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Copeland-Halperin LR, Divakar P, Stewart T, Demsas F, Levy JJ, Nigriny JF, Paydarfar JA. Predictors of Gastrostomy Tube Placement in Head and Neck Cancer Patients at a Rural Tertiary Care Hospital. J Reconstr Microsurg Open 2023. [DOI: 10.1055/s-0043-1760757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Abstract
Background Head and neck cancer is a leading cause of cancer. Treatment often requires surgical resection, free-flap reconstruction, radiation, and/or chemotherapy. Tumor burden and pain may limit swallowing and impair nutrition, increasing complications and mortality. Patients commonly require gastrostomy tubes (G-tube), but predicting which patients are in need remains elusive. This study identifies predictors of G-tube among head and neck cancer patients undergoing immediate free-flap reconstruction.
Methods Institutional Review Board approval was obtained. Retrospective database review was performed of patients at 18 years of age or older with head and neck cancer who underwent resection with immediate free-flap reconstruction from 2011 to 2019. Patients who underwent nonfree-flap or delayed reconstruction or with mortality within 7 days postoperatively were excluded. Patient demographics and comorbidities, tumor/treatment characteristics, and need for G-tube were analyzed to identify univariate and multivariate predictors.
Results In total, 107 patients were included and 72 required G-tube placement. On multivariate analysis, tracheostomy (odds ratio [OR]: 81.78; confidence interval [CI]: 7.43–1,399.92; p < 0.01), anterolateral thigh flap reconstruction (OR: 16.18; CI: 1.14–429.66; p = 0.04), and age 65 years or younger (OR: 9.35; CI: 1.47–89.11; p = 0.02) were predictors of G-tube placement.
Conclusion Head and neck cancer treatment commonly involves extensive resection, reconstruction, and/or chemoradiation. These patients are at high risk for malnutrition and need G-tube. Determining who requires a pre- or postoperative G-tube remains a challenge. In this study, the need for tracheostomy or ALT flap reconstruction and age 65 years or younger were predictive of postoperative G-tube placement. Future research will guide a multidisciplinary perioperative pathway to facilitate the optimization of nutrition management.
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Affiliation(s)
| | - Prashanthi Divakar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Talia Stewart
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Falen Demsas
- Department of Surgery, The Massachusetts General Hospital, Boston, Massachusetts
| | - Joshua J. Levy
- Department of Biomedical Sciences, Geisel School of Medicine, Hanover, New Hampshire
| | - John F. Nigriny
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Joseph A. Paydarfar
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Ortengren CD, Blasdel G, Damiano EA, Scalia PD, Morgan TS, Bagley P, Blunt HB, Elwyn G, Nigriny JF, Myers JB, Chen ML, Moses RA. Urethral outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) and vaginectomy: a systematic review. Transl Androl Urol 2022; 11:1762-1770. [PMID: 36632157 PMCID: PMC9827403 DOI: 10.21037/tau-22-174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 10/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background There is currently a paucity of data on urethral-related outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) with urethral lengthening (UL)and vaginectomy. Methods A systematic review was performed utilizing MEDLINE, Web of Science, Cochrane Library, Europe PMC, OSF Preprints, and EMBASE. Methodologic quality was scored using Methodological Index for Non-Randomized Studies (MINORS) criteria. Four independent reviewers performed the article evaluation, data extraction, and methodologic quality assessment. Primary outcomes included standing to urinate/pee (STP), penile length, glanular meatus, urethral stricture, fistula, and flap necrosis. Results were summarized qualitatively with descriptive statistics. Results A total of 2,881 articles of which 11 retrospective reviews of 13 cohorts met criteria; 4.3/16 average (avg) MINORS score. Six metoidioplasty cohorts had an average penile length of 6 cm, 74% reported successful STP, and a quarter developed stricture or fistula. Phalloplasty cohorts included radial forearm flap (RF) and Anterolateral Thigh flap (ALT). Of the 4 RF studies nearly a third developed a stricture or fistula and only one study reported 99% STP with a glanular meatus. Three ALT studies reported no length but had 80-90% STP with a glanular meatus and a quarter with stricture or fistula. Conclusions Urethral complications in MaPGAS-UL in a cohort with prior vaginectomy are common and variably reported. Patient centered outcome measures as well as clearly defined outcome metrics created in partnership with community members are needed.
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Affiliation(s)
| | - Gaines Blasdel
- Langone Medical Center, New York University, New York, NY, USA
| | - Ella A. Damiano
- Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Peter D. Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, Lebanon, NH, USA
| | - Tamara S. Morgan
- Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Pamela Bagley
- Biomedical Libraries, Dartmouth College, Hanover, USA
| | | | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, Lebanon, NH, USA
| | - John F. Nigriny
- Section of Plastic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jeremy B. Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Rachel A. Moses
- Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Stewart T, Copeland-Halperin LR, Demsas F, Divakar P, Shank N, Blunt H, J Levy J, Nigriny JF, Paydarfar JA. Predictors of gastrostomy tube placement in patients with head and neck cancer undergoing resection and flap-based reconstruction: systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 79:1-10. [PMID: 36780787 DOI: 10.1016/j.bjps.2022.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/17/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Nutritional status may be impaired in patients with head and neck cancer undergoing surgical treatment, often necessitating gastrostomy tube (G-tube) placement. Identifying which patients will require a G-tube remains a challenge. This study identifies predictors of G-tube requirement in patients undergoing tumor resection and reconstruction with pedicled or free flaps. METHODS Systematic review of the PubMed, Cochrane, and Scopus databases was performed of English language articles, discussing risk factors of perioperative G-tube placement among patients >18 years. Data on patient, tumor, and treatment factors, as well as need for G-tube, were collected. Univariable meta-analysis was conducted to identify predictors for G-tube placement. RESULTS Eleven studies (1,112 patients) met inclusion criteria. Overall pooled prevalence of postoperative G-tube placement was 25%. Patients with advanced cancer stage IV/recurrence were more likely to require a G-tube (OR 2.81 [CI 1.03-7.69]; p<0.05), as were those who had undergone preoperative radiation (OR 3.55 [CI 2.03-6.20], p<0.05). Reconstruction with a radial forearm free flap was associated with a lower need for G-tube versus rectus abdominis (OR 0.25 [CI 0.08-0.83], p=0.02) and latissimus dorsi flap (OR 0.21 [CI 0.04-1.09], p=0.06). There was no difference in G-tube placement between those receiving pedicled flaps versus free flaps (OR 1.54 [CI 0.38-6.20], p=0.54). CONCLUSIONS Among patients with head and neck cancer undergoing resection with immediate pedicled or free flap reconstruction, advanced tumor stage and history of prior radiation therapy are associated with increased likelihood of G-tube placement. More randomized controlled trials are needed to develop a decision-making algorithm.
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Affiliation(s)
| | | | | | | | - Nina Shank
- Dartmouth-Hitchcock Medical Center; Lebanon, NH
| | - Heather Blunt
- Department of Quantitative Biomedical Sciences, Geisel School of Medicine; Hanover, NH
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Krishnan NM, Chatterjee A, Rosenkranz KM, Powell SG, Nigriny JF, Vidal DC. The cost effectiveness of acellular dermal matrix in expander–implant immediate breast reconstruction. J Plast Reconstr Aesthet Surg 2014; 67:468-76. [DOI: 10.1016/j.bjps.2013.12.035] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 10/26/2013] [Accepted: 12/21/2013] [Indexed: 11/25/2022]
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Krishnan NM, Chatterjee A, Van Vliet MM, Powell SG, Rosen JM, Nigriny JF. A Comparison of Acellular Dermal Matrix to Autologous Dermal Flaps in Single-Stage, Implant-Based Immediate Breast Reconstruction. Plast Reconstr Surg 2013; 131:953-961. [DOI: 10.1097/prs.0b013e3182865a24] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nigriny JF, Wu P, Butler CE. Perineal reconstruction with an extrapelvic vertical rectus abdominis myocutaneous flap. Int J Gynecol Cancer 2010; 20:1609-12. [PMID: 21119371 DOI: 10.1111/igc.0b013e3181fc11ee] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Extensive perineal resections often require autologous tissue reconstruction, especially in wide oncological resections. Local and regional pedicled flaps from the lower extremity and abdominal sites have been described. Defects of the pelvis and perineum rarely require free-tissue transfer. The vertical rectus abdominis myocutaneous (VRAM) flap, traditionally delivered to the perineum through an intraperitoneal transpelvic route, is a workhorse flap for combined pelvic and perineal defects because of its ability to provide substantial coverage of the perineum, reliable vascular supply, and larger volume to obliterate dead space. We propose and describe an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion. METHODS A 54-year-old woman with a prior history of anal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy followed by abdominoperineal resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Three years later, she developed vulvar squamous cell carcinoma with vascular and lymphatic invasion and underwent radical vulvectomy and distal urethrectomy. The resection defect was 10 × 15 cm, including the distal 1 cm of the urethra, distal vaginal orifice, and wide exposure of the pubic bone. An extrapelvic extended VRAM flap was used for reconstruction. RESULTS The flap was harvested and transposed into the defect via a wide suprapubic subcutaneous tunnel. A neovaginal and urethral orifice was created in the flap by splitting the muscle in the direction of its fibers, taking care to protect the vascular pedicle, and inset to the vaginal orifice. There were no postoperative complications. She has maintained urinary continence with follow-up of 38 months. CONCLUSIONS Introduction of a rectus abdominis flap to the perineum through an extrapelvic route is preferred if laparotomy is not used for the resection. We successfully report and advocate the use of an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.
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Affiliation(s)
- John F Nigriny
- Department of Plastic Surgery, The University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA
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