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Observational Study
. 2025 May;72(5):768-779.
doi: 10.1007/s12630-025-02941-3. Epub 2025 May 12.

The effect of major abdominal surgery on the sublingual microcirculation: an observational study

Moritz Flick  1 , Gyde P Jannsen  1 , Linda Krause  2 , Jonathan Montomoli  3 , Franziska Pollok  1 , Parisa Moll-Khosrawi  1 , Karim Kouz  1   4 , Alina Bergholz  1 , Kristen K Thomsen  1   4 , Matthias P Hilty  5 , Can Ince  6 , Christian Zöllner  1 , Bernd Saugel  7   8
Affiliations
Observational Study

The effect of major abdominal surgery on the sublingual microcirculation: an observational study

Moritz Flick et al. Can J Anaesth. 2025 May.

Abstract
in English, French

Purpose: It remains unknown whether the sublingual microcirculation is impaired during noncardiac surgery. We, therefore, aimed to investigate the sublingual microcirculation in patients undergoing major abdominal surgery. Specifically, we sought to test the primary hypothesis that the sublingual microcirculation is persistently impaired during major abdominal surgery.

Methods: In this prospective observational study, we assessed the sublingual microcirculation using vital microscopy before induction of general anesthesia, at the time of surgical incision, every 20 min during surgery, and on the first postoperative day in 46 patients undergoing major abdominal surgery. The primary endpoint was the area under a proportion of perfused vessels (PPV) of 92% as a measure of the duration and severity of capillary red blood cell flow impairment.

Results: The median [interquartile range (IQR)] intraoperative area under a PPV of 92% was 71%⋅min [2%⋅min-278%⋅min], and the median [IQR] time-weighted average PPV < 92% was 0.3% [0%-0.9%]. Twelve patients (26%) had an area under a PPV of 92% of 0%⋅min, and five patients (11%) had an area under a PPV of 92% of 400%⋅min or higher. The duration of surgery had no clinically important persistent effect on intraoperative PPV or any other sublingual microcirculation variable. The lowest intraoperative PPV was lower than the PPV at incision (estimated difference, -5.3%; 95% confidence interval, -6.3 to -4.4; P < 0.001).

Conclusions: The area under a PPV of 92% during elective major abdominal surgery was small, indicative of little impairment of sublingual microcirculation. The duration of surgery had no clinically important effect on sublingual microcirculatory variables.

RéSUMé: OBJECTIF: On ne sait pas si la microcirculation sublinguale est altérée lors d’une chirurgie non cardiaque. Pour cette raison, notre objectif était d’étudier la microcirculation sublinguale chez les personnes bénéficiant d’une chirurgie abdominale majeure. Plus précisément, nous avons cherché à tester l’hypothèse primaire selon laquelle la microcirculation sublinguale est altérée de manière constante lors d’une chirurgie abdominale majeure. MéTHODE: Dans cette étude observationnelle prospective, nous avons évalué la microcirculation sublinguale à l’aide de la microscopie vitale avant l’induction de l’anesthésie générale, au moment de l’incision chirurgicale, toutes les 20 min pendant l’intervention, et le premier jour postopératoire chez 46 patientes et patients bénéficiant d’une chirurgie abdominale majeure. Le critère d’évaluation principal était l’aire sous une proportion de vaisseaux perfusés de 92 % comme mesure de la durée et de la gravité de l’altération du débit des globules rouges capillaires. RéSULTATS: La région médiane [écart interquartile (ÉIQ)] peropératoire sous une proportion de vaisseaux perfusés de 92 % était de 71 %⋅min [2 %⋅min–278 %⋅min] et la proportion médiane [ÉIQ] pondérée dans le temps de vaisseaux perfusés < 92 % était de 0,3 % [0 % à 0,9 %]. Douze personnes (26 %) avaient une aire sous proportion de vaisseaux perfusés de 92 % de 0 %⋅min, et cinq (11 %) avaient une aire sous une proportion de vaisseaux perfusés de 92 % de 400 %⋅min ou supérieur. La durée de la chirurgie n’a pas eu d’effet persistant cliniquement significatif sur la proportion peropératoire de vaisseaux perfusés ou toute autre variable de la microcirculation sublinguale. La proportion peropératoire de vaisseaux perfusés la plus faible était inférieure à la proportion de vaisseaux perfusés à l’incision (différence estimée, −5,3 %; intervalle de confiance à 95 %, −6,3 à −4,4; P < 0,001). CONCLUSION: L’aire sous une proportion de vaisseaux perfusés de 92 % lors d’une chirurgie abdominale majeure non urgente était petite, indiquant une faible altération de la microcirculation sublinguale. La durée de la chirurgie n’a pas eu d’effet cliniquement significatif sur les variables de la microcirculation sublinguale.

Keywords: anesthesia; endothelium; glycocalyx; hemodynamic management; hemodynamic monitoring; incident darkfield imaging; tissue perfusion; vital microscopy.

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Conflict of interest statement

Moritz Flick is a consultant for and has received honoraria for giving lectures from Edwards Lifesciences (Irvine, CA, USA). Moritz Flick has received honoraria for consulting and giving lectures from CNSystems Medizintechnik (Graz, Austria). Jonathan Montomoli is a co-founder and shareholder of Callisia srl University Spin-off at Università Politecnica delle Marche developing a smart bracelet collecting patient data intelligently for real-time visualization and data analysis. Karim Kouz is a consultant for and has received honoraria for giving lectures from Edwards Lifesciences. Karim Kouz is a consultant for Vygon (Aachen, Germany). Matthias P. Hilty and Can Ince are shareholders of Active Medicals BV (Leiden, Netherlands), a company that offers services, hardware, software (MicroTools), and education (microcirculationacademy.org) related to clinical microcirculation. In the past, Can Ince has received educational grants from Fresenius Kabi (Bad Homburg, Germany), Cytosorbents (Monmouth Junction, NJ, USA), and La Jolla Pharameceuticals (San Diego, CA, USA). Bernd Saugel is a consultant for and has received institutional restricted research grants and honoraria for giving lectures from Edwards Lifesciences (Irvine, CA, USA). Bernd Saugel is a consultant for Philips North America (Cambridge, MA, USA) and has received honoraria for giving lectures from Philips Medizin Systeme Böblingen (Böblingen, Germany), has received institutional restricted research grants and honoraria for giving lectures from Baxter (Deerfield, IL, USA), is a consultant for and has received institutional restricted research grants and honoraria for giving lectures from GE HealthCare (Chicago, IL, USA), and has received institutional restricted research grants and honoraria for giving lectures from CNSystems Medizintechnik (Graz, Austria). Bernd Saugel is a consultant for Maquet Critical Care (Solna, Sweden), has received honoraria for giving lectures from Getinge (Gothenburg, Sweden), is a consultant for and has received institutional restricted research grants and honoraria for giving lectures from Pulsion Medical Systems (Feldkirchen, Germany), and is a consultant for and has received institutional restricted research grants and honoraria for giving lectures from Vygon (Aachen, Germany). Bernd Saugel is a consultant for and has received institutional restricted research grants from Retia Medical (Valhalla, NY, USA), has received honoraria for giving lectures from Masimo (Neuchâtel, Switzerland), is a consultant for Dynocardia (Cambridge, MA, USA), has received institutional restricted research grants from Osypka Medical (Berlin, Germany), and was a consultant for and has received institutional restricted research grants from Tensys Medical (San Diego, CA, USA). Bernd Saugel is an editor of the British Journal of Anaesthesia.

Figures

Fig. 1
Fig. 1
Perioperative sublingual microcirculation. Spaghetti plots for individual patients (grey) with overlaying box plots (black) showing perioperative sublingual microcirculation variables per time point. Dotted lines connect the last intraoperative measurement with the measurement on the first postoperative day. POD1 = first postoperative day; PPV = proportion of perfused vessels; RBCv = red blood cell velocity; tRBCp = tissue red blood cell perfusion; TVD = total vessel density
Fig. 2
Fig. 2
Glycocalyx markers. Spaghetti plots for individual patients (grey) with overlaying box plots (black) showing perioperative glycocalyx markers syndecan-1 and hyaluronan. The asterisk indicates a P value < 0.05 between the connected timepoints. POD1 = first postoperative day
Fig. 3
Fig. 3
Additional variables. Spaghetti plots for individual patients (grey) with overlaying box plots (black) showing perioperative blood-gas derived and macrohemodynamic variables per time point. Dotted lines connect the last intraoperative measurement with the measurement on the first postoperative day. Pcv-aCO2 = central venous–arterial carbon dioxide partial pressure gap; POD1 = first postoperative day; ScvO2 = central venous oxygen saturation
See this image and copyright information in PMC

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