Kuo Pao-Jen, Lin Pi-Chieh, Hsieh Ching-Hua
Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital Chang Gung University and College of Medicine, Kaohsiung, Taiwan.
Risk Manag Healthc Policy. 2025 Aug 5;18:2551-2563. doi: 10.2147/RMHP.S538063. eCollection 2025.
Head and neck free flap reconstruction presents complex airway challenges due to postoperative swelling, bleeding, and anatomical distortion that can jeopardize breathing. Many centers once performed routine prophylactic tracheostomy for major cases, yet modern evidence favors a selective strategy. Avoiding an unnecessary tracheostomy when feasible can reduce morbidity, shorten hospital stay, accelerate return to oral intake, and lower cost. Contemporary practice relies on careful intraoperative assessment. Low-risk patients can be extubated immediately or after brief observation, whereas high-risk features-extensive tongue or base of tongue resection, bilateral neck dissection, bulky flap, or marked edema-mandate a tracheostomy to avert obstruction. There is new update to TRACHY (an acronym that represents Tumor extent, Reconstruction type, Airway anatomy, Coexisting conditions, History of prior treatment, and bilateral neck dissection "lateralitY") scoring systems and risk stratification tools, which assign risk points to support decisions. Once a tracheostomy is placed, decannulation proceeds when airway patency is secure, the patient is alert with a strong cough, the surgical site is stable, swallowing is safe or alternative feeding is available, capping trials are successful, and the multidisciplinary team agrees. A tailored approach therefore balances airway safety with the benefits of tracheostomy avoidance, optimizing outcomes for patients undergoing complex head and neck reconstruction.
头颈部游离皮瓣重建术因术后肿胀、出血和解剖结构变形而带来复杂的气道挑战，这些情况可能危及呼吸。许多中心曾经对重大病例常规进行预防性气管切开术，但现代证据支持采用选择性策略。在可行的情况下避免不必要的气管切开术可以降低发病率、缩短住院时间、加快恢复经口进食并降低成本。当代实践依赖于仔细的术中评估。低风险患者可立即拔管或经过短暂观察后拔管，而高风险特征——广泛的舌部或舌根切除术、双侧颈部清扫术、皮瓣体积大或明显水肿——则需要进行气管切开术以避免梗阻。TRACHY（代表肿瘤范围、重建类型、气道解剖结构、并存疾病、既往治疗史和双侧颈部清扫术“侧别”的首字母缩写）评分系统和风险分层工具已有新更新，这些工具通过分配风险点来辅助决策。一旦进行了气管切开术，当气道通畅、患者清醒且咳嗽有力、手术部位稳定、吞咽安全或有替代喂养方式、堵管试验成功且多学科团队达成一致意见时，即可进行拔管。因此，一种量身定制的方法在气道安全与避免气管切开术的益处之间取得平衡，为接受复杂头颈部重建术的患者优化治疗效果。
