Comparison of reconstruction plate and double flap for reconstruction of an extensive mandibular defect

Functional reconstruction of the anterior mandibular defect in combination with a significant glossectomy is a challenging problem for reconstructive micro‐surgeons. In this retrospective study, clinical results were compared between mandibular reconstruction plate (MRP) procedures and double flap transfers. The subjects were 23 patients who underwent immediate reconstruction, after an anterior segmental mandibulectomy in combination with a significant glossectomy, from 1993 to 2009. The patients were divided into two groups based on the reconstructive methods used: MRP and soft tissue free flap transfer (MRP group: 12 patients) or double free flap transfer (double flap group: 11 patients). Operative stress, postoperative complications and oral intake ability were compared between the groups. The rate of recipient‐site complication in the double flap group tended to be lower than that in the MRP group. The most frequent complications in the MRP group included infection and orocutaneous fistula. Operative stresses (operation time and blood loss) were significantly less in the MRP group than in the double flap group. Overall, 19 patients (82.6%) were able to tolerate an oral diet without the need for tube feeding. This study demonstrates that laryngeal preservation is possible in more than 80% of patients even after such an extensive ablation. Double flap transfer provides a more stable wound closure than MRP and should be the preferred reconstructive procedure if the patients can tolerate the associated operative stresses. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

High mortality associated with intracardiac and intrapulmonary thromboses after cardiopulmonary bypass

Purpose  

Intrapulmonary or intracardiac thrombosis is a rare but catastrophic event following complex cardiothoracic surgery. Although there have been multiple cases reported in the literature, the causes of these events are largely unknown. In this retrospective review, we attempt to identify risk factors and propose possible mechanisms of thromboses after cardiopulmonary bypass (CPB).     

Rapid growth hormone measurement during transsphenoidal surgery: analysis of 252 acromegalic patients

The usefulness of rapid growth hormone (GH) measurement was retrospectively evaluated as an indicator of total tumor removal during surgery and compared with several reported criteria in 252 acromegalic patients who underwent transsphenoidal surgery at Toranomon Hospital between 2006 and 2008. GH levels were measured in blood samples obtained before surgery, at the start of tumor removal, and every 20 minutes thereafter until 20 minutes after total tumor removal as judged by the operator. Intraoperative GH dynamics were compared between 201 patients fulfilling the Cortina consensus criteria (successful group) and 37 patients who did not (unsuccessful group). Among several criteria indicating total tumor removal, only the ratio of serum GH level 20 minutes after the end of tumor removal to GH level at the end of tumor excision was significantly different between the groups; a reduction ratio of 65% was the most appropriate cut-off value based on sensitivity (59.2%) and specificity (59.5%). The ratio of GH level 20 minutes after the end of tumor removal/GH level at the end of tumor excision was the most reliable index to judge tumor removal during surgery, but this index is neither necessary nor sufficient and should be used as one of the indicators to judge complete tumor removal during surgery.     

Deep sequencing reveals stepwise mutation acquisition in paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is a nonmalignant clonal disease of hematopoietic stem cells that is associated with hemolysis, marrow failure, and thrombophilia. PNH has been considered a monogenic disease that results from somatic mutations in the gene encoding PIGA, which is required for biosynthesis of glycosylphosphatidylinisotol-anchored (GPI-anchored) proteins. The loss of certain GPI-anchored proteins is hypothesized to provide the mutant clone with an extrinsic growth advantage, but some features of PNH argue that there are intrinsic drivers of clonal expansion. Here, we performed whole-exome sequencing of paired PNH⁺ and PNH^– fractions on samples taken from 12 patients as well as targeted deep sequencing of an additional 36 PNH patients. We identified additional somatic mutations that resulted in a complex hierarchical clonal architecture, similar to that observed in myeloid neoplasms. In addition to mutations in PIGA, mutations were found in genes known to be involved in myeloid neoplasm pathogenesis, including TET2, SUZ12, U2AF1, and JAK2. Clonal analysis indicated that these additional mutations arose either as a subclone within the PIGA-mutant population, or prior to PIGA mutation. Together, our data indicate that in addition to PIGA mutations, accessory genetic events are frequent in PNH, suggesting a stepwise clonal evolution derived from a singular stem cell clone.