Anticoagulative strategies in reconstructive surgery--clinical significance and applicability

Implementing Our Microsurgical Breast Reconstruction Enhanced Recovery after Surgery Pathway: Consensus Obstacles and Recommendations

Enhanced recovery after surgery pathways are well established in other surgical specialties but are relatively new in plastic surgery. These guidelines focus on improving patient care by incorporating evidence-based recommendations. Length of stay is shorter, and overall hospital costs are lower without compromising patient satisfaction. When care is standardized, ambiguity is removed and physician acceptance is improved. Yet, implementation can be challenging on an institutional level. The Johns Hopkins microsurgical breast reconstruction team identified areas of dogmatic dissonance during 3 focus groups to formalize an enhanced recovery pathway for microsurgical breast reconstruction. Six microsurgeons used nominal group technique to reach consensus. Four discussion points were identified: multidisciplinary buy-in, venous thromboembolism (VTE) chemophylaxis, early feeding, and dietary restrictions. Evidence-based recommendations and our enhanced recovery after surgery protocol are provided.

The value of postoperative anticoagulants to improve flap survival in the free radial forearm flap: a systematic review and retrospective multicentre analysis

BACKGROUND

Free radial forearm flap (FRFF) reconstruction is a valuable technique in head and neck surgery, which allows closure of large defects while striving to maintain functionality. Anticoagulative drugs are often administered to improve flap survival, although evidence regarding effectiveness is lacking.

OBJECTIVE OF REVIEW

To investigate the effectiveness of postoperative anticoagulants to improve survival of the FRFF in head and neck reconstruction.

TYPE OF REVIEW

Systematic review and multicentre, individual patient data meta-analysis.

SEARCH STRATEGY

MEDLINE, EMBASE, Web of Science and CINAHL were searched for synonyms of 'anticoagulants' and 'free flap reconstruction'.

EVALUATION METHOD

Studies were critically appraised for directness of evidence and risk of bias. Authors of the highest quality publications were invited to submit their original data for meta-analysis.

RESULTS

Five studies were of adequate quality, and data from four studies (80%) were available for meta-analysis, describing 759 FRFF procedures. Anticoagulants used were as follows: aspirin (12%), low molecular weight dextran (18.3%), unfractioned heparin (28.1%), low molecular weight heparin (49%) and prostaglandin-E1 (2.1%). Thirty-one per cent did not receive anticoagulants. Flap failure occurred in 40 of 759 patients (5.3%) On univariate analysis, use of unfractioned heparin was associated with a higher rate of flap failure. However, these regimens were often administered to patients who had revision surgery of the anastomosis. In multivariate logistic regression analysis, anticoagulant use was not associated with improved flap survival or flap-related complications.

CONCLUSIONS

The studied anticoagulative drugs did not improve FRFF survival or lower the rate of flap-related complications. In addition, some anticoagulants may cause systemic complications.

Testing a New Anticoagulation Method for Free Flap Reconstruction of Head and Neck Cancers

Objectives

Free flaps are widely used to reconstruct head and neck defects. Despite the improvement in the surgical techniques and the surgeons’ experiences, flap failures still occur due to thrombotic occlusion after small vessels anastomosis. To reduce the possibility of flap loss as a result of thrombotic occlusion, various anticoagulants have been used. In this study we decided to evaluate a new protocol for anticoagulation therapy and its effect on flap survival and complications.

Methods

In this interventional study, 30 patients with head and neck cancer underwent surgical defects were reconstructed by microvascular free flap between 2013 and 2014. In the postoperative period patients have taken aspirin (100 mg/day) for 5 days and enoxaparin (40 mg/day subcutaneously) for 3 days. The flap survival was followed for three weeks.

Results

Given that there was no complete necrosis or loss of flap, the free flap success rate was as much as 100%. The need for re-exploration occurred in 3 patients (10%). Only in one patient the need for re-exploration was due to problem in venous blood flow.

Conclusion

The aspirin-enoxaparin short-term protocol may be a good choice after free flap transfer in reconstruction of head and neck surgical defects.