Lymphatic drainage patterns of malignant skin tumors in the head and neck region: a single-center retrospective study

BACKGROUND

This study aimed to clarify the relationship between primary site and lymphatic drainage pattern for malignant skin tumors in the head and neck region. Malignant melanoma and squamous cell carcinoma in the head and neck region are known to have poor prognosis because of lymph node metastasis. Nevertheless, numerous aspects of lymphatic drainage patterns remain elusive.

METHODS

We statistically analyzed data of 47 patients with malignant skin tumors in the head and neck region. Information was collected on the patients' clinical characteristics, primary tumor site, and lymphatic drainage patterns.

RESULTS

The parotid lymph nodes drained the greatest amount of lymph from skin tumors of the head and neck. Important lymphatic drainage pathways were the superficial cervical nodes for primary tumors in the buccal/nasal region, level IA and level IB nodes for primary tumors in the lip region, the occipital nodes, posterior auricular nodes, and level VA nodes in the parietal/occipital region, and the preauricular nodes in the auricular region.

CONCLUSION

These findings have considerable significance in terms of understanding lymphatic drainage patterns for malignant skin tumors in the head and neck and may be useful for clinical decision-making and when planning treatment. Further research and clinical applications are expected to contribute to an improved prognosis in patients with cutaneous head and neck malignancies.

Efficacy of hyperbaric oxygen after microtia reconstruction using costal cartilage: A retrospective case-control study

Introduction

Microtia reconstruction with autologous costal cartilage framework grafting is challenging because the three-dimensional structure of the ear is highly complex, and meeting the high aesthetic demands of patients can be difficult. If the skin flap overlying the framework is thinned to achieve a smooth and accentuated outline, a poor blood supply in the thin skin flap may lead to skin necrosis, exposure of the framework, and poor surgical results. Hyperbaric oxygen (HBO2) therapy can promote the healing of complex wounds and flaps. This study sought to determine the effectiveness of HBO2 therapy for the prevention of postoperative complications after framework grafting in microtia reconstruction.

Methods

We retrospectively evaluated postoperative complications and compared outcomes in pediatric patients who underwent costal cartilage grafting for microtia reconstruction at our institution between 2011 and 2015, according to whether or not they received postoperative HBO2 therapy. HBO2 therapy was applied once daily for a total of 10 sessions starting on the first postoperative day.

Results

During the study period, eight patients received HBO2 therapy after costal cartilage grafting, and 12 did not. There was no significant difference in the incidence of postoperative ulcers. However, the incidence of framework exposure was lower, and the healing time was shorter in patients who received HBO2 therapy than in those who did not.

Discussion

HBO2 therapy can be used safely in pediatric patients to reduce postoperative complications and improve the aesthetic outcome of microtia reconstruction. After costal cartilage grafting, HBO2 therapy should be considered as adjuvant therapy.

[Hemorrhagic Colon Cancer with Left Atrial Thrombus Formation after Anticoagulant Therapy Discontinuation-A Case Report]

The patient was a 72-year-old female. She had been taking rivaroxaban for chronic atrial fibrillation; however, she stopped taking it due to anemia and was hospitalized urgently. A contrast-enhanced computed tomography(CT)scan showed a 30 mm mass in the ascending colon, and a colonoscopy revealed ascending colon cancer(cT3, cN0, cM0, cStage Ⅱa). The tumor was hemorrhagic and was thought to have caused the anemia. On day 6 of hospitalization, another contrast- enhanced CT scan showed a poorly contrast-enhanced area in the left atrium, and transesophageal echocardiography revealed 2 left atrial thrombi(27 mm and 17 mm). Since early induction of anticoagulation therapy was considered, an emergency open right colectomy was performed to remove the cause of the bleeding. Intravenous heparin therapy was started the day after surgery and was switched to oral apixaban therapy on the fourth postoperative day. The postoperative course was good, and she was discharged home on the 17th postoperative day. This patient had conflicting clinical problems simultaneously; however, immediate decision-making and initiation of treatment were effective.

Targeted next-generation sequencing for detection of PIK3CA mutations in archival tissues from patients with Klippel-Trenaunay syndrome in an Asian population : List the full names and institutional addresses for all authors

BACKGROUND

Klippel-Trenaunay syndrome (KTS) is a rare slow-flow combined vascular malformation with limb hypertrophy. KTS is thought to lie on the PIK3CA-related overgrowth spectrum, but reports are limited. PIK3CA encodes p110α, a catalytic subunit of phosphatidylinositol 3-kinase (PI3K) that plays an essential role in the PI3K/AKT/mammalian target of rapamycin (mTOR) signaling pathway. We aimed to demonstrate the clinical utility of targeted next-generation sequencing (NGS) in identifying PIK3CA mosaicism in archival formalin-fixed paraffin-embedded (FFPE) tissues from patients with KTS.

RESULTS

Participants were 9 female and 5 male patients with KTS diagnosed as capillaro-venous malformation (CVM) or capillaro-lymphatico-venous malformation (CLVM). Median age at resection was 14 years (range, 5-57 years). Median archival period before DNA extraction from FFPE tissues was 5.4 years (range, 3-7 years). NGS-based sequencing of PIK3CA achieved an amplicon mean coverage of 119,000x. PIK3CA missense mutations were found in 12 of 14 patients (85.7%; 6/8 CVM and 6/6 CLVM), with 8 patients showing the hotspot variants E542K, E545K, H1047R, and H1047L. The non-hotspot PIK3CA variants C420R, Q546K, and Q546R were identified in 4 patients. Overall, the mean variant allele frequency for identified PIK3CA variants was 6.9% (range, 1.6-17.4%). All patients with geographic capillary malformation, histopathological lymphatic malformation or macrodactyly of the foot had PIK3CA variants. No genotype-phenotype association between hotspot and non-hotspot PIK3CA variants was found. Histologically, the vessels and adipose tissues of the lesions showed phosphorylation of the proteins in the PI3K/AKT/mTOR signaling pathway, including p-AKT, p-mTOR, and p-4EBP1.

CONCLUSIONS

The PI3K/AKT/mTOR pathway in mesenchymal tissues was activated in patients with KTS. Amplicon-based targeted NGS could identify low-level mosaicism from low-input DNA extracted from FFPE tissues, potentially providing a diagnostic option for personalized medicine with inhibitors of the PI3K/AKT/mTOR signaling pathway.

Successful omental flap coverage repair of a rectovaginal fistula after low anterior resection: a case report

BACKGROUND

Rectovaginal fistula (RVF) is a troublesome and refractory complication after low anterior resection (LAR) for rectal cancer. An omental flap repair was performed for the RVF caused due to Crohn's disease and childbirth trauma. However, there are few cases of an omental flap repair for RVF after LAR. Herein, we present a successfully repaired case of RVF by omental flap coverage after LAR for rectal cancer.

CASE PRESENTATION

A 50-year-old female patient with advanced rectal cancer underwent laparoscopic LAR with double-stapling technique anastomosis and achieved curative resection. She complained of a stool from the vagina and was diagnosed with RVF on the postoperative day (POD) 18. Conservative therapy was ineffective. We performed laparoscopic fistula resection and direct closure of the vagina and rectum, designed the omentum that could reach the pelvis, repaired RVF by omental flap coverage, and performed transverse colostomy on POD 25. She was discharged on initial POD 48. Seven months after the initial operation, colostomy closure was administered. There was no recurrence of RVF found 1 year after the initial operation.

CONCLUSIONS

The patient achieved an omental flap coverage for RVF. We successfully performed the omental flap coverage repair in patients with RVF after the leakage of LAR. An omental flap may become an alternative treatment for muscle flap or an effective treatment for RVF.

Maggot debridement therapy in critical limb ischaemia: a case study

OBJECTIVE

In critical limb ischaemia (CLI), first-line therapy is revascularisation, but alternative treatment options are needed in certain cases. Maggot debridement therapy (MDT) is historically considered to be contraindicated in ischaemic ulcers. Wound care in patients with CLI is becoming increasingly diverse with the development of novel revascularisation strategies; therefore, CLI now needs to be reconsidered as an indication for MDT.

METHOD

We retrospectively reviewed five legs with CLI (five male, one female) treated with MDT between January 2013 and December 2017. Changes in skin perfusion pressure (SPP) around the ulcer before and after MDT were evaluated. One or two cycles of MDT were performed (eight in total). We also evaluated the proportion of necrotic tissue in the ulcer and the presence of exposed necrotic bone. The proportion of necrotic tissue in the ulcer was classified as NT 1+ (<25%), NT 2+ (25-50%), NT 3+ (50-75%) or NT 4+ (>75%).

RESULTS

When the proportion of necrotic tissue was >50%, with no exposed necrotic bone in the wound, an increase in SPP was observed after five (62.5%) of eight cycles of MDT. And with a proportion of necrotic tissue of <25% and/or exposed necrotic bone in the wound, a decrease in SPP was observed after three (37.5%) of eight cycles. Wound healing was accelerated in the presence of increased SPP.

CONCLUSION

Effective MDT with increased SPP requires an ulcerative state of necrotic tissue grade > NT 3+, with no exposed necrotic bone.

Combined internal and external negative pressure wound therapy: breakthrough treatment for lymphocutaneous intractable fistula

PURPOSE

Lymphocutaneous fistula after lymph node dissection is intractable, yet there is no established treatment strategy. This study demonstrates the wound closure time achieved by a new method of combined internal and external negative pressure wound therapy (CIEN) in patients with lymphocutaneous fistula.

METHODS

The subjects of this study were six consecutive patients with lymphocutaneous fistula after lymphatic surgery, who were treated with CIEN between 2018 and 2020. The CIEN technique can be summarized as follows: first, internal foam is inserted into the fistula from the opening of the fenestration. Next, a slightly larger area of external foam is applied above the fistula flap outside the external margin of the foam-filled fistula. After bridging the internal foam and external foam, negative-pressure wound therapy is carried out on this bridging foam block.

RESULTS

CIEN led to rapid and complete wound healing in all six patients. Fistula flap margin ischemia developed in one patient, but adjusting the mode and pressure settings resulted in improvement. Three patients suffered contact dermatitis. There were no signs of tumor or fistula recurrence in any patients after at least 3 months of follow-up.

CONCLUSION

CIEN is an effective and less invasive treatment modality than the conventional method of managing lymphocutaneous fistula.

Long-term outcomes and recurrence-free interval after the treatment of keloids with a standardized protocol

BACKGROUND

Recurrence rates of keloids have generally been reported at one time point. However, the longer the duration after treatment, the greater the likelihood that such lesions will recur. In this study, we analysed the time to recurrence during long-term follow-up.

MATERIAL AND METHODS

We retrospectively reviewed recurrence-free interval in 52 patients with keloid (age 8-79 years) who had been treated between June 2006 and January 2011 using a standardised protocol developed by our group.

RESULTS

Mean duration of follow-up was 37.5 (range, 7-120) months in patients with keloid. Kaplan-Meier survival curves revealed a statistically significant difference in recurrence-free interval between ear keloids and keloids excluding ear keloids. Recurrence rate for keloids was high in the first 2 years after treatment.

CONCLUSIONS

Kaplan-Meier analysis was useful for understanding the tendency of recurrence of keloids after treatment using a standardised protocol.

Diagnosis and Treatment of Keloids and Hypertrophic Scars-Japan Scar Workshop Consensus Document 2018

There has been a long-standing need for guidelines on the diagnosis and treatment of keloids and hypertrophic scars that are based on an understanding of the pathomechanisms that underlie these skin fibrotic diseases. This is particularly true for clinicians who deal with Asian and African patients because these ethnicities are highly prone to these diseases. By contrast, Caucasians are less likely to develop keloids and hypertrophic scars, and if they do, the scars tend not to be severe. This ethnic disparity also means that countries vary in terms of their differential diagnostic algorithms. The lack of clear treatment guidelines also means that primary care physicians are currently applying a hotchpotch of treatments, with uneven outcomes. To overcome these issues, the Japan Scar Workshop (JSW) has created a tool that allows clinicians to objectively diagnose and distinguish between keloids, hypertrophic scars, and mature scars. This tool is called the JSW Scar Scale (JSS) and it involves scoring the risk factors of the individual patients and the affected areas. The tool is simple and easy to use. As a result, even physicians who are not accustomed to keloids and hypertrophic scars can easily diagnose them and judge their severity. The JSW has also established a committee that, in cooperation with outside experts in various fields, has prepared a Consensus Document on keloid and hypertrophic scar treatment guidelines. These guidelines are simple and will allow even inexperienced clinicians to choose the most appropriate treatment strategy. The Consensus Document is provided in this article. It describes (1) the diagnostic algorithm for pathological scars and how to differentiate them from clinically similar benign and malignant tumors, (2) the general treatment algorithms for keloids and hypertrophic scars at different medical facilities, (3) the rationale behind each treatment for keloids and hypertrophic scars, and (4) the body site-specific treatment protocols for these scars. We believe that this Consensus Document will be helpful for physicians from all over the world who treat keloids and hypertrophic scars.

Chondrocutaneous Bilateral Advancement Flap with Postoperative Radiation Therapy for a Helical Rim Keloid

Keloids can be recalcitrant, and a well-planned treatment strategy is essential. Multiple ear piercings have recently become popular, particularly among younger age groups. Management of keloids that develop after piercing of the ear cartilage may be particularly problematic. Helical rim keloids are difficult to excise because of the complex, three-dimensional, cartilaginous structure of the helix and its thin and tightly adherent covering layer of skin. The chondrocutaneous advancement flap introduced by Antia and Buch may be a useful reconstructive option for a helical rim keloid after marginal loss of a segment of the helix as a result of trauma, a burn, or excision of a malignant tumor. However, this technique is limited to wounds that involve only the helix. In this technical note, we describe the use of a chondrocutaneous bilateral advancement flap with postoperative radiation therapy to treat a more invasive and relatively large keloid on the scapha. This technique is straightforward and safe in terms of preserving the blood supply. The addition of adjuvant radiation therapy can help to decrease the risk of recurrence and preserve the morphological structure of the ear and patient satisfaction.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical and histopathological characteristics and survival analysis of 4594 Japanese patients with melanoma

Background

The incidence of melanoma among those of an Asian ethnicity is lower than in Caucasians; few large‐scale Asian studies that include follow‐up data have been reported.

Objectives

To investigate the clinical characteristics of Japanese patients with melanoma and to evaluate the prognostic factors.

Methods

Detailed patient information was collected from the database of Japanese Melanoma Study Group of the Japanese Skin Cancer Society. The American Joint Committee on Cancer seventh Edition system was used for TNM classification. The Kaplan‐Meier method and Cox proportional hazards model were used to estimate the impact of clinical and histological parameters on disease‐specific survival in patients with invasive melanoma.

Results

In total, 4594 patients were included in this analysis. The most common clinical type was acral lentiginous melanoma (40.4%) followed by superficial spreading melanoma (20.5%), nodular melanoma (10.0%), mucosal melanoma (9.5%), and lentigo maligna melanoma (8.1%). The 5‐year disease‐specific survival for each stage was as follows: IA = 98.0%, IB = 93.9%, IIA = 94.8%, IIB = 82.4%, IIC = 71.8%, IIIA = 75.0%, IIIB = 61.3%, IIIC = 41.7%, and IV = 17.7%. Although multivariate analysis showed that clinical classifications were not associated with survival across all stages, acral type was an independent poor prognostic factor in stage IIIA.

Conclusions

Our study revealed the characteristics of melanoma in the Japanese population. The 5‐year disease‐specific survival of each stage showed a similar trend to that of Caucasians. While clinical classification was not associated with survival in any stages, acral type was associated with poor survival in stage IIIA. Our result might indicate the aggressiveness of acral type in certain populations.

[Locally Advanced Rectal Cancer Presenting with Perforation That Was Successfully Resected after Preoperative Chemotherapy with mFOLFOX6 plus Panitumumab]

We report a case of locally advanced rectal cancer presenting with perforation that was successfully resected after preoperative chemotherapy. A 66-year-old woman visited our emergency room complaining of lower abdominal pain. Abdominal CT showed a rectal tumor with fluid collection and free air in the pelvis. The patient was diagnosed with panperitonitis secondary to cancerous perforation and underwent sigmoid colostomy. A biopsy specimen of the rectal tumor showed well-differentiated tubular adenocarcinoma and wild-type RAS. After 8 courses of mFOLFOX6 plus panitumumab, the tumor shrank remarkably, and radical surgery(low anterior resection with D3 lymph node dissection)was performed. Microscopic examination of the resected specimen showed that almost half of the tumor cells were replaced by histiocytes and necrotic tissue. Preoperative chemotherapy with panitumumab may be an effective treatment for RAS wild-type locally advanced colon cancer, even if the primary tumor develops perforation.

Changes in high endothelial venules in lymph nodes after vascularized and nonvascularized lymph node transfer in a murine autograft model

BACKGROUND AND OBJECTIVES

Vascularized lymph node transfer (LNT) is gaining popularity in the treatment of lymphedema. However, it is unclear whether the vascularization of transferred lymph nodes (LNs) contributes to functional improvement. High endothelial venules (HEVs) are specialized vessels that allow lymphocytes to enter LNs. In this study, we compared the numbers of HEVs and lymphocytes in LNs after vascularized and nonvascularized LNT.

METHODS

Fifty mice were divided into three groups (group 1, pedicled vascularized LNT; group 2, pedicled nonvascularized LNT; group 3, free nonvascularized LNT). Afferent lymphatic reconnection was confirmed by patent blue staining. The transferred LNs were harvested 4 weeks after surgery. HEVs, B-cells, and T-cells were subjected to immunohistochemical staining and quantified.

RESULTS

Afferent lymphatic reconnection was observed in 13 of 20 transferred LNs in group 1, 11 of 15 in group 2, and 7 of 15 in group 3. The ratio of dilated/total HEVs in transferred LNs with afferent lymphatic reconnection was significantly higher in group 1 than in groups 2 and 3. No significant differences in numbers of B-cells and T-cells were found in the transferred LNs.

CONCLUSIONS

We found that more functional HEVs were preserved in cases with successful afferent lymphatic reconnection after vascularized LNT than after nonvascularized LNT.

Feasibility of pedicled vascularized inguinal lymph node transfer in a mouse model: A preliminary study

PURPOSE

Vascularized lymph node transfer is becoming more common in the treatment of lymphedema, but suitable small animal models for research are lacking. Here, we evaluated the feasibility of pedicled vascularized inguinal lymph node transfer in mice.

METHODS

Twenty-five mice were used in the study. An inguinal lymph node-bearing flap with a vascular pedicle containing the superficial caudal epigastric vessels was transferred into the ipsilateral popliteal fossa after excision of the popliteal lymph node. Indocyanine green (ICG) angiography was used to confirm vascularity of the flap. ICG lymphography was performed to evaluate lymphatic flow at 3 and 4 weeks postoperatively. Patent blue dye was injected into the ipsilateral hind paw to observe staining of the transferred lymph node at 4 weeks postoperatively. All transferred lymph nodes were then harvested and histologically evaluated by hematoxylin and eosin staining.

RESULTS

In 16 of the 25 mice, ICG lymphography showed reconnection between the transferred lymph node and the afferent lymphatic vessels, as confirmed by patent blue staining. Histologically, these transferred lymph nodes with afferent lymphatic reconnection significantly regressed in size (0.37 ± 0.24 mm² ) and showed clear follicle formation, whereas those without afferent lymphatic reconnection showed less size regression (1.31 ± 1.17 mm² ); the cell population was too dense to allow identification of follicles.

CONCLUSIONS

We established a mouse model of vascularized lymph node transfer with predictable afferent lymphatic reconnection. Both the vascularization and reconnection might be necessary for functional regeneration of the transferred lymph node.

Clinical Characteristics and Surgical Treatment for Inguinal Endometriosis in Young Women of Reproductive Age

AIM

To study the characteristics and surgical treatment of inguinal endometriosis (IEM), which can occur in women of reproductive age.

METHODS

Patients who underwent groin surgery at the Hiroshima City Funairi Citizens Hospital between 2004 and 2017 were retrospectively examined. Patients with IEM were divided into 3 groups based on the site of occurrence as follows: at a hernia sac or hydrocele of Nuck's canal (type I), round ligament (type II), or subcutaneous area (type III). Clinical characteristics were compared among groups.

RESULTS

Of 2,798 patients investigated, 28 were pathologically diagnosed as having IEM with 15, 10, and 3 classified as type I, II, and III respectively. All patients presented with a mass (median 20 mm) and/or bulge that mainly occurred at the right inguinal region. Sixteen patients presented with inguinal pain associated with menstruation. While the groups did not differ in terms of most clinical characteristics, the lack of a preoperative diagnosis of IEM occurred more frequently for type I than for types II and III.

CONCLUSIONS

Because IEM-type I might be underdiagnosed preoperatively, complete resection of a hernia sac or hydrocele of Nuck's canal with subsequent pathological examination is required for women of reproductive age with an inguinal disease.

Pharmacokinetics of piperacillin-tazobactam in plasma, peritoneal fluid and peritoneum of surgery patients, and dosing considerations based on site-specific pharmacodynamic target attainment

Piperacillin-tazobactam (PIP-TAZ) is commonly used to treat intraabdominal infections; however, its penetration into abdominal sites is unclear. A pharmacokinetic analysis of plasma, peritoneal fluid, and peritoneum drug concentrations was conducted to simulate dosing regimens needed to attain the pharmacodynamic target in abdominal sites. PIP-TAZ (4 g-0.5 g) was intravenously administered to 10 patients before abdominal surgery for inflammatory bowel disease. Blood, peritoneal fluid, and peritoneum samples were obtained at the end of infusion (0.5 h) and up to 4 h thereafter. PIP and TAZ concentrations were measured, both noncompartmental and compartmental pharmacokinetic parameters were estimated, and a simulation was conducted to evaluate site-specific pharmacodynamic target attainment. The mean peritoneal fluid:plasma ratios in the area under the drug concentration-time curve (AUC) were 0.75 for PIP and 0.79 for TAZ, and the mean peritoneal fluid:plasma ratios in the AUC were 0.49 for PIP and 0.53 for TAZ. The mean PIP:TAZ ratio was 8.1 at both peritoneal sites. The regimens that achieved a bactericidal effect with PIP (time above minimum inhibitory concentration [MIC] >50%) at both peritoneal sites were PIP-TAZ 4.5 g twice daily for an MIC of 8 mg/L, as well as 4.5 g three times daily, and 3.375 g four times daily for an MIC of 16 mg/L. These findings clarify the peritoneal pharmacokinetics of PIP-TAZ, and help consider the dosing regimens for intraabdominal infections based on site-specific pharmacodynamic target attainment.

Review and proposal of regional surgical management for melanoma: revisiting of integumentectomy and incontinuity dissection in treatment of skin melanoma

BACKGROUND

Past studies showed that integumentectomy and incontinuity could be effective procedures in the surgical management of melanoma patients. The present study reports on the historical background of these procedures. In addition, we analyze the ICG assisted integumentectomy and incontinuity techniques and algorithms that we had created when performing this procedure.

METHOD

In accordance with our algorithm, we performed ICG assisted integumentectomy/incontinuity procedures on 17 patients with stage III melanomas between 2008 and 2016. We also investigated the locoregional recurrence rate in a control group comprising 60 patients at stage III without using the algorithm.

RESULTS

The former group exhibited a tendency of locoregional recurrence rate suppression. Melanoma cells in the dissected intervening tissue were microscopically identified in 2 out of 17 cases.

CONCLUSIONS

Our ICG assisted integumentectomy or incontinuity procedures could be effective in controlling locoregional recurrence rates in melanoma cases. Moreover, our method can be generally applied because the dissection is only performed within the lymphatic pathway region identified using indocyanine green.

Hand-assisted laparoscopic restorative proctocolectomy for ulcerative colitis

AIM

To evaluate the utility of hand-assisted laparoscopic restorative proctocolectomy (HALS-RP) compared with the conventional open procedure (OPEN-RP).

METHODS

Fifty-one patients who underwent restorative total proctocolectomy with rectal mucosectomy and ileal pouch anal anastomosis between January 2008 and July 2015 were retrospectively analyzed. Twenty-three patients in the HALS-RP group and twenty-four patients in the OPEN-RP group were compared. Four patients who had purely laparoscopic surgery were excluded. Restorative total proctocolectomy was performed with mucosectomy and a hand-sewn ileal-pouch-anal anastomosis. Preoperative comorbidities, intraoperative factors such as blood loss and operative time, postoperative complications, and postoperative course were compared between two groups.

RESULTS

Patients in both groups were matched with regards to patient age, gender, and American Society of Anesthesiologists score. There were no significant differences in extent of colitis, indications for surgery, preoperative comorbidities, and preoperative medications in the two groups. The median operative time for the HALS-RP group was 369 (320-420) min, slightly longer than the OPEN-RP group at 355 (318-421) min; this was not statistically significant. Blood loss was significantly less in HALS-RP [300 (230-402) mL] compared to OPEN-RP [512 (401-1162) mL, P = 0.003]. Anastomotic leakage was noted in 3 patients in the HALS-RP group and 2 patients in the OPEN-RP group (13% vs 8.3%, NS). The rates of other postoperative complications and the length of hospital stay were not different between the two groups.

CONCLUSION

HALS-RP can be performed with less blood loss and smaller skin incisions. This procedure is a feasible technique for total proctocolectomy for ulcerative colitis.

Treg-enriched CD4+ T cells attenuate collagen synthesis in keloid fibroblasts

Keloid is an inflammatory and fibrotic disease with an unknown pathogenesis. Regulatory T cells (Tregs) of CD4+ lineage can suppress other effector CD4+ T cells and modulate the immune response. A relative decrease in the number of Tregs may be involved in the pathogenesis of inflammatory and fibrotic diseases. We therefore investigated the number of Tregs in keloids using immunohistochemistry and examined the interaction between Tregs and keloid fibroblasts (KFs) using a coculture system. It was found that the ratio of Tregs/CD4+ T cells was lower compared with that in other common inflammatory skin conditions. In addition, Treg-enriched CD4+ T cells reduced collagen synthesis by KFs. Our findings suggest that a local imbalance of Tregs contributes to the development of keloids and that correction of this imbalance might represent a novel therapeutic approach to keloid fibrosis.

Important points for primary cleft palate repair for speech derived from speech outcome after three different types of palatoplasty

OBJECTIVE

This study was performed to investigate speech outcomes after three different types of palatoplasty for the same cleft type. The objective of this study was to investigate the surgical techniques that are essential for normal speech on the basis of each surgical characteristic.

METHODS

Thirty-eight consecutive nonsyndromic patients with unilateral complete cleft of the lip, alveolus, and palate were enrolled in this study. Speech outcomes, i.e., nasal emission, velopharyngeal insufficiency, and malarticulation after one-stage pushback (PB), one-stage modified Furlow (MF), or conventional two-stage MF palatoplasty, were evaluated at 4 (before intensive speech therapy) and 8 (after closure of oronasal fistula/unclosed hard palate) years of age.

RESULTS

Velopharyngeal insufficiency at 4 (and 8) years of age was present in 5.9% (0.0%), 0.0% (0.0%), and 10.0% (10.0%) of patients who underwent one-stage PB, one-stage MF, or two-stage MF palatoplasty, respectively. No significant differences in velopharyngeal function were found among these three groups at 4 and 8 years of age. Malarticulation at 4 years of age was found in 35.3%, 10.0%, and 63.6% of patients who underwent one-stage PB, one-stage MF, and two-stage MF palatoplasty, respectively. Malarticulation at 4 years of age was significantly related to the presence of a fistula/unclosed hard palate (P<0.01). One-stage MF palatoplasty that was not associated with postoperative oronasal fistula (ONF) showed significantly better results than two-stage MF (P<0.01). Although the incidences of malarticulation at 8 years of age were decreased in each group compared to at 4 years of age, the incidence was still high in patients treated with two-stage MF (45.5%). On the whole, there was a significant correlation between ONF/unclosed hard palate at 4 years of age and malarticulation at 8 years of age (P<0.05).

CONCLUSION

Appropriate muscle sling formation can compensate for a lack of retropositioning of the palate for adequate velopharyngeal closure. Early closure of the whole palate and the absence of a palatal fistula were confirmed to be essential for normal speech. To avoid fistula formation, multilayer repair of the whole palate may be critical.

Combination of Tessier clefts 3 and 4: case report of a rare anomaly with 12 years' follow-up

Tessier cleft types 3 and 4 are both rare craniofacial anomalies. Here we present the first case of a girl born with a combined anomaly of Tessier clefts 3 and 4 with severe bilateral cleft lip, a displaced premaxilla, and three-dimensional underdevelopment of the hard and soft tissues of the maxilla and zygoma. This type of rare facial cleft poses a major operative challenge. Over a period of years, presurgical alveolar molding with an active appliance was followed by seven operations. A satisfactory esthetic outcome was obtained. A multidisciplinary approach to treatment with a plastic surgeon in charge of the operations and an orthodontist in charge of the cleft deformity is essential.

A new uniform protocol of combined corticosteroid injections and ointment application reduces recurrence rates after surgical keloid/hypertrophic scar excision

BACKGROUND

Published reports indicate that corticosteroid injections can prevent recurrence after keloid excision, but the side effects of repetitive intralesional steroid injections may preclude treatment maintenance. Additionally, few of these studies employed a standardized treatment protocol.

OBJECTIVES

To analyze the results of a new uniform treatment protocol combining corticosteroid injections and ointment application designed to reduce recurrence rates after excisional surgery in individuals with keloids or hypertrophic scars.

METHODS

As a standard procedure, the first corticosteroid injection took place after removal of the sutures and then once every 2 weeks after that until it had been done five times. In addition, all postsurgical wounds received self-administered steroid ointment application twice daily for 6 months after suture removal.

RESULTS

Postoperative follow-up in this series ranged from 24 to 57 months (median 32 months, mean 32.5 months). Recurrence occurred in three of the 21 keloid cases (14.3%) and one of the six hypertrophic scar cases (16.7%).

CONCLUSION

We evaluated a new standardized adjuvant corticosteroid therapy to prevent recurrence after surgical keloid or hypertrophic scar excision. Using this method, we achieved low recurrence rates.

Early entry closure for acute type B aortic dissection by open stent grafting

PURPOSE

We describe the long-term efficacy of early entry closure for acute type B aortic dissection by open stent grafting based on long-term results and changes in the false lumen on enhanced computed tomography (CT).

METHODS

We performed open stent grafting for acute type B aortic dissection in 28 28 patients between 1998 a 2008. They included 14 patients with complicated type B aortic dissection (11 patients with limb and/or visceral ischemia and 4 patients with impending rupture). Uncomplicated type B aortic dissection was present in 14 patients, including 4 patients with an ulcer-like projection and 10 patients who had stable dissection with a patent false lumen.

RESULTS

Two patients who had the ischemic type died within 30 days. Postoperative complications occurred in two patients, including one case of paraplegia and one of mediastinitis. Two more deaths occurred during a median follow-up period of 45 months (range 6-114 months), with one related to open stent-graft infection and one due to pneumonia. The overall survival rate 5 years after open stent grafting was 77%. According to follow-up by CT, the false lumen was completely thrombosed and obliterated in all 26 patients with stent grafts.

CONCLUSION

Early entry closure for both complicated and uncomplicated acute type B aortic dissection with an open stent graft has an acceptable early outcome and provides a high aortic remodeling rate.

Sentinel node biopsy versus elective lymph node dissection in patients with cutaneous melanoma in a Japanese population

BACKGROUND

In Japan, elective lymph node dissection (ELND) has been the standard treatment for patients with possible nodal melanoma. Sentinel node biopsy (SNB) has now replaced ELND, not only in Japan but also worldwide. The objective of this study was to compare the interim outcomes of SNB and ELND.

METHODS

A retrospective study was conducted among patients with clinically node-negative disease treated at our institute with either SNB (n = 30) or ELND (n = 72).

RESULTS

The background was similar in the two groups. Nodal metastases were found in 40.0% of patients in the SNB group, but in only 26.4% in the ELND group (P = 0.173). The median follow-up was 31.5 months for the SNB group and 82 months for the ELND group. The incidence of locoregional recurrence and distant metastasis in the SNB group was 10.0% and 16.7%, respectively, and for the ELND group the incidence was 5.6% and 31.9%, respectively. The 3-year disease-free survival rate was similar in the two groups (P = 0.280), and the 3-year disease-free survival rates for node-positive patients were also similar in the two groups (P = 0.90), as were the 3-year disease-free survival rates for node-negative patients (P = 0.193).

CONCLUSION

This interim result in a Japanese melanoma population with clinically node-negative disease demonstrated that SNB identified more nodal micrometastases than ELND. This increase in accurate staging likely resulted from the reliable identification of the lymph node field by lymphoscintigraphy, as well as the more detailed pathologic examination of the nodes removed in SNB. It is quite reasonable to perform SNB instead of ELND in this population.

A method for the determination of the hepatic enzyme activity catalyzing bile acid acyl glucuronide formation by high-performance liquid chromatography with pulsed amperometric detection

A method for the determination of the activity of hepatic glucuronyltransferase catalyzing formation of bile acid 24-glucuronides using high-performance liquid chromatography (HPLC) with pulsed amperometric detection (PAD) has been developed. Bile acid 24-glucuronides were simultaneously separated on a semimicrobore column, Capcell Pak C18UG120, using 20 mM ammonium phosphate (pH 6.0)-acetonitrile (27:10 and 16:10) as the mobile phase in the stepwise gradient elution mode. A 1 M potassium hydroxide solution for the hydrolysis of the 24-glucuronides, which liberates the corresponding bile acids and glucuronic acid, was mixed with the mobile phase in a post-column mode, and the resulting eluant was heated at 90 degrees C, the 24-glucuronides being monitored using a pulsed amperometric detector; the limit of detection was 10 ng. The proposed method was applied to the determination of the hepatic enzyme activity catalyzing bile acid 24-glucuronide formation and the result exhibited the efficient 24-glucuronide formation of the monohydroxylated bile acid, lithocholic acid.

Separatory determination of diastereomeric ibuprofen glucuronides in human urine by liquid chromatography/electrospray ionization-mass spectrometry

A method for the separatory determination of diastereomeric isomers of glucuronic acid conjugates of ibuprofen having a carboxyl group at the chiral center by liquid chromatography (LC)/electrospray ionization (ESI)-mass spectrometry (MS) has been developed. The authentic specimens of acyl glucuronides of R(-)- and S(+)-ibuprofen were chemically synthesized by the Mitsunobu reaction. In the ESI mode, the glucuronides were characterized by an abundant quasi-molecular ion [M-H]-, and the formation of the negative ion was markedly influenced by a drift voltage. The resolution of diastereomeric isomers was achieved on a Develosil ODS-HG-5 column with 20 mM ammonium acetate (pH 5.0):acetonitrile (5:2, v/v) as a mobile phase where diastereomers were monitored with a corresponding quasi-molecular ion. After oral administration of racemic ibuprofen, a preferential excretion of (S)-ibuprofen glucuronide into the urine was observed.

Synthesis of bile acid 24-acyl glucuronides

The synthesis of acyl glucuronides of common bile acids is described. By means of the Mitsunobu reaction employing diethylazodicarboxylate and triphenylphosphine, bile acids were condensed through the inherent C-24 carboxy group with benzyl 2,3,4-tri-O-benzyl-D-glucopyranuronate, which was prepared from 1-O-methyl-alpha-D-glucose. The separation and purification of the beta-anomers at the anomeric position of the sugar moiety were attained by preparative thin-layer chromatography and/or high-performance liquid chromatography on a column packed with phenyl-bonded silica using H2O-MeOH as a mobile phase. The removal of the benzyl group on the sugar moiety was achieved by catalytic hydrogenation with 10% palladium on carbon to yield the desired acyl glucuronides of bile acids. The structures of these acyl glucuronides were confirmed by proton nuclear magnetic resonance spectral properties.

Separation and characterization of carboxyl-linked glucuronides of bile acids in incubation mixture of rat liver microsomes

The carboxyl-linked 24-glucuronides of common bile acids have been identified by means of liquid chromatography (LC)/atmospheric pressure chemical ionization (APCI)-mass spectrometry (MS) in an incubation mixture with a male Wistar rat liver microsomal fraction. The authentic specimens of bile acid 24-glucuronide acetate-methyl esters were synthesized unequivocally using the Mitsunobu reaction, and the APCI-mass spectrometric properties of these glucuronide derivatives were also characterized. After incubation of common unconjugated bile acids with hepatic microsomes, glucuronides were extracted and purified with a Sep-Pak C18 cartridge and lipophilic ion exchange gel, piperidino-hydroxypropyl Sephadex LH-20, and then derivatized into the acetate-methyl esters. Subsequent resolution into alpha- and beta-isomers at the glucuronosyl linkage was attained by LC on Cosmosil 5C8 and Sumichiral OA-2500 columns using 200 mM ammonium acetate (pH 7.0)-methanol (1:4, v/v), where 24-glucuronides were monitored with characteristic positive ions [M + NH4]+. The 24-glucuronides of lithocholic, chenodeoxycholic, deoxycholic, ursodeoxycholic and cholic acid were definitely characterized, in contrast to no formation of corresponding 3-glucuronides.

Separation and detection of bile acid 3-glucuronides in human urine by liquid chromatography/electrospray ionization-mass spectrometry

A method for the separation and detection of bile acid 3-glucuronides by liquid chromatography (LC)/electrospray ionization (ESI)-mass spectrometry (MS) has been developed. On the ESI mode, glucuronides were characterized by an intense pseudo-molecular ion [M-h]- with a doubly charged ion [M-2H]2-, and the ratio of these negative ions were markedly influenced by an acidic component of salt added to a mobile phase, according to a pKa value of an acidic moiety at C-24. Bile acid 3-glucuronides in human urine were extracted with a SepPak C18 cartridge, followed by purification on lipophylic ion exchange gel, piperidinohydroxypropyl Sephadex LH-20. Subsequent resolution into unconjugated, glycine and taurine conjugated bile acid 3-glucuronides was attained by LC on a Develosil ODS-HG-5 column using 20 mM ammonium acetate (pH 7.0)-methanol (10:12, v/v) as a mobile phase, where 3-glucuronides were monitored with a characteristic negative ion [M-H]-. The newly developed method was applied to the quantitatiation of bile acid 3-glucuronides in human urine with satisfactory sensitivity and reliability.

Immunoaffinity extraction for liquid chromatographic determination of equilin and its metabolites in plasma

Immunoaffinity extraction for the high-performance liquid chromatographic determination of equilin and its metabolites in plasma has been achieved. The antibody raised against an equilin 3-O-carboxymethyl ether-bovine serum albumin conjugate was characterized as having a high affinity for equilin and equilenin. One mL of the immunoaffinity adsorbent prepared by immobilization of an antibody was capable of retaining up to 1 microgram of equilin and equilenin, to 100 ng of other metabolites including 2-methoxylated and 17 beta-reduced compounds, and to 0.3 micrograms of glucuronic acid conjugates at C-3. The adsorbates were recovered qualitatively by elution with 90% aqueous (v/v) methanol without any interfering peaks on the chromatogram.

[Posterior proctomucosectomy and ileal pull-through reconstruction: a new restorative procedure after total proctocolectomy]

We reported a new method of restorative proctocolectomy using posterior approach and pull-through reconstruction. This method obviated transanal manipulation, a major factor causing damage to the internal sphincter, thus preventing fecal incontinence due to sphincter dysfunction. Also, temporary ileostomy was not necessary because the spout of an S-pouch was pulled down below the anal verge and its distal free end acted as a diverting stoma while the more proximal, healing zone (future anastomotic line) was kept from fecal contamination. This method was applied to a 32-year-old woman with familial polyposis coli and a 50-year-old woman with ulcerative colitis. Their bowel movements steadily decreased to three times and five times a day, respectively. There was no fecal leakage or perianal excoriation. The advantages as well as disadvantages of this method compared with the conventional techniques were discussed.

Different inhalation lethality between micron-sized and submicron-sized aerosols of organophosphorus insecticide, chlorfenvinphos, in rats

This study was designed to evaluate that a difference in the route of absorption or the mode of lethality is responsible for the higher inhalation lethality of micron-sized organophosphorus insecticide, chlorfenvinphos (CVP), aerosols than the submicron-sized aerosols. Male Fischer 344 rats were exposed to the micron-sized (> 1 micron) or the submicron-sized aerosols (< 1 micron) for 4 h using the nose-only exposure system. LC50 of the micron-sized and the submicron-sized aerosols was 0.13 mg/l and 0.51 mg/l, respectively. Placing a drain cannula in the esophagus markedly increased LC50 of the micron-sized aerosols to 0.49 mg/l, but not that of the submicron-sized aerosols. There was no qualitative difference in lethal profile in cardiorespiration between 2 types of aerosols. The higher lethality of the micron-sized aerosols could be ascribed to swallowed CVP.