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Use of gastro-omental free flaps in major neck defects
USE OF GASTROOMENTAL FREE FLAPS MAJOR NECK DEFECTS
L
TABLE
Oral Flow (mUmin)
To the Editor: We’ve been very interested by the experience of Guedon et al’ concerning the gastro-omental flap for neck reconstruction. We use this flap for oral reconstruction and in this localisation, some specific problems appear. The treatment of oral carcinoma usually consists of surgical resection, flap reconstruction and radiotherapy depending on the microscopy findings. Irradiation results in a severe xerostomia. The gastro-omental free flap provides a thin, versatile, smooth reconstruction.* It is wet, which seems important for talking, eating and for the tolerance of dental prothesis, especially for irradiated patients.3 Its disadvantage is the acid secretion. The aim of this retrospective study was double; first to prove that the gastro-omental flap can prevent postirradiation xerostomia. Second to look for an incidence of irradiation on the acidity of the flap.4 We performed 23 gastro-omental flaps since 1989. The study took place, on average, 4.6 years after the reconstruction (range 2 to 7). Fourteen patients died from the evolution of their cancer. Among the nine patients that were still living, four underwent radiotherapy. Six patients usually take antiacid medications (omeprazole) for sensations of burning in their mouth. Among them, three refused to stop their treatment: they’ve been excluded from the study. For the six patients left (irradiated: 3, not irradiated: 3), we weighed the oral secretion: a dry compress is placed on the floor of the mouth for 1 minute and weighed. We measured the pH on the tongue and on the flap with a specific electrode connected to an electronic pH-meter. The measures were realized before and after a standard collation (corresponding to a gastrin stimulation). The results are shown in the Table. The average oral flow of our irradiated patients is 0.156 mL/min. This corresponds to the flow of a normal subject. It is much more important than the oral flow of patients who un-
148
0 1996 by Excerpta All rights reserved.
Medica,
I
IN
Inc
Case 1 2 3 4 5 6
Radiotherapy + + +
pH Tongue
pH Flap
Antiacid
Rest
Stim
Rest
Stim
Rest
Stim
No Yes Yes No No Yes
0.55 0.54 0.40 0.15 0.17 0.15
0.67 0.70 0.43 0.28 0.31 0.33
6.31 6.80 6.97 6.90 6.46 6.04
5.52 6.80 6.15 6.90 6.20 5.00
6.40 6.35 3.79 7.00 6.70 3.07
7.10 4.87 2.98 6.57 6.20 3.97
derwent a classical reconstruction and a comparable irradiation protocol (0.028-0.053 mL/min).5 In our series, the flow of nonirradiated patients is high because the salivary glands and the flap are secreting. Nonparametric test (Mann-Witney) could not find a significant correlation between the irradiation and the oral pH. We imagine that the patients who refused to stop their anti-acid medications were suffering more from oral burning, and would have presented low pH, and so were the more necessary to include. As a conclusion, the gastro-omental flap is a very interesting means of reconstruction of the mouth. In addition, when an irradiation is planed, it appears to be a prevention of postradiation xerostomia. But the acid secretion is a real disadvantage. In our series, six patients out of nine need anti-acid medications. This must be considered for the indications of this flap. The small number of gastroomental flaps and the high mortality related to the cancer make a statistically reliable study difficult. But our results may be useful for similar studies. Professor P. Breton Doctor F. Braye Service de Chirqie Maxilb-j&i& Cenrre Hospitalier Lyon Stuf Lyon, France 1. Guedon CE, Marmuse JP, Gehanno P, Barry B. Use of gastro-omental free flaps in major neck defects. Am J Surg. 1994;168:491-493. 2. Panje WR, Little AG, Moran WJ, et al. lmediate free gastro omental flap reconstruction of the mouth and throat. Ann Otol Rhino1 Laryngol. 1987;96:1521. 3. Braye F, Breton P, Caillot JL, Franc C, Freidel M. Le lambeau gastro-8pi-
pldique: un lambeau muqueux secr& tant pour la reconstruction de l’oropharynx et de la cavite buccale. Ann Chir. 1995;49:417-422. 4. Cocco AE, Mendeloff Al. Gastric irradiation for peptic ulcer: 14-year follow-up. Am J Gastroenterol. 1979;71:577-581. 5. Marunick MT, Seyedad RM, Jones M, Ahmad K, Klein B. The effect of head and neck cancer treatment on whole salivary flow. J Surg Oncol. 1991;48:81-86.
WATER-SOLUBLE CONTRAST MATERIAL To the Editor: Thank you for your editorial note and comments concerning our paper entitled, “Water-Soluble Contrast Material Has No Therapeutic Effect on Postoperative Small-Bowel Obstruction: Results of a Prospective, Randomized Clinical Trial” (Am .I Surg. 1996;171:227-229). Similar to sentiments expressed by yourself, my own bias, also based on our own retrospectively accumulated unpublished data, tended towards Gastrografin being an effective treatment modality for adhesion ileus. However, our recently accomplished and published prospective randomized study convinced me that water soluble contrast material offers no therapeutic advantage in adhesion ileus. It is certainly easy to explain the different results and conclusions of our own study vis-a-vis the study of Avrahami et al (Digestive Surgery. 1996;13:201) The study of Avrahami et al is a retrospective analysis of 355 patients treated for small bowel obstruction during a loyear period, where, “A group of paadministients . . were arbitrarily tered 100 mL of Gastrografin . . . The patients were divided into those who 0002-961 O/96/$1 PII SOOO2-9610(96)00051-2
5.00
L
TABLE
Oral Flow (mUmin)
To the Editor: We’ve been very interested by the experience of Guedon et al’ concerning the gastro-omental flap for neck reconstruction. We use this flap for oral reconstruction and in this localisation, some specific problems appear. The treatment of oral carcinoma usually consists of surgical resection, flap reconstruction and radiotherapy depending on the microscopy findings. Irradiation results in a severe xerostomia. The gastro-omental free flap provides a thin, versatile, smooth reconstruction.* It is wet, which seems important for talking, eating and for the tolerance of dental prothesis, especially for irradiated patients.3 Its disadvantage is the acid secretion. The aim of this retrospective study was double; first to prove that the gastro-omental flap can prevent postirradiation xerostomia. Second to look for an incidence of irradiation on the acidity of the flap.4 We performed 23 gastro-omental flaps since 1989. The study took place, on average, 4.6 years after the reconstruction (range 2 to 7). Fourteen patients died from the evolution of their cancer. Among the nine patients that were still living, four underwent radiotherapy. Six patients usually take antiacid medications (omeprazole) for sensations of burning in their mouth. Among them, three refused to stop their treatment: they’ve been excluded from the study. For the six patients left (irradiated: 3, not irradiated: 3), we weighed the oral secretion: a dry compress is placed on the floor of the mouth for 1 minute and weighed. We measured the pH on the tongue and on the flap with a specific electrode connected to an electronic pH-meter. The measures were realized before and after a standard collation (corresponding to a gastrin stimulation). The results are shown in the Table. The average oral flow of our irradiated patients is 0.156 mL/min. This corresponds to the flow of a normal subject. It is much more important than the oral flow of patients who un-
148
0 1996 by Excerpta All rights reserved.
Medica,
I
IN
Inc
Case 1 2 3 4 5 6
Radiotherapy + + +
pH Tongue
pH Flap
Antiacid
Rest
Stim
Rest
Stim
Rest
Stim
No Yes Yes No No Yes
0.55 0.54 0.40 0.15 0.17 0.15
0.67 0.70 0.43 0.28 0.31 0.33
6.31 6.80 6.97 6.90 6.46 6.04
5.52 6.80 6.15 6.90 6.20 5.00
6.40 6.35 3.79 7.00 6.70 3.07
7.10 4.87 2.98 6.57 6.20 3.97
derwent a classical reconstruction and a comparable irradiation protocol (0.028-0.053 mL/min).5 In our series, the flow of nonirradiated patients is high because the salivary glands and the flap are secreting. Nonparametric test (Mann-Witney) could not find a significant correlation between the irradiation and the oral pH. We imagine that the patients who refused to stop their anti-acid medications were suffering more from oral burning, and would have presented low pH, and so were the more necessary to include. As a conclusion, the gastro-omental flap is a very interesting means of reconstruction of the mouth. In addition, when an irradiation is planed, it appears to be a prevention of postradiation xerostomia. But the acid secretion is a real disadvantage. In our series, six patients out of nine need anti-acid medications. This must be considered for the indications of this flap. The small number of gastroomental flaps and the high mortality related to the cancer make a statistically reliable study difficult. But our results may be useful for similar studies. Professor P. Breton Doctor F. Braye Service de Chirqie Maxilb-j&i& Cenrre Hospitalier Lyon Stuf Lyon, France 1. Guedon CE, Marmuse JP, Gehanno P, Barry B. Use of gastro-omental free flaps in major neck defects. Am J Surg. 1994;168:491-493. 2. Panje WR, Little AG, Moran WJ, et al. lmediate free gastro omental flap reconstruction of the mouth and throat. Ann Otol Rhino1 Laryngol. 1987;96:1521. 3. Braye F, Breton P, Caillot JL, Franc C, Freidel M. Le lambeau gastro-8pi-
pldique: un lambeau muqueux secr& tant pour la reconstruction de l’oropharynx et de la cavite buccale. Ann Chir. 1995;49:417-422. 4. Cocco AE, Mendeloff Al. Gastric irradiation for peptic ulcer: 14-year follow-up. Am J Gastroenterol. 1979;71:577-581. 5. Marunick MT, Seyedad RM, Jones M, Ahmad K, Klein B. The effect of head and neck cancer treatment on whole salivary flow. J Surg Oncol. 1991;48:81-86.
WATER-SOLUBLE CONTRAST MATERIAL To the Editor: Thank you for your editorial note and comments concerning our paper entitled, “Water-Soluble Contrast Material Has No Therapeutic Effect on Postoperative Small-Bowel Obstruction: Results of a Prospective, Randomized Clinical Trial” (Am .I Surg. 1996;171:227-229). Similar to sentiments expressed by yourself, my own bias, also based on our own retrospectively accumulated unpublished data, tended towards Gastrografin being an effective treatment modality for adhesion ileus. However, our recently accomplished and published prospective randomized study convinced me that water soluble contrast material offers no therapeutic advantage in adhesion ileus. It is certainly easy to explain the different results and conclusions of our own study vis-a-vis the study of Avrahami et al (Digestive Surgery. 1996;13:201) The study of Avrahami et al is a retrospective analysis of 355 patients treated for small bowel obstruction during a loyear period, where, “A group of paadministients . . were arbitrarily tered 100 mL of Gastrografin . . . The patients were divided into those who 0002-961 O/96/$1 PII SOOO2-9610(96)00051-2
5.00