Ultrasonic Debridement of Fournier Gangrene.

Ultrasonic debridement devices are minimally invasive and effective for biofilm removal, allowing for debridement of necrotic tissue while minimizing damage to normal tissues, such as the blood vessels and nerves. The use of ultrasonic debridement has been reported for foot ulcers and pressure ulcers but not Fournier gangrene. The perineal area, which is difficult to surgically debride using electrocautery, is a suitable site for the use of an ultrasonic debridement device because of its proximity to vital organs. We report here a case of Fournier gangrene that healed with testicular sparing using an ultrasonic debridement device.

Salvage Case of Corpus Cavernosum Necrosis and Urethral Perforation associated with Infection after Penile Prosthesis Insertion.

Penile prosthesis implantation can be considered in patients with unsuccessful treatment with phosphodiesterase type 5 inhibitors for erectile dysfunction. Its associated postoperative complications include infection and urethral injury. Nevertheless, only a few studies have reported the successful management of severe cases. Herein, we report a case of corpus cavernosum necrosis and distal urethral perforation caused by infection after penile prosthesis insertion, which had favorable outcomes. A 60-year-old man with multiple atherosclerotic risks underwent penile prosthesis implantation for erectile dysfunction at another hospital. Postoperatively, he developed infectious necrosis and underwent prosthesis removal. However, he presented at our department because of technical difficulties in the treatment at other hospitals. The initial examination revealed extensive necrosis of the corpus cavernosum and perforation of the peripheral urethra. A thin urethral catheter was inserted, and the necrotic corpus cavernosum was debrided to preserve the artery and urethra. Then, the perforated urethra was sutured. Subsequent negative pressure wound therapy resulted in sufficient granulation and closure of the perforated urethra. One month after the surgery, the scar was resected and sutured following the circumcision line. Despite experiencing this severe postoperative complication, good functional and cosmetic outcomes were achieved after minimal surgery with a blood-flow-conserving method.

Reconstruction of necrotizing soft tissue infection in the auricle and temporal region: a case report.

A 43-year-old female patient had a necrotizing soft tissue infection in the temporal region. Because of the necrotic temporoparietal fascia, auricular reconstruction was attempted using the temporalis muscle flap; the flap was successfully placed. The use of the temporalis muscle flap was considered a treatment option for salvaging the auricle.

Endovascular therapy and free flap transfer in chronic limb-threatening ischemia.

Although revascularization has evolved, treating foot gangrene with chronic limb-threatening ischemia remains challenging. There have been many reports on bypass surgery and free flap transfer. Meanwhile, few studies have reported on endovascular therapy and free flap transfer, with high flap survival rates and high wound complication rates. Wound complications are a serious problem that can lead to limb amputation, but previous studies have failed to identify risk factors for wound complications. In this study, we evaluated the results of endovascular therapy and free flap transfer for chronic limb-threatening ischemia and analyzed risk factors for wound complications. A total of 31 legs from 28 patients who underwent endovascular therapy and free flap transfer for lower limb salvage between August 2016 and April 2020 were retrospectively reviewed. The primary endpoints were flap survival and limb salvage rates and wound complication rates. In addition, we performed a statistical analysis of risk factors for wound complications. The flap survival rate was 100%, with partial necrosis in 6% of the patients. The limb salvage rate was 100%. The wound complication rate was 45%. The multivariate analysis showed end-stage renal failure on dialysis as a significant risk factor for wound complications (odds ratio = 133, 95% confidence interval = 2.74-6430, p = 0.014). Endovascular therapy and free flap transfer in chronic limb-threatening ischemia achieved high flap survival rate and limb salvage, but had a high incidence of wound complications. We identified end-stage renal failure on dialysis was a significant risk factor for wound complications.

A glucocorticoid-receptor agonist ameliorates bleomycin-induced alveolar simplification in newborn rats.

BACKGROUND: Glucocorticoids (GCs) are highly effective yet problematic agents against bronchopulmonary dysplasia (BPD). The dimeric trans-activation of GCs induces unfavorable effects, while monomeric trans-repression suppresses inflammation-related genes. Recently, non-steroidal-selective glucocorticoid-receptor agonists and modulators (SEGRAMs) with only the trans-repressive action have been designed. METHODS: Using a bleomycin (Bleo)-induced alveolar simplification newborn rat model (recapitulating arrested alveolarization during BPD), we evaluated the therapeutic effects of compound-A (CpdA), a SEGRAM. Sprague-Dawley rats were administered Bleo from postnatal day (PD) 0 to 10 and treated with dexamethasone (Dex) or CpdA from PD 0 to 13. The morphological changes and mRNA expression of inflammatory mediators, including interleukin (IL)-1ß, C-X-C motif chemokine ligand 1 (CXCL1), and C-C motif chemokine 2 (CCL2) were investigated. RESULTS: Similar to the effects of Dex, CpdA exerted protective effects on morphological derangements and inhibited macrophage infiltration and production of pro-inflammatory mediators in Bleo-treated animals. The effects of CpdA were probably mediated by GC receptor (GR)-dependent trans-repression, because unlike the Dex-treated group, anti-inflammatory genes specifically induced by GR-dependent trans-activation (such as "glucocorticoid-induced leucine zipper, GILZ") were not upregulated. CONCLUSIONS: CpdA improved lung inflammation, inhibited the arrest of alveolar maturation, and restored histological and biochemical changes in a Bleo-induced alveolar simplification model. IMPACT: SEGRAMs have attracted widespread attention because they are expected to not exhibit unfavorable effects of GCs. Compound A, one of the SEGRAMs, improved lung morphometric changes and decreased lung inflammation in a bleomycin-induced arrested alveolarization, a newborn rat model representing one of the main features of BPD pathology. Compound A did not elicit bleomycin-induced poor weight gain, in contrast to dexamethasone treatment. SEGRAMs, including compound A, may be promising candidates for the therapy of BPD with less adverse effects compared with GCs.

Induction of aggressive arterial and venous dilation therapy in addition to pulmonary dilation therapy (super-Fontan strategy) improves Fontan circulation both at rest and during treadmill exercise.

Objective: Fontan circulation maintains preload and cardiac output by reducing venous capacitance and increasing central venous pressure (CVP). The resultant congestive end-organ damage affects patient prognosis. Therefore, a better circulatory management strategy to ameliorate organ congestion is required in patients with Fontan circulation. We sought to verify whether aggressive arterial and venous dilation therapy in addition to pulmonary dilation (super-Fontan strategy) can improve Fontan circulation and reduce congestion. Methods: Patients after Fontan surgery who received the super-Fontan strategy in a single center were recruited. Participants were examined using medical records between 2010 and 2018. We retrospectively analyzed the changes in hemodynamics at rest and during treadmill exercise before and after the introduction of this therapy. Results: The therapy significantly increased venous capacitance (3.21 ± 1.27 mL/kg/mm Hg to 3.79 ± 1.30 mL/kg/mm Hg, P = .017) and decreased total pulmonary resistance, leading to significantly reduced CVP (11.7 ± 2.4 mm Hg to 9.7 ± 2.2 mm Hg, P < .001) and increased cardiac index (CI) (3.09 ± 1.01 L/min/m2 to 3.54 ± 1.19 L/min/m2, P = .047). Furthermore, this strategy significantly reduced the elevations in CVP (19.6 ± 5.3 mm Hg to 15.4 ± 2.7 mm Hg, P = .002) with preserved CI in response to exercise. CVP at rest and during exercise was significantly positively correlated with serum markers of hepatic congestion and fibrosis, respectively. Conclusions: The super-Fontan strategy is a therapy that turns the heart failure condition of Fontan circulation into a more physiological condition. However, whether the strategy improves long-term prognosis warrants further studies.

Multiple free dorsal flaps for symmetrical peripheral gangrene of the extremities: A case report.

We present a case of symmetrical peripheral gangrene of the extremities due to acute infectious purpura fulminans that was reconstructed with four free flaps harvested from the bilateral backs. We reconstructed the right and left, upper and lower limbs using the parascapular flap and latissimus dorsi muscle flap from one side and the scapular flap and thoracodorsal artery perforator flap from the other side, in multiple stages. All four flaps survived, preserving the right and left heels and function of the bilateral wrist joints. Although there have been several reports of single-stage elevation of the combined scapular and latissimus dorsi flaps, there has been no report of multi-stage elevations of these flaps. When multiple flaps are required in multi-stage, raising the flaps based on the thoracodorsal artery and scapular circumflex artery from the ipsilateral back is a useful method because it does not require additional donor sites.

Sacral Pressure Ulcer in Leriche Syndrome: A Case Report.

We experienced a case of a sacral pressure ulcer complicated with Leriche syndrome, an aortoiliac artery occlusion that has not been previously reported. In this case, the abdominal aorta below the bifurcation of the renal arteries into the bilateral common iliac arteries was occluded, and wound healing was delayed. Therefore, endovascular treatment was used for managing this condition, and wound healing was accelerated. Then, reconstructive surgery with a local flap was performed, and wound healing was achieved. In the case of delayed healing of buttock pressure ulcers, it is important to evaluate the blood flow in the iliac artery as well as the infection and nutritional status of the wound. In addition, after endovascular treatment, blood flow in the local flap is a matter of concern. If the wound healing is good, and imaging confirms that there is no restenosis at the endovascular treatment site and the perforator of the flap, reconstructive surgery can be performed safely.

Phase-stable optical activity measurement by common-path spectral interferometry.

A robust optical activity (OA) spectrometer covering the visible and near-infrared regimes was designed and built via a combination of a linear polarizer and a birefringent plate. The OA spectrometer relies on common-path spectral interferometry, where the two interfering fields travel common optical paths, and ensures signal reproducibility over several hours. By detecting OA without polarization switching, the data acquisition time is shortened to 1 s, enabling real-time monitoring of the chiral complex formation. The present configuration also allows OA measurement with broadband pulses, which is promising for probing ultrafast circular dichroism and optical rotatory dispersion.

Gluteal fold flap for pelvic and perineal reconstruction following total pelvic exenteration.

BACKGROUND: The rectus abdominis myocutaneous flap has been used as the first choice for pelvic and perineal reconstruction. However, due to previous abdominal surgery and multiple stoma placements in our patients, the rectus abdominis myocutaneous flap could not be used for such reconstruction. Here, we describe the use of bilateral gluteal fold flaps for pelvic and perineal reconstruction following total pelvic exenteration to treat recurrent cervical cancer. METHODS: We performed three bilateral gluteal fold flap operations for perineal reconstruction in three patients between 2008 and 2011. The cause of the perineal defect was total pelvic exenteration, which was performed to treat recurrent cervical cancer in all patients. RESULTS: All flaps completely survived and there were no severe postoperative complication. Good cosmetic results were achieved in all patients. CONCLUSIONS: The gluteal fold flap is a useful option for reconstructing extensive pelvic and perial defect after total pelvic exenteration because of sufficient soft tissue volume, reliable blood supply, cosmetic results and minimal donor-site morbidity.

Syringomatous adenoma of the nipple: a case report.

INTRODUCTION: Syringomatous adenoma of the nipple is a very rare benign tumor. To the best of our knowledge, there are no reports of a syringomatous adenoma of the nipple metastasizing, although these tumors are known to infiltrate locally and to recur if not totally resected. CASE PRESENTATION: Our patient was a 41-year-old Japanese woman who complained of stiffness of her right nipple with abnormal discharge. Local resection of the tumor was performed. The pathological diagnosis was syringomatous adenoma of the nipple, and the resection margin was found to be positive. Accordingly, additional resection was recommended, but our patient did not allow another operation. After 1.5 years of careful follow-up, no local recurrence or distant metastasis has been observed. CONCLUSION: The optimal initial management of syringomatous adenoma of the nipple demands complete resection with histologically negative margins. However, from a cosmetic viewpoint, nipple-sparing resection could represent an alternative option for the treatment of syringomatous adenoma of the nipple.

Uncommon lymphoepithelial cyst with sebaceous glands of the pancreas.

CONTEXT: Lymphoepithelial cysts with sebaceous glands of the pancreas are extremely rare, with only 7 cases, including this case, published in English literature. CASE REPORT: We herein present the case of a 67-year-old Asian man who underwent a resection of a lymphoepithelial cyst of the pancreas during the follow up care for lung cancer. Fourteen years previously he underwent a right lower lobectomy at the right segment nine for lung cancer. A 20 mm mass in the body of the pancreas was identified by CT scan 4 years ago, and the diagnosis was intraductal papillary mucinous neoplasm (IPMN) at that time. Over a 5-year period, this mass grew to 42 mm without dilatation of the main pancreatic duct. The preoperative evaluation, including endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), indicated a cystic neoplasm with suspicion of malignancy. Intraoperative frozen section revealed a squamous-lined cyst accompanied by sebaceous glands without any malignant findings. Following this pathological finding, resection of the cyst was performed. Consequently, microscopic examination revealed that it was a lymphoepithelial cyst with sebaceous glands of the pancreas. CONCLUSIONS: Pancreatic lymphoepithelial cysts can be cured by conservative resection, but if they are asymptomatic and are diagnosed before surgery, no treatment is necessary. To our knowledge, this is the first ever published case of a lymphoepithelial cyst with sebaceous glands of the pancreas, which was found during the follow up care for lung cancer.

Digital artery perforator (DAP) flaps: modifications for fingertip and finger stump reconstruction.

UNLABELLED: Various fingertip reconstructions have been reported for situations where microsurgical finger replantation is impossible. One method is the digital artery perforator (DAP) flap. Herein we report 13 DAP flaps for fingertip and finger stump reconstruction following traumatic finger amputations, highlighting modifications to the originally described DAP flap. METHODS: From October 1998 to December 2007, a total of 13 fingers (11 patients) underwent fingertip and finger stump reconstruction with modified DAP flaps following traumatic finger amputations. We performed six adipocutaneous flaps, three adipose-only flaps, two supercharged flaps and two extended flaps. Flap size ranged from 1.44 to 8 cm(2) (average 3.25 cm(2)). RESULTS: All flaps survived completely with the exception of partial skin necrosis in two cases. One of these cases required debridement and skin grafting. Our initial three cases used donor-site skin grafting. The donor site was closed primarily in the 10 subsequent cases. No patients showed postoperative hypersensitivity of repaired fingertips. Semmes-Weinstein (SW) test result for flaps including a digital nerve branch did not differ from those without (average 4.07 vs. 3.92). CONCLUSIONS: Modified DAP flaps allow for preservation of digital length, volume and finger function. They can be raised as adiposal-only flaps or extended flaps and supercharged through perforator-to-perforator anastomoses. The donor defect on the lateral pulp can be closed primarily or by skin grafting. For traumatic fingertip and finger stump reconstructions, DAP flaps deliver consistent aesthetic and functional results.