Ann Thorac Surg 2002;73:987-989
© 2002 The Society of Thoracic Surgeons
Case report
Behavior of free jejunal flaps after early disruption of blood supply
Hung-Chi Chen, FACSa,
Bien-Keem Tan, FRCS(Ed)c,
Ming-Huei Cheng, MDa,
Chau-Hsiung Chang, FACSb,
Yueh-bih Tang, MD, PhD*d
a Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taipei, Taiwan
b Department of Cardiovascular Surgery, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taipei, Taiwan
c Department of Plastic Surgery, Singapore General Hospital, Singapore
d Department of Plastic Surgery, National Taiwan University Hospital, Taipei, Taiwan
Accepted for publication June 11, 2001.
* Address reprint requests to Dr Tang, 9, Alley 23, Lane 76, Section 2, Ho-Ping East Rd, Taipei, Taiwan
e-mail: phoebe{at}ha.mc.ntu.edu.tw
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Abstract
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We describe three free jejunal flaps that lost their axial blood supply in the early postoperative period—two flaps on the 7th day and the third on the 17th day. At 7 days, reestablishment of axial blood flow was essential to flap survival, whereas after 17 days, vascularization from the recipient bed was adequate to maintain viability. Based on these observations, a conservative approach to flap salvage for cases with pedicle disruption at 17 days or later is recommended.
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Introduction
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Following transfer of a free flap, its early survival depends on the integrity of the vascular pedicle. When the flap becomes revascularized from its recipient bed, independent survival is assured [1]. Skin and muscle flaps have been shown to survive after division of their axial blood supply at 10 days [1–3]. Survival of transferred intestinal segments after early interruption of the vascular pedicle is rare, and only two reports exist in recent literature. These described partial to near-total flap survival after pedicle disruption at 10 to 19 days [4, 5].
Our experience with jejunal flaps that have lost axial blood supply at an early stage indicate that complete survival is possible at 17 days. Three illustrative cases are detailed to discuss the outcome and implications of free jejunal flap survival following early pedicle interruption. Discussion of the worst complications in our series would be helpful for the management of difficult problems in the future.
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Case reports
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Patient 1
A 30-year-old woman sustained corrosive injury of the esophagus that resulted in a long stricture extending from the pharynx down to the gastric cardia. Because of the long stricture, a two-stage procedure was planned. In the first stage, a 25-cm jejunal segment was transferred to the neck, and revascularization was achieved by anastomosing the jejunal artery and vein to the thoracoacromial artery and venae comitantes, respectively. The second stage to bypass the thoracic esophagus was performed 3 months later, and this entailed connecting the distal end of the jejunal flap to the intraabdominal jejunum in Roux-en-Y fashion.
On postoperative day 7, the flap suddenly turned pale when the patient assumed upright posture. The flap had no peristalsis, no secretion of mucus, and no bleeding on puncture. Urgent exploration revealed a disrupted arterial anastomosis, and the blood flow was promptly restored with an interposition vein graft. The flap survived completely, and 3 months later, alimentary tract continuity was reestablished by anastomosing the neoesophagus to the intraabdominal jejunum. Over a period of 12 months thereafter, the patient resumed oral feeding and enjoyed progressive weight gain.
Patient 2
A 66-year-old man underwent a total laryngopharyngectomy, total esophagectomy, and bilateral neck dissection for a T4 N2 AM0 carcinoma of the right piriform sinus. He had received 6,840 cGy to the primary and both necks 15 weeks before the operation. Free jejunal transfer was performed to reconstitute the pharynx and esophagus, and revascularization was accomplished by anastomoses to the superior thyroid artery and external jugular vein.
On postoperative day 7, the flap became congested. Urgent exploration revealed pedicle compression by a redundant loop of jejunum. Compression was relieved by excising the redundant loop, but because of the prolonged ischemia, infection supervened, leading to flap demise.
Patient 3
A 37-year-old woman sustained extensive corrosive injury of the upper alimentary tract after ingestion of concentrated sulfuric acid. Extensive necrosis of the stomach and esophagus resulted, necessitating emergency gastrectomy and esophagectomy. Reconstruction was undertaken in two stages: first, a free jejunal flap to reconstruct the pharynx and cervical esophagus, and second, colon interposition to bypass the thoracic esophagus [6]. For the pharyngoesophagus, a 20-cm jejunal segment was transferred, and the superior end was anastomosed to the oropharynx. The distal third of the flap was exteriorized at the root of the neck for saliva drainage (Fig 1)
and would be used for the jejunocolic anastomosis at the second stage. Vascular anastomoses were performed to the transverse cervical artery and external jugular vein.
On postoperative day 17, sudden dusky discoloration of the distal external portion developed after physical exertion (Fig 2).
No recovery was seen after brief observation, indicating pedicle disruption or thrombosis. At this juncture, it was decided not to surgically explore the flap, as collateral circulation from the recipient bed would be sufficient at 17 days. Furthermore, pedicle identification and reanastomosis at this stage would be difficult because of tissue edema and adhesion. A week later, the external portion had necrosed (Fig 3)
and was excised down to its base. The buried portion was viable, and its distal end was fashioned into a stoma for observation and drainage.
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Fig 3. Patient 3: Necrosis of the distal segment. This portion was excised back to the skin opening at the root of the neck, where healthy bowel was seen.
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Seventy-six days after initial flap transfer, colon interposition was performed. The patient was able to commence oral feeding shortly after colon interposition. Peristalsis beneath the skin was clearly seen, and this confirmed the viability of the transferred jejunum. Barium swallow demonstrated healthy mucosa and intact bowel anastomoses (Fig 4).
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Fig 4. Patient 3: Barium swallow 6 months after colon interposition. Note the intact jejunal segment (J), which is in continuity with the interposed ascending colon (C). Notice the smooth passage of contrast medium and the absence of fistula and aspiration.
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Comment
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Three free jejunal flaps lost their axial blood supply in the early postoperative period—two flaps on the 7th day and the third on the 17th day. At 7 days, reestablishment of axial blood flow was essential to flap survival, whereas after 17 days, neovascularization from the recipient bed was adequate to maintain viability.
Fisher [4] in 1987 reported two cases of partial flap survival after pedicle disruption—at 14 days in 1 patient and on the 11th day for the other. In both cases, the anterior wall underwent necrosis, and survival of the posterior wall was ascribed to collateral circulation that developed between the flap and neck tissues. Keen [5] reported a third case, in which pedicle disruption occurred at 19 days. The authors stated that, aside from a small area on the antimesenteric border, the entire bowel survived. The necrosed portion, which formed a fistula, was eventually closed with local flaps.
Our report is unusual in that it describes complete survival after early disruption of axial blood supply. Interruption of blood supply was indicated by sudden discoloration of the exposed distal third of the jejunal flap (Fig 2). Survival of the remnant was evidenced by intact mucosa, visible peristalsis, and good swallowing function. The time required for the neovascular takeover by the recipient bed closely matches that of Keen [5], although that case involved a previously irradiated bed. We surmise that this process is complete by 3 weeks, because late pedicle division rarely threatens survival.
Experimental work to elucidate the timing of neovascular takeover was performed by Cordeiro and colleagues [7] in dogs. The authors showed that a minimum of 4 weeks before ligation of the pedicle was necessary for flap survival. Furthermore, they showed that revascularization occurred along the serosal surface and that new vessel formation correlated with increasing bowel perfusion and flap survival rate.
From a clinical perspective, certain implications emerge concerning jejunal survival after early pedicle interruption. The first one concerns decision making in the event of early pedicle disruption: if pedicle disruption occurs within 1 week, independent flap survival is unlikely, and no effort should be spared to reestablish blood flow. However, to maximize flap survival, exploration should be limited to the pedicle [1] and, if necessary, through a separate incision directly over the vascular pedicle. The flap should not be lifted from its bed, nor should it be separated from the cervical skin flaps. Similarly, any existing stoma should not be disturbed, to avoid disrupting newly formed vascular connections.
Between 7 and 17 days, if the vascular pedicle of the transferred jejunum is disrupted, we still suggest reexploration. However, the following principles should be observed: (1) Make minimal incision and dissection that allows exploration of only the vascular pedicle. The neovascularization that has already been established should be preserved as far as possible. (2) The transferred jejunum segment should have enough microvenous drainage at 7 days. However, it has high oxygen demand, and thus the artery should be repaired if it has been disrupted.
If loss of blood supply occurs after 3 weeks, a more conservative approach is advocated. Barring infection, the flap is best left undisturbed, because revascularization from the recipient bed is critical for flap survival. Flap viability is monitored by the color of the stoma, the presence of secretions, and active peristalsis. Any sign of sepsis is an indication of underlying flap necrosis, and, if present, the flap should be removed promptly.
The second implication pertains to the potential for jejunum prefabrication. For example, in previously irradiated necks, recipient vessels for free jejunal transfer may be unavailable. In such instances, jejunal revascularization may be accomplished by wrapping the bowel segment with a suitable vascular carrier such as a muscle flap. Once the serosal surface has picked up sufficient blood supply from the muscle flap, the mesenteric pedicle is divided and the prefabricated flap is transposed to the neck for esophageal reconstruction [8, 9]. We recently described a case of esophageal reconstruction in which an exteriorized segment of jejunum was wrapped with a latissimus dorsi muscle flap for 8 weeks before transfer [10]. At maturity, the mesenteric pedicle was divided and the jejunum successfully transposed to the neck based on the muscle carrier.
In summary, free jejunal flap neovascularization is complete after 17 days. Should pedicle disruption occur at or beyond this stage, a conservative approach to flap salvage is recommended.
The flap that was lost was in an irradiated bed, whereas the two surviving flaps were placed because of corrosive injuries. Apparently, the neovascularization also depends on the tissue bed. For early disruption of the vascular pedicle in postradiation patients, the vessels should be repaired as far as possible to ensure the survival of the jejunum segment. The loss of a difficult free flap (such as the jejunum) is a disaster to the patient, who may have no other surgical options, as well as to the surgeon. It should be pointed out that clinical judgment before reexploration should take into account the radiation therapy. Whenever there is any doubt, just go ahead to repair the disrupted vessels, which is much easier than treating the complications subsequent to the loss of a jejunal flap.
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References
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Khoo C.T.K., Bailey B.N. The behaviour of free muscle and musculocutaneous flaps after early loss of axial blood supply. Br J Plast Surg 1982;35:43-46.[Medline]
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Tsur H., Daniller A., Strauch B. Neovascularization of skin flaps: route and timing. Plast Reconstr Surg 1980;66:85-90.[Medline]
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Black M.J.M., Chait L., O’Brien B.McC., et al. How soon may the axial vessels of a surviving free flap be safely ligated: a study in pigs. Br J Plast Surg 1978;31:295-299.[Medline]
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Fisher J. Survival of transferred intestinal segments after vascular pedicle interruption. Plast Reconstr Surg 1987;79:616-617.
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Keen M. Survival of transferred intestine after interruption of blood supply. Plast Reconstr Surg 1987;80:750-751.[Medline]
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Mansour K.A., Bryan F.C., Carlson G.W. Bowel interposition for esophageal replacement: twenty-five-year experience. Ann Thorac Surg 1997;64:752-756.[Abstract/Free Full Text]
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Cordeiro P.G., Santamaria E., Hu Q.Y., et al. The timing and nature of neovascularization of jejunal free flaps: an experimental study in a large animal model. Plast Reconstr Surg 1999;103:1893-1901.[Medline]
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Fisher J., Wood M.B. Experimental comparison of bone revascularization by musculocutaneous and cutaneous flaps. Plast Reconstr Surg 1987;79:81-90.[Medline]
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Rand R.P., Jurkiewicz M.J. Formation of independently revascularized small-bowel segments using pedicled omental flaps. Ann Plast Surg 1994;33:606-610.[Medline]
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Chang S.Y., Chen H.C., Chen H.H., et al. Prefabrication of jejunum for challenging reconstruction of cervical esophagus. Plast Reconstr Surg 1999;104:2112-2115.[Medline]
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Abstract
Introduction
