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The effect of acute postoperative alcohol withdrawal (delirium tremens)
on fibular free flap survival.

The effect of acute postoperative alcohol withdrawal (delirium tremens) on fibular free flap survival.

1.
Lohr  KMedicare: A Strategy for Quality Assurance Washington, DC National Academy Press1990;
2.
Lang  NMMarek  KD The policy and politics of patient outcomes J Nurs Qual Assur. 1991;5 (2) 7- 12Article
3.
Tarlov  ARWare  JE  JrGreenfield  S  et al.  The Medical Outcomes Study: an application of methods for monitoring the results of medical care JAMA. 1989;262925- 930Article
4.
Urken  MLBuchbinder  DCostantino  PD  et al.  Oromandibular reconstruction using microvascular composite flaps: report of 210 cases Arch Otolaryngol Head Neck Surg. 1998;12446- 55Article
5.
Heinz  TRCowper  PALevin  LS Microsurgery costs and outcomes Plast Reconstr Surg. 1999;10489- 96Article
Citations 0
Original Article
October 2001

Acute Alcohol Withdrawal and Free Flap Mandibular Reconstruction Outcomes

Author Affiliations

From the Department of Otolaryngology–Head and Neck Surgery, Jefferson Medical College and Thomas Jefferson University Hospital/Jefferson Health System, Philadelphia, Pa.

 

From the Department of Otolaryngology–Head and Neck Surgery, Jefferson Medical College and Thomas Jefferson University Hospital/Jefferson Health System, Philadelphia, Pa.

Arch Facial Plast Surg. 2001;3(4):264-266. doi:
Abstract

Objective  To evaluate the effect of acute postoperative alcohol withdrawal on survival of vascularized fibular grafts for mandibular reconstruction.

Design  Retrospective case series of 17 consecutive patients.

Main Outcomes Measure  Relation between flap survival and alcohol withdrawal.

Results  Flap survival rate was 25% for patients who experienced delirium tremens and 85% in the other patients. Had all flaps in patients with postoperative alcohol withdrawal survived, the success rate would have been 89%. Flap loss was related to acute alcohol withdrawal (P = .02, χ2 analysis). The relationship between complication rate and alcohol withdrawal was also significant, using the Fisher exact test.

Conclusions  Fibular free flap reconstruction of the mandible is clearly cost-effective when it facilitates return to social function and productivity. In our experience, acute alcohol withdrawal in the first 72 hours after surgery is associated with a high incidence of flap loss. Therefore, we believe that patients at significant risk for alcohol withdrawal should undergo detoxification preoperatively. Society's economic return for investing in free flap reconstruction comes from minimizing convalescence and maximizing postoperative patient productivity. This return will not be realized for poorly selected patients. We are looking further into the effects of alcoholism on flap survival rates.

LITERATURE abounds on the definition of outcome. General acceptance of the "4 D's" of medical management (death, disease, disability, discomfort) has weakened in the face of ardent consumerism. Lohr1 cites function, satisfaction, and survival as more positive outcomes measures, whereas Lang and Marek2 describe 9 types of outcomes. These outcomes include psychosocial, physiological, behavioral, functional, quality-of-life, knowledge, resource utilization, financial, and satisfaction considerations. Tarlov et al3 offered 4 categories, including clinical end points (eg, laboratory values), functional status, general well-being, and satisfaction (in which category they place access, convenience, and physician coverage). As society's focus on the interface between socioeconomic factors and the cost of health care sharpens, we must address issues that relate patient behavior to clinical outcomes.

To date, no study has attempted to determine the effects of alcohol withdrawal syndrome on the success of mandibular reconstruction with vascularized fibula.

MATERIALS AND METHODS

We evaluated the medical records of 17 consecutive patients undergoing mandibular resection with fibular free flap reconstruction by one of us (D.R.). Defects ranged from 8 to 14 cm (mean, 11.3 cm). Nine defects were lateral and 8 included the anterior arch. Five patients had received prior radiation therapy. Nine patients had a history of regular employment, and 4 were nonsmokers and nondrinkers. Age ranged from 35 to 72 years. Twelve patients were male and 5 were female. Thirteen had squamous cell carcinoma (all stage IV), 2 had ameloblastoma, 1 had mucoepidermoid carcinoma, and 1 had osteoradionecrosis.

Medical records were reviewed for documentation of length of postoperative hospital stay, complications, route of nutrition at discharge, integrity of speech, need for nursing care on discharge, and return to work (if applicable).

RESULTS

Four of our patients developed acute alcohol withdrawal syndrome in the initial postoperative period. These patients required 12, 19, 21, and 22 days of postoperative hospitalization. Three of the 4 in this group had been unemployed before surgery. The fourth had been regularly and gainfully employed, but was found retrospectively to have been consuming several alcoholic beverages daily for years without attracting the attention of family or colleagues. Only one flap survived acute delirium tremens.

Eight of 9 patients who were gainfully employed returned to work, including the 1 employed patient who developed delirium tremens. These patients required an average of 14.4 postoperative weeks to return to work. The indication for surgery was squamous cell carcinoma in 5, ameloblastoma in 2, and mucoepidermoid carcinoma in 1.

All 6 patients who had been unemployed for quite some time had postoperative complications. Three of the 4 patients with alcohol withdrawal were in this group, and the flap survival rate was 33% (2/6). Two unemployed patients had retired after lives of active employment. Both were discharged from the hospital with the ability to eat using their mouth, and neither had postdischarge care requirements.

Flap survival in patients experiencing delirium tremens was 25%, whereas flap survival in the remaining group was 85% (Figure 1). Had all flaps in patients with alcohol withdrawal survived, the success rate would have been 89%. A χ2 analysis of data suggests a significant relationship between acute postoperative alcohol withdrawal and flap survival (P = .02). Our patients who experienced alcohol withdrawal syndrome had an average postoperative stay of 18.5 days compared with an average of 15.5 days for those not experiencing alcohol withdrawal, a relationship without statistical significance per the t test (P = .05).

Our patient group was otherwise similar to those in most prior published series on vascularized fibular reconstruction of the mandible. Average length of stay for patients with lateral defects was 12.3 days, whereas patients with anterolateral defects averaged 9.7 postoperative days to discharge. Patients with isolated anterior defects averaged 27 days to discharge. Cigarette smoking correlated moderately well with postoperative complications (correlation coefficient, 0.662) and length of stay (correlation coefficient, 0.588). Twelve of the 13 patients with squamous cell carcinoma as the indication for surgery smoked and drank. Delirium tremens developed in 4 of the 13 patients in the group who admitted to drinking alcoholic beverages. (The numerical discrepancy between total drinkers and drinkers with squamous cell carcinoma occurs because one patient required surgery for osteoradionecrosis but was tumor free following radiation therapy for prior squamous cell carcinoma.) One patient with squamous cell carcinoma was a nonsmoker and nondrinker by his history. Rates of smoking and drinking were not significantly different between the group that experienced alcohol withdrawal and the remaining patients.

The postoperative period to resumption of work averaged 14.4 weeks. However, the median was 8 weeks. The outliers were 2 and 3.2 SDs from the mean. One patient had undergone preoperative chemotherapy and radiation, whereas the other was one of the patients who experienced alcohol withdrawal and flap failure.

Nine employed patients had an average hospital stay of 12.4 days, whereas 8 unemployed patients had an average postoperative hospital stay of 20.3 days, a significant difference (P = .04) using the t test. Furthermore, 3 of the 4 patients who experienced alcohol withdrawal had been unemployed for a long duration preoperatively.

COMMENT

Urken et al4 reported that delirium tremens developed in 4 of 210 patients in their 1998 mandibular reconstruction series, with "prolonged hospital stays" required for these patients (although the reported flap survival rate is not stratified for delirium tremens). Alcohol withdrawal is anecdotally reported to complicate care in patients undergoing head and neck surgery, but no prior study attempts to relate reconstructive failure to alcohol withdrawal syndrome or other social phenomena, such as lifestyle. We observed that alcohol withdrawal syndrome seemed related causally to reconstructive failure in 75% of our patients so afflicted, although it did not correlate with prolonged length of postoperative hospital stay.

Our lack of strong correlation between cigarette smoking and postoperative complications is consistent with the findings of Heinz et al5 in 18 patients with head and neck cancer who were undergoing free flap reconstruction. Unfortunately, those of our patients who smoked also drank alcoholic beverages. Therefore, the same statistic applies to that association as well, making it impossible to stratify for either factor alone in our group. Neither smoking nor drinking rates differed between the alcohol withdrawal group and the other patients. A correlation between long-term unemployment and delirium tremens was just shy of significance (P = .053, Fisher exact test).

CONCLUSIONS

Reconstruction of the mandible with vascularized fibular flap is a reliable and cost-effective management method for patients not at risk for alcohol withdrawal syndrome. Acute postoperative alcohol withdrawal was associated with a high incidence of failure of vascularized fibular free flaps in our series. Patients should undergo active detoxification from alcohol before surgery, even if this requires residential observation in a treatment facility. The cost of complications related to delirium tremens is high for patients with free flaps, and detoxification is probably less costly than the management of patients in whom reconstruction fails. We are undertaking a large-scale study of this problem.

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Article Information

Accepted for publication August 21, 2000.

Presented at the 1998 Annual Meeting of the American Academy of Facial Plastic and Reconstructive Surgery, San Antonio, Tex, September 10, 1998.

Corresponding author: David Reiter, MD, DMD, PO Box 770, Narberth, PA 19072 (e-mail: david.reiter@mail.tju.edu).

References
1.
Lohr  KMedicare: A Strategy for Quality Assurance Washington, DC National Academy Press1990;
2.
Lang  NMMarek  KD The policy and politics of patient outcomes J Nurs Qual Assur. 1991;5 (2) 7- 12Article
3.
Tarlov  ARWare  JE  JrGreenfield  S  et al.  The Medical Outcomes Study: an application of methods for monitoring the results of medical care JAMA. 1989;262925- 930Article
4.
Urken  MLBuchbinder  DCostantino  PD  et al.  Oromandibular reconstruction using microvascular composite flaps: report of 210 cases Arch Otolaryngol Head Neck Surg. 1998;12446- 55Article
5.
Heinz  TRCowper  PALevin  LS Microsurgery costs and outcomes Plast Reconstr Surg. 1999;10489- 96Article
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