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In lateral ray polydactyly, the reconstructed toe often tends to become thicker, but no standard evaluation criteria for this thickness are available. 57 patients (68 toes) with Hirai-Togashi classification type II, III, or IV whom we were able to follow-up for more than 6 months after the operation were underwent measurement of the "Reconstructed toe width to Third toe width ratio." In addition, 16 patients who could be followed up for 3 years through the mid-term course were evaluated for mid-term progress. At 6 months after surgery, the mean R/T ratio was 1.246. In patients who could be followed up for 3 years after surgery, the mean R/T ratios at 6 months after surgery and at 3 years were significantly decreased. This result suggests that the thickness of the reconstructed toe may become relatively thin in the long term.

Summary Purpose Central polydactyly of the foot is rare, with few reports on surgical methods and treatment indications. In this study, based on the experience of central polydactyly in our department, we will consider morphological classification and describe our treatment plan. Method In this retrospective study, 11 patients (11 digits) with central polydactyly were identified among 136 patients of polydactyly of the foot (2009–2018). They were classified according to morphologic characteristics: type I, the duplicated digits are independent of each other; type II, digits of the same size are duplicated; and type III, digits of different sizes are duplicated. Results In morphologic classification, there were 4 cases of type II and 7 cases of type III, but there was no case of type I. For type II, surgery was performed using the Bilhaut-Cloquet (BC) procedure in 2 patients, bone-removing flap (flap) method in 1 patient, and simple ablation in 1 patient. For type III, surgery was performed using the BC procedure in 1 patient, flap method in 3 patients, simple ablation in 2 patients, and ligation in 1 patient with floating type. Conclusion In order to obtain good cosmetic results in digits of morphologic classifications type II and III, it is necessary to select the surgical approach with careful consideration of every feature.

Background An open abdomen with frozen adherent bowels is classified as grade 4 in Björck’s open abdomen classification, and skin grafting after wound granulation is a typical closure option. We achieved delayed primary fascia closure for a patient who developed open abdomen with enteroatmospheric fistulas due to severe adherent small bowel obstruction. We present here the details of his management. Case presentation A 52-year-old man suffered acute abdominal pain during a flight and received an emergency laparotomy due to adhesive small bowel obstruction. Repeated laparotomies were required, and later open abdomen and proximal site jejunostomy were selected. After negative pressure wound therapy, he was transferred to our institution. Two enteroatmospheric fistulas emerged on the exposed intestine, and we diagnosed the condition as a Björck grade 4 open abdomen. After 8 months of wound care and parenteral nutrition, we decided to attempt primary wound closure because the patient required permanent oral restriction and total parenteral nutrition due to short bowel syndrome. A circular incision along the circumference of the exposed bowel allowed us to take a safe approach into the abdominal cavity. We removed the intestinal adhesions completely and resected the bowels, including the fistulas and anastomosed parts. Finally, the abdominal wall defect was reconstructed using the component separation technique, and the patient was discharged without an ostomy. Conclusions Primary fascia closure for grade 4 open abdomen is hard, but leaving a long interval before radical surgery and applying pertinent wound management may help solve this adverse situation.

Summary One of the most severe complications of auricular reconstruction for microtia is exposure of the cartilage framework. Recently, negative pressure wound therapy (NPWT) has become popular for a variety of complex wounds but reports on methods for microtia reconstruction are scarce. Thus, we aimed to detail the use of NPWT for cartilage exposure in microtia reconstruction. We retrospectively analyzed 7 cartilage exposure wounds in 6 patients treated by NPWT after auricular reconstruction for microtia. All wounds appeared from postoperative days 3 to 30 with 3 on the antihelix, 2 on the helix, 1 on the triangular fossa and 1 on the scaphoid fossa. Skin defect sizes ranged from 1 to 24 mm2 and 2 cartilage frames were infected at onset. Our NPWT system was the KCI Negative Pressure Wound Therapy with V.A.C.Ⓡ GranuFoam Black™ or Silver™ and continuous suction was applied in a range of 25–125 mmHg. All wounds healed within 8 to 39 days with NPWT antecedent cases taking longer than surgery ones. All cartilage frames survived but partial cartilage atrophies remained in 4 cases. Although a secondary infection occurred in an NPWT antecedent case it was still useful as a continuous external drainage system to remove dead space exudate and stimulate granulated tissue formation. In addition to vigilance against secondary infection, surgeons should consider an additional surgical intervention if the wound fails to improve within 7 days.

Since the majority of a tendon’s dry weight is collagen fibers, tendon healing consists mainly of collagen repair and observing three-dimensional networks of collagen fibers with scanning electron microscopy (SEM) is optimal for investigating this process. In this report, a cell-maceration/SEM method was used to investigate extrasynovial tendon (unwrapped tendon in synovial tissue such as the tendon sheath) healing of an injured Achilles tendon in a rat model. In addition, since mechanical stimulation is important for tendon healing, a novel, tensionless, rat lower leg tendon injury model was established and verified by visualizing the structural change of collagen fibers under tensionless conditions by SEM. This new model was created by transplanting the leg of a rat with a tendon laceration to the back, removing mechanical stimulation. We then compared the process of tendon healing with and without tension using SEM. Under tension, collagen at the tendon stump shows axial alignment and repair that subsequently demarcates the paratenon (connective tissue on the surface of an extrasynovial tendon) border. In contrast, under tensionless conditions, the collagen remains randomly arranged. Our findings demonstrate that mechanical stimulation contributes to axial arrangement and reinforces the importance of tendon tension in wound healing.

Background: Reconstructed breast with silicone breast implants (SBIs) after nipple-sparing mastectomy (NSM) provides high patient satisfaction from a cosmetic point of view, but low patient satisfaction with respect to hypoesthesia of the reconstructed breast, and reinnervation is required. Currently, few reports are available on reinnervation in breast reconstruction with implants, and detailed data on desensitization of reconstructed breasts are lacking. Therefore, we examined perceptual data after NSM with respect to reinnervation. Methods: In our department, after NSM, tissue expander or SBI was used to perform 1-stage or 2-stage breast reconstruction, and touch, warm and cold, and pain sensations in 31 cases more than 1 year after completion of reconstruction were examined. Results: All tests of sensations tended to be better in the medial region than in the lateral region, but no correlation with postoperative years was found. In the comparison of the incision lines, in the Semmes-Weinstein monofilament test (SW test), a significant difference was observed between the inframammary fold (IMF) incision and the para-areola incision in the breast D region, between the lateral incision and the para-areola incision, and between the IMF incision and the para-areola incision in the areola b region. In addition, linear regression analysis of postoperative years did not establish a predictive formula for the SW test or pain sensation in any of the 9 regions. Conclusions: The difference in the excision range was considered to be the largest factor affecting hypoesthesia. We also speculated that preservation of the internal mammary artery perforators during mastectomy led to preservation of the anterior cutaneous branch of the intercostal nerves, and therefore, the perception of the medial region was better than that of the lateral region. In the case of NSM in which the anterior cutaneous branch was preserved, the recovery of outer perception including that of the nipple-areolar complex (NAC) was poor, so it was considered that nerve reconstruction between the lateral cutaneous branch and the NAC was effective for reinnervation.

Accessory columellas are rare congenital anomalies characterized by skin appendage in the columella of the nostril. Case reports are scattered, but there are few descriptions about the clinical features and surgical course.In this study, 3 patients with 4 lesions were identified (2013-2020). They were morphologically classified, and the accompanying nose deformity, surgical procedure, and postoperative course were examined.According to the morphologic classification, 1 lesion was of the sessile-lobed type, 2 lesions were of the sessile-nodular type, and 1 lesion was of the pedunculated-ovoid type. In terms of accompanying nose deformities, 1 lesion had a wide nasal columella, and 1 lesion had an enlarged left nostril due to a depression at the base of the lesion. Simple ablations were performed in 2 of the lesions, and plastic procedures were performed in the 2 lesions with an accompanying nose deformity.As in our cases, accessory columellas may have a variety of appearances and accompanying deformities. The surgical procedure must be considered according to the case. In addition, any changes due to growth must be observed and taken into consideration when they are reoperated.

Negative pressure wound therapy (NPWT) for treating burns has a variety of therapeutic applications. Here, we present a case of a 53-year-old woman with self-inflicted burn injuries in whom NPWT was applied for three different purposes. The injured sites were the anterior neck, bilateral arms from the wrists upwards to the chest, and back. The left arm was deeply injured, and the elbow joint cavity was opened during treatment. First, NPWT was used for bridge to skin grafting on the entire upper left limb. Second, NPWT was used as a bolster dressing for the autograft after skin grafting was performed on the left arm except the open part of the joint. Third, NPWT over flap was used on the subsequent flap surgical site to address prolonged exudate from the flap margin. The exudate resolved after about a week. Good results were obtained using NPWT during the perioperative period of free flap transplantation for extensive open elbow joint burns. The use of NPWT is an effective option in the treatment of burns.

Internal jugular vein thrombosis (IJVT) is a complication of neck dissection. After head and neck reconstruction, flap congestion due to IJVT may lead to flap necrosis, and early diagnosis and treatment should be considered. We experienced a case of disappearance of IJVT in which edoxaban was administered after free-flap reconstruction, and the entire flap survived. Edoxaban has few bleeding complications and was useful as a single drug approach for IJVT after head and neck reconstruction.

GNE myopathy is a rare disease, and there are no case reports of treatment for GNE myopathy with comorbid head and neck cancer. In the case presented here, we performed reconstruction using a free flap for patient with tongue cancer and comorbid GNE myopathy. Preservation of normal trunk and upper limb function via flap transplantation from a paralytic lower limb is a reasonable proposition. Several cases of harvesting flaps from polio infection-related paralytic limbs have been reported, and we observed similar findings to those reports in our case. With careful attention to the fibrosis of the connective tissue, harvesting flaps from paralytic limbs is a viable option and can be used safely.

BACKGROUND Oral modiolus reconstruction is important in unilateral oral commissure removal including the modiolus. However, the proper procedure is not yet established. We performed free-flap reconstruction for full-thickness oral defects involving the oral commissure combined with oral modiolus reconstruction using a fascial sling. PATIENTS AND METHODS From 2008 to 2018, six oral carcinoma patients, aged 65 to 86 years, underwent free-flap modiolus reconstruction after tumor resection. The resulting lip defects of 10% to 80% were labial (two patients), buccal (two patients), and mixed (two patients). RESULTS Five anterolateral thigh flaps including one perforator and one radial forearm flap were performed. The oral defects were covered with folded flaps (size, 11 × 6-18 × 7.5 cm2 ). The orbicularis oris stumps were connected to the masseter with a fascia lata or palmaris longus tendon (length, 15-20 cm), arranged in a Y-shape in four patients and a V-shape in two patients. All the flaps survived without complications. Almost all the patients achieved good oral static effects (lip deviation and drooping) and dynamic effects (mouth opening, oral commissure narrowing, and diet) in the 6 to 65 months' follow-up. CONCLUSION Free-flap reconstruction combined with oral modiolus reconstruction using a fascial sling achieves good oral static and dynamic effects for full-thickness oral reconstruction involving the oral commissure.

Extensive full-thickness defects of both the upper and the lower eyelids continue to be a challenge for reconstructive surgeons. Ectropion of the lower eyelid and an unnatural canthal shape are pitfalls to be avoided in total eyelid reconstruction. We here present a case in which an extensive full-thickness defect of the upper and lower eyelids after tumor resection was successfully reconstructed by means of periosteal flap canthoplasty from the infraorbital margin. A 73-year-old woman had in situ melanoma on her left eyelids. The lids were almost completely removed as a result of tumor resection. The conjunctival defect was covered with oral mucosa. And the tarsal layer was reconstructed with auricular cartilage. A periosteal flap pedicled at the origin of the lateral canthal tendon was harvested from the infraorbital margin. The flap was fixed with sutures on the cartilage graft for the lower eyelid. The cartilage graft for the upper eyelid was sutured laterally on the basal portion of the periosteal flap as the lateral canthus. The skin defect of the upper eyelid was covered with a bipedicled orbicularis oculi flap and skin graft. The lower eyelid was reconstructed with a combination of an angular artery transposition flap and a cheek rotation flap. Thirteen months after the surgery, the reconstructed eyelids had good function without ectropion. And the reconstructed canthus had a natural sharp shape. Total eyelid reconstruction using periosteal flap canthoplasty combined with auricular cartilage and oral mucosa grafts is useful for extensive full-thickness defects of the upper and lower eyelids. Level of evidence: Level V, therapeutic study.

Objectives In recent years, many studies have reported that the presurgical nasoalveolar molding method improves the nose morphology; however, the reason for its effectiveness after surgery has never been understood. We evaluated the effect of nasoalveolar molding by comparing it with a passive orthopedic method without a nasal stent and focusing on the nostril morphology after primary cheiloplasty using various measurement methods. We then analyzed the essential factors. Materials and methods The patients involved were 31 infants with unilateral complete cleft lip and palate treated with primary cheiloplasty at the University of Tsukuba Hospital from 2004 to 2011. Of the 31 infants, 16 received nasoalveolar molding treatment and 15 received passive orthopedic treatment as controls. Photographic facial measurements were performed for all patients immediately and 7 months after primary cheiloplasty. The esthetics of the nostrils were assessed according to the left-right nostril symmetry, as measured by the Hausdorff distance, area ratio, perimeter ratio, and aspect a/u (the aspect ratio of the affected side)/(the aspect ratio of the unaffected side) ratio. In addition, the inclination of the nasal ridge was assessed using anthropometric measurements (Grc-Grn∠midline and midline∠columellar axis). Results The area ratio, perimeter ratio, and Grc-Grn∠midline were significantly greater in the nasoalveolar molding group immediately after surgery (p = 0.00062, 0.016, and 0.048, respectively) than in the control group. However, the Hausdorff distance and aspect a/u ratio were more favorable (p = 0.0018 and 0.0039, respectively) in the nasoalveolar molding group after 7 months. Conclusions The results of our study suggested that using nasoalveolar molding as a presurgical orthopedic treatment could improve the shape of the nasal cartilage with surgeon's corrections.

In syndactyly, the donor site of the skin graft should have the characteristics of both the dorsal and the plantar or palmar skin because the skin defects after the dividing procedure are at the lateral sides of the digits. The plantar instep region has a color and texture border between the dorsal and plantar skin as a gradational boundary belt. We performed "gradation skin grafting" including the belt for syndactyly. We retrospectively analyzed 110 skin graft sites in 56 patients, aged ≤ 2 years, with syndactyly of the hand or foot. The follow-up durations were ≥ 6 months. The skin graft sites were divided into the gradation skin graft (G[+]) and the traditional skin graft (G[-]) groups. They were examined for matching of the skin graft with the circumferential skin, the causes of mismatching, the closing method of the donor site, and the complications. Regarding skin graft matching, the excellent rate of achievement was greater in the G(+) than in the G(-) group (P0.01). The causes of mismatching were misalignment of the gradational boundary belt in the G(+) group and postoperative pigmentation in the G(-) group. All the donor sites were closed directly without complications. The gradation skin graft for syndactyly was cosmetically superior to the traditional one from the submalleolar area. The design's hazard is that the gradational boundary belt of the skin graft should match the alignment with the gradational boundary belt around the skin defect of the digits.

Although various techniques exist for pulley reconstruction, none are useful for all patients. We performed flexor pulley reconstruction using a transverse carpal ligament which has the advantages of a useful gliding surface, sufficient width and thickness, anatomical similarity to the pulley, and adequate durability. Cosmetically, all the surgical scars are on the volar side while functionally, we can avoid invasion to both the flexion and extension sides.

In digital replantation, Kirschner wire (K-wire) fixation has commonly been used for osteosynthesis. On the other hand, K-wires are often obtrusive because of protrusion from the replanted digit. We describe a case series treated using hydroxyapatite/poly-L-lactide (HPLLA) threaded pins, which are not only bioabsorbable, but also osteoconductive, for osteosynthesis in crushed amputation or comminuted fracture, including distal phalanx amputation. Using an HPLLA threaded pin, 10 digital replantations were performed between July 2016 and April 2018. The precisely cut pin is manually pushed into the fracture site as an intramedullary nail. The pin is first pushed into the distal site, and then into the proximal site, after drilling with a K-wire of the same diameter as the pin. All amputations were crush type, and levels of amputations were Tamai zone I in three cases, zone II in two and zone III in five. Eight of the 10 digits survived. The two digits that did not survive showed venous insufficiency. Bone union of the eight digits was successfully obtained after 9-19 weeks (median 12 weeks). No adverse events occurred such as distortion of the pin, infection or foreign body reaction. The HPLLA threaded pin may be an adequate device to fix fractures in digital replantation.

Introduction In head and neck reconstruction, use of a free flap paired with end-to-side anastomosis to a preserved vein is generally performed. However, it is frequently difficult to select the recipient vein after a neck dissection in which there is only a ligated internal jugular vein/external jugular vein (IJV/EJV). Here, a new anastomosis technique using a ligated IJV/EJV stump is described. Patients and methods End-to-side anastomoses to ligated vein stump surgeries for free flap transfer in head and neck reconstruction were performed at the Department of Plastic and Reconstructive Surgery, University of Tsukuba, from 2009 to 2016. Results The subject pool comprised 6 patients. All patients received a free flap transfer after head and neck tumor excision. The free flaps used were 1 free radial forearm flap, 1 free tensor fascia lata muscle perforator flap, and 4 free rectus abdominis musculocutaneous flaps. The cervical vessels used were 3 IJVs and 3 EJVs. All veins of the free flaps could be anastomosed end-to-side to ligated vein stumps without vein grafting. All flaps survived completely without complications. Conclusions The end-to-side venous anastomosis to a ligated vein stump procedures were easy to perform and not dependent on the vessel diameters of the free flaps. No complications were observed in any patient owing to differences in vessel diameter, ease of anastomosis, and safety. Results suggest that this new technique is a simple and very useful option in head and neck reconstruction where the IJV/EJV cannot be preserved.

Objective Reconstruction plates are used to treat patients with a segmental mandibular defect after oral cancer surgery. Reconstruction plate failure analysis has rarely focused on occlusion, which conducts a mechanical force to the mandible and the plate. To determine the prognostic factors, we retrospectively evaluated patients who underwent reconstruction of a mandibular segmental defect with a reconstruction plate and assessed the number of residual paired teeth. Material and Methods From among 390 patients with oral cancer who visited University of Tsukuba Hospital (Tsukuba, Japan) between 2007 and 2017, we selected and analyzed the data of 37 patients who underwent segmental resection of the mandible and reconstruction with reconstruction plates. Prognostic factors evaluated were patient age, sex, TNM classification, plate manufacturer, treatment with radiotherapy or chemotherapy, whether the patient had diabetes or smoked, and whether the patient had a small number of residual paired teeth, plate length, and use of a fibular‐free flap. Among these 37 patients, eight reconstruction plates had intraoral or extraoral exposure and were removed in 5 years. Results Kaplan–Meier and log‐rank analyses revealed that the prognosis for the 5‐year plate exposure‐free rate was significantly poorer for patients with a small number of residual teeth than for patients with no teeth or those with a large number of residual teeth (.01). Univariate Cox regression analysis revealed that a small number of residual teeth was a significant prognostic factor in the loss of a reconstruction plate (hazard ratio: 5.63; 95% confidence interval [1.10, 25.85]; .04). Conclusions A small number of residual teeth after the segmental resection of oral cancer is significantly involved in reconstruction plate survival and may be important in predicting reconstruction plate prognosis.

Human serum amyloid A (SAA) is a precursor protein of AA amyloidosis. Although the full-length SAA is 104 amino acids long, the C-terminal-truncated SAA lacking mainly residues 77-104 is predominantly deposited in AA amyloidosis. Nevertheless, the amyloid fibril formation of such truncated forms of human SAA has never been investigated. In the present study, we examined the effect of C-terminal truncation on amyloid fibril formation of human SAA induced by heparan sulfate (HS). Circular dichroism (CD) measurements demonstrated that the C-terminal truncation induces a reduced α-helical structure of the SAA molecule. HS-induced increases in thioflavin T fluorescence for SAA (1-76) peptide and less significant increases for full-length SAA were observed. CD spectral changes of SAA (1-76) peptide but not full-length SAA were observed when incubated with HS, although the spectrum was not typical for a β-structure. Fourier transform infrared experiments clearly revealed that SAA (1-76) peptide forms a β-sheet structure. Transmission electron microscopy revealed that short fibrillar aggregates of SAA (1-76) peptides, which became longer with increasing peptide concentrations, were observed under conditions in which full-length SAA scarcely formed fibrillar aggregates. These results suggested that the C-terminal truncation of human SAA accelerates amyloid fibril formation.

Introducton In rural areas with few doctors, Penrose drains in minor surgeries for soft tissue trauma or small subcutaneous tumors are sometimes avoided, even though the drain would prevent hematoma, because of the limited availability of professional postsurgical care. The authors developed a simple fixation method for Penrose drains that can be used even in remote areas where a doctor is not present to remove the drain. A retrospective study was conducted to compare this new method of fixing Penrose drains with instances in which the Penrose drain was fixed to skin by conventional suturing. Methods The medical records of patients who underwent minor surgeries using Penrose drains were reviewed. The surgeries were performed from April 2012 to March 2015 in remote outpatient clinics in Ibaraki Prefecture, Japan. The cases were divided into two groups: those using the new method, in which the Penrose drains were sewn onto the wound dressings and could be automatically removed while changing the dressing, and those in which the Penrose drains were conventionally fixed to the skin and removed one or several days after surgery by another doctor at the outpatient clinic. The rates of drain-related complications and of automatic drain removal (ie removal without a doctor's assistance) between the two groups were compared. Results A total of 54 Penrose drains used for 48 lesions in 44 patients (25 men, 19 women) in the new-method group, and 36 Penrose drains for 25 lesions in 21 patients (12 men, 9 women) in the conventional-method (control) group were analyzed. All 54 Penrose drains in the new-method group were removed automatically, while none of the 36 drains in the control group were removed automatically. There were no drain-related complications, such as massive hematoma, retrograde infection, seroma, or drain breakage or straying, in any of the new-method or control cases. Conclusions This new Penrose-drain fixation method is safe and is particularly suitable for minor surgeries in rural areas where there are no resident doctors. The wide use of this method for appropriate minor surgeries in doctorless rural areas has the potential to reduce surgical complications and the time burden for both patients and surgeons.

The dry weight of tendon tissue is accounted for mainly by collagen fibers. Accordingly, the tendon-healing process primarily involves repair of collagen fibers. During the remodeling phase of tendon healing, newly proliferating collagen fibers are transformed into a mature repaired tendon. Despite the importance of this phenomenon, the details of fibrous rebuilding have not been reported previously. The aim of this study was to visualize the ultrastructural changes and to obtain a clear understanding of the reorganization of the collagen fibers in the tendon repair site, using rat Achilles tendons. We used scanning electron microscopy (SEM) with cell maceration as the main method of analysis. Pretreatment with cell maceration removed the cellular components successfully. This allowed precise visualization of each collagen fiber and the three-dimensional network of the fibers. This study was the first to apply the cell-maceration/SEM method to observe tendon tissue. Seven days after surgery, new collagen fibers grew extensively in the repair site in a random arrangement. Fourteen days after surgery, the collagen fibers began to form an axial arrangement. Near the tendon stump, this change progressed from the outer layer to the core region. On the other hand, in the middle of the repair site, it progressed from the core to the outer layer. Change in the axial arrangement of collagen fibers contributes to the connection between the repair site and the tendon stump and to the separation of the repair site from the paratenon.

We report six patients with adult congenital biliary dilatation treated by surgery. Of the six cases, five were female and the patients' age at diagnosis ranged from 19 to 51 years old. By Todani's classification for bile duct dilatation, three were categorized as Ia, one as Ib, and two as IVa. All six cases had anomalous arrangement of the pancreatobiliary duct. Resection of the cystic portion and hepaticojejunostomy (Roux-Y) were performed in all. After surgery, one patient classified as Ia and one as IVa had complications of cholangitis and intrahepatic stones. We removed the stones by the percutaneous transhepatic route with dilatation of the stenotic anastomosis, but cholangitis recurred in the IVa patient. Although surgical resection of the cystic portion and reconstruction of biliary tract is considered to be a standard treatment for adult congenital biliary dilatation, this IVa case had complications after surgical treatment. Thus short-term follow-up is necessary to prevent or diagnose stenotic anastomosis following the operation.

症例は60歳，男性．胃癌にて幽門側胃切除術，BillrothI法再建を行った．術後1カ月目に急性胆管炎，閉塞性黄疸が出現し，精査の結果，良性の総胆管の狭窄と診断し経皮経肝胆道ドレナージ（PTCD）を行い減黄をはかるとともに経皮経肝的バルン拡張術等試みるが成功せず，黄疸出現後2カ月目にexpandable metallic stent(EMS)を留置した．これにより症状は劇的に改善しEMS留置1カ月後に外瘻チューブも抜去し軽快退院した．しかし，EMS留置から2年9カ月後に閉塞性黄疸をきたし入院した．総胆管内に結石が充満しており，閉塞性黄疸に対しPTCDを行い胆管洗浄を行いつつ経皮経肝胆道内視鏡（PTCS）を行った．ステントに付着した結石を認めたため，生検鉗子等で結石を破砕しては洗浄吸引する操作を繰り返し一部ステントがほつれてきたところ把持鉗子にてwireを1本ずつ引き抜きEMSを抜去した．以後，総胆管の再狭窄は生じず外瘻チューブを抜去し軽快退院した．

Practical length standards are remotely measured using a tandem low coherence interferometer through an optical fiber network for communication of about 20 km length between Tsukuba City and Tsuchiura City in Japan. The reference low-coherence interferometer is installed at the National Institute of Advanced Industrial Science and Technology (AIST) and the measurement interferometer with a gauge block of 100 mm nominal length is installed at a calibration laboratory in Tsuchiura City. The optical fibers work as a common path for the tandem interferometric system. Interference fringes are generated when the optical path difference between the reference and measurement interferometers is equal, and thus the gauge block is measured within a standard uncertainty of 46 nm remotely.