秋田 新介

Since congenital curved nail of the fourth toe (CNFT) was reported by Iwasawa et al in 1991, there have been only 19 cases of CNFT in 6 reports, which were from Japan and Taiwan. We performed surgery on 4 patients with CNFT and report here good results. There has been no previous detailed report on surgical treatment for this condition. This report will describe the treatment, mainly the surgical procedure.

【背景】水治療(hydrotherapy)は創面の洗浄で治癒促進を図る方法である。共用設備でのhydrotherapyには、院内感染のリスクが報告されている。Hydrotherapyに用いていた共用シャワー設備のMRSA汚染が明らかになり、院内感染対策チーム(以下ICT)と共同で感染拡大防止に取り組んだ結果について報告する。【症例および方法】症例1:共用シャワーでのhydrotherapyを避けることで多剤耐性菌感染を回避できた症例。80歳女性、III度を主とした4%TBSA熱傷受傷、急性心筋梗塞を併発し、保存療法の方針とした。感染すれば致命的となるため、ベッドサイドでの洗浄処置を行った。第55病日上皮化が得られたため自宅退院した。創培養は連続して陰性だった。症例2:共用シャワーでのhydrotherapyによりMRSAが付着した症例。52歳女性、会陰部の非クロストリジウム性ガス壊疽、切開排膿後、ベッドサイドで創洗浄を続けた。第23病日から共用シャワーによるhydrotherapyを開始したところ、それまで検出されていなかったMRSAが陽性となった。Infection-control measures:共用シャワーがMRSA付着の原因と考えられたため、ICTに報告した。環境培養を行ったところ、複数箇所からMRSAが検出された。院内への周知、共用シャワー運用方法の制定、シャワーヘッドの消毒、により共用シャワー室からMRSAが検出されなくなった。また、対策導入後は導入前と比べて1月あたりの平均MRSA陽性患者数が有意に減少した(2.0±1.7vs0.7±0.7人/月、P<0.05)。【結論】共用シャワーの菌汚染についての多くの報告と同様、われわれの施設の共用シャワーも汚染されていた。ICTと共同で、シャワーヘッドの消毒を含む院内感染防止対策を行い、シャワー設備のMRSA陰性化とMRSA患者数減少を得た。(著者抄録)

【背景】Artzの基準等の熱傷重症度判定基準には、熱傷面積などの生命予後に関連する項目と、特殊部位熱傷などの機能的・整容的予後に関連する項目とが含まれている。特殊部位熱傷項目において基準に該当するとして拾い上げる患者対象が広くなりすぎると、軽症の患者も重症と判定されることになり診療実態との乖離が生じうる。われわれは本邦で地域の中核病院として比較的幅広く熱傷診療を行っている施設において、特殊部位熱傷に注目して診療実態との関連を調査した。【方法】一施設後方視的コホート研究にて、特殊部位熱傷に注目して重症度判定基準と熱傷診療の実際との関連を調査した。【結果】特殊部位熱傷項目を浅達性II度熱傷(以下SDB)以上、深達性II度熱傷(以下DDB)以上、III度熱傷(DB)以上と変化させた場合の入院率はおのおの48%(30/62)、63%(30/48)、68%(30/44)で、入院となった患者群は同一だった。該当する特殊部位熱傷をSDB以上またはDDB以上とした場合、項目に該当すると有意に入院率が低下した(SDB以上:相対リスク0.47;95信頼区間0.41-0.79;P=0.01、DDB以上:相対リスク0.50;95%信頼区間0.26-0.88;P=0.03)。入院と最も相関したのは熱傷面積の増加だった。【考察】特殊部位熱傷の対象が広がると有意に入院率が低下し、重症度判定基準としては自己矛盾をきたした。特殊部位熱傷については、早期から熟練したチームによる治療が機能的・整容的に良好な予後をもたらすことは論を待たない。しかし、重症度判定基準における特殊部位熱傷の位置づけはむずかしく、米国熱傷学会の基準や英国熱傷学会の基準においても診療実態との乖離の問題が報告されている。機能的・整容的予後が重要である特殊部位熱傷に関してデータ蓄積が望まれる。(著者抄録)

One-stage repair is a conventional treatment of hypospadias. If hypospadias is severe as in the scrotal type and perineal type, penile curvature sometimes cannot be corrected by dorsal midline plication alone. In addition to resection of the urethral plate, ventral grafting becomes necessary for insufficient skin and subcutaneous tissue. In recent years, there has been renewed interest in 2-stage repair for such severe cases and salvage of failed cases with scarring. In the present study, novel 2-stage urethroplasty was performed in 6 cases to repair severe proximal hypospadias which required resection of the urethral plate. This novel method consisted of a combination of a modified Bracka method using oral mucosal grafts and a modified Byars flap of the dorsal foreskin. Good results were obtained using this novel method.

2010年4月から2012年12月までの間に、当院のリンパ浮腫専門外来を受診した患者について、年齢、性別、診断、治療について検討した。受診者数246名において、初診時平均年齢57.5±15.3歳、男性27名、女性219名、このうち194名が続発性リンパ浮腫であった。また、36名はリンパ浮腫ではなかった。これらは静脈うっ滞性浮腫、脂肪性浮腫、廃用性浮腫、薬剤性浮腫などであった。さらに、12名は原因不明の浮腫であった。急激なリンパ浮腫の進行を認めた2名の患者において、脈管肉腫の発生を認めた。他科との連携により、リンパ浮腫が除外された患者の正確な診断や治療など、患者にとって有益な診療の提供が可能であった。リンパ浮腫患者においても、前述のリンパ浮腫以外の疾患を合併していることがあり、慎重な診断と病気の判定を行うことが必要であった。(著者抄録)

Background: Reconstruction of the great toe defect is difficult. The most distal point of the rotation arc of a retrograde-flow medial plantar flap is the plantar side of the proximal phalanx. The purpose of this report was to present a new procedure that extends the rotation arc of this flap. Results of anatomic study and application in two patients were presented. Methods: An anatomical study was conducted on 10 freshly frozen cadavers to determine the rotation arc of the medial plantar flap based distally on the lateral plantar vessels. To enable anterograde venous drainage, two accompanying veins of the vascular pedicle were separated and anastomosed to each other. This surgical procedure was implemented in two clinical cases with the great toe defect. The maximum size of the elevated flap was 4 x 7 cm. The status of venous congestion of the flap was determined using the blood glucose measurement index. Results: We confirmed that the rotation arc of the medial plantar flap based distally on the lateral plantar vessels could reach the tip of the great toe, preserving all lateral plantar nerves and plantar metatarsal arteries. In the two cases, the congestion of the flap improved with anterograde venous drainage and the flaps survived completely. Conclusion: A pedicled medial plantar flap with anterograde venous drainage may be a useful alternative option for the reconstruction of relatively large great toe defects. (C) 2014 Wiley Periodicals, Inc.

75歳女。右下腿外側の膝下約10cmに、径24×26mmの境界明瞭で扁平隆起した表面やや不整な淡紅色腫瘤を認めた。疼痛やそう痒感はなく、弾性硬で下床との可動性が良好であった。基底細胞上皮腫やBowenなどの低悪性度の皮膚腫瘍を否定できず、また高齢で病変も小さかったため、局所麻酔下に全切除生検を行った。病理組織学的所見では弱拡大で表皮から連続する上皮索の網目状構造、線維成分やムチン質の豊富な間質成分を、強拡大で基底細胞様細胞の柵状配列を認め、Pinkus腫瘍と診断した。術後8年の現在、再発は認めていない。

Background: The best therapeutic approach for patients with sub-clinical lymphoedema and symptomatic early-stage lymphoedema has not been determined yet. Methods: The prognosis of lymphatic function after lymphadenectomy for gynaecological cancer was observed in a cohort study of 192 lower limbs. Lymphatic function was evaluated by indocyanine green lymphography. Splash patterns were examined to determine if patients with this pattern tended to progress to symptomatic lymphoedema, and the efficacy of the compression therapy was also investigated. We also investigated the efficacy of lymphaticovenular anastomosis (LVA) in patients who exhibited a stardust pattern. Results: Patients with splash patterns on lymphography may progress to symptomatic lymphoedema with a significantly higher frequency compared with the others, with a relative ratio of 1.62. Compression therapy did not slow the progression of patients with splash patterns to stardust patterns. LVA for the patients who had recently shown stardust patterns eliminated the need for compression therapy in 44.8% of patients. Conclusion: Patients with splash patterns should be followed up carefully for sub-clinical lymphoedema. However, there is no method to completely prevent these patients from developing stardust patterns associated with symptomatic lymphoedema. When patients become symptomatic, their lymphatic function may be improved by LVA. However, the limited effectiveness of this procedure should be clearly explained to patients before surgery. (C) 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Craniofacial and cervical spinal hyperostoses are rarely seen in the absence of other abnormalities. Only seven patients with isolated cranial hyperostoses have been reported, and only a single patient with both calvarial and cervical vertebral hyperostoses. We report on an adult with late-onset right-sided asymmetrical hyperostoses of the cranium, mandible, and cervical vertebrae in the absence of an AKT1 mutation. At presentation, the patient displayed neither generalized overgrowth nor dysregulated adipose tissue. Standard polymerase chain reaction and Sanger sequencing of DNA extracted from formalin-fixed paraffin-embedded frontal bone and mandibular angular bone was negative for an AKT1 mutation. Though the patient's clinical manifestations did not fulfill the consensus diagnostic criteria of Proteus syndrome, the mosaic distribution of lesions, the sporadic occurrence, and the patient's progressive course were consistent with a somatic mosaicism similar to that syndrome. Hence, the patient's phenotype may have been caused by a very late mesodermal somatic mutation during embryogenesis. (c) 2013 Wiley Periodicals, Inc.

われわれは集中治療室(ICU)入院中の広範囲熱傷患者の一部に対して、超早期手術の実現を目的としてICU病室で熱傷手術を行っている。しかし、ICU熱傷手術中に絶縁監視装置の警報発報事案を経験し、中央手術室(OR)とは環境が異なることによるリスクが存在する可能性が考えられたため、広範囲熱傷手術をICUで行うことの利点と問題点を検討した。ORに移動することなくICUで熱傷手術を行うことには、連続した周術期管理が可能になることや、搬送に伴うリスクをなくせるという利点があるが、ICUとORとの間には環境の差違が存在し、リスクを軽減する対策を取ることが必要と考えられた。(著者抄録)

Background and aim: A caudal limb of the internal mammary vein (IMV) can be used as an additional venous drainage route in free flap transfer. However, there remains the possibility that unrecognised occlusion of the retrograde IMV occurs in the early postoperative period due to non-physiologic flow, thus affecting venous drainage. There are no reports regarding the postoperative patency rates of the anastomosed retrograde IMV. This study aimed to clarify the efficacy of the retrograde IMV as an additional venous drainage route in the case of two-vein anastomosis in free flap transfer. Patients and methods: We performed a hospital-based prospective case series study to clarify the patency rates of retrograde IMV anastomoses as an additional venous drainage route in cases of two-vein anastomosis in free flap transfer. Both antegrade and retrograde IMV anastomoses were performed in patients who underwent free flap transfer using the IMV as a recipient vein. The postoperative flow vector and peak blood velocity of the retrograde IMV anastomosis were examined using two-dimensional phase contrast magnetic resonance imaging (2D PC-MRI) and colour Doppler imaging. Result: A total of five retrograde IMV anastomoses in five patients were performed in the study period. The postoperative patency rate of the retrograde IMV was 60%. In the patent group, the postoperative peak venous blood velocity of the retrograde IMV was significantly slower than that of the antegrade IMV (4.6 +/- 0.5 vs 7.2 +/- 0.8 cm s(-1), P &lt; 0.05). Conclusion: We described the postoperative patency rate of retrograde IMV anastomosis in cases of two-vein anastomosis in free flap transfer. Further study is needed to evaluate the reliability of the retrograde IMV as an additional venous drainage route. (C) 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

BACKGROUND: Subcutaneous ecchymosis caused by venous reflux is a preventable complication following lymphaticovenular anastomosis. The authors developed a series of operative procedures to prevent venous reflux. This is probably the first report on valvuloplasty for small subcutaneous veins (diameter, &lt 1 mm). METHODS: A total of 165 anastomoses in 39 limbs were operated on using this novel procedure (study group). Extended vein dissection was performed to ensure inclusion of some venous valves. Venous regurgitation was assessed using a retrograde milking test. When regurgitation was observed at all peripheral branches, external valvuloplasty was performed at the small subcutaneous vein to prevent backflow. The rate of venous reflux was compared with 151 anastomoses in 34 limbs operated on using conventional procedures (control group). Moreover, the amount of volume reduction was compared between the patients with and without venous reflux. RESULTS: In the study group, the rate of regurgitation was reduced (3.0 percent) by extended vein dissection compared with that in the control group (9.9 percent), whereas the regurgitation ceased completely following external valvuloplasty (0 percent). In addition, postoperative ecchymosis was prevented completely in the study group (8.8 percent in the control group). Perioperative improvement in the lower extremity lymphedema index was significantly different between the patients with and without venous reflux (with venous reflux, 0.0706 ± 0.0742 without venous reflux, 0.0904 ± 0.0614). CONCLUSIONS: The authors' results suggest that these operative procedures could be highly effective in preventing venous reflux. Moreover, venous reflux, if not corrected, leads to worsening of the results. Excellent results were consistently achieved by preventing venous reflux. Copyright © 2013 by the American Society of Plastic Surgeons.

Maxillary skeletal prognathism can involve severe mandibular micrognathia with marked mandibular retrognathism or hypoplasia. For patients with such a condition, a conventional treatment is mandibular advancement by sagittal split ramus osteotomy (SSRO). This procedure has problems such as insufficient advancement, instability of jaw position, and postoperative relapse. Thus, in recent years, mandibular distraction osteogenesis has been used in some patients. Mandibular distraction has many advantages, but an ideal occlusion is difficult to achieve using this procedure. That is, 3-dimensional control cannot be attained using an internal device that is unidirectional. This report describes a case of severe mandibular micrognathia in a 14-year-old girl treated using backward distraction osteogenesis. This procedure was first reported by Ishii et al (Jpn J Jaw Deform 2004 14:49) and involves a combination of SSRO and ramus distraction osteogenesis. In the present study, intermaxillary fixation in centric occlusion was performed after osteotomy, and proximal bone segments were distracted in a posterosuperior direction. This procedure is a superior surgical technique that avoids the drawbacks of SSRO and conventional mandibular distraction. However, it applies a large load to the temporomandibular joints and requires thorough management. Thus, careful evaluation needs to be made of the indication for backward distraction osteogenesis. Copyright © 2013 by Mutaz B. Habal, MD.

Sagittal split ramus osteotomy (SSRO) has wide-ranging indications and results in simultaneous improvements in occlusion and facial appearance. Thus, it is the most frequently used osteotomy for jaw deformities. Its main intraoperative and postoperative complications are massive bleeding, atypical fractures, inferior alveolar nerve paralysis, and relapse. This report describes a case of temporomandibular joint dislocation, a rare complication of SSRO. The patient was a 23-year-old man with mandibular prognathism which was treated by bilateral SSRO. Postoperative x-ray showed that the left temporomandibular joint was dislocated anteriorly. Thus, the patient underwent reoperation, including reduction and re-fixation. Subsequently, it was discovered that the patient had a previous history of recurrent dislocation of the temporomandibular joint. This case illustrates the need for practitioners to be mindful of temporomandibular joint dislocation as a rare complication of SSRO.

慢性リンパ浮腫に発生する比較的まれな脈管肉腫であるStewart-Treves症候群の2症例を報告した。症例1(87歳男性)。15年前に上肢の悪性リンパ腫に対して化学療法+放射線療法の施行後より右上肢の浮腫が出現、1ヵ月前からリンパ漏出を伴うため外科的治療を目的にリンパ浮腫外来の紹介受診となった。初診時、右上肢全体の浮腫と屈側の皮膚硬化が認められ、上腕内側結節の生検により皮膚血管肉腫と診断された。以後、リンパ漏が持続、散在する小結節が右上腕近位まで拡大したため肩関節離断術が施行された。更に術後は補助療法としてweekly-docetaxel療法を開始した。だが、結果的に局所再発と肺転移を来し術後10ヵ月目で患者は死亡となった。症例2(65歳女性)。8年前の左腋窩リンパ節炎後より左上肢の浮腫が出現、4ヵ月前よりは浮腫の増悪を自覚し、リンパ浮腫外来で紹介受診となった。初診時、左上肢には著明な浮腫ほか、左上腕には紫斑と硬い皮下結節が認められた。また、MRIでは左上腕外側に皮膚と連続した境界不明瞭な皮下結節がみられ、同部位はT1強彫像で脂肪より低信号かつ筋と等信号であり、脂肪抑制STIR画像で淡い高信号を示した。以上、これらの所見を踏まえ、更に左上腕の皮下結節の生検にて、本症例は病理組織学的に皮膚血管肉腫と診断、腫瘍の位置と大きさから判断して離断術を施行した。その結果、目下もweekly-docetaxel療法を継続中であるが、術後11ヵ月経過現在、再発は認められていない。

Background: Reconstruction of intractable ulcers on the lateral malleolus is challenging because affected patients suffer various complications. A lateral supramalleolar flap, nourished by the superficial cutaneous branch of the perforating branch of the peroneal artery, has been described as one of the most reliable methods for reconstructing this difficult region. Although the deep descending branch of the perforating branch of the peroneal artery has a tiny cutaneous perforator, a flap based on this perforator has not been described. Methods: The vascular anatomy of an island flap based on the descending branch perforator of the perforating branch of the peroneal artery was investigated using 20 cadaver legs. Distances from the lateral malleolus and the external diameters were investigated. Based on the anatomical study results, a perforator-based island flap was developed for clinical use and implemented in five cases. Results: The anatomical study revealed the descending branch perforator diameter to be smaller than the superficial cutaneous branch diameter, and the location to be considerably closer to the lateral malleolus. All five island flaps used clinically survived without complications. Conclusions: A new perforator-based island flap of the descending branch of the perforating branch of the peroneal artery for reconstruction of the lateral malleolus was designed. The territory covered by the flap could be enlarged by including the adjacent angiosome area of the superficial cutaneous branch. This flap elevation technique was uncomplicated and sufficiently straightforward to be used for patients at high risk for complications with extended surgical procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

症例1は39歳男性で、左上腕の皮下索状腫瘤で受診した。左上腕内側皮下に4cmの索状組織を触知し、本人希望で切除生検を行った。術中所見では周囲組織と境界明瞭な太さ約3mmの脈管様索状物を認め、一部を切除して病理検査を行い、膠原線維からなる索状物の中心に内皮細胞ないし毛細血管様スリットを認め、Mondor病を疑う所見であった。術後1年で索状物は完全消失し、再発は認めていない。症例2は48歳男性で、うつ病の既往があった。左上腕橈側の皮下腫瘤と左上肢のしびれで受診した。左上腕橈側皮下に1cmの索状腫瘤と直上皮膚に陥凹を認め、上肢のしびれは不定愁訴と考えられた。MRIで同部皮下、筋膜上にT1・T2ともlow intensityで辺縁不明瞭な索状組織を認め、希望による切除生検を行い、境界不明瞭な線維組織を認めるのみで、一部の病理検査で結節状肉芽様の線維化巣内に脂肪組織が散在し、Mondor病の終末像と考えられた。術後6ヵ月で再発は認めていない。

Background: Lymphoscintigraphy is the gold-standard examination for extremity lymphoedema. Indocyanine green lymphography may be useful for diagnosis as well. We compared the utility of these two examination methods for patients with suspected extremity lymphoedema and for those in whom surgical treatment of lymphoedema was under consideration. Methods: A total of 169 extremities with lymphoedema secondary to lymph node dissection and 65 extremities with idiopathic oedema (suspected primary lymphoedema) were evaluated; the utility of indocyanine green lymphography for diagnosis was compared with lymphoscintigraphy. Regression analysis between lymphoscintigraphy type and indocyanine green lymphography stage was conducted in the secondary lymphoedema group. Results: In secondary oedema, the sensitivity of indocyanine green lymphography, compared with lymphoscintigraphy, was 0.972, the specificity was 0.548 and the accuracy was 0.816. When patients with lymphoscintigraphy type I and indocyanine green lymphography stage I were regarded as negative, the sensitivity of the indocyanine green lymphography was 0.978, the specificity was 0.925 and the accuracy was 0.953. There was a significant positive correlation between the lymphoscintigraphy type and the indocyanine green lymphography stage. In idiopathic oedema, the sensitivity of indocyanine green lymphography was 0.974, the specificity was 0.778 and the accuracy was 0.892. Conclusion: In secondary lymphoedema, earlier and less severe dysfunction could be detected by indocyanine green lymphography. Indocyanine green lymphography is recommended to determine patients' suitability for lymphaticovenular anastomosis, because the diagnostic ability of the test and its evaluation capability for disease severity is similar to lymphoscintigraphy but with less invasiveness and a lower cost. To detect primary lymphoedema, indocyanine green lymphography should be used first as a screening examination; when the results are positive, lymphoscintigraphy is useful to obtain further information. (C) 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Background: Osteoblastomas and aneurysmal bone cysts each comprise 1% of primary bone tumours. As both osteoblastomas and aneurysmal bone cysts are not common, osteoblastomas with secondary aneurysmal bone cysts of calvaria are extremely rare. Only three cases describing a secondary aneurysmal bone cyst in the setting of a calvarial osteoblastoma can be found in the literature. We report the case of the surgical resection of the frontoparietal osteoblastoma accompanying a secondary aneurysmal bone cyst. Case description: The case is a 24-year-old male with a 2-year history of a painless lump in the hair-bearing region of the left fronto-parietal area without neurologic symptoms. Computed tomography showed an intradiploic tumour with maintained inner and outer cortex of the left front-parietal bones. 3.0-T magnetic resonance imaging showed a well-circumscribed, intradiploic, multilocular cystic tumour. A gadolinium-enhanced sequence showed strong peripheral and septal enhancement. These findings were consistent with an osteoblastoma associated with secondary aneurysmal bone cyst. An en bloc tumour resection with a 10-mm horizontal margin was completed without complications. The calvarial defect was covered by calvarial bone graft harvested from the contralateral fronto-parietal bone. The postoperative course was uneventful. Pathological diagnosis was consistent with the osteoblastoma with secondary aneurysmal bone cyst. After a follow-up period of 2 years, there was no evidence of recurrence. Conclusion: The combination of osteoblastoma and aneurysmal bone cyst of the calvaria is a rare clinical entity. Careful preoperative examination and complete resection of the tumour are essential. (C) 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Background: Although early diagnosis is important for selecting an effective surgical treatment for secondary lymphedema, an efficient screening test for detecting early-stage lymphedema has not yet been established. Serial changes of lymphatic function before and after lymph node dissection and risk factors for secondary lymphedema are important indicators. Methods: A prospective cohort observational study was conducted with 100 consecutive gynecologic cancer patients who underwent pelvic lymph node dissection. Lymphatic function was assessed by noninvasive lymphography using indocyanine green fluorescence imaging on a routine schedule. Earliest findings after lymphadenectomy and risk factors for lower leg lymphedema were investigated. Results: Atypical transient dermal backflow patterns were observed in an early postoperative period in 50 cases, all of which disappeared within 3 months. Of these patterns, the splash pattern was observed in 31 patients, of which five improved to normal following a natural course. In contrast, the stardust pattern was observed in 27 patients, and none had improved with conservative therapy. Postoperative radiotherapy was a significant risk factor for the stardust pattern. Conclusions: All patients who undergo lymphadenectomy for gynecologic malignancies should be examined for secondary lower extremity lymphedema by qualitative evaluation methods on a routine schedule to determine the earliest possible diagnosis. Because the splash pattern on indocyanine green lymphography is a reversible lymphatic disorder following a natural course, surgical treatments are not recommended. The decision regarding surgical treatment can be made after observing the stardust pattern. (Plast. Reconstr. Surg. 131: 283, 2013.)

87歳,男性.15年前に右上肢の皮膚T細胞リンパ腫に対して放射線療法を行った既往があり,照射部位に一致したリンパ浮腫を認めていた.2010年7月,同部にリンパ漏出を認めるようになったため,当院形成外科でリンパ管細静脈吻合術を施行したが,術後より急速にリンパ漏出は増加し,暗紫紅色調の浸潤局面と多数の紫紅色結節が出現した.皮膚生検組織像から血管肉腫と診断した.循環動態が保てなくなったことから右肩関節離断術を施行した.術後補助療法としてweekly-docetaxel療法を開始し,現在も外来で継続中である.Stewart-Treves症候群は手術による増悪例が報告されており,自験例でもリンパ管細静脈吻合術による脈管操作を契機に急速に増悪した.(著者抄録)

症例は40歳男性で、道路横断中、トラックに接触し左側頭部を強打、耳鳴りを生じ耳鼻科、脳外科を受診した。デジタルサブトラクションアンギオグラフィ(DSA)所見から浅側頭動脈、中硬膜動脈枝、後耳介動脈、後頭動脈枝をfeeder arteryとした左頭皮動静脈瘻と診断し、11ヵ月後、GDCコイル、ポリビニルアルコール粒子による塞栓術を行った。術中浅側頭動脈への流入減少を確認し血管雑音、耳鳴りも消失したが3週間後、拍動性腫瘤、耳鳴りが再発し、DSAで動静脈瘻再発が確認され、形成外科へ紹介した。左側頭部を中心に耳前部から頭頂部に広範な皮下血管拡張による腫瘤を認め、3D-CT血管造影でコイル留置部から末梢側側頭部で臨床所見と同部位の血管拡張病変が造影され、頬骨弓頭側ではDSA所見に走行と部位が一致する蛇行した血管が病変と接し、この領域が再発原因となったシャントの存在部位と思われた。所見より再発した動静脈瘻の血流は主に顎動脈に由来しコイル留置部を迂回し浅側頭動脈末梢から逆行性に流入後、頬骨弓頭側シャントを経て浅側頭静脈に流入したと推測し頬骨弓頭側からコイル留置部までの動静脈瘻切除を再発7ヵ月に全身麻酔下に行った。本法は顔面神経を損傷せずに顎動脈分岐部に手術操作を加えられ耳下腺深部の手術操作を安全に行う上で有用と思われた。

We raised thenar island flaps that were supplied by perforators that originated in the superficial palmar arch or the superficial palmar branch of the radial artery for the reconstruction of fingertip defects in eight patients. The flap was so well-vascularised that a large flap with increased mobility could be raised. The donor site was covered with well-vascularised thick tissue, and skin grafting of the donor site was avoided in all cases. No patient developed a complication, and all flaps survived. Functional and cosmetic results of both fingertips and donor sites were excellent. A perforator island flap from the thenar eminence can be raised easily without injuring any digital and palmar arteries. They have a good colour and texture that matches the fingertips and donor site defects on the palm.

症例は20歳女性で、口蓋裂の口蓋形成術後に、硬口蓋全欠損生じたため、舌弁と欠損部周辺のturned-upにて再建術を行った。欠損は縦40mm、横32mmで、舌弁の大きさは33×55×4mm(厚さ)であった。使用した舌弁は大きく、薄く、殆どの部分が裏打ちをもたず、骨の支えも有しなかった。6年後、舌弁に軽度の収縮を認めたが、表面は平坦で、瘢痕や潰瘍、瘻孔など認めなかった。触診で線維性硬があり、舌弁の辺縁部に、軽度の知覚が存在した。舌を口腔から突出させると舌は僅かに狭小であり、口腔内に収まっている時は殆ど変形はみられなかった。舌の運動や嚥下、味覚にも特に異常はなかった。

盲腸癌の腹壁合併切除後に生じた、11×8cmの下腹壁全層欠損に対し、有茎前外側大腿皮弁を用いて再建した。有茎皮弁による下腹壁再建では、大腿筋膜張筋皮弁が知られるが、より広い生着域と到達範囲をもつ前外側大腿皮弁は、臍周囲に及ぶ下腹壁全層再建が可能であった。また本法は、血管茎を直視下に確認できるため、皮弁内に含めた筋膜と腹膜を密に縫合し易く、術後ヘルニア予防にも有用であった。但し、外側大腿回旋動脈下行枝を反転させる際には、その走向を屈曲させないよう注意が必要であり、緊張を避けるための股関節屈曲位の維持や、皮弁採取部縫縮の延期など、皮弁血管茎にかかる負担の回避には十分な配慮が必要であると思われた。(著者抄録)

45歳男。右胸膜中皮腫の診断で右胸膜肺全摘術、心膜・横隔膜合併切除が施行された。開胸は第5肋間の後側方から前方切開で行われ、広背筋は一旦切断後に再縫合されていた。術後1ヵ月に気管支瘻を伴う慢性膿胸を併発し、開窓術、洗浄などによる胸腔内の清浄化後、再建術として気管支瘻閉鎖術、筋皮弁充填術、胸郭形成術を施行した。膿胸内を掻爬した後、31×6cmの紡錘形の皮島を広背筋上にデザインした。後側方切開の瘢痕は皮島の近位1/4の部分を横断していた。まず、皮島の全周を切開し、広背筋筋膜上の剥離を進めたところ、第5肋間の高さで筋体を完全に横断する瘢痕を認めた。瘢痕より末梢の筋体の血行を確認しながら慎重に筋皮弁の挙上を進めた。広背筋全体を挙上したが、筋の最遠位部でも血行は良好であった。第3〜7肋骨を部分切除して胸郭形成した後、皮島の表皮を剥離した筋皮弁を膿胸腔内に充填した。術後経過は良好で、術後8ヵ月で気管支瘻、膿胸の再発はなく、術後10ヵ月のCTで死腔の残存は認めていない。

Thenar flap採取部の被覆に母指球部穿通枝皮弁を使用した2例を経験した。症例1は38歳男で、紙を切断する機械に挟まれ右示指末節背側を切断した。ただちにcomposit graftを行い、骨片の生着をみたが、爪床爪母部に骨膜および軟部組織の欠損を残した。受傷より1ヵ月後に、指尖背側の軟部組織欠損に対して、近位茎のthenar flapを施行した。第1回目手術より2週間後にThenar flapを切離した。術後6ヵ月の現在、再建示指、Thenar flap採取部ともに拘縮を認めず、整容的にも良好である。症例2は23歳男で、プラスティックを切断する機械に巻き込まれて右中指指尖を切断した。受傷より5日目にthenar flapを施行した。第1回目手術より2週間後に、局所麻酔下に皮弁を切り離し、切離面を縫合した。術後10日の抜糸時において再建中指、thenar flap採取部ともに拘縮を認めていない。

臀裂近傍に生じた比較的稀な皮膚腫瘤の3例を経験した。症例1(23歳男)。幼少時より臀部に腫瘤が存在し、成長とともに徐々に増大する傾向にあったが成長後は大きさに変化はない。腫瘤の形態と部位から多発型表在性脂肪腫性母斑を疑い、全摘生検した。病理組織学的診断は表皮母斑であった。症例2(15歳男)。徐々に増大する左肘部、両側臀部の皮膚腫瘤を認め、同時期より両側上眼瞼内眼角付近の黄色結節と、アキレス腱部の肥厚を認めた。眼瞼、肘部とともに黄色腫を疑い全摘生検した。病理組織学的診断は黄色腫であった。症例3(18歳女)。右臀部に発赤を伴う小丘疹が出現し、無症候性のまま徐々に増大した。臨床所見、HE染色所見から皮膚石灰沈着症と診断した。

37歳女。3年前に他院にて両側乳腺線維腺腫を指摘され経過観察中であった。今回、右腋窩から上腕の皮下腫瘤に気付き、徐々に増大傾向となったため当科受診した。腫瘤は55×30mm、弾性硬で、自発痛・圧痛はなく、皮膚および下床との可動性は良好であった。腫瘤直上の皮膚色は正常で、乳頭・乳輪様構造はなかったが、右乳房下に乳頭・乳輪を有する副乳が存在した。MRIで腫瘤はT1強調像で等信号、T2強調像で高信号を示し、造影で増強された。穿刺吸引細胞診では、血球成分を背景に結合性の保たれたシート状配列を示す上皮性細胞集塊を認めた。この細胞集塊内には筋上皮細胞と思われる濃縮核を認め、周囲には紡錘型の核を持つ間質裸核細胞がみられた。腋窩副乳から発生した線維腺腫と診断し、摘出術を施行した。病理組織所見で管状の上皮性腺成分の周囲に線維性の間質がみられ、いずれも増生性であり、免疫染色ではエストロゲンおよびプロゲステロンレセプター陽性であった。術後6ヵ月経過し、再発はない。

仙尾骨部の再建7例に、大臀筋穿通枝皮弁(GAP flap)を用いた。皮弁の大きさは最小で6×4cm,最大で24×10cmと15×9cmの双葉皮弁であった。全例で皮弁は生着し、平均術後経過観察期間の8.6ヵ月において、再発症例は認められない。GAP flapは皮弁採取部の犠牲が少なく、大臀筋皮弁と同等の皮弁の挙上が可能である。術中出血量も少ない。また、穿通枝は筋組織よりも回転移動が安全、かつ容易で、180°の回転にも耐え、皮弁移動の自由度が高い。GAP flapは仙尾骨領域の再建法として有用だと思われた。