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Pedicle pseudoaneurysm bleed and flap survival after scapular free tissue transfer
Abstracts / British Journal of Oral and Maxillofacial Surgery 53 (2015) e37–e110
requirements needed to deliver this service and justify its place in major head and neck units. http://dx.doi.org/10.1016/j.bjoms.2015.08.089 P 82 Pedicle pseudoaneurysm bleed and flap survival after scapular free tissue transfer I. Siddique ∗ , P. Hollows, D. Srinivasan, R. Rashidi Queens Medical Centre, Nottingham, United Kingdom Introduction: Pseudoaneurysm formation on a vascular pedicle is a very rare complication in free tissue transfer. For surgical management, the feeding artery is only expendable if the flap it supplies has had sufficient time to develop adequate collateral blood flow. We present a case of pseudoaneurysm formation in a scapular free flap presenting as a life threatening haemorrhage 26 days from reconstruction. The patient survived and the flap remained viable. Case discussion: A 63 year old male with osteoradionecrosis of his mandible underwent oro-mandibular reconstruction with a scapular free flap. Anastomosis involved the external carotid artery and use of forearm vein grafts. The patient presented with a life threatening neck bleed 26 postoperatively. An urgent Computer Tomography Angiogram (CTA) revealed a pseudoaneurysm arising from the arterial pedicle. On surgical exploration, it was necessary to ligate the external carotid artery. Follow-up CTA showed complete resolution of the pseudoaneurysm and the flap has remained completely intact. Discussion: We present a rare and unusual case of pseudoaneurysm formation on a free tissue transfer pedicle. The flap survived despite ligation of the pedicle at 26 days. This is in contrast to other rare reported cases of pseudoaneurysm formation that resulted in flap failures. Due to previous chemo-radiotherapy and subsequent osteoradionecrosis, poor healing may have contributed to the development of the pseudoaneurysm. The case involved the use of an interpositional vein graft connected directly to the external carotid artery. This may have contributed to the dehiscence that would be required to form an aneurysmal sac. http://dx.doi.org/10.1016/j.bjoms.2015.08.090 P 83 Free flaps in the elderly: does age make a difference to outcome? J. Thomas ∗ , R. Elledge, N. Pattni, A. Norman, T. Hall, G. James, N. Barnard University Hospitals Bristol, United Kingdom Introduction/aims: Vascularised free flaps are now the mainstay solution for reconstructing oropharyngeal defects
e67
following oncologic resections. Concerns such as donor site morbidity, flap failure and systemic complications may be more pronounced in elderly patients with limited physiologic reserve and more co-morbidities, but it is unclear to what extent these concerns are justified. Materials/methods: Case records of patients who had free flaps reconstructions following resection of oral squamous cell carcinoma between 2003 and 2013 within our unit were reviewed. The impact of age on outcomes such as flap failure, flap complications and systemic complications was sought by univariate analysis, with any statistically significant results entered into a multivariate regression model with other variables. Results/statistics: A total of 150 free flaps were performed for oral squamous cell carcinoma. Case records of 137 (91.3%) were available for review. Failure rates were 10.0% in the elderly and 1.9% in younger patients, a difference not found to be statistically significant (p = 0.07). Age appeared to have no impact on the need for a return to theatre (p = 0.73) or systemic complications (p = 0.27). Flap complication rates were higher in elderly patients (30.0% vs. 12.1%, p < 0.05). Age was the only significant predictor of flap complications on multivariate analysis (OR 3.90, 95% CI 1.30–11.66). Conclusions/clinical relevance: With life expectancy increasing, vascularized free tissue transfer for reconstruction in head and neck cancer is a legitimate treatment option in the elderly. With detailed pre-operative assessment and planning, effective post-operative monitoring and perioperative care, age should not be a contra-indication. http://dx.doi.org/10.1016/j.bjoms.2015.08.091 P 84 The role of staged extubation in head and neck surgery E. Twohig ∗ , R. Shaw Aintree University Hospital, United Kingdom Introduction: The management of the airway following elective head and neck surgery varies and may include close monitoring in the recovery room/ward, overnight intubation in an intensive care unit and tracheostomy. There are selective cases which have a small chance of developing airway compromise post operatively but are not ideally suited to these options. Methods: We describe two cases of staged extubation utilising a stainless steel guidewire which remained in the trachea following removal of the endotracheal tube. The function of the guidewire was to facilitate reintubation in the event of development of airway compromise secondary to upper airway oedema in the early post operative phase. Both patients had challenging airways preoperatively which required fibre optic assisted intubation. Results: The device was well tolerated in both cases. It was not necessary to reintubate the patients as they made an uneventful recovery on the ward. The device remained in the
requirements needed to deliver this service and justify its place in major head and neck units. http://dx.doi.org/10.1016/j.bjoms.2015.08.089 P 82 Pedicle pseudoaneurysm bleed and flap survival after scapular free tissue transfer I. Siddique ∗ , P. Hollows, D. Srinivasan, R. Rashidi Queens Medical Centre, Nottingham, United Kingdom Introduction: Pseudoaneurysm formation on a vascular pedicle is a very rare complication in free tissue transfer. For surgical management, the feeding artery is only expendable if the flap it supplies has had sufficient time to develop adequate collateral blood flow. We present a case of pseudoaneurysm formation in a scapular free flap presenting as a life threatening haemorrhage 26 days from reconstruction. The patient survived and the flap remained viable. Case discussion: A 63 year old male with osteoradionecrosis of his mandible underwent oro-mandibular reconstruction with a scapular free flap. Anastomosis involved the external carotid artery and use of forearm vein grafts. The patient presented with a life threatening neck bleed 26 postoperatively. An urgent Computer Tomography Angiogram (CTA) revealed a pseudoaneurysm arising from the arterial pedicle. On surgical exploration, it was necessary to ligate the external carotid artery. Follow-up CTA showed complete resolution of the pseudoaneurysm and the flap has remained completely intact. Discussion: We present a rare and unusual case of pseudoaneurysm formation on a free tissue transfer pedicle. The flap survived despite ligation of the pedicle at 26 days. This is in contrast to other rare reported cases of pseudoaneurysm formation that resulted in flap failures. Due to previous chemo-radiotherapy and subsequent osteoradionecrosis, poor healing may have contributed to the development of the pseudoaneurysm. The case involved the use of an interpositional vein graft connected directly to the external carotid artery. This may have contributed to the dehiscence that would be required to form an aneurysmal sac. http://dx.doi.org/10.1016/j.bjoms.2015.08.090 P 83 Free flaps in the elderly: does age make a difference to outcome? J. Thomas ∗ , R. Elledge, N. Pattni, A. Norman, T. Hall, G. James, N. Barnard University Hospitals Bristol, United Kingdom Introduction/aims: Vascularised free flaps are now the mainstay solution for reconstructing oropharyngeal defects
e67
following oncologic resections. Concerns such as donor site morbidity, flap failure and systemic complications may be more pronounced in elderly patients with limited physiologic reserve and more co-morbidities, but it is unclear to what extent these concerns are justified. Materials/methods: Case records of patients who had free flaps reconstructions following resection of oral squamous cell carcinoma between 2003 and 2013 within our unit were reviewed. The impact of age on outcomes such as flap failure, flap complications and systemic complications was sought by univariate analysis, with any statistically significant results entered into a multivariate regression model with other variables. Results/statistics: A total of 150 free flaps were performed for oral squamous cell carcinoma. Case records of 137 (91.3%) were available for review. Failure rates were 10.0% in the elderly and 1.9% in younger patients, a difference not found to be statistically significant (p = 0.07). Age appeared to have no impact on the need for a return to theatre (p = 0.73) or systemic complications (p = 0.27). Flap complication rates were higher in elderly patients (30.0% vs. 12.1%, p < 0.05). Age was the only significant predictor of flap complications on multivariate analysis (OR 3.90, 95% CI 1.30–11.66). Conclusions/clinical relevance: With life expectancy increasing, vascularized free tissue transfer for reconstruction in head and neck cancer is a legitimate treatment option in the elderly. With detailed pre-operative assessment and planning, effective post-operative monitoring and perioperative care, age should not be a contra-indication. http://dx.doi.org/10.1016/j.bjoms.2015.08.091 P 84 The role of staged extubation in head and neck surgery E. Twohig ∗ , R. Shaw Aintree University Hospital, United Kingdom Introduction: The management of the airway following elective head and neck surgery varies and may include close monitoring in the recovery room/ward, overnight intubation in an intensive care unit and tracheostomy. There are selective cases which have a small chance of developing airway compromise post operatively but are not ideally suited to these options. Methods: We describe two cases of staged extubation utilising a stainless steel guidewire which remained in the trachea following removal of the endotracheal tube. The function of the guidewire was to facilitate reintubation in the event of development of airway compromise secondary to upper airway oedema in the early post operative phase. Both patients had challenging airways preoperatively which required fibre optic assisted intubation. Results: The device was well tolerated in both cases. It was not necessary to reintubate the patients as they made an uneventful recovery on the ward. The device remained in the