Retroperitoneoscopic Simple Nondismembered Pyeloplasty with Da Vinci Si Assistance to Prevent Alignment Shift.

Aims: Retroperitoneoscopic simple nondismembered pyeloplasty (SNDP) with da Vinci Si assistance was developed because of a possible risk for alignment shift after retroperitoneoscopic diamond-shaped bypass pyeloplasty (Diamond-Bypass; DP). Outcomes of SNDP and DP were compared. Materials and Methods: For SNDP, a small longitudinal incision is made on the border of the dilated pelvis and narrowed ureter at the ureteropelvic junction (UPJ). Extending this incision toward the pelvis allows identification of mucosa while maintaining the integrity of surrounding tissues that are so thin and fragile that they will not influence lumen alignment. Data for DP were obtained from a previously published article. Results: For SNDP (n = 3), mean age at surgery was 2.67 years (range: 1-4), mean operative time was 176 minutes. Mean postoperative Society of Fetal Urology (SFU) grades for hydronephrosis were 1.2, 0.7, and 0.6, 1, 2, and 3 months after stent removal, respectively. Postoperative diethylenetriaminepentaacetic acid (DTPA) was normal (n = 3). For DP (n = 5) mean age at surgery was 4.3 years (range: 1-14), mean operative time was 189 minutes. Mean postoperative SFU grades were 2.8, 2.2, and 1.6, respectively. Postoperative DTPA was normal (n = 4) and delayed (n = 1). All SNDP and DP were asymptomatic by 3 months after stent removal. Conclusion: Both SNDP and DP have favorable outcomes. If the UPJ is located at the lowest end of the renal pelvis, SNDP may improve hydronephrosis more quickly.

Comparative assessment of fully laparoscopic Duhamel-Z with minimal rectorectal dissection vs. laparoscopy-assisted Duhamel-Z with blunt manual rectorectal dissection for total colonic aganglionosis.

Aims: Early postoperative outcome (EPO) was compared between fully laparoscopic Duhamel-Z (F-Dz) and laparoscopy-assisted Duhamel-Z (A-Dz) anastomoses performed for total colonic aganglionosis (TCA). Methods: EPO was assessed quarterly for the first year after F-Dz/A-Dz using a continence evaluation score (CES) based on stool frequency (motions/day) and stool consistency (0 = liquid, 1 = soft, 2 = formed), presence of anal erosion (0 = severe, 1 = moderate, 2 = mild), and incidence of enterocolitis.Surgical technique involved taking the ileostomy down, dissecting the colon laparoscopically, and preparing the pull-through ileum through the stoma wound. In F-Dz (n = 3), a working port (SILS trocar) was inserted, and laparoscopic retrorectal dissection with forceps used to create a retrorectal tunnel from the peritoneal reflection extending downward as narrow as possible along the posterior wall of the rectum to prevent lateral nerve injury and preserve vascularity. After completing the tunnel, the ileum was pulled-through from an incision on the anorectal line and a Z-shaped ileorectal side-to-side anastomosis performed without a blind pouch. In A-Dz (n = 11), the retrorectal pull-through route was created through a Pfannenstiel incision using blunt manual (finger) dissection along the anterior surface of the sacrum. Results: Subject backgrounds were similar. Mean quarterly data were: frequency (F-Dz: 4.67, 4.67, 4.67, 3.33) vs. (A-Dz: 7.27, 7.09, 6.18, 5.36) p < .05; consistency (F-Dz: 0.33, 0.67, 0.67, 0.67) vs. (A-Dz: 0.27, 0.45, 0.70, 0.73) p = ns; anal erosion (F-Dz: 0.33, 0.33, 0.33, 0.67) vs. (A-Dz: 0.18, 0.36, 0.45, 0.64) p = ns; and enterocolitis (F-Dz: 1 episode in 1/3 cases or 33.3%) vs. (A-Dz: 7 episodes in 6/11 cases or 54.5%) p = ns. Conclusions: Overall, EPO after F-Dz was better than after A-Dz.

Robot-Assisted Retroperitoneoscopic Diamond Bypass Pyeloplasty.

AIM: Robot (da Vinci Si; Intuitive Surgical, Sunnyvale, CA) assisted retroperitoneoscopic diamond bypass pyeloplasty (R-RDBP) performed for ureteropelvic junction (UPJ) obstruction (n = 5) is presented. METHODS: Patients were placed affected side up and the retroperitoneal space accessed conventionally using 3-4 trocars. The diamond-shaped anastomosis involved incising the lowest part of the renal pelvis 12-15 mm transversely and the ureter distal to the obstruction 10-12 mm longitudinally. The first two sutures were placed retroperitoneoscopically; one from the mid-caudal line of the renal pelvis to the apex of the ureteric incision (the apex of the diamond) and the other from the corner of the incision in the renal pelvis to halfway along the ureteric incision. Trocars were replaced and the robot system docked. The first robot suture was placed between these two sutures, and the anastomosis completed by suturing from posterior to ventral applying minimal tension to keep the anastomosis close to the renal pelvis. All sutures were interrupted absorbable 5-0 monofilament. RESULTS: Mean age at R-RDBP was 4.3 (range: 1-14) years old. Height/weight were average. Preoperative Society for Fetal Urology (SFU) grading was 4.0 in all cases. All repairs were primary and progressed smoothly without perioperative complications; 3/5 had improved appetite postoperatively. Mean SFU grades 1-3 months postoperatively were 2.8, 2.2, and 1.6, respectively. Diuretic renography that was obstructive in all cases preoperatively was normal in four and delayed in one case, postoperatively. CONCLUSION: R-RDBP prevented rotation/kinking of the ureter, enhanced precision of suturing, and maximized the diameter at the anastomosis, facilitating smooth urine flow. LEVEL OF EVIDENCE: LEVEL IV.

Umbilical microflora and pediatric surgery.

INTRODUCTION: In pediatric surgery, the umbilicus with humid environment prone to bacterial colonization has become the most common site of entrance into the peritoneum. However, the umbilical flora in children has never been reported. This study aimed to describe the characteristics of umbilical microflora in children before antiseptic skin preparation. PATIENTS AND METHODS: We prospectively reviewed all children (age, ≤ 15 years) undergoing surgical procedures using umbilical access between April 2020 and June 2021. Before antiseptic skin preparation, culture swabs were taken from the umbilicus. Data on age, sex, and surgical procedure as well as microflora results and clinical findings were analyzed. RESULTS: Overall, data on 123 children aged between 9 days and 15 years (median: 3 years) were obtained. In the umbilicus, the most frequent colonizing bacteria were coagulase-negative Staphylococcus species and Corynebacterium. The isolation of intestinal bacteria from children aged ≤ 3 years was significantly increased (P = 0.03). The results of the multidrug resistance test revealed that the bacteria from the umbilicus exhibited a high frequency of cefazolin (CEZ) resistance (46.1%). No postoperative surgical site infection was recorded in our study. CONCLUSIONS: This prospective study is the first report to investigate the umbilical microflora in over 100 children. In this study, a large spectrum of both resident and transient microflora was cultured from the umbilicus. This umbilical microflora was similar to previous reports of adult microflora except in children aged ≤ 3 years. Our data suggest that in children ≤ 3 years, preoperative and postoperative antibiotics should be chosen by considering CEZ resistance and intestinal bacteria. The result of umbilical microflora would be useful to select the antibiotics for treatment of surgical site infection (SSI), and the culture swabs from the umbilicus before the operation for the children at high risk for SSI are highly recommended.

A retinoic acid receptor agonist tamibarotene suppresses iron accumulation in the liver.

OBJECTIVE: Hepatic iron overload (HIO) and iron-induced oxidative stress have recently emerged as an important factor for the development and progression of insulin resistance. The aim of this study was to evaluate the effect of tamibarotene, a selective retinoic acid receptor α/ß agonist, on hepatic iron metabolism, based on our previous findings that retinoids suppress hepatic iron accumulation by increasing hepatic iron efflux through the regulation of hemojuvelin and ferroportin expression. DESIGN AND METHODS: We quantitated the non-heme iron content and iron metabolism-related gene expression in the liver, and serum lipid and blood glucose levels in KK-A(y) mice after dietary administration of tamibarotene. RESULTS: It was demonstrated that tamibarotene significantly reduced blood glucose and hepatic iron, but not serum lipids, and that hemojuvelin expression significantly decreased while ferroportin increased, as observed previously. CONCLUSIONS: These results suggest that tamibarotene is a promising alternative for the treatment of insulin resistance associated with HIO.

High-fat, high-fructose diet induces hepatic iron overload via a hepcidin-independent mechanism prior to the onset of liver steatosis and insulin resistance in mice.

OBJECTIVE: Excess iron deposition in tissues leads to increased oxidative stress. The clinical observation that non-alcoholic fatty liver disease (NAFLD) is frequently associated with hepatic iron overload (HIO) indicates that iron-induced oxidative stress may be related to NAFLD pathology. Decreased expression of hepcidin, a hepatic hormone that suppresses dietary iron absorption in the duodenum, is frequently observed in NAFLD patients and has been postulated to be a cause of HIO. MATERIALS/METHODS: Because dietary fat and fructose intake play roles in the onset of NAFLD, we fed C57BL/6J mice a high-fat, high-fructose (HFHFr) diet for 16 weeks to study the relationship between hepatic iron content and NAFLD. RESULTS: Within 4 weeks after the start of the experiment, the mice exhibited significant increases in hepatic free fatty acid (FFA) content, serum insulin levels, and the homeostasis model assessment of insulin resistance. Interestingly, hepatic iron content and oxidative stress significantly increased with the HFHFr diet 2 weeks earlier than hepatic FFA accumulation and decreased insulin sensitivity. Moreover, hepatic hepcidin expression was significantly downregulated, as is also observed in NAFLD patients, but much later than the onset of HIO. CONCLUSIONS: Accordingly, our data demonstrated that HIO may have a pathogenic role in the onset of liver steatosis and insulin resistance. Moreover, distinct mechanisms, in addition to hepcidin, may underlie NAFLD-related HIO. These data suggest that the HFHFr diet can be used for establishing a suitable model to study the precise mechanism of HIO in NAFLD patients.

Presence of glyceraldehyde-derived advanced glycation end-products in the liver of insulin-resistant mice.

Insulin resistance is a fundamental feature of metabolic disorders such as metabolic syndrome. The formation of advanced glycation end-products (AGEs) is increased in patients with hyperglycemia, which results in the loss of protein function. Therefore, considerable attention has been paid to the pathological significance of AGEs in diseases associated with insulin resistance. We previously demonstrated that all-trans-retinoic acid (ATRA) ameliorated insulin resistance in mice that were fed a high-fat, high-fructose (HFHFr) diet. However, it is unclear whether the HFHFr diet increases the production of AGEs in the liver, and whether ATRA affects this production. In the present study, we investigated the production of glyceraldehyde-derived AGEs (Glycer-AGEs) in the liver of HFHFr diet-induced insulin-resistant mice using an antibody against Glycer-AGEs. We noted a remarkable formation of Glycer-AGEs with estimated molecular weights of approximately 265, 282, and 312 kDa in the liver of the insulin-resistant mice; however, the production of Glycer-AGEs was limited in the control. In accordance with previous observations, these Glycer-AGEs in mice disappeared after treatment with ATRA. These results suggest that hepatic Glycer-AGEs can be useful markers for the diagnosis and therapeutic evaluation of insulin resistance and may play a pathological role in the development of insulin resistance.

Retinoids ameliorate insulin resistance in a leptin-dependent manner in mice.

UNLABELLED: Transgenic mice expressing dominant-negative retinoic acid receptor (RAR) α specifically in the liver exhibit steatohepatitis, which leads to the development of liver tumors. Although the cause of steatohepatitis in these mice is unknown, diminished hepatic expression of insulin-like growth factor-1 suggests that insulin resistance may be involved. In the present study, we examined the effects of retinoids on insulin resistance in mice to gain further insight into the mechanisms responsible for this condition. Dietary administration of all-trans-retinoic acid (ATRA) significantly improved insulin sensitivity in C57BL/6J mice, which served as a model for high-fat, high-fructose diet-induced nonalcoholic fatty liver disease (NAFLD). The same effect was observed in genetically insulin-resistant KK-A(y) mice, occurring in concert with activation of leptin-signaling pathway proteins, including signal transducer and activator of transcription 3 (STAT3) and Janus kinase 2. However, such an effect was not observed in leptin-deficient ob/ob mice. ATRA treatment significantly up-regulated leptin receptor (LEPR) expression in the livers of NAFLD mice. In agreement with these observations, in vitro experiments showed that in the presence of leptin, ATRA directly induced LEPR gene expression through RARα, resulting in enhancement of STAT3 and insulin-induced insulin receptor substrate 1 phosphorylation. A selective RARα/ß agonist, Am80, also enhanced hepatic LEPR expression and STAT3 phosphorylation and ameliorated insulin resistance in KK-A(y) mice. CONCLUSION: We discovered an unrecognized mechanism of retinoid action for the activation of hepatic leptin signaling, which resulted in enhanced insulin sensitivity in two mouse models of insulin resistance. Our data suggest that retinoids might have potential for treating NAFLD associated with insulin resistance.