Abstract
Cold storage remains the clinical standard for composite tissue preservation but is time-limited. A long ischemia time during surgery will adversely affect postoperative outcomes due to ischemia-reperfusion injury. Extracorporeal perfusion (ECP) seems to be a promising alternative for prolonged preservation, but more evidence is needed to support its use and to identify optimal perfusion fluids. This article assessed musculocutaneous flap vitality after prolonged ECP and compared outcomes after replantation to short static cold storage (SCS). Unilateral musculocutaneous rectus abdominis flaps were raised from 15 pigs and preserved by 4 h SCS (n = 5), 18 h mid-thermic ECP with Histidine–Tryptophan–Ketoglutarate (HTK, n = 5) or University of Wisconsin solution (UW, n = 5). Flaps were replanted and observed for 12 h. Skeletal muscle histology was assessed (score 0–12; high scores equal more damage), blood and perfusate samples were collected and weight was recorded as a marker for oedema. Mean histological scores were 4.0 after HTK preservation, 5.6 after UW perfusion and 5.0 after SCS (p = 0.366). Creatinine kinase (CK) was higher after ECP compared to SCS (p < 0.001). No weight increase was observed during UW perfusion, but increased 56% during HTK perfusion. Following 12 h reperfusion, mean weight gain reduced 39% in the HTK group and increased 24% in the UW group and 17% in the SCS group. To conclude, skeletal muscle seemed well preserved after 18 h ECP with HTK or UW perfusion, with comparable histological results to 4 h SCS upon short reperfusion. The high oedema rate during HTK perfusion remains a challenge that needs to be further addressed.
Highlights
Skeletal muscle is one of the most vulnerable tissues to ischemia, with a maximum ischemia time of six hours at hypothermia [1,2,3,4,5]
Cold storage is the gold standard in composite tissue preservation and early revascularisation remains the mainstay approach to minimise ischemic damage [8,9]
These findings confirm that flap histology is well preserved in the early replantation phase following prolonged Extracorporeal perfusion (ECP) with retained muscle architecture
Summary
Skeletal muscle is one of the most vulnerable tissues to ischemia, with a maximum ischemia time of six hours at hypothermia [1,2,3,4,5]. It is not always possible to reduce ischemia time to the 6 h maximum, for instance when vascular anastomoses are difficult and revisions are needed or in complex procedures such as vascularised composite allotransplantations (VCA, e.g., abdominal wall transplant) or limb replantation [10]. This raises the need for new techniques that can safely prolong composite tissue preservation [11]. ECP for composite tissue preservation is still experimental and studies that evaluated the reperfusion phase are scarce [13]. The longest described acellular ECP period followed by successful replantation is 24 h in porcine forelimbs [14]
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