Comparative evaluation in pharyngo-oesophageal reconstruction: radial forearm flap compared with jejunal flap. A 10-year experience

We reviewed 109 consecutive patients with cancer of the hypopharynx or cervical oesophagus who underwent free flap transfer for immediate reconstruction after total pharyngolaryngo-oesophagectomy. The free flaps used were either free jejunal (n = 70) or radial forearm flaps (n = 39). Significantly more fistulas (3/70 compared with 15/39, p < 0.0001) and strictures (6/64 compared with 13/33, p = 0.0008) developed in the radial forearm than the jejunal flap group. However, functional donor site morbidity was minimal and there were no cases of total flap necrosis in the forearm flap group. We consider that the free jejunal flap should be the first choice for total reconstruction of pharyngo-oesophageal defects. However, the forearm flap is suitable for elderly, high risk patients, because it is less invasive and has minimal donor site morbidity, which facilitates early recovery.

Laryngeal preservation surgery using a free flap patch following resection of a carcinoma of the posterior wall of the oropharynx

A carcinoma originating from the posterior wall of the oropharynx is not common, and radiotherapy has been used for years in this event without acceptable success. A free flap patch was used in 4 patients to reconstruct the defect after resection of a T2 or T3 carcinoma on the posterior wall of the oropharynx without laryngectomy. The free flaps used were the radial forearm and the free jejunal patch in 2 patients each. There was no flap loss, and successful laryngeal preservation was obtained in 3 of 4 patients. Laryngeal preservation surgery using a free flap patch proved very useful in selected patients with carcinoma of the posterior wall of the oropharynx. Based on our clinical experience, the free jejunal patch seems superior to the free forearm flap with regard to postoperative functional results.

A new concept and technique for reconstruction of the lower pharyngeal space using the free jejunal graft

OBJECTIVE

To report on a new concept and simple operative procedure to conform the diameter of the oral end of free jejunal grafts to that of pharyngeal defects for reconstruction of the lower pharyngeal space.

DESIGN AND METHODS

A preliminary study showed that the jejunum is supplied by a highly vascular network and that longitudinal paramesenteric incisions can be made without disturbing the blood supply of the jejunum. We then developed the following operative procedure. The position of the highest point of the pharyngeal defect and the site of the recipient vessels are determined. The free jejunal graft is positioned with its mesentery in correspondence with the location of the recipient vessels. The position of a longitudinal incision 180 degrees to the highest point of the defect is then determined. After the oral border of the jejunum is opened with scissors, a pharyngojejunal end-to-end anastomosis is performed.

PATIENTS

Eighteen patients with defects of the lower pharyngeal space after cancer treatment.

RESULTS

We transferred jejunal grafts in 18 patients using this operative procedure. In 7 of these patients, paramesenteric incisions were made. The lengths of the incisions ranged from 2 to 8 cm. Transfer was successful in all 18 patients. Postoperative leakage occurred in 1 patient in whom an antimesenteric incision had been made; however, a fistula did not develop.

CONCLUSIONS

Our method allows defects of the lower pharyngeal space to be reconstructed with end-to-end anastomosis of free jejunal grafts regardless of the location of the defect or of recipient vessels. This method is simple and appropriate for correcting large pharyngeal defects.

Free forearm flap reconstruction of the posterior tracheal wall invaded by esophageal carcinoma

A patient with a locally advanced cervical esophageal carcinoma invading the trachea underwent total esophagopharyngolaryngectomy and resection of the posterior wall of the trachea. The esophagus was repaired with a gastric pull-up, and the posterior defect in the trachea was repaired with a free radial forearm flap, obtaining a satisfactory result.

Immediate free flap reconstruction for head and neck pediatric malignancies

We performed six immediate free flap reconstructions after tumor ablation in 5 children under the age of 15 years presenting with head and neck malignancy. One patient underwent free flap transfer on two separate occasions because of tumor recurrence. There were no flap losses nor were there any complications related to microvascular surgery. Although a pediatric head and neck malignant tumor is rare, surgical resection is the primary therapeutic role for those that are amenable to complete excision. Pediatric microsurgery provides a safe and reliable procedure for reconstruction of head and neck defects after extirpation of the tumor.

Closure of large pharyngo-oesophageal fistulas with free flap transfer after resections for cancer

Postoperative salivary fistulas still remain a serious and potentially lethal problem in head and neck reconstruction particularly if the fistula is large and involving one half or more of the circumference of the pharyngo-oesophagus. Pedicled flaps have traditionally been the flaps of choice for closure of these fistulas, but the results are often disappointing. During the period 1982 to 1995, we have used either a radial forearm free flap or a jejunal free flap to close large and complex pharyngo-oesophageal fistulas after resection for cancer in 15 patients. Although two patients developed major fistulas that required additional operations for closure, successful closure was achieved in all but one case: the success rate was therefore 14/15 (93%). We consider that jejunal flaps are suitable for circumferential pharyngo-oesophageal reconstruction and forearm flaps for non-circumferential defects.

Chromosomal mapping of the gene encoding serotonin N-acetyltransferase to rat chromosome 10q32.3 and mouse chromosome 11E2

Pineal melatonin is produced during the night. Its nocturnal increase regulates circadian rhythms and the photoperiodic reproductive response. Serotonin is acetylated to N-acetylserotonin by serotonin N-acetyltransferase (SNAT) and then methylated to form melatonin by hydroxyindole-O-methyltransferase (HIOMT). The rhythmicity of melatonin synthesis is regulated by the rhythmic activity of SNAT. Most laboratory mice do not have melatonin because of a genetic defect in the activity of SNAT and/or HIOMT. In a previous study using a recombinant inbred strain, we have found that the locus controlling pineal SNAT activity (Nat4) is located on mouse Chromosome 11. Recently, SNAT has been cloned in the rat. In the present study, the gene encoding SNAT was localized, using a rat cDNA fragment, on rat and mouse chromosomes by direct R-banding fluorescence in situ hybridization (FISH). In addition, using molecular linkage analysis with interspecific backcross mice, a gene encoding SNAT was mapped on a mouse chromosome. The gene encoding SNAT was localized to rat chromosome 10q32.3 and mouse Chromosome 11E2 by FISH. The molecular linkage analysis demonstrated that the gene encoding SNAT maps 1.5 cM distal to D11Mit11. The data suggest that Nat4 encodes SNAT. These chromosomal locations are in a region of conserved linkage homology between the two species.

Phase-relationship and mutual effects between circadian rhythms of ocular melatonin and dopamine in the pigeon

In order to study the mechanisms of ocular circadian rhythms in the pigeon, we measured melatonin and dopamine simultaneously from the eye using in vivo microdialysis. In experiment 1, the phase relationship between circadian rhythms of ocular melatonin and dopamine under light-dark cycles (LD) and continuous dim light (LLdim) was examined. Under LD, melatonin was high during the dark and low during the light. On the other hand dopamine was high during the light and low during the dark. These rhythms with the anti-phase relationship were maintained after the birds were transferred from LD to LLdim. In experiment 2, effects of a single light pulse on melatonin and dopamine rhythms were examined. A light pulse at CT18 rapidly suppressed melatonin release to the daytime level, whereas it rapidly increased dopamine release to the daytime level. The light pulse also affected the phases of melatonin and dopamine rhythms, inducing phase advances of both rhythm without changing the anti-phase relationship before the light pulse. In experiment 3, effects of an intraocular injection of dopamine or melatonin on their circadian rhythms were examined. A dopamine injection during the subjective night suppressed melatonin release and induced a light-pulse type phase shift in both melatonin and dopamine rhythms. On the other hand, a melatonin injection during the subjective day suppressed dopamine release and induced a dark-pulse type phase shift. These results are compatible with either one or two oscillator models, but the interaction between melatonin and dopamine is, in either case considered as an important mechanism regulating ocular circadian rhythms of the pigeon.

Tumor thickness predicts cervical metastasis in patients with stage I/II carcinoma of the tongue

BACKGROUND

The incidence of cervical metastases after surgery for Stages I/II carcinoma of the tongue is 30-40%. Postoperative cervical metastases are an adverse prognostic factor for patients with this malignancy. The purpose of this study was to evaluate the clinicopathologic factors associated with late cervical metastases in patients with carcinoma of the tongue.

METHODS

The clinicopathologic features of 44 patients with previously untreated Stage I/II carcinoma of the tongue were reviewed. All patients were treated with partial glossectomy only.

RESULTS

Cervical metastases developed in 21 of 44 patients within 5 years. Factors significantly associated with the development of cervical metastases were invasive growth, differentiation, nuclear polymorphism in the deep portion, tumor border, nest formation, infiltrative growth ratio, depth, and thickness. No statistical correlations between cervical metastases and age, gender, tumor location, clinical stage, Brinkman index, alcohol index, mitosis, connective tissue, lymphocytic infiltration, or perineural invasion were found. Multivariate analysis demonstrated that only tumor thickness > 4 mm had a predictive value for cervical metastasis (risk ratio 9.4; 95% confidence interval, 1.5-57.7).

CONCLUSIONS

The current study data indicate that patients with Stage I/II carcinoma of the tongue > 4 mm in thickness are at increased risk for subsequent cervical metastasis. Thus, conservative supraomohyoid neck dissection is indicated in patients with Stage I/II carcinoma of the tongue > 4 mm in thickness.

Identification of rhodopsin in the pigeon deep brain

We detected rhodopsin gene expression in the pigeon lateral septum, a photosensitive deep brain region that is responsible for the photoperiodic gonadal response. The nucleotide sequence of the deep brain rhodopsin cDNA clone exactly matched that of the retinal one, indicating that a single rhodopsin gene is transcribed in the two tissues. Immunohistochemical analysis localized rhodopsin in the cerebrospinal fluid-contacting neurons, which have been assumed to be photoreceptive cells in the deep brain. Pigeon rhodopsin seems to play dual important roles in the visual and non-visual systems, the latter of which contributes to the photoperiodic response.

Decline of circadian photosensitivity associated with retinal degeneration in CBA/J-rd/rd mice

Although it is well known that visual image formation is mediated by rods and cones, photoreceptors implicated in entrainment of circadian rhythms remain unknown. In our previous study, 12-week-old CBA/J-rd/rd mice were found to show decreased sensitivity in circadian photoreception. Because rd gene induces different age-related degeneration of cones and rods, we have examined age-related changes in the sensitivity to a light pulse for phase-shifting the locomotor activity rhythms in CBA/J-rd/rd mice. Since mice have middlewave-sensitive cones (M-cone, 510 nm) and shortwave-sensitive cones (S-cone, 360 nm), a 15-min monochromatic light pulse (501.6 or 359 nm; 10 microW cm(-2) s(-1)) was given at circadian time (CT) 16, 2 weeks after being transferred to constant darkness (DD) and the magnitude of phase shift was determined. The amount of phase shift by a green light pulse (501.6 nm) gradually declined from 8 to 16 weeks after birth and the similar tendency was also observed on a UV pulse (359 nm). The similar pattern of age-related decline in the number of cones and circadian photosensitivity in CBA/J-rd/rd mice suggest that cones are involved in the circadian photoreception in mice.

Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects

OBJECTIVE

The anterolateral thigh flap has many advantages in head and neck reconstruction. However, it has not yet come into widespread use because of the anatomic variations of its perforators. Herein, we describe a safe operative technique related to the patterns of the perforators and discuss its wide versatility.

SETTING

A national cancer center hospital.

PATIENTS

Thirty-eight anterolateral thigh flaps were transferred. Confirmation and dissection of the flap pedicle were simultaneously performed with tumor resection. The design and elevation of the flap were carried out immediately after the tumor resection was completed.

RESULTS

From the study of the anatomic variations of the perforators, septocutaneous patterns were recognized in 10 cases (26.3%) and musculocutaneous patterns in 28 cases (73.7%). All flaps were easily and safely elevated with our techniques. Thirty-six flaps survived. Partial necrosis was noted owing to excessive thinning procedure in one patient and total necrosis was noted owing to venous thrombosis at the anastomosis part in another patient.

CONCLUSIONS

We found that the anterolateral thigh flap has numerous advantages. It is possible to perform the flap elevation and the tumor resection simultaneously. The flap is generally thin and is suitable for reconstruction of intraoral defects. Combined flaps with neighboring tissues and other, distant flaps can be used. Furthermore, since our technique minimizes the problems of confirmation and dissection of the perforators, we conclude that this flap can be successfully used to repair a variety of large defects of the head and neck.

Immunocytochemical identification of pinopsin in pineal glands of chicken and pigeon

Pinopsin is a blue-sensitive photoreceptive molecule possibly involved in photic entrainment of the circadian pacemaker in the chicken pineal gland. To characterize pinopsin as a circadian photoreceptor, antibodies were raised against the C-terminal portion of pinopsin. As expected from the divergence of the amino acid sequence of this region, the resultant antibody cross-reacted with neither chicken rhodopsin nor red-sensitive cone pigment (chicken red). In Western blot analysis, the antibody stained a single band of 42-kDa protein in a detergent-extract of chicken pineal membranes, suggesting that pinopsin (calculated molecular weight, 38187) might be glycosylated and/or palmitoylated. Immunocytochemical examination of pineal sections of the chicken and the pigeon with this antibody revealed strong positive images for most of the membrane structures in the lumen of the follicles. This antibody also stained string- and bulb-shaped structures of the chicken parafollicular cells, the morphology of which resembles those of retinal photoreceptor cells. In contrast to the predominant distribution of pinopsin, a monoclonal antibody specific for chicken red stained a smaller number of membrane structures in the lumen of chicken pineal follicles. These results strongly suggest that the chicken pineal gland contains at least two types of photoreceptive molecules, pinopsin (major) and chicken red (minor). We show that the former molecule is localized in parafollicular pinealocytes and in the outer segments of pinealocytes that make contact with the follicular lumen.

Thyroglossal duct carcinoma: a case report

We describe a 47-year-old woman with a 13-year history of asymptomatic midline submental swelling. Cytologic examination of a fine-needle aspiration specimen from the solid mass revealed adenocarcinoma. The preoperative diagnosis was thyroglossal duct carcinoma. A Sistrunk procedure was performed and microscopic examination revealed papillary adenocarcinoma. The postoperative course was uneventful and there were no signs of local recurrence or metastasis at one year after surgery.

Circadian rhythms of cardiovascular functions are modulated by the baroreflex and the autonomic nervous system in the rat

BACKGROUND

We assessed the hypothesis that the baroreflex and the autonomic nervous system are important in the control of the circadian rhythms of cardiovascular functions.

METHODS AND RESULTS

We continuously measured blood pressure (BP), heart rate (HR), and locomotor activity in sinoaortic denervated (SAD), sympathectomized, and atropine-injected rats by use of a radiotelemetry system. The circadian rhythm of mean blood pressure (MBP) was selectively disrupted in SAD rats under 12-hour light-dark (LD12:12) cycles as a result of an increase in MBP during the light period and disappeared under constant darkness (DD). The locomotor activity and HR were not remarkably affected by SAD. The circadian rhythm of MBP was suppressed in sympathectomized rats by a decrease in the MBP during the dark period, and the abrupt changes in MBP when the lighting was altered were not seen under LD. Under DD, an MBP rhythm similar to that observed under LD was obtained. Sympathectomized rats also showed lower HR levels during the dark period than intact rats under LD cycles. In atropine-injected rats, the MBP and HR increased, especially during the light period, resulting in a reduction of light-dark differences in MBP and HR. The locomotor activity showed an apparent 24-hour variation in the sympathectomized and atropine-injected rats.

CONCLUSIONS

The disruption of the baroreflex selectively eliminates the circadian rhythm of BP, and the circadian rhythms of BP and HR are modulated by the autonomic nervous system in rats. The circadian rhythms of BP and HR are regulated by different mechanisms involving the autonomic nervous system.

Improvement of exercise performance with short-term nasal continuous positive airway pressure in patients with obstructive sleep apnea

We examined the effects of nasal continuous positive airway pressure (CPAP) on exercise performance in patients with obstructive sleep apnea (OSA). Six patients were treated with nasal CPAP on seven successive days and underwent overnight sleep studies and multiple sleep latency test (MSLT) at the beginning and after the last day of the treatment. The subjects also performed incremental exercise testing using a bicycle ergometer followed by 0-w, 25-w, 50-w,--(3 minutes each) until maximum level. Arterial oxygen pressure, arterial carbon dioxide pressure at rest while awake, apnea/ hypopnea index, longest apnea duration, the lowest percutaneous oxygen saturation measured by a pulse oximeter and the value of MSLT were significantly improved after nasal CPAP. Moreover, maximal oxygen consumption was significantly increased from 1841 ml/min +/- 350 to 2125 ml/min +/- 351 (p < 0.05); however, other cardiorespiratory parameters did not change significantly. The improvement of exercise performance by short-term nasal CPAP treatment in OSA patients may correlate with the improvement of sleepiness.

Immunoelectron-microscopic investigation of the subcellular localization of pinopsin in the pineal organ of the chicken

Pinopsin is a photoreceptive molecule cloned from the chicken pineal organ. An antibody highly specific for pinopsin was applied in light- and electron-microscopic immunocytochemical studies of the pineal organ of 1 to 2-month-old chickens. Intense immunoreactivity was found in the follicular lumen at the light-microscopic level. In addition, small immunoreactive spherical or fibrous structures were diffusely distributed at the parafollicular aspect of the pineal organ. To identify immunoreactive elements precisely, we used pre-embedding immunoelectron microscopy. These studies revealed immunoreactive outer segments of pinealocytes arranged closely side by side in the follicular lumina. The thin initial portion of the outer segment arose from a basal body located in the inner segment. Immunoreactive pear-shaped outer segments occupied small lumina. Follicular lumina displayed immunonegative arrays of whorl-like lamellar membranes. Occasionally, these immunonegative structures were surrounded by immunoreactive concentric lamellar complexes. In the parafollicular pineal parenchyma, long slender cilium-like structures or enlarged cilia and concentric lamellar arrays showed intense immunoreactivity. All immunoreactive structures observed in this study were considered to represent outer segments of pinealocytes of the chicken pineal organ.

In vivo microdialysis studies of pineal and ocular melatonin rhythms in birds

Pineal and retinal melatonin has an important role in the control of avian circadian rhythms. In order to study the mechanisms of circadian rhythms of melatonin synthesis in the pineal and in the eye, in vivo microdialysis was applied to these organs. In both pigeons and Japanese quails, pineal and ocular melatonin levels were high during the dark and low during the day under light-dark (LD) cycles. These rhythms persisted under constant dim light (LLdim) conditions indicating the circadian nature of pineal and ocular melatonin release. Light has two effects on melatonin synthesis. One is acute inhibition of melatonin synthesis and the other is entrainment of circadian melatonin rhythms. We have examined photoreceptors mediating these effects in the pigeon. The results have indicated that the eyes are not involved in light-induced suppression and photic entrainment of pineal melatonin release, and pineal photoreceptors themselves are likely to mediate these effects. Concerning ocular melatonin, retinal photoreceptors seem to mediate light-induced suppression and photic entrainment and no evidence supporting mediation of extraretinal photoreceptors was obtained. Because dopamine is implicated in retinal melatonin synthesis, we measured dopamine and melatonin release simultaneously from the eye of pigeon. In contrast to melatonin rhythms, dopamine increased during the day and decreased during the dark. This antiphase relationship between melatonin and dopamine persisted in LLdim, suggesting an interaction between these two rhythms. The results of an intraocular injection of dopamine or melatonin in the phase of melatonin and dopamine rhythms indicated that the interaction is required for maintaining the antiphase relationship between the two rhythms.

Role of cyclic ADP-ribose in ATP-activated potassium currents in alveolar macrophages

There is growing evidence that extracellular ATP causes a dramatic change in the membrane conductance of a variety of inflammatory cells. In the present study, using the nystatin perforated patch recording configuration, we found that ATP (0.3-30 microM) induced a transient outward current in a concentration-dependent manner and that the reversal potential of the ATP-induced outward current was close to the K+ equilibrium potential, indicating that the membrane behaves like a K+ electrode in the presence of ATP. The first application of ATP to alveolar macrophages perfused with Ca2+-free external solution could induce the outward current, but the response to ATP was diminished with successive applications. Intracellular perfusion with a Ca2+ chelator, 1,2-bis(2-aminophenoxy)ethane-N,N,N', N'-tetraacetic acid, also diminished the response. When cyclic ADP-ribose (cADPR) was applied to the macrophage cytoplasm, a transient outward current was elicited. Thereafter, the successive outward current was inhibited, suggesting the involvement of cADPR in the response. Intracellular perfusion with inositol 1,4, 5-trisphosphate also induced a transient outward current, but the successive current was not inhibited. The ATP-induced outward current was abolished when 8-amino-cADPR (as a blocker of cADPR, 10(-6)-10(-5) M) was introduced into the cytoplasm. Homogenates of alveolar macrophages showed both ADP-ribosyl cyclase and cADPR hydrolase activities, and CD38 (ADP-ribosyl cyclase/cADPR hydrolase) expression was confirmed by reverse transcriptase-polymerase chain reaction and Western blot analyses. These results indicate that ATP activates K+ currents by releasing Ca2+ from cADPR-sensitive internal Ca2+ stores.

Preservation of the larynx after resection of a carcinoma of the posterior wall of the hypopharynx: versatility of a free flap patch graft

BACKGROUND

Preservation of the larynx after resection of a pharyngeal tumor remains a challenging problem for the head and neck surgeon.

METHODS

Nine patients with T1 or T2 carcinoma of the posterior wall of the hypopharynx (UICC 1987), who were treated surgically between 1984 and 1994, were studied. All patients underwent surgical resection of the tumor with laryngeal preservation and immediate reconstruction with free flap transfer. A free forearm flap was transferred in four patients and a free jejunal patch graft, in five patients.

RESULTS

There was one flap loss, due to venous thrombosis. Successful larynx preservation was achieved in the remaining eight patients (89%). Although there was one local control failure, three patients remained free of disease for more than 5 years.

CONCLUSIONS

Laryngeal preservation surgery using a free flap patch graft has proven very beneficial in selected cases with a carcinoma of the posterior wall of the hypopharynx.

Lack of ventilatory threshold in patients with chronic obstructive pulmonary disease

We investigated whether the ventilatory threshold (VET) could be detected in 25 patients with severe chronic obstructive pulmonary disease (COPD). Exercise on a treadmill was performed until symptom-limited maximum oxygen uptake (VO2SL) was obtained. VET was absent in 14 patients (56%, VET(-) group) and present in the others (44%, VET(+) group). Basal pulmonary functions and dyspnea index (VE,SL/MVV) were not different between the two groups. Endurance time and exercise tolerance (VO2SL/bw) were significantly less in VET(-) than in VET(+). In the former group, PaO2 and pH at maximal exercise decreased and PaCO2 increased significantly, but HCO3- did not change compared with the corresponding values before exercise. In the latter group, PaCO2 at maximal exercise increased significantly, and pH and HCO3- decreased significantly compared with the values before exercise, but PaO2 did not. The changes in PaO2 and PaCO2 were not different between the two groups, but changes in pH and HCO3- in VET(+) were greater than those in VET(-). These results suggest that the absence of VET in some COPD patients indicates a lower exercise capacity without producing metabolic acidosis. This may be caused by rapidly developing dyspnea.

Free colon transfer: a versatile method for reconstruction of pharyngoesophageal defects with a large pharyngostoma

Free transverse colon transfers based on the middle colic vessels were used to reconstruct a pharyngoesophageal defect in 9 patients. In all patients, cancer invaded up to the oropharynx. Resection resulted in a larger pharyngostoma than normally seen following standard total pharyngolaryngoesophagectomy. In such cases, it can be difficult to achieve good swallowing function after reconstruction using the free jejunal transfer. This mainly results from a significant discrepancy between the diameter of the pharyngostoma and that of the jejunum. Compared to the jejunum, the transverse colon has a larger diameter with a longer vascular pedicle and can provide a longer, straight intestinal tube, facilitating easy passage of a food bolus. In our series, all transfers survived well and all patients had good swallowing function postoperatively. We consider that a free colon transfer is more suitable than a free jejunal transfer for pharyngoesophageal reconstruction in patients with a large pharyngostoma.