Changes in spike protein antibody titer over 90 days after the second dose of SARS-CoV-2 vaccine in Japanese dialysis patients.

OBJECTIVES: There is no report on antibody titers after vaccination against SARS-CoV-2 in Japanese dialysis patients. As dialysis is different between Japan and other countries, changes in antibody titers were examined. METHODS: Baseline characteristics and anti-spike protein antibody titers (Roche) over 90 days after administration of the BNT162b2 messenger RNA vaccine were investigated in dialysis patients. RESULTS: The maximum anti-spike protein antibody titer after the second dose was 738 (327 to 1143) U/mL and was reached at 19 (17 to 24) days after the second dose. Antibody titers decreased over time, with titers of 770 (316 to 1089) U/mL at 15 days, 385 (203 to 690) U/mL at 30 days, 254 (138 to 423) U/mL at 60 days, and 208 (107 to 375) U/mL at 90 days after the second dose. When an antibody titer of 137 U/mL was assumed to be a measure related to breakthrough infection, the proportion of subjects with antibody titers exceeding this level was 90.1% at 15 days, 85.3% at 30 days, 75.0% at 60 days, and 65.4% at 90 days after the second dose. When a decrease in antibody titers below the assumed breakthrough level was defined as an event, subjects with a pre-dialysis albumin ≥ 3.5 g/dL were significantly less likely to experience an event than subjects with a pre-dialysis albumin < 3.5 g/dL. CONCLUSIONS: The presence of anti-spike protein levels ≥ 313 U/mL at 30 days after the second vaccine dose might be a factor in maintaining enough antibody titers at 90 days after. Whether an additional vaccine dose is needed should be determined based on indicators serving as factors in maintaining antibody titers as well as the status of the spread of infection.

Recent advances in reconstructive surgery: head and neck reconstruction.

Although advances in radiotherapy and chemotherapy for cancers of the head and neck have been remarkable, surgical resection followed by reconstructive surgery is still the mainstay of treatment. Of the reconstructive procedures, microsurgical tissue transfer has been considered the standard method for restoring postoperative functions and morphology. In this review article, we discuss the history of reconstructive surgery for treating cancers of the head and neck, current problems, and future challenges.

Significant correlations between focal photopic negative response and focal visual sensitivity and ganglion cell complex thickness in glaucomatous eyes.

PURPOSE: To determine whether there are significant correlations between the focal photopic negative response (PhNR), the focal visual sensitivity and the ganglion cell complex (GCC) thickness in glaucomatous eyes. STUDY DESIGN: Single-center observational study. METHODS: Fifty-two eyes of 52 patients (71.4 ± 9.42 years) with clinically diagnosed open angle glaucoma were studied. Thirty-six age-matched normal subjects served as controls. The focal PhNR of the focal macular electroretinograms (fmERGs) were elicited by a 15° circular, a superior semicircular or an inferior semicircular stimulus centered on the fovea. The thickness of the GCC was measured in the corresponding retinal areas in the spectral-domain optical coherence tomographic images. The visual sensitivities (dB) were measured by microperimetry at the retinal area where the fmERGs were elicited and were converted to liner values (1/Lambert). RESULTS: The focal PhNR amplitudes were significantly correlated with the visual sensitivities of the full-circle (R = 0.532), the superior (R = 0.530) and inferior (R = 0.526) semicircular responses (P < 0.0001). The GCC thickness was correlated with the visual sensitivities in the same areas with stronger correlations (R = 0.700, 0.759 and 0.650, respectively; P < 0.0001). The focal PhNR amplitudes were proportionally reduced with the thinning of the GCC thickness (R = 0.494, 0.518 and 0.511, respectively; P < 0.0001). CONCLUSIONS: The significant correlations between the focal PhNR amplitudes, the focal visual sensitivities and the GCC thickness indicate that these may be good biomarkers to track the changes in the physiology and anatomy of the macular area in glaucomatous eyes.

[A case of meningovascular syphilis presenting with bilateral oculomotor nerve palsy, cerebral aneurysm, and cerebral hemorrhage].

The patient was a 32-year-old man with no HIV infection and possible syphilis infection at the age of 22 years. At the age of 29 years, he visited an ophthalmologist for diplopia due to right oculomotor nerve palsy. He underwent diplopia strabismus surgery for unexplained oculomotor nerve palsy. At the age of 31 years, he had a left oculomotor nerve palsy and was referred to our department. He was diagnosed with neurosyphilis based on positive serum and cerebrospinal fluid syphilis antibodies. MRI showed aneurysm, asymptomatic cerebral hemorrhage, and contrast enhancement of the left oculomotor nerve, leading to the diagnosis of meningovascular syphilis. The patient's symptoms improved with penicillin and corticosteroids. The oculomotor nerve palsy may be due to microcirculatory disorder caused by syphilitic cerebral endarteritis.

Long-Term Observations of Thickness Changes of Each Retinal Layer following Macular Hole Surgery.

PURPOSE: To determine the long-term changes of the thickness of each retinal layer following macular hole (MH) surgery combined with internal limiting membrane (ILM) peeling. METHOD: The medical records of 42 eyes of 42 patients (41 to 86 years of age) who underwent MH surgery with ILM peeling between February 2016 and October 2018 were reviewed. A single surgeon operated on all patients, and all were followed for at least 24 months postoperatively. Spectral-domain optical coherence tomography (OCT) was performed to obtain retinal thickness maps of the parafoveal region corresponding approximately to the ILM peeled area. Each retinal layer was automatically segmented by the embedded software, and thickness maps were constructed for the total retinal layer (TRL), inner RL (IRL), middle RL (MRL), and outer RL (ORL). The averaged value of each retinal layer thickness was analyzed in the temporal/upper, temporal/lower, nasal/upper, and nasal lower quadrants. RESULTS: The TRL thickness was significantly decreased in the temporal areas postoperatively. The IRL thickness thinned progressively and significantly until 6 months without further thinning in the temporal quadrants. The MRL thickness of all areas was significantly thicker than the baseline values at 0.5 months and then gradually decreased in the temporal regions. However, the thickening in the nasal regions returned to the baseline values after 1.5 months. The ORL decreased transiently relative to the baseline values at 0.5 months in all areas. CONCLUSIONS: The ILM peeling does not affect only the thickness of the inner retina but also the middle and outer retinae in the parafoveal region. The chronological changes of the thickness after surgeries varied among the retinal layers and macular regions.

Relationships between the vascular structure and neural function of the macula in patients with diabetes mellitus.

PURPOSE: To determine the significance of the correlation between the vascular structure and neural function of the macula in patients with diabetes mellitus. STUDY DESIGN: Single-center observational study. PATIENTS AND METHODS: Ninety eyes of 90 diabetic patients with an average (SD) age of 63.5 (3.8) years were studied. Fifty of the eyes had no clinically apparent diabetic retinopathy (non-DR), and 40 eyes had mild-to-moderate nonproliferative DR (NPDR). Thirty age-matched healthy individuals were also studied in the same way. Swept-source optical coherence tomography angiography (OCTA) was performed to obtain 3 × 3-mm en face images of the posterior pole of the eye. The vascular densities (VDs) of the superficial capillary plexus (SCP) and the deep capillary plexus (DCP) were determined. The focal macular electroretinograms (ERGs) elicited by a 15° circular stimulus centered on the fovea were recorded. The amplitudes of the a- and b-waves, sum of the oscillatory potentials (ΣOPs), photopic negative response (PhNR), and implicit times of the individual OPs (OP1-OP3) were measured. RESULTS: The VDs of the SCP and DCP were reduced in eyes with advanced DR (P < .01 for SCP). The implicit times of OP1-OP3 were significantly prolonged in eyes with a lower VD of the SCP and DCP in the non-DR group (P < .05). The amplitudes of the ΣOPs were significantly smaller in eyes with a reduced VD of the SCP and DCP in the NPDR group (P < .05). The correlation coefficients were higher for the OP implicit times than for the ΣOP amplitudes in the non-DR group. CONCLUSIONS: The OPs of the focal macular ERG are smaller with prolonged implicit times in association with capillary loss in the macula of diabetic patients. The implicit times are the most sensitive functional parameter that reflects the early changes of the microvasculature in the macula caused by diabetes.

Usefulness of narrow-band imaging for detecting the primary tumor site in patients with primary unknown cervical lymph node metastasis.

OBJECTIVE: We sometimes experienced patients with primary unknown cervical lymph node metastasis. In such cases, if computed tomography, magnetic resonance imaging, laryngoscopy and gastrointestinal endoscopy cannot detect a primary site, there is no other effective method to identify a possible primary tumor. We investigated whether narrow-band imaging can detect a possible primary tumor in such. METHODS: Forty-six patients with primary unknown cervical lymph node metastasis were surveyed about primary tumors, from January 2003 to December 2006. All cervical lymph nodes were histologically proved to be squamous cell carcinoma by fine-needle aspiration cytology. Narrow-band imaging combined with magnifying endoscopy was used to identify the primary site in the head and neck region and cervical esophagus. Histological analysis was performed for all suspicious lesions by a biopsy specimen. RESULTS: Twenty-six lesions were suspected to be cancerous lesions by narrow-band imaging in the head and neck region. Sixteen lesions in 16 (35%, 16/46) patients were squamous cell carcinoma. Ten lesions were located in the hypopharynx and the remaining six lesions were located in the oropharynx. White light endoscopy could not point out any lesion. CONCLUSIONS: Narrow-band imaging endoscopy can detect possible primary cancer in patients with primary unknown cervical lymph node metastasis.

Comparisons of photopic negative responses elicited by different conditions from glaucomatous eyes.

PURPOSE: To compare the clinical significance of the photopic negative response (PhNRs) elicited by different stimuli from glaucomatous eyes. STUDY DESIGN: Single-center observational study METHOD: Eighty-four eyes of 84 patients with open angle glaucoma (OAG) and 40 eyes of 40 normal subjects were studied. Cone electroretinograms (ERGs) were elicited by white stimuli on a white background (W/W) or red stimuli on a blue background (R/B). The luminance of the stimuli was 0.5, 1.0, 2.0 or 3.0 cd-s/m2, and of the background light was 10 cd/m2. The first and second troughs of the ERGs that appeared following the b-wave were designated as PhNR1 and PhNR2, respectively. The thickness of the circumpapillary retinal nerve fiber layer (cpRNFL) was measured by spectral-domain optical coherence tomography. The mean deviation (MD) was determined by standard automated perimetry. The area under the receiver operating characteristic curves (AUCs) was created to determine the diagnostic ability of the PhNRs elicited by the different stimulus conditions. RESULTS: The correlation coefficients of the amplitudes of the PhNR1 elicited by W/W stimuli to the MDs and cpRNFL thickness were generally stronger, and the regression lines steeper than for the amplitudes of the PhNR1 elicited by R/B stimuli. In contrast, the correlation coefficients of the amplitudes of the PhNR2 elicited by R/B stimuli to the MDs and cpRNFL thickness were generally stronger, and the regression lines were steeper than the amplitudes of the PhNR2 elicited by W/W stimuli. With both types of stimuli, the slopes of the regression lines became steeper when the ERG recorded with higher stimulus intensities. The AUCs were significantly larger for the PhNR2 elicited by the R/B stimuli at 3.0 cd-s/m2 than for PhNR1 and PhNR2 elicited by W/W stimuli at the same intensity when the PhNRs were used for diagnosing advanced glaucoma. CONCLUSION: The PhNR1 and PhNR2 elicited by the W/W and R/B stimuli are suitable measures to assess the function of the RGCs in eyes with OAG. The PhNR2 elicited by R/B stimuli at higher stimulus intensities is most effective in detecting functional and structural changes of the RGCs with the highest diagnostic capacity in discriminating advanced glaucoma.

Functional outcomes and reevaluation of esophageal speech after free jejunal transfer in two hundred thirty-six cases.

Swallowing and communication are occasionally impaired after free jejunal transfer. Here, the relationship between surgical procedure and functional outcome was analyzed in 236 patients undergoing free jejunal transfer after total laryngopharyngectomy from 1992 through 2003. Swallowing and communication functions were also investigated with a questionnaire in 40 long-surviving patients. Although oral feeding could be resumed after surgery in most patients, anastomotic stricture and nasal regurgitation occurred in 12.7% and 29.7% of patients, respectively. Use of our standardized procedure, the tensed jejunal method, significantly reduced the incidence of stricture (P < 0.01) but increased the rate of nasal regurgitation; however, in most cases regurgitation gradually resolved. Of the 40 long-surviving patients, 17 attended a speech rehabilitation program at which 12 learned to perform esophageal speech without voice restoration procedures (11 of the 12 had received a tensed jejunal graft). Our standardized procedure helps prevent strictures and encourages esophageal speech.

Three-dimensional reconstruction of supraglottic structures after partial pharyngolaryngectomy for hypopharyngeal cancer.

OBJECTIVE: Larynx-preserving surgery is frequently performed for advanced hypopharyngeal cancer involving the larynx. However, reconstruction after partial pharyngolaryngectomy (PPL) remains a challenging problem because of the high risk of postoperative aspiration. In this report, we describe our new three-dimensional method for reconstructing supraglottic structures with a radial forearm flap. This is a retrospective analysis of 20 patients who underwent PPL for having hypopharyngeal cancer involving the larynx at our institution from 1996 to 2005. METHODS: The resulting pharyngolaryngeal defects were reconstructed with radial forearm flaps in all patients. Three-dimensional structures were reconstructed with a single nylon suture, which was used to hoist the flap and ensures that the arytenoids and the aryepiglottic fold were of appropriate height. RESULTS: Radial forearm flaps were transferred successfully in all but one case. Swallowing function was satisfactory in all patients, and decannulation could be performed in all but one patient. Postoperative conversational function in all patients was rated as excellent with Hirose's scoring system. CONCLUSIONS: Free jejunum transfer is the method of first choice for reconstruction of a defect after partial hypopharyngectomy. However, the complex supraglottic structures of the larynx are difficult to reconstruct with a free jejunal graft after PPL. In such cases, we perform three-dimensional reconstruction of the pharyngolaryngeal defect with a radial forearm flap and have achieved satisfactory postoperative function. We believe that our new procedure is a useful method for functional reconstruction after PPL.

Palliative total pharyngo-laryngo-esophagectomy.

OBJECTIVE: To evaluate the outcomes of total pharyngo-laryngo-esophagectomy (TPLE) as a palliative procedure for achieving oral intake without tube placement. BACKGROUND: Patients with head and neck cancers require airway maintenance achieved by the placement of a tracheostomy tube and nutrition provided through a gastric fistula or a central vein, which may markedly decrease the quality of life (QOL) of the patients. CASES: Two patients with cervical esophageal cancer are described. The first patient was a 69-year-old male with cervical esophageal cancer with vertebral invasion, for which complete resection was not possible. Following TPLE, oral intake was initiated on post-operative day 9 and was maintained for 138 days. The second patient was a 73-year-old male with recurrent cervical esophageal cancer and unresectable lymph node metastasis for which lymph node dissection was not applicable. Following TPLE, oral intake was initiated on post-operative day 7 and was maintained for 199 days. Both patients were satisfied with the outcome. CONCLUSIONS: The QOL of the two patients was improved following the restoration of oral intake ability. Palliative TPLE may be appropriate for patients with advanced head and neck cancers.

Standardization of free jejunum transfer after total pharyngolaryngoesophagectomy.

OBJECTIVE: Our latest free jejunum transfer procedure was reviewed and compared with previous procedures to standardize the operation. METHODS: This was a retrospective study of 269 patients who had undergone total pharyngolaryngoesophagectomy and free jejunum transfer from 1992 through 2004. The patients were divided into two groups: a late group, in which surgery was performed with our latest standard procedure from 2000 through 2004, and an early group, in which various procedures had been used from 1992 through 1999. Surgical times, postoperative progress, and complications were evaluated. RESULTS: The mean surgical time was shortened from 3 hours 25 minutes in the early group to 3 hours 9 minutes in the late group, and ischemic time was shortened from 2 hours 44 minutes to 2 hours 20 minutes. For recipient vessels, branches of the external carotid artery and the internal jugular vein were more often used in the late group. Length of hospitalization decreased from 31.7 days in the early group to 24.4 days in the late group, although the start of drinking was similar (15.4 days versus 12.1 days). The rates of complications were significantly reduced in the late group, particularly those associated with the enteric anastomosis such as minor leakage (18.2-5.2%) and stenosis (17.6-3.0%). CONCLUSION: Our latest method of free jejunum transfer reconstruction has become reliable and expeditious through simple and stable minor revisions of procedures.

Predictive markers for late cervical metastasis in stage I and II invasive squamous cell carcinoma of the oral tongue.

PURPOSE: Patients with oral tongue carcinoma treated by intraoral excision only should be followed up carefully for cervical lymph node metastasis and salvaged immediately if found, because some patients have a more aggressive clinical course. The purpose of this study was to find useful markers for predicting late cervical metastasis in patients with stage I and II invasive squamous cell carcinoma of the oral tongue. EXPERIMENTAL DESIGN: We investigated clinicopathologic factors and immunohistochemical biomarkers predicting late cervical metastasis in surgical specimens from 56 patients with T(1-2)N(0)M(0) invasive squamous cell carcinoma of the oral tongue who did not undergo elective neck dissection. Histopathologic factors including tumor thickness, mode of invasion, Broders grade, total score of three different malignancy grading systems, eight other clinicopathologic parameters, and immunohistochemical expression of p53, cyclin D1, Ki-67, epidermal growth factor receptor, microvessel density, cyclooxygenase-2, MUC1, laminin-5 gamma2, E-cadherin, and beta-catenin were examined. All of the clinicopathologic factors and immunohistochemical expression of biomarkers were compared in terms of survival. RESULTS: In the univariate analysis, tumor thickness (P = 0.009), Broders grade (P = 0.017), nest shape (P = 0.005), mode of invasion (P < 0.001), Anneroth score (P = 0.029), Bryne score (P < 0.001), and E-cadherin expression (P = 0.003) were correlated with late cervical metastasis. Multivariate analysis on late cervical metastasis revealed that tumor thickness >4 mm, mode of invasion grade 3 or 4, and E-cadherin expression were independent factors. Late cervical metastasis was the only prognostic factor for overall survival (P = 0.002). CONCLUSIONS: Our results indicate that patients with stage I and II invasive squamous cell carcinoma of the oral tongue with tumor thickness >4 mm, mode of invasion grade 3 or 4, and low expression of E-cadherin should be considered a high-risk group for late cervical metastasis when a wait-and-see policy for the neck is adopted.

Free vascularized nerve grafting for immediate facial nerve reconstruction.

OBJECTIVES/HYPOTHESIS: To obtain better functional results after reconstruction to treat facial palsy in the patients with preoperative and intraoperative factors that might inhibit functional recovery, the authors have used free vascularized nerve grafts to immediately reconstruct severed facial nerves. STUDY DESIGN: The indications for vascularized nerve grafts were 1) scarred recipient bed attributable to previous operations, 2) a history of previous irradiation at the wound, 3) facial skin defects over the nerve graft after tumor ablation, 4) patient age greater than 60 years, and 5) preoperative facial palsy. METHODS: Four types of free vascularized nerves were used. Functional recovery after reconstruction could be assessed with two facial nerve grading systems.Ten patients who underwent immediate reconstruction of severed facial nerve after ablative surgery of malignant tumors of the parotid gland were reviewed. RESULTS: Functional recovery after reconstruction could be assessed with the House-Brackmann grading system and a 40-point grading system in 6 of the 10 patients after a mean follow-up period of 29.8 months (range, 10-60 mo). Results with the House-Brackmann system were grade II in 1 patient, grade III in 4 patients, and grade IV in 1 patient; scores on the 40-point grading system were 20 in 1 patient, 22 in 3 patients, 24 in 1 patient, and 28 in 1 patient. CONCLUSION: The study results indicated that muscle movement recovers satisfactorily after free vascularized nerve grafting. Although a study comparing vascularized nerve grafts and conventional nerve grafts would be necessary to confirm the superiority of vascularized nerve grafts, free vascularized nerve grafts are effective for immediate reconstruction of the severed facial nerve in patients with preoperative and intraoperative factors that might inhibit functional recovery.

Dose escalation study of carbon ion radiotherapy for locally advanced head-and-neck cancer.

PURPOSE: To evaluate the toxicity and efficacy of carbon ion radiotherapy for head-and-neck cancer in a Phase I/II dose escalation clinical trial. METHODS AND MATERIALS: Between June 1994 and January 1997, 36 patients with locally advanced, histologically proven, and new or recurrent cancer of the head and neck were treated with carbon ions. A dose escalation study was conducted, delivering 18 fractions through 6 weeks for 17 patients (Group A) and 16 fractions through 4 weeks for 19 patients (Group B). Eligibility and ineligibility criteria were the same in both groups. The dosages were escalated in increments of 10% after careful observation of at least 3 patients treated with the same dosages. The endpoints of the study were a Grade 3 reaction of the skin and the mucous membrane or local control of the tumors. RESULTS: Follow-up time ranged from 77 to 108 months with a median of 90 months. Grade 3 acute reaction of the skin was detected in 1 of the 2 patients in Group A who were treated with 70.2 GyE/18 fractions/6 weeks. In Group B, Grade 3 acute skin reaction was detected in 20% (1/5), 27% (2/11), and 67% (2/3) patients treated with 52.8 GyE, 57.6 GyE, and 64.0 GyE through 16 fractions for 4 weeks, respectively. There was only 1 patient with a Grade 3 acute reaction of the mucous membrane. Only 1 patient developed a Grade 2 late reaction of the mucous membrane (superficial ulcer), which was located close to the tumor. No other Grade 2 or greater late reaction was noted until the time of analysis. Acute tumor reactions in 34 patients consisted of 10 patients of complete response 19 of partial response, 4 of no change, and 1 of progressive disease. Local control of 34 patients calculated by the Kaplan-Meier method was 75% at 5 years. Five years' local control of five malignant melanomas showed 100%, and that of 9 patients with adenoid cystic carcinoma was 90%. Also, local control of 8 patients of salivary glands and 4 patients of ears was 100% at 56 months and 5 years. CONCLUSIONS: The dose fractionation methods of 70.2 GyE through 18 fractions for 6 weeks and 64.0 GyE through 16 fractions for 4 weeks showed equal clinical outcome in terms of morbidity and local control. The outcome of carbon ion radiotherapy showed a specific effectiveness in local control of non-squamous cell carcinoma such as adenoid cystic carcinomas and malignant melanomas. From the results of this study, it can be concluded that carbon ion radiotherapy will deliver a high local control rate without unacceptable injuries to the surrounding normal tissues.

Analysis of the relations between the shape of the reconstructed tongue and postoperative functions after subtotal or total glossectomy.

OBJECTIVES/HYPOTHESIS: For reconstruction after subtotal or total glossectomy, both preserving the larynx and maintaining postoperative swallowing and speech functions can greatly improve quality of life; however, postoperative functional results are often unstable. Our experiences suggest that insufficient flap volume in the oral area and postoperative prolapse of the preserved larynx affect postoperative function. The objective was to investigate the relations of the shape of the reconstructed tongue to postoperative swallowing and speech functions. STUDY DESIGN: The shape of the reconstructed tongue was classified on the basis of magnetic resonance and intraoral inspection as protuberant, semi-protuberant, flat, or depressed. Speech intelligibility was evaluated, and body weight, which might affect the shape of the transferred flap, was measured before and after surgery. METHODS: Thirty patients who had undergone subtotal or total glossectomy and subsequent reconstruction were reviewed. RESULTS: We found that speech intelligibility (P <.001), food (P <.01), and deglutition (P <.003) scores were significantly lower in patients with flat or depressed tongues than in patients with semi-protuberant or protuberant tongues. Weight loss after surgery was significantly greater in patients with depressed tongues than in other patients (P <.013). Our results indicate that postoperative function is related to the shape of the reconstructed tongue. CONCLUSIONS: We suggest that 1) wider and thicker flaps, such as rectus abdominis musculocutaneous flaps, be used; 2) flaps be designed to be approximately 30% wider than the defect; 3) laryngeal suspension be used to prevent prolapse of the transferred flap; and 4) careful general management and sufficient nutrition are important in the early postoperative period.

Velopharyngeal function after microsurgical reconstruction of lateral and superior oropharyngeal defects.

OBJECTIVES/HYPOTHESIS: Defects of the lateral and superior oropharyngeal wall are difficult to reconstruct because of their complicated anatomy and the possibility of causing velopharyngeal incompetence. The objective was to investigate problems of reconstruction and postoperative velopharyngeal function. STUDY DESIGN: Defects were classified into three types (I, II, and III) according to their extent. Four operative procedures were performed: the Patch, Jump, Denude, and Gehanno methods, which include a lateral-posterior pharyngeal advancement flap. Speech intelligibility, velopharyngeal function, and wound dehiscence between the flap and the remaining soft palate were evaluated. METHODS: Forty patients who had undergone resection of the lateral and superior oropharyngeal walls and subsequent reconstruction were reviewed. RESULTS: Most patients with type I or II defects had satisfactory velopharyngeal function. However, in patients with type III defects, speech function was worse and severe velopharyngeal incompetence was more common. The type of defect and the presence of wound dehiscence were related to postoperative function. The rates of wound dehiscence were lower with the Patch and Gehanno methods. CONCLUSIONS: Postoperative function in patients with type III defects can be affected by various factors. We suggest that the Gehanno method be the treatment of choice for reconstruction of extensive defects of the oropharynx. However, patients in whom more than two-thirds of the superior and posterior oropharyngeal walls has been resected are poor candidates for reconstruction because of the difficulty of maintaining both nasal airway patency and velopharyngeal function.

Simple maxillary reconstruction using free tissue transfer and prostheses.

Prosthetic rehabilitation is essential for maintaining postoperative oral function after maxillary reconstruction. However, the maxillary prosthesis becomes unstable in some patients because of extensive palatomaxillary resection and drooping of the transferred flap. In such patients, maintaining sufficient oral function is difficult, especially if the patient is edentulous. To achieve prosthetic retention, the authors performed microvascular maxillary reconstruction with a slit-shaped fenestration in the midline of the hard palate. Maxillary defects after subtotal or total maxillectomy were reconstructed with rectus abdominis musculocutaneous flaps in five patients. Defects of the nasal lining and palate were reconstructed with the single cutaneous portion of the flap, and a slit-shaped fenestration was left between the cutaneous portion of the flap and the edge of the remaining hard palate. Postoperatively, patients were fitted with maxillary prostheses that had a flat projection for the palatal fenestration. In all patients, the prosthesis was stable enough for mastication and prevented nasal regurgitation. Speech function was rated as excellent on Hirose's scoring system for Japanese speech ability. The authors believe that their method of palatomaxillary reconstruction is both simple and reliable.

Importance of additional microvascular anastomosis in esophageal reconstruction after salvage esophagectomy.

Esophageal reconstruction after salvage esophagectomy in patients who have undergone curative-intent chemoradiotherapy for esophageal cancer is associated with a significant risk of perioperative morbidity and mortality. In particular, anastomotic leakage can cause severe and potentially fatal complications, including mediastinitis and pneumonia. The authors performed esophageal reconstruction with a pedicled right colon graft after salvage esophagectomy in eight patients. To decrease the rate of anastomotic leakage, the authors performed an additional microvascular anastomosis at the distal end of the graft. The distal stumps of the ileocolic artery and vein were anastomosed to the cervical vessels. After surgery, aspiration pneumonia and localized wound infection were observed in two patients each, but slight anastomotic leakage was observed in only one patient. Postoperative swallowing function was satisfactory in all patients. Although the incidence of anastomotic leakage is reportedly high, the authors observed anastomotic leakage in only one of eight patients. The authors believe that additional microvascular anastomosis helps prevent anastomotic leakage, especially in patients who have undergone salvage esophagectomy after curative chemoradiotherapy.