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Ferreira PRC, De Oliveira RIP, Vaz MD, Bentes C, Costa H. Opioid-Free Anaesthesia Reduces Complications in Head and Neck Microvascular Free-Flap Reconstruction. J Clin Med 2023; 12:6445. [PMID: 37892584 PMCID: PMC10607324 DOI: 10.3390/jcm12206445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/29/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
Head and neck free-flap microvascular surgeries are complex and resource-intensive procedures where proper conduct of anaesthesia plays a crucial role in the outcome. Flap failure and postoperative complications can be attributed to multiple factors, whether surgical- or anaesthesia-related. The anesthesiologist should ensure optimised physiological conditions to guarantee the survival of the flap and simultaneously decrease perioperative morbidity. Institutions employ different anaesthetic techniques and results vary across centres. In our institution, two different total intravenous approaches have been in use: a remifentanil-based approach and a multimodal opioid-sparing approach, which is further divided into an opioid-free anaesthesia (OFA) subgroup. We studied every consecutive case performed between 2015 and 2022, including 107 patients. Our results show a significant reduction in overall complications (53.3 vs. 78.9%, p = 0.012), length of stay in the intensive care unit (3.43 ± 5.51 vs. 5.16 ± 4.23 days, p = 0.046), duration of postoperative mechanical ventilation (67 ± 107 vs. 9 ± 38 h, p = 0.029), and the need for postoperative vasopressors (10% vs. 46.6%, p = 0.001) in the OFA group (vs. all other patients). The multimodal and OFA strategies have multiple differences regarding the fluid therapy, intraoperative type of vasopressor used, perioperative pathways, and various drug choices compared to the opioid-based technique. Due to the small number of cases in our study, we could not isolate any attitude, as an independent factor, from the success of the OFA strategy as a whole. Large randomised controlled trials are needed to improve knowledge and help define the ideal anaesthetic management of these patients.
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Affiliation(s)
- Paulo-Roberto Cardoso Ferreira
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
- Medical Sciences Department, University of Aveiro, 3810-193 Aveiro, Portugal
| | | | - Marta Dias Vaz
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
| | - Carla Bentes
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
| | - Horácio Costa
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
- Medical Sciences Department, University of Aveiro, 3810-193 Aveiro, Portugal
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Rhee H, Jeong HY, Yi CC, Kim JH. Role of a fluid-restrictive strategy in flap-surgery: A single center retrospective cohort study. Medicine (Baltimore) 2023; 102:e33673. [PMID: 37171357 PMCID: PMC10174412 DOI: 10.1097/md.0000000000033673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
In this study, we evaluated the outcomes of flap surgery and the incidence of acute kidney injury (AKI) in patients who underwent flap surgery using a fluid-restrictive strategy. We retrospectively reviewed the consecutively collected medical records of patients who underwent flap surgery using the fluid-restrictive strategy of our hospital. The patients were divided into 2 groups based on the period of flap surgery: 2011 to 2014 (initiation period of the fluid-restrictive strategy) and 2015 to 2020 (implementation period). Outcomes of flap surgery and the incidence of AKI were evaluated based on percentage changes in cumulative fluid balance to initial body weight (%FO) on post-operative day 7. A total of 140 patients were enrolled in the study; 50 (35.7%) underwent flap surgery in 2011 to 2014 and 90 (64.3%) in 2015 to 2020. In 2015 to 2020, the median %FO significantly decreased from 2.7 (interquartile range [IQR]: 0.8-7.1) to 0.1 (IQR: -2.2 to 3.4%, P < .001), whereas the success rate significantly increased from 53.3% to 70.5% (P = .048) compared to 2011 to 2014. The incidence of AKI remained unchanged. In multivariate analysis, the odds ratio for success was 2.759 (95% confidence interval: 1.140-6.679) in 2015 to 2020 compared to 2011 to 2014. After successfully implementing the fluid-restrictive strategy, the success rate of flap surgery significantly increased without any further increase in the incidence of AKI. Our experience could serve as a model for implementing a fluid-restrictive strategy in flap surgery.
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Affiliation(s)
- Harin Rhee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Division of Nephrology, Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea
| | - Ho Yoon Jeong
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Division of Plastic Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea
| | - Changryul Claud Yi
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Division of Plastic Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea
| | - Joo Hyoung Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Division of Plastic Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan, Republic of Korea
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Banda CH, Wilson E, Malata CM, Narushima M, Ogawa T, Hassanein ZM, Shiraishi M, Okada Y, Ghorra DT, Ishiura R, Danno K, Mitsui K, Oni G. Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:2035-2048. [PMID: 35643598 DOI: 10.1016/j.bjps.2022.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/20/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa. METHODS Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates. RESULTS Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84). CONCLUSION This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care. REVIEW REGISTRATION Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.
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Affiliation(s)
- Chihena H Banda
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan; Department of Surgery, Arthur Davison Children's Hospital, Ndola, Zambia.
| | - Emma Wilson
- Division of Epidemiology and Public Health, The University of Nottingham, Nottingham, United Kingdom
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom; Anglia Ruskin University, School of Medicine, Chelmsford, Cambridge, United Kingdom
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Tomoko Ogawa
- Department of Breast Surgery, Mie University, Tsu, Japan
| | - Zeinab M Hassanein
- Division of Epidemiology and Public Health, The University of Nottingham, Nottingham, United Kingdom
| | - Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Yoshimoto Okada
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Dina T Ghorra
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Plastic and Reconstructive Surgery, Alexandria University, Alexandria, Egypt
| | - Ryohei Ishiura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Kanako Danno
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Kohei Mitsui
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Georgette Oni
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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