Risk
Stratification

 

Patients
presenting for head and neck free flap surgery and breast reconstructive
surgery are fragile cancer patients with a number of significant co-morbidities
(5). Hence, pre-operative assessment and investigation plays an important role
in the risk stratification (6). Although technical issues are
dominant factors, patients and clinical characteristics also contribute to flap
failure (7). The Division of Plastic and Reconstructive Surgery, University of
Southern California, Los Angeles, investigated a number of non-technical
variable in 2015, using the American College of Surgeons’ National Surgical
Quality Improvement Program (NSQIP) database. Univariate analysis was performed
to determine the association of free flap failure with the following factors:
age, gender, ethnicity, body mass index, intraoperative transfusion, diabetes,
smoking, alcohol, American Society of Anaesthesiologists classification, year
of operation, operative time, number of flaps, and type of reconstruction. The overall
flap loss rate was 4.4%. Operative time was the only significant independent
risk factor for flap failure after the
multivariate logistic regression (8). According
the analysis conducted by another plastic unit, patient’s age is
not an independent variable for increased risk in microvascular reconstruction.
However, operative time, and location of the reconstruction site are associated
with higher rate of medical complications and ITU referral (9). Another
important study, held in Toronto in 2016, identified the operative time and
smoking as the only independent risk factors for intraoperative complications in
reconstructive breast free flap surgery (10).  Several preoperative investigations play
a role to assess the risk of patients in flap reconstructive surgery. Different
studies revealed that cardiopulmonary exercise testing (CPET) in complex
patients is pivotal to assess the functional capacity. Many studies are ongoing
and many centres routinely use CPET to plan the type of surgery, and to inform
our patients regarding risks and benefits of surgery (11). In conclusion, flap
loss is a multifactorial event and, according recent literature, demographics and
medical patient’s characteristics such as: age, ethnicity, radiation,
chemotherapy, medical comorbidities, smoking, are not independent risk factors
for surgical complications. In the preoperative, they need to be assessed to
ensure the best perioperative management and to reduce medical complications
but intraoperative and technical variable may have higher importance for the outcome
(12).

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Nutrition, preoperative
fasting and preoperative education

 

According
recent evidences, the basic nutritional state should be assessed and optimised:
preoperative albumin levels have an inverse correlation with dehiscence,
pleural effusion, salivary leakage, cardiac complications, suture removal (13).
 Preoperative fasting should be minimal.
In patients eligible for oral intake, clear solids should be allowed up to 2
hours and clear fluids up to 6 hours before anaesthesia. (14, 15).  All patients undergoing major head and
neck cancer surgery with free flap and breast reconstructive surgery should be
adequately prepared and informed regarding the surgical journey and evidences
suggest they should receive a structured teaching. If anaesthetists and
qualified health professional should play a role together in this discussion, is
still not clarified, due to paucity of high quality studies specifically
focused on this (16). In conclusion, the implementation of a
multidisciplinary pre-operative evaluation conducted by anaesthetists, nutritionists,
physiotherapists, other medical specialities, and health practitioner may
reduce post-operative complications arising from pre-existing conditions (17).