Free Flap Anastomosis Research Articles

A modified technique of radial forearm free flap anastomosis

A modified technique of radial forearm free flap anastomosis

Histomorphologische Strukturveränderungen von Kopf-Hals-Gefäßen nach prä- oder postoperativer Radiotherapie

Patients with squamous cell carcinomas of the oral cavity are being increasingly treated by multimodal interdisciplinary regimes using a combination of surgery, chemo- and radiotherapy. Inflammatory alterations of the vascular endothelium following preoperative radiotherapy frequently cause healing delays of free flaps in the irradiated graft bed. The aim of the study was to investigate quantitative and qualitative changes of irradiated neck recipient vessels and transplant vessels used for microsurgical anastomoses in free flaps in patients undergoing preoperative radiotherapy or radiochemotherapy. In 348 patients (October 1995-March 2002) receiving primarly or secondary 356 microvascular hard- and soft tissue reconstruction, a total of 209 vessels were obtained from neck recipient vessels and transplant vessels during anastomosis. Three groups were analysed: group 1 (27 patients) treated with no radiotherapy or chemotherapy; group 2 (29 patients) treated with preoperative irradiation (40-50 Gy) and chemotherapy (800 mg/m2/day 5-FU and 20 mg/m2/day cisplatin) 1.5 months prior to surgery; group 3 (20 patients) treated with radiotherapy (60-70 Gy) (median interval 78.7 months; IQR: 31.3 months) prior to surgery. From each of the 209 vessel specimens, 3 sections were investigated histomorphometrically, qualitatively and quantitatively (ratio media area/total vessel area) by NIH-Image-digitized measurements. To evaluate these changes as a function of age, radiation dose and chemotherapy, a statistical analysis was performed using an analysis of covariance and chi 2 tests (p > 0.05, SPSS V10). In group 3, qualitative changes (intima dehiscence, hyalinosis) were found in recipient arteries significantly more frequently than in groups 1 and 2. For group 3 recipient arteries, histomorphometry revealed a significant decrease in the ratio media area/total vessel area (median 0.51, IQR 0.10) in comparison with groups 1 (p = 0.02) (median 0.61, IQR 0.29) and 2 (p = 0.046) (median 0.58, IQR 0.19). No significant difference was found between the vessels of groups 1 and 2 (p = 0.48). There were no significant differences in transplant arteries and recipient or transplant veins between the groups. Age and chemotherapy did not appear to have a significant influence on vessel changes in this study (p > 0.05). Following irradiation with 60-70 Gy, significant qualitative and quantitative histological changes to the recipient arteries, but not to the recipient veins, could be observed. In contrast, irradiation at a dose of 40-50 Gy and chemotherapy given at a median interval of 1.5 months prior to operation did not lead to significant histological changes to the recipient vessels.

VCS auto suture stapled microvascular anastomoses in lower leg free flaps.

VCS auto suture stapled microvascular anastomoses in lower leg free flaps.

Histomorphometric analysis of irradiated recipient vessels and transplant vessels of free flaps in patients undergoing reconstruction after ablative surgery

The aim of the study was to investigate, histomorphometrically, quantitative and qualitative changes in irradiated neck recipient vessels and transplant vessels used for microsurgical anastomoses in free flaps in patients undergoing preoperative radiotherapy and chemotherapy. In 55 patients receiving 42 radial forearm flaps, 6 latissimus dorsi flaps, 6 osteomyocutaneous fibula grafts and 1 lateral arm flap, a total of 220 vessels were obtained from neck recipient vessels and transplant vessels during anastomosis. Three groups were formed: Group 1 (16 patients) treated with no radiotherapy or chemotherapy; Group 2 (20 patients) treated with preoperative irradiation (40–50 Gy) and chemotherapy (800 mg/m2 5-FU and 20 mg/m2 cisplatin) 1.5 months prior to surgery; Group 3 (19 patients) treated with radiotherapy (60–70 Gy) (median interval 78.7 months; IQR 31.3 months) prior to surgery. From each of the 220 vessel specimens, 3 sections each were histomorphometrically investigated, both qualitatively and quantitatively. To evaluate these changes as a function of age, radiation dose and chemotherapy, a statistical analysis was performed using analysis of covariance and chi-square tests. In Group 3, qualitative changes (intima dehiscence, hyalinosis) were found in recipient arteries significantly more frequently (25%, P=0.009) than in Groups 1 and 2. For Group 3 recipient arteries, histomorphometry revealed a significant decrease in the ratio of media area/total vessel area (median 0.53, IQR 0.10) in comparison with Group 1 (P=0.02) (median 0.60, IQR 0.29) and Group 2 (P=0.046) (median 0.59, IQR 0.10). No significant differences were found between the vessels of Groups 1 and 2 (P=0.48). Age and chemotherapy did not appear to have a significant influence on vessel changes in this study.

Histomorphometric analysis of irradiated recipient vessels and transplant vessels of free flaps in patients undergoing reconstruction after ablative surgery

The aim of the study was to investigate, histomorphometrically, quantitative and qualitative changes in irradiated neck recipient vessels and transplant vessels used for microsurgical anastomoses in free flaps in patients undergoing preoperative radiotherapy and chemotherapy. In 55 patients receiving 42 radial forearm flaps, 6 latissimus dorsi flaps, 6 osteomyocutaneous fibula grafts and 1 lateral arm flap, a total of 220 vessels were obtained from neck recipient vessels and transplant vessels during anastomosis. Three groups were formed: Group 1 (16 patients) treated with no radiotherapy or chemotherapy; Group 2 (20 patients) treated with preoperative irradiation (40–50 Gy) and chemotherapy (800 mg/m2 5-FU and 20 mg/m2 cisplatin) 1.5 months prior to surgery; Group 3 (19 patients) treated with radiotherapy (60–70 Gy) (median interval 78.7 months; IQR 31.3 months) prior to surgery. From each of the 220 vessel specimens, 3 sections each were histomorphometrically investigated, both qualitatively and quantitatively. To evaluate these changes as a function of age, radiation dose and chemotherapy, a statistical analysis was performed using analysis of covariance and chi-square tests. In Group 3, qualitative changes (intima dehiscence, hyalinosis) were found in recipient arteries significantly more frequently (25%, P=0.009) than in Groups 1 and 2. For Group 3 recipient arteries, histomorphometry revealed a significant decrease in the ratio of media area/total vessel area (median 0.53, IQR 0.10) in comparison with Group 1 (P=0.02) (median 0.60, IQR 0.29) and Group 2 (P=0.046) (median 0.59, IQR 0.10). No significant differences were found between the vessels of Groups 1 and 2 (P=0.48). Age and chemotherapy did not appear to have a significant influence on vessel changes in this study.

Reconstruction and Functional Evaluation of the Hypopharynx and Cervical Esophagus

A total of 225 patients with carcinoma of the hypopharynx and the cervical esophagus were treated surgically between 1986 and 1996 at Osaka Medical Center for Cancer and Cardiovascular Diseases. There were the following three types of defect resulting from resection of carcinoma ; 119 partial (non-circumferential) pharyngeal, including nine with the preservation of the larynx, 91 circumferential pharyngeal and 15 pharyngoesophageal. Our principle of reconstruction was as follows ; Primary closure of the pharynx was indicated when the width of the pharyngeal remnant was more than 2 cm. For the partial pharyngeal defect with the width of less than 2 cm, the radial forearm free flap was utilized (patch reconstruction). And the free jejunal autogreft and gastric pull-up were utilized for the cicrcumferential type and the pharyngoesophageal type, respectively. There were 91 patients who had primary closures, 30 who had free forearm flaps, 57 who had free jejunal autografts, and 13 who had gastric pull-ups. Functions of these reconstructive techniques were evaluated by the interviews to the patients who had more than six-month follow-up. About 80% of the patients in each groups had no disturbance of diet passage ; 74% in primary closure (n=31), 80% in free forearm flap (n=5) and 77% in free jejunal autograft (n=13). More than 70% in each the three groups were able to take a fairely normal diet; 81%, 100% and 77%, respectively. The rates of use of neoesophageal speech in primary closure and free forearm were 58% and 80%, respectively, higher than that of 23% in free jejunal autograft. The only one case of severe dysphagia was reconstructed by free jejunal autograft, which was anastomosed to pharyngeal stump in end-to-side manner. There were two cases of pocket formation in the lower part of patch-on forearm flap, complaining of stagnant feeling of diet; which might result from too wide flap-width. An analysis using videofluorography revealed that neoglottis were located at the remnant mucosa near the lower or the upper anastomosis of free forearm flap and free jujunal autografts. These results suggested that the reconstructive method should be selected with reference to the type of defect, because of no significant difference of functions among reconstructive methods, and the reliability of materials, the simplicity of harvesting and the donor-site morbidity should be considered.

Flushing the vessel ends: the effect on ischemic free flap survival.

During vascular anastomosis of experimental ischemic free flaps it is common to observe that stagnant blood in the vessel ends has clotted. A study was performed to investigate if flushing away the stagnant blood on division of the vessels would increase flap survival. Flushing did not influence flap survival. Clinically, clot is rarely seen, except in conditions of prolonged ischemia or damaged vessels. Current surgical practice does not involve flushing the vessel ends upon division of the vessels and this approach is affirmed by our results.