头颈部游离组织瓣移植术后预防性气管切开的临床分析

doi:10.19723/j.issn.1671-167X.2022.02.026

Abstract

Abstract:

Objective: To discover the factors that may affect the use of selective tracheostomy among patients who have undergone head and neck surgeries with free flap reconstruction, so that the patients will not need tracheostomy nor receive the unnecessary treatment. Methods: Five hundred and thirty-three patients who had undergone head and neck surgery with free flap reconstruction operated by the same team of surgery at Department of Oral and Maxillofacial Surgery at Peking University School of Stomatology from 2015 to 2016 were reviewed. Three hundred and twenty-one (60.2%) of these patients underwent selective tracheostomy. All the patients’ demographic information, operation-related information, prior treatments, comorbidities and complications were recorded and analyzed. Results: The patients with defects of the tongue, mouth floor, oropharynx and bilateral mandible, who underwent neck dissection and with previous radiotherapy and smoking habit were more likely to get selective tracheostomy. Usage of bulky soft tissue flap might also add to the risk of airway obstruction and the need of selective tracheostomy, while other factors were not significantly related to the risk of postoperative airway obstruction and the patients could be kept safe without selective tracheostomy. Most cases without tracheostomy were kept safe except one case, while 8.39% of the patients with tracheostomy suffered from tracheostomy related complications, mainly pneumonia and hemorrhage of the tracheostomy wound, yet none led to serious consequences or even death. Conclusion: Selective tracheostomy is not necessary for patients who have undergone head and neck surgeries with free flap reconstruction except that there are defects at the tongue, oropharynx and mandible. Neck dissection, bulky soft tissue flap reconstruction, previous radiotherapy and smoking habit may also add to the risk of postoperative airway obstruction, while a favorable decision would involve a combination of all the above factors to assure the safety of the postoperative airway for the patients undergone head and neck surgeries with free flap reconstruction.

Key words: Tracheostomy, Airway management, Free flap reconstruction, head and neck

CLC Number:

R782

CAI Tian-yi,ZHANG Wen-bo,YU Yao,WANG Yang,MAO Chi,GUO Chuan-bin,YU Guang-yan,PENG Xin. Clinical analysis of selective tracheostomy necessary for patients undergoing head and neck surgery with free flap reconstruction[J].Journal of Peking University (Health Sciences), 2022, 54(2): 363-368.

Figures/Tables 6

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

References 25

[1]	Coyle MJ, Shrimpton A, Perkins C, et al. First do no harm: Should routine tracheostomy after oral and maxillofacial oncological operations be abandoned[J]. Br J Oral Maxillofac Surg, 2012, 50(8):732-735. doi: 10.1016/j.bjoms.2012.01.003
[2]	Archer SM, Baugh RF, Nelms CR. Tracheostomy: 2000 clinical indicators compendium[R]. Alexandria: American Academy of Otolaryngology Head and Neck Surgery, 2000: 45.
[3]	Cramer JD, Samant S, Greenbaum E, et al. Association of airway complications with free tissue transfer to the upper aerodigestive tract with or without tracheotomy[J]. JAMA Otolaryngol Head Neck Surg, 2016, 142(12):1177-1183. doi: 10.1001/jamaoto.2016.2002
[4]	Patel RS, McCluskey SA, Goldstein DP, et al. Clinicopathologic and therapeutic risk factors for perioperative complications and prolonged hospital stay in free flap reconstruction of the head and neck[J]. Head Neck, 2010, 32(10):1345-1353. doi: 10.1002/hed.v32:10
[5]	Marsh M, Elliott S, Anand R, et al. Early postoperative care for free flap head & neck reconstructive surgery: A national survey of practice[J]. Br J Oral Maxillofac Surg, 2009, 47(3):182-185. doi: 10.1016/j.bjoms.2008.06.004 pmid: 18640751
[6]	Halfpenny W, McGurk M. Analysis of tracheostomy-associated morbidity after operations for head and neck cancer[J]. Br J Oral Maxillofac Surg, 2000, 38(5):509-512. doi: 10.1054/bjom.2000.0310
[7]	Ong SK, Morton RP, Kolbe J, et al. Pulmonary complications following major head and neck surgery with tracheostomy: A prospective, randomized, controlled trial of prophylactic antibiotics[J]. Arch Otolaryngol Head Neck Surg, 2004, 130(9):1084-1087. doi: 10.1001/archotol.130.9.1084
[8]	Haspel AC, Coviello VF, Stevens M, Retrospective study of tracheostomy indications and perioperative complications on oral and maxillofacial surgery service[J]. J Oral Maxillofac Surg, 2012, 70(4):890-895. doi: 10.1016/j.joms.2011.09.022
[9]	Ardekian L, Barak M, Rachmiel A. Subcutaneous emphysema following emergent surgical conventional tracheostomy[J]. Craniomaxillofac Trauma Reconstr, 2014, 7(4):290-293. doi: 10.1055/s-0034-1378186 pmid: 25383149
[10]	朱莹, 徐辉, 朱也森, 等. 影响颌面肿瘤手术后气道管理的手术因素分析[J]. 组织工程与重建外科, 2011, 7(5):286-289.
[11]	Ernard AC, Kenady DE. Conventional surgical tracheostomy as the preferred method of airway management[J]. J Oral Maxillofac Surg, 1999, 57(3):310-315. doi: 10.1016/S0278-2391(99)90679-1
[12]	Teo N, Garrahy A. Elective surgical cricothyroidotomy in oral and maxillofacial surgery[J]. Br J Oral Maxillofac Surg, 2013, 51(8):779-782. doi: 10.1016/j.bjoms.2013.04.002
[13]	Bobek S, Bell RB, Dierks E, et al. Tracheotomy in the unpro-tected airway.[J]. J Oral Maxillofac Surg, 2011, 69:2198-2203. doi: 10.1016/j.joms.2011.01.041
[14]	Kainulainen S, Törnwall J, Koivusalo AM, et al. Dexamethasone in head and neck cancer patients with microvascular reconstruction: No benefit, more complications[J]. Oral Oncol, 2017, 65:45-50. doi: S1368-8375(16)30243-3 pmid: 28109467
[15]	Crosher R, Baldie C, Mitchell R. Selective use of tracheostomy in surgery for head and neck cancer: An audit[J]. Br J Oral Maxillofayic Surg, 1997, 35(1):43-45.
[16]	Meerwein C, Pézier TF, Beck-Schimmer B, et al. Airway management in head and neck cancer patients undergoing microvascular free tissue transfer: delayed extubation as an alternative to routine tracheotomy[J]. Swiss Med Wkly, 2014, 144:13941.
[17]	Moubayed SP, Barker DA, Razfar A, et al. Microvascular reconstruction of segmental mandibular defects without tracheostomy.[J]. Otolaryngol Head Neck Surg, 2015, 152(2):250-254. doi: 10.1177/0194599814556625
[18]	Cameron M, Corner A, Diba A, et al. Development of a tracheostomy scoring system to guide airway management after major head and neck surgery[J]. Int J Oral Maxillofac Surg, 2009, 38(8):846-849. doi: 10.1016/j.ijom.2009.03.713
[19]	Kruse-Lösler B, Langer E, Reich A, et al. Score system for elective tracheotomy in major head and neck tumour surgery[J]. Acta Anaesthesiol Scand, 2005, 49(5):654-659. doi: 10.1111/aas.2005.49.issue-5
[20]	Gupta K, Mandlik D, Patel D, et al. Clinical assessment scoring system for tracheostomy (CASST) criterion: Objective criteria to predict pre-operatively the need for a tracheostomy in head and neck malignancies[J]. J Craniomaxillofac Surg, 2016, 44(9):1310-1313. doi: 10.1016/j.jcms.2016.07.008
[21]	Leiser Y, Barak M, Ghantous Y, et al. Indications for elective tracheostomy in reconstructive surgery in patients with oral Cancer[J]. J Craniofac Surg, 2017, 28(1):e18-e22. doi: 10.1097/SCS.0000000000003168
[22]	Mohamedbhai H, Ali S, Dimasi I, et al. TRACHY score: A simple and effective guide to management of the airway in head and neck cancer[J]. Br J Oral Maxillofac Surg, 2018, 56(8):709-714. doi: S0266-4356(18)30245-6 pmid: 30126752
[23]	Singh T, Sankla P, Smith G. Tracheostomy or delayed extubation after maxillofacial free-flap reconstruction[J]. Br J Oral Maxillofac Surg, 2016, 54(8):878-882. doi: S0266-4356(16)30110-3 pmid: 27287181
[24]	Weaver TS, Wester JL, Gleysteen JP, et al. Surgical outcomes in the elderly patient after osteocutaneous free flap transfer[J]. Laryngoscope, 2014, 124(11):2484-2488. doi: 10.1002/lary.v124.11
[25]	Chen XF, Chen YM, Gokavarapu S, et al. Free flap reconstruction for patients aged 85 years and over with head and neck cancer: clinical considerations for comprehensive care[J]. Br J Oral Maxillofac Surg, 2017, 55(8):793-797. doi: S0266-4356(17)30233-4 pmid: 28735639

Metrics

Viewed

Full text

Abstract

Cited

Shared

Discussed

Comments

Recommended 0

No Suggested Reading articles found!

Items	Tracheostomy	Non-tracheostomy
Median age/years	55	45
Male/female	220 ∶101	109 ∶103
Etiology
Benign tumor	28	99
Malignant tumor	270	99
Inflammation	17	7
Tissue defect	6	12

Items	Tracheostomy	Non-tracheostomy	P
Maxilla
Unilateral	7	33	<0.001
Bilateral	8	11	0.100
Mandible
Unilateral	38	98	<0.001
Bilateral	37	9	0.003
Cutaneous, lip and buccal	15	3	<0.001
Tongue	55	2	<0.001
Mouth floor^a	48	17	0.017
Oropharynx^a	126	27	<0.001

Items	Tracheostomy	Non-tracheostomy	P
Unilateral	143	77	<0.001
Bilateral	97	6	<0.001

Items	Tracheostomy	Non-tracheostomy	P
Thin soft-tissue flap			0.416
Radial forearm flap	47	38
Lateral upper-arm flap	1	0
Gastrocnemius flap	1	0
Total	49	38
Thick soft-tissue flap			<0.001
Anterolateral thigh flap	89	35
Posteromedial thigh flap	10	0
Total	99	35
Osseous tissue flap			0.015
Fibula myocutaneous flap	171	128
Iliac Flap	4	10
Total	175	138

Items	Tracheostomy	Non-tracheostomy	P
History of surgery	112	83	0.358
History of radiotherapy	41	15	0.029
History of chemotherapy	18	5	0.068
Diseases of respiratory system	24	4	0.004
High blood pressure	76	34	0.027
Diabates	30	12	0.108
Cardio & cerebrovascular diseases	34	18	0.404
Hepatopathy	8	4	0.633
Nephropathy	1	0	0.412
Hemopathy	6	3	0.945
Smoking	133	43	<0.001
Alcohol abusing	101	25	<0.001

Clinical analysis of selective tracheostomy necessary for patients undergoing head and neck surgery with free flap reconstruction

RICH HTML

PDF (PC)

Abstract

Cite this article

share this article

Figures/Tables 6

References 25

Related Articles 6

Metrics

Comments

Recommended 0

Items		OR	95%CI		P
Items		OR	Lower	Upper	P
Defect	Unilateral maxilla	0.500	0.126	1.984	0.335
	Unilateral mandible	1.470	0.454	4.755	0.520
	Bilateral mandible	18.640	4.863	71.454	<0.001
	Cutaneous, lip and buccal	0.417	0.070	2.470	0.335
	Tongue	15.484	7.578	72.999	<0.001
	Mouth floor	4.818	1.403	16.547	0.013
	Oropharynx	10.632	3.373	33.512	<0.001
Neck dissection	Unilateral	3.345	1.884	5.939	<0.001
Neck dissection	Bilateral	12.931	4.360	38.346	<0.001
Reconstruction^a	Thick soft-tissue flap	2.623	1.176	5.850	0.018
Reconstruction^a	Osseous tissue flap	1.469	0.661	3.263	0.345
Others	Radiotherapy	3.180	1.386	7.297	0.006
	Respiratory diseases	3.115	0.772	12.564	0.110
	High blood pressure	0.871	0.425	1.600	0.657
	Smoking	1.998	1.108	3.602	0.021
	Alcohol abusing	1.176	0.816	1.695	0.386

[1]	ZHANG Qing-fen,ZHAO Hong,FENG Yi. Different anesthesia management in preterm infants undergoing surgeries for retinopathy of prematurity: A retrospective study [J]. Journal of Peking University (Health Sciences), 2021, 53(1): 195-199.
[2]	Jing WANG,Jun-peng CHEN,Yang WANG,Xiang-liang XU,Chuan-bin GUO. Application of digital mandibular movement record and masticatory muscle electromyography in the evaluation of stomatognathic function in patients with mandibular tumor [J]. Journal of Peking University(Health Sciences), 2019, 51(3): 571-578.
[3]	LI Jian-nan, FENG Zhi-en, WANG Lin, WANG Yi-xiang, GUO Chuan-bin. Expression of hypoxiainducible factor 1α is associated with lymph node metastasis in oral squamous cell carcinoma [J]. Journal of Peking University(Health Sciences), 2018, 50(1): 26-32.
[4]	YU Yao, ZHANG Wen-bo, WANG Yang, LIU Xiao-jing, GUO Chuan-bin, YU Guang-yan, PENG Xin. Application of three-dimensional reconstruction of the enhanced CT with iPlan CMF software in head and neck neoplasms [J]. Journal of Peking University(Health Sciences), 2017, 49(5): 878-882.
[5]	WANG Wei, ZHENG Lei, LIU Shu-ming, HUANG Ming-wei, SHI Yan, LV Xiao-ming, ZHANG Jie, ZHANG Jian-guo. Distant metastases of malignant salivary gland carcinoma after treated by 125Ⅰinternal brachy therapy alone [J]. Journal of Peking University(Health Sciences), 2017, 49(3): 547-550.
[6]	ZHENG Yi-lin, SONG Wen-fang, WANG Dong-xin. Comparison between flexible laryngeal mask airway and reinforced tracheal tube used for lumbar vertebral surgery in prone position [J]. Journal of Peking University(Health Sciences), 2017, 49(2): 262-266.