International Journal of Surgery 17 (2015) 72e78
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
A retrospective study of end-to-side venous anastomosis for free flap in extremity reconstruction Haijun Mao, Guangyue Xu* Orthopedics, Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
h i g h l i g h t s The overall surgery success rate of ETS anastomosis was 96.6%. The occurrence of the ETS anastomosis-related venous thrombosis was 2.3% (4/117). ETS anastomosis success rate was not affected by local condition of surgery site.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 October 2014 Received in revised form 20 January 2015 Accepted 16 March 2015 Available online 28 March 2015
Introduction: The success of end-to-side (ETS) venous anastomosis primarily depends on several mandatory factors including recipient vessel selection and reconstruction site. This retrospective study was designed to analyze the success rate of ETS venous anastomosis for free flap extremity reconstruction. Methods: Between 2009 and 2011, ETS venous anastomosis was performed in 117 patients to reconstruct soft tissue defects of extremity at Nanjing Drum Tower Hospital. The patients were divided into three groups: (1) only one large recipient vein left, (2) two deep venas, (3) one deep vein and one superficial vein. Medical records and the follow-up data were retrospectively reviewed. The success rates of the three groups were compared with Chi-squared test. Results: Totally, 5, 52, and 60 patients were included in Group 1, Group 2, and Group 3, respectively. The overall surgery success rate was 96.6% (113/117) with four failures: zero in Group 1, two in Group 2 (2/52, 3.8%) and two in Group 3 (2/60, 3.3%), due to venous thrombosis. The re-anastomosis rate in reexploration in Group 1, 2 and 3 was 0%, 1.9% (1/52), and 1.7% (1/60), respectively. No complication was observed during the operation. Discussion: No statistical difference was observed in flap failure rate among the three different types of ETS anastomosis. This suggests that differences of the ETS anastomosis surgical site might not affect the surgery success rate. Conclusion: These results confirmed that the success rate of ETS anastomosis was not affected by the local conditions of surgery site. © 2015 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
Keywords: End-to-side anastomosis Reconstruction Free flap
1. Introduction Microvascular anastomosis, which is crucial to the survival rate of transferred tissues, could be performed either in an end-to-end (ETE) or in an end-to-side (ETS) anastomosis. Traditionally, the recipient artery and vein is sacrificed to provide the pedicle ETE anastomosis [1]. ETS anastomosis has been introduced to address
* Corresponding author. E-mail address: [email protected] (G. Xu). http://dx.doi.org/10.1016/j.ijsu.2015.03.016 1743-9191/© 2015 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
cases where the recipient artery is necessary for distal circulation or when there is only a single artery [2]. Previous studies have shown that ETS arterial anastomosis has advantages such as decreased vessel spasm, elimination of vessel mismatch, and preservation of the distal run-off [3]. Thus, it has been widely used in free flap grafting. However, the incidence of venous thrombosis is higher in ETS anastomosis than that in the arterial thrombosis in lower-extremity reconstruction [2,4,5]. Despite of all that, studies have suggested that ETS venous anastomosis is a safe alternative to ETE anastomosis and definitively is the straightforward option for microvascular anastomosis [6].
H. Mao, G. Xu / International Journal of Surgery 17 (2015) 72e78
Besides, ETS venous anastomosis is firstly proposed in the cases where one recipient vein remains and the caliber of the donor's vein is smaller than the recipient vein. However, seldom literature have been focused on whether the choice of recipient vein locations, such as superior or deep veins, affect venous survival or surgery success rate or not. In this study, 117 patients with ETS venous anastomosis for free flap reconstruction in extremity were reviewed retrospectively. To explore the feasibility of ETS anastomosis and demonstrate whether the location conditions of the surgical site affect the success rate or not, patients were grouped into different groups according to the local condition of the surgical site. The success rates of the groups would be discussed. 2. Materials and methods Between 2009 and 2011, 117 cases (including 75 males and 42 females) undergone microsurgical reconstruction of the extremity at Nanjing Drum Tower Hospital affiliated to Nanjing University. Patients with diabetes, smoking, arterial or venous transplantation were excluded in this study. Indications for surgery included wound bone with exposed tendons, nerves and blood vessels unable to flap transfer (island flap or skin graft); open reduction external fixation with open fractures. All patients were received anterolateral free flaps which required salvaged venous ETS anastomosis in the reconstruction. Failure ETS was defined as the complete flap loss regardless of its origin (arterial, venous, and/or perforator). 2.1. Operative procedures All patients underwent one or more debridement. All surgeries were performed under general anesthesia by the same surgical team in Nanjing Drum Tower Hospital. Exploration was performed to locate and prepare a recipient artery and vein. If there was only one remained vein or a large difference in the diameters of recipient and flap vein the venous ETS anastomosis technique was chosen for flap grafting. The recipient arteries and vena were radial, ulnar, brachial, anterior tibial, posterior tibial artery and deep,
73
superficial vena, respectively. How to choose venous ETS anastomosis? According to our experience, the implementation of ETS anastomosis was depended on the local condition of the surgical site including both the compatibility of the recipient and donor vessels. Patients were divided into three groups according to three different choices of venous ETS anastomosis (Fig. 1). For Group 1, only one larger recipient vein was left. In this group, two venas of the flap were connected to the same one recipient vein. The appropriate distance between the two stomas had not been studied up to now (Fig. 2). For Group 2, two unobstructed deep venas were left without available superficial vena. In this case, a skilled physician might be needed (Fig. 3). In Group 3, there was one remained deep vein and one superficial vein. It was better and easier to anastomose vessels if the superficial vein was available and unobstructed (Fig. 4). Anastomosis was performed under a microscope with interrupted suture using 8e0 or 9e0 monofilament nylon (Ethicon Co. Johnson and Johnson). During the operation, a pair of microscissors was used to excise a portion of the vessel wall according to the pedicle. The lateral aperture does not exceed 1/2 of the circumferences of the recipient venous. At the end of the operation, the ballooning patency test was performed to evaluate whether the venous stoma was obstructed or not. At the end of microvascular anastomoses, low molecular weight dextran was routinely infused into patients (500 mL at 20 mL/h) for 5 days postoperatively. Sensitive antibiotics, papaverine hydrochloride (30 mg/6 h), low molecular heparin (5000 I.U./day) were included in the postoperative protocol for patients remained in bed, which usually stopped shortly after mobilization, unless otherwise indicated. Postoperative flap viability was inspected and controlled by a resident by evaluating color, temperature, and appearance of the flap, and by pin pricking the skin paddle, skin monitor or muscular portion of the flap every 2 h in the following 24 h and every 3e4 h in the following days. In each instance of suspected arterial and/or venous thrombosis, the patient was re-operated to explore the anastomosis immediately. Medical records were retrospectively reviewed for demographics, operative and follow-up data.
Fig. 1. Patient selection flowchart.
74
H. Mao, G. Xu / International Journal of Surgery 17 (2015) 72e78
Fig. 2. Indication (A), before (B) and after (C) surgery, and result (D) of the patient in group 1. In this group, 2 venas of the flap were connected to the same one recipient vein.
2.2. Data analysis Statistical analysis was done using SPSS 19 (SPSS Inc., IL,USA). Surgical success rates were presented as percentages and were analyzed using Chi-squared. Mean values of continuous variables were expressed as mean ± SD (standard deviation). The significant level of surgical success rate was set at p-value < 0.05. 3. Results Totally, 51 patients had soft tissue defects in upper extremities and 66 patients in lower extremities. Among them, 73, 31, and 13 patients were caused by traffic accident, mechanical injury, and
crushing, respectively. Patient characteristics were given in Table 1. Totally, 5 (4.3%, 5/117) cases were enrolled in Group 1, 52 (44.4%, 52/ 117) cases were enrolled in Group 2 due to the evident caliber mismatch, and 60 cases (51.3%, 60/117) were included in Group 3. Mean follow-up was 13 ± 4.5 months (ranged from 12 months to 18 months). Mean age of the patients was 49 ± 10 years old ranging from 32 to 60 years. Venous re-exploration was performed in all patients at 4 h and 12 h after surgery. Totally, the mean successes rate of ETS was 97.6 ± 2.1%, with two failures in Group 2 (2/52, 3.8%) and two in Group 3 (2/60, 3.3%). Four failures were appeared due to venous thrombosis (2.3%, 4/117) (Table 2). The first two failures developed venous congestion at 12 h after surgery and subsequently received
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75
Fig. 3. Indication (A), before (B) and after (C) surgery, and result (D) of the patient in group 2. In this group, 2 unobstructed deep venas were remained without available superficial vena.
secondary reconstruction with skin grafting. The second one suffered from postoperative bleeding during the night and developed flap venous congestion and underwent reconstruction using ALT flap. During the re-exploration, the other two failures, one in Group 2 and one in Group 3, respectively, was performed skin graft and secondary skin flap due to both the absence of extensive flap intravenous thrombosis within flap and the absence of venous return after thrombectomy. Thus the re-anastomosis rate in reexploration in Group 1, 2 and 3 was 0%, 1.9% (1/52), and 1.7% (1/ 60), respectively. No complications were observed during the operation. There was no ETS anastomosis related mortality during follow-up (mean, 13 ± 4.5 months).
4. Discussion Microvascular anastomosis is obviously of paramount importance and plays an important role in the outcome of free flap. The success of ETS primarily depends on several mandatory factors including anastomotic technique, recipient vessel selection, reconstruction site, previous treatments as well as patient characteristics [3,7e10]. The use of the ETS arterial anastomosis in extremity reconstruction was described and popularized by Godina [11]. He analyzed the results of 65 free flaps and showed a lower failure rate with ETS anastomosis than ETE anastomosis. The advantages of ETS
76
H. Mao, G. Xu / International Journal of Surgery 17 (2015) 72e78
Fig. 4. Indication (A), before (B) and after (C) surgery, and result (D) of the patient in group 3. In this group, one deep vein and one superficial vein was available.
anastomosis for extremity reconstruction have been well established, including less incidence of vessel spasm, elimination of vessel mismatch, as well as preservation of the distal run-off [12e14]. Miyamoto et al. [15] confirmed the high tolerance of arterial and venous ETS anastomosis to epinephrine-induced vasospasm and a marked advantage in flap survival in a rat model. Bas et al. compared ETE and ETS venous microanastomoses in 70 rat vessels [16]. No statistically significant difference was noted in anastomosis patency in similar-diameter vessels, while in size-discrepant veins, ETS anastomosis presented a significantly lower vibration-translation rate. Moreover, Lorenzetti et al. [17] reported that the vascular resistance and the blood flow in the thoracodorsal artery, respectively, was significantly decreased and increased after flap transplantation with ETS anastomosis followed
Table 1 The demographic characteristics of 117 patients. Characteristics
Total/Mean
No. of patients Age (years) Mean Range Location Upper extremity Lower extremity Cause Traffic accident Mechanical injury Crushing
117 49 ± 10 32e60 51 66 73 31 13
H. Mao, G. Xu / International Journal of Surgery 17 (2015) 72e78
77
Table 2 The outcomes of end-to-side anastomosis in the three groups. Group
No. of patient
Surgery failure (rate)
Success rate
Re-anastomosis
Final failure
p-Value
1 2 3 Total/Mean
5 52 60 117
0 2 (3.8%) 2 (3.3%) 4 (2.3%)
100% 96.2% 96.7% 97.6 ± 2.1%
0 1 1 2
0 1 1 2
>0.05
by flap raising and anastomosis. These informed us that ETS anastomosis could be a favorable choice in these cases. Microvascular free-tissue transfer is a reliable pillar of reconstructive surgery, yet pedicle thrombosis remains a challenge for the success rate of ETS anastomosis [2,4]. Several studies have shown that venous thrombosis is the most frequent cause of free flap failure [18e20]. Moreover, some analyses showed that there was a significant reduction in flap failure and venous thrombosis when performing two venous anastomoses versus one in free flap surgery [21]. In this study, the mean success rate of ETS anastomosis was 97.6 ± 2.1%. There were 4 failures due to venous thrombosis. This demonstrated that venous thrombosis is the common phenomenon resulting in ETS anastomosis failures. The limitation of our study is that the patient number was limit. This is a cohort study and all the surgeries were performed by one single team. However, there was an imbalance in patient numbers among the 3 groups. A selection bias also existed in this study: patients with diabetes, smoking, arterial or venous transplantation were excluded to avoid the confounding factors which might influence the statistical differences [22,23]. Thus this study was limited by the lack of an enough large sample cases. That might be the cause for the fact that no statistical difference was observed in the flap failure rate among the different choices of ETS anastomosis. This suggested that, in some degree, different choices of the ETS anastomosis surgical site might not affect the success rate of surgery. This may increase the clinical application of venous ETS anastomosis. 5. Conclusion ETS venous anastomosis is a useful technique in reconstruction surgery without sacrificing the recipient vena. There was no statistically significant difference in the failure rates among the three different choices of ETS venous anastomosis (p > 0.05). The mean success rate was 97.6 ± 2.1% with 100%, 96.2%, and 96.7% in Group 1, 2, and 3, respectively. Venous thrombosis was the common phenomenon resulting in ETS anastomosis failure. However, a larger number of sample cases might provide a more convincing result. Ethical approval All studies have been approved by The Affiliated Drum Tower Hospital of Nanjing University Medical School Ethics Committee and performed in accordance with the ethical standards. Financial support None. Author contribution Guangyue Xu participated in the design of this study, and performed the statistical analysis. Haijun Mao carried out the study, together with Guangyue Xu, collected important background information, and drafted the manuscript. Guangyue Xu conceived of this study, and participated in the design and helped to draft the manuscript. All authors read and approved the final manuscript.
Conflicts of interest None. Guarantor Guangyue Xu. Acknowledgements None. References [1] Y.-T. Tsai, T.-S. Lin, The suitability of end-to-side microvascular anastomosis in free flap transfer for limb reconstruction, Ann. Plast. Surg. 68 (2012) 171e174. [2] Y.J. Jang, M.C. Park, Y.S. Hong, J.H. Won, S.H. Lim, D.H. Park, H.S. Song, I.J. Lee, Successful lower extremity salvage with free flap after endovascular angioplasty in peripheral arterial occlusive disease, J. Plast. Reconstr. Aesthet. Surg. 67 (2014) 1136e1143. [3] P. Ashjian, C.M. Chen, A. Pusic, J.J. Disa, P.G. Cordeiro, B.J. Mehrara, The effect of postoperative anticoagulation on microvascular thrombosis, Ann. Plast. Surg. 59 (2007) 36e40. [4] J.A. Nelson, E.M. Kim, K. Eftakhari, D.W. Low, S.J. Kovach, L.C. Wu, J.M. Serletti, Late venous thrombosis in free flap breast reconstruction: strategies for salvage after this real entity, Plast. Reconstr. Surg. 129 (2012) 8ee15e. [5] K. Muramatsu, M. Shigetomi, K. Ihara, S. Kawai, Vascular complication in free tissue transfer to the leg, Microsurgery 21 (2001) 362e365. [6] C. Piazza, V. Taglietti, A. Paderno, P. Nicolai, End-to-end versus end-to-side venous microanastomoses in head and neck reconstruction, Eur. Arch. Otorhinolaryngol. 271 (2014) 157e162. [7] N. Chernichenko, D.A. Ross, J. Shin, C.T. Sasaki, S. Ariyan, End-to-Side venous anastomosis with an anastomotic coupling device for microvascular FreeTissue transfer in head and neck reconstruction, Laryngoscope 118 (2008) 2146e2150. [8] V. Valentini, A. Cassoni, T.M. Marianetti, V. Mitro, P. Gennaro, C. Ialongo, G. Iannetti, Diabetes as main risk factor in head and neck reconstructive surgery with free flaps, J. Craniofac Surg. 19 (2008) 1080e1084. [9] H. Ogihara, K. Takeuchi, Y. Majima, Risk factors of postoperative infection in head and neck surgery, Auris Nasus Larynx 36 (2009) 457e460. [10] P. Yu, D.W. Chang, M.J. Miller, G. Reece, G.L. Robb, Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction, Head Neck 31 (2009) 45e51. [11] M. Godina, Preferential use of end-to-side arterial anastomoses in free flap transfers, Plast. Reconstr. Surg. 64 (1979) 673e682. [12] Y. Ikuta, S. Watari, K. Kawamura, R. Shima, Y. Matsuishi, K. Miyoshi, K. Tsuge, Free flap transfers by end-to-side arterial anastomosis, Br. J. Plast. Surg. 28 (1975) 1e7. [13] R.J. Dotson, A.T. Bishop, M.B. Wood, A. Schroeder, End-to-end versus end-toside arterial anastomosis patency in microvascular surgery, Microsurgery 18 (1998) 125e128. [14] B.-K. Tan, C.-H. Wong, W. Chew, S.-W. Hong, Use of the slit arteriotomy for end-to-side arterial anastomosis in free-tissue transfers to the extremities, J. Plast. Reconstr. Aesthet. Surg. 62 (2009) 1519e1523. [15] S. Miyamoto, A. Takushima, M. Okazaki, N. Ohura, A. Momosawa, K. Harii, Comparative study of different combinations of microvascular anastomosis types in a rat vasospasm model: versatility of end-to-side venous anastomosis in free tissue transfer for extremity reconstruction, J. Trauma Acute Care Surg. 66 (2009) 831e834. [16] L. Bas, J.W. May Jr., J. Handren, J. Fallon, End-to-end versus end-to-side microvascular anastomosis patency in experimental venous repairs, Plast. Reconstr. Surg. 77 (1986) 442e448. [17] F. Lorenzetti, S. Giordano, E. Tukiainen, Intraoperative hemodynamic evaluation of the latissimus dorsi muscle flap: a prospective study, J. Reconstr. Microsurg 28 (2012) 273e278. [18] S.H. Kim, H.K. Kim, K. Kim, Y.M. Shim, Outcome of free jejunal transfer using the end-to-side arterial anastomosis technique as a pharyngo-oesophageal substitute: a 15-year experience, Eur. J. Cardiothorac. Surg. (2013) ezt058. [19] F. Ensat, R. Wakolbinger, H.M. Schubert, G. Moser, M. Hladik,
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G. Wechselberger, Venous thrombosis of free flap immediately after intravenous application of desmopressin, Microsurgery 33 (2013) 79e80. [20] J.M. Serletti, S.L. Moran, G.S. Orlando, T. O'connor, R.H. Herrera, Urokinase protocol for free-flap salvage following prolonged venous thrombosis, Plast. Reconstr. Surg. 102 (1998) 1947e1953. [21] I. Ahmadi, P. Herle, W.M. Rozen, J. Leong, One versus two venous anastomoses in microsurgical free flaps: a meta-analysis, J. Reconstr. Microsurg 30 (2014) 413e418.
[22] O. Schouten, M. Hoedt, C. Wittens, W. Hop, M. van Sambeek, H. van Urk, VASCAN Study Group, End-to-end versus end-to-side distal anastomosis in femoropopliteal bypasses; results of a randomized multicenter trial, Eur. J. Vasc. Endovasc. 29 (2005) 457e462. [23] L. Haverkamp, P.C. Van Der Sluis, R.J. Verhage, P.D. Siersema, J.P. Ruurda, R. Van Hillegersberg, End-to-end cervical esophagogastric anastomoses are associated with a higher number of strictures compared with end-to-side anastomoses, J. Gastrointest. Surg. 17 (2013) 872e876.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
A retrospective study of end-to-side venous anastomosis for free flap in extremity reconstruction Haijun Mao, Guangyue Xu* Orthopedics, Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
h i g h l i g h t s The overall surgery success rate of ETS anastomosis was 96.6%. The occurrence of the ETS anastomosis-related venous thrombosis was 2.3% (4/117). ETS anastomosis success rate was not affected by local condition of surgery site.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 October 2014 Received in revised form 20 January 2015 Accepted 16 March 2015 Available online 28 March 2015
Introduction: The success of end-to-side (ETS) venous anastomosis primarily depends on several mandatory factors including recipient vessel selection and reconstruction site. This retrospective study was designed to analyze the success rate of ETS venous anastomosis for free flap extremity reconstruction. Methods: Between 2009 and 2011, ETS venous anastomosis was performed in 117 patients to reconstruct soft tissue defects of extremity at Nanjing Drum Tower Hospital. The patients were divided into three groups: (1) only one large recipient vein left, (2) two deep venas, (3) one deep vein and one superficial vein. Medical records and the follow-up data were retrospectively reviewed. The success rates of the three groups were compared with Chi-squared test. Results: Totally, 5, 52, and 60 patients were included in Group 1, Group 2, and Group 3, respectively. The overall surgery success rate was 96.6% (113/117) with four failures: zero in Group 1, two in Group 2 (2/52, 3.8%) and two in Group 3 (2/60, 3.3%), due to venous thrombosis. The re-anastomosis rate in reexploration in Group 1, 2 and 3 was 0%, 1.9% (1/52), and 1.7% (1/60), respectively. No complication was observed during the operation. Discussion: No statistical difference was observed in flap failure rate among the three different types of ETS anastomosis. This suggests that differences of the ETS anastomosis surgical site might not affect the surgery success rate. Conclusion: These results confirmed that the success rate of ETS anastomosis was not affected by the local conditions of surgery site. © 2015 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
Keywords: End-to-side anastomosis Reconstruction Free flap
1. Introduction Microvascular anastomosis, which is crucial to the survival rate of transferred tissues, could be performed either in an end-to-end (ETE) or in an end-to-side (ETS) anastomosis. Traditionally, the recipient artery and vein is sacrificed to provide the pedicle ETE anastomosis [1]. ETS anastomosis has been introduced to address
* Corresponding author. E-mail address: [email protected] (G. Xu). http://dx.doi.org/10.1016/j.ijsu.2015.03.016 1743-9191/© 2015 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
cases where the recipient artery is necessary for distal circulation or when there is only a single artery [2]. Previous studies have shown that ETS arterial anastomosis has advantages such as decreased vessel spasm, elimination of vessel mismatch, and preservation of the distal run-off [3]. Thus, it has been widely used in free flap grafting. However, the incidence of venous thrombosis is higher in ETS anastomosis than that in the arterial thrombosis in lower-extremity reconstruction [2,4,5]. Despite of all that, studies have suggested that ETS venous anastomosis is a safe alternative to ETE anastomosis and definitively is the straightforward option for microvascular anastomosis [6].
H. Mao, G. Xu / International Journal of Surgery 17 (2015) 72e78
Besides, ETS venous anastomosis is firstly proposed in the cases where one recipient vein remains and the caliber of the donor's vein is smaller than the recipient vein. However, seldom literature have been focused on whether the choice of recipient vein locations, such as superior or deep veins, affect venous survival or surgery success rate or not. In this study, 117 patients with ETS venous anastomosis for free flap reconstruction in extremity were reviewed retrospectively. To explore the feasibility of ETS anastomosis and demonstrate whether the location conditions of the surgical site affect the success rate or not, patients were grouped into different groups according to the local condition of the surgical site. The success rates of the groups would be discussed. 2. Materials and methods Between 2009 and 2011, 117 cases (including 75 males and 42 females) undergone microsurgical reconstruction of the extremity at Nanjing Drum Tower Hospital affiliated to Nanjing University. Patients with diabetes, smoking, arterial or venous transplantation were excluded in this study. Indications for surgery included wound bone with exposed tendons, nerves and blood vessels unable to flap transfer (island flap or skin graft); open reduction external fixation with open fractures. All patients were received anterolateral free flaps which required salvaged venous ETS anastomosis in the reconstruction. Failure ETS was defined as the complete flap loss regardless of its origin (arterial, venous, and/or perforator). 2.1. Operative procedures All patients underwent one or more debridement. All surgeries were performed under general anesthesia by the same surgical team in Nanjing Drum Tower Hospital. Exploration was performed to locate and prepare a recipient artery and vein. If there was only one remained vein or a large difference in the diameters of recipient and flap vein the venous ETS anastomosis technique was chosen for flap grafting. The recipient arteries and vena were radial, ulnar, brachial, anterior tibial, posterior tibial artery and deep,
73
superficial vena, respectively. How to choose venous ETS anastomosis? According to our experience, the implementation of ETS anastomosis was depended on the local condition of the surgical site including both the compatibility of the recipient and donor vessels. Patients were divided into three groups according to three different choices of venous ETS anastomosis (Fig. 1). For Group 1, only one larger recipient vein was left. In this group, two venas of the flap were connected to the same one recipient vein. The appropriate distance between the two stomas had not been studied up to now (Fig. 2). For Group 2, two unobstructed deep venas were left without available superficial vena. In this case, a skilled physician might be needed (Fig. 3). In Group 3, there was one remained deep vein and one superficial vein. It was better and easier to anastomose vessels if the superficial vein was available and unobstructed (Fig. 4). Anastomosis was performed under a microscope with interrupted suture using 8e0 or 9e0 monofilament nylon (Ethicon Co. Johnson and Johnson). During the operation, a pair of microscissors was used to excise a portion of the vessel wall according to the pedicle. The lateral aperture does not exceed 1/2 of the circumferences of the recipient venous. At the end of the operation, the ballooning patency test was performed to evaluate whether the venous stoma was obstructed or not. At the end of microvascular anastomoses, low molecular weight dextran was routinely infused into patients (500 mL at 20 mL/h) for 5 days postoperatively. Sensitive antibiotics, papaverine hydrochloride (30 mg/6 h), low molecular heparin (5000 I.U./day) were included in the postoperative protocol for patients remained in bed, which usually stopped shortly after mobilization, unless otherwise indicated. Postoperative flap viability was inspected and controlled by a resident by evaluating color, temperature, and appearance of the flap, and by pin pricking the skin paddle, skin monitor or muscular portion of the flap every 2 h in the following 24 h and every 3e4 h in the following days. In each instance of suspected arterial and/or venous thrombosis, the patient was re-operated to explore the anastomosis immediately. Medical records were retrospectively reviewed for demographics, operative and follow-up data.
Fig. 1. Patient selection flowchart.
74
H. Mao, G. Xu / International Journal of Surgery 17 (2015) 72e78
Fig. 2. Indication (A), before (B) and after (C) surgery, and result (D) of the patient in group 1. In this group, 2 venas of the flap were connected to the same one recipient vein.
2.2. Data analysis Statistical analysis was done using SPSS 19 (SPSS Inc., IL,USA). Surgical success rates were presented as percentages and were analyzed using Chi-squared. Mean values of continuous variables were expressed as mean ± SD (standard deviation). The significant level of surgical success rate was set at p-value < 0.05. 3. Results Totally, 51 patients had soft tissue defects in upper extremities and 66 patients in lower extremities. Among them, 73, 31, and 13 patients were caused by traffic accident, mechanical injury, and
crushing, respectively. Patient characteristics were given in Table 1. Totally, 5 (4.3%, 5/117) cases were enrolled in Group 1, 52 (44.4%, 52/ 117) cases were enrolled in Group 2 due to the evident caliber mismatch, and 60 cases (51.3%, 60/117) were included in Group 3. Mean follow-up was 13 ± 4.5 months (ranged from 12 months to 18 months). Mean age of the patients was 49 ± 10 years old ranging from 32 to 60 years. Venous re-exploration was performed in all patients at 4 h and 12 h after surgery. Totally, the mean successes rate of ETS was 97.6 ± 2.1%, with two failures in Group 2 (2/52, 3.8%) and two in Group 3 (2/60, 3.3%). Four failures were appeared due to venous thrombosis (2.3%, 4/117) (Table 2). The first two failures developed venous congestion at 12 h after surgery and subsequently received
H. Mao, G. Xu / International Journal of Surgery 17 (2015) 72e78
75
Fig. 3. Indication (A), before (B) and after (C) surgery, and result (D) of the patient in group 2. In this group, 2 unobstructed deep venas were remained without available superficial vena.
secondary reconstruction with skin grafting. The second one suffered from postoperative bleeding during the night and developed flap venous congestion and underwent reconstruction using ALT flap. During the re-exploration, the other two failures, one in Group 2 and one in Group 3, respectively, was performed skin graft and secondary skin flap due to both the absence of extensive flap intravenous thrombosis within flap and the absence of venous return after thrombectomy. Thus the re-anastomosis rate in reexploration in Group 1, 2 and 3 was 0%, 1.9% (1/52), and 1.7% (1/ 60), respectively. No complications were observed during the operation. There was no ETS anastomosis related mortality during follow-up (mean, 13 ± 4.5 months).
4. Discussion Microvascular anastomosis is obviously of paramount importance and plays an important role in the outcome of free flap. The success of ETS primarily depends on several mandatory factors including anastomotic technique, recipient vessel selection, reconstruction site, previous treatments as well as patient characteristics [3,7e10]. The use of the ETS arterial anastomosis in extremity reconstruction was described and popularized by Godina [11]. He analyzed the results of 65 free flaps and showed a lower failure rate with ETS anastomosis than ETE anastomosis. The advantages of ETS
76
H. Mao, G. Xu / International Journal of Surgery 17 (2015) 72e78
Fig. 4. Indication (A), before (B) and after (C) surgery, and result (D) of the patient in group 3. In this group, one deep vein and one superficial vein was available.
anastomosis for extremity reconstruction have been well established, including less incidence of vessel spasm, elimination of vessel mismatch, as well as preservation of the distal run-off [12e14]. Miyamoto et al. [15] confirmed the high tolerance of arterial and venous ETS anastomosis to epinephrine-induced vasospasm and a marked advantage in flap survival in a rat model. Bas et al. compared ETE and ETS venous microanastomoses in 70 rat vessels [16]. No statistically significant difference was noted in anastomosis patency in similar-diameter vessels, while in size-discrepant veins, ETS anastomosis presented a significantly lower vibration-translation rate. Moreover, Lorenzetti et al. [17] reported that the vascular resistance and the blood flow in the thoracodorsal artery, respectively, was significantly decreased and increased after flap transplantation with ETS anastomosis followed
Table 1 The demographic characteristics of 117 patients. Characteristics
Total/Mean
No. of patients Age (years) Mean Range Location Upper extremity Lower extremity Cause Traffic accident Mechanical injury Crushing
117 49 ± 10 32e60 51 66 73 31 13
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77
Table 2 The outcomes of end-to-side anastomosis in the three groups. Group
No. of patient
Surgery failure (rate)
Success rate
Re-anastomosis
Final failure
p-Value
1 2 3 Total/Mean
5 52 60 117
0 2 (3.8%) 2 (3.3%) 4 (2.3%)
100% 96.2% 96.7% 97.6 ± 2.1%
0 1 1 2
0 1 1 2
>0.05
by flap raising and anastomosis. These informed us that ETS anastomosis could be a favorable choice in these cases. Microvascular free-tissue transfer is a reliable pillar of reconstructive surgery, yet pedicle thrombosis remains a challenge for the success rate of ETS anastomosis [2,4]. Several studies have shown that venous thrombosis is the most frequent cause of free flap failure [18e20]. Moreover, some analyses showed that there was a significant reduction in flap failure and venous thrombosis when performing two venous anastomoses versus one in free flap surgery [21]. In this study, the mean success rate of ETS anastomosis was 97.6 ± 2.1%. There were 4 failures due to venous thrombosis. This demonstrated that venous thrombosis is the common phenomenon resulting in ETS anastomosis failures. The limitation of our study is that the patient number was limit. This is a cohort study and all the surgeries were performed by one single team. However, there was an imbalance in patient numbers among the 3 groups. A selection bias also existed in this study: patients with diabetes, smoking, arterial or venous transplantation were excluded to avoid the confounding factors which might influence the statistical differences [22,23]. Thus this study was limited by the lack of an enough large sample cases. That might be the cause for the fact that no statistical difference was observed in the flap failure rate among the different choices of ETS anastomosis. This suggested that, in some degree, different choices of the ETS anastomosis surgical site might not affect the success rate of surgery. This may increase the clinical application of venous ETS anastomosis. 5. Conclusion ETS venous anastomosis is a useful technique in reconstruction surgery without sacrificing the recipient vena. There was no statistically significant difference in the failure rates among the three different choices of ETS venous anastomosis (p > 0.05). The mean success rate was 97.6 ± 2.1% with 100%, 96.2%, and 96.7% in Group 1, 2, and 3, respectively. Venous thrombosis was the common phenomenon resulting in ETS anastomosis failure. However, a larger number of sample cases might provide a more convincing result. Ethical approval All studies have been approved by The Affiliated Drum Tower Hospital of Nanjing University Medical School Ethics Committee and performed in accordance with the ethical standards. Financial support None. Author contribution Guangyue Xu participated in the design of this study, and performed the statistical analysis. Haijun Mao carried out the study, together with Guangyue Xu, collected important background information, and drafted the manuscript. Guangyue Xu conceived of this study, and participated in the design and helped to draft the manuscript. All authors read and approved the final manuscript.
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