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Patients presenting for head and neck free flap surgery and breast reconstructive surgery are fragile cancer patients with a number of dangerous co-morbidities. Hence, pre-operative assessment and investigations play a role for the risk stratification. Although technical issues are prevailing factors, clinical characteristics also contribute to flap failure. The Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, investigated a number of non-technical variable in 2015, using the American College of Surgeons” National Surgical Quality Improvement Program (NSQIP) database. Univariate analysis was performed to determine the association of free flap failure with the following factors: age, gender, ethnicity, body mass index, intraoperative transfusion, diabetes, smoking, alcohol, American Society of Anaesthesiologists classification, year of operation, operative time, number of flaps, and type of reconstruction. Flap loss rate was 4.4%. Operative time was the only significant independent risk factor, as resulted from the multivariate logistic regression. According the analysis conducted by another plastic unit, patient’s age is not an independent variable for increased risk in microvascular reconstruction. However, operative time and reconstruction sites are associated with higher incidence of complications and ITU admissions. Another important study, held in Toronto in 2016, recognized operative time and smoking as the independent risk factors for intraoperative complications in reconstructive breast flap surgery. Several preoperative investigations play a role in the risk assessment of these patients. Studies revealed how cardiopulmonary exercise testing (CPET) in complex patients is pivotal to assess the functional capacity. Many institutions routinely use CPET to design the operation and to inform patients about risks and benefits of surgery. In conclusion, flap ischemia is a multifactorial event and, according recent literature, demographics and medical patient’s characteristics such as: age, ethnicity, radiation, chemotherapy, medical comorbidities, smoking, are not independent risk factors for surgical complications in microsurgery. Preoperatively, they need to be assessed to ensure the best perioperative management but intraoperative management and technical variables may have higher importance for the outcome.
Nutrition, preoperative fasting and preoperative education
According recent evidences, the basic nutritional state should be estimated and optimised: preoperative quantity of albumin has inverse correlation with wound dehiscence, pleural effusion, salivary leak, suture removal, fistula. Preoperative fasting should be minimal. In patients eligible for oral intake, clear solids should be allowed up to 2 hours and clear fluids up to 6 hours before anaesthesia. All patients undergoing major head and neck cancer surgery with free flap and breast reconstructive surgery should be adequately prepared regarding the surgical journey and evidences suggest they should receive a systematic teaching. If anaesthetists and qualified health professionals should share this discussion, is still not clarified, due to shortage of specifically focused trials.
In conclusion, the implementation of a multidisciplinary pre-operative evaluation driven by anaesthetists, nutritionists, other medical specialists and health practitioners may reduce post-operative complications deriving from pre-existing conditions.
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