A multi-institutional international study of risk factors for hematoma after thyroidectomy.

BACKGROUND: Cervical hematoma can be a potentially fatal complication after thyroidectomy, but its risk factors and timing remain poorly understood. METHODS: We conducted a retrospective, case-control study identifying 207 patients from 15 institutions in 3 countries who developed a hematoma requiring return to the operating room (OR) after thyroidectomy. RESULTS: Forty-seven percent of hematoma patients returned to the OR within 6 hours and 79% within 24 hours of their thyroidectomy. On univariate analysis, hematoma patients were older, more likely to be male, smokers, on active antiplatelet/anticoagulation medications, have Graves' disease, a bilateral thyroidectomy, a drain placed, a concurrent parathyroidectomy, and benign pathology. Hematoma patients also had more blood loss, larger thyroids, lower temperatures, and higher blood pressures postoperatively. On multivariate analysis, independent associations with hematoma were use of a drain (odds ratio, 2.79), Graves' disease (odds ratio, 2.43), benign pathology (odds ratio, 2.22), antiplatelet/anticoagulation medications (odds ratio, 2.12), use of a hemostatic agent (odds ratio, 1.97), and increased thyroid mass (odds ratio, 1.01). CONCLUSION: A significant number of patients with a postoperative hematoma present >6 hours after thyroidectomy. Hematoma is associated with patients who have a drain or hemostatic agent, have Graves' disease, are actively using antiplatelet/anticoagulation medications or have large thyroids. Surgeons should consider these factors when individualizing patient disposition after thyroidectomy.

The angular branch: maximizing the scapular pedicle in head and neck reconstruction.

OBJECTIVE: To evaluate the scapular free flap based on the angular artery in complex head and neck reconstruction. DESIGN: Case series. SETTING: A tertiary referral center. PATIENTS: A series of 25 osteocutaneous scapular flaps was performed from August 2000 through January 2005. Of these 25 flaps, 7 procedures of scapular bone solely vascularized by the angular artery and vein were performed to reconstruct head and neck defects. The angular vessels were used to reach the neck for anastomosis in midfacial reconstruction (n = 2), to carry a separate second bone flap in complex oromandibular defects (n = 2), and to reach the contralateral neck for anastomosis in through-and-through oromandibular defects encompassing overlying facial skin (n = 3). MAIN OUTCOME MEASURES: Pedicle length and flap viability. RESULTS: Postoperative bone scans revealed all bone segments to be vascularized. The pedicle length originating from the circumflex scapular vessels varied from 6.7 to 9.0 cm (mean length, 7.5 cm). The pedicle length of the angular vessels varied from 13.0 to 15.0 cm (mean length, 14.1 cm), a mean length of 6.6 cm longer than the circumflex scapular flap. Vein grafts were not necessary to perform remote anastomoses with the additional pedicle length. CONCLUSIONS: The angular vessels can reliably supply the scapula. Use of the angular vessels over the circumflex scapular vessels increases the bone pedicle length by a mean length of 6.6 cm (88%) and is a useful technique to avoid vein grafting for remote anastomosis.

Gastro-omental free flap reconstruction of the head and neck.

OBJECTIVE: To present the use of an infrequently used tool, gastro-omental free flaps, available to head and neck surgeons in the modern reconstruction era. METHODS: In this case series, 25 gastro-omental free flaps were performed. The technical aspects of harvest are reviewed, and the advantages and disadvantages of this flap are described, as well as illustrative cases displaying this flap's utility when other donor sites cannot be harvested. RESULTS: Flap survival was 96%, with 1 flap being successfully salvaged after the development of a venous thrombosis and 1 flap failing as a result of a kink in the arterial pedicle. Exteriorization of the omentum as an external marker heralded vascular compromise in both cases. Complications included 2 delayed gastric outlet obstructions, 1 salivary leak, 1 delayed abscess and fistula formation 7 months following reconstruction, and 1 case of mild superficial bleeding from the transplanted gastric mucosa. CONCLUSION: The gastro-omental flap has proven to be a reliable and valuable tool in head and neck reconstruction, particularly in complex oropharyngeal wounds with large soft tissue components.

Erectile function following unilateral cavernosal nerve replacement.

INTRODUCTION: With nerve-sparing techniques, patients undergoing a radical prostatectomy may avoid the morbidity of erectile dysfunction. Certain patients who are not candidates for nerve-sparing procedures may be eligible for nerve interposition grafts. While bilateral cavernosal nerve grafting after radical prostatectomy has shown efficacy, the effect of unilateral nerve grafting following prostatectomy remains unclear. We evaluate a large group of patients who underwent a unilateral cavernosal nerve replacement. METHODS: Forty patients underwent unilateral nerve sparing surgery with concomitant contralateral cavernosal nerve replacement. Patients were selected for this procedure based upon preoperative nomogram risk assessment, endorectal MRI evidence of extra capsular disease (ECE) or intraoperative histology demonstrating margin positivity. Age, demographic data, Gleason score, clinical and pathologic stage and pre and post operative IIEF data was collected and prospectively analyzed. RESULTS: Median follow-up was 19 months. Median change in IIEF scores was 7.5. Twenty-one of 29 patients (72%) report being able to penetrate after prostatectomy. Sixteen of those 21 (76%) continue to require PDE-5 inhibitors to facilitate penetration. Four of the 6 patients (67%) who were unable to have intercourse following cavernosal nerve replacement received adjuvant hormonal and/or radiation therapy. Twenty-eight patients (97%) reported numbness at the graft harvest site. One patient experienced a graft site infection. Two of 29 (7%) patients reported pain at the harvest site. CONCLUSION: Unilateral sural nerve grafting is a feasible and well-tolerated approach for patients who must undergo wide resection of a NVB. While men do show a decrease in their IIEF score, 76% are able to achieve penetration following surgery. The majority of men continue to require PDE-5 inhibitors to facilitate intercourse.

Graft harvesting for revascularization in the head and neck.

The techniques for revascularization in the neurocranium, skull base, and neck continue to evolve at an exciting pace. In this body of literature, however, techniques for harvesting radial artery and saphenous vein grafts are mainly reported using traditional open techniques. Minimally invasive procedures are fast becoming an alternative to open techniques in many fields and have the potential to become the standard of care. The cardiovascular literature is replete with reports of endoscopically harvested vascular grafts. This article reviews both methods, since the current state of the art involves knowledge of open and endoscopic harvesting techniques.

Cerebrospinal fluid rhinorrhea: diagnosis and management.

Advances in imaging and endoscopic techniques have improved the ability to diagnose, localize, and treat in a less morbid fashion CSF leaks of the anterior skull base. An appreciation for the mechanism of leak and of the relationship between CSF production and absorption must be kept in mind when individualizing a repair. Increased CSF pressure caused by overproduction or underabsorption may result in persistence of a leak despite one's best efforts. Numerous advances in dural replacement grafts and tissue sealants have improved the ability to achieve watertight closure of the cranial vault. Microvascular techniques have allowed larger defects previously not reconstructable to be handled with relative ease by trained personnel. With expanded reconstructive techniques, the ability to handle larger disease processes of the skull base continues to expand.

Operative prevention and management of voice-limiting pharyngoesophageal spasm.

Voice-limiting pharyngoesophageal spasm presents a challenge to the surgeon who is trying to optimize functional voice outcomes in the laryngectomy patient. Modified closure techniques, adjunctive myotomy, and pharyngeal plexus neurectomy have the ability to improve or prevent pharyngoesophageal spasm. Attempts to maximize vocal outcome should be considered at the original time of laryngectomy and tracheoesophageal voice restoration because salvage treatment can be challenging.

Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for Zenker's diverticulum.

OBJECTIVES/HYPOTHESIS: To compare open and CO2 laser-assisted endoscopic surgical management of Zenker's diverticulum. STUDY DESIGN: A retrospective review of 49 consecutive surgically treated patients with Zenker's diverticulum was conducted. METHODS: Patients' records were reviewed and analyzed for patient age and sex, size of diverticulum, incision time (time recorded from start of incision to surgical completion of case), length of hospital stay, complications, and follow-up management. A postoperative questionnaire inquiring about swallow function was conducted by mail or telephone. Swallow function was assessed on a four-point scale. RESULTS: Various procedures performed included endoscopic CO2 laser-assisted diverticulotomy (n = 24) and open diverticulectomy with cricopharyngeal myotomy (n = 28). The average incision time of laser endoscopic cases (47 min) was significantly shorter (P <.001) than that of open diverticulectomy cases (170 min). Length of hospital stay did not significantly vary between the two groups. Five patients (21%) initially treated with laser endoscopic diverticulotomy demonstrated symptomatic persistent Zenker's diverticulum; three underwent repeat operation. No open cases required repeat operation. One endoscopic case was aborted secondary to esophageal injury from placement of the endoscope. Postoperative fever was seen in two (8%) endoscopic cases and four (14%) open approach cases. No major complications (recurrent laryngeal nerve paralysis, mediastinitis, or death) were encountered. More than 90% of respondents in each treatment group reported normal or near-normal swallow function. CONCLUSION: Laser endoscopic management is a reasonable and safe method for surgical treatment of Zenker's diverticulum in comparison with the open technique. Employment of the endoscopic approach reduces operative time and the complexity of postoperative care. Practitioners should be aware that the endoscopic approach may result in a higher failure rate.