Application of the Knotting After Half-Side Threaded Anastomosis Method in free anterolateral thigh flap repair

doi:10.21203/rs.3.rs-4848308/v1

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Research Article

Application of the Knotting After Half-Side Threaded Anastomosis Method in free anterolateral thigh flap repair

https://doi.org/10.21203/rs.3.rs-4848308/v1

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Backgrounds:

The prognosis of free anterolateral thigh (ALT) flap repair is critically tied to the quality of vascular anastomosis. In this study, we introduced Knotting After Half-Side Threaded Anastomosis Method (KAHTAM) and conducted a comparative analysis to assess its performance in relation to the conventional Half-Side Interrupted Anastomosis Method (HIAM).

Methods

149 cases of ALT flap repair were included and our analysis encompassed the evaluation and comparison of variations in patients' general information, the state of the vascular lumen at the final stitch, outcomes of flap repair, complications, along with the surgical data of vascular anastomosis, and the clinical data of the surgery between two groups.

Results

Compared to the HIAM group, the KAHTAM group exhibited a larger and more distinct vascular lumen, leading to a higher success rate and fewer postoperative complications. The KAHTAM group also showed a superior immediate patency rate after the first anastomosis and a lower rate of supplementary sutures for blood leakage during arterial anastomosis. Additionally, the time for vascular anastomosis was shorter in the KAHTAM group.

Conclusions

The utilization of KAHTAM has showcased its potential in enhancing the overall quality of vascular anastomosis and improving the success rate and efficiency of free ALT flap repair.

Maxillofacial tumor

Anterolateral thigh flap

Vascular anastomosis

Interrupted anastomosis

Knotting After Half-Side Threaded Anastomosis

frequently ensue. To facilitate the healing of local tissue, as well as the repair of tissue defects and contours, the imperative recourse lies in flap transplantation. The common methods of repairing soft tissue defects in maxillofacial region include forearm flap, anterolateral thigh (ALT) flap, pectoral major musculocutaneous flap and submental island flap. Pectoralis major musculoflap and submental island flap are non-free flaps with high survival rate after operation. Nonetheless, owing to the limitations posed by restricted flap dimensions, the presence of residual metastatic lymph nodes, or substantial traumatic injury, they are typically not favored as the primary option for restorative procedures. Forearm flap also has some problems, such as limited flap size, poor blood vessel pressure resistance and obvious scar in the donor area, which can only be used for the repair of maxillofacial defects under certain conditions. Generally speaking, the ALT flap is the most commonly used repair method for soft tissue defects in maxillofacial region.

The ALT flap, as an important free repair method, has been widely used for maxillofacial defects since first proposed by Song et al [1] in 1984 [2-5]. However, the successful harvesting and surgical application of this flap pose considerable challenges. On the one hand, the perforators and pedicles of ALT flaps have great anatomic variability [6-8]; on the other hand, ALT flap is a free flap, and the repair operation needs to complete a difficult microvascular anastomosis. The quality of vascular anastomosis is a key factor to guarantee the blood supply of ALT flap and to influence the successful repair of free flap.

The common method for vascular anastomosis is the Half-Side Interrupted Anastomosis Method (HIAM), in which the vascular anastomosis was completed by traditional interrupted anastomosis method. Due to the small diameter of anastomotic vessel in ALT flap repair, anastomosis operation and flap repair often fail due to unclear field of view even when anastomosis operation is performed with the aid of microscope. In a concerted effort to elevate the success rate of free flap repair, we endeavored to refine the anastomotic technique by introducing Knotting After Half-Side Threaded Anastomosis Method (KAHTAM). In the new method, all vascular sutures were initially threaded without being knotted, followed by simultaneous knotting of all threads. The KAHTAM was expected to ensure a clearer field of vision, reduce the difficulty of suture and improve the quality of vascular anastomosis. This investigation delves into a comparative analysis of the clinical efficacy between the two anastomotic methodologies.

Study design and participants

This study comprised 149 cases of anterolateral thigh (ALT) flap reconstruction at our hospital from May 2020 to December 2023. All instances pertained to free ALT flap reconstruction subsequent to surgery for maxillofacial malignant tumors. They were divided into the HIAM group and the KAHTAM group according to different vascular anastomosis methods of free flap repair. There were 69 cases in the HIAM group, and 80 cases in the KAHTAM group. All aspects of this study were approved by the ethics committee of our hospital. Informed written consent was obtained from all participants.

Operation method

Lymph node dissection was performed based on pathology, then the tumor was surgically removed until the margin was negative [9], and the ALT flap was obtained [10]. The supply artery in the neck was dissected, and the superior thyroid artery was the preferred artery (Fig. 1A). If this artery could not be used due to vascular quality problems or tumors, other adjacent arteries such as lingual artery, facial artery and maxillary artery were selected in turn. The return vein in the neck was dissected, the internal jugular vein was preferred, and the flap vein was anastomosed at the lateral wall opening of the internal jugular vein (Fig. 1B). If the vein could not be used due to vascular quality problems or tumor reasons, other adjacent veins such as the external jugular vein was selected for replacement. After the preparation of blood vessels in the neck were completed, the ALT flap vessel pedicle was cut off and successively anastomosed to the recepient area with the aid of microscope (Zumax Medical Technology Co. LTD, Suzhou, China). After vascular anastomosis, the flap was sutured to the defect area and the wound was closed.

Vascular anastomosis method

In the HIAM group, blood vessels that needed to be sutured were prepared (Fig. 2A), then two stitchs were sutured respectively at the at the corners (6 and 12 o’clock) of vascular anastomosis, and the vascular anastomosis was evenly divided into two parts (Fig. 2B). Either side of the blood vessel was chosen and anastomosed intermittently initially. The next suture was continued after each suture and knot were completed (Fig. 2C), continuing suturing until the vascular anastomosis on this side was completed (Fig. 2D). After the anastomosis on one side was completed, the blood vessel on the other side was anastomosed in the same way. If there was local blood leakage after anastomosis, sutures could be added.

In the KAHTAM group, blood vessels that needed to be sutured were prepared (Fig. 2E) and divided into two parts in method the same as that in the HIAM group (Fig. 2F). On either side of the blood vessel, a suitable number of stitches were carefully placed initially, with the sutures being threaded but the knots left untied temporarily (Fig. 2G). After all the stitches finished threading the blood vessel wall, tied the knots in turn (Fig. 2H). After the anastomosis on one side was completed, the blood vessel on the other side was anastomosed in the same way. If there was local blood leakage after anastomosis, sutures could be added.

Statistical analysis

The general information of patients, the state of vascular lumen at the final stitch, outcomes and complications of the flap, the surgical data of vascular anastomosis and the clinical data of the surgery in the HIAM group and the KAHTAM group were compared and analyzed.

Successful cases were defined as those cases in which ALT flap was successfully obtained and survived. The failure cases included those cases in which ALT flap was successfully obtained but to be with vascular thrombosis which needed surgical exploration or to be necrosis post-operation and cases in which ALT flap was successfully obtained but with a poor evaluation of survivability and free flap repair was directly abandoned during the operation. Postoperative complications included effusion, bleeding and wound dehiscence. The flap survaival rate was investigated postoperatively on day 30 in following-up visit.

The surgical data of vascular anstomosis including flap size, types of recipient vessels, immediate patency rate after the first anastomosis and supplementary sutures rate after vascular anastomosis for blood leakage. The clinical data of the surgery including operation time, flap harvesting time, vascular anastomosis time, intraoperative blood loss, drainage time and volume in the neck, drainage time and volume of donor site, pain score and hospitalization time. The immediate patency rate was assessed at 10 min by the milking test [11].

The measurement data were expressed as mean ± standard error. To compare two groups, the statistical significance for normally distributed variables was assessed through unpaired Student's t-tests, while for non-normally distributed variables, Mann–Whitney U tests were employed [12]. The chi-square test was applied for categorical data analysis. Statistical data were analyzed by SPSS 17.0 statistical software (IBM, Armonk New York, USA). p < 0.050 was considered statistically significant.

The state of vascular lumen at the final stitch in two vascular anastomosis methods

There was no statistical difference in patients’ general information between two groups (p > 0.050) (Table 1). The vascular lumen of arteries was bigger and clearer in KAHTAM (Fig. 3A) than that in HIAM (Fig. 3B), and the vascular lumen of veins was bigger and clearer in KAHTAM (Fig. 3C) than that in HIAM (Fig. 3D) when completing the final stitch.

Table 1

Patients' general information (mean ± standard error) [cases (%)].
	HIAM group (n = 69)	KAHTAM group (n = 80)	p-value
Age (years)	59.83 ± 11.93	58.40 ± 10.32	0.435
Gender			0.151
Males	45(65.22)	61(76.25)
Females	24(34.78)	19(23.75)
Lesion location			0.194
Buccal	22(31.88)	24(30.00)
Tongue and floor of mouth	43(62.32)	48(60.00)
Gingiva	4(5.80)	3(3.75)
Palatine	0(0.00)	5(6.25)
Tumor size (cm²)	4.66 ± 0.56	8.94 ± 1.00	0.084
Pathologic diagnosis			0.157
Squamous cell carcinoma	66(95.65)	75(93.75)
Adenoid cystic carcinoma	2(2.90)	1(1.25)
Others	1(1.45)	4(5.00)
Defect tissue type			0.106
Mucosa	58(73.91)	74(92.50)
Mucosa and skin	11(26.09)	6(7.50)
Hypertension	33(47.83)	44(55.00)	0.764
Diabetes	12(17.39)	8(10.00)	0.175

Outcomes and complications of flap repair

There were 61 successful cases and 8 failed cases of ALP flap repair in the HIAM group, the success rate was 88.41%. There were 78 successful cases and 2 failed cases of ALP flap repair in the KAHTAM group, the success rate was 97.50%. The success rate of ALT flap repair in the KAHTAM group was higher than that in the HIAM group, the difference was statistically significant (p = 0.045). There were 18 cases with complications in the HIAM group (26.09%) while 8 cases in the KAHTAM group (10.00%). The incidence of postoperative complications in the KAHTAM group was statistically lower than that in the HIAM group (p = 0.016) (Table 2).

Table 2

Outcomes and complications of the flap (mean ± standard error) [cases (%)].
	HIAM group (n = 69)	KAHTAM group (n = 80)	p-value
Repair outcomes			0.045
Success	61(88.41)	78(97.50)
Failure	8(11.59)	2(2.50)
Complications			0.016
With	18(26.09)	8(10.00)
Without	51(73.91)	72(90.00)

The surgical data of flap vascular anastomosis

There were 57 cases with a immediate patency after the first arterial anastomosis of ALP flap repair and 12 cases without in the HIAM group, the immediate patency rate after the first arterial anastomosis was 82.61%. There were 77 cases with a immediate patency after the first arterial anastomosis of ALP flap repair and 3 case without in the KAHTAM group, the immediate patency rate after the first arterial anastomosis was 96.25%. The immediate patency rate after the first arterial anastomosis in the KAHTAM group was higher than that in the HIAM group, and the difference was statistically significant (p = 0.006). There were 27 cases with supplementary sutures after arterial anastomosis for blood leakage in the HIAM group (39.13%) and 8 cases in the KAHTAM group (10.00%). The proportion of cases with supplementary sutures after arterial anastomosis for blood leakage in the KAHTAM group was statistically lower than that in the HIAM group (p < 0.001). There was no significant difference in other surgical data of flap vascular anastomosis, including flap size (p = 0.090), types of recipients supplying artery (p = 0.198), types of recipient return vein (p = 0.560), times of venous anastomosis (p = 0.063), and supplementary sutures after venous anastomosis for blood leakage (p = 0.900), between two groups (Table 3).

Table 3

The surgical data of vascular anastomosis (mean ± standard error) [cases (%)].
	HIAM group (n = 69)	KAHTAM group (n = 80)	p-value
Flap size (cm²)	46.01 ± 12.83	51.21 ± 22.37	0.090
Types of recipient artery			0.198
Superior thyroid artery	62(89.86)	66(82.50)
Other arteries	7(10.14)	14(17.50)
Types of recipient vein			0.560
Internal jugular vein	60(86.96)	72(90.00)
Other veins	9(13.04)	8(10.00)
Immediate patency after the first arterial anastomosis			0.006
With	57(82.61)	77(96.25)
Without	12(17.39)	3(3.75)
Supplementary sutures after arterial anastomosis for blood leakage			< 0.001
With	27(39.13)	8(10.00)
Without	42(60.87)	72(90.00)
Immediate patency after the first venous anastomosis			0.063
With	64(92.75)	79(98.75)
Without	5(7.25)	1(1.25)
Supplementary sutures after venous anastomosis for blood leakage			0.900
With	9(13.04)	11(13.75)
Without	60(86.96)	69(86.25)

Clinical data of flap repair surgery

Comparative analysis of clinical data of flap repair surgery showed that the vascular anastomosis time in the HIAM group was 2.23 ± 0.46 h, and that in the KAHTAM group was 1.84 ± 0.18 h. The anastomosis time of ALP flap in the KAHTAM group was statistically shorter than that in the HIAM group (p < 0.001). There was no significant difference in other clinical data of flap repair surgery, including operation time (p = 0.061), flap harvesting time (p = 0.097), intraoperative blood loss (p = 0.056), drainage time in the neck (p = 0.281), drainage volume in the neck (p = 0.689), drainage time of donor area (p = 0.150), drainage volume of donor area (p = 0.799), pain score (p = 0.513), and hospitalization time (p = 0.111), between two groups (Table 4).

Table 4

The clinical data of the surgery (mean ± standard error).
	HIAM group (n = 69)	KAHTAM group (n = 80)	p-value
Operation time (h)	9.43 ± 1.33	9.02 ± 1.28	0.061
Flap harvesting time (h)	1.91 ± 0.43	1.81 ± 0.29	0.097
Vascular anastomosis time (h)	2.23 ± 0.46	1.84 ± 0.18	< 0.001
Intraoperative blood loss (ml)	301.74 ± 23.90	293.94 ± 25.27	0.056
Drainage time in the neck (days)	7.65 ± 2.04	8.15 ± 3.32	0.281
Drainage volume in the neck (ml)	587.70 ± 367.82	617.15 ± 504.64	0.689
Drainage time of donor site (days)	4.57 ± 1.10	4.34 ± 0.94	0.150
Drainage volume of donor site (ml)	110.36 ± 65.38	107.09 ± 87.54	0.799
Pain score (points)	2.73 ± 0.36	2.69 ± 0.31	0.513
Hospitalization time (days)	20.68 ± 4.83	19.41 ± 4.80	0.111

Due to the advantages of large flap area, many types of repairable tissue, strong pressure tolerance of vascular pedicle and perforator of the flap, and small postoperative complications in the donor area, the ALT flap are widely used in clinic [13, 14]. However, numerous factors during the operative and perioperative phases may directly impact the success rate of flap repair. Among these, vascular anastomosis stands out as a pivotal factor. HIAM, while being the prevailing approach for vascular anastomosis in free flap repair, exhibits a low success rate and efficiency. The primary cause may be attributed to the gradual reduction of the vascular lumen during interrupted anastomosis, leading to heightened difficulty in suturing due to impaired visibility, particularly during the final stitch (Fig. 3). For some cases with small blood vessel diameter, the blurred visual field is more obvious, and often resulting in the failure of blood flow after the completion of vascular anastomosis due to the inappropriate suture position on the vascular wall. For some cases with soft texture of the blood vessel wall, the blood vessel wall tissue may even tear because of the repeated pulling. In order to reduce the influence of blurred visual field on the quality of vascular anastomosis, we propose to improve the anastomosis method by KAHTAM, in which we complete all the threads of the vascular wall without been knotted firstly, then tie all the knots in turn. In the new anastomosis method, an ideal position of each stitch of anastomosis can be ensured because of a more adequate visual field. Thus, the KAHTAM is expected to improve the quality of vascular anastomosis, and improve the success rate of free ALT flap repair accordingly. Considering the problem of blurred vision mainly exists in the last few stitches of vascular anastomosis and there may be a confusion for too many sutures, we project to perform a two-step vascular anastomosis for the new method, in which the blood vessel wall is averagely divided into two sides according to its circumference firstly, then the two sides are sutured respectively.

In order to study the clinical effect of KAHTAM used in vascular anastomosis of free ALT flap repair, we compared and analyzed the relevant clinical data in the KAHTAM group by taking the HIAM group as the control. The results showed that there was no significant difference between two groups in patients' general information. The vascular lumen was bigger and clearer in KAHTAM than that in HIAM when completing the final stitch, which could make suture surgery easier and ensure the quality of vascular suture more reliable. The success rate of flap repair in the KAHTAM group was higher than that in the HIAM group, and the incidence of postoperative complications in the KAHTAM group was lower than that in the HIAM group, indicating that the improved method could increase the success rate of free ALT flap and reduce complications. We further analyzed the surgical data of vascular anastomosis and found that the immediate patency rate after the first arterial anastomosis in the KAHTAM group was statistically higher than that in the HIAM group. The proportion of cases with supplementary sutures after arterial anastomosis for blood leakage in the KAHTAM group was statistically lower than that in the HIAM group. It is concluded that KAHTAM's improvement on the success rate of ALT flap repair may be due to the immediate patency rate after the first arterial anastomosis and a reduced need for supplementary sutures to address blood leakage in arterial vascular anastomosis. Comparative analysis of the clinical data of the surgery showed that the time for vascular anastomosis in the KAHTAM group was shorter than that in the HIAM group, indicating that the flap anastomosis speed was increased in the KAHTAM group. Reducing the ischemia time of free flap is also an important factor for successful repair of free flap.

Vascular anastomosis is an important factor for successful free flap repair. In the study, KAHTAM have improved the success rate and efficiency of free ALT flap repair compared to the traditional HIAM. With the continuous exploration and improvement of vascular anastomosis methods, instruments and materials, many new vascular anastomosis techniques have been researched and applied clinically, in addition to KAHTAM. These include interrupted suture and continuous suture [15], end-side suture, side-side suture, telescopic suture [15], parachute suture [16], eversion suture, intravascular suture, etc. In recent years, some non-vascular anastomosis techniques have also been studied and applied, mainly including stapler anastomosis [17, 18], adhesive anastomosis[19] and thermal anastomosis [20]. These new vascular anastomosis techniques can improve the efficiency of vascular anastomosis to a certain extent and have pointed out the direction for the development of anastomosis technology, although they still have some limitations [21–24]. The success rate of anastomosis is always the first consideration in the selection of vascular anastomosis methods and artificial suture anastomosis is still the cheapest, most reliable, and basic vascular anastomosis method. In the future, based on the artificial suture anastomosis method, the most appropriate and more efficient vascular anastomosis method can be selected after comprehensively evaluating the specific conditions of cases. The combination of various anastomosis methods may also be tried to take into account both the quality and efficiency.

The survival of free ALT flap mainly depends on a good blood supply. The high variability of the ALT perforators, even some cases have no sizable perforating branch [7], has long been a great challenge for the repair of ALT flap. Many previous studies focused on the ALT perforators and has greatly alleviated the influence of their anatomic variability on the operation and prognosis [25–27]. Vascular anastomosis is another challenging factor to ensure the blood supply of free ALT while there are few clinical studies about it. In this study, the difficulty of vascular anastomosis was reduced and the reliability of vascular anastomosis was improved for a wider and clearer vision by using KAHTAM. The shortcoming of this study lies in the limited number of cases, and the clinical efficacy of the new method needs further clinical observation and analysis. In addition, the KAHTAM may be cumbersome for some physicians skilled in vascular anastomosis surgery because of the addition of surgical procedures, but one thing is certain that the new method is more friendly and helpful for a beginner who engaged in free flap repair because of a visible and basic guarantee for the quality of vascular anastomosis. The KAHTAM have improved another key problem affecting the blood supply of ALT repair and further increased its survival rate.

Through a comparative analysis of the HIAM group and the KAHTAM group, this study has substantiated that KAHTAM holds the potential to enhance both the success rate and the efficiency of vascular anastomosis in free ALT flap repair, rendering its clinical application notably commendable.

The authors declare no conflict of interest.

Ethics approval and consent to participate

The study was approved by the First Affiliated Hospital of USTC Ethics Committee and performed in accordance with the ethical standards (Nos. 2023RE399). The study followed the guidelines of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by the China Postdoctoral Science Foundation (Nos. 2023T160624), China Postdoctoral Science Foundation (Nos. 2022M713043), National Natural Science Foundation of China (Nos. 82203277), Fundamental Research Funds for the Central Universities (Nos. WK9110000146), and Fundamental Research Funds for the Central Universities (Nos. WK9100000052).

Author Contribution

Yu Zhou, Zong-Cheng Yang, Li-Yu Zhang, Chuan-Jun Chen and Guang-Xing Yan designed the study. Li-Yu Zhang, Chuan-Jun Chen, Hui Peng, Yi Wang, Wei-Zheng Zhu and Xian-Wang Xiang collected clinical samples. Li-Yu Zhang, Guang-Xing Yan, Shu-Tong Li, Xin-Feng Yao, Nian-Ping Liu, and Yin-Lei Hu analyzed the data. Li-Yu Zhang, Qiao-Ni Yu and Qing Sha prepared the figures. Li-Yu Zhang and Zong-Cheng Yang wrote the manuscript. Yu Zhou and Zong-Cheng Yang supervised the study. All authors reviewed and approved the final manuscript.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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No competing interests reported.

Fig.1.png
Vessels before vascular anastomosis. (A) The supplying artery STA (red arrow) and flap artery adLCFA (black arrow) before vascular anastomosis. (B) The return vein IJV (red arrow) and flap vein vdLCFA (black arrow) before vascular anastomosis. STA: superior thyroid artery, adLCFA: the artery of the descending branch of lateral circumflex femoral artery, IJV: internal jugular vein, vdLCFA: the vein of the descending branch of lateral circumflex femoral artery.
Fig.2.png
Schematic diagram of HIAM and KAHTAM. (A) The blood vessels are prepared before anastomosis in the HIAM group. (B) The blood vessels are evenly divided into two parts by two sutures firstly in the HIAM group. (C) Each side of the blood vessels is anastomosed in HIAM. (D) The vascular anastomosis is completed in the HIAM group. (E) The blood vessels are prepared before anastomosis in the KAHTAM group. (F) The blood vessels are evenly divided into two parts by two sutures firstly in the KAHTAM group. (G) Each side of the blood vessels is anastomosed in KAHTAM. (H) The vascular anastomosis is completed in the KAHTAM group.
Fig.3.png
The state of vascular lumen at the final stitch of vascular anastomosis. (A) The state of artery vascular lumen at the final stitch of vascular anastomosis in KAHTAM. (B) The state of artery vascular lumen at the final stitch of vascular anastomosis in HIAM. (C) The state of venous vascular lumen at the final stitch of vascular anastomosis in KAHTAM. (D) The state of venous vascular lumen at the final stitch of vascular anastomosis in HIAM.

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First submitted to journal
02 Aug, 2024

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Application of the Knotting After Half-Side Threaded Anastomosis Method in free anterolateral thigh flap repair

Status:

Version 1

Abstract

Backgrounds:

Methods

Results

Conclusions

Introduction

Methods

Study design and participants

Operation method

Vascular anastomosis method

Statistical analysis

Results

The state of vascular lumen at the final stitch in two vascular anastomosis methods

Outcomes and complications of flap repair

The surgical data of flap vascular anastomosis

Clinical data of flap repair surgery

Discussion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1