Language：English   Publisher：Auris Nasus Larynx  

Objective: Peritracheostomal pharyngocutaneous fistula (PCF), a direct connection between the PCF and tracheal stoma due to a skin defect, is among the most problematic complications after total laryngectomy or pharyngolaryngectomy. Peritracheostomal PCFs can cause lethal complications, including severe pneumonia or carotid blowout, secondary to salivary leakage directly into the tracheal stoma, and their management is challenging without early invasive surgical closure. We aimed to evaluate the utility of our novel and minimally invasive combined local skin flap placement and negative-pressure wound therapy (NPWT) method for the management and conservative closure of peritracheostomal PCFs. Methods: We retrospectively enrolled patients who developed a peritracheostomal PCF from July 2015 to September 2021 at our institution and affiliated hospitals. Postoperative PCFs were all initially managed with appropriate wound bed preparation. Subsequently, a small local flap of healthy, lower neck skin was elevated and transferred anterior to the PCF to replace the peritracheostomal skin defect. The flap served to provide a sufficient surface for film dressing attachment and facilitated airtight sealing during NPWT. We initiated NPWT after confirming the local skin flap was firmly sutured to the tracheal mucosa. A flexible hydrocolloid dressing was applied to the peritracheostomal skin flap, and a film dressing was placed on the flexible hydrocolloid dressing and surrounding cervical skin. We inserted the NPWT foam shallowly into the fistula tract and applied negative pressure (73.5–125 mmHg). NPWT was continued until the PCF was closed or became so small that salivary leakage was minimal and could be managed by conventional compression dressings. Results: We enrolled six patients [male, n = 6; mean age, 66.5 years (range, 57–80 years)]. NPWT was applied for an average of 18.2 days (range, 2–28 days). During NPWT, air leakage occurred once (2 cases), only a few times (2 cases), or not at all (2 cases). In all patients, complete fistula closure was achieved in an average of 28.2 days (range, 15–55 days) after the start of NPWT, and no patient required further surgical intervention. There were no lethal complications (e.g., severe pneumonia) during treatment. Conclusion: Our method of combined local flap placement and NPWT enabled effective management of salivary aspiration and accelerated wound healing, which allowed conservative fistula closure in all patients. We believe combined local flap placement and NPWT should be considered a first-line treatment for intractable peritracheostomal PCF.

DOI： 10.1016/j.anl.2024.09.008

Scopus

PubMed

Language：English   Publisher：Japan Society for Surgical Wound Care  

Lymphorrhea, which is a challenging disease to manage, can be treated using noninvasive or invasive procedures. We herein report a case of intractable lymphorrhea that did not respond to multimodal treatments, including direct suture after excision, lymphaticovenous anastomosis, and negative-pressure wound therapy; however, complete resolution was achieved by free flap transfer. A 47-year-old woman presented with severe lymphorrhea in her right upper arm due to repeated partial excision of a large lymphangioma extending from the upper arm to the cervicothoracic region. Despite multiple attempts to manage lymphorrhea using noninvasive procedures, she experienced persistent lymph leakage and recurrent cellulitis. Surgical interventions, including lymphaticovenous anastomosis, were tried but were ineffective, and negative-pressure wound therapy also did not show satisfactory outcomes. Free-flap transplantation was performed using an anterolateral thigh flap. Following anterolateral thigh flap transplantation, the patient experienced complete resolution of lymphatic leakage. There were no signs of lymphedema or cellulitis, indicating successful relief of these complex symptoms for six months postoperatively. This report highlights the successful treatment of intractable lymphorrhea with free anterolateral thigh flap transplantation. For refractory lymphatic leakage, a comprehensive approach that considers both lymphatic flow reduction and the promotion of wound healing around the fistula is crucial. In cases of uncontrolled lymphorrhea, an alternative option, such as free flap transfer, should be recommended as surgical intervention.

DOI： 10.36748/ijswc.5.2_46

CiNii Research

Language：English   Publisher：(一社)日本創傷外科学会  

症例は47歳女性で、右上腕の潰瘍性病変からの重度リンパ漏を呈して当院受診となった。潰瘍からの持続性リンパ分泌によってQOLが大きく損なわれ、他院で複数回にわたる部分的リンパ管腫切除を受けていた。受診時、右上腕尺側に肉芽組織形成を伴う二つのリンパ瘻を認め、リンパ浮腫はみられず、MRIではT2強調像で右頸部から上縦隔、右鎖骨、腋窩、上腕尺側に及ぶ多結節性の高信号を呈する病変が検出された。リンパ管腫は上腕尺側に表在性に存在しており、リンパシンチグラフィーでは右前腕の線形パターンのほか、右上腕のリンパ漏に沿ったリンパ管腫に一致して増強を示す領域が認められた。リンパ瘻への過剰なリンパ流を抑制するため、右前腕と瘻孔発生部の4ヶ所にリンパ管細静脈吻合術(LVA)を施行したが、4日後にリンパ瘻の再発がみられ、6ヵ月後に再手術を施行、LVAを行い創閉鎖には局所陰圧閉鎖療法を適用した。しかし、術後14日目にリンパ漏の再発をきたし、創部治癒が不良のため瘻孔の閉鎖が得られないものと判断し、血管柄付き筋皮弁移植術を行った。初回手術の1年後、左キメラ前外側大腿皮弁と外側広筋の移植術を施行、リンパ瘻領域を、超音波エネルギー機器を用いて切除処理した。術後に上腕の腫脹をきたしたが、数週後には改善し、6ヵ月後、リンパ瘻の再発やリンパ浮腫、蜂窩織炎の発症は認めていない。

Language：Japanese   Publisher：The Japan Broncho-esophagological Society  

DOI： 10.2468/jbes.75.102

CiNii Research

Language：English   Publisher：Annals of Plastic Surgery  

Klippel-Trenaunay syndrome (KTS) is characterized by port-wine stains, mixed vascular malformations, and soft tissue and bone hypertrophy. Klippel-Trenaunay syndrome is occasionally complicated by chyluria, for which there is no effective treatment currently. We report a case of KTS complicated by intractable chyluria and hematuria due to a lymphatic-ureteral fistula. The patient was successfully treated with multiple lymphaticovenular anastomoses (LVAs). A 66-year-old woman with an enlarged left lower extremity since childhood was diagnosed with KTS. At 60 years of age, she developed chyluria (urine albumin, 2224 μg/mL) and hematuria. Lymphoscintigraphy showed a lymphatic-ureteral fistula near the ureterovesical junction. Conservative treatment was ineffective. She also developed left lower extremity lymphedema, which gradually worsened. Leg cellulitis and purulent pericarditis developed because of hypoalbuminemia (minimum serum albumin level, 1.3 g/dL). We performed 14 LVAs in 2 surgeries to reduce lymphatic fluid flow through the lymphatic-ureteral fistula. The chyluria and hematuria resolved soon after the second operation, and the urine albumin level decreased (3 μg/mL). After 28 months, she had no chyluria or hematuria recurrence and her serum albumin level improved (3.9 g/dL). Multiple LVAs can definitively treat chyluria caused by a lymphatic-ureteral fistula in patients with KTS.

DOI： 10.1097/SAP.0000000000003744

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Japanese Society of Reconstructive Microsurgery  

<p>　In 2012, we reported on the clinical observation method following 544 free flap transfers for head and neck reconstruction. After 10 years, we reviewed the postoperative outcomes using the similar monitoring approach. The success rates of free flap transfer were 97.8% for 495 head and neck defects and 80.8% for 26 lower extremities defects. Compromised flaps were observed in 21 patients. Flap color change was identified as the first clinical sign of flap compromise in 14 out of 21 patients. Of the 14 head and neck cases, emergency salvage surgeries were performed in six cases, and three flaps were salvaged. The other eight flaps were observed conservatively, however, all of them suffered total necrosis. In the five cases of lower extremity reconstruction with flap compromise, one patient underwent salvage surgery; however, the flap could not be salvaged. The other four flaps that did not undergo salvage surgery developed total necrosis. The flap salvage rate using the clinical observation method was comparable to previously reported rates. To further improve the salvage rate, it is essential to inspect the anastomosis site directly and perform salvage surgery promptly upon recognizing subtle and characteristic color changes in the flap.</p>

DOI： 10.11270/jjsrm.37.137

CiNii Research

Language：English   Publisher：Plastic and Reconstructive Surgery  

Surgeons have traditionally believed that swallowing is mainly dependent on gravity after total glossolaryngectomy. However, swallowing function after total glossolaryngectomy varies widely among patients, and a thorough analysis is lacking. The authors aimed to clarify the swallowing function after total glossolaryngectomy and determine whether it is primarily dependent on gravity. The authors retrospectively analyzed videofluorographic examinations of patients who underwent total glossolaryngectomy and free or pedicle flap reconstruction. The authors enrolled 20 patients (12 male; mean age, 61 years; age range, 43 to 89 years). All patients demonstrated constriction of the reconstructed pharynx to some degree, and no patient's ability to swallow was dependent on gravity alone. Videofluorography showed excellent barium clearance in eight patients and poor clearance in 12. All patients with excellent clearance showed strong constriction of the posterior pharyngeal wall, whereas only 8.3 percent of the patients with poor clearance showed adequate constriction, which was significantly different (p = 0.0007). Velopharyngeal closure and lip closure also contributed significantly to excellent clearance (p = 0.041). The shape of the reconstructed pharynx (depressed, flat, protuberant) showed no statistically significant association with excellent clearance. Contrary to previous understanding, constriction of the remnant posterior pharyngeal wall played an important role in swallowing after total glossolaryngectomy, and gravity played a secondary role. Dynamic posterior pharyngeal wall movement might result from the increased power of the pharyngeal constrictor muscle and compensate for the immobility of the transferred flap. A well-functioning pharyngeal constrictor muscle and complete velopharyngeal and lip closures can contribute to excellent barium clearance in patients after total glossolaryngectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

DOI： 10.1097/PRS.0000000000009639

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Japan Society of Cranio-Maxillo-Facial Surgery  

<p>　　Problems of orbital fracture surgeries include the narrow and deep surgical field, the difficulty of detecting the correct position of deep fractures, and the insufficiency of methods of teaching young surgeons. To overcome these problems, we introduced a combination therapy consisting of transorbital endoscopy, image-guided navigation system, and a 3D model.<br>　　Using endoscopy to assist with surgery, all medical staff can share a clear and magnified surgical vision through the high-resolution monitor. Transorbital endoscopic surgeries facilitate finding the microfracture easily even in the deep part of the orbit; thus, the image-guided navigation system adds accuracy and objectiveness to endoscopic surgeries. By a combination of endoscopy and image-guided navigation, we can avoid inadequate reduction of deep orbital fractures, which make orbital surgeries safer and easier and shortens the learning curve of young surgeons. Furthermore, 3D modeling can replicate real orbital shape and facilitate preoperative training of orbital surgeries. Using a mirrored 3D model, a precisely shaped bone graft can be manufactured and placed to the orbital defect.<br>　　Combining endoscopy, image-guided navigation system, and 3D modeling can contribute to safe and accurate orbital surgeries.</p>

DOI： 10.32154/jjscmfs.38.4_113

CiNii Research

Language：Japanese   Publishing type：Research paper (scientific journal)  

Language：Japanese   Publishing type：Research paper (scientific journal)  

Event date： 2022.11

Language：Japanese   Presentation type：Oral presentation (general)  

Venue：愛知県名古屋市   Country：Japan  

Event date： 2021.12

Language：Japanese   Presentation type：Symposium, workshop panel (public)  

Venue：つくば市   Country：Japan  

Event date： 2021.11

Language：Japanese   Presentation type：Oral presentation (general)  

Venue：東京都   Country：Japan  

Event date： 2020.12

Language：Japanese   Presentation type：Oral presentation (general)  

Venue：徳島   Country：Japan  

Event date： 2019.5

Language：Japanese   Presentation type：Oral presentation (general)  

Venue：札幌   Country：Japan  

Event date： 2019.5

Language：Japanese   Presentation type：Oral presentation (general)  

Venue：大阪   Country：Japan  

Event date： 2018.12 - 2019.5

Language：Japanese   Presentation type：Symposium, workshop panel (public)  

Venue：大阪   Country：Japan  

Event date： 2018.10

Language：Japanese   Presentation type：Oral presentation (general)  

Venue：札幌   Country：Japan  

Event date： 2018.6

Language：Japanese  

Venue：東京   Country：Japan  

Event date： 2018.6

Language：Japanese  

Venue：大宮   Country：Japan  

Event date： 2018.4

Language：Japanese   Presentation type：Symposium, workshop panel (public)  

Venue：福岡   Country：Japan  

Event date： 2017.11

Language：Japanese  

Venue：宮崎   Country：Japan  

Event date： 2017.6

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Venue：京都   Country：Japan  

Event date： 2017.4

Language：Japanese  

Venue：大阪   Country：Japan  

Event date： 2015.6

Language：Japanese   Presentation type：Oral presentation (general)  

Country：Japan  

Event date： 2013.5

Language：Japanese   Presentation type：Oral presentation (general)  

Venue：札幌   Country：Japan  

当科における上顎再建方法について報告した

Event date： 2013.4

Language：Japanese   Presentation type：Oral presentation (general)  

Venue：那覇   Country：Japan  

Event date： 2012.6 - 2012.8

Presentation type：Oral presentation (general)  

Venue：島根   Country：Japan  

【目的】口腔咽頭再建において移植皮弁の委縮により、嚥下障害や構音障害を生ずる可能性がある。そのため、あらかじめ皮弁を大きめに移植したり、より委縮の少ない脂肪織を多く移植するなどの工夫を行っている。今回我々は移植皮弁の容積をMRI画像をもとに算出しその継時的変化を解析し、さらに術後放射線治療と皮弁容積の継時的変化の関連を含め検討したので報告する。【症例】2009年1月～2010年12月までの２年間当院にて口腔咽頭癌切除後遊離皮弁による再建施行され、術後12か月以上の期間、3回以上MRI撮影し、評価可能であった1８症例（男性１３例、女性５例）を対象とした。平均年齢は62.1（30～85）才、再建皮弁は前外側大腿皮弁13例、腹直筋皮弁症例5例であった。術後5０Gy以上の照射は6症例において施行された。【方法】MRI画像の水平断、冠状断、矢状断より簡易的に皮弁部の容積を算出し、その継時的変化を調べた。【結果】皮弁容積が最小となるのは術後平均8.1ヶ月（４～20ヶ月）であった。術後50Gy以上の照射症例6例の平均は7.7ヶ月であった観察期間中皮弁容積が減少し続けた症例は2例で16例では容積の増加をみとめた。【結論】術後皮弁容積が最小となるのは半年ほどの時期であった。また、皮弁容積が最小となる期間に関して術後放射線治療は影響しないと考えられた。

Event date： 2012.5 - 2012.8

Presentation type：Oral presentation (general)  

Venue：新潟   Country：Japan  

頭頸部領域において、化学放射線治療は臓器温存を目指す治療の重要な選択肢となっている。しかし再発などに対する手術において、合併症率の上昇が問題となっている。
今回我々は頭頸部悪性腫瘍に対し60Gy以上の化学放射線治療後、遊離皮弁による再建を行った症例における合併症の検討を行ったので報告する。
症例２００８年９月より２０１１年９月までの３年間に当科で遊離皮弁による再建を行った１０２症例中術前に化学放射線同時併用療法が行われていた２６症例について検討した。術後合併症は１０症例（３８％）に認めた。そのうち外科的処置を要す重篤なものが３症例（１１％）に認めらた。重篤な合併症は皮弁の全壊死が１症例、遅発性の瘻孔が２症例であった。
化学放射線治療後の遊離皮弁移植は、通常に比べ合併症率は高くなるため注意が必要である。さらに遅発性の瘻孔が発症すると難治化しやすいため的確な対応が必要である。

Event date： 2011.11 - 2012.11

Venue：新潟   Country：Japan  

【目的】頭頸部領域において、放射線化学療法は臓器温存を目指す治療の重要な選択肢となっている。しかしながら再発時の救済手術において、特に再建を要する症例では合併症率の上昇が問題となっている。今回我々は放射線化学療法施行症例で遊離空腸再建を行った後、陳旧性に咽頭瘻孔を発症した２症例を経験したので報告する。【症例１】６０歳男性。下咽頭癌T3N2bM0。放射線化学療法７０Gy 施行後T:CR、N:PRにて右頸部廓清施行。２年３か月後T再発認め咽喉摘、遊離空腸再建施行。２か月後頸部より浸出液認めたが保存的に軽快。さらに１か月後頸部より排膿あり咽頭瘻孔認めた。DP皮弁による瘻孔閉鎖術行うも改善せず、大胸筋皮弁による 瘻孔閉鎖術施行した。【症例２】５５歳男性。下咽頭癌T2N3M0。放射線化学療法７０Gy、後療法としての化学療法施行後T:CR、N：CR。３年３ヶ月後中咽頭癌（前壁）T4a N0M0認め咽喉摘、遊離空腸再建施行。術後１年８か月後空腸後方に膿の貯留認め切開 排膿行った。咽頭瘻孔認め保存的に改善しなかったため大胸筋皮弁による瘻孔閉鎖術を施行した。【考察】遊離空腸は血流が豊富で、安定した再建材料と考えられ、陳旧性の咽頭瘻孔は起こりにくいと考えられる。しかしながら本２症例のように放射線化学療法後、頚部郭清施行症例や 巨大な腫瘍が消失した症例などは周囲の組織が高度に変性し瘢痕化していると予想される。このような症例においては再建に際し、通常よりも細心の注意を払うべきであると考えられる。また瘻孔閉鎖には大胸筋皮弁のような血流が豊富で創傷治癒能力が高い皮弁の選択が必要であると考えられた。【結論】放射線化学療法後空腸による再建を行い遅発性に発症した咽頭瘻孔２症例を経験した。放射線化学療法施行症例においては再建に際し、細心の注意が必要であり、また、瘻孔閉鎖には血流が豊富な皮弁の選択が重要であると考えられた。

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