Enhanced-view totally extraperitoneal repair in a morbidly obese patient with epigastric and umbilical hernias in combination with rectus diastasis: A case report.

INTRODUCTION: The use of enhanced-view totally extraperitoneal (eTEP) repair for patients with ventral hernias has become more widespread due to its ability to prevent mesh-and-tacker-related complications by placing the mesh in the retrorectus space. However, the efficacy of eTEP repair in obese patients remains unknown. Herein, we report a case of a morbidly obese patient with epigastric and umbilical hernias in combination with a rectus diastasis repaired using the eTEP technique. PRESENTATION OF CASE: A 42-year-old man with a history of spontaneously reduced incarcerated epigastric hernia two weeks previously was referred to our hospital. His body mass index (BMI) was 42.9 kg/m2. Abdominal computed tomography revealed a small epigastric hernia, an umbilical hernia, and a rectus diastasis. We performed eTEP repair. The postoperative course was uneventful, and the patient was discharged on postoperative day 3. There has been no evidence of hernia recurrence after a follow-up period of 2 years. DISCUSSION: We consider that the eTEP technique is rarely affected by intra-abdominal fat because endoscopic manipulation is performed in the bilateral retrorectus and preperitoneal spaces. Moreover, the eTEP allows the epigastric artery perforator to be spared. Therefore, eTEP repair is considered the best surgical option for morbidly obese patients with ventral hernias in combination with rectus diastasis. CONCLUSIONS: This case provides support for the efficacy of eTEP repair in morbidly obese patients with epigastric and umbilical hernias in combination with a rectus diastasis.

Simplified risk stratification in early cholecystectomy for acute cholecystitis based on age: A report from an institution with zero mortality.

BACKGROUND/PURPOSE: The existing risk stratification for early cholecystectomy in patients with acute cholecystitis (AC) is complex. This study aims to establish a simpler risk assessment for surgical complications after cholecystectomy based on age group. METHODS: This single-center retrospective observational study enrolled 350 patients diagnosed with AC who underwent early cholecystectomy within 72 h of diagnosis from 2013 to 2021. Patients were divided into three subgroups based on age: young (<65 years), elderly (65-79 years), and very elderly (≥80 years). Since no mortality was observed, risk factors for the Clavien-Dindo (CD) grade ≥ II complications were identified within the entire cohort and in each subgroup. RESULTS: There were 120 young, 130 elderly, and 100 very elderly patients. The overall prevalence of complications with CD grade ≥ II was 11.1%. Age and Tokyo Guidelines 18 (TG18) severity were independent risk factors for surgical complications in the whole cohort. Subgroup analysis revealed that there was no independent risk factor in the young group. Meanwhile, age and poor physical status were independent risk factors in the elderly group, and TG18 severity in the very elderly group. CONCLUSION: Evaluation of only age, physical status, and TG18 severity may be sufficient for risk stratification of surgical complications of AC.

Laparoscopic repair for interparietal hernia after enhanced-view totally extraperitoneal hernia repair: A case report.

INTRODUCTION: The enhanced-view totally extraperitoneal (eTEP) technique, an endoscopically performed Rives-Stoppa method, has been used extensively for ventral hernia repairs. However, in this technique, the necessity of posterior rectus sheath re-approximation and mesh fixation remains unclear. There are a few reports of post-eTEP interparietal hernias (IHs) occurring because of dehiscence of the re-approximated posterior rectus sheath; however, IH secondary to mesh migration is rare. Herein, we report a rare case of IH due to mesh migration after eTEP repair for an incisional hernia. PRESENTATION OF CASE: A 70-year-old man underwent eTEP repair for an incisional hernia using a self-gripping mesh without mesh fixation and posterior rectus sheath re-approximation one year previously, developed an IH. An elective laparoscopic surgery revealed an orifice to the retrorectus space as though the IH sac between the retrorectus muscle and the posterior layer including the bilateral posterior rectus sheaths, peritoneum, and mesh. We placed eight transmural sutures with 0 nylon thread and closed the orifice. The patient was then discharged on postoperative day two and was asymptomatic at 24 months without evidence of ventral hernia recurrence. DISCUSSION: We consider that strenuous activity and deep bending may cause mesh migration or dislocation. If that occurs in the early post-eTEP period without posterior rectus sheaths closure, the vulnerable peritoneal area will be exposed, which consider to be an IH orifice. CONCLUSIONS: Even after using the self-gripping mesh in eTEP repair, mesh fixation remains the best option to prevent postoperative complications, including IH.

Is Palliative Gastrojejunostomy for Malignant Gastric Outlet Obstruction an Optimal Choice for Very Elderly Patients? A Report from a Long-Lived Country.

BACKGROUND: Gastrojejunostomy (GJ) is a surgical option for malignant gastric outlet obstruction (mGOO). Confronting an aging society, the demand to treat elderly cancer patients with unresectable malignancies is increasing; however, the benefit of GJ to the very elderly (≥ 80 years of age) has never been investigated. METHODS: This multicenter, retrospective review included 108 patients who had undergone GJ for mGOO from two medical centers in Japan, one of the most long-lived countries. Patients were divided into two groups, with 80 years of age as the cut-off. Various factors, including surgical complications and patient survival, were compared. RESULTS: GJ in the very elderly (aged ≥ 80 years) was associated with a higher incidence of surgical complications (p = 0.049), such as delayed gastric emptying (DGE; p < 0.001), aspiration pneumonia (p = 0.029), and consequent mortality (p = 0.016). Age ≥80 years was also identified as an independent predictor of DGE (odds ratio 6.444, p = 0.005) and survival after GJ (hazard ratio 7.767, p = 0.016). In particular, the median survival time after GJ in the population aged ≥80 years with gastric cancer was only < 2 months. About the surgical procedure, antiperistaltic anastomosis with partial stomach partitioning (PSP) yielded the lowest occurrence rate of DGE (3.4%) and aspiration pneumonia (1.7%). CONCLUSIONS: GJ does not seem to be the optimal choice for very elderly patients, particularly those with gastric cancer. If performed, antiperistaltic anastomosis with PSP should be employed to reduce the surgical complications.

miR-451a levels rather than human papillomavirus vaccine administration is associated with the severity of murine experimental autoimmune encephalomyelitis.

Human papilloma virus (HPV) vaccine is currently the most effective prophylaxis to prevent cervical cancer. However, concerns regarding its potential severe adverse reactions have limited the vaccination rate. HPV vaccines have been determined to contain adjuvants which induce inflammation by the innate immune system and are crucial for triggering adaptive immunity. MicroRNA-451a (miR-451a) is located within circulating extracellular vesicles (EVs) and regulates the innate immune response. In this study, we examined the effect of HPV vaccines and EV miR-451a on murine experimental autoimmune encephalomyelitis (EAE), which is an autoimmune disorder that affects the central nervous system. Although HPV vaccine induced pro-inflammatory cytokine expression and macrophage cell death, it failed to exacerbate mouse EAE, whereas circulating EV miR-451a levels were associated with the severity of EAE. Since miR-451a knockout exhibited only marginal effect on the murine EAE clinical score, our data suggest that miR-451a levels reflect an unknown condition associated with EAE severity. Interestingly, excessive uptake of glucose increased EV miR-451a levels both in vitro and in vivo and also exacerbated mouse EAE. Therefore, environmental factors that increase EV miR-451a levels exacerbate the autoimmune disorder more than the HPV vaccine. These observations provide evidence for the safety of HPV vaccines.

Immune-regulatory microRNA expression levels within circulating extracellular vesicles correspond with the appearance of local symptoms after seasonal flu vaccination.

Extracellular vesicles (EVs) contain microRNAs (miRNAs) that regulate the innate immune responses, such as the production of pro-inflammatory cytokines. The excessive production of pro-inflammatory cytokines after vaccination can cause local adverse reactions, such as pain, itching, swelling, and redness. Previous studies have shown that circulating EV miR-451a regulates innate immune responses, and miR-451a levels in serum EVs are negatively correlated with the pro-inflammatory cytokine expression levels in response to the influenza vaccine. Since excessive pro-inflammatory cytokine production is a cause of the local adverse reactions to vaccination, we investigated whether miR-451a levels in serum EVs correlate with local symptoms at the vaccination site, such as pain, itching, swelling, and redness. Interestingly, miR-451a levels in serum EVs were inversely correlated with the number of symptoms after vaccination. We determined the level of several other immune-regulatory miRNAs in serum EVs. Using the immune-regulatory miRNA levels of miR-22, miR-29a, miR-451a, and miR-107, we calculated a normalized miRNA level for each healthy donor and found that the normalized miRNA levels were significantly correlated with the number of local symptoms after vaccination. Our data indicated that immune-regulatory miRNA levels in serum EVs can be used as biomarkers to assess local symptoms after influenza vaccination.

Activation of TLR3 and its adaptor TICAM-1 increases miR-21 levels in extracellular vesicles released from human cells.

Pattern-recognition receptors (PRRs) recognizes viral RNAs and trigger the innate immune responses. Toll-like receptor 3 (TLR3), a PRR, recognizes viral double-stranded RNA (dsRNA) in endolysosomes, whereas cytoplasmic dsRNA is sensed by another PRR, MDA5. TLR3 and MDA5 utilize TICAM-1 and MAVS, respectively, to trigger the signal for inducing innate immune responses. Extracellular vesicles (EVs) include the exosomes and microvesicles; an accumulating body of evidence has shown that EVs delivers functional RNA, such as microRNAs (miRNAs), to other cells and thus mediate intercellular communications. Therefore, EVs carrying miRNAs affect innate immune responses in macrophages and dendritic cells. However, the mechanism underlying the regulation of miRNA levels in EVs remains unclear. To elucidate the mechanism, we sought to reveal the pathway that control miRNA expression levels in EVs. Here, we found that TLR3 stimulation increased miR-21 levels in EVs released from various types of human cells. Ectopic expression of the TLR3 adaptor, TICAM-1, increased miR-21 levels in EVs but not intracellular miR-21 levels, suggesting that TICAM-1 augmented sorting of miR-21 to EVs. In contrast, the MDA5 adaptor, MAVS, did not increase miR-21 levels in EVs. The siRNA for TICAM-1 reduced EV miR-21 levels after stimulation of TLR3. Collectively, our data indicate a novel role of the TLR3-TICAM-1 pathway in controlling miR-21 levels in EVs.

Comparison of the paralogous transcription factors AraR and XlnR in Aspergillus oryzae.

The paralogous transcription factors AraR and XlnR in Aspergillus regulate genes that are involved in degradation of cellulose and hemicellulose and catabolism of pentose. AraR and XlnR target the same genes for pentose catabolism but target different genes encoding enzymes for polysaccharide degradation. To uncover the relationship between these paralogous transcription factors, we examined their contribution to regulation of the PCP genes and compared their preferred recognition sequences. Both AraR and XlnR are involved in induction of all the pentose catabolic genes in A. oryzae except larA encoding L-arabinose reductase, which was regulated by AraR but not by XlnR. DNA-binding studies revealed that the recognition sequences of AraR and XlnR also differ only slightly; AraR prefers CGGDTAAW, while XlnR prefers CGGNTAAW. All the pentose catabolic genes possess at least one recognition site to which both AraR and XlnR can bind. Cooperative binding by the factors was not observed. Instead, they competed to bind to the shared sites. XlnR bound to the recognition sites mentioned above as a monomer, but bound to the sequence TTAGSCTAA on the xylanase promoters as a dimer. Consequently, AraR and XlnR have significantly similar, but not the same, DNA-binding properties. Such a slight difference in these paralogous transcription factors may lead to complex outputs in enzyme production depending on the concentrations of coexisting inducer molecules in the natural environment.