Dawson Rebecca, Phung Daniel, Every James, Gunawardena Dulan, Low Tsu-Hui, Ch'ng Sydney, Clark Jonathan, Wykes James, Palme Carsten E
Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.
Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Sydney, New South Wales, Australia.
ANZ J Surg. 2021 Jun;91(6):1246-1250. doi: 10.1111/ans.16762. Epub 2021 Apr 6.
Head and neck surgeons are moving away from routine tracheostomy in free-flap reconstruction. We reviewed prophylactic tracheostomy use in patients undergoing oral cavity or oropharynx free-flap reconstruction to identify patient groups who avoided tracheostomy. Secondary aims were to describe complications associated with and without tracheostomy.
A retrospective cohort study was undertaken, using a prospectively maintained database. Inclusion criteria was free-flap reconstruction for an oral cavity or oropharyngeal defect, excluding partial or total laryngectomy. Variables collected included demographics, comorbidity, American Society of Anesthesiologists grade, Charlson Comorbidity Index, tumour site and subsite, extent of resection, surgery duration, tracheostomy, complications, return to theatre and re-intubation.
A total of 344 head and neck free-flap reconstructions were performed between January 2017 and July 2019. A total of 164 (87.7%) oral cavity and 23 (12.3%) oropharyngeal reconstructions were included totalling 187 free flaps. A total of 107 (57.2%) were males and 80 (42.8%) females, mean age 62.4 years (range 21-89). Of 187 patients, 100 (53.5%) underwent prophylactic tracheostomy at time of reconstruction. Longer operative time (P < 0.001), resection site (P < 0.001), number of subsites resected (P = 0.007), segmental mandibulectomy (P = 0.04), lip-split (P = 0.05), floor of mouth resection (P < 0.001), lingual release (P = 0.007), glossectomy (P < 0.001), extent of tongue resection (P < 0.001), extent of hard palate resection (P = 0.04), soft palate resection (P < 0.001) and double free-flap reconstruction (P = 0.04) were associated with tracheostomy use.
A personalized approach to postoperative airway management allowed almost half of our cohort to avoid tracheostomy. In high-volume institutions with the necessary expertise and support, appropriately selected patients may be safely managed without routine tracheostomy.
头颈外科医生在游离皮瓣重建手术中逐渐摒弃常规气管切开术。我们回顾了接受口腔或口咽游离皮瓣重建手术患者的预防性气管切开术使用情况，以确定避免行气管切开术的患者群体。次要目的是描述气管切开术相关和无关的并发症。
采用前瞻性维护的数据库进行回顾性队列研究。纳入标准为口腔或口咽缺损的游离皮瓣重建，不包括部分或全喉切除术。收集的变量包括人口统计学资料、合并症、美国麻醉医师协会分级、查尔森合并症指数、肿瘤部位和亚部位、切除范围、手术时间、气管切开术、并发症、返回手术室和再次插管情况。
2017年1月至2019年7月期间共进行了344例头颈游离皮瓣重建手术。其中包括164例（87.7%）口腔重建和23例（12.3%）口咽重建，共187个游离皮瓣。男性107例（57.2%），女性80例（42.8%），平均年龄62.4岁（范围21 - 89岁）。187例患者中，100例（53.5%）在重建时接受了预防性气管切开术。手术时间较长（P < 0.001）、切除部位（P < 0.001）、切除的亚部位数量（P = 0.007）、节段性下颌骨切除术（P = 0.04）、唇裂（P = 0.05）、口底切除术（P < 0.001）、舌松解术（P = 0.007）、舌切除术（P < 0.001）、舌切除范围（P < 0.001）、硬腭切除范围（P = 0.04）、软腭切除术（P < 0.001）和双游离皮瓣重建（P = 0.04）与气管切开术的使用相关。
个性化的术后气道管理方法使我们近一半的队列患者避免了气管切开术。在具备必要专业知识和支持的大型机构中，经过适当选择的患者可以在不进行常规气管切开术的情况下得到安全管理。
