A prospective study comparing the gasless endoscopic thyroidectomy trans-axillary approach to conventional open thyroidectomy: health and quality of life outcomes.

BACKGROUND: The relationship between different surgical treatments and quality of life remains uncertain for differentiated thyroid carcinoma (DTC). The aim of this study is to compare the gasless endoscopic thyroidectomy trans-axillary approach (ET) and traditional open thyroidectomy (OT) through a prospective cohort study focusing on the rate of the efficacy, and quality of life (QoL). METHODS: This prospective observational longitudinal cohort study enrolled 134 female patients diagnosed with DTC from December 01/2021 to December 31/2022. Multiple scales were applicated to evaluate the differences in quality of life, effectiveness, safety, etc. between the two groups during preoperative and postoperative follow-up periods, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, version 3.0 (QOL-C30), Symptom Checklist (SCL-90), Scar Cosmesis Assessment and Rating (SCAR-Q), voice impairment score (VIS), swallowing impairment score (SIS), and neck impairment score (NIS). RESULTS: Among them, 68 accepted ET and 66 patients underwent OT. To enhance comparability between the two groups, the patients enrolled in this study are female. Compared with the OT group, the ET group performed significantly better postoperative physical quality of life, including sound (p = 0.036), swallowing (p < 0.001), and neck function (p = 0.010). The ET group was also associated with significantly better cosmetic satisfaction (p < 0.001), and relatively faster recovery in psychological and emotional situation. CONCLUSIONS: Gasless endoscopic thyroidectomy through an axillary approach leads to good cosmetic and psychological effects, improves postoperative QoL, and could be recommended for rapid postoperative recovery and involvement in daily and social activities.

Beyond the Square knot: A validation study for a novel knot-tying method named "inverse 9".

Purpose: We compared the "inverse 9" laparoscopic suturing and knot-tying (LSKT) method to the traditional LSKT method in a validation study to demonstrate the "inverse 9" method's superiority and effectiveness in laparoscopy. Methods: On the basis of their experience in laparoscopic surgery, 78 trainees were divided into two groups, with 52 inexperienced trainees in group A and 26 experienced trainees in group B. In group A, 52 trainees were randomly allocated to either group A1 ("inverse 9" LSKT training) or group A2 (traditional LSKT training). In group B, experienced trainees were randomly assigned to receive "inverse 9" LSKT training (group B1) or continuing training in the traditional LSKT method (group B2). All trainees received the same instruction and assessment and were asked to provide a subjective assessment of the two training methods at the end of the training. Results: The trainees in groups A1, A2, and B had similar average ages and were mostly male. After training, all showed preliminary mastery of LSKT (P < 0.05). The trainees in groups A1 and B1 achieved learning proficiency in the fifth assessment, while those in group A2 achieved it in the sixth assessment. The trainees in groups A1 and B1 showed lower difficulty in achieving mastery and lower operation fatigue scores (P < 0.05), and 61.50 % of the trainees in group B preferred the "inverse 9" method in subjective evaluation. Conclusion: As a novel LSKT technique, "inverse 9" offers a multitude of benefits. In addition to ensuring a simpler operation and effectively reducing the knot-tying time, it also involves a shorter learning curve than traditional LSKT methods. As such, it can be easily mastered and widely adopted as a standard LSKT technique.

Anchoring a Structurally Editable Proximal Cofactor-like Module to Construct an Artificial Dual-center Peroxygenase.

A recent novel strategy for constructing artificial metalloenzymes (ArMs) that target new-to-nature functions uses dual-functional small molecules (DFSMs) with catalytic and anchoring groups for converting P450BM3 monooxygenase into a peroxygenase. However, this process requires excess DFSMs (1000 equivalent of P450) owing to their low binding affinity for P450, thus severely limiting its practical application. Herein, structural optimization of the DFSM-anchoring group considerably enhanced their binding affinity by three orders of magnitude (Kd ≈10-8  M), thus approximating native cofactors, such as FMN or FAD in flavoenzymes. An artificial cofactor-driven peroxygenase was thus constructed. The co-crystal structure of P450BM3 bound to a DFSM clearly revealed a precatalytic state in which the DFSM participates in H2 O2 activation, thus facilitating peroxygenase activity. Moreover, the increased binding affinity substantially decreases the DFSM load to as low as 2 equivalents of P450, while maintaining increased activity. Furthermore, replacement of catalytic groups showed disparate selectivity and activity for various substrates. This study provides an unprecedented approach for assembling ArMs by binding editable organic cofactors as a co-catalytic center, thereby increasing the catalytic promiscuity of P450 enzymes.

Prospective cohort study of parathyroid function and quality of life after total thyroidectomy for thyroid cancer: robotic surgery vs. open surgery.

OBJECTIVE: To compare robot-assisted thyroidectomy (RT) and open thyroidectomy (OT) through a prospective cohort study focusing on the rate of postoperative hypoparathyroidism, efficacy, and quality of life (QoL). SUMMARY BACKGROUND DATA: Hypoparathyroidism is a frequent complication after thyroidectomy. Reducing the risk of hypoparathyroidism after total thyroidectomy is a crucial and difficult task for thyroid surgeons. METHODS: We prospectively enroled 306 patients with papillary thyroid carcinoma into an RT group and OT group. The former used "super-meticulous" capsular dissection) and the latter used traditional meticulous capsular dissection. Patients were evaluated by scales [Short Form (SF)-36, Visual Impairment Scale (VIS), Swallowing Impairment Scale (SIS), Neck Impairment Scale (NIS), Scar questionnaire (SCAR-Q)]. RESULTS: The rates of transient hypoparathyroidism, permanent hypoparathyroidism, and transient hypocalcemia after surgery in the OT group and RT group were significantly different ( P <0.001). SIS and VIS scores in the two groups were significantly different ( P <0.001). SF-36 showed significant differences ( P <0.001) in the subsections of "physiological function", "body pain", "general health", "vitality", "social function", "role emotional", and "mental health" between the two groups. SCAR-Q showed that the length and appearance of scars showed significant differences between the two groups. CONCLUSIONS: RT with Super-meticulous capsular dissection can protect parathyroid function and improve postoperative QoL, and could be a new option for robot-assisted surgery against thyroid cancer.

Enabling Peroxygenase Activity in Cytochrome P450 Monooxygenases by Engineering Hydrogen Peroxide Tunnels.

Given prominent physicochemical similarities between H2O2 and water, we report a new strategy for promoting the peroxygenase activity of P450 enzymes by engineering their water tunnels to facilitate H2O2 access to the heme center buried therein. Specifically, the H2O2-driven activities of two native NADH-dependent P450 enzymes (CYP199A4 and CYP153AM.aq) increase significantly (by >183-fold and >15-fold, respectively). Additionally, the amount of H2O2 required for an artificial P450 peroxygenase facilitated by a dual-functional small molecule to obtain the desired product is reduced by 95%-97.5% (with ∼95% coupling efficiency). Structural analysis suggests that mutating the residue at the bottleneck of the water tunnel may open a second pathway for H2O2 to flow to the heme center (in addition to the natural substrate tunnel). This study highlights a promising, generalizable strategy whereby P450 monooxygenases can be modified to adopt peroxygenase activity through H2O2 tunnel engineering, thus broadening the application scope of P450s in synthetic chemistry and synthetic biology.

Three-Pedicle Reduction Mammaplasty Technique in the Treatment of Greater Breast Hypertrophy Patients With or Without Breast Cancer: Surgical and Patient-reported outcomes.

BACKGROUND: Reduction mammoplasty (RM) is an important procedure in the management of symptomatic greater breast hypertrophy with or without early-stage breast cancer. We aim to introduce a new procedure: the three-pedicle reduction mammaplasty technique. METHODS: A prospectively maintained database was reviewed, and two prospectively registered clinical studies were included of all breast hypertrophy patients with or without breast cancer who underwent three-pedicle RM with inverted T incision at West China Hospital or the Fourth People's Hospital of Sichuan Province from 2018 to 2022. Patient demographics, patient-reported cosmetic results, quality of life (QoL), surgical outcomes and complications were assessed. RESULTS: During a median period of 22.5 months, 101 reduction mammaplasties were performed (Mage= 35.80; MBMI= 27.05). Mean reduction weight was 880.9 g ranging from 423-1630 g per breast. The nipple-to-sternal notch distance (N-SN) at post-operation was significantly shorter than preoperatively (left, 34.51 cm; right, 34.69 cm). Major complications and minor complications were 1.9% (1/52 patients) and 13.5% (7/52 patients), respectively. Multivariate logistic regression analyses showed that BMI > 30 was independent risk factors for a complication. Except for sexual and physical well-being at 1-month post-operation, patients gave a higher score on the BREAST-Q (breast satisfaction, physical well-being, psychosocial well-being) after the operation than before the operation (P<0.001). CONCLUSIONS: The three-pedicle RM technique was demonstrated to be an effective and safe RM procedure for moderate to severe breast hypertrophy patients with or without breast cancer, with the advantages of removing the lesions, reducing hypertrophic breasts and accomplishing mammoplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   http://www.springer.com/00266.

Engineering Cytochrome P450BM3 Enzymes for Direct Nitration of Unsaturated Hydrocarbons.

Applications of the peroxidase activity of cytochrome P450 enzymes in synthetic chemistry remain largely unexplored. We present herein a protein engineering strategy to increase cytochrome P450BM3 peroxidase activity for the direct nitration of aromatic compounds and terminal aryl-substituted olefins in the presence of a dual-functional small molecule (DFSM). Site-directed mutations of key active-site residues allowed the efficient regulation of steric effects to limit substrate access and, thus, a significant decrease in monooxygenation activity and increase in peroxidase activity. Nitration of several phenol and aniline compounds also yielded ortho- and para-nitration products with moderate-to-high total turnover numbers. Besides direct aromatic nitration by P450 variants using nitrite as a nitrating agent, we also demonstrated the use of the DFSM-facilitated P450 peroxidase system for the nitration of the vinyl group of styrene and its derivatives.

Regiodivergent and Enantioselective Hydroxylation of C-H bonds by Synergistic Use of Protein Engineering and Exogenous Dual-Functional Small Molecules.

It is a great challenge to optionally access diverse hydroxylation products from a given substrate bearing multiple reaction sites of sp3 and sp2 C-H bonds. Herein, we report the highly selective divergent hydroxylation of alkylbenzenes by an engineered P450 peroxygenase driven by a dual-functional small molecule (DFSM). Using combinations of various P450BM3 variants with DFSMs enabled access to more than half of all possible hydroxylated products from each substrate with excellent regioselectivity (up to >99 %), enantioselectivity (up to >99 % ee), and high total turnover numbers (up to 80963). Crystal structure analysis, molecular dynamic simulations, and theoretical calculations revealed that synergistic effects between exogenous DFSMs and the protein environment controlled regio- and enantioselectivity. This work has implications for exogenous-molecule-modulated enzymatic regiodivergent and enantioselective hydroxylation with potential applications in synthetic chemistry.

Endoscopic Nipple- or Skin-Sparing Mastectomy and Immediate Breast Reconstruction with Endoscopic Harvesting of the Latissimus Dorsi Flap: A Preliminary Experience of an Innovative Technique.

Background: Endoscopic nipple- or skin-sparing mastectomy (E-N/SSM) and endoscopic latissimus dorsi muscle flap (E-LDMF) harvest have been operational difficulties over decades. The aim of this study was to describe the preliminary outcomes of our novel surgical technique, which allows the performance of E-N/SSM and E-LDMF harvest for immediate breast reconstruction (IBR) through a single cosmetic axillary incision for breast cancer patients. Methods: This prospective study included 20 breast cancer patients who underwent E-N/SSM and E-LDMF harvesting through a single axillary incision in our hospital from September 2020 to June 2022. The outcomes were statistically calculated, including patient characteristics, operative data, complication rate, hospital length of stay and costs, and patient-reported outcomes. Results: A total of 20 breast cancer patients underwent our sufficiently mature novel endoscopy technique. The mean LD flap harvest time was 96.5 ± 25.3 min, the mean operation time was 262.6 ± 54.4 min, and the average length of LDMF was 26.9 ± 3.1. During the median follow-up time of 7.5 months, 4 patients developed donor-site seroma. One of them was also complicated by hypopigmentation of the nipple areola, and one of them suffered from breast cellulitis. No bleeding or flap necrosis happened. No tumor recurrence or metastasis was found until the last follow-up. In the BREAST-Q evaluation, although they gave a lower score beginning at 1-month post-operation than preoperatively (P > 0.05, except for physical well-being: chest and physical well-being: back and shoulder, P < 0.01), there was an uptrend at 3 months postoperatively. Because of the hidden and short incision, the mean score of the appearance scale of the SCAR-Q at 3 months post-operation was 74.2 ± 8.8. Conclusions: The novel endoscopy technique, which was first reported to perform lymph node surgery, N/SSM, and LDMF harvesting in an operation for breast cancer patients through a single axillary incision, is associated with a shorter surgery time, lower complication rates, and better patient-reported outcomes.

Co-Crystal Structure-Guided Optimization of Dual-Functional Small Molecules for Improving the Peroxygenase Activity of Cytochrome P450BM3.

We recently developed an artificial P450-H2O2 system assisted by dual-functional small molecules (DFSMs) to modify the P450BM3 monooxygenase into its peroxygenase mode, which could be widely used for the oxidation of non-native substrates. Aiming to further improve the DFSM-facilitated P450-H2O2 system, a series of novel DFSMs having various unnatural amino acid groups was designed and synthesized, based on the co-crystal structure of P450BM3 and a typical DFSM, N-(ω-imidazolyl)-hexanoyl-L-phenylalanine, in this study. The size and hydrophobicity of the amino acid residue in the DFSM drastically affected the catalytic activity (up to 5-fold), stereoselectivity, and regioselectivity of the epoxidation and hydroxylation reactions. Docking simulations illustrated that the differential catalytic ability among the DFSMs is closely related to the binding affinity and the distance between the catalytic group and heme iron. This study not only enriches the DFSM toolbox to provide more options for utilizing the peroxide-shunt pathway of cytochrome P450BM3, but also sheds light on the great potential of the DFSM-driven P450 peroxygenase system in catalytic applications based on DFSM tunability.

The role of radiotherapy in HER2+ early-stage breast cancer patients after breast-conserving surgery.

Background: Due to radioresistance, some HER2+ patients may gain limited benefit from radiotherapy (RT) after breast-conserving surgery (BCS). This study aimed to develop an individualized nomogram to identify early-stage HER2+ patients who could omit RT after BCS. Methods: The data of HER2+ patients with T0-2N0M0 breast cancer after BCS between 2010 and 2015 were extracted from Surveillance, Epidemiology, and End Results (SEER). Based on the independent prognostic factors determined by the Cox analysis in patients without RT after propensity score matching (PSM), the nomogram and risk stratification model were constructed, and then the prognosis of patients with and without RT was compared in each stratified group. Results: A total of 10799 early-stage HER2+ patients after BCS were included. Baseline characteristics were similar between groups after PSM. Multivariate Cox analysis indicated that RT could improve overall survival (OS) (HR: 0.45, P<0.001) and breast cancer-specific survival (BCSS) (HR: 0.53, P<0.001). Age, marital status, tumor location, tumor size, and chemotherapy were identified by multivariate Cox analysis in patients without RT and were incorporated into a well-validated nomogram. The risk stratification model based on the nomogram indicated that RT was associated with improved OS (HR 0.40, P< 0.001) and BCSS (HR 0.39, P< 0.001) in the high-risk group but not in the low-risk group [OS: HR 1.04, P = 0.94; BCSS: HR 1.06, P = 0.93]. Conclusion: RT could significantly improve the OS and BCSS of HER2+ early-stage breast cancer patients after BCS on the whole. For high-risk patients, RT is an essential component of cancer therapy. However, the omission of radiotherapy may be considered for low-risk HER2+ early-stage patients. Further validation and improvement of the nomogram by prospective study or randomized controlled trials are warranted.

[Application of three-pedicle reduction mammaplasty in breast cancer patients with moderate or greater breast hypertrophy and/or moderate-to-severe breast ptosis].

OBJECTIVE: To explore the application and effectiveness of three-pedicle reduction mammoplasty in breast cancer patients with moderate or greater breast hypertrophy and/or moderate-to-severe breast ptosis. METHODS: The clinical data of 15 breast cancer female patients with hypertrophy and/or moderate-to-severe breast ptosis treated by three-pedicle reduction mammaplasty with inverted T incision between January 2019 and March 2021 were retrospectively analysed. The patients were aged 31-58 years, with a median age of 39 years. The disease duration ranged from 10 days to 9 months (median, 3.4 months). All patients had unifocal tumor, with a maximum diameter of primary tumor of 0.5-3.9 cm (mean, 2.0 cm), of which 12 were diagnosed with invasive carcinoma and 3 carcinoma in situ. Tumor stage: T isN 0M 0 in 3 cases, T 1N 0M 0 in 4 cases, T 1N 2M 0 in 2 cases, T 2N 0M 0 in 4 cases, and T 2N 1M 0 in 2 cases. The preoperative cup sizes of patients were D cup in 3 cases, DD cup in 1 case, E cup in 2 cases, EE cup in 2 cases, F cup in 2 cases, FF cup in 1 case, and ≥G cup in 4 cases. The distance from nipple to inframammary fold was 8-18 cm (mean, 12.2 cm) before operation. The patients were followed up regularly after operation to evaluate the breast reduction effect and complications; Breast cancer reporting outcome scale (BREAST-Q) was used to assess patients' satisfaction and quality of life; and ultrasound, chest and abdominal CT, whole-body bone scan were performed to assess local tumor recurrence or distant metastasis. RESULTS: The postoperative nipple position was slightly higher than inframammary fold in all patients. Postoperative cup sizes were A cup in 3 cases, B cup in 6, C cup in 4, D cup in 1, and DD cup in 1, which showing significant difference when compared with preoperative cup sizes ( Z=3.420, P=0.001). The median follow-up time was 9 months (range, 6-33 months). Postoperatively, 2 cases (13.3%) had wound-site cellulitis, 1 (6.7%) had mild fat liquefaction, 2 (13.3%) had nipple and areola hypoesthesia but recovered after 3 months. No complication such as fat necrosis, papillary areola complex, or flap necrosis occurred. All patients had undergone adjuvant radiotherapy, of which 1 (6.7%) showed mild skin color change after radiotherapy, but no radiotherapy-related complication occurred in all patients. No patient was readmitted, received reoperation, or delayed to adjuvant therapy due to complications. In the BREAST-Q score, breast satisfaction and quality of life scores at 3 and 6 months after operation were significantly better than those before operation and at 1 month after operation ( P<0.05); no significant difference was found between at 1 month after operation and before operation ( P>0.05). Nipple satisfaction scores at 1, 3, and 6 months after operation were 15.6±2.2, 18.5±1.4, 19.3±0.7, respectively. At discharge after operation, the patient's satisfaction with the outcome of the operation was scored 84.7±11.4. The score of adverse events of radiotherapy at 6 months after operation was 6.5±0.8. During the follow-up, patient had no local recurrence, distant metastasis, or breast cancer related death. CONCLUSION: For breast cancer patients with moderate or greater breast hypertrophy and/or moderate-to-severe breast ptosis, three-pedicle reduction mammoplasty can not only remove the lesions, but also reduce hypertrophic breasts, accomplish the mammoplasty, reduce the radiotherapy complications, and improve the satisfaction and quality of life of patients.

Breakthrough in breast reconstruction in the context of COVID-19: safety and efficiency of endoscopic breast reconstruction at a day surgery center.

BACKGROUND: In recently years, breast endoscopic reconstruction surgery is becoming increasingly popular. And we have explored a series of endoscopic breast reconstruction procedures and applied it to our day surgery under the epidemic control of the novel coronavirus. METHODS: The present study was a retrospective analysis. Patients who underwent unilateral breast endoscopic reconstruction surgery in the West China Hospital from April 2017 to February 2021 were included in the study. Patients were divided into the following three groups: ward exploration period (WEP), ward maturation period (WMP), and day surgery period (DSP), respectively. We compared the results of postoperative complications, hospitalization costs, operation time, and BREAST-Q (a patient-reported outcome instrument measuring health-related quality-of-life and patient satisfaction in breast surgery) scale scores among the three groups of patients. RESULTS: A total of 66 patients were included (WEP n=30, WMP n=14, DSP n=22). Four people refused to complete the BREAST-Q scale, and five patients missed complication record sheets. Patients in the DSP and WMP groups had slightly higher postoperative satisfaction with their breasts than WEP, but there was no statistically significant difference (3 months postoperatively: WEP vs. WMP =0.515, WEP vs. DSP =0.418, WMP vs. DSP =0.982). On the postoperative BREAST-Q scale scores of psychosocial, sexual life and chest well-being, patients with DSP scored slightly higher than those with WEP versus WMP, but there was no statistically significant difference. The incidence of postoperative complications was generally higher in the WEP group than in the WMP and DSP groups, but there was no statistically significant incidence of either major or minor complications (P=1.000). With the use of prostheses and mesh, patients in the DSP group had lower hospitalization costs than other two groups. In terms of operative time, patients in the WMP and DSP groups had shorter operative times compared with the WEP group, and the results were statistically significant (WEP vs. WMP =0.000, WEP vs. DSP =0.000, WMP vs. DSP =0.243). CONCLUSIONS: We believe that performing our newly developed endoscopic breast reconstructive surgery at a day surgery center is safe and reliable.

Enabling highly (R)-enantioselective epoxidation of styrene by engineering unique non-natural P450 peroxygenases.

Unlike the excellent (S)-enantioselective epoxidation of styrene performed by natural styrene monooxygenases (ee > 99%), the (R)-enantioselective epoxidation of styrene has not yet achieved a comparable efficiency using natural or engineered oxidative enzymes. This report describes the H2O2-dependent (R)-enantioselective epoxidation of unfunctionalized styrene and its derivatives by site-mutated variants of a unique non-natural P450BM3 peroxygenase, working in tandem with a dual-functional small molecule (DFSM). The observed (R)-enantiomeric excess (ee) of styrene epoxidation is up to 99% with a turnover number (TON) of 918 by the best enantioselective mutant F87A/T268I/L181Q, while the best active mutant F87A/T268I/V78A/A184L (with 98% ee) gave a catalytic TON of 4350, representing the best activity of a P450 peroxygenase towards styrene epoxidation to date. Following this approach, a set of styrene derivatives, such as o-, m-, p-chlorostyrenes and fluorostyrenes, could also be epoxidized with modest to very good TONs (362-3480) and high (R)-enantioselectivities (95-99% ee). The semi-preparative scale synthesis of (R)-styrene oxide performed at 0 °C with high conversion, maintaining enantioselectivity, and moderate isolated yields, further suggests the potential application of the current P450 enzymatic system in styrene epoxidation. This study indicates that the synergistic use of protein engineering and an exogenous DFSM constitutes an efficient strategy to control the enantioselectivity of styrene epoxidation, thus substantially expanding the chemical scope of P450 enzymes as useful bio-oxidative catalysts.