Skin grafting is a common operative method widely used in the field of plastic, reconstructive, and aesthetic surgery. However, we offer five suggestions to reduce complications and surgical invasiveness. Our tips are as follows. (1) Skin grafts should be harvested on the basis of a swimsuit with high-cut leg openings. (2) A drum dermatome is still useful when a split-thickness skin graft is needed after a full-thickness graft has been harvested. (3) A flower holder is useful for making drainage holes. (4) A tie-over dressing using external wire-frame fixation is recommended. (5) Povidone-iodine gel is recommended with a tie-over dressing. These procedures have been found to be extremely helpful for ensuring the success of skin-grafting procedures.

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Background: Left ventricular (LV) diastolic function has received much attention recently. However, few studies have evaluated LV diastolic function in the perioperative period. The aim of this study was to elucidate perioperative changes in diastolic function using tissue Doppler imaging (TDI) in patients undergoing repair of an infrarenal abdominal aortic aneurysm (AAA).
Methods: Eight patients undergoing repair of an infrarenal AAA were studied prospectively using transesophageal echocardiography. Doppler echocardiographic examinations were performed before the surgical procedure (T1), immediately before aortic unclamping (T2), 30 minutes after aortic unclamping (T3), and at the end of surgery (T4).
Results: Pulmonary edema developed in two patients on postoperative day 1. These two patients had the lowest early diastolic mitral annular velocity (Ea) of the study group at the end of surgery. The ratio of the peak velocity of early mitral inflow (E) to the peak velocity of atrial inflow was significantly decreased at T3 and T4. The systolic ejection velocity was significantly decreased at T3, but returned to the baseline value at T4. The Ea was significantly decreased at T3 and T4. The E/Ea ratio showed a progressive rise and was significantly increased at T3 and T4.
Conclusions: In patients undergoing repair of an infrarenal AAA, the Ea derived using TDI decreases at T3 and is still reduced at T4. The E/Ea ratio, which is used to estimate LV filling pressures, is significantly increased at T3 and T4. Further research is required to confirm the development of diastolic dysfunction and determine its possible association with increased postoperative morbidity and mortality.

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Background: The Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire, which consists of a core questionnaire (the General Measure of FACT [FACT-G]) and a 9-item Additional Concerns comprised of a 7-item Lung Cancer Subscale (LCS), was developed in an English-speaking culture. The validation of the Japanese FACT-G was reported previously, and this report describes the cross-cultural validation of the LCS.
Methods: The Japanese version of the LCS was developed through an iterative forward-backward translation sequence used throughout the FACT Multilingual Translation Project. In evaluating psychometric performance, its construct validity was investigated with Cronbach's alpha coefficient and factor analysis. Clinical validities of a known-groups comparison and longitudinal validity were also investigated.
Results: The FACT-L was administered twice to 180 patients with lung cancer within 2 weeks. The Japanese LCS had borderline values for Cronbachs alpha coefficients (0.62-0.67). Factor analysis indicated that the LCS had the three dimensions of respiratory symptoms, appetite plus body weight, and clear thinking. For clinical validity, a known-groups comparison showed that the LCS could differentiate patients according to truth disclosure, as Japanese doctors sometimes do not fully inform terminally ill patients. However, responsiveness was not proved when performance status was used as an anchor, probably owing to the short interval between the administration of the two measures.
Conclusion: The Japanese version of the LCS asked questions about multiple symptoms of patients with lung cancer, as did the original English LCS. The longitudinal clinical validity of the Japanese version should be investigated in future clinical trials.

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The effectiveness of the clinical pathway for laparoscopic cholecystectomy was evaluated, and the efficiency of medical care was analyzed. The duration of hospitalization and the number of National Health Insurance (NHI) points for medical service fees were compared between 86 patients treated after introduction of the clinical pathway (pathway group) and 56 patients treated before introduction of the clinical pathway (pre-pathway group). In the pathway group, variance from the pathway occurred in 24 patients (27.9%) due to postponement of discharge in 7 patients, to earlier discharge in 5 patients, and to insertion of a bile duct catheter in 5 patients. Total and postoperative hospitalization times were significantly shorter in the pathway group than in the pre-pathway group (8.0 ± 1.6 vs 13.7 ± 9.0 days, p<0.0001, 5.4 ± 1.1 vs 6.5 ± 2.2 days, p<0.0001, respectively). In the pathway group, the total number of NHI points was lower and the number of points per day was higher. By simulation, the total number of NHI points for the 5-day pathway (discharge on postoperative day 3 or earlier) was significantly lower than that for the current 7-day pathway. Moreover, the weekly profit per bed with the 3-day pathway (discharge on postoperative day 1) was more than twice that with the current pathway. The results suggest that the clinical pathway for laparoscopic cholecystectomy is beneficial for patients and useful for the introduction of diagnosis procedure combination in our hospital.

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We examined vaginal deliveries of twins to identify factors most strongly associated with the increased risk of postpartum hemorrhage (estimated blood loss ≥ 1,000 mL). We reviewed the obstetric records of all 171 twin vaginal deliveries at Japanese Red Cross Katsushika Maternity Hospital from January 2002 through August 2006. Of these deliveries, 41 (24%) were complicated by postopartum hemorrhage. Postpartum hemorrhage was significantly more likely in cases with gestational age ≥ 39 weeks (odds ratio [OR], 3.47; 95% confidence interval [CI], 1.65-7.28), a combined birth weight of more than 5,500 g (OR, 2.53; 95% CI, 1.00-6.45), induction of labor (OR, 2.87; 95% CI, 1.38-5.98), oxytocin administration during labor (OR, 2.86; 95% CI, 1.27-6.48), or a duration of labor ≥ 24 hours (OR, 2.55; 95% CI, 1.15-5.62). Postpartum hemorrhage is a frequent complication in twin pregnancies. Therefore, special attention should be given after birth to patients with induction of labor or intervened delivery especially at ≥ 39 weeks gestation.

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A 55-year-old woman underwent a low anterior resection for rectal cancer 7 years earlier at a different hospital. Thereafter, she often had such symptoms as abdominal pain, frequent bowel movements, and constipation. We considered postoperative bowel adhesion to be the cause of these symptoms, and a laparoscopic adhesiotomy was therefore performed twice. However, the symptoms did not substantially improve thereafter. A colonoscope of conventional diameter could barely pass through the anastomotic site of the operation, but we initially judged the anastomotic stricture to not be severe. However, we finally determined the anastomotic stricture to be the cause of these symptoms; X-ray examinations frequently showed the blockage of feces or the collection of gas images in the colon when the symptoms occurred. We therefore performed endoscopic balloon dilation (EBD) after performing electroincision of the scar tissue of the anastomotic ring. We dilated the area of the lesion to a diameter of 20 mm using the EBD technique, and thereafter the patient finally showed an improvement in quality of life. There have been some reports describing the usefulness of EBD for the treatment of colorectal anastomotic stricture. Past studies have reported the indications of EBD to include stricture, which is defined as a narrowed anastomosis through which a 12-mm-diameter colonoscope cannot be passed. Nevertheless, it seemed that when the clinical manifestations of anastomotic stricture are clear, such as those observed in our case, we should not too strictly adhere to this definition.

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Immunosuppressive therapy and stem cell transplantation from an HLA-identical donor are the major effective treatments for severe aplastic anemia. However, treatments still need to be developed for patients who do not have a HLA-identical donor and have not shown a clinical response to immunosuppressive therapy. We herein report on 2 patients in whom this problem could be overcome by transplantation of HLA-mismatched umbilical cord blood from unrelated donors. Two Japanese patients with severe aplastic anemia underwent conditioning with fludarabine, cyclophosphamide, and low-dose total-body irradiation and then received transplants of umbilical cord blood. Engraftment of the three lineages occurred without problems. We conclude that umbilical cord blood transplantation with a reduced-intensity conditioning regimen of fludarabine, cyclophosphamide, and total-body irradiation for patients with aplastic anemia is a practical treatment and may be an attractive alternative for patients who does not have an HLA-identical donor and have shown no clinical response to immunosuppressive therapy.

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Here, we report the case of patient with multiple gastric carcinoids showing histopathological behavior similar to that of type I carcinoid tumors of the stomach. The patient was a 61-year-old man diagnosed as having a gastric tumor, which was revealed by follow-up computed tomography. Upper gastrointestinal endoscopy revealed a protruded tumor in the greater curvature and a small polyp in the anterior wall of the upper stomach. A biopsy revealed gastric carcinoid. Because he refused to be operated for gastric carcinoid, upper gastrointestinal endoscopy was performed 5 months later. A malignant transformation of the gastric carcinoid was strongly suspected. Therefore, the patient was admitted for operation. Laboratory findings were normal. With the diagnosis of type III gastric carcinoid, total gastrectomy was performed. Microscopic examination revealed that the carcinoid tumor was confined to the submucosa and that the small polyp mentioned earlier was also a carcinoid. Microcarcinoids and numerous enterochromaffin-like cell hyperplasias were observed along the muscularis propria of the fundus. The tumor differed from typical type I gastric carcinoids in several ways. Immunohistochemical staining for chromogranin A, synaptophysin, and cytokeratin was positive. However, p53 was absent, and the MIB-1 index was low. Two years after surgery, the patient is alive without recurrence.

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Preeclampsia has been classified into two types on the basis of the T helper (Th)1/Th2 balance: Th1-predominant type and Th2 predominant type. In this study, we examined the Th1/Th2 ratio in peripheral Th cells in 11 patients with preeclamptic twin pregnancies, 11 normal (nonpreeclamptic) twin pregnancies, 11 preeclamptic singleton pregnancies, and 11 normal singleton pregnancies. The average Th1/Th2 ratio in the patients with preeclamptic twin pregnancy was 8.3 ± 3.4 (mean ± SD), which was similar to those in patients with normal singleton and twin pregnancies and significant lower than that in patients with preeclamptic singleton pregnancies (p = 0.003). The present results suggest that the mechanisms of preeclampsia differ between singleton and twin pregnancies.

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