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Does anticoagulation improve outcomes of microvascular free flap reconstruction following head and neck surgery: A Systematic Review and Meta-Analysis

Published:September 16, 2022DOI:https://doi.org/10.1016/j.bjoms.2022.07.016

      Abstract

      Background

      The commonest cause of microvascular free flap failure is thrombosis at the anastomosis. Pharmacological anti-thrombotic therapies have been used to mitigate this risk, but they carry the risk of bleeding and haematoma formation. To justify any intervention, it is necessary to evaluate the benefits and balance of risks. This meta-analysis aims to quantify the value of systemic anticoagulation during head and neck free tissue reconstruction.

      Methods

      We performed a systematic review on the impact of additional prophylactic anti-thrombotic therapy on H&N free tissue transfer (on top and above the low molecular weight heparin use to prevent DVT). We carried a PRISMA-guided literature review, following registration with PROSPERO. All studies analysing the possible impact of prophylactic anticoagulants on free flap surgery in the head and neck were eligible. The primary outcome was peri-operative free flap complications (peri-operative thrombosis, partial or total free flap failure, thrombo-embolic events, or re-exploration of anastomosis). Secondary outcomes included haematoma formation or bleeding complications requiring further intervention.

      Results

      We identified 8 eligible studies out of 454. These included 3531 free flaps for H&N reconstruction. None of the assessed interventions demonstrated a statistically significant improvement in free flap outcomes. Accumulative analysis of all anti-coagulated groups demonstrated an increased relative risk of free flap complications [RR 1.54 (0.73-3.23)] compared to control albeit not statistically significant (p=0.25). Pooled analysis from the included studies showed that the prophylactic use of therapeutic doses of anticoagulants significantly (p=0.003) increased the risk of haematoma and bleeding requiring intervention [RR 2.98 (1.47-6.07)], without reducing the risk of free flap failure.

      Conclusion

      Additional anticoagulation does not reduce the incidence of free flap thrombosis and failure. Unfractionated heparin consistently increased the risk of free flap complications. The use of additional anticoagulation as “prophylaxis” in the peri-operative setting, increases the risk of haematoma and bleeding.

      Keywords

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