Comparison of Single-Incision Laparoscopic Cholecystectomy versus Needlescopic Cholecystectomy: A Single Institutional Randomized Clinical Trial.

BACKGROUND: Both single-incision laparoscopic cholecystectomy (SILC) and needlescopic cholecystectomy (NSC) are superior to conventional laparoscopic cholecystectomy in terms of cosmetic outcome and incisional pain. We conducted a prospective, randomized clinical trial to evaluate the surgical outcome, postoperative pain, and cosmetic outcome for SILC and NSC procedures. METHODS: In this trial, 105 patients were enrolled (52 in the SILC group; 53 in the NSC group). A visual analogue scale (VAS) was used to evaluate the cosmetic outcome and incisional pain for patients. Logistic regression analyses were used to evaluate the operative difficulty that was present for both procedures. RESULTS: There were no significant differences in patient characteristics or surgical outcomes, including operative time and blood loss. The mean VAS scores for cosmetic satisfaction were similar in both groups. There were significant differences in the mean VAS scores for incisional pain on postoperative day 1 (p = 0.009), and analgesics were required within 12 h of surgery (p = 0.007). Obesity (body mass index ≥25 kg/m2) was the only significant influential factor for operating time over 100 min (p = 0.031). CONCLUSION: NSC is superior to SILC in terms of short-term incisional pain. Experienced laparoscopic surgeons can perform both SILC and NSC without an increase in operative time.

Retrospective case-matched study between reduced port laparoscopic rectopexy and conventional laparoscopic rectopexy for rectal prolapse.

INTRODUCTION: Reduced port laparoscopic Well's procedure (RPLWP) is a novel technique used to overcome the limitations of single-incision laparoscopic surgery. The aim of this study was to compare outcomes between RPLWP and conventional laparoscopic Well's procedure (CLWP) and to investigate the learning curve of RPLWP. PATIENTS AND METHODS: From January 2006 to March 2017, a retrospective review of a prospectively maintained laparoscopic surgery database was performed to identify patients had undergone CLWP and RPLWP. From these patients, each of 10 cases were manually matched for age, sex, body mass index. From January 2006 to March 2015, CLWP was used for all procedures whereas, from April 2015, RPLWP was routinely performed as a standard procedure for rectal prolapse. RESULTS: No significant differences were observed between the two groups in terms of operating time, blood loss, intraoperative complications, and conversion to CLWP or open rectopexy. Based on the postoperative outcomes, the hospital stay was significantly shorter in the RPLWP group. The estimated learning curve for RPLWP was fitted and defined as y = 278.47e-0.064x with R2 = 0.838; therefore, a significant decrease in operative time was observed by using the more advanced surgical procedure. CONCLUSIONS: RPLWP is an effective, safe, minimally invasive procedural alternative to CLWP with no disadvantage for patients when a skilled surgeon performs it.

An autopsy case of sporadic amyotrophic lateral sclerosis associated with the I113T SOD1 mutation.

A 64-year-old man noticed weakness in his arms and dyspnea upon exertion. Four months later he was admitted to our hospital, where muscle atrophy and hyperactive deep tendon reflexes in the arms were observed upon examination. A needle electromyograph study revealed acute and chronic denervation in the extremities, and he was diagnosed as having amyotrophic lateral sclerosis (ALS). Seven months after onset of the disease, he died of respiratory failure. Neuropathologically, neuronal cell loss was observed in the motor cortex, hypoglossal nuclei, cervical and lumbar anterior horns and Clarke's nuclei. Some of the remaining neurons contained neurofilamentous conglomerate inclusions (CIs). A small number of Lewy body-like hyaline inclusions (LBHIs) were also observed. No the Bunina bodies, skein-like inclusions or basophilic inclusions were detectable. Tract degeneration was moderate in the dorsal and ventral spinocerebellar tracts, mild in the pyramidal tract, but not discerned in the posterior column. Immunohistochemical examinations revealed that the CIs were strongly positive for phosphorylated neurofilament and moderately positive for ubiquitin and Cu/Zn superoxide dismutase 1 (SOD1). Moreover, a number of phosphorylated tau protein-positive globose neurofibrillary tangles (NFTs) and threads were observed in the periaqueductal gray matter, oculomotor nuclei and trochlear nuclei. Although the family history was negative for neuromuscular diseases, the neuropathological findings indicated features of familial ALS with a SOD1 mutation. In fact, DNA analysis of frozen-brain tissue revealed the presence of the I113T SOD1 mutation. This case represents the first one of this mutation in a patient who showed CIs as well as LBHIs in the motor neurons at the same time, in addition to the NFTs in the mesencephalic tegmentum.

Effect of combining motivational interviewing with cognitive remediation on personal recovery in patients with schizophrenia.

Background/objective: We have been practising the Neuropsychological and Educational Approach to Remediation (NEAR) as cognitive remediation (CR) in a psychiatric hospital and have implemented it in combination with regular interviews based on Motivational Interviewing (MI) approximately 2 years after launching NEAR. In this study, we investigated whether combining MI with CR affected completion of the programme, cognitive functions, global functioning, and personal recovery of patients with schizophrenia by analysing medical records. Methods: In this retrospective observational study, 14 participants were assigned to the NEAR group and 12 participants were assigned to the NEAR + MI group. Fifteen participants in the NEAR group (n = 6) and NEAR + MI group (n = 9) completed the programme. First, the difference in the completion rate between the groups was examined using the chi-squared test. Second, measures of cognitive functions, global functioning, and personal recovery pre-and post-intervention were examined using the Wilcoxon signed-rank tests for those in each group who completed the programme. Third, therapeutic responses for each group were compared using the Mann-Whitney U tests. Results: There were no statistically significant differences in completion rates between the groups. In the NEAR group, verbal memory and overall cognition improved after the intervention. On the other hand, not only cognitive functions but also global functioning and personal recovery improved in the NEAR + MI group. Moreover, changes in global functioning and personal recovery were significantly higher in the NEAR + MI group. Conclusion: Study findings indicated that combining MI with CR improves cognitive functions, global functioning, and personal recovery in patients with schizophrenia.

Localization of O-GlcNAc-modified proteins in neuromuscular diseases.

O-linked N-acetylglucosamine (O-GlcNAc) is a ubiquitous post-translational modification of nucleocytoplasmic proteins that induces the attachment of N-acetylglucosamine to serine or threonine residues of a protein. In contrast to other protein glycosylations, this modification is highly reversible and, similar to phosphorylation, it plays important roles in various cell signals. Here, we immunolocalized O-GlcNAc-modified proteins in muscle biopsy specimens from 40 patients with neuromuscular diseases and controls. In normal muscle fibers, O-GlcNAc was found along plasma membranes and in nuclei. Diffuse and increased cytoplasmic staining of O-GlcNAc was detected in (1) regenerating muscle fibers in muscular dystrophy, myositis, and rhabdomyolysis; (2) a proportion of atrophic fibers in myositis, such as those found in perifascicular regions in dermatomyositis; and (3) vacuolated fibers in sporadic inclusion body myositis (s-IBM) and distal myopathy with rimmed vacuoles (DMRV). Target formations in neurogenic muscular atrophy were O-GlcNAc positive. Increase of O-GlcNAc glycosylation could be associated with the stress response, as these lesions have been shown to be positive for several stress markers. Vacuolar rims in s-IBM and DMRV were sometimes sharply lined by O-GlcNAc-positive deposits, which reflects myonuclear breakdown occurring from the disease.

[A case of cerebellar syndrome associated with HIV infection].

A 36-year-old man was hospitalized because of subacutely progressive gait disturbance. Neurological examination disclosed severe ataxia of gait and trunk and moderate ataxia of the four limbs, without signs of cognitive impairment. There were no manifestations of systemic infections. Brain MRI showed mild atrophy of the cerebellar vermis and hemispheres. Extensive laboratory search failed to disclose the cause of subacute ataxia. Cerebellar ataxia progressed, leading to the patient becoming wheelchair-bound two months after admission, when PCR analysis of the cerebrospinal fluid was positive for Epstein-Barr, JC, and hepatitis B viruses. In addition, the quantity of serum HIV1-RNA was 2.9 x 10(4) copies, the absolute count of CD4+ lymphocyte was 28/mm3, and the CD4/CD8 ratio was 0.04, despite clear denials by both the patient and his wife regarding any apparent infectious opportunities. Accordingly thereafter, highly active antiretroviral therapy was initiated. Several weeks after the initiation of therapy, ataxia stabilized with disappearance of serum HIV and cerebrospinal fluid JCV viral load. He returned to his occupation 20 months after disease onset without progression of ataxia or development of other neurological dysfunctions including dementia. We could not establish the exact pathogenesis of ataxia in this patient It could have been primary cerebellar degeneration caused by HIV, or the other viruses detected (EBV, JCV) or autoimmune mechanisms caused by these viruses. However, HIV infection should be considered as an etiology in clinical setting of subacute ataxia, particularly in a young or immunocompromised patient.

Cardiopulmonary Impairments Caused by a Large Hiatal Hernia with Organoaxial Gastric Volvulus Showing Upside-Down Stomach: A Case Report.

BACKGROUND Upside-down stomach (UDS) is the rarest type of hiatal hernia (HH), with organoaxial gastric volvulus. A large HH sometimes causes cardiopulmonary impairments owing to multiple factors. CASE REPORT We herein report a case of a large HH with UDS that had induced weight loss and severe cardiopulmonary dysfunction in a 74-year-old female patient who presented with shortness of breath, chest pain, severe anorexia, and weight loss of 5 kg over the 3 previous months. Chest X-ray and CT examination revealed that her heart was retracted on the right side, and the hernia contents had induced physical compression of the left lung on the cranial side. Spirometry revealed that the patient's vital capacity (VC), percentage VC, and percentage forced expiratory volume (% FEV) at 1 s were 1.32 L, 60.2%, and 67.5%, respectively. A barium swallow test confirmed a diagnosis of HH with UDS. On the basis of these findings, we performed a laparoscopic Nissen procedure, which resulted in the patient's dramatic recovery. Postoperative examinations showed that the stomach and heart were once again normally located, and the left lung had re-inflated. Postoperative spirometry dramatically improved. CONCLUSIONS A large HH causes cardiac and pulmonary compression due to mass effects and leads to cardiopulmonary dysfunction. For cases that have both a complicated HH and cardiopulmonary dysfunction owing to the mass effects of hernia contents, laparoscopic HH repair can be a good alternative procedure.

Laparoscopic Repair for Recurrent Bilateral Inguinal Bladder Hernia following Bilateral Transabdominal Preperitoneal Repair.

INTRODUCTION: Although a recurrent inguinal hernia is sometimes observed as a supravesical hernia, it is extremely rare to encounter a bilateral bladder sliding hernia recurrence. In this report, we describe an extremely rare case of a recurrent bilateral supravesical bladder hernia after bilateral transabdominal preperitoneal repair (B-TAPP). CASE PRESENTATION: A 69-year-old man visited our hospital with complaints of bilateral groin swelling and frequent voiding after B-TAPP. A plain CT revealed that the urinary bladder was herniating into the bilateral supravesical hernias. He underwent laparoscopic bilateral supravesical bladder hernia repair using a bladder takedown approach and median TAPP. DISCUSSION: In Japan, the current mainstream method of hernioplasty is TAPP. However, an immature surgical technique and inadequate mesh placement may increase the risk of recurrent hernias. We successfully repaired this patient's recurrent bilateral supravesical bladder hernias laparoscopically. CONCLUSION: This rare condition (recurrent bilateral supravesical bladder hernias after B-TAPP) was successfully treated by using the bladder takedown approach and median TAPP. During surgical training and later in clinical practice, surgeons should master a surgical technique for this procedure in order to reduce recurrent hernias.

Pure Laparoscopic Left Hemihepatectomy for Hepatic Peribiliary Cysts with Biliary Intraepithelial Neoplasia.

Introduction. Hepatic peribiliary cysts (HPCs) usually originate due to the cystic dilatation of the intrahepatic extramural peribiliary glands. We describe our rare experience of pure laparoscopic left hemihepatectomy (PLLH) in a patient with HPCs accompanied by a component of biliary intraepithelial neoplasia (BilIN). Case Presentation. A 65-year-old man was referred for further investigation of mild hepatic dysfunction. Contrast-enhanced computed tomography showed dilatation of the left-sided intrahepatic bile duct, and biliary cytology showed class III cells. The patient was highly suspected of having left side-dominated cholangiocarcinoma and underwent PLLH. Microscopic findings revealed multiple cystic dilatations of the extramural peribiliary glands; hence, this lesion was diagnosed as HPCs. The resected intrahepatic bile duct showed that the normal ductal lumen comprised low columnar epithelia; however, front formation on the BilIN was observed in some parts of the intrahepatic bile duct, indicating that the BilIN coexisted with HPCs. Conclusion. We chose surgical therapy for this patient owing to the presence of some features of biliary malignancy. We employed noble PLLH as a minimally invasive procedure for this patient.

[Patient with chronic sarcoid myopathy without other organ involvement].

We herein report the patient of a 69-year-old woman who presented with the chronic myopathic form of sarcoid myopathy. She had experienced slowly progressive limb muscle weakness for three years. She was found to be thin, but otherwise normal, on a physical examination. Neurologically, proximal muscles are predominantly involved without any sensory or other focal deficits. Electromyography revealed myopathic motor unit potentials exhibiting spontaneous discharge. Muscle biopsy demonstrated extensive connective tissue and few residual muscle fibers with a hint of granuloma formation. Repeated sectioning of the muscle biopsy revealed noncaseatious granuloma with a multinucleated giant cell, confirming the diagnosis. The findings of all imaging studies, including a systemic PET (positron emission tomography) scan, were unremarkable. Without careful pathological observation with repeated sectioning, this patient would have been misdiagnosed with limb-girdle muscular dystrophy

Prednisolone-sparing effect of cyclosporin A therapy for very elderly patients with myasthenia gravis.

Three very elderly (over 80years old) patients having generalized myasthenia gravis without thymoma were treated with cyclosporin A and followed for up to 24months. Cyclosporin A therapy quickly improved myasthenia gravis symptoms in all cases, which allowed a rapid reduction in the prednisolone dose and improvement of prednisolone-related hyperglycemia and hypertension. Combination therapy with prednisolone and low-dose cyclosporin A not only improved the clinical symptoms of the very elderly myasthenia gravis patients but also resulted in a rapid reduction in prednisolone dosage and prednisolone-related side effects. Attention should be paid to cyclosporin A-related renal dysfunction.

Myonuclear breakdown in sporadic inclusion body myositis is accompanied by DNA double strand breaks.

Rimmed vacuoles in sporadic inclusion body myositis (s-IBM) contain nuclear remnants. We sought to determine if the nuclear degeneration seen in s-IBM is associated with DNA damage. In muscle biopsy specimens from ten patients with s-IBM and 50 controls, we immunolocalized 1) phosphorylated histone H2AX (γ-H2AX), which is a sensitive immunocytochemical marker of DNA double-strand breaks and 2) DNA-PK, which is an enzyme involved in double-strand break repair. In s-IBM, vacuolar peripheries often showed strong immunoreactivity to γ-H2AX and the three components of DNA-PK (DNA-PKcs, Ku70, and Ku80). A triple fluorescence study of Ku70, emerin, and DNA displayed nuclear breakdown and it suggested impaired nuclear incorporation of Ku70. The percentage of positive nuclei for γ-H2AX was significantly higher in vacuolated fibers than non-vacuolated fibers in s-IBM, or fibers in polymyosits. We hypothesize that a dysfunction of nuclear envelope may cause nuclear fragility, double-strand breaks and impaired nuclear transport in s-IBM.