A defect of the abdominal wall with intestinal fistulas after the repair of incisional hernia using Composix Kugel Patch

INTRODUCTIONIn the present paper, we show a rare case of the large abdominal wall defect and enterocutaneous fistulas after the tension free repair using prostheses for incisional hernia.PRESENTATION OF CASEThe patient, a 70-year-old man, had a history of a hemicolectomy for a perforating colon cancer, complicated by a large incisional hernia that was closed primarily but recurred. Three years later, the hernia was repaired at the time of a second colectomy using a Composix Kugel Patch. His course was complicated by a chronic postoperative wound infection with eventual development of enterocutaneous fistulas. The patient was successfully treated with extirpation of the prosthesis, resection of the fistulized bowel, and placement of a tensor fasciae latae myocutaneous flap.DISCUSSIONEnterocutaneous fistulas are a known complication of incisional hernia repairs using prostheses. Additional clinical data are required to confirm the safety and efficacy of this procedure as it becomes more widely adopted.CONCLUSIONExtirpation of the prosthesis should be performed without delay to prevent serious complications. Reconstruction with a tensor fasciae latae myocutaneous flap was useful for the large abdominal wall defect.     

A novel technique for relieving anastomotic tension using halo-vest immobilization after tracheal sleeve resection

We describe a novel technique of using halo-vest-enforced immobilization to relieve anastomotic tension after tracheal sleeve resection. Immediately after the tracheal sleeve resection, four halo titanium pins were inserted in the skulls of the patients to secure the halo-vest. All patients fitted with halo-vests were able to eat and drink and their clinical course was good. Bronchoscopy confirmed the absence of anastomotic leaks and stenoses, and there were no complications associated with the halo-vest. We believe that ensuring neck flexion using a halo-vest after tracheal sleeve resection is an excellent way of relieving anastomotic tension that would predispose the wound to dehiscence.     

A technique for the prevention of hoarseness during surgery for distal aortic arch aneurysm.

Hoarseness occurs frequently after surgery to repair distal aortic arch aneurysms when using only a median sternotomy approach. We describe a useful technique which protects the left recurrent laryngeal nerve during this procedure and reduces the incidence of postoperative hoarseness.     

Irregular Defects in Hepatocellular Carcinomas During the Kupffer Phase of Contrast-Enhanced Ultrasonography with Perfluorobutane Microbubbles: Pathological Features and Metastatic Recurrence After Surgical Resection

The present study aimed to elucidate the association between post-vascular–phase (Kupffer-phase) images from contrast-enhanced ultrasonography (CEUS) with perfluorobutane microbubbles and metastatic recurrences after the resection of hepatocellular carcinoma (HCC). The study examined 73 patients with solitary HCC ≤5 cm in diameter who underwent CEUS before resection. HCC was defined as irregular type (including an irregular defect on Kupffer-phase images) or non-irregular type. Intrahepatic metastatic recurrence was defined as >3 intrahepatic recurrences. Metastatic recurrence included both extrahepatic and intrahepatic recurrences. Frequencies of microscopic portal invasion and intrahepatic metastasis were significantly higher in the irregular group than in the non-irregular group. Cumulative 5-y metastatic recurrence rates in the irregular and non-irregular groups were 43% and 7% (p = 0.028), respectively. Multivariate analyses identified Kupffer-phase findings as a factor significantly related to metastatic recurrence. In conclusion, HCCs with an irregular defect during Kupffer-phase CEUS are characterized by more frequent microscopic vascular invasion and intrahepatic metastasis and are significantly associated with metastatic recurrence after resection.     

Injection of basic fibroblast growth factor for unilateral vocal cord paralysis*

Objective: Unilateral vocal cord paralysis (UVCP) not only induces severe dysphonia, but aspiration as well. Although laryngeal framework surgery is usually performed to treat this condition, the procedure is not tolerated by some patients. In the previous study, basic fibroblast growth factor (bFGF) injections for vocal cord scarring and sulcus have been reported to provide favorable outcomes while being minimally invasive. In this study, the authors retrospectively investigated phonological outcomes after bFGF injection in patients with UVCP.

Methods: This study was registered in University hospital Medical Information Network – Clinical Trials Registry (UMIN000019347). Nineteen patients with unilateral cord paralysis were treated with bFGF injection. The treatment regimen involved a single injection of 50?μg of bFGF into the muscle layer. More than six months after the injection, aerodynamic and acoustic outcomes were examined.

Results: The voice handicap index, maximum phonation time, mean airflow rate, and pitch range improved significantly after injection of bFGF. No sex-related differences were observed in any phonological parameter.

Conclusion: bFGF injection, an easy method and suitable as an office procedure, significantly improved the hoarseness caused by UVCP. It is expected to be widely adopted and effective adjunctive drugs, and procedures are anticipated to be developed.     

Ultrasonographically predicting the extent of collateral flow through superficial temporal artery-to-middle cerebral artery anastomosis

BACKGROUND AND PURPOSE: This study was performed to elucidate whether the extent of bypass flow through superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis could be indirectly estimated by measuring the blood flow velocity in the superficial temporal artery (STA) by using duplex ultrasonography. METHODS: We analyzed 29 patients (31 sides) who underwent STA-MCA bypass surgery for occlusive cerebrovascular disease (28 sides) or unclippable cerebral aneurysm that required therapeutic occlusion of the internal carotid artery (three sides). The flow velocities of the STA were measured by using ultrasonography. For patients who underwent the surgery unilaterally, the flow velocity ratios of the operated side to the contralateral side for the individual arteries were calculated. The correlation between these flow velocity parameters and the extent of bypass flow, which was graded based on the findings of cerebral angiography, was investigated. RESULTS: Both the affected STA flow velocity and the STA flow velocity ratio, particularly those in the end diastole, increased in patients with more extensive bypass flow. In patients with extensive, moderate, and poor bypass flow, the end diastolic flow velocities of the operated STA were 27.4 +/- 8.8, 23.0 +/- 7.8, and 13.5 +/- 7.5 cm/s, respectively and the end diastolic flow velocity ratios of the STA were 3.4 +/- 0.8, 2.1 +/- 0.5 and 1.3 +/- 0.4, respectively. The pulsatility index and resistance index of the affected STA were significantly lower in the patients with more extensive bypass flow. The optimal threshold value of the end diastolic flow velocity ratio of STA for the group with extensive bypass flow was 2.75, whereas that for the group with poor bypass flow was 1.60. With the obtained values, the sensitivity and specificity were 87.5% and 93.9% for the group with extensive bypass flow and 95.2% and 95.0% for the group with poor bypass flow, respectively. CONCLUSION: The blood flow velocity in the operated STA seems to be a highly sensitive parameter for predicting the extent of bypass flow in patients undergoing STA-MCA anastomosis.     

Benefits of combined radioimmunotherapy and anti-angiogenic therapy in a liver metastasis model of human colon cancer cells

The combined use of anti-angiogenic therapy (AT) and radioimmunotherapy (RIT) may improve the therapeutic outcome in patients with cancer lesions. This hypothesis is based on the ability of AT to suppress tumour endothelial compartments and the direct action of RIT against tumour cells. We previously confirmed this hypothesis in an established subcutaneous xenograft model of colon cancer. The purpose of the current investigation was to determine the benefit of this combination within a liver metastasis model, which mimics treatment of minimal disease in an adjuvant setting. Liver metastases were established in nude mice by intrasplenic inoculation of LS180 colon cancer cells; following such inoculation, metastases of <1 mm in diameter can be observed at 1 week and these lesions can attain a size of several millimetres at 2 weeks. Daily AT with 2-methoxyoestradiol (2-ME), 75 mg/kg, was initiated at 1 week. RIT with 7 MBq of (131)I-A7, an IgG1 anti-colorectal monoclonal antibody, was conducted at 2 weeks. RIT employing an irrelevant IgG1, (131)I-HPMS-1, was implemented for comparison. The weight of liver metastases was measured 4 weeks after cell inoculation. The effect of AT on (131)I-A7 accumulation in metastases was also observed. Toxicity of treatment was monitored by blood cell counts. Monotherapy with 2-ME AT or (131)I-A7 RIT significantly suppressed metastasis growth ( P<0.0001): metastasis weight was 5.96+/-0.87 g in non-treated controls, 2.67+/-1.89 g in cases receiving AT and 0.85+/-0.68 g in those receiving (131)I-A7 RIT. Combination of AT and (131)I-A7 RIT more effectively suppressed the growth to 0.28+/-0.32 g ( P<0.05 vs RIT alone). The effect of (131)I-HPMS-1 RIT, which suppressed metastasis growth to 2.25+/-0.88 g, was significant in comparison with the control ( P<0.0001); however, the combination of AT and (131)I-HPMS-1 RIT (which suppressed growth to 1.41+/-0.68 g) was far less effective than the combination of AT and (131)I-A7 RIT. AT did not decrease (131)I-A7 accumulation in metastases. AT did not affect RIT myelotoxicity. The results of this study demonstrating the combined effects of AT and (131)I-A7 RIT in a small metastasis model indicate that such combination therapy may be suitable for the treatment of minimal disease.