DALLAS – Prolonged ischemic time without cost-tissue transfer in head and neck (H&N) reconstruction used to be no longer linked with intraoperative or postoperative concerns, a researcher reported here.
Among sufferers in the quartile of fastest cases — a median of 104 minutes of ischemic time in the free flap surgical treatment — the postop complication price used to be 21.3%, while in the fourth quartile (imply ischemic time 276 minutes), the complication price used to be 25% (P=0.634), reported Osama Hamdi, MD, of the University of Virginia (UVA) College of Medications in Charlottesville, in a poster at the American Head and Neck Society annual meeting.
Within the period of shorter ischemic cases, there were no free flap losses, while in the longer ischemia crew, there were three losses (5% of the sufferers), but the outcomes were no longer statistically critical (P=0.083), Hamdi told MedPage On the original time.
Hamdi and colleagues notorious in the poster that “Microvascular free tissue transfer is the gold customary in reconstruction of complex head and neck defects, allowing for improved cosmetic and purposeful outcomes with flap survival charges bigger than 95%. Harvest of free tissue requires a period of ischemia between division of the vascular pedicle at the donor situation and anastomosis to recipient vessels. Once the donor pedicle is split, ischemic cases begins and the reconstructive surgeon has the blueprint in which to proceed straight to microvascular anastomosis or assemble flap contouring and inset first.”
Hamdi explained to MedPage On the original time that “Surgeons discontinue free flaps in two predominant ways. They both discontinue the inset first — making definite the flap is in the honest map after which perfusing the flap — while others will discontinue the anastomosis first to be definite that the shortcoming of blood waft doesn’t compromise the flap. There is a battle in conception as to how prolonged that period of ischemia can final sooner than there’s harm carried out to the flap. There is moderately a gigantic selection of literature on this, but little is consistent.”
The authors carried out the retrospective cohort be taught about at a single tertiary care tutorial medical heart in sufferers (n=249) who underwent free flap reconstruction between August 2014 and April 2021. Practical affected person age used to be 61 and nearly 71% of the sufferers were male. By the utilization of produce of flap, nearly half had a radial forearm free flap (RFFF).
The imply ischemic time used to be 182.2 minutes, with 57% of the sufferers coming in below that time. By the utilization of ischemic time by flap kind, they stumbled on that the latissimus flap had the shortest common ischemic time at 158.4 minutes, while the scapula flap had the longest at 251.5 minutes.
“It is obvious that flaps containing perfect silent tissue (RFFF, ALT [anterolateral thigh], and Latissimus) have a shorter ischemic time (common 161.2 minutes) when in contrast to the bone-containing flaps (common 254 minutes),” they stated.
Hamdi and colleagues reported that sufferers all the blueprint in which by the fourth quartile for ischemic cases were “enormously extra inclined to have a historical past of radiation, malignant indication for surgical treatment, boney defect, a boney flap and plate employ, as well to longer interoperative cases and length of cease [LOS].”
The authors furthermore reported that, in step with a univariate diagnosis, there used to be a critical make bigger in ischemic time for sufferers with benign pathology (P=0.004) and these with an ablative defect encompassing resection of oral cavity (P=0.011). They furthermore stumbled on that harvest of bone-containing free flap, and the necessity for placement of reconstructive plates. were tied to enormously increased ischemic time (P<0.001). While the used to be an affiliation between ischemic time and free flap working room takebacks and LOS, that significance did no longer address multivariate diagnosis.
“Our outcomes display camouflage that ischemic time as much as 7.2 hours is wisely tolerated and has no affiliation with flap survival, postoperative concerns, want for takeback/revision, or length of inpatient cease,” they wrote. “If a long ischemic time doesn’t compromise the outcomes of the flap, the surgeon may maybe well perchance also employ extra time on distinct aspects of the reconstruction along side insetting and contouring.”
The authors if truth be told useful that “the predominant focal level of microvascular surgical treatment ought to be to are trying for the particular likely reconstructive consequence without inserting undue emphasis on ischemic time. Our outcomes ought to silent allay some fears of extended ischemia, particularly for the extra newbie reconstructive surgeon with inherently longer ischemic and operative cases. The largest notify is to entire it appropriate.”
Zainab Farzal, MD, MPH, of the University of North Carolina at Chapel Hill, told MedPage On the original time, that “In frequent, we discontinue an inset first and when that is in part in map, we discontinue that anastomosis,” but she acknowledged that “All people has their very own blueprint of doing things.”
Farzal, who used to be no longer concerned in the be taught about, called it “considerably reassuring that we form no longer must head making an strive over out shoulder at the clock while doing these procedures, as prolonged as you form no longer take a crazy period of time to entire it.”
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Ed Susman is a contract medical author essentially based in Citadel Pierce, Florida, USA.
Disclosures
Hamdi and Farzal disclosed no relationships with alternate.
