Volume 11, Issue 1 (3-2022)                   WJPS 2022, 11(1): 23-29 | Back to browse issues page

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Pontell M E, Trinh A L A, Chaker S, Winocour J S, Thayer W P. Free Tissue Transfer during the COVID-19 Pandemic: A Proposed Evidence-Based Protocol for Early Discharge. WJPS. 2022; 11 (1) :23-29
URL: http://wjps.ir/article-1-865-en.html
Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Abstract:   (1674 Views)
            As free tissue transfer outcomes improve, institutions are examining early discharge protocols. “Early” is generally defined as between one and five days postoperatively, which correlates with the timing of most major complications and most opportunities for flap salvage. Given the trend towards early discharge, the need for healthcare cost reductions and shortage of ICU beds during a viral pandemic, we aimed to propose an evidence-based protocol to select patients for discharge within 72 h of free tissue transfer.
            A retrospective review of all patients who underwent free tissue transfer at Vanderbilt University Medical Center, Tennessee, USA since the onset of the COVID-19 (2020-2021) pandemic was performed. Patients were included for review if they were discharged within 72 h of surgery. Literature relating to expedited discharge after free tissue transfer was also reviewed.
Six patients met inclusion criteria for retrospective review. None suffered intraoperative or postoperative inpatient complications and all were discharged within 72 h postoperatively. There were no flap failures within 30 d of reconstruction.
This study reviews a patient cohort undergoing free tissue transfer during the COVID-19 pandemic. These cases were reviewed for factors that may have contributed to their postoperative success after discharge within 72 hours. These data points were combined with published evidence on risks for failure after free flap reconstruction to design a protocol to select patients for early discharge. The benefits of early discharge include reducing healthcare costs, risks of inpatient hospitalization, and ICU utilization, which is of paramount importance in the midst of a global pandemic.
Full-Text [PDF 285 kb]   (880 Downloads)    
Type of Study: Original Article | Subject: Special
Received: 2021/11/24 | Accepted: 2021/10/26 | Published: 2022/03/4

1. Veith J, Donato D, Holoyda K, Simpson A, Agarwal J. Variables associated with 30-day postoperative complications in lower extremity free flap reconstruction identified in the ACS-NSQIP database. Microsurgery 2019;39(7):621-628. 2. Ninkovic M, Voigt S, Dornseifer U, Lorenz S, Ninkovic M. Microsurgical advances in extremity salvage. Clin Plast Surg 2012;39(4):491-505. 3. Egeler SA, de Jong T, Luijsterburg AJM, Mureau MAM. Long-Term Patient-Reported Outcomes following Free Flap Lower Extremity Reconstruction for Traumatic Injuries. Plast Reconstr Surg 2018;141(3):773-783. 4. Kapoor T, Banuelos J, Adabi K, Moran SL, Manrique OJ. Analysis of clinical outcomes of upper and lower extremity reconstructions in patients with soft-tissue sarcoma. J Surg Oncol 2018;118(4):614-620. 5. Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. Plast Reconstr Surg 2006;117(4):1315-1322; discussion 1323-1314. 6. Soteropulos CE, Chen JT, Poore SO, Garland CB. Postoperative Management of Lower Extremity Free Tissue Transfer: A Systematic Review. J Reconstr Microsurg 2019;35(1):1-7. 7. Riley CA, Barton BM, Lawlor CM, Cai DZ, Riley PE, McCoul ED, Hasney CP, Moore BA. NSQIP as a Predictor of Length of Stay in Patients Undergoing Free Flap Reconstruction. OTO Open 2017;1(1):1-7. 8. McCrory AL, Magnuson JS. Free tissue transfer versus pedicled flap in head and neck reconstruction. Laryngoscope 2002;112(12):2161-2165. 9. Frederick JW, Sweeny L, Carroll WR, Peters GE, Rosenthal EL. Outcomes in head and neck reconstruction by surgical site and donor site. Laryngoscope 2013;123(7):1612-1617. 10. Haughey BH, Wilson E, Kluwe L, Picirillo J, Frederickson J, Sessions D, Spector G. Free flap reconstruction of the head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg 2001;125(1):10-17. 11. Clark JR, McCluskey SA, Hall F, Lipa J, Neligan P, Brown D, Irish J, Gullane P, Gilbert R. Predictors of morbidity following free flap reconstruction for cancer of the head and neck. Head Neck 2007;29(12):1090-1101. 12. Ryan MW, Hochman M. Length of stay after free flap reconstruction of the head and neck. Laryngoscope 2000;110(2 Pt 1):210-216. 13. Hanick A, Meleca JB, Fritz MA. Early discharge after free-tissue transfer does not increase adverse events. Am J Otolaryngol 2020;41(2):102374. 14. Devine CM, Haffey TM, Trosman S, Fritz MA. Short-stay hospital admission after free tissue transfer for head and neck reconstruction. Laryngoscope 2016;126(12):2679-2683. 15. Lindeborg MM, Sethi RKV, Puram SV, Parikh A, Yarlagadda B, Varvares M, Emerick K, Lin D, Durand ML, Deschler DG. Predicting length of stay in head and neck patients who undergo free flap reconstruction. Laryngoscope Investig Otolaryngol 2020;5(3):461-467. 16. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002;287(4):487-494. 17. Pirson M, Dehanne F, Van den Bulcke J, Leclercq P, Martins D, De Wever A. Evaluation of cost and length of stay, linked to complications associated with major surgical procedures. Acta Clin Belg 2018;73(1):40-49. 18. Blackwell KE. Unsurpassed reliability of free flaps for head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1999;125(3):295-299. 19. Suh JD, Sercarz JA, Abemayor E, Calcaterra TC, Rawnsley JD, Alam D, Blackwell KE . Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg 2004;130(8):962-966. 20. Singh B, Cordeiro PG, Santamaria E, Shaha AR, Pfister DG, Shah JP. Factors associated with complications in microvascular reconstruction of head and neck defects. Plast Reconstr Surg 1999;103(2):403-411. 21. Disa JJ, Pusic AL, Hidalgo DH, Cordeiro PG. Simplifying microvascular head and neck reconstruction: a rational approach to donor site selection. Ann Plast Surg 2001;47(4):385-389. 22. Nuara MJ, Sauder CL, Alam DS. Prospective analysis of outcomes and complications of 300 consecutive microvascular reconstructions. Arch Facial Plast Surg 2009;11(4):235-239. 23. le Nobel GJ, Higgins KM, Enepekides DJ. Predictors of complications of free flap reconstruction in head and neck surgery: Analysis of 304 free flap reconstruction procedures. Laryngoscope 2012;122(5):1014-1019. 24. Karaca-Mandic P, Sen S, Georgiou A, Zhu Y, Basu A. Association of COVID-19-Related Hospital Use and Overall COVID-19 Mortality in the USA. J Gen Intern Med 2020. 25. Song CT, Koh K, Tan BK, Goh T. Free-Flap Lower Extremity Reconstruction: A Cohort Study and Meta-Analysis of Flap Anastomotic Outcomes between Perforator and Nonperforator Flaps. J Reconstr Microsurg 2018;34(6):455-464. 26. Sakurai H, Yamaki T, Takeuchi M, Soejima K, Kono T, Nozaki M. Hemodynamic alterations in the transferred tissue to lower extremities. Microsurgery 2009;29(2):101-106. 27. Fischer JP, Wink JD, Nelson JA, Cleveland E, Grover R, Wu LC, Levin LS, Kovach SJ. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013;29(6):407-416. 28. Ridgway EB, Kutz RH, Cooper JS, Guo L. New insight into an old paradigm: wrapping and dangling with lower-extremity free flaps. J Reconstr Microsurg 2010;26(8):559-566. 29. Fujiki M, Miyamoto S, Sakuraba M. Flow-through anastomosis for both the artery and vein in leg free flap transfer. Microsurgery 2015;35(7):536-540. 30. Chow SP, Chen DZ, Gu YD. The significance of venous drainage in free flap transfer. Plast Reconstr Surg 1993;91(4):713-715. 31. Chen KT, Mardini S, Chuang DC, Lin CH, Cheng MH, Lin YT, Huang WC, Tsao CK, Wei FC. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007;120(1):187-195. 32. Xipoleas G, Levine E, Silver L, Koch RM, Taub PJ. A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care. Ann Plast Surg 2008;61(3):280-284. 33. Xipoleas G, Levine E, Silver L, Koch RM, Taub PJ. A survey of microvascular protocols for lower-extremity free tissue transfer I: perioperative anticoagulation. Ann Plast Surg 2007;59(3):311-315. 34. Novakovic D, Patel RS, Goldstein DP, Gullane PJ. Salvage of failed free flaps used in head and neck reconstruction. Head Neck Oncol 2009;1:33. 35. Pohlenz P, Klatt J, Schon G, Blessmann M, Li L, Schmelzle R. Microvascular free flaps in head and neck surgery: complications and outcome of 1000 flaps. Int J Oral Maxillofac Surg 2012;41(6):739-743. 36. Hyodo I, Nakayama B, Kato H, Hasegawa Y, Ogawa T, Terada A, Torii S. Analysis of salvage operation in head and neck microsurgical reconstruction. Laryngoscope 2007;117(2):357-360. 37. Wu CC, Lin PY, Chew KY, Kuo YR. Free tissue transfers in head and neck reconstruction: complications, outcomes and strategies for management of flap failure: analysis of 2019 flaps in single institute. Microsurgery 2014;34(5):339-344. 38. Yu P, Chang DW, Miller MJ, Reece G, Robb GL. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 2009;31(1):45-51. 39. Bonde C, Khorasani H, Eriksen K, Wolthers M, Kehlet H, Elberg J. Introducing the fast track surgery principles can reduce length of stay after autologous breast reconstruction using free flaps: A case control study. J Plast Surg Hand Surg 2015;49(6):367-371. 40. Hill JB, Patel A, Del Corral GA, Sexton KW, Ehrenfeld JM, Guillamondegi OD, Shack RB. Preoperative anemia predicts thrombosis and free flap failure in microvascular reconstruction. Ann Plast Surg 2012;69(4):364-367. 41. Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg 2011;128(1):173-180. 42. Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013;66(2):243-250. 43. Cho EH, Garcia RM, Pien I, Kuchibhatla M, Levinson H, Erdmann D, Levin LS, Hollenbeck ST. Vascular considerations in foot and ankle free tissue transfer: Analysis of 231 free flaps. Microsurgery 2016;36(4):276-283. 44. Sbitany H, Xu X, Hansen SL, Young DM, Hoffman WY. The effects of immunosuppressive medications on outcomes in microvascular free tissue transfer. Plast Reconstr Surg 2014;133(4):552e-558e. 45. Ozkan O, Ozgentas HE, Islamoglu K, Boztug N, Bigat Z, Dikici MB. Experiences with microsurgical tissue transfers in elderly patients. Microsurgery 2005;25(5):390-395. 46. Serletti JM, Higgins JP, Moran S, Orlando GS. Factors affecting outcome in free-tissue transfer in the elderly. Plast Reconstr Surg 2000;106(1):66-70. 47. Wong AK, Joanna Nguyen T, Peric M, Shahabi A, Vidar EN, Hwang BH, Leilabadi SN, Chan LS, Urata MM. Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database. Microsurgery 2015;35(1):6-12. 48. Kim BD, Ver Halen JP, Grant DW, Kim JY. Anesthesia duration as an independent risk factor for postoperative complications in free flap surgery: a review of 1,305 surgical cases. J Reconstr Microsurg 2014;30(4):217-226. 49. Offodile AC, 2nd, Aherrera A, Wenger J, Rajab TK, Guo L. Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database. Microsurgery 2017;37(1):12-20. 50. White LJ, Zhang H, Strickland KF, El-Deiry MW, Patel MR, Wadsworth JT, Chen AY. Factors Associated With Hospital Length of Stay Following Fibular Free-Tissue Reconstruction of Head and Neck Defects: Assessment Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Criteria. JAMA Otolaryngol Head Neck Surg 2015;141(12):1052-1058. 51. Horn D, Jonas R, Engel M, Freier K, Hoffmann J, Freudlsperger C. A comparison of free anterolateral thigh and latissimus dorsi flaps in soft tissue reconstruction of extensive defects in the head and neck region. J Craniomaxillofac Surg 2014;42(8):1551-1556. 52. Ettinger KS, Arce K, Lohse CM, Peck BW, Reiland MD, Bezack BJ, Moore EJ. Higher perioperative fluid administration is associated with increased rates of complications following head and neck microvascular reconstruction with fibular free flaps. Microsurgery 2017;37(2):128-136. 53. Vyas K, Wong L. Intraoperative management of free flaps: current practice. Ann Plast Surg 2014;72(6):S220-223.

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