Longitudinal and long-term effects of radiotherapy on swallowing function after tongue reconstruction.

OBJECTIVE: This study evaluated the longitudinal and long-term effects of radiotherapy on swallowing function after tongue reconstruction. METHODS: The study comprised 16 patients who had: undergone glossectomy and tongue reconstruction with free flap transfer, received adjuvant radiotherapy, and survived without recurrence for at least 1 year. Swallowing function, as indicated by tolerance of oral intake, was evaluated before radiotherapy, at radiotherapy completion, and at 6 and 12 months after radiotherapy completion. RESULTS: Before radiotherapy, all patients could tolerate oral intake. At radiotherapy completion, only three patients could consume all nutrition orally. However, swallowing function improved over time, and by 12 months after radiotherapy completion it had returned nearly to that before radiotherapy. CONCLUSION: Acute dysphagia due to radiotherapy after tongue reconstruction is severe, but can improve gradually. Multidisciplinary support of patients during percutaneous endoscopic gastrostomy dependence is important to improve long-term functional outcomes.

Immediate soft-tissue reconstruction using a rectus abdominis myocutaneous flap following wide resection of malignant bone tumours of the pelvis.

Resection of malignant bony tumours of the pelvis creates large bone and soft-tissue defects, and is frequently associated with complications such as wound dehiscence and deep infection. We present the results of six patients in whom a rectus abdominis myocutaneous (RAM) flap was used following resection of a malignant tumour of the pelvis. Bony reconstruction was performed using a constrained hip tumour prosthesis in three patients, vascularised fibular graft in two and frozen autograft in one. At a mean follow-up of 63 months (16 to 115), no patients had a problem with the wound. Immediate reconstruction using a RAM flap may be used after resection of a malignant tumour of the pelvis to provide an adequate volume of tissue to eliminate the dead space, cover the exposed bone or implants with well-vascularised soft tissue and to reduce the risk of complications.

Hepatic artery reconstruction following ablative surgery for hepatobiliary and pancreatic malignancies.

OBJECTIVE: Hepatic artery (HA) reconstruction is an important part of resective surgery for advanced hepatobiliary and pancreatic malignancies, but few reports have been published. To identify indications for HA reconstruction, we retrospectively analyzed our surgical procedures and outcomes. METHODS: En-bloc resection of advanced hepatobiliary and pancreatic malignancies followed by HA reconstruction was performed in 35 patients. Patients ranged in age from 27 to 81 years and included 18 men and 17 women. The primary site of cancer included the bile duct in 22 patients, the pancreas in 7, and others in 6. Reconstruction of the HA was necessitated by HA resection due to direct cancer invasion in 29 patients and by accidental arterial injury during surgical procedure in 6 patients. RESULTS: The HA was reconstructed with end-to-end anastomosis between hepatic arteries in 17 patients. Transposition of an intra-abdominal artery, such as the gastroepiploic artery, was required in 14 patients, and arterial grafting was required in 4 patients. Although the HA patency was achieved in 30 patients, 4 cases of arterial thrombosis and 1 case of arterial rupture developed postoperatively. The overall RFS time was analyzed in all patients, and mean and median RFS times were 18 and 9 months, respectively. CONCLUSION: Although oncologic outcomes remain poor, HA resection and reconstruction can be performed in selected patients. We believe that the method of first choice for HA reconstruction is end-to-end anastomosis between HAs. A vascular autograft should be used only in selected cases.

Transient receptor potential channel m4 and m5 in magnocellular cells in rat supraoptic and paraventricular nuclei.

The neurohypophysial hormones, vasopressin (VP) and oxytocin (OT), are synthesised by magnocellular cells in the supraoptic nucleus (SON) and the paraventricular nucleus (PVN) of the hypothalamus. The release of VP into the general circulation from the neurohypophysis increases during hyperosmolality, hypotension and hypovolaemia. VP neurones increase hormone release by increasing their firing rate as a result of adopting a phasic bursting. Depolarising after potentials (DAPs) following a series of action potentials are considered to be involved in the generation of the phasic bursts by summating to plateau potentials. We recently discovered a fast DAP (fDAP) in addition to the slower DAP characterised previously. Almost all VP neurones expressed the fDAP, whereas only 16% of OT neurones had this property, which implicates the involvement of fDAP in the generation of the firing patterns in VP neurones. Our findings obtained from electrophysiological experiments suggested that the ionic current underlying the fDAP is mediated by those of two closely-related Ca(2+) -activated cation channels: the melastatin-related subfamily of transient receptor potential channels, TRPM4 and TRPM5. In the present study, double/triple immunofluorescence microscopy and reverse transcriptase-polymerase chain reaction techniques were employed to evaluate whether TRPM4 and TRPM5 are specifically located in VP neurones. Using specific antibodies against these channels, TRPM5 immunoreactivity was found almost exclusively in VP neurones, but not in OT neurones in both the SON and PVN. The most prominent TRPM5 immunoreactivity was in the dendrites of VP neurones. By contrast, most TRPM4 immunoreactivity occurred in cell bodies of both VP and OT neurones. TRPM4 and TRPM5 mRNA were both found in a cDNA library derived from SON punches. These results indictate the possible involvement of TRPM5 in the generation of the fDAP, and these channels may play an important role in determining the distinct firing properties of VP neurones in the SON.

Reconstruction of an enterocutaneous fistula using a superior gluteal artery perforator flap.

Enterocutaneous fistula is an uncommon complication of surgery for colorectal cancer. However, once a fistula has developed, treatment is complicated by previous treatments. Here, we describe an enterocutaneous fistula that developed after multiple treatments for rectal cancer in a 62-year-old woman. The woman had previously undergone several colorectal surgeries, radiation therapy and five courses of chemotherapy. Four years after the final surgery, an enterocutaneous fistula developed between the small intestine and the sacral skin. The fistula was resected, and the resulting defect was successfully reconstructed with a superior gluteal artery perforator flap.

Immediate maxillary reconstruction after malignant tumor extirpation.

AIMS: Immediate maxillary reconstruction after malignant tumor extirpation differs from other types of maxillary reconstruction. Our reconstruction algorithm is described in this article. METHODS: One hundred ninety-four patients who had undergone maxillectomy for malignant tumors were reviewed, and maxillectomy defects were classified with the method of Cordeiro and Santamaria. RESULTS: Mean total blood loss was 848 ml, and 71 patients died within 2 years after surgery. For type IIIa defects of the orbital floor, titanium mesh or vascularized bone or cartilage was used for reconstruction, but the rate of postoperative complications did not differ between titanium and autografts. Therefore, to reconstruct orbital floor defects we have recently used only titanium mesh. For type I or II defects, we use autografts for only selected cases. CONCLUSIONS: We strive to perform less-invasive reconstructive surgery after resection for maxillary malignancy.

[Stenting in obstruction of superior vena cava; clinical experience with the self-expanding endovascular prosthesis].

From August 1997 to December 2002, 14 consecutive patients with superior vena cava syndrome with the self-expanding endovascular prosthesis. Diagnoses were adenocarcinoma in 6, small cell carcinoma in 4, squamous cell carcinoma in 1, metastatic lung cancer in 2, and invasive thymoma in 1. Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) were measured on their admission and perioperative period. Expecting only 1 patient complete symptomatically relieved within 3 days of stent implantation. Superior vena cava pressure or radial pressure of the stent was sufficient to relieve obstruction. Preoperative ANP level were normal, BNP level were increased. Postoperatively both ANP level and BNP level were slightly increased under intravenous dopamine hydrochloride. Implantation of the self-expanding stent endovascular prosthesis for superior vena cava syndrome provides rapid symptomatic relief and improves the patient's quality of life.

[Technique for vascular management under thoracoscopic surgery].

Vascular injury is the most life-threatening complication under thoracoscopic surgery. To reduce the risk of vascular injury, knowledge of the anatomy of the pulmonary artery, variations in its branching, skillful techniques and careful maneuver are necessary. Pulmonary artery being adherent to bronchus is dangerous to dissect under thoracoscopy, so it is better to convert to open thoracotomy. A3 of the left upper lobe is occasionally injured during dissection. It is a safety technique for using vascular stapler under thoracoscopic surgery. Stapler leader can allow the passage of a stapler to encircle the vessel.

[Video-assisted thoracic surgery for the resection of pulmonary metastases].

We report the use of video-assisted thoracic surgery (VATS) as a treatment or pulmonary metastases. Between July 1994 and March 2002, 75 patients were treated for metastatic lung tumor by VATS. These patients included 45 males and 30 females with an average age of 60.6 years. Their primary diseases were Colon cancer (38), renal cell carcinoma (12), breast cancer (6), seminoma (3), thyroid carcinoma (3), parotid cancer (2), pharyngeal cancer (2) and the others (9). Tumor size ranged from 6 to 62 mm in diameter. A preoperative high resolution spiral computed tomography (CT) scan was used to locate the nodule in all patients. Ten recurrence cases were performed re-resection by VATS approach with an average period was 22 month. We conclude that VATS is a good candidate for the resection of lung metastases in the selected cases.

Deep circumflex iliac perforator flap with iliac crest for mandibular reconstruction.

The deep circumflex iliac myocutaneous perforator (DCIP) flap with iliac crest was used to reconstruct oromandibular defects in 10 patients. In seven of the patients a dominant perforator was found preoperatively using a Doppler flowmeter; in five of these seven patients a DCIP flap was successfully transferred. In two of the seven patients the dominant perforators were too narrow: one patient underwent a standard osteocutaneous flap transfer and one patient underwent a second flap transfer. In three patients no dominant perforator was found before or during surgery. The freedom of the DCIP flap from the harvested iliac crest facilitates correct positioning. However, to ensure that the DCIP flap can be safely elevated, the presence of perforators must be confirmed preoperatively. Even when a perforator has been identified, complicated dissection may be necessary. We stress the importance of a thorough knowledge of the anatomy of second flaps and of obtaining informed consent to use them.

Nitinol stent for the treatment of tracheobronchial stenosis.

OBJECTIVE: The purpose of this study was to evaluate the potential utility of implantation of a nickel-titanium alloy (nitinol) stent for the treatment of malignant or benign tracheobronchial stenosis. METHODS: We evaluated 18 patients (14 men and 4 women) who received 24 nitinol stents, between November 1997 and May 2000. All 18 patients had severe dyspnea caused by tracheobronchial stenosis. The underlying condition was malignant disease in 15 patients, and benign tracheal collapse in the other 3 patients. RESULTS: Implantation of the stent was successfully performed in all patients. Seventeen patients experienced immediate clinical improvement in respiratory symptoms. The remaining 1 patient with a bronchial fistule after lobectomy did not benefit, and died of pneumonia at 16 days after the implantation. In 15 patients, the procedure was performed using a flexible bronchoscope under local anesthesia alone, while the remaining 3 patients needed intravenous sedation. There was no complication resulting from the stent implantation. Among the 3 patients with benign tracheal collapse, 2 patients were alive at 746 and at 401 days after the stent implantation, at the time of this report. One patient with cicatricial stenosis after intubation died of heart failure due to previous myocardial infarction. Among the 15 patients with malignant disease, 4 patients have survived for 177 to 305 days to date, while the other 11 patients have died of primary malignancy with a mean survival duration of 60.2 days. CONCLUSION: The nitinol stent was effective in treating malignant or benign tracheobronchial stenosis, and had some remarkable advantages compared with other tracheobronchial stents. In stenting, most procedures can be performed using flexible bronchoscope under local anesthesia.

Wallstent endovascular prosthesis for the treatment of superior vena cava syndrome.

OBJECTIVE: We assessed the clinical outcome of self-expanding Wallstent endovascular prosthesis in the treatment of superior vena cava syndrome due to malignant tumors. METHODS: Eleven patients with malignant superior vena cava syndrome were treated by percutaneous implantation of the self-expanding Wallstent endovascular prosthesis across the stricture site. Patency was defined by the absence of symptoms and signs of superior vena cava syndrome. RESULTS: Ten of the 11 experienced complete symptomatic relief within 3 days of stent implantation. The remaining 1 did not benefit, and required a second procedure, dying of heart failure 5 days after stent implantation. Ten patients remain symptomatically free of superior vena cava syndrome to date or until death in follow-up lasting 17 to 227 days. CONCLUSION: Implantation of the self-expanding Wallstent endovascular prosthesis for malignant superior vena cava syndrome provides rapid symptomatic relief and improves the patient's quality of life.

Measurement of antiacetylcholine receptor antibody in patients with thymoma without myasthenia gravis complications.

OBJECTIVE: Some patients with thymoma reported to show higher antiacetylcholine receptor antibody titers without the preoperative occurrence of myasthenia gravis and some have suffered postoperative complications of myasthenia gravis despite being negative for antiacetylcholine receptor antibody preoperatively. We evaluated changes in antiacetylcholine receptor antibody titers and the occurrence of myasthenia gravis in thymoma patients. METHODS: Subjects were 31 of 44 patients with thymoma undergoing thymothymectomy at Tokyo Women's Medical University Hospital between 1987 to 1999 in whom antiacetylcholine receptor antibody titers were measured preoperatively. We studied postoperative changes in antiacetylcholine receptor antibody titers and the presence or absence of myasthenia gravis. RESULTS: Eight patients were positive for antiacetylcholine receptor antibody preoperatively, suggesting the presence of subclinical myasthenia gravis. Neither postoperative changes in antiacetylcholine receptor antibody titers nor the occurrence of myasthenia gravis was observed in these 8 patients. Recurrent thymoma and rapid elevation of antiacetylcholine receptor antibody titers were observed postoperatively in 1 patient negative for antiacetylcholine receptor antibody preoperatively, resulting in manifestation of myasthenia gravis symptoms. CONCLUSION: We found no correlation between preoperative titers and myasthenia gravis symptoms. Rapid titer elevation indicates the occurrence of myasthenia gravis symptoms or the recurrence of thymoma.

[Three cases of primary pulmonary malignant lymphoma].

Primary pulmonary malignant lymphoma is a rare disease that is thought to belong to a category of malignant lymphomas arising from mucosa- or bronchus-associated lymphoid tissue (MALT or BALT). We encountered 3 cases of primary pulmonary malignant lymphoma, Case 1: In a 51-year-old male, an abnormal shadow was detected in chest radiography in the right S9 after an operation for thyroid carcinoma. A right lower lobectomy was performed. The diagnosis was malignant lymphoma (marginal zone B-cell lymphoma). Immunohistochemical staining for IgM gave a positive result. Case 2: Multiple nodular shadows were noted in both lungs of a 55-year-old man after a bout of pneumonia. Video-assisted thoracoscopic surgery was performed, and the diagnosis was malignant lymphoma (marginal zone B-cell lymphoma). Gene analysis revealed rearrangement of a heavy chain gene. Case 3: An abnormal shadow was seen in the chest radiograph of a 60-year-old man. He was treated by right upper and middle lobectomy. The diagnosis was Hodgkin's disease, nodular sclerosing type. Chemotherapy was given after surgery and the patient is now alive without recurrence. As the pulmonary malignant lymphoma was difficult to diagnosepreoperatively, it was necessary to resect the mass for diagnostic purposes. The prognosis of a resected solitary lesion in the lobe was good. Therefore lobectomy was performed as the treatment of choice. Systemic chemotherapy is performed for the diffuse type of pulmonary lymphoma.

Anterolateral thigh flap donor-site complications and morbidity.

The authors examined donor-site complications and morbidity in 37 patients after reconstruction with free or pedicled anterolateral thigh flaps. Intraoperative assessment included damage to the vastus lateralis muscle and whether the main pedicle of the rectus femoris muscle had been killed. Postoperative assessment of the donor site included wound healing, range of motion, muscle strength, gait, and sensation. Patients were surveyed with a questionnaire about fatigue in their activities of daily life and the appearance of the donor site. All 32 patients who underwent primary skin closure could perform activities of daily life normally, and most (87.5 percent) reported that donor-site appearance was satisfactory. However, the severity of donor-site dysfunction was related to the degree of damage to the vastus lateralis muscle, and most patients (87.5 percent) had some loss of sensation at the anterolateral aspect of the thigh. Because of adhesions between the meshed skin graft and the underlying fascia, range of motion at the hip and knee was limited in significantly more patients who had received split-thickness skin grafts (60 percent) than patients who had undergone primary skin closure (3.1 percent). Therefore, wider flaps or flaps harvested nearer the knee may increase donor-site morbidity. The authors concluded that the incidence of long-term morbidity with the anterolateral thigh flap is low, although it is increased when the flap includes the vastus lateralis muscle or is wider and requires additional skin grafting at the donor site.

[A case of aneurysm of the ductus arteriosus in the adult].

Aneurysm of the ductus arteriosus in the adults is rare. A 60-year-old male with no symptoms was admitted to our hospital. 3 D-CT scans and aortograms indicated a diagnosis of aneurysm of the ductus arteriosus. Operation was done through median sternotomy with the aid of partial cardiopulmonary bypass. The saccular aneurysm was located between the aortic isthmus and the left pulmonary artery. The aneurysm was resected and closed a patch. The post-operative course was uneventful.

[Clonal rearrangement of intratumoral T-cell receptor beta-chain gene in two patients with thymoma accompanied by pure red cell aplasia].

We encountered two cases of thymoma accompanied by pure red cell aplasia and demonstrating clonal rearrangement of the T-cell receptor beta-chain gene (TCR-beta) in lymphocytes. Patient 1 was a 55-year-old man and Patient 2 was a 43-year-old woman. Both had severe anemia and mediastinal tumors. Bone marrow aspiration was performed and pure red cell aplasia diagnosed. Thymoma was the presumptive diagnosis for the mediastinal tumors, and extended thymectomy was performed. The post-operative diagnosis was invasive thymoma (spindle-cell type) in Patient 1 and non-invasive thymoma (mixed lympho-epithelial type) in Patient 2. The cell compositions (%) obtained with T-cell surface marker analysis were as follows: [table: see text] Southern blot analysis disclosed clonal rearrangement of TCR-beta genes in thymoma thymocytes from both patients.

Lattice-like collagen fiber meshwork in the iris stroma of the cat: a possible mechanism to generate the tension directed towards the iris root which is required for pupillary dilatation in the sympathectomized eye.

NaOH digestion technique for collagen fiber dissection and scanning electron microscopy demonstrated a lattice-like meshwork in the anterior surface of the iris stroma of the cat. The mesh threads were made of collagen fibril bundles. In the constricted pupil, the meshes were square to rhomboid with the diagonals in the direction of the radius or circumference of the iris. In the dilated pupil, however, the meshes were strongly flattened rhomboid or ellipse with a longer diagnoal or axis in the circumferential direction. At the mesh corners facing the pupillary margin or the iris root, the collagen fibril bundles were strongly bent in the iris of the constricted pupil, while they were almost straight or slightly wavy in the iris of the dilated pupil. Accumulation of elasticity tension generated by this small distortion of the iris-mesh threads in the constricted pupil was considered to generate a tension directed towards the iris root, which is required for pupillary dilatation in the sympathectomized eye. On the posterior surface of the iris stroma, numerous thin pleats tightly woven with collagen fibrils traversed straightway through the radial length of the ciliary zone of the iris in both constricted and dilated pupils. The structural changes of these pleats in miosis and mydriasis were very small compared with the meshwork of the anterior aspect of the iris. Therefore, they were considered to work mainly as an iris skeleton.

[The use of the Wallstent prosthesis in the treatment of superior vena cava syndrome].

Five patients (4 men and one woman) aged 48-82 years who were suffering from superior vena cava (SVC) syndrome had Wallstent implanted percutaneously to relieve the obstruction. After stent placement, all cases received anticoagulant therapy with heparin. However one transient stent thrombosis occurred, stent placement resulted in complete relief of all patients. Wallstent placement could be an extremely useful treatment for SVC syndrome and should be the treatment of choice in all cases where SVC obstruction occurs or recurs, following chemotherapy or radiotherapy.