Flap reconstruction in major surgery of the head and neck

The challenging restoration of form and function in radical surgery of the head and neck demands sound concepts and proper execution in reconstruction. Flaps are most frequently employed in reconstruction, following major surgery because of their rich blood supply and cosmetic superiority. Of the many types of flaps known, the midline forehead flap, tem-poroforehead flap, mastoid-occipital flap, tongue flap, and deltopectoral flap have enjoyed most popularity. The design and application of these flaps are discussed. Our techniques in reconstruction of the oral cavity, hypopharynx, esophagus, nose, Andy-Gump deformities (anterior jaw complex resection), pharyngo-orocutaneous fistulas, and radionecrosis of the mandible are presented.     

Swallowing outcomes after microvascular head and neck reconstruction: a prospective review of 191 cases

BACKGROUND: The use of microvascular free tissue flaps tailored specifically to the ablative surgical defects has allowed precise anatomic reconstructions to be performed and, in turn, has improved patient outcomes. We report here the postoperative swallowing outcomes of patients undergoing microvascular reconstructions for a range of head and neck defects at the Cleveland Clinic. METHODS: The study includes 191 consecutive reconstructions for varied defects. All patients were reconstructed with four specific microvascular flaps based on their surgical defect, and postoperative swallowing outcomes were evaluated and recorded on a prospectively maintained database. Pre- and postoperative swallowing was graded on an ordinal scale. Data were simultaneously collected on the precise anatomic ablative defect in each patient, subdividing the head and neck into 16 subsites. The data were analyzed using a multivariate analysis accounting for comorbid factors, type of flap used, and subsite of defect. RESULTS: The findings are summarized as follows. There were no flap failures. The percent of patients who were able to swallow and maintain an exclusively oral diet postoperatively was 78.5%. Only 16.8% were unable to have an oral diet (NPO) and dependent on a gastric tube (G-tube) for feeding. The factors that predicted an inability to swallow include tongue resection, preoperative radiation therapy, and hypopharyngeal defects. In contrast, floor of mouth, mandibular, and pharyngeal defects, regardless of size, had excellent long-term swallowing outcomes. Most patients with these defects were able to tolerate at least a soft solid diet. CONCLUSIONS: In summary, we report excellent postoperative swallowing outcomes after microvascular reconstructions at our institution that compare favorably with outcomes with pedicled flaps and historic controls. The type of flap used and the size of defect had minimal effects on swallowing outcomes. The most difficult subsites to reconstruct were tongue defects, which strongly correlated with poor swallowing outcomes. The other factor that strongly impacted outcomes was preoperative radiation treatment. We believe these results highlight the utility of free flaps in recreating the precise anatomy required to maintain swallowing function. These data will hopefully support numerous previous studies that have established the use of microvascular reconstruction as standard of care for ablative surgical defects in the head and neck.     

Myocardial infarction after microvascular head and neck reconstruction

OBJECTIVE/HYPOTHESIS: Microvascular flap transfer is a popular method for immediate reconstruction of defects in the head and neck resulting after the treatment of head and neck cancer. Head and neck cancer occurs most commonly in elderly patients with a high prevalence of heavy smoking. Surgery in this patient population is frequently prolonged and is associated with significant intraoperative blood loss. The present study seeks to identify factors contributing to perioperative myocardial infarction and to determine the best course of management. STUDY DESIGN: Retrospective analysis of 193 consecutive free flap surgeries.METHODS A series of 193 microvascular free flaps performed over a 5-year period for reconstruction of defects in the head and neck was retrospectively analyzed to identify the incidence, management, and outcome of perioperative myocardial infarction in this patient population. RESULTS: Myocardial infarctions occurred in seven patients, for an overall incidence of 3.6%. Statistical analysis using logistic regression failed to demonstrate any significant relationship between age, sex, total operative time, operative blood loss, net intraoperative fluid shifts, tumor stage, American Society of Anesthesiology (ASA) preoperative classification, type of free flap, and the occurrence of perioperative myocardial infarction. Hemodynamic instability manifested by hypotension occurred in four patients who had perioperative myocardial infarction. Three of these patients underwent urgent coronary artery bypass surgery, whereas one patient underwent urgent endovascular therapy with subsequent stabilization of the hemodynamic instability. All free flaps survived despite myocardial infarction and hemodynamic instability. Two patients (29%) died after postoperative intervals of 74 and 99 days, never having left the hospital. CONCLUSIONS: Systemic hypotension is a well-recognized risk factor for free flap failure. Our experience suggests that aggressive intervention to reverse coronary ischemia associated with hemodynamic instability has a favorable outcome on free flap survival, and free flap thrombosis is not an inevitable outcome of the low-flow state associated with perioperative cardiopulmonary bypass. Although the overall incidence of perioperative myocardial infarction in patients undergoing microvascular head and neck reconstruction is low, patient mortality is high, so emphasis should be placed on preoperative identification of patients with coronary artery disease.     

手术预案汇报制度在耳鼻咽喉头颈外科住院医师规范化培训中的应用

目的 探讨手术预案汇报制度在耳鼻咽喉头颈外科住院医师规范化培训中的应用效果。方法 以2016—2020年在首都医科大学宣武医院耳鼻咽喉头颈外科进行住院医师规范化培训的15名住院医师为研究对象,分为实验组(8名)和对照组(7名)。对照组按照住院医师规范化培训大纲进行培训,实验组要求住院医师在完成培训大纲的基础上,制作并汇报手术预案,通过比较两组的出科考核成绩和年度考核成绩,分析手术预案汇报在教学中的效果。结果 实验组住院医师出科考核成绩为(92.44±2.41)分,而对照组为(88.79±2.67)分,差异具有统计学意义(t=-2.78,dF=13,P<0.05)。实验组住院医师年度考核成绩为(85.87±3.64)分,对照组为(80.29±2.98)分,差异具有统计学意义(t=-3.22,dF=13,P<0.05)。实验组8名住院医师共汇报预案397例,平均(49.62±17.20)例。结论 在耳鼻咽喉头颈外科住院医师规范化培训中,住院医师通过制作和汇报手术预案,巩固了基础理论知识、提高了临床思维能力,指导教师对预案中暴露出的问题进行针对性指导,提高了教学效果。     

Structured training in otorhinolaryngology- head and neck surgery

Although mut ENT departments in India are now departments of OtolaryHifniogy-Head and Neck surgery there is no uniform structured training programme to ensure that the postgraduates will receive a thorough grounding in the various subspecialties that make up modern otolaryngology. .4 model programme is presented which may serve as a basis for future discussion.     

Extended use of perioperative antibiotics in head and neck microvascular reconstruction

Purpose

Many head and neck surgical procedures are considered clean-contaminated wounds and antibiotic prophylaxis is recommended. Despite prophylaxis, the incidence of surgical site infections remains significant – especially in the setting of free tissue transfer. The antibiotic course is often of a longer duration after free tissue transfer than the recommended 24 hour post-operatively. Currently, there is no consensus on appropriate antibiotic regimen or duration at this time. This study investigates the outcomes of a 7-day perioperative antibiotic regimen after microvascular reconstruction of the head and neck at our institution.

Assessment of functional outcomes in head and neck cancer

The goals of the present publication are (a) to identify standardised methods and tools applied in clinical trials and cohort studies to assess key functional aspects in HNC, using the Brief ICF Core Set for head and neck cancer (ICF-HNC) as a reference and (b) to propose a set of sound standardised methods and tools suitable to assess functional problems in HNC. This work contributed to the development of practical ICF-HNC based guidelines targeting the standardised measurement of functional outcomes in HNC follow-up and clinical research in Germany. A systematic review of randomised and clinical controlled trials, and observational studies in HNC were carried out to identify standardised methods and tools. Suitable methods and tools were then selected based on pre-defined criteria. 210 assessment methods and tools were identified in 136 studies: 146 patients reported outcomes (PRO) and 64 tools rated by health professionals. Altogether 59 tools were considered suitable to be included in guidelines: four side effects classifications, two performance status scales, 31 PROs, 10 assessment criteria for clinical examinations, seven assessment methods and tools for the evaluation of technical, equipment-based procedures and five technical, equipment-based procedures. It was possible to identify and select sound and standardised assessment methods and tools for almost all functioning areas defined in the ICF-HNC. Since no tool sufficiently covers support provision by immediate family and by health professionals as well as economic self-sufficiency, we recommend a corresponding update of existing tools.     

Quality-of-life outcomes in the evaluation of head and neck cancer treatments

OBJECTIVES: To review the published literature to evaluate the design, use of terminology, and interpretation of results in studies using quality-of-life (QOL) instruments to measure differences between head and neck cancer treatments at a point in time or to report changes over time in one or more treatment groups. DATA SOURCE: MEDLINE search for subject headings "head and neck neoplasms" (as a main topic) and "quality of life" or "health status" restricted to English-language sources and a 10-year period from 1989 to 1999. STUDY SELECTION: Four hundred forty-five abstracts were reviewed to find articles using an instrument to compare head and neck cancer therapy groups with a QOL outcome (13.7% included). DATA EXTRACTION: Two readers reviewed each article to determine how terminology was used, if a scientific study design was used, and if differences or changes in scores were clinically interpreted. RESULTS: Sixty-one articles were reviewed. Forty different instruments were used. Terminology was used inconsistently in 21 (34.4%) of the 61 articles. A scientific study design was used in only 11 (18.0%) of the 61 articles (P<.001). A clinical interpretation of results was given in 16 (26.2%) of the 61 articles (P<.001). CONCLUSIONS: While QOL outcomes show promise for assisting with treatment decisions in head and neck cancer therapy, few studies using instruments to measure QOL outcomes are hypothesis driven and clinical interpretations of results are not commonly provided. We recommend that future studies identify the construct to be measured, specify comparator groups and hypotheses a priori, and provide clinical interpretations of results.     

Outcomes in microvascular head and neck reconstruction in the setting of restricted residency hours

Background

Resident duty hour restrictions can limit the frequency of resident flap checks at smaller institutions with “home” call. Institutions are compensating with adjuvant nursing flap checks as well as incorporating technology; however, this management remains controversial.

Venous thrombosis after microvascular free-tissue transfer in head and neck cancer reconstruction

OBJECTIVE: Microvascular free-tissue transfer is essential for functional reconstruction in head and neck cancer surgery. The risk of free flap failure depends on venous thrombosis rather than arterial thrombosis, and any type of failure caused by venous thrombosis is often diagnosed late. In this study, we studied the flap survival rate achieved by this technique depending on the recipient vein. Further, the risk factor was analyzed for venous thrombosis with regard to preservation of recipient vein during neck dissection. METHODS: This study is a retrospective review of 102 consecutive free flaps performed by a single head and neck surgical team from 2000 to 2006 at the Department of Otolaryngology, Head and Neck Surgery at Kagoshima University Hospital. The recipient vessels such as the external jugular (EJ) vein and internal jugular (IJ) system were carefully preserved during neck dissection. All patients received 80 microg of prostaglandin E1 (Alprostadil) for 5 days after surgery. RESULTS: The overall success rate was 94.1%. All the six cases of unsuccessful free flap transfer were caused by venous thrombosis. Microvascular free flaps anastomosed to the EJ vein failed at a significantly higher rate (13.3%) than those anastomosed to the IJ system (2.8%) (p<0.05). On studying the failed cases after IJ system anastomosis, we found that all complications were caused by internal jugular vein thrombosis (IJVT) and not by microvascular anastomotic thrombosis. In all the three cases of flap failure with IJVT, the dissected IJ vein was patently ballooning because of the remaining connective tissue, including the adventitia around the IJ vein in the supraclavicular lesion. CONCLUSIONS: Although the IJ system is the ideal recipient vessel when compared with EJ vein, there is another risk of flap failure due to IJVT. To improve the survival rate, IJVT should be prevented by a careful manipulation of IJ system during neck dissection to avoid ballooning of the IJ vein in head and neck cancer surgery.     

Arterial coupling for microvascular free tissue transfer in head and neck reconstruction

OBJECTIVE: To demonstrate the efficacy of arterial coupling. DESIGN: We report our experience in head and neck reconstruction with the Unilink Microvascular Anastomotic System (Synovis MCA, Birmingham, Ala). Data were collected in a consecutive series of 49 patients undergoing composite resection of head and neck tumors followed by free tissue transfer. SETTING: All patient care took place at Yale-New Haven Hospital, New Haven, Conn, a university-based tertiary care facility. PATIENTS: Forty-nine consecutive patients aged 43 to 85 years underwent a total of 50 microvascular free tissue transfers using the Unilink coupling device. There were 18 women and 31 men, and the following 3 types of flaps were performed: radial forearm (n = 36), fibula (n = 12), and rectus abdominus (n = 2). INTERVENTIONS: The Unilink coupling device was used in this case series. Each arterial and venous anastomosis was performed with the coupling device. Free tissue transfers were monitored clinically and outcomes were recorded. MAIN OUTCOME MEASURES: Flap survival and thrombosis of the arterial anastomoses were determined, as was median length of stay. RESULTS: There were no flap failures in the series. Of the 50 coupled arterial anastomoses, the predominant coupler size used was 2.5 mm in diameter. Reconstructions included 36 radial forearm, 12 fibular osteocutaneous, and 2 rectus abdominus myocutaneous free flaps. One intraoperative arterial thrombosis occurred, requiring hand-sewn anastomosis, and another pulled away from the intact coupler in a steroid-dependent patient. There were no complications related to technical performance of the coupling device. The median length of stay was 14 days. CONCLUSION: While hand-sewn anastomoses in free tissue transfer remain the preferred technique for many microsurgeons, use of the coupler is a viable alternative to sutured anastomoses.     

Limited English proficiency and head and neck cancer outcomes

PurposeLimited English proficiency (LEP) is common among hospitalized patients and may impact clinical care and outcomes. This study aimed to examine the relationship between LEP and clinical oncological outcomes for patients with head and neck cancer (HNC).Materials and methodsA single center retrospective review was conducted including adult patients with squamous cell carcinoma of the head and neck who received treatment with curative intent between January 1, 2014 and July 1, 2019. Clinical data collected included patient demographics and clinical variables. Univariate and multivariate analysis was performed to determine whether there was an association between LEP and demographic and clinical factors.ResultsThere were 477 patients included in the study; 426 (81%) were English proficient (EP) while 51 (10.7%) were LEP. The LEP patients were diagnosed with cancer at a later overall stage (p = 0.03) and less frequently treated with surgery alone compared to English speaking patients (p < 0.001). After adjusting for overall stage and primary site, LEP patients were significantly more likely to receive primary surgical management compared to primary non-surgical management [OR = 2.29 95% CI (0.93, 5.58), p = 0.008]. There was also a significant association between LEP and primary site of tumor (p < 0.01). Kaplan-Meyer curves for overall survival and disease specific survival showed no significant differences between the two cohorts (p = 0.8063 and p = 0.4986, respectively).ConclusionsLEP may impact access to care resulting in more advanced overall tumor stage at presentation and treatment with primary surgery compared to non-surgical management after adjusting for tumor stage and primary site. Interventions to provide better access to care, awareness of HNC in the LEP populations, and earlier detection may improve outcomes for LEP patients.