Search

Autologous costal cartilage grafts remain the gold standard method for microtia reconstruction. However, reports on its long-term outcomes are limited. We present two cases with >40-year outcomes after auricular reconstruction with autologous costal cartilage. A 56 year-old woman and a 53 year-old man presented to our institution with complaints of wire exposure. In both cases, the reconstructed ear was deformed. A computerized tomography scan revealed calcification of the reconstructed costal cartilage graft framework. To our knowledge, these cases present the longest outcomes (50 and 42 years for the 56 year-old woman and 53 year-old man, respectively) of microtia reconstruction using autologous cartilage grafts. We found that ear frameworks constructed from costal cartilage tended to calcify in the long term, as in the natural course of costal cartilage. Therefore, the possibility of calcification of costal cartilage grafts should be relayed to patients and parents, and lifelong surveillance after reconstruction should be recommended.

Background:. Recently, significant inframalleolar disease seems to increase in chronic limb-threatening ischemia (CLTI) patients, making identifying sufficient outflow vessels in the foot challenging. In these difficult situations, free tissue transfer is a valuable tool to provide a low-resistance vascular bed to the affected part. However, there remains concern that free tissue transfer may impede adequate perfusion of the higher resistance diseased vascular bed. Methods:. To improve perfusion of the affected area directly, the authors have developed a concept of a free bypass flap, adding bypass surgery to free tissue transfer. After anastomosis with the recipient vessels in a conventional manner for free tissue transfer, bypass surgery to the foot is performed by anastomosis of the branch of the flap pedicle with the diseased artery to the foot. A retrospective chart review of nine CLTI patients was performed to analyze the outcomes of free bypass flap transfer between 2018 and 2023. Results:. The flap success rate was 100% (n = 9). Postoperative angiography or echo confirmed the patency of all but one bypass vessel (n = 8). There were six fatalities, however, due to causes other than foot lesions, with an average observation period of 16 months. The limb salvage rate was 89% (n = 8). Conclusions:. A free bypass flap enhances the overall blood circulation to the foot. Due to its high patency rate of bypass vessels, it is a valuable method for preserving the limbs of highly comorbid patients with CLTI.

Attogram-level of proteins can be detected using light-induced acceleration of antigen-antibody interactions in a microchannel platform.

Abstract Wearable sensors have seen remarkable recent technological developments, and their role in healthcare is expected to expand. Specifically, monitoring tissue circulation in patients who have undergone reconstructive surgery is critical because blood flow deficiencies must be rescued within hours or the transplant will fail due to thrombosis/haematoma within the artery or vein. We design a wearable, wireless, continuous, multipoint sensor to monitor tissue circulation. The system measures pulse waves, skin colour, and tissue temperature to reproduce physician assessment. Data are analysed in real time for patient risk using an algorithm. This multicentre clinical trial involved 73 patients who underwent transplant surgery and had their tissue circulation monitored until postoperative day 7. Herein, we show that the overall agreement rate between physician and sensor findings is 99.2%. In addition, the patient questionnaire results indicate that the device is easy to wear. The sensor demonstrates non-invasive, real-time, continuous, multi-point, wireless, and reliable monitoring for postoperative care. This wearable system can improve the success rate of reconstructive surgeries.

Microbial interactions are closely related to human health, and secreted signal molecules from bacteria determine the gene expression of bacteria following bacterial cell density and signal molecule density. However, the conventional quantitative analysis of the number of bacteria requires several days using standard cultivation methods, and the detection of molecules secreted via microbial interactions is difficult since they are in extremely small amounts. In this study, we performed local fluorescence spectroscopy to quantitatively evaluate the density of the assembly of dispersoids (fluorescent microparticles and bacteria) under optical condensation at a solid–liquid interface on our developed bubble-mimetic substrate, which exhibits extremely low thermal damage after a few minutes of laser irradiation. The obtained results showed that the fluorescence intensity spectrum was positively correlated with the concentration of dispersoids even when only several tens of assembled microparticles were observed. Furthermore, a calibration curve was obtained by plotting the integrated fluorescence intensity by integrating the fluorescence intensity spectrum over the observed wavelength, and the concentration of living bacteria was quantitatively analyzed. The clarified mechanism of local fluorescence spectroscopy under optical condensation will pave the way for rapid and precise analysis of bacteria and their secreted biomolecules labeled with fluorescent dye.

Hayashi et al. propose a method to realise rapid, damage-free, remote light-induced assembly of microbes over a submillimeter area with the “bubble-mimetic substrate”. They assemble 104–105 cells of lactic acid bacteria with a survival rate higher than 95% around a laser spot. This technique is promising in developing methods for rapid and high-efficiency functional analysis of microbes.

Background: Although free jejunal transfer is an established and reliable procedure for reconstruction after total pharyngolaryngectomy (TPL), vascular thrombosis remains a surgical challenge. To reduce the risk, a double-pedicled free jejunal flap transfer has been attempted using a root jejunal artery and an arcade artery, although several drawbacks exist. The vasa recta are terminal straight vessels that arborize from an arcade artery without branching. We present a novel double-pedicled free jejunum transfer using vasa recta anastomosis. Methods: Between 2011 and 2015, we performed 14 double-pedicled free jejunal flap transfers for reconstruction after TPL. Vasa recta were used for second arterial anastomosis in 5 out of 14 patients. Others include a root artery in three patients and an arcade artery in six patients. Indocyanine green (ICG) angiography was performed to confirm the patency and perfusion of the entire flap by the second artery alone. Results: The flaps survived completely in all cases. The vasa recta (average diameter; 0.8 mm) were anastomosed to the superior thyroid artery and transverse cervical artery in four and one cases, respectively. Supramicrosurgical end-to-side anastomosis was performed in two cases. ICG angiography showed sufficient perfusion of the entire flap with the second artery alone in all cases. Conclusion: As vasa recta were confirmed as being capable of perfusing the entire flap up to 25 cm, the double-pedicle method using vasa recta might be an option to reduce the risk of flap necrosis, particularly in high-risk patients. Keywords: Vasa recta, Free jejunum, Double pedicle, Supermicrosurgery

Summary:. Although the great toe plays important roles in walking, loading, and maintaining balance when compared with other toes, there are few reports on great toe reconstruction, including the reconstruction of distal phalanx. This report aims to describe the use of a superficial circumflex iliac artery perforator (SCIP)–osteocutaneous flap for reconstructing a complex tissue defect of the great toe. A 62-year-old man presented with a crush injury to the forefoot. Because the great toe was severely crushed, the defect distal to the proximal phalanx of the great toe was reconstructed using a SCIP-osteocutaneous flap. The immediate postoperative course was uneventful; however, surgical revision was necessary. Signs of osseous union could be observed on radiographic images taken 2 months after the initial surgery. Twenty-four months after surgery, the patient could freely walk without resorption of the transferred bone. We demonstrated that SCIP-osteocutaneous flaps may be promising free flaps in complex tissue defect reconstruction of the great toe.

Background:. Free flaps have evolved from musculocutaneous flaps to perforator-based cutaneous flaps. The subdermal plexus is now thought to play a significant role in skin paddle perfusion. We propose a new concept, the “intradermal plexus,” allowing survival of dermis flaps, according to our study. Methods:. A dermis flap was used in 6 cases to reconstruct small defects. The superficial branch of the superficial circumflex iliac artery was traced distally using an ultrasound device with a 70-MHz linear array transducer until the artery’s branch entered the dermis. The location of the dermis entry site was marked and the vessels running inside the dermis were observed and video-recorded. A flap was elevated above the superficial fascia, and the adipose tissue was removed using scissors after confirmation of the vessels’ dermis entry point. Results:. The use of 70-MHz ultrasonography permitted observation in all patients of small arteries entering the dermis layer. The artery was observed to give off branches after entering the dermis, in effect constituting an “intradermal plexus.” Small veins entering the dermis were similarly visualized using 70 MHz ultrasonography. All flaps survived completely. Conclusions:. Small arteries and veins entering and running inside the dermis were visualized for the first time with 70 MHz real-time ultrasonography. Knowledge of the existence of this “intradermal plexus” made it possible to discard nearly all subdermal adipose tissue quickly and safely, without resorting to the elaborate measures described in previous reports.

Lymphatic malformation (LM), also known as lymphangioma, is a rare condition that can occur anywhere in the body in adults and children. LM, especially micro-cystic type, consists of multiple clustering skin/subcutaneous cysts that may involve deeper functional tissue. Although LM is generally benign, it may cause serious location-dependent problems. Periorbital LM, for example, often causes facial disfigurement and visual impairment. Especially, micro-cystic type of lymphatic malformation (mLM), is a challenging condition to treat. Currently available therapies for mLM have limited effectiveness and carry a high risk of complications. Thus, it is necessary to develop a novel treatment for mLM that is less invasive and highly effective. There has been a question of the exact location and direction of lymphatic flow into, within, and out of LM. There were some reports investigating the intra-cystic flow of LM; however, only a few focused on the afferent and efferent lymphatic flow of LM. With our detailed study using lymphography, we were able to determine the lymphatic flow pattern in periorbital LM, which was large enough to perform lymphatic venous anastomosis (LVA). LVA is a surgically-placed bypass between afferent collecting lymphatic vessels and veins, which in our study resulted in decreasing both the influx and the total volume of lymph in the LM. To our knowledge, this is the first study of Indocyanine green (ICG) lymphography on mLM, and LVA for its treatment. Here we present our case of periorbital mLM with LVA and discuss its less invasive surgical strategy.

Summary:. Microtia with congenital aural atresia is challenging to achieve aesthetically and functionally good results. We herein present a case where a vascularized superthin superficial circumflex iliac artery perforator (SCIP) flap was used for reconstruction of the external auditory canal (EAC) and a full-thickness skin graft was used for reconstruction of the postauricular region for a 10-year-old male who suffered from microtia with congenital aural atresia. After costal cartilage grafting (the first operation), EAC reconstruction and auricle elevation (the second surgery) was performed. After the atticoantrostomy, a superthin SCIP flap was rolled up in a sac and was inset to the newly created EAC. The postauricular skin defect was covered with full-thickness skin graft. The SCIP flap survived completely and good patency of the reconstructed EAC was accomplished, which results in an improvement of previous hearing loss. The skin graft survived completely, which eventually demonstrated aesthetically satisfactory results.

Background:. Less-invasive surgeries, such as lymphaticovenular anastomosis (LVA), are the widely accepted intervention for lymphedema. This study aimed to assess the outcomes of flow-oriented LVA modification on lymphatic malformation (LM). Methods:. We included 19 patients diagnosed with LM mixed type or microcystic type, who came to our clinic from June 2015 to December 2017. Under general anesthesia, all patients were administered an indocyanine green lymphography injection subcutaneously. In the case of a strong inflow, the patient underwent afferent lymph vessel of LM to venous anastomosis (LMVA). Otherwise, the side wall of LMVA was performed to the cysts. Outcomes were classified into the following groups based on the size changes: treatment effect (TE) 4 = >80% reduction rate; TE 3 = 50%–80% reduction rate; TE 2 = 20%–50% reduction rate; and TE 1 = 0%–20% reduction rate. Results:. All cases underwent surgery, with no case having an increased size. The results were as follows: TE 4 = 4 (21%) patients; TE 3 = 6 (32%) patients; TE 2 = 5 (26%) patients; and TE 1 = 4 (21%) patients. No case required study termination due to disease progression. Minor complication occurred in 3 cases. One vesicle increased at the labial mucosa and one wound dehiscence that epithelized within 1 month. Conclusion:. LMVA could be a novel, minimally invasive lymph flow-oriented surgical method for intractable LM.

Background:. Superficial circumflex iliac artery (SCIA) perforator flap is one of the demanding flaps. However, little is known about SCIA anatomy, which is crucial for successful SCIA perforator flap elevation, in children. We assessed the efficacy of our incision design to detect the superficial branch of the SCIA in vivo. Methods:. Eleven consecutive pediatric patients who required harvesting (eg, skin grafts or vascularized lymph node transfer) were assessed. All possible congenital vascular malformation cases were excluded. To reduce potential bias, all groin procedures were performed on the contralateral side of malformations. After inguinal area mapping, 1.5-cm skin incision was made. From the window opened by the skin incision, tiny perforation to the skin surface was detected for further dissection. Following the tiny branch, the main trunk of the superficial circumflex vascular bundle was dissected. The whole vascular bundle, artery, and major vein from the bundle were dissected and their sizes were measured. Results:. Of the 11 patients, 4 were boys; the age range was 5 months to 14 years (mean age: 3.2 years). Vessel bundle size was 0.7–1.5 (mean: 1.1 mm). In all cases, the bundle was detected within 5 min (1–5, mean: 2.5 min). No vascular damage was observed, and all arteries pulsated well, without requiring additional skin incision. The superficial branch of the SCIA was mainly detected right below the initial skin incision. Conclusions:. Our skin incision design can effectively detect the SCIA in pediatric patients and may be used in adult patients.

Summary:. Orbital roof fracture is a relatively rare trauma. In most cases, surgical intervention is not needed since the fracture is slight. However, invasive surgical procedures are inevitable once pulsatile exophthalmos occurs if vision impairment is to be avoided. We report our rare experience of orbital roof fracture in a child with pulsatile exophthalmos. Good reconstruction of the anterior cranial base was achieved using a custom-made titanium mesh and a minimally invasive approach. A 3-year-old girl who had been diagnosed with subdural hematoma, brain contusion, and fracture of the right orbital roof caused by facial bruising underwent emergent external decompression by coronal skin incision and a transcranial approach on the same day as the trauma. Cranioplasty using autologous frozen bone in the same approach was performed 103 days posttrauma, but this was followed by pulsatile exophthalmos. After recovering from critical stage, the girl was brought to our department for reconstruction of the anterior base. Risk of vision impairment was also one reason for reconstruction, but the neurosurgeon hesitated to approach the region using a coronal approach considering the possibility of infection in the frozen autologous bone. Through cross-team discussion, reconstruction using a subeyebrow incision was performed with a custom-made titanium mesh plate. Pulsatile exophthalmos completely disappeared. Pulsatile exophthalmos is a very rare but serious complication that carries a risk of vision impairment. By applying a custom-made titanium mesh plate, precise reconstruction was enabled with minimal invasiveness and low risk.

Background:. In free-flap reconstruction of the midface, options for the recipient artery are quite limited; the superficial temporal artery and the facial artery are the most commonly used arteries. We report our approach for the use of the angular artery (the terminal branch of the facial artery) as the recipient artery in free-flap reconstruction of the midface. Methods:. Nine patients with midface defects underwent free-flap reconstructions using the angular artery as the recipient artery. Identification and marking of the facial artery were performed preoperatively using handheld Doppler ultrasound. The angular artery was located through an incision made on the side of the nose. When present, a vena comitans of the facial artery or any subcutaneous vein in the vicinity of the defect was used as the recipient vein. In other cases, the facial vein in the submandibular region was chosen as the recipient vein, using a vein graft. Results:. The average diameter of the angular artery was 0.9 mm (range, 0.7–1.0 mm). In all cases, arterial anastomosis was performed in an end-to-end fashion, and flaps survived completely. In 4 cases, a vein graft was used to bridge the pedicle vein and the facial vein. Conclusions:. Although supermicrosurgical skills may be required for its anastomosis, the angular artery is an anatomically consistent artery, which is suitable for use as the recipient artery in free-flap reconstruction of the midface. Use of the angular artery as the recipient artery allows shorter flap pedicles and decreases the number of vein grafts necessary.

Bottom-up processing of nanobiomaterials enables the creation of a variety of macroscopic structures in natural systems. Here, we use optical means to produce macroscopic-assembled structures of nanoparticles (NPs) from protein molecules by using light-induced bubble (LIB) generation under asymmetric pressure-driven flow in a microchannel. The broadband optical response of assembled NPs facilitates the application of photon pressure and photothermal convection when irradiated by using an infrared laser. The presence of a large amount of protein allows the generation of a vast number of stable LIBs from optically assembled metallic NP-fixed beads (MNFBs). In the case of more diluted albumin solutions, the shrinking of a single LIB can cause the aggregation of MNFBs via fg-level albumin (3.4 fg in the observation region), like a microscale bubblegum. The size of the resulting aggregate can be controlled by changing the concentration of protein. These findings can be used to devise production methods not only for broadband optical nanocomposites but also for label-free methods to detect an extremely small amount of protein.

Klippel-Trenaunay syndrome (KTS) is a congenital vascular anomaly in children, which requires treatment but challenging. The characteristics of KTS include disproportionality of the affected limbs, usually with enlargement due to lymphatic malformation (LM) [1]. Sometimes the condition is accompanied by pain that is difficult to treat. Compression therapy is one option for reducing the swelling; however, this has limitations [2]. We previously reported that lymphatic venous anastomosis (LVA) may be a safe and effective procedure for reducing the size of micro cystic type LM by decreasing the intra cystic lymph [3]. We treated a case of KTS in a 9-year-old boy who had improvement of lower abdominal swelling and penile pain after a single LVA. The method involved is to make a bypass, from the afferent lymph-collecting vessel to subcutaneous veins. However, to apply LVA to LM, it is sometimes problematic to detect the afferent flow in combined vascular malformations, such as KTS. Therefore, we performed VA making a bypass directly from LM, instead. We classify two types of LVA methods for LM: afferent lymph vessel LMVA (A-LMVA), and sidewall LMVA (S-LMVA). S-LMVA has more merits than the previously reported A-LMVA.

Summary:. Fingertip replantation is a technical challenge for microsurgeons. For successful fingertip replantation, it is important to monitor the replanted fingertip vascularity for the early detection and revision of vascular compromise. Laser speckle contrast imaging (LSCI) is a camera-based technique that measures the perfusion by illuminating the tissue with a 785-nm-wavelength divergent laser beam. This creates a speckle pattern over the illuminated area. We present a case in which postoperative monitoring of the replanted fingertip microcirculation using LSCI allowed for successful Tamai zone I fingertip replantation. Postoperative monitoring using LSCI has 3 main advantages. First, this method is harmless to the patient and the replanted fingertip. A camera-based technique enables microcirculation monitoring without touching the patient or the replanted fingertip. Second, tissue perfusion is measured in real time and recorded continuously, allowing for the rapid response to the arterial or venous occlusion to be observed. Third, using LSCI, the skin perfusion can be measured quantitatively. Although further clinical investigations will be required to confirm its efficacy, LSCI has the potential to be a useful monitoring device.

Background:. In a setting of flap congestion, early detection and rapid reexploration are important. Some studies described the efficacy of blood glucose measurement for flap monitoring.1 However, the sensitivity and specificity of this method were not high enough to determine whether reexploration should be done or not. The purpose of this study was to evaluate and establish a method using the ratio of blood glucose level change (RBGC) measurement for detecting venous thrombosis and to propose an algorithm for flap salvage after congestion. Methods:. Blood glucose level was measured in 36 free tissue transfers over time postoperatively and RBGC was calculated. When flap congestion was suspected, frequent blood glucose measurement and some countermeasures were performed complying with an algorithm. If the venous thrombus was suspected, the reexploration was performed. The RBGCs at the points in time when the venous thrombosis was detected were compared with those at the points in time when the flap demonstrated no venous thrombosis. Results:. Of the 36 flaps, 30 flaps demonstrated no venous thrombosis and 6 flaps demonstrated venous thrombosis. Four flaps demonstrated signs of congestion but improved after the reexploration. The mean RBGCs at the points in time when the venous thrombosis was detected was −7.61 mg/dl h and those at times when the flap demonstrated no venous thrombosis was 0.10 mg/dl h, the former being significantly lower than the latter. Conclusion:. Using the flap monitoring method using RBGC measurement, we could salvage some flaps from the congestion due to the venous thrombosis without unnecessary reexploration.

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

Summary:. Bone perfusion evaluation methods in cadaver studies have yet to be established. The aim of this report was to introduce and validate the feasibility of indocyanine green (ICG) fluorescence angiography for evaluation of bone perfusion in the femoral medial condyle in cadavers. In 4 fresh nonembalmed cadavers (2 female), the descending genicular artery was dissected and carefully cannulated bilaterally. A 10 mL solution containing 5 mL ICG solution and 5 mL methylene blue solution was injected into the descending genicular artery. After the injection, the medial femoral condyle was cut with an oscillating saw. A photograph was taken of the cut ends of the bone. The cut ends of the bones were observed using a near-infrared camera. Images corresponding to the previously taken photographs of the cut ends were captured for comparative analysis. After injection of methylene blue and ICG, the blue dye could be seen in the periosteum in all specimens, but not inside the cortex or the cancellous region of the bone. When observed with ICG fluorescence angiography, however, the cancellous region was highlighted through small perforators penetrating the periosteum. Perfusion inside the medial femoral condyle in cadavers was confirmed using ICG fluorescence angiography. Our method can be especially beneficial in confirming the bone perfusion of a new bone flap based on a particular artery, both in cadavers as well as in patients, because ICG can be injected into specific arteries.

The complex reconstruction of nerves and soft tissue in the head and neck region is still challenging, especially in cases requiring external auditory canal reconstruction with facial nerve reconstruction. We report a case of left facial schwannoma extending into the external auditory canal beyond the tympanic membrane with facial paralysis in which the reconstruction of both the facial nerve and external auditory canal was successfully performed using an anterolateral thigh flap as a super-thin full-thickness skin flap, including vascularized lateral femoral cutaneous nerve. Resection of 20 mm × 46 mm facial schwannoma, including the skin of the external auditory canal, tympanic membrane, incus and malleus, was performed. The 8-cm nerve gap was repaired using a vascularized lateral femoral cutaneous nerve included in the anterolateral thigh flap. An 8 cm × 2 cm super-thin, free anterolateral thigh flap was then rolled up as a sac (diameter of 2 cm, height of 2 cm) and inset to the external auditory canal defect. The postoperative course was uneventful, and the flap survived completely. One year and nine months after the surgery, the patient’s facial movement has improved to the pre-surgery level.

Background:. A lymphangioma, also called a lymphatic malformation, is a congenital condition that frequently occurs in young children. It is classified into 3 groups depending on the size of the cysts (macrocystic, microcystic, and mixed). Spontaneous regression occurs in some cases; however, the characteristics of patients who show regression have not been studied previously. Furthermore, the types and the timing of the initial treatment are still controversial. Therefore, we statistically analyzed the occurrence of short-term spontaneous regression, patient age at original occurrence, cyst types, cyst sizes, and cyst locations in patients diagnosed with peripheral localized lymphangiomas in a single children center over 34 years. Methods:. We retrospectively collected the data of 153 patients and reviewed the medical charts. Results:. Spontaneous regression occurred only in macrocystic or mixed type; regression was most frequent in patients who, at the time of onset, were more than 2 years old. Conclusions:. We concluded that elderly patients with macrocystic or mixed type lymphangioma may have to wait for treatment for over 3 months from the initial onset. Conversely, microcystic type could not be expected to show regression in a short period, and prompt initiation of the treatments may be required. The difference of the regression or not may depend on the characteristics of the lymph flow.

ObjectiveThe number of bypasses is the most important factor in lymphaticovenular anastomosis (LVA) for lymphedema treatment. Side-to-end (S-E) LVA, which can bypass bidirectional lymph flows via one anastomosis, is considered to be the most efficient bypass, but creation of lateral window to a small lymphatic vessel is technically demanding. To overcome the difficulty, we introduced S-E anastomosis through temporary lymphatic expansion (SEATTLE) procedure in S-E LVA.MethodsThis was a retrospective observational study set in a teaching hospital. Forty eight lower extremity lymphedema (LEL) patients underwent LVA. S-E LVAs were performed with (SEATTLE group) or without (non-SEATTLE group) temporary lymphatic expansion. S-E LVAs were evaluated to compare anastomosis result in SEATTLE and non-SEATTLE groups.ResultsS-E LVAs resulted in 44 anastomoses in SEATTLE group (n = 25) and 37 anastomoses in non-SEATTLE group (n = 23). LEL index reduction in SEATTLE group was significantly greater than that in non-SEATTLE group (16.5±14.5 vs. 10.9±11.8, P = 0.041). Success rate of S-E LVA in SEATTLE group was significantly higher than that in non-SEATTLE group (95.5% vs 81.1%, P = 0.040). Thirty seven of 44 (84.1%) lymph vessels in SEATTLE group were successfully dilated by temporary lymphatic expansion maneuver. All of 9 failed S-E LVAs used a lymphatic vessel with diameter of 0.35 mm or smaller.ConclusionsThe SEATTLE procedure facilitates S-E LVA by a simple and easy maneuver. When the diameter of the lymphatic vessel is 0.35 mm or smaller even after the temporary lymphatic expansion maneuver, S-E LVA is not recommended due to relatively high failure rate.

BACKGROUND: Anorectal transplantation is a method for patients who have lost their anorectal function or suffer from congenital anorectal dysfunction to recover this function, and this has been investigated in experimental animal models using pigs, dogs, and rats. In this study, we performed an examination of anorectal transplantation in human cadavers to investigate whether this procedure could be performed in patients. METHODS: A 77-year-old woman cadaver 1 was used as the donor and a 98-year-old woman cadaver 2 was used as the recipient. Initially, abdominoperineal excision of the anus and rectum (the Miles' operation) was performed on the recipient. Next, an anorectal graft containing the pudendal nerve (PN), pudendal artery (PA), pudendal vein (PV), inferior mesenteric artery (IMA), and inferior mesenteric vein (IMV) was harvested from the donor. The donor graft was transplanted into the recipient by intestinal anastomosis and microneurovascular anastomoses orthotopically. RESULTS: The diameters of the PN (right/left), IMA, and IMV were 2.5 mm/2.5 mm, 2.0 mm, and 1.5 mm, respectively, in cadaver 1, and 2.0 mm/2.0 mm, 2.0 mm, and 2.0 mm, respectively, in cadaver 2. The length of the PN, PA, PV, IMA, and IMV in the graft was sufficient to allow proper anastomosis. CONCLUSION: This preliminary study indicated that human anorectal transplantation was possible anatomically and technically. We anticipate our study will aid in the potential future application of this procedure to human patients.

BACKGROUND: Secondary lymphedema causes swelling in limbs due to lymph retention following lymph node dissection in cancer therapy. Initiation of treatment soon after appearance of edema is very important, but there is no method for early diagnosis of lymphedema. In this study, we compared the utility of four diagnostic imaging methods: magnetic resonance imaging (MRI), computed tomography (CT), lymphoscintigraphy, and Indocyanine Green (ICG) lymphography. PATIENTS AND METHODS: Between April 2010 and November 2011, we examined 21 female patients (42 arms) with unilateral mild upper limb lymphedema using the four methods. The mean age of the patients was 60.4 years old (35-81 years old). Biopsies of skin and collecting lymphatic vessels were performed in 7 patients who underwent lymphaticovenous anastomosis. RESULTS: The specificity was 1 for all four methods. The sensitivity was 1 in ICG lymphography and MRI, 0.62 in lymphoscintigraphy, and 0.33 in CT. These results show that MRI and ICG lymphography are superior to lymphoscintigraphy or CT for diagnosis of lymphedema. In some cases, biopsy findings suggested abnormalities in skin and lymphatic vessels for which lymphoscintigraphy showed no abnormal findings. ICG lymphography showed a dermal backflow pattern in these cases. CONCLUSIONS: Our findings suggest the importance of dual diagnosis by examination of the lymphatic system using ICG lymphography and evaluation of edema in subcutaneous fat tissue using MRI.

BACKGROUND: Uterine blood flow is an important factor in uterine viability, but the number of blood vessels required to maintain viability is uncertain. In this study, indocyanine green (ICG) fluorescence imaging was used to examine uterine hemodynamics and vessels associated with uterine blood flow in cynomolgus macaque. METHODS: The uterus of a female cynomolgus macaque was cut from the vaginal canal to mimic a situation during trachelectomy or uterine transplantation surgery in which uterine perfusion is maintained only with uterine and ovarian vessels. Intraoperative uterine hemodynamics was observed using ICG fluorescence imaging under conditions in which various nutrient vessels were selected by clamping of blood vessels. A time-intensity curve was plotted using imaging analysis software to measure the T(max) of uterine perfusion for selected blood vessel patterns. Open surgery was performed with the uterus receiving nutritional support only from uterine vessels on one side. The size of the uterus after surgery was monitored using transabdominal ultrasonography. RESULTS: The resulting time-intensity curves displayed the average intensity in the regions of the uterine corpus and uterine cervix, and in the entire uterus. Analyses of the uterine hemodynamics in the cynomolgus macaque showed that uterine vessels were significantly related to uterine perfusion (P=0.008), whereas ovarian vessels did not have a significant relationship (P=0.588). When uterine vessels were clamped, ovarian vessels prolonged the time needed to reach perfusion maximum. Postoperative transabdominal ultrasonography showed that the size of the uterus was not changed 2 months after surgery, with recovery of periodic menstruation. The cynomolgus macaque has got pregnant with favorable fetus well-being. CONCLUSION: Uterine vessels may be responsible for uterine blood flow, and even one uterine vessel may be sufficient to maintain uterine viability in cynomolgus macaque. Our results show that ICG fluorescence imaging is useful for evaluation of uterine blood flow since this method allows real-time observation of uterine hemodynamics.

INTRODUCTION: To date, an electron microscopy study of the collecting lymphatic vessels has not been conducted to examine the early stages of lymphedema. However, such histological studies could be useful for elucidating the mechanism of lymphedema onset. The aim of this study was to clarify the changes occurring in collecting lymphatic vessels after lymphadenectomy. METHODS: The study was conducted on 114 specimens from 37 patients who developed lymphedema of the lower limbs after receiving surgical treatment for gynecologic cancers and who consulted the University of Tokyo Hospital and affiliated hospitals from April 2009 to March 2011. Lymphatic vessels that were not needed for lymphatico venous anastomosis surgery were trimmed and subsequently examined using electron microscopy and light microscopy. RESULTS: Based on macroscopic findings, the histochemical changes in the collecting lymphatic vessels were defined as follows: normal, ectasis, contraction, and sclerosis type (NECST). In the ectasis type, an increase in endolymphatic pressure was accompanied by a flattening of the lymphatic vessel endothelial cells. In the contraction type, smooth muscle cells were transformed into synthetic cells and promoted the growth of collagen fibers. In the sclerosis type, fibrous elements accounted for the majority of the components, the lymphatic vessels lost their transport and concentrating abilities, and the lumen was either narrowed or completely obstructed. CONCLUSIONS: The increase in pressure inside the collecting lymphatic vessels after lymphadenectomy was accompanied by histological changes that began before the onset of lymphedema.