Reconstruction of the oral cavity after a Commando procedure

Abstract

Nakon Commando operacije zaostaje opsežan defekt u usnoj šupljini koja je iznimno zahtjevno područje za rekonstrukciju. Potrebno je, uz uspostavljanje strukturnog integriteta te funkcija žvakanja, gutanja i govora, maksimizirati i estetski učinak. Ključan korak za postizanje povoljnog ishoda jest pravilan odabir rekonstrukcijske metode. Najčešće se koriste regionalni ili slobodni režnjevi, iako se potonji danas smatraju „zlatnim standardom“ u rekonstrukciji usne šupljine. Svrha ove studije bila je usporediti ishod rekonstrukcije usne šupljine s četiri metode: primarno zatvaranje, lokalni režnjevi, regionalni režnjevi i slobodni režnjevi. Nadalje, cilj je bio odrediti indikacije za pojedinu metodu i procijeniti opravdanost upotrebe pektoralnog režnja. U istraživanje su bili uključeni svi bolesnici kojima je Commando operacija učinjena zbog primarnog planocelularnog karcinoma u razdoblju od 5 godina. Analizirane su demografija bolesnika i karakteristike tumora te prikazane 4 rekonstrukcijske metode. U istraživanje je bilo uključeno 157 bolesnika od koji su 131 muškarci (83%) i 26 žene (17%). Prosjek dobi bio je 58,6 godina (±10,1), a prosjek duljine hospitalizacije: 25,9 dana (±15,5). Učestalost konzumiranja duhanskih i alkoholnih proizvoda bila je, očekivano, visoka (89% i 77%). Bio je primijenjen 121 režanj u 114 bolesnika, a u 43 bolesnika defekt je bio primarno zatvoren. Bolesnici s primarnim zatvaranjem bili su najlošijeg općeg zdravstvenog stanja, ali su u toj skupini karcinomi T3 i T4 stadija bili najmanje zastupljeni. U grupi lokalnih režnjeva, demografija bolesnika (osim dobi) i karakteristike tumora, bile su najpovoljnije, te u toj skupini nije bilo nekroza režnja ni komplikacija. U grupi regionalnih režnjeva, demografija bolesnika i karakteristike tumora bile su nepovoljnije nego u slobodnih režnjeva. Najveća učestalost komplikacija primijećena je u skupini slobodnih režnjeva (31%) dok je kod regionalnih režnjeva iznosila 29%. Stopa nekroza režnja je, također, bila najveća u slobodnih režnjeva, 6% djelomičnih i 8% potpunih nekroza. Kod regionalnih režnjeva nije bilo potpunih nekroza, a stopa djelomičnih je iznosila 6%. Kao najrizičniji čimbenici za komplikacije smatraju se komorbiditet, duljina anestezije i T stadij karcinoma. Iz rezultata ovog istraživanja zaključuje se da su regionalni režnjevi, prvenstveno pectoralis major, još uvijek važna i sigurna metoda za pacijente s većim rizikom od komplikacija. Slobodni režnjevi, međutim, što zbog medicinskih što zbog ekonomskih razloga, sve rjeđe dolaze u prvi plan, osobito za rizičnije pacijente.Commando procedure leaves a complex defect in the oral cavity which is an exceptionally difficult area for reconstruction. Restoring structural integrity, functions of chewing, swallowing and speaking and maximizing the esthetic effect is required. The key step in acheiving a satisfactory outcome is the right choice of the reconstructive method. Regional and free flaps are most commonly used. Free flaps are considered to be a „gold standard“ in head and neck reconstruction today. The purpose of this study was to compare the outcome of oral cavity reconstruction by four different reconstructive methods: primary closure, local flaps, regional flaps and free flaps. Furthermore, the goal was to determine the indications for a specific method and to evaluate the validity of using a pectoral flap. All patients who underwent commando procedure for a primary Squamous cell carcinoma in a period of five years were enrolled. Patient demographics and tumor characteristics were analyzed and shown through four methods of reconstruction. The study was comprised of 131 men (83%) and 26 women (17%). The mean of age was 58,6 years (±10,1) and of post-operative stay 25,9 days (±15,5). Smoking and alcohol consumption were expectedly high (89% and 77%). Flaps were used in 121 cases and primary closure in 43 cases. Patients with primary closure were of poorest health but T3 and T4 stage tumors were rarest in that group. Demographics (except age) and tumor characteristics were the most favourable in patients with local flaps. There were no complications or necroses in that group. Complication rate was largest in free flap group (31%) while it amounted to 29% in regional flaps Necrosis rate was also largest in free flaps, 6% for partial and 8% for total necrosis. No total necroses were registered in regional flaps, and partial necrosis rate was 6%. Patient demographics and tumor characteristics were less favourable in regional flaps. Comorbidities, operation length and T stage are considered to be most risky factors for complications. Comparing the results of this study with a string of other studies, it was concluded that regional flaps, primarily the Pectoralis major flap, are still an important and safe method for patients at greater risk of complications. Free flaps, however, are recently being less favoured, partly due to medical, partly economical reasons, especially in patients at greater risk of complications