Superficial versus deep system single venous anastomosis in the radial forearm free flap: a meta-analysis

The selection of the superficial or deep drainage system for use with the radial forearm free flap (RFFF) remains controversial. The aim of this study was to identify the optimal drainage system for single venous anastomosis. A systematic review and cumulative meta-analysis was performed to assess superficial and deep system single venous anastomosis for use with the RFFF in postoperative reconstruction of the head and neck. This study included 1073 flaps (495 superficial system-based flaps, 578 deep system-based flaps) reported in six studies. The outcomes assessed in the studies selected for this meta-analysis included venous compromise, flap failure, and the salvage success rate. Venous compromise was more common in the superficial system group (odds ratio (OR) 2.29, 95% confidence interval (CI) 1.36-3.86, P=0.002). The rate of successful salvage was higher with the superficial system (OR 8.19, 95% CI 1.75-38.3, P=0.008). The rate of flap failure was lower in the superficial system group (OR 0.30, 95% CI 0.04-2.48, P=0.27). Although the deep system showed a lower risk of venous compromise, the evidence provided by the meta-analysis was insufficient to determine which type of drainage system is more suitable for single venous anastomosis in RFFF. All included studies were cohort studies; therefore, findings must be interpreted with caution.

Free flap reconstruction in paediatric patients with head and neck cancer: clinical considerations for comprehensive care

Free flap reconstruction after resection in paediatric patients with head and neck cancer (HNC) has various clinical challenges, which have not yet been fully investigated. This retrospective study was implemented to investigate these factors. Paediatric patients (≤14 years old) who underwent free flap reconstructions following surgery for HNC at a tertiary referral centre during the years 2009-2018 were included. Clinical, pathological, and imaging data were collected and analysed. Overall, 47 patients were included, 26 male and 21 female. Thirty-four patients were ASA status I and 13 were ASA status II. The median operative time was 415 minutes, while the median intraoperative blood loss was 500 ml. Seventeen patients had a tracheotomy. Fourteen medical complications (six pulmonary infection, six diarrhoea, two pulmonary aspiration) and six surgical complications (one haematoma beneath flap, two wound dehiscence, one salivary fistula, one effusion, one tracheotomy haemorrhage) were observed. Tracheotomy was associated with medical complications (P = 0.003) and total complications (P = 0.024). It was confirmed that microvascular reconstruction can be adopted in paediatric HNC patients, while tracheotomy and nasal feeding tubes should be used with caution. Comprehensive preoperative assessment, gentle handling of the tissues during operative procedures, and appropriate postoperative management will reduce the risk of complications.

One Versus 2 Venous Anastomoses in Free Flap Surgery: A Systematic Review and Meta-Analysis

Background

The necessity of a second venous anastomosis in free flap surgery is controversial. The purpose of this systematic review is to determine whether venous flap failure and reoperation rates are lower when 2 venous anastomoses are performed. The secondary objective is to determine whether venous flap failure and reoperation rates are lower when the 2 veins are from 2 different drainage systems.

Methods

A comprehensive search of the literature identified relevant studies. Investigators independently extracted data on rates of flap failure and reoperation secondary to venous congestion. A meta-analysis was performed; odds ratios (ORs) were pooled using a random-effects model and 95% confidence intervals (CIs).

Results

Of 18 190 studies identified, 15 were included for analysis. The mean sample size was 287 patients (minimum = 102, maximum = 564). No statistically significant difference in venous flap failure was found when comparing 1 versus 2 venous anastomoses (OR: 1.35; 95% CI: 0.46-3.93). A significant decrease in reoperation rate due to venous congestion was shown (OR: 3.03; 95% CI: 1.64-5.58). The results favor using 2 veins from 2 different systems over veins from the same system (OR: 0.16; 95% CI: 0.02-1.27).

Conclusions

There is low-quality evidence suggesting that the use of 2 venous anastomoses will lower the rate of reoperation due to venous congestion. There are insufficient data published to meaningfully compare outcomes of flaps with 2 venous anastomoses from different systems to flaps with anastomoses from the same system.

Perioperative serum levels of procalcitonin, C-reactive protein, and leukocytes in head and neck free flaps

Microvascular free flaps are considered to be the gold standard in reconstructive head and neck surgery. However, reduced postoperative transplant perfusion is one of the serious postoperative complications and calls for close and reliable monitoring. Procalcitonin, C-reactive protein, and leukocytes are closely associated with local and systemic inflammatory reactions and might have prognostic capacity concerning tissue necrosis. This study aimed to evaluate perioperative serum levels of these three biomarkers to assess their potential in postoperative flap monitoring. A total of 100 patients with microvascular head and neck reconstructions were included in the study. Perioperative serum levels of parameters were measured and the clinical data were analyzed and correlated. A total of 13% of all flaps developed reduced postoperative perfusion. Analysis of the parameters revealed statistically significant differences in the overall patient collective over time, irrespective of clinically reduced flap perfusion. Co-factors such as sex and history of tobacco and alcohol abuse showed significant differences. The efficacy of the parameters in free flap monitoring has not been verified, although the role of procalcitonin in postoperative monitoring, with special regard to the early detection of infections, is underlined by the present study results.

Single Superficial versus Dual Systems Venous Anastomoses in Radial Forearm Free Flap: A Meta-Analysis

Background

The radial forearm free flap (RFFF) has been widely used with increasing frequency in head and neck reconstruction following extirpative surgery. The controversy of the venous anastomoses patterns still exists. Thus, we conducted a meta-analysis to assess the relationship between the venous anastomoses patterns and venous compromise.

Methods

MEDLINE, PubMed, Web of Science, and Wanfang databases were searched for studies reporting the different venous anastomoses patterns of the RFFF. A meta-analysis was conducted using the random effects models. Publication bias and sensitivity analysis were also assessed.

Results

6 studies with 992 cases were included in this meta-analysis. The dual anastomosis group tended to have a lower incidence of venous compromise (RR = 1.39). However, the difference was not statistically significant (95%CI: 0.59, 3.24).

Conclusions

This meta-analysis indicated that performing dual venous anatomoses consisting of superficial and deep systems conferred a tendency of the reduction with regard to venous compromise.

Influence of irradiation and oncologic surgery on head and neck microsurgical reconstructions

Despite the refinement of microsurgical techniques, microsurgical free flap transfer in patients with a history of previous radiotherapy, neck dissection or free flaps remains a challenge in oncologic reconstructive surgery. Previous studies on the prognostic factors for postoperative complications have been largely retrospective and shown conflicting results. Our aim was to design a prospective study to identify negative outcome predictors of free flap surgery in previously treated oral cancer patients. Prospective study including all patients who required microsurgical free flap transfer for reconstruction of the oral cavity between July of 2007 and June of 2010 with subset analysis of those cases in whom previous surgical or nonsurgical oncological treatment for head and neck cancer had been carried out. A total of 360 free flaps were performed in 358 patients, of whom 61 had previous neck dissection and 58 had undergone radiation therapy. Operation time was significantly found to be longer in irradiated patients. The need for microsurgical revision, postoperative wound infection and free flap loss were significantly associated with the ASA score and a previous neck dissection. Wound infection was seen significantly more often after radiotherapy. Previous neck dissections and radiotherapy as well as the ASA score are significant negative predictors for success in free flap transfer. For patients with prior oncologic treatments in their medical history, we recommend detailed preoperative assessment of the vascular status and an intensified postoperative care to reduce complication rates to improve outcome in oncologic reconstructive surgery.