Iain Whitaker

Cronfa at Swansea University

 Cronfa -  Swansea University Open Access Repository   _____________________________________________________________   This is an author produced version of a paper published in :Anticancer Research                                       Cronfa URL for this paper:http://cronfa.swan.ac.uk/Record/cronfa21389_____________________________________________________________ Paper:Rozen, W., Acosta, R. & Whitaker, I. (2010).  Venous coupler for free-flap anastomosis: outcomes of 1,000 cases..Anticancer Research, 30(4), 1293-1294.        _____________________________________________________________  This article is brought to you by Swansea University. Any person downloading material is agreeing to abide by theterms of the repository licence. Authors are personally responsible for adhering to publisher restrictions or conditions.When uploading content they are required to comply with their publisher agreement and the SHERPA RoMEOdatabase to judge whether or not it is copyright safe to add this version of the paper to this repository. http://www.swansea.ac.uk/iss/researchsupport/cronfa-support/  Abstract. Since the advent of microvascular free tissuetransfer, adjunctive surgical techniques have become soughtas a means to improving overall surgical time and outcomesin oncological surgery. Anastomotic devices have providedone such avenue, with staples and coupling devicessuggested as an alternative to traditional suturing. Wedescribe our experience with two such devices, automaticstaples and the anastomotic ring coupler, in 1,000 cases offree tissue transfer. In 1,400 anastomoses, there was asignificant reduction in anastomotic time from suturing (22minutes) with the use of staples (15 minutes) or the ringcoupler (4 minutes), p<0.01. This was without any increasein complication rates. These findings support the use of thesedevices and suggest an increasing role for modern devicesin microvascular surgery.Reconstructive surgery following oncological resections hasadvanced considerably since the advent of microvascularfree-flap techniques in 1973 (1, 2). Free tissue transfer hasenabled larger and more complex defects to be adequatelyreconstructed with a range of donor sites, and has facilitatedwider oncological resections. Free-flap surgery necessarilyrequires the anastomosis of an artery and vein at the recipientsite in order to provide a blood supply to the transferredtissue, and for many years the gold standard has beenmicrovascular anastomosis with sutures.More recently, advanced anastomotic devices have beendeveloped to aid arterial and venous anastomosis, with the useof staples and the ‘anastomotic ring coupler’ being the morewidely discussed modern techniques. A recent article byCamara et al. described the use of anastomotic couplers for usein free deep inferior epigastric artery perforator (DIEP) flapsurgery (3), which demonstrated the utility of the anastomoticcoupler in 12 free flaps. We have now utilized these devices inover 1000 free flaps and would like to share our experience.Patients and MethodsA cohort study was undertaken, with 1,000 consecutive patientsundergoing a range of reconstructive procedures recruited through asingle institution. This comprised breast reconstructive cases (600cases), extremity reconstruction (150 cases) and head and neck cases(250 cases). Three modes of vascular anastomosis were performed:standard sutures, the ‘Anastoclip’ Vascular Closure Staples (VCS)micro-staple clips (AnastoClip Vessel Closure System, Le MaitreVascular Inc, Sulzbach, Germany) and a microvascular anastomoticcoupling device (Microvascular Anastomotic Coupling System, SynovisMicro Companies Alliance Inc, St Paul, MN, USA). Our preliminaryuse of these anastomotic procedures has been described (4).The devices were applied intraoperatively by the primary surgeonin each case, with decision to use the particular device at thediscretion of the surgeon. There were no particular intraoperativecriteria for selection of a particular anastomotic technique. For thering coupler, vessel wall eversion was achieved with the deviceitself, while for stapled anastomoses eversion was achieved with acombination of stay sutures and everting forceps in order to achieveideal intima-to-intima apposition.Two main outcome parameters were assessed: anastomotic timeand anastomotic failure. Anastomotic times were recorded by thescout nurse in each case, and anastomotic failure was confirmed intheatre at revision surgery. Data were analysed statistically with theFisher exact test, with a p-value of less than 0.05 considered ashaving statistical significance.ResultsIn 1,000 reconstructive cases, 2,500 vascular anastomoseswere performed, of which 1,400 comprised the use of eitherof the two adjunctive anastomotic devices. These devices1293Correspondence to: Dr. Warren M. Rozen, Jack BrockhoffReconstructive Plastic Surgery Research Unit, Room E533,Department of Anatomy and Cell Biology, The University ofMelbourne, Grattan St, Parkville, 3050, Victoria, Australia. Tel: +61393475939, email: warrenrozen@hotmail.comKey Words: Breast reconstruction, deep inferior epigastric artery,perforator flap, venous, arterial, anastomosis.ANTICANCER RESEARCH 30: 1293-1294 (2010)Venous Coupler for Free-Flap Anastomosis: Outcomes of 1,000 CasesWARREN M. ROZEN1, IAIN S. WHITAKER2 and RAFAEL ACOSTA31Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Room E533, Department of Anatomy and Cell Biology,The University of Melbourne, Grattan St, Parkville, 3050, Victoria, Australia;2Department of Plastic, Reconstructive and Burns Surgery, The Welsh National Plastic Surgery Unit, The Morriston Hospital, Swansea, U.K.;3Department of Plastic Surgery, Uppsala Clinic Hospital, Uppsala, 75185, Sweden0250-7005/2010 $2.00+.40were thus used in 80% of all venous anastomoses and 10% ofall arterial anastomoses, with the anastomotic ring coupler usedin 1,000 cases and staples in 400 cases. In cases of suturedanastomoses, mean anastomotic time was 22 minutes,compared to 15 minutes with staples and 4 minutes for the ringcoupler, a significant reduction in anastomotic times with theuse of these devices (p<0.01). In terms of anastomotic failures,there were 90 failures overall, of which 12 were arterial failuresand 78 were venous failures. Of these, all arterial failures weresutured (no stapled or coupled arterial anastomoses failed), andof the venous failures, 29 were sutured, 20 were stapled and29 were coupled (p>0.05).DiscussionWe have used the Unilink ring system anastomotic coupler(Meteko Instrument AB, Stockholm, Sweden) for over 10years, in a range of donor site and recipient sites for a range ofreconstructive needs, including reconstruction of the breast,head and neck and extremities. In addition, we have usedanastomotic couplers for both arterial and venous anastomoses.The range of potential applications for anastomotic couplers isthus ever increasing. An additional device that works as anadjunctive tool to the coupler is the use of micro-clips. TheVCS clip-applier system (Autosuture Norden, Stockholm,Sweden) is particularly useful for vessels with somewhatthicker walls than would be suitable for an anastomotic coupler.In our experience, both techniques are able to reduce operativetimes over sutured anastomoses, without any detriment tosurgical outcomes. In 1,000 free flaps in which we used theanastomotic coupler, the mean reduction in time with the use ofa ring coupled anastomosis was 15 minutes as compared tosutured anastomosis (p<0.001).The surgical anastomosis itself is just one of several aspectsof microvascular surgery that have reaped the reward oftechnological advances in the field. The ability topreoperatively select the optimal vessels of choice for inclusionin the vascular pedicle has been shown to improve a range ofoperative outcomes, with techniques that have now beenestablished comprising color duplex ultrasound (5), computedtomographic angiography (6), and magnetic resonanceangiography (7). Developing and future techniques include theuse of ‘virtual’ image-guided stereotactic navigation pre- andintra-operatively (8). In addition to preoperative techniques,new techniques in the intraoperative mapping of vasculaturehave been shown to accurately map the vascular territories ofselected vessels, enabling improved flap design and harvest (9).Vascular monitoring postoperatively has also beenrevolutionized with the use of pedicle monitoring techniquessuch as the implantable Doppler probe, which has been shownto rapidly identify vascular complications (such as thrombosis,compression or kinking) and potentiate rapid return to theatreand flap salvage (10).ConclusionThe use of adjunctive anastomotic devices can improveoperating times without detriment to free-flap outcomes. Withongoing advances, it is likely that outcomes in free-flap surgerywill continue to improve, surgical times continue to be reduced,and this complex surgery will be able to be more widelyincorporated into routine clinical practice.AcknowledgementsThe content of this article has not been submitted or publishedelsewhere. There was no source of funding for the article. The authors declare that there is no source of financial or othersupport, or any financial or professional relationships which may posea competing interest.Conflicts of InterestNone.References1 Daniel RK and Taylor GI: Distant transfer of an island flap bymicrovascular anastomoses. Plast Reconstr Surg 52: 111-117, 1973.2 Taylor GI and Daniel RK: The free flap: composite tissue transferby vascular anastomosis. Aust N Z J Surg 43: 1-3, 1973.3 Camara O, Herrmann J, Egbe A, Koch I, Gajda M and RunnebaumIB: Venous coupler for free-flap anastomosis. Anticancer Res 29:2827-2830, 2009.4 Zeebregts C, Acosta R, Bölander L, van Schilfgaarde R andJakobsson O: Clinical experience with non-penetrating vascularclips in free-flap reconstructions. Br J Plast Surg 55: 105-110, 2002.5 Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN andTaylor GI: Preoperative imaging for DIEA perforator flaps: acomparative study of computed tomographic angiography andDoppler ultrasound. Plast Reconstr Surg 121: 9-16, 2008.6 Rozen WM, Garcia-Tutor E, Alonso-Burgos A, Acosta R, StillaertF, Zubieta JL, Hamdi M, Whitaker IS and Ashton MW: Planningand optimizing DIEP flaps with virtual surgery: the Navarraexperience. J Plast Reconst Aesth Surg 63: 289-297, 2010.7 Rozen WM, Stella DL, Bowden J, Taylor GI and Ashton MW:Advances in the preoperative planning of DIEA perforator flaps:magnetic resonance angiography. Microsurgery 29: 119-123, 2009.8 Rozen WM, Ashton MW, Stella DL, Phillips TJ and Taylor GI:Stereotactic image-guided navigation in the preoperative imagingof perforators for DIEP flap breast reconstruction. Microsurgery28: 417-423, 2008.9 Holm C, Mayr M, Höfter E, Raab N and Ninkovic M:Interindividual variability of the SIEA angiosome: effects onoperative strategies in breast reconstruction. Plast Reconstr Surg122: 1612-1620, 2008.10 Smit JM, Whitaker IS, Liss AG, Audolfsson T, Kildal M andAcosta R: Postoperative monitoring of microvascular breastreconstructions using the implantable Cook-Swartz doppler system:a study of 145 probes and technical discussion. J Plast ReconstrAesthet Surg 62: 1286-1292, 2009.Received December 1, 2009Revised March 16, 2010Accepted March 16, 2010ANTICANCER RESEARCH 30: 1293-1294 (2010)1294

Venous coupler for free-flap anastomosis: outcomes of 1,000 cases.

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