Chris A. Grant

Aggressive surgical treatment of oral and oropharyngeal cancers may be compromised by significant surgical complications. Early identification of patients at risk for postoperative complications may assist in clinical decision-making. The objective of this study was to assess the value of the Acute Physiology and Chronic Health Evaluation (APACHE II) score in predicting early postoperative surgical complications. There were 510 cases of free tissue transfer surgery identified on the Liverpool Oncology Head and Neck Database for 1995 to 2002. APACHE II data were collected independently from critical care records and by case note retrieval. The authors' main a priori outcomes were total flap failure and any immediate complication requiring further surgery (including any from hemorrhage, hematoma, partial flap failure, airways, and anastomosis exploration). Overall total flap loss and immediate complication rates were 6.2 percent (30 of 485) and 13.6 percent (66 of 485), respectively. APACHE II data were known for 399 operations (82 percent) and, of these, 90 percent (360 of 399) were managed postoperatively in the critical care unit. There were clear correlations between APACHE II scores with total flap loss and with other immediate complications. The APACHE II score is associated with immediate postoperative surgical complications involving flap compromise and thus may be a useful tool in postoperative decision-making.

Tracheo-innominate artery fistula (TIF) is an uncommon yet life threatening complication after a tracheostomy. Rates of 0.1–1% after surgical tracheostomy have been reported, with a peak incidence at 7–14 days post procedure. It is usually fatal unless treatment is instituted immediately. Initial case reports of TIF resulted from surgically performed tracheostomies. We present three fatalities attributable to TIF, confirmed by histopathology, after percutaneous dilatational tracheostomy (PDT). The use of PDT has resulted in tracheostomies being performed by specialists from different backgrounds and the incidence of this complication may be increasing. Pressure necrosis from high cuff pressure, mucosal trauma from malpositioned cannula tip, low tracheal incision, radiotherapy and prolonged intubation are all implicated in TIF formation. Massive haemorrhage occurring 3 days to 6 weeks after tracheostomy is a result of TIF until proven otherwise. We present a simple algorithm for management of this situation. The manoeuvres outlined will control bleeding in more than 80% of patients by a direct tamponade effect. Surgical stasis is obtained by debriding the innominate artery proximally, then transecting and closing the lumen. Neurological sequelae are few. Post-mortem diagnosis of TIF may be difficult, but specific pathology request should be made to assess innominate artery abnormalities.