Treatment of Squamous Cell Carcinoma of the Esophagus Synchronously Associated with Head and Neck Cancer.

BACKGROUND/AIM: The aim of this study was to clarify the treatment strategy for synchronous squamous cell carcinoma of the esophagus (ESCC) and head and neck cancer (HNC). PATIENTS AND METHODS: Treatment outcomes of 91 patients with synchronous ESCC and HNC were evaluated. Thirty-eight patients received simultaneous definitive chemoradiotherapy (CRT) and 15 patients underwent simultaneous resection. RESULTS: Among the patients who received simultaneous CRT, adverse events (grade 3-5) were recognized in 14 patients (40%), including one case of death due to aspiration pneumonia. Complete response was observed in 22 patients with ESCC (58%) and 19 patients with HNC (50%). The five-year survival rate was 44%. There were no in-hospital deaths after simultaneous resection; however, postoperative complications were recognized in 4 patients. The five-year OS was 70%. CONCLUSION: The treatment of synchronous ESCC and HNC must be decided by adopting a strategy that is appropriate for each case. Both simultaneous CRT and simultaneous resection are feasible and effective treatment options.

Surgical correction of extensive scarring of the limbs with an unfolded cube advancement flap.

We devised a cube advancement flap and reported its usefulness for treating defects of the face. Here we report its use to treat five cases of extensive scarring of the limbs with similar satisfactory results.

Effects of short-term venous augmentation on the improvement of flap survival: an experimental study in rats.

INTRODUCTION: Flap necrosis due to blood circulation disorders is a serious problem in reconstructive surgery. Methods to achieve both arterial and venous microvascular augmentation at the flap periphery have therefore been developed to prevent post-surgical circulation problems, especially for large pedicle flaps and free flaps containing three more vascular territories. Moreover, the benefits of microvascular venous augmentation (VA; superdrainage) alone have been established, but the optimal duration of post-surgical venous drainage has not yet been determined. METHODS: The surviving flap area was compared after standard and short-term VA in the extended island flap model of the rat abdomen. A flap model using the left superficial inferior epigastric artery/vein as the vascular pedicle was used as a control group (n = 6). The lateral branch of the right superficial inferior epigastric vein remained unresected at the end of the flap in the VA group (n = 7), but was ligated at 24 h post-surgery in the temporary venous augmentation (TVA) group (n = 7). RESULTS: The flap survival rates on postoperative day 7 in the control, VA and TVA groups were 74.8 ± 8.4%, 90.1 ± 3.7% and 89.9 ± 3.5%, respectively. The surviving areas were significantly improved in the VA and TVA groups in comparison to the control group (p ＜ 0.01), but there was no significant difference between the VA and TVA groups. CONCLUSIONS: The short-term venous drainage from the flap end after surgery was as effective as long-term VA. Flap transplantation could therefore be clinically easier and more reliable when starting short-term venous drainage during surgery.

Treatment strategies for refractory pulmonary fistulae using a latissimus dorsi muscle flap.

BACKGROUND: As a common treatment for pulmonary fistula, pleurosclerosis is performed. However, in the case of pulmonary fistula with empyema, it is difficult to develop adhesion through pleurosclerosis. Therefore, it is necessary to fill the dead space with a tissue graft. METHOD: This surgical procedure is performed in two stages. In the first-stage surgery, the thoracic empyema cavity is opened widely, and sufficient drainage and debridement are performed within the thoracic empyema cavity. After the surgery, the wound is washed every day to suppress infection and promote the proliferation of benign granulation tissue (wound bed preparation). In the following second-stage surgery, a graft of latissimus dorsi muscle flap is performed to fill the dead space and close the fistula. In this case, a negative pressure drain is placed around the fistula to reliably drain air leaks from the pulmonary fistula, and thus the latissimus dorsi muscle flap and the tissue surrounding the pulmonary fistula can reliably adhere to the site. CASES AND RESULTS: Treatment with this method was performed in five cases, all of which successfully healed with no complications or recurrence. CONCLUSION: When treating pulmonary fistula that has developed into thoracic empyema, it is believed that the following three points are important: (1) wound bed preparation around the pulmonary fistula, (2) inserting a latissimus dorsi muscle flap having a high wound-healing capacity and (3) promoting strong adhesion of the muscle flap and tissue surrounding the pulmonary fistula by reliably draining air leaks from the pulmonary fistula with a negative pressure drain.

V-Y fasciocutaneous flap of the medial thigh including the long saphenous vein for reconstruction of intrapelvic dead space.

Some patients develop an intrapelvic infection and fistula caused by the presence of intrapelvic dead space after the resection of rectal cancer, and the treatment is sometimes quite difficult. We have developed a new surgical technique for the treatment and prevention of such fistulas that uses a fasciocutaneous flap from the medial thigh. A V-shaped fasciocutaneous flap with a pedicle on the anterior side of the thigh is designed on the medial thigh and gluteal region. After raising the fasciocutaneous flap that contains the long saphenous vein, the gluteal section including a thick layer of fatty tissue is de-epithelialised, and the flap is rotated and advanced towards the dead space to fill it. Four patients were operated on using our technique. One was a secondary reconstruction: the patient had developed a small fistula after reconstructive surgery, but it healed with conservative treatment. As a result, all four patients achieved satisfactory outcomes. The advantages of our technique include: no change in the position of the body is required for reconstruction; operations are simple; sufficient volume of tissue is obtained from the thick fatty tissues of the gluteal region; and the fasciocutaneous flap contains the long saphenous vein and has good venous circulation. We consider this technique useful for the reconstruction of intrapelvic dead space.

Objective assessment of the efficacy of supermicrosurgical lymphaticovenous anastomosis and microsurgical lymphaticovenous implantation in a case of axillary lymphorrhea.

Supermicrosurgical lymphaticovenous anastomosis and microsurgical lymphaticovenous implantation are procedures currently used to treat lymphedema. However, because in most cases concomitant conservative treatments are included, it is difficult to objectively assess the direct effect of the procedures. The present report is a case in which supermicrosurgical lymphaticovenous anastomosis and microsurgical lymphaticovenous implantation were performed to treat axillary lymphorrhea that developed after the treatments for lymph node metastases of esophageal carcinoma. Prior to surgery, the volume of lymphorrhea was approximately 300 mL/d, but from postoperative day 1, this amount decreased by half, and healing was obtained by postoperative day 20. This result objectively indicates that creating new lymphatic routes with these two procedures is clearly effective.

New continuous negative-pressure and irrigation treatment for infected wounds and intractable ulcers.

BACKGROUND: Continuous irrigation and the vacuum-assisted closure system are effective methods for the treatment of infected wounds and intractable ulcers. The objective of this study was to simultaneously use both of the above methods as a new approach for obtaining more satisfactory, accelerated wound healing. METHODS: After debridement of the wound, indwelling irrigation and aspiration tubes are placed in the wounds that have been sutured closed. With open wounds, a sponge with the same shape as the wound is placed directly onto the wound surface, and after the two tubes are inserted in the sponge, the wound is covered with film dressing to make the wound completely airtight. A bottle of physiologic saline solution is then attached to the irrigation tube, and a continuous aspirator (Mera Sacume) is attached to the aspiration tube. The bottle of physiologic saline solution is placed at the same height as the wound, and with a pressure gradient between the two of 0, continuous aspiration is applied. RESULTS: All nine cases treated as closed air cavity wounds with this method healed after 2 to 3 weeks. In eight cases of open wound, recurrence of infection was observed in only one case. CONCLUSIONS: The two treatments of continuous irrigation and negative pressure were observed to have an additive and synergistic effect for earlier wound healing. Furthermore, the present method can dramatically reduce the number of dressing changes required, patient pain, psychological stress, and treatment cost.

Surgical treatment of pharyngeal atresia.

Congenital pharyngeal atresia is a very rare gastrointestinal anomaly, with only seven cases of complete pharyngeal atresia having been reported. Five of these cases were autopsy reports and success in surgery to enable oral ingestion was not reported even for the two surviving cases. This is a report of a 1.5-year-old boy with complete congenital pharyngeal atresia who was saved by an emergency tracheostomy directly after birth, and on whom we performed surgery to reconstruct the pharyngeal cavity and prevent re-occlusion and restonosis. Approximately four years after the surgery, no restenosis of the pharyngeal cavity has been observed, and the patient is capable of orally ingesting ordinary meals and breathing and vocalizing by closing the tracheal lumen for nearly satisfactory results.

Two-stage reconstructive surgery of a patient with head trauma resulting in extensive cranial bone and dura mater loss caused by postoperative infection: usefulness of a pericranial flap for dura mater reconstruction.

After external decompression for a case of head trauma, epidural abscess formation resulted in extensive cranial bone and dura mater loss, for which two-stage reconstructive surgery was conducted. In the first operation, after thorough debridement of the infected wound, the dura mater was reconstructed using a bipedicle pericranial flap with posterior and anterior pedicles. After the infection had completely subsided, the second operation was performed, reconstructing the cranium with grafted outer-table calvarial bone and cutting bone to reposition an old zygomatic fracture. At this point, the pericranial flap used for dura mater reconstruction in the first operation became a satisfactory graft bed for the grafted bone. The postoperative course was satisfactory, and there was no cranial bone absorption after roughly 2 year, and a favorable shape has been maintained for an extremely satisfying result.

Refinements in the elevation of reconstructed auricles in microtia.

BACKGROUND: In the treatment of microtia, the search has been for surgical techniques that prevent postoperative complications and realize sufficient and stable projection of the constructed ear. METHODS: Cartilage was fixed with absorbable synthetic thread instead of wire because wire has a high risk of exposure. A subcutaneous pedicle was added to the concha to prevent skin necrosis. Dead space and hematoma creation were prevented with vacuum aspiration, bolster fixation, and microdrainage with small tubes. A triangular skin flap connecting to the ear lobe was used to prevent shrinkage on the posteroinferior portion of the concha. Projection of the inferior portion of the auricle was supported with a hydroxyapatite-tricalcium phosphate ceramic. RESULTS: Our technique was applied to 42 patients, and none of them experienced slip of the fixed cartilage, auricular deformation, skin necrosis, or infections. Shrinkage of the inferior portion of the auricle was minimal, and good projection was obtained. CONCLUSIONS: The authors' technique prevents complications and realizes good shape and projection of the auricle in total reconstruction of the auricle. Hydroxyapatite-tricalcium phosphate ceramic is a useful material that complements the cartilage shortage.

Reconstruction of the form and function of lateral malleolus and ankle joint.

Soft-tissue reconstruction alone cannot obtain normal ankle function in patients with large defects in the area of the lateral malleolus. The authors report a functional reconstructive method for the lateral malleolus, utilized in a male patient whose osteosarcoma in the fibula was resected with surrounding soft tissue. In order to reconstruct the lateral malleolus, the remaining half of the fibula at the knee was removed, and the fibular head was fixed with the tibia at the ankle joint. Ligaments were reconstructed with tendon grafts. Skin and soft-tissue defects were reconstructed with a combined composite flap comprised of a latissimus dorsi myocutaneous flap and a serratus anterior muscle flap. Dead space around the bone graft was filled with the serratus anterior muscle flap that was divided into two portions. The surface was covered with the latissimus dorsi myocutaneous flap. The patient regained almost normal function of the ankle joint. This technique would be a useful functional reconstructive method for patients with large defects in the area of the lateral malleolus.

Surgical treatment following huge arteriovenous malformation extending from the lower lip to the chin: combination of embolization, total resection, and a double cross lip flap.

A huge arteriovenous malformation (AVM) extending from the lower lip to the chin was surgically resected and the area was reconstructed during the same surgery in three patients. To control hemorrhage during surgery, a radiologist performed embolization of major arteries in the lesion 2 or 3 days before the surgery. After total resection of the AVM, facial reconstruction was performed by using a double cross lip flap from the upper lip and a local skin flap from the lower jaw. As a result, bleeding was well controlled, the AVM was totally resected, and satisfactory functional and esthetic results were obtained.

Minimally invasive functional reconstruction after extended oropharyngeal resection including soft palate and base of tongue using a pectoralis major myocutaneous flap.

Excision of large oropharyngeal carcinomas that affect the base of the tongue and the soft palate severely impairs swallowing and articulation. In the present study we describe a minimally invasive technique that effectively restores swallowing and articulation by the insertion of a pectoralis major myocutaneous flap with a bilobular skin island. One lobe of the skin island is used to reconstruct the base of the tongue and the other to reconstruct the oropharynx. The soft palate is reconstructed by folding the tip of the lobe that is used to reconstruct the oropharynx in half along the long axis to fill the rhinopharynx. We have done this procedure for 13 patients with oropharyngeal carcinoma. Six months postoperatively all 13 were able to swallow without aspiration. Nine of the 13 patients were able to hold a normal conversation, but the remaining four had severe rhinolalia aperta. However, this condition was easily corrected by secondary reconstruction using a pharyngeal flap and a palatal mucoperiosteal flap (n = 3) or by the use of a small speech aid (n = 1).

A new regenerative approach to oromandibular reconstruction after the resection of head and neck malignant tumor.

We developed a new regenerative oromandibular reconstruction technique. In our technique, bone marrow was removed from surgically resected mandible, and then the mandible was heat-treated and prepared into a cortical bone tray. This tray was fixed on the defect area, iliac cancellous bone was grafted into its lumen, the entire circumference was covered with the muscle part of pectoral major myocutaneous flap, and the oral defect and the skin defect on the lower jaw were reconstructed with the skin paddles of the skin island of the flap. Two patients were treated with this technique after the removal of oral cavity cancer. The patients did not develop postoperative complications, the reconstructed mandible as well as the flap were completely taken, and normal shape of the mandible was regained. This technique would be one of the useful oromandibular reconstruction methods.