En bloc groin node resection reconstructed with external oblique flap for solitary metastatic cholangiocarcinoma: a case report.

Cholangiocarcinoma requires complete surgical resection for cure. Even so, the recurrence and metastasis rates are high, and further treatment is typically through palliative systemic chemotherapy. Curative-intent resection of metastatic site may provide survival benefit in selected cases. However, there were no previous reports of groin node dissection in cholangiocarcinoma. We have reported the first case of intrahepatic mass-forming cholangiocarcinoma with isolated synchronous groin node metastasis, successfully treated with   resection of the liver mass followed by groin node resection, reconstructed with musculofascial flap. A 73-year-old man presented with right upper quadrant abdominal pain radiating to the right groin for two months. Magnetic resonance cholangiopancreatography revealed a 3.1 × 1.2 cm enhancing mass between hepatic segment 4 and the anterior peritoneum, invading the abdominal wall. Computed tomography of the abdomen revealed a 2.4 × 2.2 cm focal enhancing mass at the anterior aspect of the right lower abdominal wall, just anterior to the right inguinal ligament and iliac vessel. He underwent en bloc resection of hepatic segment 4, gallbladder, and anterior abdominal wall, and the histology result is cholangiocarcinoma. After systemic chemotherapy, he underwent en bloc resection of the right groin mass, reconstructed with external oblique musculofascial flap. The patient was able to achieve a 20-month recurrence free survival after the final operation. This case has demonstrated that in a carefully selected case, resection of distant metastasis cholangiocarcinoma can provide survival benefits, even in the rare site of metastasis.

Increased tissue expression of IL-31 in patients with psoriasis.

Psoriasis is a chronic inflammatory skin disease, and its pathogenesis remains unclear. Although many studies have demonstrated the role of serum interleukin-31 (IL-31) in psoriasis, only one study has examined histopathological expression in lesional skin. This study aimed to investigate the expression of IL-31 in skin biopsy specimens of psoriasis patients compared to healthy subjects and identify its possible correlation to disease severity and itch intensity. Psoriasis patients and healthy volunteers were recruited. Four-millimeter punch biopsy was performed at the lesional skin of psoriasis patients and normal skin of healthy subjects. Expression of IL-31 was measured by immunohistochemistry. Baseline characteristics, disease activity, itch intensity, and related laboratory results were collected. Twenty-six biopsy specimens of psoriasis patients and 10 tissue samples of healthy subjects were evaluated. Epidermal and dermal psoriasis lesions had significantly higher IL-31 expression compared to the healthy skin (P < 0.001). However, there was no significant difference in lesional expression of IL-31 by disease severity or itch intensity. Increased IL-31 expression in the lesions of psoriasis patients suggests the involvement of IL-31 in the pathogenesis of psoriasis.

The Effect of Presurgical Nasoalveolar Molding on Oronasal Fistula Following Primary Palatoplasty.

OBJECTIVE: Presurgical nasoalveolar molding (PNAM) is widely used in cleft care protocol. This study investigated the correlation between PNAM and oronasal fistula after primary palatoplasty. METHODS: A case-controlled study of 80 unilateral and bilateral complete cleft palate patients who underwent cleft palate repair were enrolled. Patients were divided into 2 groups: (1) no PNAM use and (2) PNAM use. The incidence of oronasal fistula and postoperative complications were compared between groups. RESULTS: Forty patients in each group demonstrated the same baseline characteristics. The PNAM group showed a significantly lower postoperative oronasal fistula rate (15% versus 50%, P=0.003). Palatal cleft width wider than 12.5 mm increases the odds ratio of fistula formation by 1.19-fold (P=0.037), and the PNAM protected against postoperative palatal fistula formation (odds ratio 0.20, P=0.003). CONCLUSION: Presurgical nasoalveolar molding can reduce postoperative oronasal fistula in wide-gap Veau type III and IV cleft palate.

Lymphaticovenular Anastomosis: Superficial Venous Anatomical Approach.

Background Lymphaticovenular anastomosis (LVA) is an effective, functional treatment for limb lymphedema. This study reports an alternative surgical approach to lymphedema treatment without the use of indocyanine green mapping. Methods A retrospective analysis was performed on 29 consecutive lymphedema patients who underwent LVAs from January 2015 to December 2020, whereby incisions were made along the anatomy of the superficial venous systems in both upper and lower extremities around the joint areas. The evaluation included qualitative assessments and quantitative volumetric analyses. Result The mean number of anastomoses was 3.07, and the operative time was 159.55 minutes. Symptom improvement was recorded in 86.21% of the patients, with a mean volume reduction of 32.39%. The lymphangitis episodes decreased from 55.17% before surgery to 13.79% after surgery, and the median number of lymphangitis episodes per year decreased from 1 before surgery to 0 after surgery. Conclusions The superficial venous anatomical approach is an easy way to start a lymphedema practice using LVA without other advanced surgical equipment. With this reliable technique, microsurgeons can perform LVA procedures and achieve good results.

Increased IL-31 expression in serum and tissue protein in prurigo nodularis.

Background: Prurigo nodularis (PN) is a chronic pruritic skin disease which can greatly impact patients' quality of life. Moreover, the pathogenesis remains unclear, making it a difficult-to-treat condition. Aims: To investigate the expression of interleukin-31 (IL-31) in serum and skin biopsy specimens of PN patients and healthy subjects and identify its possible correlation to disease severity and itch intensity. Methods: Patients with PN and healthy volunteers were recruited for the study. Expression levels of IL-31 were measured by enzyme-linked immunosorbent assay and immunohistochemistry. Baseline characteristics, disease activity, itch intensity, and related laboratory results were collected. Results: Forty-three PN patients and 31 healthy subjects participated in our study. The PN patients had significantly higher mean serum IL-31 levels than the healthy subjects (52.9 ± 18.2 versus 36.3 ± 10.7 pg/ml, p < 0.001). Epidermal and dermal PN lesions also exhibited significantly higher IL-31 expression compared with the healthy skin (p < 0.001 and p = 0.01, respectively). However, there was no significant difference in serum or lesional expression of IL-31 by disease severity or itch intensity. Conclusion: Increased IL-31 expression in serum and PN lesions suggests that IL-31 has a potential role in the pathogenesis of PN.

Buccal Fat Pad: Adjunctive Procedure for Lateral Defect Coverage following Primary Palatoplasty.

BACKGROUND: The buccal fat flap is an encapsulated mass originating from a specific fat tissue that is easily accessed and richly vascularized. The aim of this study was to report the effect of using the buccal fat flap on the oronasal fistula rate in primary palatoplasty. METHODS: A case-controlled study of 94 patients who underwent primary cleft palate repair. Patients were divided into two groups: (1) two-flap palatoplasty with buccal fat flap for coverage of lateral hard palate defect and (2) conventional two-flap palatoplasty. The incidence of oronasal fistula and postoperative complications were compared between groups. Multivariate analysis was performed to determine the risk factors of oronasal fistula development. RESULT: Forty-seven patients in each group demonstrated the same baseline characteristics. The buccal fat group showed a significant lower postoperative oronasal fistula rate (2.13 percent versus 21.28 percent, p = 0.008) and smaller fistula size (2 mm versus 4 mm, p = 0.049). A cleft width wider than 11.5 mm increased the odds ratio of fistula formation by 8.44-fold (p = 0.047), and the use of buccal fat protected against postoperative palatal fistula formation (OR, 0.08, p = 0.019). CONCLUSION: The use of buccal fat flaps for lateral hard palatal defect coverage in primary palatoplasty can reduce the rate of postoperative palatal fistula, especially in cases of wide palatal cleft. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Significant Prognostic Factors Influencing the Survival Difference of Oral Tongue Squamous Cell Carcinoma.

BACKGROUND: Oral tongue squamous cell carcinoma is the most common malignancy in the oral cavity. Overall survival varies across many countries, and poor prognosis is prevalent in developing countries, including Thailand. Our study aimed to identify prognostic factors that affected survival for oral tongue cancer in Thailand. METHODS: We performed a retrospective study of 183 patients diagnosed with oral tongue squamous cell carcinoma between January 2012 and December 2016 and who underwent multidisciplinary treatment. The disease stage was classified by tumor-nodes-metastasis (TNM) staging system. The survival outcome was calculated and represented in median survival time. Univariate and multivariate Cox proportional hazards models were used to identify factors that impacted survival outcomes. RESULTS: A clear margin was achieved in 88.8% of the 125 operated patients. Radiotherapy was given to 115 patients (62.84%). The survival shown in Kaplan-Meier curves was significantly lower according to advanced TNM stage, poor histologic grade, nonsurgical treatment, and patients treated with radical neck dissection. Radiotherapy was a good prognostic factor [hazard ratio (HR) 0.25, P = 0.022]. Poor prognostic factors were body mass index less than 18.5 kg per m2 (HR 3.03), vertical tumor dimension 20 mm or more (HR 5.84), non-well-differentiated grade tumor (HR 3.09), and operated cases with radical neck dissection (HR 4.29). CONCLUSIONS: Surgical treatment can improve the survival outcome, whereas advanced stage and poor histological grading can worsen the overall survival. For oral tongue squamous cell carcinoma, radiotherapy was a good prognostic factor. On the contrary, a tumor with large vertical size, closed surgical margin, poor histologic grade, and radical neck dissection in the operated group were poor prognostic factors.

Anterolateral Thigh and Vascularized-tensor Fascia Lata Flaps for Long-gap Achilles Tendon Reconstruction.

We demonstrated our surgical technique of 8-cm segmental loss Achilles tendon reconstruction and repair of posterior heel skin and soft tissue defects with composite anterolateral thigh and 4-layer folding vascularized-tensor fasciae latae flaps of a 15-year-old adolescent boy's post-traumatic injury and infection after primary repair. This technique highlights the ease of harvesting the flap, short operative time, and facilitation of the strong and sustainable motion of the Achilles tendon after reconstruction.

Indocyanine Green Angiography Precise Marking for Indeterminate Burn Excision: A Prospective, Multi-centered, Double-blinded Study.

BACKGROUND: During burn excision, the clinical judgment whether to excise or not excise the area with indeterminate burn depth is difficult. Indocyanine green angiography (ICGA) has been reported to provide high accuracy in diagnosing indeterminate burns. This study aims to evaluate the complete wound closures in both short-term and long-term outcomes after using ICGA precise marking to guide indeterminate burn excision. METHODS: This was a prospective, multi-centered, double-blinded, experimental study. The participants were admitted to the hospital with indeterminate burn wounds. ICGA precise marking was performed. The deep second-degree burn was painted, excised, and subsequently covered with skin grafts and measured on day 5. The superficial burns were measured on day 21. All wounds were followed-up at two months. RESULTS: Thirty indeterminate burn sites were included in this study. Using ICGA precise marking, the overall rate of short-term complete wound closure, which combined superficial and deep burns, was found to be as high as 96.7% (29/30). The long-term complete wound closures at two months confirmed the short-term result and yielded 100.0% of complete wound closure. The complete wound closures between the short-term and long-term measurements were not significantly different (P > 0.999). CONCLUSIONS: Using ICGA precise marking to guide indeterminate burn excision resulted in an excellent rate of complete wound closure and an insignificant difference between short-term and long-term wound outcomes. ICGA is a competent method to aid decision-making in burn surgery of the indeterminate area.

An Inconvenient Truth of Clinical Assessment and Indocyanine Green Angiography Precise Marking for Indeterminate Burn Excision.

The clinical assessment of indeterminate burn wounds has relatively poor accuracy. Indocyanine green angiography (ICGA) has high accuracy and can be used to mark wounds precisely so as to guide burn excision. This study aimed to assess the differences between ICGA and clinical assessment marking and compare the marking result with the long-term wound outcome. METHODS: This was a prospective, multicentered, triple-blinded, experimental study. Indeterminate burn wounds were clinically assessed, and the area to be excised was firstly marked by the attending surgeon. ICGA marking was then performed by a second surgeon. Measurement of the marked area was conducted by a third surgeon. Three surgeons were each blinded to the others' processes. The wounds were followed up to assess complete wound closures on day 21. RESULTS: There were 20 burn sites included in the study. There was a significant difference in the marked areas between clinical assessment and ICGA (mean, 57.3 ± 44.1%; P = 0.001). The maximum difference found was as high as 160.9%. The correction rate of ICGA marking to complete wound closure on day 21 was 95.0%. Over 90% of the decreased areas of excision-which were assessed by ICGA to be superficial burns but evaluated by clinical assessment to be deep burns-were completely healed on day 21. CONCLUSIONS: ICGA contributes to a significant difference versus clinical assessment in the marking for excision of indeterminate burns and strongly associates with long-term wound outcomes. The burn wounds can be assessed precisely to reduce unnecessary excision and prevent inadequate excision.

Risk Factors of Fistula Following Primary Palatoplasty.

BACKGROUND: Oronasal fistula (ONF) is a common complication following cleft palate surgery. This study aims to determine the prevalence of ONF and the factors that influence development of ONF following primary palatoplasty. MATERIALS AND METHODS: There were 234 patients undergoing primary palatoplasty during 2012 to 2016 included in this cross-sectional study. Patient demographics, surgeon's experience, age at the time of primary palatoplasty, cleft type by Veau classification, cleft width, and operative technique were recorded. The prevalence of fistulae was the primary outcome. Association of age at the time of repair, cleft type, cleft associated with syndromes, cleft width, and surgeon's experience with fistula rate were secondary outcomes. RESULTS: There were 234 consecutive patients (128 boys [54.7%] and 106 girls [45.3%]). The mean age at primary palatoplasty was 13 months. Oronasal fistulae occurred in 61 (26.07%) patients. There was a statistically significant association between postoperative oronasal fistulae and the following independent variables: Veau classification (adjusted odds ratio 2.1; 95% confidence interval [CI] = 1.45-3.1, P < 0.01), cleft associated with syndromes (adjusted odds ratio 4.76; 95% CI = 1.48-15.2, P < 0.01) and cleft width more than 11.5 mm (adjusted odds ratio 1.96; 95% CI = 1.00-3.85, P = 0.04). CONCLUSION: The overall number of fistulae was moderate in patients who had undergone primary palatoplasty in our center. Cleft severity as defined by the Veau classification, cleft width, and cleft associated with syndromes were predictive factors for development of postoperative fistulae.

Birth Prevalence and Risk Factors Associated With CL/P in Thailand.

INTRODUCTION: The objectives of this study were to obtain the birth prevalence of cleft lips and/or cleft palates (CL±P) and to identify potential associated risk factors in the population of the Northeast (NE) region of Thailand. METHODS: The data were collected from October 1, 2012, to September 30, 2013, for infant deliveries with nonsyndromic CL±P in all hospitals of 4 provinces in the region. Workshops were conducted to establish diagnostic criteria, treatment guidelines, referral systems, data collection, and data reporting. All patients included in this study, including a case (the child born with cleft lip and palate [CLP]) and 2 control cases (2 following children born without CLP in the same hospital), completed a questionnaire regarding demographics, cleft characteristics, and factors of interest such as alcohol intake, smoking, vitamin use, and medication. Unadjusted and adjusted odds ratio were presented for the magnitude of associations between proposed risk factors and CL±P along with 95% CIs. RESULTS: The overall birth prevalence of CL±P was 1.93 per 1000 live births. There was a significant difference in percentages of infants with low birth weights (P = .03), family history of CL±P (P = .01) in cases than controls. Mothers who took self-medication or a menstrual regulation supplement were more likely to have the child with CL±P (P = .01 adjusted). CONCLUSIONS: The prevalence of CL±P in the NE Thailand was high. Low infant birth weight, family history of CL±P, and the use of self-medication or menstrual regulation herbal supplement was significant factors.

Increased serum IL-31 levels in chronic spontaneous urticaria and psoriasis with pruritic symptoms.

BACKGROUND: Chronic spontaneous urticaria (CSU) is a common pruritic skin condition, the pathogenesis of which remains unclear. Interleukin-31 (IL-31) is a major pruritogenic cytokine that plays a role in inducing pruritus in various skin diseases. AIM: To 1) compare serum IL-31 levels among CSU patients, psoriasis patients with pruritic symptoms, and healthy subjects, 2) examine the correlations between serum IL-31 levels and disease severity, and 3) compare IL-31 levels in patients with and without CSU-associated auto-antibodies. METHODS: Patients with CSU, psoriasis with pruritic symptoms, and healthy volunteers were recruited in the study. Serum IL-31 levels were measured with commercial kits. Baseline characteristics, urticaria activity score, psoriasis area severity index, pruritic intensity score, and related laboratory results were collected. RESULTS: Sixty-five CSU patients, 30 psoriasis patients who had pruritus, and 31 healthy subjects participated in our study. The CSU patients had significantly higher mean serum IL-31 levels than the psoriasis patients (252.4 ± 115.5 vs 121.4 ± 16.6 pg/mL, P < 0.001). Both CSU and psoriasis patients also had significantly higher mean serum IL-31 when compared with the healthy subjects. Serum IL-31 levels of CSU and psoriasis patients did not differ significantly according to disease or itching severity. Thyroid antibodies and antinuclear antibodies were positive in 22 (33.8%) and 28 (43.1%) CSU patients, respectively. The CSU patients with ANA titers ≥1:160 had significantly higher mean serum IL-31 levels than in those who were negative for ANA and those with titers of 1:80 (P < 0.003 and P < 0.008, respectively). CONCLUSION: Higher serum IL-31 levels were found in patients with CSU and psoriasis with pruritic symptoms. This suggests that IL-31 has a possible role in the pathogenesis of CSU and psoriasis with pruritic symptoms.

Radiation ulcer treatment with hyperbaric oxygen therapy and haemoglobin spray: case report and literature review.

OBJECTIVE: To explore the effectiveness of a combination of hyperbaric oxygen therapy and haemoglobin spray in radiation ulcer treatment. METHOD: We reviewed the available literature and present a case report in which radiation ulcer was treated with a combination of hyperbaric oxygen therapy and haemoglobin spray. RESULTS: After 30 sessions of hyperbaric oxygen therapy (2.4 ATA; 90 minutes each session) and administration of haemoglobin spray, the wounds showed gradual progress towards healing and a good granulating base was achieved. The wounds were closed after two months using a small split thickness skin graft. CONCLUSION: A combination of hyperbaric oxygen therapy and haemoglobin spray was effective as a short course of treatment for radiation ulcers.

Interleukin-31 and Chronic Pruritus of Unknown Origin.

Chronic pruritus of unknown origin (CPUO) is a refractory condition. The expression of Interleukin-31 (IL-31), a major pruritogenic cytokine, in CPUO patients has not been investigated. This study aimed to investigate the potential association of IL-31 with CPUO. This was a cross-sectional, analytical study. Patients diagnosed with CPUO and healthy subjects were included at a ratio of 1:2. Serum IL-31 levels were measured in both groups and compared. There were 10 CPUO and 20 healthy subjects who participated in this study. The median IL-31 level in the CPUO group was significantly higher than in the healthy group (127.3 vs 34.4 pg/mL; P < .001). The presence of CPUO was independently associated with IL-31 levels with a coefficient of 89.678 (P < .001). The serum IL-31 cutoff point for CPUO was 56.8 pg/mL, with an area under the receiver operating characteristic curve (ROC) of 100%. Chronic pruritus of unknown origin was significantly and independently associated with higher IL-31 levels. Further clinical trials of IL-31-related treatment may be justified in CPUO patients.

A Prospective Randomized Double-blind study of silicone gel plus Herbal Extracts Versus Placebo in Pre-sternal hypertrophic scar prevention and amelioration.

OBJECTIVE: Post-surgical hypertrophic scar is more frequently reported in Asians. Many modalities can treat scars but there have not been any publications to define the efficacy of silicone gel plus herbal extracts for scar prevention or amelioration. DESIGN: 48 patients, who underwent median sternotomy were randomized and double-blinded to 2 groups to use topical silicone gel plus herbal extract gel or placebo for 6 months. Patients were treated either with topical silicone gel plus herbal extract gel or control using only placebo for 6 months. The scars were observed by experienced plastic surgeons using the Vancouver scar scale. SETTING: A single tertiary care center at Khon Kaen University. PATICIPANTS: 48 patients who underwent median sternotomy were enrolled in this study. All patients were aged over 18 years. All the wounds were sutured with polyglycolic 4/0 subcuticular suture material and did not receive other scar management before participating in this study. INTERVENTION: The silicone gel plus herbal extract gel (Bangkok Botanica, Bangkok, Thailand) in semi-liquid form was formulated from 15% Herbal extract (Allium Cepa extract, Centella Asiatica extract, Aloe Vera extract and Paper Mulberry extract), 50% polydemethysiloxane, 30% cyclopentasiloxane and 5% silica. The placebo gel was a composite of water, acrylate, C10-30 alkyl acrylate cross-polymer, polysorbate 20 and fragrance that was similar in color and consistency as that of the active gel and packed in the similar sealed packages. MAIN OUTCOME MEASURES: The scar was assessed using the Vancouver scar scale to determine pigmentation, vascularity, pliability and height. RESULTS: the study showed the silicone gel plus herbal extract gel could improve scar amelioration in height (p = 0.005) and pliability (p < 0.001) when compared to the placebo. The vascularity and pigmentation showed improvement using silicone gel plus herbal extracts but the improvement was not statistically significant. CONCLUSION: The silicone gel plus herbal extracts gel was effective for scar improvement in median sternotomy wounds.

Adding herbal extracts to silicone gel on post-sternotomy scar: a prospective randomised double-blind study.

OBJECTIVE: Silicone gel has been shown effective in improving healing post-sternotomy scars. It remains to be determined whether adding herbal extracts to the gel would augment the healing effect. METHOD: After median sternotomy, patients were randomised into two groups. Group 1: topical silicone gel plus herbal extract gel (Allium cepa, Centella Asiatica, Aloe vera and Paper Mulberry) and Group 2: silicone gel. Patients were treated for six months. The postoperative scars were assessed at three and six months by plastic surgeons using the Vancouver Scar Scale (VSS) and the patient assessment scar scale. RESULTS: Each group comprised 23 patients (n=46 in total). The VSS was significantly lower in Group 1 than in Group 2 (p=0.018 and p=0.051, respectively). In Group 1, the four differences from baseline were vascularity scores at three and six months (-0.391, p=0.025; -0.435, p=0.013, respectively), and pigmentation scores at three and six months (-0.391, p=0.019; -0.609, p=0.000, respectively). In Group 2, differences from baseline were the pigmentation and vascularity score at six months (-0.6609, p=0.000; -0.348, p=0.046, respectively). CONCLUSION: Our results suggest, post-sternotomy scars trend to have better vascularity and pigmentation when treated with silicone gel plus herbal extracts.

Preschool Age Anthropometric Evaluation of the Nose After Bilateral Complete Cleft Lip Repair.

OBJECTIVE: To evaluate the aesthetic outcomes of surgery in preschool-aged bilateral complete cleft lip patients by comparing their nasal aesthetic parameters with those of normal children. SETTING AND SAMPLE POPULATION: Twenty-six 4 to 6-year-old (preschool age) patients with bilateral complete cleft lip who underwent primary cheiloplasty and a control group of 30 children in Northeast Thailand of the same age were enrolled. MATERIALS AND METHODS: Nasal aesthetic parameters were analyzed in terms of 3 ratios and 1 angle using three-dimensional photographs. The data from bilateral cleft lip patients were compared with those from a control group. RESULTS: The nasal parameters of patients in the cleft group were the same as those in the control group in terms of nasal tip height (NTH), columella height (CH), and dome height (DH) (P values were 0.361, 0.494, and 0.086), but nasal width (NW) was greater in the cleft group (P < 0.001). The nasal aesthetic parameters differed significantly between the 2 groups in terms of CLA (P < 0.001) and ratio of NTH and NW (P < 0.001), but not in terms of the CH:NW (P = 0.190) and DH:CH ratios (P = 0.147). CONCLUSION: This treatment protocol for bilateral cleft lip was able to achieve most of the aesthetic goals in terms of NTH, CH, DH, ratio of CH to NW, and ratio of DH to CH. However, more surgical correction of NW and CLAs may be needed.