Case of giant juvenile angiofibroma resected by external incision with temporary double balloon occlusion of the internal carotid artery by intraoperative endovascular treatment.

We report the first case of a juvenile nasal angiofibroma (JNA) fed by multiple arteries from the internal carotid artery (ICA), removed without complications by temporarily blocking the ICA with two balloons. An early adolescent with JNA underwent preoperative embolisation of feeding arteries arising from the external carotid artery (ECA) (University of Pittsburgh Medical Centre classification IV). Endoscopic resection was attempted once but discontinued due to massive bleeding (7000 mL). 17 months later, the JNA had grown to fill both nasal cavities. Repeated preoperative embolisation of the feeders from the ECA was performed, followed by surgery combined with endoscopic and external incision. Intraoperatively, two balloons were inserted into the right ICA, which were inflated at the proximal and distal sites of the feeder vessels to cut-off blood flow to the tumour. The tumour was almost completely resected with 6270 mL of blood loss and no postoperative neurological deterioration.

Comparison of complications and functional outcomes following total or subtotal glossectomy with laryngeal preservation using a deep inferior epigastric artery perforator free flap versus a rectus abdominis musculocutaneous free flap.

OBJECTIVE: Wide defects resulting from subtotal or total glossectomy are commonly reconstructed using a bulk flap to maintain oral and speech functions. The flap, including muscle tissue, diminishes with time. This study aimed to compare the surgical outcomes of deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions after glossectomy with laryngeal preservation. METHODS: Medical records of 13 and 26 patients who underwent deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions, respectively, from 2014 to 2022 at our institution were reviewed. Patients who underwent middle pharynx resection except for the base of the tongue, mandibular bone resection, and sensory reinnervation were excluded. RESULTS: The rectus abdominis musculocutaneous groups showed a higher number of lymph node dissection and shorter operative time than the deep inferior epigastric artery perforator groups. No significant differences in postoperative complications or functional oral intake scale scores at 6 months were observed. Volumetric changes on computed tomography images at 6 and 12 months were significantly lower in the deep inferior epigastric artery perforator group. Cancer recurrence was significantly associated with reduced oral function. CONCLUSIONS: Oral function in patients with cancer is influenced by various other factors. However, the deep inferior epigastric artery perforator flap may be suitable for tongue reconstruction because of the minimal postoperative changes in flap volume, easy adjustment of flap thickness, elevation of multiple flaps, and minimal complications at the donor site.

Long-term surgical and functional outcomes after anterolateral thigh flap and free jejunal transfer reconstruction of circumferential pharyngoesophageal defects.

BACKGROUND: Circumferential pharyngoesophageal defects resulting from total pharyngolaryngectomy are commonly reconstructed using free jejunal (FJ) transfer or an anterolateral thigh (ALT) free flap. METHODS: We reviewed the medical records of 92 patients with ALT free flaps and 140 who underwent FJ transfer between 2009 and 2022, and compared their surgical outcomes. RESULTS: Total flap loss occurred in two (2%) and five (4%) patients in the ALT free flap and FJ transfer groups, respectively. Fistula rates were 5% in both groups. Stricture rates were 21% and 5% in the ALT free flap and FJ transfer groups, respectively (p < 0.01). At the 5-year follow-up evaluation, intelligible speech was achieved by 83% and 28% of patients (p < 0.01) in the ALT free flap and FJ transfer groups, respectively. CONCLUSIONS: Each reconstructive method can be further optimized by proficient surgeons with expertise in the available methods and by considering patient-specific factors and available evidence.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan.

BACKGROUND: There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction. METHODS: This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence. RESULTS: Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15. CONCLUSION: The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Management of recurrent acquired choanal atresia with radial forearm free flap transfer.

Acquired choanal atresia is a rare complication of pharyngeal surgical interventions. Here, we report the case of a 72-year-old woman who was treated in our institution for acquired choanal atresia after failed previous treatments. We have excised the obstructing fibrotic scar tissue and then reconstructed the area using a mucosal local flap and free radial forearm flap transfer. Choanal stenosis caused by abnormal granulation was identified in the months after surgery; however, this was treated with endoscopic dilatation and steroid injections in the outpatient setting. No restenosis was identified 1 year after the operation. Postoperative evaluation of speech was satisfactory. Free flap transfer could be an option for refractory choanal atresia, and endoscopic dilatation with local steroid injections may be an effective method to treat postoperative restenosis.

Hemorrhagic Complication in Surgical Resection for Massive Plexiform Neurofibroma in Body Trunk: The Flow-Void Sign as a Predictor and Preoperative Embolization as Prevention.

BACKGROUND: Plexiform neurofibromas (PNs) are highly vascularized and potentially malignant tumors. Surgical resection of a PN can be complicated by perioperative hemorrhagic events (PHE), including excessive intraoperative blood loss and postoperative hematoma at the surgical site. This study aimed to evaluate the predictive factors of PHE and the usefulness of preoperative embolization for PN. MATERIALS AND METHODS: Consecutive surgical resections of 24 massive PNs in the body trunk with a maximum diameter > 5 cm in 22 patients between January 2015 and December 2020 were reviewed. Patient demographics, laboratory analyses, MRI findings, preoperative transcatheter arterial embolization (TAE), and pathological findings were evaluated between PNs with and without PHE, which consists of intraoperative blood loss over 15% of their estimated total blood volume and/or postoperative hematoma requiring surgical intervention or blood transfusion. RESULTS: PHE was observed in 7 out of 24 PNs (29.2%), with 5 events of excessive intraoperative bleeding and 2 postoperative hematomas. The PHE group (n = 7) showed a significantly higher flow-void effect inside the tumor on preoperative MRI than the non-PHE group (n = 17) (P = 0.0186). Preoperative TAE was not associated with PHE occurrence for the 24 PNs; however, it significantly reduced the PHE risk by 12 PNs with a flow-void sign (P = 0.00126). Other characteristics showed no significant differences between groups. CONCLUSION: The flow-void sign on MRI can be the only predictive factor of PHE in surgical resection for massive PNs in the body trunk. Preoperative TAE can reduce the PHE risk for PNs with a flow-void sign.

Recurrent Pott's Puffy Tumor Treated With Anterior Skull Base Resection With Reconstruction of the Anterolateral Thigh Flap.

Pott's puffy tumor (PPT) is a rare, life-threatening complication of frontal sinusitis that is treated with a combination of appropriate antibiotics and surgery for the removal of infected tissue. A 56-year-old man with recurrent forehead swelling was admitted and diagnosed with recurrent PPT. He had undergone endoscopic sinus surgery and pericranial abscess drainage. We planned to remove the infected tissue and bones and perform reconstruction with an anterolateral thigh (ALT) flap. Eight weeks after surgery, the patient showed no inflammation, and the antibiotics were discontinued. No recurrence was observed at 1 year and 7 months after surgery. Combined surgical and antibiotic treatment is effective for PPT. Reconstructive treatment can be chosen for refractory recurrent cases with intracranial complications. To our knowledge, this is the first report of PPT treated by anterior skull base resection with reconstruction using an ALT flap in an immunocompromised patient.

A Simple Way to Measure Glucose and Lactate Values During Free Flap Head and Neck Reconstruction Surgery.

PURPOSE: Evaluation of flap blood flow is necessary to detect flap blood flow abnormalities and perform salvage surgery. This study determined whether intra-flap blood glucose and lactate values measured with a simple instrument could detect impaired blood flow during head and neck reconstruction. MATERIALS AND METHODS: We prospectively analyzed 82 cases of head and neck cancer reconstruction (62 men and 20 women; mean age, 64.0 years [range, 20 to 88 years]), of which 74 had impeded blood flow. Glucose and lactate levels were regularly measured over a period of 48 hours, from the time of flap elevation, as predictor variables. Blood flow obstruction was the outcome variable. Other study variables included primary site, flap type, gender, age at operation, height, weight, body mass index, presence or absence of diabetes, ischemia time, and operative time. Logistic analysis, using glucose and lactate values at the time of blood flow failure, was performed. Cutoff values were calculated using a receiver operating characteristic analysis. RESULTS: The breakdown of the flaps was as follows: 20 free jejunum, 19 anterolateral thigh, 12 fibular, 11 radial forearm, 8 rectus abdominis myocutaneous, and 4 other flaps. Congestion was observed in 8 of the 82 flaps, including 3 anterolateral thigh flaps, 3 radial forearm flaps, 1 free jejunum flap, and 1 rectus abdominis myocutaneous flap. The intra-flap blood glucose values in the normally progressing cases gradually decreased until 16 hours postoperatively and thereafter recovered to normal levels. Intra-flap blood lactate values increased until 8 hours postoperatively and subsequently decreased. The odds ratio during congestion was only significantly different for lactate (odds ratio, 2.55, P = .014), and the cutoff values for sensitivity and specificity were 4.2 mmol/L and 6.7 mmol/L, respectively. CONCLUSIONS: Intra-flap blood glucose and lactate values may reflect the transition of the postoperative circulation of free flaps. During congestion, lactate values change more sensitively than blood glucose values.

Outcomes of laparoscopic resection of urachal remnants followed by novel umbilicoplasty.

OBJECTIVE: The purpose of the study was to report the outcomes of our modified techniques of laparoscopic urachal resection, followed by novel umbilical-plasty using dermal regenerative grafts for symptomatic urachal remnants. METHODS: Between March 2014 and December 2016, laparoscopic urachal resection was carried out on 45 patients with complaints of urachal remnants. After extraction of the specimen and closure of the fascia at the umbilical site, a 1-cm square section of dermal regeneration sheet (TERUDERMIS®, Olympus) was suture retained between the fascia and the skin. Patient satisfaction with cosmesis was scored prospectively using the visual analogue scale (VAS). Perioperative records were reviewed to assess surgical outcomes. RESULTS: Laparoscopic urachal resection was successfully conducted via the transperitoneal approach. Postoperative bleeding was experienced in one patient (2.2%), which was subsequently controlled laparoscopically. Infection subsided with symptomatic relief in all patients. No symptomatic recurrences were encountered. Over 80% of patients (37/45) rated the cosmetic outcome of the plasty as good to excellent, with the median scores of 8 (range 5-10). CONCLUSIONS: Laparoscopic urachal resection is safe and curative with reasonable risk of complications. Novel umbilicoplasty using dermal regenerative graft is very simple technique and offers satisfactory cosmetic outcomes. Further follow-up and cosmesis evaluation are required.

The association between surgical complications and the POSSUM score in head and neck reconstruction: a retrospective single-center study.

The Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is widely used to predict surgical complications affecting various organs. However, there are few reports about objective evaluation methods for head and neck surgery. In this study, we retrospectively examined the association between POSSUM score and actual surgical complications of head and neck reconstruction surgery. In total, 711 patients who underwent head and neck reconstruction after cancer extirpation between January 2007 and January 2015 were studied. The predicted risk of complications was calculated using the POSSUM score and compared with the actual rate of perioperative complications. Perioperative complications occurred in 178 (25%) patients, comprising systemic complications in 52 (7%) patients, surgical site infection of the head and neck area in 78 (11%) patients and failure of the free flap in 55 (8.8%) patients. When patients were divided into a perioperative complication group and a no-complication group, a significant difference between the two groups was observed in the predicted postoperative rate calculated from the POSSUM score (p < .0001, odds ratio 1.03, 95% confidence interval = 1.02-1.04). Furthermore, the cutoff value of the POSSUM score calculated from the receiver operating characteristic curve using Youden's index was 43.0%. POSSUM is a useful risk indicator for head and neck reconstruction surgery. It is possible to objectively calculate the prediction level using a standard assessment method without adding burden to any medical facility. Therefore, patients may be considered at high risk for perioperative complications when the POSSUM score is 43.0% or higher.

Efficacy of Tensed and Straight Free Jejunum Transfer for the Reduction of Postoperative Dysphagia.

BACKGROUND: Free jejunal transfer (FJT) is a standard method of reconstruction after total pharyngo-laryngo-cervical esophagectomy (TPLE) in patients with advanced head and neck cancer. However, it is related to various degrees of postoperative swallowing dysfunction. This study aimed to assess whether the tensed and straight FJT method results in a reduced rate of postoperative dysphagia compared with historical controls. METHODS: Patients who were undergoing FJT after TPLE for squamous cell carcinoma of the hypopharynx or cervical esophagus were enrolled. The primary endpoint was the rate of not developing dysphagia within 6 months of the surgery, and we compared this value with that obtained from historical data of patients who underwent FJT. The secondary endpoint was the rate of developing surgical complications. RESULTS: Although 128 patients were registered between August 2012 and July 2015, 7 were excluded based on the exclusion criteria. Of the remaining 121 patients, FJT with the craniocaudally tensed and straight method was performed in all patients. The rate of not developing dysphagia and its 95% confidence interval (CI) were 66.1% and 57.0-74.5%, respectively. The lower limit of the CI was higher than the prespecified threshold value of 50.0%. The rate of developing complications of total necrosis of the jejunum was 3.3%, cervical infection was 9.9%, and major anastomotic leakage was 4.1%. CONCLUSIONS: Our findings revealed that the proportion of postoperative dysphagia decreased in patients who underwent tensed and straight FJT. This method may become the standard surgical method in reconstruction of defects after TPLE.

Comparison of Transumbilical and Conventional Defunctioning Ileostomy in Laparoscopic Anterior Resections for Rectal Cancer.

BACKGROUND/AIM: Laparoscopic surgery has made possible anterior resections with small incisions suitable for creating stomas. We retrospectively compared surgical results and stomal complications between transumbilical defunctioning ileostomy (TDI) and conventional defunctioning ileostomy (CDI) in laparoscopic anterior resections for rectal cancer. PATIENTS AND METHODS: We compared patients who underwent laparoscopic anterior resection with TDI (n=47) with those undergoing CDI (n=27) for rectal cancer between February 2011 and January 2015. RESULTS: For the initial operations, the TDI group had significantly less intraoperative blood loss (30.3 ml vs. 117.0 ml; p=0.014). For stomal closure, the TDI group experienced significantly fewer wound infections (2 vs. 8 cases; p=0.002) and bowel obstructions (none vs. 3 cases; p=0.039). No significant differences in stomal complication rates were observed. CONCLUSION: TDI is associated with better surgical results and fewer complications than CDI after laparoscopic anterior resection for rectal cancer.

Free skin flap reconstruction after partial hypopharyngectomy with laryngeal preservation.

Surgical resection of hypopharyngeal cancer often affects laryngeal function. The aim of this study is to assess the reliability and efficacy of free skin flap transfer after partial hypopharyngectomy with laryngeal preservation. This study designs a retrospective analysis. The subjects were 54 patients who underwent free skin flap reconstruction immediately after partial pharyngolaryngectomy or hypopharyngectomy with laryngeal preservation. The defects were classified into four types based on the location of the hypopharyngeal defect. Functional results were evaluated by routine physical examination findings and parameters related to swallowing function and X-ray barium deglutition examination. Perioperative mortalities and morbidities were reviewed. There were no perioperative mortalities and 98% of the flaps survived. Forty-three patients (80%) were able to eat an unrestricted diet and experienced no aspiration. Restriction of the diet was significantly associated with the extent of oesophageal mucosal resection. In conclusion, free skin flap reconstruction is confirmed to be a safe and effective strategy to maintain laryngeal function and good quality-of-life.

Transumbilical defunctioning ileostomy: A new approach for patients at risks of anastomotic leakage after laparoscopic low anterior resection.

BACKGROUND: The use of a protective defunctioning stoma in rectal cancer surgery has been reported to reduce the rates of reoperation for anastomotic leakage, as well as mortality after surgery. However, a protective defunctioning stoma is not often used in cases other than low rectal cancer because of the need for stoma closure later, and hesitation by patients to have a stoma. We outline a novel and patient-friendly procedure with an excellent cosmetic outcome. This procedure uses the umbilical fossa for placement of a defunctioning ileostomy followed by a simple umbilicoplasty for ileostomy closure. PATIENTS AND METHODS: This study included a total of 20 patients with low rectal cancer who underwent a laparoscopic low anterior resection with defunctioning ileostomy (10 cases with a conventional ileostomy in the right iliac fossa before March 2012, and 10 subsequent cases with ileostomy at the umbilicus) at the Jikei University Hospital in Tokyo from August 2011 to January 2013. The clinical characteristics of the two groups were compared: operative time, blood loss, length of hospital stay and postoperative complications of the initial surgery, as well as the stoma closure procedure. RESULTS: There were no differences between the groups in the median operative time for initial surgery (248 min vs. 344 min), median blood loss during initial surgery (0 ml vs. 115 ml), and median hospital stay after initial surgery (13 days vs. 16 days). Complication rates after the initial surgery were similar. There were no differences between the groups in median operative time for stoma closure (99 min vs. 102 min), median blood loss during stoma closure (7.5 ml vs. 10 ml), and median hospital stay after stoma closure (8 days in both groups). Complications after stoma closure such as wound infection and intestinal obstruction were comparable. Thus, no significant differences in any factor were found between the two groups. CONCLUSION: The transumbilical protective defunctioning stoma is a novel solution to anastomotic leakage after laparoscopic rectal cancer surgery, with patient-friendliness as compared to conventional procedures in light of the cosmetic outcome.

The thoracodorsal vascular tree-based combined fascial flaps.

In this study, combined fascial flaps pedicled on the thoracodorsal artery and vein were raised and used for thin coverage of dorsal surfaces of the fingers and the dorsum of hand and foot with favorable results. The combined fascial flaps consist of the serratus anterior fascia and the axillary fascia at the entrance of the latissimus dorsi. These flaps were used for reconstruction of the hand, fingers, or foot in nine patients. Reconstruction was performed for burn or burn scar contracture, after resection of malignant tumors, posttraumatic skin defects, and chronic regional pain syndrome. The sites of reconstruction were dorsal surfaces of fingers, dorsum of hand, wrist and palm, forearm, lower leg, and foot. The flaps were used in various configurations including two independent fascial flaps, two-lobed fascial flap with separate feeding vessels, and composite fascial and thoracodorsal artery perforator flap. The fascial and skin flaps survived in all nine patients, with favorable results both functionally and esthetically. Good coverage of soft tissue defects and good recovery of range of motion in resurfaced joints were achieved. There were no complications. The scars at the sites of harvest were not noticeable. The advantage of this method is that not only a single flap but flaps of a variety of configurations can be harvested for different purposes. The thoracodorsal vascular tree-based combined fascial flaps are useful for the reconstruction of soft tissue defects in the extremities.