Prediction of outcomes in 150 patients having microvascular free tissue transfers to the head and neck

doi:10.1016/S0007-1226(96)90154-X

British Journal of Plastic Surgery

Volume 49, Issue 5, July 1996, Pages 267-273

https://doi.org/10.1016/S0007-1226(96)90154-X Get rights and content

Abstract

Medical records of 150 patients who had undergone microvascular free tissue transfer to the head and neck (85% for malignancy) were retrospectively assessed to identify predictors of postoperative outcomes and complications. 5% of flaps failed and 20% required re-exploration. Surgical and medical problems occurred in 23% and 67% patients respectively; mortality was 4.7%. 132 records were analysed by logistic regression. Mortality and stroke were commoner in patients with previous myocardial infarction or steroid medication. Chest infection was commoner in men and with increasing age. Hypoxaemia was associated with bronchodilator therapy. Thromboembolism was commoner in patients on diuretics. Nutritional problems were more frequent in patients on opioids, with low weight or hypertension. Donor site infection was related to haemoglobin concentration, cerebrovascular disease, hypertension, opioid consumption or previous radiotherapy. Recipient site infection was associated with hypertension. Flap failure was related to nitrate or bronchodilator treatment. Re-exploration was associated with opioid or bronchodilator therapy. It was concluded that several factors predicted complications and death following microvascular surgery to the head and neck.

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Cited by (75)

Jehovah's witness head and neck free flap reconstruction patient outcomes
2023, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Citation Excerpt :
Free autologous tissue transfers reconstruct large, complex defects of the head and neck secondary to tumor resection, trauma, infection, and/or necrosis. Free flaps are reliable and provide excellent functional and aesthetic outcomes, with a success rate of 94–96% [4–6] and a perioperative mortality rate of 0.48 %–4.7 % [7–9]. Free flap surgery may be associated with significant blood loss, and approximately 24.6–28.4 % of patients undergoing free flap surgery receive perioperative blood transfusions [12–14].
Jehovah's Witnesses are members of a Christian religious denomination that rejects the transfusion of whole blood and component blood products. Given new transfusion-free strategies, Jehovah's Witness patients are undergoing free flap reconstructions with increased regularity. However, outcome data remains limited. With this study, we sought to examine post-operative outcomes in Jehovah's Witness patients undergoing free flap reconstruction of the head and neck, compare their outcomes to non-Jehovah's Witness patients, and enumerate strategies to enhance the safety of transfusion-free surgery.
A retrospective chart review was carried out on 10 patients who identified as Jehovah's Witness and 63 patients who did not. Demographic information, pre-operative laboratory values, peri-operative resuscitative interventions, and peri-operative outcome measures were compiled. Descriptive data analysis, Mann-Whitney, Chi-square tests, and multivariate analysis were used.
Jehovah's Witness patients were significantly older than non-Jehovah's Witness patients (p = 0.03) and had significantly higher ASA scores (p = 0.009). Head and neck cancer was the primary surgical indication in both groups (p = 0.71). Jehovah's witness patients have significantly less intraoperative blood loss (p = 0.011) and lower post-operative hemoglobin (p = 0.002) compared to non-Jehovah's Witness patients. While Jehovah's Witness patients had significantly higher rates of severe anemia (p = 0.014), there was no significant difference between the two groups in other post-operative complications and readmission rates even in a multivariate analysis accounting for age and ASA score.
Free flap microvascular reconstruction can be reliably performed on Jehovah's Witness head and neck patients without an increased risk of complication. Policies such as the use of non-blood volume expanders, albumin, Epogen, perioperative iron supplementation, cell saver and acute normovolemic hemodilution are key to ensuring good outcomes.
Multidisciplinary reconstructive management of residual recalcitrant empyema cavity: A retrospective observational cohort study
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
This method is illustrated in Figures 2–4. Patients were managed following our established protocol for microsurgical free tissue transfer.17,18 Antibiotic therapy was continued following microbiological analysis and specialist advice.
Patients with stage III empyema require chest wall fenestration to enable lung re-expansion and continuous drainage of the persisting empyema cavity. This chronic wound negatively affects patients’ exercise tolerance, ability to carry out activities of daily living, and quality of life.
Eight consecutive patients underwent chest wall reconstruction following fenestration and were followed up over a minimum of 12 months. This study included adult patients (over 18 years of age). There were no exclusion criteria. Data were collected retrospectively.
Eight patients (six male and two female), with a mean age of 56 years (range, 22–76), were included. All of them had comorbidities including history of neoplasia (n = 6), atrial fibrillation (n = 3), and hypertension (n = 2). Aetiology of empyema included lung cancer resection complicated by bronchopleural fistula (n = 4), pneumonia (n = 2), and pleural effusion (n = 2). Five patients had a low metabolic reserve evident by a low BMI (range, 16–22), and a median malnutrition universal screen tool (MUST) score of 2 (range, 1–4). Following intensive infection control and nutritional support, patients underwent reconstruction 11 months (median; range 5–51) after fenestration. Seven patients were followed up and had no recurrence of empyema and bronchopleural fistula. They all reported significant improvements in their quality of life, and their Eastern Cooperative Oncology Group (ECOG) performance status improved from three to one. One patient died 56 days post-reconstruction from cardiorespiratory failure, which required readmission to hospital.
We demonstrate that free tissue reconstruction including multidisciplinary input and optimisation at all stages of care successfully closes residual recalcitrant empyema cavity without recurrence and leads to significant improvements in the quality of life.
Current practice trends in microvascular free flap reconstruction by fellowship-trained otolaryngologists
2018, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
However, approximately 25% self-reported <95% success rates, which is not consistent with the literature, likely due to publication bias, as surgeons with higher success rates or higher volume are more likely to publish their results. Published surgical re-exploration rates have a larger degree of variability, ranging from 3% to 20% (Wu et al., 2014; Bianchi et al., 2009; Devine et al., 2001; Jones et al., 1996; Simpson et al., 1996; Zafereo et al., 2009). Of those cases of re-exploration, vascular compromise is the underlying cause an estimated three-quarters of the time (Wu et al., 2014; Bianchi et al., 2009; Devine et al., 2001; Pohlenz et al., 2012; Kubo et al., 2002; Brown et al., 2003).
In the field of head and neck microvascular surgery, there are currently no clear, universally accepted recommendations on the intraoperative, preoperative, and postoperative management of these patients.
A 23-question cross-sectional survey was distributed to otolaryngologists who perform microvascular reconstruction. Information about practice setting, fellowship training background, intraoperative practice, postoperative practice, and surgical complications were analyzed.
Complete survey responses were received from 102 (32.8% response rate) of surveyed otolaryngologists who perform microvascular surgery. A great degree of variability was noted in intraoperative and postoperative care of free flap patients. Overall, self-reported free flap survival-rates were relatively high, despite the variability in practice, with the majority of surgeons (74%) reporting flap survival rate of 96–100%. Complication rates requiring return to the operating room were low; all respondents reported <20% overall complications with <10% re-operation rates due to vascular complications.
An increasing number of microvascular-trained otolaryngologists are performing free flaps. Self-reported free flap survival rates are high and complication rates are low, despite significant variability in intraoperative and postoperative practices among otolaryngologists performing microvascular flap reconstruction. By identifying these differences among surgeons, we hope to provide the impetus for further academic dialog and prospective trials.
Perforator free flaps in head and neck reconstruction: a single-center low-volume experience
2017, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Citation Excerpt :
Half of our failures were due to venous thrombosis, and this finding is consistent with the literature.18,22,23 The perioperative mortality in our study was 2%, which is comparable with rates reported in the literature (Haughey et al.,2 2.1%; Klosterman and Tatum,3 0.7%; Simpson et al.,24 4.7%; Suh et al.,25 1.3%). Despite the extensive comorbidities of our patients, we report a relatively low complication rate with few major complications.
The aim of this article is to investigate the results of free-flap reconstructions in the head and neck area in a secondary low-volume institution and compare these with the literature.
A retrospective study was performed of all patients who underwent free-flap reconstructive surgery in our institution from January 9, 2011, to July 12, 2015, by one young surgeon in a one-team approach. The types of flaps applied, defect sites, pathology, anastomotic details, success and complication rates, lengths of stay, and patients' ages and comorbidities were analyzed.
A total of 97 patients received 100 free flaps. Perforator flaps comprised 85% of the total (63% anterolateral thigh, 22% fibular). Thirty-six percent of free flaps were performed in patients who received previous chemotherapy radiation to the head and neck. Free-flap survival was 96%.
From our data, it seems that free-flap surgery not only is a safe and successful technique in tertiary academic hospitals, but also can be performed in smaller institutions, even in salvage situations and in patients with comorbidities. Therefore, we believe that free tissue transfer is predictable in all centers when performed by skilled microsurgeons and well-trained nursing teams.
Multivariate analysis as an advantageous approach for prediction of the adverse outcome in head and neck microvascular reconstructive surgery
2017, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
The use of a free flap has become a mainstay of reconstruction following the ablative surgery in head and neck. The success rates are about 90%, however, several factors have been described to have an adverse effect on free flap survival.
We have performed a retrospective analysis of the treatment outcome of 93 microvascular flaps and evaluated the factors influencing the risk of flap loss including patients' age, body mass index, smoking, general medical history and previous oncological treatment.
Out of 93 flaps the total necrosis have been observed in 15 flaps with gradual improvement in the consecutive years. In individual analysis the patients age, BMI, and comorbidities did not reveal any significant relation. The history of any previous oncological treatment represented a significant adverse factor of success rate (p = 0.035), and was even more significant when patients experienced all treatment modalities prior to the reconstructive procedure (p = 0.009). Multivariate logistic regression model indicated that only surgery (p = 0.0008), chemotherapy (p = 0.02), cardiovascular diseases (p = 0.05) and patient's age (p = 0.02) represented significant factors impairing the success rate.
Incorporating multivariate analysis represents important statistical approach for better prediction of free flaps survival in head and neck reconstructive surgery. Incorporation of additional collective information could provide more precise approach in the risk of the flap loss assessment.
Microvascular surgery
2017, Oral, Head and Neck Oncology and Reconstructive Surgery

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Prediction of outcomes in 150 patients having microvascular free tissue transfers to the head and neck

Abstract

Clin Plast Surg

Br J Anaesth

Br J Anaesth

Am J Med

Clin Plast Surg

Clin Plast Surg

Clin Plast Surg

Br J Plast Surg

Normal blood flow and abnormal flow

Head and neck cancer: the problem

Clin Plast Surg

Calculating confidence intervals for relative risks, odds ratios, and standardised ratios and rates

SPSS for Windows advanced statistics release 6.0.

Effect of advanced age and medical diagnosis on the outcome of microvascular reconstruction for head and neck cancer defects

Head Neck

Analysis of recurrence, complications and functional results with free jejunal flaps

Head Neck