秋田 新介

Reconstructing the structural images of human body compartments as a point-of-care imaging could be possible using electrical impedance tomography (EIT) but the reconstructed image deteriorates due to high conductivity contrast μ between anomaly and background. In this study, a multifrequency EIT with a ratiometric preprocessing (ratiometric EIT) has been developed in order to minimize μ while maintaining high distinguishability without any a priori information. The preprocessing of ratiometric EIT is achieved by extending the framework of ratiometric methods that uses the ratio of two measurement signals. Based on the proposed ratiometric preprocessing, ratiometric frequency-difference adjacent EIT (rfda-EIT) is newly derived. The rfda-EIT is qualitatively and quantitatively evaluated by numerical simulation under the variant conditions of μ (= 95%-10%) and experiment with eight subjects’ calves. As the results, the rfda-EIT scores the area ratio error of subcutaneous adipose tissue (SAT) 17.09% < ARESAT < 28.13%, the position error of bone tibia 0.14% < PEtibia < 10.19%, the position error of bone fibula 9.51% < PEfibula < 1.74%, and the correlation coefficients 0.79 < CC < 0.91 in the numerical simulation. The total-mean area ratio error <ARESAT> by the rfda-EIT is lower than the error by the classical frequency-difference adjacent EIT (fda-EIT) from 12.70% to 5.18% in the experiment. Moreover, the true positive rate TPRtibia for the bone tibia detection by the rfda-EIT is increased from 50.0% to 87.5% as compared with the rate by the fda-EIT.

In addition to the symptoms of aging, the main symptoms in Werner syndrome (WS), a hereditary premature aging disease, include calcification of subcutaneous tissue with solid pain and refractory skin ulcers. However, the mechanism of calcification in WS remains unclear. In this study, the histological analysis of the skin around the ulcer with calcification revealed an accumulation of calcium phosphate in the lymphatic vessels. Moreover, the morphological comparison with the lymphatic vessels in PAD patients with chronic skin ulcers demonstrated the ongoing lymphatic remodeling in WS patients because of the narrow luminal cross-sectional area (LA) of the lymphatic vessels but the increment of lymphatic microvessels density (MLVD). Additionally, fluorescence immunohistochemical analysis presented the cytoplasmic distribution and the accumulation of WRN proteins in endothelial cells on remodeling lymphatic vessels. In summary, these results point out a relationship between calcification in lymphatic vessels and the remodeling of lymphatic vessels and suggest the significance of the accumulation of WRN mutant proteins as an age-related change in WS patients. Thus, cytoplasmic accumulation of WRN protein can be an indicator of the decreasing drainage function of the lymphatic vessels and the increased risk of skin ulcers and calcification in the lymphatic vessels.

BACKGROUND: The central polydactyly of the foot is a rare congenital disorder, and its characteristics are not well known. This study aims to investigate its disease concept. METHODS: We obtained the medical records of patients who were treated surgically for central polydactyly of the foot at our hospital during a 32-year period from 1990 to 2021 retrospectively. We compared our clinical data with other case series reports to investigate the characteristics of this disorder further. RESULTS: There were 22 patients (13 males and 9 females) included in our case series. Unilateral and bilateral involvements were observed in 19 (right side: 6 patients; left side: 13 patients) and 3 patients, respectively. The second toe is the commonest duplicated toe (observed in 19 toes). 19 patients had distally duplicated toes (with normal metatarsal bone). Proximally duplicated toes were observed in only two patients. CONCLUSIONS: The incidence of central polydactyly of the foot is almost equal among male and female, and bilateral involvements are few. As this abnormality is rarely reported, further investigations are needed to clarify the clinical presentation of central polydactyly of the foot.

Although the functional and anatomical differences between the left and right eyelids are important in the evaluation of age-related changes in the eyelids, they have not been described clearly as indications for surgical treatments. This study aimed to investigate how laterality of the eyelids affects evaluation of age-related changes. Methods: Photographs of either one or both eyelids of 100 people were evaluated in four stages by 10 plastic surgeons. To investigate the consistency of the results between evaluations, surgeons evaluated the single-eyelid photographs (group U) or two-eyelid photographs (group B). It was investigated whether the difference in margin reflex distance 1, height of the upper eyelid crease, height of eyebrow, and levator contractile function were associated with mismatched evaluations. Results: The weighted kappa coefficient for groups B and U was 0.77 (substantial agreement). One-point difference in scores was observed in 23 cases. In the multiple logistic regression analysis, only the laterality the height of the eyelid crease was significantly different between patients whose evaluations were matched and those whose evaluations were mismatched (0.9 ± 0.1 mm versus 1.7 ± 0.2 mm; OR = 1.06, 95%CI: 1.01-1.10; P = 0.01). Conclusions: Besides the structure and function of each eyelid, the laterality of the height of the eyelid crease was important in the evaluation of the age-related changes in the eyelids. This factor may be important in evaluating the aesthetic and visual impressions of age-related changes in the eyelids.

OBJECTIVE: Indocyanine green fluorescent lymphography may be useful in patients undergoing lymphatic surgery for secondary lymphedema. This clinical trial aimed to confirm whether indocyanine green fluorescent lymphography is useful for evaluating lymphedema, identifying lymphatic vessels suitable for anastomosis, and confirming patency of a lymphaticovenular anastomosis in patients with secondary lymphedema. METHODS: This phase III, multicenter, single-arm, open-label clinical trial (HAMAMATSU-ICG study) investigated the accuracy of lymphedema diagnosis via indocyanine green fluorescent lymphography compared with lymphoscintigraphy, the identification rate of lymphatic vessels at the incision site, and the efficacy for confirming patency of a lymphaticovenular anastomosis. The external diameter of the identified lymphatic vessels and the distance from the skin surface to the lymphatic vessels based on preoperative indocyanine green fluorescent lymphography were measured intraoperatively under surgical microscopy. RESULTS: When the clinical decision for surgical indication at each research site was made, the standard diagnosis of lymphedema was considered to be correct. In 26 upper extremities, a central judgment committee blinded to the clinical presentation confirmed the imaging diagnosis as accurate in 100.0% of cases, whether assessments were made via lymphoscintigraphy or indocyanine green lymphography. In contrast, in 88 lower extremities, the accuracy rates of diagnosis based on those made by the central judgment committee were 70.5% and 88.2% for lymphoscintigraphy and indocyanine green lymphography, respectively. The external diameter of the identified lymphatic vessels was significantly greater in the lower extremities than in the upper extremities (0.54 ± 0.21 mm vs. 0.42 ± 0.14 mm, p < 0.0001), and the distance from the skin surface to the lymphatic vessels was significantly longer in the lower extremities than in the upper extremities (5.8 ± 3.5 mm vs. 4.4 ± 2.6 mm, p = 0.01). In 263 skin incisions determined using indocyanine green fluorescent lymphography findings, the identification rate of lymphatics vessels suitable for anastomosis was 97.7% (95% confidence interval: 95.1-99.2). In total, 267 lymphaticovenular anastomoses were performed. Indocyanine green fluorescent lymphography was judged as "useful" in confirming patency after anastomosis in 95.1% of cases. CONCLUSIONS: Indocyanine green fluorescent lymphography may be useful for improving the management of patients with secondary lymphedema from the outpatient setting to the operating room.

Axiality of lymphatic flow is possibly an important consideration for stimulating recanalization of flow between the transferred flap and the recipient site during wound healing. Antegrade lymphatic flow reconstruction has previously been reported. Here we report the first case where lymph stasis following groin lymph nodes dissection could be recanalized in a pedicled anterolateral thigh flap in which the collecting lymphatics were arranged retrograde. A 78-year-old male patient presented with bilateral lower extremity lymphedema and bilateral inguinal skin ulcers with lymphorrhea. He had been treated for rectal cancer by low-anterior resection, lymph nodes dissection, colostomy, and subsequent heavy particle radiotherapy for a local recurrence involving pelvic lymph nodes. We planned a reconstruction using a pedicled anterolateral thigh flap that included retrograde collecting lymphatic vessels, with the flap rotated as a propeller flap. The flap successfully survived and clinical symptoms of edema in both lower limbs improved during the short postoperative course. Although the collecting lymphatic vessels within the flap were arranged retrograde to the direction of the anatomical lymphatic flow at the recipient site, linear lymphatic flow consistent with the transferred flap was confirmed by lymphoscintigraphy. This case shows that the lymphatic flow may recanalize after tissue transplantation, even if the collecting lymphatic vessels in the flap are arranged retrograde to the direction of lymphatic flow.

BACKGROUND: The perfusion concept of free abdominal flap for breast reconstruction shares the common perception. We believed that free abdominal flap without Zone 4 could be performed. The purpose of this study is to introduce the "without Zone 4 procedure" and compare with the conventional technique (without 4 vs. conventional groups). METHODS: The "without 4 group" included 61 patients, while the conventional group 55 patients. The inclusion criterion for the "without Zone 4 procedure" was defined as the thickest part of flap was more than half of the contralateral breast projection. The centerline of the skin island was adjusted to the position with the most medial side of the perforator. We compared basic characteristics (age, BMI, operation time, blood loss, contralateral breast size, smoking status, and history of laparotomy), the flaps' horizontal and vertical widths, thickness of the thickest part of the flap, elevated flap weight, and operative procedure. RESULTS: The mean length of the flaps' horizontal width was significantly shorter (19.2 cm vs. 26.3 cm; p < .001) and the mean flap thickness was significantly greater in the without 4 group. The mean contralateral breast height and projection length were significantly longer in the conventional group. No significant differences were found with respect to the other characteristics. CONCLUSIONS: Patients with a lower breast projection compared with the abdominal fat thickness could undergo reconstruction with a shorter flap horizontal width. Because of the esthetic outcome of the donor site, this procedure is more appropriate for low-BMI patients.

AIM: Ceiling culture-derived preadipocytes (ccdPAs) and adipose-derived stem cells (ASCs) can be harvested from human subcutaneous fat tissue using the specific gravity method. Both cell types possess a similar spindle shape without lipid droplets. We previously reported that ccdPAs have a higher adipogenic potential than ASCs, even after a 7-week culture. We performed a genome-wide epigenetic analysis to examine the mechanisms contributing to the adipogenic potential differences between ccdPAs and ASCs. MATERIALS AND METHODS: Methylation analysis of cytosines followed by guanine (CpG) using a 450K BeadChip was performed on human ccdPAs and ASCs isolated from three metabolically healthy females. Chromatin immunoprecipitation sequencing (ChIP-seq) was performed to evaluate trimethylation at lysine 4 of histone 3 (H3K4me3). RESULTS: Unsupervised machine learning using t-distributed stochastic neighbor embedding (tSNE) to interpret 450,000-dimensional methylation assay data showed that the cells were divided into ASC and ccdPA groups. In KEGG pathway analysis of 1,543 genes with differential promoter CpG methylation, the peroxisome proliferator-activated receptor (PPAR) and adipocytokine signaling pathways ranked in the top 10 pathways. In the PPAR gamma gene, H3K4me3 peak levels were higher in ccdPAs than in ASCs, whereas promoter CpG methylation levels were significantly lower in ccdPAs than in ASCs. Similar differences in promoter CpG methylation were also seen in the fatty acid-binding protein 4 (FABP4) and leptin genes. CONCLUSION: We analyzed the epigenetic status of adipogenesis-related genes as a potential mechanism underlying the differences in adipogenic differentiation capability between ASCs and ccdPAs.

Blepharoplasty for thyroid eye disease (TED) has been indicated for the purpose of improving upper and lower eyelid retraction caused by exophthalmos. Both aponeurotic blepharoptosis and aging lower eyelid are common conditions that require plastic surgeries and could be complicated with other disease conditions, such as TED. This is the first report of planned and staged treatment of the contradictory pathophysiologies of aging changes of upper and lower eyelids associated with TED. A 59-year-old woman suffered complicated bilateral asymmetric aponeurosis blepharoptosis of the lower and upper eyelids, caused by both advanced aging and TED. To achieve aesthetic improvement, three-stage surgical treatments were planned, as follows: (1) Orbital decompression for exophthalmos; (2) Extraocular muscle surgery, if necessary; (3) Blepharoplasty for functional and aesthetic abnormalities due to loosening of the upper and lower eyelids. After medial and lateral orbital floors were opened bilaterally, the patient did not need extraocular surgery. As the final step, levator aponeurosis advancement procedure was performed in the upper eyelids for bilateral asymmetrical aponeurotic blepharoptosis, and transitional lower blepharoplasty using a skin-muscle flap technique via a sub-ciliary incision was performed in the lower eyelids for age-related loosening. The typical face displayed by Graves' disease disappeared, and the symptoms associated with loosening of the upper and lower eyelids improved substantially. Improvement of exophthalmos by orbital decompression revealed the severity of the blepharoptosis and the aging change of lower eyelid. Step-by-step planning from decompression surgery to upper and lower blepharoplasty could lead to sufficient improvement in the facial appearance in TED.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a common complication. Indocyanine green (ICG) lymphography has been performed to assess lymphatic functionality. We found that some BCRL patients had a difference in circumference in partial regions only. The purpose of this study was to evaluate the patients with BCRL about the correlation between the difference in circumference and the findings of ICG lymphography. METHODS: One hundred fifty-five patients with unilateral BCRL were enrolled in this study. We evaluated the differences in circumference taken at 4 parts on the upper limb (at around the wrist, forearm, elbow, and brachium). The difference in circumference was evaluated between the affected part (Caf) and the unaffected part (Cun). We calculated the circumference difference rate (CDR) as follows: CDR = 100 (Caf - Cun)/Caf. First, we classified each part of all BCRL patients (620 parts) based on the findings of ICG lymphography (linear, collateral, dermal back flow [DBF], and no enhancement) and evaluated the correlation. Second, in the patients with partial volume change, we compared the mean CDR in each part. RESULTS: One hundred six parts were of a linear pattern, 31 parts were collateral, 350 parts were DBF, and 133 parts had no enhancement. The mean CDR of each finding was 3.3% in linear, 4.0% in collateral, 9.6% in DBF, and 9.4% in no enhancement. There was no significant difference between linear and collateral (P = 0.62), DBF, and no enhancement (P = 0.89) patterns. However, there was a significant difference between linear or collateral and DBF or no enhancement (all P < 0.001). In the 22 patients with distal DBF and proximal linear, the CDR was significantly higher in the forearm compared with the brachium (6.4% and 3.0%; P = 0.003). In the 26 patients with distal linear and proximal DBF, the CDR was significantly higher in the brachium compared with the forearm (4.3% and 7.7%; P = 0.005). CONCLUSIONS: There was a significant correlation between the difference in circumference and the severity of ICG findings.

BACKGROUND: Increased skin and subcutaneous tissue stiffness in patients with early-stage lymphedema has been reported. The purpose of this study was to examine the use of shear wave elastography (SWE) for evaluating lower extremity lymphedema (LEL). METHODS: For 10 lower extremities of normal controls and 72 limbs of patients with gynecological cancer whose lymphatic function was categorized into six stages based on the range of dermal backflow (DBF) observed in indocyanine green (ICG) lymphography, SWE was performed and shear wave velocity (SWV) of the dermis and three layers of subcutaneous tissue at the thigh and calf were recorded. Twenty-five patients underwent thigh tissue histological and dermal thickness examinations. RESULTS: The strongest correlation between the ICG DBF stage and SWV during SWE was observed on the dermal layer of the thigh (p < 0.01, R = 0.67). There was a significant correlation between the dermal thickness of the thigh and the ICG DBF stage (p < 0.01, R = 0.87) and also between the dermal thickness of the thigh and SWV (p < 0.01, R = 0.73). CONCLUSION: Noninvasive, objective evaluation of LEL severity using SWE was well correlated with lymphatic function as determined by ICG lymphography. The DBF changes in the dermis of the thigh best reflected the changes in lymphatic function. Dermal thickness variations may partially account for differences in SWV.

BACKGROUND: Seroma formation at the donor site is a common complication of breast reconstruction using free abdominal flap. In this study, we assessed the benefits of use of autologous fibrin glue (AFG) at the donor site. METHODS: This randomized controlled study compared AFG group (n = 61) with commercial fibrin glue (CFG) group (n = 79). Owing to the high volume of AFG (10 mL), AFG group received fibrin glue at both the anastomosis and the donor sites, whereas CFG group received fibrin glue only at the anastomosis site. Operative protocols and the criteria for postoperative drain removal were identical in both groups. Patient characteristics and abdominal discharge were compared between the two groups. RESULTS: Since anemia was a contraindication for use of AFG, preoperative Hb in CFG group was significantly lower than that in AFG group; other factors were comparable in the two groups. The mean total abdominal drain volumes on first postoperative day (POD1) and POD2 was (AFG vs. CFG) 130.9 vs. 169.4 mL (P < 0.001) and 131.0 vs. 162.8 mL (P = 0.03), respectively. On POD3, there was no significant difference in this respect (116.2 vs. 128.4 mL, P = 0.19). The mean time for removal of all abdominal drains was significantly lower in AFG group (7.4 vs. 8.4 days; P = 0.01). CONCLUSIONS: AFG reduced the discharge at the donor site of free abdominal flap, especially in the early postoperative period. AFG helped to reduce the abdominal drainage period.

BACKGROUND: Changes of the lymph flow from the chest wall after mastectomy and sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (Ax) has yet to be understood. This study aimed to investigate the effect of axillary surgery on lymphatic flow from the chest wall in patients who have undergone mastectomy, including those have undergone breast reconstruction and vascularized lymph node transfer (VLNT). METHODS: Following mastectomy in 100 breasts, the directions of lymph flow from the chest wall was compared between the SLNB omission, SLNB, Ax, and Ax followed by VLNT groups using indocyanine green (ICG) lymphography in cross-sectional study. Lymph flow on the deep epigastric artery perforator (DIEP) flap was also investigated. RESULTS: Lymph flow directing to the ipsilateral axilla was observed more frequently after SLNB than Ax (48% vs. 12.5%; p = 0.005); however, no significant difference was observed in the frequency of contralateral axillary route adoption between them (8% vs. 15%; p = 0.65). In the VLNT group, lymph flow to the ipsilateral axilla was not observed at a significantly higher frequency than in the Ax group (12.5% vs. 12.5%, p = 1.00). On the transferred DIEP flap, the lymph flowed anterograde or retrograde parallel to the anatomic course of the lymphatic vessels. CONCLUSION: To visualize the direction of lymph flow of the chest following mastectomy, ICG lymphography may be useful to discern the direction in which malignant neoplasms, including lymphoma, are transported and to plan for lymph flow restoration.

症例は19歳男性で、1ヵ月前より左上腹部皮下にしこりを自覚していた。徐々に増大し5日ほど前より咳をすると同部位の疼痛を感じ、精査および治療目的で当科を受診した。結節性筋膜炎やデスモイドなどの線維組織系腫瘍を鑑別疾患として想定し、針生検や切開生検を行うには腫瘤の大きさが小さいため、全身麻酔下に切除生検を施行した。MRIで筋組織への浸潤が確認され悪性腫瘍も否定できないため、腫瘍直上の切開から進入し腫瘤が露出しないよう周囲に脂肪織をつけて剥離を進め、前鞘および筋体の一部を周囲につけて全切除した。細胞増殖が亢進していたが細胞異型が乏しく、患者の臨床年齢が若いことより、最終的には結節性筋膜炎と診断した。術後2年6ヵ月経過するが再発なく経過している。

OBJECTIVE: Cervical chondrocutaneous branchial remnants (CCBRs) are rare masses located in the anterior region of the neck. Though the basic characteristics of these rare masses were first described by Atlan in 1997, a critical amount of information about these masses remains unknown. This study aimed to further clarify the characteristics of these rare masses. METHODS: We retrospectively reviewed the clinical records of patients with CCBRs in our facility during a 32-year period ranging from 1988 to 2019. We then compared our clinical records with other case reports. RESULTS: There were 29 patients with CCBRs in our facility, including 19 males and ten females, Three patients were involved bilaterally (among patients involved unilaterally, the right side included 11 patients, and the left side was 15 patients), eight patients also had associated abnormalities. We submitted CCBRs from 18 patients to pathology, and all of them contained elastic cartilages. Among all the surgical data could be confirmed, cartilages did not reach beyond the musculature of the neck. We could confirm a similar tendency with Atlan regarding sex, the location of CCBRs (involvement side, localization in the neck), and the depth of CCBRs. Among the cases contained in this study, there was a disparity in the rate of associated abnormalities and pathology of contained cartilages. CONCLUSION: Some critical characteristics of CCBRs included, a male predominance, scarcity of bilateral cases and common left side involvement among unilateral involved cases, a common location of CCBRs in the inferior third of the neck and anterior to the sternocleidomastoid muscle, and an involvement of cartilage in CCBRs which has no connections to deep underlying structure of the neck. Further investigations are required to determine the origin of CCBRs and the precise incidence of the associated abnormalities. Systemic examination in patients with CCBRs is recommended because many associated abnormalities have been reported.

A 78-year-old man presented with lymphatic fluid collections in bilateral inguinal area after bilateral inguinal lymph node dissections. Because no inguinal or popliteal lymph nodes were observed under ultrasound examination, intranodal lymphangiography was not applicable. Although traditional pedal lymphangiography was required, it was difficult to perform this procedure owing to the decreasing frequency over the past 20 years and being unavailable in not only our institution, but also other in institutions. Therefore, we performed catheterization using the 29-guage Argyle PI catheter into the lymphatic duct in lower legs under a microscope and achieved successful percutaneous embolization using N-butyl cyanoacrylate for inguinal lymphatic leakage.

In plastic surgery, free tissue graft procedures are an essential part of fixing tissue-lack injuries or diseases. However, tissue necrosis caused by vascular occlusions or poor vascular anastomosis is a severe problem for prognosis. Follow-up surgery in the early-stage of necrosis caused by congestion or ischemia is essential to salvage the tissue, but making a diagnosis is difficult because of the slight features of these states. Therefore, a diagnosis support system that can capture the features of blood circulation of the skin flap is required to improve prognosis. We focused on system design and analysis by using spectral characteristics of blood circulation of a skin flap for this purpose. The system to be constructed is composed of a two-channel narrow-band illuminant and a color camera and can capture six-channel spectral signals. The narrow-band illuminant is designed by combining 13 kinds of light-emitting diode (LED) spectra. In this study, we first measured reflectance spectra of the early-stage skin flap necrosis of the rat model to design the narrow-band illuminant spectra. We blocked the flow of the target vessel and observed necrosis progression. A prototyped skin flap chamber was used for stable observation of spectral reflectance measurements. An evaluation experiment was conducted using a color camera and the spectrally tunable light source. Skin flap images were captured under the designed-illuminants and a conventional illuminant reproduced by the spectrally tunable light source. We confirmed the effectiveness of the designed system by improvements in necrosis region detection.

症例1(48歳女性)。左アキレス腱部の難治性皮膚潰瘍を主訴に前医より当院へ紹介となった。症例2(44歳男性)。右足背部の難治性潰瘍を主訴に前医より当院へ紹介となった。両症例とも鳥様顔貌、白内障の既往などから遺伝子検査を行い、Werner症候群と診断された。いずれも腱露出を伴う難治性潰瘍に対して細胞外マトリックスグラフトと局所陰圧閉鎖療法を併用したところ、創部には良好な肉芽形成が得られた。更に鼠径部からの全層植皮術を行うことで、植皮は全生着し、目下、術後1年経過で潰瘍の再発は認められていない。

BACKGROUND: The physical activity (PA) of patients may change after microsurgical treatment for lower extremity lymphedema (LEL). We investigated whether PA changes perioperatively and whether it influences the treatment result. PATIENTS AND METHODS: Sixty patients with unilateral LEL (56 secondary and 4 primary) underwent lymphatic microsurgeries. Patients were divided into two groups based on improvement in International Physical Activity Questionnaire Short Form (IPAQ-SF) categories; the outcomes were compared. RESULTS: Fifty-three patients in whom linear pattern could be partially observed in indocyanine green lymphography or lymphoscintigraphy underwent lymphaticovenular anastomosis (LVA); seven patients in whom no linear pattern was observed underwent simultaneous LVA and vascularized lymph node transfer. No surgical complication was observed. The median IPAQ-SF score significantly improved from 990 (interquartile range: 231-2,376) to 1,386 (interquartile range: 940.5-4,158; p < .0001). The IPAQ-SF category improved in 22 patients (33.7%), who were categorized into the IPAQ-improved group. Improvement in excess limb volume was significantly larger in the IPAQ-improved group than that in the unimproved group (8.0 ± 4.2 vs. 3.5 ± 2.4%; p < .0001). CONCLUSION: The PA of patients may change after surgical treatment for unilateral LEL. Perioperative improvement in PA significantly correlated with the perioperative change in the excess limb volume. The change in PA is an important factor that might affect the outcome of surgical treatment for LEL. In evaluating the results of microsurgery for lymphedema, it may be necessary to consider changes in PA to avoid bias.

Unplanned excision (UE) is defined as a procedure wherein a surgeon operates a tumor resection without appropriate preoperative diagnostic modalities and without the intent to achieve tumor-free margins. Generally, the reconstruction rate after UE is higher than that after planned excision (PE). The present study aimed to investigate how the reconstructive procedure and size of skin defect could be influenced. We reviewed the cases of 442 patients who underwent the resection of soft tissue sarcoma. Patients were stratified into two groups (UE vs. PE). We compared the histologic grade, skin defect, reconstructive procedures, depth of the reconstruction layer. For superficial reconstructions, we also compared procedures involving skin graft-only or flap. 105 cases (23.8%) were UE. Histologic grade in PE was significantly higher (p = .024). The reconstruction rate and size of skin defect in UE was significantly higher (76.2% vs. 27.3%, p < .001) and larger (124.5 cm2 vs. 65.7 cm2, p < .001). The rate of deep layer reconstruction was significantly higher in PE (7.5% vs. 26.1%, p = .001). In superficial reconstructions, 18 (24.3%) skin graft-only procedures were performed in UE and 15 (22.1%) in PE, all other superficial reconstructive procedures involved flap, and there was no significant difference (p = .45). Skin defects were 1.9 times larger after UE than PE. UE did not affect the superficial reconstructive procedure.

BACKGROUND: Although microsurgical treatment for lower extremity lymphedema (LEL) can improve lower abdominal morphology, methods to evaluate the volume change of the lower abdomen have yet to be established. This study aimed to determine the accuracy and reproducibility of three-dimensional stereophotogrammetry (3DSM) in measuring the volume change in the lower abdomen. METHODS: The perioperative volume changes in the lower abdomen were estimated using tape measurement (TM) and 3DSM in 26 patients with LEL. Thirteen patients with suprapubic lymphedema underwent abdominoplasty simultaneously. Each of them underwent multiple lymphaticovenular anastomoses (LVAs), and five of them underwent vascularized lymph node transfer, simultaneously. Thirteen patients with pelvic lymphatic fluid underwent multiple LVAs. Two patients underwent this surgery twice. When assessed on the Internal Society of Lymphology scale, eight patients were Stage I, 10 patients were Stage II, four patients were late Stage II, and four patients were Stage III. The difference between the two measurement methods and reproducibility of each method were analyzed. RESULTS: During a mean follow-up period of 6 months, all patients had no postoperative complications and their chief complaint improved. The calculated reduction volume between TM and 3DSM showed a high correlation (p < .0001, r = .84). The reduction volume based on TM was significantly larger than 3DSM (991.1 ± 460.3 ml vs. 862.3 ± 333.5 ml, p = .02). The interrater ICC was 0.94 and 0.98 based on TM and 3DSM, respectively. CONCLUSION: 3DSM may be a useful method for assessment of the lower abdominal morphology due to its high accuracy and reproducibility.

Background: It is not always possible to detect nonpalpable small lymph nodes (LNs) surrounded by adipose tissue under the wavelength of visible light. A newly developed near-infrared camera with InGaAs element was able to capture photographs using light at >1000-nm wavelength, at which the difference in absorbance between water and lipids is large. This study investigated the ability to detect nonvisible small LNs using light at 1300-nm wavelength. Methods and Results: Following retrieval of LNs through axillary LN dissection from 20 patients with breast cancer, residual specimens were simultaneously photographed using light at 970-, 1070-, 1200-, 1300-, 1450-, and 1600-nm wavelengths. A total of 45 specimens were observed pathologically at the selected portions in which the 1300-nm light was absorbed (high absorbance group [HA group], n = 25) and those in which the 970-nm light was absorbed instead (low absorbance group [LA group], n = 20). All specimens categorized in the HA group detected the LNs, whereas none of those categorized in the LA group detected an LN. The sensitivity and specificity in the identification of an LN were 1.0. The LNs detected using this camera were significantly smaller than those detected by surgeons (3.00 ± 2.93 mm vs. 5.90 ± 3.91 mm, p < 0.01). Discussion: The light at 1300-nm wavelength was absorbed by axillary LNs. This camera detected LNs that were undetectable by surgeons. This novel technology may be applied to lymphatic microsurgery and contribute to the development of a minimally invasive LN dissection method.

血流のある皮膚・皮下組織や深部組織により構成される皮弁を用いた遊離皮弁移植術は重要な手技であるが,術後の血管吻合不良や血管閉塞に伴う壊死が発生する可能性がある.壊死の回避には早期の血管再吻合が必要だが,目視での早期発見は困難である.そこでわれわれは,壊死領域を早期に診断するための簡便な撮影システム構築を目指している.具体的には,適当な波長帯と強度を選択したLED光源を2種類用意し,この光源の連続切替とRGBカメラ撮影により,6次元の信号を取得し診断に利用する.本研究では基礎実験として,ラットの皮弁壊死モデルを作製し,ラット皮弁の血管結紮後早期の分光反射率を取得することで光源設計を行った.得られた光源スペクトルを用いて,設計した光源下と従来光源下で得られるRGBカメラ画像をシミュレーションにより作成し,壊死領域の抽出を行った.従来の白色光下のRGB画像に比べて,提案システム光源のRGB画像では,より高い感度で壊死領域の抽出を実現した.(著者抄録)

血流のある皮膚・皮下組織や深部組織により構成される皮弁を用いた遊離皮弁移植術は重要な手技であるが,術後の血管吻合不良や血管閉塞に伴う壊死が発生する可能性がある.壊死の回避には早期の血管再吻合が必要だが,目視での早期発見は困難である.そこでわれわれは,壊死領域を早期に診断するための簡便な撮影システム構築を目指している.具体的には,適当な波長帯と強度を選択したLED光源を2種類用意し,この光源の連続切替とRGBカメラ撮影により,6次元の信号を取得し診断に利用する.本研究では基礎実験として,ラットの皮弁壊死モデルを作製し,ラット皮弁の血管結紮後早期の分光反射率を取得することで光源設計を行った.得られた光源スペクトルを用いて,設計した光源下と従来光源下で得られるRGBカメラ画像をシミュレーションにより作成し,壊死領域の抽出を行った.従来の白色光下のRGB画像に比べて,提案システム光源のRGB画像では,より高い感度で壊死領域の抽出を実現した.(著者抄録)

Introduction: Secondary lymphoedema of the extremities is an important quality-of-life issue for patients who were treated for their malignancies. Indocyanine green (ICG) fluorescent lymphography may be helpful for assessing lymphoedema and for planning lymphaticovenular anastomosis (LVA). The objective of the present clinical trial is to confirm whether or not ICG fluorescent lymphography using the near-infrared monitoring camera is useful for assessing the indication for LVA, for the identification of the lymphatic vessels before the conduct of LVA, and for the confirmation of the patency of the anastomosis site during surgery. Methods and analysis: This trial is a phase III, multicentre, single-arm, open-label clinical trial to assess the efficacy and safety of ICG fluorescent lymphography when assessing and treating lymphoedema of patients with secondary lymphoedema who are under consideration for LVA. The primary endpoint is the identification rate of the lymphatic vessels at the incision site based on ICG fluorescent lymphograms obtained before surgery. The secondary endpoints are 1) the sensitivity and specificity of dermal back flow determined by ICG fluorescent lymphography as compared with 99mTc lymphoscintigraphy-one of the standard diagnostic methods and 2) the usefulness of ICG fluorescent lymphography when confirming the patency of the anastomosis site after LVA. Ethics and dissemination: The protocol for the study was approved by the Institutional Review Board of each institution. The trial was filed for and registered at the Pharmaceuticals and Medical Devices Agency in Japan. The trial is currently on-going and is scheduled to end in June 2020. Trial registration number: jRCT2031190064; Pre-results.

BACKGROUND: Pressure sores are sometimes refractory to treatment, often due to malnutrition. Small intestinal bacterial overgrowth (SIBO) obstructs absorption in the digestive tract and causes malnutrition. However, little is known about the association between pressure sore wound healing and SIBO. Here, we report a case of a patient with a refractory sacral pressure sore and SIBO. CASE PRESENTATION: A 66-year-old woman who was spinal cord injured 14 years before visiting our hospital presented with the chief complaint of a sacral pressure sore, 10.0 × 6.5 cm in size, which was refractory to treatment. Physical examination showed abdominal distension and emaciation, with a body mass index of 15. Further examination revealed elevated serum alkaline phosphatase (1260 U/L), bilateral tibial fracture, multiple rib fracture, and osteoporosis. We diagnosed the patient with osteomalacia with vitamin D deficiency. Despite oral supplementation, serum levels of calcium, phosphorous, and vitamin D remained low. Also, despite concentrative wound therapy for the sacral pressure sore by plastic surgeons, no wound healing was achieved. Due to a suspicion of disturbances in nutrient absorption, we performed bacterial examination of collected gastric and duodenal fluid, which showed high numbers of bacteria in gastric content (104 E. coli, 105 Streptococcus species, and 105 Neisseria species) and duodenal content (106 E. coli, 104 Candida glabrata). Therefore, we diagnosed the patient with SIBO and started selective decontamination of the digestive tract using polymyxin B sulfate and amphotericin B. After starting treatment for SIBO, the sacral pressure sore began to heal and was nearly healed after 285 days. The patient's serum levels of calcium, phosphorous, vitamin D, and other fat-soluble vitamins also gradually increased after starting treatment for SIBO. CONCLUSION: We report a case of a patient with a refractory sacral pressure sore that healed after starting treatment for SIBO. We conclude that SIBO may be an overlooked cause of malnutrition and poor wound healing in patients with chronic pressure sores.

70歳男。悪寒、嘔気、嘔吐、背部脂肪腫摘出術後の創部痛を主訴とした。発熱と創部の疼痛・腫脹・熱感の急激な拡大を認め、壊死性軟部組織感染症(NSTI)の疑いで救急搬送された。糖尿病の既往があったが、コントロールは良好で臨床所見、血液検査および画像検査は非特異的な所見であり、手術創分類はClass Iであった。全身麻酔下に緊急手術を行ったところ、右背部と肩甲骨周囲の筋層上に15cm大のスペースがあり、棘下筋筋膜を中心として僧帽筋筋膜と一部の広背筋筋膜上で筋膜壊死を認め、NSTIに特徴的な所見を確認できた。壊死組織の切除と洗浄を行い、抗菌薬投与とデブリードマンの追加施行により次第に感染徴候の改善と発赤範囲の縮小がみられたため、洗浄機能付き局所陰圧閉鎖療法を行い、縫合のみで機能障害を残すことなく創部を閉鎖できた。

心臓カテーテル治療に伴う放射線潰瘍に対してデブリードマンと皮弁移植を行った症例4例を報告した。患者の内訳は男性3例、女性1例、手術時年齢は平均68.8歳、術後観察期間は平均28.5ヵ月であった。皮膚潰瘍の大きさは平均16.8cm2、デブリードマン後の皮膚欠損は平均95cm2であった。皮弁は全例が有茎で、皮弁の大きさは平均157cm2であった。4例とも皮弁は生着し、観察期間中に潰瘍の再発は認めなかった。代表例2例を提示した。心臓カテーテル治療後の放射線皮膚潰瘍は比較的大きい欠損が背部全体に生じうるため、部位に応じた再建計画を立てる必要があり、使用する皮弁は広背筋皮弁が主となるが、広背筋皮弁の被覆範囲から外れる下背部・腰部の潰瘍では肋間動脈穿通枝筋皮弁が有用と考えられた。

© 2020 The Japan Society of Applied Physics. We studied the effect of acoustic and histopathological features on the ultrasound backscatter properties of lymphedema (LE) dermis. Experimental effective scatterer diameter (ESD) and effective acoustic concentration (EAC) were calculated from a backscatter coefficient using the reflector method for backscattered signals. Predicted parameters were also analyzed using two-dimensional Fourier transforms of the acoustic impedance and histopathological distributions. Backscattered signals were obtained from ex vivo human tissues negative (n = 5) and positive (n = 5) for LE using a laboratory-made scanner with a 14 MHz transducer. Acoustic impedance was analyzed using scanning acoustic microscopy with a 68 MHz transducer, and histopathological features, such as fiber number density and thickness, were assessed with digital histopathology. Both experimental and predicted EACs showed differences (in the range 25.7%-102%) between negative and positive LE. Although the mean and standard deviation of the acoustic impedance were related to the difference in EACs, the ESD and histopathological features were the same regardless of the presence of LE.

It is widely accepted that the internal mammary vein (IMV) is valveless. However, few anatomical studies are available on the presence or absence of IMV valves. To test the hypothesis that the IMV is valveless, we performed microscopic histological examination of the IMV. IMV samples were collected from 10 human fresh frozen cadavers. For a control, the small saphenous vein (SSV) was obtained. Histological stains were performed. Microscopic examination showed that a venous valve was found in 8 of 20 IMVs. The structure of the valve leaflet consisted of two parts. There was a "thick part" located near the wall of the vein that consisted of smooth muscle cells and fibers. There was also a "thin part" located near the center of the venous lumen that lacked smooth muscle cells. The size of the thick part of the IMV valve was smaller than the SSV valve, whereas there was no difference in the size of the thin part between the IMV and SSV. IMV valves exist. Our results that an IMV valve was present in less than half of IMVs and there was a small-sized valve leaflet suggest that the IMV valve may be rudimentary.

<title>Abstract</title>There is a strong need for a non-invasive measurement technique that is capable of accurately identifying the physiological condition change or heterogeneity of subcutaneous adipose tissue (SAT) by localizing the abnormalities within the compartment. This paper aims to investigate the feasibility of Electrical Impedance Tomography (EIT) to assess the interstitial fluid in subcutaneous adipose tissue as an enhancement method of bioelectrical impedance spectroscopy (BIS). Here, we demonstrate the preliminary result of EIT with a wearable 16 electrodes sensor. The image-based reference EIT with fat weighted threshold method is proposed. In order to evaluate the performance of our novel method, a physiological swelling experiment is conducted, and Multi-Frequency Bioelectrical Impedance Analysis (MFBIA) is also applied as a comparison with EIT results. The experimental results showed that the proposed method was able to distinguish the physiological swelling condition and effectively to remove the unexpected background noise. Furthermore, the conductivity variation in the subcutaneous layer had a good correlation with extracellular water volume change from MFBIA data; the correlation coefficient R² = 0.927. It is concluded that the proposed method provides a significant prospect for SAT assessment.

BACKGROUND: Intraoperative retrograde blood flow from the vein to the lymphatic vessels in lymphaticovenular anastomosis (LVA) for lower extremity lymphedema (LEL) leads to poor results. This study aimed to establish a treatment strategy to control venous reflux in LVA. METHODS: A unified strategy to prevent venous reflux was used in 95 limbs (study group). Dilated perforating veins were ligated, and LVA at the small branch of the ligated vein was considered. External valvuloplasty in the small vein was performed to eliminate venous reflux pre- and post-LVA. A Y-shaped venoplasty for the relatively large vein was considered in cases without adequate-sized vein stump with a functional valve. The results were compared with the 34 limbs undergoing conventional multiple LVAs (control group). RESULTS: Intraoperative venous reflux and postoperative ecchymosis significantly decreased in the study group (0/462 anastomosis vs. 15/148 anastomosis, p < 0.0001 and 0/81 patients vs. 3/25 patients, p = 0.01, respectively). The average frequency of cellulitis during a year following LVA was significantly smaller in the study group than in the control group (0.05 ± 0.03 vs 0.20 ± 0.06, p = 0.04).The amount of improvement in the LEL index a year after LVA was significantly larger in the study group than in the control group (22.2 ± 9.6 vs. 18.3 ± 9.8, p = 0.04). CONCLUSION: Using the new strategy developed in this study, venous reflux could be completely prevented, and stable clinical results were obtained in patients with LEL. Prevention of venous reflux with full utilization of venoplasty might improve the LVA result.

BACKGROUND: Lymphedema is a major complication of treatment for breast cancer. Although chemotherapy can cause lymphedema, there have been few reports about histological changes in skin and subcutaneous tissue after chemotherapy. The aim of our study was to determine whether chemotherapy affects blood and lymphatic vessels in the skin and subcutaneous fat and to investigate the relationship between these changes and extent of post-chemotherapy edema. METHODS: We compared histological findings in skin and subcutaneous fat of mastectomy specimens from 38 patients who had received NAC (neoadjuvant chemotherapy) and 56 who had not (non-NAC) attending our institution from 2007 to 2016. Patients whose tumor may have affected the area examined were excluded. Blood and lymphatic vessels were identified by CD31 and D2-40, respectively. We assessed microvessel density (MVD), lymphatic microvessel density (MLVD), lumen cross-sectional area (LA), and amount of endothelium (AE) in blood and lymphatic vessels. To minimize surgical effects, we measured edema, defined as ≥ 15% thicker dorsal subcutaneous tissue than baseline, on the contralateral side. RESULTS: MVD, LA, and AE of blood vessels were greater and MLVD not significantly different in the skin of NAC patients than in that of non-NAC patients. MVD was greater and AE of blood vessels less in subcutaneous fat of NAC patients than in that of non-NAC patients. Patients with edema had significantly less AE of blood vessels in skin than did those without it. CONCLUSIONS: These pathological findings can help to identify patients who will develop edema and improve their treatment.

PURPOSE: Radio-frequency (RF) signals from the most dominant scatterer in a dermis, i.e., collagen fibers, are collected as backscattered signals. We aim to confirm the frequency dependence of the spatial distribution of features in ultrasound images, as well as the attenuation coefficient (AC) and backscatter coefficient (BSC) of skin tissue without [LE (-)] and with lymphedema [LE (+)]. METHODS: Measurement samples (n = 13) were excised from human skin tissue with LE (-) and middle severity LE (+). A laboratory-made scanner and single-element concave transducers (range 9-47 MHz) were used to measure RF data. A localized AC was computed from the normalized power spectrum using the linear least squares technique. The reflector method and compensation technique of the attenuation of tissue were applied to calculate the BSC. In addition, effective scatterer diameter (ESD), effective acoustic concentration (EAC), and integrated BSC (IBS) were calculated from the BSC as the benchmark to differentiate LE (-) and LE (+) tissues. RESULTS: High-frequency ultrasound displayed different echogenicity and texture compared between LE (-) and LE (+) in all transducers. The AC for LE (-) (0.22 dB/mm/MHz) and LE (+) (0.29 dB/mm/MHz) was comparable. BSC in LE (-) and LE (+) increased linearly with each transducer. The difference of intercept of the BSC between LE (-) and LE (+) indicated that both EAC and IBS of LE (+) were higher than that of LE (-). In contrast, ESD correlated with the slope of the BSC demonstrated the same tendency for both LE (-) and LE (+). These tendencies appeared for each transducer independent of the frequency bandwidth. CONCLUSION: Frequency independence of AC and BSC in LE (-) and LE (+) was confirmed. Several 9- to 19-MHz ultrasound beams are sufficient for BSC analysis to discriminate LE (-) and LE (+) in terms of the penetration depth of the ultrasound.

Various methods to generate the lining for a full-thickness nasal reconstruction have been reported. We used bilateral septal mucoperichondrial flaps, the distal portion of an expanded median forehead flap, and a nonlaminated vascularized free temporal fascia flap as a lining during total nasal reconstruction of a total full-thickness nasal defect in a 45-year-old woman with a nasal squamous cell carcinoma. In the first step of the two-stage surgery, a tissue expander was inserted into the forehead simultaneously with tumor resection. In the second step, the expanded median forehead flap, cartilage graft, bilateral septal mucoperichondrial flaps, and short pedicle vascularized free temporal fascia transfer were performed. Total nasal reconstruction could be completed without any skin graft or skin paddle of the free flap. Epithelialization of the mucosa on the transferred vascularized free temporal fascia without contracture deformity of the nasal cavity was confirmed by endoscopic examination after 8 years of follow-up. In the surgical procedure described, the facial skin, including the lining of the nostril rim, and the mucous membrane of the nasal cavity were reconstructed using facial skin and mucous membrane without long-term contracture, respectively.

Hochu-ekki-to (HET) is a traditional Japanese herbal (Kampo) medicine for the treatment of severe weakness, loss of appetite, and indigestion in elderly patients and for the prevention of opportunistic infections. The impact of HET on patients with chronic wounds refractory to conventional therapies was investigated in a prospective, randomized trial, including 18 patients divided into medication (7.5 g oral HET per day, n = 9) and control (n = 9) groups. Wound healing during the 12-week study period was scored based on depth, exudate, size, inflammation/infection, granulation tissue, necrotic tissue, and pocket size. At 12 weeks, wound healing progressed in all nine patients in the medication group, whereas wound healing progressed in only three patients in the control group (significant difference, p < 0.01; relative risk: 3.00). In the medication group, the total score decreased significantly at 8 weeks and later. To the best of our knowledge, this study was the first to show that HET promoted the healing of chronic wounds resistant to conventional treatments. HET may be a choice as an adjunctive therapy for chronic wounds, particularly for patients with malnutrition. This trial was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000031620).

BACKGROUND: In breast reconstruction, a superdrainage procedure using the superficial inferior epigastric vein has been described. The purpose of this study was to investigate whether the utility of cephalic vein (CV) was equivalent to that of serratus anterior muscle branch of the thoracodorsal vein (SA) and lateral thoracic vein (LTV) for recipient vein. METHODS: Eighty-eight patients were enrolled in this study. The superdrainage was not performed if the internal mammary vein diameter was greater than, or equal to, that of the deep inferior epigastric vein diameter. In superdrainage cases, the SA or LTV was used as the recipient vein firstly, and the CV was used when both of them were unsuitable. RESULTS: The superdrainage was performed in 45 (51.1%) patients. No significant differences were observed between with and without superdrainage. In superdrainage group, the CV was used in 7 (15.5%) patients. In two groups (CV vs. LTV and SA), because we added to perform superdrainage to the CV at the time of re-exploration and tried to use the SA or the LTV firstly, the re-exploration rate (28.6 vs. 0%) and operating time (652.1 vs. 591.1 min) of CV group were significantly high (p = .023 and .028). No complications were observed, due to CV harvesting. Other characteristics showed no significant differences. CONCLUSIONS: At the point of superdrainage, the CV was equivalent to the SA and LTV. Using of the CV would only be essential in rare cases; nonetheless, the possibility of its use should be considered.

BACKGROUND: Adipose-derived stem cells and ceiling culture-derived preadipocytes can be harvested from subcutaneous adipose tissue. Little is known about the epigenetic differences, which may contribute to differences in osteogenic potential, between these cell types. The purpose of this study was to address the osteogenic potential and underlying epigenetic status of adipose-derived stem cells and ceiling culture-derived preadipocytes. METHODS: Adipose-derived stem cells and ceiling culture-derived preadipocytes were cultured from abdominal subcutaneous fat tissues of four metabolically healthy, lean female patients. After 7 weeks of culture, cellular responses to osteogenic differentiation media were examined. To evaluate the osteogenic potentials of undifferentiated adipose-derived stem cells and ceiling culture-derived preadipocytes, two types of epigenetic assessment were performed using next-generation sequencing: DNA methylation assays with the Human Methylation 450K BeadChip, and chromatin immunoprecipitation assays for trimethylation of histone H3 at lysine 4. RESULTS: Human ceiling culture-derived preadipocytes showed greater osteogenic differentiation ability than did adipose-derived stem cells. In an epigenetic survey of the promoters of four osteogenic regulator genes (RUNX2, SP7, ATF4, and BGLAP), the authors found a general trend toward decreased CpG methylation and increased trimethylation of histone H3 at lysine 4 levels in ceiling culture-derived preadipocytes as compared to adipose-derived stem cells, indicating that these genes were more likely to be highly expressed in ceiling culture-derived preadipocytes. CONCLUSIONS: The surveyed epigenetic differences between adipose-derived stem cells and ceiling culture-derived preadipocytes were consistent with the observed differences in osteogenic potential. These results enhance the authors' understanding of these cells and will facilitate their further application in regenerative medicine.