Basic and clinical studies of percutaneous radiofrequency ablation of osteoid osteoma using a standard electrosurgical generator

 For percutaneous radiofrequency ablation of osteoid osteoma for pain management, we used a standard electrosurgical generator instead of the radiofrequency generator system. First, we used the standard electrosurgical generator to determine the diameter of the coagulated area of normal femurs and humeruses of dogs under general anesthesia and to detect damage to normal tissue around the bone. We then used a standard electrosurgical generator to perform percutaneous radiofrequency ablation of the osteoid osteoma. All three patients were almost pain-free within the first 24 h after the procedure, and they were discharged the day after the operation, being hospitalized for only 2 days. We thus confirmed that percutaneous radiofrequency ablation using a standard electrosurgical generator produced results similar to those achieved with the radiofrequency generator system. Received: August 19, 2002 / Accepted: January 11, 2003 RID="*" ID="*" Offprint requests to: A. Takeda     

Feasibility of a new approach for creating a preperitoneal space in transabdominal preperitoneal repair inguinal hernia repair: using a sandwich approach

Purpose

In Japan, transabdominal preperitoneal (TAPP) inguinal hernia repair is performed by firmly pulling the peritoneum inwards to lift it from the underlying deep layer of subperitoneal fascia. It decreases the postoperative pain and discomfort in the inguinal area. The aim of this study was to evaluate the feasibility of the sandwich approach, which is a new technique for creating a preperitoneal space.

Methods

The operation was performed via the sandwich approach. We made sure to protect the preperitoneal fascia areolar layer when making the preperitoneal space.

Results

We performed TAPP in 745 patients (876 hernias) treated between October 2006 and April 2015 at Himeji Medical Center and Kurashiki Central Hospital. Before October 2010, we did not use the sandwich approach, and recurrence was observed in three patients. From October 2010, we always used the sandwich approach and never experienced any cases of recurrence. Clavien–Dindo classification Grade 3 or higher postoperative complications occurred in 6 patients (0.8%) between October 2006 and April 2015. Mesh-related ileus was the most frequently observed morbidity. There were no cases of vas differentia or spermatic vessel injury, postoperative chronic pain, or urinary retention.

Conclusion

The sandwich approach is feasible as another standard dissective procedure for TAPP.

     

Significance of lymph node metastasis in pancreatic neuroendocrine tumor

Purpose

Pancreatic neuroendocrine tumor (PNET) is relatively rare and has a generally better prognosis than does pancreatic cancer. However, as its prognosis in patients with lymph node metastasis (LNM) is unclear, lymph node dissection for PNET is controversial. Our study aimed to clarify the significance of LNM in PNET.

Methods

We retrospectively examined 83 PNET patients who underwent pancreatic resections with lymph node dissection at Kumamoto University Hospital, Saiseikai Kumamoto Hospital, and Kumamoto Regional Medical Center from April 2001 to December 2014. Their clinicopathological parameters were analyzed by the absence or presence of LNM, and with regard to the disease-free survival (DFS) and overall survival (OS). A predictive score of LNM was also made using the age, tumor size, primary tumor location, and tumor function.

Results

Although the 5-year OS was 74.8% for LNM⁺ and 94.6% for LNM^? (P?=?0.002), LNM was not an independent risk factor for the OS in a multivariate analysis. However, tumors larger than 1.8 cm were found to be an independent prognostic factor, and the cut-off value for the predictive score was 1.69.

Conclusions

Although LNM was not an independent prognostic factor, lymph node dissection is recommended for patients whose predictive score is larger than 1.69.

     

A comparison of gastric emptying of soluble solid meals and clear fluids matched for volume and energy content: a pilot crossover study

We previously demonstrated that the gastric emptying time of different liquids with the same volume mainly depended on their energy content, regardless of differences in composition. In this crossover study, we investigated whether the same applies when soluble solid foods are ingested with water. Ten healthy volunteers ingested one of five test diets consisting of two test meals (Calorie Mate^® 100 and 200 kcal) and three test solutions (water and glucose solutions of 100 and 200 kcal), each given in a volume of 400 ml, and then underwent ultrasonography to measure the gastric antral cross‐sectional area every 10 min for 120 min. The gastric emptying time was defined as the time for the antral cross‐sectional area to revert to its initial value. When test diets with the same energy content were ingested, the gastric emptying curves were nearly identical, regardless of whether the original form was solid or liquid. The median (IQR[range]) gastric emptying times of Calorie Mate^® of 100 kcal with water vs. isocaloric glucose solution were 65 (60–78 [50–80]) vs. 65 (60–70 [50–80]) min (p = 0.58), and for Calorie Mate^® of 200 kcal with water vs. isocaloric glucose solution they were 100 (93–108 [90–120]) vs. 105 (90–110 [90–120]) min (p = 0.54). The median (IQR [range]) for water was 40 (30–40 [30–50]) min. Energy content may be a critical determinant of the gastric emptying time when ingesting soluble solid diets with water.     

Negative Impact of Blood Transfusion on Recurrence and Prognosis of Hepatocellular Carcinoma After Hepatic Resection

Background  In perioperative management of hepatic resection for hepatocellular carcinoma, excessive blood loss and blood transfusion greatly influence postoperative complications and prognosis of the patients. We evaluated the influence of blood products use on postoperative recurrence and prognosis of patients with hepatocellular carcinoma. Methods  The subjects were 66 patients who underwent elective hepatic resection for hepatocellular carcinoma without concomitant microwave or radiofrequency ablation therapy nor other malignancies between January 2001 and June 2006. We retrospectively investigated the influence of the use of blood products including red cell concentration and fresh frozen plasma on recurrence of hepatocellular carcinoma and overall survival. Results  In multivariate analysis, the dose of blood products transfusion was a significant predictor of disease-free and overall survival. Both disease-free and overall survival rates of those who were given blood products were significantly worse than those who did not receive. On the other hand, in univariate analysis of disease-free and overall survival after hepatic resection and clinical variables, the amount of blood loss was not a significant predictor of recurrence or death. Conclusion  Transfusion of blood products is associated with increased recurrence rate and worse survival after elective hepatic resection for patients with hepatocellular carcinoma.     

Availability of Pancreatic Allograft Biopsies Via a Laparotomy

Objective

The aim of this study was to evaluate the availability of a pancreatic allograft biopsy via a laparotpmy.

Patients and Methods

From September 2004 to November 2007, 17 pancreas transplantations were performed: 15 simultaneous pancreas and kidney transplantations (SPK), 1 pancreas transplant alone (PTA), and one pancreas after kidney transplantation (PAK). Thirteen pancreatic allograft biopsies were obtained via an open laparotomy. This study evaluated the complications associated with this procedure, the rate of obtaining an adequate sample, and the relationship between biopsy-proven rejections and laboratory markers. In SPK cases we evaluated the synchronization between pancreas and kidney rejection. The pancreatic samples were diagnosed according to the Drachenberg classification.

Results

No complications resulted from the procedure. The rate of obtaining adequate samples was 84.6%. Pancreas rejection correlated with elevation of the laboratory markers in 71.4%. Simultaneous pancreas and kidney rejection occurred in 62.5%, only kidney in 25%, and only pancreas in 12.5%.

Conclusion

A pancreas graft biopsy was absolutely imperative to improve the outcome in PTA, and even in SPK cases. A pancreatic allograft biopsy via a laparotomy was a safe, necessary and easy procedure to obtain an accurate diagnosis of rejection among pancreas transplantation patients.     

Inhibition of Contraction-Stimulated AMP-Activated Protein Kinase Inhibits Contraction-Stimulated Increases in PAS-TBC1D1 and Glucose Transport Without Altering PAS-AS160 in Rat Skeletal Muscle

OBJECTIVE

Phosphorylation of two members of the TBC1 domain family of proteins, Akt substrate of 160 kDa (AS160, also known as TBC1D4) and TBC1D1, has been implicated in the regulation of glucose transport in skeletal muscle. Insulin-stimulated phosphorylation (measured using the phospho-Akt substrate [PAS] antibody) of AS160 and TBC1D1 appears to occur in an Akt-dependent manner, but the kinases responsible for contraction-stimulated PAS-AS160 and PAS-TBC1D1 remain unclear. AMP-activated protein kinase (AMPK) and Akt, both activated by contraction, can each phosphorylate AS160 and TBC1D1 in cell-free assays.

RESEARCH DESIGN AND METHODS

To evaluate the roles of AMPK and Akt on insulin- or contraction-stimulated PAS-AS160, PAS-TBC1D1, and glucose transport, rat epitrochlearis was incubated with and without compound C (inhibitor of AMPK) or Wortmannin (inhibitor of phosphatidylinositol [PI] 3-kinase, which is upstream of Akt) before and during insulin stimulation or contraction.

RESULTS

Insulin-stimulated glucose transport and phosphorylation of both AS160 and TBC1D1 were completely inhibited by Wortmannin. Wortmannin eliminated contraction stimulation of phospho-Ser^21/9glycogen synthase kinase 3α/β (pGSK3; Akt substrate) and PAS-AS160 but did not significantly alter pAMPK, phospho-Ser⁷⁹acetyl CoA carboxylase (pACC; AMPK substrate), PAS-TBC1D1, or glucose transport in contraction-stimulated muscle. Compound C completely inhibited contraction-stimulated pACC and PAS-TBC1D1 and partially blocked glucose transport, but it did not significantly alter pAkt, pGSK3, or PAS-AS160.

CONCLUSIONS

These data suggest that 1) insulin stimulates glucose transport and phosphorylation of AS160 and TBC1D1 in a PI 3-kinase/Akt–dependent manner, 2) contraction stimulates PAS-AS160 (but not PAS-TBC1D1 or glucose transport) in a PI 3-kinase/Akt–dependent manner, and 3) contraction stimulates PAS-TBC1D1 and glucose transport (but not PAS-AS160) in an AMPK-dependent manner.Insulin and contractile activity, the two most important physiological stimuli that increase glucose transport in skeletal muscle, can each induce the translocation of GLUT4 glucose transporters from the cell''s interior to its surface membranes (1,2). However, they regulate glucose transport via distinct signaling pathways (3). Insulin-stimulated glucose transport requires phosphatidylinositol (PI) 3-kinase activation, which leads to Akt activation without stimulating AMP-activated protein kinase (AMPK) (3–6). A great deal of evidence suggests that contraction stimulates glucose transport by a mechanism independent of PI 3-kinase/Akt (7–10) and attributable to the effects of multiple inputs, with AMPK- and calcium-mediated processes being major factors (11,12).In 3T3-L1 adipocytes, insulin stimulates phosphorylation of Akt substrate of 160 kDa (AS160; also called TBC1D4) in an Akt-dependent manner on sites identifiable by the phospho-Akt substrate (PAS) antibody (13,14). AS160 includes a Rab GTPase-activating protein domain (RabGAP) that inhibits Rab proteins involved in regulating vesicular traffic (15). The insulin-mediated increase in PAS phosphorylation of AS160 (PAS-AS160) appears to inhibit RabGAP activity, thereby allowing GLUT4 to be recruited to surface membranes and elevate glucose transport (14–17). In skeletal muscle, insulin or contraction results in elevated PAS-AS160 (18,19), and AS160 phosphorylation appears to regulate glucose transport (20).Recently, TBC1D1, a RabGAP protein paralog to AS160, was also shown to become PAS-phosphorylated (PAS-TBC1D1) in response to insulin in an Akt-dependent manner (21). However, whereas AS160 knockdown in 3T3-L1 adipocytes resulted in elevated basal cell-surface GLUT4 (17,22), TBC1D1 knockdown had no effect on basal cell-surface GLUT4 in 3T3-L1 cells (23). TBC1D1 protein is only ∼5% as abundant as AS160 protein in 3T3-L1 adipocytes, which may explain why TBC1D1 does not appear to play a major role in regulating glucose transport in these cells (23). TBC1D1 protein abundance is much greater in skeletal muscle versus adipose tissue (24), and silencing TBC1D1 in L6 myotubes resulted in increased basal cell-surface GLUT4 (25), supporting the idea that TBC1D1 inhibits GLUT4 translocation in the basal state. However, in contrast to the results for L6 cells with AS160 knockdown (which did not alter the insulin-stimulated net increase in cell-surface GLUT4), silencing TBC1D1 in L6 cells resulted in greater insulin-induced GLUT4 translocation versus control cells (25). In other words, TBC1D1 knockdown allowed insulin to induce a greater amount of GLUT4 translocation than in cells that express TBC1D1. These findings suggest that at least a portion of the inhibitory effects of TBC1D1 on GLUT4 may not be restrained by insulin. However, they do not eliminate the possibility that TBC1D1 can regulate an insulin-independent increase in glucose transport (e.g., with contraction). PAS-TBC1D1 is elevated in response to contraction in rodent skeletal muscle (19,24). Therefore, it seems possible that PAS-TBC1D1 may play a role in mediating contraction-stimulated glucose transport.Experiments using purified Akt or AMPK demonstrated that each kinase can phosphorylate both AS160 and TBC1D1 in cell-free assays (26,27). Considerable evidence indicates that the insulin-stimulated increase in PAS-AS160 is Akt dependent in skeletal muscle (18,28), and increased AS160 phosphorylation appears to be important for the full effect of insulin on glucose transport (20). However, the specific kinases responsible for contraction-stimulated PAS-AS160 need to be clarified because: 1) Wortmannin can completely inhibit the contraction-stimulated increase in PAS-AS160 in rat skeletal muscle, suggesting that Akt is responsible for the increased PAS-phosphorylation of AS160 during contraction (18), but 2) muscles from mice with genetically disrupted AMPK versus wild-type littermates had reduced contraction-stimulated increase in immunoreactivity toward PAS antibody at ∼160 kDa (PAS-160) (28,29).The primary aim of this study was to elucidate the contributions of Akt and AMPK on increases in PAS-AS160 and PAS-TBC1D1 in skeletal muscle stimulated by insulin or contraction. The PI 3-kinase inhibitor Wortmannin was used to prevent Akt activation (without altering AMPK activation), and compound C, a potent AMPK inhibitor (30), was used to prevent AMPK activation (without altering Akt activation). A secondary aim was to determine whether inhibition of insulin- or contraction-stimulated increases in PAS-AS160 or PAS-TBC1D1 was accompanied by attenuated insulin- or contraction-stimulated glucose transport. We hypothesized that in isolated rat epitrochlearis muscle: 1) Akt-dependent mechanisms are essential for the insulin-stimulated increases in glucose transport and phosphorylation of AS160 and TBC1D1; 2) Akt-dependent (but not AMPK-dependent) mechanisms are essential for contraction-stimulated increases in PAS-AS160, but not glucose transport; and 3) AMPK-dependent (but not Akt-dependent) mechanisms are essential for contraction-stimulated increases in PAS-TBC1D1 (but not PAS-AS160) and glucose transport.     

Hepatic CCR7lowCD62LlowCD45RClow allograft dendritic cells migrate to the splenic red pulp in immunologically unresponsive rats

Donor dendritic cells (DC) migrate into the recipient spleen after hepatic transplantation. Immunological unresponsiveness to rat hepatic allografts can be induced by prior donor-specific blood transfusion (DST). We investigated homing receptor phenotype and splenic distribution of donor DC after allografting and DST. Immunostaining revealed OX62+ cells in the splenic red pulp of animals receiving pre-transplant DST but only in the white pulp of untreated animals. Most OX62 cells were positive for OX76. There were two subsets of DC in the spleen, CD45RChighOX62+ and CD45RClowOX62+ cells. RT-PCR revealed that CD45RClowOX62+ cells expressed interleukin (IL)-10, while CD45RChighOX62+ cells expressed IL-2 and low levels of IL-10 mRNA. CD45RChighOX62+ cells strongly expressed CCR5 and CCR7, compared with weak expression in CD45RClowOX62+ cells. The Epstein-Barr virus-induced molecule 1 (EBI-1) ligand chemokine (ELC/MIP3beta) was expressed mainly within the splenic white pulp. Mucosal vascular addressin-cell adhesion molecule-1 (MAdCAM-1) was expressed in the marginal zone and white pulp, but expression of splenic MAdCAM-1 was down-regulated in DST-treated animals. L-selectin (CD62L), the ligand for MAdCAM-1, was strongly expressed on CD45RChighOX62+ cells but not on CD45RClowOX62+ cells. In conclusion, differential splenic migration of CCR5lowCCR7lowCD62Llow CD45RClow DC expressing Th2-type cytokines is associated with immunological unresponsiveness to rat hepatic allografts.     

Three-dimensional identification of hemangiomas and feeding arteries in the head and neck region using combined phase-contrast MR angiography and fast asymmetric spin-echo sequences.

OBJECTIVE: To evaluate a proposed technique for the 3-dimensional (3D) detection of hemangiomas, including vascular malformation and their feeding arteries, in the head and neck. The new technique combines phase-contrast magnetic resonance angiography (PCMRA) without contrast medium and 3D fast asymmetric spin-echo (FASE) sequences. METHODS: The technique was applied to 3 patients having hemangiomas in the head and neck region. In 1 patient the image obtained with the proposed technique was compared to that obtained by standard contrast angiography. RESULTS: In all 3 patients, the 3D presence of the hemangiomas and the feeding arteries were well defined in images created by the proposed technique. Additionally, the characterization of the hemangioma's 3D structure and distribution of the feeding arteries coincided with those observed using contrast angiography in the case for which contrast angiography was also performed. CONCLUSIONS: Preliminary experience shows that the proposed technique combining 3D-FASE and 3D-PCMRA is useful to visualize both the 3D structure of hemangiomas and to identify the 3D distribution of the feeding arteries without using contrast medium.     

Endoscopic thoracic sympathectomy for palmar hyperhidrosis: efficacy of T2 and T3 ganglion resection

BACKGROUND: Endoscopic thoracic sympathectomy has been considered an effective treatment for palmar hyperhidrosis. However, the extent of resection has not been determined in terms of efficacy and complications. We compared the efficacy and complications of 2-ganglion and single-ganglion resection in patients with palmar hyperhidrosis. METHODS: From 1995 to 2000, 75 patients underwent resection of thoracic ganglion T2 and T3. From 2000 to 2003, 67 patients underwent resection of only the T2 ganglion. Eighty of the 142 patients (56%) answered a detailed questionnaire, the results of which were analyzed. RESULTS: Gender, age, family history, and distribution of sweating were similar in both groups. Recurrence rates 1 and 2 years after endoscopic thoracic ganglionectomy were between 0% and 3% in T2 and T3 resection, and between 15% and 19% in T2 resection only. In the combined T2 and T3 resection group, 100% of patients noticed compensatory sweating; in T2 resection, 90% of patients noticed compensatory sweating. As for rates of satisfaction, T2 and T3 resection was superior to T2 resection. CONCLUSIONS: High recurrence rates of palmar hyperhidrosis after single-ganglion resection are reported in the present study. Two-ganglion resection is a superior surgical method to prevent recurrence of palmar hyperhidrosis.