Date of Award

January 2015

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Deepak Narayan

Subject Area(s)

Surgery

Abstract

Hypothesis and specific aims

Intraoperative brachytherapy (IOBT) placed following extirpative surgery for head and neck cancer is able to supply tumoricidal doses of radiation within a limited volume. Both pedicle and microvascular free flaps can provide vascularized tissue to cover the radioactive seeds in an effort to reconstruct the patients' anatomy and protect the surgical wound. The aims of this study were, first, to better characterize the overall wound healing complications experienced by patients undergoing reconstruction in the setting of IOBT following tumor ablation, as well as to identify risk factors predicting complications and the need for re-operation. Secondly, we sought to distinguish complication rates between pedicle flap and free flap groups used for resurfacing of IOBT implants to help clarify the ideal reconstructive procedure. We hypothesized that there would be a high but manageable complication rate overall, and that pedicle flaps would experience fewer complications because of their generally increased muscle bulk.

Methods

A retrospective chart review of patients receiving IOBT for head and neck cancer at Yale-New Haven Hospital between 2005 - 2013 was conducted. Patient, tumor, treatment, and reconstructive details were recorded. The number and type of flap complications, as well as instances of re-operation were documented. Bivariate and multivariate logistic regressions were performed to identify risk factors associated with the occurrence of one or more flap complications, as well as with the need for re-operation. Bivariate and multivariate logistic regressions were performed to compare complications between pedicle and free flap groups

Results

Ninety-three patients aged ¬¬¬¬31 - 93 years (mean 64 ± 12 years) who underwent IOBT with flap reconstruction were included in the evaluation of overall complication occurrences. Overall, 48 patients (51.6% of the cohort) experienced at least one flap complication, the most common of which was flap dehiscence (32% of patients). Forty-one patients (44% of the cohort) had to be taken back to the operating room at least once for flap debridement or a revision procedure. On multivariate analysis, only the placement of mandibular hardware during flap reconstruction was significantly associated with the risk of developing any type of flap complication (OR = 3.7, p = 0.009) or with subsequent return to the operating room (OR = 3.9, p = 0.012). Fifty free flaps and 55 pedicle flaps were included in the comparison between free and pedicle flap groups. On multivariate analysis, free flap reconstruction with IOBT was associated with both an increased risk of having any flap complication (OR = 2.9, p = 0.037) and with the need for operative revision (OR = 3.5, p = 0.048) compared to pedicle flap reconstruction.

Conclusions

This study demonstrated a very high complication rate for flaps used to cover brachytherapy implants in this patient cohort. However, many of the patient complications could be managed non-operatively. In the setting of IOBT, free flaps are associated with an increased risk of having complications and of requiring operative revisions. Avoiding the use of mandibular hardware with IOBT suggests a method of reducing complications with reconstruction.

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