Abstract
Objective
Microvascular anastomosis is generally performed by attending surgeons or fellows, with published success rates > 95%. Since otolaryngology residents do not typically perform microvascular anastomosis, it is unknown if they achieve similar results. The objective of this study is to determine the success rate and complication rate during free flap reconstruction when microvascular anastomosis is performed in part by otolaryngology chief residents.
Study Design
Multi-institutional retrospective review.
Setting
Academic, tertiary-care referral centers.
Subjects and Methods
Consecutive patients who underwent microvascular reconstruction by the Department of Otolaryngology from 2004 through 2011. All patients had > 50% of the arterial and venous anastomoses performed by the chief resident.
Results
The study included 93 consecutive free flaps in 88 patients: 43 radial forearm, 14 anterolateral thigh, and 36 fibula. There were 71 males and 22 females with mean age of 53. The pre-operative diagnosis was squamous cell carcinoma in 78%, with 27% of patients having previously received radiotherapy and 13% of patients having had previous neck surgery. There were no instances when resident-placed sutures required revision, nor was there a perceived need to revise such an anastomosis intraoperatively. Overall flap success rate was 97%. The anastomotic complication rate was 4.3%, with venous thrombosis in three cases and arterial hemorrhage in one case.
Conclusion
Overall free flap success rate and anastomosis-related complications with residents performing portions of the microvascular anastomosis are comparable to published studies. Otolaryngology chief residents can safely participate in microsuturing, which is a single facet in the broader skill set of a microvascular surgeon.
1
Introduction
In the field of Otolaryngology–Head and Neck Surgery, free tissue transfer with microvascular anastomosis has become a standard method of head and neck reconstruction . There are several components of this surgery including flap harvest, flap inset, and the anastomosis itself. Such procedures require specialty equipment and surgical expertise to be performed reliably. Although considered an arduous and more complicated method of reconstruction, the outcomes and effect on quality of life in these patients are inarguably worth the tedious nature of the cases. With appropriate fellowship training and experience, high rates of flap success in the range of 95%–99% are routinely achieved .
Training in microvascular reconstruction has become a well-accepted portion of Otolaryngology–Head and Neck Surgery training in the past decade. Otolaryngology residents are intimately involved in these cases as well as the often extended post operative hospital care for the patients who undergo free flap reconstruction. While most otolaryngology residents gain some exposure to free flap reconstruction during residency, it is not until subspecialty fellowship training that microvascular surgical skills are obtained .
At Northwestern University and Cook County Hospital (Stroger), microvascular anastomosis has been considered part of resident training, with residents routinely performing a significant portion of the anastomosis with the attending surgeon assisting since 2004. We believe this is not a common practice nationwide, and there are currently no reports of head and neck free flap results with otolaryngology residents performing microvascular anastomosis as the operating surgeon. The objective of this study is to determine the success rate and the complication rate of free flap reconstruction when microvascular anastomosis is performed by an otolaryngology chief resident.
2
Methods
2.1
Data collection
After obtaining approval from the Institutional Review Board at Cook County Hospital and Northwestern University, the database of the Head and Neck Cancer Conference at each institution was reviewed retrospectively to identify all patients who underwent free flap reconstruction between July, 2004 and September, 2011. The study was restricted to cases where the chief resident performed 50% or greater of the arterial and venous anastomosis as described below. One surgeon (UAP) was the fellowship-trained attending microsurgeon in all cases reviewed. This yielded 93 consecutive free flaps on 88 patients. The medical records were reviewed and a database was created to extract relevant information such as demographic information (age and gender), tumor related data (primary site, pathology or cause of the defect) and the patient’s medical history (history of prior surgery or radiation). Operative notes were reviewed to determine resident involvement and for information regarding the artery and vein used for anastomosis, the use of a venous coupler, and the use of two venous anastomoses. The medical record was reviewed for complications which were divided into anastomotic complications and non-anastomotic complications. Anastomotic complications were regarded to be complications that were caused by a fault in the venous or arterial anastomosis and included anastomotic hematoma/hemorrhage, venous thrombosis, and flap failure resulting from either of these conditions. Non-anastomotic complications included non-anastomotic hematoma, seroma, salivary fistula, neck wound infection, and flap failure resulting from these conditions. Return to the operating room was also recorded and separated between the groups based on cause of return. Donor site complications were not analyzed in this study. Results from the current study were tabulated and then compared to normative data obtained from previously published studies.
2.2
Data analysis
The demographic information was analyzed. The complication rate was calculated from the database. We also calculated the total flap success rate. The frequency of each type of complication was noted.
2.3
Surgical technique
Microvascular anastomosis was performed by a single attending surgeon in conjunction with the chief resident (post-graduate year 5) of the otolaryngology service under a dual opposing-head surgical microscope. Beginning in 2004, microvascular surgery was integrated into the surgical functions of the chief resident, and the resident would routinely perform at least half of the anastomosis of each vessel. Residents did not perform any particular laboratory training prior to assisting and performing microsurgery. All chief residents were permitted to assume this role with no selection based on perceived skill. Chief residents generally participated in three to eight cases during their final year of residency. The arterial anastomosis was performed first with interrupted 8-0 nylon suture, with the attending surgeon doing the first 180°. The vessel was then turned over with the resident placing interrupted sutures over the remaining 180°. The same technique was applied to anastomosis of generally a single vein; however, this was sutured with 8-0 nylon suture in a running fashion. The attending sutured the first 180° and the resident completed the remaining 180°. Since neither the entire artery nor vein was sutured by the resident, results of this study may not be generalized to situations where a resident does complete the entire vessel. Beginning in 2009, microvascular coupling rings were used to perform the venous anastomosis. After determining the correct size of rings, the attending surgeon would hold the coupling apparatus while the resident surgeon actually handled the vessels, drew them through the rings, and then situated the vessel edges over the spokes of the rings. In certain cases, the resident was permitted to do greater than 50% of the microvascular anastomosis depending on resident interest. This included dissection of the flap vessels, stripping of adventitia, and vessel dilation. In rare cases, the setup of the vascular anastomosis was deemed suboptimal (vessel size mismatch, challenging angulation of vessels, difficult exposure with narrow surgical field, etc.) and the resident was not permitted to perform microsurgery. Such cases were excluded from the current study. Also on rare occasion, a second venous anastomosis was performed to offer redundancy of venous drainage, and notation of this was made in the operative record.
2
Methods
2.1
Data collection
After obtaining approval from the Institutional Review Board at Cook County Hospital and Northwestern University, the database of the Head and Neck Cancer Conference at each institution was reviewed retrospectively to identify all patients who underwent free flap reconstruction between July, 2004 and September, 2011. The study was restricted to cases where the chief resident performed 50% or greater of the arterial and venous anastomosis as described below. One surgeon (UAP) was the fellowship-trained attending microsurgeon in all cases reviewed. This yielded 93 consecutive free flaps on 88 patients. The medical records were reviewed and a database was created to extract relevant information such as demographic information (age and gender), tumor related data (primary site, pathology or cause of the defect) and the patient’s medical history (history of prior surgery or radiation). Operative notes were reviewed to determine resident involvement and for information regarding the artery and vein used for anastomosis, the use of a venous coupler, and the use of two venous anastomoses. The medical record was reviewed for complications which were divided into anastomotic complications and non-anastomotic complications. Anastomotic complications were regarded to be complications that were caused by a fault in the venous or arterial anastomosis and included anastomotic hematoma/hemorrhage, venous thrombosis, and flap failure resulting from either of these conditions. Non-anastomotic complications included non-anastomotic hematoma, seroma, salivary fistula, neck wound infection, and flap failure resulting from these conditions. Return to the operating room was also recorded and separated between the groups based on cause of return. Donor site complications were not analyzed in this study. Results from the current study were tabulated and then compared to normative data obtained from previously published studies.
2.2
Data analysis
The demographic information was analyzed. The complication rate was calculated from the database. We also calculated the total flap success rate. The frequency of each type of complication was noted.
2.3
Surgical technique
Microvascular anastomosis was performed by a single attending surgeon in conjunction with the chief resident (post-graduate year 5) of the otolaryngology service under a dual opposing-head surgical microscope. Beginning in 2004, microvascular surgery was integrated into the surgical functions of the chief resident, and the resident would routinely perform at least half of the anastomosis of each vessel. Residents did not perform any particular laboratory training prior to assisting and performing microsurgery. All chief residents were permitted to assume this role with no selection based on perceived skill. Chief residents generally participated in three to eight cases during their final year of residency. The arterial anastomosis was performed first with interrupted 8-0 nylon suture, with the attending surgeon doing the first 180°. The vessel was then turned over with the resident placing interrupted sutures over the remaining 180°. The same technique was applied to anastomosis of generally a single vein; however, this was sutured with 8-0 nylon suture in a running fashion. The attending sutured the first 180° and the resident completed the remaining 180°. Since neither the entire artery nor vein was sutured by the resident, results of this study may not be generalized to situations where a resident does complete the entire vessel. Beginning in 2009, microvascular coupling rings were used to perform the venous anastomosis. After determining the correct size of rings, the attending surgeon would hold the coupling apparatus while the resident surgeon actually handled the vessels, drew them through the rings, and then situated the vessel edges over the spokes of the rings. In certain cases, the resident was permitted to do greater than 50% of the microvascular anastomosis depending on resident interest. This included dissection of the flap vessels, stripping of adventitia, and vessel dilation. In rare cases, the setup of the vascular anastomosis was deemed suboptimal (vessel size mismatch, challenging angulation of vessels, difficult exposure with narrow surgical field, etc.) and the resident was not permitted to perform microsurgery. Such cases were excluded from the current study. Also on rare occasion, a second venous anastomosis was performed to offer redundancy of venous drainage, and notation of this was made in the operative record.
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