Free Flap Transfer for Head and Neck Reconstruction Using Local Anesthesia in Elderly Patients.

BACKGROUND: The incidence of skin cancer appearing on the head and neck areas is higher in elderly patients. Although free flap reconstruction is the mainstay after tumor excision, it is challenging to complete in elderly patients, owing to the high risk of complications and/or mortality rates associated with the use of general anesthesia. In this study, we used only local anesthesia in free tissue reconstruction of the head and neck in five elderly patients. MATERIALS AND METHODS: From 2013 to 2016, 5 elderly patients with high risk of general anesthesia underwent reconstruction with either anterolateral thigh free flaps or groin free flap under local anesthesia, after wide excision of malignant tumors at head and neck. For each patient, the following information was collected: age, gender, body weight, anesthesia agents, intravenous fluid, blood loss, site of lesion, flap size, operation time, complications, and follow-up time. RESULTS: All flaps survived completely. The mean age of 5 patients (3 male patients and 2 female patients) was 84 years (range, 68-100 years), and mean flap size was 199.6 cm (range, 120-330 cm). The mean follow-up period was 26.6 months (range, 5-38 months). No complications were found. CONCLUSIONS: With proper local anesthesia, successful head and neck reconstruction with free flap was possible, and patient prognosis was positive. There are numerous advantages, including: (1) a safer and inexpensive operation; (2) no complications from general anesthesia; (3) the fact that free flap transfer can be performed in elderly patients, even if they cannot tolerate general anesthesia; and (4) allowance of the performance of free tissue transferring in countries without adequate medical resources.

Experience in Reconstruction for Small Digital Defects With Free Flaps.

Traumatic injuries to the digits resulting in soft tissue or bone loss require reconstruction. Traditionally, local flaps, such as homodigital flaps, heterodigital flaps, pedicled flaps, or distant flaps, are used for digital resurfacing. However, free tissue transfers can be used in selected patients. In this study, we present the use of different free flaps including groin skin flaps, groin osteocutaneous flaps, groin chimeric flaps, second dorsal metacarpal artery flaps, and partial toe flaps for digital reconstruction. A total of 19 digits were treated with 16 free flaps in our hospital. Of the flaps used, 5 were free groin skin flaps, 4 were free partial toe flaps, 3 were free groin chimeric flaps, 2 were free groin osteocutaneous flaps, and 2 were free second dorsal metacarpal artery flaps. The average flap size was 4.7 × 2.0 cm (range, 1.5 × 1 to 5 × 4 cm), and the average operative time was 6.0 hours (range, 4-9 hours). All flaps survived without partial or total necrosis. In conclusion, the free flap is a reliable and safe alternative for digital reconstruction. Moreover, the free groin flap provides not only a chimeric pattern for multiple fingers coverage but also an osteocutaneous pattern for thumb lengthening. The free second dorsal metacarpal artery flap provides a tenocutaneous pattern for tendon reconstruction and soft tissue coverage simultaneously, and the free partial toe flap is an excellent alternative for pulp reconstruction in terms of aesthetic appearance and functional outcome.

Chimeric groin free flaps: Design and clinical application.

BACKGROUND: Reconstruction of composite extremity defects or through-and-through oral defects remains challenging for surgeons. Chimeric flaps are ideal for repairing these lesions. In this article, we report the design of various chimeric groin free flaps for the reconstruction of both complex oral and extremity defects in 18 patients. METHODS: Between 2010 and 2014, 18 patients with composite tissue defect or two defects in the extremities or head and neck region, underwent reconstruction with cutaneous-cutaneous, musculo-cutaneous, or osteo-cutaneous chimeric groin free flaps. The size and pedicles length of the chimeric groin flaps based on the superficial circumflex iliac artery (SCIA) were tailored to the lesions. Patient-reported post-operative outcomes at the out-patient department were evaluated. RESULTS: The types of chimeric groin free flaps included cutaneous-cutaneous (n = 12), musculo-cutaneous (n = 1), and osteo-cutaneous (n = 5) flaps. Three to four SCIA branches (mean: 3.33) could be used for flap design. The cutaneous flap size ranged from 1.5 cm × 6 cm to 11 cm × 30 cm, and the bone flap size ranged from 1 cm × 1.5 cm to 2.5 cm × 6 cm. All flaps survived, and no significant complications developed at recipient or donor sites. Functional recovery after reconstruction was satisfactory in most patients after a mean of 17.27 months (ranging 2-42 months) of follow-up. CONCLUSION: The innovative flap technique presented herein has advantages including greater reliability, as well as the ability to tailor the dimensions and flap paddles to specific lesions and reconstruct two defects or one composite defect using only one (chimeric) flap.

Freestyle groin flaps: the real axial flap design and clinical application.

BACKGROUND: The groin flap represents a milestone in the history of flap development, since it was the first successful free cutaneous flap. Once widely used, it is currently less popular owing to the variations in vascular anatomy and the small, short pedicle. To enhance the clinical applications of the groin flap, its merits need to be promoted and its faults improved, including making some useful innovations. METHODS: From February 2010 to February 2014, we successfully treated 35 patients with soft tissue defects in the extremities (28 patients), buttock (1 patient), and head (6 patients) using new designs in groin flaps: axial free (34 patients) or pedicle (1 patient) groin flaps. RESULTS: All types of axial groin flaps survived successfully in the 2 to 38 months' (mean, 15.6 months) follow-up. The branches of the superficial circumflex iliac artery used for the axial flap design were 2 to 4 (mean, 3.09). The flap size ranged from 1×1.5 cm to 11×30 cm. No significant complications developed in any of the patients, with the exception of 2 mildly bulky flaps. CONCLUSIONS: This axial design of freestyle groin flaps not only preserves the earlier merits of the groin flap but also creates many new advantages: (1) reliability is greater, (2) ability to tailor the dimensions and flap paddles to the lesions, (3) options available to "lengthen" flap pedicles, and (4) local anesthesia usable with free flaps for reconstruction.

Seasonality, clinical types and prognostic factors of Vibrio vulnificus infection.

INTRODUCTION: Vibrio vulnificus infection, an uncommon but life-threatening illness, manifests as two main types, primary septicemia and primary wound infections.  Little information regarding the seasonality of V. vulnificus infections in tropical areas and prognostic factors of primary V. vulnificus wound infections is available. METHODOLOGY: This retrospective study was conducted to include 159 V. vulnificus-infected admissions at our institution in southern Taiwan, 63 with primary septicemia (Group 1) and 96 with primary wound infections (Group 2), from 1999 to 2008, for analysis. RESULTS: The case-fatality rate was 24%. Eighty-eight percent of these cases occurred during April to November. During December to March, patients in Group 2 were less likely to have acquired the infection compared with those in Group 1. Group 1 was more likely to have comorbidities and a higher case-fatality rate compared to Group 2. In multivariate analysis, hemorrhagic bullous skin lesions/necrotizing fasciitis (P=0.024), lesions involving two or more limbs (P=0.043), and shock on admission (P=0.015) were related to an increased mortality risk, while surgery < 24 hours after admission (P=0.001) was related to a decreased mortality risk in Group 1; however, hemorrhagic bullous skin lesions/necrotizing fasciitis (P=0.045) was the only prognostic factor in Group 2. CONCLUSION: The presence of hemorrhagic bullous lesion/necrotizing fasciitis is the main prognostic factor for primary septicemia or primary wound infections caused by V. vulnificus. Persons with an underlying immunocompromised status should avoid consuming raw/undercooked seafood or exposing wounds to seawater and should wear clothing during handling of seafood/fishing, especially in warmer months.

Rapid Emergency Medicine Score as a main predictor of mortality in Vibrio vulnificus-related patients.

OBJECTIVES: Vibrio vulnificus causes potentially life-threatening and rapidly progressing infections. Therefore, the severity-of-illness assessment appears to be important for V vulnificus-infected patients at the time of admission. The aim of our study was to evaluate the performance of the severity-of-illness scoring model on admission in V vulnificus-infected patients. METHODS: One hundred seventy-one consecutive patients (mean age: 63.1 ± 12.3 years) with V vulnificus infection who were admitted to a teaching hospital between January 1999 and June 2010 were included in the study. Demographic and clinical characteristics, illness severity on admission, treatment, and outcomes were collected for each patient and extracted for analysis. Logistic regression and receiver operating characteristic curve analyses were performed. RESULTS: The mean Rapid Emergency Medicine Score (REMS) on admission was 6.5 ± 3.0 points. During hospitalization, 68 patients (40%) required intensive care. The overall case-fatality rate was 25%. In multivariate analysis, the presence of underlying liver disease (P = .002), hemorrhagic bullous lesions/necrotizing fasciitis (P = .012), and higher REMS values on admission (P < .0001) were associated with increased mortality risk; a time span <24 hours between arrival and surgical treatment was associated with a decreased mortality risk (P = .007). Additionally, the area under the receiver operating characteristic (ROC) curve for the REMS in predicting mortality risk was 0.895 (P < .0001). An optimal cut-off REMS ≥8 had a sensitivity of 81% and a specificity of 85%, with a 26.6-fold mortality risk (P < .0001) and a 12.5-fold intensive care unit admission risk (P < .0001). CONCLUSION: The REMS could provide clinicians with an effective adjunct risk stratification tool for V vulnificus-infected patients.

Mortality in Emergency Department Sepsis score as a prognostic indicator in patients with pyogenic liver abscess.

OBJECTIVES: The purpose of this study was to explore the predictor index of mortality in patients with pyogenic liver abscess (PLA). METHODS: We performed a retrospective review that enrolled 431 patients 18 years and older hospitalized due to PLA between January 2005 and December 2010. Clinical characteristics, laboratory results, treatments, and outcomes retrieved from medical records were analyzed. Multiple logistic regression and receiver operating characteristic curve analyses were performed. RESULTS: The mean age of the 431 patients identified with PLA was 56.9 ± 15.0 years. The mean Mortality in Emergency Department Sepsis (MEDS) score on admission was 4.8 ± 4.1 (range, 0-17). During hospitalization, 94 patients (22%) required intensive care. Of the 431 patients, 63 died, yielding a 15% case fatality rate. Multivariate analysis revealed that higher MEDS scores on admission (P < .0001) and the presence of underlying malignancy (P = .006), multiple abscesses (P = .001), anaerobic infections (P < .0001), hyperbilirubinemia (P < .0001), and higher serum creatinine levels (P < .0001) were significantly associated with PLA mortality. The estimated area under the receiver operating characteristic curve for MEDS in predicting PLA mortality was 0.829 (95% confidence interval, 0.791-0.864; P < .0001). The optimal cutoff MEDS value of 7 or higher had a sensitivity of 76% sensitivity and a specificity of 81%, with a 10.7-fold PLA mortality risk (P < .0001) and a 26.2-fold intensive care unit admission risk (P < .0001). CONCLUSIONS: The MEDS scores on admission represent a significant prognostic indicator for patients with PLA.

Impact of timing of surgery on outcome of Vibrio vulnificus-related necrotizing fasciitis.

BACKGROUND: The aim of this study was to evaluate the impact of timing of surgery on mortality risk in patients with necrotizing fasciitis (NF) caused by Vibrio vulnificus infection. METHODS: Medical records of 121 patients (mean age, 65.2 ± 11.6 years) with V vulnificus-related NF who underwent surgical intervention between July 1998 and June 2011 were collected and reviewed retrospectively. These patients were divided into 3 groups according to the time between admission and surgical treatment as follows: those who received surgical treatment less than 12 hours after admission, those who received treatment 12 to 24 hours after admission, and those who received treatment more than 24 hours after admission. Cox regression analysis was performed to assess the effect of the timing of surgery after admission on mortality risk across the 3 groups by adjusting for potential confounding covariates. RESULTS: During their hospitalization, 35 patients died, yielding a case-fatality rate of 29%. After adjustment for potential confounding covariates (age, sex, duration of prodrome before admission, severity of illness on admission, the presence of primary septicemia, hepatic disorders, chronic renal insufficiency, blood pressure less than 90/60 mm Hg on admission, surgical and antibiotic modalities, and intensive care needed), patients who underwent surgery less than 12 hours after admission had a significantly lower mortality risk compared with those who had surgery either 12 to 24 hours after admission (adjusted hazard ratio [HR], .064; 95% confidence interval [CI], 1.6 × 10⁻7 to .25; P = .037) or more than 24 hours after admission (adjusted HR, .0043; 95% CI, 2.1 × 10⁻5 to .0085; P = .002). There was no difference in mortality risk between patients who underwent surgery 12 to 24 hours after admission and those who had surgery more than 24 hours after admission (P = .849). CONCLUSIONS: Our data provide important clinically based evidence for the beneficial effects of surgical treatment within 12 hours of admission for V vulnificus-related NF.

The Laboratory Risk Indicator for Necrotizing Fasciitis score for discernment of necrotizing fasciitis originated from Vibrio vulnificus infections.

BACKGROUND: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis (NF). Its application, however, is mainly for NF types I and II. The practical relevance of the LRINEC score for Vibro vulnificus-related skin and soft tissue infection (SSTI) was hardly ever investigated. The aim of this study was to assess the applicability of the LRINEC scoring system and to identify NF-predicting factors in patients with V. vulnificus-caused SSTI. METHODS: A retrospective study was conducted, enrolling 125 consecutive patients diagnosed with V. vulnificus-related SSTI who were admitted to a teaching hospital between January 2003 and December 2011. Demographics, laboratory data, comorbidities, treatment, and outcomes were collected for each patient and extracted for analysis. Logistic regression and receiver operating characteristic curve analyses were performed. RESULTS: The mean (SD) age of the 125 patients was 63.0 (10.9) years; 58% of the patients were male. The mean (SD) LRINEC score at admission was 2.4 (1.9) points. Of the 125 patents, 72 (58%) had NF. Multivariate analysis revealed that the presence of hemorrhagic bullous lesions (p = 0.002) and higher LRINEC scores at admission (p < 0.0001) were significantly associated with the presence of NF. In addition, the area under the receiver operating characteristic curve for the LRINEC scoring model for detecting NF was 0.783 (p < 0.0001). An optimal cutoff LRINEC score of 2 or greater had a sensitivity of 71%, a specificity of 83%, and a positive predictive value of 85%, with an 11.9-fold increased risk for the presence of NF (p < 0.0001). CONCLUSION: We have demonstrated that the LRINEC score and hemorrhagic bullous/blistering lesions are significant predictors of NF in patients with V. vulnificus-related SSTI. V. vulnificus-infected patients having hemorrhagic bullous/blistering lesions or with an LRINEC score of 2 or greater should be thoughtfully evaluated for the presence of NF. LEVEL OF EVIDENCE: Diagnostic test study, level II.

Antibiotic therapy for necrotizing fasciitis caused by Vibrio vulnificus: retrospective analysis of an 8 year period.

OBJECTIVES: To compare the effectiveness of a third-generation cephalosporin alone, a third-generation cephalosporin plus minocycline, and a fluoroquinolone in patients with necrotizing fasciitis (NF) caused by Vibrio vulnificus. METHODS: A retrospective review of case notes was performed for 89 patients who presented with NF caused by V. vulnificus and underwent surgical intervention within 24 h of admission between 2003 and 2010. Data on comorbidities, clinical manifestations, laboratory studies, treatments and outcomes were extracted for analysis. These patients were grouped according to the antimicrobials prescribed: those who received only a third-generation cephalosporin (Group 1; n = 18); a third-generation cephalosporin plus minocycline (Group 2; n = 49); or a fluoroquinolone with/without minocycline (Group 3; n = 22). RESULTS: The mean age of the 89 patients included in the study was 64.0 ± 12.0 years (range 33-89 years); 55% of the patients were male. There were no differences in age, sex or clinical characteristics among the three groups except that patients in Group 3 had a higher frequency of underlying chronic renal insufficiency than those in Groups 1 and 2 (P = 0.009). Groups 2 and 3 each had a significantly lower case fatality rate than Group 1 (61% in Group 1 versus 14% in Group 2, P = 0.0003; 61% in Group 1 versus 14% in Group 3, P = 0.0027), while no difference in case fatality rate was noted between Groups 2 and 3. CONCLUSIONS: Our data suggested that, in addition to primary surgery, fluoroquinolones or third-generation cephalosporins plus minocycline are the best option for antibiotic treatment of NF caused by V. vulnificus.

Clinical outcomes and prognostic factors for patients with Vibrio vulnificus infections requiring intensive care: a 10-yr retrospective study.

OBJECTIVE: Vibrio vulnificus infection is uncommon but potentially life-threatening. The aim of this study was to evaluate clinical outcomes and prognostic factors for patients with V. vulnificus infections admitted to an intensive care unit. DESIGN: Retrospective study. SETTING: Multidisciplinary intensive care unit in a 2300-bed teaching hospital. PATIENTS: Eighty-five adult patients (≥ 18 yrs) with V. vulnificus infections who required intensive care were enrolled and reviewed during a 10-yr period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-four of the 85 patients died, giving an intensive care unit mortality rate of 40%. The mean Acute Physiology and Chronic Health Evaluation II score on intensive care unit admission was 18.4 (95% confidence interval, 17.1-19.8). The most common underlying disease was hepatic disease (48%) followed by diabetes mellitus (22%). Multivariate analysis showed that risk factors for intensive care unit mortality were the presence of hemorrhagic bullous skin lesions/necrotizing fasciitis (relative risk, 2.4; 95% confidence interval, 1.3-4.5; p = .006), skin/soft tissue infections involving two or more limbs (relative risk, 2.5; 95% confidence interval, 1.1-5.7; p = .025), and higher Acute Physiology and Chronic Health Evaluation II scores on intensive care unit admission (relative risk, 1.2; 95% confidence interval, 1.1-1.3; p = .0001). In contrast, surgical treatment < 24 hrs after arrival was inversely associated with intensive care unit mortality (relative risk, 0.35; 95% confidence interval, 0.15-0.79; p = .012). In addition, the area under the receiver operating characteristic curve for Acute Physiology and Chronic Health Evaluation II for predicting intensive care unit mortality was 0.945 (95% confidence interval, 0.873-0.983; p = .0001). An optimal cutoff Acute Physiology and Chronic Health Evaluation II score of ≥ 20 had a sensitivity of 97% and a specificity of 86% with a 41.4-fold increased risk of fatality (p = .0003). CONCLUSIONS: This study found that V. vulnificus-infected patients with hemorrhagic bullous skin lesions/necrotizing fasciitis, skin/soft tissue infections involving two or more limbs, or higher Acute Physiology and Chronic Health Evaluation II scores have high risks of intensive care unit mortality. However, patients receiving prompt surgical treatments within 24 hrs after admission have better prognoses.

Prognostic factors for primary septicemia and wound infection caused by Vibrio vulnificus.

OBJECTIVES: The purpose of this study was to explore the predictive factors for mortality in primary septicemia or wound infections caused by Vibrio vulnificus. METHODS: A retrospective review of 90 patients 18 years and older who were hospitalized due to V vulnificus infection between January 2000 and December 2006 was performed. Clinical characteristics, laboratory studies, treatments, and outcomes retrieved from medical records were analyzed. Multiple logistic regression and receiver operating characteristic curve analyses were performed. RESULTS: Of 90 patients identified as V vulnificus infections, 39 had primary septicemia and 51 had wound infection. The mean age was 63.0 +/- 11.9 years. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) and Mortality in Emergency Department Sepsis (MEDS) scores on admission were 11.1 +/- 4.9 and 5.5 +/- 3.8, respectively. Fifteen patients died, yielding an in-hospital mortality rate of 17%. Multivariate analysis revealed that higher APACHE II (odds ratio, 1.5; 95% confidence interval [CI], 1.2-1.8; P< .0001) and MEDS (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .0201) scores on admission were significantly associated with mortality. The area under the receiver operating characteristic curves values for APACHE II and MEDS in predicting in-hospital mortality were 0.928 (95% CI, 0.854-0.972) and 0.830 (95% CI, 0.736-0.901), respectively. CONCLUSIONS: The APACHE II and MEDS scores on admission are significant prognostic indicators in primary septicemia or wound infections caused by V vulnificus. A further prospective study to strengthen this point is required.

Predictors of mortality in skin and soft-tissue infections caused by Vibrio vulnificus.

BACKGROUND: Vibrio vulnificus infection can progress rapidly in skin or soft tissue, and it is potentially life-threatening. The purpose of the present study was to explore the predictors of mortality in patients with V. vulnificus infections of skin or soft tissue. METHODS: The medical records of 119 consecutive patients aged > or =18 years, hospitalized for V. vulnificus infections of skin or soft tissue between January 2000 and December 2007 were reviewed. Co-morbidities, clinical manifestations, laboratory studies, treatments, and outcomes were analyzed. Multiple logistic regression with the exact method was performed. RESULTS: The mean age of the patients was 63.7 +/- 12.0 years. Twenty-four patients died, yielding an overall case fatality rate of 20%. Of the 24 deaths, 20 (83%) occurred within 72 h after hospital admission. Of 119 patients, 45 patients had primary septicemia, and 74 patients had wound infection. Multivariate analysis revealed that the following factors were associated with mortality: hemorrhagic bullous skin lesions/necrotizing fasciitis (p = 0.003), primary septicemia (p = 0.042), a greater organ dysfunction and/or infection score (p = 0.005), absence of leukocytosis (p = 0.0001), and hypoalbuminemia (p = 0.003). Treatment with surgical intervention plus antibiotics (p = 0.038) and surgical intervention within 24 h after admission (p = 0.017) were protective factors. CONCLUSIONS: This study demonstrates that the presence of hemorrhagic bullous skin lesions/necrotizing fasciitis, primary septicemia, a greater severity-of-illness, absence of leukocytosis, and hypoalbuminemia were the significant risk factors for mortality in these patients. Moreover, patients treated with surgery plus antibiotics, especially those receiving a prompt surgical evaluation within 24 h after hospital admission, may have a better prognosis.

Evolution of the free groin flap: the superficial circumflex iliac artery perforator flap.

BACKGROUND: The free groin flap, revolutionary in 1972, has gradually lost its relative popularity because of the new free flaps available as well as because of some of its inherent disadvantages, including a short arterial pedicle, variable arterial anatomy, the generally small caliber of the included blood vessels, its bulkiness, and numbness at the donor site. METHODS: From December of 2002 to May of 2004, the authors successfully overcame a number of these disadvantages by means of clinical application of the superficial circumflex iliac artery perforator flap in 12 patients (age range, 15 to 67 years). These surgical procedures involved nine recipient sites in the upper limbs, two in the foot, and one in the buccal region. RESULTS: This flap not only overcomes most of the disadvantages of the free groin flap but also demonstrates many of its advantages, including the following: (1) concealment of the donor-site scar; (2) primary closure of the donor site; (3) the availability of a large cutaneous flap (25 x 8 cm to 6 x 4 cm); (4) non-hair-bearing skin; (5) longer arterial pedicle (3 to 13 cm); (6) typically requiring no vessel grafting; (7) seldom being a "bulgy" flap; (8) smaller are of numbness at the donor site; and (9) less time required for flap dissection (0.5 to 1.5 hours). CONCLUSIONS: The superficial circumflex iliac artery perforator flap is an evolution of the conventional free groin flap. This flap not only overcomes most of the disadvantages of the free groin flap but also offers the many advantages of the successful application of the free groin flap.