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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 34  |  Issue : 2  |  Page : 106-110

Role of flap blood glucose measurement in monitoring of flap incorporating skin and to detect flap congestion and flap salvage


Department of Plastic and Reconstructive Surgery, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission08-Dec-2020
Date of Acceptance09-Dec-2020
Date of Web Publication25-Jan-2021

Correspondence Address:
Akoijam Ibohal Singh
Department of Plastic and Reconstructive Surgery, Regional Institute of Medical Sciences, Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_127_20

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  Abstract 


Background: Flap surgery has become a reliable method of reconstruction of postsurgical and posttraumatic defects almost over any part of the body with vascularized tissue. Complications associated with flap surgeries may lead to partial or total flap failure. Scrupulous postoperative flap monitoring allows early detection of flap failure which is the only evidence-based strategy for optimizing free flap salvage. There are various methods available for flap monitoring. Classical clinical observation of the flap requires clinical expertise. Microdialysis is a method that measures certain metabolites like glucose, lactate, etc., levels in the flap blood which is objective, reliable, and reproducible method. Based on the principles of microdialysis, monitoring of capillary glucose levels in flaps using glucometer is being proposed as a cheap, rapid, and simple method for the early prediction of microvascular complications and thereby reducing flap failure.
Aims: The aim was to study blood glucose levels in flaps incorporating skin in comparison to control site to correlate flap blood glucose level with clinical changes in these flaps.
Settings and Design: A hospital-based observational study was conducted on twenty patients operated for reconstruction with flaps in a tertiary hospital setup in Manipur during the period of December 2017 to November 2019.
Statistical Analysis: The data were analyzed with IBM SPSS statistics 21 developers. Descriptive statistics mean were used for statistical analysis and paired t-test for quantitative data. P < 0.05 will be taken as statistically significant.
Results: Out of total twenty patients studied, 10 patients (50%) were in the age group of 30–50 years. Total 14 flaps (70%) were pedicled and 6 (30%) were free flaps. Total 4 flaps (20%) had complications (venous thrombosis) in the first 24 h, three flaps were pedicled and one flap was free flap. Flap capillary glucose level drops when there was venous thrombosis otherwise flap capillary glucose level fluctuates according to capillary blood glucose level of control area.
Conclusions: The measurement of free flap capillary glycemia may be used as a method of diagnosis of complications which is a simple and rapid method of flap monitoring. It can help in flap salvage but it is not superior to clinical evaluation by an experienced professional for the detection of venous thrombosis.

Keywords: Blood glucose, flap surgery, microdialysis


How to cite this article:
Choudhary AK, Singh AI, Das SI, Singh LO, Singh NS. Role of flap blood glucose measurement in monitoring of flap incorporating skin and to detect flap congestion and flap salvage. J Med Soc 2020;34:106-10

How to cite this URL:
Choudhary AK, Singh AI, Das SI, Singh LO, Singh NS. Role of flap blood glucose measurement in monitoring of flap incorporating skin and to detect flap congestion and flap salvage. J Med Soc [serial online] 2020 [cited 2021 Mar 2];34:106-10. Available from: https://www.jmedsoc.org/text.asp?2020/34/2/106/307893




  Introduction Top


Flap surgery has become a reliable method of reconstruction. It allows repair of postsurgical and posttraumatic defects almost over any part of the body with vascularized tissue.[1] Complications associated with free flap surgeries include venous and arterial thrombosis, hematoma, wound infection, flap dehiscence, fistula formation, etc., which may lead to partial or total flap failure.[2],[3],[4] Failure rates of free flap surgeries usually range from 2% to 5% in high volume centers but may be more in low volume/less experienced centers performing microvascular surgeries.[5],[6],[7]

Vascular compromise (venous>arterial) is the most common cause for flap loss.[2],[5],[7],[8] Scrupulous postoperative flap monitoring allows early detection of flap failure which is the only evidence-based strategy for optimizing free flap salvage.[9],[10] The rate of flap salvage declines as the duration of the time period from the occurrence of the complication to its detection increases.[11]

There are various methods available for flap monitoring.[12] Classically, post-operative vascular perfusion is assessed by clinical observation of the flap which includes the color, temperature, turgor, capillary refill, and pinprick/dermal scratch test. The interpretation of the clinical findings requires clinical expertise.[13] Microdialysis is a method that measures certain metabolites like glucose, lactate, etc., levels in the flap blood. It is a more objective, reliable, and reproducible method documented in the literature for postoperative monitoring of free flaps but requires much more technical expertise and resources.[14],[15]

Based on the principles of microdialysis, monitoring of capillary glucose levels in free flaps using glucometer is being proposed as a cheap, rapid, and simple method for the early prediction of microvascular complications and thereby reducing flap failure.[16]


  Materials and Methods Top


This hospital-based observational study was conducted on twenty patients operated for reconstruction with flap in a tertiary hospital setup in Manipur during the period of December 2017–November 2019. Inclusion criteria were: (a) age between 15 and 60 years (b) all flaps incorporating skin used in reconstruction purpose. Exclusion criteria were (a) age <15 years and >60 years (b) Comorbidities such as diabetes mellitus, chronic smoker, patients of vasculitis, or any other vasculopathy.

Data were collected from patients operated for reconstruction with flaps incorporating skin. A detailed history and physical examination findings, preoperative parameters and details of treatment were recorded. Intraoperative parameters recorded include operation time, blood loss during surgery, local flap or free flap, postoperative parameters, and blood pressure were recorded.

Technique of flap glucose monitoring

Flap blood glucose levels were measured at scheduled times by glucometer. Samples are taken in immediate postoperative period then after 1, 6, 24, 48, and 72 h after operation. At the same time blood glucose levels measured from adjacent normal skin (control site). Capillary blood samples are taken by the pinprick method at the distal most part of the flap. In addition to blood glucose assessment, simultaneous clinical findings of skin color changes have been noted to assess the viability of the flap [Figure 1], [Figure 2], [Figure 3].
Figure 1: Medtronic glucometer

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Figure 2: Groin flap

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Figure 3: Anterolateral thigh flap

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Statistics analysis

The data collected were entered in a data-based program, namely, IBM SPSS version 21, IBM, New York, USA developer. Descriptive statistics mean were used for statistical analysis and paired t-test for quantitative data. P < 0.05 will be taken as statistically significant.

Ethical issues

The study was carried out after obtaining approval from the Research Ethics Board (REB), Regional Institute of Medical Sciences, Imphal, Manipur.


  Results Top


Out of total 20 patients studied, 10 patients (50%) were in the age group 30-50 years, 2 patients (10%) had a history of tobacco consumption. Total 14 flaps (70%) were pedicled and 6 (30%) were free flaps. Total 4 flaps (20%) had complications (venous thrombosis) in the first 24 h, three flaps were pedicled and one flap was free flap [Table 1] and [Table 2].
Table 1: Age of the patient

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Table 2: Type of flap

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Out of twenty flaps, four flaps had fall in capillary blood glucose level as compared to control site in the first 6–24 h of surgery, later these flaps change in color and became darker in as compared to normal skin of patient and other physical signs of flap necrosis also developed [Figure 4].
Figure 4: Blood glucose level in necrosed flaps

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Out of twenty flaps, 16 flaps had almost similar capillary blood glucose level compared to control site and these flaps did not have any color changes and other physical signs of flap necrosis [Figure 5].
Figure 5: Blood glucose level in flaps survived

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Above shown graph illustrates the flap capillary glycemia of patients with and without complications, respectively. Flap capillary glucose level drops when there was venous thrombosis otherwise flap capillary glucose level fluctuates according to the capillary blood glucose level of the control area.

From the above [Table 1], it is seen that the flap glucose level compared to control is dropping in those flaps which did not survive while those which survived showed the normal flap glucose level as per control, and this relationship was found to be significant [Table 3].
Table 3: Flap glucose and flap survival

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Because of the limited number of patients with complications, it was not possible to determine a flap glycemia value that was indicative of venous thrombosis.

Moreover, it is possible to determine flap complication by measurement of capillary glycemia before clinical diagnosis of thrombosis would identify but decision of reexploration based on only capillary blood glucose level of the flap is not justifiable.


  Discussion Top


Monitoring the flap after surgery is of vital importance, for flap survival, especially during the first few hours, because the timing of reoperation may determine flap salvage or loss. Surgeons experienced in microsurgery usually monitor these flaps. However, these highly specialized professionals may not be available in all hospitals. Therefore, the use of an objective measurement technique can reduce the need for human resources, thereby reducing cost.

Flap glycemia has been studied as a diagnostic method for venous thrombosis by other authors, but larger data series are needed to determine the exact value that is indicative of thrombosis.

We monitored the flaps by measuring blood glucose levels using Medtronic glucometer [Figure 1] which is routinely used for regular capillary blood glucose measurements. The procedure is rapid and simple and requires only minimal amounts of blood (10–20 μL). Furthermore, this method is more quantitative than the traditional ways of flap monitoring, such as observing flap color, flap turgor, or the pinprick test. It provides a surrogate reflection of the adequacy of flap perfusion and allows objective comparisons between tests. On the contrary, the needle prick test only yields subjective information on flap perfusion. We performed Blood glucose monitoring (BGM) immediate postoperative period then 1, 6, 24, 48, and 72 h after operation. The mechanism of reduction in blood glucose levels in congested flaps has not been elucidated. Sakakibara et al. hypothesized that in venous thrombosis, flap blood glucose concentration is reduced due to continual uptake of glucose from the stagnated blood for tissue metabolism. Several studies showed that blood glucose is also reduced with ischemia and that this reduction is more rapid and extensive than that associated with congestion [Figure 4].

The present study confirms that there is a decrease in capillary glycemia in flaps with venous thrombosis; however, evaluation of this parameter did not enable earlier detection of complications [Figure 5].

Moreover, all complications were venous thrombosis. Other complications such as hematomas did not occur, and possibly cannot be detected using capillary blood glucose measurements. Therefore, evaluation by a professional experienced in postoperative changes in flap condition is still highly recommended.


  Conclusions Top


The measurement of free flap capillary glycemia may use as method of diagnosis of complication, but it is not superior to clinical evaluation by an experienced professional for the detection of venous thrombosis.

A limitation of the blood glucose monitoring is that this method cannot be used for buried flap and multiple pinpricks required from small flap it may damage it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yadav P. Head and neck reconstruction. Indian J Plast Surg 2013;46:275-82.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Wu CC, Lin PY, Chew KY, Kuo YR. Free tissue transfers in head and neck reconstruction: Complications, outcomes and strategies for management of flap failure: Analysis of 2019 flaps in single institute. Microsurgery 2014;34:339-44.  Back to cited text no. 2
    
3.
Wettstein R, Schürch R, Banic A, Erni D, Harder Y. Review of 197 consecutive free flap reconstructions in the lower extremity. J Plast Reconstr Aesthet Surg 2008;61:772-6.  Back to cited text no. 3
    
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Schaverien MV, Hart AM. Free muscle flaps for reconstruction of upper limb defects. Hand Clin 2014;30:165-83.  Back to cited text no. 4
    
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Yu P, Chang DW, Miller MJ, Reece G, Robb GL. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 2009;31:45-51.  Back to cited text no. 5
    
6.
Wong AK, Joanna Nguyen T, Peric M, Shahabi A, Vidar EN, Hwang BH, et al. Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database. Microsurgery 2015;35:6-12.  Back to cited text no. 6
    
7.
Chiu YH, Chang DH, Perng CK. Vascular complications and free flap salvage in head and neck reconstructive surgery: Analysis of 150 cases of reexploration. Ann Plast Surg 2017;78:S83-8.  Back to cited text no. 7
    
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Pohlenz P, Klatt J, Schön G, Blessmann M, Li L, Schmelzle R. Microvascular free flaps in head and neck surgery: Complications and outcome of 1000 flaps. Int J Oral Maxillofac Surg 2012;41:739-43.  Back to cited text no. 8
    
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Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: Indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007;119:2092.  Back to cited text no. 9
    
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Chen KT, Mardini S, Chuang D, Lin CH, Cheng MH, Lin YT, et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers: Plast Reconstr Surg 2007;120:187-95.  Back to cited text no. 10
    
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Brown JS, Devine JC, Magennis P, Sillifant P, Rogers SN, Vaughan ED, et al. Factors that influence the outcome of salvage in free tissue transfer. Br J Oral Maxillofac Surg 2003;41:16-20.  Back to cited text no. 11
    
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Chae MP, Rozen WM, Whitaker IS, Chubb D, Grinsell D, Ashton MW, et al. Current evidence for postoperative monitoring of microvascular free flaps: A systematic review. Ann Plast Surg 2015;74:621-32.  Back to cited text no. 12
    
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Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue transfer: An 11-year experience in 750 consecutive cases. Plast Reconstr Surg 1999;104:97-101.  Back to cited text no. 13
    
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Smit JM, Zeebregts CJ, Acosta R, Werker PM. Advancements in free flap monitoring in the last decade: A critical review. Plast Reconstr Surg 2010;125:177-85.  Back to cited text no. 14
    
15.
Jyränki J, Suominen S, Vuola J, Bäck L. Microdialysis in clinical practice: Monitoring intraoral free flaps. Ann Plast Surg 2006;56:387-93.  Back to cited text no. 15
    
16.
Hara H, Mihara M, Iida T, Narushima M, Todokoro T, Yamamoto T, et al. Blood glucose measurement for flap monitoring to salvage flaps from venous thrombosis. J Plast Reconstr Aesthet Surg 2012;65:616-9.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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