gms | German Medical Science

GMS German Plastic, Reconstructive and Aesthetic Surgery – Burn and Hand Surgery

Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC)
Deutsche Gesellschaft für Verbrennungsmedizin (DGV)

ISSN 2193-7052

Retrospective analysis of free flaps in elderly patients over 80 years in terms of outcome and complications

Retrospektive Analyse freier Lappenplastiken bei geriatrischen Patienten über 80 Jahren im Hinblick auf Outcome und Komplikationen

Extended Abstract Best Abstract Award DGPRÄC 2015

  • corresponding author Matthias Wähmann - Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG-Klinik Ludwigshafen, Klinik für Plastische und Handchirurgie der Universität Heidelberg, Ludwigshafen, Germany
  • Melodie Rahimi - Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG-Klinik Ludwigshafen, Klinik für Plastische und Handchirurgie der Universität Heidelberg, Ludwigshafen, Germany
  • Leila Harhaus - Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG-Klinik Ludwigshafen, Klinik für Plastische und Handchirurgie der Universität Heidelberg, Ludwigshafen, Germany
  • Thomas Kremer - Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG-Klinik Ludwigshafen, Klinik für Plastische und Handchirurgie der Universität Heidelberg, Ludwigshafen, Germany
  • Ulrich Kneser - Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG-Klinik Ludwigshafen, Klinik für Plastische und Handchirurgie der Universität Heidelberg, Ludwigshafen, Germany

GMS Ger Plast Reconstr Aesthet Surg 2016;6:Doc07

doi: 10.3205/gpras000042, urn:nbn:de:0183-gpras0000420

Published: September 29, 2016

© 2016 Wähmann et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.


Introduction

Health-care improvements and subsequently longer life expectancy lead to an increasing number of geriatric patients undergoing surgical procedures.

Overall, surgical treatment in elderly patients is challenging because of higher comorbidity rates when compared to a younger patient cohort. Comorbidities and reduced physical reserves are constantly identified as major predictors of poor postoperative outcome in this population [1].

Age-related diseases such as diabetes, atherosclerosis, and osteoporosis with resulting fractures as well as malignancies lead to an increased number of elderly patients suffering from soft tissue defects.

Surgical decision making in these patients is different from other cohorts. The question whether to perform major amputations or to undertake reconstructive attempts using microsurgical techniques should be guided by aspects such as patient safety and quality of life.

It is well known that major amputations at the lower extremity are associated with significant early and late morbidity and mortality rates [2]. Microsurgical reconstruction has been established as a gold standard for the treatment of soft tissue defects [3], [4]. Recent studies additionally provided evidence that microsurgical free flap transfer to the lower extremity is safe in elderly patients [5]. However, most of the studies focusing on elderly patients did not evaluate the subset of very old patients of more than 80 years [6], [7]. Therefore the aim of our study was to evaluate outcome of microsurgical reconstructions with free flaps in patients with soft tissue defects in this super old cohort.


Materials and methods

All patients who underwent a free-tissue transfer at BG Trauma Center Ludwigshafen in a period of eight years were evaluated retrospectively. Microsurgical techniques are standardized procedures in our unit and are performed according to established international standards [8]. Most developed world countries have accepted the chronological age of 60 or 65 years as a definition of an older person [9]. Therefore, we evaluated two different age-groups in our patients. Cohort 1 (very old) was defined as patients of more than 80 years and patients between 65 and 80 years were included in cohort 2 (old). Epidemiologic data and relevant comorbidities such as diabetes, cardiac diseases, peripheral arterial occlusion disease and renal insufficiency were recorded.

Further clinical data were also analyzed and provided: Etiology and localization of the defect, types of free flaps, operation time, postoperative stay on intensive care units (ICU), hospitalization time, general and surgical morbidity (arterial or venous thrombosis) and loss of free flaps as well as mortality within 30 days.


Results

In both cohorts a total of almost 200 free flaps were performed. The oldest patient was over 90 years old. Male patients were more frequently observed in cohort 2 when compared to older patients (cohort 1). The etiology of the defects was not significantly different between the two groups: Proportionate to the focus of our unit, most defects resulted from trauma followed by oncologic defects. The free anterolateral thigh flap (ALT) was most frequently used in both cohorts. Most of the patients in cohort 1 were observed with at least one relevant comorbidity. ICU-admissions were significantly more frequent in cohort 1.

Interestingly, morbidity rates were even lower in patients over 80 years when compared to the younger cohort. Likewise, a trend towards lower free flap failures rates (5%) was observed in cohort 1 when compared to younger patients (p>.05) More non-surgical complications such as postoperative delirium have been observed in cohort 1. The average hospital stay was even shorter in cohort 1 than in cohort 2 but this difference was not significant. The evaluation of clinical data showed a low overall mortality rate under 1% in both cohorts.


Discussion

Recent studies showed that advanced age is not a stand-alone exclusion criterion for surgical referral or treatment [10]. But it is generally important to analyze the individual risk profile of each patient concerning microsurgical-related comorbidities. Cases of reconstructive failure occurred frequently in elderly patients in the setting of peripheral vascular disease [11]. Patients with peripheral arterial occlusion disease should be evaluated regarding preoperative improvement of the vascular system. Clinical data showed a higher risk of general complications like postoperative delirium or cardiac problems. Therefore postoperative referral to an ICU might be indicated in selected patients.

The relevance of frailty as an independent risk factor for adverse postoperative outcomes is currently being demonstrated by different groups. We therefore hypothesize that assessment of frailty in elderly patients that require microsurgical free tissue transfer for extremity salvage will allow adequate patient selection and treatment of comorbidities. This will eventually improve postoperative prognosis and functional outcome [12].


Conclusion

Free-tissue transfer as a therapy concept is not contraindicated in geriatric patients over 80 years even in cases of microsurgical-relevant comorbidities. High technical expertise as well as an optimal perioperative setting are required for these patients.

Microsurgical reconstruction provides a reliable surgical treatment option with no increased risk of surgical complications or mortality rate compared to younger patients.


Competing interests

The authors declare that they have no competing interests.


Note

At the 46th meeting of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) the corresponding abstract [13] was awarded “Best Abstract”. The society highlighted the best abstract submissions with this award in 2015. The publication of the extended abstract in GMS German Plastic, Reconstructive and Aesthetic Surgery – Burn and Hand Surgery was sponsored by “Amryt Pharma”.


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