Oral And Maxillofacial Surgery In Patients Undergoing .
Mochizuki et al. BMC Oral Health(2018) E REPORTOpen AccessOral and maxillofacial surgery in patientsundergoing dialysis for advanced renaldisease: report of five casesYumi Mochizuki1*, Hiroyuki Harada1, Misaki Yokokawa1, Naoya Kinoshita1, Kazumasa Kubota2,Tomokazu Okado3 and Haruhisa Fukayama4AbstractBackground: Perioperativemanagement of hemodialysis patients involves many difficulties. High mortality rate andcirculatory or respiratory complications in these patients were reported. However, in such reports, there is no concreteinformation of perioperative management in hemodialysis patients to prevent surgical complications and successfuloutcomes.Case presentation: We retrospectively reviewed the cases of 5 hemodialysis patients who underwent oral surgeryunder general anesthesia between January 2005 and December 2017.Primary disease was oral squamous cell carcinoma (SCC) in 4 patients and mandibular ameloblastoma in 1 patient.Partial resection was performed in 2 cases, neck dissection in 1 case. Two cases underwent surgery includingvascularized reconstruction. The patients were dialyzed the day before and after surgery for the control of fluid andelectrolyte status. Patients received intraoperative and postoperative intravenous infusion of potassium-free solution at20–40 mL/h. Erythropoiesis-stimulating agents (ESAs) were used on the day of hemodialysis during hospitalization.Nafamostat mesilate as an anticoagulant during hemodialysis were used from postoperative day (POD)1 to 7. FromPOD 1 to 10, cephalosporin as prophylactic antibiotics is adjusted to quarter from half the initial dose. The resumingtime of oral intake was similar to that of other oral surgery patients without kidney disease. The daily intake limits ofprotein, salt and liquid were managed during hospitalization and no cases suffered from malnutrition. Nocardiorespiratory complications occurred during the perioperative period. In a case of vascularized osteocutaneousscapular flap reconstruction, grafted scapular bone survived and scapular cutaneous flap necrotized. Necrotic tissue wasdebrided and split thickness skin was successfully used to cover the grafted scapular bone.Conclusions: Postoperative better result could be achieved if adequate perioperative management specific tohemodialysis patients is carried out. Vascularized flap reconstruction at oral and maxillofacial region in hemodialysispatients is beneficial treatment. Even if the first flap has wound complication secondary flap reconstruction is successand aesthetically better results could be achieved by the strict wound management and debridement.Keywords: Hemodialysis, Chronic renal disease, Oral surgery, Vascularized flap reconstruction, Bone reconstruction,Surgical complication* Correspondence: mochizuki.osur@tmd.ac.jp1Department of Oral and Maxillofacial Surgery, Graduate School, TokyoMedical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549,JapanFull list of author information is available at the end of the article The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.
Mochizuki et al. BMC Oral Health(2018) 18:166BackgroundIn Japan, the number of patients on dialysis is increasingevery year, reaching 314,000 at the end of 2013, threetimes the number 20 years earlier [1]. Given the growingnumber of dialysis patients, it is expected that the number of such patients undergoing surgical resection fororal disease will likewise increase.Surgery and management of dialysis patients carries ahigh risk of complications, higher mortality rate, and require careful perioperative management [2–5].There are some recent clinical studies about the headand neck surgeries in hemodialysis patients [2, 3, 5].They suggested the mortality rate and circulatory or respiratory complications are high in these patients. However, in such reports, there is no concrete information ofperioperative management in hemodialysis patients toprevent surgical complications and successful outcomes.ObjectiveWe retrospectively reviewed the cases of 5758 patientswho underwent oral surgery under general anesthesia atour department between January 2005 and December2017. Among these cases, 5 patients were receivinghemodialysis. In this study, we evaluated the perioperativemanagement and outcomes of oral surgeries, includingvascularized bone or flap reconstructions, in patientsundergoing hemodialysis. We discuss and suggest the specific and successful management of oral surgeries including vascularized bone or flap reconstructions in dialysispatients.Case presentationPatients’ summary were showed in Table 1Case 1A 28 year-old man was referred to our departmentfor the treatment of tongue carcinoma. The etiologyof dialysis-dependent end-stage kidney disease wasAlport’s syndrome and the duration of hemodialysistreatment was 7 years and 9 months. His history included hypertension and anemia. No metastatic lymphnode was palpable in the cervical region and the clinical diagnosis was tongue cancer. Partial glossectomywas performed (surgical time; 47 min (min), intraoperative bleeding loss volume; 63 ml). Intravenoussecond-generation cephalosporin 0.5 g was administrated just before the surgery. Intraoperative intravenous infusion volume of potassium-free solution was200 mL (mean infusion speed at 20–40 mL/h). Routine hemodialysis was scheduled for 2 days before andafter surgery, and then 3 times a week. We discussed patients’ conditions and perioperative dialysis managementwith nephrologists once a week during hospitalization.Erythropoiesis-stimulating agents (ESAs) were used onthe day of hemodialysis during hospitalization. NafamostatPage 2 of 10mesilate as an anticoagulant during hemodialysis was usedfrom POD 1 to 7. From POD 1 to 5, thesecond-generation cephalosporin (0.5 g once daily intravenously) and the third-generation cephalosporin (0.2 gonce daily per mouth) during POD 6 to 10 were administered. The healing process was uneventful and oral intakewas resumed on POD 5. Daily limits of protein intake, saltintake, and liquid intake were 70 g, 7 g and 500 mL, respectively. The pathological diagnosis of surgical specimenwas squamous cell carcinoma (SCC). No adjuvant therapywas performed. The patient was free of the disease 13 yearsafter surgery.Case 2A 37-year-old man, initially treated with partial glossectomy for tongue SCC, was referred to our department forrecurrence. The cause of dialysis-dependent disease waschronic kidney failure, and the duration of dialysis treatment was9 years and 4 months. His medical historieswere hypertension, anemia, secondary hyperparathyroidism, lacunar infarction, and hepatitis C. Oral examination revealed an endophytic tumor with mucosalulceration on the left side of the tongue (Fig. 1). Preoperative magnetic resonance imaging (MRI) demonstrated a tumor measuring 5.0 4.0 2.6 cm (Fig. 2) andbilateral cervical lymph node metastasis. Tracheotomy,bilateral neck dissection, (ipsilateral: Level I-IV, contralateral: Level I-III) and subtotal glossectomy were performed with abdominal vascularized flap reconstruction(surgical time; 10 h (h) 36 min, intraoperative bleedingloss volume; 514 mL). Intravenous second-generationcephalosporin 1 g just before the surgery was used andintraoperative intravenous infusion volume ofpotassium-free solution was 814 mL (mean infusionspeed at 20–40 mL/h). Routine hemodialysis was scheduled for the day before and after surgery, and then 3times a week. We discussed patients’ conditions andperioperative dialysis management with nephrologistsonce a week during hospitalization. ESA was used onthe day of hemodialysis during hospitalization. Nafamostat mesilate was used from POD 1 to 7. From POD 1 to5, the second-generation cephalosporin (1 g once dailyintravenously) and the third-generation cephalosporin(0.2 g once daily per mouth) during POD 6 to 10 wereadministered. The healing process was uneventful andoral intake was restarted on POD 21. Daily limits of protein intake, salt intake, and liquid intake were 50 g, 5 gand 1500 mL, respectively. The pathological diagnosis ofsurgical specimen was SCC and four cervical lymphnode metastasis (level II and level III at ipsilateral side,level II and level III at contra lateral side). Postoperativeoral photograph is shown in Fig. 3. Pain control wasachieved by using pentazocine hydrochloride and oxycodone hydrochloride hydrate. Adjuvant radiation
557265345MMMMMandibular ameloblastoma1.Segmental mandibulectomy plate reconstruction2.Plate removal vascularized osteocutaneousscapular flap reconstruction3.Spilt thickness skin graftSubsequently cervical lymphnode metastasis after brachytherapy ofbuccal SCCNeck dissection (Level I-IV)Lower gingival cancerT2 N0Marginal mandibulectomyTongue cancerT3N2CTracheotomy bi-lateral neck dissection subtotal glossectomy vascularized abdominal flapreconstructionStart at operative dayy Year, m Month, h Hour, min MinuteaMedian372Tongue cancer T2 N0Partial glossectomy281MAge Sex DiagnosisTreatmentCaseNo.Diabetic nephropathyHypertensionDiabetesDiabetic retinopathyCerebral c kidney failureafter kidney ismAnemiaChronicglomerulonephritisAnemiaPeptic ulcerChronic kidney failureHypertensionLacunar infarctionHepatitis CSecondaryhyperparathyroidismAnemiaAlport’s syndromeHypertensionAnemiaRenal diseaseGeneral medicalhistoryTable 1 Patients’ background and treatments summary2y 8 m1y10m17y 6 m9y 4 m7y 9m4 h 36 min5 h 9 min9 h 42 min1 h 22 min4 h 49 min2 h 13 min10 h 36 min47 010001500500The duration Surgical time Fluid volume Bleeding volume The start day of oral Protein intake SaltDaily limit ofof dialysis(hour:h,(ml)(ml)intake after surgery (g)intake liquid intaketreatmentminute:min)(post operative day)(g)(ml)Mochizuki et al. BMC Oral Health(2018) 18:166Page 3 of 10
Mochizuki et al. BMC Oral Health(2018) 18:166Fig. 1 Oral photograph at first visit. Oral photograph showed 5.0 4.0 2.6-cm tumor on the left side of the tonguetherapy (50 Gy) was administered to the primary oral lesion and neck lesions bilaterally. Four months after thesurgery, the primary tumor recurred, and he died9 months later.Case 3A 55 year-old man visited to our department for thetreatment of lower gingival carcinoma. The etiology ofdialysis-dependent end-stage kidney disease was Chronicglomerulonephritis and the duration of hemodialysistreatment was17 years and 6 months. Peptic ulcer andanemia had been treated. No metastatic lymph node waspalpable in the cervical region and the clinical diagnosiswas lower gingival cancer. Marginal mandibulectomywas performed (surgical time; 2 h 13 min). At the daybefore surgery red blood cells were transfused becausePage 4 of 10Fig. 3 Oral photograph after flap reconstruction. Oral photographafter subtotal glossectomy and abdominal vascularizedflap reconstructionof Hb value of 7.0 g/dL and a preoperative Ht value of22.0% caused by gastrointestinal bleeding. We administrated intravenous second-generation cephalosporin0.5 g just before the surgery. Intraoperative intravenousinfusion volume of potassium-free solution was 250 mL(mean infusion speed at 20–40 mL/h). Routinehemodialysis was scheduled for the day before and aftersurgery, and then 3 times a week. We discussed assessment of patients’ conditions and perioperative dialysismanagement with nephrologists once a week duringhospitalization. As POD 1 day after surgery, Hb and Htlevels were still low (Hb 6.5 g/dL, Ht 20.5%), and redblood cells were transfused per each day at POD on the3, 6, and 8 days after surgery. By POD the 13 days aftersurgery, Hb and Ht levels improved (Hb 9.9 g/dL, Ht31.0%). ESA was used on the day of hemodialysis duringhospitalization. Nafamostat mesilate was used fromPOD 1 to 7. From POD 1 to 5, the second-generationcephalosporin (0.5 g once daily intravenously) and thethird-generation cephalosporin (0.2 g once daily permouth) during POD 6 to 10 were administered. Thehealing process was uneventful and oral intake was resumed on POD7. Daily limits of protein intake, salt intake, and liquid intake were 70 g, 7 g and 1000 mL,respectively. The pathological diagnosis of surgical specimen was SCC. The margin of the surgical specimen wasfree of tumor. No adjuvant therapy was performed. Thepatient was free of the disease 11 years after surgery.Case 4Fig. 2 MRI before surgery. T2 weighted MRI showed that the tumoroccupied beyond the half of the tongueA 72 year-old man was referred to our department for thetreatment of subsequent cervical lymph node metastasis4 months after brachy therapy of buccal SCC. For primarylesion, he received brachytherapy (first doze; 84Gy, seconddoze for tumor remaining; 83.97Gy) and external irradiation (30Gy). The etiology of dialysis-dependent end-stagekidney disease was chronic kidney failure after kidney
Mochizuki et al. BMC Oral Health(2018) 18:166Page 5 of 10rapid progress of osteoradionecrosis of the mandible anddisability of oral intake he could not come to our department and transferred to another hospital 1 year and3 months after neck dissection.Case 5Fig. 4 Oral photograph at first visit. Multiple swelling mass coveredwith normal mucosa was observed from the right lower molar areato the left lower molar areacancer surgery and the duration of hemodialysis treatmentwas 1 year and 10 months. His history included hypertension, secondary hyperparathyroidism and anemia. Neckdissection (Level I-IV) was performed (surgical time; 4 h49 min, intraoperative bleeding loss volume; 131 mL).Intravenous first-generation cephalosporin 0.5 g just before the surgery was used. Intraoperative intravenous infusion volume of potassium-free solution was 313 mL(mean infusion speed at 20-40 mL/h). Routinehemodialysis was scheduled for the day before and aftersurgery, and then 3 times a week. We discussed patients’conditions with nephrologists once a week duringhospitalization. ESA was used on the day of hemodialysisduring hospitalization. Nafamostat mesilate as an anticoagulant during hemodialysis were used from postoperative day (POD) 1 to 7. From POD 1 to 5, first-generationcephalosporins (0.5 g once daily intravenously). Oral intake was restarted on the operative day. Daily limits ofprotein intake, salt intake, and liquid intake were 70 g, 7 gand 500 mL, respectively. The pathological diagnosis ofsurgical specimen was one cervical lymph node metastasisat Level II. Postoperative adjuvant chemotherapy was notadministrated. Because of the general weakness caused byA 65-year-old man on hemodialysis was referred to ourdepartment for a mandibular tumor. The duration ofhemodialysis treatment was2 years and 8 months. Hismedical history included diabetes, hypertension, cerebralinfarction, diabetic retinopathy, and secondary hyperparathyroidism. On oral examination, a huge mass wasobserved in the right lower molar area extending to theleft lower molar area (Fig. 4). Panoramic radiographyshowed a well-defined radiolucent multilocular mass inthe mandible (Fig. 5). Segmental mandibulectomy andplate reconstruction were performed (surgical time; 5 h9 min, intraoperative bleeding loss volume; 97 mL) (Fig. 6).Intravenous second-generation cephalosporin (1 g) was administrated just before the surgery. Intraoperative intravenous infusion volume of potassium-free solution was166 mL (mean infusion speed at 20–40 mL/h) and included glucose-insulin-potassium (GIK) therapy. Routinehemodialysis was scheduled for the day before and aftersurgery, and then 3 times a week. We discussed patients’conditions and perioperative dialysis management with nephrologists once a week during hospitalization. ESA wasused on the day of hemodialysis during hospitalization.Nafamostat mesilate as an anticoagulant duringhemodialysis were used from postoperative day (POD) 1 to7. From POD 1 to 5, the second-generation cephalosporin(1 g once daily intravenously) and the third-generationcephalosporin (0.1 g once daily per mouth) during POD 6to 10 were administered. Wound healing was uneventfuland oral intake was restarted on POD 13. Daily limits ofprotein intake, salt intake, and liquid intake were 60 g, 6 gand 800 mL, respectively. The pathological diagnosis ofsurgical specimen was ameloblastoma. No recurrence wasobserved during the follow-up period.Fig. 5 Panoramic radiograph at first visit. Panoramic radiograph showed a well-defined radiolucent multilocular mass in the bilateral mandible
Mochizuki et al. BMC Oral Health(2018) 18:166Page 6 of 10Fig. 6 Panoramic radiograph after plate bone reconstruction. The mandibular defect after segmental mandibulectomy was reconstructed by thetitanium plateAt 6 years after the first surgery, exposure of theplate was noted. We provided treatment options ofplate removal alone, or reconstruction of an autologous bone graft. The patient chose the autologousbone graft. Diabetic control was poor (HbA1C 9.2%)and adequate blood glucose control was ensured withintensive insulin therapy. Preoperative computed tomography (CT) showed vascular calcification of the carotid arteries on both sides (Fig. 7). However, theDoppler signals of the facial and superior thyroid artery to be anastomosed were observed. For the second surgery, plate removal and vascularizedFig. 7 CT scan image (Axial view). In preoperative CT, vascularcalcification of carotid arteries on both sides was observed(yellow arrows)osteocutaneous scapular flap reconstruction were performed (surgical time; 9 h 42 min, intraoperativebleeding loss volume; 209 mL) (Figs. 8 and 9). Intravenous second-generation cephalosporin (1 g) was administrated just before the surgery. Intraoperativeintravenous infusion volume of potassium-free solution was 1075 mL (mean infusion speed at 20–40 mL/h) and included GIK therapy. The schedule ofroutine hemodialysis, discussion with nephrologists,drug regimen of ESA, Nanafamostat mesilate and theantibiotics were the same as the first surgery. Redblood cells were transfused because Hb and Ht levelsgradually decreased to 6.5 g/dL and 20.2%, respectively, on POD 7. Bone scintigraphy of radiolabeled99mTc-methylene-diphosphonate imaging showed viability of the vascularized bone graft (POD 5), however, the scapular cutaneous flap began to necrosis onPOD 9. Wound infection with methicillin-resistantStaphylococcus aureus (MRSA) was noted on culture.Vancomycin (0.5 g) was interveneously administeredon the day of hemodialysis. Oral intake wasFig. 8 Facial photograph during surgery. The mentum skin aroundthe plate exposure was resected
Mochizuki et al. BMC Oral Health(2018) 18:166Page 7 of 10Fig. 9 Photograph of scapular bone flap and cutaneous flap. Scapular bone was bended to fit the morphology of the mandible and fixed.Scapular cutaneous flap reconstructed the resected facial skinuneventfully restarted on POD 14. The daily intakelimits of protein, salt and liquid were the same as thefirst surgery. The scapular cutaneous flap underwentnecrosis completely by POD 16 (Fig. 10). On POD 37we performed the necrotic tissue debridement andfound the formation of granulation tissue on the surface of scapular bone (Fig. 11). We performed thenecrotic tissue debridement and split thickness skingraft on the scapular bone (surgical time; 1 h 22 min,intraoperati
CASE REPORT Open Access Oral and maxillofacial surgery in patients undergoing dialysis for advanced renal disease: report of five cases Yumi Mochizuki1*, Hiroyuki Harada1, Misaki Yokokawa1, Naoya Kinoshita1, Kazumasa
oral and maxillofacial surgery by the American Board of Oral and Maxillofacial Surgery. AND Required Current Experience: Demonstrated current competence and evidence of the performance of an adequate volume of experience in each of the major surgery categories (trauma, pathology, orthognathic surgery, reconstructive and cosmetic surgery) for which
oral and maxillofacial surgery by the American Board of Oral and Maxillofacial Surgery. AND Required Current Experience: Demonstrated current competence and evidence of the performance of an adequate volume of experience in each of the major surgery categories (trauma, pathology, orthognathic surgery, reconstructive and cosmetic surgery) for which
(ii) Oral and Maxillofacial specialists shall use Schedule A if the patient has come into their care without referral by a dentist or medical practitioner. (iii) Oral and Maxillofacial specialists shall use Schedule B if the patient has come into their care upon referral by either a dentist or a medical practitioner. Oral and Maxillofacial
Keywords: edema, oral surgery, maxillofacial surgery, postoperative period, postoperative care 1. Introduction Every surgical procedure presents pain and edema in a variable degree, and many pharmacological and alternative methods have been used in an attempt to control and reduce them. Maxillofacial surgery acts on the patient's face.
The Philip Worthington Lectureship in Oral & Maxillofacial Surgery was established in 2003 by a passionate, committed group of stakeholders in the Department of Oral & Maxillofacial Surgery who wished to honor and recognize the profound contributions of Dr . Worthington to the Department after more than 20 years of leadership and service.
7 Deliver oral and maxillofacial surgery through local networks, such as hub and spoke models, to optimise quality and efficiency. 7a Develop guidance based on existing best practice examples to support the development of a service specification for local network reconfiguration. The guidance should cover the full oral and maxillofacial workload.
Plastic surgery Cosmetic Surgery Reconstructive Surgery Aesthetic Surgical & Non-Surgical procedures Craniofacial Surgery Rhinoplasty & Otoplasty Hand Surgery or Chiroplasty Oral and Maxillofacial Surgery Trauma Surgery Skin Rejuvenation and Resurfacing Anesthesia for Plastic Surgery
facial pathology) and with oral surgery (oral and maxillofacial surgery), there is a close relationship with special care den-tistry and hospital dentistry. This book attempts to present for those interested in oral medicine and hospital dentistry, the basics of the specialty of oral
