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Year : 2019  |  Volume : 37  |  Issue : 4  |  Page : 239-240

Successful surgical treatment for squamous cell carcinoma on the finger of a hemodialysis patient using narrow tourniquet application


Department of Dermatology, Shiga University of Medical Science, Otsu, Shiga, Japan

Date of Web Publication17-Dec-2019

Correspondence Address:
Dr. Noriki Fujimoto
Department of Dermatology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga 520-2192
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ds.ds_9_19

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How to cite this article:
Kabuto M, Tanaka T, Fujimoto N. Successful surgical treatment for squamous cell carcinoma on the finger of a hemodialysis patient using narrow tourniquet application. Dermatol Sin 2019;37:239-40

How to cite this URL:
Kabuto M, Tanaka T, Fujimoto N. Successful surgical treatment for squamous cell carcinoma on the finger of a hemodialysis patient using narrow tourniquet application. Dermatol Sin [serial online] 2019 [cited 2020 Oct 28];37:239-40. Available from: https://www.dermsinica.org/text.asp?2019/37/4/239/273104



Dear Editor,

An 80-year-old Japanese male was referred to our hospital due to the intractable erosion. Physical findings demonstrated an erosive erythema on the entire circumference of his right proximal forefinger [Figure 1]a. The affected finger was swollen. He had a prior history of diabetes mellitus and chronic renal failure and had been on hemodialysis for 5 years. Histopathological findings of cutaneous biopsy specimens from erythema on the forefinger revealed atypical squamous cells in the whole layer of epidermis without invasion into dermis. An X-ray on the hand showed no abnormality such as calcification, invasion, or metastasis of the bone. Total body computed tomography scan showed no abnormality. From these findings, we diagnosed him with squamous cell carcinoma (SCC) in situ. Therefore, we ceased cilostazol and sarpogrelate and performed a wide excision of the lesion with a margin of 5 mm from the erythema under general anesthesia and reconstructed with split 0.014-inch-thick skin grafting. During surgery, we applied pressure using the Esmarch's method[1] for avascularization on the forefinger root with soft catheter and on 15-40 mm distance from the anastomotic part of the shunt with PROSHARE® tourniquet, size 25 mm wide [Figure 1]b (AS ONE Co., Ltd., Osaka, Japan). This was the nearest site not to press the shunt. We removed the tourniquet in every 30 min. These strategies led to the success of the surgery with 70 ml blood loss during the operation in 128 min. Histopathological findings of the resected specimen showed SCC in situ [Figure 1]c. The postoperative progress was favorable after 5 months [Figure 1]d.
Figure 1: (a) Initial clinical presentation. An erosive erythema presented on the entire circumference of his right proximal swollen forefinger. (b) PROSHARE® tourniquet, size 25 mm wide (AS ONE Co., Ltd., Osaka, Japan). (c) Histopathological examination of the resected specimen from the erythema on the forefinger revealed atypical squamous cells in the whole layer of epidermis without invasion into dermis (H and E, ×100). (d) Clinical presentation 5 months after surgery. No recurrence was observed. (e) Marking with preoperative Doppler echo for detecting the anastomotic part of the shunt and the running directions of the blood vessels

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The number of patients requiring hemodialysis in Japan is increasing year after year up to more than 32 million in 2014,[2] and the number of operative cases to hemodialysis patients is assumed to increase accordingly. Although many cases of invasive surgery on the extremities, including the finger, are performed using tourniquet to reduce bleeding, the application of pressure for a long time by tourniquet may cause malfunction of the shunt when the affected lesion exists on the side of the arteriovenous shunt. Whereas one paper reported that tourniquet should not be used for upper extremities with the arteriovenous shunt to not cause shunt malfunction,[3] another paper reported that the application of tourniquet led to the success of the surgery without complications.[4] There have been few previous reports of the surgical therapeutic method of the extremities on the side of the arteriovenous shunt for hemodialysis patients using tourniquet application. From these backgrounds, similar cases conventionally tend to be performed without using tourniquet in Japan, which cause a lot of blood loss or difficulty of providing a visual field of operation. Applying pressure using tourniquet on the area distal to the shunt will not cause shunt failure or malfunction.

There were two problems of the surgery in this case. The first problem was the possibility of failure in the engraftment because of edema. The second problem was the bleeding during operation due to the arteriovenous shunt or collateral circulation under a situation that general tourniquet is not available because of the risk of shunt malfunction, while the possibility of massive bleeding would be relatively low because of diabetes mellitus and age. Regarding the first problem, we intended to restructure using mesh graft because his affected finger had already been with contracture. Concerning the second problem, we grasped the running directions of the blood vessels by marking with Doppler echo before the surgery [Figure 1]e.

In our case, we considered a sufficiently better method before performing surgery. Tourniquet could be safely used when it was put on distance from the anastomotic part of the shunt. The pneumatic tourniquet, which is one of the applications for avascularization, is easy to regulate pressure. However, it cannot be used on the forearm with the arteriovenous shunt because manchette may cause shunt malfunction because of its width. Therefore, we used a narrower tourniquet. However, it is unclear whether the narrow tourniquet can be applied for longer duration than usual tourniquet. Moreover, preoperative Doppler echo is a noninvasive examination and is very useful for detecting the anastomotic part of the shunt and understanding the running directions of blood vessels. Our method brought about the favorable outcome of this surgery.

This is the first case report of the surgical therapy of SCC on the finger on the side of the arteriovenous shunt in a hemodialysis patient treated successfully using a narrow tourniquet application. Although further accumulation of cases is needed, our method may make similar cases treatable by surgical treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
  References Top

1.
Bunnell S. An essential in reconstructive surgery-;atraumatic' technique. Cal State J Med 1921;19:204-7.  Back to cited text no. 1
    
2.
Hori D, Yamaguchi A, Adachi H. Coronary artery bypass surgery in end-stage renal disease patients. Ann Vasc Dis 2017;10:79-87.  Back to cited text no. 2
    
3.
Bradish CF. Carpal tunnel syndrome in patients on haemodialysis. J Bone Joint Surg Br 1985;67:130-2.  Back to cited text no. 3
    
4.
Kenzora JE. Dialysis carpal tunnel syndrome. Orthopedics 1978;1:195-203.  Back to cited text no. 4
    


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