Intraoperative holographic image-guided surgery in a transanal approach for rectal cancer.

PURPOSE: Urethral injury is one of the most important complications in transanal total mesorectal excision (TaTME) in male patients with rectal cancer. The purpose of this study was to investigate holographic image-guided surgery in TaTME. METHODS: Polygon (stereolithography) files were created and exported from SYNAPSE VINCENT, and then uploaded into the Holoeyes MD system (Holoeyes Inc., Tokyo, Japan). After uploading the data, the three-dimensional image was automatically converted into a case-specific hologram. The hologram was then installed into the head mount display, HoloLens (Microsoft Corporation, Redmond, WA). The surgeons and assistants wore the HoloLens when they performed TaTME. RESULTS: In a Wi-Fi-enabled operating room, each surgeon, wearing a HoloLens, shared the same hologram and succeeded in adjusting the hologram by making simple hand gestures from their respective angles. The hologram contributed to better comprehension of the positional relationships between the urethra and the surrounding pelvic organs during surgery. All surgeons were able to properly determine the dissection line. CONCLUSIONS: This first experience suggests that intraoperative holograms contributed to reducing the risk of urethral injury and understanding transanal anatomy. Intraoperative holograms have the potential to become a new next-generation surgical support tool for use in spatial awareness and the sharing of information between surgeons.

A case of Gross E esophageal atresia discovered following a unique clinical course.

The patient was a 15 months-old boy who had been diagnosed CHARGE syndrome, which is a multiple congenital anomaly syndrome caused by mutations in the CHD7 gene. Mechanical ventilation management was initiated 2 hours after birth for dysphagia and respiratory failure, and tracheotomy was performed 3 months after birth for dysphagia and failed extubation. He was repeatedly hospitalized due to pneuomoniae. Approximately 1 year after birth, the boy had two consecutive episodes of sudden ventilatory insufficiency while replacing the tracheotomy cannula. A bronchoscopic examination under general anesthesia revealed a tracheoesophageal fistula directly below the tracheostomy. The patient was diagnosed with Gross E esophageal atresia, and we speculated that the cannula migrated to the esophagus via the fistula during tracheostomy cannula replacement. Gross E esophageal atresia is a rare disease. Its diagnosis is often delayed, and it is discovered by recurrent pneumonia in many cases. A tracheoesophageal fistula may also be found in children with deformities of the respiratory system. Furthermore, tracheoesophageal fistulae are often found in the neck. Therefore, when sudden ventilatory insufficiency occurs in a child with a tracheostomy after replacing the tracheostomy cannula, caution must be exercised since the cannula may have migrated to the esophagus via a fistula. J. Med. Invest. 69 : 141-144, February, 2022.

Risk factors for metachronous contralateral inguinal hernia after laparoscopic percutaneous extraperitoneal closure for unilateral inguinal hernia in children.

PURPOSES: We use the laparoscopic percutaneous extraperitoneal closure (LPEC) method as the standard procedure for pediatric inguinal hernia. Despite judging there to be no contralateral patent processus vaginalis (PPV) at the time of the first LPEC, we experienced five cases in which metachronous contralateral inguinal hernia (MCH) developed, so we report the characteristics, including the predictors. METHODS: For pediatric inguinal hernia, the LPEC method was used in 1277 cases from 2005 to 2019 in our department. Of these, 374 patients underwent unilateral LPEC, and we compared the 5 patients with MCH onset and the 369 without MCH onset. The items to be examined were the gender, age, presence of a low birth weight, initial-onset side, and contralateral internal inguinal ring classification. RESULTS: There was no significant difference in the gender, age, initial-onset side, or contralateral internal inguinal ring classification between the two groups. Low-birth-weight infants were significantly more common among those with MCH than among those without MCH. CONCLUSIONS: The only predictor of a contralateral onset after LPEC for pediatric inguinal hernia was a low birth weight. Therefore, for the above-mentioned unilateral LPEC cases, the possibility of a contralateral onset after LPEC due to acquired factors rather than congenital factors should be considered.

Peripheral neuropathy exacerbated by lenalidomide in a patient with multiple myeloma.

We evaluated a serial change in peripheral neuropathy (PN) severity during treatment with bortezomib (Bor) or lenalidomide (Len) using the Functional Assessment of Cancer Therapy scale/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx). The patient suffered from grade 2 PN and exhibited a dramatic decrease in FACT/GOG-Ntx score after intravenous and subcutaneous Bor therapy. Thereafter, he received seven cycles of Len therapy, which exacerbated existing PN; he experienced mild numbness and exhibited a transient decrease in FACT/GOG-Ntx score. Interestingly, FACT/GOG-Ntx score increased to baseline and numbness was ameliorated during the Len washout period in every cycle.

High incidence and severity of injection site reactions in the first cycle compared with subsequent cycles of subcutaneous bortezomib.

Subcutaneous (sc) administration of bortezomib (Bor) has become more common than intravenous (iv) administration in the treatment of multiple myeloma (MM), because scBor results in a lower incidence and severity of peripheral neuropathy and shows efficacy equivalent to ivBor. Bor is an irritant cytotoxic agent when it extravasates from the vasculature. Therefore, it is recommended that sc injections of Bor should be delivered on a rotating basis across eight sites on the abdomen and thighs. Previously, we reported that sc injections of Bor in the abdomen caused fewer grade 2 injection site reactions (ISRs) than those in the thigh. In the present study, we recruited more patients and expanded the scale of our analysis into ISRs following treatment with 300 scBor injections in 20 patients. ISRs of ≥grade 2 were documented in 12 of 109 (11.0 %) thigh injections, but only in three of 191 (1.6 %) abdominal injections (p < 0.001). Interestingly, ISRs of ≥grade 2 occurred more frequently in the first cycle than in the second and subsequent cycles (16.3 vs. 0.91 %, p < 0.001). These results clearly indicate that closer attention should be paid to ISR management, particularly with regard to the first cycle of scBor administration in the thigh. To our knowledge, this is the first report showing that ≥grade 2 ISRs are more common in the first cycle compared with subsequent cycles of scBor in the treatment of MM.

Higher incidence of injection site reactions after subcutaneous bortezomib administration on the thigh compared with the abdomen.

Subcutaneous (sc) rather than intravenous administration of bortezomib (Bor) is becoming more common for treating multiple myeloma (MM) because scBor results in lower incidence and severity of peripheral neuropathy and has equivalent efficacy. Bor is an irritant cytotoxic agent when it leaks out; therefore, it is recommended that injections of scBor should be rotated among eight different sites on the abdomen and thigh. However, detailed information about injection site reaction (ISR) has not been sufficiently documented. We retrospectively analyzed the incidence and severity of ISR following scBor administration in 15 Japanese patients with MM. Grade 1 ISR occurred following 40 of 158 (25.3%) scBor injections in ten patients, whereas grade 2 ISRs occurred following seven injections (4.4%) in five patients. Five patients did not develop ISR. Of note, grade 2 ISR was documented in 6 of 65 (9.2%) thigh injections but only in 1 of 93 (1.1%) abdominal injections. These data show that grade 2 ISRs were more common in the thigh compared with the abdomen possibly because the thigh contains lesser adipose tissue than the abdomen. Grade 2 ISRs resolved without any sequela within a median of 7 d. scBor administration on the abdomen instead of the thigh should be considered, especially for emaciated patients, because ISR rapidly resolves within the interval before the next injection even if it occurs.

[Qualitative research on the patient's experiences following discharge after allogeneic hematopoietic stem cell transplantation aiming to develop a continuous patient support system].

This qualitative study examined patient difficulties after allotransplantation in order to develop a continuous support system for these patients, considering the significant change in care environment following hospital discharge. Five patients were recruited for semistructured interviews. Content analysis was used to identify five categories: pain caused by disease, fluctuations in self-concept, need for counselors, changes in relationships to others, and changes in thinking. The patients, aware of the special nature of transplantation, expressed a need for counseling after discharge. Nurses acquainted with the transplantation process should coordinate with physicians to provide consistent counseling after discharge.

Cationic amino acid transporter 1-mediated L-arginine transport at the inner blood-retinal barrier.

The purpose of this study was to identify the transporter mediating l-arginine transport at the inner blood-retinal barrier (BRB). The apparent uptake clearance of [(3)H]L-arginine into the rat retina was found to be 118 microL/(min.g retina), supporting a carrier-mediated influx transport of L-arginine at the BRB. [(3)H]L-arginine uptake by a conditionally immortalized rat retinal capillary endothelial cell line (TR-iBRB2 cells), used as an in vitro model of the inner BRB, was primarily an Na(+)-independent and saturable process with Michaelis-Menten constants of 11.2 microM and 530 microM. This process was inhibited by rat cationic amino acid transporter (CAT) 1-specific small interfering RNA as well as substrates of CATs, L-arginine, L-lysine, and L-ornithine. The expression of cationic amino acid transporter (CAT) 1 mRNA was 25.9- and 796-fold greater than that of CAT3 in TR-iBRB2 and magnetically isolated rat retinal vascular endothelial cells, respectively. The expression of CAT1 protein was detected in TR-iBRB2 cells and immunostaining of CAT1 was observed along the rat retinal capillaries. In conclusion, CAT1 is localized in retinal capillary endothelial cells and at least in part mediates L-arginine transport at the inner BRB. This process seems to be closely involved in visual functions by supplying precursors of biologically important molecules like nitric oxide in the neural retina.