Stomaplasty with pannicuectomy in an obese patient with stomal retraction: A case report.

INTRODUCTION: Stomal retraction is a common complication following stoma formation. A repeat surgical procedure for stomal revision is an invasive treatment that is often required as a result. CASE PRESENTATION: An 81-year-old woman with obstructive rectal carcinoma and perforative peritonitis underwent an emergent anterior resection and colostomy (Hartmann's operation). After the operation, the patient changed the stoma pouch every day because of stomal retraction and leakage. Thirty-eight days after the operation, we performed a stomaplasty with pannicuectomy. Following this procedure, the patient changed the stoma pouch twice weekly. DISCUSSION: Stomal retraction is caused by the thick subcutaneous fat and abnormal skin folds in obese patients, as well as the excess tension that is the result of inadequate mobilization. Treatment of stomal retraction typically requires an intraperitoneal stoma revision. Our method of panniculectomy with skin excision but without stomal revision does not involve an incision around the stoma and there is no risk of fecal contamination. CONCLUSION: We report a case of an obese patient who underwent stomaplasty with pannicuectomy for stomal retraction. We believe that stomaplasty with pannicuectomy is a feasible option in obese patients with stomal retraction.

A Novel Reconstructive Procedure for the Divided Nevus of the Eyelids Using a Tissue Expander.

Expanded local flaps and skin grafts (expanded/nonexpanded) are a common approach for reconstructing medium (1.5-20 cm) and large (>20 cm) divided nevi of the eyelids. However, this approach does not often provide a satisfactory cosmetic result, particularly in Asian patients, because of different skin types. We recently devised a new surgical procedure using an extended cheek flap and tissue expander for the medium-sized divided nevus of the eyelids. The upper and lower eyelids are concurrently reconstructed by divided flaps. This method is an effective treatment method for the medium-sized divided nevus of the eyelids and can be applied in total reconstruction of the eyelids in the future. This article presents our novel technique and is illustrated using a brief case report.

Different onset pattern of oculocardiac reflex in pediatric medial wall blowout fractures.

PURPOSE: We report the 2 pediatric patients who had radiographic confirmation of a rare case of medial orbital wall "trapdoor" fracture with extraordinary symptoms of oculocardiac reflex (OCR). METHODS: This was a small interventional case series. RESULTS: This is the retrospective report of 2 boys (13 and 10 years old) who developed diplopia, pain, nausea/vomiting, and general malaise following blunt trauma. However, the onset pattern of OCR was absolutely different: delayed onset of OCR just following therapeutic forced duction test to treat the orbital content herniation in the first case and a sudden onset after injury in the second case. In both cases, urgent surgery led to complete normalization of ocular motility. CONCLUSIONS: Prompt diagnosis and proper treatment are critical to maximize clinical outcome for this rare and critical trauma.

Nasal bone clip: a novel approach to nasal bone fixation.

BACKGROUND: Nasal bone fracture is a common injury, but its repair can be unexpectedly difficult. To date, intranasal gauze packing has been used to support the nasal bone in position and to maintain contact between the mucosa of the septum and the cartilage. This gauze packing, however, has a tendency to shift, resulting in an inflammatory response characterized by a foul odor until removal, which detracts from the comfort of the patient. We developed a novel device, the nasal bone clip (NBC), which provides a satisfactory nasal airway and improved comfort. METHODS: A 1.2-mm Kirschner wire and a small piece of hydrocolloid wound dressing are used. The single wire is bent into a double-curved shape, after which each of the 2 tips is curled with pliers. The end of the wire in the nasal passage is covered with a piece of wound dressing to protect the mucosa. After reduction, the external portion of the wire is inserted on the surface of the splint. RESULTS: The NBC was applied in 14 cases: 12 instances of fresh fractures and 2 of old fractures; there were 8 men and 6 women; their mean age was 19.9 years. Complications were not observed; moreover, no patients exhibited problems during the treatment. CONCLUSIONS: The advantages of the NBC are that all materials are available in the operating room or outpatient department, it is low cost, it is readily installable and detachable, it affords superior support for gauze packing, it provides effective external splinting with intranasal support, it never disturbs the nasal airway, and it offers comfort.

Pincer nails treated using zigzag nail bed flap method: results of 71 toenails.

BACKGROUND: In instances of pincer nail deformity, patients complain of pain associated with walking, wearing shoes, or light touching. Cosmetic concerns and difficulties in terms of nail clipping also arise. Achievement of a satisfactory nail form remains elusive. OBJECTIVE: To introduce our original surgical procedure and present the satisfactory results. MATERIALS & METHODS: The zigzag nail bed flap method was used on 71 toenails in 49 patients displaying pincer nails (11 male, 38 female; age range 12-88, mean, 48.6). This investigation evaluated 70 nails from the great toe and one nail from a second toe. RESULTS: No postoperative complications, including pain, infection and conspicuous scars, were evident. The degree of improvement was determined objectively with the width and height indices, revealing the accuracy of this therapeutic measure. CONCLUSION: The authors recommend surgical intervention consequent to the vicious cycle corresponding to anatomical abnormalities associated with the nail plate-nail bed-phalanges relationship. Therefore, these architectures should be treated in conjunction rather than singularly.

Morphologic study of normal, ingrown, and pincer nails.

BACKGROUND: Pincer nail has been confused with ingrown nail for decades. OBJECTIVE: The objectives were to analyze the circumferential length of pincer nail and the relationship between nail deformity and the underlying distal phalangeal shape. METHODS: The circumferential length of 53 pincer nails was determined at successive 5-mm intervals of the nail plate. Sixty great toes, including normal (n=20), ingrown (n=20), and pincer nails (n=20), were assessed with respect to body height, body weight, body mass index, nail height, nail width index, and nail height index. Nail angle and height of osteophyte were measured. RESULTS: Despite the presence or absence of overcurvature, the circumferential length displayed nearly identical values across the proximal to distal range of the nail. In the pincer nail group, only the correlation between the width and height indices was statistically significant; 50%, 80%, and 100% of cases were confirmed based on osteophyte presence in normal, ingrown, and pincer nails. CONCLUSION: The findings suggest that the mechanical cause may be associated with the over curved nail, which is affected by nail bed contraction. Results may support the hypothesis that an osteophyte of the distal phalanx may not be a cause of, but rather a result of, an overcurving deformity.

Interferon-alpha enhances CD317 expression and the antitumor activity of anti-CD317 monoclonal antibody in renal cell carcinoma xenograft models.

A murine (mAHM) and a humanized (AHM) monoclonal antibody against CD317 (also called tetherin, BST2, or HM1.24 antigen), expressed preferentially in neoplastic B cells such as multiple myeloma, exhibited antitumor effects as a result of antibody-dependent cellular cytotoxicity (ADCC). The putative interferon (IFN) response elements IRF-1/2 and ISGF3 are present in the promoter of the CD317 gene, and IFN has been used for the treatment of not only myeloproliferative diseases but also solid tumors such as renal cell carcinoma (RCC) and melanoma. Therefore, we examined the effects of IFN on the expression of CD317 and on the antitumor activity of AHM and mAHM in RCC and melanoma. Flow cytometry and in vitro ADCC assays with human or mouse effector cells demonstrated that IFN-alpha markedly increased the amount of cell surface CD317 and augmented the ADCC activity of mAHM and AHM in RCC cells and to a lesser extent in melanoma cells. Administration of IFN-alpha to mice bearing RCC xenografts also increased the expression of CD317 in tumor cells. When coadministered with IFN-alpha, mAHM exhibited more profound antitumor activity in both IFN-alpha-sensitive and -insensitive RCC xenograft models. Thus, AHM in combination with IFN-alpha may be an effective therapy for the treatment of RCC.

Low-dose thalidomide plus low-dose dexamethasone therapy in patients with refractory multiple myeloma.

We report the results of a non-randomized phase II study of low-dose thalidomide plus low-dose dexamethasone therapy in 66 patients with refractory multiple myeloma. The overall response rate (near complete, partial and minimal response) was 63.6%, and progression-free and overall survival periods were 6.2 and 25.4 months. In adverse events, the incidence of peripheral neuropathy and deep vein thrombosis was lower than the data reported in USA and Europe. On the other hand, leukopenia was observed in 41% of patients, including 11% of those with Grade 3. Leukopenia was closely related to pretreatment pancytopenia, especially thrombocytopenia. The incidence of adverse events related to dexamethasone was low. In conclusion, low-dose thalidomide plus low-dose dexamethasone therapy was as effective as high-dose thalidomide plus high-dose dexamethasone therapy in patients with refractory multiple myeloma. Leukopenia is one of the most serious adverse events in Japanese patients, especially in patients with pretreatment pancytopenia.

Development of the 3D-cephalogram: a technical note.

INTRODUCTION: The authors developed the 3D-cephalogram via combination of 3D-CT and cephalometric analysis. METHODS: The 3D-cephalogram can directly express cephalometric data on the surface of skeletal structures in a manner similar to a conventional cephalogram. RESULTS: This analysis revealed complex facial asymmetries in particular, on either side of the mandible. Images displayed no geometric error due to magnification nor any overlap effect inherent in the conventional cephalogram. CONCLUSIONS: The 3D-cephalogram is helpful in instructing physicians, and patients themselves regarding pathological anatomy and treatment procedures.

Novel strategy for orbital tumor resection: surgical "displacement" into the maxillary cavity.

Surgical intervention consisting of lateral orbitotomy, the indication of which is extremely wide for orbital tumor surgery, has been applied in cases of large, retrobulbar cavernous hemangioma. However, no method exists involving displacement of the tumor from the crowded orbital contents, with the exception of tumor traction toward the outer side. The impact of traction force on the fragile hemangioma is extremely traumatic and dangerous. The authors examined how a tumor might be "displaced" in the absence of traction force effect, into an appropriate cavity neighboring the orbit. The maxillary sinus may afford the most suitable space to shift the laterally situated orbital tumor. Thus, the osteotomy level was extended to the lateral half of the inferior orbital floor and orbital rim in order to displace the tumor through an "escape window" of sufficient size between the orbit and maxilla. This report describes the treatment of two cases with long histories of progressive proptosis associated with retrobulbar large cavernous hemangiomas. This novel procedure resulted in a successful outcome. The current approach and management, which involves displacement of the tumor into the maxillary sinus through the orbital floor escape window, is a novel procedure for orbital tumor surgery.

Construction of a conventional non-radioisotope method to quantify HM1.24 antigens: correlation of HM1.24 levels and ADCC activity of the humanized antibody against HM1.24.

A humanized monoclonal antibody (mAb) against HM1.24 (AHM) caused antibody-dependent cellular cytotoxicity (ADCC) against multiple myeloma (MM) cells. Here, we constructed a conventional non-radioisotope method that quantifies the amount of HM1.24 using fluorescein-labeled AHM. More than 10(4) molecules/cell of HM1.24 were detected in 12 out of 14 patients' MM cells, and a linear correlation was found between ADCC by AHM and the amounts of HM1.24. Thus, AHM is likely to be more efficacious against MM cells with high levels of HM1.24. This conventional non-RI method to quantify HM1.24 will be useful to select patients most likely to respond to AHM.

Antitumor activity of humanized monoclonal antibody against HM1.24 antigen in human myeloma xenograft models.

A humanized monoclonal antibody against HM1.24 antigen (AHM), which is highly expressed on multiple myeloma (MM) cells, induced antibody-dependent cellular cytotoxicity (ADCC) in vitro. In this study, we further characterized AHM and evaluated its potency for clinical application. AHM bound to HM1.24 antigen with a dissociation constant of 0.35 nM, and its epitope resided between Leu116 and Leu127 of the HM1.24 antigen. Single intravenous injection of AHM significantly inhibited tumor growth in both orthotopic and ectopic human MM xenograft models. AHM reduced serum M protein levels and prolonged survival of mice intravenously inoculated with KPMM2 and ARH-77 cells. The number of KPMM2 cells in bone marrow or tumor volume of subcutaneously inoculated RPMI 8226 cells was also inhibited by AHM. The antitumor activity of AHM against tumor cells in bone marrow was diminished when the mice were pretreated with anti-Fcgamma receptor III/II antibody, demonstrating that antitumor activity by AHM requires effector cell functions in vivo. Experiments involving in vitro ADCC assays indicated that NK cells and monocytes/macrophages serve as effector cells for AHM-induced ADCC in mouse and human. Thus, AHM will provide an additional treatment option for MM.

Generation of potent antitumor CTL from patients with multiple myeloma directed against HM1.24.

PURPOSE: The purpose of this work was to test the suitability of the HM1.24 antigen as a CTL target for immunotherapy of patients with multiple myeloma. EXPERIMENTAL DESIGN: Antigen-specific T cells were generated from patients with multiple myeloma using stimulation with protein-pulsed dendritic cells and tested in ELISPOT and CTL assays. RESULTS: HM1.24-primed T cells responded selectively to HM1.24-loaded autologous peripheral blood mononuclear cells (PBMC) in an IFN-gamma ELISPOT assay (median, 342; range, 198-495 IFN-gamma-producing cells/10(5) cf. unloaded PBMC median, 98; range, 7-137; P < 0.05, n = 5) and also to autologous malignant plasma cells (MPC; median, 227; range, 153-335; P < 0.05 when compared with the response to allogeneic MPC median, 57; range, 22-158; n = 5). HM1.24-primed T cells lysed autologous MPC (at 20:1 E/T ratio: median, 48% specific killing; range, 23-88%; at 10:1 E/T ratio: median, 43%; range, 15-80%; n = 12) but not allogeneic MPC. Lysis of autologous MPC was inhibited by anti-MHC class I but not anti-MHC class II antibodies and was blocked by Concanamycin A. Lysis of autologous MPC was blocked by competition with autologous HM1.24-transfected dendritic cells (10:1 ratio with autologous MPC). Unmanipulated, or control plasmid-transfected dendritic cells had no effect on lysis of autologous MPC. CONCLUSION: Our results indicate that HM1.24 is a promising target for immunotherapy of multiple myeloma.

Orbital wall reconstruction with bone grafts from the outer cortex of the mandible.

AIM: The purpose of the study was to assess the efficacy of bone grafting from the mandibular outer cortex for reconstructing the orbital walls. MATERIAL AND METHODS: Bone grafting was performed in 75 patients. The site the transplants were harvested from were: A: mental region, B: area posterior to the mental foramen, C: ramus region. In order to obtain the appropriate curvature for the orbital floor, proper selection of the donor area is required. The bony defect size was confirmed pre-operatively from 3D-CT data. Bone, characteristically 2-3 mm thick, was harvested from each area and grafted into the blow-out fractures. RESULTS: Out of the 75 patients 13 cases underwent reconstruction using mandibular outer cortex bone from area A, 8 from area B, and 54 from area C. The maximum size available for harvest from area C was 7 x 4 cm; material from this area could also be used for the repair of both medial and inferior orbital wall defects if necessary. CONCLUSION: Bone harvest from the mandible affords several advantages including (1) ease of harvest, (2) ease of trimming, (3) appropriate size and curvature, (4) absence of functional disability, (5) no secondary deformity, (6) no visible scars, (7) post-operative immobilization not necessary, (8) absence of post-operative difficulties with respect to breathing and walking and (9) major complications are rare.

[Thalidomide treatment of patients with refractory myeloma in the institutes participating in the Japan Myeloma Study Group].

Thalidomide was used in 73 patients with refractory myeloma in 15 of 45 institutes participating in the Japan Myeloma Study Group. The mean age and male/female ratio were 63.8 years and 0.92 (35/38), respectively. Thirty-four patients (47%) were treated with only thalidomide, 27 patients (37%) were treated with thalidomide and steroids, and 12 (16%) were treated with thalidomide and chemotherapy. The mean initial, maximum, and maintenances dose of thalidomide were 111.0, 204.8, and 163.0 mg/day, respectively. Almost all of the patients were maintained on low-dose thalidomide between 100-200 mg/day. Complete, near complete and partial response was obtained in 31 patients (42.5%). The progression-free and overall survivals after thalidomide therapy were 9.8 and 21.3 months, respectively. The most common adverse effects were gastrointestinal disturbance, peripheral neuropathy, psychological signs, and skin eruption. In contrast to reports from Europe and America, no deep vein thrombosis was observed in this study. On the other hand, leukopenia was relatively frequently observed, and might be recognized as a serious adverse effect in myeloma patients. In conclusion, low-dose thalidomide is a useful and safe tool for the treatment of refractory myeloma.

High-dose chemotherapy and autologous peripheral blood stem cell transplantation in high-risk multiple myeloma.

We compared the effect of high-dose therapy together with autologous peripheral blood stem cell transplantation (autoPBSCT) in 60 patients with multiple myeloma (MM) with 90 patients who underwent conventional chemotherapy. We scored the prognostic factors according to our reported classification system that includes measurements of serum albumin, serum beta-2-microglobulin, and morphology of myeloma cells selected by multivariate analysis. We separated the patients into three risk groups at stratification level I (low, intermediate and high) and into two risk groups at stratification level II (low and high). AutoPBSCT tended to be as effective for high, as for low-risk patients in level I, and was obviously as helpful for high, as for low-risk patients in stratification II. In conclusion, high-risk patients with MM should be treated with high-dose therapy accompanied with autoPBSCT like low-risk patients.