Characteristics of Metachronous Remnant Gastric Cancer After Proximal Gastrectomy: A Retrospective Analysis.

PURPOSE: Despite annual endoscopy, patients with metachronous remnant gastric cancer (MRGC) following proximal gastrectomy (PG) are at times ineligible for endoscopic resection (ER). This study aimed to clarify the clinical risk factors for ER inapplicability. MATERIALS AND METHODS: We reviewed the records of 203 patients who underwent PG for cT1 gastric cancer between 2006 and 2015. The remnant stomach was categorized as a pseudofornix, corpus, or antrum. RESULTS: Thirty-two MRGCs were identified in the 29 patients. Twenty MRGCs were classified as ER (ER group, 62.5%), whereas 12 were not (non-ER group, 37.5%). MRGCs were located in the pseudo-fornix in 1, corpus in 5, and antrum in 14 in the ER group, and in the pseudo-fornix in 6, corpus in 4, and antrum in 2 in the non-ER group (P=0.019). Multivariate analysis revealed that the pseudo-fornix was an independent risk factor for non-ER (P=0.014). In the non-ER group, MRGCs at the pseudo-fornix (n=6) had more frequent undifferentiated-type histology (4/6 vs. 0/6), deeper (≥pT1b2; 6/6 vs. 2/6) and nodal metastasis (3/6 vs. 0/6) than non-pseudo-fornix lesions (n=6). We examined the visibility of the region developing MRGC on an annual follow-up endoscopy one year before MRGC detection. In seven lesions at the pseudofornix, visibility was only secured in two (28.6%) because of food residues. Of the 25 lesions in the non-pseudo-fornix, visibility was secured in 21 lesions (84%; P=0.010). CONCLUSIONS: Endoscopic visibility increases the chances of ER applicability. Special preparation is required to ensure the complete clearance of food residues in the pseudo-fornix.

Understanding the Mechanical Forces on the Sacrum Can Help Optimize Flap-based Pilonidal Sinus Reconstruction.

Background: Pilonidal sinus can be treated with excision and flap reconstruction, but treatment is often complicated by wound dehiscence, infection, and recurrence. Understanding the mechanical forces on the sacrococcygeal area during posture change could help guide optimal flap choice. Methods: Sixteen volunteers underwent measurements of skin-stretching, pressure, and shear stress on the sacrum when sitting relative to standing. Skin-stretching was measured by drawing a 4 × 4 cm square on the sacrum and measuring the vertical, horizontal, and diagonal axes. Pressure and shear stress was measured at six sacral points with a device. The data analysis highlighted the potential of the superior gluteal artery perforator (SGAP) flap for dissipating mechanical forces. Ten pilonidal sinus cases treated with SGAP flaps were retrospectively reviewed for 6-month outcomes. Results: Sitting is associated with high stretching tension in the horizontal direction [estimated marginal mean (95% confidence intervals) = 17.3% (15.4%-22.6%)]. The lower sacrum experienced the highest pressure [106.6 (96.6-116.5) mm Hg] and shear stress [11.6 (9.7-13.5) N] during sitting. The transposed SGAP flap was deemed to be optimal for releasing the horizontal tension and providing sufficient subcutaneous tissue for ameliorating pressure/shear stress during sitting. It also has high blood flow and can therefore be used with large lesions. Moreover, its donor site is above the high-pressure/stress lower sacrum. Retrospective analysis showed that no patients experienced complications. Conclusions: Sitting is associated with high mechanical forces on the sacrococcygeal skin. The transposed SGAP flap may ameliorate these forces and thereby reduce the risk of complications of pilonidal sinus reconstruction for large defects.

From Time to Timer in Wound Healing Through the Regeneration.

Hard-to-heal wounds are an important public health issue worldwide, with a significant impact on the quality of life of patients. It is estimated that approximately 1-2% of the global population suffers from difficult wounds, which can be caused by a variety of factors such as trauma, infections, chronic diseases like diabetes or obesity, or poor health conditions. Hard-to-heal wounds are often characterized by a slow and complicated healing process, which can lead to serious complications such as infections, pressure ulcers, scar tissue formation, and even amputations. These complications can have a significant impact on the mobility, autonomy, and quality of life of patients, leading to an increase in healthcare and social costs associated with wound care. The preparation of the wound bed is a key concept in the management of hard-to-heal wounds, with the aim of promoting an optimal environment for healing. The TIME (Tissue, Infection/Inflammation, Moisture, Edge) model is a systematic approach used to assess and manage wounds in a targeted and personalized way. The concept of TIMER, expanding the TIME model, further focuses on regenerative processes, paying particular attention to promoting tissue regeneration and wound healing in a more effective and comprehensive way. The new element introduced in the TIMER model is "Regeneration", which highlights the importance of activating and supporting tissue regeneration processes to promote complete and lasting wound healing. Regenerative therapies can include a wide range of approaches, including cellular therapies, growth factors, bioactive biomaterials, stem cell therapies, and growth factor therapies. These therapies aim to promote the formation of new healthy tissues, reduce inflammation, improve vascularization, and stimulate cellular proliferation to accelerate wound closure and prevent complications. Thanks to continuous progress in research and development of regenerative therapies, more and more patients suffering from difficult wounds can benefit from innovative and promising solutions to promote faster and more effective healing, improve quality of life, and reduce the risk of long-term complications.

A Case of Frostbite on Hands due to Liquid Nitrogen.

This study examines a rare case of frostbite on the hands caused by liquid nitrogen, focusing on the scar maturation process. Frostbite is typically less prone to abnormal scarring compared to burns, and this report contrasts the differences in scar maturation between the two. A 31-year-old male hospital employee sustained first- to second-degree frostbite on his gloved hands from a 20-second exposure to liquid nitrogen while changing a cylinder. Conservative treatment was applied, and the patient was monitored for 9 months. The deeply affected area took 50 days to epithelialize but healed without hypertrophic scarring. A mild extension contracture was noted in the distal interphalangeal joint of the right index finger, but the skin remained supple and soft. Incidents of liquid nitrogen-induced frostbite are uncommon, with only 14 cases reported in PubMed® previously. In frostbite, the wound healing involves a slow replacement of damaged connective tissue, which acts as an internal splint, reducing wound contraction. This contrasts with burns, where rapid connective tissue replacement occurs, often leading to significant wound contraction due to the presence of myofibroblasts in granulation tissue. In the presented case, the slow healing process and minimal wound contraction led to mature scarring without abnormalities, underlining a distinctive healing trajectory in frostbite injuries compared to burns.

Key nodal stations for predicting splenic hilar nodal metastasis in upper advanced gastric cancer without invasion of the greater curvature.

Background: Standard surgery for upper advanced gastric cancer without invasion of the greater curvature (UGC-GC) is spleen-preserving D2 total gastrectomy without dissection of the splenic-hilar nodes (#10). However, some patients with nodal metastasis to #10 survive more than 5 years due to nodal dissection of #10. If nodal metastasis to #10 is predictable based on the positivity of other nodes dissected by the current standard surgery without #10 nodal dissection, physicians may be able to consider #10 dissection. Methods: This study retrospectively reviewed data from the National Cancer Center Hospital in Japan between 2000 and 2012. We selected cases that met the following criteria: (1) D2 or more total gastrectomy with splenectomy, (2) UGC-GC, and (3) histological type is gastric adenocarcinoma. We performed univariate and multivariate analyses concerning lymph node stations associated with #10 metastasis. Results: A total of 366 patients were examined. A multivariate analysis revealed that #10 metastasis was associated with positivity of the nodes along the short gastric arteries (#4sa) and distal nodes along the splenic artery (#11d) (#4sa: p = 0.003, #11d: p = 0.016). When either key node was positive, the metastatic rate of #10 was 24.4%, and the therapeutic value index was 13.3. Conclusions: #4sa and #11d were key lymph nodes predicting #10 nodal metastasis in UGC-GC. When these key nodes are positive on computed tomography before surgery or according to a rapid pathological examination during surgery, dissection of #10 should be considered even if upper advanced tumors are not invading the greater curvature.

Head and Neck Reconstruction in Burn Patients.

Reconstruction of burns in the head and neck region is challenging. This is because it must achieve both functional reconstruction and esthetic reconstruction. Local flaps are best for minor defects, particularly in the case of deep burns, because they bear the correct texture and color. However, for large deep burn wounds, simple grafting or small local flaps will not produce satisfactory results. It is also crucial to assess the extent and depth of reconstruction that is needed throughout the face-neck-anterior chest region, and to make the choice between techniques such as Z-plasty, skin grafting, super-thin flaps, and free flaps.

Update on Hypertrophic Scar Management in Burn Patients.

Hypertrophic scars arise from burn injuries because of persistent inflammation in the reticular dermis. Several risk factors promote this chronic inflammation. One is tension on the burn wound/scar due to surrounding skin tightness and bodily movements. High estrogen levels and hypertension are also important systemic risk factors. Thus, to prevent burn wounds from developing into hypertrophic scars, it is important to focus on quickly resolving the reticular dermal inflammation. If conservative treatments are not effective and the hypertrophic scar transitions to scar contracture, surgical methods such as Z-plasty, full-thickness skin grafting, and local flaps are often used.

In the face and neck, keloid scar distribution is related to skin thickness and stiffness changes associated with movement.

Keloid scars tend to occur in high-tension sites due to mechanical stimuli that are involved in their development. To date, a detailed analysis of keloid distribution focused specifically on facial and neck areas has not been reported, and limited literature exists as to the related mechanical factors. To rectify this deficiency of knowledge, we first quantified the facial and neck keloid distribution observed clinically in 113 patients. Subsequently, we performed a rigorous investigation into the mechanical factors and their associated changes at these anatomic sites in healthy volunteers without a history of pathologic scarring. The association between keloid-predilection sites and sebaceous gland-dense and acne-prone sites was also examined. To assess skin stretch, thickness and stiffness, VECTRA, ultrasound and indentometer were utilised. Baseline skin stiffness and thickness were measured, as well as the magnitude of change in these values associated with facial expression and postural changes. Within the face and neck, keloids were most common near the mandibular angle (41.3%) and lateral submental (20.0%) regions. These areas of increased keloid incidence were not associated with areas more dense in sebaceous glands, nor linked consistently with acne-susceptible regions. Binomial logistic regression revealed that changes in skin stiffness and thickness related to postural changes significantly predicted keloid distribution. Skin stiffness and thickness changes related to prolonged mechanical forces (postural changes) are most pronounced at sites of high keloid predilection. This finding further elucidates the means by which skin stretch and tension are related to keloid development. As a more detailed analysis of mechanical forces on facial and neck skin, this study evaluates the nuances of multiple skin-mechanical properties, and their changes in a three-dimensional framework. Such factors may be critical to better understanding keloid progression and development in the face and neck.

The effects of systemic diseases, genetic disorders and lifestyle on keloids.

Keloid are a fibroproliferative disorder caused by abnormal healing of skin, specifically reticular dermis, when subjected to pathological or inflammatory scars demonstrating redness, elevation above the skin surface, extension beyond the original wound margins and resulting in an unappealing cosmetic appearance. The severity of keloids and risk of developing keloids scars are subjected to elevation by other contributing factors such as systemic diseases, general health conditions, genetic disorders, lifestyle and natural environment. In particular, recently, daily physical work interpreted into mechanical force as well as the interplay between mechanical factors such as stress, strain and stiffness have been reported to strongly modulate the cellular behaviour of keloid formation, affect their location and shape in keloids. Herein, we review the extensive literature on the effects of these factors on keloids and the contributing predisposing mechanisms. Early understanding of these participating factors and their effects in developing keloids may raise the patient awareness in preventing keloids incidence and controlling its severity. Moreover, further studies into their association with keloids as well as considering strategies to control such factors may help clinicians to prevent keloids and widen the therapeutic options.

The Square-Plus Flap: A Modification to Release Long Postburn Scar Contractures.

The square flap method has been successful in releasing contracture bands at various body regions. However, the original square flap method alone may not be efficient in releasing long contracture bands. We, therefore, proposed an extended design to the traditional design, which is called the "square-plus flap." A 4-year-old girl presented with a postburn web-like contracture band over the right axilla. We marked a square flap technique at the center of the contracture band and then two additional Z-plasties were placed on both edges of the flap. After the release and securing of the square flap, the adjacent distal Z-plasty was then transposed and sutured in their new locations. We do not need to incise the proximal Z-plasty as we could achieve complete relaxation of the contracture band. This novel modification can be added to the plastic surgeon's armamentarium for releasing long postburn contracture bands involving distinct body regions.

Posterior Auricle Bilobed Cartilage-skin Flap for Reconstructing the Earlobe: A Case Report.

Because the auricle plays an important role in facial aesthetics, all earlobe operations must seek to limit postoperative ear deformity. This report describes the single-stage posterior-auricle bilobed cartilage-skin flap technique for reconstructing the earlobe. A 31-year-old man incurred a left earlobe deficiency due to a human bite. Earlobe reconstruction was conducted 102 days later. A bilobed flap was designed on the posterior-auricular skin. Both flaps were pedicled in the caudal posterior-auricular area. The first incision raised the upper lobe, which consisted of posterior-auricle skin and conchal cartilage. The skin was sutured to the auricle base so that it formed the anterior earlobe. The cartilage was then cut to separate and processed to the natural curve. The second incision elevated the second flap from the caudal posterior-auricular area. This was sutured to the first flap so that it formed the posterior earlobe. The donor sites were closed with simple sutures. The reconstructed earlobe had no obvious contracture after surgery. Most donor-site scarring was hidden behind the auricle. At 9 months postoperative, the patient was satisfied with the result. Our technique allows us to harvest cartilage from the same operative field, perform a single-stage reconstruction, and recreate a relatively large earlobe with good size and shape. The posterior auricle bilobed cartilage-skin flap technique is useful for earlobe reconstruction.

Ear Keloid as an Unusual Complication of Prolonged Mask Use during the COVID-19 Pandemic.

The recent COVID-19 pandemic required many people to wear ear-loop face masks (ELFMs) for protracted periods, and ear injuries have been reported. Here, we report a rare case of a keloid on the right posterior ear that appeared to arise from prolonged ELFM use. A 76-year-old Japanese man presented with a 7.3 × 2.2 × 1.4-cm keloid running from the medial retroauricular sulcus to the posterior lobule. The lack of keloid history suggested the absence of genetic risk factors. The patient reported extensive mask-wearing habits that were augmented by the pandemic. The keloid developed from an ear injury. Although it healed well, it started thickening 2 months later. Because local mechanical forces (eg, pressure/friction) can promote keloid growth, the ELFM may have provoked the keloid. The patient disclosed a history of uncontrolled hypertension and diabetes mellitus, which associate with severe keloids. The whole keloid was removed via total excision, and the defect was closed primarily and subjected to 15Gy/2Fr radiotherapy. The patient was advised to use a different mask type. Twelve months later, the scar had healed without complications or recurrence and with good cosmetic outcomes. Thus, ELFMs can promote retroauricular keloid formation, possibly by imposing local pressure/friction. ELFMs may also raise local skin temperatures and humidity, thereby fostering infection, which can trigger keloids. Hypertension/diabetes may further elevate the risk of EFLM-induced keloid. Thus, an auricular keloid is an unusual complication of prolonged ELFM use. Combination therapy can have excellent outcomes. Patients with keloid risk factors should be advised to use face masks without ear loops.

Cheek Reconstruction with a Nasolabial External-Rotation Flap.

It remains difficult to reconstruct large preauricular defects in a single step with good cosmetic outcomes. We describe here the nasolabial external-rotation (NER) flap, which was combined with a cervical-rotation flap to reconstruct a large skin defect on the preauricular area that included the malar prominence. The patient in case 1 was a 91-year-old man who had a large defect on his right cheek after excision of a squamous cell carcinoma. Three weeks after excision, the 6.5 × 5.5 cm defect was covered with a 5 × 3 cm NER flap, which had a cephalad base and was rotated so its caudal tip covered the malar prominence. The resulting nasolabial defect and the remaining defect occupied the entire buccomandibular area, which was then covered with a 13 × 10 cm cervical-rotation flap. Revision surgery has not been needed for 8.5 months and the cosmetic outcomes are good. The patient in case 2 was a 90-year-old man who had a large defect on his right cheek after excision of a squamous cell carcinoma. Four weeks after excision, the 4.7 × 4 cm defect was covered with an 8 × 3 cm NER flap. The buccomandibular defect was covered with a 9.5 × 5 cm cervical-rotation flap. The flaps survived completely. The NER flap is unique because the flap is moved from the midface to the lateral face. It can reconstruct the malar prominence with thick skin tissue, and it is particularly suitable for older patients. Combining it with a cervical-rotation flap allows for natural subunit reconstruction in a relatively minimally invasive manner with good aesthetic outcomes.

168 Cases of aneurysmal dermatofibroma and 29 cases of hemosiderotic dermatofibroma: A clinicopathologic study.

OBJECTIVES: Aneurysmal dermatofibroma (ADF) and hemosiderotic dermatofibroma (HDF) are rare variants of dermatofibroma (DF) characterized by distinct histologic features. While HDF is traditionally considered a precursor to ADF, supporting evidence is limited, and the etiology remains unclear. A retrospective analysis of 2128 DF cases (2016-2019) was conducted to investigate the clinicopathologic characteristics of ADF, HDF, and other DFs. METHODS: Histopathologically diagnosed DF cases were examined for ADF and HDF. Univariate analyses were performed to compare clinicopathologic features. RESULTS: Among the cases, 168 (7.9%) were ADF and 29 (1.4%) were HDF. Aneurysmal dermatofibroma and HDF shared several common characteristics, including lower occurrence in females, larger size, and increased cellularity (all P < .0001). Notably, 29% of ADFs lacked hemosiderin deposition. Aneurysmal dermatofibroma primarily manifested on exposed areas (face and forearm, both P < .001). In contrast, 41% of HDFs occurred on the lower leg (P = .018), and all lower leg HDFs exhibited signs of venous stasis, distinguishing them from other HDFs (P < .0001). CONCLUSIONS: Our findings indicate a potential close relationship between ADF and HDF. Contrary to conventional beliefs, we also presented the possibility of ADF progressing into HDFs. Physical trauma may induce ADF, and HDFs may emerge from ADFs in conjunction with venous stasis in the lower extremities.

Continuous glucose monitoring metrics following sub-Tenon's injection of triamcinolone acetonide for diabetic macular edema.

PURPOSE: This pilot study aims to comprehensively evaluate the effects of sub-Tenon's injection of triamcinolone acetonide (STTA) on glycemic control in patients with diabetic macular edema (DME) using professional continuous glucose monitoring (CGM). METHODS: This retrospective study analyzed changes in glycemic control in 20 patients with type 2 mellitus and DME following single STTA (20 mg/0.5 mL) using The FreeStyle Libre Pro system. Professional CGM provides core CGM metrics such as the percentage of time that glucose levels fall within a target range and include the time in range (TIR) (70-180 mg/dL), time above range (TAR) (> 180 mg/dL), and time below range (TBR) (< 70 mg/dL). Outcome measures were the changes in CGM metrics (TIR, TAR and TBR) and the percentage of patients in whom TAR increased by at least 10 percentage points (ppt) 4 days before to 4 days after STTA administration. RESULTS: The mean CGM metrics (TIR/TAR/TBR) were 75.5%/19.9%/4.4% 4 days before STTA and 73.7%/22.4%/3.5% 4 days after STTA; the metrics 4 days before and 4 days after STTA were not significantly different (P = 0.625 for TIR, P = 0.250 for TAR, and P = 0.375 for TBR). TAR increased by more than 10 ppt in four (20%) patients treated with sulfonylurea and/or insulin. CONCLUSION: Although there were no significant changes in the CGM metrics, four patients developed CGM-measured hyperglycemia after STTA for DME.

The HEDGEHOG-GLI1 pathway is important for fibroproliferative properties in keloids and as a candidate therapeutic target.

Keloids are benign fibroproliferative skin tumors caused by aberrant wound healing that can negatively impact patient quality of life. The lack of animal models has limited research on pathogenesis or developing effective treatments, and the etiology of keloids remains unknown. Here, we found that the characteristics of stem-like cells from keloid lesions and the surrounding dermis differ from those of normal skin. Furthermore, the HEDGEHOG (HH) signal and its downstream transcription factor GLI1 were upregulated in keloid patient-derived stem-like cells. Inhibition of the HH-GLI1 pathway reduced the expression of genes involved in keloids and fibrosis-inducing cytokines, including osteopontin. Moreover, the HH signal inhibitor vismodegib reduced keloid reconstituted tumor size and keloid-related gene expression in nude mice and the collagen bundle and expression of cytokines characteristic for keloids in ex vivo culture of keloid tissues. These results implicate the HH-GLI1 pathway in keloid pathogenesis and suggest therapeutic targets of keloids.

Scars.

Wound healing occurs as a response to disruption of the epidermis and dermis. It is an intricate and well-orchestrated response with the goal to restore skin integrity and function. However, in hundreds of millions of patients, skin wound healing results in abnormal scarring, including keloid lesions or hypertrophic scarring. Although the underlying mechanisms of hypertrophic scars and keloid lesions are not well defined, evidence suggests that the changes in the extracellular matrix are perpetuated by ongoing inflammation in susceptible individuals, resulting in a fibrotic phenotype. The lesions then become established, with ongoing deposition of excess disordered collagen. Not only can abnormal scarring be debilitating and painful, it can also cause functional impairment and profound changes in appearance, thereby substantially affecting patients' lives. Despite the vast demand on patient health and the medical society, very little progress has been made in the care of patients with abnormal scarring. To improve the outcome of pathological scarring, standardized and innovative approaches are required.

A Case of Axillary Fibroadenoma That Grew Rapidly from Axillary Accessory Breast Tissue over 40 Days.

Axillary accessory breast (AAB) occurs in 2%-6% of women. Like normal breast tissue, ABB can undergo changes, including periodic enlargement that can result in a palpable axillary mass. Fibroadenoma is the most common benign subcutaneous tumor of the breast: it occurs in approximately 25% of women and accounts for 50% of all breast biopsies. However, fibroadenoma in AAB is rare (2.6%). Here, we describe the case of a patient who was diagnosed first with left AAB on the basis of clinical and magnetic imaging resonance findings, and then 40 days later with fibroadenoma in left AAB by histopathology of the resected mass. The tumor, which had been undetectable at the initial visit, had transformed into a clinically obvious, hard, protruding mass at surgery. Thus, fibroadenomas originating from AAB can grow quickly, and imaging-based diagnosis should be confirmed with histology. Treatment should involve complete excision of the fibroadenoma and surrounding AAB.

Utilizing 3D Printing for the Surgical Management of Orbital Floor Fractures.

We present a technique for treating orbital floor fractures using three-dimensional (3D) printing technology and a preoperative template based on the mirror image of the unaffected orbit. Our patient, a 56-year-old man, experienced persistent diplopia in the upward direction and left enophthalmos after previous open reduction internal fixation surgery. To address these complications, we used a simulation of the ideal orbital floor from computed tomography images and used a 3D printer to create a template. Subsequently, an absorbable plate was molded intraoperatively based on this template. Notably, the plate fit seamlessly into the fracture site without requiring any adjustment, reducing the operation time. Postoperative computed tomography scans confirmed successful reduction, improved visual function, and the absence of complications. Our method offers a precise and efficient approach to reconstructing fractured orbital floors. By leveraging 3D printing technology and preoperative templates, surgeons can enhance postoperative outcomes and minimize patient burden. Further investigations are warranted to assess the long-term effectiveness and cost-effectiveness of this technique. Our findings highlight the potential of this approach to improve treatment strategies for patients with orbital floor fractures.