Impact of SARS-CoV-2 lockdown and de-escalation on air-quality parameters

The SARS-CoV-2 health crisis has temporarily forced the lockdown of entire countries. This work reports the short-term effects on air quality of such unprecedented paralysis of industry and transport in different continental cities in Spain, one of the countries most affected by the virus and with the hardest confinement measures. The study takes into account sites with different sizes and diverse emission sources, such as traffic, residential or industrial emissions. This work reports new field measurement data for the studied pandemic period and assesses the air quality parameters within the historic trend of each pollutant and site. Thus, 2013-2020 data series from ground-air quality monitoring networks have been analysed to find out statistically significant changes in atmospheric pollutants during March-June 2020 due to this sudden paralysis of activity. The results show substantial concentration drops of primary pollutants, including NO_x, CO, BTX, NMHC and NH₃. Particulate matter changes were smaller due to the existence of other natural sources. During the lockdown the ozone patterns were different for each studied location, depending on the VOCs-NOx ratios, with concentration changes close to those expected from the historical series in each site and not statistically attributable to the health crisis effects. Finally, the gradual de-escalation and progressive increase of traffic density within cities reflects a slow recovery of primary pollutants. The results and conclusions for these cities, with different sizes and population, and specific emission sources, may serve as a behavioural model for other continental sites and help understand future crises.

[Consensus statement of the Chilean endocrinological society on the role of bariatric surgery in type 2 diabetes]

Diabetes Mellitus (DM) and obesity are a public health problem in Chile. Bariatric surgery is the most effective treatment alternative to achieve a significant and sustained weight reduction in patients with morbid obesity. The results of controlled clinical trials indicate that, compared to medical treatment, surgery for obese patients with DM2 allows a better control of blood glucose and cardiovascular risk factors, reduces the need for medications and increases the likelihood for remission. Consensus conferences and clinical practice guidelines support bariatric surgery as an option to treat DM2 in Class III Obesity (Body Mass Index (BMI) > 40) regardless of the glycemic control and the complexity of pharmacological treatment and in Class II Obesity (BMI 35-39,9) with inadequate glycemic control despite optimal pharmacological treatment and lifestyle. However, surgical indication for patients with DM2 and BMI between 30-34.9, the most prevalent sub-group, is only suggested. The Chilean Societies of Endocrinology and Diabetes and of Bariatric and Metabolic Surgery decided to generate a consensus regarding the importance of other factors related to DM2 that would allow a better selection of candidates for surgery, particularly when weight does not constitute an indication. Considering the national reality, we also need a statement regarding the selection and characteristics of the surgical procedure as well as the role of the diabetologist in the multidisciplinary team.

Distinct patterns in the gut microbiota after surgical or medical therapy in obese patients

Bariatric surgery is highly successful in improving health compared to conventional dietary treatments. It has been suggested that the gut microbiota is a relevant factor in weight loss after bariatric surgery. Considering that bariatric procedures cause different rearrangements of the digestive tract, they probably have different effects on the gut microbiota. In this study, we compared the impact of medical treatment, sleeve gastrectomy and Roux-en-Y gastric bypass on the gut microbiota from obese subjects. Anthropometric and clinical parameters were registered before, 6 and 12 months after treatment. Fecal samples were collected and microbiota composition was studied before and six months post treatment using 16S rRNA gene sequencing and qPCR. In comparison to dietary treatment, changes in intestinal microbiota were more pronounced in patients subjected to surgery, observing a bloom in Proteobacteria. Interestingly, Bacteroidetes abundance was largely different after six months of each surgical procedure. Furthermore, changes in weight and BMI, or glucose metabolism, correlated positively with changes in these two phyla in these surgical procedures. These results indicate that distinct surgical procedures alter the gut microbiota differently, and changes in gut microbiota might contribute to health improvement. This study contributes to our understanding of the impact of weight loss surgery on the gut microbiota, and could be used to replicate this effect using targeted therapies.

Bile acids synthesis decreases after laparoscopic sleeve gastrectomy

BACKGROUND

Bariatric surgery is the most effective treatment alternative in morbid obesity. The mechanisms contributing to these benefits remain poorly understood. Bile acids (BAs) are mediators of different regulatory functions in glucose and cholesterol homeostasis and energy expenditure. Recent evidence suggests that BAs are critically important for the beneficial effects of sleeve gastrectomy (SG).

OBJECTIVES

The aim of this study was to evaluate the effect of SG on BA synthesis.

SETTING

University Hospital. Santiago, Chile.

METHODS

Obese patients were evaluated before and after SG (1, 3, 6, and 12 months). BA synthesis was evaluated through the serum marker, 7 α-hydroxy-4-cholesten-3-one (C4). Primary and secondary BA and C4 were determined by high performance liquid chromatography coupled with tandem mass spectrometry detection (HPLC-MS/MS).

RESULTS

From June 2013 to January 2014, 19 patients (age 37.6±7.8 years; BMI 35.8±3.5 kg/m(2); 79% female) were included in this study. Mean weight loss at 1, 3, 6, and 12 months was 11.3, 17.5, 23.6, and 25.4 kg, respectively, equivalent to 11.8, 18.6, 24.8, and 26.9 of total body water percentage (%TBW) (P<.0001), respectively and 43.2, 68.2, 91, and 98.8 of percentage of excess weight loss (%EWL), respectively (P<.001). Serum C4 levels at baseline, 1, 3, 6, and 12 months were 23.4±21.1, 4.9±8.2, 8.7±12.1, 13.8±12.9, and 18.8±16.8 ng/mL (P<.0001), respectively. Fibroblast growth factor 19 (FGF19) levels at baseline, 1, 3, 6, and 12 months were 71±33.3, 130.5±66.2, 117.8±57.2, 134.6±91.7, and 124.3±85.9 pg/mL (P = .019), respectively.

CONCLUSION

Serum levels of C4 decrease after SG, indicating a reduction in the synthesis of BA. FGF19 may play a role in decreasing BA synthesis. Further studies are necessary to characterize the effect of bariatric surgery on BA homeostasis.

High frequency of internal hernias after Roux-en-Y gastric bypass

BACKGROUND

Internal hernias (IH) after Roux-en-Y gastric bypass (RYGB) are a serious concern among surgeons and are often under-diagnosed due to heterogeneity of clinical manifestations. Our aim is to assess the frequency of IH after a RYGB in symptomatic and asymptomatic patients.

METHODS

Retrospective analysis of our bariatric surgery unit's database between 2001 and 2013 is obtained. Patients are surgically explored after RYGB due to acute bowel obstruction (ABO), intermittent abdominal pain (IAP), or being asymptomatic (during an elective cholecystectomy) in whom anatomical presence of IH was established. Also, we compared patients with retrocolic and antecolic technique. Statistical analysis with non-parametric tests and chi-square are used.

RESULTS

Of the patients, 3,656 submitted to RYGB during this period, 81.9% (2,993) by laparoscopy and 26.3% (963) with retrocolic technique. Of the patients, 130 (3.5%) were surgically explored due to ABO, 27 patients (0.7%) due to IAP, and 93 patients (2.5%) submitted to an elective cholecystectomy with exploration for IH. IH was present in 75% of the obstructed patients, and in 69%, it was the cause of obstruction. Patients with IAP showed 59% of IH, but only 15% have herniated bowel. In asymptomatic patients, 25% showed IH and none of them have herniated bowel. Retrocolic technique showed a higher risk of whole causes of ABO and IH than the antecolic technique, with a relative risk of 1.53 (1.07-2.17) and 1.62 (1.06-2.47), respectively.

CONCLUSIONS

A high frequency of IH exists in all operated patients of this series. All members of the bariatric team should be aware of the symptoms related to IH and actively pursue it during follow-up.

Electrical stimulation therapy of the lower oesophageal sphincter for refractory gastro-oesophageal reflux disease - interim results of an international multicentre trial

BACKGROUND

A previous single-centre study showed that lower oesophageal sphincter electrical stimulation therapy (LES-EST) in gastro-oesophageal reflux disease (GERD) patients improves reflux symptoms and decreases oesophageal acid exposure.

AIM

To evaluate safety and efficacy of LES-EST in GERD patients with incomplete response to proton pump inhibitors (PPIs) in a prospective, international, multicentre, open-label study.

METHODS

GERD patients, partially responsive to PPIs, received LES-EST. GERD health-related quality of life (GERD-HRQL), daily symptom diaries, quality of life scores, oesophageal acid exposure, and LES resting and residual pressure were measured before and after initiation of LES-EST. Stimulation sessions were optimised based on residual symptoms and oesophageal acid exposure.

RESULTS

Forty-four patients were enrolled and 6-month data from 41 patients are available. Hiatal repair was performed in 16 patients. One device-related, one procedure-related and one unrelated severe adverse event were reported. GERD-HRQL improved from 31.0 (IQR 26.2-36.8) off-PPI and 16.5 (IQR 9.0-22.8) on-PPI to 4 (IQR 1-8) at 3-month and 5 (IQR 3-9) at 6-month follow-up (P < 0.0001 vs. on- and off-PPI). Oesophageal acid exposure (pH < 4.0) improved from 10.0% (IQR 7.5-12.9) to 3.8% (IQR 1.9-12.3) at 3 months (P = 0.0027) and 4.4% (IQR 2.2-7.2) at 6 months (P < 0.0001).

CONCLUSIONS

These interim results show an acceptable safety record of LES-EST to date, combined with good short-term efficacy in GERD patients who are partially responsive to PPI therapy. A remarkable reduction in regurgitation symptoms, without the risk of intervention-requiring dysphagia may prove to be an advantage compared with other anti-reflux procedures. ClinicalTrials.gov Identifier: NCT01574339.

[Results of bariatric surgery. Experience over 18 years]

BACKGROUND

Bariatric surgery is the gold-standard treatment for morbid obesity because it has low morbidity rates in high-volume centers and generates long term sustained weight loss.

AIM

To describe our experience in bariatric surgery since the creation of our bariatric program in 1992.

MATERIAL AND METHODS

Retrospective analysis of all patients subjected to bariatric surgery from 1992 to December 2010. Data was obtained from the electronic institutional registry. The Procedures per-formed were open and laparoscopic Roux-en-Y gastric bypass (BPGA and BPGL, respectively), laparoscopic adjustable gastric band (BGAL) and laparoscopic sleeve gastrectomy (GML).

RESULTS

A total of 4943 procedures were performed, 768 (16%) BPGA, 2558 (52%) BPGL, 199 (4%) BGAL and 1418 (29%) GML. The number of procedures progressively increased, from 100 cases in 2000 to over 700 cases in 2008. Proportion of femóles and preoperative mean body mass Índex fluctuated between 69 and 79% and 35 and 43 kg/m², respectively, among the different procedures. Early and late complications fluctuated between Oto 1% (higher on BPGA) and 3 to 32.7% (higher on BGAL), respectively. The excess weight lost at five years was 76.1% in BPGA, 92.5% in BPGL and 53.7% in BGAL. The figure for GML at three years was 73.7%.

CONCLUSIONS

The complication rates of this series of patients are similar to those reported in large series abroad. BPGL is still the most effective procedure; however GML is an attractive alternative for less obese patients.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

Safety and efficacy of Roux-en-Y gastric bypass to treat type 2 diabetes mellitus in non-severely obese patients

The efficacy of Roux-en-Y gastric bypass (RYGB) to control type 2 diabetes mellitus (T2DM) has been demonstrated in morbidly obese patients. Surgical procedures primarily focused on T2DM control in patients with body mass index (BMI) < 35 kg/m(2) have shown to effectively induce remission of T2DM. However, only few reports have evaluated the safety and efficacy of RYGB in this group of patients. The aim of this study is to assess the safety and efficacy of RYGB in TD2M patients with BMI < 35 kg/m(2). All T2DM patients with BMI < 35 kg/m(2) and at least 12 months of follow-up who underwent laparoscopic RYGB were included. Safety of the procedure was evaluated according to mortality, need of reoperation/conversion, and complication rates. Metabolic parameters were evaluated at baseline and 6, 12, and 24 months after surgery. Thirty patients were included. Seventeen (56.6%) were women. Age, BMI, and duration of diabetes were 48 ± 9 years, 33.7 ± 1.2 kg/m(2), 4 ± 2.9 years, respectively. No mortality was observed. No conversion/reoperation was needed. Average length of stay was 3.2 ± 0.9 days. Early and late postoperative complications were observed in five (16.6%) and five (16.6%) patients, respectively. Twelve months after surgery, remission was observed in 25 of 30 patients (83.3%). After 2 years, remission was achieved in 13 of 20 patients (65%), and hemoglobin A1c decreased from 8.1 ± 1.8% to 5.9 ± 1.1% and homeostasis model assessment of insulin resistance from 5.7 ± 3.2 to 1.9 ± 0.8 after 12 months. RYGB is a safe and effective procedure to induce T2DM remission in otherwise not eligible patients for bariatric surgery. Evidence from prospective studies is needed to validate this approach.

Overexpression of 11β-hydroxysteroid dehydrogenase type 1 in visceral adipose tissue and portal hypercortisolism in non-alcoholic fatty liver disease

BACKGROUND

The enzyme 11β-hydroxysteroid-dehydrogenase type 1 (11β-HSD1) catalyses the reactivation of intracellular cortisol. We explored the potential role of 11β-HSD1 overexpression in visceral adipose tissue (VAT) in non-alcoholic fatty liver disease (NAFLD) assessing sequential changes of enzyme expression, in hepatic and adipose tissue, and the occurrence of portal hypercortisolism in obese mice. 11β-HSD1 expression was also assessed in tissues from obese patients undergoing bariatric surgery.

METHODS

Peripheral and portal corticosterone levels and liver histology were assessed in ob/ob mice at two time points (8-12 weeks of age). 11β-HSD1 tissue expression was assessed in by RT-pcr in ob/ob mice and in 49 morbidly obese patients.

RESULTS

Portal corticosterone serum levels were higher in obese mice with a 26% decrease between 8 and 12 weeks of age (controls: 78.3 ± 19.7 ng/ml, 8-week-old ob/ob: 167.5 ± 14.5 ng/ml and 12-week-old ob/ob: 124.3 ± 28 ng/ml, P < 0.05). No significant differences were found in peripheral corticosterone serum levels. Expression of 11β-HSD1 was lower in the liver [-45% at 8 weeks and -35% at 12-weeks (P = 0.0001)] and highly overexpressed in VAT in obese mice, compared to controls (128-fold higher in 8-week-old ob/ob and 41-fold higher in 12-week-old ob/ob, P < 0.01). No significant differences were seen in the expression of 11β-HSD1 in subcutaneous adipose tissue. In multivariate analysis, human 11β-HSD1 expression in VAT (OR: 1.385 ± 1.010-1.910) was associated with NAFLD.

CONCLUSION

Murine NAFLD is associated with portal hypercortisolism and11β-HSD1 overexpression in VAT. In humans, 11β-HSD1 VAT expression was associated with the presence of NAFLD. Thus, local corticosteroid production in VAT may contribute to NAFLD pathogenesis.

Plasminogen activator inhibitor type 1 serum levels and 4G/5G gene polymorphism in morbidly obese Hispanic patients with non-alcoholic fatty liver disease

BACKGROUND

The plasminogen activator inhibitor type-1 (PAI-1) has been implicated in the regulation of fibrinolysis and extracellular matrix components. The single base pair guanine insertion/deletion polymorphism (4G/5G) within the promoter region of the PAI-1 gene influences PAI-1 synthesis and may modulate hepatic fibrogenesis.

AIM

To evaluate the influence of PAI-1 serum levels and 4G/5G polymorphism on the risk of liver fibrosis associated to non-alcoholic fatty liver disease (NAFLD) in morbidly obese patients.

MATERIAL AND METHODS

Case-control study of 50 obese patients undergoing bariatric surgery and 71 non-obese subjects matched by age and sex. Anthropometric and biochemical measurements were performed, including PAI-1 serum levels. Genomic DNA was obtained to assess the presence of 4G/5G polymorphism.

RESULTS

BMI, insulinemia, triglycerides, HOMA-IR, hypertension and diabetes were significantly higher in obese patients compared to control subjects. PAI-1 serum levels observed in obese patients were significantly lower (10.63 ± 4.82) compared to controls (14.26 ± 11.4; p < 0.05). No differences were observed in the PAI-1 4G/5G promoter genotypes frequencies (p = 0.12). No differences were observed in PAI-1 plasma levels among obese patients with liver fibrosis (10.64 ± 4.35) compared to patients without liver fibrosis (10.61 ± 5.2; p = 0.985). PAI-1 4G/5G promoter genotypes frequencies were similar in patients with or without liver fibrosis associated to NASH (p = 0.6).

CONCLUSIONS

Morbidly obese patients had significantly lower PAI-1 serum levels with similar PAI-1 4G/5G genotypes frequencies compared to non-obese subjects. The frequency of 4G/5G genotypes in Chilean Hispanic healthy subjects was similar to that described in other populations. No association was found between PAI-1 serum levels or 4G/5G genotype with liver fibrosis in obese patients.

Overexpression of hepatic 5α-reductase and 11β-hydroxysteroid dehydrogenase type 1 in visceral adipose tissue is associated with hyperinsulinemia in morbidly obese patients

11-β-Hydroxysteroid dehydrogenase type 1 (11β-HSD1) converts cortisone to cortisol, mainly in the liver and visceral adipose tissue (VAT), and has been implicated in several metabolic disorders. The absence of systemic hypercortisolism in central obesity could be due to increased inactivation of cortisol to its tetrahydrometabolites by the hepatic enzymes 5α- and 5β-reductases. Our aim was to assess the expression of the reductases in the liver and of 11β-HSD1 in the liver and VAT in morbidly obese patients and to analyze their association with clinical, anthropometric, and biochemical parameters. Hepatic and VAT samples were obtained during bariatric surgery. 5α- and 5β-reductases, 11β-HSD1, and 18S expression was measured using real-time polymerase chain reaction. Anthropometric and biochemical variables were analyzed. Forty-one patients were recruited (age, 41.8 ± 10.6 years; body mass index, 42.1 ± 6.6 kg/m(2); 71% women). The expression of hepatic 5α- and 5β-reductases was positively correlated (r = +0.53, P = .004), and their expression levels were correlated with hepatic 11β-HSD1 expression (r = +0.61, P < .001 for 5α-reductase and r = +0.50, P < .001 for 5β-reductase). Hepatic 5α-reductase was associated with insulin (r = +0.34, P = .015). Visceral adipose tissue 11β-HSD1 expression was associated with glucose (r = +0.37, P = .025) and insulin (r = +0.54, P = .002). Our results showed that 5α-reductase and VAT 11β-HSD1 expressions were associated with insulinemia. These findings suggest that overexpression of 5α-reductase, through a higher inactivation of cortisol in the liver, could have a protective role in preserving hepatic sensitivity to insulin. The overexpression of liver reductases in obesity could be an adaptive response to an increase in cortisol production by the liver and visceral 11β-HSD1 to avoid systemic hypercortisolism.

Completely laparoscopic versus open gastrectomy for early and advanced gastric cancer: a matched cohort study

INTRODUCTION

The application of laparoscopic gastric surgery has rapidly increased for the treatment of early gastric cancer. However, laparoscopic gastrectomy for advanced tumor remains controversial, particularly in terms of oncologic outcomes. This study was designed to compare 3-year survival of laparoscopic versus open curative gastrectomy in early and advanced gastric cancer.

METHODS

This was a retrospective matched cohort study. We included patients between 2003 and 2010 with an R0 resection. A totally laparoscopic technique was used and D2 lymph node dissection was practiced routinely. We performed an intracorporeal hand-sewn esophagojejunostomy in all laparoscopic total gastrectomy cases. We matched all laparoscopic cases 1:1 with open cases according to TNM AJCC seventh edition. We used Mann-Whitney or t test and Chi-square test to compare both groups. Kaplan-Meier analysis with log-rank test was performed to compare survival.

RESULTS

We included 31 open and 31 laparoscopic cases (mean age 63 ± 14 years; 66% males). Both groups were identical in type of gastrectomy (71% total and 29% subtotal). There were no statistical difference between laparoscopic and open groups in age, sex, N category, tumor location and size, histological differentiation, and T category (48% T1, 13% T2, 16% T3, and 23% T4 in both groups), with 48% early and 52% advanced tumors. The median number of resected lymph nodes was similar: 35 (23-53) for laparoscopic and 39 (23-45) for open cases (P = 0.81). The median follow-up was 50 months. The overall 3-year survival was 82% for laparoscopic surgery and 87% for the open surgery group (P = 0.56). There were no difference in 3-year survival for the laparoscopic versus the open surgery groups for advanced tumors (74 vs. 75%, P = 0.88), N+ tumors (73 vs. 73%, P = 0.99) and for the different AJCC stages (stage 1: 94 vs. 100%, stage 2: 89 vs. 82%, and stage 3: 50 vs. 50%, P = 0.32, 0.83, and 0.98 respectively).

CONCLUSIONS

In this preliminary report, with 52% of advanced tumor, the 3-year overall and stage-by-stage survival was comparable for laparoscopic and open curative gastrectomy.

Initial human experience with restrictive duodenal-jejunal bypass liner for treatment of morbid obesity

BACKGROUND

The duodenal-jejunal bypass liner is an endoscopically placed and removable intestinal liner that creates a duodenal-jejunal bypass, leading to diabetes improvement and weight loss. The aim of the present study was to evaluate the clinical effects and safety of the duodenal-jejunal bypass liner combined with a restrictor orifice (flow restrictor).

METHODS

The device was endoscopically implanted in 10 patients (body mass index 40.8 +/- 4.0 kg/m(2)) and removed after 12 weeks. Dilation of the restrictor orifice was performed as clinically indicated with a 6-, 8-, or 10-mm diameter through-the-scope balloon. The measured outcomes included the percentage of excess weight loss, total weight loss, adverse events, and gastric emptying (GE) at baseline, weeks 4 and 12 of implantation, and 3-5 months after device removal. GE was measured by scintigraphy at 1, 2, and 4 hours after implantation.

RESULTS

The percentage of excess weight loss and total weight loss at explantation was 40% +/- 3% (range 21-64%) and 16.7 +/- 1.4 kg (range 12.0-26.0), respectively. The 4-hour GE was 98% +/- 1% at baseline, 72% +/- 6% at 4 weeks (P = 0.001 versus baseline), and 84% +/- 5% at 12 weeks (P <.05 versus baseline). After explantation, the rate of GE returned to normal in 7 of 8 subjects, but remained slightly delayed in 1 subject (84% at 4 hours). Episodes of nausea, vomiting, and abdominal pain required endoscopic dilation of the restrictor orifice with a 6-mm through-the-scope balloon in 7 patients and a 10-mm balloon in 1, with no clinically significant adverse events.

CONCLUSION

Endoscopic implantation of a combination flow restrictor and duodenal-jejunal bypass liner induced substantial weight loss. The implanted patients exhibited delayed GE that was reversed after device removal.

Hypoadiponectinemia and its association with liver fibrosis in morbidly obese patients

BACKGROUND

Reduced serum levels of adiponectin have been associated with insulin resistance and non-alcoholic fatty liver disease (NAFLD). However, the relationship between serum adiponectin levels and hepatic histology in NAFLD is controversial. The aim of this study was to explore associations between plasma adiponectin concentrations and liver histology in morbidly obese patients.

METHODS

We conducted a case-control study including obese patients undergoing bariatric surgery and normal controls. Anthropometric, standard biochemical variables as well as plasma adiponectin and leptin levels were determined. Liver biopsy was performed in all patients at the time of surgery.

RESULTS

Seventy morbidly obese patients (mean BMI, 40.6 ± 5.6 kg/m(2)) met the inclusion criteria and were compared with 69 controls (mean BMI, 22.8 ± 1.6 kg/m(2), p = 0.0001). Thirty patients (43%) had NAFLD and 20 (28%) of them fulfilled the histological criteria for steatohepatitis. Obesity was associated with increased leptin and decreased adiponectin levels. NAFLD patients exhibited decreased levels of serum adiponectin compared with matched controls [median (Q1-Q3), 3.9 (3.2-4.3) vs. 8.6 (6.5-9.2) μg/mL, p < 0.0001]. In univariate analysis, age, gender, type 2 diabetes mellitus, BMI, HOMA-IR, aspartate aminotransferase (AST), alanine aminotransferase, serum glucose, and adiponectin levels were independently associated with hepatic fibrosis. In multivariate analysis, AST [OR = 1.082 (1.000-1.170)], age [OR = 1.119 (1.023-1.225)], and serum adiponectin levels [OR = 0.529 (0.299-0.936)] were significantly associated with the presence of liver fibrosis.

CONCLUSIONS

NAFLD patients have lower plasma adiponectin concentrations than control subjects. Low adiponectin levels are associated with more severe liver histology. Serum adiponectin may be useful to estimate the severity of liver damage in obese patients with NAFLD.

Overexpression of 11beta-hydroxysteroid dehydrogenase type 1 in hepatic and visceral adipose tissue is associated with metabolic disorders in morbidly obese patients

BACKGROUND

The enzyme 11-beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) catalyzes intracellular glucocorticoid reactivation by conversion of cortisone to cortisol in different tissues and have been implicated in several metabolic disorders associated with obesity. The aim of this study was to evaluate the 11beta-HSD1 expression in liver, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) in morbidly obese patients undergoing bariatric surgery and its correlations with clinical, anthropometric, and biochemical variables.

METHODS

A prospective study was conducted over a 27-month period. Hepatic, VAT, and SAT samples were obtained at the time of surgery. 11beta-HSD1 and 18S gene expression was measured using real-time quantitative reverse transcriptase-polymerase chain reaction.

RESULTS

Forty nine patients met the inclusion criteria [mean age: 42.2 +/- 10 years, body mass index (BMI): 42 +/- 6 kg/m(2), 71% women and 63% with metabolic syndrome (MS)]. 11beta-HSD1 mRNA levels were higher in liver than fat tissue (p < 0.001), being higher in SAT than in VAT (p < 0.001) without gender-specific differences. Hepatic expression of 11beta-HSD1 correlated positively with SAT and VAT, alanine aminotransferase (ALT), and serum glucose and was inversely associated with BMI. 11beta-HSD1 mRNA in VAT correlated positively with insulinemia, ALT, and LDL cholesterol. There were no associations between 11beta-HSD1 mRNA in SAT and the variables analyzed.

CONCLUSIONS

11beta-HSD1 expression is higher in liver in comparison to adipose tissue in obese patients. The observed correlations between hepatic and VAT 11beta-HSD1 expression with dyslipidemia and insulin resistance suggest that this enzyme might have a pathogenic role in obesity and related metabolic disorders.

Open label, prospective, randomized controlled trial of an endoscopic duodenal-jejunal bypass sleeve versus low calorie diet for pre-operative weight loss in bariatric surgery

BACKGROUND

The duodenal-jejunal bypass sleeve (DJBS) has been shown to achieve a completely endoscopic duodenal exclusion without the need for stapling. This report is the first randomized controlled trial for weight loss.

METHODS

In a 12-week, prospective, randomized study, subjects received either a low fat diet and the DJBS or a low fat diet control (no device). Twenty-five patients were implanted with the device and 14 received the control. The groups were demographically similar. Both groups received counseling at baseline only, which consisted of a low calorie diet, and exercise/behavior modification advice. No additional counseling occurred in either group. Measurements included starting and monthly body weight and serum blood tests. The device group also had a plain abdominal film post implant, a monthly KUB and a 4-week post explant EGD.

RESULTS

Twenty device (80%) subjects maintained the DJBS without a significant adverse event for the 12-week duration. At 12 weeks, the mean excess weight loss was 22% and 5% for the device and control groups, respectively (p < 0.001). Five subjects (20%) were endoscopically explanted early secondary to upper GI (UGI) bleeding (n = 3), anchor migration (n = 1) and sleeve obstruction (n = 1). The UGI bleeding occurred at a mean of 13.8 days post implant. EGD was performed in each of these cases with no distinct bleeding source identified. No blood transfusion was required. The migration occurred on day 47 and manifested as abdominal pain. The subject with the sleeve obstruction presented with abdominal pain and vomiting on day 30. Eight subjects (40%) underwent the 4 week post explant EGD at which time mild degrees of residual duodenal inflammation was noted.

CONCLUSION

The DJBS achieves noninvasive duodenal exclusion and short term weight loss efficacy. Longer term randomized controlled sham trials for weight loss and treatment of T2DM are underway.

Importance of routine preoperative upper GI endoscopy: why all patients should be evaluated?

BACKGROUND

Morbid obesity is associated with different gastrointestinal alterations and diseases. Surgically induced weight loss has become the best treatment for morbidly obese patients. Roux-en-Y gastric bypass is the most common procedure performed worldwide. Concerns regarding difficulties in further evaluation of stomach remnant for early detection of gastric cancer, however, have emphasized the routine use of preoperative upper endoscopy, even in asymptomatic patients, to detect upper gastrointestinal abnormalities. The main outcome of this study was to identify the most common preoperative endoscopic findings.

METHODS

Data was collected from a prospective database and medical records of patients with available endoscopic reports, who underwent Roux-en-Y gastric bypass from February 1999 to June 2006. Logistic regression analysis was performed to detect preoperative clinical variables that might be associated with abnormal endoscopy.

RESULTS

Six hundred twenty-six patients were identified. Four hundred fifty-two (72%) were female; age and body mass index were 38.5 +/- 11.3 years and 42 +/- 6.5 kg/m(2), respectively. Abnormalities were found in 288 (46%) patients. The age of patients with abnormal and normal endoscopy was 40 +/- 11 and 36.8 +/- 11 years, respectively (p < 0.001). The most common findings were gastritis 21% (n = 132), esophagitis 16% (n = 100), and hiatal hernia 10.7% (n = 67). Duodenitis has a frequency of 7.8% (n = 49), gastric ulcers of 2.7%(n = 17), duodenal ulcers of 2.6% (n = 16), gastric polyps of 1.3% (n = 8), Barrett's esophagus of 0.16% (n = 1), and gastric cancer of 0.16% (n = 1). Age was the only clinical variable associated to abnormal endoscopy (odds ratio = 1.03; 95% confidence interval, 1.02-1.05).

CONCLUSIONS

Routine preoperative endoscopy detects different abnormalities which need specific approach prior to surgery. Preoperative endoscopy should be performed to all patients prior to surgery.

Antecolic versus retrocolic alimentary limb in laparoscopic Roux-en-Y gastric bypass: a comparative study

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the most common surgical treatment for morbid obesity. Intestinal obstruction and internal hernias are complications more commonly observed after LRYGB than after open RYGB. The aim of this study was to evaluate the incidence of these complications in patients who had undergone LRYGB using an antecolic versus a retrocolic technique.

METHODS

From August 2001 to August 2005, LRYGB was performed in 754 patients. The retrocolic and antecolic technique was used in 300 and 454 consecutive patients, respectively. The mean patient age was 37 +/- 10 years, and 552 of the patients (73%) were women. The mean preoperative body mass index was 41.3 +/- 5 kg/m2. The median follow-up was 16 months.

RESULTS

During follow-up, 36 patients (4.7%) underwent surgical exploration secondary to intestinal obstruction. This complication was observed in 28 (9.3%) and 8 (1.8%) patients in the retrocolic and antecolic technique groups, respectively (P <.001). In the retrocolic technique group, an internal hernia developed in 24 patients compared with 3 patients in the antecolic technique group. On multivariate analysis, the retrocolic technique was identified as a risk factor (P <.001).

CONCLUSION

A greater incidence of intestinal obstruction and internal hernia was observed in the retrocolic technique group than in the antecolic technique group undergoing LRYGB. The results of our study have shown that the use of the retrocolic technique is a risk factor for intestinal obstruction after LRYGB.

[Laparoscopic Heller myotomy for esophageal achalasia]

BACKGROUND

Achalasia is characterized by an incomplete relaxation of the lower esophageal sphincter. The best treatment is surgical and the laparoscopic approach may have good results.

AIM

To assess the results of laparoscopic Heller myotomy among patients with achalasia.

MATERIAL AND METHODS

Prospective study of patients subjected to a laparoscopic Heller myotomy between 1995 and 2004. Clinical features, early and late operative results were assessed.

RESULTS

Twenty seven patients aged 12 to 74 years (12 females) were operated. All had disphagia lasting for a mean of 32 months. Mean lower esophageal sphincter pressure ranged from 18 to 85 mmHg. Eight patients received other treatments prior to surgery but symptoms persisted or reappeared. The preoperative clinical score was 7. No patient died and no procedure had to be converted to open surgery. In a follow up of 21 to 131 months, all patients are satisfied with the surgical results and the postoperative clinical score is 1. Only one patient with a mega esophagus maintained a clinical score of six.

CONCLUSIONS

In this series of patients, laparoscopic Heller myotomy was an effective and safe treatment for esophageal achalasia.

Gastrectomía laparoscópica en cáncer gástrico: Experiencia preliminar

BACKGROUND

The development of the laparoscopic surgery has allowed its incorporation to the surgical treatment of gastric cancer.

AIM

To evaluate the feasibility and safety of laparoscopic gastrectomy in gastric cancer in our institution.

PATIENTS AND METHODS

Prospective data in four patients who underwent laparoscopic gastrectomy for gastric cancer from May to August of 2005 was reviewed. Demographic data, clinical characteristics and postoperative results were registered. Patients were staged according to TNM-AJJC staging system.

RESULTS

Four patients aged 48 to 80 years (three males), underwent a completely laparoscopic R0 gastrectomy with lymph node dissection. Two patients underwent total gastrectomy. A subtotal Billroth II gastrectomy was performed in the other two patients. The mean operative time was 260 minutes (Range 180-330). There were no conversions to open surgery. The mean postoperative hospital stay was 6.5 days (Range 6-7 days). There were no complications. According to pathology, one patient presented carcinoma in stage IA, two patients in stage IB and one patient in stage IIIB. The mean number of lymph nodes dissected was 40 (Range 35-54).

CONCLUSIONS

Laparoscopic gastrectomy is a feasible procedure with good postoperative results in this preliminary experience.

Gastrojejunal anastomotic stricture after Roux-en-Y gastric bypass: ambulatory management with the Savary-Gilliard dilator

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is currently one of the most frequently performed procedures for the surgical treatment of morbid obesity. The success of this procedure's restrictive component requires a small gastrojejunostomy (GJ), which occasionally results in stenosis. The treatment of choice for this complication is balloon dilation. This study aimed to evaluate the feasibility and safety of ambulatory management for stenosis of the GJ using endoscopically guided Savary-Gilliard dilators.

METHODS

Between January 1998 and October 2003, 769 patients underwent RYGBP. The mean age of these patients was 38 +/- 12 years, and their mean body mass index (BMI) was 43 +/- 6 kg/m2. Of these 769 patients, 520 (68%) underwent open surgery and 249 (32%) underwent laparoscopic RYGBP. Patients suspected of GJ stenosis were referred for upper gastrointestinal endoscopy. Those who presented with stenosis were managed endoscopically with Savary-Gilliard dilators.

RESULTS

Stenosis at the GJ was confirmed in 53 patients (6.9%). A total of 71 dilations were performed for these patients, resulting in a mean of 1.3 dilations per patient. One dilation was needed for 41 patients (75.5%), two dilations for 9 patients (16.9%), three dilations for 3 patients (5.7%), and four dilations 1 patient (1.9%). The patients subjected to open RYGBP required a mean of 1.57 dilations, and those who had laparoscopic RYGBP required mean of 1.08 dilations. The mean time for the first dilation was 51 +/- 28 days after surgery (range, 20-178 days). All the dilations were performed in ambulatory settings. One patient (1.9%) was admitted after GJ dilation for pain. He was discharged without symptoms after 2 days with no need for invasive procedures.

CONCLUSIONS

The management and treatment of GJ stenosis after RYGBP can be effectively accomplished in ambulatory settings using endoscopically guided Savary-Gilliard dilators, with good and safe results.

Resolution of early stage diabetic nephropathy in an obese diabetic patient after gastric bypass

Epidemiological studies have proven that obesity is a significant risk factor for type 2 diabetes. Long-term progression of diabetes leads to various microvascular complications, of which diabetic nephropathy has become of increasing importance, and is the main cause of end-stage renal failure in occidental countries. Microalbuminuria is the first marker of incipient diabetic nephropathy, an early stage glomerulopathy which can progress to renal failure and which historically has been treated with angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists. We report a severely obese diabetic patient on treatment for diabetic nephropathy with ACE-inhibitors and poor results, which resolved after Roux-en-Y gastric bypass.

[Gallbladder polyps: correlation between ultrasonographic and histopathological findings]

BACKGROUND

Gallbladder polyps are becoming a common finding. The management of these polyps is complicated considering that they can bear malignant lesions.

AIM

To analyze the ultrasonographic and histopathologic findings of patients operated due to gallbladder polyps.

PATIENTS AND METHODS

The records of patients with ultrasonographic diagnosis of gallbladder polyp and that underwent cholecystectomy in a thirteen years period were reviewed, collecting their demographic, ultrasonographic and histopathological data.

RESULTS

One hundred and twenty three patients were operated. The mean age was 44+/-13 years, and 69% were women. The mean size of polyps in ultrasonography was 7.3+/-5 mm. Histopathology confirmed the presence of polyps in 79% of patients, with a mean size and number of lesions of 5.1+/-3.8 mm and 2.1+/-2, respectively. Nine percent of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p =0.003). Four cases of adenoma (3.2%) were diagnosed; one of them had in situ carcinoma. All were single and larger than 10 mm. We found a significant correlation between ultrasonographic and histopathological polyp size determination (r =0.47; p =0.002). Polyp size was also a predictor of the presence of adenoma (p =0.043; confidence intervals: 1.006-1.424).

CONCLUSIONS

There is a good correlation between the size of the gallbladder polyp in ultrasonography and the size in the histopathology report. Gallbladder adenoma is uncommon and it correlates with the size of the polyp. In this series, size was the only predictor of the presence of adenoma.

Duplication 19q13-qter and deletion 19p13-pter arising from an inversion (19)(p13.3q13.3) of maternal origin

Pericentric inversion of chromosome 19 appears to be a rare abnormality with only a few families reported. As far as we are aware, none of them were ascertained because of a recombinant individual. We describe the first identified case due to an affected patient, with duplication deficiency for chromosome 19 arising from a maternal inversion confirmed by FISH and CGH. His features included prenatal growth retardation, microcephaly, dysmorphic facies, congenital heart defect, hypoplasia of corpus callosum and psychomotor delay. The identification of recombinant individuals contribute to calculate a precise risk for inv (19) carriers and to provide a more accurate genetic counselling.

Prospective randomized study of T-tube versus biliary stent for common bile duct decompression after open choledocotomy

The T-tube has been the alternative of choice for decompression following common bile duct (CBD) exploration. The development of laparoscopic surgery has suggested using a biliary stent as an alternative to the T-tube following choledochotomy. The purpose of this prospective randomized study was to compare clinical results obtained from patients who underwent open CBD exploration using a biliary stent versus those from patients with a T-tube for decompression. Between September 2000 and June 2002 a total of 81 patients were randomly assigned to a biliary stent or a T-tube as the decompression method following choledochotomy. An open CBD exploration was performed when CBD stones were suspected, in both elective and emergency settings. The length of the postoperative hospital stay was 6.8 +/- 4.7 days for patients with the T-tube and of 5.2 +/- 3.3 days for, patients with the biliary stent (p = 0.19). Postoperative complications were observed in 13 patients (30%) with the T-tube and in 4 patients (11%) with the biliary stent (p = 0.03). One patient with a biliary stent was reoperated because of an intraabdominal abscess, and another patient was reoperated because of biliary peritonitis following T-tube removal. Three patients (7%) with a biliary stent and one patient (3%) with a T-tube were rehospitalized. There were no deaths. The T-tube and biliary stent were removed 27.1 +/- 10.8 days and 34.9 +/- 12.9 days after surgery, respectively (p = 0.24). The biliary stent is a safe alternative to the T-tube as a biliary decompression method following an open CBD exploration.

Gastric cancer after Roux-en-Y gastric bypass

Roux-en-Y gastric bypass (RYGBP) is one of the most commonly performed surgical procedures for morbid obesity. Several complications that may develop in the short- and long-term have been reported. We present a patient who presented with cancer in the bypassed stomach 8 years after RYGBP. Although the development of this lesion is rare and only a few cases have been reported, there are aspects worthy of discussion. Several monitoring, diagnostic and therapeutic alternatives are analyzed.

Wernicke's Encephalopathy after Roux-en-Y Gastric Bypass

Complications of bariatric operations include the development of nutritional deficiencies. If protracted vomiting is added, severe vitamin depletion could arise such as thiamine deficiency, resulting in the development of Wernicke's encephalopathy (WE). This article describes the rapid onset of WE in a 6-week postoperative morbidly obese woman. Because the occurrence of micronutrient deficiencies is infrequent, although reports are increasing, symptoms may be misdiagnosed leading to possible irreversible effects on the central nervous system. The importance of a prompt diagnosis of this serious complication and of adequate therapy is emphasized.

Evaluation of select variables in the ion chromatographic determination of F-, Cl-, Br-, NO(-)3, SO(-2)4, and PO(-3)4 in serum samples

A full experimental design at two levels is applied for the estimation of the significance of select factors that may influence the ion chromatography (IC) determination of F-, Cl-, Br-, NO(-)3, SO(-2)4, and PO(-3)4 in serum samples. The factors studied are various sample deproteinization procedures, eluent composition, and flow rates. Deproteinization using either acetonitrile-NaOH or ultrafiltration can be used in order to obtain a significant protein removal before IC analysis; however, the former is recommended because it is less time-consuming and cheaper. Better resolution is obtained when a sodium hydroxide solution is used as the eluent. There is no influence of the sample's deproteinization procedures on the chromatographic resolution.

Brief report: improvements in the behavior of children with autism following massage therapy

Twenty children with autism, ages 3 to 6 years, were randomly assigned to massage therapy and reading attention control groups. Parents in the massage therapy group were trained by a massage therapist to massage their children for 15 minutes prior to bedtime every night for 1 month and the parents of the attention control group read Dr. Seuss stories to their children on the same time schedule. Conners Teacher and Parent scales, classroom and playground observations, and sleep diaries were used to assess the effects of therapy on various behaviors, including hyperactivity, stereotypical and off-task behavior, and sleep problems. Results suggested that the children in the massage group exhibited less stereotypic behavior and showed more on-task and social relatedness behavior during play observations at school, and they experienced fewer sleep problems at home.

[Primitive neuroectodermal tumor of the kidney. A case report]

A 27 years old female presented with diffuse abdominal pain, malaise, weight loss and a palpable mass in the left abdomen. Abdominal CAT scan showed a 18 cm heterogeneous tumoral mass that originated in the kidney. The patient was operated on and it was not possible to completely remove the mass. In the postoperative period the patient received chemotherapy with vincristine, cyclophosphamide and adryamicin but the disease progressed and the patient died 16 months later. The pathological study of the surgical specimen disclosed a tumor with monotonous proliferation of small round cells with a basophilic nucleus and scanty cytoplasm with PAS positive granules. Immunohistochemistry was positive for specific neuronal enolase and CD99. Involvement of the urinary system with primary neuroectodermal tumors is very infrequent.