The effect of preoperative radiotherapy on complication rate after microsurgical head and neck reconstruction

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Summary

Background

The introduction of radiotherapy (XRT) has resulted in increased survival of patients diagnosed with head and neck malignancies. However, the potentially deleterious impact of radiotherapy on reconstructive efforts continues to be the subject of intense debate. The present study was designed to evaluate the effects of preoperative XRT on complication rates in patients undergoing microsurgical reconstruction of head and neck defects after oncosurgical resection.

Methods

A retrospective cohort study was conducted of all patients who underwent immediate microsurgical reconstruction of post-ablative defects over a 3-year period. Study subjects were divided into two groups: (1) those who did not receive XRT and (2) those who received preoperative XRT. Clinical variables examined and analysed included age, gender, co-morbid conditions, tobacco history, the presence of recurrent disease and ischaemia time. Outcomes of interest included length of intensive care unit (ICU) and hospital stay and postoperative complications. Complications were further classified as flap-related as well as ‘medical’.

Results

A total of 60 patients were included in this study (group 1: 26 patients; group 2: 34 patients). Results were similar between the study groups with the exception of a higher rate of flap-related complications in patients undergoing XRT. Overall, 19 patients (31.7%) experienced flap-related complications, with 12% of the patients being in group 1 (N = 3) versus 47% of patients being in group 2 (N = 16) (p = 0.003).

Conclusions

Our data suggest that preoperative radiotherapy is associated with a significant increase in postoperative flap-related complications. However, these did not result in a prolonged hospital stay, reflecting the fact that the majority of flap-related complications can be managed on an outpatient basis. Although microsurgical reconstruction is frequently successful, patients with a history of XRT should be informed preoperatively about their increased risk of complications.

Section snippets

Background

Reconstruction of head and neck defects is among the most challenging tasks in plastic surgery. Defects in this anatomic region frequently have devastating consequences as they not only affect appearance but also core aspects of daily life, such as speech, swallowing and mastication. Over the last three decades, microsurgical techniques have established free tissue transfer as the treatment of choice for head and neck reconstruction after radical oncosurgical resection.1, 2 Traditional

Patients and methods

A retrospective cohort study was conducted of all patients who underwent immediate microsurgical reconstruction of post-ablative defects over a 3-year period. The study protocol was approved by the Stanford University Institutional Review Board. The study subjects were divided into two groups: (1) those who did not receive XRT and (2) those who received preoperative external-beam XRT.

Parameters retrieved and analysed included age, gender, co-morbid conditions, tobacco history, presence of

Statistical analysis

Final data analysis was performed in STATA 9.0 (STATA Corporation, College Station, TX, USA, 2006). Exploratory analyses of continuous data included histograms, means and standard deviations for normally distributed data and medians and interquartile ranges (IQRs) for non-normally distributed data. Normality of the continuous variables was confirmed with the Shapiro–Wilks test using a critical p-value of 0.05. For categorical data, tables were generated showing frequencies and percentages.

Results

A total of 60 patients were included in this study (group 1: 26 patients; group 2: 34 patients) with a mean age of 54.5 years (group 1) and 59.8 years (group 2) (p = 0.15). Patient characteristics are presented in Table 1. In both patient subsets, a predominance of male patients was noted with 15 (58%) and 21 (62%) male patients in groups 1 and 2, respectively (p = 0.75). No difference was observed with regard to smoking habits. Twelve patients in group 1 (46.2%) and 16 patients in group 2 (47.1%)

Discussion

The detrimental effects of XRT on wound healing has been reported, as a result of chronic vascular damage.14, 15, 16 Although this is seemingly a sound concept, it has not been unanimously supported by actual clinical experience.13, 17 In a retrospective cohort study, Choi et al. evaluated whether XRT resulted in an increased rate of local complications after microvascular head and neck reconstruction.12 A total of 100 patients undergoing free fibular flap reconstruction of the mandible were

Conclusion

Our data suggest that preoperative XRT is associated with a significant increase in postoperative flap-related complications. However, these did not result in a prolonged hospital stay reflecting the fact that the majority of flap-related complications can be managed on an outpatient basis. Although microsurgical reconstruction is frequently successful, patients with a history of XRT should be informed preoperatively about their increased risk of complications.

Conflict of interest/funding

None.

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