Progress in ERAS-based anesthetic management for patients undergoing deep inferior epigastric perforator flap breast reconstruction / 复旦学报（医学版）

At present,the development of enhanced recovery after surgery(ERAS)pathways in deep inferior epigastric perforator(DIEP)flap breast reconstruction is still in the initial stage worldwide,lacking established guidelines.In the multidisciplinary ERAS pathways,the department of anesthesiology is responsible for some core elements such as optimizing anestheticprotocols,perioperative fluid management and homeostasis regulation,prevention of hypothermia,improvement of perioperative analgesia,and postoperative nausea and vomiting prophylaxis.We summarized the anesthetic management in the ERAS pathways for patients undergoing DIEP flap breast reconstruction in Fudan University Shanghai Cancer Center,along with the recent progress,aiming to establish and improve the perioperative strategy based on ERAS pathways in DIEP flap breast reconstruction.

Strategies and methods of monitoring and rescue of DIEP flap in breast reconstruction (with video) / 中华内分泌外科杂志

Autologous tissue reconstruction accounts for a certain proportion in immediate or delayed breast reconstruction. Deep infra-epigastric perforator free flap has its significant advantages, gradually being widely promoted and applied in China. The success rate of DIEP surgery is generally over 95%. However, vessel crisis and flap necrosis are inevitable. Before surgery, personnel and equipment should be prepared and patients should be thoroughly evaluated. During the surgical process, it is necessary to follow certain programmed and standardized procedures. Meticulous manipulations through entire operation are the key to reduce the risk of vessel crisis. Standard of procedure for flap monitoring during and after surgery should be established, and strictly implemented. If vessel crisis occurs, timely and orderly organization, exploration, and rescue should be carried out. The surgical team should do their best to identify problems, and rescue the flap as much as possible. Ensuring the overall safety and reducing interference with subsequent adjuvant treatment for patients should be considered. Based on the author’s long-term and extensive clinical work experience, this paper shares and discusses the strategies and methods of monitoring and rescue of free flap in breast reconstruction.

Construction and application of a perioperative management program of breast reconstruction with deep inferior epigastric perforator flap in patients with breast cancer / 中华护理杂志

Objective To construct a perioperative management program for breast reconstruction with deep inferior epigastric perforator flap with breast cancer,and to provide references for clinical practice.Methods The databases at home and abroad were searched to obtain the relevant literature,and the perioperative management program of breast reconstruction with inferior epigastric artery perforator flap for breast cancer was preliminarily constructed.3 rounds of expert inquiries were conducted by Delphi method from October 2022 to January 2023 to determine the final content of the program.14 patients who received breast reconstruction with deep inferior epigastric perforator flap in a tertiary hospital in Zhejiang Province from January to May in 2023 were selected as application subjects to implement the modified program and evaluate the clinical effect.Results A total of 15 experts completed 3 rounds of consultation.In the third round of consultation,the Kendall's concordance coefficient of the importance of the first-level indicators was 0.347(P<0.05);the Kendall's concordance coefficients of the importance of the second and third-level indicators were 0.388 and 0.200(P<0.001);the coefficient of variation of each indicator was 0～0.224.The final program included 3 first-level indicators,18 second-level indicators and 67 third-level indicators.The incidence of flap complications in 14 patients decreased by 11.9%.Conclusion The perioperative management program of breast reconstruction with deep inferior epigastric perforator flap for breast cancer is preliminarily applied in clinical practice,which is scientific,reliable and practical,and it can provide references for clinical nursing.

Digital reconstruction technology in assisted design of lobulated deep inferior epigastric perforator flap for reconstruction of large defect in lower extremity / 中华显微外科杂志

Objective:To investigate the efficacy of digital reconstruction technology in assisted design of lobulated deep inferior epigastric perforator flap (DIEPF) for surgical reconstruction of large defect in lower extremity.Methods:From January 2017 to January 2022, a study was carried out to retrospectively analyse 8 patients who had massive soft tissue defects in lower extremities were admitted in the Department of Orthopaedic Surgery of the 920 Hospital of Joint Logistic Support Force of Chinese PLA. The size of defects varied from 16.0 cm×12.0 cm-28.0 cm×22.0 cm. CTA scans were performed over abdominal aorta and the arteries of lower extremities. Three-dimensional model of DIEPF and vascular pedicles were reconstructed by Mimics software. According to the shape and size of the wound, targeted perforators were determined on the 3D images, and precisely mapped in a digitised rectangular coordinate system. The lobulated flap was then digitally designed in the 3D coordinate system. Flaps were harvested according to preoperative digital designs for the reconstruction of large defects in the lower extremities. The donor site was sutured directly. The flaps and recovery of lower extremities were observed though postoperative follow-ups and were conducted through visits of outpatient clinics and distance interviews via telephone and WeChat. Recoveries of lower extremities were evaluated using Maryland ankle-foot function scoring system.Results:The 3D reconstructed models of the vessels in donor sites were successfully completed for all patients. The harvests of lobulated DIEPF were successfully guided by the digital designs. Fifteen lobes of lobulated DIEPF survived successfully in all 8 patients. All donor sites were closed in the stage-I. Necrosis occurred at the distal tip of a lobulated flap due to a local venous occlusion, and healed after debridement and re-suture. Four patients received further flap debulking surgery. Time of postoperative follow-ups had ranged 15-27 months, with an average of 20 months. At the last follow-up, all the flaps had satisfactory appearance with linear scars at the donor sites. All fractures were healed. Five patients achieved Maryland's ankle-foot function score in excellent, 2 in good, and 1 was acceptable.Conclusion:Digital reconstruction technology can accurately map the perforators and reasonably assist the design of lobulated flaps. A lobulated DIEPF offers a wider area for flap excision and allows a primary closure of the donor sites. Combination of the 2 advantages of a lobulated DIEPF can be effectively applied in reconstruction of a large-sized defect in lower extremity.

Experience of one-stage repair of the wounds after excision of soft tissue malignant tumor in lower limb by deep inferior epigastric perforator flap in 11 cases / 中华显微外科杂志

To investigate the clinical efficacy of one-stage repairing the wounds after excision of soft tissue malignant tumor in lower limb with deep inferior epigastric perforator (DIEP) flaps. Methods From Au-gust, 2016 to July, 2018, 11 patients(8 males and 3 females; aged 35-76 years) with the soft tissue defects in the low-er limb underwent immediate reconstructive operations with DIEP flap after their tumor resection. The defects ranged in area from 11 cm×7 cm to 25 cm×10 cm after extended resection, including 5 cases of bone exposure. The DIEP flap area ranged from 11 cm×8 cm to 26 cm×18 cm.Among them, 9 cases were treated with free transplantation and 2 cases with pedicle transplantation.The donor sites were closed directly. The patients’ limb function, tumor recurrence and the healing of surgical incision had been followed-up. Results Eleven flaps survived and the donor sites healed directly. One flap had skin pigmentation due to postoperative vascular crisis, and the other flaps had satisfied texture and appearance. All patients were followed-up from 6 to 30 months. The lower limb movement was normal. All the donor sites had a good healing with no pain and abdominal complications. No tumor recurrence was observed during the followed-up period. Conclusion DIEP flap have many advantages, such as large cutting area, which is suitable for large-area wound repair after extended excision of soft tissue malignant tumor in lower limb. At the same time, the perforator vessel is constant and the caliber are thick, also the donor area is concealed and can be sutured directly.This kind of the technique for reconstruction of lower limb soft tissue defects after malignant tumor resection is well acceptable.

Clinical application of deep inferior epigastric perforator flap in repair of soft tissue defects of the calf / 中华显微外科杂志

Objective To investigate the clinical efficacy of deep inferior epigastric perforator (DIEP) flap in the repair of soft tissue defects of the calf.Methods From January,2015 to January,2017,the DIEP flap was used to repair the soft tissue defect of calf in 11 patients,which were 7 males and 4 females,aged 23-62 years,with an average age of 42 years.Among them,there were 5 cases of anterior tibial soft tissue defect and 6 cases of posterior tibial soft tissue defect.The size of soft tissue defects ranged from 9.0 cm×5.0 cm to 32.0 cm×12.0 cm.The wounds were heavily polluted and debridement exploration combined VSD surgery in emergency.After 7 to 14 days,free deep inferior epigastric perforator flap was used to repaire.The flap was cut in the range of 10.0 cm×6.0 cm-34.0 cm×13.0 cm.Nine cases of abdominal donor sutured direct,and a small part of 2 cases to take thigh thick skin graft repair.Results All the flaps survived.In only 1 patient,the distal part of the flap was necrotic and healed after appropriate treatment.Eleven patients were followed-up for 3-18 months (average of 10 months).The shape of the flap was similar to that of the affected area.The texture was soft and not bloated.Conclusion The DIEP flap can provide reliable blood supply,large cutting area and flexible design.It can be used to repair soft tissue defect of calf and obtain satisfactory clinical results.

Free DIEP and ALTP flaps in repairing skin and soft tissue defects in chest wall: A case report / 吉林大学学报(医学版)

Objective: To summarize the therapeutic effect of free deep inferior epigastric perforator (DIEP) flap and anterolateral thigh perforator (ALTP) flap in repairing skin and soft tissue defects in chest wall tumor resection.Methods: One old male patient with malignant fibrous histiocytoma of chest wall in China-Japan Union Hospital received operation,and the tumor was extendedly resected.The remaining chest wall defects were 10 cm×10 cm and 18 cm×14 cm,respectively.Free DIEP and ALTP flaps were used to repair the defects,and vascular pedicle was anastomosed with internal mammary artery and thoracic lateral artery,respectively.Results:After operation,the donor area was sutured directly,and two flaps survived with good appearance.The skin of ALTP flap was flatter than that of DIEP flap,and the texture and color of skin were close to those around chest wall.Conclusion:Free DIEP and ALTP flaps are ideal choice for repairing skin and soft tissue defects after resection in the male patient with chest wall tumor.

Satisfaction and complications of free deep inferior epigastric perforator flap for breast reconstruction / 中华医学美学美容杂志

Objective To evaluate satisfaction and complications of deep inferior epigastric perforator (DIEP) flaps breast reconstruction afer mastectomy in breast cancer patients.Methods The 26 consecutive breast cancer patients who underwent DIEP flap breast reconstruction were collected.General patient satisfaction and esthetic satisfaction with DIEP flap breast reconstruction were accessed using a study-specific questionnaire modified from the Michigan Breast Reconstruction Outcome Study.Results Flap success rate was 100％.The general satisfaction of DIEP breast reconstruction was 61.9％ (13/21),and the esthetic satisfaction was 66.7％ (14/21).Age (≤40 years old was 81.8％ [9/11],＞40 years old was 40.0％ [4/10],P=0.049) and previous abdominal wall surgery (no previous abdominal wall surgery was 75.0％ [12/16] and previous abdominal wall surgery was 20.0％ [1/5],P=0.027) were significant negative factors affecting general satisfaction;Body mass index (BMI ＜25 kg/m2 was 76.5％ [11/17],BMI 25-30 kg/m2 was 50.0％ [2/4],P=0.049) was a statistically significant factor associated with esthetic satisfaction.Four flaps presented venous congestion.One patient had fat necrosis and one had flap infection of the reconstructed breast.One patient had a decrease in abdominal rotational strength.Conclusions DIEP flap breast reconstruction will offer distinct advantages to patients,in terms of decreased donor-site morbidity and shorter recovery periods.

Perforator identification before DIEP dissection for the patient with abdominal scar: one case report / 中华显微外科杂志

Objective To investigate the effect of perforator identification before DIEP flap dissection for the patient with abdominal scar.Methods Preoperative multidetector-row computed tomography angiography was used to identify that the dominant perforators of the abdominal wall were not damaged completely.During the second stage breast reconstruction operation,the located dominant perforator and the DIEP flap were dissected.Results The dominant perforator located by MDCTA was identified with the exploration in operation.Follow-up for half a year,the flap survived well and the patient was satisfied with the appearance.Conclusion Abdominal scar was not the definite contraindication for DIEP flap.MDCTA provided a good quality evaluation of the perforator vessels.The located dominant perforator was dissected to confirm the blood supply of the DIEP flap.Identification of perforator can be used as a routine preoperative evaluation for patients with scar on donor site.

Comparison of the deep inferior epigastric perforator and pedicled transverse rectus abdominis myocutaneous flap / 中国综合临床

Objective To compare the complication and cost-effectiveness of the deep inferior epigastric perforator(DIEP) flap and transverse rectus abdominis myocutaneous(TRAM) flap.Methods From January 2000 to December 2014,all patients who underwent DIEP flap and TRAM flap in the People's Hospital of Tangshan and the Affiliated Hospital of North China University of Science and Technology, were selected.Eleven patients underwent immediate breast reconstruction with TRAM flaps and 19 patients with DIEP flaps.The treatment cost,length of hospitalization, and complication in the two year after surgery for each group were compared.Results For the major complications,there were 5 cases appeared fat necrosis in TRAM group, and 1 case in DIEP group,the differences was statistically significant(P=0.016).One case appeared flap loss in TRAM group,and DIEP group was zero,both of the two group had no abdominal wall hernia, there was no significant difference (P ＞ 0.05).For the minor complications, there were 4 cases appeared postoperative hematoma in TRAM group, and 1 case in DIEP group, the difference was statistically significant(P =0.047).Two cases appeared wound dehiscence in TRAM group,and DIEP group was 1 case, 1 case happened infection in TRAM group,there was no statistically significant difference(P＞0.05).The treatment costs were (14 133.12±1 546.88)yuan for the TRAM group and (16 838.94± 3 006.05)yuan the DIEP group, the difference was statistically significant (P =0.010).The hospital stay was (17.28± 2.08)days for the pedicled TRAM group and (18.39±2.87) days for the DIEP group,the different was not statistically significant(P＞0.05).Conclusion The DIEP flap has a better clinical outcomes,but more expensive.

Soft tissue repair of large defects of lower limbs with deep inferior epigastric perforator flap / 中华显微外科杂志

Objective To study the method and effect of deep inferior epigastric perforator flap(DIEP)in repairing the large defects of lower limbs.Methods Eight cases,from July 2009 to November 2011,including 3 cases of plantar skin defects with bone exposure after foot injuries,three cases of plate exposure after tibia fracture surgery and 2 cases of heel repeated ulceration after skin graft,were repaired by deep inferior epigastric perforator flap.Results All deep inferior epigastric perforator flaps survived with good functions,except 1 case whose distal with poor blood supply and the flap survived after treatmenting,three cases of flap bloated with good appearances after second operation.Conclusion DIEP is a proper option for repair of large defects of lower limbs.It has the advantages of abundant blood supply,large flap area,abdomen can suturing without abdominal complications.

Application of Perforator Flap for the Oral and Maxillofacial Reconstruction