Laparoscopic sleeve gastrectomy in a 2-year-old child with morbid obesity: A case report with a 2-year follow-up.

ABSTRACT: Morbid obesity in infancy or early childhood is a challenging disease to manage. Here, we present the case report of the successful management of a 2-year-old girl child with morbidly obesity who was bedridden and had sleep apnoea and underwent laparoscopic sleeve gastrectomy. Bariatric surgery in this age group comes with a lot of decision-making challenges and technical and ethical considerations, and literature is scant on paediatric bariatric surgery. We describe the case and associated challenges in detail in this report.

Laparoscopic intra-peritoneal onlay mesh plus versus robotic transabdominal pre-peritoneal for primary ventral hernias: Our technique and outcomes.

INTRODUCTION: Intra-peritoneal onlay mesh repair (IPOM) still remains the most common approach for laparoscopic repair of small to medium sized hernias worldwide. In this study, we compare our early outcomes of an established procedure, i.e. laparoscopic IPOM plus to robotic transabdominal pre-peritoneal (rTAPP) for small to medium sized primary ventral hernia. To compare laparoscopic IPOM plus with rTAPP in terms of pain score, time to ambulate, hospital stay, time to return to work as well as the expenses. PATIENTS AND METHODS: This is a retrospective analysis of prospectively collected data at our centre between July 2021 and June 2022. Operative time including docking time was recorded. Cost analysis was done in both set of patients. Pain scores were assessed using Visual Analogue Scale (VAS) at regular intervals for up to 3 months and then at the end of 1 year. Time to ambulate, return of bowel function and return to work were documented. Any complication or recurrence during the study period was recorded. RESULTS: Mean operative time for IPOM plus and rTAPP groups was 59.00 and 73.55 min, respectively. Mean pain score for IPOM at 6, 12 and 24 h was 7.35, 6.81 and 5.77, while for rTAPP, it was 4.73, 3 and 2.55, respectively. VAS scores at 1 week, 1 month and 3 month also showed similar trends. Mean time to ambulate in minutes for IPOM and rTAPP group was 357.69 and 223.64, respectively. Mean hospital stay in days for IPOM and rTAPP was 2.12 and 1.18, respectively. Mean time to return to work in days was 11.77 and 8.45 for IPOM and rTAPP groups, respectively. Expenditure wise, cost of TAPP was more and statistically significant, owing to the use of robotic platform. The mean overall cost of laparoscopic IPOM plus and rTAPP in rupees was 187,177.69 and 245,174.55, respectively. CONCLUSION: Robotic TAPP appears an excellent alternative to laparoscopic IPOM plus. Larger studies with long-term follow-up data are further required to reinforce it.

An Indian multicentre real-world study on long-term quality of life outcomes following bariatric surgery.

BACKGROUND: The purpose of this study was to assess the impact of metabolic and bariatric surgery (MBS) on Quality of Life (QoL) in Indian patients with obesity over 10 years. METHODS: A retrospective chart review was conducted at 11 centres for individuals with MBS between February 2013 and May 2022. Patient medical records provided the source of de-identified data. RESULTS: Data from 2132 individuals with a mean age of 43.28 ± 11.96 years was analysed. There were 37.43% men and 62.57% females in the study population. The study population had a mean preoperative body mass index (BMI) of 45.71 ± 10.38 kg/m2. The Bariatric Analysis and Reporting Outcome System (BAROS) scoring method showed a higher overall QoL score throughout all follow-up periods, with 'very good' outcomes at one, three and 7 years and 'good' outcomes at 5 and 10 years. Improvements in QoL were associated with a substantial improvement (p < .01) in BMI at every follow-up time point. CONCLUSIONS: Following MBS, individuals with obesity exhibited a substantial and long-term improvement in their overall QoL for up to 10 years. This study presents Indian data on QoL, which is considered one of the most important decision-making factors for or against an intervention.

Global benchmarks in primary robotic bariatric surgery redefine quality standards for Roux-en-Y gastric bypass and sleeve gastrectomy.

BACKGROUND: Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks. METHODS: Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years. RESULTS: A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass. CONCLUSION: The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.

Intra-peritoneal migration of abdominal drain after cholecystectomy - Laparoscopic retrieval: A case report.

Intra-peritoneal migration of abdominal drain is a rare complication. Cutting of abdominal drain and putting a colostomy bag over it is done to reduce the pain and infection and to increase the mobility of a patient, but it is also a risk factor for drain intra-peritoneal migration. This case report depicts a case of intra-peritoneal migration of abdominal drain after laparoscopic cholecystectomy and its retrieval.

Target-mimicry based diminution of miRNA167 reinforced flowering-time phenotypes in tobacco via spatial-transcriptional biases of flowering-associated miRNAs.

Evolutionarily conserved microRNAs such as miR156, miR159, miR167 and miR172 tightly regulate the extensive array of gene expression during flowering in plants, through instant and long-term alterations in the expression of their target genes. Here we employed a novel target-mimicry approach for the diminution of auxin signalling regulator miRNA167 by developing mimic-transgenic lines in tobacco, to investigate the transcriptional biases of flowering-associated miRNAs in apical and floral meristematic tissues and their phenotypic implications. Recorded morpho-alterations such as uneven flowering-time phenotypes, anomalous floral organ formation, and large variations in the seed forming characteristics permitted us to determine the consequence of the extent of miR167 expression diminution accompanying the transcriptional biases of interrelated miRNAs. We demonstrate that percent diminution of miR167 gene expression is proportionally associated with both early and late flowering-time phenotypes in mimic lines. Also, the associated miRNAs, miR156, miR159, and miR172 showed >90% transcriptional diminution in at least 'early-flowering' miR167 mimic lines. On contrary, low percentages of their respective diminution were recorded in 'late-flowering' lines. Evidently, the misexpression of miR156, miR159, and miR172 led to the over-expression of their respective target genes SPL9, AtMYB33-like and AP2 genes in mimic lines which resulted in assorted phenotypes. We describe the scope of spatial regulation of these microRNAs in floral bud tissues of mimic lines which showed negative- or very low (<25%) misexpression levels in early/late-flowering lines highlighting their roles in the acquisition of flowering mechanism. To our knowledge, this study represents the first characterization of transcriptional biases of flowering associated miRNAs in miR167-mimic lines and certainly augments our understanding of the importance of microRNA-mediated regulation of flowering in plants.

Bioengineering of crop plants for improved tetrahydrofolate production.

De novo synthesis of folates in plants is tightly regulated through feedback-regulation of certain pathway catalysts. Recently, we investigated the prospects of incessant production of folates in an evolutionary conjunction, through the overexpression of feedback targeted and evolutionarily conserved heterologous E.coli dihydroneopterin aldolase (EcDHNA) in tobacco. 1 The enhanced production of folates in the transgenic lines was associated with differential allosteric regulatory cavities accessible at EcDHNA surface having critical amino-acid differences as Ile 64 (His_63), Val 70 (Phe_69), His 75 (Arg_78) and Arg 79 (Glu_72). These structural characteristics are indicative of evolutionary signatures of the catalytic feedback-regulation of folate manufacturing. We exploited the biotechnological potential of such allosterically diverged trans-DHNA for improved folate production in plants. Nonetheless, genetic manipulation of single enzymes modulating complex pathways such as folate biosynthesis is often inadequate to achieve desired phenotypes; therefore, multi-gene integration with explicit genic-combination for folate enrichment in plants has also been projected for future folate agri-biofortification schemes.

Recombinant overexpression of dihydroneopterin aldolase catalyst potentially regulates folate-biofortification.

We aim to investigate the prospects of increased production of folate through the overexpression of heterologous dihydroneopterin aldolase catalyst. The gene encoding aldolase catalyst was cloned into an expression vector and the induced recombinant protein was purified through metal-affinity chromatography which appeared at 14 kDa position on polyacrylamide-gel. Remarkably, a periodic increase in the extracellular and intracellular folic acid concentration was observed at 4 h growth of induced recombinant DHNA samples than control in a pH-dependent manner. Maximum folate concentration was observed with at least twofold increase in induced recombinant samples at pH8.0 compared to the significant decline at 6 h growth. Consistently, heterologous overexpression of bacterial aldolase through Agrobacterium-mediated genetic transformation of tobacco led to more than 2.5-fold increase in the folate concentration in the transgenic leaves than control tissues. These data are veritable inspecting metabolic flux in both bacterial and plant systems, thus providing directions for future research on folate agri-fortification.

Domestication-driven Gossypium profilin 1 (GhPRF1) gene transduces early flowering phenotype in tobacco by spatial alteration of apical/floral-meristem related gene expression.

BACKGROUND: Plant profilin genes encode core cell-wall structural proteins and are evidenced for their up-regulation under cotton domestication. Notwithstanding striking discoveries in the genetics of cell-wall organization in plants, little is explicit about the manner in which profilin-mediated molecular interplay and corresponding networks are altered, especially during cellular signalling of apical meristem determinacy and flower development. RESULTS: Here we show that the ectopic expression of GhPRF1 gene in tobacco resulted in the hyperactivation of apical meristem and early flowering phenotype with increased flower number in comparison to the control plants. Spatial expression alteration in CLV1, a key meristem-determinacy gene, is induced by the GhPRF1 overexpression in a WUS-dependent manner and mediates cell signalling to promote flowering. But no such expression alterations are recorded in the GhPRF1-RNAi lines. The GhPRF1 transduces key positive flowering regulator AP1 gene via coordinated expression of FT4, SOC1, FLC1 and FT1 genes involved in the apical-to-floral meristem signalling cascade which is consistent with our in silico profilin interaction data. Remarkably, these positive and negative flowering regulators are spatially controlled by the Actin-Related Protein (ARP) genes, specifically ARP4 and ARP6 in proximate association with profilins. This study provides a novel and systematic link between GhPRF1 gene expression and the flower primordium initiation via up-regulation of the ARP genes, and an insight into the functional characterization of GhPRF1 gene acting upstream to the flowering mechanism. Also, the transgenic plants expressing GhPRF1 gene show an increase in the plant height, internode length, leaf size and plant vigor. CONCLUSIONS: Overexpression of GhPRF1 gene induced early and increased flowering in tobacco with enhanced plant vigor. During apical meristem determinacy and flower development, the GhPRF1 gene directly influences key flowering regulators through ARP-genes, indicating for its role upstream in the apical-to-floral meristem signalling cascade.