Single-incision laparoscopic transabdominal preperitoneal mesh hernioplasty: results in 182 Japanese patients.

BACKGROUND: We introduced single-incision transabdominal preperitoneal (S-TAPP) herniorrhaphy (described herein) at our institution in June 2010. We recently conducted a retrospective study to assess the feasibility and safety of the procedure. METHODS: The study involved 182 patients (159 men, 23 women) who underwent S-TAPP herniorrhaphy between June 2010 and February 2015 for 202 groin hernias (162 unilateral hernias, 20 bilateral hernias). We examined patient characteristics, hernia type and presentation, operation time, conversion to another repair procedure, intraoperative blood loss, postoperative pain, morbidities, and postoperative hospital stay. We further evaluated operation time and morbidity by comparison between cases of simple unilateral hernia and cases of complicated unilateral hernia, which was defined as (1) a recurrent hernia, (2) hernia following radical prostatectomy, or (3) an incarcerated omental or bowel hernia. RESULTS: Five types of hernia were treated: indirect inguinal, direct inguinal, femoral, combined inguinal, and other (a urinary bladder hernia). Operation time was 92.5 ± 29.1 min for the unilateral hernias and 135.7 ± 24.5 min for the bilateral hernias. No major bleeding occurred. Postoperative pain was short-lived and easily managed. Overall morbidity was 8.2% (15/182 patients), and only one postoperative complication (recurrence) required surgical intervention (repeat S-TAPP). Average postoperative stay was 6.7 ± 2.6 days. Two patients experienced numbness in the outer thigh, but this resolved naturally. One superficial surgical site infection developed and was easily treated. Operation times were greater for the complicated vs. simple hernias, but the time differed significantly (p = 0.02) only between radical prostatectomy-associated hernia and simple hernia. No complicated hernia required conversion to traditional laparoscopic repair, but in simple unilateral hernia group one conversion to traditional laparoscopic repair was required for difficulties encountered in the dissection of the large indirect inguinal hernia sac. The incidence of seroma was higher, though not statistically, in the complicated (n = 3) vs. simple hernia group. CONCLUSIONS: S-TAPP repair of groin hernia was shown to be a feasible, safe procedure. The advantages are well understood, and further studies are warranted to confirm the long-term benefits suggested by our study.

In situ hydrogelation of photocurable gelatin and drug release.

We devised an in situ tissue-adhesive, drug-release technology based on a photoreactive gelatin, which allows in situ drug-incorporated gel formation on living tissues and sustained drug release directly on diseased tissues. Styrene-derivatized gelatins, synthesized by condensation reaction of gelatin with 4-vinylbenzoic acid, were photopolymerized in the presence of a water-soluble camphorquinone derivative as a photoinitiator upon visible-light irradiation to form swollen gels. Using albumin as a drug model, gelation characteristics and drug-release characteristics easily were manipulated by material variables, formulation variables, and operation variables. Tissue adhesivity of the gel was superior to that of fibrin glue. The biologic response, which was evaluated by intraperitoneal implantation in rats, showed that the gel was biodegraded and biosorbed, without cytotoxicity, within a few months after implantation. An in situ processable tissue-adhesive local drug release system effectively may be used to help inhibit tumor recurrence.

Use of the QRS scoring system in the early estimation of myocardial infarct size following reperfusion.

While the QRS scoring system has been established as a convenient tool for estimating infarct size in nonreperfused patients during the chronic stage of myocardial infarction, its applicability to reperfused patients in the acute stage has not been established. To investigate whether infarct size could be estimated by the QRS scoring system soon after reperfusion, we evaluated QRS scores obtained serially 6 hours to 1 month after reperfusion, total creatine kinase release, and left ventricular ejection fraction in 126 patients with acute myocardial infarction who underwent successful reperfusion therapy. A significant correlation was observed between the QRS score obtained after 6 hours and that obtained after 1 month (r = .89). The QRS scores obtained after 6 hours and 1 month were significantly correlated with total creatine kinase release (r = -.65 and r = -.75, respectively) and left ventricular ejection fraction (r = .62 and r = .76, respectively). Thus, the QRS scoring system can be used as a simple and economical method for estimation of infarct size soon after reperfusion.

Right ventricular stiffness measured by a new method without volume estimation in coronary artery disease.

This study was designed to measure the right ventricular (RV) stiffness (delta P/ delta V) with a new method without estimating the RV volume itself. RV stiffness has rarely been measured due to the difficulty in estimating the RV volume. Without measuring RV volume itself, stiffness can be determined by measuring its volume change (delta V). Tricuspid filling flow volume, which is the diastolic RV delta V, is measurable by using Doppler echocardiography. Thus, RV stiffness may possibly be obtained from Doppler echocardiography combined with high-fidelity RV pressure. Subjects consisted of 8 controls, 8 patients with angina pectoris, 8 with anterior, 8 with posterior, and 8 with inferior prior myocardial infarction. Tricuspid annular dimension was measured by 2-dimensional echocardiography and the tricuspid annular area was calculated. Velocity-time integral of the tricuspid filling flow during the late diastole was measured by pulsed Doppler echocardiography. Then, the late diastolic RV delta V was obtained as the product of the tricuspid annular area and the integral. The late diastolic RV pressure rise (delta P) was also measured with a micromanometer catheter. The RV elastic chamber stiffness constant ([delta P/ delta V]/P) was obtained by dividing simple stiffness by the mean RV pressure during late diastole. The RV elastic chamber stiffness constant did not significantly differ among controls, patients with angina pectoris, and those with anterior and posterior myocardial infarction (0.0054 +/- 0.0009 vs 0.0057 +/- 0.0018 vs 0.0064 +/- 0.002 vs 0.0052 +/- 0.0019 ml-1). However, it was significantly increased in patients with inferior myocardial infarction (0.010 +/- 0.004 ml-1, p < 0.01 or 0.05) compared with those in the other 4 groups. These results suggest (1) that RV stiffness can be measured with a new method without RV volume estimation, and (2) that this new method is useful in evaluating RV diastolic pathophysiology in patients with coronary artery disease.

The effects of cardiac infarction on realistic three-dimensional left ventricular blood ejection.

The effect of cardiac infarction on the flow patterns in cardiac left ventricular ejection was studied using a realistic model which was made from the profile of the left ventricle of a dog heart in diastole. A coordinate measuring machine was used to measure the left ventricular coordinates, and these were input into a three-dimensional flow simulation package. The left ventricular wall motion was described by having the walls moved towards the center of the aortic outlet, and in the case of infarcted tissue, the ventricular wall movement was diminished to simulate infarction flow behavior. The final ventricular volume varied from 25 percent to 54.1 percent of the initial volume in cases without and with infarction, respectively. The maximum blood ejection velocities and ventricular pressure decreased significantly in the presence of infarction. Infarcted areas showed complex blood flow vortex formation not present in the healthy ventricles. The computational technique presented here predicts infarction flow effects which could be observed with measurement techniques such as ultrasound and magnetic resonance imaging, allowing a finer detail of understanding than using either simulation or experimental measurements alone.

Computational fluid mechanical study of the convective heat transfer in a closed space simulating an infant incubator.

The uneven distribution of the ambient temperature in a model of an infant incubator was demonstrated using the computational fluid mechanical (CFM) simulation of the air flow. A finite volume method of CFM calculation was performed on a three-dimensional (3D) model of an infant incubator including a model baby. The time course of the temperature distribution was computed solving the heat transfer equations simultaneously with the momentum equations. An uneven temperature distribution was observed for a long period (60 s) after the warm inflow was introduced into the incubator chamber. The temperature distribution was complex in 3D space and unsteady even after a long time, suggesting that it may take a considerable time to settle and may continue to be unsteady even if the inflow velocity is steady.

Increased heparin-releasable platelet factor 4 and D dimer in patients one month after the onset of acute myocardial infarction: persistent activation of platelets and the coagulation/fibrinolytic system.

To evaluate the activity of platelets and the coagulation/fibrinolytic system 1 month after the onset of acute myocardial infarction, we measured the plasma levels of molecular markers, i.e. beta-thromboglobulin, platelet factor 4, thrombin-antithrombin III complex and D dimer, in 16 patients with acute myocardial infarction and in 11 normal subjects. Blood was drawn through a catheter placed in the pulmonary artery before heparin injection. The heparin-releasable platelet factor 4 was calculated by subtracting the level before the injection of 5000 U of heparin, from the level 5 min after injection. The plasma beta-thromboglobulin, thrombin-antithrombin III complex and the D dimer levels in the acute phase of myocardial infarction were 134.9 +/- 121.2, 11.2 +/- 7.1 and 164.4 +/- 115.3 ng/ml, respectively. These values were significantly higher than those in the normal subjects. The plasma levels of beta-thromboglobulin and thrombin-antithrombin III complex, 1 month after the onset (36.6 +/- 16.4 and 4.6 +/- 2.3 ng/ml, respectively) were not significantly different from those of the normal subjects. In contrast, D dimer and heparin-releasable platelet factor 4 were 216.9 +/- 176.9 and 80.5 +/- 29.3 ng/ml, respectively, and significantly higher than in the normal subjects. These findings suggest a latent but persistent activation of the platelets and the coagulation/fibrinolytic system 1 month after the onset of acute myocardial infarction.

Nitric oxide reversibly suppresses xanthine oxidase activity.

The effects of nitric oxide (NO) on xanthine oxidase (XOD) activity and the site(s) of the redox center(s) affected were investigated. XOD activity was determined by superoxide (O2-) generation and uric acid formation. NO reversibly and dose-dependently suppressed XOD activity in both determination methods. The suppression interval also disclosed a dose-dependent prolongation. The suppression occurred irrespective of the presence or absence of xanthine; indicating that the reaction product of NO and O2-, peroxynitrite, is not responsible for the suppression. Application of synthesized peroxynitrite did not affect XOD activity up to 2 microM. Methylene blue, which is an electron acceptor from Fe/S center, prevented the NO-induced inactivation. The results indicate that NO suppresses XOD activity through reversible alteration of the flavin prosthetic site.

Electrical analogy of diastolic pressure difference between left atrium and ventricle.

We proposed a mathematical model to describe the early filling process of the left ventricle and applied the model to in vivo experiments. The solution of a second-order differential equation indicated that the pressure difference between the left atrium and ventricle during ventricular filling (PD) could be explained by a transient response, i.e. decremental oscillation, in an LCR circuit. Thereafter, we analysed the sequence of PD during vagal stimulation with two catheter-tip manometers in 12 anaesthetised dogs and evaluated changes in the parameters of the system under various haemodynamic conditions. The values of omega n and zeta were quite stable among beats within an episode of vagal stimulation, between episodes and even among dogs, despite the changes in haemodynamic variables. Pericardiotomy and partial discommunication of the mitral valve with the left ventricular free wall by cutting the mitral chordal tendons decreased omega n and increased zeta, mainly because of the increase in CLV. Occlusion of the coronary vascular beds with large numbers of microspheres increased omega n and decreased zeta, mainly because of the decrease in CLV. Mitral obstruction with an inflated balloon (increase in R) abolished the oscillatory changes and produced an exponential decay sequence of PD. In conclusion, both the logical and experimental approaches indicated that the sequence of PD could be considered as decremental oscillation in the LCR circuit and the parameters omega n and zeta could be good indices of the diastolic property of the left ventricle.

Inhibitory effects of nicorandil on sympathetic coronary vasoconstriction.

OBJECTIVE: The aim was to investigate whether nicorandil suppresses the rise in coronary vascular resistance that occurs during stimulation of the sympathetic nerve supply to the heart and, if so, what are the mechanisms of action. METHODS: The effects of nicorandil on coronary vascular resistance during ventrolateral cardiac nerve stimulation and on the reactivity of the coronary vasculature to intracoronary infusion of noradrenaline or neuropeptide Y (NPY) were examined under beta receptor blockade. The effects of nicorandil on the overflow of noradrenaline and NPY during ansae subclaviae stimulation were compared with those in a control group and in a group treated with glyceryl trinitrate and N omega-nitro-L-arginine (L-NNA) under both alpha and beta receptor blockade with vagotomy. RESULTS: Intracoronary infusion of nicorandil decreased coronary vascular resistance prior to cardiac nerve stimulation, and during stimulation it suppressed the percentage increase in resistance from the prestimulation value. Nicorandil suppressed the reactivity of the coronary vasculature to exogenous noradrenaline and NPY. Intra-atrial infusion of nicorandil significantly reduced the overflow of NPY but not of noradrenaline during stimulation of the ansae subclaviae at 20 Hz. This suppressive effect was not observed in the glyceryl trinitrate + L-NNA group. CONCLUSIONS: Nicorandil reduces sympathetic coronary vasoconstriction by decreasing the reactivity of the vasculature to sympathetic neurotransmitters and by suppressing NPY overflow during cardiac sympathetic nerve stimulation. The suppressive action on NPY overflow is thought to be due to the opening of ATP sensitive potassium channels in the sympathetic nerve endings rather than to a glyceryl trinitrate-like action of nicorandil.

Early assessment of reperfusion therapy using cardiac troponin T.

OBJECTIVES: The purpose of this study was to investigate the utility of cardiac troponin T for early assessment of reperfusion therapy. BACKGROUND: Several biochemical markers are used for early noninvasive detection of reperfusion during intravenous thrombolytic therapy. However, cardiac troponin T, a new myocardial-specific marker, has not been used previously for this purpose. METHODS: We measured troponin T and creatine kinase, MB isoenzyme (CK-MB) levels in 38 patients with acute myocardial infarction whose infarct-related artery was totally occluded before reperfusion therapy. Subjects comprised 14 patients with successful angioplasty (group 1), 12 patients with successful thrombolytic therapy (group 2) and 12 patients with unsuccessful attempted reperfusion (group 3). Blood samples were taken every 15 min, and coronary angiography was performed every 5 to 8 min until 60 min after reperfusion (groups 1 and 2) or after the initiation of treatment (group 3). We calculated the increase in troponin T (delta troponin T) and CK-MB (delta CK-MB) 60 min after treatment was initiated and 60 min after reperfusion in groups 1 and 2. RESULTS: Mean (+/- SD) delta troponin T and delta CK-MB levels were 9.35 +/- 7.83 ng/ml and 125 +/- 83 mU/ml in group 1 and 3.23 +/- 3.08 ng/ml and 130 +/- 137 mU/ml in group 2, respectively, 60 min after treatment and were 10.1 +/- 8.35 ng/ml and 131 +/- 84 mU/ml in group 1 and 6.84 +/- 8.30 ng/ml and 158 +/- 146 mU/ml in group 2, respectively, 60 min after reperfusion. These values were significantly higher than those 60 min after treatment in group 3: 0.16 +/- 0.19 ng/ml and 10 +/- 9 mU/ml, respectively. The predictive accuracy for detecting reperfusion using a threshold value of 0.50 ng/ml of delta troponin T and 25 mU/ml of delta CK-MB was 100% in group 1 and 92% in group 2 60 min after treatment, respectively. There was significant correlation between delta troponin T and delta CK-MB. CONCLUSIONS: Serial measurements of cardiac troponin T as well as of CK-MB are useful for early assessment of reperfusion therapy.

Three-dimensional analysis of left ventricular ejection using computational fluid dynamics.

We present in this study a method for constructing computational fluid mechanical models in order to study the effects of time-varying left ventricular ejection. A spherical left ventricular model was implemented in which three dimensional flow fields were obtained. The time course of the ventricular wall changes were assumed to have a trigonometrically varying nature. The wall grid was reformed 25 times during the calculation since the left ventricular wall motion was assumed to follow the blood flow, and the ventricle wall radius was reduced by 60 percent in 0.25 seconds. Centerline and cross-sectional velocity vectors greatly increased in magnitude at the aortic outlet, and pressure dropped from 1.17 x 10(4) dynes/cm2 (8.8 mmHg) to zero in the top 10 percent of the heart. The modeling framework will be used with left ventricular cast data coordinates in future studies. There is presently a lack of three-dimensional data based on a realistic model, and the computational method should make it possible to compare simulation results with important measurement techniques such as echocardiography and magnetic resonance imaging.

The effects of supravalvular aortic stenosis on realistic three-dimensional left ventricular blood ejection.

The effect of supravalvular aortic stenosis on cardiac left ventricular ejection was determined from a realistic left ventricle (LV) model built from the profile of a diastolic dog LV. The ejection fraction was considered to be 75% of the diastolic volume. The maximum blood ejection velocities and ventricular pressure occurred at the start of the diastolic flow since the ventricular walls moved the fastest at this point. Going from a healthy non-stenotic LV to one with 64% stenosis increased the maximum ejection velocity from 117 cm/sec to 269 cm/sec, and the maximum relative pressure increased from 10,420 dynes/cm2 to 33,550 dynes/cm2 (7.82 to 25.16 mm Hg). The supravalvular stenotic aorta showed major flow disturbances as the degree of stenosis increased. The computational technique using a realistic model gives predictions in general agreement with observed experimental results, and allows a complex determination of the three-dimensional flow patterns.

Three-dimensional visualization of air flow in infant incubators using computational fluid mechanics.

An application of three-dimensional (3D) computational fluid mechanics to the air flow in infant incubators is presented. The air flows in two numerical models were simulated by directly solving the Navier-Stokes equations for incompressible gases. The method used was a finite-volume method incorporating a body-fitted coordinate system. The basic model was based on a real infant incubator, which was slightly simplified and included a model of a baby. The number of computation grids was 56 (width) x 21 (depth) x 21 (height) = 24,696. There were several very-large-scale eddies in the incubator free space. In addition to the global structure, small-scale eddies were shown to be produced at many locations scattered in the free space. From these results, it is evident that the conventional assumption of steady and uniform flows in incubators is not always justified when considering heat loss from the body of a baby in an incubator.

Myocardial infarct size can be estimated from serial plasma myoglobin measurements within 4 hours of reperfusion.

BACKGROUND: An early estimation of infarct size is useful for the appropriate early treatment of patients with acute myocardial infarction. We evaluated how early and how accurately infarct size could be estimated from serial plasma myoglobin (Mb) measurements in patients with successful reperfusion. METHODS AND RESULTS: We measured plasma Mb and creatine kinase (CK) in 35 patients in whom reperfusion therapy was successfully performed. Blood samples were collected at 15-minute intervals for 2 hours after reperfusion, at 30-minute intervals for the subsequent 2 hours, and at 3-6-hour intervals until 52 hours after reperfusion. Plasma Mb was measured by a newly developed turbidimetric latex agglutination assay. Total Mb and CK release (sigma Mb, sigma CK) were calculated with a one-compartment model. The mean chord motion in the most hypokinetic 50% of the infarct-related artery territory was calculated from follow-up ventriculograms as an index of the severity of regional hypokinesis. There were significant correlations between sigma Mb and sigma CK (r = 0.89), between log sigma Mb and the severity of regional hypokinesis (r = -0.85), and between log sigma CK and the severity of regional hypokinesis (r = -0.74). The time required for the cumulative Mb release curves to reach a plateau was 64 +/- 28 minutes. An additional 53 +/- 14 minutes was required to calculate the disappearance rate constant of Mb, and 15 minutes was necessary for the assay. Therefore, the total time required for sigma Mb to be available was 132 +/- 40 minutes, significantly shorter than the time required for sigma CK, 24.3 +/- 9.1 hours (p < 0.001). The infarct size could be estimated from the sigma Mb in 34 of 35 patients within 4 hours of reperfusion. CONCLUSIONS: Infarct size can be estimated accurately 4 hours after reperfusion by calculating the sigma Mb in patients with successful reperfusion.

Detection of reperfusion 30 and 60 minutes after coronary recanalization by a rapid new assay of creatine kinase isoforms in acute myocardial infarction.

We measured creatine kinase (CK) isoforms by a new immunoinhibition method to evaluate their usefulness in detecting early coronary reperfusion. Blood samples were collected at 15-minute intervals from 50 patients with acute myocardial infarction. CK isoforms were determined by a 10-minute immunoinhibition method with an autoanalyzer. Values for inhibited isoforms (MM3, MM2/2, and MB2/2) were divided by those of noninhibited isoforms (MM1, MM2/2, MB1, MB2/2, and BB) to calculate the isoform ratio. In the reperfused group the increase in the isoform ratio was 2.69 +/- 1.80 (SD) 30 minutes after reperfusion and 2.41 +/- 2.01 at 60 minutes, which was significantly higher than the corresponding values in the nonreperfused group (0.17 +/- 0.16 and 0.32 +/- 0.26, respectively). When an increase of 0.70 or more in the isoform ratio was used as the criterion for reperfusion, the sensitivity and specificity were 92% and 100% at 30 minutes and 100% and 100% at 60 minutes after recanalization, respectively. We conclude that the isoform ratio obtained by the new 10-minute assay of CK isoforms is useful for the noninvasive detection of reperfusion 30 and 60 minutes after recanalization in acute myocardial infarction.

Increased responsiveness of left ventricular apical myocardium to adrenergic stimuli.

OBJECTIVE: The aim was to determine whether left ventricular apical myocardium has mechanisms to compensate for sparse sympathetic innervation. METHODS: Contractile and metabolic responses to various adrenergic stimuli and beta adrenergic receptor density were compared between left ventricular basal and apical regions in 26 anaesthetised mongrel dogs, weight 12-28 kg. RESULTS: Regional contractile changes in response to graded cardiac sympathetic nerve stimulation were compared among three basal (anterior, middle, and posterior) regions, and between basal middle and apical regions. There were significant differences in contractile changes among the three basal regions with distinct regions of innervation from right and/or left sided sympathetic ganglia, but not between apical and basal regions. Constant infusion of noradrenaline (0.2-0.4 microgram.kg-1.min-1) produced a greater response in normalised end systolic length in the apical myocardium than in the basal region, at 9.86(SEM 0.06) mm v 10.14(0.04) mm (n = 5, p < 0.025), and a greater increase in tissue cyclic AMP: 1.04(0.20) v 0.60(0.08) pmol.mg-1 (n = 5, p < 0.05). Giving a forskolin derivative (30 micrograms.kg-1, n = 5) produced a greater increase in cyclic AMP in the apical region than in the basal region: 1.26(0.18) v 0.88(0.19) pmol.mg-1 (p < 0.02). beta Adrenergic receptor density in the apical region was greater than in the basal region: 455(45) v 341(35) fmol.mg-1 protein (n = 5, p < 0.05). CONCLUSIONS: Greater beta adrenergic receptor density and/or increased myocardial responsiveness to adenylate stimulation in apical myocardium compensates, at least in part, for its sparse sympathetic innervation.

Early detection of coronary reperfusion by rapid assessment of plasma myoglobin.

We assayed plasma myoglobin and creatine kinase to elucidate the usefulness of rapid assessment of myoglobin for detecting coronary reperfusion in 31 patients with acute myocardial infarction. Reperfusion was achieved in 20 patients by thrombolytic therapy or angioplasty, and it was not in 11 patients. Blood sampling was performed before and 43 +/- 15 (+/- SD) min after the start of treatment. In the reperfused group, blood samples were obtained before and 26 +/- 10 min after reperfusion. Myoglobin was assayed by a new quantitative test based on latex agglutination turbidimetry which required an assay time of 10 min. After treatment, the rate of increase of plasma myoglobin was significantly higher than that of plasma creatine kinase in the reperfused group (9.7 +/- 9.5 and 2.8 +/- 1.6-fold), but not in the occluded group (1.8 +/- 0.6 and 1.5 +/- 0.3-fold). When a 3.0-fold or greater increase in myoglobin (1.9-fold or greater increase in creatine kinase) was taken as evidence of coronary reperfusion, the sensitivity and specificity were 95% and 100% (70% and 82% in creatine kinase), respectively. In conclusion, using the rate of increase of myoglobin, as measured by latex agglutination turbidimetry, coronary reperfusion can be diagnosed within 1 h after reperfusion.

New nonradioactive microspheres and more sensitive X-ray fluorescence to measure regional blood flow.

We developed new nonradioactive microspheres and used more sensitive X-ray fluorescence spectrometers than used previously to measure regional blood flow in the heart and other organs. We demonstrated the chemical stability of eight kinds of heavy element-loaded microspheres and validated their use for regional blood flow measurement by comparing duplicate flows measured with radioactive and/or nonradioactive microspheres in both acute and chronic dog experiments. The wavelength-dispersive spectrometer (Philips PW 1480) has a higher sensitivity than the previously described X-ray fluorescent system and reduced the number of microspheres required for accurate measurement. The fine energy resolution of this system makes it possible to increase the numbers of different kinds of microspheres to be quantitated, but at present only eight kinds are available. We also used a synchrotron radiation-excited energy dispersive spectrometer. The monochromatic synchrotron radiation allowed us to obtain much higher signal-to-background ratios of X-ray fluorescence spectra than with the wavelength-dispersive system (50 dB more for Zr-loaded microspheres) and will enable analysis of fluorescent activity in smaller regions (< 20 mg) than the radioactive method does.