Intramucosal PCO2 Measurement as a New Monitoring Method of Free Jejunal Transfer following Pharyngo-laryngo-esophagectomy

Abstract

The choices for practical monitoring of free jejunal transfer have been quite limited because of its own characteristics, such as buried form, lack of skin surface, and the structure of a hollow viscous tract. Physiologically, it is known that tissue hypoxia caused by compromised perfusion leads to an increase of partial pressure of carbon dioxide (PCO2). Because of its physiological properties, the diffusion of carbon dioxide is always equilibrated between the mucosa of a hollow viscous organ and its lumen. The intramucosal PCO2 (PiCO2) of the gastrointestinal tract can therefore be determined indirectly from the intraluminal PCO2, which is measured with the aid of the tonometer catheter. To develop an optimal monitoring method for free jejunal transfer, the authors proposed the application of PiCO2 measurement by a modified use of a tonometer catheter. Since May of 1999, the authors performed postoperative PiCO2 monitoring on 20 cases of reconstructed pharyngoesophageal tracts in 18 patients who underwent radical tumor resection and one-stage reconstruction at the Shizuoka Red Cross Hospital. All 20 cases were safely monitored by PiCO2 measurement without any complications associated with the use of the tonometer catheter. In the 17 cases that succeeded uneventfully, the mean values of PiCO2 were kept lower than 40 mmHg throughout the monitoring period. On the other hand, the other three cases (15 percent) needed reexploration due to development of vascular complications, which was alerted by an abrupt increase of PiCO2 in each case (229, 130, and 99.6 mmHg). Two of the patients were fortunately successfully treated by immediate reexploration, leading to a 95 percent overall success rate. No false-negative or false-positive cases were observed. The authors' experience suggests that PiCO2 measurement using a tonometer catheter can provide the surgeon with reliable information for evaluating the perfusion and viability of a free jejunal transfer. Simplified manipulation and the objectivity of the numerical data allow stable measurement of PiCO2 and prompt judgment of the adequacy of the perfusion, which could minimize the burden and anxiety of the surgeon, particularly in the early postoperative period.

Oxygen Consumption, pCO2 Gradients and Regional Blood Flow Distribution in an Alternative Model of Intestinal Autotransplantation1

“…Recently, Imanishi et al demonstrated that intramucosal pCO 2 measurement may provide reliable information for evaluating the perfusion and viability of a free jejunal transfer in patients submitted to pharyngolaryngo-esophagectomy. In this study three patients needed reexploration due to development of vascular complications, which was alerted by an abrupt increase of intramucosal pCO 2 [33].…”

A “watch window” technique for monitoring buried free jejunum flaps during circumferential pharyngolaryngectomy reconstruction

“…Indirect monitoring methods include the use of a buried monitor probe, external surface monitoring with an ultrasonic Doppler [24], application of a monitoring flap using an isolated segment of the jejunum supplied by the same vascular pedicle [15,25], intramucosal PCO 2 measurement [21], or tonometric pHi monitoring [22].…”

“…Using a laryngeal fiberscope, creating a surgical window [14], or externalising an indicator segment [15,16] allows for direct observation of peristalsis and mucosal or serosal colour. Indirect monitoring methods include the use of implantable and handheld Dopplers [17][18][19][20], intramucosal PCO 2 measurement [21] and tonometric pHi monitoring [22]. However, these methods are subject to various technical or validity problems.…”

Detection of Postoperative Intestinal Ischemia in Small Bowel Transplants

“…Instead of monitoring the available oxygen, the accumulation of carbon dioxide can be monitored, as demonstrated by Imanishi et al [35]. They monitored auto-SBTs in 20 patients.…”