Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

@xirurgi_2025 - 562 - файл

.pdf

Скачиваний:

Добавлен:

29.08.2026

Размер:

25 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 56 / 326 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

3 Preoperative Visit Counseling andPatient Education

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Fig. 3.2 Comparison of laryngeal tube versus Shiley tracheostomy size and curvature

Patients should be advised about postoperative reliance on laryngeal tubes, use of HME lters, and their proper care.

Postoperative swallow function is evaluated with contrast-enhanced radiographic studies, and patients should be educated on strict NPO adherence until cleared by their surgeon. As already mentioned, due to high risk of pharyngocutaneous stula, especially in radiated patients, reliance on enteral nutrition could be prolonged [16].

Implications forthePatient

• Loss of speech

• Future use of electrolarynx, esophageal

speech, or TEP

• Alterations in swallowing

Postoperative Expectations andComplications

• Need for speech and language pathology

assessment

• Prolonged liquid/puree diet or feeding tube

• Tracheoesophageal stula

• Info card/wristband to alert medical providers

Surgery-Specic Discussion: Flap Donor Sites

The selection of free ap donor site is guided primarily by the requirements of the anticipated defect, patient donor site availability, and surgeon preference. In general, a greater degree of functional limitation is expected immediately post-op due to either acute surgical pain or use of range-ofmotion restrictive dressings to facilitate surgical site healing. Flap donor sites that require application of a skin graft most often will require application of a bolster dressing or a wound VAC with possible use of splints or CAM boots. Most often, these dressings are removed within 5–10days postop. Signicant long-term postoperative functional decits are not anticipated, as loss of important function would likely serve as a contraindication to selection of that particular donor site.

Patients should be warned about the discomfort from the split-thickness skin graft harvest site. The restrictive dressing on ap donor sites reconstructed with skin grafts is intended to ensure that there is close adaptation of the graft to the wound bed. This reduces the muscle sheering forces that may increase the chance of the skin graft loss. Negative-pressure wound VAC therapy may also be utilized to improve graft survival [17].

S. R. Caruso and A. Quimby

Use of ow couplers for anastomosis monitoring and temporary drains at the ap sites should be mentioned. Patients should be advised that most drains are removed within the rst postoperative week.

Next, we will review key points of preoperative discussions depending on the donor site for the most common free aps used in head and neck reconstruction:

Radial Forearm Free Flap

Implications forthePatient

• Nondominant hand preferred.

• Advise the patient to educate medical provid-

ers (pre-admission lab draws) on not using the

arm intended for free ap harvest for IVs.

• Restricted mobility immediately post-op due

to restrictive dressing/splint for 5–7days.

• Presence of additional surgical site: split-

thickness skin graft site.

Postoperative Expectations andComplications [18–20]

• Skin graft failure partial or complete, tendon

exposure, may require secondary surgical

procedures.

• Temporary or permanent anesthesia or pares-

thesia along the supercial radial nerve

distribution.

• Unesthetic appearance.

• Poor grip strength.

• Hair growth at the site of reconstruction from

the transferred ap.

Anterolateral Thigh

Implications forthePatient

• Primary closure, a scar extending from proxi-

mal thigh to above the knee.

• Minimal to no functional limitations.

• No need for secondary surgical sites.

Postoperative Expectations andComplications [18, 21, 22]

• Temporary or permanent thigh paresthesia.

• Incisional dehiscence/breakdown.

• Seroma, hematoma.

• Unesthetic appearance.

• Musculoskeletal dysfunction (higher likelihood if signicant amount of muscle is harvested, fascia elevated, tensor fascia lata harvest, or violation of motor branch of femoral nerve to vastus lateralis, which may lead to weakness in knee extension, however not shown to have impact on long-term quality of life).

• Compartment syndrome (rare but serious possible complication).

Fibula Free Flap

Implications forthePatient

• Restricted mobility for 5–10days post-op due to restrictive dressing (ACE bandage) or CAM boot.

• Pain often more severe than at the head and neck (may discuss local anesthesia block or local catheter placement).

• PT/OT evaluation and management while inpatient and possibly after discharge.

Postoperative Expectations andComplications [23, 24]

• Skin graft failure partial or complete, tendon exposure, may require secondary surgical procedures.

• Unesthetic appearance due to scar and possible deformity depending on the amount of muscle harvested.

• Sensory decit.

• Claw toe deformity, weakness of the great toe, dorsiexion of the great toe (rare).

• Ankle instability or limited range of motion (rare).

• Gait abnormality (rare).

3 Preoperative Visit Counseling andPatient Education

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Deep Circumex Iliac Artery FreeFlap

Implications forthePatient

• Restricted mobility.

• Abdominal binder wear.

• No heavy lifting (>10lbs) for 6–8weeks.

Postoperative Expectations andComplications [25, 26]

• Sensory decit to ipsilateral anterolateral thigh, scrotum.

• Hernia, potential use of hernia mesh, and associated risk of mesh complications.

• Gait disturbance.

• Chronic pain.

Scapula System Free Flap

Implications forthePatient

• Standing cone or dog ear deformity.

• Restricted range of motion due to wear of shoulder sling.

• Need for inpatient and outpatient PT/OT to reduce long-term functional decits.

Postoperative Expectations andComplications [24, 27]

• Axillary lymphatic drainage, seroma.

• Decreased range of motion at the shoulder.

• Scapula bone fracture (rare).

Postoperative Recovery andRehabilitation

The immediate postoperative period revolves around working towards patient’s discharge from the hospital. In the rst 1–3days after microvascular reconstructive surgery, patients may spend in the intensive care unit or a dedicated specialty

unit. Patients should be advised if postoperative sedation and ventilation are planned. This period is punctuated by frequent ap checks, as timely recognition of ap perfusion issues increases chances of successful salvage. Possibility of take-back to the operating room for ap exploration and reanastomosis is important to discuss with the patient. Daily lab draws, weaning of intravenous pain medications, transition from bed rest to mobilization, initiation of tube feeds or PO intake, and removal of Foley catheter also occur within the rst few days. The following days are dedicated to downgrading patient’s status, establishment of adequate multimodal enteral/PO pain med regimen, monitoring for infection, increasing levels of mobilization, possible PO trials, tracheostomy downsizing and decannulation, and making discharge arrangements (Table3.2). Patents should be advised that they will work with physical therapists, occupational therapists, nutritionists, and speech therapists during their hospitalization. If necessary, outpatient follow-up should be arranged prior to discharge with the respective ancillary services.

Anticipated length of their hospital stay should be discussed. Free ap reconstruction of extraoral defects warrants about 4–7days of hospital stay, as tracheostomies and PO intake are usually not an issue. However, reconstruction of intraoral aps may require at least 5days and up to 2weeks or more of hospitalization depending on the patient’s comorbidities and post-op course. Patients should be advised that in the event that they do not meet the criteria for safe discharge home, they may be discharged to an acute rehab facility. A case manager is usually involved in assessing home discharge needs or identifying the appropriate acute rehab facility. For patients who are indicated for adjuvant radiation therapy, discharge to a rehabilitation center should be carefully timed, as radiation therapy treatments should start within 42–50days (6–7weeks) after surgery [29]. It is prudent to inform the patient and family members of this important timeline so that the patient’s discharge from the facility is planned in the timely manner or appropriate arrangements are made for the patient to see a radiation oncologist.

Table 3.2 Microvascular ap protocol, adopted and modied from “Clinical Pathway Implementation Improves Efciency of Care in a Maxillofacial Head and Neck Surgery Unit” Yetzer etal. [28]

S. R. Caruso and A. Quimby

It is important to ensure that patients are discharged with the necessary contact information for the required follow-ups. Outpatient speech and physical therapy as well as lymphedema and trismus management may be needed for months following surgery and radiation. Since the surgical team has the most comprehensive knowledge of the patient’s postoperative anatomy, it is in the best position to help navigate patients’ needs with the numerous supporting providers.

References

1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.

2. Kain JJ, Johns JD, Alexander D, Carroll WR, Grayson JW, Buczek EJ. Improving head and neck microvascular reconstructive care with a novel perioperative checklist. Laryngoscope. 2021;131(7):E2251–E6.

3. Cartwright LA, Dumenci L, Siminoff LA, Matsuyama RK. Cancer patients' understanding of prognostic information. J Cancer Educ. 2014;29(2):311–7.

4. van Imhoff LC, Kranenburg GG, Macco S, Nijman NL, van Overbeeke EJ, Wegner I, et al. Prognostic value of continued smoking on survival and recurrence rates in patients with head and neck cancer: a systematic review. Head Neck. 2016;38(Suppl

1):E2214–20.

5. Liu JC, Kaplon A, Blackman E, Miyamoto C, Savior D, Ragin C. The impact of the multidisciplinary tumor board on head and neck cancer outcomes. Laryngoscope. 2020;130(4):946–50.

6. Turkdogan S, Roy CF, Chartier G, Payne R, Mlynarek A, Forest VI, etal. Effect of perioperative patient education via animated videos in patients undergoing head and neck surgery: a randomized clinical trial. JAMA Otolaryngol Head Neck Surg. 2022;148(2):173–9.

7. Chan Y, Irish JC, Wood SJ, Rotstein LE, Brown DH, Gullane PJ, etal. Patient education and informed consent in head and neck surgery. Arch Otolaryngol Head Neck Surg. 2002;128(11):1269–74.

8. Shah P, Thornton I, Turrin D, Hipskind JE.Informed consent. Treasure Island (FL): StatPearls; 2022.

9. Kwon D, Genden EM, de Bree R, Rodrigo JP, Rinaldo A, Sanabria A, etal. Overcoming wound complications in head and neck salvage surgery. Auris Nasus Larynx. 2018;45(6):1135–42.

10. Paderno A, Piazza C, Bresciani L, Vella R, Nicolai P. Microvascular head and neck reconstruction after (chemo)radiation: facts and prejudices. Curr Opin Otolaryngol Head Neck Surg. 2016;24(2):83–90.

11. Arce K, Bell RB, Potter JK, Buehler MJ, Potter BE, Dierks EJ.Vascularized free tissue transfer for reconstruction of ablative defects in oral and oropharyngeal cancer patients undergoing salvage surgery following concomitant chemoradiation. Int J Oral Maxillofac Surg. 2012;41(6):733–8.

12. Thankappan K. Microvascular free tissue transfer after prior radiotherapy in head and neck reconstruction- a review. Surg Oncol. 2010;19(4):227–34.

13. Simon C, Bulut C, Federspil PA, Munter MW, Lindel K, Bergmann Z, etal. Assessment of peri- and post-

3 Preoperative Visit Counseling andPatient Education

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

operative complications and Karnofsky-performance status in head and neck cancer patients after radiation or chemoradiation that underwent surgery with regional or free-ap reconstruction for salvage, palliation, or to improve function. Radiat Oncol. 2011;6:109.

14. Bourget A, Chang JTC, Wu DB, Chang CJ, Wei FC. Free ap reconstruction in the head and neck region following radiotherapy: a cohort study identifying negative outcome predictors. Plast Reconstr Surg. 2011;127(5):1901–8.

15. Zenga J, Goldsmith T, Bunting G, Deschler DG.State of the art: rehabilitation of speech and swallowing after total laryngectomy. Oral Oncol. 2018;86:38–47.

16. Higashino T, Oshima A, Fukunaga Y, Hayashi R. Surgical outcome of Pharyngocutaneous stula after total laryngectomy: a retrospective study. Ann Plast Surg. 2021;87(4):431–4.

17. Scherer LA, Shiver S, Chang M, Meredith JW, Owings JT. The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. Arch Surg. 2002;137(8):930–3; discussion 3–4

18. Niu Z, Chen Y, Li Y, Tao R, Lei Y, Guo L, et al. Comparison of donor site morbidity between anterolateral thigh and radial forearm free aps for head and neck reconstruction: a systematic review and metaanalysis. J Craniofac Surg. 2021;32(5):1706–11.

19. Liu J, Liu F, Fang Q, Feng J. Long-term donor site morbidity after radial forearm ap elevation for tongue reconstruction: prospective observational study. Head Neck. 2021;43(2):467–72.

20. Deneuve S, Majoufre C, Testelin S, Barry B, Louis MY, Longis J, etal. Donor site sequelae and patient satisfaction after head and neck reconstruction with a radial forearm free ap. Eur Arch Otorhinolaryngol. 2021;278(10):4051–8.

21. Weise H, Naros A, Blumenstock G, Krimmel M, Hoefert S, Kluba S, et al. Donor site morbidity of

the anterolateral thigh ap. J Craniomaxillofac Surg. 2017;45(12):2105–8.

22. Agostini T, Lazzeri D, Spinelli G. Anterolateral thigh ap: systematic literature review of specic donor-site complications and their management. J Craniomaxillofac Surg. 2013;41(1):15–21.

23. Ling XF, Peng X.What is the price to pay for a free bula ap? A systematic review of donor-site morbidity following free bula ap surgery. Plast Reconstr Surg. 2012;129(3):657–74.

24. Russell J, Pateman K, Batstone M.Donor site morbidity of composite free aps in head and neck surgery: a systematic review of the prospective literature. Int J Oral Maxillofac Surg. 2021;50(9):1147–55.

25. Rendenbach C, Goehler F, Hansen L, Kohlmeier C, Amling M, Hanken H, etal. Evaluation of long-term functional donor-site morbidity after deep circumex iliac crest artery bone ap harvest. Microsurgery. 2019;39(4):304–9.

26. Schardt C, Schmid A, Bodem J, Krisam J, Hoffmann J, Mertens C.Donor site morbidity and quality of life after microvascular head and neck reconstruction with free bula and deep-circumex iliac artery aps. J Craniomaxillofac Surg. 2017;45(2):304–11.

27. Harada H, Shimamoto H, Oikawa Y, Kuroshima T, Tomioka H, Hirai H, et al. Mandibular reconstruction with scapular systems: a single-center case series involving 208 aps. Plast Reconstr Surg. 2021;148(3):625–34.

28. Yetzer JG, Pirgousis P, Li Z, Fernandes R. Clinical pathway implementation improves efciency of Care in a Maxillofacial Head and Neck Surgery Unit. J Oral Maxillofac Surg. 2017;75(1):190–6.

29. Harris JP, Chen MM, Orosco RK, Sirjani D, Divi V, Hara W. Association of Survival with Shorter Time to radiation therapy after surgery for US patients with head and neck cancer. JAMA Otolaryngol Head Neck Surg. 2018;144(4):349–59.

Part II

Intra-operative Considerations

Medical Optimization

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

RushaPatel andAnastasiyaQuimby

Hemodynamic Management

Intraoperative management of patients undergoing free tissue transfer is uniquely challenging. Surgeries can be long, and maintenance of uid balance and hemodynamic stability can be difcult. Surgeon-specic concerns around maintaining viability of the free ap have led to caution when administering vasopressors. Intraoperative hemodynamic management of patients undergoing head and neck free tissue transfer remains controversial. Although various vasoactive agents have been studied invivo and invitro, no general consensus with regard to its safety in free tissue transfer or guidelines exists. The contradicting ndings on intraoperative vasoconstrictor use may not be entirely surprising. Due to complex interplay of a multitude of physiologic variables, one study stated that it is impossible to predict the response to administration of vasopressors even in the setting of normal physiology [1]. In

R. Patel (*) Department of Otolaryngology, Oklahoma University-Stephenson Cancer Center, Oklahoma, OK, USA e-mail: rusha-patel@ouhsc.edu

A. Quimby AQ Surgery: Head and Neck, Microvascular Institute, West Palm Beach, FL, USA

Department of Surgery, Good Samaritan Hospital, West Palm Beach, FL, USA e-mail: aquimbymd@aqsurgery.com

the setting of free tissue transfer, there have been conicting reports with regard to pedicle sensitivity to alpha agonists, further casting doubt on our ability to predict a response [2, 3]. Moreover, effective tissue perfusion depends on the pressure gradient between the arterial and venous systems that encourage ow; thus, intraoperative vasoconstrictor administration could be benecial in certain circumstances during free tissue transfer [1, 3].

Successful outcomes in free tissue transfer are dependent on the establishment of adequate perfusion to the transferred tissues across the newly established anastomoses. Although it is generally accepted that adequate intraoperative blood pressure must be maintained to ensure ap perfusion, there are no standardized guidelines for management. A study by Kass etal. on a cohort of 445 patients concluded that the odds of ap failure increase with mean arterial pressure below 60 for more than 20 episodes of q 5-min measurements [4]. Crystalloid administration was cited as the rst choice for the management of intraoperative hypotension [5]. Fluid overload and hemodilution have been shown to increase the risk of ap failure [6]. Historically, over-administration of uids during free ap surgeries led to concern over pedicle edema and disruption [7]. In the early 2000s, Haughey etal. found that administration of >7L of uid during a free ap case was associated with worse ap outcomes, including higher rates of stula and wound dehiscence [8].

https://doi.org/10.1007/978-3-031-38898-9_4

R. Patel and A. Quimby

Several studies have since corroborated these results and found that intraoperative uid administration between 5 and 7L was associated with adverse patient and reconstructive outcomes [9–

11] and conrmed that excessive perioperative

uid administration leads to poor free ap outcomes in head and neck cancer patients [10, 12]. Studies continue to indicate surgeons’ reluctance to use intraoperative vasoconstrictors due to concern for vasospasm and subsequent ap failure, while acknowledging that no convincing scientic evidence exists to merit this viewpoint [5,

13]. Numerous published articles have found the

use of vasoconstrictors to be common and not associated with increase in complications [14–

17]. Paradoxically, there are papers demonstrat-

ing lower rates of ap failures in groups who received intraoperative vasopressors [18]. The lack of consensus on this subject results in varying practices based on anecdotal evidence and personal surgeon experience. Recently, an expert consensus statement from the Journal of Head and Neck Anesthesia recommended the use of hemodynamic monitoring with an arterial line to allow for goal-oriented uid repletion, while recognizing that as of yet there are no studies demonstrating superior outcomes with this method [19].

Goal-Directed Fluid Repletion

The objective of goal-directed uid therapy (GDT) is to provide effective uid resuscitation based on measured and objective hemodynamic parameters. Traditional monitoring of intraoperative uid needs has been done via estimated blood loss, urine output, and determination of insensible losses. Unfortunately, these methods are inaccurate and may not represent the hemodynamic needs of the patient. GDT instead uses objective cardiac measures, including stroke volume and stroke volume index, as discrete endpoints for uid administration. GDT has become increasingly more common with the implementation of Enhanced Recovery After Surgery (ERAS) protocols.

GDT begins in the preoperative area. While patients are traditionally expected to fast prior to surgery, GDT protocols encourage a preoperative carbohydrate drink to ensure a euvolemic status prior to surgery. Once in the operating room, the goal should be a “zero balance,” which is provided by appropriate hemodynamic monitoring and measured uid resuscitation. Both invasive and noninvasive monitoring methods exist and include devices such as the EV1000 (Edwards Lifesciences, USA) and FloTrac (Edwards Lifesciences). The former system can be completely noninvasive via a digital sensor and wrist cuff (ClearSight). FloTrac monitors uid dynamics via a pre-placed arterial line. Both systems provide information on cardiac output, stroke volume and stroke volume variation, systemic vascular resistance, and mean arterial pressure.

Given the risks of uid over-administration during free ap cases, there has been great interest in assessing the use of GDT to improve patient outcomes for these procedures. An early pilot study showed that GDT use during head and neck free tissue transfer surgery resulted in signicantly less perioperative uid administration (6.4 ± 1.9 mL/kg/h versus 10.2 ± mL/kg/h in GDT versus control groups, respectively) [20]. Several subsequent studies have conrmed that GDT during head and neck free ap surgery can reduce perioperative uid administration as well as decrease the duration of ICU stay [21, 22]. It should be mentioned that GDT often depends on the use of vasopressors to support intraoperative hemodynamics in lieu of uid-based support. As such, the interest in GDT for head and neck free ap surgeries has led to an increasing body of research surrounding the safety of vasopressors in head and neck reconstruction. The use of vasopressors during free tissue transfer has historically been avoided due to concerns surrounding vascular insufciency. The most commonly used vasoactive agents during surgery include phenylephrine and norepinephrine, both of which preferentially act on alpha-receptors and cause vasoconstriction. Due to the mechanism of action, there has been historic concern around avoiding these medications out of natural con-

4 Medical Optimization

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

cern for constriction of the ap perforators or vascular anastomosis. Despite these concerns, a large body of studies going back to the early 2000s have failed to nd an association of vasopressor use with adverse outcomes in free ap surgery [10, 14, 23–26]. In contrast, recent studies have found that vasopressor use during reconstructive procedures can positively impact a patient’s hemodynamic status [24]. In addition, GDT in conjunction with vasopressor use does not increase ap complications and can decrease ICU and hospital stay [21, 27]. Furthermore, the type and duration of vasopressor administration do not appear to impact ap outcomes in the perioperative period [28]. Given the large body of data behind the safety of vasoactive agents in free ap surgery, surgeons should feel comfortable with vasoactive agents being a part of their patients’ perioperative care.

Intraoperative Temperature Management

Patients undergoing free tissue transfer are susceptible to intraoperative hypothermia due to case duration and prolonged exposure at multiple operative sites. With regard to free ap reconstruction, overt hypothermia has been additionally associated with arterial thrombosis, ap infection, and ap loss [29, 30]. Given this, surgeons have traditionally tried to keep operating rooms warm and enable patient warming during the perioperative period. In addition to preventing ap thrombosis, this practice has been thought to promote vasodilation. However, warming has been associated with its own risks of surgical site infections [31]. As an alternative, permissive mild hypothermia has been explored as a method of improving patient outcomes. Several studies have looked at this practice in head and neck free ap patients. A retrospective review found that vessel thrombosis rate was decreased for patients maintained between

36.0°C and 36.4°C [32]. A larger review supported this nding and suggested that an average intraoperative patient temperature around 36.0°C was associated with lower ap-related outcomes

[33]. While further work remains to be done in this area, the ideal intraoperative temperature during a free ap surgery may be best within this range. In practice, temperature maintenance within a small range may not be practical. At minimum, normothermia should be maintained and overt hypothermia (<36.0 °C) should be avoided during free ap surgeries.

Pain Management

Adequate postoperative pain management is essential to improving overall patient outcomes. In the USA, opioid use for head and neck patients has been shown to be signicantly higher when compared to Italy (6X), Argentina (4X), and India (2X) [34]. Aside from the risk of developing opioid dependence, acute effects of opioids in the immediate postoperative period, such as sedation, nausea, and vomiting, can lead to prolonged ICU stay requiring ventilator support, delay of patient mobilization, and consequently increase in surgical complications. Utilization of the multimodal pain management approach and nerve blocks has demonstrated reduction in opioid use and decreased hospital length of stay in numerous other surgical specialties as well as head and neck microvascular reconstruction patients [35–37].

Multimodal analgesia (MMA) regimens most commonly include gabapentin, NSAIDs (celecoxib, ibuprofen), and Tylenol with various other adjunct medications, including opioids. Gabapentin is an anticonvulsant medication that has also demonstrated effectiveness in pain control. The precise mechanism of action of gabapentin has not been explained; however, the existing theories include potentiation of GABA- mediated pathways, indirect antagonism of NMDA receptors, calcium channels, and inhibition of peripheral nerves [38]. Preoperative use of gabapentin in doses of 600–1200mg has been associated with decreased postoperative opioid requirement [39–

41]. A meta-analysis conducted on a mixed surgi-

cal cohort showed no effect on pain scores but demonstrated earlier withdrawal from opioids in patients who took perioperative gabapentin [42].

R. Patel and A. Quimby

Nonetheless, other studies have demonstrated no effect on postoperative opioid use and pain scores [43]. Overall, gabapentin is a well-tolerated drug with low side effect prole. The most commonly cited adverse effect of gabapentin is sedation, which may be of benet in the acute postoperative setting, but should be taken into account where airway obstruction may be of concern. Given the likely benets of preemptive administration of gabapentin and low risks associated with its use, it is difcult to argue against its use.

Use of regional nerve blocks in the head and neck is limited due to the unique anatomy of the region. However, as most head and neck surgeons have experienced, patients most often complain of pain at the donor site. A study by Le etal. demonstrated that preoperative administration of brachial plexus, lateral femoral cutaneous, and sciatic nerve blocks for harvest of radial forearm, anterolateral thigh, and bula free ap has demonstrated signicant reduction in opioid requirements [44]. Availability of anesthesia personnel skilled in regional block administration may be a limiting factor in some institutions. As the nerve block administration must be completed preoperatively, additional time either in pre-op or prior to surgical incision in the operating room must be anticipated.

References

1. Magder S.The meaning of blood pressure. Crit Care. 2018;22(1):257.

2. Godden DR, Little R, Weston A, Greenstein A, Woodwards RT. Catecholamine sensitivity in the rat femoral artery after microvascular anastomosis. Microsurgery. 2000;20(5):217–20.

3. Lecoq JP, Joris JL, Nelissen XP, Lamy ML, Heymans OY. Effect of adrenergic stimulation on cutaneous microcirculation immediately after surgical adventitiectomy in a rat skin ap model. Microsurgery. 2008;28(6):480–6.

4. Kass JL, Lakha S, Levin MA, Joseph T, Lin HM, Genden EM, et al. Intraoperative hypotension and ap loss in free tissue transfer surgery of the head and neck. Head Neck. 2018;40(11):2334–9.

5. Vyas K, Wong L. Intraoperative management of free aps: current practice. Ann Plast Surg. 2014;72(6):S220–3.

6. Namdar T, Bartscher T, Stollwerck PL, Mailander P, Lange T.Complete free ap loss due to extensive hemodilution. Microsurgery. 2010;30(3):214–7.

7. Pattani KM, Byrne P, Boahene K, Richmon J.What makes a good ap go bad? A critical analysis of the literature of intraoperative factors related to free ap failure. Laryngoscope. 2010;120(4):717–23.

8. Haughey BH, Wilson E, Kluwe L, Piccirillo J, Fredrickson J, Sessions D, etal. Free ap reconstruction of the head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg. 2001;125(1):10–7.

9. Clark JR, McCluskey SA, Hall F, Lipa J, Neligan P, Brown D, etal. Predictors of morbidity following free ap reconstruction for cancer of the head and neck. Head Neck. 2007;29(12):1090–101.

10. Dooley BJ, Karassawa Zanoni D, McGill MR, Awad MI, Shah JP, Wong RJ, etal. Intraoperative and postanesthesia care unit uid administration as risk factors for postoperative complications in patients with head and neck cancer undergoing free tissue transfer. Head Neck. 2020;42(1):14–24.

11. Farwell DG, Reilly DF, Weymuller EA Jr, Greenberg DL, Staiger TO, Futran NA.Predictors of perioperative complications in head and neck patients. Arch Otolaryngol Head Neck Surg. 2002;128(5):505–11.

12. Burkhard JP, Pster J, Giger R, Huber M, Ladrach C, Waser M, et al. Perioperative predictors of early surgical revision and ap-related complications after microvascular free tissue transfer in head and neck reconstructions: a retrospective observational series. Clin Oral Investig. 2021;25(9):5541–50.

13. Chang CS, Chu MW, Nelson JA, Basta M, Gerety P, Kanchwala SK, etal. Complications and cost analysis of intraoperative arterial complications in head and neck free ap reconstruction. J Reconstr Microsurg. 2017;33(5):318–27.

14. Kelly DA, Reynolds M, Crantford C, Pestana IA. Impact of intraoperative vasopressor use in free tissue transfer for head, neck, and extremity reconstruction. Ann Plast Surg. 2014;72(6):S135–8.

15. Harris L, Goldstein D, Hofer S, Gilbert R.Impact of vasopressors on outcomes in head and neck free tissue transfer. Microsurgery. 2012;32(1):15–9.

16. Chen C, Nguyen MD, Bar-Meir E, Hess PA, Lin S, Tobias AM, etal. Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction. Ann Plast Surg. 2010;65(1):28–31.

17. Swanson EW, Cheng HT, Susarla SM, Yalanis GC, Lough DM, Johnson O 3rd, etal. Intraoperative use of vasopressors is safe in head and neck free tissue transfer. J Reconstr Microsurg. 2016;32(2):87–93.

18. Grill FD, Wasmaier M, Mucke T, Ritschl LM, Wolff KD, Schneider G, et al. Identifying perioperative volume-related risk factors in head and neck surgeries with free ap reconstructions - an investigation with focus on the inuence of red blood cell concentrates and noradrenaline use. J Craniomaxillofac Surg. 2020;48(1):67–74.

19. Healy DW, Cloyd BH, Straker T, Brenner MJ, Damrose EJ, Spector ME, et al. Expert consensus statement on the perioperative Management of Adult Patients Undergoing Head and Neck Surgery and free

<<< < Предыдущая 1 2 3 4 56 / 326 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

Соседние файлы в папке @xirurgi_2025

#
29.08.202625 Мб0@xirurgi_2025 - 545 - файл.pdf
#
29.08.202625 Мб0@xirurgi_2025 - 550 - файл.pdf
#
29.08.202625 Мб0@xirurgi_2025 - 552 - файл.pdf
#
29.08.202625 Мб0@xirurgi_2025 - 560 - файл.pdf
#
29.08.202625 Мб0@xirurgi_2025 - 561 - файл.pdf
#
29.08.202625 Мб0@xirurgi_2025 - 562 - файл.pdf
#
29.08.202625 Мб0@xirurgi_2025 - 563 - файл.pdf
#
29.08.202624 Мб0@xirurgi_2025 - 566 - файл.pdf
#
29.08.202624 Мб0@xirurgi_2025 - 570 - файл.pdf
#
29.08.202624 Мб0@xirurgi_2025 - 572 - файл.pdf
#
29.08.202624 Мб0@xirurgi_2025 - 573 - файл.pdf