Updated evidence of the effectiveness and safety of transanal drainage tube for the prevention of anastomotic leakage after rectal low anterior resection: a systematic review and meta-analysis.

BACKGROUNDS: Anastomotic leakage (AL) represents a major complication after rectal low anterior resection (LAR). Transanal drainage tube (TDT) placement offers a potential strategy for AL prevention; however, its efficacy and safety remain contentious. METHODS: A systematic review and meta-analysis were used to evaluate the influence of TDT subsequent to LAR as part of the revision of the surgical site infection prevention guidelines of the Japanese Society of Surgical Infectious Diseases (PROSPERO registration; CRD42023476655). We searched each database, and included randomized controlled trials (RCTs) and observational studies (OBSs) comparing TDT and non-TDT outcomes. The main outcome was AL. Data were independently extracted by three authors and random-effects models were implemented. RESULTS: A total of three RCTs and 18 OBSs were included. RCTs reported no significant difference in AL rate between the TDT and non-TDT groups [relative risk (RR): 0.69, 95% confidence interval (CI) 0.42-1.15]. OBSs reported that TDT reduced AL risk [odds ratio (OR): 0.45, 95% CI 0.31-0.64]. In the subgroup excluding diverting stoma (DS), TDT significantly lowered the AL rate in RCTs (RR: 0.57, 95% CI 0.33-0.99) and OBSs (OR: 0.41, 95% CI 0.27-0.62). Reoperation rates were significantly lower in the TDT without DS groups in both RCTs (RR: 0.26, 95% CI 0.07-0.94) and OBSs (OR: 0.40, 95% CI 0.24-0.66). TDT groups exhibited a higher anastomotic bleeding rate only in RCTs (RR: 4.28, 95% CI 2.14-8.54), while shorter hospital stays were observed in RCTs [standard mean difference (SMD): -0.44, 95% CI -0.65 to -0.23] and OBSs (SMD: -0.54, 95% CI -0.97 to -0.11) compared with the non-TDT group. CONCLUSIONS: A universal TDT placement cannot be recommended for all rectal LAR patients. Some patients may benefit from TDT, such as patients without DS creation. Further investigation is necessary to identify the specific beneficiaries.

The effectiveness of fascial closure with antimicrobial-coated sutures in preventing incisional surgical site infections in gastrointestinal surgery: a systematic review and meta-analysis.

The aim of this study was to conduct a systematic review and meta-analysis of the efficacy of fascial closure using antimicrobial-sutures specifically for the prevention of surgical site infections (SSIs) in gastrointestinal surgery, as part of the revision of the SSI prevention guidelines of the Japanese Society of Surgical Infectious Diseases (JSSI). We searched CENTRAL, PubMed and ICHUSHI-Web in May 2023, and included randomized controlled trials (RCTs) comparing antimicrobial-coated and non-coated sutures for fascial closure in gastrointestinal surgery (PROSPERO No. CRD42023430377). Three authors independently screened the RCTs. We assessed the risk of bias and the GRADE criteria for the extracted data. The primary outcome was incisional SSI and the secondary outcomes were abdominal wall dehiscence and the length of postoperative hospital stay. This study was supported partially by the JSSI. A total of 10 RCTs and 5396 patients were included. The use of antimicrobial-coated sutures significantly lowered the risk of incisional SSIs compared with non-coated suture (risk ratio: 0.79, 95% confidence intervals: 0.64-0.98). In subgroup analyses, antimicrobial-coated sutures reduced the risk of SSIs for open surgeries, and when monofilament sutures were used. Antimicrobial-coated sutures did not reduce the incidence of abdominal wall dehiscence and the length of hospital stay compared with non-coated sutures. The certainty of the evidence was rated as moderate according to the GRADE criteria, because of risk of bias. In conclusion, the use of antimicrobial-coated sutures for fascial closure in gastrointestinal surgery is associated with a significantly lower risk of SSI than non-coated sutures.

Association between skin suture devices and incidence of incisional surgical site infection after gastrointestinal surgery: systematic review and network meta-analysis.

BACKGROUND: Surgical site infections (SSIs) are common complications after abdominal surgery. AIM: To compare which suture devices could reduce the incidence of incisional surgical site infections (SSIs) after gastrointestinal surgery using a systematic review and network meta-analysis. METHODS: The CENTRAL, PubMed, and ICHUSHI-Web databases were searched from January 1st, 2000, to December 31st, 2022, for randomized clinical trials (RCTs) comparing the incidence of incisional SSI after gastrointestinal surgery among patients treated with different surgical suture devices, including non-absorbable sutures, absorbable sutures, skin staplers, and tissue adhesives (last searched in August 23th, 2023). The risk of bias was assessed using the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. To estimate the pooled odds ratios (ORs) for each comparison, a fixed-effect inverse-variance model based on the Mantel-Haenszel approach was employed. FINDINGS: A total of 18 RCTs with 5496 patients were included in this study. The overall SSIs in absorbable sutures were significantly lower than those in skin staplers (OR: 0.77; 95% confidence intervals (CI): 0.63-0.95) and non-absorbable sutures (OR: 0.62; 95% CI: 0.39-0.99), whereas SSIs in absorbable sutures were not significantly different from the SSIs in tissue adhesive. The highest P-score was 0.91 for absorbable sutures. A funnel plot for estimating the heterogeneity of the studies revealed that a publication bias would be minimal (Egger test, P = 0.271). CONCLUSION: This study showed that absorbable sutures reduced incisional SSIs in gastrointestinal surgical operations compared to any other suture devices.

Lung-derived mediators induce cytokine production in downstream organs via an NF-κB-dependent mechanism.

In the setting of acute lung injury, levels of circulating inflammatory mediators have been correlated with adverse outcomes. Previous studies have demonstrated that injured, mechanically ventilated lungs represent the origin of the host inflammatory response; however, mechanisms which perpetuate systemic inflammation remain uncharacterized. We hypothesized that lung-derived mediators generated by mechanical ventilation (MV) are amplified by peripheral organs in a "feed forward" mechanism of systemic inflammation. Herein, lung-derived mediators were collected from 129X1/SVJ mice after 2 hours of MV while connected to the isolated perfused mouse lung model setup. Exposure of liver endothelial cells to lung-derived mediators resulted in a significant increase in G-CSF, IL-6, CXCL-1, CXCL-2, and MCP-1 production compared to noncirculated control perfusate media (P < 0.05). Furthermore, inhibition of the NF-κB pathway significantly mitigated this response. Changes in gene transcription were confirmed using qPCR for IL-6, CXCL-1, and CXCL-2. Additionally, liver tissue obtained from mice subjected to 2 hours of in vivo MV demonstrated significant increases in hepatic gene transcription of IL-6, CXCL-1, and CXCL-2 compared to nonventilated controls. Collectively, this data demonstrates that lung-derived mediators, generated in the setting of MV, are amplified by downstream organs in a feed forward mechanism of systemic inflammation.

Remimazolam anaphylaxis confirmed by serum tryptase elevation and skin test.

Anaphylactic reactions during the induction of general anaesthesia are rare. Anaesthetists should determine the pathogenesis of anaphylaxis in order to establish appropriate treatment and prevent recurrence. Very little clinical information has been published to date about anaphylaxis induced by the recently launched drug remimazolam. A 78-year-old man, scheduled for elective surgery for colon cancer, became profoundly hypotensive and hypoxic shortly following the induction of general anaesthesia with remimazolam, remifentanil and rocuronium. His physiological derangement was successfully managed with adrenaline, vasopressors and intravenous fluid resuscitation. His serum tryptase level was significantly elevated and an intradermal test with diluted remimazolam revealed a positive reaction, confirming the diagnosis of anaphylaxis. We believe this is the first case report of remimazolam-induced anaphylactic shock diagnosed with a serum tryptase elevation and positive skin test.

Retinal degeneration in mice lacking the gamma subunit of the rod cGMP phosphodiesterase.

The retinal cyclic guanosine 3',5'-monophosphate (cGMP) phosphodiesterase (PDE) is a key regulator of phototransduction in the vertebrate visual system. PDE consists of a catalytic core of alpha and beta subunits associated with two inhibitory gamma subunits. A gene-targeting approach was used to disrupt the mouse PDEgamma gene. This mutation resulted in a rapid retinal degeneration resembling human retinitis pigmentosa. In homozygous mutant mice, reduced rather than increased PDE activity was apparent; the PDEalphabeta dimer was formed but lacked hydrolytic activity. Thus, the inhibitory gamma subunit appears to be necessary for integrity of the photoreceptors and expression of PDE activity in vivo.

Spatial and temporal patterns of bird species diversity in the Pantanal of Mato Grosso, Brazil: implications for conservation.

Analysis of a three-year bird survey in the pantanal of Poconé revealed that most of the resident and seasonal birds are habitat generalists, using two or more habitats. In this study, previously sampled habitats were ranked in relation to species richness and stability (as measured by the ratio of seasonal to resident species). In all, nine habitats were grouped into three categories; results are as follows: 1) forests: more species-rich and more stable; 2) cerrado: intermediate levels; and 3) aquatic: less species-rich and less stable. The number of seasonal species remained relatively constant in forests throughout the year, while increasing in the other habitats during the dry season. The abundance of resident species seems to be related to species use of multiple habitats. Although many species were found to be habitat generalists, we discuss possible consequences of habitat loss and other human impacts on efforts to conserve this important bird community.

Endothelin receptor antagonists in a beagle model of pulmonary hypertension: contribution to possible potential therapy?

OBJECTIVES: This study investigated the pharmacologic effect of endothelin receptor antagonists on cardiopulmonary hemodynamic variables in a beagle model of pulmonary hypertension. BACKGROUND: We recently developed a beagle model of pulmonary hypertension that allows accurate determination of cardiopulmonary hemodynamic variables and is associated with elevated plasma endothelin-1 concentrations similar to those in pulmonary hypertension in humans. METHODS: Twelve beagles (pulmonary hypertension, n = 6; control group, n = 6) were studied during baseline conditions and during right atrial infusion of FR139317 (an ETA receptor antagonist), RES-701-1 (an ETB receptor antagonist), nitroglycerin and prostaglandin E1. Pulmonary hypertension was induced in experimental beagles 8 weeks after injection with 3 mg/kg body weight of dehydromonocrotaline. RESULTS: FR139317 lowered pulmonary artery and systemic arterial pressures in both pulmonary hypertensive and control beagles, with a significantly greater effect on pulmonary artery pressure in pulmonary hypertensive dogs. RES-701-1 tended to increase pulmonary artery pressure only in pulmonary hypertensive beagles. Nitroglycerin depressed pulmonary artery and systemic arterial tone equally well in control and pulmonary hypertensive animals. Prostaglandin E1 produced a greater decrease in systemic arterial pressure in pulmonary hypertensive than in normal beagles despite having the same effect on pulmonary artery pressure in both. CONCLUSIONS: ETA receptor antagonists decrease pulmonary artery pressure in a beagle model and may therefore be clinically useful for treatment of pulmonary hypertension.

Characterization of trace elements in Casearia medicinal plant by neutron activation analysis.

Leaves of Casearia sylvestris, Casearia decandra and Casearia obliqua plant species, collected at the Atlantic Forest in Brazil, were analyzed by using instrumental neutron activation analysis (INAA). Short and long irradiations using thermal neutron flux of the IEA-R1 nuclear reactor were carried out for these analyses. Concentrations of Ca, K and Mg were found in these samples at the percentage levels, Br, Cl, Fe, Mn, Na, Rb and Zn at the microg g(-1) levels and Co, Cr, Cs, La, and Sc at the microg kg(-1) levels. Comparisons were made among the element concentrations obtained in these three Casearia species and significant differences were found for the elements Cl, Co, Cs, Cr, La, Mn, Na and Sc. The precision and the accuracy of the results were evaluated by analyzing the certified reference materials NIST-1515 Apple Leaves and NIST-1573a Tomato Leaves.

Establishment of canine pulmonary hypertension with dehydromonocrotaline. Importance of larger animal model for lung transplantation.

Single lung isografting in rats with pulmonary hypertension has been reported. However, it is hard to evaluate cardiopulmonary hemodynamics accurately or to use circulatory assists during procedures using rats. Therefore, we tried to establish a model of pulmonary hypertension in the beagle. Twenty young beagles were randomized into 3 groups. An injection of dehydromonocrotaline of 1.5 mg/kg (group 1, n = 7), 3.0 mg/kg (group 2, n = 10), or 4.5 mg/kg (group 3, n = 3) was performed via the right atrium. Two dogs in group 2 and all the dogs in group 3 died of acute pulmonary edema. During the 8 weeks after injection, the systolic pulmonary arterial pressure and pulmonary vascular resistance index increased significantly in group 2 from 21 +/- 2 to 56 +/- 9 mmHg and from 106 +/- 39 to 826 +/- 176 dynes.sec.cm-5.m2, respectively (P < 0.01). The changes in group 1 were less pronounced. The dogs in group 2 also had a rise in their plasma endothelin-1. Pathologic analysis revealed thickening of the media in small pulmonary arteries and hypertrophy of the right ventricular myocardium. Our data indicate that beagles treated with 3.0 mg/kg dehydromonocrotaline produced a unique, relatively noninvasive model of pulmonary hypertension. In the model, right ventricular failure prevented us from clamping one pulmonary artery. These relatively large animals with pulmonary hypertension will be valuable for further studies of lung transplantation.

Estrogen receptor in the human eye: influence of gender and age on gene expression.

PURPOSE: Many epidemiologic studies indicate an increased incidence of certain vision threatening conditions in postmenopausal women. These data suggest that changes in sex steroid homeostasis may affect the physiology of the eye. To provide support to this hypothesis, the expression of estrogen receptor alpha (ERalpha) in human eye tissues was investigated. METHODS: Complementary studies including RNA analysis by reverse transcription polymerase chain reaction, western blot analysis, and immunocytochemistry were used to provide evidence of ERalpha expression. Protein detection was carried out using a mouse monoclonal antibody raised against an epitope located in the ligand binding domain of the human receptor. Cellular localization was studied on formalin-fixed paraffin-embedded eye sections using conventional immunohistochemical techniques. RESULTS: Gender and age differences in ERalpha mRNA expression were observed in retina. The 65-kDa ERalpha protein was detected in the retina and retinal pigment epithelium (RPE) of young female eyes but not in eye tissues dissected from men and postmenopausal women. Immunocytochemistry corroborated ERalpha staining of a young female neurosensory retina and RPE. In addition, ERalpha could be detected in the ciliary body, in the iris, and in the epithelium of the lens. CONCLUSIONS: The presence of the ERalpha in the human eye suggests that the sex steroid hormone axis may play a role in the pathogenesis of certain ocular diseases.

The human cGMP-PDE beta-subunit promoter region directs expression of the gene to mouse photoreceptors.

PURPOSE: We previously demonstrated that 350 bp of the human rod cGMP phosphodiesterase beta-subunit (beta-PDE) gene promoter are sufficient to direct high levels of gene expression in human Y-79 retinoblastoma cells in vitro. In this study the cell specificity and expression pattern conferred by the short beta-PDE 5' flanking sequence in vivo were examined. METHODS: A construct containing the bacterial LacZ gene driven by a fragment of the beta-PDE 5' flanking region (-297 to +53) was used to generate transgenic mice. Gene expression was analyzed by measuring beta-galactosidase activity in tissue homogenates or visualizing enzymatic activity or protein production at a cellular level by in situ histochemistry or immunocytochemistry. RESULTS: Three independently derived transgenic lines were generated carrying the -297 to +53 beta-PDE 5' flanking region fragment. Within the retina, the reporter gene was specifically expressed in photoreceptors, consistent with the localization of endogenous beta-PDE. Significant expression of LacZ was not observed in other ocular or peripheral tissues. CONCLUSIONS: Photoreceptor-specific reporter gene expression is driven in vivo by a 350-bp segment of the beta-PDE 5' flanking sequence. This study demonstrates the utility of the human beta-PDE promoter for directing the expression of foreign genes to photoreceptors and suggests that the -297 to +53 beta-PDE 5' flanking region fragment may have important implications for therapeutic gene delivery to the visual cells.

Exclusion of the beta-subunit of type II calmodulin kinase for the wobbler spinal muscular atrophy gene.

The wobbler mouse (wr) is an attractive model for studying motor neuron disease but the genetic defect is unknown. The beta-subunit of calmodulin kinase II (beta-CaMK II) is a good candidate for the wr mutation because of its chromosomal localization and tissue distribution. In this report, we found normal levels of CaM KII mRNA and enzyme activity making it highly unlikely that a mutation in the beta-CaM KII gene is the cause of the wr phenotype.

Right ventricular ejection fraction in the preoperative risk evaluation of candidates for pulmonary resection.

The major determinants of postoperative morbidity and mortality after lung resection are the physiologic and functional statuses of the pulmonary and cardiac systems. In our previous study, serial measurements of right ventricular performance after pulmonary resection demonstrated significant right ventricular dysfunction in the postoperative period. This study evaluates the preoperative measurement of right ventricular ejection fraction as a predictor of postoperative complications. In addition to conventional cardiopulmonary functional tests, right ventricular function was assessed with a thermodilution technique at rest and during exercise in 18 patients before and 3 weeks after lobectomy or pneumonectomy. The patients were grouped according to severity of right ventricular functional defect: right ventricular ejection fraction of at least 45% (group Ia, n = 8), right ventricular ejection fraction less than 45% (group Ib, n = 10), exercise-induced increases in right ventricular ejection fraction (group IIa, n = 8), and exercise-induced decreases in right ventricular ejection fraction (group IIb, n = 10). Postoperative cardiopulmonary morbidity was recorded for two patients (25%) in group Ia, three patients (30%) in group Ib, no patients (0%) in group IIa, and five patients (50%) in group IIb. Postoperative hospital stay was 28.9 +/- 8.5 days in group Ia, 29.9 +/- 20.2 days in group Ib, 19.4 +/- 8.0 days in group IIa, and 37.5 +/- 15.9 days in group IIb (p < 0.05, group IIa vs group IIb). Although resection-induced changes in forced expiratory volume in 1 second did not differ significantly between group Ia and group Ib, these values appeared to be increased in groups IIa (not statistically significant) and IIb (significantly, p < 0.05). The measured postoperative values of forced expiratory volume in 1 second and vital capacity were significantly higher than the predicted postoperative values (p < 0.05) in group IIa, but not in groups Ia, Ib, and IIb. We conclude that evaluation of right ventricular performance is useful in determining which patients are at increased risk for medical complications after lung resection. Exercise-induced change in right ventricular ejection fraction may be a better indicator of high risk among candidates for pulmonary resection than the absolute value of this parameter.

Efficacy of oxygenated University of Wisconsin solution containing endothelin-A receptor antagonist in twenty-four-hour heart preservation.

BACKGROUND: The University of Wisconsin solution has been proven to be effective for prolonged heart preservation. However, 24-hour heart preservation by simple cold immersion in University of Wisconsin solution has been disappointing. We have performed hypothermic low-pressure continuous coronary perfusion with oxygenated University of Wisconsin solution for experimental prolonged heart preservation. However, the high potassium concentration of University of Wisconsin solution combined with prolonged ischemia has detrimental effects on endothelial function, which increases coronary tone during preservation and after reperfusion. The severe vasoconstriction and tissue edema result in damage to the coronary microcirculation. The purpose of this study was to determine whether hypothermic low-pressure continuous coronary perfusion technique with oxygenated University of Wisconsin solution containing a selective endothelin-A receptor antagonist (FR139317) would increase the effectiveness of the perfusion technique and improve postischemic cardiac function, both minimizing tissue edema and suppressing vasoconstriction. METHODS AND RESULTS: Preischemic and postischemic cardiac function of isolated rabbit hearts was evaluated with a Langendorff apparatus. The hearts were divided into three groups (n = 7 each): group I (hypothermic low-pressure continuous coronary perfusion with University of Wisconsin solution), group II (hypothermic low-pressure continuous coronary perfusion with oxygenated University of Wisconsin solution), and group III (hypothermic low-pressure continuous coronary perfusion with oxygenated University of Wisconsin solution containing 10 mg/L of FR139317). Preservation was performed for 24 hours. The initial perfusion pressure for continuous coronary perfusion was set at 5 mm Hg. Measurement of percentage of tissue water content and ultrastructural examination of the myocardium was then performed. In groups I, II, and III, the perfusion pressures at the end of the 24-hour preservation period increased from 5 mm Hg to 12.2 +/- 2.5, 8.1 +/- 1.3, and 5.4 +/- 0.8 mm Hg (p < 0.05), respectively. Percent recovery rate of cardiac output was 56.6 +/- 2.8, 82.3 +/- 8.2, and 93.3 +/- 6.0 (p < 0.05), respectively. And percent recovery rate of coronary flow was 55.5 +/- 8.1, 80.0 +/- 8.0, and 94.3 +/- 9.4 (p < 0.05), respectively. A significant inverse correlation was found between continuous coronary perfusion pressure at the end of preservation and the recovery rate of cardiac output (r = 0.85, p < 0.05). Tissue water content was significantly higher in group I than in groups II and III. These effects were inhibited by oxygenation of the University of Wisconsin solution (group II) and by the addition of the selective endothelin-A receptor antagonist (FR139317) (group III). Damage to coronary circulation was reduced by oxygenation and the addition of endothelin-A receptor antagonist during prolonged heart preservation. CONCLUSIONS: We concluded that hypothermic low-pressure continuous coronary perfusion technique with oxygenated UW solution containing endothelin-A receptor antagonist (FR139317) maintained coronary circulation by suppressing tissue edema and vasoconstriction during preservation, which improved postischemic functional recovery.

Single lung transplantation for canine pulmonary hypertension.

BACKGROUND: In spite of recent reports of the clinical application of single lung transplantation for pulmonary hypertension, there is little underlying experimental data because of the lack of a reliable animal pulmonary hypertensive transplant model. We have established a pulmonary hypertensive model in beagles with dehydromonocrotaline and have been able to measure cardiopulmonary hemodynamics accurately and use circulatory assists during procedures. The purpose of this study was to determine whether single lung transplantation could be performed after the protocol of clinical procedure. METHODS AND RESULTS: In six control dogs, allografting was successfully completed without cardiopulmonary bypass. Because one pulmonary hypertensive recipient dog died of right ventricular failure during the procedure without cardiopulmonary bypass, we used bypass for allografting in five pulmonary hypertensive dogs. Cardiopulmonary bypass lowered pulmonary artery pressure, allowing pulmonary arterial clamping and avoiding right ventricular overload. All pulmonary hypertensive dogs undergoing bypass were successfully weaned from bypass, indicating a good hemodynamic response to transplantation. In pulmonary hypertensive dogs, transplantation resulted in significant decreases in systolic pulmonary artery pressure and pulmonary vascular resistance, and a significant increase in blood flow to the graft lung, whereas in controls the results were the reverse. CONCLUSIONS: Thus we were able to show that hemodynamics improved after single lung transplantation with cardiopulmonary bypass in a new pulmonary hypertensive animal model. These relatively larger animals are valuable for further studies of single, double, bilateral, and heart-lung transplantation for pulmonary hypertension.