Sunday, October 10, 2004

Incidence of Peri-operative Complications Following Microsurgical Reconstruction of 211 Septuagenarians and Octogenarians

Babak J. Mehrara, MD, Michael A. Howard, MD, William Samson, MD, Peter G. Cordeiro, MD, FACS, Joseph J. Disa, MD, and Robin Schoelle, PA.

INTRODUCTION: There are an increasing number > 70 year old patients requiring free tissue transfer. The definition of elderly is subjective. Limited series of reports exist of complications in “elderly” patients greater than age 60, however, the complications and mortality have not been systematically analyzed in a large series. The purpose of this study was to review our experience with free tissue transfer in patients >70 years old.

METHODS: This was a retrospective review of all free tissue transfers performed at a tertiary care cancer center between 1993 and 2004. All patients who were >70 years old were identified. Medical records and a prospectively maintained database were analyzed with respect to co-morbidities and postoperative complications. Univariate and multivariate analysis was performed to evaluate predictors of surgical and medical complications.

RESULTS: Twenty-seven (27) patients over age 80 and 184 patients aged 70 to 79 were identified. The octogenarian and septuagenarian groups were similar in their predominance of head and neck surgery (89% and 93%), average time under anesthesia (11 and 9.9 hours), hospitalization (19.5 and 18.8 days). Flap survival was 100% in the 80 yo and 97% in 70 yo. The overall complication rate was 59.3% in the 80 yo group and 30.4% in the 70 yo group (p<.01). Peri-operative death occurred in five octogenarians (18.5%; 1 intraoperative death) and 11 septuagenarians (6%, p=0.03). All deaths were due to cardiovascular and/or respiratory arrest except for one death due to carotid rupture. Fifteen of 27 octogenarians and 97 of 184 septuagenarians died during the study follow-up period (avg. survival time = 1.1 +/- 1.5 years and 2.0 +/- 2.5 years).

Univariate analysis of the octogenarian subgroup failed to identify any independent predictors of postoperative complications. Multivariate analysis, however, demonstrated that the combination of 2 or more of the following: alcohol use, diabetes, hypertension, and pulmonary disease were significantly associated with the occurrence of complications (p=0.03). There was a trend towards statistical significance for the influence of ASA status on the occurrence of complications (p=.08). In this series, ASA status was more predictive of perioperative outcome than more complex indices such as the Charlson score.

DISCUSSION: In summary, free tissue transfer may be performed in 70 and 80 year old patients with a high degree of technical success. The procedure carries an increased risk of peri-operative mortality and morbidity particularly in patients over the age of 80. These risks are even further increased as the number of comorbid conditions increase. This review suggests that prolonged survival may be achieved in some patients; however, a highly selective approach is required in the octogenarian reconstruction population.

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