Hideo Nameki

Surgical results of skull base surgery for the treatment of head and neck malignancies involving skull base: multi-institutional studies on 143 cases in Japan

We analyzed 143 cases of skull base surgery collected from the eight institutions of the Study Group supported by the Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare of Japan. Histologically, the most common type was squamous cell carcinoma (n = 78), which was followed by olfactory neuroblastoma (n = 16) and adenoid cystic carcinoma (n = 16). The most frequent surgical approach was frontal craniotomy (n = 66), followed by front-temporal craniotomy (n = 54) and infratemporal fossa approach (n = 8). For repair of dura matter, fascia lata was used in 37 cases. galeopericranial flap in 35 and temporal muscle fascia in 16. The 5-year survival rate by Kaplan-Meier method of nose and paranasal sinus carcinoma (n = 119) was 48%. As for histological classification, the survival rates were both 65%) in adenoid cystic carcinoma (n = 12) and bone soft tissue malignancy (n = 10), 62% in olfactory neuroblastoma (n = 16), 46% in squamous cell carcinoma (n = 62) and 33% in adenocarcinoma (n = 11). All the three cases of malignant melanoma died within 1 year, so we considered skull base surgery to be contraindicated for this disease. Complications were observed in 62 out of the 143 cases (43%); local infection was most frequent in 29 cases. liquorrhea in 18, abscess in 16, necrosis of the flap and meningitis in ten cases, DIC in four, rupture of the internal carotid artery in two and cerebral thrombosis in one. Death caused directly by surgery was in ten cases (7%). It is important that a multi-center registry be maintained to have a large enough database for comparison of results, and prognosis for each histological entity and further define the role of multidisciplinary treatment.

Selective reconstructive options for the anterior skull base.

Carcinomas of the ethmoid, frontal, or maxillary sinuses sometimes invade the anterior skull base. It is necessary to perform en-bloc resection for this invasive carcinoma according to the concepts of surgical treatment for head and neck cancer. The anterior skull base consists of two parts, the orbital roof as the lateral portion and the roofs of the frontal sinus, ethmoid sinus, and/or sphenoid sinus as the central portion. Selective reconstructive options for the anterior skull base depend on the size of the defect of the skull base. A dural defect is repaired by a fascia lata or a pericranial flap. After the dura has been tacked up, reconstruction of the anterior skull base is performed simultaneously with augmentation of the defect of extracranial structures. Larger defects that consist of both central and lateral portions with orbitomaxillary structures are reconstructed by a bulky musculocutaneous flap such as a rectus abdominis or latissimus dorsi flap. The bony reconstruction of supraorbital structures is also to be considered esthetically. On the other hand, intraorbital tissues are basically preserved in cases of central defects of the anterior skull base. These defects are reconstructed by a free forearm flap or a local flap such as a de-epithelialized midline forehead flap or a pericranial flap. We have selected and applied these flaps in 37 patients as reconstructive options for the anterior skull base since 1989. Eleven of the 37 patients had larger defects and 26 had central defects. De-epithelialized midline forehead flaps were used in 20 patients and were recognized to be a very useful and reliable reconstructive option for central defects of the anterior skull base.

Intramucosal PCO2 measurement as a new monitoring method of free jejunal transfer following pharyngo-laryngo-esophagectomy.

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.

Transoral closure of pharyngeal perforation caused by gastrointestinal endoscopy

OBJECTIVE We present a case of pharyngeal perforation caused by gastrointestinal endoscopy that was successfully repaired with transoral mucosal sutures. This is the first report of a transoral surgical closure of a perforation caused by an endoscope. We describe the repair procedure, the necessary equipment, and the effectiveness of suturing pharyngeal perforations. PATIENT An 87-year-old woman brought to our emergency department by ambulance because of hematemesis and endoscopic hemostasis was successfully performed. But after hemostasis, CT scan showed emphysema extending from the right lower jaw to the superior mediastinum and pharyngeal perforation was observed by laryngeal fiberscope. INTERVENTION Even though she had received conservative treatment, exacerbation of inflammation was observed and therefore we performed transoral surgery for closing the pharyngeal perforation. MAIN OUTCOME MEASURE We followed up with CT scans, blood test and vital signs. RESULTS The pharyngeal perforation smoothly closed and exacerbation of inflammation was not observed, even after oral ingestion began. CONCLUSION Transoral closure of a pharyngeal perforation is less invasive and performing this procedure at an early stage can lead to a favorable outcome.

Use of vertical median forehead flap in the reconstruction of the anterior skull base: Report of two cases

Improvements in reconstruction of the skull base have made craniofacial surgery safe. Reconstruction of the anterior skull base must provide a seal between the cranial cavity and upper respiratory tract, as well as offer structural support for the brain. A wide variety of local flaps have been designed. The choice of flap in individual cases depends on the location and size of the defect. We report a reconstructive technique for the anterior skull base with vertical median forehead flaps which we used to treat two patients, one patient with adenocarcinoma and the other with leiomyosarcoma. Both were lesions of the ethmoid sinuses and nasal cavity.

Pico2 Monitoring of Transferred Jejunum Perfusion Using an Air Tonometry Technique After Hypopharyngeal Cancer Surgery

AbstractThis study aimed to investigate the usefulness of intraluminal PCO2 (PiCO2) monitoring by air tonometry for the assessment of the vascular condition of the transferred jejunum after surgery for hypopharyngeal cancer.PiCO2 in the transplanted jejunum of 24 patients was monitored using air tonometry after radical surgery for hypopharyngeal cancer from 2003 to 2010.All but 1 patient, who removed the catheter before monitoring began, were monitored safely. PiCO2 in the transferred jejunum correlated with arterial PCO2 (PaCO2) that was measured concurrently, and dissociation of PiCO2 from PaCO2 was observed in cases with vascular complication. In those cases without postoperative vascular complication, the PiCO2 value gradually increased for 3 hours but then decreased by 12 hours after surgery. Three patients experienced major vascular complication. All 3 patients had continuous elevation of PiCO2 >100 mm Hg, although vascular flow in 1 patient recovered by removal of a venous thrombosis and reanastomosis of the vein 7.5 hours after surgery. Four other patients who experienced elevation of PiCO2 had their skin suture released for decompression of their neck wound, resulting in a decrease in PiCO2 after treatment.The current results demonstrated that continuous monitoring of PiCO2 by air tonometry accurately reflects the vascular condition of the transferred jejunum, and this method is one of the best options for postoperative monitoring of jejunum blood perfusion.

Clinical study on prognostic factors of recurrence in thyroid carcinoma

We treated 137 patients with well-differentiated thyroid carcinoma at our hospital from 2002 to 2012. This paper clarifies the high-risk group based on prognostic factors of recurrence. The 5-year survival rate for patients with thyroid carcinoma was 94.9%. Recurrence occurred in 25 cases (18.2%). The factors of patient’s age and sex were not related to recurrence. The factors of disease, vein invasion, extracapsular spread and lymph node metastasis for D2 area made significant independent contributions. We must determine the course of treatment of patients with prognostic factors of recurrence carefully. We also need to follow the patients carefully, such as a CT scan every six months and ultrasound every three months.

SKULL BASE SURGERY FOR MAXILLARY CANCER

各頭蓋底に浸潤した上顎癌の一塊切除と再建の術式をビデオで供覧し, 頭蓋底外科を導入した上顎癌の外科的治療において, その成績を向上させるポイントについて述べた. その第一は, 前および中頭蓋底に浸潤したT4の癌を原発部位とともに一塊として根治切除すること, 第二はそれにともなう硬膜, 頭蓋底, および顔面組織 (軟部組織と硬組織) の欠損によって生じたQOLの低下を改善するために, 硬膜と頭蓋底・顔面の再建を安全に行うこと, 第三は頭蓋内外の交通を完全に遮断して頭蓋内合併症の発生を予防することであり, 第四は上顎癌とりわけ頭蓋底への上顎進行癌の治療成績の向上のためには耳鼻咽喉科, 脳外科, 形成外科によるチームサージャリーが有効に機能することである。

INDICATIONS AND LIMITATIONS OF EN BLOC RESECTION OF SKULL BASE FOR NASAL AND PARANASAL SINUS CARCINOMA

頭蓋底とくに前頭蓋底および/あるいは中頭蓋底に浸潤した鼻副鼻腔癌に対しての, 頭蓋底と顔面組織を一塊として切除する術式 (とくに前中頭蓋底一塊切除術式) の適応と限界について述べた. 一塊切除が可能か否かを規定する条件としては, 1. 癌の頭蓋底への進展範囲2. 癌の組織型3. 術野の展開の程度4. 手術手技上の限界点5. 患者の背景因子 (年齢, 糖尿病, 高血圧, 動脈硬化など) 6. 腫瘍の切除度と予後およびQOL, などが挙げられる。視力というQOLを考慮した上での前・中頭蓋底合併切除の最大切除範囲は, 一塊切除という条件を付けると, 患側中頭蓋底の卵円孔を通り, 蝶形骨体部の一部から前頭蓋底の蝶形骨平面を抜けて, 健側篩骨洞天蓋の外側縁に至る骨切り線に囲まれた範囲になる。この前中頭蓋底の骨切り範囲には, 副鼻腔癌の後方への浸潤破壊が最も多く見られる翼状突起根部, 正円孔, および上眼窩裂が含まれているということが最も重要な点である。前頭蓋底切除術の適応と限界は前後方向では蝶形骨平面が切除の後方限界であるので, これより後方に癌が進展していた場合は前中頭蓋底一塊切除の適応となる。また, 左右方向の浸潤では両側の篩骨洞天蓋と眼窩内側壁を切除し得るが, 両側失明をきたす場合は術後のQOLの点で問題が残る。一方, 前中頭蓋底切除術の成績からみた適応と限界については卵円孔, 蝶形骨体, 斜台から後方および正中側に癌の強い浸潤を認める症例では, 多くの例が死亡していることから, この部位が手技的には一塊切除が可能でも, 扁平上皮癌でこれらの部位に浸潤している症例では, すでに広範囲の硬膜表面や深く硬膜内にも浸潤している症例が多くあることを示している。これらの切除限界を理解したうえで臨床症状と画像診断から症例を選べば, 頭蓋底手術の成績は向上することが期待できる。