Risk factors for portal venous thrombosis after splenectomy in patients with cirrhosis and portal hypertension.

BACKGROUND: Portal venous thrombosis (PVT) is a potentially fatal complication following splenectomy. Its mechanisms and risk factors are poorly understood, especially in patients with cirrhosis and portal hypertension. This study investigated risk factors for PVT following splenectomy in such patients. METHODS: All consecutive patients with cirrhosis who underwent splenectomy in Kyushu University Hospital between 1998 and 2004 were included in this retrospective study. They were divided into two groups based on the presence or absence of postoperative PVT. Preoperative and operative factors were compared, and the relationships between formation of PVT and its independent variables were analysed. In some cases, portal venous flow was measured before and after splenectomy using duplex Doppler ultrasonography. RESULTS: PVT developed after surgery in 17 (24 per cent) of 70 patients studied. Multivariable analysis showed that increased splenic vein diameter and low white cell count were significant independent risk factors for PVT. Portal venous flow after splenectomy was greatly reduced in the PVT group, but not in patients without PVT. CONCLUSION: Large splenic vein diameter and low white cell count are independent risk factors for PVT after splenectomy in patients with cirrhosis and portal hypertension.

Effectiveness of endoscopic surgery training for medical students using a virtual reality simulator versus a box trainer: a randomized controlled trial.

BACKGROUND: The first step toward increasing the level of patient safety in endoscopic surgery is for all endoscopic surgeons to acquire fundamental skills, including psychomotor skills, in the preoperation stage of training. The current study aimed to evaluate the effectiveness of virtual reality (VR) simulator training and box training for training the fundamental skills of endoscopic surgery. METHODS: For this study, 35 medical students at Kyushu University were divided into three groups: simulator (SIM) group (n = 20), box trainer (BOX) group (n = 20), and control group (n = 15). None of the students had any experience assisting with endoscopic surgery or any previous training for endoscopic surgery. The students in the SIM group underwent training using a VR simulator, the Procedicus MIST, 2 h per day for 2 days. The students in the BOX group underwent training using a box trainer 2 h per day for 2 days. The students in the control group watched an educational video for 30 min. The endoscopic surgical skills of all the students were evaluated before and after training with a task of suturing and knot tying using a box trainer. RESULTS: Although no significant differences were found between the three groups in the total time taken to complete the evaluation task before training, there were significant improvements in the SIM and BOX groups after training compared with the control group. Box training increased errors during the task, but simulator training did not. CONCLUSION: The findings showed that box training and VR training have different outcomes. The authors expect that the best curriculum for their training center would involve a combination that uses the merits of both methods.

Laparoscopic cholecystectomy using a newly developed laparoscope manipulator for 10 patients with cholelithiasis.

BACKGROUND: Laparoscopic surgery has continued to gain popularity in almost all fields of abdominal surgery, and robotic systems have been introduced in general surgery. Naviot is a new remote-controlled laparoscope manipulator system controlled by the operator's hand. This study assessed its introduction into clinical practice. METHODS: A group of 10 consecutive patients with cholelithiasis underwent laparoscopic cholecystectomy assisted by the Naviot system (Naviot group). Another group of 41 patients who underwent laparoscopic cholecystectomy with a conventional human camera holder (human camera group) were selected for a comparison of their operative results with those of the Naviot group. RESULTS: The operative time of 89.3 +/- 27.1 min for the Naviot group was significantly longer than that of 74.8 +/- 28.1 min for the human camera group (p < 0.05). However, when the setup time for the Naviot system was excluded, the operative time was not significantly different from that for the human camera group. Other operative results showed no significant difference between the two groups. CONCLUSIONS: The authors believe that the new Naviot system is feasible for clinical use, and that it enables surgeons to perform solo gastrointestinal surgery.

Interventional navigation for abdominal therapy based on simultaneous use of MRI and ultrasound.

An interventional navigation system designed for percutaneous abdominal therapies was proposed, and a pilot study was carried out to assess the proposed system. Integration of US to MRI-based segmentation and 3D display of tumours can help physicians deal with instabilities such as respiratory motion and soft tissue shift that are inherent in abdominal interventions. In addition to the 3D display of the needle and tumours, we adapted the system for the abdominal applications and incorporated a process to correct the mismatch in needle path between MRI and US. The preliminary results of phantom and animal experiments indicated that the proposed method could combine the advantages of both MRI and US. The time required to determine the optimal needle insertion path by using this system was significantly less than that required when either US or MRI guidance alone was employed. The developed system was applied in two patients who underwent PEIT therapy, and its clinical feasibility was partially confirmed.

Characterization of platelet aggregation induced by the human melanoma cell line HMV-I: roles of heparin, plasma adhesive proteins, and tumor cell membrane proteins.

We investigated the in vitro mechanism of platelet aggregation induced by HMV-I human melanoma cells. HMV-I cells, in the absence of exogenous plasma proteins, induced platelet aggregation, followed by the release reaction. Heparin at an anticoagulant concentration had no effect on the aggregation. Calcium ion was essential for this tumor cell-platelet interaction and could not be replaced by magnesium. Among the adhesive proteins containing RGD sequences that have been reported to enhance experimental metastasis, fibrinogen and thrombospondin significantly enhanced the aggregation induced by HMV-I cells, fibronectin and von Willebrand factor inhibited it, and vitronectin had no effect. To identify the platelet-aggregating factor(s) of the tumor cells, we have developed a monoclonal antibody against HMV-I cells that can inhibit HMV-I cell-induced platelet aggregation. Immunoprecipitation analysis revealed that this antibody recognized an Mr 71,000 membrane protein. These results suggest that the association between the tumor cells and platelets is mediated by the Mr 71,000 membrane protein recognized by this monoclonal antibody.

Involvement of platelet membrane glycoprotein Ib and glycoprotein IIb/IIIa complex in thrombin-dependent and -independent platelet aggregations induced by tumor cells.

Involvement of platelet membrane glycoproteins (GP) in interactions between platelets and tumor cells was studied by using two human tumor cell lines and two monoclonal antibodies against platelet membrane GP. HMV-I cells derived from vaginal melanoma induced platelet aggregation in heparinized plasma, which was not followed by coagulation. M7609 cells derived from colon adenocarcinoma also induced platelet aggregation in heparinized plasma, which, on the contrary, was followed by coagulation. Aggregating activities of the HMV-I cells were abolished by pretreatment with neuraminidase or trypsin, but M7609 activity was not labile to these enzymes. Aggregations induced by M7609 were inhibited by hirudin or MD805, while those by HMV-I were not. M7609 cells dose dependently shortened the recalcification time of normal as well as Factor IX-deficient plasmas, while they were not effective in shortening the time of Factor II- or Factor VII-deficient plasmas. The procoagulant activity of HMV-I cells was 1000 times less than M7609 on the basis of cell numbers. When human platelets were preincubated with monoclonal anti-GPIb or anti-GPIIb/IIIa complex antibodies, neither cell line could cause aggregations. These findings suggest that both GPIb and the GPIIb/IIIa complex on the platelet surface are involved in the thrombin-dependent and -independent platelet aggregations induced by tumor cells.

Single-incision laparoscopic transabdominal preperitoneal mesh hernioplasty: results in 182 Japanese patients.

BACKGROUND: We introduced single-incision transabdominal preperitoneal (S-TAPP) herniorrhaphy (described herein) at our institution in June 2010. We recently conducted a retrospective study to assess the feasibility and safety of the procedure. METHODS: The study involved 182 patients (159 men, 23 women) who underwent S-TAPP herniorrhaphy between June 2010 and February 2015 for 202 groin hernias (162 unilateral hernias, 20 bilateral hernias). We examined patient characteristics, hernia type and presentation, operation time, conversion to another repair procedure, intraoperative blood loss, postoperative pain, morbidities, and postoperative hospital stay. We further evaluated operation time and morbidity by comparison between cases of simple unilateral hernia and cases of complicated unilateral hernia, which was defined as (1) a recurrent hernia, (2) hernia following radical prostatectomy, or (3) an incarcerated omental or bowel hernia. RESULTS: Five types of hernia were treated: indirect inguinal, direct inguinal, femoral, combined inguinal, and other (a urinary bladder hernia). Operation time was 92.5 ± 29.1 min for the unilateral hernias and 135.7 ± 24.5 min for the bilateral hernias. No major bleeding occurred. Postoperative pain was short-lived and easily managed. Overall morbidity was 8.2% (15/182 patients), and only one postoperative complication (recurrence) required surgical intervention (repeat S-TAPP). Average postoperative stay was 6.7 ± 2.6 days. Two patients experienced numbness in the outer thigh, but this resolved naturally. One superficial surgical site infection developed and was easily treated. Operation times were greater for the complicated vs. simple hernias, but the time differed significantly (p = 0.02) only between radical prostatectomy-associated hernia and simple hernia. No complicated hernia required conversion to traditional laparoscopic repair, but in simple unilateral hernia group one conversion to traditional laparoscopic repair was required for difficulties encountered in the dissection of the large indirect inguinal hernia sac. The incidence of seroma was higher, though not statistically, in the complicated (n = 3) vs. simple hernia group. CONCLUSIONS: S-TAPP repair of groin hernia was shown to be a feasible, safe procedure. The advantages are well understood, and further studies are warranted to confirm the long-term benefits suggested by our study.

Secondary signals mediated by GPIIb/IIIa in thrombin-activated platelets.

We have previously found that stimulation of aequorin-loaded platelets by thrombin produced a two-peaked increase in intracellular free calcium concentration ([Ca2+]i), and the development of the second peak of [Ca2+]i was closely related with the aggregation. In this report, we studied the interrelationship between the GPIIb/IIIa complex, aggregation, cytoskeletons and [Ca2+]i of platelets. The pretreatment of the platelets with dihydrocytochalasin B (4 microM), an actin polymerization inhibitor, did not inhibit aggregation and TXB2 production, but did inhibit both actin polymerization and the second peak of [Ca2+]i increase induced by thrombin, suggesting that actin polymerization and the second peak of [Ca2+]i are interrelated. GRGDSP (100 microM), a synthetic anti-adhesive peptide, has already been reported to inhibit platelet aggregation and the second peak of [Ca2+]i induced by thrombin. It also inhibited actin polymerization and TXB2 production, suggesting that aggregation was important for not only the generation of the second peak of [Ca2+]i but also for actin polymerization and TXB2 production. PGI2 (5 nM) did not abolish but only delayed aggregation, TXB2 production, actin polymerization and the second peak of [Ca2+]i increase. These findings suggest that the secondary signals are caused by aggregation (fibrinogen-binding to the GPIIb/IIIa) in thrombin-aggregated platelets, which results in the TXA2 production and the secondary peak of [Ca2+]i increase, and the latter was dependent on actin polymerization.

Neutralizing monoclonal antibody specific for alpha-bungarotoxin: preparation and characterization of the antibody, and localization of antigenic region of alpha-bungarotoxin.

We prepared an alpha-bungarotoxin-specific monoclonal antibody that neutralizes the biological activity of the toxin in vivo. The antigenic determinant combining specifically with this antibody was determined on the basis of cross-reaction experiments using three other long neurotoxins and peptide fragments of alpha-bungarotoxin. The antigenic determinant was located on the peptide fragment containing S34-S35-R36-G37-K38, which forms a part of the expected site that binds to the acetylcholine receptor proteins.

Ca2+ influx mediated through the GPIIb/IIIa complex during platelet activation.

When aequorin-loaded platelets were stimulated with thrombin, the luminescence signal of aequorin showed two peaks. From experiments with 1 mM external Ca2+ or EGTA, both one-half of the first peak and the entire second peak reflected the influx of Ca2+ from the external medium, and the remaining half of the first peak reflected the mobilization of Ca2+ from its storage site. A monoclonal antibody (TM83) that recognizes the glycoprotein IIb/IIIa (GPIIb/IIIa) complex which has binding sites for fibrinogen and the synthetic peptide GRGDSP are known to inhibit fibrinogen binding and platelet aggregation. Both eliminated the second peak of intracellular free calcium ([Ca2+]i). Similar effects were observed during activation by collagen, but not during PMA activation. It was concluded that the GPIIb/IIIa complex was intimately related to a part of the Ca2+ influx during the activation of platelets.

Localization of fibrinogen during ADP- or thrombin-induced aggregation of washed rabbit platelets.

In contrast to human platelets, which aggregate poorly in response to ADP unless fibrinogen is present in the external medium, washed rabbit platelets form large aggregates in response to ADP without fibrinogen in the suspending medium. Addition of fibrinogen to the suspending medium of rabbit platelets frequently has little or no effect on the extent of ADP-induced platelet aggregation. We examined washed rabbit platelets by immunocytochemistry during ADP-induced aggregation and deaggregation and during thrombin-induced aggregation when the external medium did not contain added fibrinogen to determine if (a) fibrinogen was expressed on the surface of rabbit platelets that could support aggregation when the platelets were stimulated, or (b) fibrinogen secreted from the alpha granules supports platelet aggregation. Glutaraldehyde-fixed samples were prepared at different times after addition of ADP or thrombin, embedded in Lowicryl K4M, sectioned, incubated with sheep anti-rabbit fibrinogen, washed, reacted with gold-labeled anti-sheep IgG, and prepared for electron microscopy. The alpha granules of rabbit platelets were heavily labeled with immunogold; the platelet membrane was not labeled. During platelet aggregation and deaggregation in response to ADP, fibrinogen was not detectable on the platelet surface. In response to thrombin, large aggregates formed before fibrinogen was secreted from the alpha granules; fibrinogen was detectable focally at sites of granule discharge by 30-60 sec and fibrin formed by 3 min. Therefore, stimulated washed rabbit platelets can adhere to each other without large amounts of fibrinogen taking part in the close platelet-to-platelet contact, since aggregation occurs before detectable secretion, and large areas where the platelets are in contact are devoid of fibrinogen between the adherent membranes. Adhesion mechanisms not involving fibrinogen may support the aggregation of washed rabbit platelets.

The electrophoretic mobility heterogeneity of human platelet subpopulations of different buoyant densities.

Human platelets were separated into density subpopulations by using a step-wise gradient of Percoll in Tris-NaCl buffer. The absolute value of the electrophoretic mobility (EPM) of the density subpopulations was found to be a linear function of the density of the platelets, with EPM becoming less negative with increasing platelet density. Platelet volume distributions, mode volume, and sialic acid and protein contents were found to increase with platelet density, while no differences were found in GPII, GPIII, and GPIV contents among the subpopulations. An estimate of charge density was made from the ratio between the PAS-staining material (membrane GP's) and platelet surface area. The ratio was found to decrease as platelet density increased, consistent with the less negative EPM values observed for the higher density platelets. This lower surface charge of heavier platelets, which would lower charge repulsion between cells, agrees with the premise that heavier platelets are more active.

Autoradiographic observation of platelets in cerebrovascular injuries induced by arachidonic acid and its prevention by ticlopidine.

The behavior of circulating 111In-labeled platelets in cerebrovascular injuries induced by arachidonic acid injection was studied. Fourteen rabbits were pretreated with the antiplatelet agent ticlopidine, and 10 rabbits were used for controls. Arachidonic acid (AA, 0.7 mg/kg) was injected into the internal carotid artery. Prior to the injection, platelets labeled with 111Inoxine were injected for autoradiography of the brain. Evans blue was injected as an indicator of blood-brain barrier disturbance. Nine control animals showed marked blue staining, and one showed slight blue staining. Seven out of the 14 pretreated animals showed slight or no staining, while 7 showed intensive staining. The distributions of the blue staining and the radioactivity showed high correlation. In the rabbits whose platelet aggregability was depressed by ticlopidine, lower blue staining as well as lower radioactivity was observed. Our findings suggest that activated platelets have an important role in the genesis of cerebrovascular injuries.

Neutralization of the local negative charge carried by glycoprotein (GP)-Ib in ristocetin-induced platelet agglutination.

Pretreatment of platelets with chymotrypsin dose-dependently decreased glycoprotein (GP)-Ib amounts as measured by SDS-PAGE, ristocetin-induced agglutination and platelet electrophoretic mobility (EPM). Decrease in platelet EPM in response to 0.75 mg/ml ristocetin alone were 7.0 +/- 2.3 and 6.8 +/- 4.3% (M +/- S.E., n = 6) for control and chymotrypsin-treated platelets, respectively (p greater than 0.2). Von Willebrand factor (vWF) alone had no effect on platelet EPM. However, in the presence of 0.75 mg/ml ristocetin, added vWF (2.9 micrograms/ml) caused a further 6.3 +/- 3.8% decrease in control platelet EPM, but caused no significant decrease in the enzyme-treated platelets (p less than 0.05). In the presence of 0.3 mg/ml ristocetin, added vWF (2.9-14.5 micrograms/ml) caused a small but significant decrease in control platelet EPM, but caused no significant decrease in the enzyme-treated platelets. These findings suggested that the GP-Ib carrying negative charge decreased by binding of vWF might facilitate a mutual approach of the GP-Ib molecules and bridge formation by vWF between different platelets.

Role of surface negative charge in platelet function related to the hyperreactive state in estrogen-treated prostatic carcinoma.

The relationship between platelet surface negative charge and hyperfunction was examined by determining electrophoretic mobility (EPM), aggregability, and sialic acid of platelets in prostatic cancer, prostatic cancer with estrogen, prostatic cancer with estrogen and aspirin, prostatic hypertrophy, and healthy aged males. Estrogen treated prostatic cancer patients had significantly higher platelet EPM. A good linear correlation was found between sialic acid and EPM (r = 0.97, p less than 0.001). EPM was negatively correlated with primary aggregations by adrenaline and ADP but not with secondary or maximum aggregations, suggesting increased surface negative charge may inhibit primary aggregation. Estrogen and platelet population changes influenced surface negative charge. Neuraminidase removal of platelet surface sialic acid resulted in dose-dependent decreases of EPM which paralleled decreases in sialic acid. Aspirin treated patients and platelets incubated with aspirin in vitro both showed increased platelet EPM. These results suggest that platelet surface negative charge may directly affect platelet function.

Specific cross-reaction of IgG anti-phospholipid antibody with platelet glycoprotein IIIa.

To study the pathological functions of anti-phospholipid (anti-PL) antibodies, we have analyzed their effect on platelet function. We identified an IgG anti-PL mAb, designated PSG3, which cross-reacted specifically with glycoprotein (GP) IIIa in human platelets and inhibited platelet aggregation. PSG3 bound also to certain polyanionic substances, such as double-stranded DNA, heparan sulfate, dextran sulfate and acetylated-LDL, but not to other polyanionic substances. The binding of PSG3 to GPIIIa was completely inhibited by heparan sulfate and dextran sulfate, indicating that PSG3 recognizes a particular array of negative charges expressed on both GPIIIa and the specified polyanionic substances. Since neither neuraminidase- nor endoglycopeptidase F-treatment of GPIIIa had any significant effect on the binding of PSG3, this array must be located within the amino acid sequence of GPIIIa but not in the carbohydrate moiety. Reduction of the disulfide bonds in GPIIIa greatly reduced its reactivity, suggesting that the negative charges in the epitope are arranged in a particular conformation. PSG3 inhibited platelet aggregation induced by either ADP or collagen, it also inhibited fibrinogen binding to activated platelets in a dose-dependent fashion. PSG3, however, did not inhibit the binding of GRGDSP peptide to activated platelets. These results suggest that the PSG3 epitope on GPIIIa contains a particular array of negative charges, and possibly affects the fibrinogen binding to GPIIb/IIIa complex necessary for platelet aggregation.

Localization of von Willebrand factor and thrombin-interactive domains on human platelet glycoprotein Ib.

Platelet membrane glycoprotein Ib (GPIb) functions as receptors for thrombin and von Willebrand factor (vWF) in the presence of ristocetin. To precisely locate the domains on GPIb interacting with vWF and thrombin, we prepared several peptides that have amino acid sequences analogous to that of the GPIb alpha-chain and examined their effects on ristocetin-induced (vWF-dependent) and thrombin-induced platelet aggregations. A peptide extending from residues Asp235 to Lys262 showed the strongest inhibitory effect on ristocetin-induced platelet agglutination, and a group of overlapping peptides composed of 24-28 amino acid residues representing sequences extending from Phe216 to Asp274 was found to inhibit platelet aggregation induced by thrombin. Other peptides did not inhibit platelet aggregations. Moreover, the binding to platelets of the monoclonal anti-GPIb antibody (TM60) which had been shown to inhibit both ristocetin- and thrombin-induced platelet aggregations was strongly inhibited by a peptide extending from Asp249 to Asp274. These data demonstrate that the vWF-binding domain exists in a small region between residues Asp235 and Lys262; the thrombin-interacting domain, in contrast, is located between residues Phe216 and Ala274, with a possible center of interaction in the sequence from Phe216 to Thr240 on the GPIb alpha-chain, and thrombin binding requires a relatively strict conformation in this domain.

Localization of a thrombin-binding site on human platelet membrane glycoprotein Ib determined by a monoclonal antibody.

To determine a thrombin-binding site on GPIb alpha on platelet membrane, we have examined the binding activities of tryptic or chymotryptic fragments of purified GPIb alpha to a monoclonal antibody against GPIb (TM60) and thrombin using (immuno)affinity chromatography. When purified GPIb alpha was digested with trypsin, two fragments (94-kDa, and 43-kDa) were obtained. The 43-kDa fragment was shown to bind to both affinity columns of TM60- and thrombin-Affi-Gel, while the 94-kDa fragment did not bind to either Affi-Gel columns. When trypsin fragments were incubated with TM60 and then applied to the column of thrombin-Affi-Gel, neither fragments were bound to the column. When the same experiment was performed using chymotrypsin, three fragments (94-kDa, 45-kDa and 39-kDa) were observed. On TM60- and thrombin-Affi-Gel columns, the smaller fragments (45-kDa and 39-kDa) were bound to the column. After incubation of these fragments with TM60, neither bound to the thrombin column. These results indicate (i) that the epitope for TM60 is located near, or on the thrombin-binding site of GPIb alpha, and (ii) that the thrombin-binding site is located on the tail portion of GPIb alpha, especially on a chymotrypsin cleavage site.

Role of heparin in tumor cell-induced platelet aggregation.

B16 mouse melanoma cell lines (B16F1, B16F10 and B16BL6) were able to induce platelet aggregation, and concomitant release of ATP in heparinized platelet-rich plasma (PRP). In citrated PRP, these tumor cells did not induce platelet aggregation. Addition of heparin to citrated PRP enabled these tumor cells to induce aggregation. In heparinized PRP, platelet aggregates induced by B16F10 cells were dissociated by the addition of either 4 mM EDTA, 10 mM CaCl2 or 0.1 micrograms/ml protamine sulfate. B16F10-induced aggregation in heparinized PRP was inhibited by preincubation with anti-fibronectin antibody, but not with antifibrinogen or anti-von Willebrand factor antibodies. B16F10 cells induced aggregation in washed platelet suspension with the addition of heparinized platelet-poor plasma (PPP). Cryoprecipitate from human plasma showed the same effect in the presence of heparin if substituted for PPP. The mixture of purified fibronectin, von Willebrand factor, fibrinogen and heparin were less effective than cryoprecipitate on B16F10-induced aggregation of washed platelets. The results suggest that an interaction between fibronectin and heparin may be important in tumor cell-induced aggregation.

Heterogeneous expression of glycoprotein Ib, IX and V in platelets from two patients with Bernard-Soulier syndrome caused by different genetic abnormalities.

Bernard-Soulier syndrome (BSS) is a rare inherited bleeding disorder, which is caused by deficiency or decrease of the platelet GPIb/IX/V complex. Analysis of two patients with BSS by flow cytometry of the blood revealed different expression patterns of the components of the GPIb/IX/V complex. In case 1, GPIX was completely absent but residual amounts of GPIb alpha and GPV were detectable; in case 2, GPIb alpha was completely absent. We amplified the coding regions of GPIb alpha, GPIb beta, GPV, and GPIX from the patients' genomic DNA with the polymerase chain reaction (PCR) and sequenced the PCR products. in case 1, we identified a point mutation in the GPIX coding region that changes the codon for tryptophan-126 (TGG) to a nonsense codon (TGA). In case 2, we found a deletion of nucleotide within seven adenine repeats at the position of 1932 to 1938 in the coding region of GPIb alpha, which causes a frame shift that results in 58 altered amino acids and a premature stop codon. These genetic changes alter the transmembrane domain of GPIX or GPIb alpha and, therefore, would prevent proper insertion of the proteins in the plasma membrane. Thus, abnormality of a single component protein (GPIX or GPIb alpha) alters the assembly of the GPIb/IX/V complex and causes heterogeneous surface expression of GPIb alpha, GPV and GPIX.