Gallbladder plication as a rare complication of endoscopic sleeve gastroplasty: A case report.

BACKGROUND: Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure used in the treatment of obesity, with a complication rate of less than 2% of cases. There have been only two reported cases worldwide of gallbladder injuries as a major complication of ESG. CASE SUMMARY: We present the case of a 34-year-old patient who developed a complication after ESG. The patient experienced epigastric and right hypochondrium pain 12 h after the procedure, and a positive Murphy's sign was identified on physical examination. Laboratory results showed a leukocyte count of 17 × 103/µL, and computed tomography indicated the presence of free fluid in the pelvic cavity and perihepatic recesses as well as a possible suture in the wall of the Hartmann's pouch toward the anterior surface of the stomach. A diagnostic laparoscopy was performed, revealing plication of the Hartmann's pouch wall to the anterior stomach wall. Laparoscopic cholecystectomy and lavage were carried out. The patient had a stable recovery and was discharged 72 h after surgery, tolerating oral intake. CONCLUSION: Gallbladder plication should be suspected if signs and symptoms consistent with acute cholecystitis occur after ESG.

Intraoperative endoscopy prevents technical defect related leaks in laparoscopic Roux-en-Y gastric bypass: A randomized control trial.

BACKGROUND: Postoperative anastomotic leaks, bleeding and stenosis are major causes of morbidity after laparoscopic Roux-en-Y gastric bypass (LRYGB). Retrospective studies suggest that intraoperative endoscopy reduces the incidence of these complications. METHODS: We conducted a prospective randomized controlled trial in a single institution between March 2013 and January 2016. Patients were assigned to one of two groups: LRYGB with Intraoperative Endoscopy (IOE) or LRYGB without IOE. Patient selection criteria were morbidly obese patients, 18 years or older who were candidates to LRYGB. The primary outcome was the frequency of technical defect related anastomotic leaks. Secondary outcomes were operative time, length of hospital stay, anastomotic related complications, reoperations and 30-day mortality. RESULTS: 50 patients were randomly assigned in the IOE group and 50 in the control group. The IOE group had statistically significant lower rate of anastomotic leak (0 vs. 8%, p = .0412), and lower need for reoperation (0 vs. 8%, p = .0412). The IOE group had longer operative time (194.10 vs. 159 min, p < .001), and shorter mean length of hospital stay (2.44 vs. 3.46 days, p = .025). No differences were found in the rate of bleeding of the anastomosis, narrow anastomosis and 30-day mortality. CONCLUSION: This study specifically provides evidence that air leak test performed by intraoperative endoscopy is superior to simple visual inspection in preventing technical defect related leaks after laparoscopic Roux-en-Y gastric bypass.

Adipocyte Size and Leptin Receptor Expression in Human Subcutaneous Adipose Tissue After Roux-en-Y Gastric Bypass.

The molecular mechanisms implicated in pronounced weight loss and metabolic benefits after bariatric surgery are still unknown. Adipocyte phenotype and metabolism have not been entirely explored. However, some features of adipocyte function have been studied, such as adipocyte size and inflammation, which are both reduced after bariatric surgery. Adipocyte fat metabolism, which is partly regulated by leptin, is likely modified, since adipocyte area is decreased. Here, we show that leptin receptor expression is increased, while adipocyte size is decreased 8 months after Roux-en-Y gastric bypass. Thus, adipocyte function is possibly modified by improved leptin signaling after bariatric surgery.

Natural killer cell subsets in cerebrospinal fluid of patients with multiple sclerosis.

Changes in blood natural killer (NK) cells, important players of the immune innate system, have been described in multiple sclerosis (MS). We studied percentages and total cell counts of different effector and regulatory NK cells in cerebrospinal fluid (CSF) of MS patients and other neurological diseases to gain clearer knowledge of the role of these cells in neuroinflammation. NK cell subsets were assessed by flow cytometry in CSF of 85 consecutive MS patients (33 with active disease and 52 with stable MS), 16 with other inflammatory diseases of the central nervous system (IND) and 17 with non-inflammatory neurological diseases (NIND). MS patients showed a decrease in percentages of different CSF NK subpopulations compared to the NIND group. However, absolute cell counts showed a significant increase of all NK subsets in MS and IND patients, revealing that the decrease in percentages does not reflect a real reduction of these immune cells. Remarkably, MS patients showed a significant increase of regulatory/effector (CD56(bright) /CD56(dim) ) NK ratio compared to IND and NIND groups. In addition, MS activity associated with an expansion of NK T cells. These data show that NK cell subsets do not increase uniformly in all inflammatory neurological disease and suggest strongly that regulatory CD56(bright) and NK T cells may arise in CSF of MS patients as an attempt to counteract the CNS immune activation characteristic of the disease.

Correlation between the gastrojejunostomosis area, documented endoscopically, and the loss of weight in laparoscopic gastric bypass postoperative patients: results of 1 year after surgery.

Laparoscopic Y Roux gastric bypass (YRGB) is the most performed bariatric surgery. There are 3 main techniques in the construction of the gastrojejunostomosis (GJA). The size of the GJA and its relation to the reduction of excess weight has been previously debated. The aim of our study was to determine whether the GJA area in YRGB correlates with the loss of excess weight at 1 year postoperatively. Patients who complied 1 year after YRGB underwent an upper gastrointestinal endoscopy. Images of the GJA were obtained and the area of the GJA was calculated. A statistical analysis, adjusting for age and body mass index preoperatively obtained an r of -0474 and P=0.032, demonstrating a significant negative correlation between the GJA area and the percentage of excess weight loss. A statistically significant negative correlation between the GJA area and the percentage of the excess weight loss was shown. The number of patients evaluated should be increased for a higher statistical significance to corroborate whether the stoma size influences the loss of weight in YRGB patients.

Anti-myelin antibodies play an important role in the susceptibility to develop proteolipid protein-induced experimental autoimmune encephalomyelitis.

Multiple sclerosis (MS) is the most common demyelinating disease of the central nervous system. It is an autoimmune disorder in which activated T cells cross the blood-brain barrier (BBB) to initiate an inflammatory response that leads to demyelination and axonal damage. The key mechanisms responsible for disease initiation are still unknown. We addressed this issue in experimental autoimmune encephalomyelitis (EAE), the animal model of MS. It is widely known that EAE manifests only in certain strains when immunized with myelin proteins or peptides. We studied the differential immune responses induced in two mouse strains that are susceptible or resistant to EAE induction when they are immunized with the 139-151 peptide of proteolipid protein, an encephalitogenic peptide capable of inducing EAE in the susceptible strain. The adequate combination of major histocompatibility complex alleles and myelin peptides triggered in susceptible mice a T helper type 17 (Th17) response capable of inducing the production of high-affinity anti-myelin immunoglobulin (Ig)G antibodies. These were not detected in resistant mice, despite immunization with the encephalitogenic peptide in junction with complete Freund's adjuvant and pertussis toxin, which mediate BBB disruption. These data show the pivotal role of Th17 responses and of high-affinity anti-myelin antibodies in EAE induction and that mechanisms that prevent their appearance can contribute to resistance to EAE.

Allergen profile of Protophormia terraenovae, other species of calliphoridae, and Lumbricus terrestris in anglers allergic to maggots in Cáceres, Spain.

BACKGROUND: Our group previously found that up to 7% of amateur anglers in Caceres, Spain may be allergic to the larvae of Protophormia terraenovae (order Diptera, family Calliphoridae) used as live bait for fishing. OBJECTIVE: To identify the pattern of major allergens in P terraenovae and other species of Calliphoridae. MATERIALS AND METHODS: Extracts of P terraenovae, Calliphora vomitoria, Lucilia sericata and Lumbricus terrestris were characterized using sodium dodecyl sulfate polyacrylamide gel electrophoresis and IgE-immunoblotting techniques in individual sera from 24 patients with a positive skin test result and/or specific IgE determination (enzyme-linked immunosorbent assay [ELISA]) to P terraenovae. ELISA and IgE-immunoblotting inhibition studies were also performed to identify potential cross-reactive allergens between these species. RESULTS: IgE-immunoblotting with P terraenovae showed a band of 15.3 kDa recognized by 15 patients, in addition to 2 further allergens of 22.8 kDa and 69 kDa. For C vomitoria, 5 bands of 73, 46, 40, 28, and 14 kDa were observed. For L sericata, 2 major allergens of 73 kDa and 14 kDa were observed. In the case of L terrestris, IgE from 13 patients recognized 1 allergen of around 15.5 kDa. IgE-immunoblotting and ELISA inhibition revealed the presence of cross-reactivity, mainly between L terrestris and P terraenovae. CONCLUSIONS: P terraenovae appears to have species-specific allergens and allergens shared with C vomitoria and L sericata. Striking immunological cross-reactivity was observed between P terraenovae and L terrestris. An allergen of 15-16 kDa could be involved in this phenomenon.

Correlación de los hallazgos endoscópicos pre y postoperatorios en pacientes sometidos a cirugía bariátrica / Correlation of pre and postoperative endoscopic findings in patients subjected to bariatric surgery

Objetivo: Establecer una correlación de los hallazgos endoscópicos preoperatorios con los síntomas gastrointestinales y hallazgos endoscópicos en el seguimiento de los pacientes sometidos a algún tipo de cirugía bariátrica. Sede: Hospital General ''Dr. Manuel Gea González''. Tercer Nivel de Atención Médica. Diseño: Estudio retrospectivo, descriptivo, transversal y comparativo. Análisis estadístico: Porcentajes como medida de resumen para variables cualitativas y χ². Pacientes y método: Pacientes que se operaron en la clínica de obesidad, de junio 2006 a junio 2010, a los cuales se les realizó endoscopia preoperatoria con un seguimiento mínimo de un año. Se identificaron las patologías gastrointestinales con mayor incidencia, hallazgos histopatológicos y la correlación de la endoscopia postoperatoria en el seguimiento de pacientes que por sus síntomas requirieron control endoscópico. Resultados: De un total de 137 pacientes que cumplieron con los criterios de inclusión (111 mujeres, 26 hombres), con edad promedio de 36.41, IMC promedio de 42.04, la patología con mayor incidencia fue gastritis inespecífica no erosiva (45.25%), el resultado histopatológico más frecuente fue gastritis asociada a Helicobacter pylori (HP) (38.6%). A un seguimiento promedio de tres años (DE ± 1.31) a 35 pacientes (25.5%) se les realizó endoscopia de seguimiento por síntomas gastrointestinales; los hallazgos endoscópicos fueron: gastritis inespecífica no erosiva (54.28%), sin alteraciones (31.42%) y estenosis de anastomosis (14.7%). Conclusión: La endoscopia preoperatoria es de gran utilidad, ya que permite identificar patologías que se pueden asociar a otras complicaciones y tomar todas las medidas para prevenirlas.

Objective: To establish a correlation between the pre-operative endoscopic findings with the gastrointestinal syndrome and endoscopic findings during follow-up of patients subjected to bariatric surgery. Setting: General Hospital ''Dr. Manuel Gea González'' (third level health care center). Design: A retrospective, descriptive, cross-sectional, comparative study. Statistical analysis: Percentages as summary measures for qualitative variables and χ². Patients and method: Patients operated in the obesity clinic from June 2006 to June 2010, in whom a preoperative endoscopy was performed with a follow-up of at least 1 years. We identified the gastrointestinal pathologies with the highest incidence, histopathological findings, and the correlation with the postoperative endoscopy during the follow-up of patients, who, due to their symptoms, required endoscopic control. Results: In a total of 137 patients that complied with the inclusion criteria (111 women and 26 men), average age of 36.41 years, average BMI of 42.04, the pathology with the highest incidence was non-specific non-erosive gastritis (45.25%), the most frequent histopathological result was gastritis associated to Helicobacter pylori (HP) (38.6%). At an average follow-up of three years (SD ± 1.31), 35 patients (25.5%) were subjected to follow-up endoscopy due to gastrointestinal symptoms. Endoscopic findings were: non-specific, non-erosive gastritis (54.28%), without alterations (31.42%), and stenosis of the anastomoses (14.7%). Conclusion: Preoperative endoscopy is very useful as it allows identifying pathologies that can be associated to other complications and taking the necessary measures to prevent them.

CD29 expressed on plasma cells is activated by divalent cations and soluble CD106 contained in the bone marrow plasma: refractory activation is associated with enhanced proliferation and exit of clonal plasma cells to circulation in multiple myeloma patients.

Malignant plasma cells (PC) in human multiple myeloma (MM) are retained in the bone marrow (BM) microenvironment. Using HUTS21 monoclonal antibody that reacts with active CD29 integrin, we demonstrate that this active form is tightly regulated by divalent cations and soluble CD106 (sCD106) contained in the BM plasma. Moreover, we also show that in vivo expression of the active CD29 on PC was clearly diminished in a minority of MM cases (HUTS21(-) patients). HUTS21(-) cells were refractory to the addition of either normal allogeneic BM plasma or optimal concentrations of exogenous divalent cations and recombinant sCD106. Furthermore, a lower binding to fibronectin was detected in comparison with HUTS21(+) PC. On the other hand, although HUTS21(-) PC showed a reduced amount of total (active+inactive) CD29, western-blot assays demonstrated that these clonal PC contained the two species of CD29, with molecular masses of 110 and 130 kDa, which were expressed on normal or HUTS21(+) PC. Finally, we detected a clear association between the presence of HUTS21(-) PC in the BM and an increased percentage of circulating PC with a high proliferative index, emphasizing the essential role of CD29 in the pathogenesis and progression of this disease.

Angioedema as a single manifestation of carcinoid syndrome in a bronchial carcinoid tumor.

BACKGROUND: The association of bronchial carcinoid tumours with carcinoid syndrome is extremely rare especially in the absence of metastasic disease, and the angioedema is not a typical sign of this syndrome. METHODS AND RESULTS: We report the case of a 39 year-old woman referred to our allergy department with recurrent episodes of angioedema. The aetiological study of angioedema did not show evidence of hypersensitivity to common inhalants, food allergens and latex. C1-inhibitor, C3, C4, C1q, proteinogram and immunoglobulins (IgA, IgG, IgM) all were normal. TSH determination gave normal results, too. Faecal analyses for parasites were negative. The haemogram showed moderate leucocytosis and hypocromic mycrocitic anaemia. The thoracic radiography showed a mediastinal node image in the right paratracheal region. Histology analyses of the samples were diagnostic of a typical carcinoid tumor. Levels of 5-hydroxyindolacetic acid (5-HIIA) were slightly increased. A superior lobectomy was performed and no new episodes of angioedema appeared after surgical intervention. CONCLUSIONS: We report the first case of typical bronchial carcionid tumour, without metastasic disease, with angioedema as a single manifestation of carcinoid syndrome. In our knowledge, only one case of Quincke's edema as part of typical carcinoid syndrome has been reported, in a case of primary midgut carcinoid tumor with metastasic disease to liver. It is very important to include complementary tests, as thoracic radiography, in the routine study of angioedema to reject malignant diseases.

Allergy to asticot maggots. Identification of allergens.

UNLABELLED: There are some written reports of allergic reactions after contact with Asticot larvae in anglers and occupationally exposed workers. Clinical and immunological studies were performed to confirm the allergens involved in the case of a 12-year-old male who developed respiratory symptoms shortly after contact with Asticot maggots used as fish bait. METHODS AND RESULTS: Aqueous extracts of Asticot maggots were taken for in vivo and in vitro tests. The protein concentration as determined by turbidimetric assay was 1.4 mg/ml. Skin prick test with Asticot extract was positive with an immediate response. Ten atopic and ten nonatopic control subjects did not react to the extract. Specific serum IgE antibodies against Asticot were found in the patient's serum (ELISA). Coomasie staining after SDS-PAGE separation of Asticot extract showed three protein bands of 30, 40 and 60 kDa. IgE immunoblot showed one antigenic band of 60 kDa specifically recognized by the patient's IgE. Specific nasal challenge test with Asticot extract using a Rhinospir 164 rhinomanometer showed immediate response (1/10 w/v), with a 200% increase in nasal resistances from baseline. CONCLUSIONS: One main allergen of MW 60 kDa was specifically recognized by our patient's IgE. There are no previous reports in the literature that characterize the allergens involved in Asticot hypersensitivity. Asticot maggots should be taken into account as a possible causative agent of respiratory symptoms due to a type I hypersensitivity mechanism in anglers who are exposed to emanations of these live fish baits.

Glia-conditioned medium induces de novo synthesis of tyrosine hydroxylase and increases dopamine cell survival by differential signaling pathways.

The mesencephalic astroglia-conditioned medium (GCM) greatly increases dopamine (DA) phenotype expression, and it also protects from spontaneous and toxin-induced cell death in midbrain cultures. In this study, we have investigated the signaling pathways implicated in those effects. Genistein at 5 microM, an inhibitor of tyrosine kinase receptors, and KT-5720, a protein kinase A inhibitor, blocked the GCM-induced effects on DA phenotype expression and DA cell survival but did not abolish the increased astrocytic (glial fibrillary acidic protein-positive; GFAP+) processes. We analyzed the role of phosphatidylinositol-3 kinase (PI-3K) on TH induction and cell survival, with the PI-3K inhibitors LY-294002 and wortmannin, and the role of the phosphorylation of mitogen-activated protein kinase (MAPK) with PD-98059, a p-ERK1/2 MAPK inhibitor. LY-294002 at 20-30 microM blocked the GCM-induced effects on TH expression and DA cell survival but did not abolish the increased astrocytic processes. PD-98059 at 20 and 40 microM blocked the GCM-induced effects on DA phenotype, cell survival, and GFAP expression. However, staurosporine at 10 nM, a protein kinase C inhibitor, only blocked the protective effects induced by GCM on midbrain cell apoptosis. The data presented herein show that tyrosine kinase receptors, cAMP-dependent protein kinase, PI-3K, and MAPK signaling pathways are implicated in de novo synthesis of TH+ cells induced by GCM as well as in DA cell apoptosis and that these effects are unrelated to increased GFAP expression. PKC inhibitors only abolished the GCM-induced effects on midbrain neuronal survival, suggesting that signaling pathways for DA phenotype expression and survival may be independent.

[Anterior rhinomanometry as a diagnostic test in occupational allergy caused by Liliaceae]. / Rinomanometría anterior como test diagnóstico en alergia ocupacional por liliáceas.

UNLABELLED: The Liliacea family has been implicated as a cause of occupational rhinoconjunctivitis and bronchial asthma. We report a patient who presented symptoms when he manipulated spices including garlic and onion dusts. Nasal challenge test with active anterior rhinomanometry was used for the diagnosis. MATERIAL AND METHODS: Skin-prick tests with common inhalants, commercial spices, fresh Liliaceae and powdered spices diluted in saline solution (10 mg/ml) were performed. Immunoblot and specific IgE (CAP-Pharmacia) were determined. Control peak expiratory flow was monitored during a period at work in an area where spices were manipulated and in an area where they were transported. Nasal challenge test with garlic and onion powder was performed. The resulting nasal obstruction was measured as nasal airway resistance and was determined by rhinomanometry. RESULTS: Skin-prick tests were positive for onion, garlic powder and fresh Liliacea. Specific IgE were positive for garlic and onion. IgE immunoblotting showed very strong bands at 14 and 40 kD with garlic extract. Nasal challenge showed an increase in inspiratory nasal resistance which was higher than 100 % of the basal value for both onion extract and garlic.

Thiolic antioxidants protect from nitric oxide-induced toxicity in fetal midbrain cultures.

Nitric oxide (NO) may act as a neuroprotector or neurotoxic agent in dopamine neurons, depending on cell redox status. We have investigated the effect of several thiolic antioxidants, glutathione (GSH), its cell permeable analog GSH ethyl ester (GSHEE), and the GSH synthesis precursor L-N-acetyl cysteine (L-NAC), as well as non-thiolic antioxidants like ascorbic acid (AA) and uric acid, on NO-induced toxicity in fetal midbrain cultures. The cultures were treated for 8-24 h with neurotoxic doses of the NO donor diethylamine/nitric oxide complex sodium DEA/NO (200-400 micro M) and/or antioxidants. Thiolic antioxidants, at equimolar concentrations, added at the same time or previous to DEA/NO, protected from cell death, from tyrosine hydroxylase (TH) positive cell number decrease and from intracellular GSH depletion, induced by DEA/NO, without increasing intracellular GSH content. In these conditions, S-nitrosothiol compound formation was detected in the culture media. Protection disappeared when antioxidants were supplied 30 min after NO treatment. Nevertheless, non-thiolic antioxidants, AA and uric acid, with similar peroxynitrite scavenging activity to thiolic antioxidants, and free radical-scavenging enzymes as catalase and Cu/Zn-superoxide dismutase, which prevent extracellular peroxynitrite ion formation, and 4,5-dihydroxy-1,3-benzene-disulfonic acid (Tiron), which prevents intracellular peroxynitrite ion formation, did not rescue cell cultures from neurotoxicity induced by NO. In addition, AA exacerbated DEA/NO-induced toxicity in a dose-dependent manner from 200 micro M AA. The present results suggest that only antioxidants with thiol group exert neuroprotection from NO-induced toxicity in fetal midbrain cultures, probably by direct interaction of NO and thiol groups, resulting in NO blocking. On the other hand, some classical antioxidants, like AA, exacerbate neurotoxicity due to NO.

Glutathione depletion switches nitric oxide neurotrophic effects to cell death in midbrain cultures: implications for Parkinson's disease.

Nitric oxide (NO) exerts neurotrophic and neurotoxic effects on dopamine (DA) function in primary midbrain cultures. We investigate herein the role of glutathione (GSH) homeostasis in the neurotrophic effects of NO. Fetal midbrain cultures were pretreated with GSH synthesis inhibitor, L-buthionine-(S,R)-sulfoximine (BSO), 24 h before the addition of NO donors (diethylamine/nitric oxide-complexed sodium and S-nitroso-N-acetylpenicillamine) at doses tested previously as neurotrophic. Under these conditions, the neurotrophic effects of NO disappeared and turned on highly toxic. Reduction of GSH levels to 50% of baseline induced cell death in response to neurotrophic doses of NO. Soluble guanylate cyclase (sGC) and cyclic GMP-dependent protein kinase (PKG) inhibitors protected from cell death for up to 10 h after NO addition; the antioxidant ascorbic acid also protected from cell death but its efficacy decreased when it was added after NO treatment (40% protection 2 h after NO addition). The pattern of cell death was characterized by an increase in chromatin condensed cells with no DNA fragmentation and with breakdown of plasmatic membrane. The inhibition of RNA and protein synthesis and of caspase activity also protected from cell death. This study shows that alterations in GSH levels change the neurotrophic effects of NO in midbrain cultures into neurotoxic. Under these conditions, NO triggers a programmed cell death with markers of both apoptosis and necrosis characterized by an early step of free radicals production followed by a late requirement for signalling on the sGC/cGMP/PKG pathway.

L-DOPA and glia-conditioned medium have additive effects on tyrosine hydroxylase expression in human catecholamine-rich neuroblastoma NB69 cells.

The aim of this study was to investigate the effect of L-DOPA and glia-conditioned medium (GCM) on cell viability, tyrosine hydroxylase (TH) expression, dopamine (DA) metabolism and glutathione (GSH) levels of NB69 cells. L-DOPA (200 microM) induced differentiation of NB69 cells of more than 4 weeks in vitro, as shown by phase-contrast microscopy and TH immunocytochemistry, and decreased replication, as shown by 5-bromodeoxyuridine immunostaining. L-DOPA did not increase the number of necrotic or apoptotic cells, as shown by morphological features, Trypan Blue, lactate dehydrogenase activity, bis-benzimide staining and TUNEL assay. Furthermore, L-DOPA (200 microM) increased Bcl-xL protein expression. Incubation of cells with L-DOPA (50, 100, 200 microM) for 24 h resulted in an increase in TH protein levels (174, 196 and 212% versus control). Neither carbidopa, an inhibitor of L-aromatic amino acid decarboxylase enzyme, nor L-buthionine sulfoximine, which inhibits GSH synthesis, or ascorbic acid, an antioxidant, blocked the L-DOPA-induced effect on TH protein expression. L-DOPA (0, 50, 100 and 200 microM) plus GCM further increased the amount of TH protein (346, 446, 472 and 424%). L-DOPA (200 microM) increased TH protein levels to 132, 191 and 245% of controls after incubation for 24, 48 and 72 h. DA metabolism in NB69 cells was increased in cultures treated with either L-DOPA (200-300 microM) or GCM and these two agents had a synergistic effect on DA metabolism. In addition, L-DOPA (200 microM) or/and GCM-treated cells increased their GSH extracellular levels (223, 257, 300% of controls) after 48 h of treatment. The L-DOPA-induced increase of TH protein expression in NB69 cells was independent of DA production, free radicals and GSH up-regulation.