Laparoendoscopic Single-site Plus 1-port Donor Nephrectomy: Division of Roles to Shorten Warm Ischemic Time.

BACKGROUND: In this study we present our new surgical procedure, laparoendoscopic single-site surgery plus 1 for donor nephrectomy (LESS+1-DN), which shortens warm ischemic time (WIT) and improves surgical outcomes. METHODS: From January 2013 to February 2017, 15 patients who underwent LESS-DN and 41 patients who underwent LESS+1-DN at our institution were evaluated retrospectively. Patients were divided into 3 groups: group A, 15 cases of LESS-DN; group B, the first 15 patients who underwent LESS+1-DN; and group C, 26 patients who underwent subsequent LESS+1-DN. To reduce WIT, we clearly defined the roles of the surgeon and first assistant in the 26 subsequent LESS+1-DN cases. The surgeon dissected the renal pedicle and harvested the kidney graft using a recovery bag and the first assistant held the recovery bag. RESULTS: The mean operative time in group C (213.7 minutes) was significantly shorter than that in groups A (253.3 minutes) and B (253.8 minutes). The WIT in group C (195.2 seconds) was significantly shorter than that in groups A (389.8 seconds) and B (313.2 seconds). Open conversion was required in 1 case in group A. None of the donors required conversion to open surgery and no perioperative complications occurred in groups B and C. Linear regression analysis of the LESS+1-DN operative times and consecutive case numbers demonstrated a shallow learning curve (R2 = 0.392, P < .05). CONCLUSION: Our new procedure that divides the roles of the operator and the first assistant contributed significantly to a shortening of WIT. Dividing roles can facilitate a safer laparoscopic donor nephrectomy.

Mesenteric malperfusion complicated with type A acute aortic dissection.

Type A acute aortic dissection (AAAD), involving the ascending aorta, is one of life-threatening disorders. Emergent surgery, such as graft replacement of the aortic root, ascending aorta, aortic arch, or these combinations, is routinely performed to avoid sudden death due to free rupture, cardiac tamponade, or coronary obstruction. Even though appropriate surgery is immediately completed, however, operative mortality remains high, between 15% and 30%. Furthermore, mesenteric malperfusion, bringing about enteric ischemia, occurs unusually in AAAD with far and away higher mortality. In the present article, we reviewed contemporary evidence regarding incidence, mortality, and treatment of mesenteric malperfusion complicated with AAAD. The incidence and early mortality rate of mesenteric malperfusion complicated with AAAD was 4% and 68%, respectively. Patients with mesenteric malperfusion had a 9.7-fold risk of mortality relative to those without it. Evidence regarding optimal treatment of mesenteric malperfusion complicated with AAAD is very limited.

Aortoduodenal syndrome.

Duodenal obstruction caused by abdominal aortic aneurysm (AAA), i.e. "aortoduodenal syndrome," first described by Osler in 1905 is a rare clinical entity, with only several dozens of cases reported in the literature. In the present paper, we systematically searched literature and reviewed them. Databases including MEDLINE and EMBASE were searched from January 1981 to April 2014 using Web-based search engines (PubMed and OVID). Eighteen papers reported 21 cases with aortoduodenal syndrome. Mean age of patients was 74.5±8.4 years, 71.4% of patients were men, and mean AAA diameter was 7.2±2.1 cm. We also discussed confusion between aortoduodenal syndrome and "superior mesenteric artery syndrome" associated with AAA.

A meta-analysis of the association of primary abdominal wall hernia with abdominal aortic aneurysm.

AIM: Aim of the study was to determine whether primary abdominal wall hernia (AWH) is associated with abdominal aortic aneurysm (AAA) presence, we performed a meta-analysis of studies investigating the association with primary AWH and AAA. METHODS: Medline and Embase were searched through January 2014 using Web-based search engines (PubMed and OVID). Studies considered for inclusion met the following criteria: the design was a comparative study; the study population was patients with AAA and subjects without AAA or patients with primary AWH and subjects without primary AWH; and outcomes included primary AWH incidence in both the AAA and control groups or AAA incidence in both the primary AWH and control groups. For each study, data regarding primary AWH incidence in both the AAA and control groups were used to generate unadjusted odds ratio (OR) and 95% confidence intervals (CIs). RESULTS: Of 151 potentially relevant articles screened initially, 14 eligible studies were identified and included. A pooled analysis of all the 14 studies demonstrated significantly higher primary AWH incidence in the AAA group than that in the control group in the random-effects model (OR 2.32; 95% CI, 1.72 to 3.14; P for effect <0.00001; P for heterogeneity <0.00001). When data from 5 studies reporting adjusted ORs and other 9 studies were combined separately, primary AWH was significantly associated with AAA presence. Eliminating 3 large-size population-based studies did not substantially change the pooled estimate. CONCLUSION: Primary AWH appears to be associated with AAA presence.

A meta-analysis of circulating homocysteine levels in subjects with versus without abdominal aortic aneurysm.

The aim of this paper was to summarize the present evidence for an association between circulating total homocysteine (tHcy) levels and abdominal aortic aneurysm (AAA) presence, we performed a meta-analysis. MEDLINE and EMBASE were searched through December 2013. Search terms included homocysteine, hyperhomocysteinemia, hyperhomocysteinaemia, and abdominal aortic aneurysm. Eligible studies were case-control or population-screening studies reporting circulating tHcy levels in cases with AAA and subjects without AAA. For each study, data regarding plasma or serum tHcy levels in both the AAA and control groups were used to generate standardized mean differences (SMDs) and 95% confidence intervals (CIs). Further, adjusted and unadjusted odds ratios (ORs) with 95% CI of AAA incidence for subjects with hyperhomocysteinemia were extracted. Of 42 potentially relevant articles screened initially, 9 eligible studies enrolling 1643 cases with AAA and 5460 subjects without AAA were identified and included. A pooled analysis demonstrated significantly greater circulating tHcy levels in the AAA than control group (SMD, 0.58; 95% CI, 0.36 to 0.79; P<0.00001). Another pooled analysis demonstrated a statistically significant 3.1-fold increase in AAA incidence for subjects with hyperhomocysteinemia (OR, 3.07; 95% CI, 1.59 to 5.92; P=0.0008). In conclusion, greater circulating tHcy levels are associated with AAA presence.

A meta-analysis of the association of obesity with abdominal aortic aneurysm presence.

AIM: The aim of this paper was to determine whether obesity is associated with abdominal aortic aneurysm (AAA) presence. We performed the first meta-analysis of currently available studies. METHODS: MEDLINE and EMBASE were searched through January 2014. Eligible studies were comparative studies comparing body mass index (BMI) in patients with AAA to that in subjects without AAA or estimating a relative risk of AAA prevalence for subjects with obesity (high BMI). RESULTS: Of 183 potentially relevant articles screened initially, 19 eligible studies enrolling 29,120 patients with AAA and 3,163,575 subjects without AAA were identified and included. A pooled analysis demonstrated no statistically significant difference between BMI in the AAA group and that in the control group: mean difference, 0.46 kg/m2; 95% confidence interval, -0.07 to 1.00 kg/m2; P=0.09. Another pooled analysis demonstrated that obesity was unassociated with a statistically significant increase in AAA prevalence: odds ratio, 1.07; 95% confidence interval, 0.94 to 1.22; P=0.30. There was no evidence of significant publication bias: P=0.69 and 0.90 for mean difference and odds ratio, respectively. CONCLUSION: Obesity appears to be unassociated with AAA presence.

A contemporary meta-analysis of the association of diabetes with abdominal aortic aneurysm.

AIM: Aim of the present study was to determine whether diabetes is independently and inversely associated with prevalence of abdominal aortic aneurysm (AAA). We performed a meta-analysis of contemporary literature in which adjusted (but not unadjusted) relative risk estimates are available. METHODS: MEDLINE and EMBASE were searched from January 1999 to April 2014 using Web-based search engines (PubMed and OVID). Studies considered for inclusion met the following criteria: the design was a prospective-cohort, population-screening, or case-control study; the study population was individuals with and without diabetes or AAA; and outcomes included adjusted (but not unadjusted) relative risks for prevalence/incidence of AAA in patients with diabetes versus subjects without diabetes. Study-specific adjusted relative risk estimate were combined using inverse variance-weighted average of logarithmic odds ratios (or hazard ratios) in the random-effects model. RESULTS: Of 324 potentially relevant articles screened initially, 13 eligible studies were identified and included. A pooled analysis of all the 13 studies demonstrated that diabetes was significantly associated with lower prevalence of AAA (odds ratio, 0.59; 95% confidence interval, 0.52 to 0.67; P<0.00001). When data from 6 prospective-cohort, 5 population-screening, and 2 case-control studies were separately pooled, diabetes was also significantly associated with lower prevalence of AAA (P for subgroup differences =0.05). CONCLUSION: Diabetes appears to be inversely associated with prevalence of AAA.

Meteorology in ruptured abdominal aortic aneurysm: an institutional study and a meta-analysis of published studies reporting atmospheric pressure.

The aim of this paper was to determine whether weather factors including atmospheric pressure are associated with the occurrence of ruptured abdominal aortic aneurysm (RAAA). We investigated our institutional experiences of RAAA in more than 150 patients during 8 years. Further, we performed a meta-analysis of published studies reporting the influence of atmospheric pressure on RAAA. We retrospectively evaluated 152 patients who underwent surgery for RAAA (including ruptured iliac arterial aneurysm) at our institute between 1 January 2006 and 31 December 2013. Daily regional meteorological data (in the nearest weather station located 3.5 km from the hospital) were obtained online from Japan Meteorological Agency. To identify comparative studies of mean atmospheric pressure on the day with RAAA versus that on the day without RAAA, MEDLINE and EMBASE were searched through January 2014 using Web-based search engines (PubMed and OVID). Mean sea level atmospheric pressure, delta mean atmospheric pressure (difference between mean sea level atmospheric pressure on the day and that on the previous day), and sunshine duration on the day with RAAA were significantly lower than those on the day without RAAA: 1012.43±7.44 versus 1013.71±6.49 hPa, P=0.039, -1.18±5.15 versus 0.05±5.62 hPa, P=0.005; and 4.76±3.76 versus 5.47±3.88 h, P=0.026; respectively. A pooled analysis of 8 studies (including our institutional study) demonstrated that mean atmospheric pressure on the day with RAAA was significantly lower than that on the day without RAAA: standardized mean difference, -0.09; 95% confidence interval, -0.14 to -0.04; P=0.0009. Atmospheric pressure on the day with RAAA appears lower than that on the day without RAAA. Atmospheric pressure may be associated with the occurrence of RAAA.

Requirement of integrin ß3 for iron transportation during enamel formation.

Rodent incisors exhibit pigmentation on their labial surfaces. Although previous studies have shown that this pigment is composed of iron, the existence of other elements has not been investigated. This study found that the lower incisors of CD61, also known as integrin ß3, null mice (CD61(-/-)) lacked pigmentation. Although ameloblasts differentiated and formed enamel normally, no ferric ion accumulation was observed in maturation-stage ameloblasts in CD61(-/-) mice. Surface elements of control and CD61-/- lower incisors were compared by x-ray photoelectron spectroscopy (XPS). XPS analysis detected C, Ca, N, O, and P on the labial surfaces of lower incisors of both mice, whereas Fe was detected only in control samples. No peak of non-ferrous metal or other element was detected in either group. Quantitative RT-PCR analysis of 18 iron-transportation-related genes with mRNA from maturation-stage ameloblasts and ALC, a pre-ameloblastic cell line, was performed. The results suggested that CD61 regulates the expressions of Slc11a2 and Slc40a1, both of which are involved in iron transportation in epithelial tissues. These results suggested that the pigment on the labial surface of mouse incisors is composed of Fe and that both anemia and reduction of iron-transporting proteins may cause the loss of pigmentation in CD61(-/-) mice.

Effects of statin therapy on abdominal aortic aneurysm growth: a meta-analysis and meta-regression of observational comparative studies.

OBJECTIVE: To determine whether statin therapy reduces the growth rate of small abdominal aortic aneurysms (AAAs). DESIGN: A meta-analysis and a meta-regression of comparative studies. MATERIALS: Eligible studies were randomized controlled trials or observational comparative studies of statin therapy versus placebo or no statin, enrolling individuals with small (<55 mm in diameter) AAAs and reporting AAA growth rate as an outcome. METHODS: Study-specific estimates (standardized mean differences [SMDs]) were combined in the fixed- and random-effects model. RESULTS: Seven adjusted and 4 unadjusted observational comparative studies enrolling 4647 patients with a small AAA were identified. Pooled analysis of all 11 studies suggested a significant reduction in AAA growth rate among patients assigned to statin therapy versus no statin (SMD, -0.420; 95% confidence interval [CI], -0.651 to -0.189). Combining the 7 high-quality studies providing adjusted data for growth rates generated an attenuated but still statistically significant result favoring statin therapy (SMD, -0.367; 95% CI, -0.566 to -0.168). The meta-regression coefficient for the baseline diameter was statistically significant (-0.096; 95% CI, -0.132 to -0.061). CONCLUSION: Statin therapy is likely effective in prevention of the growth of small AAAs, and may be more beneficial as the baseline diameter increases.

Serum high-density and low-density lipoprotein cholesterol is associated with abdominal aortic aneurysm presence: a systematic review and meta-analysis.

AIM: To summarize the present evidence for an association between high-density lipoprotein (HDL) or low-density lipoprotein (LDL) cholesterol and abdominal aortic aneurysm (AAA) presence, we performed a systematic review and meta-analysis of case-control studies that compared serum HDL or LDL cholesterol between patients with AAA and control subjects. METHODS: MEDLINE and EMBASE databases were searched to identify all case-control studies that compared serum HDL or LDL cholesterol between patients with AAA and control subjects. For each study, data regarding serum HDL or LDL cholesterol in both the AAA and control groups were used to generate mean differences (MDs) and 95% confidence intervals (CIs). Study-specific estimates were combined using inverse variance-weighted average of logarithmic MDs in both fixed- and random-effects models. RESULTS: Our search identified 8 eligible studies including 812 patients with AAA and 8 267 control subjects. Pooled analysis demonstrated significantly lower serum HDL cholesterol (MD, -0.15 mmol/L; 95% CI, -0.24 to -0.07 mmol/L; P=0.0006) and significantly higher serum LDL cholesterol (MD, 0.25 mmol/L; 95% CI, 0.08 to 0.42 mmol/L; P=0.004) in the AAA group than those in the control group in random-effect models. There was significant study heterogeneity of results but no evidence of significant publication bias. Several sensitivity analyses did not substantively alter the overall result of our analysis. CONCLUSION: We found that, based on a systematic review and meta-analysis, serum HDL cholesterol is likely lower and serum LDL cholesterol is likely higher in patients with AAA than control subjects. Lower serum HDL cholesterol and higher serum LDL cholesterol may be associated with AAA presence.

Plasma fibrinogen and D-dimer concentrations are associated with the presence of abdominal aortic aneurysm: a systematic review and meta-analysis.

OBJECTIVES: To summarise the present evidence for an association between circulating fibrinogen or D-dimer and presence of abdominal aortic aneurysm (AAA) presence. DESIGN: MEDLINE database was searched to identify all case-control studies that compared plasma fibrinogen or D-dimer concentrations between patients with AAA and subjects without AAA. For each study, data regarding fibrinogen or D-dimer concentrations in both the AAA and control groups were used to generate mean differences (MDs) and 95% confidence intervals (CIs). Study-specific estimates were combined using inverse variance-weighted average of logarithmic MDs in both fixed- and random-effects models. RESULTS: Our search identified 10 eligible studies including 834 cases with AAA and 6971 controls without AAA for fibrinogen and six studies including 264 patients with AAA and 403 subjects without AAA for D-dimer. Pooled analysis demonstrated significantly higher fibrinogen (fixed-effects MD, 0.37gl(-1); 95% CI: 0.30-0.44gl(-1)) and D-dimer (random-effects MD: 415.36ngml(-1); 95% CI: 128.97-701.76ngml(-1)) concentrations in the AAA group than those in the control group. CONCLUSIONS: We found that plasma fibrinogen and D-dimer concentrations are likely to be higher in cases with AAA than control subjects. Higher plasma fibrinogen and D-dimer concentrations may be associated with the presence of AAA.

Biological properties of the native and synthetic lipid A of Porphyromonas gingivalis lipopolysaccharide.

INTRODUCTION AND METHODS: A pentaacyl and diphosphoryl lipid A molecule found in the lipid A isolated from Porphyromonas gingivalis lipopolysaccharide (LPS) was chemically synthesized, and its characteristics were evaluated to reconfirm its interesting bioactivities including low endotoxicity and activity against LPS-unresponsive C3H/HeJ mouse cells. RESULTS: The synthesized P. gingivalis lipid A (synthetic Pg-LA) exhibited strong activities almost equivalent to those of Escherichia coli-type synthetic lipid A (compound 506) in all assays on LPS-responsive mice, and cells. LPS and native lipid A of P. gingivalis displayed overall endotoxic activities, but its potency was reduced in comparison to the synthetic analogs. In the assays using C3H/HeJ mouse cells, the LPS and native lipid A significantly stimulated splenocytes to cause mitosis, and peritoneal macrophages to induce tumor necrosis factor-alpha and interleukin-6 production. However, synthetic Pg-LA and compound 506 showed no activity on the LPS-unresponsive cells. Inhibition assays using some inhibitors including anti-human Toll-like receptor 2 (TLR2) and TLR4/MD-2 complex monoclonal antibodies showed that the biological activity of synthetic Pg-LA was mediated only through the TLR4 signaling pathway, which might act as a receptor for LPS, whereas TLR2, possibly together with CD14, was associated with the signaling cascade for LPS and native lipid A of P. gingivalis, in addition to the TLR4 pathway. CONCLUSION: These results suggested that the moderated and reduced biological activity of P. gingivalis LPS and native lipid A, including their activity on C3H/HeJ mouse cells via the TLR2-mediated pathway, may be mediated by bioactive contaminants or low acylated molecules present in the native preparations having multiple lipid A moieties.

Induction of immune responses and prevention of alveolar bone loss by intranasal administration of mice with Porphyromonas gingivalis fimbriae and recombinant cholera toxin B subunit.

INTRODUCTION: Adult periodontitis is initiated by specific periodontal pathogens represented by Porphyromonas gingivalis; however, an effective measure for preventing the disease has not yet been established. In this study, the effectiveness of a vaccine composed of fimbriae of P. gingivalis and recombinant cholera toxin B subunit (rCTB) was evaluated using BALB/c mice. METHODS: Fimbriae and rCTB were co-administered intranasally to BALB/c mice on days 0, 14, 21, and 28. On day 35, mice were sacrificed to determine immunoglobulin levels in serum, saliva, and nasal and lung extracts by enzyme-linked immunosorbent assay. The prevention effect of the vaccine on P. gingivalis-induced periodontitis in mice was evaluated by measuring alveolar bone loss. RESULTS: The rCTB significantly increased serum immunoglobulin (Ig)A levels when mice were administered with a minimal amount (0.5 microg) of the fimbrial antigen. The adjuvant effect on serum IgG production was indistinct because the minimal amount of the antigen still induced a large amount of IgG. In contrast to systemic responses, a fimbria-specific secretory IgA response was strongly induced by co-administration of rCTB and 0.5 microg fimbriae; the same amount of the antigen alone scarcely induced a response. Histopathological examination revealed IgA-positive plasma cells in the nasal mucosal tissue but no observable mast cells in the area. In addition, nasal administration of the fimbrial vaccine significantly protected the mice from P. gingivalis-mediated alveolar bone loss. CONCLUSION: Nasal vaccination with a combination of fimbriae and rCTB can be an effective means of preventing P. gingivalis-mediated periodontitis.

Postoperative incision hernia in patients with abdominal aortic aneurysm and aortoiliac occlusive disease: a systematic review.

OBJECTIVES: We conducted a systematic review to determine the incidence of postoperative incision hernia in patients with abdominal aortic aneurysm compared to those with aortoiliac occlusive disease. METHODS: Studies which compared the incidence of postoperative incision hernia in patients with abdominal aortic aneurysm and aortoiliac occlusive disease undergoing midline incision for arterial reconstruction were identified. MEDLINE was searched for articles published between January 1966 and September 2005. RESULTS: Our search identified seven studies including data on 1132 patients, 719 with abdominal aortic aneurysm and 413 with aortoiliac occlusive disease. Pooled analysis demonstrated that patients with abdominal aortic aneurysm had a 2.9-fold increased risk of inguinal hernia (odds ratio 2.85, 95% confidence interval 1.71-4.77, p<0.0001), and a 2.8-fold risk of incisional hernia (2.79, 1.88-4.13, p<0.0001). Adjusting for other known risk factors patients with aortic aneurysm had a 5-fold increased risk of incisional hernia (5.45, 2.48-11.94, p<0.0001). CONCLUSIONS: Patients with abdominal aortic aneurysm appear to have an approximately 3-fold increased risk for both inguinal and postoperative incision hernia compared to patients with aortoiliac occlusive disease. A large multi-centre prospective study is needed to confirm the results of this review.