Current Evidence for Postoperative Monitoring of Microvascular Free Flaps

Chae, Michael P.; Rozen, Warren M.; Whitaker, Iain S.; Chubb, Daniel; Grinsell, Damien; Ashton, Mark W.; Hunter-Smith, David J.; Lineaweaver, William C.

doi:10.1097/sap.0b013e3181f8cb32

Cited by 120 publications

(149 citation statements)

References 193 publications

(207 reference statements)

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“…116 Many centers use other monitoring technology in addition to these basic approaches, with some reporting improvements in flap salvage rates relative to other published series. 117 However,therearenorandomizedcontrolledtrialsinthisareaandmost publications present retrospective or prospective case series. 118 …”

Section: Postoperative Flap Monitoringmentioning

confidence: 99%

Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction

Dort

Farwell

Findlay

et al. 2017

JAMA Otolaryngol Head Neck Surg

395

257

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Importance: Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking. Objective: To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction. Evidence Review: Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent key words for each topic included "head and neck surgery," "pharyngectomy," "laryngectomy," "laryngopharyngectomy," "neck dissection," "parotid lymphadenectomy," "thyroidectomy," "oral cavity resection," "glossectomy," and "head and neck." The final selection of literature included meta-analyses and systematic reviews as well as randomized controlled trials where available. In the absence of high-level data, case series and nonrandomized studies in head and neck cancer surgery patients or randomized controlled trials and systematic reviews in non-head and neck cancer surgery patients, were considered. An international panel of experts in major head and neck cancer surgery and enhanced recovery after surgery reviewed and assessed the literature for quality and developed recommendations for each topic based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations were graded following a consensus discussion among the expert panel. Findings: The literature search, including a hand search of reference lists, identified 215 relevant publications that were considered to be the best evidence for the topic areas. A total of 17 topic areas were identified for inclusion in the protocol for the perioperative care of patients undergoing major head and neck cancer surgery with free flap reconstruction. Best practice includes several elements of perioperative care. Among these elements are the provision of preoperative carbohydrate treatment, pharmacologic thromboprophylaxis, perioperative antibiotics in clean-contaminated procedures, corticosteroid and antiemetic medications, short acting anxiolytics, goal-directed fluid management, opioid-sparing multimodal analgesia, frequent flap monitoring, early mobilization, and the avoidance of preoperative fasting. Conclusions and Relevance: The evidence base for specific perioperative care elements in head and neck cancer surgery is variable and in many cases information from different surgerical procedures form the basis for these recommendations. Clinical evaluation of these recommendations is a logical next step and further research in this patient population is warranted.

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Section: Postoperative Flap Monitoringmentioning

confidence: 99%

Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction

Dort

Farwell

Findlay

et al. 2017

JAMA Otolaryngol Head Neck Surg

395

257

View full text Add to dashboard Cite

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“…Although handheld Doppler is the most commonly used adjunct to clinical examination, there are no studies evaluating it as a stand-alone technique [2]. There are two main disadvantages to its use, one being that a Doppler signal may not always be readily identifiable in all flaps, and when it is, it may be difficult to distinguish from the underlying vessels.…”

Section: Literature Reviewmentioning

confidence: 99%

“…A series of conventional monitorings for 252 head and neck free flaps reported a 98% success rate, with a 0.4% false-positive rate, and a 61.5% salvage rate [2]. The monitoring technique described was performed by the nursing staff, half-hourly on the first postoperative day, hourly on the second day, 2-hourly on the third day, and 4-hourly thereafter [2]. The success rates in other large published series were 95% and higher, although the monitoring frequency and personnel was not specified in many of these [3].…”

Section: Literature Reviewmentioning

confidence: 99%

What Are the Optimal Monitoring Techniques in Head and Neck Microvascular Reconstruction?

Moubayed

Mourad

Urken³

2016

ORL

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Purpose: We evaluated the outcomes for widely used systems in terms of accuracy, salvage rates, and added cost compared to conventional monitoring. Methods: We performed a narrative review of the literature (high-impact report). Results: The overall free flap success for head and neck reconstruction is at least 95% using any type of monitoring. Salvage rates in decreasing frequency of monitoring techniques are 85% with near-infrared spectroscopy (NIRS), 81% with implantable Doppler, and 61.5% with conventional monitoring. False-positive rates in increasing frequency are 0% for NIRS, 0.4% for conventional monitoring, and <10% for implantable Doppler. Current data show implantable Doppler to be potentially cost-effective for institutions with a failure rate of at least 6%. Buried flaps may be monitored with conventional monitoring using an exteriorized paddle, or using implantable Doppler. Conclusions: The cost-effectiveness of advanced flap monitoring systems beyond conventional monitoring is related to the success rate of each institution. Cost-effectiveness studies are necessary to determine at what point NIRS becomes advantageous.

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“…In a recent systematic review, it was noted that only five monitoring techniques showed evidence of increased rates of microsurgical flap rescue compared to other clinical methods (implantable Doppler, NIRS, Laser Doppler Flowmetry, quantitative fluorescence and evaluation through photographs sent by smartphones); however, none of these methods has become widely used in clinical practice [23].…”

Section: Discussionmentioning

confidence: 99%

Noninvasive Flap Monitoring using Sidestream Dark Field Microscan: A Method for Real-Time Observation of Submilimmetric Vessels

Yáñez¹,

Rodríguez²,

Cifuentes³

et al. 2017

Anaplastology

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Current Evidence for Postoperative Monitoring of Microvascular Free Flaps

Abstract: Future studies need to evaluate the most promising monitoring techniques further with a focus on assessing clinically relevant outcomes, such as the flap salvage rate and the false-positive rate, and not simple clinical series reporting patient and physician satisfaction.

Cited by 120 publications

References 193 publications

Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction

Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction

What Are the Optimal Monitoring Techniques in Head and Neck Microvascular Reconstruction?

Noninvasive Flap Monitoring using Sidestream Dark Field Microscan: A Method for Real-Time Observation of Submilimmetric Vessels

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