Effectiveness and safety of a laparoscopic training system combined with modified reconstruction techniques for total laparoscopic distal gastrectomy

BACKGROUND Total laparoscopic distal gastrectomy(TLDG) is increasing due to some advantages over open surgery, which has generated interest in gastrointestinal surgeons. However, TLDG is technically demanding especially for lymphadenectomy and gastrointestinal reconstruction. During the course of training, trainee surgeons have less chances to perform open gastrectomy compared with that of senior surgeons.AIM To evaluate an appropriate, efficient and safe laparoscopic training procedures suitable for trainee surgeons.METHODS Ninety-two consecutive patients with gastric cancer who underwent TLDG plus Billroth I reconstruction using an augmented rectangle technique and involving trainees were reviewed. The trainees were taught a laparoscopic view of surgical anatomy, standard operative procedures and practiced essential laparoscopic skills. The TLDG procedure was divided into regional lymph node dissections and gastrointestinal reconstruction for analyzing trainee skills. Early surgical outcomes were compared between trainees and trainers to clarify the feasibility and safety of TLDG performed by trainees. Learning curves were used to assess the utility of our training system.RESULTS Five trainees performed a total of 52 TLDGs(56.5%), while 40 TLDGs were conducted by two trainers(43.5%). Except for depth of invasion and pathologic stage, there were no differences in clinicopathological characteristics. Trainers performed more D2 gastrectomies than trainees. The total operation time was significantly longer in the trainee group. The time spent during the lesser curvature lymph node dissection and the Billroth I reconstruction were similar between the two groups. No difference was found in postoperative complications between the two groups. The learning curve of the trainees plateaued after five TLDG cases.CONCLUSION Preparing trainees with a laparoscopic view of surgical anatomy, standard operative procedures and practice in essential laparoscopic skills enabled trainees to perform TLDG safely and feasibly.     

Understanding B-cell activation and autoantibody repertoire selection in systemic lupus erythematosus: A B-cell immunomics approach

Understanding antibody repertoires and in particular, the properties and fates of B cells expressing potentially pathogenic antibodies is critical to define the mechanisms underlying multiple immunological diseases including autoimmune and allergic conditions as well as transplant rejection. Moreover, an integrated knowledge of the antibody repertoires expressed by B cells and plasma cells (PC) of different functional properties and longevity is essential to develop new therapeutic strategies, better biomarkers for disease segmentation, and new assays to measure restoration of B-cell tolerance or, at least, of normal B-cell homeostasis. Reaching these goals, however, will require a more precise phenotypic, functional and molecular definition of B-cell and PC populations, and a comprehensive analysis of the antigenic reactivity of the antibodies they express. While traditionally hampered by technical and ethical limitations in human experimentation, new technological advances currently enable investigators to address these questions in a comprehensive fashion. In this review, we shall discuss these concepts as they apply to the study of Systemic Lupus Erythematosus.     

Robot-assisted low anterior resection for a rectal cancer patient with ileal conduit: A case report

Surgery for rectal cancer patients with an ileal conduit after total cystectomy is difficult because adhesions in the pelvis and around the ileal conduit are expected. In the present case, we performed robot-assisted low anterior resection of the rectum in a 69-year-old male patient with rectal cancer who underwent ileal conduit diversion after total cystectomy. In this procedure, the port was inserted into the left upper abdomen as a first step, and two additional ports were added on the left side. Low anterior resection was performed using two left hands to create more space in the abdominal cavity for the ileal conduit. We present this minimally invasive robotic procedure that is extremely useful for dissection of adhesions in a narrow pelvic cavity.     

A perspective on B-cell-targeting therapy for SLE

In recent years, large controlled trials have tested several new agents for systemic lupus erythematosus (SLE). Unfortunately, none of these trials has met its primary outcome. This does not mean progress has not been made. In fact, a great deal has been learned about doing clinical trials in lupus and about the biological and clinical effects of the drugs being tested. Many of these drugs were designed to target B cells directly, e.g., rituximab, belimumab, epratuzumab, and transmembrane activator and calcium modulator and cyclophilin ligand interactor?immunoglobulin (TACI?Ig). The enthusiasm for targeting B cells derives from substantial evidence showing the critical role of B cells in murine models of SLE, as well promising results from multiple open trials with rituximab, a chimeric anti-CD20 monoclonal antibody that specifically depletes B cells (Martin and Chan in Immunity 20(5):517–527, 2004; Sobel et al. in J Exp Med 173:1441–1449, 1991; Silverman and Weisman in Arthritis Rheum 48:1484–1492, 2003; Silverman in Arthritis Rheum 52(4):1342, 2005; Shlomchik et al. in Nat Rev Immunol 1:147–153, 2001; Looney et al. in Arthritis Rheum 50:2580–2589, 2004; Lu et al. in Arthritis Rheum 61(4):482–487, 2009; Saito et al. in Lupus 12(10):798–800, 2003; van Vollenhoven et al. in Scand J Rheumatol 33(6):423–427, 2004; Sfikakis et al. Arthritis Rheum 52(2):501–513, 2005). Why have the controlled trials of B-cell-targeting therapies failed to demonstrate efficacy? Were there flaws in design or execution of these trials? Or, were promising animal studies and open trials misleading, as so often happens? This perspective discusses the current state of B-cell-targeting therapies for human lupus and the future development of these therapies.     

Robotic dexterity: evaluation of three-dimensional monitoring system and non-dominant hand maneuverability in robotic surgery

There has been great progress in robotic surgical technology in recent years. The aim of this study was to objectively quantify robot-enhanced dexterity. To evaluate three-dimensional monitoring and non-dominant hand maneuverability using the da Vinci Surgical System, five surgeons were asked to thread the needle through all 11 holes on the model with handling robotic instrument. Three types of suturing were carried out. In task 1, sutures were placed using the dominant hand under 3D imaging; in task 2, suturing was performed using the dominant hand under 2D imaging; and in task 3, suturing was done with the non-dominant hand under 3D imaging. Each surgeon placed three sutures in completing each task. The time to successful completion, accuracy, and the opinion of the level of difficulty were recorded. All 45 tasks were completed. The time required to place each suture (mean ± SD) was as follows: 211.7 ± 50.5 s for task 1, 331.1 ± 121.2 s for task 2, and 237.1 ± 95.7 s for task 3. Task 1 took less time than task 2 (P = 0.02). There were no differences in the times between task 1 and task 3 (P = 0.19). Robotic suturing under 3D imaging is significantly faster than under 2D imaging, and robotic suturing using the non-dominant hand does not need significantly more time than with the non-dominant hand. Technology for robotic surgery could increase the manipulative abilities.     

Swallowing function following hypopharyngeal reconstruction with the pectoralis major musculocutaneous flap

Swallowing function was studied in three patients following the pectoralis major musculocutaneous reconstruction of the hypopharynx and cervical esophagus after extensive resection for hypopharyngeal cancer. Fluoroscopy and endoscopy revealed the formation of a sphincter-like ring at the proximal end of the remaining intact esophagus. This ring may act to prevent reflux from the lower esophagus, although its sphincteric power is weak. Manometric testing showed that no swallowing pressure was produced in the reconstructed gullet; therefore, bolus propulsion at the pharyngeal stage occurs mainly by gravity. Follow-up studies on swallowing indicate a minimum length of the suture line of 11 cm in order to prevent esophageal stenosis due to anastomotic stricture at the distal mucocutaneous junction.     

Escherichia coli translocation in experimental short bowel syndrome: probiotic supplementation and detection by polymerase chain reaction

Background  

After massive bowel resection, bacterial overgrowth is frequent and favors the occurrence of Gram-negative intestinal bacterial translocation (BT). Probiotics have been recommended in several diseases and may also have beneficial effects on BT. Conversely, polymerase chain reaction (PCR) technique has shown better sensitivity than conventional methods in bacterial detection and has not been investigated in experimental models of short bowel syndrome and BT.     

Genetic analyses using a mouse cell cycle mutant identifies magoh as a novel gene involved in Cdk regulation

Many of the genes that control cyclin-dependent kinase (Cdks) activity have been identified by genetic research using yeast mutants. Suppression analysis and synthetic enhancement analysis are two broad approaches to the identification of genetic interaction networks in yeasts. Here we show, by genetic analyses using a mammalian cell cycle mutant, that mouse magoh is involved in Cdk regulation. Magoh, a homolog of the Drosophila mago nashi gene product, is a component of the splicing-dependent exon-exon junction complex (EJC). We show that, in addition to ccnb1 and cks2, magoh is also a dosage suppressor of the mouse temperature-sensitive cdc2 mutant, and synthetic enhancement of the cdc2 ts phenotype by RNA interference (RNAi) of magoh is observed in a manner similar to RNAi of cks2. Moreover, the depletion of magoh by RNAi causes cold-sensitive defects in the cell cycle transition, and exogenous cks2 expression partially suppresses the defect. Consistent with the genetic evidence, magoh RNAi caused defects in the expression of Cdc2 or Cks proteins, and introns of cks genes strongly affected protein expression levels. Thus, these data suggest that mouse Magoh is related to cell cycle regulation.