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64 Outcomes following pharyngolaryngectomy reconstruction with the anterolateral thigh (ALT) flap
Oral presentations / British Journal of Oral and Maxillofacial Surgery 48 (2010) S1–S24
Rehabilitation of these patients with dental implants using bone grafting and distraction osteogenesis is also discussed. 63 Delays in emergency oral and maxillofacial operating – 5 years later A. Kalantzis, M. Weisters, N. Saeed. Oxford Radcliffe Hospitals, UK Introduction: Delays in emergency Oral and Maxillofacial Surgery (OMFS) lead to prolonged patient discomfort and increase the burden of acute hospital services. A published prospective study in our unit 5 years previously identified significant delays, primarily attributed to general surgical cases taking priority (system delay). The current study aims to assess progress since then. Methods: Prospective audit of delays in emergency OMFS over a 6-month period was carried out. Data included length and reason for delays occurred. These were related to type of procedure and compared to performance in the same hospital over the same period 5 years earlier. Results: There were 222 patients booked on the emergency list – workload had almost tripled in 5 years. Average delay had also increased, with 60% of patients waiting more than 12 hours and 29% breeching beyond 24 hours. Fractured mandibles were most likely to breech. System delay accounted for 83% of breeches. Conclusions: Over a 5-year period, there was no improvement in delays in emergency operating despite increasing use of elective lists for emergencies. This may be attributed to the large increase in workload without a matching increase in staffing or theatre availability. In addition, problems with communication between specialties, theatre and recovery staffing, and elective list overruns contributed to theatre utilization that did not much capacity. Towards the end of the audited period there were signs of improvement, following an inter-specialty initiative instigating measures to improve emergency theatre productivity and the addition of a dedicated OMFS trauma list. 64 Outcomes following pharyngolaryngectomy reconstruction with the anterolateral thigh (ALT) flap M.W.S. Ho, A. Zuydam, S.R. Jackson, J. Lancaster, T.K. Blackburn, J.J. Homer, S. Loughran, R.J. Shaw. University Hospital Aintree, Liverpool and Manchester Royal Infirmary, UK Introduction: The pharyngolaryngectomy defect poses a reconstructive challenge. Local audit of alternative flap reconstructions had >50% pharyngocutaneous fistula rate despite excellent flap viability. The ALT flap is reliable (98% flap survival) and recent evidence shows superior swallowing and speech outcomes compared to other methods. Methods: Retrospective review (2007–2009) of ALT reconstruction (n = 16) following pharyngolaryngectomy for laryngeal SCC. Results: Surgery: 94% received primary surgery and adjuvant radiotherapy, 6% salvage laryngectomy. 53% patch and 47% circumferential (‘tubed’) reconstructions. Per-operative salivary tubes were used in 75% of cases. Early complications: No flap failures. 20% required return to theatre for bleeding, Cook Swartz probe malfunction, or wound dehiscence. 6% early fistula formation. 7% skin graft lost to the donor site and 13% donor site infection. Late complications: 38% had no complications; 63% developed dysphagia; 38% developed a stricture; 6% had chronic fistula. Survival: 87% overall survival (at median 2.5 yrs).
S17
Functional Outcomes: At their most recent review, 47% were on normal diet, 33% soft/pureed diet, 7% managed oral fluids and 13% were PEG-dependent. 47% had immediate surgical voice restoration and 47% were managing tracheo-oesophageal speech. Conclusion: 87% were no longer dependent on enteral tubes for feeding and, in this series, the ALT reconstruction has substantially reduced fistula formation with acceptable donor site morbidity. For these reasons, the ALT flap is the authors’ preferred method for pharyngolaryngectomy reconstruction. Our late stricture formation and PEG dependence rates were inferior to other published series and the authors speculate that adjuvant radiotherapy may have contributed to stricture formation. 65 Lugol’s iodine detection of synchronous primary mucosal cancer A. Kanatas, G.W. Jenkins, D.N. Sutton, J.A. McCaul. Bradford Teaching Hospitals NHS Foundation Trust, UK Lugol’s iodine is currently under investigation as a technique to detect dysplasia, carcinoma-in-situ and invasive carcinoma at resection margins [1]. Dysplastic cells and invasive carcinoma cells fail to store glycogen and so do not stain brown when Lugol’s solution is applied [2]. This allows identification of these tissues distinct from normal oral and oropharyngeal mucosa. Lugol’s iodine is inexpensive, user friendly and appears to be effective in reducing dysplasia at surgical resection margins [1]. While synchronous second primary head and neck cancer is a rare phenomenon [3] the undetected presence of such a lesion will produce treatment failure. We present two cases where Lugols revealed abnormal mucosa (one carcinoma, one SCCa in situ) at sites distinct from index cancer within the oral cavity and oropharynx. Detection of these separate lesions allowed synchronous treatment and reduction of treatment failure. This technique is the subject of a multicentre trial funded by CRUK. We would like to invite our surgical colleagues to participate in this trial. Reference(s) [1] McMahon J, Devine JC, McCaul JA, McLellan DR, Farrow A. Use of Lugol’s iodine in the resection of oral and oropharyngeal squamous cell carcinoma. Br J Oral Maxillofac Surg 2009. [2] Inoue H, Rey JF, Lightdale C. Lugol chromoendoscopy for esophageal squamous cell cancer. Endoscopy 2001; 33(1): 75–9. [3] Chuang SC, Scelo G, Tonita JM, Tamaro S, Jonasson JG, Kliewer EV, et al. Risk of second primary cancer among patients with head and neck cancers: A pooled analysis of 13 cancer registries. Int J Cancer 2008; 123(10): 2390–6. 66 Is there wisdom in performing cone beam CT as a pre-operative investigation in removal of lower third molars? N. Ghazali, K. Christensen, D. Coombes. Queen Victoria Hospital, East Grinstead, UK Introduction: The close proximity of the inferior dental nerve (IDN) during its intrabony course in the mandible to the wisdom tooth places this nerve at risk of damage during surgical removal of wisdom teeth. Specific radiographic features are used to predict the intimate nerve–tooth relationship. This is often used in assessing the degree of surgical difficulty, options for surgical access, choice of anaesthesia and quantifying risks of post-operative complications, in particular IDN paraesthesia.
Rehabilitation of these patients with dental implants using bone grafting and distraction osteogenesis is also discussed. 63 Delays in emergency oral and maxillofacial operating – 5 years later A. Kalantzis, M. Weisters, N. Saeed. Oxford Radcliffe Hospitals, UK Introduction: Delays in emergency Oral and Maxillofacial Surgery (OMFS) lead to prolonged patient discomfort and increase the burden of acute hospital services. A published prospective study in our unit 5 years previously identified significant delays, primarily attributed to general surgical cases taking priority (system delay). The current study aims to assess progress since then. Methods: Prospective audit of delays in emergency OMFS over a 6-month period was carried out. Data included length and reason for delays occurred. These were related to type of procedure and compared to performance in the same hospital over the same period 5 years earlier. Results: There were 222 patients booked on the emergency list – workload had almost tripled in 5 years. Average delay had also increased, with 60% of patients waiting more than 12 hours and 29% breeching beyond 24 hours. Fractured mandibles were most likely to breech. System delay accounted for 83% of breeches. Conclusions: Over a 5-year period, there was no improvement in delays in emergency operating despite increasing use of elective lists for emergencies. This may be attributed to the large increase in workload without a matching increase in staffing or theatre availability. In addition, problems with communication between specialties, theatre and recovery staffing, and elective list overruns contributed to theatre utilization that did not much capacity. Towards the end of the audited period there were signs of improvement, following an inter-specialty initiative instigating measures to improve emergency theatre productivity and the addition of a dedicated OMFS trauma list. 64 Outcomes following pharyngolaryngectomy reconstruction with the anterolateral thigh (ALT) flap M.W.S. Ho, A. Zuydam, S.R. Jackson, J. Lancaster, T.K. Blackburn, J.J. Homer, S. Loughran, R.J. Shaw. University Hospital Aintree, Liverpool and Manchester Royal Infirmary, UK Introduction: The pharyngolaryngectomy defect poses a reconstructive challenge. Local audit of alternative flap reconstructions had >50% pharyngocutaneous fistula rate despite excellent flap viability. The ALT flap is reliable (98% flap survival) and recent evidence shows superior swallowing and speech outcomes compared to other methods. Methods: Retrospective review (2007–2009) of ALT reconstruction (n = 16) following pharyngolaryngectomy for laryngeal SCC. Results: Surgery: 94% received primary surgery and adjuvant radiotherapy, 6% salvage laryngectomy. 53% patch and 47% circumferential (‘tubed’) reconstructions. Per-operative salivary tubes were used in 75% of cases. Early complications: No flap failures. 20% required return to theatre for bleeding, Cook Swartz probe malfunction, or wound dehiscence. 6% early fistula formation. 7% skin graft lost to the donor site and 13% donor site infection. Late complications: 38% had no complications; 63% developed dysphagia; 38% developed a stricture; 6% had chronic fistula. Survival: 87% overall survival (at median 2.5 yrs).
S17
Functional Outcomes: At their most recent review, 47% were on normal diet, 33% soft/pureed diet, 7% managed oral fluids and 13% were PEG-dependent. 47% had immediate surgical voice restoration and 47% were managing tracheo-oesophageal speech. Conclusion: 87% were no longer dependent on enteral tubes for feeding and, in this series, the ALT reconstruction has substantially reduced fistula formation with acceptable donor site morbidity. For these reasons, the ALT flap is the authors’ preferred method for pharyngolaryngectomy reconstruction. Our late stricture formation and PEG dependence rates were inferior to other published series and the authors speculate that adjuvant radiotherapy may have contributed to stricture formation. 65 Lugol’s iodine detection of synchronous primary mucosal cancer A. Kanatas, G.W. Jenkins, D.N. Sutton, J.A. McCaul. Bradford Teaching Hospitals NHS Foundation Trust, UK Lugol’s iodine is currently under investigation as a technique to detect dysplasia, carcinoma-in-situ and invasive carcinoma at resection margins [1]. Dysplastic cells and invasive carcinoma cells fail to store glycogen and so do not stain brown when Lugol’s solution is applied [2]. This allows identification of these tissues distinct from normal oral and oropharyngeal mucosa. Lugol’s iodine is inexpensive, user friendly and appears to be effective in reducing dysplasia at surgical resection margins [1]. While synchronous second primary head and neck cancer is a rare phenomenon [3] the undetected presence of such a lesion will produce treatment failure. We present two cases where Lugols revealed abnormal mucosa (one carcinoma, one SCCa in situ) at sites distinct from index cancer within the oral cavity and oropharynx. Detection of these separate lesions allowed synchronous treatment and reduction of treatment failure. This technique is the subject of a multicentre trial funded by CRUK. We would like to invite our surgical colleagues to participate in this trial. Reference(s) [1] McMahon J, Devine JC, McCaul JA, McLellan DR, Farrow A. Use of Lugol’s iodine in the resection of oral and oropharyngeal squamous cell carcinoma. Br J Oral Maxillofac Surg 2009. [2] Inoue H, Rey JF, Lightdale C. Lugol chromoendoscopy for esophageal squamous cell cancer. Endoscopy 2001; 33(1): 75–9. [3] Chuang SC, Scelo G, Tonita JM, Tamaro S, Jonasson JG, Kliewer EV, et al. Risk of second primary cancer among patients with head and neck cancers: A pooled analysis of 13 cancer registries. Int J Cancer 2008; 123(10): 2390–6. 66 Is there wisdom in performing cone beam CT as a pre-operative investigation in removal of lower third molars? N. Ghazali, K. Christensen, D. Coombes. Queen Victoria Hospital, East Grinstead, UK Introduction: The close proximity of the inferior dental nerve (IDN) during its intrabony course in the mandible to the wisdom tooth places this nerve at risk of damage during surgical removal of wisdom teeth. Specific radiographic features are used to predict the intimate nerve–tooth relationship. This is often used in assessing the degree of surgical difficulty, options for surgical access, choice of anaesthesia and quantifying risks of post-operative complications, in particular IDN paraesthesia.