Improving the peri-operative management of patients undergoing free tissue transfer for head and neck malignancy
Abstract The cohort of patients with oral malignancy is typically of advanced age with significant comorbidity. The causative factors for such malignancies, such as tobacco and alcohol, are also those which result in cardiovascular disease. As a result patients undergoing ablative and reconstructive surgery, with free tissue transfer, are at considerable risk of peri-operative morbidity and mortality from both primary and secondary disease. Free flap failure has a significant impact upon patient outcome, with resultant delayed discharge, and increased morbidity and mortality. By optimising co-morbidity and peri-operative factors such as fluid balance, nutrition, coagulation and blood pressure support, the complications of complex surgery are reduced. The collective objectives of this thesis were to determine methods, by both routine and novel approaches, to enhance patient care following ablative and reconstructive surgery for head and neck malignancy. As a result of these investigations, fluid optimisation with LiDCO monitoring, which derives stroke volume from the blood pressure waveform, is advocated in patients undergoing ablative and reconstructive surgery. Peri-operatively when blood pressure cannot be maintained with fluids alone and pressor support is required, low dose noradrenaline is considered the optimal agent in view of the improvements in flap perfusion and reliable elevation of mean arterial pressure. Careful anticoagulation prescribing should be undertaken, with anti-Xa monitoring of low molecular weight heparin to ensure adequate response, in combination with thromboelastography to identify patients most at risk of thrombotic flap complications. This thesis has made original contributions to the literature in the peri-operative management of patients undergoing free tissue transfer following ablative surgery for head and neck malignancy in terms of pressor support, coagulation, nutrition, fluid management and hospital admission route. Collectively these recommendations may improve patient outcome with significant long term benefits for both patients and the NHS.
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