Prognostic nutritional index and postoperative outcomes in patients with colon cancer after laparoscopic surgery.

PURPOSE: The prognostic nutritional index (PNI) is calculated using the serum albumin and peripheral lymphocyte counts. We sought to assess the correlation between the preoperative PNI and postoperative outcomes in patients with colon cancer treated with laparoscopic surgery. METHODS: We included 896 colon cancer patients who underwent curative laparoscopic colectomy between January 2013 and March 2016. To identify any predictors of the postoperative outcomes, we compared the clinical characteristics and immunonutritional parameters, including the PNI, between patients classified as the Clavien-Dindo grade 2 or higher (n = 99) with those classified as grade 0 or 1 (n = 797). RESULTS: A longer surgical time and a preoperative low PNI (< 49.8) (odds ratio; 1.913, p = 0.002) were independent predictors of postoperative complications according to a multivariate analysis. A preoperative low PNI was significantly associated with an older age, a lower performance status, a lower BMI, higher CEA levels, an advanced T status, lymph node metastasis, a longer operative time, a higher blood loss, a larger tumor size, treatment with a combined resection, a longer time to bowel recovery, a longer postoperative hospital stay, and a poor overall survival. CONCLUSIONS: A preoperative low PNI was found to be significantly associated with the incidence of postoperative complications, an advanced tumor status, and a poor prognosis. Further research is needed to understand how to best clinically utilize this promising parameter.

[A Case of HER2-Positive Stage IV Advanced Gastric Cancer Treated with Chemotherapy Combined with Trastuzumab].

We report a case of human epidermal growth factor receptor(HER)2 positive stage IV advanced gastric cancer successfully treated with chemotherapy combined with trastuzumab. A 50-year-old man was diagnosed with type 3 gastric cancer complicated by liver and lymph node metastases. Owing to a HER2 immunohistochemistry tumor score of 3+, we initiated capecitabine plus CDDP plus trastuzumab chemotherapy. After 6 chemotherapy courses, computed tomography showed the liver metastasis had disappeared and the paraaortic lymph nodes had shrunk. We continued the capecitabine plus trastuzumab chemotherapy, which resulted in a progression free survival of 31 months. After 38 chemotherapy courses, the primary tumor progressed; therefore, the patient underwent surgery. Chemotherapy combined with trastuzumab can allow for resec- tion of the primary tumor.

Three-dimensional structure of seminiferous tubules in the adult mouse.

Seminiferous tubules develop from sex cords, which are embryonic structures with simple C-shaped arches. Histologically, the epithelium of adult mouse seminiferous tubules has been divided into 12 stages based on the associations of spermatogenic cells in four cycles of spermatogenesis. However, the gross characteristics of the seminiferous tubules themselves, including their number, length, run, and mutual relationships remain largely unknown. In the present study, we analyzed all seminiferous tubules in a single adult mouse testis with high resolution using serial paraffin sections and high-perfomance three-dimensional reconstruction software. There were 11 seminiferous tubules with an average length of 140 mm. Each tubule ran along circular paths within the testis while making convolutions with cranial and caudal hairpin turns. The cranial turns of all tubules were in contact with the tunica albuginea, whereas the caudal turns were not, resulting in funnel-shaped networks of these tubules with tapered caudal portions. The caudally located networks surrounded the preceding cranially located networks from the bottom and outside, similar to stacked paper cups. Five out of the 11 seminiferous tubules were continuous from one end to the other both connected with the rete testis (10 connection points). Nine branching points, one blind end, and 18 more connection points with the rete testis were detected in the remaining six seminiferous tubules, making the paths of these tubules complicated to various degrees. The present study revealed that the 3D structures of seminiferous tubules were highly regular as a whole in the adult mouse testis.

Platelet-derived Growth Factor Activates Pericytes in the Microvessels of Chronic Subdural Hematoma Outer Membranes.

Angiogenesis is one of the growth mechanisms of chronic subdural hematoma (CSDH). Pericytes have been implicated in the capillary sprouting during angiogenesis and are involved in brain ischemia and diabetic retinopathy. This study examined the pericyte expressions in CSDH outer membranes obtained during trepanation surgery. Eight samples of CSDH outer membranes and 35 samples of CSDH fluid were included. NG2, N-cadherin, VE-cadherin, Tie-2, endothelial nitric oxide synthase (eNOS), platelet-derived growth factor (PDGF) receptor-ß (PDGFR-ß), a well-known marker of pericytes, phosphorylated PDGFR-ß at Tyr751, and ß-actin expressions, were examined using western blot analysis. PDGFR-ß, N-cadherin, and Tie-2 expression levels were also examined using immunohistochemistry. The concentrations of PDGF-BB in CSDH fluid samples were measured using enzyme-linked immunosorbent assay kits. NG2, N-cadherin, VE-cadherin, Tie-2, eNOS, PDGFR-ß, and eNOS expressions in CSDH outer membranes were confirmed in all cases. Furthermore, phosphorylated PDGFR-ß at Tyr751 was also detected. In addition, PDGFR-ß, N-cadherin, and Tie-2 expressions were localized to the endothelial cells of the vessels within CSDH outer membranes by immunohistochemistry. The concentration of PDGF-BB in CSDH fluids was significantly higher than that in cerebrospinal fluid. These findings indicate that PDGF activates pericytes in the microvessels of CSDH outer membranes and suggest that pericytes are crucial in CSDH angiogenesis through the PDGF/PDGFR-ß signaling pathway.

Ring formation of the internal iliac artery.

We observed an arterial ring communicating the superior and inferior gluteal arteries in the left half of the pelvis of an 88-year-old male. Although many previous studies have shown variations in the internal iliac artery, there has been no literature describing the fenestration. Therapeutic embolization is commonly performed for intractable bleeding in pelvic region. Surgeons should be aware of the arterial ring formation because of possible danger in the intravascular treatments. In patients with similar arterial rings, embolization of the anterior trunk of the internal iliac artery could be insufficient when blood runs through the circle of the arterial ring.

[Multi-course web-learning system for supporting students of medical technology].

Web-Learning system was developed to support the self-learning for national qualification examination and medical engineering practice by students. The results from small tests in various situations suggest that the unit-learning systems are more effective, especially for the early stage of their self learning. In addition, the answers of some questionnaire suggest that the students' motivation has a certain relation with the number of the questions in the system. That is, the less number of the questions, the easier they are worked out with a higher learning motivation by students. Thus, the system was extended to enable students to study various subjects and/or units by themselves. The system enables them to have learning effects more easily by the exercise during lectures. The effectiveness of the system was investigated on medical associated subjects installed in the system. The concerning questions of Medical engineering and Pathological histology are adequately divided into several groups, of which sixteen Web-Learning subsystems were well composed for their practical application. Our concerning various unit-learning systems were confirmed much useful for most students comparing with the case of the overall Web-Learning system.

Three-dimensional anatomical structure formed by granule cell layer and pyramidal cell layer in human hippocampus.

In the human hippocampus, the pyramidal layer consists of the inferior aspect of the hippocampus which is organized segmentally. Each segment, together with granule layer of the dentate gyrus, exhibits structural unity. In humans, ellipsoidal protrusions called pyramidal hillocks (PHs), which consist of a thick pyramidal cell layer (PL), are present in the inferior aspect of the hippocampus, and are segmentally organized along a longitudinal axis. It is also known that the granule cell layer (GL) of the dentate gyrus (DG) is not a smooth but undulated structure. However, the cytoarchitectural relationships between the protrusions and undulation have yet to be studied well. Here, we aimed to clarify the three-dimensional cytoarchitecture of the PL and GL of human hippocampus. For that purpose, the GL and PL were three-dimensionally reconstructed from serial sections of human hippocampus stained with hematoxylin and eosin. The GL was shaped as tubing with an opening in the dorsal part, and undulated especially in the medial part, forming digit-like processes. In the base of a digit-like process, protrusions of the GL extended laterally, with longer ones reaching the lateral edge, whereas shorter ones disappeared around the medial 1/3 of the GL. Consequently, the lateral part of the GL was undulated loosely. In the ventral view of the PL, the ellipsoidal PHs were sagittally aligned, whereas in the top view, each PH formed an ellipsoidal trough. Each structural unit was formed by a trough of the PH along the bottom, and had a longer GL protrusion in the upper-center, and shorter GL protrusions located between the longer protrusions and the lateral edge of the GL. A digit-like process extended into a dens. It is concluded that a unit of the PH and the GL comprises the longitudinal segmental formation of the hippocampus.

Angiogenesis in the Outer Membrane of Chronic Subdural Hematomas through Thrombin-Cleaved Osteopontin and the Integrin α9 and Integrin ß1 Signaling Pathways.

BACKGROUND: A chronic subdural hematoma (CSDH) is considered to be an inflammatory and angiogenic disease. The CSDH outer membrane, which contains inflammatory cells, plays an important role in CSDH development. Osteopontin (OPN) is an extracellular matrix protein that is cleaved by thrombin, generating the N-terminal half of OPN, which is prominently involved in integrin signal transduction. We explored the expression of the N-terminal half of OPN in CSDH fluid and the expression of integrins α9 and ß1 and the downstream components of the angiogenic signaling pathways in the outer membrane of CSDHs. METHODS: Twenty samples of CSDH fluid and eight samples of CSDH outer membrane were collected from patients suffering from CSDHs. The concentrations of the N-terminal half of OPN in CSDH fluid samples were measured using ELISA kits. The expression levels of integrins α9 and ß1, vinculin, talin-1, focal adhesion kinase (FAK), paxillin, α-actin, Src and ß-actin were examined by Western blot analysis. The expression levels of integrins α9 and ß1, FAK and paxillin were also examined by immunohistochemistry. We investigated whether CSDH fluid could activate FAK in cultured endothelial cells in vitro. RESULTS: The concentration of the N-terminal half of OPN in CSDH fluid was significantly higher than that in the serum. Western blot analysis confirmed the presence of these molecules. In addition, integrins α9 and ß1, FAK and paxillin were localized in the endothelial cells of vessels within the CSDH outer membrane. FAK was significantly phosphorylated immediately after treatment with CSDH fluid. CONCLUSION: Our data suggest that the N-terminal half of OPN in CSDH fluid promotes neovascularization in endothelial cells through integrins α9 and ß1. The N-terminal half of OPN, which is part of the extracellular matrix, plays a critical role in the promotion of CSDHs.

The middle suprarenal artery arising from the superior mesenteric artery.

We observed a rare case of the middle suprarenal artery branching out from the superior mesenteric artery in a 78-year-old male. This atypical artery enters the right suprarenal gland that was also supplied by the superior and the inferior suprarenal arteries as usual. In embryonic stages, vasculature of the vitelline system and the gonadal system is differentially organized. The superior mesenteric artery has been generally thought to be pure vitelline, since there has been no evidence that the superior mesenteric artery supplies other organs than digestive. We then speculate that the present middle suprarenal artery is a remnant of the embryonic gonadal artery from the superior mesenteric artery, whereas a stem artery to the testis disappeared. Surgeons should take notice of the middle suprarenal artery when operations are conducted around the superior mesenteric artery.

Topographical relationship between the accessory hepatic duct and the hepatic artery system.

Hepatic biliary injury is one of the most common complications in cholecystectomy and is frequently accompanied by arterial injuries. Because there are several anatomical variations of the hepatic ducts, including the accessory hepatic ducts (AHDs), it is important to consider not only the anatomical position of the hepatic ducts but also those of the AHDs in cholecystectomy. However, the topographical relationships between the AHDs and the hepatic arteries are still poorly understood. In the present study we show that AHDs were observed in 7 out of 59 (11.9%) of the cadavers. There was a single AHD in the 6 out of the 7 cadavers and double AHDs in one. In these cases, the right AHDs emerged from the anterior medial segment of the liver piercing the parenchyma, while the left AHDs emerged directly from the anterior part of the caudate lobe. The right AHDs ran anterior to the right hepatic artery, while the left AHDs ran posterior to the hepatic arteries. The topographical relationship between the AHD and the hepatic artery system was thus reversed in the cases of the right and the left AHDs.

Combinational Approach of Genetic SHP-1 Suppression and Voluntary Exercise Promotes Corticospinal Tract Sprouting and Motor Recovery Following Brain Injury.

Background. Brain injury often causes severe motor dysfunction, leading to difficulties with living a self-reliant social life. Injured neural circuits must be reconstructed to restore functions, but the adult brain is limited in its ability to restore neuronal connections. The combination of molecular targeting, which enhances neural plasticity, and rehabilitative motor exercise is an important therapeutic approach to promote neuronal rewiring in the spared circuits and motor recovery. Objective. We tested whether genetic reduction of Src homology 2-containing phosphatase-1 (SHP-1), an inhibitor of brain-derived neurotrophic factor (BDNF)/tropomyosin receptor kinase B (TrkB) signaling, has synergistic effects with rehabilitative training to promote reorganization of motor circuits and functional recovery in a mouse model of brain injury. Methods. Rewiring of the corticospinal circuit was examined using neuronal tracers following unilateral cortical injury in control mice and in Shp-1 mutant mice subjected to voluntary exercise. Recovery of motor functions was assessed using motor behavior tests. Results. We found that rehabilitative exercise decreased SHP-1 and increased BDNF and TrkB expression in the contralesional motor cortex after the injury. Genetic reduction of SHP-1 and voluntary exercise significantly increased sprouting of corticospinal tract axons and enhanced motor recovery in the impaired forelimb. Conclusions. Our data demonstrate that combining voluntary exercise and SHP-1 suppression promotes motor recovery and neural circuit reorganization after brain injury.

Direct evidence of the relationship between brain metastatic adenocarcinoma and white matter fibers: A fiber dissection and diffusion tensor imaging tractography study.

It is commonly known that brain metastases usually have clear boundaries in magnetic resonance imaging. However, little is known regarding the trajectory of white matter fibers around the tumors, especially using the fiber dissection technique. Here, we focused on the anatomical interaction between white matter fibers and the tumor, using the fiber dissection in a postmortem brain with metastatic tumor and compared the findings with those of diffusion tensor imaging (DTI) tractography. One postmortem human brain hemisphere with metastatic adenocarcinoma in the Broca's area was dissected using fiber dissection following the Klingler's method. In order to compare the in vitro and in vivo results, additional brains from 15 patients with metastatic adenocarcinomas, the volumes of which were comparable to that of the adenocarcinoma in the brain used for fiber dissection, were analyzed using DTI tractographic reconstruction. Morphological findings of white matter bundles running around the tumor were compared between the two techniques. In the fiber dissection technique, the superior longitudinal fascicle, arcuate fascicle, and frontal aslant tract could be dissected, and the white matter bundles were curved and retracted to avoid the tumor. In all the cases analyzed, white matter fibers or streamlines surrounding the tumor avoided the lesion. Using the fiber dissection technique, this is the first direct evidence to elucidate the anatomy of white matter fibers affected by a metastatic brain. This suggests that brain metastatic adenocarcinoma is an intra-axial neoplasm with extra-axial white matter structures.

Laparoscopic-endoscopic cooperative surgery for ileal lipoma: A case report.

This is the first report of laparoscopic-endoscopic cooperative surgery (LECS) for an ileal tumor. A 50-year-old man was admitted to our hospital with a positive fecal occult blood test. Colonoscopy detected a submucosal tumor with intussusception located in the ileum, 10 cm oral from the Bauhin valve. On further examination, he was diagnosed with an ileal lipoma. There were no signs of malignancy. LECS was performed for the ileal tumor. After submucosal elevation by injecting saline solution, a mucosal incision was made circumferentially along the tumor. A full-thickness incision was created endoscopically and laparoscopically on the circumferential mucosal incisional line. The tumor was withdrawn intraluminally by endoscopy. The defect of the ileal wall was closed laparoscopically in an axial direction with linear staplers. Histologically, the tumor was a 25-mm ileal lipoma with negative resection margins and no malignancy.

Correlation between musculoskeletal structure of the hand and primate locomotion: Morphometric and mechanical analysis in prehension using the cross- and triple-ratios.

Biometric ratios of the relative length of the rays in the hand have been analyzed between primate species in the light of their hand function or phylogeny. However, how relative lengths among phalanges are mechanically linked to the grasping function of primates with different locomotor behaviors remains unclear. To clarify this, we calculated cross and triple-ratios, which are related to the torque distribution, and the torque generation mode at different joint angles using the lengths of the phalanges and metacarpal bones in 52 primates belonging to 25 species. The torque exerted on the finger joint and traction force of the flexor tendons necessary for a cylindrical grip and a suspensory hand posture were calculated using the moment arm of flexor tendons measured on magnetic resonance images, and were compared among Hylobates spp., Ateles sp., and Papio hamadryas. Finally, the torques calculated from the model were validated by a mechanical study detecting the force exerted on the phalanx by pulling the digital flexor muscles during suspension in these three species. Canonical discriminant analysis of cross and triple-ratios classified primates almost in accordance with their current classification based on locomotor behavior. The traction force was markedly reduced with flexion of the MCP joint parallel to the torque in brachiating primates; this was notably lower in the terrestrial quadrupedal primates than in the arboreal primates at mild flexion. Our mechanical study supported these features in the torque and traction force generation efficiencies. Our results suggest that suspensory or terrestrial quadrupedal primates have hand structures that can exert more torque at a suspensory posture, or palmigrade and digitigrade locomotion, respectively. Furthermore, our study suggests availability of the cross and triple-ratios as one of the indicators to estimate the hand function from the skeletal structure.

Three forebrain structures directly inform the auditory midbrain of echolocating bats.

Echolocating bats emit various types of vocalizations for navigation and communication, and need to pay attention to vocal sounds. Projections from forebrain centers to auditory centers are involved in the attention to vocalizations, with the inferior colliculus (IC) being the main target of the projections. Here, using a retrograde tracer, we demonstrate that three forebrain structures, namely, the medial prefrontal cortex (mPFC), amygdala, and auditory cortex (AC), send direct descending projections to the central nucleus of IC. We found that all three structures projected to the bilateral IC. A comparison of the patterns of retrogradely labeled cells across animals suggests that the ipsilateral AC-IC projection is topographically organized, whereas mPFC-IC or amygdala-IC projections did not show clear topographic organization. Together with evidence from previous studies, these results suggest that three descending projections to the IC form loops between the forebrain and IC to make attention to various vocal sounds.

Simultaneous laparoscopic left hemicolectomy and spleen-preserving distal pancreatectomy for descending colon cancer with pancreatic invasion.

Here, we describe laparoscopic colectomy with spleen-preserving distal pancreatectomy for descending colon cancer with pancreatic tail invasion. A 69-year-old man with descending colon cancer staged as clinical state IIIC (cT4b [pancreas] N1M0) underwent definitive laparoscopic surgery that was performed in collaboration with surgeons who specialize in laparoscopic colorectal and hepatobiliary-pancreatic laparoscopy. After the left colon was mobilized, tumor infiltration of the pancreas, but not the splenic vessels, was confirmed, and the spleen was preserved. The procedures were safely completed laparoscopically, without intraoperative and postoperative complications. Laparoscopic multivisceral resection could be a treatment option for similar patients but only when performed by multidisciplinary specialists.

Radial artery running beneath the biceps tendon and its interrelation between the radial recurrent arteries.

A radial artery running beneath the biceps tendon was found in the cadaver of a Japanese woman during a student dissection course at Kumamoto University School of Medicine in 2006. The brachial artery bifurcated into the radial artery and the ulnar artery in the cubital fossa, and the radial artery twisted laterally running beneath the biceps tendon, and when it was situated laterally to the tendon, twisted distally at the level of the radial tuberosity, and then twisted medially again. After the radial artery passed over the biceps tendon, it turned distally and continued as a normal radial artery. The superficial brachial artery, which coexisted with the brachial artery, was given off from the axillary artery and it continued to the final twist of the radial artery. The course of this radial artery is similar to the arterial rings surrounding the biceps tendon, found during the same dissection course. The arterial rings were formed between the brachial artery and the radial artery, and their proximal origins ran beneath the biceps tendon, while the distal origins were superficial. The present arterial variation is thought to have occurred when the normal part of the radial artery in the cubital fossa was substituted by the arterial ring, coexisting with the superficial brachial artery, which usually disappears during normal development. Furthermore, it is suggested that a part of the arterial ring always remains as a radial recurrent artery.

Left inferior vena cava with regressed right inferior vena cava.

A left inferior vena cava was found in the cadaver of an 88-year-old Japanese man during a student dissection course at Kumamoto University School of Medicine. The right common iliac vein ascended obliquely toward the left behind the right common iliac artery and united with the left common iliac vein to form the inferior vena cava in front of the fifth lumbar vertebral body behind the left common iliac artery. The inferior vena cava ascended on the left side to the aorta, and after the left renal vein joined to it at the level of the third lumbar vertebral body, it turned obliquely to the right and crossed superficially to the aorta. At the right side of the aorta, the common stem of the third lumbar vein and the posterior renal vein was joined to the oblique part. The inferior vena cava then ascended, receiving the right renal vein as it would normally. The inferior vena cava is thought to develop symmetrically but this left inferior vena cava shows a persistence of the left channel of the infrarenal part, which normally disappears. Although the common stem of the veins that joined to the oblique part on the right side did not continue to the right common iliac vein, gross anatomical findings suggested it to be the remnant of the right inferior vena cava.

Right ligamentum teres joining to the right branch of the portal vein.

Ligamentum teres joining to the right branch of the portal vein in a 79-year-old Japanese male cadaver was noted during student dissection at Kumamoto University in 2004. The ligamentum teres entered the liver along the left side of the gallbladder fossa. The quadrate lobe was not distinguished from the left lobe in the visceral surface. When the liver parenchyma was removed by tearing off to expose the branches of the portal and hepatic veins, it was clarified that the ligamentum teres unusually joined to the bifurcation of the upper anterior and lower anterior branches of the right branch of the portal vein. The ligamentum teres is the remnant of the umbilical vein working throughout fetal life. Initially a pair of the umbilical veins entered the sinus venosus. During the fourth and fifth weeks they connect to the hepatic sinusoids, which become the portal and hepatic veins, and the parts entering the sinus venosus of both umbilical veins disappear. By the eighth week, as all remainder of the right umbilical vein disappears, the left umbilical vein is the only one to carry blood from the placenta to the liver. It results in the ligamentum teres joining to the left branch of the portal vein. However, in the present case it is thought that the right umbilical vein remained instead of the left one for some reason, and it then became the right ligamentum teres joining to the right branch of the portal vein.

The middle rectal artery arising from the lateral sacral artery.

A middle rectal artery arising from the lateral sacral artery (MRAls) in the right pelvis of a 99-year-old male was observed. Although variations of the origin of the middle rectal artery have been reported on many occasions, there are few descriptions of the trajectory in the literature. In our case, the MRAls branched from the lateral sacral artery on the sacral surface close to the third sacral sympathetic ganglion and immediately penetrated the third sacral splanchnic nerve and the parasympathetic pelvic splanchnic nerve from the ventral ramus of the forth sacral nerve. The MRAls entered in the lateral wall of the rectal ampulla without giving off a prostatic branch. Preservation of the pelvic autonomic nerves are crucial in rectal cancer excision to preserve the autonomic functions. The close topography of the MRAls to the origin of the fine autonomic nerves should be noted.