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INTRODUCTION: Microvascular reconstructions after head and neck cancer are among the most complicated procedures in plastic surgery. Postoperative complications are common, which often leads to prolonged hospital stay. Enhanced recovery after surgery (ERAS) is a peri- and postoperative care concept with the aim of achieving pain- and risk-free surgery. It has been previously established as superior to conventional care for a wide variety of procedures, including microsurgical procedures such as reconstructions of the breast. Several ERAS protocols for microvascular head and neck cancer reconstructions have been proposed, although most of these are based on extrapolated evidence from different surgical specialties. Results from the implementation of ERAS for these procedures are inconsistent. METHODS: The current study investigates our clinical experience of head and neck cancer reconstruction for the period of 2014-2016 with the aim of establishing a list of functional discharge criteria. By combining these with the current published knowledge on the subject, we developed an ERAS protocol. RESULTS: We performed 89 microvascular procedures in the study period, of which 58 were in the oral cavity/sinuses and 31 were laryngopharyngeal. Most cases were squamous cell carcinoma (89%). The average LOS was 20.3 days in both groups. Postoperative complications included infection (37%), 30-days re-operations (19%), and re-admissions (17%). Furthermore, we identified the following discharge criteria: adequate pain relief, ambulation, sufficient nutritional intake, normal infection-related blood parameter results and absence of fever, bowel function, and closure of tracheostomy. CONCLUSION: Based on our retrospective analysis and identified discharge criteria, we present an approach to develop an ERAS protocol for microvascular reconstruction after head and neck cancer.
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BACKGROUND: Despite a trend towards immediate breast reconstruction in recent years, delayed breast reconstruction using a tissue expander remains a common procedure. Radiotherapy after mastectomy but before reconstruction is a risk factor, although studies examining the effect of this are limited. The aim of this retrospective cohort study is to evaluate the impact of pre-reconstructive radiotherapy (PRT) in patients undergoing breast reconstruction using an expander/implant. MATERIALS AND METHODS: Two hundred twenty-three consecutive patients underwent unilateral mastectomy followed by expander-based reconstruction over a 10-year period (2004-2013). Fifty patients (22%) received radiotherapy before reconstruction (PRT group), and 173 patients (78%) did not (non-PRT group). Descriptive patient data as well as data regarding the operations, hospitalisation and complications were collected. Statistical analyses such as logistic regression, Fisher exact test and multivariate analysis were performed using R-statistics. RESULTS: PRT was a significant predictor of loss of reconstruction, and when adjusted for smoking and body mass index (BMI), it showed an odds ratio (OR) of 17.8 [95% confidence interval (CI): 5.7-70.6; p<0.01] for loss of reconstruction, with 15 (30%) in the PRT group and 7 (4%) in the non-PRT group. We found no difference in short-term reoperations or infections at either stage of reconstruction. CONCLUSION: In patients undergoing delayed breast reconstruction using an expander/implant, radiotherapy is a significant risk factor for loss of reconstruction. It should be considered a relative contraindication for this reconstructive modality, and careful selection and advisement of the patient about the risks of complications and potential need for additional corrective surgery or later autologous breast reconstruction should be discussed.
