Shahin Bastaninejad, MD Assistant Prof. of ORL-HNS TUMS Amir’Alam Hospital.
AAO2016 SP118 Cheng AAO-HNS Poster 2016 UploadID · PDF fileIncidenceof Postoperative...
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Incidence of Postoperative Donor Site Deep Vein Thrombosis in Fibula Free Flap Reconstruction Esther Cheng, MD 1 ; Amy Pittman, MD 1 ; Eric Thorpe, MD 1 1 Loyola University Medical Center CONTACT Esther Cheng Loyola University Medical Center 2160 S 1 st Ave, Maywood, IL 60153 Email: [email protected] ABSTRACT Objectives: To describe the incidence of deep vein thrombosis (DVT) in patients undergoing fibula free flap reconstruction. To analyze the effect of prolonged immobilization on DVT formation and skin graft healing. Methods: This was a retrospective review of 126 patients undergoing 130 fibula free flap procedures between 2007 and 2016 at Loyola University Medical Center. Patient demographics, select comorbidities, length of surgery, and discharge disposition were examined to determine risk factors associated with DVT formation. Patients were immobilized for either less than 10 days or greater than 10 days to promote skin graft healing. Patients who were immobilized for less than 10 days were nonweight bearing for that time period, whereas patients immobilized for greater than 10 days were full weight bearing on postoperative day one with a boot in place. Analysis was performed to determine whether immobilization or weight bearing status influenced DVT formation and whether skin graft healing was significantly improved by prolonged immobility. Results: Eight DVTs were detected in the study. Five of 8 were present in the donor leg. The overall clinical incidence of DVT in the donor leg was 3.84%. Three out of the 5 patients with donor leg DVTs were immobilized for a prolonged period of time. There was no significant difference in skin graft healing outcomes between patients immobilized for short versus long durations. There were no statistically significant risk factors associated with DVT formation. Conclusions: Prolonged immobilization did not significantly increase the incidence of DVT formation nor did it improve skin graft outcomes. INTRODUCTION DISCUSSION RESULTS Table 3. Associations between incidence of postoperative DVT and select comorbidities. Table 2. Immobilization and skin graft outcomes. Figure 1. Skin graft harvested from leg. Figure 3. Posterior short leg splint 7 . METHODS AND MATERIALS CONCLUSIONS REFERENCES Eight DVTs were detected in the study. Five of the 8 were present in the donor leg. The overall clinical incidence of DVT in the donor leg was 3.84%. Three out of the 5 patients with donor leg DVTs were immobilized for a prolonged period of time (Table 1). There was no significant difference in the rate of DVT formation with respect to immobilization duration. In addition, there was no significant difference in skin graft healing outcomes between patients immobilized for short versus long durations (Table 2). There were no statistically significant risk factors associated with DVT formation (Table 3). Venous thromboembolism causes significant morbidity and mortality postoperatively. It accounts for 10% of hospital deaths and leads to an increased risk for further complications including recurrent VTE, venous stasis, and complications related to long term anticoagulation. In addition, it adds to the length of hospital stay and inpatient costs. Clayburgh et al performed a prospective study of 100 patients undergoing H&N surgery and found a 13% incidence of VTE; however, only a portion of these patients received routine postoperative chemoprophylaxis. Participants were screened with duplex ultrasonography on postoperative day 2 or 3. Eight percent of the discovered DVTs were clinically significant meaning they required >6 weeks of anticoagulation but only 4% were symptomatic. This reported incidence is similar to our study. We concluded that there was no significant association of the examined risk factors with DVT formation. Initial weight bearing status did not significantly impact DVT formation. Prolonged immobilization itself did not significantly increase the incidence of donor leg DVT; however, skin graft outcomes did not improve with prolonged immobilization. This may lead to a change in practice to a shorter duration of immobilization. This was a retrospective review of 126 patients undergoing 130 fibula free flap procedures between 2007 and 2016 at Loyola University Medical Center. Patient demographics, select comorbidities, length of surgery, and discharge disposition were examined to determine risk factors associated with DVT formation. Patients were immobilized for either less than 10 days or greater than 10 days to promote skin graft healing. Patients who were immobilized for less than 10 days were nonweight bearing for that time period, whereas patients immobilized for greater than 10 days were full weight bearing on postoperative day one with a boot in place. Analysis was performed to determine whether immobilization or weight bearing status influenced DVT formation and whether skin graft healing was significantly improved by prolonged immobility. The overall incidence of DVT formation in our study was similar to the rate reported in the literature. We found no significant association of the examined risk factors with DVT formation. Prolonged immobilization did not significantly increase the incidence of DVT formation nor did it improve skin graft outcomes. 1. White RH. The Epidemiology of Venous Thromboembolism. Circulation 2003107:I4I8. 2. Geerts WH, Bergqvist D, Pineo GF, Heitt JA, Samama CM, Lassen MR, Colwell CW. Prevention of Venous Thromboembolism. Chest 2008133:381S453S 3. Thai L, McCarn K, Stott W, Watts T, Wax MK,Andersen PE, Gross ND. Venous Thromboembolism in Patients With Head and Neck Cancer After Surgery. Head Neck 201335(1):49. 4. Clayburgh DR, Stott W, CordieroT, Park R, Detwiller K, Buniel M, Flint P, Schindler J, Andersen P, Wax MK, Gross N. Prospective Study of VenousThromboembolism in Patients With Head and Neck Cancer After Surgery. JAMA Otolaryngol Head Neck Surg 2013139(11):11431150. 5. Hennessey P, Semenov YR, Gourin CG. The effect of deep venous thrombosis on short term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 2012122(10):2199 2204. 6. Bahl V, Shuman AG, Hu HM, Jackson CR, Pannucci CJ, Alaniz C, Chepeha DB, Bradford CR. Chemoprophylaxis for Venous Thromboembolism in Otolaryngology. JAMA Otolaryngol Head Neck Surg 2014140(11):9991005. 7. Hsu RY, Lareau CR, Born CT. Novel Posterior Splinting Technique toAvoid Heel Ulcers. Orthopedics 2013 36(1):3132. 8. CAM Walker Boot. http://www.alimed.com/camwalkerboots/ Immobilization <10 days Immobilization >= 10 days PValue N 60 36 Skin Graft Status Full Take 51 (85.0%) 25 (69.4%) Partial Take 9 (15.0%) 11 (30.6%) .07 Figure 2. Harvested osteocutaneous fibula free flap. Venous thromboembolism (VTE) is a common and potentially fatal complication in the postoperative period. The estimated overall incidence of VTE is 100 in 100,000 per year with pulmonary embolism (PE) accounting for one third of cases and deep vein thrombosis (DVT) accounting for two thirds [1]. Death occurs in an estimated 6% of DVT cases and 12% of PE cases within 1 month of diagnosis [1]. The risk of postoperative DVT is more than doubled in cancer patients compared to noncancer patients undergoing similar procedures [2]. Among head and neck cancer patients, the incidence of postoperative VTE has been reported between 1.4 and 5.8% [3]. Patients undergoing microvascular reconstruction are at even greater risk for DVT given major surgery, relative immobility, and the presence of malignancy. Development of DVT could have a significant impact on overall postoperative morbidity, potential mortality, length of stay, and hospital costs. To date, no studies have described the incidence of postoperative donor site DVT patients undergoing fibula free flap reconstruction. We sought to investigate whether prolonged immobilization predisposes patients to the development of DVTs. Further elucidation could potentially impact the management of patients undergoing fibula free flap reconstruction. Table 1. Immobilization and DVT outcomes. Immobilization <10 days Immobilization >=10 days PValue N 67 37 DVT Incidence No 65 (97%) 34 (91.9%) Yes 2 (2.99%) 3 (8.1%) .34 Figure 4. Controlled ankle motion boot 8 .
Transcript of AAO2016 SP118 Cheng AAO-HNS Poster 2016 UploadID · PDF fileIncidenceof Postoperative...
Incidence of Postoperative Donor Site Deep Vein Thrombosis in Fibula Free Flap ReconstructionEsther Cheng, MD1; Amy Pittman, MD1; Eric Thorpe, MD1
1Loyola University Medical Center
CONTACTEsther ChengLoyola University Medical Center2160 S 1st Ave, Maywood, IL 60153Email: [email protected]
ABSTRACTObjectives: To describe the incidence of deep vein thrombosis (DVT) in patients undergoing fibula free flap reconstruction. To analyze the effect of prolonged immobilization on DVT formation and skin graft healing.Methods: This was a retrospective review of 126 patients undergoing 130 fibula free flap procedures between 2007 and 2016 at Loyola University Medical Center. Patient demographics, select comorbidities, length of surgery, and discharge disposition were examined to determine risk factors associated with DVT formation. Patients were immobilized for either less than 10 days or greater than 10 days to promote skin graft healing. Patients who were immobilized for less than 10 days were non-‐weight bearing for that time period, whereas patients immobilized for greater than 10 days were full weight bearing on postoperative day one with a boot in place. Analysis was performed to determine whether immobilization or weight bearing status influenced DVT formation and whether skin graft healing was significantly improved by prolonged immobility. Results: Eight DVTs were detected in the study. Five of 8 were present in the donor leg. The overall clinical incidence of DVT in the donor leg was 3.84%. Three out of the 5 patients with donor leg DVTs were immobilized for a prolonged period of time. There was no significant difference in skin graft healing outcomes between patients immobilized for short versus long durations. There were no statistically significant risk factors associated with DVT formation.Conclusions: Prolonged immobilization did not significantly increase the incidence of DVT formation nor did it improve skin graft outcomes.
INTRODUCTION
DISCUSSION
RESULTS
Table 3. Associations between incidence of postoperative DVT and select comorbidities.
Table 2. Immobilization and skin graft outcomes.
Figure 1. Skin graft harvested from leg.
Figure 3. Posterior short leg splint7.
METHODS AND MATERIALS
CONCLUSIONS
REFERENCES
Eight DVTs were detected in the study. Five of the 8 were present in the donor leg. The overall clinical incidence of DVT in the donor leg was 3.84%. Three out of the 5 patients with donor leg DVTs were immobilized for a prolonged period of time (Table 1). There was no significant difference in the rate of DVT formation with respect to immobilization duration. In addition, there was no significant difference in skin graft healing outcomes between patients immobilized for short versus long durations (Table 2). There were no statistically significant risk factors associated with DVT formation (Table 3).
Venous thromboembolism causes significant morbidity and mortality postoperatively. It accounts for 10% of hospital deaths and leads to an increased risk for further complications including recurrent VTE, venous stasis, and complications related to long term anticoagulation. In addition, it adds to the length of hospital stay and inpatient costs. Clayburgh et al performed a prospective study of 100 patients undergoing H&N surgery and found a 13% incidence of VTE; however, only a portion of these patients received routine postoperative chemoprophylaxis. Participants were screened with duplex ultrasonography on postoperative day 2 or 3. Eight percent of the discovered DVTs were clinically significant meaning they required >6 weeks of anticoagulation but only 4% were symptomatic. This reported incidence is similar to our study. We concluded that there was no significant association of the examined risk factors with DVT formation. Initial weight bearing status did not significantly impact DVT formation. Prolonged immobilization itself did not significantly increase the incidence of donor leg DVT; however, skin graft outcomes did not improve with prolonged immobilization. This may lead to a change in practice to a shorter duration of immobilization.
This was a retrospective review of 126 patients undergoing 130 fibula free flap procedures between 2007 and 2016 at Loyola University Medical Center. Patient demographics, select comorbidities, length of surgery, and discharge disposition were examined to determine risk factors associated with DVT formation. Patients were immobilized for either less than 10 days or greater than 10 days to promote skin graft healing. Patients who were immobilized for less than 10 days were non-‐weight bearing for that time period, whereas patients immobilized for greater than 10 days were full weight bearing on postoperative day one with a boot in place. Analysis was performed to determine whether immobilization or weight bearing status influenced DVT formation and whether skin graft healing was significantly improved by prolonged immobility.
The overall incidence of DVT formation in our study was similar to the rate reported in the literature. We found no significant association of the examined risk factors with DVT formation. Prolonged immobilization did not significantly increase the incidence of DVT formation nor did it improve skin graft outcomes.
1. White RH. The Epidemiology of Venous Thromboembolism. Circulation 2003;;107:I-4-I-8.2. Geerts WH, Bergqvist D, Pineo GF, Heitt JA, Samama CM, Lassen MR, Colwell CW. Prevention of Venous Thromboembolism. Chest 2008;;133:381S-453S
3. Thai L, McCarn K, Stott W, Watts T, Wax MK, Andersen PE, Gross ND. Venous Thromboembolism in Patients With Head and Neck Cancer After Surgery. Head Neck2013;;35(1):4-9.
4. Clayburgh DR, Stott W, Cordiero T, Park R, Detwiller K, Buniel M, Flint P, Schindler J, Andersen P, Wax MK, Gross N. Prospective Study of Venous Thromboembolism in Patients With Head and Neck Cancer After Surgery. JAMA Otolaryngol Head Neck Surg2013;;139(11):1143-1150.
5. Hennessey P, Semenov YR, Gourin CG. The effect of deep venous thrombosis on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope2012;;122(10):2199- 2204.
6. Bahl V, Shuman AG, Hu HM, Jackson CR, Pannucci CJ, Alaniz C, Chepeha DB, Bradford CR. Chemoprophylaxis for Venous Thromboembolism in Otolaryngology. JAMA Otolaryngol Head Neck Surg 2014;;140(11):999-1005.
7. Hsu RY, Lareau CR, Born CT. Novel Posterior Splinting Technique to Avoid Heel Ulcers. Orthopedics 2013;; 36(1):31-32.
8. CAM Walker Boot. http://www.alimed.com/cam-walker-boots/
Immobilization <10 days
Immobilization >= 10 days P-‐Value
N 60 36Skin Graft StatusFull Take 51 (85.0%) 25 (69.4%)Partial Take 9 (15.0%) 11 (30.6%) .07
Figure 2. Harvested osteocutaneous fibula free flap.
Venous thromboembolism (VTE) is a common and potentially fatal complication in the postoperative period. The estimated overall incidence of VTE is 100 in 100,000 per year with pulmonary embolism (PE) accounting for one third of cases and deep vein thrombosis (DVT) accounting for two thirds [1]. Death occurs in an estimated 6% of DVT cases and 12% of PE cases within 1 month of diagnosis [1]. The risk of postoperative DVT is more than doubled in cancer patients compared to non-‐cancer patients undergoing similar procedures [2]. Among head and neck cancer patients, the incidence of postoperative VTE has been reported between 1.4 and 5.8% [3]. Patients undergoing microvascular reconstruction are at even greater risk for DVT given major surgery, relative immobility, and the presence of malignancy. Development of DVT could have a significant impact on overall postoperative morbidity, potential mortality, length of stay, and hospital costs. To date, no studies have described the incidence of postoperative donor site DVT patients undergoing fibula free flap reconstruction. We sought to investigate whether prolonged immobilization predisposes patients to the development of DVTs. Further elucidation could potentially impact the management of patients undergoing fibula free flap reconstruction.
Table 1. Immobilization and DVT outcomes.
Immobilization <10 days
Immobilization >=10 days P-‐Value
N 67 37DVT IncidenceNo 65 (97%) 34 (91.9%)Yes 2 (2.99%) 3 (8.1%) .34
Figure 4. Controlled ankle motionboot8.
