East Hospital performs a challenging radical surgical removal of head and neck tumor with successive complex reconstructive surgery

A multi-disciplinary team at the Riga East Clinical University Hospital (East Hospital) performed a challenging radical surgery on a 43-year-old patient to remove a head and neck tumor, which was the last viable option to halt the spread of malignant cells. Subsequently, the oncology patient became the first one in Latvia to undergo the transplantation of three microvascular flaps. Following the successful surgery, the patient’s health has improved, and he has regained strength to move forward with his life.

This high-complexity surgery was performed by Renārs Deksnis, Head of the Head and Neck Surgery Department of the Oncological Surgery Clinic at the East Hospital, together with the plastic surgeon Dr. med. Jānis Zariņš as part of the East Hospital’s multi-disciplinary team. The surgery lasted 13 hours. Prior to the surgery, various diagnostic tests and meticulous planning of the surgery were essential to ensure a successful outcome.

About the patient: The 43-year-old patient sought an outpatient consultation with Renārs Deksnis, complaining of a mass at the floor of the mouth and in the tongue. Under the ‘Green Corridor’ system, he underwent a series of tests, including a CT scan of the head and neck soft tissues, lungs, and abdominal cavity to rule out distant metastases. A biopsy revealed a locally advanced squamous cell carcinoma affecting several anatomical areas, such as the mandible, the floor of the mouth, the tongue, and facial tissues.

Tumor metastases had already invaded the neck lymph nodes. The case was carefully reviewed by the ENT oncology council, which prescribed induction chemotherapy aimed at reducing and halting tumor growth. This approach has been used in treating oncology patients at the East Hospital since 2020.

Although the metastatic lymph nodes decreased in size following chemotherapy, the tumor itself remained the same size, but its rapid growth was successfully halted. In the follow-up multi-disciplinary council review, it was decided to proceed with radical surgical treatment which involved removing more than half of the mandible, the entire floor of the mouth, nearly the entire tongue, as well as facial and chin skin in a single block, along with bilateral removal of lymph nodes in the neck. It should be noted that it was the only way to help the patient in his battle against the malignant tumor.

The surgery was thoroughly planned in advance.  Cooperation between Dr. med. Jānis Zariņš and the Baltic Biomaterials Centre of Excellence of the Riga Technical University, operating under the Institute of Stomatology, made it possible to develop a personalized cutting guide to enable anatomically precise reconstruction of the mandible.

Course of the surgery:  “The removal of the entire tumor and lymph nodes, along with subsequent reconstruction, presented a major challenge. We can say with certainty that a surgery of this magnitude had never been performed on a head and neck tumor patient before. The removal of tumor alone took four hours. It was immediately sent to the histology lab for examination to make sure that all malignant cells had been removed. Afterwards, we proceeded with the reconstruction of the mandible, the floor of the mouth, the tongue, and face. The surgery lasted 13 hours,” explains Renārs Deksnis.

“This is the first time an oncology patient undergoes the transplantation of three microvascular flaps: a bone flap for mandibular reconstruction, a soft tissue flap to construct new tongue and the floor of the mouth, and a third soft tissue flap to repair a facial tissue defect. Nine vascular anastomoses were sutured to ensure the viability of the transplanted tissues. This intricate reconstruction was essential to fully restore the lost structures, allowing the patient to breathe, eat, drink, speak freely, and have a pleasant appearance in a short time,” says the plastic surgeon Dr. med. Jānis Zariņš with satisfaction.

Despite the complicated and difficult reconstructive surgery, the post-operative period for the patient progressed without complications. On the third post-operative day, the East Hospital’s physiotherapist and speech therapist, Emīlija Dravante, started working with the patient for him to be able to regain functionality. Currently, eight weeks after the surgery, the patient feels excellent and has commenced the next treatment phase, which involves post-operative radiation and chemotherapy.

Photo: https://www.flickr.com/photos/austrumu_slimnicas_foto/albums/72177720321536545/

The high-complexity surgery was performed by the East Hospital’s multi-disciplinary team:

Head of the Head and Neck Surgery Department of the Oncological Surgery Clinic , Renārs Deksnis

Plastic surgeon Dr. med. Jānis Zariņš

Plastic surgery resident Lidija Viktorija Artiševska

Otolaryngology resident Diāna Katoviča

Student at the Faculty of Medicine at the Riga Stradiņš University, Kristiāns Višperts

Anaesthesiologist Aija Krastiņa

Nurses anaesthetists Zane Vēja, Natālija Porhomenko

OR nurses Elita Birzniece, Zita Zaļivska, Anita Slišāne

Nurse assistants Dace Markovska, Laura Biezāka

Last year, the Head and Neck Surgery Department of the Oncological Surgery Clinic at the East Hospital saw a significant increase in the number of major and complex ENT surgeries performed by a multi-disciplinary team, from 60 surgeries in 2022 to 98 surgeries in 2023. The majority, or 98%, of patients undergoing surgeries in the Head and Neck Surgery Department of the Oncological Surgery Clinic are oncology patients requiring very complex surgical assistance. Additionally, the number of outpatient ENT consultations increased significantly, with 1421 consultations provided to patients last year.

About the East Hospital 

Riga East Clinical University Hospital is the largest and strategically significant multi-profile hospital in the country. The hospital consists of five inpatient facilities – Gaiļezers, Latvian Oncology Centre, Biķernieki, Tuberculosis and Lung Disease Centre, and Latvian Infectious Diseases Centre, along with various specialised centres and clinics. The hospital provides highly specialised inpatient and secondary outpatient healthcare, offering multidisciplinary tertiary-level treatment and care in line with modern technology and medical knowledge. Approximately 80% of all cancer patients in Latvia are treated at the hospital. It serves as a practical training base for both Latvian educational institutions and foreign students, providing further education and knowledge transfer to healthcare specialists within and beyond the country. The hospital engages in scientific research and develops innovative methods for patient treatment. As the third-largest employer in the country, the hospital employs around 5000 staff members.