Robotic thyroidectomy using gas-insufflation one-step single-port transaxillary (GOSTA) approach.

BACKGROUND: We conducted this study to report our novel robotic thyroidectomy using gas-insufflation one-step single-port transaxillary (GOSTA) approach and compare it with a conventional transaxillary (CTA) approach using a retraction method for intraoperative and postoperative outcomes. METHODS: We retrospectively analyzed 354 patients who underwent robotic thyroidectomy between January 2019 and April 2023. Of these patients, 143 underwent the procedure through the GOSTA approach, which involves a small incision of 3 cm along the axillary folds with both arms down and a gas-insufflation, from skin flap creation to the completion of thyroidectomy as a one-step single-port procedure without the need for a retractor. The remaining 211 patients underwent the CTA approach. We analyzed the GOSTA approach and compared the surgical outcomes of the GOSTA (n = 100) and CTA (n = 167) approaches in patients with differentiated thyroid cancer who underwent thyroid lobectomy. RESULTS: Out of the 143 patients who underwent the GOSTA approach, 12 underwent total thyroidectomy and 9 underwent lateral neck lymph node dissection with total thyroidectomy. GOSTA-thyroid lobectomy was performed on 122 patients; of these, 100 were diagnosed with differentiated thyroid carcinoma. A comparative study with the CTA approach was only conducted in patients who underwent thyroid lobectomy. No significant differences were found in operative time, hospital stay, or complications between the two groups. CONCLUSIONS: Despite proceeding in one-step with a single smaller incision, from skin flap creation to the completion of thyroidectomy, the GOSTA approach is as feasible and safe as the CTA approach. Additionally, the GOSTA approach allows for thyroidectomy without using a retractor and reduces the workload for the surgeon and assistants.

Comparison of robotic and laparoscopic lateral transperitoneal adrenalectomies.

Purpose: This study aimed to compare the intraoperative and postoperative outcomes between robotic and laparoscopic transperitoneal adrenalectomies. Methods: In this retrospective study, 93 patients underwent adrenalectomy using 2 surgical modalities: 45 patients underwent adrenalectomy using the da Vinci Xi system (robotic group), and 48 patients using laparoscopic devices (laparoscopic group). We compared the operation time, intraoperative bleeding, and hospital stay according to the surgical modality and tumor characteristics. Results: There were no significant differences in the operative time (P = 0.827), hospital stay (P = 0.177), and intraoperative bleeding (P = 0.174) between the groups. However, the robotic group showed a lower coefficient of variation in total operative time than that of the laparoscopic group (100.6 ± 23.3 minutes vs. 101.9±32.7 minutes, 0.230 vs. 0.321). When divided into 2 subgroups based on the tumor size (<3 cm and ≥3 cm), the robotic group with a tumor sized >3 cm had a shorter operative time than that of the laparoscopic group (P = 0.032). The robotic group also had fewer cases of intraoperative bleeding (P = 0.034). Conclusions: Compared to the laparoscopic transperitoneal adrenalectomy, the robotic one achieved a lower deviation in total operative time and showed less bleeding and a shorter operative time, especially for tumors sized >3 cm.

Lower Incidence of Postoperative Urinary Retention in Robotic Total Mesorectal Excision for Low Rectal Cancer Compared with Laparoscopic Surgery.

INTRODUCTION: The incidence and clinical significance of postoperative urinary retention (POUR) remain high. This study aimed to evaluate the incidence of POUR and related risk factors in patients who underwent total mesorectal excision (TMR) for low rectal cancer. METHODS: This study is a retrospective review of a prospectively collected colorectal database from a single center. Data from patients who underwent surgery for low rectal cancer between September 2006 and May 2017 were analyzed to assess the risk factors of POUR. POUR was considered inability to void after urinary catheter removal requiring catheter reinsertion and difficulty in bladder emptying requiring intermittent catheterization. RESULTS: Of 555 patients with low rectal cancer, 78 (14.1%) developed POUR. Based on multivariate logistic regression analysis, laparoscopic TMR (odds ratio [OR]; 2.114, 95% confidence interval [CI]; 1.212-3.689, p = 0.008) and postoperative ileus (OR; 2.389, 95% CI; 1.282-4.450, p = 0.006) were independent risk factors of POUR. Male gender, advanced age, neoadjuvant chemoradiation, longer operative time, abdominoperineal resection, and lateral pelvic lymph node dissection were not associated with POUR. Advanced age over 65 years also failed to show statistical significance (OR; 1.604, 95% CI; 0.965-2.668, p = 0.068). CONCLUSION: Laparoscopic approach and postoperative ileus are risk factors for POUR after low rectal cancer surgery. We postulate that the benefits of robotic surgical systems compared to a laparoscopic approach may reduce the incidence of POUR.

Comparison of Single Incision Endoscopic Nipple-Sparing Mastectomy and Conventional Nipple-Sparing Mastectomy for Breast Cancer Based on Initial Experience.

PURPOSE: Endoscopic breast surgery for patients with breast cancer was introduced for its superior cosmetic outcomes; it was initially studied in the field of breast-conserving surgery and, more recently, in robotic-assisted nipple-sparing mastectomy (NSM). The main purpose of this study was to investigate the feasibility and safety of endoscopic NSM (E-NSM) in patients with breast cancer by comparing E-NSM and conventional NSM (C-NSM). METHODS: Between May 2017 and October 2020, we retrieved the records of 45 patients who underwent NSM with permanent silicone implants and divided them into the E-NSM group (20 patients) and the C-NSM group (25 patients), depending on the use of the endoscopic device. We also analyzed demographic information, pathology, operative time, and complications. RESULTS: No significant differences were observed between the 2 groups based on demographic information, postoperative pathological data, mean length of hospital stay, and total number of complications. The mean preparation time for surgery was comparable between both groups. Compared to the C-NSM group, the E-NSM group had a significantly longer mean operative time and, subsequently, a significantly longer mean total operative time and number of complications. CONCLUSION: The results showed that E-NSM was feasible and safe with a more inconspicuous incision in patients with breast cancer.

Detailed comparison of the da Vinci Xi and S surgical systems for transaxillary thyroidectomy.

ABSTRACT: Robotic surgical systems have evolved over time. The da Vinci Xi system was developed in 2014 and was expected to solve the shortcomings of the previous S system. Therefore, we conducted this study to compare these 2 systems and identify if the Xi system truly improves surgical outcomes.In this retrospective study, a total of 86 patients with unilateral papillary thyroid carcinoma without central lymph node involvement underwent gasless transaxillary hemithyroidectomy using 2 robotic systems, the da Vinci S and Xi. Forty patients were in the da Vinci S group and 46 patients were in the da Vinci Xi group. All surgeries were performed by 1 surgeon (YWC). All surgery video files were analyzed to compare the duration of each surgical step.The total operation time was significantly shorter in the Xi group than in the S group (153.0 minutes vs 105.7 minutes, P < .01). Time for robot docking was shorter in the Xi group (19.8 minutes vs 10.6 minutes, P < .01), and all procedures performed in the console also required a shorter time in this group. The overall complication rate did not differ significantly (P = .464).The da Vinci Xi system made robotic thyroidectomy easier and faster without increasing the complication rate. It is a safe and valuable system for robotic thyroidectomy.

Clinical significance of pancreatic intraepithelial neoplasia in resectable pancreatic cancer on survivals.

PURPOSE: Noninvasive precursor lesions for pancreatic adenocarcinoma include pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm. PanIN is often found synchronously adjacent to resected pancreatic ductal adenocarcinoma (PDAC) tumors. However, its prognostic significance on outcome after PDAC resection is unknown. The purpose of the current study was to determine if the presence of PanIN has a prognostic or predictive effect on survival after resection for PDAC with curative intent. METHODS: We retrospectively reviewed the clinicopathologic data of patients who underwent pancreatectomy for PDAC from January 2002 to January 2013. Intraductal papillary mucinous lesions and mucinous cystic neoplasms were excluded. All available postoperative imaging and clinical follow-up data were reviewed. RESULTS: There were 95 patients who underwent pancreatectomy. Tumors were most commonly located in the pancreas head and as such pancreaticoduodenectomy was the most commonly performed operation. The median tumor size was 3.2 cm. An absence of PanIN lesions was identified in 39 patients (41%). Of the patients with PanIN lesions, high-grade PanIN (grade 3) was the most common type (64.3%) followed by grade 2 (28.6%). There was no significant difference in overall survival or disease-free survival between the non-PanIN and PanIN groups. CONCLUSION: The presence or absence of PanIN lesions did not affect survival in patients undergoing resection for pancreatic cancer. However, patients with high-grade PanINs tended to have better overall survival. Larger studies with longer follow up are needed to accurately determine its clinical significance.

Glutamine synthetase gene knockout-human embryonic kidney 293E cells for stable production of monoclonal antibodies.

Previously, it was inferred that a high glutamine synthetase (GS) activity in human embryonic kidney (HEK) 293E cells results in elevated resistance to methionine sulfoximine (MSX) and consequently hampers GS-mediated gene amplification and selection by MSX. To overcome this MSX resistance in HEK293E cells, a GS-knockout HEK293E cell line was generated using the CRISPR/Cas9 system to target the endogenous human GS gene. The GS-knockout in the HEK293E cell line (RK8) was confirmed by Western blot analysis of GS and by observation of glutamine-dependent growth. Unlike the wild type HEK293E cells, the RK8 cells were successfully used as host cells to generate a recombinant HEK293E cell line (rHEK293E) producing a monoclonal antibody (mAb). When the RK8 cells were transfected with the GS expression vector containing the mAb gene, rHEK293E cells producing the mAb could be selected in the absence as well as in the presence of MSX. The gene copies and mRNA expression levels of the mAb in rHEK293E cells were also quantified using qRT-PCR. Taken together, the GS-knockout HEK293E cell line can be used as host cells to generate stable rHEK293E cells producing a mAb through GS-mediated gene selection in the absence as well as in the presence of MSX.

Limitations to the development of recombinant human embryonic kidney 293E cells using glutamine synthetase-mediated gene amplification: Methionine sulfoximine resistance.

To investigate the feasibility of glutamine synthetase (GS)-mediated gene amplification in HEK293 cells for the high-level stable production of therapeutic proteins, HEK293E cells were transfected by the GS expression vector containing antibody genes and were selected at various methionine sulfoximine (MSX) concentrations in 96-well plates. For a comparison, CHOK1 cells were transfected by the same GS expression vector and selected at various MSX concentrations. Unlike CHOK1 cells, HEK293E cells producing high levels of antibodies were not selected at all. For HEK293E cells, the number of wells with the cell pool did not decrease with an increase in the concentration of MSX up to 500µM MSX. A q-RT-PCR analysis confirmed that the antibody genes in the HEK293E cells, unlike the CHOK1 cells, were not amplified after increasing the MSX concentration. It was found that the GS activity in HEK293E cells was much higher than that in CHOK1 cells (P<0.05). In a glutamine-free medium, the GS activity of HEK293E cells was approximately 4.8 times higher than that in CHOK1 cells. Accordingly, it is inferred that high GS activity of HEK293E cells results in elevated resistance to MSX and therefore hampers GS-mediated gene amplification by MSX. Thus, in order to apply the GS-mediated gene amplification system to HEK293 cells, the endogenous GS expression level in HEK293 cells needs to be minimized by knock-out or down-regulation methods.

Left paraduodenal hernia accompanying chylous ascites.

Paraduodenal hernia is by far the most common form of congenital internal hernia. Chylous ascites is an accumulation of lymphatic fluid in the peritoneal cavity. It develops when the lymphatic system is disrupted due to traumatic injury or obstruction. A 40-year-old, woman showed up to the Emergency Department with severe, colicky abdominal pain. Tenderness and rebound tenderness were observed at the left abdomen. Abdominal CT confirmed a cluster of dilated proximal small bowel loops with ischemic change, without ascites. The patient underwent an emergency surgery to relieve bowel ischemia. As soon as the peritoneum was exposed, 1.5 L of chylous fluid was found. A hernial sac was found along the posterior side of the mesentery of the inferior mesenteric artery. We resected the hernial sac and pulled out the herniated small bowel. On the sixth day after the surgery, she was discharged without any complication.

Effect of Bcl-x(L) overexpression on lactate metabolism in chinese hamster ovary cells producing antibody.

Previously, overexpression of anti-apoptotic proteins, such as E1B-19K and Aven, was reported to alter lactate metabolism of CHO cells in culture. To investigate the effect of Bcl-xL , a well-known anti-apoptotic protein, on lactate metabolism of recombinant CHO (rCHO) cells, two antibody-producing rCHO cell lines with regulated Bcl-xL overexpression (CS13*-0.02-off-Bcl-xL and CS13*-1.00-off-Bcl-xL ) were established using the Tet-off system. When cells were cultivated without Bcl-xL overexpression, the specific lactate production rate (qLac ) of CS13*-0.02-off-Bcl-xL and CS13*-1.00-off-Bcl-xL were 7.32 ± 0.37 and 6.78 ± 0.56 pmol/cell/day, respectively. Bcl-xL overexpression, in the absence of doxycycline, did not affect the qLac of either cell line, though it enhanced the viability during cultures. Furthermore, activities of the enzymes related to glucose and lactate metabolism, such as hexokinase, glucose-6-phosphate dehydrogenase, lactate dehydrogenases, and alanine aminotransferase, were not affected by Bcl-xL overexpression either. Taken together, Bcl-xL overexpression showed no significant effect on the lactate metabolism of rCHO cells.

Combinatorial engineering of ldh-a and bcl-2 for reducing lactate production and improving cell growth in dihydrofolate reductase-deficient Chinese hamster ovary cells.

In Chinese hamster ovary (CHO) cells, rapid glucose metabolism normally leads to inefficient use of glucose, most of which is converted to lactate during cell cultures. Since lactate accumulation during the culture often exerts a negative effect on cell growth and valuable product formation, several genetic engineering approaches have been developed to suppress lactate dehydrogenase-A (LDH-A), the enzyme converting pyruvate into lactate. However, despite the reduced lactate accumulation, such cell cultures are eventually terminated in the late period of the culture, mainly due to apoptosis. Therefore, we developed an apoptosis-resistant, less lactate-producing dhfr(-) CHO cell line (CHO-Bcl2-LDHAsi) by overexpressing Bcl-2, one of the most well-known anti-apoptotic proteins, and by downregulating LDH-A in a dhfr(-) CHO cell line. When the dhfr(-) CHO-Bcl2-LDHAsi cell line was used as a host cell line for the development of recombinant CHO (rCHO) cells producing an Fc-fusion protein, the culture longevity of the rCHO cells was extended without any detrimental effect of genetic engineering on specific protein productivity. Simultaneously, the specific lactate production rate and apparent yield of lactate from glucose were reduced to 21-65% and 37-78% of the control cells, respectively. Taken together, these results show that the use of an apoptosis-resistant, less lactate-producing dhfr(-) CHO cell line as a host cell line saves the time and the effort of establishing an apoptosis-resistant, less lactate-producing rCHO cells for producing therapeutic proteins.