Reduced SIRT1 and SIRT2 expression promotes adipogenesis of human visceral adipose stem cells and associates with accumulation of visceral fat in human obesity.

BACKGROUND/OBJECTIVES: The histone deacetylases SIRT1 and SIRT2 have been shown to be involved in the differentiation of rodent adipocyte precursors. In light of the differences in gene expression and metabolic function of visceral (V) and subcutaneous (S) adipose tissue (AT) and their resident cells, the aim of this study was to investigate the role of SIRT1 and SIRT2 in the differentiation of adipose stem cells (ASCs) isolated from SAT and VAT biopsies of nondiabetic obese and nonobese individuals. METHODS: Human ASCs were isolated from paired SAT and VAT biopsies obtained from 83 nonobese and 92 obese subjects and were differentiated in vitro. Adipogenesis was evaluated by analyzing the lipid deposition using an image processing software, and gene expression by RT-qPCR. SIRT1 and SIRT2 protein expression was modified by using recombinant adenoviral vectors. RESULTS: Visceral but not subcutaneous ASCs from obese subjects showed an intrinsic increase in both adipogenesis and lipid accumulation when compared with ASCs from nonobese subjects, and this was associated with reduced SIRT1 and SIRT2 mRNA and protein levels. Moreover, adipose tissue mRNA levels of SIRT1 and SIRT2 showed an inverse correlation with BMI in the visceral but not subcutaneous depot. Overexpression of SIRT1 or SIRT2 in visceral ASCs from obese subjects resulted in inhibition of adipocyte differentiation, whereas knockdown of SIRT1 or SIRT2 in visceral ASCs from nonobese subjects enhanced this process. Changes in SIRT1 or SIRT2 expression and adipocyte differentiation were paralleled by corresponding changes in PPARG, CEBPA, and other genes marking terminal adipocyte differentiation. CONCLUSIONS: SIRT1 and SIRT2 modulate the differentiation of human ASC. Reduced expression of SIRT1 and SIRT2 may enhance the differentiation capacity of visceral ASC in human obesity, fostering visceral adipose tissue expansion.

Exercise and apulian hypocaloric diet affect adipokine changes and gastric banding-induced weight loss: A prospective study on severe obese subjects.

BACKGROUND: Adiponectin and Resistin correlate with insulin sensitivity and cardiovascular risk, respectively. This study aimed to identify lifestyle factors that modulate changes in Adiponectin and Resistin levels after gastric banding positioning (LapGB). MATERIALS AND METHODS: Before (T0), 3 months (T3), 6 months (T6), and 12 months (T12) after LapGB, serum Adiponectin and Resistin levels were evaluated in a single-centre prospective study including a cohort of 27 non-diabetic obese subjects (S-Ob, BMI ≥35 kg/m2). After surgery, a dietitian checked the adherence of S-Ob to an Apulian hypocaloric diet (aphypoD)/physical activity (phA) and, according to their high or low compliance to aphypoD/phA, S-Ob were included in group 1 (n = 14) or 2 (n = 13) respectively. Serum Adiponectin and Resistin were also measured in 10 healthy controls. RESULTS: At baseline, Resistin levels were significantly higher and Adiponectin levels significantly lower in S-Ob than in controls. After surgery, group 1 showed a 50.2% excess weight loss (%EWL), significantly decreased Resistin levels at T12 and increased Adiponectin levels at both T6 and T12 as compared with baseline. Group 2 showed 24.6 %EWL at T12, decreased Adiponectin levels at T6 and T12 as compared with baseline, but unaltered Resistin levels. After surgery, group 1 followed aphypoD/phA, while group 2 did not. CONCLUSIONS: LapGB fails to improve cardiovascular risk markers (Resistin) in S-Ob not improving lifestyle. Future studies might investigate these findings in a larger cohort and display whether aphypoD is more effective than other dietary intervention on cardiovascular risk in subjects undergoing LapGB or other Bariatric procedures.

Laparoscopic repair of Morgagni hernia in an adult: use of a porcine small intestine submucosa biocompatible prosthesis.

Morgagni hernia is a rare cause of diaphragmatic hernia. There are few reports of laparoscopic repair in the literature. Tension-free hernia closure with synthetic mesh reduces recurrence but occasionally results in complications, such as visceral stricture, erosion or perforation. We report a case of successful laparoscopic repair of a very large symptomatic Morgagni hernia in a 78-year-old patient, treated by positioning a gradually resorbable mesh made from porcine SIS (Surgisis Soft Tissue Graft device--Cook Inc, Bloomington, Ind). After surgery, the patient reported an immediate, marked improvement in clinical symptoms. During the postoperative course, pleural and pericardial leakage occurred. The pleural leakage was immediately drained with thoracentesis, and the pericardial leakage was treated conservatively. No other complications occurred after patient discharge. One year later, the patient was in very good general condition. No recurrence was documented with abdominal CT scan, which also demonstrated connective tissue proliferation that was progressively replacing the prosthesis. Laparoscopic repair is a safe, efficacious procedure for the treatment of diaphragmatic hernia, and presents all the advantages of minimally invasive surgery. The use of new types of material featuring marked biocompatibility and gradual reabsorbability characteristics offers considerable benefits.

Laparoscopic treatment of simultaneous splenic lymphangioma and non-Hodgkin's lymphoma: report of a case.

We report, to the best of our knowledge, the first case of simultaneous splenic lymphangioma and non-Hodgkin's B-cell lymphoma with liver and bone marrow involvement arising in a 69-year-old woman suffering from chronic hepatitis C infection treated with laparoscopic splenectomy followed by polychemotherapy. After 22 months from surgical treatment, the patient is alive without signs of residual disease. According to our experience, laparoscopic splenectomy followed by polychemotherapy seems to be an effective treatment for simultaneous splenic lymphangioma and non-Hodgkin's B-cell lymphoma.

Successful Laparoscopic Sleeve Gastrectomy in Emergency for a Gastric Gastrointestinal Stomal Tumor (GIST) with Acute Bleeding: A Case Report.

BACKGROUND Gastrointestinal stomal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, and the stomach is the most commonly involved organ. Complete surgical resection with negative margins is the primary and only potentially curative treatment. Surgeon experience with minimally invasive gastric resections in addition to the tumor size and site has to be considered in the choice of laparoscopic or open surgical approach in order to remove the lesion. CASE REPORT A 67-year-old male patient with an history of gastric ulcer presented 2 days after an esophagogastroduodenoscopy with an incidental finding of a 30-mm gastric submucosal lesion that was not histologically defined (biopsies were taken), chest pain in association with hematemesis, and melena. An initial attempt to achieve endoscopic hemostasis with epinephrine injection was followed by the recurrence of the gastric bleeding until the presentation of hemorrhagic shock. An emergent laparoscopic sleeve gastrectomy was then performed for hemorrhage control. There were no intra- or postoperative major complications and the histological findings led to the diagnosis of a gastrointestinal stromal tumor (GIST). CONCLUSIONS Laparoscopic sleeve gastrectomy is a bariatric surgical treatment of morbid obesity. This report describes the application of a bariatric procedure in a life-threatening situation and illustrates how safe and effective it can be when performed by surgeons with excellent laparoscopic skills.

Intragastric balloon and binge eating.

BACKGROUND: In recent years, particular attention has been paid to the effect that eating disturbances and especially binge eating can have on the outcome of surgical treatments for obesity. Endoscopic positioning of the Bioenterics intragastric balloon (BIB) is mainly used in the work-up for surgical treatment of morbid obesity. Available data show that the BIB is a valid tool for reducing weight and co-morbidity, even if only a temporary treatment in morbidly obese patients. We evaluated the results of treatment with the BIB with the patient's tendency to indulge in binge eating. METHODS: Between April 2003 and March 2006, 89 patients with morbid obesity (BMI 39-55) were enrolled in the study. Before introducing the BIB and within 3 months after removal, patients underwent a psychiatric evaluation and the following psychodiagnostic tests: SCID (Structured Clinical Interview for DSM IV), ED-SCID (Eating Disorder Module, Structured Clinical Interview) and BSQ (Binge Scale Questionnaire). All those positive for the BED criteria according to the DSM IV, and who had at least one binge eating episode per week, were considered Binge Eaters (BE). RESULTS: Of the 89 patients enrolled, 75 were eligible for evaluations (M:F = 12:63), and 27 were positive for binge eating (BE). There were no significant differences in age and preoperative BMI between the BE group and the 48 patients without BE (NBE group). The complication and failure rates with the BIB treatment were significantly higher in the BE group (P<0.01). After treatment with the BIB, both groups showed a significant reduction in BMI (P<0.01), but the NBE-group showed a significantly higher weight (BMI 5.7 +/- 2.5 kg/m2) than the BE-group (BMI 3.3 +/- 2.2 kg/m2) (P=0.03). CONCLUSION: The results of treatment with the intragastric balloon appear to be affected by binge eating pattern in morbidly obese patients, even if the presence of this behavior does not prevent a successful reduction in the BMI. Binge eating does not seem to be a contraindication for the adjuvant use of the BIB before a bariatric operation. A limitation of our study is the short period of observation, related to the period of the BIB in the gastric lumen (not more than 6 months). Further studies may show whether the association of psychiatric treatment with the BIB in patients affected by binge eating may enhance the results of the treatment.

Comparison of hemodynamic and respiratory effects of propofol and sevoflurane during carbon dioxide pneumoperitoneum in a swine model.

The aim of this study was to compare intraoperative hemodynamic and respiratory parameters using propofol and sevoflurane during laparoscopic surgery in a porcine model. After induction of general anaesthesia in 16 pigs with fentanyl (0.005 mg kg(-1)) followed by propofol (6 mg Kg(-1)), it was maintained with fentanyl (0.01 mg kg(-1)h(-1)) and sevoflurane in O2 in group 1 (G1, n = 8) and fentanyl and propofol (12 mg kg(-1)h(-1)) in group 2 (G2, n = 8). The parameters monitored were heart rate, airway pressure (PAW), arterial and venous blood pressures and arterial blood gas analysis. The carbon dioxide pneumoperitoneum was maintained at 12 mmHg for 2 hours. Data were expressed as mean +/- standard deviation and were analysed using the Wilcoxon test (p < 0.05). G1 showed significantly higher PAW values than G2 at T60, T90 and T120. The heart rate values were significantly higher in G1 at T90 and T120. Middle arterial pressure was significantly lower in G1 than G2 at T30 and T60. The base deficit was significantly greater in G1 at T60, T90, T120 and Tpost. In this study propofol assured better hemodynamic and respiratory conditions than sevoflurane during laparoscopy in a porcine model.

Solid papillary neoplasm of the pancreas: a case report.

Solid pseudopapillary neoplasm of the pancreas, solid and cystic, is a rare disease compared to ductal adenocarcinoma. The tumor most often affects women of African race aged in their twenties or thirties. We report the case of a 48-year-old man affected by solid pseudopapillary neoplasm of the pancreas treated by distal splenopancreasectomy. The patient was discharged on the 10th postoperative day in good general condition, feeling normal and with blood chemistry values within normal limits. The main characteristic differentiating papillary tumors of the pancreas from ductal adenocarcinoma is that in the latter case surgical eradication is a definitive solution and no other treatment is required, as confirmed by our case and those reported in the literature.

Cholecystectomy in situs viscerum inversus totalis. Does laparoscopy increase the pitalls?

Situs viscerum inversus is a rare condition in which the organs are transposed, totally or partially, to the opposite side of the body. Normally, there are no organ dysfunctions. Clinically, symptoms of cholelithiasis may be clear but confused by the location of the gallbladder on the opposite side. We report the case of a 43-year-old female with occasional colic pain in the epigastrium radiating to the right side and subscapular region, particularly after lunch. The laboratory findings showed normal values and, at physical examination, deep palpation of the abdomen in the epigastric region provoked pain. X-rays, ultrasonography, and CT scan showed the presence of multiple gallstones and the situs viscerum inversus of the abdominal organs. The only pathological finding was cholecystolithiasis. Laparoscopic cholecystectomy was judged advisable. Situs viscerum inversus is not a contraindication for laparoscopic cholecystectomy. This abnormal anatomical condition may create some initial difficulty for the surgeons, because of the inverted position of the organs. The peculiarity of our case is the unlikely site of the abdominal pain, located in the epigastrium and on the right side although the patient had situs viscerum inversus. Laparoscopic cholecystectomy can be performed on the left-sided gallbladder proceeding with the "american technique". In difficult cases, open cholecystectomy can be unavoidable.

Tachyarrhythmia due to atrial fibrillation in an intragastric balloon carrier: coincidence or consequence?

A morbidly obese patient is reported who underwent insertion of a BioEnterics Intragastric Balloon (BIB) as a pre-surgical procedure (ie. prior to restrictive gastric banding). While carrying the BIB, the patient suffered an episode of severe supraventricular tachyarrhythmia (atrial fibrillation). Although such an event is not definitely correlated to the BIB, the episode led us to modify the pre-treatment protocol, introducing dynamic Holter ECG into the work-up investigations and excluding subjects with a pathological cardiac rhythm.

Retrobulbar metastasis from gallbladder carcinoma after laparoscopic cholecystectomy. A case report.

Extra-abdominal metastases from gallbladder cancer are very rare; the sites outside the abdomen most frequently affected are the skin, bone and central nervous system. In the literature, only one case of orbital metastasis from gallbladder cancer has been reported, in a patient previously treated by open cholecystectomy. We report the case of a 53-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallbladder stones. Postoperative histological examination revealed an unsuspected gallbladder adenocarcinoma. One month later she came to our observation after having developed diplopia and ophthalmic pain due to an orbital metastasis. We decided not to perform a surgical second look because of the already rapid dissemination of the malignant tumor. The few cases of uncommon gallbladder cancer metastases after laparoscopic cholecystectomy described in the literature are discussed, as well as the possible role of laparoscopy in the dissemination and localized seeding of malignant cells.

Wandering spleen as a cause of acute abdomen: a case report.

We report a case of acute abdomen due to torsion of the long vascular pedicle of a wandering spleen, displaced in the abdominal cavity, and caused by partial infarction of the spleen. The 46-year-old patient presented to the casualty department with piercing abdominal pain, fever, vomiting, leukocytosis, thrombocytopenia, and a palpable mass in the mesogastric region. US and CT scan revealed the presence of a mass compatible with an ectopic spleen in the mesohypogastric region, featuring necrotic-haemorrhagic areas, a long, contorted vascular pedicle twisted on its axis, and an empty splenic space. We performed an emergency laparoscopic splenectomy. Conservative surgery (splenopexy) could not be done because of the severe impairment of the vascular supply to the organ. Nowadays, conservative surgery is preferred in cases without vascular impairment, especially in children, by creating an omental or synthetic pouch after fixing the organ in the splenic space.