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Risk
Stratification

 

Patients
presenting for head and neck free flap surgery and breast reconstructive
surgery are fragile cancer patients with a number of dangerous co-morbidities
(5). Hence, pre-operative assessment and investigations play a role for the
risk stratification (6). Although technical issues are dominant factors, patients
and clinical characteristics also contribute to flap failure (7). 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 for flap failure, as resulted from the multivariate logistic regression (8). 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 site
are associated with higher scores of medical complications and ITU admissions
(9). Another important study, held in Toronto in 2016, identified
the operative time and smoking as the independent risk factors for
intraoperative complications in reconstructive breast flap surgery (10).  Several preoperative investigations play
a role in the risk assessment of these patients. Different studies revealed how
cardiopulmonary exercise testing (CPET) in complex patients is pivotal to
assess the functional capacity. Many instirutions routinely use CPET to plan
the type of surgery and to inform our patients regarding risks and benefits of
surgery (11). In conclusion, flap loss 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 and to
reduce medical complications but intraoperative management and technical
variables may have higher importance for the outcome (12).

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Nutrition, preoperative
fasting and preoperative education

 

According recent evidences,
the basic nutritional state should be assessed and optimised: preoperative
albumin levels have inverse correlation with wound dehiscence, pleural effusion,
salivary leak, suture removal, fistula (13).  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. (14, 15).  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 play a role together in this discussion, is still not
clarified, due to paucity of high quality studies specifically focused on this (16).
In
conclusion, the implementation of a multidisciplinary pre-operative evaluation conducted
by anaesthetists, nutritionists, other medical specialists and health
practitioners may reduce post-operative complications arising from pre-

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