Postoperative Monitoring of Free DIEP Flap in Breast Reconstruction with Near-Infrared Spectroscopy: Variables Affecting the Regional Oxygen Saturation

Salgarello, Marzia; Pagliara, Domenico; Rossi, Marco; Visconti, Giuseppe; Barone-Adesi, Liliana

doi:10.1055/s-0038-1636527

Cited by 30 publications

(30 citation statements)

References 37 publications

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“…and (2) use it as a predictive tool while counseling the patients by explaining them that there is a higher chance of needing future revision of their flaps. [19][20][21][22]…”

Section: Discussionmentioning

confidence: 99%

Tissue Oximetry Readings Accurately Predict Late Complications in Patients Undergoing Free Flap Breast Reconstruction: Exploring the Optimal Cut Point Value

Saad

Wang

Karamanos

2020

J Reconstr Microsurg

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Background The use of tissue oximetry for monitoring following free tissue transfer has become a common practice across the United States to facilitate early detection of poor flap perfusion in the postoperative setting. There is no consensus on the optimal value, below which there is a higher chance of wound complications in patients undergoing free flap breast reconstruction. Methods Patients undergoing free flap breast reconstruction from 2015 to 2018 were retrospectively reviewed. Patients who returned to the operating room for a revision of the anastomosis were excluded from analysis. Patients were divided in two groups based on the development of late complications. Those were defined as fat necrosis, wound dehiscence, or distal flap ischemia/necrosis that developed after discharge from the hospital. Mean percutaneous oximetry readings of the first 24 hours were recorded and the mean change from the initial reading was calculated. The correlation between tissue oximetry change and development of complications was explored. Results A total of 120 patients were identified. The mean age was 53, while the mean body mass index was 33. A total of 38 patients developed late wound complication. History of smoking, diabetes mellitus, neoadjuvant radiation therapy, and the mean change of the tissue oximetry reading were identified as independent predictors of wound complications. The absolute number of the tissue oximetry reading did not predict late complications. A multivariate analysis revealed that patients who experienced a mean decrease < 15% from the initial reading during the first 24 hours were significantly more likely to develop late flap-related wound complications. Conclusion In patients undergoing free tissue breast reconstruction, tissue oximetry readings do not predict late wound complications. However, the mean change at 24 hours from the initial reading does. A decrease of <15% in tissue perfusion was associated with a significant increase in the probability of developing flap-related wound complications.

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“…and (2) use it as a predictive tool while counseling the patients by explaining them that there is a higher chance of needing future revision of their flaps. [19][20][21][22]…”

Section: Discussionmentioning

confidence: 99%

Tissue Oximetry Readings Accurately Predict Late Complications in Patients Undergoing Free Flap Breast Reconstruction: Exploring the Optimal Cut Point Value

Saad

Wang

Karamanos

2020

J Reconstr Microsurg

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“…Near-infrared light is directed at the tissue of interest, and its intensity as it returns to the sensor allows for a calculation of the relative percentage of the two molecules. 15 NIRS has been demonstrated to be sensitive and specific in the detection of vascular compromise following free tissue transfer [16][17][18] and in identifying impending complications earlier than alternative flap monitoring modalities, 19 but has not previously been studied in the setting of bowel. Final Intra.Ox prices are not currently available but expected to range between $500 and $1000 for a multiuse device with an approximately $200 disposable sheath per-use.…”

Section: Discussionmentioning

confidence: 99%

Comparison of the ViOptix Intra.Ox Near Infrared Tissue Spectrometer and Indocyanine Green Angiography in a Porcine Bowel Model

Khavanin

Almaazmi

Darrach

et al. 2020

J Reconstr Microsurg

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Background This study aims to directly compare measurements of tissue oxygenation obtained using the Intra.Ox (Vioptix Inc., Fremont, CA) near infrared spectrometer with the perfusion assessment of the indocyanine green (ICG)-based SPY Elite imaging system (Stryker Co., Kalamazoo, MI) in a porcine bowel model. Methods Two live minipigs underwent laparotomy and isolation of a 30-cm segment of a large bowel. Standardized oximetry measurements were taken along the segment of bowel immediately before, after, and serially for 30 minutes following transection. A 0.5 mg/kg dose of ICG was then injected intravenously and the SPY Elite system was used to visualize and quantify tissue perfusion. Pearson's correlation coefficients were calculated using the outcomes. Results Transected and ligated bowel yielded mean Intra.Ox measurements of 61% oxygenation at the proximal base of the limb and 27.8% at the distal edges. Analysis of the relative ICG fluorescence using the SPY Elite's proprietary software yielded perfusion estimates of 64.8% proximally and 6.8% distally. Intra.Ox and SPY Elite measurements demonstrate a Pearson product–moment correlation of 0.929. Repeat measurements at 15-mm intervals along the tissue yielded decreasing Intra.Ox measurements along the length of the flap that correlate to SPY Elite measurements (r = 0.645). Conclusion Both the Intra.Ox and the SPY detected clinically relevant changes in bowel oxygenation following transection and ligation. The use of intravenous ICG dye did not appear to affect measurements of tissue oxygenation obtained using the Intra.Ox.

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“…24,25 For all practical purposes, laser Doppler flowmetry and tissue oximetry are thereby the only methods, which allow for continuously monitoring, and there limitation is on the other hand that they cannot be used in buried transfers. 23,26,27 When discussing advantages and disadvantages of the different monitoring methods, it is often mentioned if the method is invasive or noninvasive. It might be relevant instead to look at if the monitoring procedure is harmless to the patient or not.…”

Section: Discussionmentioning

confidence: 99%

“…24,25 Tissue oximetry and the implantable Doppler are both rapid and sensitive monitoring methods and can be in combination with clinical monitoring, which is highly recommended in centers performing breast reconstructions where a skin island is always visible. 23,25,27 Nevertheless, in microvascular centers performing intraoral or esophageal reconstructions, the method of MD might be recommended due to the ability to obtain reliable monitoring without access to the FTT. 29 The diagnostic delay is not a huge problem as 100% salvage of jejunal transfers, which are known to be very sensitive to ischemia has been demonstrated using MD.…”

Section: Discussionmentioning

confidence: 99%

Faster Detection of Ischemia in Free Muscle Transfer When Using Microdialysis

Rauff-Mortensen

Berggren-Olsen

Kirkegaard

et al. 2019

J reconstr Microsurg

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Background Microdialysis is a clinical method used to detect ischemia after microvascular surgery. Microdialysis is easy to use and reliable, but its value in most clinical settings is hampered by a 1- to 2-h delay in the delivery of patient data. This study evaluated the effectiveness of an increase in the microdialysis perfusion rate from 0.3 to 1.0 µL/min on the diagnostic delay in the detection of ischemia. Methods In eight pigs, two symmetric pure muscle transfers were dissected based on one vascular pedicle each. In each muscle, two microdialysis catheters were placed. The two microdialysis catheters were randomized to a perfusion rate of 0.3 or 1.0 µL/min, and the two muscle transfers were randomized to arterial or venous ischemia, respectively. After baseline monitoring, arterial and venous ischemia was introduced by the application of vessel clamps. Microdialysis sampling was performed throughout the experiment. The ischemic cutoff values were based on clinical experience set as follows: CGlucose < 0.2 mmol/L, CLactate > 7 mmol/L, and the lactate/pyruvate ratio > 50. Results The delay for the detection of 50% of arterial ischemia was reduced from 60 to 25 minutes, and for the detection of all cases of arterial ischemia, the delay was reduced from 75 to 40 minutes when the perfusion rate was increased from 0.3 to 1.0 µL/min. After the same increase in perfusion, the detection of 50% of venous ischemia was reduced from 75 to 40 minutes, and for all cases of venous ischemia, a reduction from 135 to 95 minutes was found. Conclusion When using microdialysis for the detection of ischemia in pure muscle transfers, an increase in the perfusion rate from 0.3 to 1.0 µL/min can reduce the detection delay of ischemia.

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Postoperative Monitoring of Free DIEP Flap in Breast Reconstruction with Near-Infrared Spectroscopy: Variables Affecting the Regional Oxygen Saturation

Abstract: The NIRS is a reliable additional tool in free flap monitoring. A careful evaluation should be given to patients and surgery factors that can change the oximetry data.

Cited by 30 publications

References 37 publications

Tissue Oximetry Readings Accurately Predict Late Complications in Patients Undergoing Free Flap Breast Reconstruction: Exploring the Optimal Cut Point Value

Tissue Oximetry Readings Accurately Predict Late Complications in Patients Undergoing Free Flap Breast Reconstruction: Exploring the Optimal Cut Point Value

Comparison of the ViOptix Intra.Ox Near Infrared Tissue Spectrometer and Indocyanine Green Angiography in a Porcine Bowel Model

Faster Detection of Ischemia in Free Muscle Transfer When Using Microdialysis

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