Single-incision laparoscopic surgery for gallstone ileus: An alternative surgical procedure

INTRODUCTION

Gallstone ileus (GI) results from the passage of a stone through a cholecystoenteric fistula, subsequently causing a bowel obstruction. The ideal treatment procedure for GI remains controversial.

PRESENTATION OF CASE

A 63-year-old female was admitted to our hospital following persistent nausea and vomiting for 7 days. Computed tomography revealed a partially calcified 4-cm circular object in the jejunum, and the proximal intestine was dilated, with concomitant pneumobilia. Based on the preoperative diagnosis of GI, enterotomy with stone extraction by single-incision laparoscopic surgery (SILS) was performed. The patient's postoperative course was uneventful, and the cholecystoduodenal fistula closed spontaneously 4 months after the surgery.

DISCUSSION

Recent studies have reported that enterotomy with stone extraction alone is associated with better outcomes than with more invasive techniques. This case also suggests that enterotomy with stone extraction alone and careful postoperative follow-up is feasible for the management of GI. Although the use of laparoscopy in the management of GI has been described previously, laparoscopic surgery has not been widely performed, and SILS is not generally performed. When only this less demanding procedure is required, laparoscopic surgery, including SILS, can be a viable option.

CONCLUSION

SILS can be an alternative surgical procedure for the management of GI.

Angiosarcoma of the oral cavity: a clinicopathological study and a review of the literature

Soft tissue sarcomas are uncommon in the head and neck. Primary angiosarcomas of the oral cavity area are extremely rare, and have mostly been presented as case reports. This paper presents the clinical and histological features of three such cases. All patients were diagnosed based on the presence of rapidly extending masses involving the tongue, maxillary gingiva, or mandibular gingiva; bone destruction was present in two cases. The resected specimens revealed clustered large, pleomorphic, and spindle-shaped cells with a markedly haemorrhagic background. Tumour cells showed expression of vascular endothelial markers, such a CD31, CD34, and factor VIII-related antigen. Despite undergoing radical surgery, distant metastases developed in all three cases. We also studied the clinicopathological features of a series of oral angiosarcomas. This article therefore reports the clinicopathological features of the three new cases and provides a review of the cases of primary oral angiosarcoma reported during the past 20 years.

The orally available Btk inhibitor ibrutinib (PCI-32765) protects against osteoclast-mediated bone loss

Bone-resorbing osteoclasts play an essential role in normal bone homeostasis, as well as in various bone disorders such as osteoporosis and rheumatoid arthritis. Previously we showed that the Tec family of tyrosine kinases is essential for the differentiation of osteoclasts and the inhibition of Btk is a promising strategy for the prevention of the bone loss in osteoclast-associated bone disorders. Here we demonstrate that an orally available Btk inhibitor, ibrutinib (PCI-32765), suppresses osteoclastic bone resorption by inhibiting both osteoclast differentiation and function. Ibrutinib downregulated the expression of NFATc1, the key transcription factor for osteoclastogenesis, and disrupted the formation of the actin ring in mature osteoclasts. In addition, genome-wide screening revealed that Btk regulates the expression of the genes involved in osteoclast differentiation and function in both an NFATc1-dependent and -independent manner. Finally, we showed that ibrutinib administration ameliorated the bone loss that developed in a RANKL-induced osteoporosis mouse model. Thus, this study suggests ibrutinib to be a promising therapeutic agent for osteoclast-associated bone diseases.

Analysis of NFATc1-centered transcription factor regulatory networks in osteoclast formation

Osteoclasts are bone-resorbing cells that differentiate from the macrophage/monocyte lineage. The master transcription factor NFATc1 has a central role in the process of this differentiation. Thus, it is important to understand the NFATc1-centered transcription factor regulatory networks (TFRNs) in terms of the mechanisms of NFATc1 expression and activation as well as the gene expression regulated by NFATc1. The Genome Network Project has provided a unique opportunity for the analysis of NFATc1-centered TFRNs in osteoclasts. Here we introduce a report on the application of the methods established by the project for osteoclast biology and a summarization of the results obtained in this project thus far.

Acute decrease in the stiffness of resting muscle belly due to static stretching

The purpose of the study was to examine the acute effect of static stretching exercise on the resting stiffness of gastrocnemius muscle belly. Ten healthy young adults performed standing wall stretching in dorsiflexion for 1 min at a time and repeated five times. Before and after stretching, the shear modulus was measured in medial and lateral heads of the resting gastrocnemius muscle with ultrasound shear-wave elastography. After the stretching, dorsiflexion range of motion (ROM) of the ankle joint increased (P < 0.01) by 3.9° and returned in 20 min. Immediately after stretching, shear modulus decreased (P < 0.01) by 14%, compared with before stretching across muscle heads. The decrease in shear modulus returned in 20 min after stretching. In the comparison group of 10 additional subjects, the standing intervention without stretching had no influence on these measures. There was a negative correlation between dorsiflexion ROM and shear modulus in either head before and after stretching. The results demonstrate the transient decreases in the stiffness of the resting gastrocnemius muscle belly and indicate that joint flexibility is greater in individuals with lower resting stiffness of the muscle belly.

Class IA phosphatidylinositol 3-kinase regulates osteoclastic bone resorption through protein kinase B-mediated vesicle transport

Class IA phosphatidylinositol 3-kinases (PI3Ks) are activated by growth factor receptors and regulate a wide range of cellular processes. In osteoclasts, they are activated downstream of α(v) β(3) integrin and colony-stimulating factor-1 receptor (c-Fms), which are involved in the regulation of bone-resorbing activity. The physiological relevance of the in vitro studies using PI3K inhibitors has been of limited value, because they inhibit all classes of PI3K. Here, we show that the osteoclast-specific deletion of the p85 genes encoding the regulatory subunit of the class IA PI3K results in an osteopetrotic phenotype caused by a defect in the bone-resorbing activity of osteoclasts. Class IA PI3K is required for the ruffled border formation and vesicular transport, but not for the formation of the sealing zone. p85α/β doubly deficient osteoclasts had a defect in macrophage colony-stimulating factor (M-CSF)-induced protein kinase B (Akt) activation and the introduction of constitutively active Akt recovered the bone-resorbing activity. Thus, the class IA PI3K-Akt pathway regulates the cellular machinery crucial for osteoclastic bone resorption, and may provide a molecular basis for therapeutic strategies against bone diseases.

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.

Liver tissue engineering based on aggregate assembly: efficient formation of endothelialized rat hepatocyte aggregates and their immobilization with biodegradable fibres

To realize long-term in vitro culture of hepatocytes at a high density while maintaining a high hepatic function for aggregate-based liver tissue engineering, we report here a novel culture method whereby endothelialized rat hepatocyte aggregates were formed using a PDMS microwell device and cultured in a perfusion bioreactor by introducing spacers between aggregates to improve oxygen and nutrient supply. Primary rat hepatocyte aggregates around 100 µm in diameter coated with human umbilical vein endothelial cells were spontaneously and quickly formed after 12 h of incubation, thanks to the continuous supply of oxygen by diffusion through the PDMS honeycomb microwell device. Then, the recovered endothelialized rat hepatocyte aggregates were mixed with biodegradable poly-l-lactic acid fibres in suspension and packed into a PDMS-based bioreactor. Perfusion culture of 7 days was successfully achieved with more than 73.8% cells retained in the bioreactor. As expected, the fibres acted as spacers between aggregates, which was evidenced from the enhanced albumin production and more spherical morphology compared with fibre-free packing. In summary, this study shows the advantages of using PDMS-based microwells to form heterotypic aggregates and also demonstrates the feasibility of spacing tissue elements for improving oxygen and nutrient supply to tissue engineering based on modular assembly.

TREM2 and β-catenin regulate bone homeostasis by controlling the rate of osteoclastogenesis

TREM2 is an immunoreceptor expressed on osteoclasts (OC) and microglia that transmits intracellular signals through the adaptor DAP12. Individuals with genetic mutations inactivating TREM2 or DAP12 develop the Nasu-Hakola disease (NHD) with cystic-like lesions of the bone and brain demyelination that lead to fractures and presenile dementia. The mechanisms of this disease are poorly understood. In this study, we report that TREM2-deficient mice have an osteopenic phenotype reminiscent of NHD. In vitro, lack of TREM2 impairs proliferation and β-catenin activation in osteoclast precursors (OcP) in response to M-CSF. This defect results in accelerated differentiation of OcP into mature OC. Corroborating the importance of a balanced proliferation and differentiation of OcP for bone homeostasis, we show that conditional deletion of β-catenin in OcP also results in reduced OcP proliferation and accelerated osteoclastogenesis in vitro as well as osteopenia in vivo. These results reveal that TREM2 regulates the rate of osteoclastogenesis and provide a mechanism for the bone pathology in NHD.

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.

The TREM-2-β-catenin axis is critical to regulate macrophage colony-stimulating factor proliferation and bone homeostasis (153.29)

M-CSF regulates proliferation and survival of mononuclear phagocytes through the CSF-1R. DAP12, an ITAM-containing signaling partner for various myeloid receptors, is also critical for mononuclear phagocyte function. In human, deficiency in DAP12 or the immunoreceptor TREM-2 causes Nasu-Hakola disease (NHD), with bone abnormalities including bone cysts and osteoporosis that lead to bone fractures. Paradoxically, DAP12 is necessary for osteoclastogenesis in the mouse and DAP12-deficient mice exhibit an osteopetrotic phenotype. We have previously shown that DAP12 contributes to M-CSF-induced macrophage proliferation through a pathway that involves β-catenin activation. Here we show that the DAP12-associated receptor responsible for the crosstalk of DAP12 with CSF-1R is TREM-2. M-CSF-induced proliferation is impaired in TREM-2-deficient macrophages, and M-CSF-induced DAP12 phosphorylation, but not basal phosphorylation, is abrogated. In contrast to DAP12 deficiency, mice deficient for TREM-2 or β-catenin in osteoclast precursors show accelerated osteoclastogenesis in vitro and osteoporosis in vivo, recapitulating the bone traits of the human NHD. TREM-2 and β-catenin influence osteoclast development by enhancing the proliferative response of osteoclast precursors, thereby inhibiting their differentiation.

Esophageal ruptures: triage using the systemic inflammatory response syndrome score

Esophageal rupture is a rare entity. Delay in the diagnosis and treatment may threaten the patient's life. The decision for surgical or nonsurgical treatment, however, remains controversial because advocates of both treatments have reported comparable results. To quantify the decision making, we suggest the systemic inflammatory response syndrome (SIRS) score for triage of an esophageal rupture. Using this criterion for 12 patients resulted in the survival of all of them. Therefore, we advocate use of the SIRS score for triage of an esophageal rupture.