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Background/aim: The purpose of the present study was to assess the clinical impact of body weight loss (BWL) during chemotherapy in patients with initially unresectable advanced gastric cancer who underwent conversion surgery., Patients and Methods: This retrospective study included 61 patients with stage IV gastric cancer who underwent conversion surgery after chemotherapy, and body weight changes during chemotherapy were examined. Based on receiver operating characteristic (ROC) curve analysis of body weight change for disease recurrence, the cutoff value of BWL was determined. Based on the BWL cutoff value, patients were classified into two groups., Results: Body weight change ranged from 28.2% to -21.8%. The cut-off value of BWL was set at 6% based on the ROC analysis. Of the 61 patients, 45 (74%) and 16 (26%) had <6% and ≥6% BWL, respectively. Patients with ≥6% BWL had peritoneal dissemination, pathological lymph node metastasis, residual tumor status of R1-2, and disease recurrence compared with those with <6% BWL (all p<0.05). The median survival times after conversion surgery were 21 and 63 months in the ≥6% and <6% BWL groups, respectively (p<0.01). Univariate analysis identified BWL as an independent prognostic factor (p=0.01), although histological response alone was significantly associated with survival in the multivariate analysis (p=0.02)., Conclusion: Patients with severe BWL during chemotherapy may be excluded from the indication of conversion surgery., (Copyright © 2024 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

L-type amino acid transporter 1 (LAT1) is upregulated in various cancer types and contributes to disease progression. Previous studies have demonstrated or suggested that hypoxia-inducible factors (HIFs), the key transcription factors in hypoxic responses, control the expression of LAT1 gene in several types of cancer cells. However, this regulatory relationship has not been investigated yet in colorectal cancer (CRC), one of the cancer types in which the increased LAT1 expression holds prognostic significance. In this study, we found that neither LAT1 mRNA nor protein is induced under hypoxic condition (1% O 2 ) in CRC HT-29 cells in vitro, regardless of the prominent HIF-1/2α accumulation and HIFs-dependent upregulation of glucose transporter 1. The hypoxic treatment generally did not increase either the mRNA or protein expression of LAT1 in eight CRC cell lines tested, in contrast to the pronounced upregulation by amino acid restriction. Interestingly, knockdown of von Hippel-Lindau ubiquitin ligase to inhibit the proteasomal degradation of HIFs caused an accumulation of HIF-2α and increased the LAT1 expression in certain CRC cell lines. This study contributes to delineating the molecular mechanisms responsible for the pathological expression of LAT1 in CRC cells, emphasizing the ambiguity of HIFs-dependent transcriptional upregulation of LAT1 across cancer cells., (© 2024. The Author(s).)

Background: Conversion surgery (CS) after chemotherapy is weakly recommended as a promising tool for improving prognoses in patients with unresectable gastric cancer. Moreover, several investigators have demonstrated the clinical efficacy of subtotal gastrectomy (sTG) with a small remnant stomach for the nutritional status and surgical outcome compared with total gastrectomy. Here, we report a patient with liver metastasis from human epidermal growth factor receptor 2 (HER2)-positive gastric cancer who underwent sTG and hepatectomy after trastuzumab-based chemotherapy., Case Presentation: An 84-year-old male patient was diagnosed with HER2-positive gastric cancer with a single liver metastasis. He was treated with eight courses of trastuzumab in combination with S-1 and oxaliplatin as first-line chemotherapy. The primary tumor and liver metastasis shrank significantly. The metastatic liver lesion's reduction rate was 65%. According to the Response Evaluation Criteria in Solid Tumors, the patient had a partial response. Therefore, he underwent an sTG with D2 lymphadenectomy and partial hepatectomy of segment 2. Histopathological examination revealed a grade 3 histological response without lymph node metastases from the primary tumor. No viable cancer cells were observed in the resected liver specimens. The patient received adjuvant chemotherapy with S-1. The postoperative quality of life (QOL) evaluated using the Postgastrectomy Syndrome Assessment Scale-45 was maintained, and the patient was still alive 8 months after the CS without recurrence., Conclusions: An sTG with a small remnant stomach might be clinically useful for preventing a decline in QOL and improving prognoses in patients with stage IV gastric cancer after chemotherapy., (© 2024. The Author(s).)

Purpose: This study aimed to estimate the risk factors for distal phalangeal nonunion in cases involving Kirchner wire fixation after successful fingertip replantation., Methods: This study retrospectively analyzed 116 digits of 111 patients, including 74 and 42 digits with replantation in Tamai zones I and II, respectively. Univariate and multivariable analyses were performed to assess the influences of 15 independent variables on nonunion, including age, sex, medical history of diabetes mellitus, history of smoking, injured hand and digit, injury type (clean, blunt, and crush-avulsion), amputation type (complete or incomplete), length of the distal bone fragment (mm), fracture type (simple or comminuted), presence of a bone defect, length of the fracture gap after fixation (mm), number of Kirchner wires used, evidence of venous repair, and the occurrence of pin tract infections after fixation., Results: At 12 months after replantation, 100 digits showed bony union and 16 (13.8%) digits showed radiographic nonunion or equivalent complications, including 9 digits with asymptomatic nonunion without a secondary operation, 5 that underwent an additional operation for nonunion or a complication, and 2 with distal bone resorption. A multivariable analysis indicated that the postfixation fracture gap was the only significant predictor influencing nonunion (odds ratio, 3.30; 95% confidence interval, 1.92-5.68)., Conclusions: The extent of the postfixation fracture gap had the greatest influence on preventing distal phalangeal nonunion, indicating the importance of reducing the fracture gap in primary fixation as much as possible., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Hand disorders are common in menopausal women. Equol is a soy metabolite produced in humans and its production level differs among individuals. The purpose of this research is to investigate the correlative relationship between variables indicating equol production levels and the occurrence of hand disorders in menopausal and postmenopausal women., Methods: Female subjects were divided into two groups: women 45-70 years of age with hand osteoarthritis (patient group) and women in the same age range without hand osteoarthritis (control group). The equol production level of each subject was estimated by measuring her urine equol concentration. We also surveyed the subjects' family histories of osteoarthritis., Results: Equol levels in the patient group were significantly lower than those in the control group (p < 0.05). This difference was most apparent for women in their 50s. Individuals with family histories of Heberden's and Bouchard's nodes were found to be 48.1 times more likely to develop these conditions than individuals in the control group., Conclusions: Women with early menopausal hand symptoms (i.e., stiff and arthritic hands) often develop hand osteoarthritis during their late menopausal and postmenopausal periods, which may cause their QoL to significantly deteriorate. Although a link between the probability of women developing hand osteoarthritis and their clinical backgrounds (i.e., family history) had been suspected, it had not been thoroughly investigated. Our survey of women with and without Heberden's nodes and Bouchard's nodes found a significant correlation between the likelihood of women developing osteoarthritis and a family history of this disease. We also found a significant correlation between the likelihood of women developing hand osteoarthritis and their equol production levels. These results indicate that women with family histories of finger osteoarthritis and low equol production have higher risks of developing finger osteoarthritis., (Copyright © 2024 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: This study aimed to compare the outcomes of reverse digital artery island flap (RDAIF) in primary and secondary reconstruction after failed replantation or composite graft method., Methods: This study retrospectively analyzed 42 patients that underwent RDAIF (18 primary and 24 secondary). Preoperative details (demographics, injury details, and waiting days) and postoperative outcomes (active arc of proximal interphalangeal [PIP] and distal interphalangeal (DIP) joints, extension loss of PIP, flexion arc of metacarpophalangeal joint, total active motion, flap sensation, the presence of numbness, Tinel's sign and cold intolerance) were evaluated. Quick Disabilities of the Arm, Shoulder, and Hand score (Quick-DASH) and patient satisfaction were also statistically compared between the 2 groups., Results: There was no significant difference in patient demographics between the 2 groups in sex, age, smoking and diabetic history, affected hand and finger, injury type and level, and flap area. The only difference was in waiting days. Similar sensory recovery and patient satisfaction were found in both groups. Range of motion in the DIP and PIP joints, extension loss of PIP, total active motion, and Quick-DASH were superior in the primary coverage group. Increasing age, subzone III injury, and secondary reconstruction were found to be the factors that adversely affected the postoperative range of motion., Conclusions: Secondary reconstruction was more likely to result in joint contracture. In the event of a damaged fingertip amputation in older patients, primary flap reconstruction should be considered as the initial treatment of choice, with regard to the ultimate range of motion.

Competing Interests: Conflict of Interest Keiichi Itatani has a stock option of Cardio Flow Design. Other authors have no interest declared.

Claw nail deformity is common in patients with fingertip injury. The optimal reconstruction remains unclear. We devised a unique strategy for reconstruction of claw nail deformity. We divided the approach into three parts: soft tissue reconstruction, bone graft and nail bed graft. In the soft-tissue reconstruction, a reverse digital arterial finger flap for the finger or an extended palmar flap advancement with V-Y plasty for the thumb was selected. A part of the distal phalanx of the second toe including periosteum was harvested as a bone graft. A nail bed graft from the big toe was performed. We reconstructed in 11 cases of claw nail deformity using our strategy. All cases achieved significant improvement with no recurrence of the claw nail deformity. Moreover, there was no donor site morbidity.

Background: Replantation of amputated digits at the nail bed level is surgically challenging and differs from replantation at a more proximal amputation level. This study aimed to determine the predictors influencing the success rate of fingertip replantation., Methods: Overall, 239 digits of 226 patients who underwent replantation surgery from August of 2009 to March of 2020 were considered. A total of 15 independent variables (i.e., sex; age; injured hand; digit; history of smoking; history of hypertension or diabetes; injury mechanism; amputation level; ischemia duration; surgeon's expertise; numbers of repaired arteries, veins, and nerves; and the need for a vein graft) were investigated for their effects on the survival of the replanted digits., Results: Of all 239 digits, 190 (79.5 percent) survived. Univariate analysis indicated that non-crush-avulsion injury, expertise and experience of the surgeon, vein repair, and nerve repair contributed to increasing the survival rate. Binary logistic regression analysis demonstrated that injury mechanism, vein repair, and nerve repair were significant predictive factors. In addition, in non-vein-repaired, blunt cut, or Ishikawa subzone II cases, digital nerve repair contributed significantly to promote the success rate relative to vein-repaired, crush-avulsion-type injury, and subzone I cases., Conclusions: Vein repair, nerve repair, non-crush-avulsion injury, and surgeon's expertise and experience were the predictors for successful replantation. Intraoperative vein and nerve repair are recommended to improve the survival rate of fingertip replantation at the nail bed level., Clinical Question/level of Evidence: Risk, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: Cholangiolocellular carcinoma (CoCC) is an extremely rare disease comprising less than 1% of all primary malignant liver tumors. No effective treatment other than resection has been established. Herein, we report a case of locally advanced CoCC diagnosed as unresectable, which was successfully treated with curative resection after downsizing chemotherapy., Case Presentation: A 59-year-old Japanese woman with chronic hepatitis B was diagnosed with locally advanced intrahepatic cholangiocellular carcinoma. As it was difficult to perform R0 resection in the local hospital, chemotherapy combined with gemcitabine plus cisplatin was administered every 3 weeks. After a total of 10 courses of chemotherapy over 10 months the tumor was shown to be reduced in size by computed tomography imaging, and she was referred to our department for surgical resection. The effect of chemotherapy was classified as a "partial response" in the response evaluation criteria of solid tumors. After adding one course of chemotherapy, an extended left hepatectomy with resection of the caudate lobe was performed. R0 resection was achieved. Based on the pathological findings, the final diagnosis of CoCC was determined and eight courses of S-1 adjuvant chemotherapy were administered. At 14 months after the operation, the patient was alive without tumor recurrence., Conclusions: Downsizing chemotherapy with gemcitabine and cisplatin may be an effective treatment strategy in locally advanced CoCC. Further evidence is required to establish an optimal strategy for the treatment of locally advanced CoCC.

We present outcomes of using a perforator-based ulnar parametacarpal flap in 25 patients for digital pulp defects. These included 17 free transfers to the thumb, index, middle and ring fingers and eight reverse pedicled transfers to the little fingers. This flap includes a dorsal sensory branch of the ulnar nerve, which was sutured to the digital nerve in all transfers. Each flap had one to three reliable perforators (mean 0.44 mm diameter) to the ulnar parametacarpal region and contained at least one perforator within 2 cm proximal to the palmar digital crease. All the 25 flaps survived completely. Twenty-two patients were followed for 15 months (range 12 to 24), and three were lost to follow-up. The mean static and moving two-point discrimination of the flap was 7 mm and 5 mm, respectively. At the donor site, sensory reinnervation was acceptable. We conclude that ulnar parametacarpal perforator flaps offer sensate, thick and glabrous skin for finger pulp repair, all in a single operative field. Level of evidence: IV.

A woman in her 50s developed acute coronary syndrome with de Winter pattern electrocardiogram (ECG). A coronary angiography revealed diagonal branch lesion caused by spontaneous coronary artery dissection, whereas the left-anterior descending artery was intact. The ECG change was transient and returned to normal without treatment 2 h later. ( Level of Difficulty: Beginner. )., (© 2020 The Authors.)

Guidelines advise precautionary measures for possible adverse events that may occur due to sedation during endoscopic procedures. To avoid complications, intraprocedural and postprocedural monitoring during recovery is considered important. However, since not many studies have reported on hypoxemia during the recovery period, findings for specific monitoring methods are insufficient. The aim of this retrospective study was to determine the incidence of hypoxemia during the recovery period using continuous central-monitoring by pulse oximetry and to characterize the hypoxemia cases. Among the 4065 consecutive esophagogastroduodenoscopy (EGD) procedures under planned moderate sedation, 84 (2.1%) procedures developed unexpected hypoxemia (SpO 2  ≤ 90%). Hypoxemia was observed during the procedure, at the end of the procedure, and during the recovery period in 21, 17, and 46 (1.1%) procedures, respectively. More than half of the hypoxemia cases occurred during the recovery period. Many hypoxemia cases were characterized by neither serious co-morbid illness nor low body mass index which have been reported as risk factors of hypoxemia. The lack of risk factors is no guarantee that hypoxemia will not occur. Therefore, continuous monitoring by pulse oximetry is more important during the recovery period and is recommended in all EGD procedures under planned moderate sedation.

To repair a short nerve gap, autograft, allograft, autogenous, or synthetic conduits are selected, but a vascularized nerve autograft is preferred to obtain a reliable postoperative outcome in the case of an unfavorable wound bed. The purpose of this report is to describe and evaluate two cases of repair of a proper digital nerve and volar soft tissue defect with a vascularized dorsal sensory branch of an ulnar nerve flap. The cases of two men, 40 and 20 years old, who suffered index finger defects due to crush lacerations that required a flap and a nerve graft, are presented. A 4.0 cm × 2.0 cm and a 3.2 cm × 1.6 cm flap, which were nourished by the perforators from the ulnar proper digital artery of the little finger, were elevated from the ulnar side of fifth metacarpal bone head and transferred for coverage of the soft tissue defect. A 4.6-cm and a 3.0-cm vascularized nerve graft was interposed in the nerve gap. The patients' postoperative courses were uneventful, and both patients had no complaints related to the donor site. Static and moving two-point discrimination were 8 and 6 mm, respectively, at 6 months after surgery in the first case and 5 and 3 mm, respectively, at 9 months after surgery in the second case. This flap, which could be elevated in the same operative field with a nerve having similar diameter to that of the proper digital nerve, was useful for repair of a finger volar tissue defect., (© 2019 Wiley Periodicals, Inc.)

Background: In this study, we evaluated the clinical efficacy of a biodegradable nerve conduit constructed of polyglycolic acid (PGA) tube with external and internal collagen scaffolding for digital nerve repair., Patients and Methods: A multi-center registry study was conducted in 11 locations between July 2013 and May 2016. Multiple mechanisms of injury included clean-cut (12 patients), crush (5 patients), and avulsion (3 patients) types of injuries. These patients underwent nerve repair with a biodegradable nerve conduit, with 9 patients having a primary repair and 11 patients having delayed repair. Average nerve gap was 16.7 mm (range: 1-50 mm). An average of 13 months follow-up (range: 12-15 months) was available including sensory assessments., Results: Improved s2PD was found with less severe injury as in clean-cut (7.5 ± 1.5 mm), which was statistically significant in comparison to those in crush (9.8 ± 1.9 mm, P = .0384) and in avulsion (10.7 ± 4.7 mm, P = .0013) type injuries. A meaningful recovery (S3+ or S4) was observed in 90% of the 20 digital nerve repairs with a biodegradable nerve conduit of PGA with external and internal collagen scaffolding. Avulsion injuries had significantly lower levels of meaningful recovery (67%) in comparison to those of clean-cut (P = .0291) and crush (P = .0486) types of injury. No adverse effects were reported postoperatively., Conclusion: These results indicate that a biodegradable nerve conduit of PGA with external and internal collagen scaffolding is suitable for digital nerve repair of short nerve gaps with high levels of sensory recovery as measured by two-point discrimination., (© 2018 Wiley Periodicals, Inc.)

Background: Reconstruction of the finger and thumb dorsum has been considered difficult because of the need for a thin and flexible flap, and the surrounding tissue is sometimes insufficient for a local flap. The purpose of this report is to describe our concept for finger and thumb dorsum reconstruction with free-style perforator flaps and our clinical experience with transfer of various perforator flaps., Methods: Thirty-two finger dorsum defects in 32 patients were covered with pedicled free-style perforator flaps. The perforator origin was a digital artery perforator in 22 cases and a dorsal metacarpal artery perforator in 10 cases. The flap style was advancement type in 11 cases, rotation in 2, propeller in 14, and adipofascial in 5., Results: The mean size of the digital artery perforator flap was 3.4 cm 2 and that of the dorsal metacarpal artery perforator flap was 7.9 cm 2 . All flaps, except for two propeller flaps with 180 degrees rotation, survived completely. These flaps were of elongated style, and the length-to-width ratios were approximately 3:1 and 3.5:1, respectively., Conclusions: There are multiple perforators in the finger and thumb dorsum region from the proper digital artery, which are suitable for pedicled free-style perforator flaps. These perforators increase flap flexibility and reliability in clinical applications., (Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The traditional pedicled gastrocnemius muscle flap has often been used to repair soft-tissue defects caused by trauma. However, it is difficult to cover skin defects in the distal third of the lower extremity because of its range of excursion. We have attempted use of a free ipsilateral gastrocnemius muscle flap for coverage of skin defects in the distal third of the lower extremity. In three patients with skin defects due to Gustilo type III open fractures, a free gastrocnemius flap was used for coverage of the same leg. The follow-up period ranged from 12 months to 2 years. Microsurgical anastomosis of the vascular pedicle to the tibialis posterior vessels was performed by end-to-side anastomosis proximally to the ankle. The postoperative course was uneventful and showed stable coverage of the wound. All free flaps were successfully transferred, and the defects healed primarily. Bone fusion in all of the patients in this series progressed satisfactorily. This free muscle flap is useful for reconstruction of defects in the distal third of the lower extremity in Gustilo III open fractures., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

A 66-year-old man was admitted with distal edema of his right leg. He had undergone radical prostatectomy and pelvic lymphadenectomy for prostatic cancer 23 days previously. Abdominal computed tomography (CT) showed a lymphocyst (4.5 x 3.0 cm) along the right pelvic wall compressing the right external iliac vein. CT with contrast medium showed thrombus formation (about 9 cm) in the distal portion of the right external iliac vein and femoral vein. An inferior vena cava filter was placed to prevent pulmonary embolism, and anticoagulation with warfarin was started. One week later, CT showed shrinkage of the lymphocyst and thrombus in the vein, as well as a large thrombus trapped in the filter. Follow-up CT taken 2 months later revealed marked reduction of the lymphocyst and absence of thrombus in both the vein and filter. A lymphocyst, also known as a lymphocele, is a complication of radical pelvic surgery. Most lymphocysts are asymptomatic and regress spontaneously, but may lead to deep vein thrombosis and pulmonary embolism, usually a few weeks after surgery. Careful observation is needed even after discharge from hospital.

Purpose: To discover possible risk factors for local-regional recurrence (LRR) following preoperative radiation therapy and curative surgery for head and neck squamous cell carcinoma (SCC) (stage II-IVB)., Materials and Methods: Clinical records from 1987 to 1999 of 161 patients with head and neck SCC (oral cavity, 80 patients; larynx, 50; hypopharynx, 19; oropharynx, 12) who underwent preoperative radiation therapy and surgery were retrospectively reviewed. One hundred thirty-two (82%) of the patients had stage III or IV cancer. The median radiation dose was 38 Gy., Results: The 5-year overall survival rate and LRR rate were 58% and 35%, respectively. At multivariate analysis, oral cavity cancer (P =.020), clinical T stage (P =.016), clinical N stage (P =.017), and status of surgical margins (P =.008) emerged as variables that were significantly associated with LRR. The analysis of only those patients with lymph node involvement showed that oral cavity cancer (P =.008), advanced N-stage cancer (P =.045), and long interval between the start of preoperative radiation therapy and surgery (> or =7 weeks) (P =.019) emerged as variables that were significantly associated with LRR., Conclusion: Oral cavity cancer, advanced T or N stage of disease, and unsatisfactory margins were risk factors for LRR. A long interval (> or =7 weeks) was a risk factor for LRR in patients with lymph node involvement.

Although the pedicled extensor digitorum brevis (EDB) muscle flap is a versatile flap, there are not many reports about it. Furthermore, there are few reports about the reverse vascular flow EDB muscle flap. The lateral tarsal artery coming from the dorsalis pedis artery nourishes the EDB muscle flap. Cutting the dorsalis pedis artery proximal to the flap can elevate this flap with reverse vascular flow. The authors treated eight patients with a reverse vascular flow EDB muscle flap. All flaps survived, with minor repair in two cases. The follow-up period ranged from 4 months to 1 year. This flap has two pivot points for creating a reverse vascular flow pedicled flap and a large arc of rotation for coverage of the dorsal foot. The authors confirmed that this flap is very versatile for soft-tissue reconstruction of the distal dorsum of the foot. The blood supply is reliable and the operative procedure is not complicated and can be performed under regional anesthesia. With this flap, a well-vascularized bed can be prepared for coverage with a skin graft. The major disadvantage is numbness in the first web of the foot, but this does not cause problems in daily life.

Purpose: To clarify the impact of treatment duration on the outcome of nasopharyngeal carcinoma (NPC)., Materials and Methods: Forty-three patients with NPC were treated with definitive radiotherapy from January 1980 through May 1996. The male-to-female ratio was 32:11, and median age was 58 years (10-78 years). According to the fifth UICC classification, 4 patients were stage I, 12 were stage II, 6 were stage III, and 21 were stage IV. Twenty-nine patients received chemotherapy. Each patient was treated to various doses according to their disease extension. Thus, treatment duration was defined as the duration from the start of radiotherapy to the end of 60 Gy. The median follow-up period was 63 months (2-164 months)., Results: The 5-year overall and disease-free survival rates of all patients were 66% and 59%, respectively. The 5-year disease-free survival rates of the patients treated with the short treatment duration (< or = 8 weeks) and those treated with the long treatment duration (> 8 weeks) were 76% and 38%, respectively (p = 0.008)., Conclusion: Long treatment duration may lead to poor treatment outcome in NPC.

Quantitative gated SPECT (QGS) software has been reported to demonstrate inaccurate edge detection in the left ventricular chamber in hypertrophic cardiomyopathy patients. In this study we developed a method to calculate left ventricular volume (LVV) and left myocardial volume (LMV) from gated SPECT data using a newly developed edge-detection algorithm, and we compared it with the QGS method of calculating LVV and LMV in a phantom study. Our method gave more accurate measurements LVV and LMV whereas the QGS method underestimated LMV. Compared with QGS LVV and LMV, our method yielded better results in the phantom study.

In this study, a new classification of fingertip amputation based on the surgical treatment is reported. Specifically, the necessity for special procedures to prevent venous congestion in fingertip replantation at the nail bed level was studied. There are some reports of successful replantations without venous anastomoses. In order to avoid technical factors, clinical cases operated on by a single surgeon were evaluated to determine what treatment is necessary for amputations at various levels to avoid necrosis due to venous congestion. During the 5-year period from October 1987 to October 1992, 150 replantations in 137 patients were performed, including 49 fingertip replantations in 45 patients who were operated on consecutively by a single surgeon. The distal phalanx (DP) of the finger was classified as zone DP-I, IIA, IIB, and III from distal to proximal. This classification was based not only on the amputation level but also on the difference in surgical treatment. For amputations of zone DP-I, which extends from the fingertip to the most distal dividing point of the digital artery, the amputated fingertip is attached without vascular anastomosis and the whole finger is wrapped in aluminium foil and cooled in ice water for 3 days. For amputations of zone DP-IIA and IIB, anastomosis of the digital artery is performed in the central portion of the palmar region of the finger, but Kirschner wire fixation is not performed so as not to disturb the venous drainage through the medullary cavity. For amputations of zone DP-IIA, special treatment is not necessary for venous congestion, and for those of zone DP-IIB partial resection of the nail is done if necessary. For zone DP-II amputations, venous anastomosis must be performed for salvage. All patients were operated on according to the procedures based on this classification and final survival rate was 91.5%.

Four adult Japanese monkeys were used. Donor tissues were harvested from the radial artery, saphenous vein and median nerve, 10 cm in length, and cryopreserved at -196 degrees C in a stepwise manner for long-term preservation for more than 6 months. After rapid thawing of the tissue, the allogeneic tissue transfer was performed of the radial artery to the radial artery, the saphenous vein to the ulnar artery and the median nerve to the median nerve between male and female monkeys. After one year follow-up, angiography was performed and the transferred tissue was harvested for scanning electron microscopic examination and histological examination. As a result, the allogeneic artery in the radial artery was completely patent with no stenosis, whereas there was obstruction of the allogeneic vein in the ulnar artery. Good axonal recovery of the median nerve was observed on histological examination. The cellular structure of neurovascular tissue can be maintained even after long-term cryopreservation. The antigenicity of tissue may be reduced significantly by being frozen, and cryopreserved allogeneic artery can be transferred successfully without the use of immunosuppressive agents. In this report, clinical aspects and the great potential of allogeneic neurovascular tissue transfer, especially in combination with arterial transfer, using cryopreservation are discussed.

Although the forked flap procedure has been widely used as a technique to lengthen the columella in the bilateral cleft lip deformity, often the results are unfavourable. We describe a technique to achieve a more natural shape, in which the unsatisfactory forked flap is excised and the columella is reconstructed by mobilization and rotation of nasal skin, combined with bilateral reverse-U flaps. Five consecutive patients who underwent this secondary correction procedure are presented.

The technique of using volar advancement flaps with V-Y closure to the fingers is described. It is possible to perform volar flap advancements up to 15 mm and use V-Y closures in the distal palm, avoiding a skin graft. This method is based on knowledge of the vascular anatomy of the finger dorsum, to avoid devitalising dorsal skin. This method was applied to 14 fingers of 13 patients including finger amputations, claw nail deformities, and skin defects of the middle phalanx. Favourable results were observed.

It has long been known that the antigenicity of tissues is depressed when they are kept at a very low temperature. In this study, Lewis rats and Brown Norway (B.N.) rats were used because these species are significantly dissimilar at the major histocompatibility complex (MHC) Femoral arteries were harvested from Lewis rats, frozen while lowering the temperature in a stepwise fashion to -70 degrees C. After three weeks of cryogenic storage, the arteries were transplanted into Lewis and B.N. rats. At various times from the first to the twelfth week after surgery, grafted vessels were observed, and pathological and electron microscopic studies were carried out. The vessels were found to be in good condition at the end of the 12 week observation period. These results strongly suggest that prolonged cryopreservation of vessels makes allotransplantation without immunosuppression possible.

A combination procedure was performed on the medial two toes in a 6-month-old child with preaxial polydactyly of the left foot. The first toe had the appearance of a cosmetically intact great toe, but the second toe had better function. A method to combine the advantages of these two toes was therefore applied, with favorable results seen at 1.5 years after surgery.

A case of a boy with complete duplication of the lower extremity and separation below the lower leg was described. Although x-ray examination revealed no femur, operation revealed a cartilage expected to become the femur in the future. A classification of duplication and separation of the lower extremity is proposed. The method and course of treatment in the present case were described in detail, including the application of tissue expanders on the deformity of the knee joint accompanied by a shortening of the sciatic nerve.

Clinical features of vascular leiomyoma of the upper extremity which have not been described or have been described incorrectly are documented with a report of 11 consecutive cases seen within the past 11 years. All patients were followed without recurrence or surgical morbidity. Vascular leiomyoma has been described as a painful nodule found more frequently on the extensor surfaces, but in our experience spontaneous or paroxysmal pain is exceptional and the tumour tends to be located on the volar surface when it is in the hand. In the digit, they tend to be found at the base away from the midline, and not seen distal to the DIP joint.

The cutaneous vascular anatomy of the finger dorsum was studied by dissection under loupe magnification of 71 fingers from 19 preserved cadaver hands. All specimens were injected with red latex or epoxy resin through a cannula in the brachial artery to identify the small vessels. The finger dorsum was supplied by the terminal branches from the dorsal metacarpal artery around the metacarpophalangeal joint. Other areas were nourished by the dorsal cutaneous branch from the proper palmar digital artery. There were two or three dorsal branches in the proximal phalangeal region and two in the middle phalangeal region. On the basis of these findings, we have developed a new method for one-stage reconstruction of finger pulp defect that restores sensation. Our innervated reverse vascular pedicle digital island flap includes the dorsal digital nerve and the proper palmar digital artery as a retrograde vascular pedicle. We have used the technique in three patients, with excellent results. The advantage of this procedure is that it provides a one-stage reconstruction of the pulp defect and restores sensation. The disadvantage is that the procedure requires neurorrhaphy.

Although many technological advances have been made in surgical materials, nylon is still the main suture material use for microvascular surgery. This study sought to evaluate polydioxanone (PDS) sutures for use in microvascular anastomoses. Twenty-eight male Sprague-Dawley rats were used in this experiment. Spatula-type needles with 9-0 PDS suture were used to anastomose the right femoral arteries, with 9-0 nylon used on the left side. The arteries were observed for 1, 2, 3, 4, 8, 12, and 16 weeks after surgery to determine arterial patency and to evaluate vascular pathology. Results were comparable between PDS and nylon. We suggest that if the suture material is redesigned to allow smooth passage through the tissue, and if the needle used in conjunction with the suture is improved, PDS may offer an excellent material for microvascular anastomosis.

The status of the blood supply to the hypothenar skin was investigated by anatomical and radiological studies. The investigation revealed that the hypothenar skin receives a rich blood supply from the arterial network by branches from the palmar ulnar artery of the little finger and the hypothenar branches. By making use of this abundance of vascular networking, a subcutaneous pedicle flap was obtained from this site. This method was clinically applied to 7 patients, and the procedures and advantages of the method are described.

We report the use of a two-layered free fascial flap consisting of temporoparietal and deep temporal fascia based on a single vascular pedicle, the superficial temporal artery and vein. The flap was used to reconstruct an extensive degloving injury of the dorsum of the hand, in which multiple intact extensor tendons lay fully exposed on all sides, with exposed bone beneath them. By sandwiching the tendons between the layers of vascularized fascia, gliding surfaces were provided, both superficial and deep to the exposed tendons. The single-stage reconstruction was completed with a split-thickness skin graft. The patient returned to heavy manual work within 12 weeks of injury. He obtained an excellent range of movement without the need for tenolysis.

Lateral calcaneal flaps were used to cover the skin necrosis of bilateral posterior heels, and a favorable result was obtained. During the first 5 years after surgery, the patient enjoyed hiking as before and made favorable progress, having no trouble in the region covered with the flap and attaining sensory cortical reorientation soon after surgery. Paresthesia of donor sites was reduced in its extent and caused no difficulties in everyday life, but it remained after the lapse of 5 years. The medical record of this patient during the 5 years is reviewed, and we discuss the indications of a lateral calcaneal flap.

A composite flap is presented based on the latissimus dorsi myocutaneous unit together with the underlying ninth to eleventh ribs. Three patients are presented. In two, a full-thickness chest-wall defect was present. In one, a full-thickness scalp and cranial defect was present. Use of the composite osteomyocutaneous latissimus dorsi free flap as a pedicled flap in two patients and as a free flap in one patient resulted in successful definitive reconstruction in all with no complications. This procedure necessitates no transplantation of soft tissue prior to bone grafting to maintain local vascularity, so the simultaneous one-stage reconstruction of an osseous-soft-tissue defect becomes possible easily.

The exposure-excretion relationship and possible health effects of exposure to methanol vapor were studied in 33 exposed workers during the second half of 2 working weeks. Urinary methanol concentrations were also determined in 91 nonexposed subjects. The geometric mean value for methanol in urine samples from the latter was less than 2 mg/l (95% upper limit of normal, less than 5 mg/l) when log-normal distribution was assumed. Among the exposed workers, the methanol level in urine samples collected prior to the work shift exceeded the 95% upper limit of normal. The time-weighted average intensity of exposure to methanol vapor was measured using personal sampling devices (in which water severed as an absorbent) in 48 cases of methanol exposure (i.e., 2 of the 33 exposed workers failed to provide urine samples, whereas 17 subjects were examined twice). Methanol concentrations in urine were determined in samples collected at the end of the shift from the 48 exposed cases as well as from 30 nonexposed controls. There was a significant correlation between the exposure to methanol vapor at concentrations of up to 5,500 ppm and the levels of methanol measured in the shift-end urine samples. The calculation indicated that a mean level of 42 mg methanol/l urine (95% confidence range, 26-60 mg/kg) was excreted in the shift-end urine sample following 8 h exposure to methanol at 200 ppm (the current occupational exposure limit). Dimmed vision and nasal irritation were among the most frequent symptoms complained during work. Three cases showing clinical signs of borderline significance were identified.