By D. BARISONI 1 and G. RANZOLIN From the Plastic Surgery Unit, S. Anna Hospital, Ferrara, Italy

Transcription

1 THE ACTION OF KALLIKREIN ON TUBED PEDICLE FLAPS IN RATS By D. BARISONI 1 and G. RANZOLIN From the Plastic Surgery Unit, S. Anna Hospital, Ferrara, Italy THE vitality of a tubed pedicle flap is essential in reconstructive surgery. There is a direct connection between vascularisation of the flap and its viability. Much research has been undertaken to establish techniques and drugs which would enhance survival of skin flaps. Mischchuk and Petukhova (I953), Bergonzelli and Visetti (I956), Derganc and Zdravic (I96o), DeHaan and Stark (I96I), Adamson et al. (I966) and many others have been active in this field. In the opinion of some authors (Kilner, I937 ; Braithwaite, I95I), insufficient venous outflow is the principal cause of cyanosis and subsequent damage to the skin. On the other hand, others consider the main cause to be an insufficient arterial supply (Mischchuk and Petukhova, I953 ; Grabb and Oneal, I966). Surgical trauma is capable of provoking a momentary arteriolar spasm (German et al., I933 ; Leriche, I94o; Hynes and McGregor, I949 ; Zbylski et al., I965). These authors are of the opinion that this momentary spasm does not completely relax and parts of the flap remain ischmmic, due to reduction of the " vis a tergo " (Bergonzelli and Visetti, I956). The aim of our present investigation was to ascertain whether an antispasmodic drug could be of advantage in unfavourable circulatory conditions. We used a preparation of a circulatory hormone isolated from the pancreas and salivary glands known as kallikrein. This substance exerts mainly a direct antispasmodic action on vessel walls, particularly on the walls of arterioles in the brain, heart, lungs, skin and muscles. Kallikrein is used clinically in several fields, such as vascular diseases (Hartenbach, I956), indolent wounds (Frey, -~932), Raynaud's disease (Leschke, *93I; De Brun, I934) Mdni~re's syndrome, delayed healing of bone (Bernaschek, I956) and hypertension (Sivo and Dobozy, I936). Zollner (I957) suggests the use of kallikrein in plastic surgery and states that if it is injected into the base of an endangered flap a bright red flush occurs and the flap may be saved ; this assertion is not substantiated by either clinical or experimental evidence. Otsuka (I96o) has reported a favourable effect with manetol (a hormone extracted from the medulla and concerned in blood coagulation) and kallikrein in skin transplants. According to this author the combined use of the two hormones ensured a better take of skin grafts. In order to investigate the favourable effects of kallikrein in plastic surgery operations, we thought it might be interesting to experiment with a long-acting preparation of kallikrein (" Padutin depot (Bayer) ") on tubed pedicle flaps in rats. MATERIAL AND METHODS We used white, male rats of the Wistar stock, weighing 250 to 300 g., and for anaesthesia a 2 per cent. aqueous solution of Avertin (I ml./xoo g.) by intraperitoneal injection. Flaps were raised on the back (Fig. I), and the defects closed by approxima- 4A 1 Present address : Odstock Hospital, Salisbury, Wilts. 34t

2 342 B R I T I S H JOURNAL OF PLASTIC SURGERY FIG. I Incision of the dorsal flap with cephalic pedicle. FIG. 2 Single pedicled tubed flap at the end of the operation.

3 ACTION OF KALLIKREIN ON TUBED PEDICLE FLAPS IN RATS 343 ting the wound edges. Single pedicle (proximal base) and bipedicle flaps were tubed with a 3/0 continuous silk suture. The flap was fixed to the back avoiding tension (Fig. 2). After the operation each animal was kept in a separate cage ; 20 per cent. of the animals ate their flaps ; these animals were discarded. The rats used as controls were injected daily with 0'3 ml. of the Polyvynylpyrrolidone solvent intra-peritoneally. A dose of 2 b.u. 1 of Padutin depot was administered to the treated animals by intraperitoneal injection six hours before the operation and every 24 hours after operation for nine days. RESULTS The animals were divided into three groups. In all groups we proposed to make skin flaps which, on account of their size, would certainly present difficulty with blood supply. FIG. 3 Single pedicled tubed flap 8o zo mm. in control rat. The size of the necrotic portion 72 hours after the operation is evident. The first group was made up of 13 animals with a single pedicle flap, 8o mm. long, 20 mm. broad. In the control animals 20 mm. of flap survived (Fig. 3). In the animals treated with kauikrein 4 ram. of flap survived (Fig. 4). In both groups the necrosis was dry, appeared early, and, was fully established by 72 hours. The second group consisted of I I animals with a single pedicle tubed flap, 50 mm. long and 2o mm. broad. The controls showed an average surviving length of about 15 mm. (Fig. 5), while the treated animals showed a surviving length of about 39 mm. (Fig. 6). 1 One biological unit (b.u.) is the amount of kallikrein which, injected intravenously in the dog, exerts the same effect on the carotid pressure as 5 ml. of normal human urine extracted from a specimen of 50 litres, dialysed for 24 hours against running water.

4 344 BRITISH JOURNAL OF PLASTIC SURGERY The third group comprised 16 animals with a bipedicle flap 8o ram, long and 2o mm, broad; in this group the average surviving length of the control flap was FIG. 4 Animal with single pedicled flap 8ox2o mm. injected with kallikrein intra~ peritoneally. The necrosis after 72 hours is less extensive than in Figure 3. FIG. 5 FIG. 6 Fig. 5.--Single pedicled flap 50 x 2o mm. in control rat 78 hours after operation. Fig. 6.--Animal with single pedicled flap 50 x 2o mm. injected with kallikrein after seven days. Necrosis occupies only a short terminal zone. 43 mm. (Fig. 7); in the animals treated with kallikrein, only a small part showed necrosis, and this did not always include the entire circumference of the tube which survived for a length of 68 mm. (Fig. 8).

5 ACTION OF KALLIKREIN ON TUBED PEDICLE FLAPS IN RATS 345 FIG. 7 FIG. 8 Fig. 7.--Bipedicled flap 8ox2o ram. in control animal. The dark zones indicate the amount of necrosis. Fig. 8.--Animal with bipedicled flap 8ox2o mm. treated with kallikrein. A small zone of necrosis is evident in the central part of the tube. Some points of necrosis can be seen at the site of the sutures. COMMENT AND CONCLUSIONS The table shows the effects of kallikrein on single or bipedicle tubed flaps. In the first and second group of animals the vascular conditions were particularly unfavourable. In both these groups the pedicle 20 mm. broad had the same blood supply and the average length of surviving pedicle was almost the same. TABLE Control Treated Increase of the surviving length in the treated animals ISt group single pedicled flap mm. 2nd group single pedicled flap 20 x 5 mm. 3rd group bipedicled flap mm. 19.6_+4.4 mm. (5) 15"2_+ 2" 9 mm. (4) 39" ram. (8) 39'0--+ 8"4 ram. (7) 43'o±5"I mm mm. (6) (IO) x9'9 mm. 23'8 mm. 25' 5 mm. The third group of animals came closest to the clinical requirements in these experimental conditions. With regard to the treated animals, no differentiation was made between pedicles in which necrosis extended only part of the way round the circumference, and those in which necrosis was complete. In all the three groups the treated animals showed an increase in the surviving length between 20 and 25 mm., and this increase was constant. The consistently favourable effect of kallikrein in every treated animal leads us to suppose that this substance could be used for clinical purposes, especially when the vascular condition of a tubed pedicle is thought to be unsatisfactory.

6 346 BRITISH JOURNAL OF PLASTIC SURGERY SUMMARY The effect of kallikrein on three groups of rats with tubed pedicle flaps on the back has been investigated. In each group of animals, differing in size and type of tube, kallikrein showed a considerable effect in increasing the survival of the tube. A clinical trial is suggested. It is a pleasure to thank Professor M. Aloisi, Director of the General Pathology Institute of Padova, for the hospitality given by his Institute, and Mr T. L. Barclay, F.R.C.S., for help in the preparatzbn of this paper. REFERENCES ADAMSON, J. E., HORTON, CH.E., CRAWFORD, H. H., and AYERES, W. T. (I966). Plastic reconstr. Surg., 37, ro5- BERGONZELLI, V., and VISETTI, M. (I956). Minerva Derm., 3 I, for. B :RNASCHEK, W. (I956). Arch. orthop. Unfallchir., 48, 209. BRAITHWAITE, F. (I95I). Br. J. plast. Surg., 3, 40. DE BRUN, R. (I934). Prat. (Paris), p DE HAAN, C. R., and STARK, R. B. (I96I). Plastic reconstr. Surg., 28~ 577. DERGANC, M., and ZDRAVIC, F. (I960). Br. ft. plast. Surg., I3, I87. FREY, E. K. (I932). Dtseh. med. Wschr., 58, 795. GERMAN, W., FINESILVER, E. M., and DAVIS, J. S. (I933). Archs Surg., Chicago, 26, 27. GRABB, W. G., and ONEAL, R. M. (I966). Plastic reconstr. Surg.~ 37, 4 6. HARTENBACH, W. (I956). MUnch. med. Wschr., 98, I657. HYNES, W., and MCGREGOR, A. (r949). Br. J. plast. Surg., 2, 4. KILNER, T. P. (I937). In " Postgraduate Surgery", Vol. 3, ed. Maingot, R. London: Medical Publications Ltd. LERICHE, R. (i940). Presse m~d., 48, 75. LESCHKE, E. (I93I). Medsche Welt, 5, 754. MISCHC}tUK, N. N., and PETUKHOVA, N. K. (I953). Vest. Khir., 73, 26. OTSUKA, T. (I96o). Shinyaku to Rinsh~, 8, I75. SIvo, R., and Dosoz, E. (I936). Klin. Wschr., I6, 636. ZBYLSKI, J. R., ORDER, S. E., WALKER, H. L., and MONCRmF, J. A. (I965). Plastic reconstr. ZBYLSKI, J. R., ORDER, S. E., WALKER, H. L., and MONCRIEF, J. A. (r965). Plastic reconstr. Surg., 36, 420. ZOLLNER, W. (I957)- S. Afr. Practnr., ~, 54.