Kenichi Kamizono

Mandible preserving pull-through oropharyngectomy for advanced oropharyngeal cancer: A pilot study

OBJECTIVE Through our experiences in the parapharyngeal space (PPS) surgery, we have learned that it is possible to gain wide exposure of the PPS near to the skull base with a transcervical approach alone. Thus, we presumed that if this type of transcervical approach would be combined with a transoral approach, a less invasive oropharyngectomy without mandibulotomy and lip-splitting might be feasible for the resection of advanced oropharyngeal cancer, sparing the morbidities associated with conventional mandibular swing approach or its modified procedures. We termed this method as a mandible preserving pull-through oropharyngectomy (MPPO) and evaluated its feasibility and efficacy in this pilot study. MATERIALS AND METHODS MPPO was applied for a series of 7 patients with advanced lateral and/or upper oropharyngeal cancer including 2 patients with T4 stage. Our current application of MPPO excludes tumors, which involves mandibular bone, the higher part of the medial pterygoid muscle, and the lateral pterygoid muscle. RESULTS Safe and sufficient excision of tumors was feasible by MPPO avoiding morbidities associated with mandibulotomy or lip-splitting without compromising oncological outcomes. CONCLUSIONS Although preliminary, our favorable outcomes indicate that MPPO might be a useful alternative to conventional mandibular swing approach or its modified procedures for selected cases with advanced oropharyngeal cancer. Further accumulation of data is encouraged.

A minimally invasive method to prevent postlaryngectomy major pharyngocutaneous fistula using infrahyoid myofascial flap

INTRODUCTION To prevent postoperative pharyngocutaneous fistula (PCF) after total (pharyngo)laryngectomy, simultaneous coverage of pharyngeal anastomosis with vascularised flaps such as pectoralis major muscle, anterolateral thigh or radial forearm, has been reported to be effective. As an alternative to the invasive methods using distant flaps, we used the infrahyoid myofascial flap (IHMFF), which was harvested from the same operation field of (pharyngo)laryngectomy, for covering the site of pharyngeal anastomosis. Herein, we describe the safety and effectiveness of our minimally invasive method for preventing PCF. METHODS Eleven patients who were at a high risk of developing PCF due to previous chemoradiotherapy underwent simultaneous coverage of pharyngeal anastomosis with IHMFF after total (pharyngo)laryngectomy. The incidence of PCF and the rate of major fistula requiring surgical closure were determined, and the results were compared with the control group (23 patients without IHMFF cover after laryngectomy). RESULTS PCF developed in 2 of the 11 patients (18.2%). The fistulae of these two patients were closed conservatively and did not require additional surgery. PCF developed in 6 of 23 patients (26.1%) in patients without IHMFF cover. All the six patients with fistula required additional closure surgery. The incidence of PCF did not differ in patients with or without IHMFF cover (Fishers exact probability test; p=0.939, NS). However, the rate of major PCF requiring surgical closure was significantly lower in patients with IHMFF cover (Fishers exact probability test; p=0.036<0.05). CONCLUSIONS For (pharyngo)laryngectomy patients, IHMFF cover is a minimally invasive method that can prevent major PCF.

Tracheal reconstruction with a modified infrahyoid myocutaneous flap

Reconstruction of a tracheal defect is a challenge because it often requires invasive surgery associated with relatively high morbidity. We recently invented a less‐invasive method using a modified infrahyoid myocutaneous (IHMC) flap for the reconstruction of a tracheal defect in an 83‐year‐old male. A tracheal defect, the right half of the cricoid cartilage plus the right three quarters of the I‐IV tracheal cartilage (about 3 × 4 cm), was reconstructed with a modified IHMC flap composed of the sternohyoid and platysma muscles and a skin pedicle. Considering the age of patient, we avoided rigid reconstruction and used a soft silicone tracheal opening retainer (Koken Co., Ltd., Tokyo, Japan) as an anterior wall dilator after surgery and waited for the scarring of the flap until it become rigid enough. The postoperative course was uneventful and the trachea was reconstructed safely. Tracheal reconstruction with an IHMC flap is a useful and less‐invasive alternative compared to end‐to‐end anastomosis or reconstruction with a forearm flap, which is currently used as a mainstay.

Microsurgical free flap transfer in previously irradiated and operated necks: Feasibility and safety

OBJECTIVES Microsurgery is difficult to perform in necks that have been previously irradiated and operated upon because of the limited availability of recipient vessels. The objective of this study was to clarify the feasibility and safety of performing microsurgery in necks that are scarred and fibrous owing to previous treatment. METHODS Twenty patients whose necks were previously irradiated and operated upon and who underwent free tissue transfer were included in this study. All patients had been previously administered an average of 60.7 (range, 30-95)Gy of radiotherapy. Thirteen patients had undergone hemilateral neck dissections, 5 patients had undergone bilateral neck dissections, 8 patients had undergone (pharyngo)laryngectomies, and 10 patients had undergone prior flap transfer. The success rate of microsurgery and the selection of recipient vessels were examined. RESULTS All recipient vessels could be adopted in the neck field without vessel grafting. One patient developed necrosis of the flap, which was salvaged with retransfer of another flap after trimming the same cervical vessels. For the remaining 19 patients, free tissue transfers were successful. CONCLUSIONS Suitable recipient vessels are residual and available even in the previously irradiated and operated neck field. When performed properly, free tissue transfer in the previously treated neck is not as risky a surgery as was generally believed.

Roles of Therapeutic Selective Neck Dissection in Multidisciplinary Treatment

In the treatment of head and neck squamous cell carcinoma (HNSCC), management of cervical lymph nodal metastases has a crucial impact on the prognosis of patients. The “radical neck dissection (RND)”, which was proposed by Crile (Crile, 1906) in 1906, had long been played a role of standard treatment for neck metastases due to its high curability. However, during the last two to three decades, modified neck dissection (MND), also called as “functional neck dissection”, which preserves non-lymphatic structures, has replaced the position of RND, because patients as well as surgeons have become more aware of the significance of the quality of life. In addition, it has become apparent that under current multimodality treatment protocols, MND can achieve improved functional results without compromising oncological outcomes, compared to the conventional RND (Ferlito et al., 2003). Of note, in this study, MND implies the comprehensive (I-V) ND that is generally termed as “modified radical neck dissection (MRND)”, unless described otherwise. Moreover, the detailed studies on the patterns of potential neck metastases clearly demonstrated that the laryngeal and pharyngeal cancers seldom metastasize to the level I and V, while the oral cavity cancers to the level IV and V (Lindberg, 1972; Shah, 1990). These data have strongly encouraged the application of selective neck dissection (SND) that spares the dissection of at least one level in the treatment of clinically N0 neck as “elective” SND (ESND). It is now widely accepted that ESND can achieve similar regional control rates compared to comprehensive neck dissection (CND) (i.e., RND or MRND) in this N0 clinical setting with improved functional outcomes as summarized in a comprehensive review (Ferlito et al., 2006). Recent remarkable advancements in chemoradiation have further extended the application of SND to clinically N+ cases as “therapeutic” SND (TSND) instead of therapeutic CND (TCND). Efficacy of TSND performed either as an initial treatment or as a planed ND (PND) in the course of multidisciplinary treatments has been reported by an increasing number of studies (Ambrosch et al., 2001; Byers et al., 1999; Ferlito et al., 2009; Lohuis et al., 2004; Muzaffar, 2003; Patel et al., 2008; Shepard et al., 2010). Moreover, a recent study by Robins et. al., (Robbins et al., 2005) demonstrated that super selective (i.e., only two levels) neck dissection can achieve quite favorable outcomes, when performed as a PND after RADPLAT. In view of these observations, neck dissection (ND)

Flow-through divided latissimus dorsi musculocutaneous flap for large extremity defects

AbstractReconstructing large defects of the extremities is a challenging problem for reconstructive microsurgeons. The latissimus dorsi musculocutaneous flap (LDMCF) is widely used for this purpose, but a skin graft is needed when the defect is wider than available flaps. We used flow-through divided LDMCFs to reconstruct large defects of the extremities in 5 consecutive patients from 2010 through 2012. The semicircular skin island was split longitudinally, and 1 skin island was advanced over the other to close a round or oval defect without a skin graft. Postoperatively, all flaps survived completely, and the mean Enneking score was 90.0%. The flow-through divided LDMCF is a reliable and versatile option for reconstructing large defects of the extremities.

Selective epithelial ischemia of transferred free jejunum after late loss of its vascular pedicle

Free flaps are considered to revascularize from the surrounding tissue and survive without their original pedicle flow after a certain period postoperatively. We report 2 patients who developed mucosal ischemia of the transferred jejunum by ligation of its vascular pedicle 10 and 25 months after microvascular free jejunal transfer. Both patients had a history of heavy smoking, and had undergone definitive radiotherapy and previous surgery to the recipient bed. Both were treated conservatively; however, a stenotic change of the transferred jejunum remained in 1 patient. If poorly revascularized flaps, such as jejunal flaps, were transferred to the irradiated and scarred recipient bed, revascularization might never reach completion. If pedicle division is required in such cases, reanastomosis of the pedicle would be ideal regardless of the time after the transfer.

Successful treatment of severe facial lymphedema by lymphovenous anastomosis

BACKGROUND Facial edema is a common complication after neck dissection and/or chemoradiotherapy for head and neck cancer. Edema subsides spontaneously in most cases but sometimes persists, in which case surgical intervention is required. We report a case of severe facial edema that showed significant improvement upon lymphovenous anastomosis (LVA). METHODS A 66-year-old man with oral floor cancer developed progressive facial lymphedema after tumor resection, bilateral neck dissections, chemoradiotherapy, and fibular and rectus abdominis musculocutaneous flap transfer. His eyesight was completely disturbed due to severe eyelid edema. The LVAs were performed in the bilateral preauricular area. Surgical findings showed stagnation of the lymphatic fluids in dilated lymphatic vessels, which were drained to the superficial temporal veins by LVA. RESULTS The edema subsided rapidly and the patients eyesight returned as soon as 4 days postoperatively. CONCLUSION Using LVA in the preauricular region can be a choice of surgical treatment for severe facial edema.

A useful approach for making the correct diagnosis of mucosal melanoma

Abstract Oral macule and mucosal melanoma are often difficult to differentiate from each other, and a conclusive diagnosis of mucosal melanoma is difficult to make, either clinically or pathologically, in younger adults. We report the case of a 26-year-old female who presented with a black pigmented lesion of the left upper gingiva. The lesion was finally diagnosed as a mucosal melanoma 10 months after the patient’s first visit to a hospital. She received partial left maxillectomy. She has been alive without active disease for 3 years after first operation. Considering that in general, subepithelial invasion is seen even from the early phase in cases of mucosal melanoma, prompt and precise pathological diagnosis is necessary to ensure appropriate therapy.