平山 貴浩

Polycythemia vera is a myeloproliferative neoplasm that can cause opposite complications: thrombosis and bleeding. Since arterial or venous thrombosis is often fatal, prevention of thrombogenesis is the main treatment measure for polycythemia vera, both in daily life and perioperatively. However, reports of bleeding are less frequent than reports of thrombosis. Herein, we report a case of polycythemia vera in which significant postoperative bleeding was a perioperative complication. A 72-year-old woman with polycythemia vera had a subcutaneous hematoma after bruising her left lower leg, and was admitted to another hospital. As skin necrosis gradually appeared, the patient was transferred to our hospital. Following debridement and wound bed preparation, we applied a split-thickness skin graft using the right inguinal region as the donor site. After surgery, significant bleeding was observed at the donor and recipient sites, and this persisted until the next morning, which required transfusion of four units of blood. Hemostasis was difficult but finally achieved with strong and firm pressure. The skin graft survived, and the troublesome wound healed. Regarding the perioperative complications of polycythemia vera, not only thrombosis, but also bleeding should be considered. Strict control of patients' hematocrit and platelet count with phlebotomy and/or hydroxyurea as cytoreduction therapy is essential.

BACKGROUND: Many approaches have been reported to repair soft-tissue defects of the hand using dorsal metacarpal artery flaps. Use of a perforator-based propeller flap from the first intermetacarpal space to the dorsum of the hand has been described. The aim of this study was to confirm the functional anatomy of a first dorsal metacarpal artery (FDMA) perforator flap. METHODS: Twenty-nine fixed cadaveric hands were dissected to determine the origin, course, and branches of the FDMA. Clinically, five cases of soft tissue defects of the hand underwent reconstructive surgery using an FDMA perforator-based propeller flap. RESULTS: The FDMA was found in 27 specimens (93%). The ulnar branch of the FDMA always supplied the cutaneous perforator (mean ± SD, 4.3 ± 1.6), and the most distal cutaneous perforating branch was found along the metacarpal long axis within 25 mm of the tip of the metacarpal head with high frequency (28/29, 97%). In the two hands that had aplasia of the FDMA, well-developed perforators arose directly from the radial artery and advanced to the metacarpal head. Seven hands (24%) had perforators arising from the palmar arterial system, penetrating through or passing close by the second metacarpal bone. In clinical application, all the flaps survived completely without major complications. CONCLUSIONS: The FDMA perforator-based propeller flap is minimally invasive and technically simple. It is expected to be a new option for hand reconstruction.

2015年10月から2019年10月までの4年間に、当センターにて、手術を施行した先天性胸鎖関節部皮膚瘻孔10例を対象に、臨床所見、画像所見、手術所見、病理組織所見を検討した。男児1例、女児9例(平均年齢2歳0ヵ月)で、全例で胸鎖関節部に皮膚瘻孔(右側4例、左側5例、両側1例)を認めた。超音波検査は7例に施行され、うち4例で胸鎖関節近傍への連続性が疑われた。3例で皮下脂肪内に盲端を同定できた。瘻孔の長さは7～13.2mmで、嚢胞等の形成は認められなかった。手術は周囲皮膚とともに瘻孔を一塊に摘出した。全例で瘻孔の盲端が皮下脂肪内に確認され、胸鎖関節への明らかな連続は同定できなかった。2例で瘻孔が瘢痕組織と一塊になっていた。病理組織学的所見は、9例で扁平上皮に裏打ちされた管腔構造を認めた。うち1例では深部に線毛円柱上皮を認め、8例では、深部まで扁平上皮であった。残りの1例では上皮成分と異物型巨細胞の出現を伴う肉芽腫性炎の所見が認められた。術後の合併症は、全例で再発は認められなかった。

The local flap method is a minimally invasive, quick, and common technique of closing skin defects. Several methods using multiple local flaps are employed for the purpose of closing relatively large defects, and minimizing the resultant scar and deformity. We present a combined local flap method using a banner flap with an adjacent rotation flap (B-R flap) with the potential for closing circular defects. A retrospective analysis was performed in 15 patients treated with the B-R flap for circular skin defects over a 2-year period. The sizes of the flap and the healthy skin excision area were evaluated using image analysis software, and were compared to a model of a conventional rotation flap that would be necessary to close the same defect. All flaps were successfully engrafted. The B-R flap required a 39.1% smaller rotation flap and an 85.9% smaller area of healthy skin compared to the conventional rotation flap technique. There was one adverse event, partial epidermal necrosis that was conservatively treated and healed. The B-R flap is comparatively less invasive; it allows a smaller area of healthy skin to be excised. It can be a useful option for closing a circular defect.

脱細胞化組織を利用した、生体における細胞機能を発揮させるための細胞培養基質デバイスを開発した。はじめに、脱細胞を促進する簡易技術を開発し、生体組織系足場を効率よく作りだすための条件検討を行った。次に、脱細胞化組織のモジュール化を図った。脱細胞処理においては、0.1%SDSの使用で効率的な脱細胞が行えた。脱細胞化組織をリングクランプで挟み込み、細胞培養実験に供する実験用モジュールを構築し、レシピエント細胞の形態・機能の観察・計測のための実験を容易に実施することができるようにした。脱細胞化血管を足場とし、レシピエント細胞として血管内皮細胞、血管平滑筋細胞を用いた検討で、これらの細胞が生体内において示す形状(超紡錘形)に酷似する形状で培養でき、さらに細胞内カルシウム上昇に対する刺激感受性が亢進した。