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Min S, Zhang G, Hu A, Petito GT, Tripathi SH, Shukla G, Kumar A, Shah S, Phillips KM, Forbes JA, Zuccarello M, Andaluz NO, Sedaghat AR. A Comprehensive Analysis of Tobacco Smoking History as a Risk for Outcomes after Endoscopic Transsphenoidal Resection of Pituitary Adenoma. J Neurol Surg B Skull Base 2024; 85:255-260. [PMID: 38778915 PMCID: PMC11111311 DOI: 10.1055/a-2043-0263] [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: 10/08/2022] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
Objectives This study seeks to comprehensively analyze the impact of smoking history on outcomes after endoscopic transsphenoidal hypophysectomy (TSH) for pituitary adenoma. Design This was a retrospective study. Setting This study was done at the tertiary care center. Participants Three hundred and ninety-eight adult patients undergoing TSH for a pituitary adenoma. Main Outcome Measures Clinical and tumor characteristics and operative factors were collected. Patients were categorized as never, former, or active smokers, and the pack-years of smoking history was collected. Years since cessation of smoking was obtained for former smokers. Specific outcomes included postoperative cerebrospinal fluid (CSF) leak, length of hospitalization, 30-day return to the operating room, and 30-day readmission. Smoking history details were comprehensively analyzed for association with outcomes. Results Any history of smoking tobacco was associated with return to the operating room (odds ratio [OR] = 2.67, 95% confidence interval [CI]: 1.05-6.76, p = 0.039), which was for persistent CSF leak in 58.3%. Among patients with postoperative CSF leak, any history of smoking was associated with need for return to the operating room to repair the CSF leak (OR = 5.25, 95% CI: 1.07-25.79, p = 0.041). Pack-years of smoking was positively associated with a return to the operating room (OR = 1.03, 95% CI: 1.01-1.06, p = 0.048). In all multivariable models, all negative outcomes were significantly associated with the covariate: occurrence of intraoperative CSF leak. Conclusion This is the first study to show smoking may have a negative impact on healing of CSF leak repairs after TSH, requiring a return to the operating room. This effect appears to be dose dependent on the smoking history. Secondarily, intraoperative CSF leak as covariate in multivariable models was significantly associated with all negative outcomes.
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Affiliation(s)
- Susie Min
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Grace Zhang
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Alex Hu
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Gabrielle T. Petito
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Siddhant H. Tripathi
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Geet Shukla
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Adithya Kumar
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Sanjit Shah
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Katie M. Phillips
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Jonathan A. Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Norberto O. Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Ahmad R. Sedaghat
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
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Shilo S, Muhanna N, Fliss DM, Horowitz G, Warshavsky A, Mansour J, Ianculovici C, Fliss E, Barnea Y, Zaretski A, Yanko R. Early outcomes of osteofascial versus osteocutaneous fibula free flap mandibular reconstruction. Head Neck 2024; 46:1168-1177. [PMID: 38279002 DOI: 10.1002/hed.27661] [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: 07/20/2023] [Revised: 11/23/2023] [Accepted: 01/17/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND This study compares early outcomes of osteofascial fibula free flap (OF-FFF) with donor-site primary closure and osteocutaneous (OC) FFF with donor-site skin grafting in segmental mandibular reconstruction. METHODS A retrospective chart review of FFF mandibular reconstruction patients (2006-2022) divided into OF-FFF and OC-FFF groups. Clinical data, operative parameters, and early postoperative outcomes (≤ 90 days) were analyzed. RESULTS The study included 67 patients (39 OF-FFF, 28 OC-FFF). OF-FFF had significantly lower donor-site complications (12.8% vs. 53.6%, p < 0.001) and revision surgeries (7.7% vs. 35.7%, p = 0.004) compared to OC-FFF. Recipient-site (28.2% vs. 25%, p = 0.77) and flap (15.4% vs. 17.9%, p > 0.99) complications were comparable. CONCLUSIONS OF-FFF mandibular reconstruction with donor-site primary closure is a safe and reliable technique associated with superior donor-site and comparable flap and recipient-site outcomes to OC-FFF, thus may be considered as a viable alternative to OC-FFF for selected patients.
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Affiliation(s)
- Shahaf Shilo
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nidal Muhanna
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- The University of Nicosia Medical School, Nicosia, Cyprus
| | - Gilad Horowitz
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anton Warshavsky
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jobran Mansour
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Clariel Ianculovici
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Fliss
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Yoav Barnea
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Arik Zaretski
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Ravit Yanko
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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3
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Njoroge MW, Karwoski AS, Gornitsky J, Resnick E, Galaria A, Lopez CD, Boahene KDO, Yang R. Socioeconomic Disparities in Postoperative Outcomes of Osteocutaneous Fibula Free Flaps for Head and Neck Reconstruction. Ann Plast Surg 2024; 92:S167-S171. [PMID: 38556668 DOI: 10.1097/sap.0000000000003869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND Osteocutaneous fibula free flaps (FFFs) are a fundamental component of reconstructive surgery in the head and neck region, particularly after traumatic injuries or oncologic resections. Despite their utility, FFFs are associated with various postoperative complications, such as infection, flap failure, and donor site morbidity, impacting up to 54% of cases. This study aimed to investigate the influence of socioeconomic variables, with a particular focus on median household income (MHI), on the incidence of postoperative complications in FFF reconstruction for head and neck cancer. METHODS A retrospective analysis of 80 patients who underwent FFF reconstruction for head and neck cancer at a single center from 2016 to 2022 was conducted. Demographic and patient characteristics, including race, MHI, insurance type, history of radiation therapy, and TNM (tumor, node, metastasis) cancer stage, were evaluated. Logistic regression, controlling for comorbidities, was used to assess the impact of MHI on 30-, 90-, and 180-day postoperative complications. RESULTS The patient population was predominantly male (n = 51, 63.8%) and White (n = 63, 78.8%), with the majority falling within the $55,000 to $100,000 range of MHI (n = 51, 63.8%). Nearly half of the patients had received neoadjuvant radiation treatment (n = 39, 48.75%), and 36.25% (n = 29) presented with osteoradionecrosis. Logistic regression analysis revealed that the $55,000-$100,000 MHI group had significantly lower odds of developing complications in the 0- to 30-day postoperative period when compared with those in the <$55,000 group (odds ratio [OR], 0.440; 95% confidence interval [CI], 0.205-0.943; P = 0.035). This trend persisted in the 31- to 90-day period (OR, 0.136; 95% CI, 0.050-0.368; P < 0.001) and was also observed in the likelihood of flap takeback. In addition, the $100,000-$150,000 group had significantly lower odds of developing complications in the 31- to 90-day period (OR, 0.182; 95% CI, 0.035-0.940; P = 0.042). No significant difference was found in the >$150,000 group. CONCLUSIONS Median household income is a significant determinant and potentially a more influential factor than neoadjuvant radiation in predicting postoperative complications after FFF reconstruction. Disparities in postoperative outcomes based on income highlight the need for substantial health care policy shifts and the development of targeted support strategies for patients with lower MHI.
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Affiliation(s)
- Moreen W Njoroge
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | | | | | | | | | - Christopher D Lopez
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Kofi D O Boahene
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robin Yang
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
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Gengler I, Min S, Jiang M, Zhang G, Altaye M, Radulesco T, Lechien JR, Hsieh TY. The Impact of the Post-Traumatic Facial Reconstruction on Postoperative Weight Loss. EAR, NOSE & THROAT JOURNAL 2024:1455613241241114. [PMID: 38509737 DOI: 10.1177/01455613241241114] [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: 03/22/2024] Open
Abstract
Objectives: To identify risk factors and evaluate the impact of various facial fractures and reconstruction surgeries on postoperative weight change. Methods: Retrospective, monocentric study was performed at a tertiary care center. Medical history, type and mechanism of fracture, operative factors, and postoperative weights at follow-up appointments for 145 adult patients undergoing surgical repair for maxillofacial fractures were collected. Further information was obtained on postoperative diet and whether patients received maxillomandibular fixation (MMF). Univariate and multivariate analyses were utilized to evaluate effects of surgical reconstruction after facial trauma on postoperative weight loss. Results: Patients lost 3.2 ± 4.9 kg (95% confidence interval = 2.7-4.1, P < .0001) on average, with maximum loss between date of surgery and first follow-up. Univariate analysis demonstrated that intensive care unit admission (5.9 kg, SD 5.4, P = .001), nasogastric tube placement (5.1 kg, SD 4.6, P = .012), and MMF (4.4 kg, SD 5.4, P < .0001) were associated with more severe weight loss. Multivariate analyses showed that only MMF remained a significant risk factor for increased weight loss (avg. 6.0, standard error 1.93, t value 3.11, P = .0024). Conclusions: We report significant weight loss following facial trauma and reconstruction, which emphasizes the need to perform further studies on nutrition protocols for this patient population to optimize wound healing.
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Affiliation(s)
- Isabelle Gengler
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Young Otolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Paris, France
| | - Susie Min
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Megan Jiang
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Grace Zhang
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mekibib Altaye
- Mekibib Altaye, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas Radulesco
- Young Otolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Paris, France
- Aix-Marseille Univ, APHM, IUSTI, CNRS, Department of Oto-Rhino-Laryngology and Head and Neck Surgery, La Conception University Hospital, Marseille Cedex, France
| | - Jerome R Lechien
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Young Otolaryngologists of International Federation of Otorhinolaryngological Societies (YO-IFOS), Paris, France
- Department of Laryngology and Bronchoesophagology, EpiCURA Hospital, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), Mons, Belgium
| | - Tsung-Yen Hsieh
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Yang JJ, Liang Y, Wang XH, Long WY, Wei ZG, Lu LQ, Li W, Shao X. Prediction of vascular complications in free flap reconstruction with machine learning. Am J Transl Res 2024; 16:817-828. [PMID: 38586098 PMCID: PMC10994789 DOI: 10.62347/zxjv8062] [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: 10/07/2023] [Accepted: 03/06/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE This study aims to explore the risk factors of vascular complications following free flap reconstruction and to develop a clinical auxiliary assessment tool for predicting vascular complications in patients undergoing free flap reconstruction leveraging machine learning methods. METHODS We reviewed the medical data of patients who underwent free flap reconstruction at the Affiliated Hospital of Zunyi Medical University retrospectively from January 1, 2019, to December 31, 2021. Statistical analysis was used to screen risk factors. A training data set was generated and augmented using the synthetic minority oversampling technique. Logistic regression, random forest and neural network, models were trained, using this dataset. The performance of these three predictive models was then evaluated and compared using a test set, with four metrics, area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. RESULTS A total of 570 patients who underwent free flap reconstruction were included in this study, 46 of whom developed postoperative vascular complications. Among the models tested, the neural network model exhibited superior performance on the test set, achieving an AUC of 0.828. Multivariate logistic regression analysis identified that preoperative hemoglobin levels, preoperative fibrinogen levels, operation duration, smoking history, the number of anastomoses, and peripheral vascular injury as statistically significant independent risk factors for vascular complications post-free flap reconstruction. The top five predictive factors in the neural network were fibrinogen content, operation duration, donor site, body mass index (BMI), and platelet count. CONCLUSION Hemoglobin levels, fibrinogen levels, operation duration, smoking history, and anastomotic veins are independent risk factors for vascular complications following free flap reconstruction. These risk factors enhance the ability of machine learning models to predict the occurrence of vascular complications and identify high-risk patients. The neural network model outperformed the logistic regression and random forest models, suggesting its potential to aid clinicians in early identification of high-risk patients thereby mitigating patient suffering and improving prognosis.
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Affiliation(s)
- Ji-Jin Yang
- Nursing Department, Affiliated Hospital of Zunyi Medical UniversityZunyi, Guizhou, China
- School of Nursing, Zunyi Medical UniversityZunyi 563000, Guizhou, China
| | - Yan Liang
- School of Nursing, Zunyi Medical UniversityZunyi 563000, Guizhou, China
| | - Xiao-Hua Wang
- Nursing Department, Affiliated Hospital of Zunyi Medical UniversityZunyi, Guizhou, China
- Information Department of Affiliated Hospital of Zunyi Medical UniversityZunyi, Guizhou, China
- School of Medical Informatics and Engineering, Zunyi Medical UniversityZunyi, Guizhou, China
| | - Wen-Yan Long
- School of Nursing, Zunyi Medical UniversityZunyi 563000, Guizhou, China
| | - Zhen-Gang Wei
- School of Nursing, Zunyi Medical UniversityZunyi 563000, Guizhou, China
| | - Li-Qin Lu
- School of Nursing, Zunyi Medical UniversityZunyi 563000, Guizhou, China
| | - Wen Li
- School of Nursing, Zunyi Medical UniversityZunyi 563000, Guizhou, China
| | - Xing Shao
- Department of Burn and Plastic, Affiliated Hospital of Zunyi Medical UniversityZunyi, Guizhou, China
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Maier MA, Palines PA, Guidry RF, Stalder MW. Use of Flow-through Free Flaps in Head and Neck Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5588. [PMID: 38504941 PMCID: PMC10950194 DOI: 10.1097/gox.0000000000005588] [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: 03/30/2023] [Accepted: 12/11/2023] [Indexed: 03/21/2024]
Abstract
Background Reconstructive obstacles in composite head and neck defects are compounded in reoperated, traumatized, irradiated, and vessel-depleted surgical fields. In cases that require multiple free flaps, recipient vessel accessibility and inset logistics become challenging. Strategic flow-through flap configurations mitigate these issues by supplying arterial inflow and venous outflow to a second flap in a contiguous fashion. This approach (1) permits the use of a singular native recipient vessel, (2) increases the reach of the vascular pedicle, avoiding the need for arteriovenous grafting, and (3) allows for a greater three-dimensional flexibility in configuring soft tissue and bony flap inset. Methods To demonstrate this technique, we conducted a retrospective review of all head and neck reconstruction patients presenting to us from March 2019 to April 2021. Results We present seven oncological and two traumatic patients (N = 9) who received flow-through free flaps for head and neck reconstruction. The most common flap used as the flow-through flap was the anterolateral thigh flap (N = 7), followed by the fibula flap (N = 2). Mean follow-up time was 507 days. No flap failures occurred. Conclusion In head and neck reconstruction, the use of the flow-through principle enables uninterrupted vascular flow for two distinct free flaps in single-stage reconstruction for patients with vessel-depleted, irradiated, and/or reoperated fields. We demonstrate that flow-through flaps in the head and neck may be used successfully for a variety of cases and flaps.
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Affiliation(s)
- Mark A. Maier
- From the School of Medicine, Louisiana State University Health Sciences Center, New Orleans, La
| | - Patrick A. Palines
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, La
| | - Richard F. Guidry
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, La
| | - Mark W. Stalder
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, La
- University Medical Center—LCMC Health, New Orleans, La
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Verdura V, Cagiano L, Molle M, Bisceglia P, Fini N, Annacontini L, Mazzarella V, Parisi D, Portincasa A. Borderline Case in Reconstructive Plastic Surgery of the Lower Limb Treated with Bone Drilling and Use of Dermal Regeneration Template. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5694. [PMID: 38533518 PMCID: PMC10965198 DOI: 10.1097/gox.0000000000005694] [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: 11/16/2023] [Accepted: 02/05/2024] [Indexed: 03/28/2024]
Abstract
The traumatic pathology of the lower limb represents a very complex branch of medicine, which, despite the wide presence of guidelines, aimed at regulating the various therapeutic procedures, and is still greatly influenced by random variables and by the multiple responses to treatments. In this report, we present our experience with a borderline case, where the timing of the trauma and the patient's characteristics made it difficult to use the most recommended procedures in trauma management.
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Affiliation(s)
- Vincenzo Verdura
- From U.O.C Chirurgia Plastica e Ricostruttiva, OO.RR Riuniti, Foggia, Italy
| | - Luigi Cagiano
- From U.O.C Chirurgia Plastica e Ricostruttiva, OO.RR Riuniti, Foggia, Italy
| | - Marcello Molle
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania “Luigi Vanvitelli,” Naples, Italy
| | - Pasquale Bisceglia
- From U.O.C Chirurgia Plastica e Ricostruttiva, OO.RR Riuniti, Foggia, Italy
| | - Nicola Fini
- From U.O.C Chirurgia Plastica e Ricostruttiva, OO.RR Riuniti, Foggia, Italy
| | - Luigi Annacontini
- From U.O.C Chirurgia Plastica e Ricostruttiva, OO.RR Riuniti, Foggia, Italy
| | - Vincenzo Mazzarella
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania “Luigi Vanvitelli,” Naples, Italy
| | - Domenico Parisi
- From U.O.C Chirurgia Plastica e Ricostruttiva, OO.RR Riuniti, Foggia, Italy
| | - Aurelio Portincasa
- From U.O.C Chirurgia Plastica e Ricostruttiva, OO.RR Riuniti, Foggia, Italy
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Contrera KJ, Hassan AM, Shuck JW, Bobian M, Ha AY, Chang EI, Garvey PB, Roubaud MS, Lee ZH, Hanasono MM, Gross ND, Myers JN, Yu P, Largo RD. Outcomes for 160 Consecutive Lateral Arm Free Flaps for Head and Neck Reconstruction. Otolaryngol Head Neck Surg 2024; 170:747-757. [PMID: 38037485 DOI: 10.1002/ohn.596] [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: 06/15/2023] [Revised: 09/10/2023] [Accepted: 10/21/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVE Examine outcomes for lateral arm autologous tissue transfer in head and neck reconstruction. STUDY DESIGN Retrospective cohort study. SETTING Tertiary cancer center. METHODS All patients who underwent traditional lateral arm, extended lateral arm, and lateral forearm flaps for head and neck reconstruction from 2012 to 2022 were assessed. Disabilities of the arm, shoulder, and hand (DASH) was measured. Factors associated with complications and enteral or mixed diet were evaluated by multivariable regression. RESULTS Among 160 patients followed for a median of 2.3 ± 2.1 years, defects were 54% oral tongue, 18% external, 9% maxilla, 8% buccal mucosa, 9% floor of mouth, and 3% pharynx. Flap types (and median pedicle lengths) were 41% traditional lateral arm (8 cm), 25% extended lateral arm (11.5 cm), and 34% lateral forearm (14 cm). All donor sites were closed primarily; 19.6% and 0% of patients had increased DASH scores 2 and 12 weeks after reconstruction. Major complications occurred in 18.1% of patients, including 6.3% reoperation, 6.9% readmission, 3.7% fistula, and 1.8% flap loss. Complications were independently associated with peripheral vascular disease (odds ratio [OR]: 5.71, 95% confidence interval [CI]: 1.5-21.6, P = .01), pharyngeal defects (OR: 11.3, 95% CI: 1.4-94.5, P = .025), and interposition vein grafts (OR: 3.78, 95% CI: 1.1-13.3, P = .037). CONCLUSION The lateral arm free flap was safe, versatile, and reliable for head and neck reconstruction with low donor-site morbidity. Complications occurred in a fifth of patients and were associated with peripheral vascular disease, pharyngeal defects, and vein grafts.
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Affiliation(s)
- Kevin J Contrera
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abbas M Hassan
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John W Shuck
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Bobian
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Austin Y Ha
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Edward I Chang
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick B Garvey
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Margaret S Roubaud
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Z-Hye Lee
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mathew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rene D Largo
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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9
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Kim M, Wu MP, Miller LE, Meyer CD, Feng AL, Varvares MA, Deschler DG, Lin DT, Richmon JD. Early Weight-Bearing After Fibula Free Flap Surgery. JAMA Otolaryngol Head Neck Surg 2024; 150:127-132. [PMID: 38127340 PMCID: PMC10853825 DOI: 10.1001/jamaoto.2023.4024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/27/2023] [Indexed: 12/23/2023]
Abstract
Importance Despite the widespread use of fibula free flap (FFF) surgery for head and neck reconstruction, there are no studies assessing if early weight-bearing (EWB) affects postoperative recovery, and the timing of weight-bearing initiation following FFF surgery varies considerably across institutions. Therefore, it is important to understand the effect of EWB in these patients and whether it could improve postoperative recovery. Objective To assess the association of EWB after FFF surgery with donor-site complications, length of stay, and discharge to home status. Design, Setting, and Participants This retrospective cohort study took place at Massachusetts Eye and Ear, a single tertiary care institution in Boston, Massachusetts. A total of 152 patients who received head and neck reconstruction with a fibula osteocutaneous free flap between January 11, 2010, and August 11, 2022, were included. Exposure EWB on postoperative day 1 vs non-EWB on postoperative day 2 or later. Main Outcomes and Measures Patient characteristics, including demographic characteristics and comorbidities, surgical characteristics, donor-site complications, length of stay, and discharge disposition, were recorded. Descriptive statistics and multivariate logistic regressions were used to compute effect sizes and 95% CIs to compare postoperative outcomes in EWB and non-EWB groups. Results A total of 152 patients (median [IQR] age, 63 [55-70] years; 89 [58.6%] male) were included. The median (IQR) time to postoperative weight-bearing was 3 (1-5) days. Among all patients, 14 (9.2%) had donor-site complications. EWB on postoperative day 1 was associated with shorter length of stay (adjusted odds ratio [AOR], 0.10; 95% CI, 0.02-0.60), increased rate of discharge to home (AOR, 7.43; 95% CI, 2.23-24.80), and decreased donor-site complications (AOR, 0.11; 95% CI, 0.01-0.94). Conversely, weight-bearing 3 or more days postoperatively was associated with an increased risk of pneumonia (AOR, 6.82; 95% CI, 1.33-34.99). Conclusions and Relevance In this cohort study, EWB after FFF surgery was associated with shorter length of stay, increased rate of discharge to home, and decreased donor-site complications. These findings support the role of early mobilization to optimize postoperative recovery after FFF surgery.
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Affiliation(s)
- Minjee Kim
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Michael P. Wu
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Lauren E. Miller
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Charles D. Meyer
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Allen L. Feng
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Mark A. Varvares
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Daniel G. Deschler
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Derrick T. Lin
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Jeremy D. Richmon
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
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10
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Chang VKO, See L, Griffin A, Breik O, Batstone MD, Liu TPJ. Impact of dental state and surgical factors on postoperative neck infection in oral cancer patients. Br J Oral Maxillofac Surg 2024; 62:51-57. [PMID: 38044253 DOI: 10.1016/j.bjoms.2023.10.013] [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: 06/04/2023] [Revised: 08/29/2023] [Accepted: 10/17/2023] [Indexed: 12/05/2023]
Abstract
Postoperative neck infection (PONI) is a known complication of neck dissection. In this study we explored the impact of dental status on the development of PONI, using orthopantomograms to assess edentulism, periodontal health, and caries status. Retrospective analysis was performed for all new oral cancer patients who had neck dissection between January 2008 and January 2020 in a tertiary head and neck centre. PONI risk factors assessed included patient characteristics, dental status, tumour, and surgical factors. Development of PONI was the primary outcome. Edentulous patients had lower risk of PONI (OR 0.06, p = 0.026) compared to those with 21 or more teeth. Periodontitis and dental caries were not statistically significant. Current smokers (OR 2.09, p = 0.044) and free flap reconstruction (OR 5.41, p < 0.001) were also significant predictors for development of PONI. This study highlights the presence of teeth as a potential source of infection post neck dissection and that orthopantomogram assessment may be inadequate to identify at risk patients. Future studies are required on direct clinical assessment of dentition to evaluate the impact of dental optimisation in prevention of PONI.
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Affiliation(s)
- Victor K O Chang
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia.
| | - Lydia See
- Metro North Oral Health Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Dentistry, University of Queensland, Brisbane, Queensland, Australia; Adjunct Research Fellow School of Dentistry, University of Western Australia, Perth, Australia
| | - Alison Griffin
- Statistics Unit, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Queensland, Australia
| | - Omar Breik
- Oral and Maxillofacial Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Martin D Batstone
- Oral and Maxillofacial Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Timothy P J Liu
- Metro North Oral Health Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Dentistry, University of Queensland, Brisbane, Queensland, Australia; Adjunct Research Fellow School of Dentistry, University of Western Australia, Perth, Australia
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11
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Vu JV, Lussiez A. Smoking Cessation for Preoperative Optimization. Clin Colon Rectal Surg 2023; 36:175-183. [PMID: 37113283 PMCID: PMC10125302 DOI: 10.1055/s-0043-1760870] [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: 04/29/2023]
Abstract
Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.
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Affiliation(s)
- Joceline V. Vu
- Department of Surgery, Temple University Hospital System, Philadelphia, Pennsylvania
| | - Alisha Lussiez
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
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12
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Strübing F, Wenz F, Etminan N, Bigdeli AK, Siegwart LC, Thomas B, Vollbach F, Vogelpohl J, Kneser U, Gazyakan E. Scalp Reconstruction Using the Latissimus Dorsi Free Flap: A 12-Year Experience. J Clin Med 2023; 12:jcm12082953. [PMID: 37109289 PMCID: PMC10142007 DOI: 10.3390/jcm12082953] [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: 03/13/2023] [Revised: 04/07/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Complex scalp defects are regularly reconstructed using microvascular tissue transfer. The latissimus dorsi free flap is one of the workhorse flaps used in scalp reconstruction. These cases necessitate, particularly in the elderly, a close cooperation between plastic surgeons and neurosurgeons. The purpose of this study was to evaluate the suitability of the latissimus dorsi free flap for complex scalp reconstructions and to analyze potential risk factors. METHODS A retrospective study identified 43 patients undergoing complex scalp reconstruction using a latissimus dorsi free flap at our department between 2010 and 2022. RESULTS The mean patient age was 61 ± 18 years. Defects were mostly caused by oncologic tumor resections (n = 23; 55%), exposure to a cranioplasty (n = 10; 23%) or infection (n = 4; 9%). The most frequent recipient vessels were the superficial temporal artery (n = 28; 65%), external carotid artery (n = 12; 28%) and the venae comitantes (n = 28; 65%), external jugular vein (n = 6; 14%). The reconstructive success rate was 97.7%. There was one total flap loss (2%). Partial flap loss occurred in five cases (12%). Follow-up was 8 ± 12 months. Major complications were seen in 13 cases, resulting in a revision rate of 26%. Multivariate logistic regression identified active tobacco use as the only risk factor for major complications (odds ratio 8.9; p = 0.04). CONCLUSION Reconstruction of complex scalp defects using the latissimus dorsi free flap yielded high success rates. Among the potential risk factors, active tobacco use seems to affect the outcome of complex scalp reconstructions.
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Affiliation(s)
- Felix Strübing
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Fabian Wenz
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Laura C Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Felix Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Julian Vogelpohl
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, 69117 Heidelberg, Germany
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13
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Varman R, Miller MQ. Microvascular Gracilis Free Flap: Single and Double Innervation. Atlas Oral Maxillofac Surg Clin North Am 2023; 31:33-41. [PMID: 36754505 DOI: 10.1016/j.cxom.2022.09.005] [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: 02/09/2023]
Abstract
Facial paralysis (FP) is a devastating condition that can lead to significant aesthetic, social, and emotional morbidities for patients. For some patients with FP, free gracilis muscle transfer (FGMT) is the best option for smile restoration. Masseteric-driven FGMT produces a reliable voluntary smile. Cross-face nerve graft-driven FGMT can produce a spontaneous smile, but this technique has higher failure rates. Early studies suggest dual-innervation FGMT can produce a spontaneous smile while maintaining the reliability of masseteric-driven procedures. Great care should be taken during FGMT surgery to minimize facial bulk and place medial inset sutures that create a natural-appearing smile.
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Affiliation(s)
- Rahul Varman
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Matthew Q Miller
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, NC, USA.
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14
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Plonowska-Hirschfeld KA, Zebolsky AL, Lindeborg MM, McNeill C, Knott PD, Seth R, Park AM, Heaton CM. Restarting Therapeutic Antibiotics Following Postoperative Prophylaxis in Head and Neck Microvascular Free Tissue Transfer. Otolaryngol Head Neck Surg 2023; 168:357-365. [PMID: 35972809 DOI: 10.1177/01945998221117794] [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: 03/21/2022] [Accepted: 07/18/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine factors associated with restarting therapeutic antibiotics within 30 days of head and neck microvascular free tissue transfer (HN-MFTT). STUDY DESIGN Retrospective study of consecutive HN-MFTTs performed from January 2015 to July 2020. SETTING Tertiary academic medical center. METHODS Thirty-day postoperative antibiotic use and post-HN-MFTT surgical and medical complications were assessed. Univariable analyses and multivariable logistic regression were used to evaluate risk factors associated with restarting antibiotics. RESULTS overall 482 patients with 501 HN-MFTTs were stratified by duration of prophylaxis: ≤24 hours (n = 136, 27.1%), 25-72 hours (n = 54, 10.8%), and >72 hours (n = 311, 62.1%). Antibiotics were restarted in 199 patients (209 procedures, 42%). The most common indications for antibiotic reinitiation were flap recipient site infection (n = 59, 28%); hospital-acquired pneumonia (n = 44, 21%); and wound dehiscence, fluctuance, or change in quality of drain output (n = 44, 21%). Shorter antibiotic prophylaxis (≤24 hours) (odds ratio [OR], 1.95; 95% CI, 1.2-3.0; P = .003), osteocutaneous flaps (OR, 2.15; 95% CI, 1.3-3.4; P = .001), and prior immunotherapy/chemotherapy (OR, 2.29; 95% CI, 1.2-4.3; P = .01) were associated with reinitiation of antibiotics for surgical infections. Restarting antimicrobials for nosocomial infections was associated with aerodigestive defects (OR, 2.45; 95% CI, 1.1-5.2; P = .019), cardiovascular disease (OR, 3.00; 95% CI, 1.5-5.9; P = .001), and medical comorbidities approximated by American Society of Anesthesiologists class 3 or 4 (OR, 2.83; 95% CI, 1.5-5.4; P = .002). CONCLUSION Aerodigestive reconstruction, 24-hour postoperative antimicrobial prophylaxis, American Society of Anesthesiologists class 3 and 4, prior chemotherapy/immunotherapy, cardiovascular disease, and osteocutaneous flaps are associated with reinitiation of antibiotics within 30 days of HN-MFTT.
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Affiliation(s)
| | - Aaron L Zebolsky
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Michael M Lindeborg
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Christian McNeill
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - P Daniel Knott
- Division of Facial Plastics and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Rahul Seth
- Division of Facial Plastics and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Andrea M Park
- Division of Facial Plastics and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Chase M Heaton
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
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15
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Stevens MN, Freeman MH, Shinn JR, Kloosterman N, Carr S, Mannion K, Rohde SL. Preoperative Predictors of Free Flap Failure. Otolaryngol Head Neck Surg 2023; 168:180-187. [PMID: 35412879 DOI: 10.1177/01945998221091908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure. STUDY DESIGN Retrospective cohort study of 1070 patients. SETTING Head and neck surgical oncology service at a tertiary care center from 2005 to 2019. METHODS Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (<8 days from surgery). RESULTS In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure. CONCLUSION Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.
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Affiliation(s)
- Madelyn N Stevens
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael H Freeman
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Austin, Texas, USA
| | | | - Shane Carr
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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16
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Nunna RS, Ansari D, Ostrov PB, Dettori JR, Godolias P, Ortiz-Torres M, Elias E, Gruber M, Oskouian RJ, Chapman JR. The Risk of Adverse Events in Smokers Undergoing Spinal Fusion: A Systematic Review and Meta-Analysis. Global Spine J 2023; 13:242-253. [PMID: 36367824 PMCID: PMC9837502 DOI: 10.1177/21925682221110127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES Determine if tobacco use is associated with increased risk of postoperative adverse events within 90 days in patients undergoing spinal fusion surgery. METHODS Databases were queried to identify cohort studies that directly compared smokers with non-smokers and provided the absolute number of adverse events and the population at risk. Data quality was evaluated using the Quality in Prognosis Studies tool. Risk ratios (RR) and 95% confidence intervals were calculated and compared between studies. The grading of recommendation, assessment, development and evaluation (GRADE) criteria were used to assess the strength of the evidence. RESULTS Seventeen studies assessing 37 897 participants met the inclusion criteria. Of these, 10 031 (26.5%) were smokers and 27 866 (73.5%) were nonsmokers. The mean age for the study population was 58 years, and 45% were males. Smoking was not associated with increased risk of one or more major adverse events within 90 days following spine surgery (seven studies, pooled RR 1.13, 95% CI [.75-1.71], I2 = 41%). However, smoking was significantly associated with one or more major adverse events in ≤2 level fusion (three studies, pooled RR 2.46, 95% CI [1.18-5.12], I2 = 0%), but not in fusions of ≥3 levels (four studies, pooled RR .87, 95% CI [.70-1.08], I2 = 0%). Additionally, there was no statistically significant association between smoking and any adverse event, nor increased reoperation risk due to adverse events. CONCLUSIONS In this meta-analysis, tobacco use was not associated with a statistically significant increased risk of adverse events within 90 days in patients undergoing spinal fusion surgery. Our results are limited by the variable reporting methodology for both complication rates as well as smoking incidence between the included individual studies.
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Affiliation(s)
- Ravi S. Nunna
- Department of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Darius Ansari
- Department of Neurosurgery, University of Illinois at
Chicago, Chicago, IL, USA
| | - Philip B. Ostrov
- Department of Neurosurgery, University of Illinois at
Chicago, Chicago, IL, USA
| | | | | | | | - Elias Elias
- Department of Neurosurgery, University of
Texas-Southwestern, Dallas, TX, USA
| | - Max Gruber
- Elson S. Floyd College of
Medicine, Spokane, WA, USA
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17
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Is There a Smoking Gun for Nicotine? A Review of the Role of Nicotine in Dermatologic Surgery. Dermatol Surg 2022; 48:1171-1175. [PMID: 35862721 DOI: 10.1097/dss.0000000000003547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Dermatologic surgeons are faced with a dilemma when counseling actively smoking patients who require dermatologic surgery: recommend total cessation of all nicotine that is associated with extremely high rates of cessation failure or recommend nicotine replacement therapy (NRT). OBJECTIVE To determine the safety of NRT in dermatologic surgery. MATERIALS AND METHODS PubMed was queried: [(nicotine OR electronic cigarettes) AND (flap OR wound healing)]. RESULTS Smoking tobacco is detrimental to wound healing, supported by ample evidence (1A). Perioperative smoking cessation reduces risk (1B). Basic science demonstrates both a benefit and detriment of nicotine depending on the factor studied (2A). Human studies suggest no detrimental effect of nicotine on perioperative complications (1B). Nicotine may be detrimental to flaps, but evidence is limited to basic science (2A). CONCLUSION Dermatologists should consider recommending nicotine replacement for smokers in the perioperative period. Evidence is lacking to determine safety in flaps. It is presumed based on animal studies that nicotine has a negative effect on flaps; however, it is likely less than tobacco. Weighing the risk of cessation failure without nicotine replacement versus nicotine replacement after flap is challenging. Electronic cigarettes should be discouraged as a means of NRT.
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18
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Ooms M, Puladi B, Houschyar KS, Heitzer M, Rashad A, Bickenbach J, Hölzle F, Modabber A. Smoking and microvascular free flap perfusion in head and neck reconstruction: radial free forearm flaps and anterolateral thigh flaps. Sci Rep 2022; 12:13902. [PMID: 35974131 PMCID: PMC9381556 DOI: 10.1038/s41598-022-18216-6] [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: 03/03/2022] [Accepted: 08/08/2022] [Indexed: 11/09/2022] Open
Abstract
Head and neck reconstruction with microvascular free flaps is frequently performed in smokers. Smoking causes various alterations in the cardiovascular system. The aim of this study was to investigate the effects of smoking on flap perfusion as a critical factor for flap survival. A total of 370 patients reconstructed with a radial free forearm flap (RFFF) or anterolateral thigh flap (ALTF) in the head and neck region between 2011 and 2020 were retrospectively analyzed. Flap perfusion measurements with the O2C tissue oxygen analysis system were compared between nonsmokers, light smokers (< 20 pack-years), and heavy smokers (≥ 20 pack-years). The blood flow was intraoperatively equal in RFFFs (84.5 AU vs. 84.5 AU; p = 0.900) and increased in ALTFs (80.5 AU vs. 56.5 AU; p = 0.001) and postoperatively increased in RFFFs (114.0 AU vs. 86.0 AU; p = 0.035) and similar in ALTFs (70.5 AU vs. 71.0 AU; p = 0.856) in heavy smokers compared to nonsmokers. The flap survival rate was similar in nonsmokers, light smokers, and heavy smokers (97.3%, 98.4%, and 100.0%). Smoking partially increases rather than decreases microvascular free flap perfusion, which may contribute to similar flap survival rates in smokers and nonsmokers.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Behrus Puladi
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Khosrow Siamak Houschyar
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ashkan Rashad
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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19
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Iida H, Kai T, Kuri M, Tanabe K, Nakagawa M, Yamashita C, Yonekura H, Iida M, Fukuda I. A practical guide for perioperative smoking cessation. J Anesth 2022; 36:583-605. [PMID: 35913572 DOI: 10.1007/s00540-022-03080-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022]
Abstract
The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.
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Affiliation(s)
- Hiroki Iida
- Japanese Society of Anesthesiologists Perioperative Smoking Cessation Working Group, Kobe, Japan. .,Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu, Japan. .,Anesthesiology and Pain Relief Center, Central Japan International Medical Center, 1-1 Kenkonomachi, Minokamo, Gifu, 505-8510, Japan.
| | - Tetsuya Kai
- Japanese Society of Anesthesiologists Perioperative Smoking Cessation Working Group, Kobe, Japan.,Department of Anesthesiology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Michioki Kuri
- Japanese Society of Anesthesiologists Perioperative Smoking Cessation Working Group, Kobe, Japan.,Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kumiko Tanabe
- Japanese Society of Anesthesiologists Perioperative Smoking Cessation Working Group, Kobe, Japan.,Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masashi Nakagawa
- Japanese Society of Anesthesiologists Perioperative Smoking Cessation Working Group, Kobe, Japan.,Department of Intensive Care Medicine, Tokyo Women's Medical University, Shinjuku, Japan
| | - Chizuru Yamashita
- Japanese Society of Anesthesiologists Perioperative Smoking Cessation Working Group, Kobe, Japan.,Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hiroshi Yonekura
- Japanese Society of Anesthesiologists Perioperative Smoking Cessation Working Group, Kobe, Japan.,Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Mami Iida
- Japanese Society of Anesthesiologists Perioperative Smoking Cessation Working Group, Kobe, Japan.,Department of Internal Medicine, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Ikuo Fukuda
- Japanese Society of Anesthesiologists Perioperative Smoking Cessation Working Group, Kobe, Japan.,Cardiovascular Center, Suita Tokushukai Hospital, Suita, Japan
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20
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Sobti N, Ahmed KS, Polanco T, Chilov M, Cohen MA, Boyle J, Shahzad F, Matros E, Nelson JA, Allen RJ. Mini-plate versus reconstruction bar fixation for oncologic mandibular reconstruction with free fibula flaps: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:2691-2701. [PMID: 35752590 PMCID: PMC9391286 DOI: 10.1016/j.bjps.2022.04.097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 03/01/2022] [Accepted: 04/12/2022] [Indexed: 11/25/2022]
Abstract
Introduction There is currently no consensus as to the comparative complication profiles of mini-plate (MP) and reconstruction bar (RB) osseous fixation in fibula flap mandibular reconstruction. The aim of this study is to compare complication rates associated with the use of MP versus RB fixation for vascularized fibula free flap (FFF) reconstruction of oncologic mandibular defects in an effort to better guide hardware utilization and pre-operative virtual surgical planning methods. Methods A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Library databases were queried to identify studies related to FFF-based mandibular reconstruction with either MP or RB fixation. Primary endpoints of interest were plate complications, wound infection, mal- or non-union, and total flap loss. Complication rates were calculated as weighted proportions and compared via Fisher's exact testing. Results Sixteen studies met inclusion criteria, which examined 1,513 patients. Only three studies directly compared MP fixation with RB fixation. MP fixation was used in 828 (54.7%) cases and RB fixation in 685 (45.3%) cases. MP fixation demonstrated greater rates of plate-related complications (32.5% versus 18.8%, p < 0.01, respectively), fistula formation (15.8% versus 4.7%, p = 0.04), total flap loss (9.4% versus 4.7%, p = 0.02), partial flap loss (20.6% versus 6.1%, p < 0.01), and re-operation for vascular compromise (13.3% versus 4.0%, p < 0.01). Rates of infection, mal-union/non-union, and wound dehiscence were similar across both groups. Conclusion Our results suggest that MP use may be associated with higher rates of plate-related complications. Though limited by outcome reporting heterogeneity, this review can serve as a template for future investigations evaluating the safety profiles of MP and RB fixation in head and neck surgery.
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Affiliation(s)
- Nikhil Sobti
- Section of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
| | | | - Thais Polanco
- Section of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Marina Chilov
- Section of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
| | | | - Jay Boyle
- Medical College, Aga Khan University, Pakistan
| | - Farooq Shahzad
- Section of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Evan Matros
- Section of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Jonas A Nelson
- Section of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, NY, USA.
| | - Robert J Allen
- Section of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, NY, USA; Head and Neck Service, Memorial Sloan Kettering Cancer Center, NY, USA.
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21
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Denis B, Gourbeix C, Coninckx M, Foy JP, Bertolus C, Constantin JM, Degos V. Maxillofacial free flap surgery outcomes in critical care: a single-center investigation looking for clues to improvement. Perioper Med (Lond) 2022; 11:11. [PMID: 35264210 PMCID: PMC8908562 DOI: 10.1186/s13741-022-00244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Maxillofacial surgery for free flap reconstructions is associated with many complications due to technical complexity and comorbidity of patients. With a focus on critical care, the authors studied the impact of complications to highlight predictors of poor postoperative outcomes in order to implement optimization protocols. Methods This case-control study analyzed the relationship between perioperative variables and postoperative medical and surgical complications of patients who underwent head and neck surgery using fibular and forearm free flaps. The primary objective was the incidence of prolonged intensive care unit (ICU) length of stay (LOS). Secondary objectives were the incidence of ICU readmissions, postoperative infections, and 1-year mortality. A univariable logistic regression model was used. A study of mortality was performed with survival analysis. Regarding our primary objective, we performed a Benjamini-Hochberg procedure and a multivariable Poisson regression with defined variables of interest. Results The data of 118 hospital stays were included. Prolonged ICU LOS was observed in 47% of cases and was associated with chronic obstructive pulmonary disease, pneumopathies, intraoperative blood transfusion, and surgical duration. Medical and surgical complications were associated with prolonged ICU LOS. After the Benjamini-Hochberg procedure, infectious complications, complications, major complications, total number of pneumopathies, and operative time remained significant. At least one complication was experienced by 71% of patients during the hospitalization, and 33% of patients suffered from major complications. Infectious complications were the most common (40% of patients) and were mainly caused by pneumonia (25% of patients); these complications were associated with low preoperative hemoglobin level, intraoperative blood transfusion, accumulation of reversible cardiovascular risk factors, chronic alcohol consumption, and duration of surgery. Pneumonia was specifically associated with chronic obstructive pulmonary disease. The ICU readmission rate was 10% and was associated with lower preoperative hemoglobin level, pneumopathies, surgical duration, and use of a fibular flap. The 1-year mortality was 12%, and the survival analysis showed no association with prolonged ICU LOS. Poisson regression showed that ICU LOS was prolonged by smoking history, lower preoperative hemoglobin level, intraoperative blood transfusion, major complication, and pneumopathies. Conclusions Practices such as blood management and respiratory prehabilitation could be beneficial and should be evaluated as a part of global improvement strategies.
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Affiliation(s)
- Bruno Denis
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France. .,Intensive Care Unit, Saint-Luc Hospital, Université Catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Claire Gourbeix
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Marine Coninckx
- Maxillofacial Surgery Unit, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Jean-Philippe Foy
- Maxillofacial Surgery Unit, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Chloé Bertolus
- Maxillofacial Surgery Unit, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Jean-Michel Constantin
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Vincent Degos
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
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22
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Are Perforators Reliable as Recipient Arteries in Lower Extremity Reconstruction? Analysis of 423 Free Perforator Flaps. Plast Reconstr Surg 2022; 149:750-760. [PMID: 35080525 DOI: 10.1097/prs.0000000000008873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perforator flaps have revolutionized lower limb reconstruction by offering single-stage thin, pliable coverage with an excellent aesthetic match. Although anastomosis of the flap to a major artery remains the gold standard, perforator-to-perforator anastomosis has several advantages, including expedient recipient dissection and increased recipient options in vessel-depleted extremities. The aim of this study was to compare flap survival when a perforator or major artery was used as a recipient vessel. METHODS A retrospective cohort of free perforator flaps for lower limb reconstruction was reviewed. Demographics, comorbidities, vascular status, defect characteristics, operative details, and complications were recorded. Outcomes for perforator and major artery recipients were compared. RESULTS Four hundred twenty-three flaps were performed for various reasons using perforator flaps. The total limb salvage rate was 98.8 percent. Total and partial flap failure rates were 6.1 percent and 9.0 percent, respectively. Comparing perforator recipients [n = 109 (25.8 percent)] to major artery recipients [n = 314 (74.2 percent)], there was no significant difference in total (p = 0.746) or partial flap failure (p = 0.212). Significant factors between the groups included larger flap size with major artery recipients (p = 0.001) and shorter operative time when using a perforator recipient (p = 0.012). CONCLUSIONS Perforator-to-perforator anastomosis is a reliable option that affords equivalent rates of flap success compared to major artery anastomosis in lower extremity reconstruction. The authors advocate using a major artery recipient in defects where the axial vessels are easily accessible. A perforator recipient is a viable alternative in defects where access to the axial vessels is inconvenient and in patients with limited recipient options. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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23
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Panayi AC, Haug V, Kauke-Navarro M, Diehm YF, Pomahac B. The Impact of Metabolic Syndrome on Microvascular Head and Neck Reconstruction: An ACS-NSQIP data analysis. J Plast Reconstr Aesthet Surg 2021; 75:1360-1371. [PMID: 34955390 DOI: 10.1016/j.bjps.2021.11.074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 10/05/2021] [Accepted: 11/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Metabolic syndrome (MetS) can predispose patients to poorer surgical outcomes. In this study, we sought to evaluate the impact of MetS on the postoperative outcomes of head and neck microvascular reconstruction. METHODS Review of the 2015-2019 NSQIP database identified 5,323 cases of microvascular reconstruction, of which 3,809 were head and neck cases. Of the included patients, 184 had MetS and 3625 did not. The groups were compared in terms of demographics and comorbidities. Postoperative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and nonhome discharge. RESULTS The MetS group had higher rates of medical complications (p<0.0001), sepsis (p=0.02), septic shock (p=0.01), and skilled care-discharge (p=0.0004). Analysis by flap type revealed that MetS patients receiving free skin flaps experienced higher rates of organ space infection (p=0.02), sepsis (p<0.0001), and lower home-discharge (p=0.01). In the free muscle group, superficial incisional infection (p=0.04), UTI (p=0.02), and septic shock (p=0.01) were higher in MetS patients. Stratification by surgical site showed that the occurrence of sepsis was significantly higher in the patients receiving microvascular flap reconstruction of the larynx (p=0.04) or tongue(p=0.03). Stratification of the MetS patients according to treatment for diabetes showed that patients receiving insulin experienced a higher rate of superficial incisional infection (p=0.04). A multivariate analysis verified significantly higher rates of medical complications (p<0.0001), sepsis (p=0.03) and septic shock (p=0.01) in the MetS group. CONCLUSION Patients with MetS undergoing head and neck microvascular reconstruction are at increased risk of postoperative medical complications, including sepsis and septic shock, and are more likely to be discharged to a skilled care facility. Surgical outcomes were found to depend on the type of flap and site of surgery.
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Affiliation(s)
- Adriana C Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA
| | - Yannick F Diehm
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA.
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24
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The Opportunity Cost of Resident Involvement in Adult Craniofacial Surgery: An Analysis of Relative Value Units. J Craniofac Surg 2021; 33:125-128. [PMID: 34456286 DOI: 10.1097/scs.0000000000008104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Within the academic surgical setting resident involvement may confer longer operative times. The increasing pressures to maximize clinical productivity and decreasing reimbursement rates, however, may conflict with these principles. This study calculates the opportunity cost of resident involvement in craniofacial surgery. METHODS Retrospective analysis was conducted with patients who underwent craniofacial procedures from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Patients were selected based on relevant Current Procedural Terminology codes for craniofacial pathologies (ie, trauma, head and neck reconstruction, orthognathic surgery, and facial reanimation). Variables included patient demographics, operative time, and presence or absence of resident trainee. Average relative value units were calculated to determine the opportunity cost of resident involvement for each craniofacial procedure. RESULTS In total, 2096 patients were identified through the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Resident involvement was associated with a statistically significant higher operative time (P < 0.001) for facial reanimation, facial trauma, orthognathic surgery, and head and neck reconstruction. The opportunity costs per case associated with resident involvement were the highest for head and neck reconstruction ($1468.04), followed by orthognathic surgery ($1247.03), facial trauma ($533.03), and facial reanimation ($358.32). Resident involvement was associated with higher rate of complications for head and neck reconstruction (P < 0.043). CONCLUSIONS Resident involvement is associated with longer operative times, higher complications, and higher re-operations, compared to attending exclusive surgical care. Future studies may consider how reimbursements should align incentives to promote resident education and training.
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25
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Karamanos E, Saad N, Smith KE, Patnaik R, Wang HT, Cromack D. Not all flaps are created equal: Assessing the impact of active smoking in muscle-only versus perforator flaps for patients undergoing nonelective extremity-free tissue transfer-A case control study. Microsurgery 2021; 41:513-521. [PMID: 34390277 DOI: 10.1002/micr.30797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/26/2021] [Accepted: 08/05/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Active smoking is known to impair wound healing following free tissue transfer for reconstruction due to its vasoconstrictive effect on the microcirculation. The aim of this study was to evaluate the impact of flap selection on flap loss, in nonelective, traumatic extremity-free soft tissue transfer in active smokers. METHODS All patients undergoing a free tissue transfer for acute trauma of the extremity at a level I trauma center from 2011 to 2017 were identified. Breast reconstruction and osseous/osseocutaneous flaps were excluded. The study population was divided in two groups based on the type of flap used (muscle versus perforator flap). Factors known to be associated with impaired wound healing were extracted from the database. Primary outcome was major smoking related complications (complete/partial flap loss). Secondary outcomes included minor flap-related complications (infection, dehiscence) and donor site complications. The impact of smoking was assessed for the different type of flaps using multivariate analyses. RESULTS A total of 118 flaps were identified during the study period. Out of those, 52 were perforator-based fasciocutaneous flaps, while 66 were muscle flaps. Active smoking status resulted in a statistically significant increase in the incidence of major and minor complications in the perforator flap group (36% vs. 4%, adjusted odds ratio, AOR [95%CI]: 2.31[1.48,19.30], adj-p = 0.021 and 32% vs. 17%, AOR [95% CI]: 1.23[1.11,14.31], adj-p = 0.034) but had no impact in the muscle group. CONCLUSIONS The present study suggests a higher incidence of flap related complications in smokers when a perforator flap was selected but no impact when a muscle flap was utilized.
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Affiliation(s)
- Efstathios Karamanos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Long School of Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Noah Saad
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Long School of Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Kari E Smith
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Long School of Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Ronit Patnaik
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Long School of Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Howard T Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Long School of Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Douglas Cromack
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Long School of Medicine, UT Health San Antonio, San Antonio, Texas, USA
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26
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The Effect of Smoking on the Postoperative Course After Head and Neck Reconstruction With a Vascularized Free Flap: A Retrospective Study. J Craniofac Surg 2021; 32:1810-1812. [PMID: 34319682 DOI: 10.1097/scs.0000000000007526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The objective of the present study is to determine the impact of smoking on hospital and intensive care unit stay, need for surgical reintervention, Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, and surgical complications after head and neck reconstructions. METHODS All 153 patients who underwent head and neck reconstructions with free tissue transfer at the department of oral and maxillofacial surgery at the University Hospitals of Leuven between January 1, 2015 and December 31, 2018 were enrolled in this retrospective cohort study. Data from medical charts were extracted. Univariate and multiple regression analyses were performed. A level of significance of P < 0.05 (α = 0.05) was used. RESULTS Smoking was not associated with Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, hospital or ICU stay, the incidence of postoperative complications in both flap and donor site, or surgical reintervention. CONCLUSIONS Regarding the outcomes included in this study, smoking status should not be considered as a critical factor in patient selection for head and neck reconstructions with a vascularized free flap.
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27
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Healy DW, Cloyd BH, Straker T, Brenner MJ, Damrose EJ, Spector ME, Saxena A, Atkins JH, Ramamurthi RJ, Mehta A, Aziz MF, Cattano D, Levine AI, Schechtman SA, Cavallone LF, Abdelmalak BB. Expert Consensus Statement on the Perioperative Management of Adult Patients Undergoing Head and Neck Surgery and Free Tissue Reconstruction From the Society for Head and Neck Anesthesia. Anesth Analg 2021; 133:274-283. [PMID: 34127591 DOI: 10.1213/ane.0000000000005564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.
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Affiliation(s)
- David W Healy
- From the Department of Anesthesiology, The University of Michigan Medical School, Ann Arbor, Michigan
| | - Benjamin H Cloyd
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Tracey Straker
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York
| | - Michael J Brenner
- Department of Otolaryngology, Michigan Medicine-University of Michigan, Ann Arbor, Michigan
| | - Edward J Damrose
- Department of Otolaryngology/Head & Neck Surgery & Anesthesiology/Perioperative Medicine (by courtesy)
| | - Matthew E Spector
- Department of Otolaryngology, Michigan Medicine-University of Michigan, Ann Arbor, Michigan
| | - Amit Saxena
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Joshua H Atkins
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Arpan Mehta
- Department of Anesthesiology, Perioperative Medicine & Pain Management, The University of Miami, Miami, Florida
| | - Michael F Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Davide Cattano
- Department of Anesthesiology, McGovern Medical School, UTHealth Houston, Houston, Texas
| | - Adam I Levine
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samuel A Schechtman
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Laura F Cavallone
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Basem B Abdelmalak
- Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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28
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Crippen MM, Ganti RS, Xu V, Swendseid B, Tzeng DL, Curry J. Outcomes in Head and Neck Free Flap Reconstruction Among Patients With a History of Venous Thromboembolism. Otolaryngol Head Neck Surg 2021; 166:267-273. [PMID: 34060945 DOI: 10.1177/01945998211011999] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate if a history of venous thromboembolism (VTE) is a risk factor for complications in head and neck free flap surgery by assessing outcomes among patients with a history of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). STUDY DESIGN Retrospective cohort study. SETTING Single tertiary care center. METHODS All patients undergoing head and neck free flap reconstruction at our institution between September 1, 2006, and April 2, 2020, were assessed for inclusion. Patients with and without a history of DVT or PE preoperatively were identified and grouped for comparison. Groups were compared for demographics, comorbidities, and 30-day complications. Significance was assessed with chi-square and binary logistic regression analyses. RESULTS Of the 1061 patients meeting inclusion criteria, 40 (3.8%) had a history of VTE. These patients were significantly older (mean [SD], years: 67.8 [11.7] vs 63.0 [14.1], P = .038) and significantly more likely to have history of chemotherapy (35.0% vs 18.7%, P = .010) and stroke (27.5% vs 4.5%, P < .001). After accounting for patient characteristics via binary logistic regression, VTE was independently associated with an increased risk for postoperative thrombosis of the free flap pedicle (odds ratio [95% CI] = 3.65 [1.12-11.90], P = .032) and reoperation (2.45 [1.25-4.80], P = .009). Patients with history of PE had a significantly increased risk for flap failure (7.70 [1.77-33.52], P = .007). Prior VTE was not independently associated with an increased risk for medical complications or readmission. CONCLUSION Patients with a history of VTE may be at an increased risk for free flap compromise secondary to postoperative pedicle thrombosis. This risk should be considered in preoperative workup and postoperative monitoring.
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Affiliation(s)
- Meghan M Crippen
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rohan S Ganti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vivian Xu
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian Swendseid
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Diana L Tzeng
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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29
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Ramos-Zayas A, López-Medrano F, Urquiza-Fornovi I, Zubillaga I, Gutiérrez R, Sánchez-Aniceto G, Acero J, Almeida F, Galdona A, Morán MJ, Pampin M, Cebrián JL. The Impact of Healthcare-Associated Infections in Patients Undergoing Oncological Microvascular Head and Neck Reconstruction: A Prospective Multicentre Study. Cancers (Basel) 2021; 13:cancers13092109. [PMID: 33925543 PMCID: PMC8123773 DOI: 10.3390/cancers13092109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/10/2021] [Accepted: 04/22/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Healthcare-associated infections (HAIs) result in an increased morbidity and a delay in adjuvant therapy—thus increasing the cancer recurrence rates—in patients undergoing oncological microvascular head and neck reconstruction. HAIs also result in a cost increase for the Health System. We prospectively analysed the incidence, clinical characteristics, risk factors and impacts of these infections in 65 patients undergoing head and neck free-flap reconstruction in three third-level university hospitals in Madrid (Spain). The three of them implemented the same antibiotic prophylactic regimen for surgical interventions. The rate of HAIs was 61.54%. The following complications were significantly more frequent in patients with HAIs: need to reoperate (p = 0.009), duration of hospital admission (p < 0.001) and delay in starting radiotherapy (p = 0.009). This manuscript aims to point out the importance of preventing HAIs in head and neck cancer patients, as they have shown a higher risk of postoperative complications. Abstract (1) Background: Healthcare-associated infections (HAIs) after head and neck free-flap reconstruction are a common postoperative complication. Risk factors for HAIs in this context and their consequences have not been adequately described. (2) Methods: Ongoing prospective multicentre study between 02/2019 and 12/2020. Demographic characteristics and outcomes were analysed, focusing on infections. (3) Results: Forty out of 65 patients (61.54%) suffered HAIs (surgical site infection: 52.18%, nosocomial pneumonia: 23.20%, bloodstream infection: 13% and urinary tract infection: 5.80%). Methicillin-resistant Staphylococcus aureus (MRSA) and resistant Pseudomonas aeruginosa, Klebsiella pneumoniae and Enterobacter cloacae were the most frequently implicated. The significant risk factors for infection were: previous radiotherapy (Odds ratio (OR): 5.42; 95% confidence interval (CI), 1.39–21.10), anaemia (OR: 8.00; 95% CI, 0.96–66.95), salvage surgery (eight out of eight patients), tracheostomy (OR: 2.86; 95% CI, 1.01–8.14), surgery duration (OR: 1.01; 95% CI, 1.00–1.02), microvascular reoperation <72 h (eight/eight) and flap loss (eight/eight). The major surgical complications were: a need to reoperate (OR: 6.89; 95% CI, 1.42–33.51), prolonged hospital admission (OR: 1.16; 95% CI, 1.06–1.27) and delay in the initiation of postoperative radiotherapy (OR: 9.07; 95% CI, 1.72–47.67). The sixth month mortality rate in patients with HAIs was 7.69% vs. 0% in patients without HAIs (p = 0.50). (4) Conclusions: HAIs were common after this type of surgery, many of them caused by resistant microorganisms. Some modifiable risk factors were identified. Infections played a role in cancer prognosis by delaying adjuvant therapy.
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Affiliation(s)
- Ana Ramos-Zayas
- Oral and Maxillofacial Surgery Department, “12 de Octubre” University Hospital, Institute for Biomedical Research (i+12), Universidad Complutense, 28041 Madrid, Spain; (I.U.-F.); (I.Z.); (R.G.); (G.S.-A.)
- Correspondence: ; Tel.: +34-617955504
| | - Francisco López-Medrano
- Unit of Infectious Diseases, “12 de Octubre” University Hospital, Institute for Biomedical Research (i+12), Department of Medicine, School of Medicine, Universidad Complutense, 28041 Madrid, Spain;
| | - Irene Urquiza-Fornovi
- Oral and Maxillofacial Surgery Department, “12 de Octubre” University Hospital, Institute for Biomedical Research (i+12), Universidad Complutense, 28041 Madrid, Spain; (I.U.-F.); (I.Z.); (R.G.); (G.S.-A.)
| | - Ignacio Zubillaga
- Oral and Maxillofacial Surgery Department, “12 de Octubre” University Hospital, Institute for Biomedical Research (i+12), Universidad Complutense, 28041 Madrid, Spain; (I.U.-F.); (I.Z.); (R.G.); (G.S.-A.)
| | - Ramón Gutiérrez
- Oral and Maxillofacial Surgery Department, “12 de Octubre” University Hospital, Institute for Biomedical Research (i+12), Universidad Complutense, 28041 Madrid, Spain; (I.U.-F.); (I.Z.); (R.G.); (G.S.-A.)
| | - Gregorio Sánchez-Aniceto
- Oral and Maxillofacial Surgery Department, “12 de Octubre” University Hospital, Institute for Biomedical Research (i+12), Universidad Complutense, 28041 Madrid, Spain; (I.U.-F.); (I.Z.); (R.G.); (G.S.-A.)
| | - Julio Acero
- Oral and Maxillofacial Surgery Department, “Ramón y Cajal” University Hospital, Institute for Biomedical Research IRYCIS, Universidad de Alcalá, 28034 Madrid, Spain; (J.A.); (F.A.); (A.G.)
| | - Fernando Almeida
- Oral and Maxillofacial Surgery Department, “Ramón y Cajal” University Hospital, Institute for Biomedical Research IRYCIS, Universidad de Alcalá, 28034 Madrid, Spain; (J.A.); (F.A.); (A.G.)
| | - Ana Galdona
- Oral and Maxillofacial Surgery Department, “Ramón y Cajal” University Hospital, Institute for Biomedical Research IRYCIS, Universidad de Alcalá, 28034 Madrid, Spain; (J.A.); (F.A.); (A.G.)
| | - María José Morán
- Oral and Maxillofacial Surgery Department, “La Paz” University Hospital, Institute for Biomedical Research IdiPAZ, Universidad Autónoma, 28046 Madrid, Spain; (M.J.M.); (M.P.); (J.L.C.)
| | - Marta Pampin
- Oral and Maxillofacial Surgery Department, “La Paz” University Hospital, Institute for Biomedical Research IdiPAZ, Universidad Autónoma, 28046 Madrid, Spain; (M.J.M.); (M.P.); (J.L.C.)
| | - José Luis Cebrián
- Oral and Maxillofacial Surgery Department, “La Paz” University Hospital, Institute for Biomedical Research IdiPAZ, Universidad Autónoma, 28046 Madrid, Spain; (M.J.M.); (M.P.); (J.L.C.)
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The Impact of Smoking on Early Postoperative Complications in Hand Surgery. J Hand Surg Am 2021; 46:336.e1-336.e11. [PMID: 32868099 DOI: 10.1016/j.jhsa.2020.07.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 05/25/2020] [Accepted: 07/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Smoking is a prevalent modifiable risk factor that has been associated with adverse postoperative outcomes across numerous surgical specialties. We examined the impact of smoking on 30-day complications in patients undergoing hand surgery procedures. METHODS The American College of Surgeons National Surgical Quality Improvement Program data sets were queried for patients who underwent common hand surgery procedures from 2011 to 2016. Cohorts were divided into smoking and nonsmoking and compared in terms of demographic characteristics, comorbidities, and postoperative complications. Multivariable logistic regression models were used to control for demographic characteristics and comorbidities in assessing the association between smoking and postoperative infections as well as other major and minor complications. RESULTS We identified a cohort of 48,370 patients in the National Surgical Quality Improvement Program who underwent certain outpatient and inpatient hospital facility-based hand surgery procedures from 2011 to 2016. Up to 22% of these patients reported active smoking. Compared with nonsmokers, smokers were more likely to be younger and male and to have a lower body mass index. In addition, they were more likely to have a higher American Society of Anesthesiologists classification and to report dyspnea and chronic obstructive pulmonary disease. Multivariable logistic regression identified an independent association between smoking and major complications. Smoking was not significantly associated with minor complications. When regrouped by complication type, smoking was associated with infectious and wound healing complications. In subgroup analysis, smokers undergoing elective hand surgery had increased odds of wound healing complications but not major, minor, or infectious complications. CONCLUSIONS Smokers may be at a significantly higher odds of certain complications compared with nonsmokers. For patients undergoing the elective procedures evaluated in this study, perioperative smoking may increase the risk of wound-healing complications. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Moroco AE, Saadi RA, Patel VA, Lehman EB, Gniady JP. 30-Day Postoperative Outcomes Following Transcervical Zenker's Diverticulectomy in the Elderly: Analysis of the NSQIP Database. Otolaryngol Head Neck Surg 2020; 165:129-136. [PMID: 33287659 DOI: 10.1177/0194599820970503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To compare the effect of patient factors, including age, on 30-day postoperative outcomes and complications for patients undergoing transcervical Zenker's diverticulectomy. STUDY DESIGN Retrospective cross-sectional analysis. SETTING American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database. METHODS Patients who underwent open Zenker's diverticulectomy (Current Procedural Terminology code 43130) were queried via the NSQIP (2006-2018). Outcomes analyzed include patient demographics, medical comorbidities, admission type, operative characteristics, length of admission, postoperative complication, readmission, and reoperation. RESULTS A total of 614 patients were identified. Mean age at time of surgery was 71.1 years, with 13.4% older than 85 years. Outpatient procedures were performed in 29.8%. Postoperative complications occurred in 6.7%, with reoperation and readmission rates of 6.4% and 7.2%, respectively. A mortality rate of 0.3% was observed. Only smoking status (odds ratio, 2.94; P = .008) and history of congestive heart failure (odds ratio, 10.00; P = .014) were shown to have a significant effect on postoperative complications. CONCLUSION Smoking status confers a high risk for postoperative complication. Age was not an independent risk factor associated with adverse outcomes following open diverticulectomy, suggesting this procedure can be safely performed in patients with advanced age.
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Affiliation(s)
- Annie E Moroco
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert A Saadi
- Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Vijay A Patel
- Department of Otolaryngology, University of Pittsburgh School of Medicine, UPMC Centers for Cranial Base Surgery & Sinonasal Disorders and Allergy, Pittsburgh, Pennsylvania, USA
| | - Erik B Lehman
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - John P Gniady
- Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
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Falcone M, Blecher G, Anfosso M, Christopher AN, Ralph DJ. Total Phallic Reconstruction in the Genetic Male. Eur Urol 2020; 79:684-691. [PMID: 32800729 DOI: 10.1016/j.eururo.2020.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/21/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Total phallic reconstruction (TPR) is a reconstructive challenge. OBJECTIVE To report both surgical outcomes and patient-reported outcomes (PROs) of genetic male patients undergoing TPR utilising a radial artery forearm free flap (RAFFF). DESIGN, SETTING, AND PARTICIPANTS A retrospective tertiary referral centre analysis of a series of genetic male patients with penile insufficiency (PI) either due to congenital micropenis, or from traumatic or surgical amputation was conducted. SURGICAL PROCEDURE RAFFF phalloplasty was conducted as a multistaged procedure: (1) TPR, (2) glans sculpting with second-stage urethroplasty when indicated, and (3) penile prosthesis implantation. MEASUREMENTS A descriptive analysis of the patient's baseline features, surgical outcomes, and PROs was conducted. RESULTS AND LIMITATIONS A total of 108 patients were enrolled. The median age was 32.5 yr (interquartile range [IQR] 24-46) and median follow-up was 78.5 mo (IQR 30-129). A primary anastomotic urethroplasty was performed in 90 patients (83.4%) and a staged procedure in the remainder. Four patients experienced an acute arterial thrombosis, leading to complete loss of the phallus in two. Immediate surgical exploration saved the flap in two cases of venous thrombosis. Urethral complication occurred in 49.1% of patients. The multivariate logistic regression analysis showed an association (p=0.04) between the staged urethral reconstruction and the incidence of urethral complications. The limitations of our study are its retrospective nature and the lack of control. CONCLUSIONS Despite the high incidence of postoperative complications and the possible need for revisions, TPR in the genetic male with PI using a RAFFF yields satisfactory aesthetic and functional results. PATIENT SUMMARY: in this report, we looked at the outcomes from TPR in a large population of male patients with penile inadequacy either due to congenital micropenis, or from traumatic or surgical amputation. Our results support the idea that penile reconstruction with a forearm free flap leads to satisfactory outcomes.
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Affiliation(s)
- Marco Falcone
- Department of Neurourology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy; Department of Urology, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Gideon Blecher
- Monash University School of Clinical Sciences, Melbourne, Australia; Alfred Hospital, Melbourne, Australia
| | - Mattia Anfosso
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
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Garip M, Van Dessel J, Grosjean L, Politis C, Bila M. The impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap: a systematic review and meta-analysis. Br J Oral Maxillofac Surg 2020; 59:e79-e98. [PMID: 33546845 DOI: 10.1016/j.bjoms.2020.07.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 07/17/2020] [Indexed: 12/15/2022]
Abstract
Reconstructive surgery with a free vascularised tissue flap is indicated in large defects in the head and neck region, which arise mostly because of head and neck cancer. Tobacco smoking is a major risk factor for head and neck cancer, and many patients undergoing reconstructive surgery in the head and neck have a history of smoking. The objective of this meta-analysis was to determine the impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap. A systematic review was undertaken for articles reporting and comparing the incidence of overall surgical complications after reconstructive surgery with a free vascularised tissue flap between smokers and nonsmokers. Relevant articles were searched using PubMed, Cochrane, and Embase databases, and screened for eligibility according to the PRISMA guidelines. The risk of bias analysis was conducted using the Newcastle-Ottawa quality assessment scale. A meta-analysis was performed to quantitatively compare the incidence rate of overall surgical complications, flap failure, surgical site infection, fistula, and haematoma between smokers and nonsmokers using OpenMetaAnalyst (open source) software. Only qualitative analysis was performed for wound dehiscence, bleeding, nerve injury, and impaired wound healing. Forty-six articles were screened for eligibility; 30 full texts were reviewed, and 19 studies were included in the quantitative meta-analysis. From the 19 studies, 18 were retrospective and 1 was a prospective study. In total, 2155 smokers and 3124 nonsmokers were included in the meta-analysis. Smoking was associated with a significantly increased risk of 19.12% for haematoma (95% Confidence Interval (CI): 4.75-33.49; p<0.01), and of 4.57% for overall surgical complications (95% CI: 1.97-7.15; p<0.01). No significant difference in risk was found for flap failure (95% CI: -4.33-9.90; p=0.44), surgical site infection (95% CI: -0.88-2.60; p=0.33) and fistula formation (95% CI: -3.81-3.71; p=0.98) between smokers and nonsmokers. Only for flap failure was a significant heterogeneity found (I2=63.02%; p=0.03). Smoking tobacco was significantly associated with an increased risk of overall surgical complications and haematoma, but did not seem to affect other postoperative complications. Encouraging smoking cessation in patients who need reconstructive head and neck surgery remains important, but delaying surgery to create a non-smoking interval is not needed to prevent the investigated complications. More high-quality retrospective or prospective studies with a standardised protocol are needed to allow for definitive conclusions.
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Affiliation(s)
- M Garip
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium.
| | - J Van Dessel
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium; OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
| | - L Grosjean
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium; OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
| | - C Politis
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium; OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
| | - M Bila
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium; OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
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Kiong KL, Lin F, Yao CMKL, Guo T, Ferrarotto R, Weber RS, Lewis CM. Impact of neoadjuvant chemotherapy on perioperative morbidity after major surgery for head and neck cancer. Cancer 2020; 126:4304-4314. [DOI: 10.1002/cncr.33103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/16/2020] [Accepted: 06/20/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Kimberley L. Kiong
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Fang‐Yu Lin
- Department of Symptom Research The University of Texas MD Anderson Cancer Center Houston Texas
| | - Christopher M. K. L. Yao
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Theresa Guo
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Renata Ferrarotto
- Department of Thoracic Head and Neck Medical Oncology The University of Texas MD Anderson Cancer Center Houston Texas
| | - Randal S. Weber
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
| | - Carol M. Lewis
- Department of Head and Neck Surgery The University of Texas MD Anderson Cancer Center Houston Texas
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Reply to Comment on "Suprapubic Pedicled Phalloplasty in Transgender Men: a Multicentric Retrospective Cohort Analysis". Int J Impot Res 2020; 33:862-863. [PMID: 32376882 DOI: 10.1038/s41443-020-0274-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 11/08/2022]
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Falcone M, Timpano M, Oderda M, Cocci A, Morelli G, Preto M, Polito C, Giorgio IR, Gideon B, Gontero P. Suprapubic pedicled phalloplasty in transgender men: a multicentric retrospective cohort analysis. Int J Impot Res 2020; 33:808-814. [PMID: 32034312 DOI: 10.1038/s41443-020-0238-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/19/2020] [Accepted: 01/23/2020] [Indexed: 11/09/2022]
Abstract
A variety of approaches are available to address a genital gender affirming surgery (GGAS) in transgender men. The aim of the present study is to report surgical and functional outcomes after a suprapubic pedicled phalloplasty (SPP). From November 2008 to August 2018, a consecutive series of 34 patients underwent an SPP in two tertiary referral centers. GGAS was conducted as a multistaged procedure, consisting (1) SPP with subsequent radial artery-based forearm free-flap urethroplasty, (2) glans sculpting, urethral anastomosis, and scrotoplasty, and (3) penile prosthesis implantation. The duration of surgery, intra and postoperative complications, and hospital stay were selected as variables for surgical outcomes. Functional outcomes were extrapolated from a four-item questionnaire.A partial necrosis of phallus was detected in two cases (5.8 %). Two cases of seroma formation with wound dehiscence (5.8%) were detected. Overall, 89% of patients declared to be fully satisfied of the SPP, 83% would recommend the procedure to someone else, and 89% would undergo the same procedure again. Overall, 66% of patients could achieve an orgasm during sexual penetrative intercourses. The retrospective design, the lack of randomization and validated questionnaire for outcomes reporting, and the limited follow-up represent the main drawbacks of our study. Our evidences suggest that SPP represents as an acceptable option for GGAS.
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Affiliation(s)
- Marco Falcone
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy.
| | - Massimiliano Timpano
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| | - Marco Oderda
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| | - Andrea Cocci
- Urology department, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Mirko Preto
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| | | | | | - Blecher Gideon
- Urology Department, University of Melbourne, Melbourne, VIC, Australia
| | - Paolo Gontero
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
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de la Iglesia JV, Slebos RJC, Martin-Gomez L, Wang X, Teer JK, Tan AC, Gerke TA, Aden-Buie G, van Veen T, Masannat J, Chaudhary R, Song F, Fournier M, Siegel EM, Schabath MB, Wadsworth JT, Caudell J, Harrison L, Wenig BM, Conejo-Garcia J, Hernandez-Prera JC, Chung CH. Effects of Tobacco Smoking on the Tumor Immune Microenvironment in Head and Neck Squamous Cell Carcinoma. Clin Cancer Res 2019; 26:1474-1485. [PMID: 31848186 DOI: 10.1158/1078-0432.ccr-19-1769] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/05/2019] [Accepted: 12/11/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE Patients with head and neck squamous cell carcinoma (HNSCC) who actively smoke during treatment have worse survival compared with never-smokers and former-smokers. We hypothesize the poor prognosis in tobacco smokers with HNSCC is, at least in part, due to ongoing suppression of immune response. We characterized the tumor immune microenvironment (TIM) of HNSCC in a retrospective cohort of 177 current, former, and never smokers. EXPERIMENTAL DESIGN Tumor specimens were subjected to analysis of CD3, CD8, FOXP3, PD-1, PD-L1, and pancytokeratin by multiplex immunofluorescence, whole-exome sequencing, and RNA sequencing. Immune markers were measured in tumor core, tumor margin, and stroma. RESULTS Our data indicate that current smokers have significantly lower numbers of CD8+ cytotoxic T cells and PD-L1+ cells in the TIM compared with never- and former-smokers. While tumor mutation burden and mutant allele tumor heterogeneity score do not associate with smoking status, gene-set enrichment analyses reveal significant suppression of IFNα and IFNγ response pathways in current smokers. Gene expression of canonical IFN response chemokines, CXCL9, CXCL10, and CXCL11, are lower in current smokers than in former smokers, suggesting a mechanism for the decreased immune cell migration to tumor sites. CONCLUSIONS These results suggest active tobacco use in HNSCC has an immunosuppressive effect through inhibition of tumor infiltration of cytotoxic T cells, likely as a result of suppression of IFN response pathways. Our study highlights the importance of understanding the interaction between smoking and TIM in light of emerging immune modulators for cancer management.
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Affiliation(s)
- Janis V de la Iglesia
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Robbert J C Slebos
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Laura Martin-Gomez
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Xuefeng Wang
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Jamie K Teer
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Aik Choon Tan
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Travis A Gerke
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | - Garrick Aden-Buie
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | - Tessa van Veen
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Jude Masannat
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Ritu Chaudhary
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Feifei Song
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | | | - Erin M Siegel
- Total Cancer Care, Moffitt Cancer Center, Tampa, Florida
| | - Matthew B Schabath
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | - J Trad Wadsworth
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Jimmy Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Louis Harrison
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Bruce M Wenig
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | | | | | - Christine H Chung
- Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida.
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Boudreaux AM, Simmons JW. Prehabilitation and Optimization of Modifiable Patient Risk Factors: The Importance of Effective Preoperative Evaluation to Improve Surgical Outcomes. AORN J 2019; 109:500-507. [PMID: 30919430 DOI: 10.1002/aorn.12646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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