Post-Partum Diastasis Recti Abdominis Treatment Using the Extended-View Totally Extraperitoneal Approach, Rives-Stoppa Technique, and Transversus Abdominis Release Procedure.

Introduction: Diastasis recti abdominis usually occurs during pregnancy and delivery in young women with no surgical history, and can induce a severely negative body image, urogynecological symptoms, and musculoskeletal pain. However, the optimal surgical procedure for diastasis recti abdominis is undetermined, and minimally invasive surgery has not been adopted. Additionally, open repair causes scarring that is unlikely to improve negative body image and may even worsen it. We present a case of diastasis recti abdominis surgically treated using an extended-view totally extraperitoneal approach, Rives-Stoppa technique, and transversus abdominis release procedure. Case Description: The patient was a 29-year-old woman who delivered transvaginally two weeks before presenting with bulging of the abdominal wall. Computed tomography revealed separation of the rectus. A three-month course of conservative therapy comprising exercises to strengthen the transversus abdominis was ineffective, and the patient had newly developed abdominal pain. Therefore, we performed surgical repair using the Rives-Stoppa technique and transversus abdominis release via the extended-view totally extraperitoneal approach. The postoperative course was uneventful, with no recurrence. This procedure may be superior to other methods in terms of cosmetic appearance, preventing infection, bowel adhesion, and recurrence. Discussion: In the case study, the Rives-Stoppa technique and transversus abdominis release via the extended-view totally extraperitoneal approach achieved a good therapeutic outcome for diastasis recti abdominis.

Relationship Between Lymphaticovenular Anastomosis Outcomes and the Number and Types of Anastomoses.

BACKGROUND: Lymphaticovenular anastomosis (LVA) is the first-line treatment for lymphedema in many hospitals. However, many aspects of its effects remain unclear. This study aimed to analyze problems with regard to the relationship between lymphaticovenular anastomosis and outcomes of surgery for lymphedema in the upper and lower extremities. METHODS: Eighteen articles were selected for review. The following information was extracted from these articles as factors associated with LVA for lymphedema in the upper and lower extremities: number of cases, average patient age, mean number of bypasses, lymphedema stage, duration and type of lymphedema, anastomotic technique, follow-up period, type of scale, and treatment outcomes. RESULTS: Upper extremity lymphedema: The average age of patients was 54.2 (range: 41.3-60.1) years. The mean number of anastomoses was 3.91 (range: 1.0-7.2). Six of nine articles provided data for volume change, and the mean volume change was 29% (-5%-50%). Lower extremity lymphedema: The average age of patients was 50.3 (range: 34-64 years). The mean number of anastomoses was 4.6 (range: 2.1-9.3). Comparison was difficult as different methods were used for postoperative evaluation (lower extremity lymphedema index in three patients, limb circumference in one, volume change in two, and restaging in three). CONCLUSIONS: We obtained useful information with regard to the effects of LVA in this review. An increased number of anastomoses between the lymphatic ducts and veins did not seem to improve the effectiveness of LVA. With regard to the stage of lymphedema, LVA may be useful for both early and advanced stages.

Erratum: Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunum Transfer: Erratum.

[This corrects the article DOI: 10.1097/GOX.0000000000002663.].

Investigation of Free-Flap Transfer Reconstruction in Elderly Patients and Oral Intake Function.

The authors retrospectively examined 39 patients with head and neck reconstruction using a free-flap transfer with microsurgery in elderly patients aged over 80 years in our hospital. They investigated postoperative local complications, postoperative systemic complications, day of ambulation, the presence of delirium, the postoperative oral intake ratio, and the reconstructive method in mandibular reconstruction patients. There were 12 postoperative local complications. And postoperative systemic complications were detected in 19 patients; however, 17 of these were respiratory disorders due to pneumonia. There were 17 patients with postoperative delirium. Oral intake was resumed after an average of 14.9 days. Of these, 34 patients were eventually able to eat some kind of food. The incidence of local complications in elderly free-flap reconstruction patients was similar to that in young people. However, the rate of systemic complications was much higher in elderly patients. The authors suggest that free-flap reconstruction can be performed relatively safely in elderly people when a detailed preoperative surgical plan.

Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunal Flap Transfer.

BACKGROUND: The purpose of this study was to examine the relationship between the incidence of dysphagia or fistula formation in an anastomotic region and factors such as extent of resection, gastric tube formation, and irradiation among patients who underwent free jejunal flap transfer. METHODS: We retrospectively examined 100 cases (88 men and 12 women; average age, 65.8 years; range, 46-88 years) in whom the evaluation of postoperative oral intake was possible after undergoing total pharyngo-laryngo-esophagectomy (TPLE) and free jejunal flap transfer. Chi-square test (with Fisher transformation, if necessary) was performed to analyze the relationship among resection styles (the resection margin extended to the oropharynx or to the cervical esophagus and gastric tube elevation), radiation therapy history, and incidence of dysphagia or fistula formation. RESULTS: One hundred patients were analyzed, and complications such as postoperative fistula and dysphagia occurred in 8 (8.0%) and 20 patients (20.0%), respectively. However, no significant correlation was found between various resection factors and fistula formation or adverse events. At the reconstruction site, other complications such as postoperative lymphorrhea (7%), postoperative hematoma (4%), trachea necrosis (4%), cervical flap necrosis (1%), and thyroid necrosis (1%) occurred. These complications were managed by a cervical open wound and additional minor operation as needed. CONCLUSION: Thus, free jejunal transfer for TPLE is a good reconstruction technique with few complications and postoperative adverse events, regardless of the extent of resection and preoperative radiation therapy.

Salvage Surgery for Jejunal Necrosis After a Free Jejunal Transfer.

INTRODUCTION: Given the few reports regarding the salvage methods for managing jejunal necrosis, finding candidates for a meta-analysis or systematic review is difficult. Thus, this study aimed to describe the interventions for jejunal necrosis and investigate important points relating to this condition. METHODS: The interventions used to treat free jejunal necrosis are external fistula formation with jejunal debridement, secondary reconstruction of the local site, and overall status improvement, and re-free jejunal transfer with removal of the necrotic jejunum. Selecting the optimal procedure for each patient depends on the following factors. First, patients must have a good overall status to be able to endure re-free jejunal transfer, and next, the procedure is also dependent on local factors, including the intensity of the infections of the postoperative wound. RESULTS: One of the most common factors of jejunal necrosis is necrosis due to blood flow deficiency of the transferred tissue. However, among jejunal necrotic cases, some patients had no blood circulation disorder. We inferred that a non-occlusive mesenteric ischemia like occurred in the transferred jejunum, and also considered patients' overall status and necrotic association. Thus, patients who underwent re-free jejunal transfer are at an increased risk of experiencing re-necrosis. Based on these findings, we designed a jejunal necrosis algorithm. CONCLUSIONS: Early debridement and re-free jejunal transfer are optimal treatment options for patients with early-stage jejunal necrosis. Because re-jejunum transfer is a possible state after necrosis, it was thought that coping was the most important aspect of detection at an early stage.

A Subtype of Olfactory Bulb Interneurons Is Required for Odor Detection and Discrimination Behaviors.

UNLABELLED: Neural circuits that undergo reorganization by newborn interneurons in the olfactory bulb (OB) are necessary for odor detection and discrimination, olfactory memory, and innate olfactory responses, including predator avoidance and sexual behaviors. The OB possesses many interneurons, including various types of granule cells (GCs); however, the contribution that each type of interneuron makes to olfactory behavioral control remains unknown. Here, we investigated the in vivo functional role of oncofetal trophoblast glycoprotein 5T4, a regulator for dendritic arborization of 5T4-expressing GCs (5T4 GCs), the level of which is reduced in the OB of 5T4 knock-out (KO) mice. Electrophysiological recordings with acute OB slices indicated that external tufted cells (ETCs) can be divided into two types, bursting and nonbursting. Optogenetic stimulation of 5T4 GCs revealed their connection to both bursting and nonbursting ETCs, as well as to mitral cells (MCs). Interestingly, nonbursting ETCs received fewer inhibitory inputs from GCs in 5T4 KO mice than from those in wild-type (WT) mice, whereas bursting ETCs and MCs received similar inputs in both mice. Furthermore, 5T4 GCs received significantly fewer excitatory inputs in 5T4 KO mice. Remarkably, in olfactory behavior tests, 5T4 KO mice had higher odor detection thresholds than the WT, as well as defects in odor discrimination learning. Therefore, the loss of 5T4 attenuates inhibitory inputs from 5T4 GCs to nonbursting ETCs and excitatory inputs to 5T4 GCs, contributing to disturbances in olfactory behavior. Our novel findings suggest that, among the various types of OB interneurons, the 5T4 GC subtype is required for odor detection and discrimination behaviors. SIGNIFICANCE STATEMENT: Neuronal circuits in the brain include glutamatergic principal neurons and GABAergic interneurons. Although the latter is a minority cell type, they are vital for normal brain function because they regulate the activity of principal neurons. If interneuron function is impaired, brain function may be damaged, leading to behavior disorder. The olfactory bulb (OB) possesses various types of interneurons, including granule cells (GCs); however, the contribution that each type of interneuron makes to the control of olfactory behavior remains unknown. Here, we analyzed electrophysiologically and behaviorally the function of oncofetal trophoblast glycoprotein 5T4, a regulator for dendritic branching in OB GCs. We found that, among the various types of OB interneuron, the 5T4 GC subtype is required for odor detection and odor discrimination behaviors.

Npas4 regulates Mdm2 and thus Dcx in experience-dependent dendritic spine development of newborn olfactory bulb interneurons.

Sensory experience regulates the development of various brain structures, including the cortex, hippocampus, and olfactory bulb (OB). Little is known about how sensory experience regulates the dendritic spine development of OB interneurons, such as granule cells (GCs), although it is well studied in mitral/tufted cells. Here, we identify a transcription factor, Npas4, which is expressed in OB GCs immediately after sensory input and is required for dendritic spine formation. Npas4 overexpression in OB GCs increases dendritic spine density, even under sensory deprivation, and rescues reduction of dendrite spine density in the Npas4 knockout OB. Furthermore, loss of Npas4 upregulates expression of the E3-ubiquitin ligase Mdm2, which ubiquitinates a microtubule-associated protein Dcx. This leads to reduction in the dendritic spine density of OB GCs. Together, these findings suggest that Npas4 regulates Mdm2 expression to ubiquitinate and degrade Dcx during dendritic spine development in newborn OB GCs after sensory experience.

Development of a technique for the investigation of folding dynamics of single proteins for extended time periods.

A technique was developed for the detection of fluorescence signals from free single molecules for extended time periods and was applied to the characterization of the unfolded states of iso-1-cytochrome c (cyt c). Protein molecules labeled with fluorescent dye were slowly injected into a capillary at concentrations that allow for the observation of one molecule at a time. A laser was introduced into the capillary coaxially, and the fluorescence was imaged as traces by using a lens with a large focal depth and wide field of view. Thus, the traces reflect the time-dependent changes in the fluorescence signals from single proteins. Cyt c was labeled with Alexa Fluor 532 at the C-terminal cysteine (cyt c-Alexa). In bulk experiments, cyt c-Alexa was shown to possess different fluorescence intensity for the native state, the unfolded state (U), and the intermediate state. Single-molecule traces of cyt c-Alexa were recorded by using the device. Intensity histograms of the traces revealed two distributions with broad and narrow widths, which were interpreted to correspond to the U and intermediate state, respectively, observed in the bulk measurements. The broad width of the U suggested the existence of a relatively slow conformational dynamics, which might be consistent with the correlation time ( approximately 15 ms) estimated from the traces assignable to the U. The technique was expected to reveal dynamics of proteins along the folding processes without artifacts caused by immobilization.