Jones Neil F, Jarrahy Reza, Song J I, Kaufman Matthew R, Markowitz Bernard
Los Angeles, Calif. From the Division of Plastic and Reconstructive Surgery, University of California Los Angeles School of Medicine.
Plast Reconstr Surg. 2007 Jun;119(7):2053-2060. doi: 10.1097/01.prs.0000260591.82762.b5.
Immediate reconstruction of composite head and neck defects using free tissue transfer is an accepted treatment standard. There remains, however, ongoing debate on whether the costs associated with this reconstructive approach merit its selection, especially considering poor patient prognoses and the high cost of care.
A retrospective review of the last 100 consecutive patients undergoing microsurgical reconstruction for head and neck cancer by the two senior surgeons was performed to determine whether microsurgical complications or postoperative medical complications had the more profound influence on morbidity and mortality outcomes and the true costs of these reconstructions.
Two patients required re-exploration of the microsurgical anastomoses, for a re-exploration rate of 2 percent, and one flap failed, for a flap success rate of 99 percent. The major surgical complication rate requiring a second operative procedure was 6 percent. Sixteen percent had minor surgical complications related to the donor site. Major medical complications, defined as a significant risk to the patient's life, occurred in 5 percent of the patients, but there was a 37 percent incidence of "minor" medical complications primarily caused by pulmonary problems and alcohol withdrawal. Postsurgical complications almost doubled the average hospital stay from 13.5 days for those patients without complications to 24 days for patients with complications. Thirty-six percent of the true cost of microsurgical reconstruction of head and neck cancer was due to the intensive care unit and hospital room costs, and 24 percent was due to operating room costs. Postsurgical complications resulted in a 70.7 percent increase in true costs, reflecting a prolonged stay in the intensive care unit and not an increase in operating room costs or regular hospital room costs.
Postoperative medical complications in these elderly, debilitated patients related to pulmonary problems and alcohol withdrawal were statistically far more important in negatively affecting the outcomes and true costs of microsurgical reconstruction.
采用游离组织移植立即重建头颈部复合缺损是一种公认的治疗标准。然而，对于这种重建方法所涉及的成本是否值得选择，仍存在持续的争论，尤其是考虑到患者预后不佳和护理成本高昂。
对两位资深外科医生最近连续进行的100例头颈部癌显微外科重建患者进行回顾性研究，以确定显微外科并发症或术后医疗并发症对发病率、死亡率结果以及这些重建的实际成本是否有更深远的影响。
两名患者需要再次探查显微外科吻合口，再次探查率为2%，一块皮瓣失败，皮瓣成功率为99%。需要二次手术的主要手术并发症发生率为6%。16%的患者有与供区相关的轻微手术并发症。严重医疗并发症，定义为对患者生命有重大风险，发生在5%的患者中，但有37%的“轻微”医疗并发症主要由肺部问题和戒酒引起。术后并发症使平均住院时间几乎翻倍，从无并发症患者的13.5天增加到有并发症患者的24天。头颈部癌显微外科重建实际成本的36%归因于重症监护病房和病房费用，24%归因于手术室费用。术后并发症导致实际成本增加70.7%，这反映了在重症监护病房停留时间延长，而非手术室费用或普通病房费用增加。
在这些老年体弱患者中，与肺部问题和戒酒相关的术后医疗并发症在对显微外科重建的结果和实际成本产生负面影响方面，在统计学上要重要得多。
