Transumbilical laparoscopic surgery using GelPort through an umbilical zigzag skin incision

INTRODUCTION

We report herein a new method of transumbilical laparoscopic surgery using a GelPort through an umbilical zigzag skin incision. The method involves collaborating with plastic surgeons to ensure the procedure was minimally invasive.

MATERIALS AND SURGICAL TECHNIQUE

After marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a GelPort double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The Gelport was latched on the wound retractor ring, following the inflation of the pneumoperitoneum by CO (2). One or more additional ports were inserted as necessary. All operations were performed in the standard fashion. The specimen was easily extracted from the abdomen through the umbilical incision, and anastomosis was performed. Using the above method, we performed the following procedures: one total gastrectomy, one distal gastrectomy, three gastric local resections, five right hemicolectomies, two high anterior resections, three cholecystectomies, and seven transabdominal preperitoneal hernioplasties. All cases were accomplished without any complications using this method. The wounds of the umbilical region were almost "scarless" in all cases.

DISCUSSION

We developed an umbilical zigzag skin incision technique to perform abdominal laparoscopic operations using a GelPort, with a minimal number of skin incisions. We consider that our method reduces the technical difficulties associated with laparoscopic surgery and maintains cosmesis.

Identification of a novel mutation and prevalence study for fabry disease in Japanese dialysis patients

Fabry disease--a genetic disorder characterized by the accumulation of globotriaosylceramide in cell lysosomes resulting from an X-linked deficiency of α-galactosidase A activity--presents with multiorgan manifestations, including progressive renal disease. Recently, its prevalence has been reported to be higher in hemodialysis (HD) patients than in the general population. We, therefore, examined patients on maintenance dialysis living in the Nagasaki Prefecture, Japan, to clarify the prevalence of Fabry disease. We screened 933 patients on maintenance dialysis, who were residents of Nagasaki Prefecture in Japan, for α-galactosidase A activity using a dried blood spot on filter paper. Patients with low α-galactosidase A activity were clinically assessed; subsequently, genetic analysis of the α-Galactosidase A gene (MIM:30064) was performed in these patients. Of the 933 patients, 55 had low α-galactosidase A activity; of these, one male and two females had α-Galactosidase A mutations. The prevalence of Fabry disease was thus 0.32%, which was similar to that reported previously. However, one mutation was newly identified, while the E66Q mutation observed in two patients was as previously identified. These two patients with the E66Q mutation were excluded because of the possibility of polymorphism; the prevalence of Fabry disease in the HD population was finally calculated to be 0.11%. The prevalence of Fabry disease in patients on maintenance dialysis living in Nagasaki Prefecture was 0.32%. Dried blood spot screening was considered as a simple and effective method for screening patients on maintenance dialysis for Fabry disease.

Glutamatergic changes in the cerebral white matter associated with schizophrenic exacerbation

OBJECTIVE

Glutamatergic dysfunction in the brain has been implicated in the pathophysiology of schizophrenia. This study was aimed to examine several brain chemical mediators, including Glx (glutamate + glutamine), using (1)H magnetic resonance spectroscopy (MRS) in medicated patients with schizophrenia, with and without psychotic exacerbation.

METHOD

(1)H MRS was acquired in 24 patients with schizophrenia, with psychotic exacerbation; 22 patients without exacerbation; and 27 age- and sex-matched healthy volunteers. The levels of metabolites were measured in the left frontal and inferior parietal white matter and compared across the three groups.

RESULTS

The Glx level was significantly elevated in the left inferior parietal white matter in the patients with psychotic exacerbation in comparison with that in the healthy volunteers and the patients without exacerbation (P < 0.05). We also detected that there was a significant correlation between Positive and Negative Syndrome Scale-positive scale and Glx level in the left parietal white matter (r = 0.51, P < 0.001).

CONCLUSION

Higher than normal Glx levels indicate glutamatergic overactivity in the left inferior parietal white matter with schizophrenic exacerbation, a finding that is in accordance with the glutamatergic hypothesis in schizophrenia. The Glx level measured by (1)H MRS could be a biomarker for exacerbation in schizophrenia.

Transumbilical laparoscopic surgery using GelPort through an umbilical zigzag skin incision

INTRODUCTION

We report herein a new method of transumbilical laparoscopic surgery using a GelPort through an umbilical zigzag skin incision. The method involves collaborating with plastic surgeons to ensure the procedure was minimally invasive.

MATERIALS AND SURGICAL TECHNIQUE

After marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a GelPort double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The Gelport was latched on the wound retractor ring, following the inflation of the pneumoperitoneum by CO (2). One or more additional ports were inserted as necessary. All operations were performed in the standard fashion. The specimen was easily extracted from the abdomen through the umbilical incision, and anastomosis was performed. Using the above method, we performed the following procedures: one total gastrectomy, one distal gastrectomy, three gastric local resections, five right hemicolectomies, two high anterior resections, three cholecystectomies, and seven transabdominal preperitoneal hernioplasties. All cases were accomplished without any complications using this method. The wounds of the umbilical region were almost "scarless" in all cases.

DISCUSSION

We developed an umbilical zigzag skin incision technique to perform abdominal laparoscopic operations using a GelPort, with a minimal number of skin incisions. We consider that our method reduces the technical difficulties associated with laparoscopic surgery and maintains cosmesis.

Acute CO2-independent vasodilatation of penetrating and pre-capillary arterioles in mouse cerebral parenchyma upon hypoxia revealed by a thinned-skull window method

AIM

Investigating spatio-temporal relationship between regional metabolic changes and microvascular responses in hypoxic brain is critical for unravelling local O(2) -sensing mechanisms. However, no reliable method to examine the relationship has been available because of inherent disadvantages associated with use of a conventional cranial window preparation. We aimed to devise a method to solve the problem.

METHODS

Anaesthetized mice were equipped with either a conventional cranial window with craniotomy or a thinned-skull preparation. Mice were mechanically ventilated to avoid hypercapnia and exposed to systemic isobaric hypoxia for 30 min. Using two-photon laser scanning microscopy, nicotinamide adenine dinucleotide, reduced form (NADH) autofluorescence and diameter changes in penetrating and pre-capillary arterioles within the parenchyma were visualized to examine their temporal alterations.

RESULTS

With the conventional cranial window preparation, marked vertical displacement of the tissue occurred through oedema within 30 s after inducing hypoxia. With a thinned-skull preparation, however, such hypoxia-induced displacement was diminished, enabling us to examine acute spatio-temporal changes in diameters of penetrating and pre-capillary arterioles and NADH autofluorescence. Vasodilatation of these microvessels was evoked within 1 min after hypoxia, and sustained during the entire observation period despite the absence of hypercapnia. This event coincided with parenchymal NADH elevation, but the onset and peak dilatory responses of the penetrating arterioles preceded the local metabolic response of the parenchyma.

CONCLUSION

Observation of hypoxia-exposed brain by the thinned-skull preparation combined with two-photon intra-vital microscopy revealed rapid vasodilatory responses in penetrating arterioles preceding parenchymal NADH elevation, suggesting the presence of acute hypoxia-sensing mechanisms involving specific segments of cortical arterioles within the neurovascular unit.

High incidence of fatty liver and insulin resistance in long-term adult survivors of childhood SCT

Overweight/obesity among adult survivors of childhood SCT has been considered to be predictive of eventual development of metabolic abnormalities. Fatty liver is increasingly recognized as a major cause of liver-related morbidity and mortality in the general population. However, the real incidence of fatty liver in adult survivors of SCT has not been fully elucidated. We determined whether adult survivors are at risk for overweight/obesity, metabolic abnormalities and fatty liver and whether these risks are associated with cranial radiotherapy (CRT) before SCT. Among the 51 patients (30 males), only two male patients were overweight/obese at the last evaluation. On the other hand, 9 male (30%) and 15 female (71%) patients were underweight. Fatty liver was diagnosed in 11 male (37%) and 10 female (48%) patients during the follow-up period, although patients who had fatty liver did not tend to be overweight/obese. Significantly more patients who received CRT before SCT developed fatty liver with insulin resistance than those who did not (P<0.05). Even patients who are not overweight/obese may develop fatty liver and metabolic abnormalities. We recommend that healthcare professionals recognize these risks and give life-long attention to detecting, preventing and treating late complications after SCT.

Spectrocolorimetric evaluation of human articular cartilage

OBJECTIVE

The aim of this study was to investigate whether human articular cartilage can be quantitatively evaluated using a spectrocolorimeter.

MATERIALS AND METHODS

Human articular cartilage specimens were analyzed using a spectrocolorimeter after macroscopic evaluation using the Outerbridge classification. The cartilage characteristics were examined, the L*, a*, b* colorimetric system, the spectral reflectance distribution and the yellow/red spectral reflectance percentage (Y/R SRP). Moreover, the results of the spectrocolorimetric evaluation were compared with the histological score described by Mankin et al.

RESULTS

There were significant differences among the macroscopic four grades in the L*, a* and Y/R SRP values. The spectral reflectance distribution of grade 1 cartilage exhibited a gradual increase in the spectral reflectance ratio as the wavelength increased. The spectral reflectance curves of grades 2 to 4 cartilage had dips at a wavelength of around 580 nm. Across all the measured wavelengths, there were lower reflectance ratios with the progression of cartilage degeneration. Moreover, correlations were observed between the spectrocolorimetric values and Mankin score. A strong relationship existed between Mankin score and he Y/R SRP values.

CONCLUSIONS

The present study is the first to clearly demonstrate the relationship between spectrocolorimetric evaluation and the degeneration of human articular cartilage. The spectrocolorimeter may be a new quantitative evaluation tool for articular cartilage with clinical potential.

Prevalence and cardiovascular features of Japanese hemodialysis patients with Fabry disease

BACKGROUND

Fabry disease (FD) is a rare disease and one of the causes of progressive renal dysfunction. It results from an X-linked deficiency of alpha-galactosidase A activity. It has been reported that its prevalence is much higher in hemodialysis patients than in the general population. However, its prevalence in Japanese hemodialysis patients and cardiovascular manifestations remain unclear.

METHODS

We screened the alpha-galactosidase A activity of 1,024 Japanese hemodialysis patients using a dried blood spot test. Patients with a low alpha-galactosidase A activity were assessed clinically, and a genetic study of the alpha-galactosidase A gene was performed for these patients. Furthermore, patients with FD underwent detailed cardiovascular examination.

RESULTS

Forty-six patients had low alpha-galactosidase A activity, and 1 man and 2 women had alpha-galactosidase A mutations (0.29%). All of these patients had a previously identified mutation (E66Q). The result of detailed cardiovascular examination showed that 2 patients had significantly impaired coronary flow reserve, reduced myocardial contraction and relaxation tissue Doppler velocities, and left ventricular hypertrophy.

CONCLUSIONS

Measurement of the alpha-galactosidase A activity and the results of a genetic analysis indicated that the prevalence of FD in our hemodialysis patients was 0.29% (0.16% in men and 0.5% in women). Furthermore, comprehensive examination detected cardiovascular abnormalities in Japanese hemodialysis patients with FD.

Isolation of tissue progenitor cells from duct-ligated salivary glands of swine

Tissue stem cells participate in the repopulation of tissue after injury. Tissue injury stimulates the normally quiescent tissue stem cells to differentiate and proliferate, in the process of replacing and/or repairing the damaged cells, and hence effecting tissue regeneration. The salivary glands retain the ability for frequent regeneration. Previously, we isolated progenitor cells from the injured salivary glands of mice and rats that differentiated into hepatic and pancreatic lineages. The isolated progenitors were CD49f-positive and intracellular laminin-positive, and proliferated on type I collagen while maintaining their multipotency. In this study, we analyzed the tissue stem cells induced by ligating the main excretory duct of the salivary gland in swine. After duct ligation of the gland, acinar cells receded due to apoptosis, and epithelial cells subsequently proliferated. We cultured cells obtained from the duct-ligated salivary gland and purified the cells by limited dilution. The isolated cells were positive for CD29, CD49f, intracellular laminin, AFP, CK19, CK18, and Thy-1(CD90), and weakly positive for c-Kit (CD117). After three-dimensional formation, the cells expressed insulin and albumin. We designated the cells as swine salivary gland-derived progenitor cells. Gene expression of insulin and albumin was significantly increased (five-fold) and that of insulin was also increased (3.8-fold) with differentiation medium with nicotinamide and/or GLP-1 treatment in spherical culture. The expressions of albumin and insulin were 1/10-fold and 1/4-fold compared to porcine hepatocytes and pancreatic endocrine cells. The differentiated SGP cells could release insulin, which were stimulated by glucose and potassium. These results indicate that swine SGP cells could differentiate into hepatocytes and beta-cells, functionally. Swine SGP cells were useful tools for therapy and analyzing endodermal regenerative models in large animals.

Arrhythmia induced by spatiotemporal overexpression of calreticulin in the heart

Calreticulin (CRT) is a Ca(2+)-binding protein of the endoplasmic reticulum essential for cardiac development. For further investigation of the functional mechanism of calreticulin, we generated transgenic mice with spatiotemporal overexpression of calreticulin using a cre-loxP system. To elucidate the role of the protein in cardiogenesis, we adopted Nkx2.5-cre mice for heart specific overexpression. The overexpression of calreticulin was associated with arrhythmia, chamber dilation and sudden death, as observed in 6- to 10-week-old mice. Furthermore, transgenic mice displayed marked edema at 7-weeks of age. RT-PCR analysis revealed that the expression of hyperpolerization-activated cyclic nucleotide-gated channel1 (HCN1), an essential component for cardiac pace maker activity, had receded in the heart of transgenic mice. In addition, the protein level of connexin40 (Cx40), connexin43 (Cx43), components of gap junction, and myocyte-enhancer factor (MEF) 2C, a cardiac-specific transcriptional factor, were reduced in the transgenic mice hearts. These findings suggest that calreticulin affects cardiac arrhythmia with disruption of cardiac signaling, such as the HCN family members, and with low levels of Cx40 and Cx43. Overepression of calreticulin also leads to a decreased protein level of MEF2C and this may cause changes in cardiac structure. Our findings support calreticulin being critical for normal heart function and structure. These mice are a useful model for the study of endoplasmic reticulum proteins, such as calreticulin, in various tissues.

Isolation, Tissue Localization, and Cellular Characterization of Progenitors Derived from Adult Human Salivary Glands

Progenitors that can transdifferentiate into cells with hepatic or pancreatic phenotypes can be isolated from experimentally injured salivary glands of rodents. In this study, we isolated progenitors from "uninjured" adult human salivary glands by fluorescence-activated cell sorting using anti-CD49f and anti-Thy-1 antibodies. The sorted cells that were contained in the CD49f+/Thy-1+ fraction showed good proliferation on type I collagen. Single purified progenitor cells in plate culture expressed intracellular laminin, CD49f, Thy-1, and NGF receptor p75 (p75(NGFR)). Immunohistological analysis revealed the expression of Thy-1 and p75(NGFR) in stromal cells in the periductal area of the salivary gland. Under overconfluent conditions in plate culture, cell clusters containing insulin and glucagon-positive cells were occasionally formed. In order to produce differentiated cell clusters with uniform quality, we used a spherical culture system. Autonomous differentiation of cells in clusters into insulin-positive cells was induced in the spherical culture system. We measured C-peptide to estimate the endogenously produced insulin content. The C-peptide content of the spheroid bodies was low (3.5 ng/mg of protein), and they simultaneously expressed the early islet differentiation factor Nkx6.1, proendocrine gene neurogenin3, and ductal cell marker cytokeratin19. The progenitors existing in the interstitium of the salivary gland were able to transdifferentiate into cells with a pancreatic endocrine phenotype.