Intraoperative evaluation of perfusion in free flap surgery: A systematic review and meta‐analysis

Smit, Jan Maerten; Negenborn, Vera L.; Jansen, Sanne; Jaspers, Mariëlle E. H.; Vries, Ralph de; Heymans, Martijn W.; Winters, H.A.H.; Leeuwen, Ton G. van; Mullender, Margriet G.; Krekel, N.M.A.

doi:10.1002/micr.30320

Cited by 52 publications

(56 citation statements)

References 88 publications

(465 reference statements)

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“…In line with this, Smit et al recently published a systematic review and meta-analysis on intraoperative evaluation of perfusion in free flap surgery. 25 We fully agree with their conclusion that ICG-NIR-VA is one of the most suitable methods to measure intraoperative free flap tissue perfusion, resulting in improved free flap survival. 25 In our previous study, ICG-NIR-VA predicted full tissue viability in all flaps which healed uneventfully but also predicted the exact extent of tissue necrosis in flaps with partial flap necrosis.…”

Section: Discussionsupporting

confidence: 82%

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: Discussionsupporting

confidence: 82%

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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“…A meta-analysis by Smit et al concluded that fluorescent imaging and laser Dopplers are the most suitable modalities for intraoperative free flap tissue perfusion assessment and that utilizing them can improve flap survival. 6 …”

Section: Discussionmentioning

confidence: 99%

“…A meta-analysis found that fluorescence imaging and laser Doppler are the most suitable methods to assess tissue perfusion in free flaps. 6 As for the pedicle TRAM flap, the use of indocyanine green (ICG) fluorescence imaging has been reported by Yamaguchi et al as a safe, quick, and accurate technique of flap perfusion analysis and may reduce fat necrosis. 7 However, there is currently no study that describes the vascular distribution in the subcutaneous fat layer of the zone 4 border identified by the ICG technique.…”

Section: Introductionmentioning

confidence: 99%

Is It Reasonable to Use Indocyanine Green Fluorescence Imaging to Determine the Border of Pedicled TRAM Flap Zone IV?

Chirappapha

Chansoon

Bureewong

et al. 2020

Plastic and Reconstructive Surgery - Global Open

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Background: The contralateral lateral section (zone IV) of a pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is generally removed intraoperatively. The border of zone IV is usually identified anatomically using the Hartrampf classification. In this study, we used the indocyanine green (ICG) fluorescence method to determine the border of zone IV and find the correlation with clinical flap outcome. Methods: The study recruited breast cancer patients who underwent a pedicled TRAM flap reconstruction. The border of zone IV was identified using the intraoperative ICG fluorescence imaging. The medial border of the removed specimen was sent for a pathological examination of vascular density. Results: A total of 29 patients underwent a pedicled TRAM reconstruction. In 16 patients, the border of zone IV identified by ICG fluorescent imaging was identical to the anatomical border. The ICG imaging showed distinct perfusion patterns, which we divided into 4 categories: sequential, simultaneous, low midline scar, and delayed pattern. Overall, there were no patient with total flap loss, 1 patient had a partial flap loss and 4 patients had a fat necrosis. Neither the ICG perfusion time nor the pathological vascular density correlates with the clinical flap outcome. The delayed ICG perfusion pattern (category IV) has the highest fat necrosis rate, although it is not statistically significant. Conclusions: In this study, more than half of the patients have ICG perfusion corresponding with the Hartrampf zone, which reflected the conventional practice of zone IV pedicled TRAM flap removal. Some ICG perfusion patterns could be helpful, especially in low midline and delayed pattern.

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“…Our study revealed the metabolic changes in bone tissue after a period of ischemia (intraoperatively and during the first 5 days postsurgery). In a recent review of objective methods for the intraoperative assessment of free flap perfusion, Smit et al () cited only one article on microdialysis (Edsander‐Nord, Röjdmark, & Wickman, ) and concluded that additional studies were necessary.…”

Section: Discussionmentioning

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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Intraoperative evaluation of perfusion in free flap surgery: A systematic review and meta‐analysis

Cited by 52 publications

References 88 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

Is It Reasonable to Use Indocyanine Green Fluorescence Imaging to Determine the Border of Pedicled TRAM Flap Zone IV?

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

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