Improved Head and Neck Free Flap Outcome—Effects of a Treatment Protocol Adjustment from Pre- to Postoperative Radiotherapy

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Abstract

Background:

The impact of preoperative radiotherapy on microvascular reconstructive surgery outcome has been a subject of debate. However, data are conflicting and often dependent on local treatment protocols. We have studied the effects of radiotherapy in a unique, single-center setting where a treatment protocol change was undertaken from pre- to postoperative radiotherapy administration for microsurgical head and neck reconstructions.

Methods:

A cohort study was conducted for 200 consecutive head and neck free flap cases, where 100 were operated on before and 100 after the treatment protocol adjustment in 2006. Only direct cancer reconstructions were included. Complication rates of anastomosis-related (flap necrosis) and flap bed–related (infection, fistula, and wound dehiscence) complications were compared between irradiated and nonirradiated patients. A multivariate analysis was performed to correct for treatment period.

Results:

One hundred twenty-six patients had received radiotherapy before reconstruction due to cases of cancer recurrence. There were no significant differences in demographic data or risk factors between irradiated and nonirradiated cases. Irradiated cases had a higher rate of both flap loss (9.5% versus 1.4%; P = 0.034) and flap bed–related complications (29% versus 13%; P = 0.014). However, after multivariate analysis, there was only a significant relationship between preoperative irradiation and infection (odds ratio = 2.51; P = 0.033) and fistula formation (odds ratio = 3.13; P = 0.034).

Conclusions:

The current single-center study clearly indicates that preoperative radiotherapy is a risk factor for both infection and fistula formation, most likely related to an impaired flap bed. We suggest postoperative radiotherapy administration whenever possible for oncological reasons, otherwise proper antibiotic cover and meticulous flap insetting to prevent radiation-related infection and fistula formation.

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Most cited references 17

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Effects of radiation on normal tissue: consequences and mechanisms.

Helen B. Stone, C. Norman Coleman, Mitchell Anscher … (2003)

The use of radiation therapy to treat cancer inevitably involves exposure of normal tissues. As a result, patients may experience symptoms associated with damage to normal tissue during the course of therapy for a few weeks after therapy or months or years later. Symptoms may be due to cell death or wound healing initiated within irradiated tissue, and may be precipitated by exposure to further injury or trauma. Many factors contribute to risk and severity of normal tissue reactions; these factors are site specific and vary with time after treatment. Treatments that reduce the risk or severity of damage to normal tissue or that facilitate the healing of radiation injury are being developed. These could greatly improve the quality of life of patients treated for cancer.

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Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps.

Andrea Pusic, J J Disa, Arthur Cordeiro … (2007)

Microvascular free tissue transfer is a reliable method for reconstruction of complex surgical defects. However, there is still a small risk of flap compromise necessitating urgent reexploration. A comprehensive study examining the causes and methods of avoiding or treating these complications has not been performed. The purpose of this study was to review the authors' experience with a large number of microvascular complications over an 11-year period. This was a retrospective review of all free flaps performed from 1991 to 2002 at Memorial Sloan-Kettering Cancer Center. All patients who required emergent reexploration were identified, and the incidence of vascular complications and methods used for their management were analyzed. A total of 1193 free flaps were performed during the study period, of which 6 percent required emergent reexploration. The most common causes for reexploration were pedicle thrombosis (53 percent) and hematoma/bleeding (30 percent). The overall flap survival rate was 98.8 percent. Venous thrombosis was more common than arterial thrombosis (74 versus 26 percent) and had a higher salvage rate (71 versus 40 percent). Salvaged free flaps were reexplored more quickly than failed flaps (4 versus 9 hours after detection; p = 0.01). There was no significant difference in salvage rate in flaps requiring secondary vein grafting or thrombolysis as compared with those with anastomotic revision only. Microvascular free tissue transfer is a reliable reconstructive technique with low failure rates. Careful monitoring and urgent reexploration are critical for salvage of compromised flaps. The majority of venous thromboses can be salvaged. Arterial thromboses can be more problematic. An algorithm for flap exploration and salvage is presented.

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A systematic review of antibiotic use and infection in breast reconstruction: what is the evidence?

Asad U Khan, Muath Bishawi, Brett T. Phillips … (2012)

The literature reports overall complication rates in breast reconstruction to be as high as 60 percent. Infection rates can exceed 20 percent, much higher than anticipated in clean elective surgery. There is no consensus among surgeons regarding the necessary duration of antibiotic prophylaxis, although the Centers for Disease Control and Prevention guidelines suggest only 24 hours. This systematic review examines antibiotic regimens and associated infection rates in breast reconstruction. Systematic electronic searches were performed in the PubMed, Ovid, and Cochrane databases using Medical Subject Headings terms for studies reporting antibiotic use and infection in all forms of breast reconstruction. Studies between 1970 and 2011 were reviewed. Included publications were required to report an antibiotic protocol and infection rate. A total of 834 abstracts were identified, 81 of which met inclusion criteria and were included in the review. The overall reported infection rates in the included studies varied between 0 and 29 percent (average, 5.8 percent). When comparing combined patient cohorts receiving no antibiotics, less than 24 hours, and greater than 24 hours, the average infection rates were 14.4, 5.8, and 5.8 percent, respectively. There is no consensus on the necessary duration of antibiotic prophylaxis following breast reconstruction. No benefit was found in patients who received more than 24 hours of postoperative antibiotics. Standardized definitions for antibiotic regimens, unit of analysis reporting, and a new breast reconstruction surgical-site infection grading system are offered to improve standardized outcome documentation. Randomized controlled trials are warranted to best determine an optimal antibiotic regimen. Therapeutic, III.

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Author and article information

Journal

Journal ID (nlm-ta): Plast Reconstr Surg Glob Open

Journal ID (iso-abbrev): Plast Reconstr Surg Glob Open

Journal ID (publisher-id): GOX

Title: Plastic and Reconstructive Surgery Global Open

Publisher: Wolters Kluwer Health

ISSN (Electronic): 2169-7574

Publication date Collection: March 2017

Publication date (Electronic): 30 March 2017

Volume: 5

Issue: 3

Electronic Location Identifier: e1253

Affiliations

From the [* ]Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, Sweden; †Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden, Stockholm, Sweden; ‡Department of Clinical Sciences Intervention and Technology, Karolinska Institute, Stockholm, Sweden; and §Department of ENT Head & Neck Surgery, Karolinska University Hospital, Stockholm, Sweden.

Author notes

Martin Halle, MD, PhD, Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden, E-mail: martin.halle@ 123456karolinska.se

Article

Accession ID: 00010

DOI: 10.1097/GOX.0000000000001253

PMC ID: 5404438

PubMed ID: 28458967

SO-VID: 37b27cf0-4ad4-411d-bcd1-f1738b7facfe

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

History

Date received : 26 November 2016

Date accepted : 10 January 2017

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Improved Head and Neck Free Flap Outcome—Effects of a Treatment Protocol Adjustment from Pre- to Postoperative Radiotherapy

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Abstract

Background:

Methods:

Results:

Conclusions:

Related collections

JMIR: Research Protocols

Most cited references 17

Effects of radiation on normal tissue: consequences and mechanisms.

Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps.

A systematic review of antibiotic use and infection in breast reconstruction: what is the evidence?

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Cited by 10

Most referenced authors 164