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Proton therapy for paediatric cancer patients is an effective treatment; however, young children have may have difficulties staying still during irradiation. This study investigated the indication of general anaesthesia in paediatric proton therapy. Background information and anaesthesia/treatment protocols were retrospectively extracted from the medical records of cancer patients under 15 years who underwent proton therapy at Southern TOHOKU General Hospital, Fukushima, Japan between April 2016 and December 2018. The anaesthesia and non-anaesthesia groups were compared to evaluate factors determining the need for general anaesthesia. Thirty-two patients who received 285 irradiations were analysed. The median age was 5 years old (range: 1–15), and 13 patients (40.6%) were female. Twelve (37.5%) patients received general anaesthesia. In the general anaesthesia group, airway management using a laryngeal mask was performed in 11 patients (91.6%). Patient age was significantly lower in the general anaesthesia group than in the non-anaesthetised group (p P

Background Radical esophagectomy for esophageal squamous cell carcinoma has improved survival, but the rate of recurrence is high. Patients of recurrent esophageal squamous cell carcinoma after failure of chemotherapy have a poor prognosis. We herein report the achievement of long-term survival after definitive proton beam therapy for oligorecurrent esophageal squamous cell carcinoma after failure of chemotherapy. Case presentation A 60-year-old Japanese man was diagnosed as having squamous cell carcinoma of the lower thoracic esophagus (cT2N0M0, stage IIA). He underwent two courses of neoadjuvant chemotherapy with cisplatin and 5-fluorouracil, and esophagectomy with three-field lymphadenectomy was performed. Microscopic findings after resection showed two lymph node metastases (ypT2N1M0, stage IIB). Five months after resection, a computed tomography scan revealed a solitary liver metastasis in the S4 area. He underwent three courses of chemotherapy with cisplatin and 5-fluorouracil; however, positron emission tomography revealed two lymph node metastases. Surgeons recommended second-line chemotherapy, but the patient refused chemotherapy and requested proton beam therapy. We performed proton beam therapy without chemotherapy for the liver metastasis and lymph node metastases, with total doses of 79.2 and 60 Gy relative biological effectiveness, respectively, according to the tumor location. An acute side effect of grade 1 dermatitis occurred after proton beam therapy, but there was no acute or late complication of more than grade 2. The patient remains in complete remission 5 years after treatment without surgery or chemotherapy. Discussion and conclusions Proton beam therapy exerted a curative effect on oligorecurrent esophageal squamous cell carcinoma. This is the first report on the achievement of long-term survival after definitive proton beam therapy for oligorecurrent esophageal squamous cell carcinoma.

ObjectiveThe purpose of this cross-sectional study was to evaluate the efficacy and safety of proton beam therapy for liver metastatic recurrence in gastric cancer patients.MethodsConsecutive patients who underwent proton beam therapy from 2010 to 2015 were isolated from our institutional database. Patients with extrahepatic metastatic lesions were excluded. Seven patients were enrolled. The median diameter of target lesions was 31 mm (13–68 mm). The most frequent dosage was 72.6 Gy equivalent in 22 fractions. The effectiveness was assessed based on the local control, overall survival and progression-free survival rates. The local control, overall survival and progression-free survival rates were calculated using the Kaplan–Meier method. Adverse events were described according to the patients’ medical records.ResultsThe median follow-up period was 41.7 months (20.7–66.3 months). The 3-year local control, overall survival and progression-free survival rates were 85.7, 68.6 and 43%, respectively. All patients completed proton beam therapy without interruption. No grade ≥3 adverse events were observed.ConclusionsProton beam therapy might be a treatment option for patients with liver metastasis of gastric cancer.

Background Perioperative oral management has been reported to be effective for preventing postoperative infectious complications. In addition, severe periodontal disease was identified as the significant risk factor for complications after gastrointestinal surgery. We investigated the bacteriological association between the periodontal pocket, stomach mucosa and drainage fluid to determine whether oral bacteria directly cause intra-abdominal infection after gastrectomy. Methods Patients who were scheduled to undergo surgery for gastric cancer were prospectively enrolled. We evaluated the similarity of bacterial strains in periodontal pocket, stomach mucosa and fluid from drainage tube. Gingival crevicular fluid and dental plaque were collected from the periodontal pocket and cultured to detect bacteria. Specimens from the resected stomach were collected and used for bacterial culturing. Drainage fluid from the abdominal cavity was also cultured. Results All of 52 patients were enrolled. In the periodontal pocket, α-Streptococcus spp., Neisseria sp., and Prevotella sp. were mainly detected. Bacterial cultures in the stomach mucosa were positive in 26 cases. In 20 cases (76.9%), the detected strains were the same as those in the periodontal pocket. Six patients had the postoperative intra-abdominal infection after gastrectomy, and the same bacterial strains was detected in both of drainage fluid and periodontal pocket in two patients with severe periodontal disease. Conclusions We found the bacteriological association that same strain detected in periodontal pocket, stomach and in intra-abdominal drainage fluid after gastrectomy in patients with periodontal disease.

The effectiveness of perioperative oral management in gastrointestinal surgery remains unclear. To elucidate the clinical significance of oral care, we investigated the relationship between the oral environment and postoperative infectious complications (POICs) in patients undergoing gastrointestinal surgery. This was a single-institute and historical cohort study of 341 patients. The participants were isolated from consecutive patients undergoing planned radical resection for gastrointestinal carcinoma from January 2016 to June 2017. Dentists assessed the oral environment for periodontal disease, hygiene status, dry mouth, fur on tongue, and tooth stumps. All patients received scaling and tooth brushing instructions. A stepwise logistic regression analysis was conducted to identify risk factors for POICs among the different oral statuses. The surgical procedures performed were gastrectomy in 123 (36.1%), colorectal resection in 185 (54.2%), and pancreatoduodenectomy or others in 38 (11.1%). POICs occurred in 48 patients (14.1%), including deep organ space infection in 20, surgical site infection in 11, anastomotic leakage in 5, urinary tract infection in 4, pneumonia in 2, and others in 6. After adjusting for confounding factors, periodontal disease was isolated as an independent risk factor for POICs (odds ratio 2.091, p = 0.037, 95% confidence interval 1.045–4.183). Other variables of oral environment such as hygiene status, dry mouth, fur on tongue, and tooth stumps did not have a significant impact on POICs. Periodontal disease is a risk factor for infectious complications after gastrointestinal surgery.

Purpose We sought to evaluate the effectiveness and the complications related to the use of Ethisorb (resorbable alloplastic material) in the reconstruction of orbital floor fractures. Patients and methods We retrospectively reviewed the charts of all patients who underwent orbital floor fracture reconstruction with Ethisorb since 2001. We only included patients with a minimum follow-up of 3 months. The following data were recorded for every patient: age, gender, cause of trauma, time from trauma to surgery, signs and symptoms, concomitant ocular injuries, radiographic analysis, pertinent intraoperative findings (including the type of approach), follow-up time, and postoperative complications. Results Eighty-seven patients were included in the study. Twenty-one patients (24.1%) experienced postoperative complications. Of these, only 3 patients (3.4%) had permanent complications directly related to the Ethisorb membrane (diplopia, enophthalmos). Two of these patients required revision surgery and are discussed in the article. Conclusions The results of our study demonstrate the effectiveness of Ethisorb in the repair of small-to-moderate orbital floor fracture defects (up to a maximum size of 2 × 2 cm).

This study reports on 15 mandibular reconstructions using the Dumbach Titan Mesh-System and particulate cancellous bone and marrow harvested from bilateral posterior ilia. All cases showed segmental defects. Eleven cases involved patients with malignant tumor. Six patients had received irradiation of 40-50 Gy. Reconstructions were performed immediately in 1 patient and secondarily in the remaining 14 patients. In 13 cases, mandibles were successfully reconstructed. Of these 13 patients, 9 reconstructions were completed without complications, whereas the other 4 cases showed complications. In 2 cases, reconstruction failed completely. Overall success rate was 87%. Statistical analysis revealed the extent of mandibular defect, but not malignancy of the original disease or radiotherapy of

In alveolar distraction, the bone segment tends to incline palatally or lingually, making rigid control of the segments difficult. The aim of this study was to evaluate the usefulness of a newly developed bi-directional extraosseous alveolar distractor (Medartis V2-Alveolar distractor) for pre- and perioperative vector management.Seven patients with segmental alveolar atrophy following traumatic tooth loss were treated using the distraction device. The patients were followed up clinically and radiologically. Preoperatively, the initial vector for distraction was determined using CT by measuring the cross-section of the bone. The morphology of the alveolar bone was also analyzed in relation to the planned implant position. Postoperatively, the rate of osteogenesis was monitored with plane radiographs and CT scan.All cases had bone deficit at the anterior surface of the alveolar ridge, showing a typical inclination of the long axis of the bone. Using the distractor, vertical distraction and positioning of the segments with labial orientation was possible. After a consolidation period of 12 weeks on average, sufficient bone formation for implant installation was radiologically observable. Histologic and histomorphometric analysis of one bone biopsy showed very dense mineralized bone (area fraction=78%) with a multidirectional, complex architecture. Implant-supported prosthetic oral rehabilitation was successfully performed in all cases.All complications observed in this study were related to the bone deficiency at the anterior surface of the alveolar process. If the technique can be improved, this type of bi-directional distraction is a promising method for alveolar bone repair.

Objective The objective of this study was to determine alternative ratios of soft-to-hard tissue movement after mandibular setback, taking skeletal relapse and differing patterns of facial divergence into account. Study design Thirty patients were analyzed cephalometrically over a mean follow-up period of 14 months. Results The relationship between skeletal and soft tissue movements in the mentolabial folds and at the pogonion was 1:1. Final skeletal relapse was 0.8 mm at the B-point and 0.5 mm at the pogonion. Hence, the alternative ratios were 81% and 68%, respectively. The alternative ratio for the mentolabial sulcus was considerably lower in the low- than in the high- and medium-angle groups of patients. However, there was no statistically significant difference between the patient groups with different facial patterns. Conclusion When the smallness of the measured relapse and the tracing error are taken into account, the difference between the alternative and the conventional ratios was insignificant.

Background: The development of endosseous implants and free vascularized bone grafting has permitted increased possibilities of oromandibular reconstruction in patients with oral cancer. In this study, a concept combining surgical and prosthodontic treatments for mandibular fibula free flap reconstruction after tumor surgery was made based on a classification of bone defects. A follow-up study was performed to evaluate the treatment concept for oral rehabilitation in order to identify possible factors which may influence the functional result. Material and methods: A follow-up examination included 28 patients who underwent the ablative tumor surgery and mandibular reconstruction during a 4-year period. The follow-up protocol included clinical examination, radiological evaluation, and an interview using a standardized questionnaire. The timing of the study was set to allow for a minimum 2-year follow-up (mean 45 months). Results and conclusion: At the time of examination, prosthesis-based oral rehabilitation was completed in six patients (21%), and the prosthodontic work was still unfinished in four other patients. The other 18 had no dental prosthetic rehabilitation. Thirteen patients received a total of 37 oral implants, and 23 implants were functionally loaded. No implant loss was recorded. Oral functions such as speech, diet tolerance and oral competence were not directly affected by the presence of dentures. A decisive factor affecting the oral function was the extent of soft-tissue loss. According to the classification described here, the extent of the mandibular defect did not correlate with oral functions. The application of oral implants seemed to be advantageous for the oral rehabilitation of patients who had undergone intraoral resections.

Bone morphogenetic proteins have been found to be one of the most promising osteoinductive substances and they are expected to be utilized clinically for the reconstruction of defective mandibles. However, newly formed bone induced by recombinant human bone morphogenetic protein-2 (rhBMP-2) has not yet been proven able to withstand the masticatory force applied by oral implants. In this study, we examined the qualitative changes in an rhBMP-2-induced mandible from the functional force of osseointegrated oral implants. Segmental (30 mm) bone defects were created in the mandibles of beagles. A poly D,L-lactic coglycolic acid-coated gelatin sponge impregnated with rhBMP-2 was grafted to the resected canine mandible. The new bone was formed 8 weeks after surgery and the Brånemark system fixtures were implanted into the reconstructed mandible. After another 8 weeks, the prosthesis was placed over the oral implants. The prosthesis was maintained in occlusion with the opposing natural dentition for 0, 4, 12, 24, or 48 weeks before the animal was euthanized. The quality of regenerated bone was then evaluated histologically and the osseointegration ratio between oral implants and the bonemeasured. During the first 4 weeks, the ratio remarkably increased from 48.9% to 64.5%. After 48 weeks, the ratio approached about 74.5%. The bone loaded for 48 weeks had undergone extensive remodeling and consolidation; its quality was better and maturer than that of bone that was not loaded. These results indicated that the newly formed bone induced by rhBMP-2 was able to withstand the masticatory force applied by oral implants and had become as functionally mature as a natural bone.

The purpose of this study was to evaluate the long-term functional properties of regenerated bone induced by recombinant human bone morphogenetic protein -2 (rhBMP-2) in segmental bone defects of primate mandibles. The 30-mm defects were created in the mandibles of six young monkeys and the mandibles were fixed with titanium plates. Then 9 mg of rhBMP-2 permeating a poly-D, L-lactic-co-glycolic acid-coated gelatin sponge (PGS) was implanted into the bone defect. Dental implants were placed into the regenerated mandible 20 weeks after surgery, then suprastructures were placed and masticatory force loading was begun 8 weeks after the insertion of the dental implants. Bone formation and the quality of new bone were evaluated radiologically and histologically at 15 and 30 weeks after surgery, and 4 and 24 weeks after masticatory force loading. The resected mandibles were completely regenerated with the rhBMP-2-induced bone. Excellent remodelling and consolidation of new bone were observed after loading. This study demonstrated that the new bone induced by rhBMP-2 in large segmental defects was maintained and functional for at least 1 year. Bone regeneration induced by rhBMP-2 holds promise as a future therapy and may be an effective alternative to autogenous bone grafts for implant dentistry and reconstructive surgery.

The efficacy of bone morphogenetic protein (BMP) for bone reconstruction has been widely studied in numerous animal experiments, but insufficient information exists about its ability to regenerate bone in primates. The purpose of this study was to evaluate the effects of recombinant human BMP-2 (rhBMP-2) on bone formation in alveolar bone defects in the mandibles of young primates. Marginal bone defects were created in the mandibles of nine 5-year-old rhesus monkeys and rhBMP-2 permeated in a polylactic-co-glycolic acid-coated gelatin sponge (PGS) was implanted into the bone defects. The resected bone treated with rhBMP-2 regenerated completely at 12 weeks postoperatively, and remodelling and consolidation of new bone were seen histologically. This study provides evidence of considerable bone regeneration in alveolar defects after surgical implantation of rhBMP-2 in non-human primates. This technique may be an effective alternative to autogenous bone grafts for reconstructive surgery in clinical practice.

In this study, an attempt was made to transform a muscle vascularized pedicle raised on host vessels into a vascularized bone flap, using recombinant human bone morphogenetic protein 2 (rhBMP-2). The purpose of this study was to produce new bone vascularized in nature to increase the survival rate of the subsequently grafted bone and to fabricate the newly formed bone into the desired shape. Silicone molds in the shape of a rat mandible were used to deliver rat bone matrix impregnated with or without rhBMP-2. A muscle pedicle the same size as the mold was raised on the saphenous vessels in the rat thigh and then sandwiched in the center of the silicone molds. The molds were sliced in half and each section was filled with rat bone matrix that was impregnated either with 25 microg of rhBMP-2 for the experimental group or with diluting material alone for the control group. The sandwiched flaps were then secured by tying them to the adjacent muscles and were harvested at 2 and 4 weeks after surgery. Three and six rats were used in the control and experimental groups at each time point, respectively. Bone formation was assessed in the ex vivo specimens by macroscopic, radiologic, and histologic evaluation. Macroscopically, the continuation of the vascular pedicle was clearly visible for both the control and experimental muscle flaps. However, no evidence of muscle-tissue transformation was observed in the control flaps, whereas all the flaps treated with rhBMP-2 produced new bone that replicated the shape of the mold exactly and had saphenous vessels supplying the newly formed bone. This study demonstrates that this experimental model has the potential to be therapeutically applied for effective bone reconstruction.

Objectives To clarify the patterns of frontobasal and frontosinal fractures in children and teenagers and to analyze whether the patterns relate to developmental stage of the facial skeleton. Design Retrospective study. Setting Level I trauma center in Bern, Switzerland. Patients Forty-three consecutive patients aged 18 years or younger with fracture of the frontal skull base. Main Outcome Measures Age at the time of injury and site, type, and degree of displacement among frontobasal and frontosinal fractures. Results The orbital roof was the most common frontobasal fracture site (86.0% [37 of 43]), and a combined lateral and central frontobasal fracture was the most common fracture type (55.8% [24 of 43]). Frontosinal fractures were observed in 46.5% of patients (20 of 43). Displacement or communitation of frontobasal fractures occurred in 46.5% of patients (20 of 43) and of frontosinal fractures in 70.0% (14 of 20). Isolated central frontobasal fractures were significantly more frequent in teenagers than in children aged 6 years or younger, but isolated lateral frontobasal fractures were significantly more frequent in children aged 6 years or younger than in teenagers ( P = .02 for both). Dislocation or communition of frontosinal fractures was significantly more frequent in teenagers than in children aged 6 years or younger ( P = .04). Conclusion Frontobasal fracture patterns are related to age, reflecting their correlation with the developmental phase of the facial skeleton, particularly size and degree of pneumatization of the paranasal sinuses.