An ergonomic study of single-port versus multi-port laparoscopic mesh insertion for ventral hernia repair.

PURPOSE: To assess the mental effort and physical discomfort of placement of a prosthetic mesh into the abdominal cavity with single-incision laparoscopic surgery (SILS) or multi-port laparoscopic access for incisional ventral hernia repair. METHODS: A total of 10 surgeons with previous experience in conventional laparoscopic surgery performed four surgical tasks through a multi-port laparoscopic access and a SILS access in a porcine model during a first 4-hour working session and a second 2-hour working session. These tasks included (a) introduction of a prosthetic mesh for abdominal wall surgery, (b) manipulation of the mesh inside the abdomen, (c) manipulation of the laparoscopic instruments and (d) mesh insertion to the intraperitoneal abdominal wall and fixation with tackers. The level of mental effort was assessed with the Subjective Mental Effort Questionnaire (SMEQ) and physical discomfort with the Local Experienced Discomfort Scale (LED). RESULTS: Seventy percent were men, with a mean age of 45 years and a mean of 18 years of experience in practicing surgery. The SMEQ questionnaire showed a median physical effort of 24.4 (range 9-36.1) points for the multi-port laparoscopic access and 107.4 (range 74.7-128.4) for SILS (p < 0.01). Statistically significant differences between multi-port laparoscopic surgery and SILS were consistently demonstrated in all tasks as well as in both the 4-hour and 2-hour working sessions. The median (interquartile range) score of the LED scale was 12.5 (2-34.5) for tasks during multi-port laparoscopic surgery and 53.5 (29-89.2) for SILS (p < 0.001). All individual tasks were associated with a significantly higher physical effort for SILS than for conventional laparoscopic access, which were also independent of being performed during the 4-hour or 2-hour working periods. CONCLUSIONS: Placement and manipulation of a prosthetic mesh for incisional ventral hernia repair is more difficult with SILS than using multi-port laparoscopic access, independently of previous experience with standard laparoscopic techniques. This greater difficulty was observed both in terms of mental effort and physical discomfort. More experimental and clinical studies are needed to define specific training aspects and clinical advantages of incisional ventral hernia repair through SILS.

Use of a bioabsorbable mesh in midline laparotomy closure to prevent incisional hernia: randomized controlled trial.

INTRODUCTION: The objective was to assess the effectiveness and safety of a bioabsorbable mesh at the time of closure of a midline laparotomy for IH prevention. MATERIALS AND METHODS: A multicenter, randomized clinical trial including patients undergoing abdominal surgical procedures through a midline laparotomy incision was designed. In the group of mesh (n = 167) the incision was closed using a continuous polydioxanone suture (PDS) plus a bioabsorbable mesh. In the control group (n = 165) a continuous PDS single layer suture was only used. Patients were randomly assigned (1:1) to the two groups. The primary outcome was the incidence of IH at 6, 12 and 24 months. Assessment of IH was done using a CT scan. RESULTS: At 6 months, the rates of IH were 15.2% and 24.8% in the experimental and control groups, respectively (relative risk [RR] 0.66, 95% confidence interval [CI] 0.38-0.98, P = 0.042). At 12 months, the rate of IH continued to be significantly lower in the experimental group (21.4% vs. 33.1%, P = 0.033), but at 24 months, there were no significant differences between the study groups with a follow-up rate of only 37.5%. The number needed to treat (NNT) was 11 and 9 at 6 and 12 months, respectively. CONCLUSION: The bioabsorbable mesh significantly prevented IH during the first year. Not reliable conclusions can be drawn across the second year. This may suggest that the any of the closing technique assessed in this study would have a "palliative" transient effect for preventing IH in the long-term.

Improved surgical mesh integration into the rat abdominal wall with arginine administration.

Prosthetic meshes are used as the standard of care in abdominal wall hernia repair. However, hernia recurrences and side effects remain unsolved problems. The demand by health care providers for increasingly efficient and cost-effective surgery encourages the development of newer strategies to improve devices and outcomes. Here, we evaluated whether l-arginine administration was able to ameliorate long-term polypropylene prostheses incorporation into the abdominal wall of Sprague-Dawley rats. Meshes were placed on-lay and continuous l-arginine was administered. In vivo biocompatibility was studied at 7, 25 and 30 days post-implantation. Effectively, l-arginine administration in combination with mesh triggered subtle changes in ECM composition that impinged on critical biochemical and structural features. Lastly, tensile strength augmented and stiffness decreased over the control condition. This could help to restructure the mechanical load transfer from the implant to the brittle surrounding tissues, i.e., impact load and fatigue load associated with mechanical tensions could be distributed between the mesh and the restored tissue in a more balanced manner, and ultimately help to reduce the incidence of loosening, recurrences, and local wound complications. Since the newly formed tissue is more mechanically stable, this approach could eventually be introduced to human hernia repair.

Antibiotic-loaded polypropylene surgical meshes with suitable biological behaviour by plasma functionalization and polymerization.

Hernia repair is one of the most common operations in general surgery, and its associated complications typically relate to infections, among others. The loading of antibiotics to surgical meshes to deliver them locally in the abdominal hernia repair site can be one way to manage infections associated with surgical implants. However, the amount of drug loaded is restricted by the low wettability of polypropylene (PP). In this work, plasma has been used to tailor the surface properties of PP meshes to obtain high loading of ampicillin while conserving the desired biological properties of the unmodified samples and conferring them with antibacterial activity. It was demonstrated that the new surface chemistry and improved wettability led to 3-fold higher antibiotic loading. Subsequently, a PEG-like dry coating was deposited from tetraglyme with low-pressure plasma which allowed maintaining the high drug loading and kept cell properties such as chemotaxis, adhesion and morphology to the same levels as the untreated ones which have shown long-standing clinical success.

Familial multiple symmetric lipomatosis associated with the A8344G mutation of mitochondrial DNA.

We describe familial multiple symmetric lipomatosis in a pedigree harboring the 8344 mutation in the tRNA(Lys) gene of mitochondrial DNA (mtDNA). The proband showed neuromuscular involvement but lacked the typical manifestations of myoclonic epilepsy and ragged-red fibers disease. The distribution of the mutation was unusual because the proportion of mutated genomes was higher in blood and lipomas than in muscle tissue.

Molecular genetic analysis of McArdle's disease in Spanish patients.

We analyzed leukocyte DNA of 19 patients from 12 Spanish families with McArdle's disease (myophosphorylase deficiency). In 15 patients, the enzyme defect was documented histochemically in muscle, and in four the diagnosis was based on clinical and laboratory data. Three patients were homozygous and six were heterozygous for the nonsense mutation at codon 49 (R49X). Our findings indicate that the R49X mutation, which is common in English and American patients, is also present in Spanish patients with McArdle's disease, but at a lower frequency.

Thiolprotease activity in skeletal and myocardial muscle and liver of fasted rats.

The activity of the thiolproteases, cathepsins B, H, and B + L, one of the most important groups of endoproteases, was measured in skeletal and myocardial muscle and liver of Sprague-Dawley rats submitted to fasts of different duration (control and 24, 48, and 72 h). After the fasting period, the animals were killed, and fresh tissue samples were collected. Enzyme activity was determined in vitro with the specific substrates Z-Arg-Arg-MCA for cathepsin B, Z-Phe-Arg-MCA for cathepsin B + L, and Arg-MCA for cathepsin H. Results show different patterns in the organs studied: activity increased linearly in liver, decreased in myocardial muscle, and had no change in skeletal muscle. These results suggest that the expected alteration observed in proteolytic activity in fasted tissues is produced to a certain degree by changes in thiolprotease activity.

Quality goals for hormone testing.

Estimates of intra-individual biological variation in normal subjects have been made for 17 hormones commonly measured for diagnostic purposes and the results have been compared with state-of-the-art analytical imprecision data. The implications of using these results for setting goals for analytical performance are discussed.

Ketoisocaproate contamination errors in protein synthesis determinations using L[1-14C]leucine.

Protein synthesis rate determinations in vivo using L-[1-14C]-leucine may be underestimated because of contamination by radioactive ketoisocaproate (KIC) resulting from leucine metabolism. The aim of this work was to set up a reliable method to determine the KIC/leucine radioactivity ratio in protein-free homogenates, and to apply it to study the extent of the protein synthesis ratio error due to KIC contamination. Cation-exchange chromatography using Dowex AG 50W-X8 resin was used to separate KIC from leucine, eluting KIC with water and leucine with 4 M ammonia. The errors found in the protein synthesis ratio were 6.20% in liver and 2.34% in jejunum.

Inhibition of visceral protein synthesis by certain amino acid supplements.

This study was focused on the effects produced by diets with different amino acid proportions on visceral protein synthesis (liver and jejunal mucosa). Eight groups of rats received an enteral modular diet supplemented with different amino acids (Group 1: Ile, Leu, Val; Group 2: Phe, Met, Gly; Group 3: Glu, Arg, Gly; Group 4: Gly, Group 5: Orn-Asp, Cys, Pro; Group 6: Lys, Ser, Thr; Group 7: Tyr, His, Ala). Group 8 was the control group. Rats were fed for four days. At the end of this period a flooding dose of 14C-Leu was injected and animals were killed. Liver and jejunal mucosa were removed and protein synthesis rate was determined. Results show a decreased liver protein synthesis in group fed with aromatic amino acids (53.8 +/- 8.4 vs. 88.6 +/- 12.1) and Glu-Arg (68.6 +/- 10.9). In jejunal mucosa there was a decrease of protein synthesis in groups fed with aromatic amino acids (98.7 +/- 16 vs 160.5 +/- 49). These changes seem to be related to the intracellular amino acid pool size and its influence on protein metabolism.

Modification of organ protein synthesis after surgical stress by low energy diets with different supplements.

We have studied the effects of hypocaloric diets with different supplements on liver and jejunal mucosa protein synthesis. The supplements assayed were medium chain triglycerides (diet MCT, with 50% carbohydrates: 25% long chain triglycerides (LCT): 25% medium chain triglycerides (MCT), standard amino acids), branched-chain amino acids (diet BCA, identical to control diet L50, with 15.3% of nitrogen replaced by branched-chain amino acids) and glutamine (diet GLN, identical to diet L50, with 15.3% of nitrogen replaced by glutamine). The control diet (L50) had 50% carbohydrates: 50% LCT and standard amino acids. The diets were assayed on 86 rats with femoral fracture immobilized by Kirschner pin insertion. Nutrition was administered for 4 days. On the fifth day, liver and jejunal mucosa protein synthesis was determined. A branched-chain amino acid supply in a proportion higher than 21.2% of amino acid nitrogen significantly decreased liver and jejunal mucosa protein synthesis, while the same amount of glutamine did not modify it. MCT had no effect on jejunal mucosa protein synthesis, while it was decreased significantly in the liver.

Modification of organ protein synthesis after surgical stress by low energy diets with different lipid/glucose ratios.

The aim of this work was to study the effects of low energy parenteral diets with different lipid/glucose ratios on rat liver and jejunal mucosa protein synthesis. The studied diets were: L0 (100% glucose, control diet), L25 (25% lipids: 75% glucose), L50 (50% lipids: 50% glucose) and L75 (75% lipids: 25 % glucose). All diets were isoenergetic and isonitrogenated, with a standard amino acid content. The diets were assayed in 93 rats with open femoral fracture immobilized by Kirschner pin insertion. The diets were administered for 4 days. On the fifth day, liver and jejunal mucosa protein synthesis were determined. Highest liver protein synthesis rates were obtained with the diet compositions: lipid/carbohydrate ratio: 25% lipids and 75% carbohydrates (expressed as energy ratio). A higher proportion of lipids significantly decreases liver protein synthesis (p <0.05). Jejunal mucosa protein synthesis followed the same pattern, with the same statistical differences.

Addition of glutamine does not improve protein synthesis and jejunal mucosa morphology in non-hypercatabolic stress.

To investigate the effect of glutamine-enriched total parenteral nutrition (TPN) on the protein synthesis and morphology of jejunal mucosa in non-hypercatabolic stress, sixty-two male Sprague-Dawley rats were subjected to surgical stress by femoral fracture. The rats were divided into 3 groups and received TPN for 8 days. One group received a standard amino acid solution without glutamine, the second group a standard solution enriched with glycine and glutamic acid, and the third group a standard solution enriched with glycyl-glutamine. All regimens were isocaloric and isonitrogenous-nitrogen (2.2 g/kg.day), glucose (150 Kcal/kg.day), and lipids (150 Kcal/kg.day). There were no statistically significant differences in jejunal mucosal thickness, DNA content, protein content, fractional synthesis rate or absolute protein synthesis among the groups after eight days of parenteral nutrition. In conclusion, the addition of glutamine to TPN did not influence either protein metabolism or morphology of the jejunal mucosa in non-hypercatabolic surgical stress.

Effect of starvation on organ blood flow in the senescent rat.

To investigate the amino acid requirements of the senescent rat, as part of a study directed toward nutritional support in the aged, it was necessary to determine amino acid levels in plasma and tissue, but also regional blood flow of the animals subjected to fast. Only this latter allows the determination of the amounts of each amino acid present in the tissue before starvation by extrapolation of values measured during starvation. As plasma and tissue amino acid had been previously determined, the aim of this study had been to measure regional blood flow in the liver, kidney, testis, spleen, stomach, small intestine and large intestine in senescent rats submitted to 1, 5, 9 and 15 days of starvation. Twenty-four-month-old male Wistar rats (n = 16) were divided into four groups (n = 4), and submitted to starvation for 1, 5, 9 and 15 days. Blood flow in the liver, kidney, testis, spleen, stomach, and small and large intestine was measured by injecting 0.5 ml of a microsphere solution (15 microns diameter) labelled with 57Co, 0.25 microCi/ml. Over the 15-day period studied, the response to starvation showed two distinct phases: an early effect (from day 1 to day 9) in which there were decreases in the weight of the organs and in organ blood flow, and a second phase (from day 9 to day 15) in which blood flow and organ weight were maintained. However, organ blood flow related to mass was not substantially affected by starvation. This implies that measurement of substrate plasma concentration alone can reliably reflect organ substrate flow.

Clinical significance of proliferative inflammatory atrophy in prostate biopsy.

INTRODUCTION: Proliferative inflammatory atrophy (PIA) is a frequently observed lesion in prostate biopsies and some authors have postulated its involvement in prostate carcinogenesis. However, the mechanisms that would permit its neoplastic transformation and the clinical significance of its finding in a prostate biopsy is currently not well known. OBJECTIVE: To analyze the characteristics of the PIA lesion, its possible role in prostate carcinogenesis and its relation with the tumor aggressiveness. MATERIAL AND METHOD: A systematic review was made of the literature in PubMed with the terms «proliferative inflammatory atrophy¼ or «PIA¼ and «prostate.¼ The most important findings are summarized in accordance with the study objective. RESULTS: PIA seems to be involved in prostate carcinogenesis. This hypothesis is based on its frequent association to cancer lesions (CaP) and on some genetic alterations that are common to the high grade prostatic intraepithelial neoplasia (HGPIN) and to the CaP, fundamentally deficit in GSTP1 expression and overexpression of AGR2. Currently, there are no epidemiological studies that evaluate the incidence of PIA or its association with HGPIN and CaP. Only one study, carried out by our group, has determined the global incidence of PIA in 30% of the prostate biopsies, a lower association to CaP than the HGPIN lesion and an association between PIA and tumors of lower and insignificant grade. CONCLUSIONS: PIA shares genetic alterations with HGPIN and CaP. Currently, there is no epidemiologic evidence to consider that the PIA is associated to a greater incidence of CaP and the genetic and epidemiological data available suggest its association to not very aggressive tumors.

Glucose-induced activation of transglutaminase in pancreatic islets.

Transglutaminase activity in rat islet homogenates was increased after preincubation of the islets at high glucose concentration, and severely decreased after preincubation in the presence of either 1,2-bis(2-chloroethyl)-1-nitrosurea or 2-cyclohexene-1-one. The stimulatory action of glucose was still observed when the islets were preincubated in the absence or extracellular Ca2+. The enzymic activity was decreased by NAD+ or NADP+ but not NADH or NADPH, and inhibited by GSSG more than by GSH. These findings suggest that the glucose-induced activation of transglutaminase may be related to induction of a more reduced redox state with subsequent change in thiol-disulfide balance.

Acute effect of glibenclamide upon red cell transglutaminase activity in diabetic patients.

The acute effect of glibenclamide, a hypoglycemic sulfonylurea, upon transglutaminase activity was investigated in 6 type II diabetic patients by perfusing 1 mg glibenclamide during 1 h. Blood samples were drawn 0, 10, 20, 30, 60 min during and 30 and 60 min after perfusion to determine insulin, glucose and transglutaminase activity. No significant modifications in plasma insulin, plasma glucose and transglutaminase activity in red cells was induced by glibenclamide perfusion. Nevertheless, glibenclamide induced a significant decrease (p less than 0.005) in transglutaminase activity after 20 min of perfusion (629.83 +/- 53.08 and 521.18 +/- 43.92, mean +/- SE, at 0 and 20 min). No correlation was observed between glucose or insulin plasma levels and transglutaminase activity.

Effect of medium chain triglycerides (MCT) on jejunal mucosa mass and protein synthesis.

The effects of medium chain triglycerides (MCT) on jejunal mucosa mass and protein synthesis were compared with results from previous experiments with rats fed by parenteral nutrition or enteral nutrition. Other published studies have also been analysed. Three experimental models were studied. In the traumatic model, production of a femoral fracture was followed by Kirschner pin insertion into the medullary canal of both fragments at reduction. (Forty ras were fed enteral nutrition and 93 were given parenteral nutrition.) A second model entailed resection under ether anaesthesia using the technique described by Higgins. (Fifty five rats were fed enteral nutrition and 28 with parenteral nutrition.) A third model entailed a terminolateral portocaval shunt under anaesthesia with pentobarbital. (Sixty nine rats were treated this way and then given enteral nutrition.) Proportions of medium chain/long chain triglycerides (LCT) were as follows: 0/100, 20/80, 40/60, 50/50, and 92/8 for enteral nutrition and 0/100, 30/70, 50/50, and 70/30 for parenteral nutrition. Faecal losses of alpha amino nitrogen, protein, total fats, and free fatty acids were analysed together with the quantitative intake, weight gain of the rats, jejunal mucosal mass, and protein synthesis in relation to the MCT proportion ingested or given by enteral nutrition or parenteral nutrition. From analysis of our results and those of others, several conclusions could be drawn. Firstly, the route of administration of MCT is extremely important and enterocytes might be considered one of the main target sites. Secondly, a high proportion of MCT (more than 80%) offers no advantage for jejunal mucosa and produces undesirable side effects. Thirdly, the effect of MCT on jejunal mucosal protein synthesis depends on the metabolic state. Finally, an increase in jejunal mucosal mass directly correlated with MCT concentrations, but no correlation was found between mass and protein synthesis. A positive correlation, however, between MCT proportion and enzyme activity (alkaline phosphatase and sucrase) in the brush border membrane was seen as well as a positive correlation with the concentration of phospholipids in the microvilli.

Stress relaxation tests in polypropylene monofilament meshes used in the repair of abdominal walls.

The objective of this work has been to characterize stress relaxation in the polymer material on applying different levels of constant strain. The meshes were strained at values of 5.2%, 5.4% and 5.6% which are the values at which the mesh is strained in clinical use for the repair of abdominal walls. Laws have been obtained to model the viscoelastic behavior at different strains for this material. Finally, fracture studies were carried out by environmental scanning electron microscopy to determine the fracture mechanisms of these meshes. Besides, the implantation of the meshes was practised in two different layers of abdominal wall: the superficial or preaponeurotic layer and deep or preperitoneal layer, showing the neoformation of connective tissue on the mesh, which tended to be organized differently in each layer studied; more roughly and densely in the superficial layer than in the deep one.