The Role of Intraoperative Perfusion Assessment: What Is the Current State and How Can I Use It in My Practice?

Evolving intraoperative technology has an increased presence and usefulness in aiding surgeon clinical judgment. Many surgical devices are readily available as an adjunct to this gold standard assessment of adequate tissue perfusion. Intraoperative perfusion monitoring provides surgeons with the ability to interpret additional information that enhances surgical decision-making in real-time. Technologies include various dye-based and non-dye-based near-infrared angiography, tissue oximetry measurements, and ultrasound-based tools. This review summarizes the available intraoperative technologies for planning and assessment of tissue perfusion in plastic and reconstructive surgery. The authors discuss the available literature for the individual devices and supporting evidence for their use. The authors recommend the evidence-based use of these tools in indicated surgical cases to improve clinical outcomes.

The perforated duodenal diverticulum.

OBJECTIVE: To perform a literature review of perforated duodenal diverticulum with attention to changes in management. DATA SOURCES: We searched PubMed for relevant studies published from January 1, 1989, through August 1, 2011. In addition, we identified and reviewed 4 cases at our institution. STUDY SELECTION: Search phrases were perforated duodenal diverticulum and duodenal diverticulitis. DATA EXTRACTION: Patient demographics, clinical characteristics, radiologic findings, treatment, and outcomes were obtained. RESULTS: We reviewed 39 studies producing 57 cases, which were combined with the 4 at our institution for a total of 61 patients. The addition of 2 previous series revealed a total of 162 patients in the world literature. Perforations were most commonly located in the second or third portion of the duodenum (60 of 61 cases [98%]), and the most frequent cause was diverticulitis (42 of 61 [69%]). There has been a dramatic improvement in the preoperative diagnosis of perforated diverticula. Only 13 of 101 reported cases (13%) were correctly diagnosed before 1989, and 29 of 61 (48%) in the present series were identified with radiologic examinations. Most patients in the current series (47 of 61) underwent operative treatment for their perforation, although 14 underwent successful nonoperative management. Complications were reported in 17 of 47 patients in the surgical group (36%), whereas only 1 complication was seen in patients undergoing nonoperative management. Mortality in the surgical group was 6% (3 of 47), and no deaths were reported in the nonoperative group. CONCLUSIONS: Perforation of a duodenal diverticulum is rare, with only 162 cases reported in the world literature. Nonoperative management has emerged as a safe, practical alternative to surgery in selected patents.