Intraoperative Use of Indocyanine Green Fluorescence Angiography during Distally Based Radial Artery Perforator Flap for Squamous Cell Carcinoma of the Thumb

Summary: Distally based radial artery perforator flap (DBRAPF) is useful for hand defects; however, the location of the perforator varies among individuals. Preoperative evaluation has been a problematic issue when performing this flap. A 64-year-old man developed squamous cell carcinoma on an old burn scar at the dorsal thumb and was referred to our clinic for further treatment. After wide resection of the tumor, including the long and short extensors of the thumb, we reconstructed the defect with DBRAPF. At that time, near-infrared fluorescence angiography with indocyanine green (ICG) was used to identify the position of the perforator. After injecting ICG intravenously, we could observe its uptake at approximately 5 cm proximal to the styloid process. We designed a 10 × 6 cm island flap with that uptake as pivot point. During flap elevation, the perforator could be confirmed at the point of uptake; the flap was then transferred to the defect by rotating the pedicle at the identified point. The vascularity of the flap could also be checked intraoperatively through ICG angiography. The tip of the flap that showed weak ICG fluorescence indicated epidermal necrosis. Nevertheless, the entire flap was viable and enabled good functionality without tumor recurrence and metastasis after 5 years. Using ICG angiography, DBRAPF could be performed smoothly, easily, and safely

Massive Myoepithelial Carcinoma Originating from the Submandibular Gland That Was Successfully Treated with Surgical Excision, Using a Part of the Lengthened Skin as a Local Flap

Summary: Myoepithelial carcinoma is rare and mostly originates from the major salivary glands. Sometimes, it is difficult to differentiate the benign from the malignant histologically, and its clinical behavior and histological features may vary. Here, we describe the case of a 55-year-old woman who presented with a massive myoepithelial carcinoma, which hung like a temple bell from her right side of the jaw, and she refused to go to the hospital for 3 years. Based on its size and location, we initially thought that, before surgical resection, neoadjuvant therapy would be necessary to reduce the tumor volume. However, after careful evaluation of the tumor characteristics (low-grade histology with outward expansion and little invasion of the adjacent tissues) and imaging findings, we decided that excision was possible. The tumor was encapsulated and had a clear border; it weighed 10.5 kg. By setting the incision line posterior to the equatorial plane and using the lengthened skin posterior to the tumor as a large local flap for the skin defect, we successfully reconstructed the skin defect without harvesting additional flap from other areas. No additional treatment was administered because a sufficient surgical margin was maintained, pathologically. She regained her daily life without recurrence or distant metastasis for 2 years. When treating a massive tumor, careful consideration of its characteristics and location is important, and in this case, we were able to use a simpler and less invasive treatment than we initially envisioned

Observational study of the effects of dabigatran on gastrointestinal symptoms in patients with non-valvular atrial fibrillation

Background: Dyspepsia (including upper abdominal pain, abdominal pain, abdominal discomfort, epigastric discomfort, and dyspepsia) is a symptom that is carefully monitored during dabigatran treatment. However, detailed information on dyspepsia, including onset, duration, severity, and use of drug treatment, has not yet been established in Japanese patients. Methods: We conducted a multi-center, prospective, open-label, randomized, and parallel-group-comparison observational study of 309 patients with non-valvular atrial fibrillation who had been newly prescribed dabigatran at 19 institutes in Japan. Gastrointestinal adverse events were evaluated using the Global Overall Severity (GOS) scale self-reports to describe symptoms and to assess frequency and severity of symptoms (Part 1). Thereafter, patients with a GOS score ≥3 were randomized to receive a 4-week course of a proton pump inhibitor, an H2-receptor antagonist or a gastric mucosal protective drug (Part 2). Results: The incidence of dyspepsia symptoms due to dabigatran was 17.2% (53/309, 95% confidence interval 13.1–21.8%), with 77% of events occurring within 10 days of initiation. Five patients discontinued the study because of dyspepsia. At the end of the observation period, the mean GOS score of those reporting dyspepsia was 3.5±1.7, with 11.3% (35/309) reporting a score ≥3. Substantial differences in the incidence of dyspepsia were observed between the study institutes (0–41%). In the multivariate regression analysis, no significant factor was found to affect incidence or severity of dyspepsia. The majority (83–100%) reported that symptoms improved with treatment (GOS score ≤2), and there was no significant difference between the three different treatment groups. Conclusions: The reported symptoms of dyspepsia were generally mild, but were moderate in approximately 10% of patients. Proton pump inhibitors, H2-receptor antagonists, and rebamipide seemed to be equally effective in relieving dabigatran-related dyspepsia (umin-CTR UMIN000007579)