Perioperative fluid overload increases anastomosis thrombosis in the free TRAM flap used for breast reconstruction

Abstract

To increase perfusion pressure with vasoactive drugs may be in conflict with the opinion of the reconstructive surgeon who maintains that the systemic administration of vasoactive agents causes vasoconstriction of the pedicle artery and the microvasculature. In free flap surgery, deliberate fluid therapy is used with a minimum of vasoactive drugs. This retrospective study was performed to analyse the perioperative fluid therapy, its effect on hemodynamic parameters and on the outcome of free flap surgery. One hundred and four patients were included in this retrospective study. The muscle sparing free transverse rectus abdominis myocutaneous flap was used for breast reconstruction. Perioperative hemodynamic data was used for this study. Twenty-seven patients had one or two complications requiring return to the operating room (OR). Two cases returned to the OR because of postoperative bleeding; in 11 patients, the anastomosis was revised. The reason for surgery in the latter group was venous stasis, due to thrombus formation at the venous anastomosis. The volume of fluid therapy was significantly higher in patients who returned to the OR due to thrombus formation at the anastomosis. Based on the results of this study, restricted intravenous fluid therapy or guided fluid therapy is recommended. Invasive monitoring such as central venous pressure and invasive arterial monitoring is recommended. Fluid loss should be replaced, and fluid overload should be avoided when the breast is reconstructed using free-tissue transfers.

Emerging Paradigms in Perioperative Management for Microsurgical Free Tissue Transfer

“…[22][23][24][56][57][58] In a retrospective study of 104 free transverse rectus abdominis myocutaneous (TRAM) flaps, patients requiring flap revision because of anastomotic thrombosis had received significantly higher fluid volumes during the original operation. 57 High volumes of crystalloid administration, either greater than 130 ml/ kg per day or greater than 7 liters during surgery, have been associated with major medical and flap complications. 22,24 A retrospective review of 354 breast reconstructions indicated that crystalloid infusion rate is a significant independent predictor of complications.…”

Intraoperative perfusion management impacts postoperative outcomes: An analysis of 682 autologous breast reconstruction patients

“…These results bring question to the literature suggesting that patients at the upper extreme of resuscitation are at higher risk for complications in breast reconstruction. 7,8 In fact, it supports the opposite, that high normal fluid resuscitation rates may in fact protect against thrombotic events, and that it is really the low resuscitation rates that we must be concerned about. Higher rates of resuscitation may lead to an increased degree of hemodilution and increased blood velocity resulting in decreased viscosity.…”

“…11e14 Booi also suggested that higher fluid volumes were related to return to the OR for thrombus formation. 8 However, these studies tended to address total fluid volume or overall 24 h postoperative day zero resuscitation as opposed to intraoperative volume per kilogram per hour. Our current study provides more real-time information for the microsurgeon and anesthesiologist to potentially improve patient care.…”

“…7,8 Early papers suggested hypervolemic hemodilution to improve microvascular circulation, 2 which has in more recent times, fallen from favor. The principle of avoiding hypovolemia; however, is a continuous focus of many microsurgeons for fear of increasing the risk of thrombotic events secondary to a low flow state even though little data supports this practice.…”

“…Although the majority of related studies emerge from otolaryngology literature and suggest that varying degrees of resuscitation may impact outcomes, it is less well understood in the free autologous breast reconstruction patient. 7,8 The importance of elucidating these potentially modifiable factors is profound and underscores the importance of a comprehensive evaluation of perioperative care and the need for potential interdisciplinary collaboration. The purpose of this study is to critically examine intraoperative perfusion management in autologous breast reconstruction in order to further clarify its effect on the risk of major complications.…”