Modern postoperative monitoring of free flaps

Kääriäinen, Minna; Halme, Elina; Laranne, Jussi

doi:10.1097/moo.0000000000000467

Cited by 24 publications

(21 citation statements)

References 46 publications

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“…According to Kääriäinen et al, such a method should be repeatable, reliable, recordable, rapidly responsive, accurate, inexpensive, and applicable to all kinds of flaps. 19 For this reason, a broad range of objective methods have been introduced but, however, none of the aforementioned methods have yet been applied systematically to the best of our knowledge. In a recent review, Li et al attribute this to high procedural costs, methodological complexity, low sensitivity, and high false positive as well as false negative rates.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Indocyanine-Green Fluorescence Angiography on Intraoperative Decision-Making and Postoperative Outcome in Free Flap Surgery

Bigdeli

Thomas

Falkner

et al. 2020

J Reconstr Microsurg

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Background Reliable perfusion of the distal portions of free flaps is decisive for the reconstructive success. Indocyanine green near-infrared video angiography (ICG-NIR-VA) has been adopted for objective assessment of free flap tissue perfusion but is thus far not used on a routine basis. Therefore, we investigated its intraoperative impact on decision-making and postoperative outcome. Methods From January 2017 to June 2019, 88 consecutive adipo- or fasciocutaneus free flaps were performed in conjunction with intraoperative ICG-NIR-VA. Free flap tissue perfusion was first assessed clinically and then compared with ICG-NIR-VA findings. Based on the results, the decision for intraoperative trimming of critically perfused flap zones was made. The way of decision-making, flap success, and failure rates as well as intra- and postoperative complication rates were analyzed. Results The overall free flap success rate was 92.0%. Partial flap necrosis occurred in five cases (5.7%) and total flap necrosis in two cases (2.3%). ICG-NIR-VA aided decision-making and flap design in 34 cases (38.6%) and led to complication-free postoperative courses. When ICG-NIR-VA was relied on (82 out of 88 flaps; 93.2%), there was no unpredicted postoperative tissue necrosis (overestimation). When ICG-NIR-VA was not relied on (6 out of 88 flaps; 6.8%), there were five cases of postoperative partial flap necrosis and one case of uneventful healing (underestimation). The sensitivity of ICG-NIR-VA was 100% (95% confidence interval [CI]: 64.6–100) and the specificity was 98.8% (95% CI: 93.3–100) with a positive predictive value of 87.5% (95% CI: 52.9–99.4) and a negative predictive value of 100% (95% CI: 95.4–100). Conclusion Intraoperative ICG-NIR-VA objectified free flap perfusion and thus refined surgical decision-making on flap design in all cases. It could always predict tissue necrosis and subjectively improved outcomes in free flap surgery at our institution. Furthermore, it could be easily implemented in intraoperative routine, only adding minimal additional operative time.

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Section: Discussionmentioning

confidence: 99%

The Impact of Indocyanine-Green Fluorescence Angiography on Intraoperative Decision-Making and Postoperative Outcome in Free Flap Surgery

Bigdeli

Thomas

Falkner

et al. 2020

J Reconstr Microsurg

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“…The failure rate in reconstructive surgery with bone free flaps (11-25%, depending on the study) is higher than that with muscle, fasciocutaneous, or cutaneous flaps (1-17%) (Benacquista, Kasabian, & Karp, 1996;Bui et al, 2007;Ferguson Jr & Yu, 2009;Jallali, Ridha, & Butler, 2005). Over the past 15 years, several monitoring methods for head and neck reconstructive surgery have therefore been developed: implantable Doppler, color duplex sonography, near-infrared spectroscopy, laser Doppler flowmetry, and microdialysis (Abdel-Galil & Mitchell, 2009;Hölzle et al, 2010;Kääriäinen, Halme, & Laranne, 2018). At present, many surgeons consider that microdialysis (initially developed by Delgado, DeFeudis, Roth, Ryugo, and Mitruka (1972)) is a reliable monitoring method for buried free flaps and can detect flap compromise early (Brix, Muret, Ricbourg, & Humbert, 2006;Frost et al, 2015;Jyränki, Suominen, Vuola, & Bäck, 2006;Nielsen, Gutberg, & Birke-Sørensen, 2011).…”

Section: Introductionmentioning

confidence: 99%

Intraosseous microdialysis for bone free flap monitoring in head and neck reconstructive surgery: A prospective pilot study

et al. 2019

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Background Although some researchers have positioned microdialysis catheters in the soft tissue surrounding bone, the results did not accurately reflect bone metabolism. The present study's objective was to establish the feasibility of microdialysis with a catheter positioned directly in bone. Methods Thirty‐four patients (19 males, 15 females; median age: 59) were included in a prospective, nonrandomized clinical trial in the Department of Maxillofacial Surgery at Amiens‐Picardie University Hospital (Amiens, France). Fibula or iliac crest free flaps were used in reconstructive head and neck surgery (for cancer, osteoradionecrosis, trauma, or ameloblastoma) and monitored with microdialysis catheters positioned in a hole drilled into the bone. Glucose, lactate, pyruvate, and glycerol concentrations were analyzed for 5 days. Results All catheters were positioned successfully, and thrombosis did not occur during the monitoring. In two patients, an increase in the lactate concentration and a glucose level close to 0 were associated with signs of flap necrosis, with removal on Days 9 and 50. In viable flaps, the mean glucose level was 2.02 mmol/L, the mean lactate level was 8.36 mmol/L, and the mean lactate/pyruvate ratio was 53. Forty percent of the glucose values were below 1 mmol/L, and 50% of the lactate/pyruvate ratio values were above 50—suggesting a specific metabolic pattern because these values would be considered as alert values in soft tissue. Conclusion Monitoring bone free flaps with intraosseous microdialysis is feasible. This technique specifically assesses bone viability, and further studies are now necessary to define the alert values in bone.

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“…Other systems for superficial assessment are near-infrared spectroscopy and thermography. [59][60][61] The other principle is to measure blood flow directly on the anastomosed vessels. Since this value represents the total blood flow in the flap, it gives a very good estimation of the viability of the flap.…”

mentioning

confidence: 99%

“…Implantable systems offer continuous evaluation of the blood flow, but require a second procedure to remove the implanted probe. [61][62][63][64][65] Using laser to assess microcirculation in the skin A laser is a device that generates an intense beam of coherent monochromatic light (or other electromagnetic radiation) by stimulated emission of photons from excited atoms or molecules.…”

mentioning

confidence: 99%

Laser Speckle Contrast Imaging in Reconstructive Surgery

Zötterman

2020

Linköping University Medical Dissertations

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Modern postoperative monitoring of free flaps

Abstract: More research with practical and clinically relevant parameters, that is flap salvage rate, false positive rate and cost-efficiency are needed before objective comparisons between different monitoring techniques can be made.

Cited by 24 publications

References 46 publications

The Impact of Indocyanine-Green Fluorescence Angiography on Intraoperative Decision-Making and Postoperative Outcome in Free Flap Surgery

The Impact of Indocyanine-Green Fluorescence Angiography on Intraoperative Decision-Making and Postoperative Outcome in Free Flap Surgery

Intraosseous microdialysis for bone free flap monitoring in head and neck reconstructive surgery: A prospective pilot study

Laser Speckle Contrast Imaging in Reconstructive Surgery

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