Mucosal Defect Research Articles

Reconstruction of oral cavity defects using myogenous-only scapular tip free-flaps.

BackgroundOral cavity reconstruction is very challenging anatomical subsite to reconstruct. Large defects often require free tissue reconstruction to provide the best chance of form and function. Additionally, free tissue reconstruction aids to prevent fistula formation. We aimed to determine outcomes of oral cavity defect reconstruction using scapular tip free flaps with a myogenous intraoral component.MethodsAll patients with a mandibular or maxillary bony defect that included a disruption of the intraoral mucosa component between 07/1/14 and 07/31/17. Patients were reconstructed with a scapular tip free flap, which included a muscular component that was used to recreate the oral mucosa. The primary study outcomes were flap success rates, development of orocutaneous or oronasal fistula, rate of resuming oral diet as well as the occurrence of medical and surgical complications in the first month following surgery. The tested hypothesis was formulated before data collection began.ResultsTwenty‐five patients were identified by the study criteria. There was one (4%) flap that failed, while orocutaneous fistula occurred in two patients (8%). Prior history of osteoradionecrosis was a statistically significant predictor of overall complication (p < .05).ConclusionsIntraoral myogenous reconstruction allows for re‐mucosalization of the oral cavity defect and is associated with high viability and low‐complication rates. In patients with amenable oral mucosal defects, a myogenous scapular tip free flap is a suitable reconstructive option.

Modified Technique of Pectoralis Major Myocutaneous Flap Inset for Buccal Mucosa Reconstruction.

BACKGROUNDConventional technique of flap inset in buccal mucosa reconstruction is by direct suturing of cutaneous margin of Pectoralis Major Myocutaneous (PMMC) flap to hard and soft palate mucosa and margin of floor of mouth with simple interrupted sutures. We have done a prospective study of the efficacy of anchoring the upper margin of PMMC flap to the hard palate by a modified method in reconstruction of buccal mucosa defects following tumour excision. This is to prevent disruption of suture line from the mucoperiosteum of hard palate and resultant oro-cutaneous fistula. METHODSThis hospital-based prospective study was carried out in the Department of Plastic Surgery at Bangalore, India for a period of 18 months (2015–2017). Patients (N=48) with buccal mucosa defects requiring reconstruction with PMMC flap either with conventional (n=24) or modified method (n=24) following tumour excision were included. Clinico-demographic profile of the patients including age, gender, size of defect, staging of illness, site and type of reconstruction, disruption of suture margin in the hard palate, development of oro-cutaneous fistula (OCF), day of starting oral feeds, removal of Ryle’s tube and post-operative average length of stay in the hospital were recorded. RESULTSDisruption of suture line in hard palate and Oro-cutaneous fistula were statistically significant in study group in both the variables (P-0.033, P-0.033). The median days on which patients were started with oral clear liquids and removal of Ryle’s tube were also statistically significant between study and control groups. Post-operative average length of hospital stay which is the outcome of favourable results in the study group was found to be statistically significant (P-0.021) between the groups. CONCLUSIONOverall, modified technique of anchorage of PMMC flap can be considered as a reliable technique in buccal mucosa reconstruction because of its stability, lower complication rates and shorter length of hospital stay.

Complete closure of a large mucosal defect (100 mm) after gastric endoscopic submucosal dissection, using the "accordion fold" method.

Complete closure of a large mucosal defect (100 mm) after gastric endoscopic submucosal dissection, using the "accordion fold" method.

Myofascial iliac crest flap for reconstruction of combined oral mucosa-mandibular defects: A single-centre experience

BackgroundDeep circumflex iliac artery (DCIA) myofascial iliac crest flap has been used for combined oral mucosa-mandibular defects reconstruction. The bone component of this composite flap can reconstruct the mandible with superior contour match, and the muscle fascia which used for repairing the oral mucosa defect will transform into an oral mucosa-like appearance. To explore its scope of clinical application and how the fascia transformed into oral mucosa will give surgeons flexibility to reconstruct the combined oral mucosa-mandibular defects. MethodsA retrospective review of 18 patients who received combined oral mucosa-mandibular defects reconstruction with DCIA myofascial iliac crest flaps from Dec 2016 to Dec 2020 was performed. The characteristics of the mandibular defects and the flaps were recorded. The postoperative dynamic changes of one graft's fascia were observed from serial photographs. ResultsAll myofascial iliac crest flaps survived successfully. The bone grafts were from 4.0 to 9.5 cm (mean 7.6 ± 1.5 cm) in length and from 2.0 to 3.5 cm (mean 2.7 ± 0.4 cm) in height. The sizes of fascia were from 13.5 to 48.0 cm2 (mean 27.2 ± 9.4 cm2). The grafted fascia firstly changed into a yellow pseudomembrane-like appearance, and then experienced muscle oedema before finally transformed into an oral mucosa-like appearance at about 60 days after operation. ConclusionMyofascial iliac crest flap is a good option for reconstruction of combined oral mucosa-mandibular defects because of its excellent bone and oral mucosa matches.

Endoscopic suturing for GI applications: initial results from a prospective multicenter European registry

OverStitch devices (OverStitch and OverStitch Sx; Apollo Endosurgery, Inc, Austin, Tex, USA) are used for a wide range of applications. A European registry was created to prospectively collect technical and clinical data regarding both systems to provide procedural outcomes and to find correlation between procedural characteristics and outcomes. This study shows the initial results of the first 3 years of the registry. Patients who underwent endoscopic suturing from January 2018 to January 2021 at 9 centers were enrolled. Data regarding the disease treated,suturing pattern and outcomes were registered. Technical feasibility (success reaching the target area), technical success (success placing sutures), and clinical success (complete resolution of the clinical issue) were recorded and analyzed. During the study period, 137 patients (57.7% men) were enrolled with 100% technical feasibility rate. Endoscopic suturing was successfully performed in 136 cases (16.7% with OverStitch Sx), obtaining a technical success rate of 99.3%. No adverse events were recorded. Overall clinical success was 89%. Mucosal defects were sutured in 32 patients (100% clinical success). Leaks/fistulas were treated in 23 patients (64.7% clinical success). The clinical success of stent fixations (n= 38) was 85%. Perforations (n= 22) were repaired with a clinical success of 94.7%. No significant correlation between location, suture pattern or number, and the success was found, except in case of fistulas where fistulas<1 cm treated by a continuous suture were more likely to achieve clinical success in the follow-up (P< .001). OverStitch-based suturing is technically feasible regardless of site and method of suturing, with no cases of failure. The overall technical success rate of 99.3% and the clinical outcome success rate of 89% demonstrate that OverStitch technology provides reliable suturing with clinical advantages, especially with fistulas<1 cm.

Reopenable clip over line method for the closure of full-thickness defect after gastric endoscopic full-thickness resection.

In recent years, the efficacy of endoscopic full-thickness resection for submucosal tumors has been reported [1] [2]. However, a reliable closure method for large full-thickness defects in the stomach remains unclarified. We developed the reopenable clip over line method for closing the mucosal defect after endoscopic submucosal dissection using reopenable clips and a line placed at the muscle layer and edge of the mucosal defect [3] [4] [5]. We report a new method of this type of closure of a 25-mm full-thickness defect in a porcine model ([Video 1]).

Acellular Dermal Matrix Prevents Esophageal Stricture After Full Circumferential Endoscopic Submucosal Dissection in a Porcine Model.

Esophageal stricture is a common complication after endoscopic submucosal dissection (ESD), especially in full circumferential ESD. This study investigated fully covered self-expanding metal stent (FCSEMS) placement with an acellular dermal matrix (ADM) for preventing post-ESD esophageal stricture. Twelve Bama minipigs were randomly divided into two groups, which underwent full circumferential ESD in the distal esophagus. In group A, an FCSEMS with ADM was placed at the mucosal defect, whereas group B underwent standard FCSEMS placement. The stent was removed during gastroscopy 2 weeks after the ESD procedure. At the fourth week, gastroscopy was repeated to evaluate local healing and stenosis. The animals were sacrificed, esophageal specimens were obtained for macroscopic and histological evaluation, and serum C-reactive protein (CRP) levels were quantified. Four weeks post ESD, dysphagia occurrence was lesser in group A than in group B. Group A demonstrated lesser esophageal stricture on macroscopic evaluation (21.02 ± 16.65% vs. 57.41 ± 8.48%, p = 0.001) in the form of enhanced re-epithelization (99.13 ± 0.98% vs. 96.63 ± 1.64%, p = 0.009), diminished submucosal fibrosis (1117.53 ± 188.83 um vs. 1834.69 ± 421.99 um, p = 0.003), and attenuated inflammatory infiltration (121.00 ± 30.66 vs. 188.17 ± 64.92, p = 0.045). The increase in the serum CRP level was lower in group A than in group B at 4 weeks post-ESD. FCSEMS combined with ADM can enhance re-epithelization in the process of wound healing and significantly reduce the degree of esophageal stenosis after circumferential ESD. This study provided important preclinical findings for subsequent clinical trials.

MP22-11 SUCCESSFUL TRANSURETHRAL ENGRAFTMENT OF BUCCAL MUCOSAL CELLS EXPANDED IN VITRO, TRANSPLANTED IN A POLYMER SCAFFOLD CARRIER IN A RABBIT URETHRAL STRICTURE MODEL, AND PROVEN WITH IMMUNOHISTOCHEMICAL BIOMARKERS

You have accessJournal of UrologyCME1 May 2022MP22-11 SUCCESSFUL TRANSURETHRAL ENGRAFTMENT OF BUCCAL MUCOSAL CELLS EXPANDED IN VITRO, TRANSPLANTED IN A POLYMER SCAFFOLD CARRIER IN A RABBIT URETHRAL STRICTURE MODEL, AND PROVEN WITH IMMUNOHISTOCHEMICAL BIOMARKERS Akio Horiguchi, Toshihiro Kushibiki, Kenichiro Ojima, Masayuki Shinchi, Yusuke Hirano, Yoshine Mayumi, Keiichi Ito, Kosuke Miyai, Ichiro Miura, Masayuki Takeda, Masaru Iwasaki, Shojiro Kato, Senthilkumar Rajappa, and Samuel J.K. Abraham Akio HoriguchiAkio Horiguchi More articles by this author , Toshihiro KushibikiToshihiro Kushibiki More articles by this author , Kenichiro OjimaKenichiro Ojima More articles by this author , Masayuki ShinchiMasayuki Shinchi More articles by this author , Yusuke HiranoYusuke Hirano More articles by this author , Yoshine MayumiYoshine Mayumi More articles by this author , Keiichi ItoKeiichi Ito More articles by this author , Kosuke MiyaiKosuke Miyai More articles by this author , Ichiro MiuraIchiro Miura More articles by this author , Masayuki TakedaMasayuki Takeda More articles by this author , Masaru IwasakiMasaru Iwasaki More articles by this author , Shojiro KatoShojiro Kato More articles by this author , Senthilkumar RajappaSenthilkumar Rajappa More articles by this author , and Samuel J.K. AbrahamSamuel J.K. Abraham More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002561.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Buccal mucosal (BM) cell therapies with different processing methods have been developed to treat male urethral stricture (US). Our earlier studies with six human subjects (DOI: 10.1111/iju.13852) and an animal model (DOI: 10.1016/j.reth.2021.05.004) confirmed the transurethral engraftment of autologous BM cells at urethral stricture sites when transplanted after encapsulation in a thermoreversible gelation polymer (TGP) scaffold. We report the reproducibility of the procedure in rabbit US models, proving engraftment with an immunohistochemical analysis. METHODS: The urethra of six male Japanese white rabbits were electro coagulated; US development was confirmed by endoscopy and urethrography 4 weeks later. The BM tissue was harvested, and its epithelial cells isolated and cultured for 7 days. After incising the US with a urethrotome, an 8 Fr-Nelaton catheter was placed in the urethra, and cultured epithelial cells suspended in TGP were injected into it. On the third day, the catheter was removed. On the seventh day after transplantation, the urethra was harvested and subjected to conventional hematoxylin and eosin (HE) staining and immunostaining with an anti-cytokeratin 14 (CK14) antibody (a marker for BM epithelial cells) and anti-GATA binding protein 3 (GATA3) antibody (a marker for urothelium). RESULTS: All animals developed US at the electrocoagulation site. HE staining showed that the urethral mucosal defect caused by the urethrotomy was covered with a multilayered squamous epithelium in all rabbits (Fig. 1A and D). The CK14 was positive on the lumen covered with a squamous epithelium (Fig. 1B and E). The GATA3 was negative in the region positive for CK14 while positively staining the remaining urothelium (Fig. 1C and F)). CONCLUSIONS: Autologous BM cells with highly suggestive cell engraftment at the urethrotomy site based on immunohistochemical biomarkers are worth considering for a larger clinical study in male US. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e375 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Akio Horiguchi More articles by this author Toshihiro Kushibiki More articles by this author Kenichiro Ojima More articles by this author Masayuki Shinchi More articles by this author Yusuke Hirano More articles by this author Yoshine Mayumi More articles by this author Keiichi Ito More articles by this author Kosuke Miyai More articles by this author Ichiro Miura More articles by this author Masayuki Takeda More articles by this author Masaru Iwasaki More articles by this author Shojiro Kato More articles by this author Senthilkumar Rajappa More articles by this author Samuel J.K. Abraham More articles by this author Expand All Advertisement PDF DownloadLoading ...

Crescent‐shaped skin paddle for a fibular flap: Avoiding skin grafting at the donor site

A fibular osteocutaneous flap is the mainstay of oromandibular reconstruction. This report aimed to present a crescent-shaped skin paddle, a novel fibular skin paddle designed to achieve both sufficient intraoral lining and primary closure of the donor site. A 3-5-cm-wide crescent-shaped skin paddle was harvested according to the locations of the distal septocutaneous perforators on preoperative color Doppler sonography. This narrow skin paddle fits well morphologically into the mucosal defect, enabling a reliable intraoral lining. This advantage becomes more evident when the mandibular defect crosses the midline or extends posteriorly to the maxillary tuberosity as the shape of the mucosal defect becomes arcuate. Primary closure of the donor site is easier to achieve because the required width of the crescent-shaped skin paddle is minimized. This method reduces donor-site morbidity associated with skin grafting while ensuring safe intraoral closure with a fibular osteocutaneous flap.

Clinical benefit of tunnel endoscopic submucosal dissection for esophageal squamous cancer: a multicenter, randomized controlled trial

Endoscopic submucosal dissection (ESD) is widely accepted as a primary treatment modality for dysplastic and early cancerous lesions of the GI tract. However, prolonged procedure time and life-threatening adverse events remain obstacles to the successful treatment of esophageal cancer. This study aimed to compare the efficacy and safety of tunnel ESD (T-ESD) with conventional ESD (C-ESD) for superficial esophageal squamous neoplasms. A prospective, multicenter trial was conducted at 5 hospitals in China. Patients with esophageal squamous neoplasms were enrolled and randomly assigned to undergo C-ESD or T-ESD. Randomization was stratified by tumor location and circumference extent (<1/2 or≥1/2). The primary endpoint was procedure time. Between January and July 2018, 160 patients were enrolled. One hundred fifty-two patients (76 in the C-ESD group and 76 in the T-ESD group) were included in the final analysis. The median procedure time was 47.3 minutes (interquartile range, 31.7-81.3) for C-ESD and 40.0 minutes (interquartile range, 30.0-60.0) for T-ESD (P= .095). However, T-ESD specifically reduced the median procedure time 34.5% (29.5 minutes) compared with C-ESD for lesions≥1/2 circumference (P< .001). Among the multiple secondary outcomes, muscular injury was less frequent in the T-ESD group compared with the C-ESD group (18.4% vs 38.2%, P= .007), but complete healing of artificial mucosal defect in 1-month follow-up was more common in the T-ESD group than the C-ESD group (95.9% vs 84.7%, P=.026). Our study suggests that T-ESD results in shorter procedure time, specifically for lesions≥1/2 circumference of the esophagus. In addition, T-ESD has a better safety profile indicated by less frequent muscular injury and improved healing of artificial mucosal defects caused by ESD procedures. (Clinical trial registration number: NCT03404921.).

Free Colon Tissue Transfer for the Management of Xerostomia in Head and Neck Cancer Patients: A Bacteriological Study and Clinical Case Series

<h2>Summary</h2><h3>Introduction</h3> Patients with head and neck cancer may suffer from xerostomia after repetitive surgery or radiation therapy. Free colon tissue transfer was used to restore the lubrication of the oral cavity, and a bacteriological study in mice was conducted to evaluate how the intestine transfer from the intra-abdominal to extra-abdominal locations may affect bacterial colonization. <h3>Patients and methods</h3> Twelve patients received free colon transfer for the reconstruction of their intraoral mucosal defect following trismus release. Thirty-five patients received ileocolon flap transfer to fill the pharyngeal defects. In an animal study with mice, a pedicled ileum segment was transferred to the subcutaneous space of the abdominal wall. The transferred ileum segments were biopsied for bacterial genome analysis after 3 months. <h3>Results</h3> All but one transferred flap survived. Colon secretion was suitable for oral lubrication without the unpleasant smell 1 month postoperatively. In an animal study, genome analysis showed that the same bacterial species still existed in the transferred intestinal tissue. <h3>Conclusions</h3> No unpleasant smell or infections were noted in this clinical series despite the animal study showing that the bacterial spectrum did not change in the transferred intestine. Therefore, free colon tissue transfer could safely provide lubrication in patients with xerostomia.

Comparison of the Efficacy of Amniotic Membrane Versus Buccal Fat Pad in Treatment of Oral Submucous Fibrosis.

Oral and maxillofacial surgery deals with wide range of oral defects, wound closure, tissue resection, and tissue reconstruction. The purpose of our study is to use amniotic membrane for closure of post surgery defect in patient of oral submucous fibrosis to utilize its growth factor and scaffold nature for effective healing and to evaluate effectiveness of amniotic membrane in treatment outcome. The objectives are to compare post-operative mouth opening, healing of amniotic membrane and buccal fat pad. Diagnosed patients with OSMF are divided into two surgical site Group I (n = 5patients)-Left side buccal mucosa in which resection of fibrous band with coronoidectomy followed by reconstruction of the mucosal defect with BFP. Group II-Right side buccal mucosa in which resection of fibrous band with coronoidectomy followed by reconstruction of the mucosal defect with freeze dried irradiated amniotic membrane. This study suggested that in comparison to buccal fat pad flap, the HAM graft is a better option for oral reconstruction in terms of infection, graft failure, MMO, inflammation, pain. Outcome indicated that the HAM is biologically ideal graft for oral wounds and could be used as clinical alternative for various repair surgery for oral defects. The amniotic membrane was found easy to handle and easy to use with inherent hemostatic property which is observed in all patients. No patients had shown any evidence of any complications. Good pain control observed in patients throughout postoperative period.

Endoscopic follow-up of mucosal defect after hot versus cold snare polypectomy in animal model.

Cold snare polypectomy (CSP) has received increasing attention in recent years, but few studies have assessed defect repair after polypectomy. Therefore, we compared the repair of mucosal defect after CSP and hot snare polypectomy (HSP) in a rabbit model. Resection of normal colonic mucosa using both HSP and CSP were performed in 40 male New Zealand white rabbits by an experienced endoscopist. Follow-up colonoscopy was performed after 7 and 15days by another endoscopist. We assessed mucosal defect repair, status of healing, scar formation, and intraoperative or delayed complications (including perforation and bleeding). Eight animals died of intraoperative or delayed perforation; follow-up colonoscopy was performed in 32 animals. On follow-up colonoscopy at 7days after operation, 78.1% cases in the CSP group showed healing of mucosal defect compared with none in the HSP group (P<0.001); mucosal repair score in the CSP group was significantly higher than HSP group (P<0.001). On follow-up colonoscopy at 15days, mucosal defect after CSP had completely healed in all cases (100%) versus 96.9% after HSP (P=0.313). Among these healed defects, scar formation was observed in 2 of 32 cases in the CSP group compared with 19 of 31 in the HSP group (P<0.001). Intraoperative perforation rate was significantly higher in the HSP group (15% vs 2.5%; P=0.048). Mucosal defect repair after CSP is quicker compared with HSP and is more likely to result in scarless healing. HSP is more likely to cause perforation in the thin colon walls.

Follow-up outcomes of mucosal defect closures after endoscopic resection using a helix tacking system and endoclips.

Background and AimsThe X-Tack endoscopic HeliX tacking system (Apollo Endosurgery, Austin, Tex, USA) has recently been approved by the Food and Drug Administration and is slowly gaining popularity for the closure of large tissue defects. Despite its increasing use, outcome data of using the X-Tack system for mucosal defect closure after endoscopic resection (ER) are limited. Here, we report the follow-up outcomes of a series of cases that underwent ER and mucosal closure aided by the HeliX tacking system.MethodsWe identified a total of 5 cases in which the X-Tack system and endoclips were used for mucosal defect closure after ER. The cases involved ER of large and/or flat polyps in the duodenum and colon. The patients were followed up at 4, 6, and 9 months after ER.ResultsIn all cases, X-Tacks with endoclips achieved complete closure of the large mucosal defects. None of the patients experienced any adverse events, such as abdominal pain or bleeding. At follow-up, the X-Tacks either fell off or were seen grouped or situated as a single piece (tack) in the mucosa where initially placed. None of the endoclips were found during the follow-up endoscopic examinations.ConclusionsThe X-Tack system together with endoclips facilitated complete closure of large mucosal defects, especially for lesions located in difficult locations. At follow-up, several retained X-Tacks were found either in groups or as a single piece. The X-Tacks seen in groups will likely fall off with repetitive pulling forces with food or feces. However, the single tacks that were secured in the wall may stay indefinitely. The novel HeliX tacking system seems to be a promising aid for the effective closure of large mucosal defects; however, further studies are needed to assess the long-term outcome of this novel system.

Prophylactic clip closure for mucosal defects is associated with reduced adverse events after colorectal endoscopic submucosal dissection: a propensity-score matching analysis

BackgroundIt is unclear whether prophylactic endoscopic closure after colorectal endoscopic submucosal dissection (ESD) reduces the risk of postoperative adverse events due to variability in lesion characteristics. Therefore, we conducted a retrospective study using propensity score matching to evaluate the efficacy of prophylactic clip closure in preventing postoperative adverse events after colorectal ESD.MethodsThis single-center retrospective cohort study included 219 colorectal neoplasms which were removed by ESD. The patients were allocated into the closure and non-closure groups, which were compared before and after propensity-score matching. Post-ESD adverse events including major and minor bleeding and delayed perforation were compared between the two groups.ResultsIn this present study, 97 and 122 lesions were allocated to the closure and non-closure groups, respectively, and propensity score matching created 61 matched pairs. The rate of adverse events was significantly lower in the closure group than in the non-closure group (8% vs. 28%, P = 0.008). Delayed perforation occurred in two patients in the non-closure group, whereas no patient in the closure group developed delayed perforation. In contrast, there were no significant differences in other postoperative events including the rate of abdominal pain; fever, white blood cell count, and C-reactive protein; and appetite loss between the two groups.ConclusionsPropensity score matching analysis demonstrated that prophylactic closure was associated with a significantly reduced rate of adverse events after colorectal ESD. When technically feasible, mucosal defect closure after colorectal ESD may result in a favorable postoperative course.

Esophageal tuberculosis induced dysphagia: a case report

BackgroundPatients can present for a wide variety of etiologies for dysphagia, and it is important to consider less common causes once common etiologies have been ruled out. Extrapulmonary Mycobacterium tuberculosis (TB) presentations are rare to see in the western populations due to relative lack of TB exposure and overall less immunocompromised populations, but should be considered for at-risk patients. Gastrointestinal (GI) TB is rare, and the GI tract is considered only the sixth most frequent site of extrapulmonary TB (EPTB).Case presentationThis is a case report of a 35-year-old Ethiopian male presenting with dysphagia and retrosternal odynophagia who was found to have infiltration of mediastinal lymphadenopathy into the esophageal wall secondary to TB. This patient underwent an upper endoscopy, which revealed a linear 2 cm full thickness mucosal defect in the middle esophagus concerning for an infiltrative process with full thickness tear. Computed tomography (CT) of the chest demonstrated a subcarinal soft tissue mass that was inseparable from the esophagus. He was referred to thoracic surgery and underwent an exploratory mediastinal dissection. A mediastinoscopy scope was inserted and the mediastinal dissection was made until the subcarinal nodes were identified and removed. Biopsy results showed necrotizing and non-necrotizing granulomas, and acid-fast bacilli (AFB) culture from the surgically removed lymph node showed Mycobacterium TB complex growth. He had no known TB exposures and did not have any TB risk factors. He then followed up in infectious disease clinic and was managed with anti-tuberculosis treatment (ATT) with complete resolution of symptoms.ConclusionsOur patient was ultimately found to have esophageal TB secondary to mediastinal invasion into the esophageal wall from lymphadenopathy associated with TB. This is an extremely rare presentation in western populations due to diminished exposure rates and overall less immunocompromised populations compared to impoverished countries with increased TB exposure and human immunodeficiency virus (HIV) infection rates. Although TB is not as commonly seen in western populations, it should be considered on the differential for any atypical presentations of GI diseases for patients with clinical or geographic risk factors.

Application of a strip design to monitor the viability of buried radial forearm free flap in East Asians: A case series study

ObjectivesThe objectives of this study were to evaluate the reliability of a strip design as a monitoring flap in buried flap and to investigate whether strip design of radial forearm free flap (RFFF) could affect donor site morbidity in East Asian. MethodsPatients with externalized flap in buried RFFF were consecutively included in this study. For cases with mucosal defect repair, a skin strip with a 1.5 cm width was proximally positioned to the primary flap along with the pedicle. Compared to a mucosal defect, a skin strip was distally positioned overlying the pedicle (near the wrist) when the flap was used for reinforcing the facial contour, reconstructing sacrificed facial nerve, or reanimating facial expression. The externalized flap formation was performed after completion of anastomoses of vessels. Monitoring results of flap failure using an externalized monitoring flap and additional morbidity of donor site were evaluated. ResultsNine patients were included in this study. Although there were two cases of pharyngeal fistula due to mucosal necrosis of resection margin, transferred RFFF was viable in all cases. The externalized flap provided reliable monitoring for the buried RFFF without a case of necrosis even in two cases with a partial detachment of septocutaneous branches between the radial artery and the designed skin strip. There was no false - positive case. Therefore, the sensitivity and positive predictive value of the externalized monitoring flap were 100%. All defects of radial forearm caused by skin strip harvest were also primarily closed without an additional skin graft. ConclusionA strip design for externalized monitoring flap in RFFF can facilitate an easier creation of externalized monitoring flap in cases with buried RFFF without additional morbidity at the donor site compared to a conventional techniques.

Seeking Relevant Biomarkers in Common Variable Immunodeficiency.

Common variable immunodeficiency (CVID) is the most common symptomatic form of primary immunodeficiency. More than 50% of patients in some series suffer from autoimmune or inflammatory complications (the “CVID+” phenotype), and these are not adequately addressed by current treatments. Despite major advancements in genetics, the pathogenesis of the CVID+ phenotype has remained unexplained for most patients, necessitating the need for relevant biomarkers in both the clinic and research settings. In the clinics, reduced isotype-switched memory B cells (≤ 0.55% of B cells) and reduced T cells (CD4) can be utilized to identify those with increased complication risks. Additionally, condition-specific markers have also been suggested for lymphoma (normal or elevated IgM) and progressive interstitial lung disease (increased BAFF, normal or elevated IgM). Additional biomarkers have provided insights into disease pathogenesis, demonstrating wider systemic inflammation (increased LBP, sCD14, and sCD25; expanded ILC3), mucosal defects (increased zonulin, I-FABP), and perhaps reduced anti-inflammatory capability (reduced HDL) in CVID. Most recently, efforts have revealed elevated circulating bioactive bacterial DNA levels – marking microbial translocation and potentially linking the causation of multiple inflammatory changes previously observed in CVID. The implementation of high throughput profiling techniques may accelerate the search of relevant biomarker profiles in CVID and lead to better clinical risk stratification, revealing disease insights, and identifying potential therapeutic targets.

A novel, simple, and dedicated device for endoscopic mucosal defect closure

ObjectivesEndoscopic submucosal dissection (ESD) has become popular, but complications such as postoperative bleeding remain an issue. Although some methods of closing a mucosal defect with a snare and clips have been reported to be effective and safe, the snare is not a dedicated device, and the procedure is difficult and time‐consuming. We aimed to find an alternative method for defect closure after ESD by developing a dedicated device.MethodsWe have improved five prototypes. The load on the stopper when starting to tighten and loosen a loop and the maximum load on the stopper and the movement distance of the thread when sliding the stopper were measured five times for each prototype. With the 5th prototype, we finalized the design and named it FLEXLOOP. Additionally, the material and shape of the outer tube were improved. Then, the usability of FLEXLOOP was evaluated in pigs. The operation time for closing mucosal defects with the snare or FLEXLOOP was measured five times.ResultsWe made FLEXLOOP, which had a lower load when sliding and a higher load when loosening than the snare. The improvement of the outer tube significantly reduced the load on the sheath when sliding it. We confirmed the feasibility of mucosal defect closure with FLEXLOOP in pigs. The median operation time was 563 s (range 340–679 s) with the snare and 355 s (range 303–455 s) with FLEXLOOP (p = 0.047).ConclusionsFLEXLOOP can be a promising option for defect closure after ESD.

A Rare Cause of Hemoperitoneum

A Rare Cause of Hemoperitoneum