Motone Kuriyama

Comparison of Vascularized Supraclavicular Lymph Node Transfer and Lymphaticovenular Anastomosis for Advanced Stage Lower Extremity Lymphedema

BackgroundVascularized lymph node transfer has become a popular surgical option to improve lower extremity lymphedema (LEL), although potential donor sites are limited. The free supraclavicular flap with deep cervical lymph nodes has been recently associated with a minimal risk of secondary lymphedema caused by donor site dissection. However, the effectiveness of this procedure has not yet been evaluated. MethodsVascularized supraclavicular lymph node transfer (VSLNT) was performed for patients with International Society of Lymphology late stage II or more severe LEL. The results were compared with lymphaticovenular anastomosis (LVA) performed for patients with the same stages of severity. To evaluate improvement in lymphatic function, indocyanine green lymphography and lymphoscintigraphy were performed. ResultsVascularized supraclavicular lymph node transfer was performed in 13 limbs of 13 patients. The results were compared with 43 limbs of 33 patients who underwent multiple LVA. No severe complications were observed in either group. Improvement in lymphatic function, as measured by the LEL index, was 26.5 ± 4.4 and 21.2 ± 2.0 in the VSLNT and LVA groups, respectively. Lymphatic function was improved in 7 cases in the VSLNT group and 10 cases in the LVA group. ConclusionsVascularized supraclavicular lymph node transfer is an effective technique for the treatment of advanced stage LEL. Lymphaticovenular anastomosis is also effective, but to a lesser degree than VSLNT. However, LVA is less invasive and requires a shorter hospital stay.

DNA Methylation Changes During Cleft Palate Formation Induced by Retinoic Acid in Mice

Objectives: The aim of this study was to analyze epigenetic (specifically, DNA methylation) participation in the mechanisms of cleft palate only induced by maternal exposure to all-trans retinoic acid in mice. Design: Cleft palate only was induced in fetuses by maternal exposure to all-trans retinoic acid. Their secondary palates were excised for analysis. Cytosine extension assay and restriction landmark genomic scanning were performed to analyze DNA methylation status. The expression levels of the DNA methyltransferases were examined by real-time reverse transcriptase–polymerase chain reaction. Results: Using cytosine extension assay, on gestation day 14.5, the status of DNA methylation within CpG islands and in global DNA was decreased significantly in all-trans retinoic acid–treated groups compared with the controls (p < .01 and p < .05). In the controls, the status within CpG islands on gestation day 14.5 was significantly increased compared with gestation days 13.5 and 18.5 (p < .01). Using real-time reverse transcriptase–polymerase chain reaction, there was no significant change in the expression of DNA methyltransferases, except on gestation day 18.5. Using restriction landmark genomic scanning on gestation day 18.5, five spots (0.49%) in the controls and one spot (0.1%) in all-trans retinoic acid–treated groups were specifically detected. Conclusions: These results indicate that changes in DNA methylation may play an important role in the manifestation of cleft palate only caused by environmental factors such as maternal exposure to all-trans retinoic acid.

Suitable therapy options for sub-clinical and early-stage lymphoedema patients

BACKGROUND The best therapeutic approach for patients with sub-clinical lymphoedema and symptomatic early-stage lymphoedema has not been determined yet. METHODS The prognosis of lymphatic function after lymphadenectomy for gynaecological cancer was observed in a cohort study of 192 lower limbs. Lymphatic function was evaluated by indocyanine green lymphography. Splash patterns were examined to determine if patients with this pattern tended to progress to symptomatic lymphoedema, and the efficacy of the compression therapy was also investigated. We also investigated the efficacy of lymphaticovenular anastomosis (LVA) in patients who exhibited a stardust pattern. RESULTS Patients with splash patterns on lymphography may progress to symptomatic lymphoedema with a significantly higher frequency compared with the others, with a relative ratio of 1.62. Compression therapy did not slow the progression of patients with splash patterns to stardust patterns. LVA for the patients who had recently shown stardust patterns eliminated the need for compression therapy in 44.8% of patients. CONCLUSION Patients with splash patterns should be followed up carefully for sub-clinical lymphoedema. However, there is no method to completely prevent these patients from developing stardust patterns associated with symptomatic lymphoedema. When patients become symptomatic, their lymphatic function may be improved by LVA. However, the limited effectiveness of this procedure should be clearly explained to patients before surgery.

Tessier number 7 cleft with oblique clefts of bilateral soft palates and rare symmetric structure of zygomatic arch

Craniofacial clefts are very rare congenital deformities. Tessiers numbering classification is a simple system universally accepted. Excluding cleft lip and palate, the transverse or lateral cleft (Tessier number 7) is the most common type of craniofacial cleft, manifesting macrostomia without skeletal abnormalities. We present a case of Tessier number 7 cleft with oblique clefting of the soft palate bilaterally and rare symmetric structures of the zygomatic arch.

External valvuloplasty for subcutaneous small veins to prevent venous reflux in lymphaticovenular anastomosis for lower extremity lymphedema.

Background: Subcutaneous ecchymosis caused by venous reflux is a preventable complication following lymphaticovenular anastomosis. The authors developed a series of operative procedures to prevent venous reflux. This is probably the first report on valvuloplasty for small subcutaneous veins (diameter, <1 mm). Methods: A total of 165 anastomoses in 39 limbs were operated on using this novel procedure (study group). Extended vein dissection was performed to ensure inclusion of some venous valves. Venous regurgitation was assessed using a retrograde milking test. When regurgitation was observed at all peripheral branches, external valvuloplasty was performed at the small subcutaneous vein to prevent backflow. The rate of venous reflux was compared with 151 anastomoses in 34 limbs operated on using conventional procedures (control group). Moreover, the amount of volume reduction was compared between the patients with and without venous reflux. Results: In the study group, the rate of regurgitation was reduced (3.0 percent) by extended vein dissection compared with that in the control group (9.9 percent), whereas the regurgitation ceased completely following external valvuloplasty (0 percent). In addition, postoperative ecchymosis was prevented completely in the study group (8.8 percent in the control group). Perioperative improvement in the lower extremity lymphedema index was significantly different between the patients with and without venous reflux (with venous reflux, 0.0706 ± 0.0742; without venous reflux, 0.0904 ± 0.0614). Conclusions: The authors’ results suggest that these operative procedures could be highly effective in preventing venous reflux. Moreover, venous reflux, if not corrected, leads to worsening of the results. Excellent results were consistently achieved by preventing venous reflux. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Regional Oxygen Saturation Index: A Novel Criterion for Free Flap Assessment Using Tissue Oximetry.

Background: Tissue oximetry is a useful tool for postoperative free flap monitoring. Reported criterion values have been accurate; however, there are various complicated author-dependent criteria, and sometimes it is too late for flap salvage. The authors offer a new, simple criterion for faster and accurate detection of perfusion problems. Methods: Intraoperatively, perfusion areas of various free perforator flaps were assessed by both indocyanine green angiography and regional oxygen saturation. The elevated flap was categorized into the early-stained area, the delayed-stained area, and the no-stained area by indocyanine green angiography. The regional oxygen saturation index (regional oxygen saturation on the flap on the control nondissected portion) of each area was calculated. Postoperative continuous flap monitoring was conducted, recording the value of the regional oxygen saturation index at the early-stained area. The blood glucose measurement index was also recorded periodically. Results: In 60 cases of perforator-based free flaps, intraoperative indocyanine green areas were significantly correlated with the values of regional oxygen saturation index. The postoperative regional oxygen saturation index showed very stable values in various types of perforator flaps, provided that no vascular problem occurred, and it never went below 0.75. When vascular problems occurred, the regional oxygen saturation index dropped below 0.75 in all three cases before the blood glucose measurement index and the absolute value of regional oxygen saturation dropped below the criterion value. Conclusion: The regional oxygen saturation index may be a simple and fast criterion for detecting vascular problems following free flap reconstruction compared with existing criteria. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Reconstruction using a divided latissimus dorsi muscle flap after conventional posterolateral thoracotomy and the effectiveness of indocyanine green-fluorescence angiography to assess intraoperative blood flow

PurposeIn most general thoracic operations performed via standard posterolateral thoracotomy, such as for descending aortic aneurysms and lung cancer, the latissimus dorsi (LD) muscle is divided. However, division of the LD can hamper reconstructive surgery because the initial operation creates unstable blood flow to the divided LD. We conducted this study to assess blood flow in a divided distal LD muscle flap using intraoperative indocyanine green-fluorescence angiography (ICG-FA) with the Hyper Eye Medical System® (Mizuho Medical Co., Ltd., Tokyo, Japan).MethodsThe subjects were 11 patients who underwent posterolateral thoracotomy with reconstructive surgery using a divided distal LD and other peripheral muscle flaps. Intraoperative ICG-FA was conducted to assess blood flow to the LD.ResultsIntraoperative ICG-FA revealed that at least two intercostal perforators from the sixth to the tenth intercostal spaces were preserved as feeding vessels to the divided distal LD. There were no major complications associated with inadequate blood flow to the muscle flaps.ConclusionIntraoperative ICG-FA proved extremely useful for assessing altered blood flow of the divided LD and for selecting preserved intercostal perforators.

Reconstruction of the great toe using a pedicled medial plantar flap with anterograde venous drainage

Reconstruction of the great toe defect is difficult. The most distal point of the rotation arc of a retrograde‐flow medial plantar flap is the plantar side of the proximal phalanx. The purpose of this report was to present a new procedure that extends the rotation arc of this flap. Results of anatomic study and application in two patients were presented.

Preoperative arterial embolisations of a huge, chronic, expanding haematoma to inhibit intra-operative massive bleeding: A case report

Chronic expanding haematoma is a rare disease that occurs months or years after surgical treatment or trauma and continues a slow growth thereafter. The first choice of treatment is complete resection, including the fibrous capsule; however, abundant new vascularisations beneath the capsule and fibrous adhesion to the surrounding tissues cause intra-operative massive bleeding. This article presents a case of a huge, chronic, expanding haematoma of the right chest 48 years after two surgical treatments. Preoperative arterial embolisations and covering the remaining capsule with a muscle flap inhibited massive bleeding and recurrence.

Two-stage repair for severe proximal hypospadias using oral mucosal grafts: combination of a modified Bracka method and a modified Byars flap method.

AbstractOne-stage repair is a conventional treatment of hypospadias. If hypospadias is severe as in the scrotal type and perineal type, penile curvature sometimes cannot be corrected by dorsal midline plication alone. In addition to resection of the urethral plate, ventral grafting becomes necessary for insufficient skin and subcutaneous tissue. In recent years, there has been renewed interest in 2-stage repair for such severe cases and salvage of failed cases with scarring. In the present study, novel 2-stage urethroplasty was performed in 6 cases to repair severe proximal hypospadias which required resection of the urethral plate. This novel method consisted of a combination of a modified Bracka method using oral mucosal grafts and a modified Byars flap of the dorsal foreskin. Good results were obtained using this novel method.