Evaluation of reconstructive techniques of oropharyngeal defects

Clinical Outcomes of a 14-Day In-Hospital Stay Program in Patients Undergoing Head and Neck Cancer Surgery With Free Flap Reconstruction Under the National Health Insurance System

Objectives

Length of in-hospital stay (LOS) is often regarded as a surrogate marker of efficiency in medical care. A shorter stay can redistribute medical resources to more patients if patient outcomes would not be worsened. However, the adequate LOS remains largely understudied for a complex head and neck cancer (HNC) surgery and free flap reconstruction.

Methods

Active management of LOS (14-day LOS program) included detailed preoperative surgical planning, intensive wound care, postoperative early ambulation and positive psychological encouragement. It was applied to 43 patients undergoing HNC surgery and free flap reconstruction. Outcomes such as noninferior oncological results, rates of timely adjuvant treatments and complications were compared with those of 125 patients without active management of LOS. In addition, the medical costs of shortened LOS were compared with those of the control group. Cases undergoing HNC surgery as a salvage treatment were excluded from both groups for analyses.

Results

Active management of LOS resulted in less in-hospital period compared to the control group (15.0 vs. 21.0 days, P=0.001), and reduced medical costs significantly. Incidence of postoperative complications was comparable between the two groups. Oncological outcomes did not differ significantly according to LOS. In all patients in both groups, initial high T status (T3–4) and occurrence of postoperative complications were independent risk factors for long LOS (>30 days).

Conclusion

In patients undergoing HNC surgery with free flap reconstruction as an initial treatment, a 14-day LOS could be safe in terms of comparable oncological outcomes and postoperative complications. To achieve this goal safely, careful management for T3–4 tumors and prevention of postoperative complications seem to be necessary.

Pedicled Temporoparietal Galeal Flap for Reconstruction of Intraoral Defects

Objectives:

In this report we aim to describe the surgical technique required to utilize the pedicled temporoparietal galeal flap for repair of selected intraoral defects and to report our experience with this type of reconstructive procedure.

Methods:

The charts of 6 consecutive patients submitted to reconstruction of intraoral defects using the pedicled temporoparietal galeal flap were reviewed. All of the defects were located in the posterior oral cavity and oropharynx. After resection of the oral cancer, the temporoparietal galeal flap, based on the superficial temporal vessels, was raised and transposed to the mouth through a tunnel under the zygomatic arch. The oral defect was repaired, and no skin graft was applied over the flap.

Results:

There were no flap losses, and the reconstructive goal was achieved in all cases. The patients' deglutition and phonation abilities were restored, and the donor site scars were well hidden by hair growth.

Conclusions:

The pedicled temporoparietal galeal flap is another option for selected cases of reconstruction of intraoral defects — Mainly those located in the posterior oral cavity and oropharynx, in which thin and pliable tissues are usually required.

Reliable, minimally invasive oromandibular reconstruction using metal plate rolled with pectoralis major myocutaneous flap

The purpose of this study was to minimize the surgical invasiveness to the donor site and the amount of the primary reconstruction time after oromandibular tumor resection. Oromandibular reconstruction was performed only using a pectoralis major myocutaneous flap and a metal plate. The pectoralis major myocutaneous flap was grafted to the oral cavity defect by rolling and wrapping around the metal plate with the muscle of the flap. No early postoperative complications have been noted in all seven patients. An average of 2 years and 1 month has past since surgery, and to date no infections, plate exposure, or plate breakage have been observed in any of the patients. The safety of the oromandibular reconstruction using a metal plate was improved by rolling the muscle of the pectoralis major myocutaneous flap around the metal plate. The present method was shown to be a rational technique that allowed primary reconstruction of the oral cavity and mandible in a minimally invasive manner in a short time.

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

BACKGROUND

Malnourished head and neck cancer patients are at increased risk of postoperative complications.

OBJECTIVE

We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss >10% of body weight) head and neck cancer patients undergoing major surgery.

DESIGN

Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding.

RESULTS

Patients in both prefed groups received approximately 9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1, 2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor alpha and P = 0.042 for interleukin 6) at the start of the study than did patients who died.

CONCLUSIONS

Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses.

Length of stay after free flap reconstruction of the head and neck

OBJECTIVES

To analyze the incidence and timing of postoperative complications after free tissue transfer (FTT) and relate that to length of stay (LOS.)

STUDY DESIGN

We reviewed one surgeon's experience with 97 patients undergoing 100 head and neck reconstructions via FTT for a variety of traumatic and ablative defects

METHODS

Charts were reviewed for demographic data, type of defect and flap, complications, LOS, length of intensive care unit (ICU) stay, date of decannulation, and first oral intake, any readmission to the hospital, and preoperative radiation status.

RESULTS

Using strict guidelines, 31% of patients had some form of complication, including a 9% flap failure rate. Average postoperative LOS for all patients was 11 days. Average LOS for uncomplicated cases was 9 and for complicated cases was 16 days. For cases with flap-related complications the average LOS rose to 20 days. All reconstructive failures (defined as patients requiring subsequent surgical procedures after a flap-related complication, regardless of outcome) occurred within the first 7 postoperative days. Three patients were readmitted for various reasons: a partial flap dehiscence (postoperative day [POD] 9), meningitis (POD 24), and orocutaneous fistula (POD 22), for a 3.2% readmission rate. Fourteen percent of patients were on a regimen of oral intake, and 13% had decannulation by the time of discharge. Resumption of oral intake and tracheostomy decannulation were accomplished on an outpatient basis in the remainder of patients.

CONCLUSIONS

There were no preventable complications associated with early hospital discharge, nor was there evidence of adverse patient outcome. We conclude that early hospital discharge is feasible after FTT reconstruction and is consistent with quality care.

Microsurgical reconstruction in recurrent oral cancer: use of a second free flap in the same patient

Primary microsurgical reconstruction is the treatment of choice for ablative defects of oral carcinoma. As a result of this trend, more and more patients with recurrent oral carcinoma who have been initially treated with surgical excision and reconstructed with free flaps are being seen. However, a second microsurgical reconstruction attempt in these cases raises questions about the flap choices, availability of recipient vessels, and effects of previous treatment modalities. Herein, 35 patients with perioral carcinoma who had two successive tumor resections and reconstruction with free flaps on each occasion are presented. A total of 75 free tissue transfers were carried out for the first and second reconstructions. After the first tumor resection, 28 radial forearm fasciocutaneous flaps, 7 fibula osteoseptocutaneous flaps, 1 iliac osteomyocutaneous flap, and 2 rectus abdominis myocutaneous flaps were used. For reconstruction after the recurrence, 17 radial forearm fasciocutaneous flaps, 13 fibula osteoseptocutaneous flaps, 3 rectus abdominis myocutaneous flaps, 2 anterolateral thigh flaps, 1 jejunum flap, and 1 tensor fasciae latae flap were used. More vascularized bone transfers were performed during the second reconstruction since the excision for the recurrence frequently required segmental mandibulectomy. The complete flap survival rate was 97.3 percent and 94.6 percent with a reexploration rate of 7.9 percent and 13.5 percent for the first and second free tissue transfers, respectively. The mean follow-up time throughout the procedures was 37.5 months. Disease-free interval between reconstructions was 20.8 months. At the time of evaluation, 54.3 percent of the patients were surviving an average of 19 months since the second reconstruction. The results suggest that free flaps represent an important option in reconstruction of recurrent perioral carcinoma cases undergoing reexcision. When used in this indication they are as safe and effective as the initial procedure.

A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps

A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.

The fabricated radial forearm flap in pharyngolaryngeal surgery: saliva leakage and its prevention

Reconstruction of the circular pharyngo-oesophageal defect continues to represent a formidable challenge for the head and neck surgeon. The fabricated radial forearm flap can provide thin and pliable skin and has potential in this one-stage reconstructive surgery. However, major problems with this technique are saliva leakage, fistula formation and stricture of the oesophageal anastomosis. Our experience with this flap for 11 pharyngo-oesophageal reconstructions has given us a better understanding of how to prevent these complications. Fistula formation and stricture were problems in our first two cases. With the 9 following cases, prevention of these complications was achieved by positioning the T-shaped suture lines of the tubed flap posteriorly. Our results suggest that adequate protection of the T-shaped suture lines during fabrication and anastomosis of the forearm flap is important in the prevention of saliva leakage.

Microvascular free flaps in head and neck surgery

This study is a retrospective review of 60 patients who had microvascular free flap reconstructions in the head and neck region. They were all performed over a 10-year period by a single surgeon. The series includes a wide range of flap types and analyses pre-operative risk factors for flap failure as well as complications and outcome. Smoking and advanced age did not appear to prejudice flap survival but peripheral vascular disease, cardiac disease and alcohol withdrawal were found to increase the likelihood of flap failure. The most frequent complications encountered were thrombosis of one of the anastomosis and haematoma. The most successful flap in terms of survival and function was the fasciocutaneous radial forearm flap. The literature is reviewed in relation to the general principles of microvascular free flap surgery and the results of this series are placed in context.

Reliability of microvascular free flaps in head and neck reconstruction

Reliable reconstructive techniques are essential in the surgical treatment of head and neck cancer patients. Free flaps have often been used as reconstructive options of last resort in the head and neck because of the need for added technical skill, a longer operating time, and a perception of poor reliability. This study reviews our experience with 39 free flaps performed by the Otolaryngology-Head and Neck Surgery Service. For the first 17 cases, an interrupted anastomotic technique was used; a running technique was performed in the remaining 22 cases. The average total ischemic time (3.7 vs. 2.7 hours; p < 0.001) was significantly less with a running technique. There were 10 complications: 7 minor would problems, 1 death from aspiration without surgical wound/flap problem, and 2 cases requiring second flaps (1 flap necrosis, 1 fistula with healthy free flap). No statistical correlation was found between complications and ischemic time, suture technique, age, or hospital (five hospitals). Free flaps are reliable and may obviate the need for sacrifice of trunk muscles for wound closure (e.g., fascicocutaneous free flaps instead of myocutaneous flaps); therefore we recommend revascularized free flaps as the primary mode of reconstruction for head and neck defects.

Clinical evaluation of the pectoralis major flap for reconstruction in head and neck cancer

Sixty two patients (7 women and 55 men) with head and neck cancer underwent 64 musculocutaneous or osteomusculocutaneous reconstructions in the Department of Head and Neck Tumours, Estonian Cancer Centre, from May 1988 to December 1991. Two men had two reconstructions. The patients were evaluated for surgical, functional, aesthetic, and also for oncological results. The flap-related complication rate was higher among women than men (6/7 (86%) compared with 19/57 (33%), p = 0.012), and in the group of osteomusculocutaneous flaps which contained a segment of the fifth or sixth rib compared with the musculocutaneous ones (5/6 (83%) compared with 20/58 (34%), p = 0.03). The functional results were good or satisfactory in 41/60 (68%) of the cases. Mean follow-up time was 32 months; 31/58 (53%) of patients operated on due to primary or recurrent cancer are alive, with or without recurrent disease. We do not recommend the inclusion of rib segments in pedicled pectoral flaps for reconstructions of head and neck defects.

Complications in head and neck microsurgery

Microvascular surgery plays a vital role in head and neck reconstruction. This paper deals with the complications arising from this form of surgery. They can be classified as general complications, anastomotic problems, and specific problems related to particular donor and recipient sites.