Ablative Cancer Surgery Research Articles

Combined Use of Liposuction and Arthroscopic Shaving for Delayed Debulking of Free Flaps in Head and Neck Reconstruction.

Bulky appearance after free flap reconstruction in patients with head and neck cancer is common and requires revision to achieve improved final outcomes. Although different delayed debulking methods have been reported, the procedure can be technically difficult in patients with severe scaring after adjuvant radiotherapy. The present study proposes a combined method of liposuction and arthroscopic shaving for delayed contouring of free flaps in head and neck reconstruction. In this study, 12 patients with head and neck cancer who had bulky flaps after cancer ablation surgery and immediate free anterolateral thigh flap reconstruction were included. These patients underwent delayed debulking through the combined arthroscopic shaving and liposuction method at least 3 months after the initial reconstruction or the completion of adjuvant radiotherapy (if required). Age, sex, cancer stages, the presence or absence of adjuvant radiotherapy, the interval between the initial free flap reconstruction and the debulking procedure, complications, and subjective satisfaction ratings were recorded 1 and 6 months after the revision surgery. All patients were men, with an average age of 56.3 years (43-69 years), and 9 (75%) patients underwent adjuvant radiotherapy. Partial flap loss was not observed in the study patients, and subjective satisfaction ratings improved after the debulking procedure. The combined liposuction and arthroscopic shaving method can facilitate the debulking and contouring procedures in patients with head and neck cancer after free flap reconstruction. With appropriate timing, the combined procedure can be simple and safe, even in patients with severe scaring after adjuvant radiotherapy.

Overall Survival and Local Recurrence Among Breast Cancer Patients in Hospital Sultanah Nora Ismail Batu Pahat, 2007-2013

Objective:To gauge surgical outcome in breast cancer patients with particular reference to overall survival and recurrence free survival among breast cancer patients in Hospital Sultanah Nora Ismail Batu Pahat, Johor, Malaysia.Methods:Patients undergoing ablative breast cancer surgery were identified and clinical records were assessed. Inclusion criteria for enrolment were stage I-IV breast malignancy necessitating resection with or without radiotherapy/ chemotherapy from 2007 to 2013. All individuals had a pre-operative assessment. The post operative assessment period ranged from 1 year to 5 years. Survival distributions were analyzed using Kaplan-Meier curves.Results:A total of 121 patients were included in this study, with an age range of 28-78 years. Some 98% had undergone local excision/ lumpectomy/ mastectomy with axillary clearance. While 81% of patients underwent chemotherapy, only 69% had radiotherapy. Tumours were oestrogen receptor positive in 58% of cases and progesterone receptor positive in 62%. Local recurrence was detected in 10%. The mean age at diagnosis was 51.3 + 10.4 years. The overall survival analysis was based on 22 deaths among the 121 patients (18.2%). Three-year and five-year survival rates were 87.6% and 78.4%, respectively. Analysis of recurrence-free-survival (RFS) was based on 12 events among 121 patients. The Kaplan-Meier RFS analysis revealed that in 90% of the patients with recurrence, it occurred within 45 months. The five year RFS rate was 84.5%. The median time taken from diagnosis to ablative surgery was 51 days (upper limit of 791 days). Only distant metastasis was a significant factor that impacted on both overall survival and recurrence-free survival (p<0.001).Conclusion:Overall survival among our breast cancer patients in our facility is comparable to other in other tertiary centres in the country. A trend for earlier detection was noted.

Change in reimbursement and costs in German oncological head and neck surgery over the last decade: ablative tongue cancer surgery and reconstruction with split-thickness skin graft vs. microvascular radial forearm flap.

Defects after ablative tongue cancer surgery can be reconstructed by split-thickness skin grafts or free microvascular flaps. The different surgical options may influence costs, reimbursement, and therefore possible profits. Our goal was to analyze the development of these parameters for different procedures in head and neck reconstruction in Germany over the last decade. After tumor resection and neck dissection of tongue cancer, three different scenarios were chosen to calculate costs, reimbursement, length of stay (LoS), and profits. Two options considered were reconstruction by split-thickness skin graft with (option Ia) and without (option Ib) tracheotomy. In addition, we analyzed microvascular reconstruction with radial forearm flap (option II). Furthermore, unsatisfactory results after options Ia and Ib may make secondary tongue plastic with split-thickness skin grafting necessary (option I+). The calculations were performed considering the German Diagnosis Related Group (DRG) system and compared to the specific DRG cost data of 250 German reference hospitals. The overall average length of stay (aLoS) declined from 16.7 to 12.8days with a reduction in every option. Until 2011, all options showed similar accumulated DRG reimbursement. From 2012 onwards, earnings almost doubled for option II due to changes in the DRG allocation. As was expected, the highest costs were observed in option II. Profits (reimbursement minus costs) were also highest for option II (mean 2052 €, maximum 3630 Euros in 2015) followed by options Ia (765 €) and Ib/I+ (681 €). Average profits over time would be 17 to 19% higher if adjusted for inflation. We showed the development of the DRG allocation of two commonly used methods of reconstruction after ablative tongue cancer surgery and the associated LoS, reimbursement, costs, and profits. As expected, the highest values were found for microvascular reconstruction. Microvascular reconstruction may also be the primary choice of treatment from a medical point of view. However, prolonged operation times, intensive care, and hospital stay in connection with complex microvascular operations can easily turn profits into losses as opposed to the results of simple, reliable, and fast split-thickness skin grafting. The inflation rate influences profits in reimbursement systems where costs are based on a previous period of time. Surgeons find themselves daily in an area of conflict between economic interests and medical decision-making. Due to its multidimensional aspects, the choice of the reconstructive technique should be primarily based on the best medical care for the patient. But there should also be awareness of the economic risk of all three surgical procedures.

Short report: interim safety results for a phase II trial measuring the integration of stereotactic ablative radiotherapy (SABR) plus surgery for early stage non-small cell lung cancer (MISSILE-NSCLC)

A phase II trial was launched to evaluate if neoadjuvant stereotactic ablative radiotherapy (SABR) before surgery improves oncologic outcomes in patients with stage I non-small cell lung cancer (NSCLC). We report a mandated interim safety analysis for the first 10 patients who completed protocol treatment. Operable patients with biopsy-proven T1-2 N0 NSCLC were eligible. SABR was delivered using a risk-adapted fractionation (54Gy/3 fractions, 55/5 or 60/8). Surgical resection was planned 10 weeks later at a high-volume center (>200 lung cancer resections annually). Patients were imaged with dynamic positron emission tomography-computed tomography scans using 18F-fludeoxyglucose (18F-FDG-PET CT) and dynamic contrast-enhanced CT before SABR and again before surgery. Toxicity was recorded using CTCAE version 4.0. Twelve patients were enrolled between 09/2014 and 09/2015. Two did not undergo surgery, due to patient or surgeon preference; neither patient has developed toxicity or recurrence. For the 10 patients completing both treatments, median age was 70 (range: 54–76), 60% had T1 disease, and 60% had adenocarcinoma. Median FEV1 was 73% predicted (range: 54–87%). Median time to surgery post-SABR was 10.1 weeks (range: 9.3–15.6 weeks). Surgery consisted of lobectomy (n = 8) or wedge resection (n = 2). Median follow-up post-SABR was 6.3 months. After combined treatment, the rate of acute grade 3–4 toxicity was 10%. There was no post-operative mortality at 90 days. The small sample size included herein precludes any definitive conclusions regarding overall toxicity rates until larger datasets are available. However, these data may inform others who are designing or conducting similar trials.Trial registrationNCT02136355. Registered 8 May 2014.

Development of a nomogram for predicting the probability of postoperative delirium in patients undergoing free flap reconstruction for head and neck cancer

PurposeTo develop nomogram for prediction of postoperative delirium (POD) in patients undergoing ablative and reconstruction surgery for head and neck cancer. MethodsTotal 341 patients were retrospectively analyzed, and clinical variables in preoperative, intraoperative and postoperative periods were compared between delirium group (n = 89) and non-delirium group (n = 252). Multivariate logistic regression, receiver operating characteristics curve, and area under the curve (AUC) were used to generate and test a nomogram, which performance was evaluated by 10-fold cross validation (CV) procedure. ResultsIn univariate and multivariate analysis, age, history of psychiatric disorder, marital status, preoperative numeric rating scale for pain, ASA classification, and ICU stay period were identified as significant risk factors. Using these factors, nomogram for predicting the POD was developed and it showed sensitivity of 61.8%, specificity of 75.4%, PPV of 47.0%, and NPV of 84.8% (Youden's index of 0.372). In 10-fold cross validation set, corresponding values were 44.9%, 84.1%, 50.0% and 81.2% (Youden's index of 0.337). AUC was comparable between two sets (0.7407 and 0.6898). ConclusionsProposed nomogram showed fair discriminative power for POD risk in head and neck cancer patients undergoing major surgery.

Quality of Life Following Stereotactic Ablative Radiation Therapy Versus Surgery for Early-Stage Lung Cancer: Results From the ROSEL Randomized Controlled Trial and a Systematic Review

Purpose/Objective(s) One of the purported advantages of stereotactic ablative radiation therapy (SABR) as an alternative treatment option to surgery for early-stage non-small cell lung cancer (ES-NSCLC) is health-related quality of life (HRQOL). The objectives of this study are 1) to assess HRQOL and indirect costing outcomes from the ROSEL randomized trial comparing surgery and SABR for ES-NSCLC and 2) to perform a systematic review of HRQOL following SABR for ES-NSCLC. Materials/Methods In ROSEL, 22 patients with ES-NSCLC were randomized to either SABR or surgery before the trial closed due to poor accrual. HRQOL was evaluated at baseline, and then 3, 6, 12, 18, and 24 months posttreatment using the 30 item EORTC QLQ-C30, its corresponding 13-item lung cancer supplement, and the EuroQol disease-generic questionnaire. Indirect costs of productivity loss were evaluated using the short form health and labor questionnaire, which includes work absences, reduced efficiency at work, and substitution for unpaid work. Time to deterioration (TTD) in HRQOL was calculated from time to randomization to first appearance of clinically significant change. TTD was analyzed using Cox proportional hazard models. The Embase and MEDLINE databases were systematically reviewed to obtain English language articles investigating patient-reported HRQOL after SABR for ES-NSCLC up to August 1, 2015. Review articles, meta-analyses, and decision analyses were excluded. Relevant data regarding patient characteristics and study outcomes were abstracted and analyzed. Results In the ROSEL study, only TTD of global health status was significantly worse on univariable modeling for surgical patients compared to SABR (HR 0.19, P = 0.038). Indirect costing analysis revealed lower total productivity costs to society for SABR compared to surgery (€95 vs €3,513, P = 0.044). Patients reported a lower total degree of hindrance in paid and unpaid work for SABR compared to surgery (mean hindrance scores for SABR: 1.9, for surgery: 6.0, P = 0.010). In the SABR HRQOL systematic review, 9 out of 204 potential studies met all inclusion criteria and were analyzed. All studies were prospective in design. Overall, SABR appeared to be well-tolerated in a mostly medically inoperable patient population. Clinically and statistically significant deteriorations in fatigue and dyspnea were individually reported in two studies. An isolated report found clinically and statistically significant improvements in emotional functioning over time. Deterioration in dyspnea and physical functioning were noted in other studies, but were neither statistically nor clinically significant. Conclusion SABR is an overall well-tolerated modality in patients with ES-NSCLC who either declined surgery or were unfit. Exploratory results in operable ES-NSCLC suggest that SABR may be better tolerated than surgery and incur indirect costing savings. Future clinical trials comparing SABR and surgery would benefit from the inclusion of HRQOL metrics in study design.

Versatility of pedicled anterolateral thigh flap in gynecologic reconstruction after vulvar cancer extirpative surgery.

Ablative surgery for vulvar cancer can involve the resection of perineum, vagina, urethra, groins, mons pubis, and abdominal wall creating complex defects. In our opinion, ALT flap is an ideal flap for reconstruction, because of low incidence of complications, long pedicle outside the radiotherapy field, capability of carrying fascia and muscle, possibility of sensate reconstruction, and low donor site morbidity. The purpose of this report is to describe our experience with ALT flap for reconstruction after vulvar cancer extirpative surgery, discussing our indications for complex defects and focusing on its versatility. We performed a retrospective review of 15 cases of complex postoncologic gynecological wounds, reconstructed with 16 pedicled ALT flap, after vulvar cancer ablative surgery between 2014 and 2016. Age of the patients ranged from 44 to 77, with mean age of 62.6. Postoperative outcomes were evaluated. The flap size ranged from 12 × 8 cm to 22 × 15 cm., in two cases we harvested vastus lateralis to fill the dead space after pelvic exenteration. In nine flaps, we could include only 1 perforator, in 7 we could use two, 5 were septocutaneous and 18 myocutaneous with a pedicle length ranging from9cm.to15cm.We had no flap necrosis.3 flaps showed dehiscence of a part of the wound that healed by dressings. In one case of obese patient the donor site showed partial wound edge necrosis, and required secondary grafting. During follow-up that ranged from 1 month to 2 years, cancer relapsed locally in 5 patients. Global performance and specific pain improved after surgery. ALT flap should be included in the first line options for reconstructions of complex defects resulting from vulvar cancer surgery because of its reliability and versatility. © 2016 Wiley Periodicals, Inc. Microsurgery 37:516-524, 2017.

Reconstructive considerations in head and neck surgical oncology: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. The reconstructive needs following ablative surgery for head and neck cancer are unique and require close attention to both form and function. The vast experience accrued with microvascular reconstructive surgery has meant a significant expansion in the options available. This paper discusses the options for reconstruction available following ablative surgery for head and neck cancer and offers recommendations for reconstruction in the various settings. Recommendations •Microsurgical free flap reconstruction should be the primary reconstructive option for most defects of the head and neck that need tissue transfer. (R) •Free flaps should be offered as first choice of reconstruction for all patients needing circumferential pharyngoesophageal reconstruction. (R) •Free flap reconstruction should be offered for patients with class III or higher defects of the maxilla. (R) •Composite free tissue transfer should be offered as first choice to all patients needing mandibular reconstruction. (R) •Patients undergoing salvage total laryngectomy should be offered vascularised flap reconstruction to reduce pharyngocutaneous fistula rates. (R).

Use of systemic low-dose unfractionated heparin in microvascular head and neck reconstruction: Influence in free-flap outcomes

Background: Intravenous heparin administration is used to prevent thrombosis in free-flap transfer. However, it is unknown whether the use of heparin affects free-flap survival. The purpose of this study is to investigate the effect of heparin in free flap transfer. Methods: Two hundred and six patients who received ablative surgery for head and neck cancer were classified into three groups. Group A received ablative surgery, neck dissection, and free-flap reconstruction, and postoperatively they were administered continuous intravenous unfractionated heparin (5000–10 000 units/day) until postoperative day 7 (POD7); group B received the same procedures as group A but without heparin; group C received only ablative surgery and neck dissection without heparin. As indicators of coagulation time, the prothrombin time-international normalised ratio (PT-INR) and the activated partial thromboplastin time (APTT) were measured, before surgery and on POD1, 3, and 7. Flap failure, bleeding, haematoma formation, re-exploration, and thromboembolic events were recorded. Results: The PT-INR and APTT were 1.3–1.5-times longer in group A (p < 0.01), and 1.3-times longer (p < 0.01) in group B. The PT-INR and APTT were higher in groups A and B than C (p < 0.01). The free-flap success rate was not affected. Only the incidence of haematoma was increased in group A (p = 0.04). Conclusion: Heparin increased the haematoma formation, but did not change the incidence of free-flap failure. Thus, the intravenous low-dose heparin use does not affect microvascular flap survival.

Head and neck reconstructive surgery: what the radiologist needs to know.

Head and neck reconstructive surgery after cancer ablative surgery is now commonly performed with closure of the surgical defects by microvascular free tissue transfer. The most common flaps used for reconstruction are the radial forearm flap, the anterolateral thigh flap and fibula flap. Radiographic appearance of these flaps depends on the individual components of the flap, and may consist of skin, fat, muscle and/or bone. There are various adverse outcomes in these patients, the most significant being tumour recurrence that typically occurs at the flap margins. Other flap complications include flap necrosis from vascular thrombosis or infection. The goal of this article is to enhance radiologists' familiarity with different methods of flap reconstruction, flap margins and vascular anastomoses that will lead to a better appreciation of expected postoperative radiographic appearance. • Flaps are the most common reconstructive techniques used in neck cancer surgery. • Imaging appearance of flaps depends on their components and time since surgery. • Most tumour recurrence after reconstruction occurs at the margins of the flap.

Reconstruction of oro-facial region; challenges and opportunities

Event Abstract Back to Event Reconstruction of oro-facial region; challenges and opportunities Ashraf A. Ayoub1, Randa Al Fotawi1, K E. Tanner2, Matthew J. Dalby3 and Kurt Naudi1 1 University of Glasgow, Glasgow Dental Hospital & School, United Kingdom 2 University of Glasgow, Biomedical Engineering Division, School of Engineering, United Kingdom 3 University of Glasgow, Institute of Molecular, Cell and Systems Biology, College of Medical, Veterinary and Life Sciences, United Kingdom Background: Surgical reconstruction of functional and aesthetic defects, particularly following ablative cancer surgery, is often compromised by limited vascularity and the associated donor site morbidity. A compromised vascular bed is a major obstacle for the successful uptake of a micro-vascular flap. Aim: Investigate a novel approach of using an injectable scaffolding into a pedicled muscle flap for reconstruction of a critical size mandibular defect. Materials and Methods: Under general anesthesia bone marrow was aspirated from both the rabbit’s anterior iliac crest. Cells were cultured and expanded according to a validated standard protocol before application in the surgical defect[1]. A critical size bony defect, 20mm x 15mm, was created in the rabbit’s mandibular body[2]. A fixation plate was applied at the inferior border to maintain the mandibular integrity, while the superior border was maintained. A pedicled masseter muscle flap was rotated and adapted to fill the created surgical defect. An injectable calcium sulfate/hydroxyapatite scaffolding material (Cerament Spine Support) loaded with BMP-7 and mesnechymal stem cells was injected into the muscle flap to induce bone formation. Animals were sacrificed at three months following surgery. The quality of bone regeneration was assessed using Cone Beam Computerised Tomography (CBCT), micro CT and histological assessment. Results: In all the cases sporadic areas of bone regeneration were detected within the muscle flap. In some cases the volume of newly formed bone was more than the volume of bone resected to the create the defect. Bone formation was in close proximity to the injectable scaffold material. Micro CT showed a different trabecular pattern in the regenerated bone to the native bone tissue. Fig 1 Micro CT showing new bone formed in the defect. Histologically, the regenerated tissue consisted of a mixture of mature bone with clear Haversion structure and areas of woven bone. Some areas of fibrous tissue “muscle metaplasia” was detected between the newly generated bone and the surrounding muscle fibres. New bone formation was either from the defect edges or Fig 2 Undecalcified section stained with Goldner’s trichrome, showing resorption of the graft material and new bone formation. Conclusions: The muscle flap acted as a bioreactor for bone induction under the influence of calcium sulfate/hydroxyapatite, stem cells and BMP-7. Three months is insufficient for complete restoration of the bony defect. The new bone formation concentrated around the areas of the injected cells and material. Randa Alfotawi was funded by King Saud University, Ministry of Higher Education; Bone Support AB (Lund, Sweden) is thanked for provision of the Cerament™ bone cements

Surgical therapy of vulvar cancer: how to choose the correct reconstruction?

ObjectiveTo create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect.MethodsWe retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer.ResultsWe employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall.ConclusionThe algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.

Double-layered collagen graft to the radial forearm free flap donor sites without skin graft.

BackgroundRadial forearm free flap is the most reliable flap for intraoral soft tissue reconstruction after cancer ablation surgery. However, unesthetic scar of the donor site and the need for a second donor site for skin graft are major disadvantages of the forearm flap. The purpose of this study was to report the clinical results of double-layered collagen graft to the donor site of the forearm free flap without skin graft.MethodsTwenty-two consecutive patients who underwent oral cancer ablation and forearm reconstruction between April 2010 and November 2013 were included in this study. Male to female ratio was 12:10, and average age was 61.0 years old (27–84). Double-layered collagen was grafted to the donor site of the forearm free flap and healed for secondary intention. Upper silicone had been trimmed at the periphery during secondary intention, and dry dressing was used. Postoperative scar healing and esthetic results and function were evaluated.ResultsAn average follow-up period was 34.9 months. The scar area was decreased to 63.9 % in average. The complete healing was obtained between 1.5 and 3 months according to the defect size. There was no functional defect or impairment 3 months after operation. All patients were satisfied with the esthetic results. Three patients died of recurred cancer.ConclusionsDouble-layered collagen graft was successfully performed in this study. Without the thigh skin graft, patients had experienced less painful postoperative healing periods and discomfort.

A case of idiopathic thrombocytopenic purpura that developed after oral cancer ablation surgery

A case of idiopathic thrombocytopenic purpura that developed after oral cancer ablation surgery

Esthetic and functional surgery and reconstruction after oral cancer ablation

Oral cancer ablation surgery results in tissue defects with functional loss. Accompanying neck dissection results in facial nerve weakness and dysmorphic changes. To minimize the complications after oral cancer surgery, accurate dissection without damaging facial nerve and vital structures are mandatory. Marginal mandibular branch of facial nerve should be dissected or contained in the superficial layer of deep cervical fascia to minimized facial palsy after operation. Reconstruction after cancer ablations is routine procedures and free flap reconstruction is the most commonly used. Radial forearm free flap is the most versatile flap to reconstruct soft tissue defects and it is easy to design according to the defect size and shape. However, donor site scar and secondary skin graft from thigh result in unesthetic and cumbersome wounds. Double layered collagen graft in the donor site could reduce secondary donor site for skin graft. In conclusion, oral and maxillofacial surgeon should know the exact anatomy of the face and neck during neck dissection. Radial forearm free flap is most versatile flap for soft tissue reconstruction and double collagen graft can reduce postoperative scar and there is no need for secondary skin graft.

191. Causes of variation in immediate breast reconstruction after ablative surgery for invasive breast cancer

Background: In recent years there has been an increased interest in performing immediate breast reconstruction after ablative surgery for invasive breast cancer. However, in the Netherlands, considerable variation exists in the performance of immediate breast reconstruction between hospitals. Possible explanations for this variation could be related to several patient, surgeon, or hospital factors, but the exact causes are not known.

Functional and esthetic rehabilitation with maxillary prosthesis supported by zygomatic implants for a patient with maxillary defect resulting from cancer ablative surgery

Functional and esthetic rehabilitation with maxillary prosthesis supported by zygomatic implants for a patient with maxillary defect resulting from cancer ablative surgery

Effect of comorbidity on short-term outcomes and cost of care after head and neck cancer surgery in the elderly

With increased life expectancy, there is growing awareness of the effect of comorbidity on physiologic reserves in elderly patients. Data in the area of head and neck cancer surgery is lacking. Retrospective data from 61,740 elderly patients who underwent a head and neck cancer ablative surgery from 2001 to 2010 using the Nationwide Inpatient Sample were analyzed to examine associations between comorbidity and in-hospital mortality, postoperative complications, length of hospitalization, and hospital-related costs. Advanced comorbidity was present in 18% of elderly patients, who were more likely to experience acute medical complications (odds ratio [OR], 3.7; p < .001), in-hospital death (OR, 3.6; p < .001), increased length of hospitalization (mean, 2.2 days; p < .001), and hospital-related costs (mean, $6874; p < .001). Advanced comorbidity in elderly surgical patients with head and neck cancer is associated with increased mortality, morbidity, length of hospitalization, and hospital-related costs. This increased utilization of health care resources may pose challenges to health care reform efforts as the population ages.

Impact of Flap Reconstruction on Perineal Wound Complications Following Ablative Surgery for Advanced and Recurrent Rectal Cancers

To determine the effect of flap reconstruction on perineal complications in locally advanced rectal cancers (LARC) and locally recurrent rectal cancers (LRRC). Prior studies have suggested that flap reconstruction may decrease wound complications after ablative surgery for rectal cancer but are limited by small sample sizes, heterogeneity of pathologies, and lack of comparison groups. A retrospective cohort study (1999-2010) was performed on consecutive patients undergoing abdominoperineal resection (APR) or pelvic exenteration for locally advanced/locally recurrent rectal cancers. Differences in perineal complications between patients treated with and without perineal flap reconstruction were analyzed by using univariable, multivariable, and propensity score regression analyses. Flap reconstruction was performed in 52 of 177 patients (29%). Patients receiving flap reconstruction had multiple risk factors for perineal morbidity, including longer operative times and more complex procedures. In our final multivariable analyses that were stratified by type of ablative procedure, we found a trend toward lower odds of perineal complications in patients receiving flaps (p=0.065) compared with primary closure after pelvic exenteration. Although operative time and sacrectomy were significant determinants of perineal morbidity for pelvic exenteration patients, no significant predictors of perineal outcomes were identified for patients undergoing APR. This study suggests that flap reconstruction may provide some protective effect against perineal complications in patients undergoing pelvic exenteration, although this was not observed for APR. The most important determinants of perineal complications after pelvic exenteration were operative time and sacral resection, but no predictive factors for post-APR perineal outcomes were identified.

Maneuvers in Regional Flap Use in Reconstruction of Primary Defects in Head and Neck Cancer Patients: Presentation of Three Cases

ABSTRACT This case series highlights the advantages in the use of three regional flaps, submental flap, sternocleidomastoid flap and transverse cervical flap in maxillofacial primary defect reconstruction after ablative cancer surgery through presentation of three head and neck cancer patients in whom it was decided to do pedicled flaps rather than free flaps. Aim and objective This article is done in an attempt for encouraging for more introduction of these three flaps in head and neck reconstruction practice, and to encourage more studies be done to describe skin territory of cervical flap. Materials and methods Three patients presented to oral and maxillofacial department, diagnosed as having different kinds of cancer. All were managed according to the evidence-based guideline of head and neck cancer management, including the work up, diagnosis, TNM classification, surgical treatment, adjuvant treatment and follow-up. In all the three cases, regional flaps were used to close the primary defect. For the first patient, transverse cervical flap was used, the sternocleidomastoid flap in the second and submental flap in the third one. Results All flaps were easy to be harvested, in term of time and technique, and successful in term of viability, extension and in achieving the functional and cosmetic aim of reconstruction, with minimum donor site morbidity, all the patient are enjoying good quality of life. Conclusion and recommendations The regional flaps have their place to overcome limitation of free flaps due to the shortage in the armamentarium available in the hospital, especially in low resources regions, or limitations related to patients general condition, in addition, regional flaps are the best option available in case of failed free flap, or when free flap failure is anticipated and avoided. Highlighting the different maneuvers in harvesting and using regional pedicled flaps for further extensions widens the scope of indications and giving the reconstructive surgeon variability of options in reconstruction, obviates the need for special microvascular expertise in free flaps with comparable results and relatively less complication. How to cite this article Aloosi SN. Maneuvers in Regional Flap Use in Reconstruction of Primary Defects in Head and Neck Cancer Patients: Presentation of Three Cases. Int J Head Neck Surg 2014;5(1):48-55.