Language：English   Publishing type：Research paper (scientific journal)  

Leakage from gastrointestinal flap anastomoses remains a significant challenge in reconstructive esophageal surgery, occurring in 10%-25% of cases, leading to prolonged hospital stays and high mortality rates. We explored a novel preventive approach, where the flap anastomosis is wrapped with a pectoralis major muscle (PMM) flap. We describe 3 patients (men aged 70-78 y) with esophageal cancer who underwent esophageal reconstruction with a jejunal flap followed by prophylactic PMM flap coverage. In case 1, the jejunal flap was supercharged and underwent esophagojejunal anastomosis. The esophagojejunal anastomosis was covered with the PMM flap. In case 2, pharyngojejunal and jejunogastric anastomoses were performed, and the latter was wrapped with a PMM flap. In case 3, the patient initially underwent a retrosternal gastric pull-up, which failed due to complications. During salvage surgery, a free jejunal flap was used, and the pharyngojejunal and jejunogastric anastomoses were both prophylactically covered with a PMM flap. Anastomotic leakage was not observed on postoperative endoscopy. PMM flap coverage may reduce anastomotic leakage by providing well-vascularized muscle tissue that promotes wound healing and by protecting the anastomosis from gravitational traction forces and mechanical stress. Although preliminary, our results suggest that prophylactic use of PMM flaps may prevent complications after esophageal reconstruction, particularly in patients requiring high-risk esophageal reconstruction.

DOI： 10.1097/GOX.0000000000007152

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Machine-learning technology is currently being introduced into the medical field and has been shown to aid diagnostic imaging, patient examinations, patient-data analysis, various surgical aspects, and medical education. Recent advances in exoscopes and monitors are prompting a shift from optical microscope-based microsurgery to heads-up microsurgery. The high-definition exoscope images are highly suitable for machine learning. Since an algorithm that detects predictive signs of thrombus formation would aid microsurgery and help train surgeons to identify vessels at risk of unsafe microvascular anastomosis, we here asked whether we could use exoscope images to train such a machine-learning algorithm. METHODS: Arterial clots, intimal-wall damage, debris, and stumps in 9150 ORBEYE™ exoscope images of arterial anastomosis obtained in 2023-2024 were annotated with RectLabel pro™. These images were used to train the You Only Look Once (YOLO) model (Ultralytics) to detect the thrombus-predicting signs. The YOLO code was executed within Google Colaboratory™. RESULTS: After algorithm training for 100 epochs, the four objects were detected in real time, albeit with high levels of false-positive and false-negative detections. CONCLUSION: Our study shows the potential of machine learning on exoscope images to generate algorithms that promote safe microsurgical anastomosis. It also shows how the recent emergence of Python code, Google Colaboratory™, and machine-learning models such as YOLO has made it possible for even programming amateurs to develop effective machine-learning algorithms. Further development of new central and graphics processing units and computational processing methods will likely lead to machine-learning applications that improve surgery and facilitate medical training.

DOI： 10.1016/j.jpra.2025.06.008

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Language：English   Publishing type：Research paper (scientific journal)  

This case report presents a novel approach for vulvovaginal reconstruction using a modified pedicled anterolateral thigh (ALT) flap. The patient was a 62-year-old woman with a history of vulvar squamous cell carcinoma and radiation therapy, after which the cancer recurred. Total vulvectomy was performed with preservation of the urethra and vaginal introitus. The resulting defect was reconstructed using a boomerang-shaped ALT flap measuring 16 × 7 cm. The flap was harvested via intramuscular dissection and transposed into the vulvar defect through a subcutaneous tunnel. The excess skin was de-epithelialized and used to fill the defect around the urethra. Six months postoperatively, the patient had recovered successfully with satisfactory cosmetic and functional results. The advantages of the ALT flap include its versatility, long vascular pedicle, and the ability to harvest it from a nonirradiated area. The modified technique used a boomerang-shaped design and careful placement of the perforators. This technique eliminates the disadvantages associated with fenestrated and split ALT flaps, provides well-vascularized tissue, restores function, minimizes donor-site morbidity, and achieves a natural-looking aesthetic result. The modified pedicled ALT flap is a safe and effective method for vulvovaginal reconstruction, particularly in patients with a history of radiation therapy or large, complex vulvar defects.

DOI： 10.1097/GOX.0000000000006581

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Open-window thoracostomy is an effective treatment for refractory postpneumonectomy empyema. However, it can leave large thoracic dead space, and bronchopleural fistulas (BPF) are a common major complication. These problems can be treated with myocutaneous flap transfer or negative-pressure wound therapy (NPWT). However, treatment is often difficult and prolonged. Here, we report 2 cases of free anterolateral thigh flap transfer followed immediately by NPWT combined with Penrose drains. Both patients, including 1 with BPF, had favorable postoperative courses and were discharged 28 and 14 days after reconstruction. Dead space infection and BPF recurrence were not observed after discharge. Following free flap transfer with NPWT combined with Penrose drains may efficiently eliminate dead space and accelerate wound healing in a large three-dimensional space.

DOI： 10.1097/GOX.0000000000006383

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: The superior gluteal artery (SGA) perforator (SGAP) flap is used more rarely for breast reconstruction with autologous tissue than other flaps because the SGA is often narrow, and the SGAP can be short. However, it provides ample fat, including in lean women. To improve its safety and utility, the preoperative SGA course in women who underwent autologous breast reconstruction was determined with three-dimensional computed tomography angiography. METHODS: Consecutive deep inferior epigastric perforator, profunda artery perforator, and SGAP flap cases in 2019-2023 were identified. Frequencies of the following favorable preoperative SGA-anatomy variables were determined: branching of the main-SGA trunk on top/posterior of the greater sciatic foramen (designated M1/2), which allows access to a sufficiently wide SGA artery; superolateral perforating location of the superficial-SGA branch (SP3), which means the perforator is sufficiently long for uncomplicated flap placement; and nonbranching of the deep-SGA branch (D1/D2), which means this branch can used a venous and an arterial graft to extend an insufficiently long perforator. RESULTS: A total of 100 cases of deep inferior epigastric perforator (n = 80), profunda artery perforator (n = 13), and SGAP flap-based breast reconstructions (n = 7) were identified. Out of 200 buttocks, 89%, 91.5%, and 62% had the favorable M1/2, SP3, and D1/D2 variables, respectively. An atypical descending branch feeding the lower buttocks (DES1/2) was observed in 34%. CONCLUSIONS: The branching position of the main-SGA trunk, perforating location of the SGAP, and the shape of the deep branch were classified in detail in 100 patients. By creating a surgical plan that understands the anatomy taking preoperative three-dimensional computed tomography angiography, the SGAP flap can accommodate many patterns, increasing the possibility of safe execution.

DOI： 10.1097/GOX.0000000000006188

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Language：Japanese   Publisher：日本医科大学医学会  

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Language：Japanese   Publisher：日本医科大学医学会  

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Language：Japanese   Publisher：(一社)日本マイクロサージャリー学会  

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Language：Japanese   Publisher：日本医科大学医学会  

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Language：Japanese   Publisher：日本外科系連合学会  

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