Thoracoscopic Esophagectomy for a Patient With Perforated Esophageal Epiphrenic Diverticulum After Kidney Transplantation: A Case Report.

A 58-year-old man who underwent cadaveric kidney transplantation twice presented to hospital with a perforated epiphrenic diverticulum. Computed tomography revealed epiphrenic diverticulitis and right pleural effusion. Upper gastrointestinal fibroscopy showed an epiphrenic diverticulum full of food residue. He was transferred to our hospital, where we performed percutaneous endoscopic gastrostomy under general anesthesia in the supine position before thoracoscopy. Thoracoscopic esophagectomy was performed in the semi-prone position under 6-10 mmHg artificial pneumothorax via the right thoracic cavity. We performed subtotal esophagectomy to remove sources of infection because the esophageal wall surrounding the diverticulum was too thick to close or to perform diverticulectomy. A cervical esophagostomy was constructed after the thoracic procedure. The patient was managed with continuous hemodiafiltration and administered immunosuppressants and steroids to preserve the transplanted kidney. Continuous hemodiafiltration was stopped on postoperative day (POD) 4. The patient was discharged from the intensive care unit on POD 10 and transferred to the original hospital on POD 24 for rehabilitation. The second operative stage was performed on POD 157 at our hospital. We performed gastric tube reconstruction via the ante-sternal route and anastomosed the tube to the cervical esophagus. The postoperative course was uneventful; the patient was transferred to the original hospital on POD 15 after the second operation. Minimally invasive surgery was sufficient to treat perforated epiphrenic diverticulum while preserving the transplanted kidney. We recommend completely removing the source of infection and reducing surgical invasiveness to preserve the transplanted kidney in cases of esophageal perforation following kidney transplantation.

The comparative anatomy of the folds, fossae, and adhesions around the duodenojejunal flexure in mammals.

BACKGROUND: Anatomical knowledge of the duodenojejunal flexure is necessary for abdominal surgeries, and also important for physiologic studies about the duodenum. But little is known about the anatomy of this region in mammals. Here, we examined comparative anatomy to understand the anatomical formation of the duodenojejunal flexure in mammals. MATERIALS AND METHODS: The areas around the duonenojejunal flexure were ob-served in mouse, rat, dog, pig, and human, and the anatomical structures around the duodenojejunal junction in the animals were compared with those in human. RESULTS: The superior and inferior duodenal folds, and the superior and inferior duodenal fossae were identified in all examined humans. In pig, the structures were not clearly identified because the duodenum strongly adhered to the retroperitoneum and to the mesocolon. In mouse, rat, and dog, only the plica duodenocolica, which is regarded as the animal counterpart of the superior duo-denal fold in human, was identified, and other folds or fossae were not observed, probably because the duodenum was not fixed to the parietal peritoneum in those animals. Transection of the plica duodenocolica could return the normally rotated intestine back to the state of non-rotation in rat. CONCLUSIONS: This study showed the anatomical similarities and dissimilarities of the duodenojejunal flexure among the mammals. Anatomical knowledge of the area is useful for duodenal and pancreatic surgeries, and for animal studies about the duodenum. (Folia Morphol 2018; 77, 2: 286-292).

A groundbreaking new suturing device: the Excalibur.

BACKGROUND: Laparoscopic knot tying can be stressful. We reported two simple techniques, known as the Thumbs up! knot and the Tornado knot. We have further refined these procedures with the development of a new needle holder, called the Excalibur suturing needle holder. MATERIALS: This forceps differ from most conventional forceps in that the hinge is designed to stick out. The large hinge is stored out of the way when the forceps are closed, to prevent the thread accidentally catching. RESULTS: The thread is hooked on the projected hinge, which resembles the heel of a high-heel shoe. By using this forceps, the laparoscopic knot tying becomes easier for not only well experienced but also less experienced surgeons. CONCLUSIONS: The Excalibur, with its high heel, can complete knots with simple straight-line motion, making knot tying easier. This forceps will help reduce the stresses associated with intra-corporeal knot tying.

Studying the visceral physiology of tadpoles through their naturally transparent abdominal walls.

We propose using anuran tadpoles with naturally transparent abdominal skin to study the visceral physiology of amphibian larvae under microgravity. The transparency of the abdominal wall in certain tadpoles enables one to evaluate the basal physiological state and temporal changes in viscera from their movements without any invasive treatment. In order to validate our experimental design, the intestinal motility and heart rate of Rhacophorus tadpoles were examined as indices of physiological responses to stepwise changes in temperature.

Gastrointestinal transit and stress response after laparoscopic vs conventional distal pancreatectomy in the canine model.

BACKGROUND: Several authors have presented the feasibility of laparoscopic pancreatic surgery. However, the pathophysiological effect of laparoscopic pancreatic surgery is not well known. METHODS: Ten mongrel dogs were randomly operated for laparoscopic and conventional distal pancreatectomy. Fed state gastrointestinal transit times were assessed using radiopaque markers. To assess surgical stress, we determined serum IL-1 and cortisol. RESULTS: Postoperative mouth-to-anus transit time in the laparoscopic group was not prolonged while it was significantly prolonged in the conventional group compared with the baseline study, but no significant differences between groups were detected. First defecation was observed significantly earlier in the laparoscopic group. Serum cortisol levels were elevated significantly at 4 h after skin incision in both groups and decreased thereafter. In the laparoscopic group, they returned close to the normal level at 8 h after incision, but were still significantly higher in the conventional group. The level of IL-1 was elevated significantly higher in conventional group at 24 h after the skin incision. CONCLUSION: Thus, we conclude that laparoscopic distal pancreatectomy demonstrated faster recovery of the bowel transit and less stress than conventional distal pancreatectomy in dogs.

Tumor necrosis factor-alpha is induced through phorbol ester--and glycated human albumin-dependent pathway in THP-1 cells.

Tumor necrosis factor-alpha (TNF-alpha) is involved in insulin resistance. Since the fact that peroxisome proliferator-activated receptor gamma (PPARgamma) ligands inhibit the induction of TNF-alpha by phorbol ester, but not by lipopolysaccharide (LPS), suggests two pathways to induce TNF-alpha, we investigated the mechanisms of glycated human albumin (GHA)- or phorbol ester-induced TNF-alpha in THP-1 cells. GHA induced TNF-alpha release in differentiated THP-1 cells, while phorbol ester induced TNF-alpha release in undifferentiated cells but did not induce TNF-alpha in differentiated cells. Forskolin (adenylate cyclase activator) affected more the GHA-induced TNF-alpha release than the phorbol 12-myristate 13-acetate (PMA)-induced one in undifferentiated cells. Staurosporine [protein kinase-C (PK-C) inhibitor] and PD98059 [mitogen-activated protein kinase inhibitor (MAPK)] only partially inhibited GHA-induced TNF-alpha. Catalase completely inhibited GHA-induced TNF-alpha release; however, superoxide dismutase (SOD) had no effect. These results suggest at least two pathways to induce TNF-alpha (phorbol ester- and GHA-dependent ways) and that GHA-induced TNF-alpha release is through predominantly catalase-dependent way in differentiated THP-1 cells.

Laparascope-assisted versus conventional restorative proctocolectomy with rectal mucosectomy.

To assess the advantages of a laparoscope-assisted proctocolectomy with ileal J-pouch anal anastomosis compared with conventional procedures, we retrospectively analyzed the results of the two procedures as follows: Eleven patients including five patients with familial adenomatous polyposis (FAP) and six with ulcerative colitis (UC) underwent a laparoscope-assisted proctocolectomy and hand-sewn ileal J-pouch anal anastomosis at our department from June 1997 to November 1999. This laparoscope-assisted colectomy (LAC) group was then compared with a group of 13 patients who had undergone conventional ileal pouch anal anastomosis using a standard laparotomy from 1986 to 1997. The median operative time of the LAC group was 8h 23min, which was 81 min longer than that of the standard colectomy (SC) group. The number of days during which eating was prohibited were similar in the two groups but the median postoperative hospital stay was significantly shorter in the LAC group (24.1 days). In the LAC group, the small incisions showed better cosmetic results and there was also a remarkable reduction in the degree of postoperative pain. In conclusion, a laparoscope-assisted proctocolectomy with ileal J-pouch anal anastomosis can be employed widely in patients with FAP and also in selected patients with UC.

Prostaglandin F(2)alpha enhances glucose consumption through neither adipocyte differentiation nor GLUT1 expression in 3T3-L1 cells.

Arachidonic acid (AA) at 0.2 mM enhances glucose uptake through increased levels of glucose transporter (GLUT) 1 protein in 3T3-L1 adipocytes. Since AA is a precursor of prostaglandins (PGs), we investigated the effect of PGs on glucose consumption in 3T3-L1 cells. Among several PGs, only prostaglandin F(2)alpha (PGF(2)alpha) enhanced glucose consumption in 3T3-L1 cells treated with dexamethasone (DEX), 3-isobutyl-1-methyl-xanthine (IBMX), and insulin. To study the mechanism of PGF(2)alpha-enhanced glucose consumption, we investigated the effect of PGF(2)alpha on glycerol-3-phosphate dehydrogenase (GPDH) activity, triglycerides (TGs) content, and the expression of GLUT1 protein. PGF(2)alpha suppressed GPDH activity and did not increase the expression of GLUT1 protein in 3T3-L1 cells treated with DEX, IBMX, and insulin. These results suggest that AA-stimulated glucose uptake is not through the effect of PGF(2)alpha. Our results indicate that PGF(2)alpha is a unique regulator of adipocyte differentiation (suppression) and glucose consumption (enhancement) in 3T3-L1 cells.

Factors influencing the susceptibility of anurans to motion sickness.

We examined the propensity for motion sickness in five anuran species, concentrating our efforts on the treefrog Rhacophorus schlegelii, because it had shown the greatest susceptibility to motion sickness in a previous study. We used parabolic flight as our provocative stimulus and fed all specimens a known volume of food 1.5-3 h before flight. The presence of vomitus in a frog's cage was our indicator of motion sickness. Significantly more emesis was observed in flight-exposed than in control R. schlegelii (P < 0.05). There was no sex difference in susceptibility to motion sickness (P > 0.5). Individuals that vomited were significantly larger (P < 0.02) than those that did not. Among microgravity-treated frogs, those that vomited spent on average 85% more time airborne and tumbling in microgravity than those that did not vomit (P=0.031). Our data support the view that postural instability and sensory conflict are elements of motion sickness in anurans. Specifically, conflicts between tactile, vestibular and visual input seem essential for producing motion-induced emesis in anurans. Since the factors that induce motion sickness in R. schlegelii are the same ones that produce motion sickness in humans, arboreal frogs may be useful alternative models to mammals in motion sickness research.

The effect of activation of peroxisome proliferator-activated receptor gamma (PPARgamma) on human monocyte function: PPARgamma ligands do not inhibit tumor necrosis factor-alpha release in human monocytic cell line THP-1.

Peroxisome proliferator-activated receptor gamma (PPARgamma) activation by its ligands reportedly inhibits monocyte function. However, because the concentrations of PPARgamma ligands used in previous studies were higher than typically expected to activate PPARgamma, we clarified whether PPARgamma ligands influence monocyte function and cell viability of the human monocyte cell line THP-1. We determined tumor necrosis factor-alpha (TNF-alpha) release as a monocyte function and cell viability using 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide. Both troglitazone and 15-deoxy-delta12,14-prostaglandin J2 (15-d-PGJ2) seemed to inhibit phorbol ester-induced TNF-alpha release from THP-1 cells. On the other hand, neither pioglitazone nor rosiglitazone inhibited phorbol ester-induced TNF-alpha release. Because the cytotoxicity of troglitazone and 15-d-PGJ2 was significantly (p<0.05, Tukey-Kramer) stronger than that of pioglitazone and rosiglitazone, the inhibition of TNF-alpha release seemed to parallel the lack of cell viability. We concluded that PPARgamma ligands did not directly inhibit TNF-alpha release in THP-1 cells.

Effects of carnitine palmitoyltransferase I inhibitors on hepatic hypertrophy.

We investigated the effect of two types of carnitine palmitoyltransferase I inhibitors, ethyl 2-(6-(4-chlorophenoxy)hexyl)oxirane-2-carboxylate (etomoxir) and (R)-3-carboxy-N,N, N-trimethyl-2-¿[hydroxy(tetradecyloxy)phosphinyl]oxy¿-1-propana minium hydroxide (SDZ CPI 975), on cardiac and hepatic hypertrophy in ddY mice. One-week administration of etomoxir caused cardiac and hepatic hypertrophy, 19% and 22% as a ratio to body weight, respectively. Although 4-week administration of etomoxir caused hepatic hypertrophy, there was no significant change in liver triglyceride content in the first or second week. In cultured HepG(2) cells, etomoxir treatment (1 week) did not cause triglyceride to accumulate. One-week administration of SDZ CPI 975 caused neither cardiac nor hepatic hypertrophy. In vitro, neither drug had selectivity for carnitine palmitoyltransferase I isozymes. These findings suggest that the hepatic hypertrophy following 1- or 2-week treatment with etomoxir is caused by mechanisms different from those responsible for triglyceride accumulation, and that inhibition of carnitine palmitoyltransferase I may not necessarily induce hepatic hypertrophy.

Laparoscopic cholecystectomy, Calot's triangle, and variations in cystic arterial supply.

BACKGROUND: The extrahepatic biliary tree with the exact anatomic features of the arterial supply observed by laparoscopic means has not been described heretofore. Iatrogenic injuries of the extrahepatic biliary tree and neighboring blood vessels are not rare. Accidents involving vessels or the common bile duct during laparoscopic cholecystectomy, with or without choledocotomy, can be avoided by careful dissection of Calot's triangle and the hepatoduodenal ligament. METHODS: We performed 244 laparoscopic cholecystectomies over a 2-year period between January 1, 1995 and January 1, 1997. RESULTS: In 187 of 244 consecutive cases (76.6%), we found a typical arterial supply anteromedial to the cystic duct, near the sentinel cystic lymph node. In the other cases, there was an atypical arterial supply, and 27 of these cases (11.1%) had no cystic artery in Calot's triangle. A typical blood supply and accessory arteries were observed in 18 cases (7.4%). CONCLUSION: Young surgeons who are not yet familiar with the handling of an anatomically abnormal cystic blood supply need to be more aware of the precise anatomy of the extrahepatic biliary tree.

Emesis and space motion sickness in amphibians.

Amphibians possess the ability to vomit in response to a variety of stimuli that provoke emesis in mammals. Pharmacological studies have establish that the ejection of gastric contents and the basic mechanism for vomiting have been phylogenetically conserved among these tetrapods. As part of on-going comparative studies on emesis in vertebrates, we previously documented that some postmetamorphic anurans and salamander larvae experience motion-induced emesis when exposed to the provocative stimulus of parabolic aircraft flight. However, more recent experiments suggest that there are strict conditions for inducing emesis in amphibians exposed to parabolic flight and that amphibians are not as sensitive to this stimulus as mammals. Further studies on emesis in lower vertebrates may help us understand the processes that cause emesis in abnormal gravitational regimes.

Molecular characterization and functional regulation of a novel rat liver-specific organic anion transporter rlst-1.

BACKGROUND & AIMS: Recently, we isolated a new complementary DNA (cDNA) encoding human liver-specific organic anion transporter (LST-1), representing the multispecificity of human liver. The aim of this study was to isolate a rat counterpart of human LST-1 and examine the expression regulation of its messenger RNA (mRNA) to clarify the molecular basis of cholestasis. METHODS: A rat liver cDNA library was screened with human LST-1 cDNA as a probe. Xenopus oocyte expression system was used for functional analysis. Northern blot analyses were performed using the isolated cDNA (termed rlst-1). The bile duct ligation model and the cecum ligation and puncture model were used for expression analyses. RESULTS: rlst-1 encodes 652 amino acids, predicting at least 11 transmembrane regions. The overall homology with human LST-1 was 60.2%, which is the highest among all known organic anion transporters. rlst-1 also belongs to the same new gene family as human LST-1, located between the organic anion transporter family and the prostaglandin transporter. rlst-1 preferably transports taurocholate (K(m), 9.45 micromol/L) in an Na(+)-independent manner. The rlst-1 mRNA is exclusively expressed in the liver. In both the bile duct ligation model and the cecum ligation and puncture model, mRNA expression levels of rlst-1 were down-regulated. CONCLUSIONS: rlst-1 is a counterpart of human LST-1 and is one of the important transporters in rat liver for the clearance of bile acid. The expression of rlst-1 may be under feedback regulation of cholestasis by biliary obstruction and/or sepsis.

Identification of a novel gene family encoding human liver-specific organic anion transporter LST-1.

We have isolated a novel liver-specific organic anion transporter, LST-1, that is expressed exclusively in the human, rat, and mouse liver. LST-1 is a new gene family located between the organic anion transporter family and prostaglandin transporter. LST-1 transports taurocholate (Km = 13.6 microM) in a sodium-independent manner. LST-1 also shows broad substrate specificity. It transports conjugated steroids (dehydroepiandrosterone sulfate, estradiol-17beta-glucuronide, and estrone-3-sulfate), eicosanoids (prostaglandin E2, thromboxane B2, leukotriene C4, leukotriene E4), and thyroid hormones (thyroxine, Km = 3.0 microM and triiodothyronine, Km = 2.7 microM), reflecting hepatic multispecificity. LST-1 is probably the most important transporter in human liver for clearance of bile acids and organic anions because hepatic levels of another organic anion transporter, OATP, is very low. This is also the first report of the human molecule that transports thyroid hormones.