Trends in free flap reconstruction of the head and neck: a single surgeon series of 1027 free tissue transfers.

BACKGROUND: Free tissue transfer has fundamentally changed head and neck surgery, enabling reliable reconstruction of large defects with better function and aesthetics. This study assesses two decades of trends in free flap reconstruction, and how disease incidence, survival, surgeon caseload, team approach, and technology have impacted practice. METHODS: Retrospective analysis of 1027 head and neck free flaps from 2006 to 2022. Outcomes examined include chronological changes in flap selection, indication, length of stay, incorporation of virtual surgical planning (VSP), annual caseload, survival, and their associations with the single versus multi-team approach. RESULTS: There were 764 soft-tissue and 263 osseous reconstructions utilizing 21 different flaps. Anterolateral thigh and radial forearm accounted for 76.7% of soft tissue flaps, with recent increase in superficial circumflex iliac perforator flaps in young patients. Osseous flap proportion remained stable, but fibula flaps increased five-fold with more VSP, dental implants, oral cancer, and multi-team surgery. Outcomes such as complication rates, length of stay and disease specific/overall survival have improved over time despite increasing complexity (P = 0.001, P = 0.001, P < 0.001, and P < 0.001, respectively). However, there was no significant difference in operative time, complication rate, or disease specific/overall survival between single team or multi-team approaches (P = 0.45, P = 0.054, P = 0.57, and P = 0.60, respectively). CONCLUSION: Single and multi-team approaches may have similar fundamental outcomes, but as caseload, complexity, and life-expectancy increases, both patients and surgeons benefit from a collaborative multi-team approach that focuses on improving long-term functional outcomes.

Australian experience of side-to-side isoperistaltic stricturoplasty in Crohn's disease.

BACKGROUND: The Michelassi stricturoplasty has demonstrated efficacy for Crohn's disease in European and American series but has not had uptake in Australia. We report the short-term results of side-to-side isoperistaltic stricturoplasty (SSIS) in an Australian Practice. METHODS: Between March 2015 and October 2021 SSIS procedures were performed on Crohn's patients with long segment Crohn's strictures associated with obstructive symptoms, despite best medical therapy. Surgical demographics and results were recorded via inpatient and outpatient follow-up in a prospective database. RESULTS: Twenty-one SSIS performed in 16 patients, nine female, mean age 40 years. Single incision laparoscopic surgery (SILS) was used in 10 patients. The standard Michelassi SSIS used for 11 strictures and a Poggioli variant used for 10. Mean stricture length 32 cm (range 5-100); mean SSIS length 24 cm (range 6-55). Associated bowel resection in seven cases with a mean length of 47 mm. Ten patients had an average of three additional stricturoplasties. Complications included central line sepsis in one, deep surgical site infection in one and superficial wound infection in four patients. Mean duration of operation; 346 min and length of stay 10 days. CONCLUSION: SSIS techniques are safe for the management of long segment stricturing Crohn's disease. Although not widely used in Australia, surgeons should consider the Michelassi stricturoplasty, and its variants, for long Crohn's strictures as they are isoperistaltic whilst avoiding bowel resection and blind pouches.

Anterolateral thigh, radial forearm and superficial circumflex iliac perforator flaps in oral reconstruction: a comparative analysis.

BACKGROUND: Anterolateral thigh (ALT) and Radial forearm free flaps (RFFF) are historically the most common methods of oral reconstruction. The Superficial circumflex iliac artery perforator flap (SCIP) is an alternative providing a donor site that can be readily closed primarily with improved cosmesis in younger patients, due to its concealability. METHODS: We reviewed 135 patients who received ALT, RFFF or SCIP flaps for oral reconstruction in our institution. Our aim was to compare operative and perioperative outcomes between each cohort. ANOVA and χ2 test were used for statistical analysis. RESULTS: There were 37 ALT, 64 RFFF and 35 SCIP reconstructions. Patients reconstructed with SCIP flaps had smaller resection volumes (P < 0.001) and earlier T and N classifications (P = 0.001, P = 0.008), and consequently reduced tracheostomy rates (P < 0.001), reduced need for enteral feeding at discharge (P < 0.001) and shorter length of stay and perioperative times (P < 0.001). SCIP flaps were more common in younger patients (P < 0.01). ALT flaps were used for more advanced disease (P = 0.001) and had larger resection volumes (P < 0.001) and increased need for assisted enteral feeding (P < 0.001). There were no significant differences in flap or donor site outcomes. There were two flap failures, both RFFF. CONCLUSION: Each flap plays an important role in the reconstruction of oral defects, with larger defects preferentially reconstructed with ALT flaps. SCIP appears to be a reliable alternative in small defects with excellent perioperative and postoperative outcomes.

Frail patients having vascular surgery during the early COVID-19 pandemic experienced high rates of adverse perioperative events and amputation.

BACKGROUND: Frailty predicts adverse perioperative outcomes and increased mortality in patients having vascular surgery. Frailty assessment is a potential tool to inform resource allocation, and shared decision-making about vascular surgery in the resource constrained COVID-19 pandemic environment. This cohort study describes the prevalence of frailty in patients having vascular surgery and the association between frailty, mortality and perioperative outcomes. METHODS: The COVID-19 Vascular Service in Australia (COVER-AU) prospective cohort study evaluates 30-day and six-month outcomes for consecutive patients having vascular surgery in 11 Australian vascular units, March-July 2020. The primary outcome was mortality, with secondary outcomes procedure-related outcomes and hospital utilization. Frailty was assessed using the nine-point visual Clinical Frailty Score, scores of 5 or more considered frail. RESULTS: Of the 917 patients enrolled, 203 were frail (22.1%). The 30 day and 6 month mortality was 2.0% (n = 20) and 5.9% (n = 35) respectively with no significant difference between frail and non-frail patients (OR 1.68, 95%CI 0.79-3.54). However, frail patients stayed longer in hospital, had more perioperative complications, and were more likely to be readmitted or have a reoperation when compared to non-frail patients. At 6 months, frail patients had twice the odds of major amputation compared to non-frail patients, after adjustment (OR 2.01; 95% CI 1.17-3.78), driven by a high rate of amputation during the period of reduced surgical activity. CONCLUSION: Our findings highlight that older, frail patients, experience potentially preventable adverse outcomes and there is a need for targeted interventions to optimize care, especially in times of healthcare stress.

Suprapubic penetrating abdominal trauma - defining peritoneal breach and choices in operative intervention.

Penetrating abdominal trauma is an uncommon cause of presentation to emergency departments in Australia and is frequently associated with the clinical need for emergent operative intervention. Advances in imaging modalities, improved laparoscopic techniques and structured approaches to resuscitation in trauma have now allowed potential minimally invasive management of such injuries, avoiding laparotomy and therefore defining peritoneal breach; the major determinant of intra-abdominal organ injury in this setting is critical. We present the case of a self-inflicted stab injury to the suprapubic region in an otherwise healthy man and describe the combination of imaging and operative modalities used to define peritoneal breach in this case which successfully reduced the patient's morbidity by avoiding non-therapeutic laparotomy.