Abstract
Simple SummaryBased on the proven benefits of goal directed therapy (GDT) in the perioperative management of different surgical procedures and in high-risk patients, we hypothesised that this approach would also be beneficial in microvascular free flap reconstruction in head and neck cancer. In this study, we investigated whether GDT would directly benefit flap viability in addition to improving morbidity and mortality. As this reconstructive technique is gradually being introduced in more specialist fields, particularly radical oncological surgery, the benefits of GDT in this context could be extended to numerous procedures.(1) Background: Surgical outcomes in free flap reconstruction of head and neck defects in cancer patients have improved steadily in recent years; however, correct anaesthesia management is also important. The aim of this study has been to show whether goal directed therapy can improve flap viability and morbidity and mortality in surgical patients. (2) Methods: we performed an observational case control study to analyse the impact of introducing a semi invasive device (Flo Trac®) during anaesthesia management to optimize fluid management. Patients were divided into two groups: one received goal directed therapy (GDT group) and the other conventional fluid management (CFM group). Our objective was to compare surgical outcomes, complications, fluid management, and length of stay between groups. (3) Results: We recruited 140 patients. There were no differences between groups in terms of demographic data. Statistically significant differences were observed in colloid infusion (GDT 53.1% vs. CFM 74.1%, p = 0.023) and also in intraoperative and postoperative infusion of crystalloids (CFM 5.72 (4.2, 6.98) vs. GDT 3.04 (2.29, 4.11), p < 0.001), which reached statistical significance. Vasopressor infusion in the operating room (CFM 25.5% vs. GDT 74.5%, p < 0.001) and during the first postoperative 24h (CFM 40.6% vs. GDT 75%, p > 0.001) also differed. Differences were also found in length of stay in the intensive care unit (hours: CFM 58.5 (40, 110) vs. GDT 40.5 (36, 64.5), p = 0.005) and in the hospital (days: CFM 15.5 (12, 26) vs. GDT 12 (10, 19), p = 0.009). We found differences in free flap necrosis rate (CMF 37.1% vs. GDT 13.6%, p = 0.003). One-year survival did not differ between groups (CFM 95.6% vs. GDT 86.8%, p = 0.08). (4) Conclusions: Goal directed therapy in oncological head and neck surgery improves outcomes in free flap reconstruction and also reduces length of stay in the hospital and intensive care unit, with their corresponding costs. It also appears to reduce morbidity, although these differences were not significant. Our results have shown that optimizing intraoperative fluid therapy improves postoperative morbidity and mortality.
Highlights
Microvascular free flaps are the preferred method of reconstruction for most major head and neck cancer defects, giving better functional and cosmetic outcomes and generally higher success rates compared to local and regional flaps [1].With the introduction of more advanced microvascular instruments and the refinement of microvascular techniques, free flap surgery has become a reliable and efficient method for reconstructing complex defects [2,3,4]
Our results have shown that optimizing intraoperative fluid therapy improves postoperative morbidity and mortality
Our findings show that goal directed therapy in free flap reconstruction in head and neck cancer improves free flap survival and reduces the morbidity and mortality associated with the procedure
Summary
Microvascular free flaps are the preferred method of reconstruction for most major head and neck cancer defects, giving better functional and cosmetic outcomes and generally higher success rates compared to local and regional flaps [1].With the introduction of more advanced microvascular instruments and the refinement of microvascular techniques, free flap surgery has become a reliable and efficient method for reconstructing complex defects [2,3,4]. Microvascular free flaps are the preferred method of reconstruction for most major head and neck cancer defects, giving better functional and cosmetic outcomes and generally higher success rates compared to local and regional flaps [1]. It is useful to bear in mind that haemodynamic monitoring is important in patients with generalised hypoperfusion undergoing microvascular free flap reconstruction [10]. Goal directed therapy (GDT) involves administering fluids and vasoactive drugs according to haemodynamic objectives [10]. It was originally used in surgical patients in whom normal or supranormal cardiac output and oxygenation values were required to meet increased perioperative oxygen demands and prevent organ failure. Individualizing fluid management means tailoring fluid administration to individual needs by ensuring that the patient’s heart is operating close to the inflection point on the Frank Starling curve, far from the dangerous hypovolemic and fluid overload zones [11]
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