Postoperative medical complications - Not microsurgical complications - Negatively influence the morbidity, mortality, and true costs after microsurgical reconstruction for head and neck cancer
ABSTRACT Immediate reconstruction of composite head and neck defects using free tissue transfer is an accepted treatment standard. There remains, however, ongoing debate on whether the costs associated with this reconstructive approach merit its selection, especially considering poor patient prognoses and the high cost of care.
A retrospective review of the last 100 consecutive patients undergoing microsurgical reconstruction for head and neck cancer by the two senior surgeons was performed to determine whether microsurgical complications or postoperative medical complications had the more profound influence on morbidity and mortality outcomes and the true costs of these reconstructions.
Two patients required re-exploration of the microsurgical anastomoses, for a re-exploration rate of 2 percent, and one flap failed, for a flap success rate of 99 percent. The major surgical complication rate requiring a second operative procedure was 6 percent. Sixteen percent had minor surgical complications related to the donor site. Major medical complications, defined as a significant risk to the patient's life, occurred in 5 percent of the patients, but there was a 37 percent incidence of "minor" medical complications primarily caused by pulmonary problems and alcohol withdrawal. Postsurgical complications almost doubled the average hospital stay from 13.5 days for those patients without complications to 24 days for patients with complications. Thirty-six percent of the true cost of microsurgical reconstruction of head and neck cancer was due to the intensive care unit and hospital room costs, and 24 percent was due to operating room costs. Postsurgical complications resulted in a 70.7 percent increase in true costs, reflecting a prolonged stay in the intensive care unit and not an increase in operating room costs or regular hospital room costs.
Postoperative medical complications in these elderly, debilitated patients related to pulmonary problems and alcohol withdrawal were statistically far more important in negatively affecting the outcomes and true costs of microsurgical reconstruction.
SourceAvailable from: Kidakorn Kiranantawat[Show abstract] [Hide abstract]
ABSTRACT: Background: Postoperative monitoring of free flap tissue perfusion is vital. Devices available are expensive and complex to operate. Most surgeons rely on direct clinical observation. A monitoring system that is reliable, inexpensive, and easy to operate is needed. Using mobile phone technology, the authors developed and evaluated a new free flap monitoring system: SilpaRamanitor. Methods: Software was developed for Android-operated mobile phones. Forty-two normal subjects were recruited to assess its effectiveness. Varying degrees of pressure were applied around the index finger to produce partial venous occlusion, partial arterial occlusion, complete venous occlusion, and complete arterial occlusion sequentially. Photographs of each subject's index and middle fingers were taken using the smartphone camera. To detect the abnormal perfusion presented on the index finger, the application was instructed to analyze photographs for color difference, with the unoccluded middle finger serving as the control. Results: The sensitivity, specificity, accuracy, false-negative results, and false-positive results were 94, 98, 95, 6, and 1 percent, respectively. The accuracy of the application in grading occlusion severity was also evaluated. Thirty-nine cases (93 percent) were correctly identified as venous occlusion. The occlusion severity was correctly identified in 33 cases (85 percent). Likewise, for the 40 cases (95 percent) correctly identified as arterial occlusion, the method correctly categorized its severity in 33 cases (83 percent). Conclusions: The authors developed a new, accurate, and reliable diagnostic system for postoperative microsurgery monitoring using a smartphone application. SilpaRamanitor is inexpensive and easy to use, making it applicable in many microsurgical settings.Plastic & Reconstructive Surgery 07/2014; 134(1):130-139. DOI:10.1097/PRS.0000000000000276 · 3.33 Impact Factor
The Laryngoscope 01/2011; 121(S4). DOI:10.1002/lary.21957 · 2.03 Impact Factor
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ABSTRACT: Background There is an increasing demand for successful free tissue transfer, with postoperative monitoring of flaps a key to early salvage. Monitoring methods have ranged from clinical techniques to invasive options, of which two are particularly applicable to buried flaps (Cook-Swartz Doppler probe and microdialysis). The evidence for these options has been represented largely in separate cohort studies, with no single study comparing these three techniques. We aim to perform this comparison in a single cohort of patients.MethodsA prospective, consecutive cohort study comparing clinical monitoring, microdialysis and the implantable Doppler probe was undertaken. In 20 patients receiving 22 flaps, 21 flaps were monitored with microdialysis, 18 flaps with clinical observation, and 21 flaps with the Cook-Swartz Implantable Doppler probe. Exclusion was based on applicability and availability intra-operatively. Efficacy was assessed through sensitivity, specificity, positive, and negative predictive values.ResultsNineteen of 22 flaps had no suspected anastomotic problems; 3 of 22 flaps were explored for anastomotic problems, with two salvaged and one lost. The implantable Doppler and microdialysis were found to detect flap statistically earlier than clinical assessment, with microdialysis better at detecting flap compromise: 100% specificity (confidence interval 31–100%) when compared to the implantable probe and clinical assessment (67%: 13–98% and 33%: 2–87%, respectively).Conclusions Each of the Cook-Swartz Doppler probe, microdialysis and clinical assessment was found suitable for monitoring in free tissue transfer. The implantable Doppler and microdialysis offer the potential for earlier detection of flap compromise. © 2014 Wiley Periodicals, Inc. Microsurgery, 2014.Microsurgery 10/2014; DOI:10.1002/micr.22331 · 2.42 Impact Factor