Precise highlighting of the pancreas by semantic segmentation during robot-assisted gastrectomy: visual assistance with artificial intelligence for surgeons.

BACKGROUND: A postoperative pancreatic fistula (POPF) is a critical complication of radical gastrectomy for gastric cancer, mainly because surgeons occasionally misrecognize the pancreas and fat during lymphadenectomy. Therefore, this study aimed to develop an artificial intelligence (AI) system capable of identifying and highlighting the pancreas during robot-assisted gastrectomy. METHODS: A pancreas recognition algorithm was developed using HRNet, with 926 training images and 232 validation images extracted from 62 scenes of robot-assisted gastrectomy videos. During quantitative evaluation, the precision, recall, intersection over union (IoU), and Dice coefficients were calculated based on the surgeons' ground truth and the AI-inferred image from 80 test images. During the qualitative evaluation, 10 surgeons answered two questions related to sensitivity and similarity for assessing clinical usefulness. RESULTS: The precision, recall, IoU, and Dice coefficients were 0.70, 0.59, 0.46, and 0.61, respectively. Regarding sensitivity, the average score for pancreas recognition by AI was 4.18 out of 5 points (1 = lowest recognition [less than 50%]; 5 = highest recognition [more than 90%]). Regarding similarity, only 54% of the AI-inferred images were correctly differentiated from the ground truth. CONCLUSIONS: Our surgical AI system precisely highlighted the pancreas during robot-assisted gastrectomy at a level that was convincing to surgeons. This technology may prevent misrecognition of the pancreas by surgeons, thus leading to fewer POPFs.

Treatment strategy for successful conversion surgery in clinical stage IVB gastric cancer.

INTRODUCTION: Recent advances in chemotherapy have resulted in successful conversion surgery (CS) for clinical stage (cStage) IVB gastric cancer (GC). This study aimed to evaluate the success rate of CS in clinical practice and determine optimal treatment strategies. METHODS: Totally, 166 patients with cStage IVB gastric and gastroesophageal junction adenocarcinoma, who underwent chemotherapy at Hyogo Medical University Hospital between January 2017 and June 2022, were included. CS was performed after confirming tumor to be M0 based on imaging and/or staging laparoscopy, except for resectable liver metastases. Preoperative chemotherapy was continued for at least 6 months provided that adverse events were manageable. RESULTS: Of 125 eligible patients, 23 were treated with CS, achieving a conversion rate of 18.4% and an R0 resection rate of 91.3%. The median duration of preoperative chemotherapy was 8.5 months; the median number of cycles was eight. The highest conversion rate was observed in patients receiving first-line treatment (14.4%), followed by those receiving second and third lines (5.8% and 2.3%, respectively). The median survival time in patients who received CS was significantly longer than that in patients who continued chemotherapy alone (56.7 versus 16 months, respectively, P < 0.0001). There was no significant difference in the 3-year overall survival between the patients who achieved CS after first-line treatment (63.2%, n = 18) and those who achieved CS after second- or third-line treatment (66.7%, n = 5). CONCLUSION: Consistent chemotherapy strategies could lead to successful CS and improved prognosis in a greater number of patients with cStage IVB GC, regardless of line of treatment.

Analysis of Crop Consumption Using Scatological Samples from the Red-Crowned Crane Grus japonensis in Eastern Hokkaido, Japan.

Total DNA extracts from the intestinal contents of 60 flying red-crowned cranes (juveniles, subadults and adults) found dead in 2006-2021, and the feces of 25 chicks collected in June and July of 2016-2018, were used for PCR reactions with primers specific for 16 crops, followed by high-throughput sequencing. The most predominant crop detected was corn in adult and subadult cranes (61.7%). Other grains (barley, wheat, soybean) (5.0-8.3%) and vegetables (tomatoes, Chinese cabbage, etc.) (1.7-6.7%) were also detected in flying cranes. Surprisingly, some of the detected crops were not grown in the Kushiro and Nemuro regions. There was no significant difference in crop intake status in winter and that in other seasons for most of the crops. Corn (28.0%), soybeans (8.0%), wheat and beet (4.0%) were detected in crane chicks in summer, though the detection rates were generally lower than those in flying cranes. Alfalfa, which is not grown in eastern Hokkaido but is used in some cattle feed, was detected in some cranes. Rice, buckwheat, adzuki beans, common beans, potatoes and carrots were not detected at any life stage, indicating the preferences of red-crowned cranes. The results suggest that red-crowned cranes in Hokkaido are dependent on dairy farmers for their feed supply.

Production profile of lipid mediators in conjunctival lavage fluid in allergic and infectious conjunctivitis in guinea pigs.

Introduction: Conjunctivitis is a major ocular disease classified into allergic or infectious. The pathological features of conjunctivitis are not fully understood despite its high morbidity rate; thus, its differentiation can be difficult. Materials and methods: We used ovalbumin-induced allergic conjunctivitis and lipopolysaccharide-induced infectious conjunctivitis models of guinea pigs. Both models showed conjunctival swelling. Histological studies revealed that numerous eosinophils infiltrated the conjunctiva in the allergic model, whereas neutrophils infiltrated the conjunctiva in the infectious model. We collected conjunctival lavage fluid (COLF) and comprehensively analyzed lipid production using liquid chromatography-tandem mass spectrometry. Results: COLF showed increase of 20 and 12 lipid species levels in the allergic and infectious models, respectively. Specifically, the levels of a major allergic mediator, prostaglandin D2 and its three metabolites and several cytochrome P450-catalyzed lipids increased in the allergic model. In the infectious model, the levels of prostaglandin E2 and 8-iso-prostaglandin E2 increased, indicating tissue inflammation. Moreover, the level of 12-oxo-eicosatetraenoic acid, a lipoxygenase metabolite, increased in the infectious model. Conclusion: These differences in lipid production in the COLF reflected the pathological features of allergic and infectious conjunctivitis.

Proposal for T3 classification of esophagogastric junction carcinoma based on the interconnection of extramural anatomical structures.

Classification of extramural invasion of esophagogastric junction carcinoma (EGJC) is not yet established. The anatomy surrounding the EGJ alters between the mediastinum and the abdominal cavity. This review proposed a T3 classification of EGJC based on anatomical continuity. Analysis of endoscopic ultrasound images, review of intraoperative images, and detailed observation of surgical specimens were followed by a review of the literature. In the EGJ, the muscularis propria of the esophagus is enclosed in mediastinal adipose tissue called the adventitia, which is surrounded by the diaphragmatic crus and contains the paraesophageal lymph nodes (LNs). After passing through the esophageal hiatus along with the vagus nerves and blood vessels, the adventitia joins the adipose tissue containing the paracardial LNs, which is covered by the peritoneum, and then further divides into the lesser and greater omentum. The connective tissue outside the muscularis propria of the stomach, including the adipose tissue of the omentum, is called the subserosa. According to the TNM classification, T3 esophageal and gastric cancer is defined as invasion of the adventitia and subserosa, respectively. Given that the adventitia is anatomically continuous with the subserosa, T3 tumors of the EGJ can be described as those that extend through the muscularis propria but do not invade the peritoneum or diaphragmatic crus. We propose classifying T3 EGJC as "tumor extends through muscularis propria" rather than using the separate terms "adventitia" and "submucosa". T4 could be "tumor perforates serosa or invades adjacent structures", as per the current gastric cancer classification.

Mast cell-derived prostaglandin D2 limits the subcutaneous absorption of honey bee venom in mice.

Mast cells play pivotal roles in innate host defenses against venom. Activated mast cells release large amounts of prostaglandin D2 (PGD2). However, the role of PGD2 in such host defense remains unclear. We found that c-kit-dependent and c-kit-independent mast cell-specific hematopoietic prostaglandin D synthase (H-pgds) deficiency significantly exacerbated honey bee venom (BV)-induced hypothermia and increased mortality rates in mice. BV absorption via postcapillary venules in the skin was accelerated upon endothelial barrier disruption resulting in increased plasma venom concentrations. These results suggest that mast cell-derived PGD2 may enhance host defense against BV and save lives by inhibiting BV absorption into circulation.

Augmentation of Pectoral Fin Teratogenicity by Thalidomide in Human Cytochrome P450 3A-Expressing Zebrafish.

The pharmacological and toxicological effects of active metabolites of enzymes including cytochrome P450 (CYP) are important. While it has been believed for a long time that thalidomide causes characteristic limb malformation only in rabbits and primates including humans, the involvement of their CYP3A subtypes (CYP3As) has been suggested. Recently, however, it was reported that zebrafish were sensitive to thalidomide, showing defects of pectoral fins, homologous organs of forelimbs in mammals, as well as other deformities. In this study, we prepared human CYP3A7 (hCYP3A7)-expressing zebrafish (F0) using a transposon system. Thalidomide caused pectoral fin defects and other malformations including pericardial edema in hCYP3A7-expressing embryos/larvae but not in wild-type and hCYP1A1-expressing embryos/larvae. Thalidomide also reduced the expression of fibroblast growth factor 8 in pectoral fin buds in only hCYP3A7-expressing embryos/larvae. The results suggest the involvement of human-type CYP3A in thalidomide teratogenicity.

Transgenic Zebrafish Expressing Rat Cytochrome P450 2E1 (CYP2E1): Augmentation of Acetaminophen-Induced Toxicity in the Liver and Retina.

Metabolic activation is the primary cause of chemical toxicity including hepatotoxicity. Cytochrome P450 2E (CYP2E) is involved in this process for many hepatotoxicants, including acetaminophen (APAP), one of the most common analgesics and antipyretics. Although the zebrafish is now used as a model for toxicology and toxicity tests, the CYP2E homologue in zebrafish has not been identified yet. In this study, we prepared transgenic zebrafish embryos/larvae expressing rat CYP2E1 and enhanced green fluorescent protein (EGFP) using a ß-actin promoter. Rat CYP2E1 activity was confirmed by the fluorescence of 7-hydroxycoumarin (7-HC), a metabolite of 7-methoxycoumarin that was specific for CYP2 in transgenic larvae with EGFP fluorescence (EGFP [+]) but not in transgenic larvae without EGFP fluorescence (EGFP [-]). APAP (2.5 mM) caused reduction in the size of the retina in EGFP [+] larvae but not in EGFP [-] larvae, while APAP similarly reduced pigmentation in both larvae. APAP at even 1 mM reduced the liver size in EGFP [+] larvae but not in EGFP [-] larvae. APAP-induced reduction of liver size was inhibited by N-acetylcysteine. These results suggest that rat CYP2E1 is involved in some APAP-induced toxicological endpoints in the retina and liver but not in melanogenesis of the developing zebrafish.

The effect of exposure on cattle thyroid after the Fukushima Daiichi nuclear power plant accident.

Nuclear plant accidents can be a risk for thyroid cancer due to iodine radioisotopes. Near the Fukushima Daiichi nuclear power plant, cattle were exposed to radiation after the accident occurred in May 2011. Here we estimated the total radiation exposure to cattle thyroid and its effects on thyroid function. Until October 2016, the estimated external exposure dose in Farm A was 1416 mGy, while internal exposure dose of 131I, 134Cs, and 137Cs were 85, 8.8, and 9.7 mGy in Farm A and 34, 0.2, and 0.3 mGy in Farm B, respectively. The exposed cattle had thyroid with relatively lower weight and lower level of stable iodine, which did not exhibit any pathological findings. Compared with the control, the plasma level of thyroid-stimulating hormone (TSH) was higher in Farm A cattle born before the accident, while the plasma thyroxine (T4) was higher in Farm A cattle born after the accident, suggesting that exposed cattle showed slight hyperactivation of the thyroid gland. In addition, Farm A cattle have higher level of cortisol, one of the anterior pituitary gland-derived hormones. However, we did not observe a causal relationship between the radiation exposure and cattle thyroid.

Urinary lipid profile of patients with coronavirus diseases 2019.

The coronavirus diseases 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is ongoing. Over 490 million people have been infected with this virus worldwide. Although many patients present with lower respiratory symptoms, some may progress to acute respiratory distress syndrome and even multi-organ damage. Therefore, there is an urgent need to establish treatment and management methods for this infectious disease. Here, we comprehensively analyzed urinary lipid mediators and their metabolites to identify non-invasive biomarkers that reflect the disease status of COVID-19 patients. We diagnosed 16 patients by polymerase chain reaction (PCR) analysis, who presented with mild-to-moderate symptoms, including fever and cough, between May and October 2020 in Japan, and collected their urine samples. Using mass spectrometry, we analyzed the lipid metabolites in these urine samples. In all the urine samples from the patients, 21 types of fatty acids and their metabolites were consistently detected in the samples among the 214 metabolites which were analyzed. Interestingly, urinary levels of fatty acids, docosahexaenoic acid was increased by approximately 3-fold in patients with COVID-19 compared to those in healthy subjects. Metabolites of major proinflammatory lipid mediators, PGE2, TXA2, and PGF2α, were also detected at significantly higher levels in the urine of patients with COVID-19. These observations suggest that urinary lipids can reflect the inflammatory status of patients with COVID-19, which can be a useful index to manage this disease.

Urinary lipid production profile in canine patients with splenic mass.

Polyunsaturated fatty acids (PUFAs), including arachidonic acid (AA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA), are metabolized to various lipid mediators. The profile of these lipid metabolites excreted into the urine reflects inflammatory state of the body and disease conditions. In this study, we quantified 156 types of lipids in urine samples of dogs with splenic mass, using liquid chromatography-tandem mass spectrometry. We found that metabolites of prostaglandin (PG) E2, F2α, and D2, 8-iso-PGF3α, lyso-platelet activating factor, and 14,15-leukotrien C4 significantly increased in urine samples of dogs with splenic mass compared to that of healthy dogs. These observations may reflect general inflammatory responses and will help better understanding of the canine splenic mass.

Marked improvement of severe reflux esophagitis following proximal gastrectomy with esophagogastrostomy by the right gastroepiploic vessels-preserving antrectomy and Roux-en-Y biliary diversion.

Duodenogastroesophageal reflux (DGER) following esophagectomy or gastrectomy can cause severe esophagitis, which impairs patients' quality of life and increases the risk of esophageal carcinogenesis. It is sometimes resistant to medical treatment, and surgical treatment is considered effective in such cases. However, an optimal operative procedure for medical treatment-resistant reflux esophagitis (RE) after proximal gastrectomy (PG) with esophagogastrostomy (EG) has not yet been established. We performed the right gastroepiploic vessels-preserving antrectomy and Roux-en-Y biliary diversion in a 70-year-old man with medical treatment-resistant severe esophagitis caused by DGER following PG with EG for esophagogastric junction cancer. The postoperative course was uneventful, and esophagogastroduodenoscopy performed on the 19th postoperative day showed marked improvement in the esophageal erosions. The patient reported symptomatic relief. The right gastroepiploic vessels-preserving antrectomy and Roux-en-Y biliary diversion were considered safe and feasible for medical treatment-resistant RE following PG with EG.

Transhiatal lower mediastinal lymph node dissection for esophagogastric junction carcinoma by interconnecting four body cavities.

BACKGROUND: Due to the limited number of landmark structures, it is difficult to standardize the surgical procedures for advanced esophagogastric junction cancer such as Ivor Lewis esophagectomy that require transhiatal lower mediastinal lymph node dissection (TH-LMND). We demonstrate an easily reproducible procedure for TH-LMND, wherein four body cavities, namely, the abdominal cavity, infracardiac bursa (ICB), and left and right thoracic cavities are interconnected. METHODS: First, the dissection between the right crus and the esophagus was used to connect the abdominal cavity to the ICB - a lower mediastinal cavity separated from the omental bursa during embryonic development [1,2]. Second, the right thoracic cavity was opened with the shortest distance by dissecting the cranial side of the ICB. The right pulmonary ligament was dissected from the right lung. Third, the dissection to the contralateral side while exposing the aorta and the pericardium connected the left and right thoracic cavities. Then, the left pulmonary ligament was dissected from the left lung. The dissected tissues, including the lymph nodes, were subsequently peeled from the esophagus. RESULTS: Between April 2018 and August 2021, 14 patients underwent laparoscopic or robotic TH-LMND via the procedure above. The median time required to complete the dissection was 75 min. None of the procedures were converted to open surgery, and none of the patients experienced intraoperative complications such as pericardial injury, lung injury, or massive bleeding. CONCLUSION: The surgical concept of interconnecting four body cavities made the procedure more accessible and reproducible while achieving en bloc TH-LMND.

Comprehensive profiling of lipid metabolites in urine of canine patients with liver mass.

Fatty acids are an essential component of mammalian bodies. They go through different metabolic pathways depending on physiological states and inflammatory stimuli. In this study, we conducted a liquid chromatography-tandem mass spectrometry (LC-MS/MS)-based comprehensive analysis of lipid metabolites in urine of canine patients with liver mass. There were significant differences in quantity of some lipid metabolites that may be closely associated with the disease and/or general inflammatory responses, including increased metabolites of prostaglandin E2 and/or PGF2α. We demonstrated that our approach of profiling lipid metabolites in the urine is useful in gaining insights into the disease. These findings may also have an application as a screening test or a diagnosis tool for canine liver mass.

The urinary lipid profile in cats with idiopathic cystitis.

Although feline idiopathic cystitis (FIC) distresses of many cats, its pathogenesis is unknown and the diagnosis is challenging. Polyunsaturated fatty acids (PUFAs) are metabolized into various lipid mediators. Lipid mediators such as prostaglandins (PGs) modulate inflammation and many of them are excreted into the urine. Thus, the investigation of the urinary lipid profile may reveal pathogenesis and help diagnosis of FIC. We collected urine samples from five FIC cats by spontaneous urination and analyzed 158 types of lipid mediators in urines using liquid chromatography-mass spectrometry. The urinary levels of PUFAs were higher in FIC compared to those of the healthy group. The excretions of a major inflammatory mediator, PGD2, were less in FIC. Other well-known inflammatory mediators such as PGE2, PGI2, and their metabolites did not show a difference. In contrast, the levels of PGF2α and its 2 metabolites and PGF3α were higher in FIC. These results may provide new insights into the future management of cat FIC.

The profile of urinary lipid metabolites in healthy dogs.

Polyunsaturated fatty acids, including arachidonic acid (AA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA), are converted to hundreds of lipid mediators by cyclooxygenases (COX), lipoxygenases (LOX), and cytochrome P450 (CYP), or through non-enzymatic processes, and they reflect inflammatory states of the body. We comprehensively analyzed lipid metabolites in dog urine using a liquid chromatograph-mass spectrometry (LC-MS/MS) to describe their metabolic characteristics. We detected 31 AA-derived metabolites, four EPA-derived metabolites, and a DHA-derived metabolite in all urine samples. Among AA-derived metabolites, 15, 5, 3, and 8 were generated by COX, LOX, CYP, and non-enzymatic oxidation respectively. This study will be the first step to use profiles of urinary lipid metabolites for better understanding and diagnosis of canine diseases.

Potential advantages of robotic total gastrectomy for gastric cancer: a retrospective comparative cohort study.

Laparoscopic total gastrectomy (LTG) is a highly technical surgery that can lead to postoperative complications. Whether the recently introduced robotic surgery overcomes the drawbacks of laparoscopic surgery in total gastrectomy remains controversial. Therefore, we aimed to elucidate the potential benefits of robotic total gastrectomy (RTG) and compare the short-term outcomes of RTG and LTG. We retrospectively analyzed 56 patients with primary gastric or esophagogastric junction cancer who underwent RTG or LTG between June 2017 and July 2021. The groups were compared in terms of operative outcomes and postoperative complications. Potential risk factors associated with postoperative complications were assessed by performing multivariable analysis using logistic regression models via the exact method. Operation time was significantly longer, and postoperative hospital stay was significantly shorter in the robotic group (550 vs. 466 min, P < 0.001; 13 vs. 18 days, P = 0.013, respectively). The incidence of overall postoperative complications of Clavien-Dindo grade ≥ II was 18.5% and 24.1% in the RTG and LTG groups, respectively. Pancreatic fistulas were not observed, but other local complications were observed in 0% and 17.2% of the RTG and LTG groups, respectively (P = 0.052). In the multivariable analysis, the independent risk factors for local complications were laparoscopic surgery (odds ratio [95% confidence interval] 8.542 [1.065-∞], P = 0.045) and esophagogastric junction cancer (16.646 [2.559-∞], P = 0.005). Compared with LTG, RTG was associated with fewer local complications (mainly anastomotic leakage), especially in cases of esophagogastric junction cancer with high anastomotic sites.