Non-occlusive mesenteric ischaemia of a free jejunal flap

doi:10.1016/j.bjps.2012.12.031

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 66, Issue 5, May 2013, Pages e133-e136

https://doi.org/10.1016/j.bjps.2012.12.031 Get rights and content

Summary

Free jejunal transfer using microsurgery after oesophageal or pharyngeal cancer resection is a useful operative approach. However, the disadvantage of free tissue transfer is the risk of necrosis of the transferred tissue due to impaired blood supply. In addition, jejunal flaps are more prone to blood-flow disorders such as ischaemia and congestion compared with other types of flaps. The causes of local blood supply disorders after microsurgery are divided broadly into two classes: one is thrombosis of an artery and/or vein in the anastomotic region and the other consists of local physical factors such as compressive pressure derived from haematoma formation and the effect of infection of the vascular pedicle. In this report, two rare cases of blood-flow disorder of the transferred free jejunum are described. In both cases, no signs of significant infection or occlusion of the vascular pedicles were present and late necrosis progressed gradually. The patients showed remarkable weight loss and a poor nutritional state due to inadequate preoperative nutritional intake. The necrosis was considered to be a result of non-occlusive mesenteric ischaemia of a free jejunal flap, and the factors contributing to free jejunal necrosis were reviewed.

Section snippets

Case reports

Case 1 was a 63-year-old man with cervical oesophageal cancer who had undergone three surgeries and chemoradiotherapy before referral. The condition of the operative field had been altered because of the effects of the earlier surgeries and chemoradiotherapy. At the first reconstructive surgery, a free jejunal flap was transferred (Figure 1). However, after the primary reconstruction, the patient went into preshock on the second postoperative day. At this time, the blood flow of the monitoring

Discussion

NOMI accounts for 20–30% of mesenteric ischaemia cases, and its aetiology and pathogenesis are poorly understood.3, 4, 5 Acute NOMI is generally associated with haemodialysis⁶ and cardiac or major aortic surgery.⁷ The two present cases developed jejunal flap necrosis without evidence of thrombosis in the mesenteric blood vessels at the time of reoperation, appearing to have NOMI-FJ. We considered the difference between the cases and a general necrosis case.

Partial necrosis of the free jejunum

Conclusion

Two cases of possible NOMI-FJ, apparently related to aggravation of the postoperative circulatory dynamics, were reported. It is better to avoid invasive surgery, including free jejunal transfer, and immediate reconstruction in patients with poor nutrition or multiple systemic complications.

Ethical approval

Not required.

Funding

None.

Conflicts of interest

None declared.

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Non-occlusive mesenteric ischemia detected by ultrasound
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There are more references available in the full text version of this article.

Cited by (12)

Near-infrared spectroscopy for monitoring free jejunal flap
2021, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
However, these are invasive and/or intermittent. Furthermore, the monitoring flap does not always reflect graft ischemia.6,9 Graft failure can also develop due to nonocclusive ischemia.6
Although the free jejunal graft is commonly used for reconstruction after resection of a tumor of the pharynx or cervical esophagus, adequate monitoring for detecting graft failure is not available. We employed near-infrared spectroscopy to measure regional oxygen saturation (rSO₂) in the graft.
In 25 consecutive cases who underwent reconstructive surgery using a free jejunal graft, the feasibility of postoperative rSO₂ monitoring was examined along with the changes in rSO₂ values following vascular clamping or reperfusion.
No operative mortality occurred, and except for one case of subcutaneous hematoma that necessitated evacuation surgery, no complications related to surgery or graft failure occurred. Postoperative rSO₂ monitoring was feasible for >50 hours in most cases. It mostly remained >55% with a stable hemoglobin index (HbI) which reflects tissue hemoglobin density. A marked increase in the HbI was noted in a patient with hematoma. Intraoperatively, the rSO₂ of intact jejunal tissue was >60% in every case but dropped within a few minutes after arterial clamping because of decreased oxygenated hemoglobin concentration. With venous clamping, the HbI was elevated while the rSO₂ remained unchanged or was slightly decreased. Upon graft reperfusion, the rSO₂ rapidly recovered in all 18 cases because of the recovery of oxygenated hemoglobin concentrations.
The near-infrared spectroscopic assessment sensitively and accurately reflected the condition of the jejunal graft. It appears to be a promising postoperative method for monitoring graft perfusion. An rSO₂ value of 55% appears to be an adequate criterion for ischemia.
Morphological analysis of ischemia-reperfusion injury in a cold ischemia model of jejunal free flap for hypopharyngeal reconstruction
2020, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
–9 However, total graft necrosis remains a major complication due to artery or vein thrombosis at the anastomotic site. Other factors not related to vascular occlusion but depending on the surgical procedure can cause ischemic damage with progressive necrosis, delayed graft dysfunction,10,11 or minor complications. When a mucosal damage due to ischemia-reperfusion injury (IRI) occurs, it is associated with a cascade of events, which include inflammatory cytokine production and oxygen free radical formation.
Jejunal free flap (JFF) reconstruction is a popular treatment option for advanced hypopharyngeal cancer. Several factors including ischemia-reperfusion injury (IRI) can cause mucosal damage and progressive flap necrosis. We investigated the development and time-related progression of morphological and cellular changes in patients with JFF reconstruction including cold preservation of the graft.
Eleven patients were enrolled. Biopsies were taken during surgery from normally perfused tissue, before loop isolation (T0), at the end of back-table surgery (T1), immediately before reperfusion (T2), 15′ after reperfusion (T3), and at the end of the digestive anastomoses (T4) and from the external monitor daily from the 1st to the 5th postoperative day (M1–M5). Histomorphological and immunohistochemical parameters in the intraoperative and postoperative samples were evaluated and compared.
Delayed flap necrosis was observed in 2 patients. The cold ischemia phase did not negatively affect mucosal regeneration after reperfusion; morphological and cellular damage parameters returned to normal by the end of surgery or along the early postoperative period. Significant enterocyte replication activity was observed at the end of revascularization, which continued in the postoperative phase, leading to recovery of the epithelial morphological integrity and disappearance of apoptotic cells. An inflammatory infiltrate persisted in the M samples, and in a significant proportion of samples, mucosal fibrosis developed by the end of the postoperative observation.
Cold perfusion and preservation of the JFF can effectively limit the negative effects of IRI and to prevent short- and medium-term complications that can compromise the final outcome.
Transfer of anterolateral thigh flaps in elderly oral cancer patients: Complications in oral and maxillofacial reconstruction
2015, Journal of Oral and Maxillofacial Surgery
Although a promising approach, the use of anterolateral thigh (ALT) free flaps has been limited in the reconstruction of oral and maxillofacial defects in elderly patients. The aim of this study was to estimate the frequency of postoperative complications and identify factors associated with complications.
The authors designed and implemented a retrospective study on the frequency of postoperative complications in elderly patients. They enrolled a sample composed of patients who underwent ALT free flap transfers for the repair of defects created during oral and maxillofacial cancer surgery from February 2002 to March 2013. The χ² test, t test, and multivariate regression model were used.
A total of 1,100 patients were studied (859 men and 241 women). One hundred four patients (9.5%) were at least 70 years old (elderly group) at the time of surgery; the other 996 patients were younger than 70 years (younger group). The overall success rate of ALT free flap transfer was 97.2% (97.0% in the younger group, 99.0% in the elderly group; P > .05). The overall complication rate was 27.5% (27.2% in the younger group, 29.8% in the elderly group; P = .572). Multivariate analysis showed that operation time, American Society of Anesthesiologists class, and comorbidity were independent risk factors for postoperative complications in elderly patients.
Oral and maxillofacial reconstruction using ALT free flaps in elderly patients can achieve outcomes similar to those obtained in younger patients. Limiting the operation time is important for improving surgical outcomes.
Acute mesenteric ischemia
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Multimodality Diagnosis of Mesenteric Ischemia
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Case reportNon-occlusive mesenteric ischaemia of a free jejunal flap

Summary

Section snippets

Case reports

Discussion

Conclusion

Ethical approval

Funding

Conflicts of interest

J Plast Reconstr Aesthet Surg

Am J Clin Nutr

Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment

Ann Surg

Non-occlusive mesenteric ischemia detected by ultrasound

Intensive Care Med

Case report
Non-occlusive mesenteric ischaemia of a free jejunal flap