Der sichere Lappen – Präoperatives Gefäß-Mapping und intraoperative Perfusionsmessung zur Reduktion der lappenbedingten Morbidität

D. Schmauss; J.P. Beier; S.U. Eisenhardt; R.E. Horch; A. Momeni; M. Rab; B. Rieck; U. Rieger; D.J. Schaefer; V.J. Schmidt; U. Kneser

doi:10.1055/a-0987-0118

Handchirurgie · Mikrochirurgie · Plastische Chirurgie, Table of Contents

Handchir Mikrochir Plast Chir 2019; 51(06): 410-417
DOI: 10.1055/a-0987-0118

Consensus Statement

Der sichere Lappen – Präoperatives Gefäß-Mapping und intraoperative Perfusionsmessung zur Reduktion der lappenbedingten Morbidität

Konsensuspapier der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und GefäßeThe „safe“ flap – Preoperative perforator-mapping and intraoperative perfusion assessment to reduce flap-associated morbidityConsensus statement of the German Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels

D. Schmauss

¹Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Schweiz

²Klinik für Plastische Chirurgie und Handchirurgie, Klinikum Rechts der Isar, Technische Universität München

,

J.P. Beier

³Klinik für Plastische Chirurgie, Hand- und Verbrennungschirurgie, Universitätsklinik RWTH Aachen

,

S.U. Eisenhardt

⁴Klinik für Plastische und Handchirurgie, Medizinische Fakultät, Universitätsklinikum Freiburg

,

R.E. Horch

⁵Plastisch- und Handchirurgische Klinik, Universitätsklinikum Erlangen, Friedrich Alexander Universität Erlangen-Nürnberg FAU

,

A. Momeni

⁶Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA, USA

,

M. Rab

⁷Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Klinikum Klagenfurt, Österreich

,

B. Rieck

⁸Klinik für Plastische, Ästhetische und Handchirurgie, Helios Klinikum Hildesheim

,

U. Rieger

⁹Klinik für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus Frankfurt

,

D.J. Schaefer

¹⁰Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Schweiz

,

V.J. Schmidt

¹¹Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Hand- und Plastische Chirurgie der Universität Heidelberg

,

U. Kneser

¹¹Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Hand- und Plastische Chirurgie der Universität Heidelberg

› Author Affiliations

Abstract

Zusammenfassung

Die rekonstruktive Mikrochirurgie mittels freier und gefäßgestielter Lappenplastiken ist heutzutage ein zuverlässiges Standardverfahren mit hohen Erfolgsraten. Um die Lappen-bedingte Morbidität noch weiter zu senken und die Eingriffe noch sicherer und vorhersehbarer zu gestalten, gewinnt das präoperative Gefäß-Mapping und die intraoperative Perfusionsmessung immer mehr an Bedeutung. Sowohl für das Gefäß-Mapping, als auch die Perfusionsmessung stehen verschiedene Methoden zur Verfügung, für deren Verwendung es jedoch keine Empfehlung gibt. In einem Konsensus-Workshop der 40. Jahrestagung der deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) wurde die Datenlage in einer Expertenrunde kritisch geprüft und ein Konsensus erarbeitet. Dieser stellt zum einen das Meinungsbild der Expertenrunde dar und gibt zum anderen vor dem Hintergrund der aktuellen Literatur Empfehlungen zur Verwendung des präoperativen Gefäß-Mappings und der intraoperativen Perfusionsmessung.

Abstract

Reconstructive microsurgery using free and pedicled flaps has become a reliable method with a high success rate. Preoperative perforator mapping and intraoperative assessment of perfusion might further reduce flap-associated morbidity.

There are various techniques for perforator mapping and perfusion measurement, but no guidelines regarding their use. Therefore, an expert panel at the 40th Annual Meeting of the German-Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels (DAM) discussed and critically reviewed the current literature. The consensus statement represents the expert opinion based on the available literature and provides recommendations regarding the use of preoperative perforator mapping and intraoperative perfusion measurement.

Schlüsselwörter

Mikrochirurgie - freie Lappenplastiken - gestielte Lappenplastiken - Perforans-Lappenplastiken - bildgebende Verfahren

Key words

Microsurgery - free flap grafts - pedicled flap grafts - perforator flap grafts - imaging procedures

Full Text

References

Literatur
1 Ludolph I, Lehnhardt M, Arkudas A. et al. [Plastic reconstructive microsurgery in the elderly patient – Consensus statement of the German Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels]. Handchir Mikrochir Plast Chir 2018; 50: 118-125
2 Bigdeli AK, Gazyakan E, Schmidt VJ. et al. Indocyanine Green Fluorescence for Free-Flap Perfusion Imaging Revisited: Advanced Decision Making by Virtual Perfusion Reality in Visionsense Fusion Imaging Angiography. Surg Innov 2016; 23: 249-260
3 Zhang Y, Gazyakan E, Bigdeli AK. et al. Soft tissue free flap for reconstruction of upper extremities: A meta-analysis on outcome and safety. Microsurgery. 2019 [Epub ahead of print] Review
4 Wade RG, Watford J, Wormald JCR. et al. Perforator mapping reduces the operative time of DIEP flap breast reconstruction: A systematic review and meta-analysis of preoperative ultrasound, computed tomography and magnetic resonance angiography. J Plast Reconstr Aesthet Surg 2018; 71: 468-477
5 Teunis T, Heerma van Voss MR, Kon M. et al. CT-angiography prior to DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurgery 2013; 33: 496-502
6 Malhotra A, Chhaya N, Nsiah-Sarbeng P. et al. CT-guided deep inferior epigastric perforator (DIEP) flap localization – better for the patient, the surgeon, and the hospital. Clin Radiol 2013; 68: 131-138
7 Ludolph I, Arkudas A, Schmitz M. et al. Cracking the perfusion code?: Laser-assisted Indocyanine Green angiography and combined laser Doppler spectrophotometry for intraoperative evaluation of tissue perfusion in autologous breast reconstruction with DIEP or ms-TRAM flaps. J Plast Reconstr Aesthet Surg 2016; 69: 1382-1388
8 Taylor GI, Doyle M, McCarten G. „The Doppler probe for planning flaps: anatomical study and clinical applications.“. Br J Plast Surg 1990; 43: 1-16
9 Blondeel PN, Beyens G, Verhaeghe R. et al. „Doppler flowmetry in the planning of perforator flaps.“. Br J Plast Surg 1998; 51: 202-209
10 Dorfman D, Pu LL. The value of color duplex imaging for planning and performing a free anterolateral thigh perforator flap. Ann Plast Surg 2014; 72 (Suppl. 01) 6-8
11 Giunta RE, Geisweid A, Feller AM. „The value of preoperative Doppler sonography for planning free perforator flaps.“. Plast Reconstr Surg 2000; 105: 2381-2386
12 Ensat F, Babl M, Conz C. et al. [Doppler sonography and colour Doppler sonography in the preoperative assessment of anterolateral thigh flap perforators]. Handchir Mikrochir Plast Chir 2011; 43: 71-75
13 Ensat F, Babl M, Conz C. et al. The efficacy of color duplex sonography in preoperative assessment of anterolateral thigh flap. Microsurgery 2012; 32: 605-610
14 Debelmas A, Camuzard O, Aguilar P. et al. Reliability of Color Doppler Ultrasound Imaging for the Assessment of Anterolateral Thigh Flap Perforators: A Prospective Study of 30 Perforators. Plast Reconstr Surg 2018; 141: 762-766
15 Masia J, Clavero JA, Larrañaga JR. et al. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006; 59: 594-599
16 Masia J, Clavero JA, Larrañaga J. et al. Preoperative planning of the abdominal perforator flap with multidetector row computed tomography: 3 years of experience. Plast Reconstr Surg 2008; 122: 80-81
17 Smit JM, Dimopoulou A, Liss AG. et al. Preoperative CT angiography reduces surgery time in perforator flap reconstruction. J Plast Reconstr Aesthet Surg 2009; 62: 1112-1117
18 Haubenreisser H, Bigdeli A, Meyer M. et al. From 3D to 4D: Integration of temporal information into CT angiography studies. Eur J Radiol 2015; 84: 2421-2424
19 Schaverien MV, Ludman CN, Neil-Dwyer J. et al. „Contrast-enhanced magnetic resonance angiography for preoperative imaging of deep inferior epigastric artery perforator flaps: advantages and disadvantages compared with computed tomography angiography: a United Kingdom perspective.“. Ann Plast Surg 2011; 67: 671-674
20 Ahn CY, Narayanan K, Shaw WW. „In vivo anatomic study of cutaneous perforators in free flaps using magnetic resonance imaging.“. J Reconstr Microsurg 1994; 10: 157-163
21 Cina A, Barone-Adesi L, Rinaldi P. et al. Planning deep inferior epigastric perforator flaps for breast reconstruction: a comparison between multidetector computed tomography and magnetic resonance angiography. Eur Radiol 2013; 23: 2333-2343
22 Rozen WM, Anavekar NS, Ashton MW. et al. Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction?. Microsurgery 2008; 28: 516-523
23 Schaverien MV, Ludman CN, Neil-Dwyer J. et al. Contrast-enhanced magnetic resonance angiography for preoperative imaging in DIEP flap breast reconstruction. Plast Reconstr Surg 2011; ; 128: 56-62
24 Schaverien MV, Ludman CN, Neil-Dwyer J. et al. „Relationship between venous congestion and intraflap venous anatomy in DIEP flaps using contrast-enhanced magnetic resonance angiography.“. Plast Reconstr Surg 2010; 126: 385-392
25 Burnier P, Niddam J, Bosc R. et al. Indocyanine green applications in plastic surgery: A review of the literature. J Plast Reconstr Aesthet Surg 2017; 70: 814-827
26 Alonso-Burgos A, García-Tutor E, Bastarrika G. et al. Preoperative planning of DIEP and SGAP flaps: preliminary experience with magnetic resonance angiography using 3-tesla equipment and blood-pool contrast medium. J Plast Reconstr Aesthet Surg 2010; 63: 298-304
27 Casey 3rd WJ, Chew RT, Rebecca AM. et al. Advantages of preoperative computed tomography in deep inferior epigastric artery perforator flap breast reconstruction. Plast Reconstr Surg 2009; 123: 1148-1155
28 Busic V, Das-Gupta R, Mesic H. et al. The deep inferior epigastric perforator flap for breast reconstruction, the learning curve explored. J Plast Reconstr Aesthet Surg 2006; 59: 580-584
29 Offodile 2nd AC, Chatterjee A, Vallejo S. et al. A cost-utility analysis of the use of preoperative computed tomographic angiography in abdomen-based perforator flap breast reconstruction. Plast Reconstr Surg 2015; 135: 662-669
30 Brenner DJ, Hall EJ. Cancer risks from CT scans: now we have data, what next?. Radiology 2012; 265: 330-331
31 Chernyak V, Rozenblit AM, Greenspun DT. et al. Breast reconstruction with deep inferior epigastric artery perforator flap: 3.0-T gadolinium-enhanced MR imaging for preoperative localization of abdominal wall perforators. Radiology 2009; 250: 417-424
32 Scott JR, Liu D, Said H. et al. Computed tomographic angiography in planning abdomen-based microsurgical breast reconstruction: a comparison with color duplex ultrasound. Plast Reconstr Surg 2010; 125: 446-453
33 Rother U, Lang W, Horch RE. et al. Pilot Assessment of the Angiosome Concept by Intra-operative Fluorescence Angiography After Tibial Bypass Surgery. Eur J Vasc Endovasc Surg 2018; 55: 215-221
34 Rother U, Lang W, Horch RE. et al. Microcirculation Evaluated by Intraoperative Fluorescence Angiography after Tibial Bypass Surgery. Ann Vasc Surg 2017; 40: 190-197
35 Rother U, Krenz K, Lang W. et al. Immediate changes of angiosome perfusion during tibial angioplasty. J Vasc Surg 2017; 65: 422-430
36 Griffiths M, Chae MP, Rozen WM. Indocyanine green-based fluorescent angiography in breast reconstruction. Gland Surg 2016; 5: 133-149
37 Buehrer G, Taeger CD, Ludolph I. et al. Intraoperative flap design using ICG monitoring of a conjoined fabricated anterolateral thigh/tensor fasciae latae perforator flap in a case of extensive soft tissue reconstruction at the lower extremity. Microsurgery 2016; 36: 684-688
38 Beier JP, Horch RE, Arkudas A. et al. Decision-making in DIEP and ms-TRAM flaps: the potential role for a combined laser Doppler spectrophotometry system. J Plast Reconstr Aesthet Surg 2013; 66: 73-79