Abstract
Background: Anaesthetic management for microvascular reconstructive surgery is challenging and clearly affects the risk of major complications such as flap hypo-perfusion. In this systematic review we explore recent (last 7 years) clinical evidences related to perioperative management and anaesthetic controversy of patients undergoing microvascular reconstructive surgery, especially focused on head and neck surgery with free flaps (FF) and breast reconstructive surgery with deep inferior epigastric perforator flap (DIEP-flap). Methods: A literature search of published clinical studies between 2011 and 2018 was conducted, yielding a total of 4307 papers. Only 150 were eligible, according inclusion and exclusion criteria. Results: 62 studies were selected for this review and categorized in 3 groups: preoperative-intraoperativepostoperative anaesthetic management and areas of controversy for patients undergoing head and neck surgery with FF and breast reconstructive surgery with DIEP-flap. Discussion: Anaesthetic management for flap reconstructive surgery remains an open field of interest with limited evidences regarding a standard care. Main components of research currently are: the need to join standard multidisciplinary enhanced recovery pathways, as well as the necessity to develop a standard intraoperative management. In theatre, the recent hemodynamic parameter “Hypotension Probability Indicator” (HPI) is promising: the advantage to predict a drop in the mean arterial pressure can be more effective than a fluid therapy titrated to maintain SVV less than 13%. Prospective studies are necessary to clarify.
Highlights
IntroductionMicrovascular flap surgery is one of the best and fine options for reconstruction in head and neck cancer patients, plastic, trauma and burns [1]
Microvascular flap surgery is one of the best and fine options for reconstruction in head and neck cancer patients, plastic, trauma and burns [1].Anaesthetic management in these settings has limited evidences of standard care and clearly affects the outcome, with high impact on flap survival
Key words used for literature search were “Intraoperative management for free flap surgery”; “Anaesthetic management for microvascular reconstructive surgery”; “Perioperative management for microvascular surgery”; “Anaesthetic assessment for flap reconstructive surgery”; “Anaesthesia for head and neck reconstructive surgery”; “Anaesthesia for plastic reconstructive surgery”; “ERAS protocols for microvascular reconstructive surgery”; “Haemodynamic monitoring in flap reconstructive surgery”; “Goal-directed therapy for reconstructive surgery”; “Blood loss management in reconstructive flap surgery”; “Postoperative care for flap reconstructive surgery”
Summary
Microvascular flap surgery is one of the best and fine options for reconstruction in head and neck cancer patients, plastic, trauma and burns [1]. Anaesthetic management in these settings has limited evidences of standard care and clearly affects the outcome, with high impact on flap survival. In this systematic review we explore recent (last 7 years) clinical evidences related to perioperative management and anaesthetic controversy of patients undergoing microvascular reconstructive surgery, especially focused on head and neck surgery with free flaps (FF) and breast reconstructive surgery with deep inferior epigastric perforator flap (DIEP-flap)
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