Perioperative management of patients undergoing major reconstructive head and neck surgery
Persson, Karolina LU
(2025)
In Lund University, Faculty of Medicine Doctoral Dissertation Series
- Abstract
- Abstract: For patients with locally advanced head and neck tumours or other defects, the preferred curative treatment is extensive reconstructive surgery using free microvascular flap(s), oftentimes followed by postoperative radiotherapy. The procedure offers superior functional and aesthetic advantages, but the treatment course is long and complex and burdened with a significant risk of complications. The aim of this thesis is to address certain key perioperative aspects, with the extended objective of reducing complications
and improving the quality of care for head and neck reconstructive surgery patients.
Paper I evaluated the use of a continuous popliteal nerve block for patients undergoing head and neck surgery with... (More) - Abstract: For patients with locally advanced head and neck tumours or other defects, the preferred curative treatment is extensive reconstructive surgery using free microvascular flap(s), oftentimes followed by postoperative radiotherapy. The procedure offers superior functional and aesthetic advantages, but the treatment course is long and complex and burdened with a significant risk of complications. The aim of this thesis is to address certain key perioperative aspects, with the extended objective of reducing complications
and improving the quality of care for head and neck reconstructive surgery patients.
Paper I evaluated the use of a continuous popliteal nerve block for patients undergoing head and neck surgery with reconstruction using a fibular graft. This prospective, double-blind trial included 24 patients randomised to receive an infusion of local anaesthetic or placebo during the first postoperative week. Results showed that patients in the local anaesthetic group had significantly fewer episodes of severe pain and a nearly halved opioid consumption during the study period, compared to patients in the placebo group. These results have led to the incorporation of popliteal nerve blocks into the local treatment protocol for this patient group.
In paper II focus was on preoperative risk prediction of perioperative complications. A retrospective review of medical records was conducted, including 388 patients. Uni- and multivariable regression analyses were
performed to establish associations between biochemical and physiological parameters and serious medical and flap-related complications. In addition, several risk prediction instruments were evaluated. Results showed that longer duration of surgery and perioperative red blood cell transfusion were factors associated with flap compromise. For medical complications, several of the risk prediction instruments showed a strong association, as did lower preoperative albumin levels.
Paper III was a prospective observational study of haemostasis during surgery and the first postoperative week in 39 patients undergoing head and neck reconstructive surgery. Conventional routine coagulation tests, such as prothrombin time (PT-INR), activated partial thromboplastin time (APTT), and platelet count, showed tendencies toward impaired haemostasis, while more advanced tests, such as rotational thromboelastometry (ROTEM) and anticoagulant factor activity, indicated an enhanced haemostatic capacity. From these inconsistent results, the conclusion was drawn that conventional analyses are insufficient to monitor haemostasis during the complex perioperative course for this patient group.
In paper IV the same patient cohort was studied as in paper III, but with focus on vitamin K, which, in addition to haemostasis, is involved in several other physiological processes. Vitamin K-dependent proteins (VKDPs), formed as a result of vitamin K deficiency, are implicated in, among others, vascular calcification, inflammation and carcinogenesis. However, very little is known about the profile and functions of VKDPs in head and neck cancer patients and free flap surgery. The results from this prospective, descriptive study showed increased protein induced by vitamin K absence/antagonist-II (PIVKA-II), as a sign of subclinical vitamin K deficiency, and a rise in growth-arrest specific gene 6 (Gas6), potentially as an acute-phase reaction to the surgical trauma.
Limitations of the studies in the thesis include a limited number of patients, and an, in some respects, heterogeneous study population. The retrospective design in paper II also limits the ability to establish causal relationships. However, the results contribute to a broader knowledge in several key areas of perioperative
management of patients undergoing major reconstructive head and neck surgery. Paper I establishes safety and efficacy of popliteal blocks for fibular graft harvest, and paper II highlights important aspects of preoperative risk assessment. The exploratory nature of papers III and IV can aid further studies on haemostasis and vitamin K physiology. (Less)
Please use this url to cite or link to this publication:
https://lup.lub.lu.se/record/61a1eae2-8d8c-45eb-845e-07af921973ba
- author
- Persson, Karolina
LU
- supervisor
- opponent
-
- Associate Professor Frykholm, Peter, Department of Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
- organization
- publishing date
- 2025
- type
- Thesis
- publication status
- published
- subject
- keywords
- Perioperative care, Perioperative risk management, Perioperative complications, Head and neck cancer, Microvascular free flaps, Haemostasis, Coagulation, Vitamin K, PIVKA-II, Gas6, dp-uc-MGP, Reconstructive surgery, Free Tissue Flaps
- in
- Lund University, Faculty of Medicine Doctoral Dissertation Series
- issue
- 2025:127
- pages
- 87 pages
- publisher
- Lund University, Faculty of Medicine
- defense location
- Belfragesalen, BMC D15, Klinikgatan 32 i Lund
- defense date
- 2025-11-21 09:00:00
- ISSN
- 1652-8220
- ISBN
- 978-91-8021-780-4
- language
- English
- LU publication?
- yes
- id
- 61a1eae2-8d8c-45eb-845e-07af921973ba
- date added to LUP
- 2025-10-29 10:26:50
- date last changed
- 2025-10-31 09:06:58
@phdthesis{61a1eae2-8d8c-45eb-845e-07af921973ba,
abstract = {{Abstract: For patients with locally advanced head and neck tumours or other defects, the preferred curative treatment is extensive reconstructive surgery using free microvascular flap(s), oftentimes followed by postoperative radiotherapy. The procedure offers superior functional and aesthetic advantages, but the treatment course is long and complex and burdened with a significant risk of complications. The aim of this thesis is to address certain key perioperative aspects, with the extended objective of reducing complications<br/>and improving the quality of care for head and neck reconstructive surgery patients.<br/>Paper I evaluated the use of a continuous popliteal nerve block for patients undergoing head and neck surgery with reconstruction using a fibular graft. This prospective, double-blind trial included 24 patients randomised to receive an infusion of local anaesthetic or placebo during the first postoperative week. Results showed that patients in the local anaesthetic group had significantly fewer episodes of severe pain and a nearly halved opioid consumption during the study period, compared to patients in the placebo group. These results have led to the incorporation of popliteal nerve blocks into the local treatment protocol for this patient group. <br/>In paper II focus was on preoperative risk prediction of perioperative complications. A retrospective review of medical records was conducted, including 388 patients. Uni- and multivariable regression analyses were<br/>performed to establish associations between biochemical and physiological parameters and serious medical and flap-related complications. In addition, several risk prediction instruments were evaluated. Results showed that longer duration of surgery and perioperative red blood cell transfusion were factors associated with flap compromise. For medical complications, several of the risk prediction instruments showed a strong association, as did lower preoperative albumin levels. <br/>Paper III was a prospective observational study of haemostasis during surgery and the first postoperative week in 39 patients undergoing head and neck reconstructive surgery. Conventional routine coagulation tests, such as prothrombin time (PT-INR), activated partial thromboplastin time (APTT), and platelet count, showed tendencies toward impaired haemostasis, while more advanced tests, such as rotational thromboelastometry (ROTEM) and anticoagulant factor activity, indicated an enhanced haemostatic capacity. From these inconsistent results, the conclusion was drawn that conventional analyses are insufficient to monitor haemostasis during the complex perioperative course for this patient group.<br/>In paper IV the same patient cohort was studied as in paper III, but with focus on vitamin K, which, in addition to haemostasis, is involved in several other physiological processes. Vitamin K-dependent proteins (VKDPs), formed as a result of vitamin K deficiency, are implicated in, among others, vascular calcification, inflammation and carcinogenesis. However, very little is known about the profile and functions of VKDPs in head and neck cancer patients and free flap surgery. The results from this prospective, descriptive study showed increased protein induced by vitamin K absence/antagonist-II (PIVKA-II), as a sign of subclinical vitamin K deficiency, and a rise in growth-arrest specific gene 6 (Gas6), potentially as an acute-phase reaction to the surgical trauma.<br/>Limitations of the studies in the thesis include a limited number of patients, and an, in some respects, heterogeneous study population. The retrospective design in paper II also limits the ability to establish causal relationships. However, the results contribute to a broader knowledge in several key areas of perioperative<br/>management of patients undergoing major reconstructive head and neck surgery. Paper I establishes safety and efficacy of popliteal blocks for fibular graft harvest, and paper II highlights important aspects of preoperative risk assessment. The exploratory nature of papers III and IV can aid further studies on haemostasis and vitamin K physiology.}},
author = {{Persson, Karolina}},
isbn = {{978-91-8021-780-4}},
issn = {{1652-8220}},
keywords = {{Perioperative care; Perioperative risk management; Perioperative complications; Head and neck cancer; Microvascular free flaps; Haemostasis; Coagulation; Vitamin K; PIVKA-II; Gas6; dp-uc-MGP; Reconstructive surgery; Free Tissue Flaps}},
language = {{eng}},
number = {{2025:127}},
publisher = {{Lund University, Faculty of Medicine}},
school = {{Lund University}},
series = {{Lund University, Faculty of Medicine Doctoral Dissertation Series}},
title = {{Perioperative management of patients undergoing major reconstructive head and neck surgery}},
url = {{https://lup.lub.lu.se/search/files/231648582/Doctoral_Thesis_Public_Karolina_Persson.pdf}},
year = {{2025}},
}