Garcia C, Pons Playa G, Fernandez Garrido M, Masia Ayala J. The Effect of Perioperative Blood Transfusions on Microvascular Anastomoses. J Clin Med 2021; 10:jcm10061333. [PMID: 33807085 PMCID: PMC8004983 DOI: 10.3390/jcm10061333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/12/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Perioperative transfusions are associated with complications of free flaps. The purpose of the present study was to find out whether there is a significant relationship between the risk of developing complications in vascular anastomoses and the history of transfusions. Methods: We studied 372 patients retrospectively with microsurgical reconstruction between 2009 and 2017 with regards to the number of red blood cell concentrates transfused. Complications were analyzed relative to flap loss and complications in microvascular anastomoses. Results: 130 patients (34.9%) received blood transfusions. Some 55% of them were transfused between the day of the intervention and the first postoperative day. Ninety-six patients were reoperated on (25.7%). Of those, thirty-six patients (37.5%) corresponded to anastomosis failure. The percentage of patients transfused among those who required reoperation was 55.2%. The percentage of patients transfused among those who were reoperated on within the first 72 h due to an alteration in the anastomosis was 60.6%, while it was 25.6% (Chi square P = 0.0001) for the rest of the patients. Conclusions: Although there is a strong association between transfusion and vascular anastomosis failure, it is not possible to establish the causation between the two.
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Affiliation(s)
- Lidia Sanchez-Porro Gil
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
- Correspondence: or
| | - Xavier Leon Vintro
- Department of Otolaryngology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain;
| | - Susana Lopez Fernandez
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Carmen Vega Garcia
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Gemma Pons Playa
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Manuel Fernandez Garrido
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Jaume Masia Ayala
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
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17
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Xie T, Liu Y, Han T, Zhu S, Zang M, Chen B, Li S. [Flap design and preliminary clinical experience of the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:349-355. [PMID: 33719245 DOI: 10.7507/1002-1892.202009114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To explore the reliability and effectiveness of soft tissue defect reconstruction using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle. Methods Between December 2014 and December 2019, 13 patients underwent the reconstruction of soft tissue defects in various sites using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle. There were 10 males and 3 females, with an average age of 52.1 years (range, 29-83 years). Twelve wounds were resulted from resection of various malignant tumor, including 6 cases of head and neck tumors, 5 cases of shoulder and back tumors, 1 case of chest and back tumors. Among the 12 cases, 4 cases were complicated with wound infection and bone exposure, 1 case with skull defect and cerebral dura exposure, and 1 case with wound infection, skull necrosis, and cerebrospinal fluid leakage. One case was injured in a traffic accident, which resulted in infection wound in the back and shoulder and bone exposure. The sizes of the defect and musculocutaneous flap ranged from 11 cm×7 cm to 23 cm×15 cm and 25 cm×8 cm to 40 cm×14 cm, respectively. According to the spatial relationship between the donor and recipient sites, propeller flaps (8 cases) or percutaneous tunnel island flaps (5 cases) were used to transfer the myocutaneous flap to the recipient area to repair the wound. The donor site was directly closed and sutured in 9 cases, and those with excessive tension were repaired with free skin grafts in 2 cases or transferred flaps in 2 cases. Results After the operation, necrosis of the distal 4-cm of the musculocutaneous flap occurred in 2 cases. After debridement, the resultant wounds were reconstructed using a local flap and a posterior intercostal artery perforator flap, respectively. The remaining 11 myocutaneous flaps survived completely without arteries and veins crisis. The wounds in the donor and recipient areas healed by first intention. All the patients were followed up 1 to 48 months (mean, 7.4 months). The color and texture of the flap were good. During the follow-up, 1 patient underwent tumor resection again due to tumor recurrence, and 1 patient with a scalp hemangiosarcoma died due to unexplained thoracic hemorrhage. Tumor recurrence was not found in the remaining patients. The musculocutaneous flap coverage was stable and the infection was controlled. Conclusion The lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle can be an alternation option to reconstruct refractory wounds with exposure of vital structures and organs and infection.
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Affiliation(s)
- Tingjun Xie
- Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P.R.China
| | - Yuanbo Liu
- Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P.R.China
| | - Tinglu Han
- Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P.R.China
| | - Shan Zhu
- Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P.R.China
| | - Mengqing Zang
- Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P.R.China
| | - Bo Chen
- Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P.R.China
| | - Shanshan Li
- Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P.R.China
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18
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Burkhard JP, Pfister J, Giger R, Huber M, Lädrach C, Waser M, Olariu R, Engel D, Löffel LM, Schaller B, Wuethrich PY. Perioperative predictors of early surgical revision and flap-related complications after microvascular free tissue transfer in head and neck reconstructions: a retrospective observational series. Clin Oral Investig 2021; 25:5541-5550. [PMID: 33686470 PMCID: PMC8370926 DOI: 10.1007/s00784-021-03864-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/25/2021] [Indexed: 11/15/2022]
Abstract
Objectives The aim of this study was to determine the influence of perioperative fluid management and administration of vasopressors on early surgical revision and flap-related complications in free tissue transfer. Materials and methods Intraoperative amount of fluid and of vasopressors, relevant perioperative parameters, and comorbidities were recorded in 131 patients undergoing head and neck microvascular reconstruction and compared with early surgical complications, defined as interventions requiring surgery after a flap-related complication, and/or other surgical problems in the operating room within 30 days after initial surgery. The relationship between perioperative variables for each revision category was determined using an optimized multiple logistic regression. Results The administration of diuretics (p=0.001) as a treatment for perioperative fluid overload and the type of flap (p=0.019) was associated with a higher risk of early surgical revisions. Perioperative fluid overload (p=0.039) is significantly related to flap-related complications. We found no effect of intraoperative administration of vasopressors on early surgical revisions (p=0.8) or on flap-related complications (norepinephrine p=0.6, dobutamine p=0.5). Conclusion Perioperative fluid overload is associated with higher risks of early surgical revision and flap-related complications. In contrast, the administration of vasopressors seemed to have no effect on either surgical revision rate or flap-related complications. Clinical relevance In patients receiving microvascular reconstructions, a balanced fluid administration perioperatively and a targeted use of vasopressors should be the necessary strategy to reduce the complication rates in head and neck surgery.
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Affiliation(s)
- John-Patrik Burkhard
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
| | - Jelena Pfister
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Roland Giger
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Claudia Lädrach
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Manuel Waser
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Lukas M Löffel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Benoît Schaller
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
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19
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Hahn HM, Lee DH, Lee IJ. Influence of time interval between endovascular intervention and free flap transfer on flap outcomes in critical limb-threatening ischemia: A retrospective analysis of 64 consecutive cases. J Plast Reconstr Aesthet Surg 2020; 74:1544-1552. [PMID: 33454224 DOI: 10.1016/j.bjps.2020.12.051] [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: 07/28/2020] [Revised: 11/18/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Arterial revascularization and free flap reconstruction is safe and effective for limb salvage in patients with critical limb-threatening ischemia (CLTI). This study aimed to determine whether reconstruction outcomes were affected by the time interval between endovascular treatment and free flap transfer in lower extremity reconstruction for critical limb ischemia. METHODS Patients who underwent endovascular intervention and subsequent free flap reconstruction with >6 months of follow-up were reviewed. Those with wounds with oncological and traumatic etiologies were excluded. Patients' demographics, risk factors, details of microsurgical procedures, details of endovascular intervention, and flap outcomes were collected. RESULTS Overall, 64 consecutive patients (M:F = 50:14 and mean age, 57.3 [range, 29-82] years) were evaluated between November 2011 and October 2019. Angioplasty failed in three patients. For soft-tissue reconstruction, anterolateral free flaps were used most frequently (n = 54 and 84.4%). Flap-related complications developed in 12 cases, of which five cases included total flap necrosis. The interval between endovascular intervention and free flap transfer was not associated with flap loss in multivariate regression analysis. Patients with kidney transplants and higher serum creatinine were associated with total flap necrosis. Advanced age, failed angioplasty, and perfusion status of the pedal arch were associated with major flap complications. CONCLUSION The time interval between endovascular treatment and free flap reconstruction was not associated with flap complications. Free flap reconstruction of chronic wounds caused by CLTI can be safely planned regardless of the time duration from preoperative angioplasty.
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Affiliation(s)
- Hyung Min Hahn
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea
| | - Dong Hwan Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea
| | - Il Jae Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea.
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20
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McLean A, Lowe D, Rogers SN. Administration of intravenous iron and tranexamic acid in the management of postoperative iron deficiency anaemia following free flap reconstruction: re-audit. Br J Oral Maxillofac Surg 2020; 59:97-101. [PMID: 33168366 DOI: 10.1016/j.bjoms.2020.08.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/12/2020] [Indexed: 11/17/2022]
Abstract
Following free tissue transfer, intravenous iron (IVI) has a role in reducing the rates of blood transfusion and more rapidly restoring haemoglobin (Hb) levels. Anaemia has a detrimental effect on survival, postoperative complications, fatigue, and health-related quality of life, therefore early correction is recommended. The aim of this re-audit is to assess the use of IVI, of tranexamic acid intraoperatively, and of perioperative blood transfusions. A total of 148 consecutive patients who underwent ablative surgery and free flap reconstruction between May 2018 and September 2019 were audited. The median (IQR) age was 66 (59,72) years and 36% were female. For two-thirds, surgery was for cancer located in the oral cavity and two-thirds of the free flaps were soft tissue. Tranexamic acid (TXA) was used intraoperatively for 30%, red blood cells (RBC) were transfused for 20% and 55 patients (37%) received IV iron. This compares with 4%, 26%, and 0, respectively, in the initial audit. Those having IVI were more likely (56%) to have had a composite flap, a lower postoperative haemoglobin and lower discharge Hb. The Hb between four and twelve weeks' follow up, known for 40, was a median (IQR) of 122 (104,138). There were no adverse reactions to IV iron. Although it is straightforward to administer IVI postoperatively, this re-audit demonstrates that it can be a challenge to embed change in protocols. Through raised awareness of the benefits of IVI, lack of adverse events and clarification of selection criteria, it is hoped that rates of IVI use will increase.
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Affiliation(s)
- A McLean
- Regional Maxillofacial Unit, Aintree University Hospital, Liverpool L9 7AL, UK.
| | - D Lowe
- Astraglobe Ltd., Congleton, Cheshire.
| | - S N Rogers
- Regional Maxillofacial Unit, Aintree University Hospital, Liverpool L9 7AL, UK.
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21
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Myatra SN, Gupta S, Pai PS. Anesthesia for oral surgeries during the COVID-19 pandemic. J Anaesthesiol Clin Pharmacol 2020; 36:S96-S104. [PMID: 33100656 PMCID: PMC7574004 DOI: 10.4103/joacp.joacp_355_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 06/27/2020] [Accepted: 07/04/2020] [Indexed: 11/05/2022] Open
Abstract
The severe acute respiratory syndrome corona virus 2(SARS-Cov2) virus replicates in the nasal cavity, nasopharynx, and the oropharynx. During oral surgery, the risk of viral transmission is high during instrumentation in these areas, while performing airway management procedures, the oral surgery itself, and related procedures. During the corona virus disease 2019 (COVID-19) pandemic, patients with an oral pathology usually present for emergency procedures. However, patients with oral cancer, being a semi-emergency, may also present for diagnostic and therapeutic procedures. When elective surgeries are resumed, these patients will come to the operating room. In asymptomatic patients, the false-negative rate can be as high as 30%. These patients are a source of infection to the healthcare workers and other patients. This mandates universal precautions to be taken for all patients presenting for surgery. Lesions along the airway, distorted anatomy secondary to cancer therapy, shared airway with the surgeon, surgical handling of the airway and the risk of bleeding, make airway management challenging in these patients, especially while wearing personal protective equipment. Airway management procedures, oral surgery, use of cautery, and other powered surgical instruments in the aero digestive tract, along with constant suctioning are a source of significant aerosol generation, further adding to the risk of viral transmission. Maintaining patient safety, while protecting the healthcare workers from getting infected during oral surgery is paramount. Meticulous advance planning and team preparation are essential. In this review, we discuss the challenges and recommendations for safe anesthesia practice for oral surgery during the COVID-19 pandemic, with special emphasis on risk mitigation.
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Affiliation(s)
- Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sushan Gupta
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prathamesh S Pai
- Department of Head and Neck Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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22
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Amoroso M, Apelgren P, Elander A, Säljö K, Kölby L. The effect of hemodilution on free flap survival: A systematic review of clinical and experimental studies. Clin Hemorheol Microcirc 2020; 75:457-466. [PMID: 32417763 DOI: 10.3233/ch-200832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Acute normovolemic hemodilution (ANH) has been proposed as a microsurgical technique to improve blood flow in free flaps. OBJECTIVE Here, we present the first systematic review of clinical and experimental studies on the effect of ANH. METHODS We performed a systematic literature search of PubMed, Medline, the Cochrane Library, Google Scholar, and ClinicalTrials.gov using search strategies and a review process in agreement with the PRISMA statement and the Cochrane Handbook for systematic reviews of interventions. PICO criteria were defined before bibliometric processing of the retrieved articles, which were analyzed with the SYRCLE RoB tool for risk of bias and the GRADE scale for level of evidence. RESULTS We retrieved 74 articles from the literature search, and after processing according to PICO criteria, only four articles remained, all of which were experimental. The rating for risk of bias was uncertain according to SYRCLE RoB results, and the level of evidence was low according to GRADE evaluation. CONCLUSIONS There is no clinical evidence for the effect of ANH on microcirculation in free flaps, and experimental studies provide weak evidence supporting the use of hemodilution in reconstructive microsurgery.
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Affiliation(s)
- Matteo Amoroso
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Apelgren
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Elander
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karin Säljö
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Kölby
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
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Comment on: Predictors of blood transfusion in autologous breast reconstruction surgery: A retrospective study using the nationwide inpatient sample database. J Plast Reconstr Aesthet Surg 2019; 73:783-808. [PMID: 31883691 DOI: 10.1016/j.bjps.2019.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 11/22/2019] [Indexed: 11/21/2022]
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Masoomi H, Greives MR, Cantor AD, Marques ES. Effect of Anemia in Postoperative Outcomes of Autologous Breast Reconstruction Surgery. World J Plast Surg 2019; 8:285-292. [PMID: 31620328 PMCID: PMC6790262 DOI: 10.29252/wjps.8.3.285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The true effects of anemia on postoperative surgical outcomes in autologous breast reconstruction surgery are unknown. We intended to evaluate the effect of chronic anemia on surgical outcomes in autologous breast reconstruction surgeries using a large national database. METHODS Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed autologous breast reconstruction surgery from 2012 to 2014. Univariate and multivariate regression analyses were performed to independently evaluate the effect of chronic anemia on postoperative outcomes. RESULTS Totally, 55,839 patients underwent autologous breast reconstruction surgery (immediate: 40% vs. delayed: 60%) during this period. Overall, 6.0% of patients had chronic anemia at the time of surgery. Compared with patients without chronic anemia, patients with chronic anemia had a significantly higher complication rate (19.8% vs. 9.4%) and a longer mean length of hospital stay (5.4 vs. 3.7 days). Postoperative complications were significantly higher in patients with chronic anemia compared with patients without chronic anemia except for venous thromboembolism (VTE) and fat necrosis. Multivariate regression analyses demonstrated that chronic anemia was independently associated with an increased overall complication rate (adjusted odds ratio: 2.20). Also, multivariate regression analyses showed that chronic anemia was an independent risk factor of all the evaluated postoperative complications except VTE, stroke and fat necrosis. CONCLUSION This study demonstrated that chronic anemia was a significant predictor factor of morbidity in autologous breast reconstruction including flap failure. Correction of anemia prior to breast reconstruction may help reduce poor surgical outcomes related to chronic anemia.
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Affiliation(s)
- Hossein Masoomi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas, Health Science Center at Houston, Houston, USA
| | - Matthew R Greives
- Division of Pediatric Plastic Surgery, Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, USA
| | - Andrew D Cantor
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas, Health Science Center at Houston, Houston, USA
| | - Erik S Marques
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas, Health Science Center at Houston, Houston, USA
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Masoomi H, Blumenauer BJ, Blakkolb CL, Marques ES, Greives MR. Predictors of blood transfusion in autologous breast reconstruction surgery: A retrospective study using the nationwide inpatient sample database. J Plast Reconstr Aesthet Surg 2019; 72:1616-1622. [DOI: 10.1016/j.bjps.2019.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 04/29/2019] [Accepted: 06/09/2019] [Indexed: 01/05/2023]
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Veith J, Donato D, Holoyda K, Simpson A, Agarwal J. Variables associated with 30-day postoperative complications in lower extremity free flap reconstruction identified in the ACS-NSQIP database. Microsurgery 2019; 39:621-628. [PMID: 31418906 DOI: 10.1002/micr.30502] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/15/2019] [Accepted: 07/29/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Lower extremity free flaps are a common way to treat both traumatic and oncologic lower extremity wounds. These patients often suffer postoperative complications. We sought to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify variables associated with postoperative complications. METHODS Patients who had free flap procedure and a primary diagnosis code for lower extremity pathology were identified in the NSQIP database from 2006 to 2017. NSQIP includes data on preoperative, intraoperative, and postoperative variables, including information up to 30 postoperative days. Current procedural terminology (CPT) codes for free flaps and international classification of diseases (ICD) 9 and 10 codes for lower extremity pathology were used for our cohort. We examined overall and major complication rates. Major complications were defined as reoperation, readmission, organ space infection, or death. Univariate and multivariate analyses were used to identify associations with complications. RESULTS Four hundred and eighty-three patients underwent lower extremity free flaps. Overall complication rate was 31.6% and major complication rate was 14.9%. Prolonged operative time (OR = 2.81, CI:1.76-4.48, p < .001), preoperative steroid use (OR = 3.04, CI:1.12-8.29, p = .030), and preoperative anemia (OR = 4.10, CI:2.00-8.41, p < .001) were independently associated with any complication. Diabetes (OR = 2.56, CI:1.24-5.29, p = .011) and prolonged operative time (OR = 3.75, CI:2.17-6.47, p < .001) were independently associated with major complications. CONCLUSIONS In lower extremity flap reconstruction, associations with overall complications include prolonged operative time, steroid use, and anemia. Associations with major complications included diabetes and prolonged operative time. These associations can be used to guide interventions on patients identified to have greater risk of complications.
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Affiliation(s)
- Jacob Veith
- Division of Plastic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Daniel Donato
- Division of Plastic and Hand Surgery, Regions Hospital, St. Paul, Minnesota
| | - Kathleen Holoyda
- Division of Plastic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Andrew Simpson
- Division of Plastic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jayant Agarwal
- Division of Plastic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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Thomas AB, Shammas RL, Orr J, Truong T, Kuchibhatla M, Sergesketter AR, Hollenbeck ST. An Assessment of Bleeding Complications Necessitating Blood Transfusion across Inpatient Plastic Surgery Procedures. Plast Reconstr Surg 2019; 143:1109e-1117e. [DOI: 10.1097/prs.0000000000005537] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sato T, Abe T, Ichioka S. Factors impairing cell proliferation in the granulation tissue of pressure ulcers: Impact of bacterial burden. Wound Repair Regen 2018; 26:284-292. [PMID: 30265416 DOI: 10.1111/wrr.12675] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 07/24/2018] [Accepted: 09/05/2018] [Indexed: 11/30/2022]
Abstract
The authors aimed to assess the factors that impair cell proliferation in the granulation tissue of pressure ulcers using immunohistochemistry for the cell proliferation marker Ki-67. This was a single center, cross-sectional study. The study included 86 patients with stage III or IV pressure ulcers. Two granulation tissue biopsy specimens were obtained from 86 patients. The specimens were used for histological examination, Ki-67 immunohistochemistry, and bacterial count assessment. The % of Ki-67-stained cells was considered as the Ki-67 index. Pearson's product-moment correlation coefficient (r) was used to assess the relationship between the Ki-67 index and other quantitative variables, including age, body mass index, bacterial count (Log10 CFU/g), serum albumin level, hemoglobin level, white blood cell count, and C-reactive protein level. The Mann-Whitney U test was used to compare the mean Ki-67 index according to gender, diabetes, smoking status, and wound culture. Univariate and multivariate linear regression analyses were used to assess the association between the Ki-67 index and other parameters. The Mann-Whitney U test revealed that the bacteria-positive group had a lower Ki-67 index (p = 0.045). Bacterial count demonstrated a significant negative correlation with the Ki-67 index (r = -0.325, p = 0.002). Multivariate linear regression analysis showed that bacterial count was a significant predictor of the Ki-67 index. The adjusted β-coefficient was -1.34 (95% confidence interval, -2.01 to -0.66, p < 0.001). Among the isolated bacteria, Corynebacterium spp. and Staphylococcus aureus were significantly associated with a low Ki-67 index, but Pseudomonas aeruginosa was not. These results suggest a negative relationship between bacterial count and cell proliferation in pressure ulcer granulation tissue, as indicated by the Ki-67 index. Granulation tissue formation in pressure ulcers may be accelerated if high bacterial load is treated appropriately.
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Affiliation(s)
- Tomoya Sato
- Department of Plastic and Reconstructive Surgery, Saitama Medical University, Saitama, Japan
| | - Takahiro Abe
- Department of Oral and Maxillofacial Surgery, The University of Tokyo, Tokyo, Japan
| | - Shigeru Ichioka
- Department of Plastic and Reconstructive Surgery, Saitama Medical University, Saitama, Japan
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Continuous Validity of Temporalis Muscle Flap in Reconstruction of Postablative Palatomaxillary Defects. J Craniofac Surg 2018; 28:e130-e137. [PMID: 28033186 DOI: 10.1097/scs.0000000000003323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Postablative palatomaxillary defects (PAPMDs) represent a challenging reconstructive problem. Temporalis muscle flap (TMF) has been widely used for reconstruction of these defects with minimal morbidity and satisfactory outcome. AIM OF THE STUDY To presents the authors' experience in the reconstruction of PAPMDs with TMF and to evaluate the validity of TMF in the reconstruction of such defects. METHODS This prospective study was conducted between July 2011 and July 2016 on selected patients for primary reconstruction of PAPMDs with TMF. Temporalis muscle flaps were assessed during surgery and postoperatively. Patients were followed up to evaluate functional and esthetic outcomes and detect complications. RESULTS This study included 32 patients with mean age 48.3 years. The pathology was squamous cell carcinoma in 15 patients (46.9%). Twenty-one patients (65.6%) had type II maxillectomy. Mean time of flap harvesting was 43 minutes. Zygomatic arch osteotomy was done in 3 patients while Coronoid osteotomy in 4 patients. Postoperatively, flaps were viable in 31 patients (96.9%) with good healing of recipient site. Flap epithelization completed within 28 to 59 days. Follow-up period was 13 to 55 months. Satisfactory functional and esthetic outcomes were reported in most of patients with no recurrence. Transient temporal nerve palsy occurred in 2 patients, limited mouth opening in 5 patients. One patient had Transient diplopia with enopthalmos and hypophthalmos. Flap failure occurred in another patient. CONCLUSIONS Temporalis muscle flap is still a valid reliable and versatile reconstructive tool in palatomaxillary reconstruction after ablative surgery. It has a good cosmetic and functional outcomes and minimal morbidity.
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Magyar Z, Molnar A, Nachmias DB, Mann D, Sogor V, Mester A, Peto K, Nemeth N. Impact of groin flap ischemia-reperfusion on red blood cell micro-rheological parameters in a follow-up study on rats. Clin Hemorheol Microcirc 2017; 79:245-255. [PMID: 28550242 DOI: 10.3233/ch-170277] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Flap hypoperfusion or ischemia-reperfusion (I/R) may occur during preparation-transposition procedures and by postoperative thrombotic complications. Behind the microcirculatory disturbances micro-rheological alterations are also supposed. OBJECTIVE We aimed to investigate the groin flap I/R with following-up micro-rheological parameters. METHODS Anesthetized rats were subjected to Control or I/R groups. Groin flaps were prepared bilaterally, pedicled on the superficial epigastric vessels. In Control group the flaps were re-sutured after one hour, while in I/R group microvascular clips were applied on the pedicles for 60 minutes, then the flaps were repositioned. Besides daily wound control, before the operation and on the 1st, 3rd, 5th, 7th and 14th postoperative days blood samples were collected for testing red blood cell (RBC) deformability (rotational ektacytometry) and aggregation (light-transmission aggregometry). RESULTS RBC deformability significantly worsened by the 3rd-7th postoperative day in I/R group. RBC aggregation enhanced significantly by the 1st day, in I/R group it remained elevated on the 3rd day as well. In a complicated case with unilateral flap necrosis, RBC deformability and aggregation worsening was outlined from its group (base, 1st, 3rd day). CONCLUSION Wound healing affected micro-rheological parameters in the early postoperative period. Flap I/R exacerbated the alterations. The parameters markedly worsened in case of flap necrosis.
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Affiliation(s)
- Zsuzsanna Magyar
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Abel Molnar
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - David Belkin Nachmias
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Din Mann
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Viktoria Sogor
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anita Mester
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Peto
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Norbert Nemeth
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Sigaux N, Philouze P, Boucher F, Jacquemart M, Frobert P, Breton P. Efficacy of the postoperative management after microsurgical free tissue transfer. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2017; 118:173-177. [PMID: 28391079 DOI: 10.1016/j.jormas.2017.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 02/06/2017] [Accepted: 03/29/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The physical and medical postoperative measures after free flap reconstruction vary substantially between surgical units. The objective of this review was to identify the postoperative measures which proved a significant positive effect on free flap survival. METHOD A review was conducted in the MEDLINE database on the English and French literature. RESULTS AND DISCUSSION Twenty-eight articles were retained. A meta-analysis of 4984 patients who were given antithrombotics (viz. antiplatelets and anticoagulants) postoperatively found that these treatments were of no significant benefit to free flap survival and increased the risk of postoperative hematoma. Postoperative transfusions did not favor free flap survival and were associated with a higher incidence of medical complications. Preoperative anemia was a risk factor for free flap failure. Blood pressure control, vasodilators, antioxidants, corticotherapy, oxygen therapy, and prolonged immobilization were of no proven benefit. CONCLUSION No postoperative therapy, whether drug-based or not, has been shown to have a significant positive effect on free flap survival.
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Affiliation(s)
- N Sigaux
- Department of Maxillofacial Surgery, Stomatology and Facial Plastic Surgery, Hospices Civils de Lyon - Claude-Bernard-Lyon 1 University, 165 Chemin du Grand Revoyet, 69495 Pierre-Bénite, France.
| | - P Philouze
- Department of Otorhinolaryngology, Head and Neck Surgery, Hospices Civils de Lyon - Claude-Bernard-Lyon 1 University, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - F Boucher
- Department of Plastic, Reconstructive and Esthetic Surgery - Croix Rousse Hospital, Hospices Civils de Lyon - Claude-Bernard-Lyon 1 University, 103 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - M Jacquemart
- Department of Maxillofacial Surgery, Stomatology and Facial Plastic Surgery, Hospices Civils de Lyon - Claude-Bernard-Lyon 1 University, 165 Chemin du Grand Revoyet, 69495 Pierre-Bénite, France
| | - P Frobert
- Department of Plastic, Reconstructive and Esthetic Surgery, Centre Léon-Bérard - Cancer Treatment Center, 28 rue Laënnec, 69008 Lyon, France
| | - P Breton
- Department of Maxillofacial Surgery, Stomatology and Facial Plastic Surgery, Hospices Civils de Lyon - Claude-Bernard-Lyon 1 University, 165 Chemin du Grand Revoyet, 69495 Pierre-Bénite, France
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Kloeters O, Vasilic D, Hupkens P, Ulrich D. Markers of blood coagulation and fibrinolysis in patients with early and delayed microsurgical reconstructions in the lower extremities. J Plast Surg Hand Surg 2017; 51:420-426. [PMID: 28319440 DOI: 10.1080/2000656x.2017.1303499] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND In this study, markers of coagulation and fibrinolysis were assessed during early and delayed microsurgical reconstruction in patients with traumatic defects of their lower legs to analyse whether an imbalance of the hemostasis after trauma might predispose the development of vascular complications. METHODS The prospective study included 70 patients. In 35 patients, surgery was performed within 72 hours after injury. In 35 other patients, delayed free flap transfer was performed between 14-21 days after trauma. In each group, reconstruction was performed with a fasciocutaneous anterior-lateral thigh flap (ALT, n = 18) or a myocutaneous flap (latissimus dorsi flap; n = 17). Blood samples were collected preoperatively, intraoperatively, and 3, 6, 12, 24, 36, 48, 72, 96 and 120 hours after the operation. Analysed parameters included markers of coagulation such as prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin III-complex (TAT), and antithrombin, as well as fibrinolysis markers such as plasminogenactivator inhibitor-I (PAI-1), tissue-plasminogenactivator (t-PA), and plasminogen. RESULTS Preoperatively, levels of F1 + 2, TAT, and PAI-1 were significantly higher in patients with delayed reconstruction (p < .05). Patients with later vascular complications in this group (n = 5) presented a significant higher concentration of TAT, F1 + 2, and PAI-1 (p < .05). Twelve and 24 hours after free flap surgery, patients with vascular complications presented significant elevated levels of these markers (p < .05). CONCLUSIONS Patients with delayed free flap surgery after lower leg trauma present a hypercoagulable state in their blood due to activation of the coagulation system and hypofibrinolysis. Early reconstruction might minimise the risk of flap failure caused by hypercoagulability.
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Affiliation(s)
- Oliver Kloeters
- a Department of Hand, Plastic and Reconstructive Surgery , Radboud University Hospital , Nijmegen , The Netherlands
| | - Dalibor Vasilic
- a Department of Hand, Plastic and Reconstructive Surgery , Radboud University Hospital , Nijmegen , The Netherlands
| | - Pieter Hupkens
- a Department of Hand, Plastic and Reconstructive Surgery , Radboud University Hospital , Nijmegen , The Netherlands
| | - Dietmar Ulrich
- a Department of Hand, Plastic and Reconstructive Surgery , Radboud University Hospital , Nijmegen , The Netherlands.,b Department of Plastic and Reconstructive Surgery , University Hospital, Aachen University of Technology , Aachen , Germany
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A comparison of patient-centered economic and clinical outcomes of post-mastectomy breast reconstruction between obese and non-obese patients. Breast 2016; 30:118-124. [DOI: 10.1016/j.breast.2016.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/18/2016] [Accepted: 09/08/2016] [Indexed: 02/05/2023] Open
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Kolbenschlag J, Diehm Y, Daigeler A, Kampa D, Fischer S, Kapalschinski N, Goertz O, Lehnhardt M. Insufficient fibrinogen response following free flap surgery is associated with bleeding complications. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2016; 5:Doc22. [PMID: 27975041 PMCID: PMC5120259 DOI: 10.3205/iprs000101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: Microvascular tissue transfer has become a safe and reliable tool in the reconstructive armamentarium, yielding high success rates. However, little is known about the changes in coagulation after free tissue transfer and their potential impact on morbidity. Methods: Fibrinogen concentration and platelet count among other values were available and assessed in 139 undergoing free tissue transfer before, immediately after, and 1-3 as well as 8-11 days after surgery. In patients undergoing urgent revision for either bleeding or microvascular thrombosis, blood samples were drawn directly before re-exploration. Results: In the patients without any surgical revision and in those with thrombosis of the microvascular pedicle, both fibrinogen concentration and platelet count increased significantly during the early and late post-operative window. Patients that developed bleeding necessitating re-exploration showed an inadequate increase in fibrinogen levels, resulting in significantly lower concentrations compared to the other two groups. There were no significant differences in platelet count or PTT between these groups. Conclusion: Free flap surgery induces acute and subacute changes in coagulation, comparable to other major surgeries and severe injuries. This leads to an increase in platelet count and fibrinogen over the post-operative course. Patients that developed bleeding requiring surgical re-exploration showed an insufficient increase in fibrinogen, resulting in significantly lower fibrinogen levels. Therefore, monitoring and correction of fibrinogen levels might aid in preventing or treating bleeding complications following free flap surgery.
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Affiliation(s)
- Jonas Kolbenschlag
- Department of Plastic Surgery, Reconstructive and Esthetic Surgery, Handsurgery, Martin-Luther-Hospital Berlin, Germany; Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
| | - Yannick Diehm
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Adrien Daigeler
- Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
| | - David Kampa
- Department of Surgery, BG University Hospital Bergmannsheil, Ruhr University, Bochum, Germany
| | - Sebastian Fischer
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Nicolai Kapalschinski
- Department of Plastic Surgery, Reconstructive and Esthetic Surgery, Handsurgery, Martin-Luther-Hospital Berlin, Germany
| | - Ole Goertz
- Department of Plastic Surgery, Reconstructive and Esthetic Surgery, Handsurgery, Martin-Luther-Hospital Berlin, Germany; Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
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O'Neill AC, Barandun M, Cha J, Zhong T, Hofer SOP. Restrictive use of perioperative blood transfusion does not increase complication rates in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69:1092-6. [PMID: 27236504 DOI: 10.1016/j.bjps.2016.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/24/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION With increasing appreciation of the possible adverse effects of peri-operative blood transfusion, restrictive policies regarding use of blood products have been adopted in many surgical specialties. Although microvascular breast reconstruction has become a routine procedure, high peri-operative transfusion rates continue to be reported in the literature. In this study we examine the impact of our restrictive approach on blood transfusion rates and postoperative complications in patients undergoing microvascular blood transfusion. METHODS A retrospective review of patients undergoing microvascular breast reconstruction with abdominal flaps at a single institution was performed. Patient age and body mass index as well as type, timing and laterality of reconstruction was recorded. Pre-operative and post-operative hemoglobin and hematocrit were recorded. Peri-operative blood transfusion rates were calculated. Post-operative complication rates were compared between patients with higher and lower post-operative hemoglobin levels. RESULTS Five hundred and twelve patients were included in this study. The peri-operative transfusion rate was 0.98% in this series. There was no significant difference between transfusion rates in unilateral and bilateral reconstructions (0.68 vs 1.36% p = 0.08) or immediate and delayed reconstructions (1.02 vs 0.51% p = 0.72 and 1.01 vs 1.60% p = 0.09 for unilateral and bilateral respectively). Lower post-operative hemoglobin levels were not associated with increased flap related, surgical or medical complications rates. CONCLUSION A restrictive approach to peri-operative blood transfusion can be safely adopted in microvascular breast reconstruction without compromising flap viability or overall complication rates.
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Affiliation(s)
- Anne C O'Neill
- Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Marina Barandun
- Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Plastic Surgery, University Hospital of Basel, Basel, Switzerland
| | - Jieun Cha
- Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Toni Zhong
- Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stefan O P Hofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Post-mastectomy breast reconstruction and its subsequent complications: a comparison between obese and non-obese women with breast cancer. Breast Cancer Res Treat 2016; 157:373-383. [PMID: 27178333 DOI: 10.1007/s10549-016-3832-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
To compare the utilization pattern of breast reconstruction between obese and non-obese patients and assess the association between obesity and postoperative complications as well as healthcare costs. Using MarketScan databases, we identified 2558 breast cancer patients who underwent mastectomy between 2009 and 2012. Temporal trends in breast reconstruction were assessed using the Cochran-Armitage test. Logistic regression models were performed to determine the association between obesity and the occurrence of postoperative complications. Healthcare costs were compared using a generalized linear model. Among 2558 patients treated with mastectomy, the breast reconstruction rate of non-obese patients (76.2 %) was significantly higher than patients in obese class I and class II&III (63.3 and 60.2 %, respectively; P < 0.001). Compared with non-obese patients, obese patients had significantly higher rates of infection (OR 1.53, for obese class I, and OR 1.60, for obese class II&III, both P < 0.01), wound (OR 1.51, P = 0.01 for obese class I, and OR 1.98, P < 0.001 for obese class II&III), and perfusion complications (OR 1.73, P = 0.01 for obese class I, and OR 2.21, P < 0.01 for obese class II&III). The mean postoperative complication cost for non-obese patients ($4684) was significantly lower than those for obese class I patients ($6250) and obese class II&III patients ($7868; P < 0.001). Our analysis demonstrated a significant gap in breast reconstruction between obese and non-obese patients, and our finding underscores the need for careful preoperative assessment of obese patients and call for additional research to minimize the risk of complications.
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The Effect of Normovolemic and Hypervolemic Hemodilution on a Microsurgical Model. Plast Reconstr Surg 2015; 136:512-519. [DOI: 10.1097/prs.0000000000001525] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg 2015; 135:290-299. [PMID: 25539313 DOI: 10.1097/prs.0000000000000839] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Microsurgical free tissue transfer has become an increasingly valuable technique in reconstructive surgery. However, there is a paucity of evidence-based guidelines to direct management. A systematic review was performed to define strategies to optimize perioperative management. METHODS A systematic review of the literature was performed using key search terms. Strategies to guide patient management were identified, classified according to level of evidence, and used to devise recommendations in seven categories: patient temperature, anesthesia, fluid administration/blood transfusion, vasodilators, vasopressors, and anticoagulation. RESULTS A total of 106 articles were selected and reviewed. High-level evidence was identified to guide practices in several key areas, including patient temperature, fluid management, vasopressor use, anticoagulation, and analgesic use. CONCLUSIONS Current practices remain exceedingly diverse. Key strategies to improve patient outcomes can be defined from the available literature. Key evidence-based guidelines included that normothermia should be maintained perioperatively to improve outcomes (level of evidence 2b), and volume replacement should be maintained between 3.5 and 6.0 ml/kg per hour (level of evidence 2b). Vasopressors do not harm outcomes and may improve flap flow (level of evidence 1b), with most evidence supporting the use of norepinephrine over other vasopressors (level of evidence 1b). Dextran should be avoided (level of evidence 1b), and pump systems for local anesthetic infusion are beneficial following free flap breast reconstruction (level of evidence 1b). Further prospective studies will improve the quality of available evidence.
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Offodile AC, Aherrera A, Wenger J, Rajab TK, Guo L. Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database. Microsurgery 2015; 37:12-20. [DOI: 10.1002/micr.22387] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 01/13/2015] [Accepted: 01/20/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Anaeze C. Offodile
- Department of Plastic Surgery; Lahey Hospital and Medical Center; Burlington MA
| | - Andrew Aherrera
- Department of Plastic Surgery; Lahey Hospital and Medical Center; Burlington MA
| | - Julia Wenger
- Department of Nephrology; Massachusetts General Hospital; Boston MA
| | - Taufiek K. Rajab
- Department of General Surgery; Brigham and Women's Hospital; Boston MA
| | - Lifei Guo
- Department of Plastic Surgery; Lahey Hospital and Medical Center; Burlington MA
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Hand WR, McSwain JR, McEvoy MD, Wolf B, Algendy AA, Parks MD, Murray JL, Reeves ST. Characteristics and intraoperative treatments associated with head and neck free tissue transfer complications and failures. Otolaryngol Head Neck Surg 2014; 152:480-7. [PMID: 25550221 DOI: 10.1177/0194599814564366] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the association between perioperative patient characteristics and treatment modalities (eg, vasopressor use and volume of fluid administration) with complications and failure rates in patients undergoing head and neck free tissue transfer (FTT). STUDY DESIGN A retrospective review of medical records. SETTING Perioperative hospitalization for head and neck FTT at 1 tertiary care medical center between January 1, 2009, and October 31, 2011. SUBJECTS AND METHODS Consecutive patients (N=235) who underwent head and neck FTT. Demographic, patient characteristic, and intraoperative data were extracted from medical records. Complication and failure rates within the first 30 days were collected RESULTS In a multivariate analysis controlling for age, sex, ethnicity, reason for receiving flap, and type and volume of fluid given, perioperative complication was significantly associated with surgical blood loss (P=.019; 95% confidence interval [CI], 1.01-1.16), while the rate of intraoperative fluid administration did not reach statistical significance (P=.06; 95% CI, 0.99-1.28). In a univariate analysis, FTT failure was significantly associated with reason for surgery (odds ratio, 5.40; P=.03; 95% CI, 1.69-17.3) and preoperative diagnosis of coronary artery disease (odds ratio, 3.60; P=.03; 95% CI, 1.16-11.2). Intraoperative vasopressor administration was not associated with either FTT complication or failure rate. CONCLUSIONS FTT complications were associated with surgical blood loss but not the use of vasoactive drugs. For patients undergoing FTT, judicious monitoring of blood loss may help stratify the risk of complication and failure.
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Affiliation(s)
- William R Hand
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Julie R McSwain
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Matthew D McEvoy
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bethany Wolf
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Matthew D Parks
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - John L Murray
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Scott T Reeves
- Medical University of South Carolina, Charleston, South Carolina, USA
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Selber JC, Sarhane KA, Ibrahim AE, Holsinger FC. Transoral robotic reconstructive surgery. Semin Plast Surg 2014; 28:35-8. [PMID: 24872777 DOI: 10.1055/s-0034-1368166] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Transoral robotic surgery (TORS) has emerged as a technique that allows head and neck surgeons to safely resect large and complex oropharyngeal tumors without dividing the mandible or performing a lip-split incision. These resections provide a reconstructive challenge because the cylinder of the oropharynx remains closed and both physical access and visualization of oropharyngeal anatomy is severely restricted. Transoral robotic reconstruction (TORRS) of such defects allows the reconstructive surgeon to inset free flaps or perform adjacent tissue transfer while seeing what the resecting surgeon sees. Early experience with this technique has proved feasible and effective. Robotic reconstruction has many distinct advantages over conventional surgery, and offers patients a less morbid surgical course. In this review, we discuss the clinical applicability of transoral robotic surgery in head and neck reconstruction, highlighting the benefits and limitations of such an approach, and outlining the guidelines for its utilization.
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Affiliation(s)
- Jesse C Selber
- Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Karim A Sarhane
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amir E Ibrahim
- Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Floyd C Holsinger
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
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Effect of perioperative transfusion of old red blood cells on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous flap surgery for breast reconstruction. Microsurgery 2014; 34:434-8. [DOI: 10.1002/micr.22240] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/06/2014] [Accepted: 02/14/2014] [Indexed: 11/07/2022]
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Chesnutt JKW, Han HC. Effect of Red Blood Cells on Platelet Activation and Thrombus Formation in Tortuous Arterioles. Front Bioeng Biotechnol 2013; 1:18. [PMID: 25022613 PMCID: PMC4090894 DOI: 10.3389/fbioe.2013.00018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 11/20/2013] [Indexed: 11/13/2022] Open
Abstract
Thrombosis is a major contributor to cardiovascular disease, which can lead to myocardial infarction and stroke. Thrombosis may form in tortuous microvessels, which are often seen throughout the human body, but the microscale mechanisms and processes are not well understood. In straight vessels, the presence of red blood cells (RBCs) is known to push platelets toward walls, which may affect platelet aggregation and thrombus formation. However in tortuous vessels, the effects of RBC interactions with platelets in thrombosis are largely unknown. Accordingly, the objective of this work was to determine the physical effects of RBCs, platelet size, and vessel tortuosity on platelet activation and thrombus formation in tortuous arterioles. A discrete element computational model was used to simulate the transport, collision, adhesion, aggregation, and shear-induced platelet activation of hundreds of individual platelets and RBCs in thrombus formation in tortuous arterioles. Results showed that high shear stress near the inner sides of curved arteriole walls activated platelets to initiate thrombosis. RBCs initially promoted platelet activation, but then collisions of RBCs with mural thrombi reduced the amount of mural thrombus and the size of emboli. In the absence of RBCs, mural thrombus mass was smaller in a highly tortuous arteriole compared to a less tortuous arteriole. In the presence of RBCs however, mural thrombus mass was larger in the highly tortuous arteriole compared to the less tortuous arteriole. As well, smaller platelet size yielded less mural thrombus mass and smaller emboli, either with or without RBCs. This study shed light on microscopic interactions of RBCs and platelets in tortuous microvessels, which have implications in various pathologies associated with thrombosis and bleeding.
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Affiliation(s)
- Jennifer K W Chesnutt
- Cardiovascular Biomechanics Laboratory, Department of Mechanical Engineering, The University of Texas at San Antonio , San Antonio, TX , USA ; Department of Pathology, University of Texas Health Science Center at San Antonio , San Antonio, TX , USA
| | - Hai-Chao Han
- Cardiovascular Biomechanics Laboratory, Department of Mechanical Engineering, The University of Texas at San Antonio , San Antonio, TX , USA ; Biomedical Engineering Program, UTSA-UTHSCSA , San Antonio, TX , USA
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Reconstruction of palatomaxillary defects following cancer ablation with temporalis muscle flap in medically compromised patients: a 15-year single institutional experience. Clin Oral Investig 2013; 18:1663-70. [DOI: 10.1007/s00784-013-1135-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 10/31/2013] [Indexed: 10/26/2022]
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Nelson JA, Fischer JP, Grover R, Cleveland E, Erdmann-Sager J, Serletti JM, Wu LC. The impact of anemia on microsurgical breast reconstruction complications and outcomes. Microsurgery 2013; 34:261-70. [DOI: 10.1002/micr.22202] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 10/14/2013] [Accepted: 10/21/2013] [Indexed: 12/14/2022]
Affiliation(s)
- Jonas A. Nelson
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - John P. Fischer
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Ritwik Grover
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Emily Cleveland
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Jessica Erdmann-Sager
- Division of Plastic Surgery at Brigham and Women's Hospital; Harvard University; Boston MA
| | - Joseph M. Serletti
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Liza C. Wu
- Division of Plastic Surgery; Hospital of the University of Pennsylvania; Philadelphia PA
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Kolbenschlag J, Daigeler A, Lauer S, Wittenberg G, Fischer S, Kapalschinski N, Lehnhardt M, Goertz O. Can rotational thromboelastometry predict thrombotic complications in reconstructive microsurgery? Microsurgery 2013; 34:253-60. [DOI: 10.1002/micr.22199] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 10/03/2013] [Accepted: 10/04/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Jonas Kolbenschlag
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
| | - Adrien Daigeler
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
| | - Sarah Lauer
- BG Trauma Center; Department of Plastic and Hand Surgery; Ludwigshafen Germany
| | - Gerhard Wittenberg
- BG Trauma Center; Department of Anaesthesiology and Intensive Care Medicine; Ludwigshafen Germany
| | - Sebastian Fischer
- BG Trauma Center; Department of Plastic and Hand Surgery; Ludwigshafen Germany
| | - Nicolai Kapalschinski
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
| | - Marcus Lehnhardt
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
| | - Ole Goertz
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
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Sarhane KA, Flores JM, Cooney CM, Abreu FM, Lacayo M, Baltodano PA, Ibrahim Z, Alrakan M, Brandacher G, Rosson GD. Preoperative Anemia and Postoperative Outcomes in Immediate Breast Reconstructive Surgery: A Critical Analysis of 10,958 Patients from the ACS-NSQIP Database. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2013; 1:e30. [PMID: 25289224 PMCID: PMC4174195 DOI: 10.1097/gox.0b013e3182a18c6f] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 06/12/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Preoperative anemia is independently associated with adverse outcomes after general and cardiac surgery. Outcomes after breast reconstruction are not established. We assessed the effect of preoperative anemia on 30-day postoperative morbidity and length of hospital stay (LOS) in patients undergoing immediate breast reconstruction. METHODS We identified patients undergoing immediate breast reconstruction from 2008 to 2010 from the American College of Surgeons' National Surgical Quality Improvement Program database (a prospective outcomes-based registry from hospitals worldwide). De-identified data were obtained for demographics, preoperative risk factors, 30-day morbidity, and LOS. Morbidity variables included flap/graft/prosthesis, cardiac, respiratory, neurological, urinary, wound, and venous thromboembolism outcomes. Logistic regression assessed the crude and adjusted effect of anemia (hematocrit <36%) on postoperative 30-day morbidity. Measures of central tendency of LOS were compared across increasing severities of anemia in patients developing adverse events versus controls. RESULTS The study population included 10,958 patients; 1556 (16.74%) had preoperative anemia. Crude odds ratio for 30-day morbidity was significantly higher in anemic patients, unadjusted odds ratio = 1.33 (P < 0.008). This prevailed after extensive adjustment for confounding, yielding an adjusted odds ratio = 1.38 (P < 0.03). Patients who experienced adverse effects had protracted LOS, and the presence of anemia significantly amplified this effect. CONCLUSIONS These data provide new insight into the effect of anemia in immediate breast reconstruction, demonstrating an independent association between preoperative anemia and 30-day morbidity. These findings suggest treating anemia when possible; however, prospective studies should explore the efficacy, safety, and cost-effectiveness of such treatments.
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Affiliation(s)
- Karim A. Sarhane
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
| | - José M. Flores
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
| | - Carisa M. Cooney
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
| | - Francis M. Abreu
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
| | - Marcelo Lacayo
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
| | - Pablo A. Baltodano
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
| | - Zuhaib Ibrahim
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
| | - Mohammed Alrakan
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
| | - Gerald Brandacher
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
| | - Gedge D. Rosson
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Md.; and Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Md
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Mlodinow AS, Ver Halen JP, Rambachan A, Gaido J, Kim JY. Anemia is not a predictor of free flap failure: A review of NSQIP data. Microsurgery 2013; 33:432-8. [DOI: 10.1002/micr.22107] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 02/22/2013] [Accepted: 02/25/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Alexei S. Mlodinow
- Division of Plastic and Reconstructive Surgery; Northwestern University; Feinberg School of Medicine; Chicago IL
| | - Jon P. Ver Halen
- Department of Plastic Surgery; University of Tennessee Health Science Center; Memphis TN
| | - Akshar Rambachan
- Division of Plastic and Reconstructive Surgery; Northwestern University; Feinberg School of Medicine; Chicago IL
| | - Jessica Gaido
- Division of Plastic and Reconstructive Surgery; Northwestern University; Feinberg School of Medicine; Chicago IL
| | - John Y.S. Kim
- Division of Plastic and Reconstructive Surgery; Northwestern University; Feinberg School of Medicine; Chicago IL
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