ANALYSIS OF THE MORBIDITY ASSOCIATED WITH IMMEDIATE MICROVASCULAR RECONSTRUCTION IN HEAD AND NECK CANCER PATIENTS Mark A. Schusterman, MD, and Gary Horndeski, MD
Free tissue transfer has become an important adjunct in the reconstruction of head and neck cancer patients. Despite the success, the added time required to perform free flap reconstructions continues to be a concern for some head and neck surgeons. In order to investigate whether this added time increases the risk of medical complications to the patient, 20 consecutive free flap patients were compared to 20 age-, site-, and histology-matched controls. These patients were analyzed for demographic data, American Society of Anesthetic risk scores, stage, tumor site, and pre- and postoperative medical problems. The mean occurrence of medical problems preoperatively was 1.1 occurrences per patient for the flap group and 1.5 occurrences per patient for the control group. Postoperatively, there were 0.75 occurrences per flap group and 0.9 occurrences for the control group. Neither of these was statistically significant. The length of hospitalizationwas 13.5 days for the control group and 15.9 days for the flap group. Again, this was not statistically significant. The only significant statistic difference was the length of the procedure: 6.95 hours for the control group and 11.O hours for the flap group, which had a p value of less than 0.001.In conclusion, this study indicates that length of procedure alone should not be a determining factor in deciding whether or not to use immediate microvascular reconstruction in head and neck cancer patients. HEAD & NECK 1991; 135155
From the Reconstructive Plastic Surgery Service, The University of Texas M D. Anderson Cancer Center, Houston, Texas. Address reprint requests to Dr. Schusterman at the Department of Head & Neck Surgery, M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030. Accepted for publication June 8, 1990. CCC 0148-6403/91/01051-05 $04.00 0 1991 John Wiley & Sons, Inc.
Morbidity of Head and Neck Free Flaps
I n 1959, Seidenberg and colleagues began the modern era of free flap reconstruction for head and neck defects by performing the first free jejunal transfer in a human.' Harashina et al. and Panje et al. published the first reported cases of free skin flap transfer in 1976, and Taylor and coworkers published their results using free bone transfer for mandibular reconstruction soon thereafter.2-5 Despite the numerous published reports demonstrating the some surgeons still view free tissue transfer as unduly intricate, time consuming, and unreliable, and they therefore reserve use of free flaps for young cancer patients with low-stage disease and a good prognosis. When performed along with resection, any reconstructive procedure can add considerably to the length of operation time, and this increase is of concern t o some surgeons, because the additional anesthesia time increases perioperative morbidity in the form of cardiac, pulmonary, renal, hepatic, or metabolic complications. Less ideal forms of reconstruction are sometimes advocated with the reasoning that they take less time and are therefore better tolerated by the patient. To determine whether free flap reconstruction is associated with increased morbidity, the results of 20 consecutive patients who underwent immediate free flap reconstruction were compared with results of 20-matched control patients.
HEAD & NECK
JanuarylFebruary 1991
51
MATERIALS AND METHODS
Twenty consecutive patients who underwent resection of a head and neck tumor and immediate microvascular reconstruction were matched by age, tumor site, and disease stage with 20 control patients who underwent a head and neck cancer resection without a microvascular reconstruction. The control group included patients who had had primary closure, skin grafts, and pedicle flaps, such as the pectoralis major myocutaneous flap. The medical charts of all the patients were reviewed retrospectively for the following data: patient characteristics; tumor type, site, histology, and stage; type of surgery and reconstruction; anesthetic risk, as graded according t o the American Society of Anesthesiologists (ASA) ranking (Table 1);length of procedure in hours; length of hospitalization; medical problems; and medical complications. Medical problems were divided into preoperative or postoperative occurrences. A preoperative occurrence was a medical condition for which the patient had been previously diagnosed and/or treated, as noted in the history in the chart. A postoperative occurrence was either an exacerbation of an existing condition or the onset of a new condition as noted in the chart. The data were cataloged in a microcomputer and statistically analyzed using SPSS software. The differences between the means were tested for significance using Student’s t test, and the discrete variables were tested for significance with chi-square analysis.
Table 2. Patient characteristics. Characteristic Mean age (years) Male:fernale Smoking history (mean pack years)
39.5 3:2 47.0
46.9 3:2 47.9
mean age of the flap group was slightly, but not significantly, younger. The male-to-female ratio and smoking history were essentially the same for both groups. The ASA grade was also similar, with the majority of patients in both groups being either grade 3 or 4 (Figure 1).The primary tumor site was fairly heterogeneous for both groups, and although minor differences were present between the flap and control groups, these were not statistically significant (Figure 2). The overwhelming histological tumor type in both groups was squamous cell carcinoma (Figure 3). T and N stages (Figures 4 and 5 ) were also found to be similar between groups. The medical problems were categorized as cardiac, renal, pulmonary, hepatic, or metabolic and were noted as occurring preoperatively or postoperatively. Neither mean preoperative and postoperative occurrences (Figure 6) nor overall numbers of postoperative medical occurrences by type (Figure 7) were significantly different between the groups. Surgical complications were broken down by fistula, flap loss, hematoma, wound dehiscence, complications requiring another operation, and wound infection. These complications were very similar between groups, with no statistically sig-
RESULTS
A comparison of the characteristics of the free flap and control groups demonstrated that the two groups were fairly similar (Table 2). Although there were minor differences between the groups, none were statistically significant. The
~~
~
Table 1. American Society of Anesthesiologists physical status classification scale. ASA class
ASA description
I
Normal, healthy Systemic disease, mild Systemic disease, severe but not incapacitating Systemic disease, severe and life-threatening Moribund Emergency operation
II 111 IV
V E
52
Morbidity of Head and Neck Free Flaps
FIGURE 1. Anesthetic risk as defined by ASA grade. There were no significant differences between groups by chi-square analysis.
HEAD & NECK
January/February 1991
FIGURE 2. Site. Comparison of control and flap groups according to primary tumor site. FOM, floor of mouth; BUC, buccal mucosa; MAND, mandible; TEMP BONE, temporal bone.
FIGURE 4. T Stage by type of case. Comparison between control and flap groups according to T stage. There were no significant differences. NS, no staging.
nificant differences (Figure 8). Length of hospitalization was 13.5 days for the control group and 15.9 days for the flap group; this difference was also not statistically significant (Table 3). The only mean value that was significantly different between the two groups was the length of the procedure, which averaged 6.95hours for the control group and 11.05 hours for the flap group, with a p value of
Free tissue transfer has become an important adjunct in the reconstruction of head and neck cancer patients. Despite the success, the added time required to perform free flap reconstructions continues to be a concern for some head and neck surgeons. In order to investigate whether this added time increases the risk of medical complications to the patient, 20 consecutive free flap patients were compared to 20 age-, site-, and histology-matched controls. These patients were analyzed for demographic data, American Society of Anesthetic risk scores, stage, tumor site, and pre- and postoperative medical problems. The mean occurrence of medical problems preoperatively was 1.1 occurrences per patient for the flap group and 1.5 occurrences per patient for the control group. Postoperatively, there were 0.75 occurrences per flap group and 0.9 occurrences for the control group. Neither of these was statistically significant. The length of hospitalizationwas 13.5 days for the control group and 15.9 days for the flap group. Again, this was not statistically significant. The only significant statistic difference was the length of the procedure: 6.95 hours for the control group and 11.O hours for the flap group, which had a p value of less than 0.001.In conclusion, this study indicates that length of procedure alone should not be a determining factor in deciding whether or not to use immediate microvascular reconstruction in head and neck cancer patients. HEAD & NECK 1991; 135155
From the Reconstructive Plastic Surgery Service, The University of Texas M D. Anderson Cancer Center, Houston, Texas. Address reprint requests to Dr. Schusterman at the Department of Head & Neck Surgery, M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030. Accepted for publication June 8, 1990. CCC 0148-6403/91/01051-05 $04.00 0 1991 John Wiley & Sons, Inc.
Morbidity of Head and Neck Free Flaps
I n 1959, Seidenberg and colleagues began the modern era of free flap reconstruction for head and neck defects by performing the first free jejunal transfer in a human.' Harashina et al. and Panje et al. published the first reported cases of free skin flap transfer in 1976, and Taylor and coworkers published their results using free bone transfer for mandibular reconstruction soon thereafter.2-5 Despite the numerous published reports demonstrating the some surgeons still view free tissue transfer as unduly intricate, time consuming, and unreliable, and they therefore reserve use of free flaps for young cancer patients with low-stage disease and a good prognosis. When performed along with resection, any reconstructive procedure can add considerably to the length of operation time, and this increase is of concern t o some surgeons, because the additional anesthesia time increases perioperative morbidity in the form of cardiac, pulmonary, renal, hepatic, or metabolic complications. Less ideal forms of reconstruction are sometimes advocated with the reasoning that they take less time and are therefore better tolerated by the patient. To determine whether free flap reconstruction is associated with increased morbidity, the results of 20 consecutive patients who underwent immediate free flap reconstruction were compared with results of 20-matched control patients.
HEAD & NECK
JanuarylFebruary 1991
51
MATERIALS AND METHODS
Twenty consecutive patients who underwent resection of a head and neck tumor and immediate microvascular reconstruction were matched by age, tumor site, and disease stage with 20 control patients who underwent a head and neck cancer resection without a microvascular reconstruction. The control group included patients who had had primary closure, skin grafts, and pedicle flaps, such as the pectoralis major myocutaneous flap. The medical charts of all the patients were reviewed retrospectively for the following data: patient characteristics; tumor type, site, histology, and stage; type of surgery and reconstruction; anesthetic risk, as graded according t o the American Society of Anesthesiologists (ASA) ranking (Table 1);length of procedure in hours; length of hospitalization; medical problems; and medical complications. Medical problems were divided into preoperative or postoperative occurrences. A preoperative occurrence was a medical condition for which the patient had been previously diagnosed and/or treated, as noted in the history in the chart. A postoperative occurrence was either an exacerbation of an existing condition or the onset of a new condition as noted in the chart. The data were cataloged in a microcomputer and statistically analyzed using SPSS software. The differences between the means were tested for significance using Student’s t test, and the discrete variables were tested for significance with chi-square analysis.
Table 2. Patient characteristics. Characteristic Mean age (years) Male:fernale Smoking history (mean pack years)
39.5 3:2 47.0
46.9 3:2 47.9
mean age of the flap group was slightly, but not significantly, younger. The male-to-female ratio and smoking history were essentially the same for both groups. The ASA grade was also similar, with the majority of patients in both groups being either grade 3 or 4 (Figure 1).The primary tumor site was fairly heterogeneous for both groups, and although minor differences were present between the flap and control groups, these were not statistically significant (Figure 2). The overwhelming histological tumor type in both groups was squamous cell carcinoma (Figure 3). T and N stages (Figures 4 and 5 ) were also found to be similar between groups. The medical problems were categorized as cardiac, renal, pulmonary, hepatic, or metabolic and were noted as occurring preoperatively or postoperatively. Neither mean preoperative and postoperative occurrences (Figure 6) nor overall numbers of postoperative medical occurrences by type (Figure 7) were significantly different between the groups. Surgical complications were broken down by fistula, flap loss, hematoma, wound dehiscence, complications requiring another operation, and wound infection. These complications were very similar between groups, with no statistically sig-
RESULTS
A comparison of the characteristics of the free flap and control groups demonstrated that the two groups were fairly similar (Table 2). Although there were minor differences between the groups, none were statistically significant. The
~~
~
Table 1. American Society of Anesthesiologists physical status classification scale. ASA class
ASA description
I
Normal, healthy Systemic disease, mild Systemic disease, severe but not incapacitating Systemic disease, severe and life-threatening Moribund Emergency operation
II 111 IV
V E
52
Morbidity of Head and Neck Free Flaps
FIGURE 1. Anesthetic risk as defined by ASA grade. There were no significant differences between groups by chi-square analysis.
HEAD & NECK
January/February 1991
FIGURE 2. Site. Comparison of control and flap groups according to primary tumor site. FOM, floor of mouth; BUC, buccal mucosa; MAND, mandible; TEMP BONE, temporal bone.
FIGURE 4. T Stage by type of case. Comparison between control and flap groups according to T stage. There were no significant differences. NS, no staging.
nificant differences (Figure 8). Length of hospitalization was 13.5 days for the control group and 15.9 days for the flap group; this difference was also not statistically significant (Table 3). The only mean value that was significantly different between the two groups was the length of the procedure, which averaged 6.95hours for the control group and 11.05 hours for the flap group, with a p value of
