Background
Perioperative management of advanced osteoradionecrosis of the head and neck requiring free flap (FF) reconstruction varies. Our objectives included assessment of practice patterns and ...outcomes.
Methods
Multi‐institutional, retrospective review of FF reconstruction for head and neck osteoradionecrosis (n = 260).
Results
Administration of preoperative antibiotics did not correlate with reduction in postoperative complications. Preoperative alcohol use correlated with higher rates of hardware exposure (p = 0.03) and 30‐day readmission (p = 0.04). Patients with FF compromise had higher TSH (p = 0.04) and lower albumin levels (p = 0.005). Prealbumin levels were lower in patients who required neck washouts (p = 0.02) or a second FF (p = 0.03). TSH levels were higher in patients undergoing postoperative debridement (p = 0.03) or local flap procedures (p = 0.04).
Conclusion
Malnutrition, hypothyroidism, and substance abuse correlated with a higher incidence of postoperative wound complications in patients undergoing FF reconstruction for advanced osteoradionecrosis. Preoperative antibiotics use did not correlate with a reduction in postoperative wound complications.
•Reconstructing complex midfacial anatomy with free flaps is challenging.•Parascapular free flaps are well-suited for the demands of midface reconstruction.•Virtual surgical planning (VSP) aids in ...complex midface scapula reconstruction.•More resected subunits are successfully reconstructed when VSP is used.•VSP is associated with more successful bone appositions between free flap segments.
Reconstruction of the midface has many inherent challenges, including orbital support, skull base reconstruction, optimizing midface projection, separation of the nasal cavity and dental rehabilitation. Subscapular system free flaps (SF) have sufficient bone stock to support complex reconstruction and the option of separate soft tissue components. This study analyzes the effect of virtual surgical planning (VSP) in SF for midface on subsite reconstruction, bone segment contact and anatomic position.
Retrospective cohort of patients with midface defects that underwent SF reconstruction at a single tertiary care institution.
Nine cases with VSP were compared to fourteen cases without VSP. VSP was associated with a higher number of successfully reconstructed subunits (5.9 vs 4.2, 95% CI of mean difference 0.31–3.04, p = 0.018), a higher number of successful bony contact between segments (2.2 vs 1.4, 95% CI of mean difference 0.0–1.6, p = 0.050), and a higher percent of segments in anatomic position (100% vs 71%, 95% CI of mean difference 2–55%, p = 0.035). When postoperative bone position after VSP reconstruction was compared to preoperative scans, the difference in anteroposterior, vertical and lateral projection compared to the preoperative ‘ideal’ bone position was <1 cm in 82% of measurements. There were no flap losses.
VSP may augment SF reconstruction of the midface by allowing for improved subunit reconstruction, bony segment contact and anatomically correct bone segment positioning. VSP can be a useful adjunct for complex midface reconstruction and the benefits should be weighed against cost.
Background
Fibula free flaps (FFF) are often considered the first choice for mandibular reconstruction, but scapular system free flaps (SFF) have increased in popularity due to versatility, donor ...site advantages, and patient factors.
Methods
Retrospective chart review of patients undergoing mandibulectomy with FFF or SFF reconstruction from 2016 to 2021.
Results
Hundred and seventy‐six patients (FFF n = 145, SFF n = 31) underwent the aforementioned procedures. Mean FFF operative time was 9.47 h versus 9.88 for SFF (p = 0.40). Two‐flap reconstructions required 12.65 h versus 10.09 for SFF with soft tissue (p = 0.002). Donor site complications were identified in 65.6% of FFF with skin grafting.
Conclusions
These findings suggest that SFF requires similar operative time and results in reduced donor site morbidity as compared to FFF. Supine, concurrent harvesting of SFF allows for single‐flap harvest with significantly shorter operative time. SFF could be considered a primary option for mandible reconstruction for complex defects and in select patients.
Background
Locoregional recurrence rates following parotidectomy for cancer remain as high as 20‐30%. The auriculotemporal nerve (ATN) may allow parotid cancers to spread from the facial nerve (FN) ...toward the skull base, causing local recurrence.
Methods
Retrospective review of 173 parotidectomies for malignancy. Preoperative and post‐recurrence imaging were reviewed by a neuroradiologist for signs of tumor adjacent to the ATN.
Results
Clinical and imaging signs of possible ATN involvement correlated with FN weakness and sacrifice. Eight patients had pathologically confirmed tumor from the ATN or V3. Forty‐four percent of local recurrences had post‐recurrence imaging showing tumor along the course of the ATN. Locoregional failure along the ATN was also associated with preoperative FN weakness, intraoperative FN sacrifice, and failure to complete recommended adjuvant therapy.
Conclusions
Parotid cancers may invade the FN and spread to the skull base via the ATN. If not appropriately managed, this may lead to local recurrence.
Abstract Background Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when ...sphincter preservation is performed, are not fully demonstrated. Methods A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation. Results Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma. Conclusions Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.
Abstract Background Our objective was to evaluate ileostomy reversal patients managed with a standardized enhanced recovery pathway to identify factors associated with readmissions. Methods ...Prospective review database identified ileostomy reversal patients. Variables for the index admission and readmission were evaluated. Results Three hundred thirty-two patients were analyzed. The primary diagnosis was colorectal cancer (57.6%). Thirteen percent of the patients were discharged by postoperative day (POD) 1, 47% by POD 2, and 65% by POD 3. The complication rate was 16.8%. The main complication was ileus/small bowel obstruction ( n = 27). Thirty-day readmission rate was 12.4% ( n = 41); small bowel obstruction ( n = 27) was the most frequent readmission diagnosis. The median readmission POD was 7. Only 1 patient had a follow-up visit before readmission. The median readmission length of stay was 4 days. Conclusions Most ileostomy reversal readmissions occur before the first follow-up and stem from preventable causes. An enhanced recovery pathway modification may improve outcomes and utilization in this group.
Abstract Background To evaluate readmissions to determine predictors and patterns of readmission. Methods Prospective database review identified readmitted and non-readmitted patients after ...colorectal surgery. Variables for the index and readmission episode were examined. Results A total of 212 readmissions and 3,292 nonreadmissions were analyzed. The majority was elective. Readmitted patients were older ( P = .003), had more comorbidities ( P < .0001), longer operative times ( P < .0001), length of stay ( P < .0001), and higher costs ( P = .002). At the time of discharge, more readmitted patients required temporary nursing ( P < .0001). Independent readmission predictors were higher American Society of Anesthesiologists score, previous abdominal operation, intensive care unit stay, and dysmotility/constipation surgery. At the time of readmission, 29.2% required reoperation. More than half had an open procedure initially (55.2%). After initial open procedures, reoperative time ( P = .05) and LOS were longer ( P = .028), and more patients required temporary nursing care at the time of discharge ( P = .046). Readmissions caused an additional mean hospital cost of $12,670.89. Conclusions Readmitted patients have distinct demographic and outcomes variables. As most were elective cases, stratifying patients preoperatively may enable perioperative planning for this higher risk group.
Background
Unplanned readmissions after colorectal surgery impact patient and financial outcomes. Our goal was to identify factors related to readmission in ostomy reversal patients.
Methods
Review ...of a prospective department database was performed from 2006 to 2012 to identify patients who underwent an ostomy reversal. Patients were stratified into nonreadmitted and readmitted within 30 days of ostomy reversal. The main outcome measures were predictors of readmission and characteristics of patients readmitted and not readmitted.
Results
A total of 351 ostomy reversals (86 % ileostomy and 14 % colostomy) were analyzed; 44 patients were readmitted (12.5 %). Readmitted and nonreadmitted patients were similar in age, body mass index, gender, comorbidities, indications for the index operation, and time to ostomy reversal. Readmitted patients had longer operative times (
p
= 0.002) and length of stay (
p
= 0.001), more intraoperative blood loss (
p
= 0.003), intraoperative complications (
p
= 0.005), ICU requirements (
p
< 0.0001), need for temporary nursing at discharge (
p
< 0.001), and higher total hospital costs than nonreadmitted patients (
p
= 0.0162). Longer operative time odds ratio (OR) 1.006, 95 % confidence interval (CI) 1.001–1.012, intraoperative complications (OR 7.334, 95 % CI 1.23–43.761), ICU stay (OR 1.291, 95 % CI 1.18–1.893), delayed discharge (OR 1.085, 95 % CI 1.003–1.173), and discharge to skilled nursing facility (OR 6.936, 95 % CI 1.531–31.332) were independent predictors of readmission. Ostomy type had no independent effect on readmission.
Conclusions
Differences in perioperative and outcomes variables exist between readmitted and nonreadmitted patients after ostomy reversal. Longer operative times, intraoperative complications, intensive care unit care, longer length of stay, and skilled nursing at discharge were independently predictive of readmission. These findings can be used to identify high-risk patients prospectively, potentially improving clinical outcomes and healthcare utilization.
Background and objectives
The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) ...rectal cancer resections have excellent patient and oncologic outcomes.
Methods
Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach.
Results
Overall, 294 patients were analyzed—116 LAP (39.5 %), 153 OPEN (52.0 %), and 25 (8.5 %) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1–20) LAP, 6 days (range 3–13) CONVERTED, and 8 days (range 1–35) OPEN (
p
< 0.01). More OPEN had postoperative complications (
p
< 0.01)—complication rates were 43.8 % OPEN, 32.0 % CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6 % OPEN, 16.0 % CONVERTED, 12.1 % LAP). Overall 3-year disease-free survival (DFS) was 98.3 %, and local recurrence rate was 2.0 %. By approach, DFS was 100 % CONVERTED, 93.1 % LAP, and 87.6 % OPEN (
p
= 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1 % LAP, and 97.4 %. OPEN. Local recurrence was 0 % CONVERTED, 2 % OPEN, and 2.6 % LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (
p
= 0.05), with comparable local recurrence (
p
= 0.07) and OS rates (0.43).
Conclusions
LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.
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