Soft tissue free flap for reconstruction of upper extremities: A meta-analysis on outcome and safety.

BACKGROUND: The aim of this study was to evaluate outcome and safety of free flaps to the upper extremity by pooled, summarized rates, compared with the existing pooled results of the lower extremity from literature, and to improve the level of evidence in a meta-analysis. METHODS: A literature search of PubMed and Embase was conducted addressing publications between January 2000 and April 2018. Publications were selected by inclusion/exclusion criteria on safety and outcome. Postoperative complications were statistically analyzed: flap loss, vessel thrombosis; recipient-site infection, hematoma, seroma, wound dehiscence, dysesthesia; donor-site morbidity. RESULTS: Two hundred and seventy-nine patients with 283 free flaps from 23 publications were extracted and eligible for this meta-analysis. The predominant donor site was the lower extremity (56%), with the anterolateral thigh flap as the major workhorse (30%). The summarized rate of total and partial flap loss was 6.0% (95% CI = 3.0-9.0%, PQ = 1.0000) and 8.0% (95% CI = 6.0-13.0%, PQ = 0.9973), respectively. The rate of arterial and venous thrombosis was 5.0% (95% CI = 3.0-9.0%, PQ = 0.9999) and 8.0% (95% CI = 9.0-37.0%, PQ = 0.9804), respectively. Complication rates of recipient site were: early infection with 7.0% (95% CI = 4.0-11.0%, PQ = 0.9788), hematoma with 6.0% (95% CI = 3.0-8.0%, PQ = 1.0000), seroma with 6.0% (95% CI = 4.0-10.0%, PQ = 0.9948), dehiscence with 7.0% (95% CI = 4.0-11.0%, PQ = 0.9988), and dysesthesia with 6% (95% CI = 4.0-10.0%, PQ = 0.9988). The rate of donor-site morbidity was 14% (95% CI = 8.0-21.0%, PQ = 0.0895). CONCLUSIONS: Soft tissue free flaps to the upper extremity have comparable success rates, but higher perioperative complication rates (e.g., partial flap loss, infection, and wound dehiscence) compared to the pooled data of lower extremity reconstruction from existing meta-analysis.

Impact of diagnostic bronchoscopy in burned adults with suspected inhalation injury.

INTRODUCTION: Inhalation injury is a common complication of thermal trauma. Fiberoptic bronchoscopy (FOB) is regarded as current standard practice in diagnosing and grading inhalation injury. Nonetheless, its predictive value in terms of therapeutic decision-making and clinical outcome is controversial. METHODS: Adult burn patients with inhalation injury (InI) were selected from the National Burn Repository of the American Burn Association. Subjects were propensity score pair-matched based on injury severity and grouped based on whether or not FOB had been performed (FOB, CTR, respectively). Mortality, incidence of pneumonia, length of hospitalization, length of ICU stay and dependency on mechanical ventilation were compared between the two groups. RESULTS: 3014 patients were matched in two groups with a mean TBSA of 22.4%. There was no significant difference in carboxyhemoglobin fraction at admission. Patients, who underwent FOB on admission had a significantly increased incidence of pneumonia (p < 0.001), mortality (p < 0.05), length of hospitalization (p = 0.002), ICU stay (p < 0.001) and duration of mechanical ventilation (p = 0.006). In a subgroup analysis of patients with TBSA of at least 20%, incidence of pneumonia was significantly higher in the FOB group (p < 0.001) and longer mechanical ventilation was required (p = 0.036). DISCUSSION: Diagnosis and grading of InI through FOB is the current standard, although its predictive value regarding key outcome parameters and therapeutic decision-making, remains unclear. The potential procedural risk of FOB itself should be considered. This study demonstrates correlations of FOB with major clinical outcomes in both a general collective of burned adults as well as severely burned adults. Although these findings must be interpreted with caution, they may induce further research into potential harm of FOB and critical review of routine diagnostic FOB in suspected inhalation injury in thermally injured patients.