Free Jejunal Flaps Can Be Monitored by Use of Microdialysis

ABSTRACT

When new combinations of preoperative treatments of carcinoma of the esophagus are implemented, surgical morbidity and mortality become even more important risk factors. This study investigated whether the risk of postoperative complications caused by ischemia in the reconstructed esophagus can be reduced using microdialysis as monitoring method. This is a retrospective study of 14 patients undergoing resection of carcinoma in the upper part of the esophagus and reconstruction with a free jejunal flap. The metabolism in all 14 jejunal transfers was monitored by use of microdialysis. The data were analyzed looking for reliable parameters detecting critical ischemia. Critical ischemia was suspected in two cases. Both of these cases were surgically revised, ischemia in the jejunal flap was verified, and the jejunal flaps were revascularized. All 14 jejunal flaps survived. Using the concentration of glucose in the microdialysate, it was possible to detect the two cases of critical ischemia. Yet, the most reliable parameter seemed to be the retrospectively calculated lactate:glucose ratio; in both the ischemic flaps, the lactate:glucose ratio exceeded more than 1000% the maximum values found in all the nonischemic flaps. Microdialysis is a promising monitoring method for surveillance of free jejunal flaps.

KEYWORDS

Jejunal flaps - microdialysis - monitoring

REFERENCES

• 1 Wu P C, Posner M C. The role of surgery in the management of oesophageal cancer.  Lancet Oncol. 2003;  4 481-488
• 2 Gebski V, Burmeister B, Smithers B M, Foo K, Zalcberg J, Simes J. Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis.  Lancet Oncol. 2007;  8 226-234
• 3 Disa J J, Pusic A L, Hidalgo D A, Cordeiro P G. Microvascular reconstruction of the hypopharynx: defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases.  Plast Reconstr Surg. 2003;  111 652-660
• 4 Tsujimoto H, Ono S, Chochi K, Sugasawa H, Ichikura T, Mochizuki H. Preoperative chemoradiotherapy for esophageal cancer enhances the postoperative systemic inflammatory response.  Jpn J Clin Oncol. 2006;  36 632-637
• 5 Fiorica F, Di Bona D, Schepis F et al.. Preoperative chemoradiotherapy for oesophageal cancer: a systematic review and meta-analysis.  Gut. 2004;  53 925-930
• 6 Seidenberg B, Rosenak S S, Hurwitt E S, Som M L. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment.  Ann Surg. 1959;  149 162-171
• 7 Jurkiewicz M J. Vascularized intestinal graft for reconstruction of the cervical esophagus and pharynx.  Plast Reconstr Surg. 1965;  36 509-517
• 8 Hester T R, McConnel F M, Nahal F, Jurkiewicz M J, Brown R G. Reconstruction of cervical esophagus, hypopharynx and oral cavity using free jejunal transfer.  Am J Surg. 1980;  140 487-491
• 9 Disa J J, Cordeiro P G, Hidalgo D A. Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases.  Plast Reconstr Surg. 1999;  104 97-101
• 10 Olding M, Jeng J C. Ischemic tolerance of canine jejunal flaps.  Plast Reconstr Surg. 1994;  94 167-173
• 11 Hikida S, Takeuchi M, Hata H et al.. Free jejunal graft autotransplantation should be revascularized within 3 hours.  Transplant Proc. 1998;  30 3446-3448
• 12 Hallock G G, Koch T J. External monitoring of vascularized jejunum transfers using laser Doppler flowmetry.  Ann Plast Surg. 1990;  24 213-215
• 13 Homma K, Mitani M, Fujita M T, Ezoe K, Tsubota H, Himi M T. Color Doppler sonography in monitoring after free jejunum transplantation.  Ann Plast Surg. 2001;  47 625-628
• 14 Ungerstedt U, Pycock C. Functional correlates of dopamine neurotransmission.  Bull Schweiz Akad Med Wiss. 1974;  30(1–3) 44-55
• 15 Ungerstedt U. Microdialysis: principles and applications for studies in animals and man.  J Intern Med. 1991;  230 365-373
• 16 Delgado J M, DeFeudis F V, Roth R H, Ryugo D K, Mitruka B M. Dialytrode for long term intracerebral perfusion in awake monkeys.  Arch Int Pharmacodyn Ther. 1972;  198 9-21
• 17 Röjdmark J, Hedén P, Ungerstedt U. Comparison of flap ischemia induced by arterial or venous occlusion in pigs with the aid of microdialysis.  Eur J Plast Surg. 2000;  23 278-282
• 18 Röjdmark J, Blomqvist L, Malm M, Adams-Ray B, Ungerstedt U. Metabolism in myocutaneous flaps studied by in situ microdialysis.  Scand J Plast Reconstr Surg Hand Surg. 1998;  32 27-34
• 19 Setala L P, Korvenoja E M, Harma M A, Alhava E M, Uusaro A V, Tenhunen J J. Glucose, lactate, and pyruvate response in an experimental model of microvascular flap ischemia and reperfusion: a microdialysis study.  Microsurgery. 2004;  24 223-231
• 20 Jyranki J, Suominen S, Vuola J, Back L. Microdialysis in clinical practice: monitoring intraoral free flaps.  Ann Plast Surg. 2006;  56 387-393
• 21 Udesen A, Lontoft E, Kristensen S R. Monitoring of free TRAM flaps with microdialysis.  J Reconstr Microsurg. 2000;  16 101-106
• 22 Setälä L, Papp A, Romppanen E L, Mustonen P, Berg L, Harma M. Microdialysis detects postoperative perfusion failure in microvascular flaps.  J Reconstr Microsurg. 2006;  22 87-96
• 23 Sommer T, Larsen J F. Detection of intestinal ischemia using a microdialysis technique in an animal model.  World J Surg. 2003;  27 416-420
• 24 Katsaros J, Banis J C, Acland R D, Tan E. Monitoring free vascularised jejunum grafts.  Br J Plast Surg. 1985;  38 220-222
• 25 Röjdmark J, Hedén P, Ungerstedt U. Microdialysis—a new technique for free flap surveillance: methodological description.  J Reconstr Microsrug. 2000;  16 129-134
• 26 Cho B C, Shin D P, Byun J S, Park J W, Baik B S. Monitoring flap for buried free tissue transfer: its importance and reliability.  Plast Reconstr Surg. 2002;  110 1249-1258
• 27 Gwanmesia I, Butler P E, Withey S. The use of a monitoring flap in vascularized free jejunum grafts.  Plast Reconstr Surg. 2004;  113 1529-1530
• 28 Okazaki M, Asato H, Okochi M, Suga H. One-segment double vascular pedicled free jejunum transfer for the reconstruction of pharyngoesophageal defects.  J Reconstr Microsurg. 2007;  23 213-218
• 29 Röjdmark J, Ungerstedt J, Blomqvist L, Ungerstedt U, Hedén P. Comparison of the metabolism during ischemia and reperfusion in free flaps of different tissue composition.  Eur J Plast Surg. 2002;  24 349-355