Risk Factors for Free Flap Failure in 2,846 Patients With Head and Neck Cancer: A National Database Study in Japan

doi:10.1016/j.joms.2016.01.009

Journal of Oral and Maxillofacial Surgery

Volume 74, Issue 6, June 2016, Pages 1265-1270

https://doi.org/10.1016/j.joms.2016.01.009 Get rights and content

Purpose

The risk factors for an unfavorable outcome after microvascular free flap reconstruction in head and neck cancer are not fully understood. We sought to identify factors affecting the occurrence of free flap failure.

Materials and Methods

This was a retrospective cohort study using data from the national inpatient database in Japan between 2010 and 2012. We identified patients diagnosed with head and neck cancer who underwent tumor resection and consecutive free flap reconstruction. Cox proportional hazards regression was used to assess risk factors for free flap failure. The threshold for significance was P < .05. Missing data were imputed by using multiple imputation.

Results

We identified 2,846 eligible patients. The overall proportion of free flap failure was 3.3%. Free flap failure was associated with diabetes mellitus (hazard ratio [HR], 1.80; 95% confidence interval [95% CI], 1.18 to 2.76; P = .007), peripheral vascular disease (HR, 4.49; 95% CI, 1.61 to 12.52; P = .004), renal failure (HR, 3.67; 95% CI, 1.45 to 9.33; P = .006), preoperative radiotherapy (HR, 2.14; 95% CI, 1.11 to 4.13; P = .022), and duration of anesthesia greater than 18 hours (compared with <12 hours; HR, 2.72; 95% CI, 1.19 to 6.22; P = .018).

Conclusions

Diabetes mellitus, peripheral vascular disease, renal failure, preoperative radiotherapy, and a longer duration of anesthesia were significant predictors of the occurrence of free flap failure.

Section snippets

Data Source

We used the Diagnosis Procedure Combination database, a national administrative claims and discharge abstract database in Japan. The details of the database have been described elsewhere.¹⁸ In brief, the number of contributing hospitals exceeded 1,000 and the database included the data of approximately 7 million patients recorded in 2012. The Diagnosis Procedure Combination database includes the following information: patient demographic characteristics; main diagnoses, comorbidities at

Results

We identified 2,899 patients with head and neck cancer who underwent tumor resection and consecutive free flap reconstruction during the study period. Of these patients, 53 met one or more of the exclusion criteria; we therefore included 2,846 eligible patients in our final analysis.

There were 94 free flap failures, for an incidence of 3.3%. Of the patients, 42 (1.5%) died during their hospital stay. Five of the patients who died had free flap failure. The median follow-up period was 65 days

Discussion

Using a national database in Japan, we performed a survival analysis for free flap failure of 2,846 patients with head and neck cancer undergoing tumor resection and consecutive free flap reconstruction. Overall, the incidence of free flap failure was 3.3%, and the in-hospital mortality rate was 1.5%. Cox proportional hazards regression indicated that diabetes mellitus, peripheral vascular disease, renal failure, preoperative radiotherapy, and duration of anesthesia greater than 18 hours

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Flap loss in head and neck reconstruction: Is there a singular cause for failure?
2024, Journal of Plastic, Reconstructive and Aesthetic Surgery
Despite the high success rates reported in head and neck reconstruction, free flap failures continue to persist. Understanding the factors associated with flap loss and improving overall success are paramount. This study aimed to comprehensively assess the factors influencing flap revision and free tissue transfer survival in head and neck reconstruction.
The study included 70 patients with defects in the lower two-thirds of the head and neck region and underwent reconstruction using free flaps. Patient age, gender, smoking status, comorbidities and data on the location and aetiology of the defect, the specific type of flap employed, the recipient artery and vein chosen, instances of revision and the overall success of the flap were collected. The investigation aimed to establish correlations between these variables as well as flap success and revision rates. No statistically significant differences were observed in arterial and venous anastomosis revision rates, or flap survival, in relation to variables such as age, gender, flap type, smoking status, comorbidities, recipient artery or vein and the number of vein anastomoses. The malignant tumour group exhibited a lower requirement for arterial revision and a higher flap survival rate compared to the benign tumour group.
This study underscores the comparable safety profiles of perforator-based and conventional flaps in head and neck reconstruction. Furthermore, it reveals that patient characteristics are not contraindications for free tissue transfer. Additionally, the quantity of the veins and choice of recipient vessels are flexible and do not significantly impact flap success. The higher rates of flap success in patients with malignant aetiology requires further investigation.
Heparin regimes in head and neck cancer flap surgery: A retrospective cohort study of free flap complications graded by Clavien-Dindo
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The purpose of the current study was to compare two different antithrombotic protocols for free flap reconstruction in head and neck squamous cell carcinoma (HNSCC) patients. Postoperative complications were graded using the Clavien–Dindo (CD) classification and compared between the two groups: the low-molecular-weight heparin (LMWH) group (n = 57) and the unfractionated heparin (UFH) group (n = 59). Patients with HNSCC from January 2010 to January 2022 were included. A total of 116 patients with a mean age of 60.46 years (range 43–83 years) were included in this study. In all, 81 were male (69.8%), and 35 were female (30.2%). Most patients (48.3%) had only grade 1 or 2 complications. CD grades (1–5) were similar between the two groups. Flap loss occurred in 2 patients (1.7%) in the LMWH group (p = 239). Prognostic factors of flap loss were high BMI, hypertension, high T stage, and high N stage. No differences were found between the groups in regard to age, sex, operating times, flap source, recipient vessels and overall complications. The results of this study demonstrate that UFH was as safe and effective as LMWH regarding postoperative complications. Free flap surgery is safe and effective for head and neck reconstruction.
Outcome analysis of free flap reconstruction for head and neck cancer with intraoperative indocyanine green angiography
2023, Journal of Plastic, Reconstructive and Aesthetic Surgery
Intraoperative indocyanine green (ICG) angiography is used in free flap surgery to evaluate the patency of vessel anastomosis. This study evaluated the outcomes of intraoperative ICG angiography in free flap surgery for head and neck cancer.
This was a retrospective study of free flap reconstruction for head and neck cancer performed between 2015 and 2021. The outcomes analyzed were the total flap failure rate, re-exploration rate, and flap salvage rate. Differences in outcomes were compared in patients treated using intraoperative ICG angiography and those treated without.
Of the 520 free flap surgeries in the 486 enrolled patients, 259 cases underwent intraoperative ICG angiography. In this group, there were 10 (3.9%) cases of total flap failure. In the non-ICG group, there were 22 cases (8.4%). There were 35 (13.5%) cases requiring re-exploration in the ICG group and 40 (15.3%) in the non-ICG group. The difference was not statistically significant. The flap salvage rate was 75.8% (25/33) in the ICG group and 51.4% (18/35) in the non-ICG group, which was a significant difference.
We found that free flap surgery with intraoperative ICG angiography significantly decreased total flap failure rate and significantly increased salvage rate but did not significantly affect the re-exploration rate.
The volume–outcome relationship in free-flap reconstruction: A nationwide study based on the Clinical Database
2023, Journal of Plastic, Reconstructive and Aesthetic Surgery
The association between successful reconstructive surgery with a free flap and hospital volume has not been well established. This study was designed to retrospectively analyze the outcome of free-flap surgery registered in a nationwide surgical registration system in Japan to clarify the relationship between free-flap survival and facilities’ average annual number of free-flap surgeries.
We analyzed data from 19,482 free flaps performed during 2017–2020 at 407 facilities throughout Japan. After adjusting for sex, age, and disease classification that differ between the groups, we examined the differences in the flap survival rates among the different facilities in terms of the average number of free-flap surgeries performed annually.
The total overall necrosis rate was 2.8%. Of all procedures, 14.9%, 12.9%, 33.4%, and 38.8% were performed at facilities with an average number of free-flap procedures <10, 10–19, 20–49, and ≥ 50 per year, respectively, and the respective rates of total necrosis were 6.0%, 3.8%, 2.1%, and 1.7%, respectively. The odds ratios and 95% confidence intervals of flap necrosis for facilities with ≥ 50 cases per year relative to those <10 were 2.70 (1.98–3.68) for nonbreast reconstruction cases and 5.72 (2.77–11.8) for breast reconstruction cases.
This analysis of a nationwide plastic surgery database showed that free-flap surgeries in institutions with a low average annual number of free-flap surgeries had a higher risk of total necrosis. Measures should be taken to either aggregate cases into high-volume centers or improve management at low-volume centers.
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Risk factors associated with postoperative complications following free flap reconstruction of head and neck defects
2022, Journal of Stomatology, Oral and Maxillofacial Surgery
Free flap reconstruction of head and neck defects is routinely performed with a high success rate nowadays. However, postoperative complications are still commonly observed. The aim of this study is to investigate risk factors correlated with postoperative complications following free flap reconstruction of head and neck defects.
A retrospective study of all patients undergoing free flap reconstruction of head and neck defects between January 2018 and January 2020 at Sun Yat-sen Memorial Hospita, Guangzhou, China was performed. Preoperative, intraoperative, and postoperative data were collected retrospectively. The primary outcome variables were postoperative complications, which were divided into medical and surgical complications. All patients were grouped by either complications or no complications. Univariate and multivariate logistic regression models were used to identify risk factors predicting complications.
850 patients underwent free flap reconstruction of head and neck defects during the study period (Male: 65.29%; Mean [SD] age: 54.90 [13.78] years). Postoperative complications developed in 125 (14.71%) patients, among which, 101 (11.88%) patients developed surgical complications, 29 (3.41%) patients developed medical complications and 5 (0.59%) patients developed both surgical and medical complications. Total flap necrosis was observed in 11 (1.29%) patients. After multivariate analysis, several risk factors incluing postoperative ICU admission, coronary heart disease, post radiotherapy surgery and flap types were identified correlated with postoperative complications.
Our study identified related variables for a higher risk of postoperative complications development following free flap reconstruction of head and neck defects. Early detection of these risk factors will improve prognosis.

View all citing articles on Scopus

: Supported by grants for Research on Policy Planning and Evaluation from the Ministry of Health, Labour and Welfare, Japan (grant Nos. H27-Policy-Designated-009 and H27-Policy-Strategy-011).

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Surgical oncology and reconstructionRisk Factors for Free Flap Failure in 2,846 Patients With Head and Neck Cancer: A National Database Study in Japan

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Data Source

Results

Discussion

Free flap failure in head and neck reconstruction

Head Neck

What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure

Laryngoscope

Are females predisposed to complications in head and neck cancer free flap reconstruction?

J Oral Maxillofac Surg

Free flaps in elderly patients: Outcomes and complications in head and neck reconstruction after oncological resection

J Craniomaxillofac Surg

The safety of microvascular free tissue transfer in the elderly population

Plast Reconstr Surg

Microvascular reconstruction in elderly oral cancer patients: Does diabetes status have a predictive role in free flap complications?

J Oral Maxillofac Surg

Diabetes as main risk factor in head and neck reconstructive surgery with free flaps

J Craniofac Surg

Influence of diabetes mellitus on postoperative complications and failure in head and neck free flap reconstruction: A systematic review and meta-analysis

Head Neck

Low prealbumin level is a risk factor for microvascular free flap failure

J Oral Maxillofac Surg

Factors associated with complications in microvascular reconstruction of head and neck defect

Plast Reconstr Surg

Predictors of complications of free flap reconstruction in head and neck surgery: Analysis of 304 free flap reconstruction procedures

Laryngoscope

Vascular complications after radiotherapy in head and neck free flap reconstruction: Clinical outcome related to vascular biology

Ann Plast Surg

Impact of preoperative radiotherapy on head and neck free flap reconstruction: A report on 429 cases

J Plast Reconstr Aesthet Surg

Free flap reconstruction in the head and neck region following radiotherapy: A cohort study identifying negative outcome predictors

Plast Reconstr Surg

A prospective study on prognostic factors for free-flap reconstructions of head and neck defects

Int J Oral Maxillofac Surg

Surgical oncology and reconstruction
Risk Factors for Free Flap Failure in 2,846 Patients With Head and Neck Cancer: A National Database Study in Japan