Division of Plastic Surgery, Department of Surgery, West Virginia University, Morgantown, West Virginia.
Midwest Breast and Aesthetic Surgery, Gahanna, Ohio.
J Reconstr Microsurg. 2019 Nov;35(9):682-687. doi: 10.1055/s-0039-1693454. Epub 2019 Jul 21.
There is a growing trend across health care to perform increasingly complex procedures in less acute settings. This shift has been fueled, in part, by enhanced recovery protocols, which have shortened hospital stays after major surgeries. We set out to determine the timing of microvascular complications after deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction in a high-volume practice using continuous flap monitoring technologies.
The medical charts of all patients who underwent breast reconstruction with DIEP flaps over 24 consecutive months were reviewed. Postoperatively, all flaps were monitored according to a protocol that included continuous tissue oximetry with near-infrared spectroscopy. The primary end points evaluated included any unplanned return to the operating room, time to takeback, and flap loss rate.
A total of 196 patients underwent breast reconstruction with a total of 301 DIEP flaps. Five of the flaps (1.7%) were taken back to the operating room for microvascular issues, and nine (3.0%) were taken back for nonvascular issues. Of patients who were brought back for microvascular issues, all five (100.0%) were initially identified by continuous noninvasive monitoring and taken back to the operating room within the first 14 hours (range: 1.2-13.6 hours). In the series, the flap failure rate was 0.66% ( = 2).
All of the microvascular issues were detected in the initial 23 hours after surgery, leading to prompt flap salvage. The results of this study bring into question the need for lengthy flap monitoring protocols and suggest that shorter inpatient, or even observation admissions, may be reasonable, particularly when flap monitoring protocols incorporating continuous noninvasive flap monitoring are used.
在医疗保健领域，越来越多的复杂手术正在向非急性治疗环境转移。这一趋势部分源于加速康复方案的推动，该方案缩短了大手术后的住院时间。我们旨在使用连续皮瓣监测技术，确定高容量实践中深层腹壁下动脉穿支（DIEP）游离皮瓣乳房再造后微血管并发症的发生时间。
回顾了 24 个月内连续接受 DIEP 皮瓣乳房再造的所有患者的病历。术后，所有皮瓣均根据包括近红外光谱连续组织血氧饱和度监测的方案进行监测。评估的主要终点包括任何计划外返回手术室、重新取回时间和皮瓣丢失率。
共有 196 名患者接受了乳房重建，共进行了 301 个 DIEP 皮瓣。其中 5 个皮瓣（1.7%）因微血管问题返回手术室，9 个（3.0%）因非血管问题返回手术室。在因微血管问题而返回的患者中，所有 5 例（100.0%）最初通过连续非侵入性监测发现，并在术后前 14 小时内（范围：1.2-13.6 小时）返回手术室。在该系列中，皮瓣失败率为 0.66%（2 例）。
所有微血管问题均在术后 23 小时内发现，导致皮瓣及时抢救。本研究的结果质疑了长期皮瓣监测方案的必要性，并表明较短的住院时间，甚至观察入院时间可能是合理的，特别是在使用纳入连续非侵入性皮瓣监测的皮瓣监测方案时。
