Kensuke Tashiro

Navigation Lymphatic Supermicrosurgery for the Treatment of Cancer-Related Peripheral Lymphedema

Background: Lymphatic supermicrosurgery is becoming the treatment of choice for refractory lymphedema. Detection and anastomosis of functional lymphatic vessels are important for lymphatic supermicrosurgery. Methods Navigation lymphatic supermicrosurgery was performed using an operating microscope equipped with an integrated near-infrared illumination system (OPMI Pentero Infrared 800; Carl Zeiss, Oberkochen, Germany). Eight patients with extremity lymphedema who underwent navigation lymphatic supermicrosurgery were evaluated. Results: A total of 21 lymphaticovenular anastomoses were performed on 8 limbs through 14 skin incisions. Lymphatic vessels were enhanced by intraoperative microscopic indocyanine green (ICG) lymphography in 12 of the 14 skin incisions, which resulted in early dissection of lymphatic vessels. All anastomoses showed good anastomosis patency after completion of anastomoses. Postoperative extremity lymphedema index decreased in all limbs. Conclusions: Navigation lymphatic supermicrosurgery, in which lymphatic vessels are visualized with intraoperative microscopic ICG lymphography, allows a lymphatic supermicrosurgeon to find and dissect lymphatic vessels earlier and facilitates successful performance of lymphaticovenular anastomosis.

Normothermic preservation of the rat hind limb with artificial oxygen-carrying hemoglobin vesicles.

Background For managing major limb amputation, it is important to consider ischemic time and reperfusion injury by free radicals after the blood supply is reestablished. State of preservation during transplant surgery is crucial for the survival and function of the tissue, graft, or organ. In this study, we confirmed the effect of intermittent blood flow in rat ischemic hind limb and developed a new oxygenic preservation method using artificial oxygen carrying hemoglobin vesicles (HbVs). Methods We first compared a continuous ischemic model and an intermittent reflow model on rat hind limb. At postoperative day 7, hind limbs were evaluated. Next, we performed total amputation, normothermic preservation by perfusion with extracellular-trehalose-Kyoto (ETK) solution or HbV, and microsurgical replantation of the left hind limb. Venous efflux was analyzed, the amputated limb evaluated after 6 hr perfusion, and the replantation outcome of each model was compared. Results In our early study, 24 hr continuous ischemic model necrotized, but intermittent reflow model almost survived except for partial necrosis at postoperative day 7. Scar tissue on the right limb showed myonecrosis and infiltration of inflammatory cells. Skeletal muscle on the right limb was structurally well maintained. Hemoglobin vesicle–treated limbs appeared to have much better oxygenation than ETK-treated limbs. Aerobic respiration remained in the amputated limb, gastrocnemius muscle was well maintained, and the overall replantation was successful in the limb preserved using HbV. Conclusion These studies demonstrated that oxygenic preservation is effective for rat ischemic limb, suggesting that this method may be useful for other replantation and transplantation surgeries.

Locating recipient perforators for perforator-to-perforator anastomosis using color Doppler ultrasonography.

BACKGROUND The authors investigated the efficacy of color Doppler ultrasonography (US) to locate perforators prior to performing perforator-to-perforator anastomosis in free flap reconstruction. METHODS The authors examined 20 patients who had undergone free flap transfers between April 2013 and July 2014 at the Department of Plastic and Reconstructive Surgery, University of Tokyo Hospital. On the day before surgery, color Doppler US examination was performed to locate lower-extremity perforators. During surgery, the perforators were dissected, observed directly, and used for perforator-to-perforator anastomosis. RESULTS Perforator-to-perforator anastomosis was performed in 20 patients. The mean diameters of the perforators used in anastomosis were 0.69 mm in the anterolateral thigh lesion, 0.65 mm in the medial thigh lesion, 0.66 mm in the medial lower-extremity lesion, and 0.63 mm in the lateral lower leg lesion. Comparing preoperative data with the direct observation of perforators, no false-positive results were registered in the localization of the perforators. CONCLUSIONS By using color Doppler US as a preoperative examination technique, we can locate perforators in the lower extremity efficiently to perform perforator-to-perforator anastomosis, with shorter time, less invasiveness, lower cost, and no risk of radiation exposure.

Indocyanine Green Lymphographic Signs of Lymphatic Collateral Formation in Lower Extremity Lymphedema After Cancer Resection.

AbstractIndocyanine green lymphography has recently been used to assess lymphatic vessel function in lymphedema patients. Postoperative collateral lymphatic vessels toward ipsilateral axillary lymph nodes are rarely seen above the umbilical level in lower lymphedema patients. Between January 2012 and December 2014, we performed indocyanine green lymphography of 192 limbs in 96 lower extremity lymphedema cases. As a result, dermal back flow appeared in 95 cases, with 38 in the lower abdominal area and 31 in the genital area. We confirmed 3 cases of superficial lymphatic collateral ways extending above the umbilical level to the axillary lymph nodes. All 3 cases had similarity in lower abdominal edema, so excessive lymphatic fluid in the lower abdomen was assumed to be the cause. Lymphatic collateral ways from abdomen to axillary lymph nodes in this study was likely to be designed to prevent the progress of lymphedema.

Anorectal autotransplantation in a canine model: the first successful report in the short term with the non-laparotomy approach

Colostomy is conventional treatment for anal dysfunction. Recently, a few trials of anorectal transplantation in animals have been published as a potential alternative to colostomies; however, further development of this technique is required. In this study, we utilized a canine model of anorectal transplantation, evaluated the patency of our microsurgical anastomoses, and assessed the perfusion of the transplanted anus. We designed a canine anorectal transplantation model, wherein anorectal autotransplantation was performed in four healthy beagle dogs by anastomoses of the lower rectum, the bilateral pudendal arteries (PAs) and veins (PVs), and pudendal nerves (PNs). Postoperative graft perfusion was measured by indocyanine green (ICG) angiography and histological examination. The length of the anorectal graft including perianal skin, anal sphincter muscle, bilateral PAs, PVs, and PNs was 4.9 ± 0.3 cm. All diameters of the PAs, PVs, and PNs were large enough to be microscopically anastomosed. Both ICG angiography and histological examination demonstrated good graft perfusion, except for one case that lead to venous congestion. These results show that anastomosis of the bilateral PAs, PVs, and PNs is required for anorectal transplantation. This is the first successful report of canine anorectal autotransplantation.

Anorectal Transplantation in Human Cadavers: Mock Anorectal Allotransplantation

Background Anorectal transplantation is a method for patients who have lost their anorectal function or suffer from congenital anorectal dysfunction to recover this function, and this has been investigated in experimental animal models using pigs, dogs, and rats. In this study, we performed an examination of anorectal transplantation in human cadavers to investigate whether this procedure could be performed in patients. Methods A 77-year-old woman cadaver 1 was used as the donor and a 98-year-old woman cadaver 2 was used as the recipient. Initially, abdominoperineal excision of the anus and rectum (the Miles’ operation) was performed on the recipient. Next, an anorectal graft containing the pudendal nerve (PN), pudendal artery (PA), pudendal vein (PV), inferior mesenteric artery (IMA), and inferior mesenteric vein (IMV) was harvested from the donor. The donor graft was transplanted into the recipient by intestinal anastomosis and microneurovascular anastomoses orthotopically. Results The diameters of the PN (right/left), IMA, and IMV were 2.5 mm/2.5 mm, 2.0 mm, and 1.5 mm, respectively, in cadaver 1, and 2.0 mm/2.0 mm, 2.0 mm, and 2.0 mm, respectively, in cadaver 2. The length of the PN, PA, PV, IMA, and IMV in the graft was sufficient to allow proper anastomosis. Conclusion This preliminary study indicated that human anorectal transplantation was possible anatomically and technically. We anticipate our study will aid in the potential future application of this procedure to human patients.

Pathological changes of adipose tissue in secondary lymphedema

The pathophysiology of lymphoedema is poorly understood. Current treatment options include compression therapy, resection, liposuction and lymphatic microsurgery, but determining the optimal treatment approach for each patient remains challenging.

Reconstruction of a full‐thickness, complex nasal defect that includes the nasal septum using a free, thin superficial inferior epigastric artery flap

Complex nasal defects present a surgical challenge, particularly in cases with a full‐thickness defect that extends into the nasal septum. Although the superficial inferior epigastric artery (SIEA) flap has been widely used as a bulky flap for soft tissue augmentation, reports on its use as a thin flap are limited. We present a case of complex nasal defect reconstruction using a free, thin SIEA flap. A 65‐year‐old man with a recurrent malignant peripheral nerve sheath tumor around the left nose and cheek underwent wide tumor resection, leaving a full‐thickness nasal defect that included portions of the nasal septum, nasal bone, and maxilla. A free, thin SIEA flap was elevated and primarily thinned by microdissecting the pedicle distally. The flap was then folded and inset to close the nasal septum and skin. The flap survived completely and complete closure of the nasal septum was observed. As the SIEA runs toward superficial layers as it is traced distally, primary thinning of the flap is possible. We believe that this method may represent an alternative to the superficial circumflex iliac artery perforator flap in cases in which the superficial circumflex iliac artery system is hypoplastic.

Preoperative color Doppler ultrasound assessment of the lateral thoracic artery perforator flap and its branching pattern

The anatomy of the lateral thoracic artery perforator flap remains controversial, but this region is extremely useful as a reconstructive donor site. In this report, we describe the usefulness of the preoperative color Doppler ultrasound evaluation for the harvesting of the lateral thoracic artery perforator flap, and we clarify its branching pattern. Twenty-seven patients underwent the preoperative color Doppler ultrasound assessment before perforator flaps were harvested. We evaluated the branching pattern and the diameter of the flaps by direct observation. All flaps were successfully transferred, and it was found that the branching pattern of the lateral thoracic perforator is divided into three groups: the superficial branch, the medial branch, and the deep branch. Their appearance ratios were 48.1% (13/27), 14.8% (4/27), and 81.5% (22/27), respectively. The lateral thoracic artery perforator flap has a great deal of anatomical variation, and vessels with relatively small diameters compared to those of other flaps. This is why flaps from this region are not currently popular. This study revealed the superiority of the color Doppler ultrasound for preoperative planning of the lateral thoracic artery perforator flap elevation. Furthermore, the branching pattern and the diameters of the different branches were specified.

Visualization of Accessory Lymphatic Pathways in Secondary Upper Extremity Lymphedema Using Indocyanine Green Lymphography

Introduction The anatomical variations in accessory lymphatic pathways around the axillary region may work as a drainage route for excess lymphatic fluid accumulation in secondary upper extremity lymphedema. In this report, accessory lymphatic pathways extending to the shoulder, neck, and breast regions in secondary upper extremity lymphedema patients are shown using indocyanine green (ICG) lymphography. Patients and Methods Between January 2012 and May 2015, 30 limbs of 29 patients with upper extremity lymphedema after malignant tumor resection were evaluated. ICG lymphography was performed after chronic lymphedema formation. Results Of the 30 limbs, accessory lymphatic pathways were identified across the axillary region in 3 patients using ICG lymphography. In 2 of these 3 patients, accessory drainage lymphatics were connected to the cervical lymph nodes. In regard to the distribution of dermal backflow patterns, dermal backflow appeared in 26 patients—in the forearm in 26 patients and in the upper arm in 20 patients. Conclusions Accessory lymphatic pathways are thought to be the drainage routes in the affected arm, which may prevent edema progression to the terminal stage. Variations in the lymphatic system are easily visualized using ICG lymphography. Understanding of accessory lymphatic routes in lymphedema patients may provide new insight for further understanding the pathophysiology of lymphedema.