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Nobis CP, Grottschreiber K, Olmos M, Moest T, Weber M, Kesting M, Lutz R. Development of a porcine training model for microvascular fasciocutaneous free flap reconstruction. Head Face Med 2024; 20:35. [PMID: 38831370 PMCID: PMC11145860 DOI: 10.1186/s13005-024-00435-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/26/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND In reconstructive surgery, improvements are needed in the effective teaching of free flap surgery. There is a need for easily accessible and widely available training without high financial costs or ethical concerns while still providing a realistic experience. Our aim was to develop an appropriate training model for microvascular flaps. METHODS We identified pig head halves as most appropriate regarding availability, cost, and realism. These accrue largely by the food industry, so no animals need to be sacrificed, making it more ethical from an animal welfare perspective. We evaluated the suitability as flap donor site and analyzed the vascular anatomy of 51 specimens. RESULTS Anatomical evaluation revealed a reliable and constant vascular anatomy, allowing the design of a flap model that can effectively illustrate the entire process of microvascular flap surgery. The process was divided into 6 key steps. The flap can be harvested after marking the vascular pedicle 5.3 cm from the lateral corner of the mouth. Skin island design and subsequent tissue dissection follow until a fasciocutaneous flap is raised, similar to a radial flap. Upon completion of flap harvesting, it can be freely transferred for defect reconstruction. Microvascular anastomosis can be performed on recipient vessels in the cervical region, and the difficulty can be individually adjusted. CONCLUSIONS The developed training model is a reasonable compromise in terms of surgical realism, availability, didactic value, and cost/time effectiveness. We believe it is a powerful and effective tool with high potential for improving surgical education and training.
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Affiliation(s)
- Christopher-Philipp Nobis
- Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Glueckstrasse 11, D-91054, Erlangen, Germany.
| | - Katharina Grottschreiber
- Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Glueckstrasse 11, D-91054, Erlangen, Germany
| | - Manuel Olmos
- Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Glueckstrasse 11, D-91054, Erlangen, Germany
| | - Tobias Moest
- Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Glueckstrasse 11, D-91054, Erlangen, Germany
| | - Manuel Weber
- Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Glueckstrasse 11, D-91054, Erlangen, Germany
| | - Marco Kesting
- Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Glueckstrasse 11, D-91054, Erlangen, Germany
| | - Rainer Lutz
- Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Glueckstrasse 11, D-91054, Erlangen, Germany
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Salehi S, Lippert Lozano E, Zhang Y, Guo Y, Liu R, Tran K, Messner F, Brandacher G, Grayson WL. Design of a Multiparametric Perfusion Bioreactor System for Evaluating Sub-Normothermic Preservation of Rat Abdominal Wall Vascularized Composite Allografts. Bioengineering (Basel) 2024; 11:307. [PMID: 38671729 PMCID: PMC11047557 DOI: 10.3390/bioengineering11040307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 04/28/2024] Open
Abstract
Static cold storage (SCS), the current clinical gold standard for organ preservation, provides surgeons with a limited window of time between procurement and transplantation. In vascularized composite allotransplantation (VCA), this time limitation prevents many viable allografts from being designated to the best-matched recipients. Machine perfusion (MP) systems hold significant promise for extending and improving organ preservation. Most of the prior MP systems for VCA have been built and tested for large animal models. However, small animal models are beneficial for high-throughput biomolecular investigations. This study describes the design and development of a multiparametric bioreactor with a circuit customized to perfuse rat abdominal wall VCAs. To demonstrate its concept and functionality, this bioreactor system was employed in a small-scale demonstrative study in which biomolecular metrics pertaining to graft viability were evaluated non-invasively and in real time. We additionally report a low incidence of cell death from ischemic necrosis as well as minimal interstitial edema in machine perfused grafts. After up to 12 h of continuous perfusion, grafts were shown to survive transplantation and reperfusion, successfully integrating with recipient tissues and vasculature. Our multiparametric bioreactor system for rat abdominal wall VCA provides an advanced framework to test novel techniques to enhance normothermic and sub-normothermic VCA preservations in small animal models.
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Affiliation(s)
- Sara Salehi
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Ernesto Lippert Lozano
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Yichuan Zhang
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (Y.G.); (F.M.); (G.B.)
| | - Yinan Guo
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (Y.G.); (F.M.); (G.B.)
| | - Renee Liu
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Kenny Tran
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Franka Messner
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (Y.G.); (F.M.); (G.B.)
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Gerald Brandacher
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (Y.G.); (F.M.); (G.B.)
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Warren L. Grayson
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
- Institute for Nanobiotechnology, Johns Hopkins University, Baltimore, MD 21218, USA
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 2121, USA
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Orizondo RA, Bengur FB, Komatsu C, Strong KR, Federspiel WJ, Solari MG. Machine Perfusion Deters Ischemia-Related Derangement of a Rodent Free Flap: Development of a Model. J Surg Res 2024; 295:203-213. [PMID: 38035871 DOI: 10.1016/j.jss.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 09/12/2023] [Accepted: 10/27/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Machine perfusion can enable isolated support of composite tissues, such as free flaps. The goal of perfusion in this setting is to preserve tissues prior to transplantation or provide transient support at the wound bed. This study aimed to establish a rodent model of machine perfusion in a fasciocutaneous-free flap to serve as an affordable testbed and determine the potential of the developed support protocol to deter ischemia-related metabolic derangement. METHODS Rat epigastric-free flaps were harvested and transferred to a closed circuit that provides circulatory and respiratory support. Whole rat blood was recirculated for 8 h, while adjusting the flow rate to maintain arterial-like perfusion pressures. Blood samples were collected during support. Extracellular tissue lactate and glucose levels were characterized with a microdialysis probe and compared with warm ischemic, cold ischemic, and anastomosed-free flap controls. RESULTS Maintenance of physiologic arterial pressures (85-100 mmHg) resulted in average pump flow rates of 360-430 μL/min. Blood-based measurements showed maintained glucose and oxygen consumption throughout machine perfusion. Average normalized lactate to glucose ratio for the perfused flaps was 5-32-fold lower than that for the warm ischemic flap controls during hours 2-8 (P < 0.05). CONCLUSIONS We developed a rat model of ex vivo machine perfusion of a fasciocutaneous-free flap with maintained stable flow and tissue metabolic activity for 8 h. This model can be used to assess critical elements of support in this setting as well as explore other novel therapies and technologies to improve free tissue transfer.
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Affiliation(s)
- Ryan A Orizondo
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Fuat Baris Bengur
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chiaki Komatsu
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelly R Strong
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William J Federspiel
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Clinical and Translational Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mario G Solari
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Haug V, Peng Y, Tchiloemba B, Wang AT, Buerger F, Romfh P, Kneser U, Polizzotti BD, Pomahac B. Normothermic Ex Situ Machine Perfusion of Vascularized Composite Allografts with Oxygen Microcarriers for 12 Hours Using Real-Time Mitochondrial Redox Quantification. J Clin Med 2023; 12:6568. [PMID: 37892706 PMCID: PMC10607057 DOI: 10.3390/jcm12206568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Normothermic ex situ perfusion of vascularized composite allografts (VCAs) necessitates high oxygen demand and, thus, increased metabolic activity, which, in turn, requires the use of blood-based perfusion solutions. However, blood-derived perfusates, in turn, constitute an antigenic load. To circumvent this immunogenic problem, we used a perfusate enriched with acellular dextrane oxygen microcarriers to perfuse rat hindlimbs. METHODS Rat hindlimbs (n = 11) were perfused with either (non-), oxygenated dextrane-enriched Phoxilium, or Phoxilium enriched with dextrane oxygen microcarriers (MO2) for 12 h at 37 °C or stored on ice. Oxygenation of the skeletal muscle was assessed with Raman spectroscopy, tissue pO2-probes, and analysis of the perfusate. Transmission electronic microscopy was utilized to assess the ultrastructure of mitochondria of the skeletal muscle. RESULTS For all evaluated conditions, ischemia time until perfusion was comparable (22.91 ± 1.64 min; p = 0.1559). After 12 h, limb weight increased significantly by at least 81%, up to 124% in the perfusion groups, and by 27% in the static cold storage (SCS) group. Raman spectroscopy signals of skeletal muscle did not differ substantially among the groups during either perfusion or static cold storage across the duration of the experiment. While the total number of skeletal muscle mitochondria decreased significantly compared to baseline, mitochondrial diameter increased in the perfusion groups and the static cold storage group. CONCLUSION The use of oxygen microcarriers in ex situ perfusion of VCA with acellular perfusates under normothermic conditions for 12 h facilitates the maintenance of mitochondrial structure, as well as a subsequent recovery of mitochondrial redox status over time, while markers of muscle injury were lower compared to conventional oxygenated acellular perfusates.
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Affiliation(s)
- Valentin Haug
- Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (V.H.)
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Yifeng Peng
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bianief Tchiloemba
- Division of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Alice T. Wang
- Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (V.H.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Florian Buerger
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Brian D. Polizzotti
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT 06510, USA
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Ton C, Salehi S, Abasi S, Aggas JR, Liu R, Brandacher G, Guiseppi-Elie A, Grayson WL. Methods of ex vivo analysis of tissue status in vascularized composite allografts. J Transl Med 2023; 21:609. [PMID: 37684651 PMCID: PMC10492401 DOI: 10.1186/s12967-023-04379-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/21/2023] [Indexed: 09/10/2023] Open
Abstract
Vascularized composite allotransplantation can improve quality of life and restore functionality. However, the complex tissue composition of vascularized composite allografts (VCAs) presents unique clinical challenges that increase the likelihood of transplant rejection. Under prolonged static cold storage, highly damage-susceptible tissues such as muscle and nerve undergo irreversible degradation that may render allografts non-functional. Skin-containing VCA elicits an immunogenic response that increases the risk of recipient allograft rejection. The development of quantitative metrics to evaluate VCAs prior to and following transplantation are key to mitigating allograft rejection. Correspondingly, a broad range of bioanalytical methods have emerged to assess the progression of VCA rejection and characterize transplantation outcomes. To consolidate the current range of relevant technologies and expand on potential for development, methods to evaluate ex vivo VCA status are herein reviewed and comparatively assessed. The use of implantable physiological status monitoring biochips, non-invasive bioimpedance monitoring to assess edema, and deep learning algorithms to fuse disparate inputs to stratify VCAs are identified.
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Affiliation(s)
- Carolyn Ton
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Sara Salehi
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Sara Abasi
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Media and Metabolism, Wildtype, Inc., 2325 3rd St., San Francisco, CA, 94107, USA
| | - John R Aggas
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Test Development, Roche Diagnostics, 9115 Hague Road, Indianapolis, IN, 46256, USA
| | - Renee Liu
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Reconstructive Transplantation Program, Center for Advanced Physiologic Modeling (CAPM), Johns Hopkins University, Ross Research Building/Suite 749D, 720 Rutland Avenue, Baltimore, MD, 21205, USA.
| | - Anthony Guiseppi-Elie
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA.
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA.
- Department of Cardiovascular Sciences, Houston Methodist Institute for Academic Medicine and Houston Methodist Research Institute, 6670 Bertner Ave., Houston, TX, USA.
- ABTECH Scientific, Inc., Biotechnology Research Park, 800 East Leigh Street, Richmond, VA, USA.
| | - Warren L Grayson
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA.
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA.
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Institute for Nanobiotechnology, Johns Hopkins University, Baltimore, MD, USA.
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Strudthoff LJ, Focke J, Hesselmann F, Kaesler A, Martins Costa A, Schlanstein PC, Schmitz-Rode T, Steinseifer U, Steuer NB, Wiegmann B, Arens J, Jansen SV. Novel Size-Variable Dedicated Rodent Oxygenator for ECLS Animal Models-Introduction of the "RatOx" Oxygenator and Preliminary In Vitro Results. MICROMACHINES 2023; 14:800. [PMID: 37421033 DOI: 10.3390/mi14040800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 07/09/2023]
Abstract
The overall survival rate of extracorporeal life support (ECLS) remains at 60%. Research and development has been slow, in part due to the lack of sophisticated experimental models. This publication introduces a dedicated rodent oxygenator ("RatOx") and presents preliminary in vitro classification tests. The RatOx has an adaptable fiber module size for various rodent models. Gas transfer performances over the fiber module for different blood flows and fiber module sizes were tested according to DIN EN ISO 7199. At the maximum possible amount of effective fiber surface area and a blood flow of 100 mL/min, the oxygenator performance was tested to a maximum of 6.27 mL O2/min and 8.2 mL CO2/min, respectively. The priming volume for the largest fiber module is 5.4 mL, while the smallest possible configuration with a single fiber mat layer has a priming volume of 1.1 mL. The novel RatOx ECLS system has been evaluated in vitro and has demonstrated a high degree of compliance with all pre-defined functional criteria for rodent-sized animal models. We intend for the RatOx to become a standard testing platform for scientific studies on ECLS therapy and technology.
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Affiliation(s)
- Lasse J Strudthoff
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Jannis Focke
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Felix Hesselmann
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Andreas Kaesler
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Ana Martins Costa
- Department of Biomechanical Engineering, Faculty of Engineering Technologies, University of Twente, 7522 LW Enschede, The Netherlands
| | - Peter C Schlanstein
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Ulrich Steinseifer
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Niklas B Steuer
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
| | - Bettina Wiegmann
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, 30625 Hanover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), 30625 Hanover, Germany
- German Center for Lung Research (DLZ), 30625 Hanover, Germany
| | - Jutta Arens
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
- Department of Biomechanical Engineering, Faculty of Engineering Technologies, University of Twente, 7522 LW Enschede, The Netherlands
| | - Sebastian V Jansen
- Institute of Applied Medical Engineering, Department of Cardiovascular Engineering, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany
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Ritschl LM, Niu M, Wolff CT, Schwarz M, Roth M, Wolff KD, Fichter AM. Blood flow analyses by intraoperative transit-time flow measurements of free flaps for head and neck reconstructions: A prospective single-center study. Microsurgery 2023; 43:99-108. [PMID: 36193758 DOI: 10.1002/micr.30967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 08/03/2022] [Accepted: 09/16/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The behavior of blood flow changes within free flaps following microvascular anastomosis is not well described in the literature. The aim of this study was to determine the immediate blood flow behavior of different free flaps as reference values for various clinical applications. METHODS Intraoperative transit-time flow measurements were performed on patients receiving free flap transfer in the head and neck area comprising radial forearm flaps (RFF), peroneal artery perforator flaps (PAP), anterolateral thigh flaps (ALT), vastus lateralis flaps (VLF), parascapular flaps (PSF), latissimus dorsi flaps (LDF), fibula free flaps (FFF), deep circumflex iliac artery flaps (DCIA), and scapular flaps (SF). In accordance with a structured protocol, measurements took place at the pedicle directly before flap harvesting and at the recipient vessels 1 h after flap transfer. Heart rate, transplant weight, and other patient characteristics were recorded and analyzed. RESULTS A total of 129 were enrolled, comprising 66 RFF, 8 ALT, 6 PAP, 11 VLF, 3 PSF, 2 LDF, 24 FFF, 7 DCIA, and 2 SF. In most of the transplant groups, arterial perfusion increased after anastomosis at the recipient site. The arterial pulsatility index developed indirectly proportionally to arterial blood flow, whereas venous blood drainage did not show any statistically significant changes. Muscle flaps had the highest arterial perfusion before flap transfer. Composite transplants with hard and soft tissue presented the greatest increase in arterial perfusion. The lowest arterial blood flow after anastomosis was measured in PAP and RFF. In contrast, RFF and PAP presented the highest arterial perfusion per 100 g transplant weight. CONCLUSIONS Arterial perfusion changed, whereas venous blood flow did not show any statistically significant variations in any transplant group. Perfusion of free flaps does not only depend on the recipient vessel and the recipient bed, but also on flap-specific anatomy and physiology.
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Affiliation(s)
- Lucas M Ritschl
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Munich, Germany
| | - Minli Niu
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Munich, Germany
| | - Constantin T Wolff
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias Schwarz
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Munich, Germany
| | - Maximilian Roth
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Munich, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Munich, Germany
| | - Andreas M Fichter
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Munich, Germany
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8
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Burlage LC, Lellouch AG, Taveau CB, Tratnig-Frankl P, Pendexter CA, Randolph MA, Porte RJ, Lantieri LA, Tessier SN, Cetrulo CL, Uygun K. Optimization of Ex Vivo Machine Perfusion and Transplantation of Vascularized Composite Allografts. J Surg Res 2022; 270:151-161. [PMID: 34670191 PMCID: PMC8712379 DOI: 10.1016/j.jss.2021.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 08/30/2021] [Accepted: 09/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Machine perfusion is gaining interest as an efficient method of tissue preservation of Vascularized Composite Allografts (VCA). The aim of this study was to develop a protocol for ex vivo subnormothermic oxygenated machine perfusion (SNMP) on rodent hindlimbs and to validate our protocol in a heterotopic hindlimb transplant model. METHODS In this optimization study we compared three different solutions during 6 h of SNMP (n = 4 per group). Ten control limbs were stored in a preservation solution on Static Cold Storage [SCS]). During SNMP we monitored arterial flowrate, lactate levels, and edema. After SNMP, muscle biopsies were taken for histology examination, and energy charge analysis. We validated the best perfusion protocol in a heterotopic limb transplantation model with 30-d follow up (n = 13). As controls, we transplanted untreated limbs (n = 5) and hindlimbs preserved with either 6 or 24 h of SCS (n = 4 and n = 5). RESULTS During SNMP, arterial outflow increased, and lactate clearance decreased in all groups. Total edema was significantly lower in the HBOC-201 group compared to the BSA group (P = 0.005), 4.9 (4.3-6.1) versus 48.8 (39.1-53.2) percentage, but not to the BSA + PEG group (P = 0.19). Energy charge levels of SCS controls decreased 4-fold compared to limbs perfused with acellular oxygen carrier HBOC-201, 0.10 (0.07-0.17) versus 0.46 (0.42-0.49) respectively (P = 0.002). CONCLUSIONS Six hours ex vivo SNMP of rodent hindlimbs using an acellular oxygen carrier HBOC-201 results in superior tissue preservation compared to conventional SCS.
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Affiliation(s)
- Laura C Burlage
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Department of Surgery, University Medical Center Groningen, Groningen, Netherlands; Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children, Boston, Massachusetts.
| | - Alexandre G Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery within the Department of Surgery, European George Pompidou Hospital, University of Paris, Paris, France
| | - Corentin B Taveau
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children, Boston, Massachusetts
| | - Philipp Tratnig-Frankl
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children, Boston, Massachusetts
| | - Casie A Pendexter
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children, Boston, Massachusetts
| | - Mark A Randolph
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children, Boston, Massachusetts
| | - Robert J Porte
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Laurent A Lantieri
- Division of Plastic and Reconstructive Surgery within the Department of Surgery, European George Pompidou Hospital, University of Paris, Paris, France
| | - Shannon N Tessier
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children, Boston, Massachusetts
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children, Boston, Massachusetts
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts; Shriners Hospitals for Children, Boston, Massachusetts
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Taeger CD, Friedrich O, Horch RE, Drechsler C, Weigand A, Hopf F, Geppert CI, Münch F, Birkholz T, Wenzel C, Geis S, Prantl L, Buchholz R, Präbst K. Extracorporeal perfusion - reduced to a one-way infusion. Clin Hemorheol Microcirc 2021; 79:257-267. [PMID: 28759964 DOI: 10.3233/ch-170298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Extracorporeal perfusion (EP) is moving into focus of research in reconstructive and transplantation medicine for the preservation of amputates and free tissue transplants. The idea behind EP is the reduction of ischemia-related cell damage between separation from blood circulation and reanastomosis of the transplant. Most experimental approaches are based on a complex system that moves the perfusate in a circular course. OBJECTIVE AND METHODS In this study, we aimed to evaluate if a simple perfusion by an infusion bag filled with an electrolyte solution can provide acceptable results in terms of flow stability, oxygen supply and viability conservation for EP of a muscle transplant. The results are compared to muscles perfused with a pump system as well as muscles stored under ischemic conditions after a one-time intravasal flushing with Jonosteril. RESULTS With this simple method a sufficient oxygen supply could be achieved and functionality could be maintained between 3.35 times and 4.60 times longer compared to the control group. Annexin V positive nuclei, indicating apoptosis, increased by 9.7% in the perfused group compared to 24.4% in the control group. CONCLUSIONS Overall, by decreasing the complexity of the system, EP by one-way infusion can become more feasible in clinical situations.
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Affiliation(s)
- Christian D Taeger
- Department of Plastic and Hand Surgery, University Hospital of Regensburg, Regensburg, Germany
| | - Oliver Friedrich
- Institute of Medical Biotechnology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Caroline Drechsler
- Department of Plastic and Hand Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Annika Weigand
- Department of Plastic and Hand Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Fabio Hopf
- Institute of Bioprocess Engineering, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carol I Geppert
- Pathology and Anatomy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Frank Münch
- Department of Paediatric Cardiac Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Torsten Birkholz
- Department of Anaesthesiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carina Wenzel
- Department of Plastic and Hand Surgery, University Hospital of Regensburg, Regensburg, Germany
| | - Sebastian Geis
- Department of Plastic and Hand Surgery, University Hospital of Regensburg, Regensburg, Germany
| | - Lukas Prantl
- Department of Plastic and Hand Surgery, University Hospital of Regensburg, Regensburg, Germany
| | - Rainer Buchholz
- Institute of Bioprocess Engineering, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Konstantin Präbst
- Institute of Bioprocess Engineering, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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10
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Tissue Viability of Free Flaps after Extracorporeal Perfusion Using a Modified Hydroxyethyl Starch Solution. J Clin Med 2020; 9:jcm9123929. [PMID: 33287393 PMCID: PMC7761798 DOI: 10.3390/jcm9123929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In free flap surgery, tissue is stored under hypothermic ischemia. Extracorporeal perfusion (EP) has the potential to extend storage time and the tissue's perspective of survival. In the present study, the aim is to improve a recently established, simplified extracorporeal perfusion system. METHODS Porcine musculus rectus abdominis were stored under different conditions. One group was perfused continuously with a simplified one-way perfusion system for six hours, while the other received only a single flush but no further treatment. A modified hydroxyethyl starch solution was used as a perfusion and flushing solution. Vitality, functionality, and metabolic activity of both groups were analyzed. RESULTS Perfused muscles, in contrast to the ischemically stored ones, showed no loss of vitality and significantly less functionality loss, confirming the superiority of storage under continuous perfusion over ischemic storage. Furthermore, in comparison to a previous study, the results were improved even further by using a modified hydroxyethyl starch solution. CONCLUSION The use of EP has major benefits compared to the clinical standard static storage at room temperature. Continuous perfusion not only maintains the oxygen and nutrient supply but also removes toxic metabolites formed due to inadequate storage conditions.
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11
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Tochigi K, Omura K, Miyashita K, Aoki S, Otori N, Tanaka Y. Pathological Features of Free Graft and Pedicled Flap in the Nasal Cavity: An Animal Study. Laryngoscope 2020; 131:E428-E433. [PMID: 32207858 DOI: 10.1002/lary.28630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/05/2020] [Accepted: 03/03/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Recent developments in reconstructive techniques for mucosal defects using mucoperiosteal materials have enabled rapid recovery of physiological function after endoscopic sinus surgery. Clinical trials have described the advantages, disadvantages, and different outcomes of free graft and pedicled flap, which, respectively, sacrifice or preserve blood flow. However, histological changes, that affect the postoperative outcomes after reconstruction, remain unclear. We created an animal model for the reconstruction of mucosal defects using free grafts and pedicled flaps, and evaluated them histologically. STUDY DESIGN Animal study. METHODS We created mucosal defects in the left nasal septum of 20 rabbits and performed reconstruction with free grafts and pedicled flaps. The distribution of ciliary and goblet cells at the reconstruction site was evaluated after 7 and 28 days using hematoxylin and eosin-stained sections to calculate the Ciliary Cell Index and Goblet Cell Index. The severity of inflammation was assessed using the Cartilage Inflammatory Cell Score. RESULTS Crusting and changes in the mucosal morphology at the reconstruction site occurred only in the free graft group. In addition, the pedicled flap group had significantly greater preservation of ciliary and goblet cells and less inflammatory cell infiltration into the septal cartilage (P < .05) than the free graft group. CONCLUSIONS After reconstruction procedures for mucosal defects, histopathological differences were observed between the free graft and pedicled flap. Reconstruction with pedicled flaps had advantages including preservation of healthy mucosal epithelium and suppression of inflammation on the reconstruction site. This indicated that reconstruction with pedicled flaps might have advantages over that with free grafts. LEVEL OF EVIDENCE NA Laryngoscope, 131:E428-E433, 2021.
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Affiliation(s)
- Kosuke Tochigi
- Department of Otorhinolaryngology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuhiro Omura
- Department of Otorhinolaryngology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan.,Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| | - Keisuke Miyashita
- Department of Otorhinolaryngology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Satoshi Aoki
- Department of Otorhinolaryngology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Nobuyoshi Otori
- Department of Otorhinolaryngology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yasuhiro Tanaka
- Department of Otorhinolaryngology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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12
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Wolff KD, Ritschl LM, von Bomhard A, Braun C, Wolff C, Fichter AM. In vivo perfusion of free skin flaps using extracorporeal membrane oxygenation. J Craniomaxillofac Surg 2019; 48:90-97. [PMID: 31874806 DOI: 10.1016/j.jcms.2019.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 08/18/2019] [Accepted: 12/02/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The vessel-depleted, irradiated, and frozen neck, as well as severe atherosclerosis of recipient vessels represent challenging problems in free flap transfer. Extracorporeal free flap perfusion theoretically allows free flap reconstructions in the absence of local donor vessels, but is associated with a number of technical issues. In this study, a novel technique is presented using a commercially available system for extracorporeal membrane oxygenation (ECMO), modified for small blood volumes. METHODS After preclinical testing, an ECMO system certified for lung support was used to establish blood flow through the flap's artery with oxygenation, decarboxylation and warming of diluted packed blood cells. Venous blood was allowed to flow passively into a separate container. Perfusion was performed for 15 min at intervals of 4 h over 4-6 days. RESULTS Five patients with soft tissue defects requiring free flap reconstruction were included. Either primarily thinned anterolateral thigh (ALT) flaps (n = 3) or radial forearm flaps (n = 2) were used. We observed infection of the perfusate, with consequent subtotal flap loss, in one patient, complete epithelial loss in two patients, venous congestion in one case, and almost uneventful healing in the fifth patient. With conservative wound care and a split thickness skin graft in one case, stable wound coverage was achieved in all patients except one, who had secondary healing. None of the patients required a second flap for sufficient coverage. CONCLUSIONS The technique described is associated with the risks of infection, flap congestion, nutritive hypoperfusion, and consequent tissue loss. Nevertheless, stable defect closure seems to be achievable even in patients with depleted recipient vessels.
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Affiliation(s)
- Klaus-Dietrich Wolff
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany.
| | - Lucas M Ritschl
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany
| | - Achim von Bomhard
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany
| | - Christian Braun
- University of Munich, School of Medicine, Institute of Legal Medicine, Nußbaumstraße 26, Munich, 80336, Germany
| | - Constantin Wolff
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany
| | - Andreas M Fichter
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany.
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Extracorporeal Free Flap Perfusion Using Extracorporeal Membrane Oxygenation Device: An Experimental Model. Ann Plast Surg 2019; 83:702-708. [PMID: 31688101 DOI: 10.1097/sap.0000000000002014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Extracorporeal perfusion of organs has a wide range of clinical applications like prolonged vital storage of organs, isolated applications of drugs, bridging time to transplant, and free composite tissue transfer without anastomosis, but there are a limited number of experimental models on this topic.This study aimed to develop and evaluate a human extracorporeal free flap perfusion model using an extracorporeal membrane oxygenation device. Five patients undergoing esthetic abdominoplasty participated in this study. Deep inferior epigastric artery perforator flaps were obtained abdominoplasty flaps, which are normally medical waste, used in this model. Deep inferior epigastric artery perforator flaps were extracorporeally perfused with a mean of 6 days. The biochemical and pathological evaluations of the perfusions were discussed in the article.
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14
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Successful Long-term Extracorporeal Perfusion of Free Musculocutaneous Flaps in a Porcine Model. J Surg Res 2018; 235:113-123. [PMID: 30691784 DOI: 10.1016/j.jss.2018.09.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/26/2018] [Accepted: 09/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Extracorporeal perfusion is a technique that aims to safely prolong tissue preservation by reducing ischemia-reperfusion injury. Free muscle flaps provide a sensitive research model due to their low ischemic tolerance. However, long-term perfusion of free muscle flaps is scarcely researched. The aim of this study was to compare tissue damage in musculocutaneous flaps during 36 h of extracorporeal perfusion versus static cold storage. MATERIALS AND METHODS Bilateral free rectus abdominis flaps were harvested from five Dutch Landrace pigs (weight: 53-59 kg). Flaps were treated for 36 h according to the following study groups: (1) cold storage at 4°C-6°C (n = 4), (2) perfusion with histidine-tryptophan-ketoglutarate (HTK) at 8°C-10°C (n = 3), (3) perfusion with University of Wisconsin solution (UW) at 8°C-10°C (n = 3). Perfusion fluid samples (creatinine kinase, blood gas) and biopsies for quantitative polymerase chain reaction were collected at multiple time points. Microcirculation was assessed at 24 h of preservation using indocyanine-green fluorescence angiography. Flap weight was measured at the start and end of the preservation period. RESULTS Successful and stable perfusion for 36 h was achieved in all perfused flaps. The mean creatinine kinase increase in the perfusion fluid was comparable in both the groups (UW: +43,144 U/L, HTK: +44,404 U/L). Mean lactate was higher in the UW group than in the HTK group (6.57 versus 1.07 mmol/L). There were homogenous and complete perfusion patterns on indocyanine-green angiography in both the perfusion groups, in contrast to incomplete and inhomogeneous patterns during cold storage. Expression of genes related to apoptosis and inflammation was lower in perfused flaps than in the cold storage group. Weight increase was highest in the HTK group (78%; standard deviation [SD], 29%) compared with UW (22%; SD, 22%) and cold storage (0.7%; SD, 4%). CONCLUSIONS Long-term extracorporeal perfusion of free rectus abdominis flaps is feasible. Outcomes in the perfusion groups seemed superior compared to cold storage. Hypotheses gained from this research need to be further explored in a replantation setting.
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15
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Kruit AS, Winters H, van Luijk J, Schreinemachers MCJM, Ulrich DJO. Current insights into extracorporeal perfusion of free tissue flaps and extremities: a systematic review and data synthesis. J Surg Res 2018; 227:7-16. [PMID: 29804865 DOI: 10.1016/j.jss.2018.01.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/19/2017] [Accepted: 01/12/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Extracorporeal perfusion is a promising new technique for prolonged preservation of free flaps and extremities; however, uncertainties on perfusion settings and efficacy still exist. No overview of literature is currently available. This review systematically appraised available evidence comparing extracorporeal perfusion to static storage. MATERIALS AND METHODS An electronic systematic search was performed on June 12, 2016, in MEDLINE and EMBASE. Articles were included when evaluating the effect of extracorporeal perfusion of free flaps or extremities compared to that of a control group. Two independent researchers conducted the selection process, critical appraisal, and data extraction. RESULTS Of 3485 articles screened, 18 articles were included for further analyzation. One article studied discarded human tissue; others were studies conducted on rats, pigs, or dogs. Perfusion periods varied from 1 h to 10 d; eight articles also described replantation. Risk of bias was generally scored high; none of the articles was excluded based on these scores. Tissue vitality showed overall better results in the perfused groups, more pronounced when perfusing over 6 h. The development of edema was a broadly described side effect of perfusion. CONCLUSIONS Although tissue vitality outcomes seem to favor extracorporeal perfusion, this is difficult to objectify because of large heterogeneity and poor quality of the available evidence. Future research should focus on validating outcome measures, edema prevention, perfusion settings, and maximum perfusion time for safe replantation and be preferably performed on large animals to increase translation to clinical settings.
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Affiliation(s)
- Anne Sophie Kruit
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Harm Winters
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Judith van Luijk
- Department of SYstematic Review Centre for Laboratory Animal Experimentation (SYRCLE), Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Dietmar J O Ulrich
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Fichter AM, Ritschl LM, Rau A, Schwarzer C, von Bomhard A, Wagenpfeil S, Wolff KD, Mücke T. Free flap rescue using an extracorporeal perfusion device. J Craniomaxillofac Surg 2016; 44:1889-1895. [DOI: 10.1016/j.jcms.2016.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/11/2016] [Accepted: 09/19/2016] [Indexed: 11/17/2022] Open
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18
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Impact of different antithrombotics on the microcirculation and viability of perforator-based ischaemic skin flaps in a small animal model. Sci Rep 2016; 6:35833. [PMID: 27767060 PMCID: PMC5073281 DOI: 10.1038/srep35833] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 10/04/2016] [Indexed: 12/02/2022] Open
Abstract
The effects of antithrombotic drugs on random and free flap survival have been investigated in the past, but the experimental and clinical results are not in agreement. A perforator-based critical ischaemia model was used to evaluate the effects of different perioperatively administered pharmaceutical agents on tissue ischaemia and to assess the potential additional haemorheological or vasodilative effects of antithrombotics on flap microcirculation. Combined laser Doppler flowmetry and remission spectroscopy revealed an increase in certain microcirculation parameters in most groups in comparison with saline controls, and these changes correlated with flap survival. Clopidogrel and hirudin significantly improved the amount of viable flap tissue in comparison with controls, while unfractioned heparin had a negative effect on flap survival. Low molecular weight heparin, aspirin, pentoxifylline, and hydroxyethyl starch had no impact on the amount of viable flap tissue. A higher complication rate was observed in all experimental groups, but only clopidogrel had a negative impact on the flap viability. Our results add to the body of evidence supporting the conclusion that perioperative antithrombotic treatment improves flap survival. Clopidogrel and hirudin are effective pharmacological agents that significantly increased the viability of perforator-based skin flaps in rats, but at a higher risk of postoperative bleeding.
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