Seguridad y factibilidad de la reconstrucción microquirúrgica en tumores de cabeza y cuello en pacientes mayores de 70 años / Safety and feasibility of free-flap reconstruction in head and neck tumors in patients aged 70 years or older

RESUMEN Antecedentes: debido al aumento en la expectativa de vida, se ha incrementado la incidencia de tumores de cabeza y cuello en pacientes añosos. Objetivo: evaluar los resultados de la reconstrucción con colgajos microquirúrgicos luego de la resección radical (RRMC) de tumores de cabeza y cuello en pacientes de 70 años o mayores. Material y métodos: se analizó una serie de pacientes sometidos a RRCM por tumores de cabeza y cuello en el período 2000-2020. Se dividió la muestra en dos grupos: G1: ≥ de 70 años y G2: < de 70 años. Se analizaron variables demográficas, quirúrgicas, posoperatorias y factores de riesgo de trombosis del colgajo en los pacientes ≥ de 70 años. Resultados: se incluyó un total de 178 pacientes, 61 en G1 y 117 en G2. Ambos grupos fueron homogéneos respecto del sexo, IMC (índice de masa corporal), alcoholismo, tabaquismo, tratamiento neoadyuvante e incidencia de HPV (virus del papiloma humano). Hubo mayor cantidad de pacientes con riesgo ASA ≥ III en G1 vs. G2; (p: 0,005). En G1, 33 (54%) correspondieron a estadio oncológico ≥ III vs. 99 (87%) en G2 (p: 0,001). Cuarenta y dos (69%) pacientes en G1 recibieron adyuvancia vs. 94 (83%) en G2 (p: 0,02) y no hubo diferencias en la morbimortalidad global y en fallas del colgajo. El sexo femenino fue el único factor de riesgo de trombosis del pedículo vascular (p: 0,05). Conclusión: la RRCM para tumores de cabeza y cuello es factible y segura en pacientes añosos, con una incidencia de morbimortalidad similar a la del resto de la población.

ABSTRACT Background: The higher life expectancy has increased the incidence of head and neck tumors in elder patients. Objective: the aim of this study was to evaluate the outcomes of free flap reconstructions after radical resection (FFRR) of head and neck tumors in patients aged 70 years or older. Material and methods: We analyzed a series of patients undergoing FFR due to head and neck tumors between 2000-2020. The patients were divided into two groups: G1: ≥ 70 years, and G2: < 70 years. The demographic, operative and postoperative variables and the risk factors for flap thrombosis in patients ≥ 70 years were analyzed. Results: A total of 178 patients were included, 61 in G1 and 117 in G2. Both groups were homogeneous regarding sex, BMI (body mass index), alcohol consumption, smoking habits, neoadjuvant treatment, and incidence of HPV (human papillomavirus). The incidence of ASA grade ≥ III was significantly higher in G1 vs. G2; (p: 0,005). In G1, 33 patients (54%) corresponded to cancer stage ≥ III vs. 99 (87%) in G2 (p: 0.001). Forty-two (69%) patients in G1 received adjuvant therapy vs. 94 (83%) in G2 (p = 0.02) and there were no differences in overall morbidity and mortality and in flap failure. Female sex was the only predictor of vascular flap thrombosis (p = 0.05). Conclusion: FFRR in head and neck tumors is feasible and safe in elderly patients, with morbidity and mortality rates similar to those of the general population.

Microsurgical Reconstruction of the Thumb

Compared with non-microsurgical reconstruction of the thumb, microsurgical reconstruction can provide more desirable postoperative results regarding to the function as well as appearance. Toe transfer in one of its forms offers many of the best ways to reconstruct defects of the thumb. For reconstruction of the pulp, nail, and the first web space, microsurgical transfer of required tissues provides excellent sensory restoration leaving little morbidity at the foot. For composite defect of the partial thumb amputations, wrap-around procedure and trimmed great toe transfer is one of the best options in cosmesis. Trimmed great toe transfer technique is to circumvent the lack of motion of the wrap-around flap. In cases of loss of the entire thumb, preliminary procedure is inevitable to avoid foot morbidity. After distant groin flap and autogenous bone graft, secondary toe-to-hand transfer is possible with great toe or second toe. Regarding to operation timing, preoperative planning is very important to induce rapport formation between patient and doctor. In case of malignant tumor resection, immediate reconstruction is much better than delayed reconstruction. Transfer of all parts of the great toe imparts some morbidity to the foot, but the effect when evaluated with gait studies is generally minimal. Certainly, the tradeoff of a thumb for the loss of the great toe is usually well-accepted by the patient. The primary disadvantage of these techniques is their inherent complexity and, although they offer superb reconstructive options in patients with loss of all or part of the thumb, their application should probably be limited to those practitioners with experience.

Usefullness with 3D CT Angiography in Microsurgical Reconstruction

Preoperative angiography is frequently used in the planning of microsurgical reconstruction for identification of vascular abnormality that influence the planning of operation. But, recently 3D CT angiography is considered as new technique that can provide detailed information about vascular anatomy as well as soft and bony tissue without the risks of invasive angiography. 3D CT angiograms were performed in 19 patients before microsurgical reconstruction for the lower extremity and hand between May of 2003 and Oct of 2004. Sixteen of the studies were of the donor site and all of 19 studies were of the recipient site. No complications were found from the 3D CT angiograms. In one case of the bone exposed open wound, the injury of anterior tibial artery was identified and the zone of injury was adequately demonstrated. With the improvement in quality of CT imaging, 3D CT angiograms may provide a favorable alternative to invasive angiography. It is capable of providing high-resolution, three dimensional vascular imaging without the need for arterial puncture and prolonged post-procedure observation. The relation among blood vessels, bones, and soft tissue is well demonstrated in 3D CT angiogram. Also The acquisition time and examination cost were considerably lower in comparison with invasive angiography. In conclusion, this study demonstrates that 3D CT angiography may provide accurate, safe, and cost-effective preoperative imaging. The 3D CT angiography with relatively low morbidity, low cost, ease of image acquisition can have an broader role in microsurgical reconstructive surgery.

Immediate Microsurgical Reconstruction of Fingertip Injuries

During the recent 8 years, 45 fingertip injuries were reconstructed with immediate microsurgical free flap in 36 patients. There were 21 patients of pulp reconstruction (great toe pulp flap 8 cases, pulp flap from the second toe 3 cases, innervated arterialized venous flap 5 cases and first web space flap 5 cases) for pulp defect proximal to the most distal palmar crease of the fingers, 5 cases of onychocutaneous flap for thumb nail reconstruction, and 10 cases of partial toe transfer(partial great toe transfer 8 cases and second toe wrap-around procedure 2 cases). Overall survival rate of flap transfer was 97.2%(35/36). The static 2-point discrimination averaged 8 mm in pulp reconstruction of the thumb, 12 mm in index and 16 mm for other fingertip reconstruction. There was 1-2 mm atrophy of the nail width after onychocutaneous flap for thumb nail reconstruction. The subjective satisfaction of self-assessment score on the new fingertip was 85 and 88 of the thumb reconstruction in function and appearance, respectively. The score of the index was higher than that of other fingers. Immediate microsurgical reconstruction of the fingertip injuries provides many advantages over other procedures such as single stage reconstruction, early exercise and shortened convalescent period, and high satisfaction score by self-assessment in both functional and aesthetic aspects. Therefore, immediate microsurgical reconstruction of fingertip injury is a safe and reliable procedure in case of limited indications.

Clinical Outcome of Microsurgical Multiple Renal Artery Reconstruction in Renal Transplantation / 대한이식학회지

The incidence of multiple renal arteries has been reported as 18~30% in cadaveric organ procurement. There has been many cases in which the reconstruction of renal arteries were needed because of the use of donor kidney with multiple renal arteries or the injuries of renal arteries during organ harvest. We studied on the graft function and survival following reconstruction of multiple renal arteries. Between January 1990 and December 1996, we have performed 500 renal transplants, among which 65 cases(13%) of the multiple donor renal arteries were encountered either from the multiple number of donor renal artery itself or from the injury of renal artery during harvest. The remaining 435 cases had a single donor renal artery. The type of reconstruction under the microscope and graft material that we have used were illustrated as follows; ligation of a polar artery or two polar arteries in 8 cases, end to side anastomosis between a polar artery and main renal artery in 26 cases, side to side anastomosis between a polar artery and main renal artery in 12 cases, separate anastomosis of two renal arteries to external iliac or internal iliac artery in 2 cases, side to side anastomosis between two polar arteries then end to side anastomosis between reconstructed polar artery and a main renal artery in 3 cases, Carrel aortic patch in 3 cases, and interposition graft in 10 cases using inferior epigastric artery in 6 cases, branched internal iliac artery in 3 cases, and saphenous vein in 1 case. In the kidneys with reconstructed multiple renal arteries, the rate of vascular and urologic complications such as bleeding, stenosis, thrombosis of anastomotic site, ureteral obstruction and urinary leakage did not show any difference with the single renal artery group. And there was no difference in 1-year graft survival between the two groups. We think that the donor kidney with reconstructed multiple renal arteries does not have any negative impact on graft survival resulting in same early and late vascular and urologic complications as a single renal artery group when proper revascularization can be performed.

Microsurgical Reconstruction of Extremities by Cutaneous or Myocutaneous Free Flaps / 대한정형외과학회잡지

The authors performed microsurgical reconstruction by free cutaneous or myocutaneous flaps transfer in 104 cases, who were sustained of extensive soft tissue injuries on their extremities by accident. These 104 cases were operated in 6 years from 1980 to 1986 and were consisted of 47 cases of latissimus dorsimyocutaneous free flaps, 36 cases of scapular free flaps, 18 cases of dorsalis pedis sensible free flaps, and 3 cases of groin flaps. Most of them were males(80 cases) and were in third decade(28 cases). The youngest case was 2-year-old baby and the oldest one was 76-year-old woman. The traffic accident was the most frequent cause of injuries(55 cases), and the others were burn, industrial injuries, and cultivator accidents. Most of the microsurgical reconstruction were performed in lower extremity injuries(81 cases), especially below the ankle joints(65 cases). The average dimension(width and length) of free flaps were 7.3×14.3cm in latissimus dorsi free flaps, 5.6×8.2cm in scapular free flaps, and 4.5×5.9cm in dorsalis pedis free flaps. The dorsalis pedis free flaps were successful in 100%, the scapular free flaps were in 83.3%, the latissimus dorsi myocutaneous free flaps were in 89.4%, and the groin free flaps were in 33.3%, And the overall viability of 104 free flaps was 87.5%.