Clock genes are implicated in the human metabolic syndrome.

BACKGROUND: Clock genes play a role in adipose tissue (AT) in animal experimental models. However, it remains to be elucidated whether these genes are expressed in human AT. OBJECTIVE: We investigated the expression of several clock genes, Bmal1, Per2 and Cry1, in human AT from visceral and subcutaneous abdominal depots. A second objective was to elucidate whether these clock genes expressions were related to the metabolic syndrome features. METHODS: Visceral and subcutaneous AT samples were obtained from morbid obese men (n=8), age: 42+/-13 years and body mass index>/=40 kg/m(2), undergoing laparoscopic surgery due to obesity. Biopsies were taken as paired samples at the beginning of the surgical process (1100 hour). Metabolic syndrome features such as waist circumference, plasma glucose, triglycerides, total cholesterol, high-density lipoprotein cholesterol and low-density lipoprotein (LDL) cholesterol were also studied. Homeostasis model assessment index of insulin resistance was also calculated. The expression of the different clock genes, hBmal1, hPer2 and hCry1, was determined by quantitative real-time PCR. RESULTS: Clock genes were expressed in both human AT depots. hBmal1 expression was significantly lower than hPer2 and hCry1 in both AT (P<0.001). All genes were highly correlated to one another in the subcutaneous fat, while no correlation was found between Bmal1 and Per2 in the visceral AT. Clock genes AT expression was associated with the metabolic syndrome parameters: hPer2 expression level from visceral depot was inversely correlated to waist circumference (P<0.01), while the three clock genes studied were significantly and negatively correlated to total cholesterol and LDL cholesterol (P<0.01). CONCLUSION: We have demonstrated for the first time in humans that clock genes are expressed in both subcutaneous and visceral fat. Their association with abdominal fat content and cardiovascular risk factors may be an indicator of the potential role of these clock genes in the metabolic syndrome disturbances.

Insulin effect on adipose tissue (AT) adiponectin expression is regulated by the insulin resistance status of the patients.

OBJECTIVE: The objective of the present study was to determine a possible depot-specific effect of insulin-stimulation on adiponectin gene expression in adipose tissue (AT) explants from subcutaneous and visceral AT. A secondary aim was to analyse the associations of adiponectin plasma levels, as well as control and insulin-stimulated gene expression levels with different features of the metabolic syndrome. DESIGN: Visceral and subcutaneous AT biopsies were obtained from 20 subjects (10 men and 10 women) with morbid obesity. Metabolic syndrome and other clinical features were studied. Adiponectin expression from isolated adipocytes was measured both in control and after insulin-stimulation conditions by quantitative PCR. RESULTS: Subcutaneous adipocytes expressed significantly higher amounts of adiponectin mRNA than visceral tissue (P = 0.027). Insulin increased adiponectin expression specifically in the omental tissue (P = 0.011). In these patients, waist : hip ratio was directly correlated with adiponectin expression in the visceral depot (r = 0.660; P = 0.014), while fasting glucose levels were inversely associated with adiponectin mRNA in the subcutaneous tissue (r =-0.604; P = 0.022). Adiponectin expression after addition of insulin was positively correlated with some metabolic risk factors (cholesterol, LDL-cholesterol, insulin, C-peptide). Interestingly, local insulin induced an up-regulation of adiponectin expression in the AT of those patients with higher metabolic syndrome disturbances. CONCLUSIONS: Our results clearly demonstrate that insulin exerts a stimulating effect on adiponectin gene expression in a depot-specific manner. The AT response to insulin stimulus depends on the physiopathological situation, being higher in those individuals with impaired insulin-sensitivity and lipid metabolism.

Duodenogastric reflux quantification in peptic ulcer surgery: comparison between different surgical techniques.

BACKGROUND: We quantified duodenogastric reflux with 6-hour continuous intravenous infusion of technetium 99m-labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequent quantification in gastric juice. METHODS: For this purpose, 50 patients were studied who had undergone surgery on the stomach with different surgical techniques: bilateral vagotomy plus Heineke-Mikulicz pyloroplasty, bilateral truncal vagotomy plus anterior pylorectomy, proximal gastric vagotomy, antrectomy and Billroth I reconstruction, and antrectomy and Billroth II reconstruction, comparing them with 10 healthy subjects used as a control group. We also studied the existing correlation between the rates of reflux determined by 99mTc-HIDA and those of total bile acids in gastric juice. RESULTS AND CONCLUSIONS: Patients who underwent gastric surgery had significantly greater quantities of duodenogastric reflux (p < 0.001) than had the control group. When the groups undergoing gastric surgery were compared, the patients who underwent resection showed higher reflux rates (p < 0.001) than did the patients who did not undergo resection. We found no differences among the groups of patients who did or did not undergo resection. We also found a highly significant correlation (p < 0.001) between the concentrations of 99mTc-HIDA and bile acids in gastric juice.

Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis: a prospective study.

OBJECTIVE: To compare the results of laparoscopic cholecystectomy (LC) with those of open cholecystectomy (OC) in the treatment of acute cholecystitis. DESIGN: A prospective, nonrandomized trial. SETTING: "Virgen de la Arrixaca" University Hospital, El Palmar (Murcia), Spain. PATIENTS: One hundred fourteen patients underwent LC, and 110 underwent OC. The patients underwent surgery within 72 hours of the onset of symptoms. The patients were selected for LC or OC depending on the surgeon's experience in laparoscopic surgery. MAIN OUTCOME MEASURES: Operating time, rate of conversion from LC to OC, complications, and length of hospital stay. RESULTS: Conversion from LC to OC was necessary in 15% of the patients. The mean operating time was 77 minutes for the OC group and 88 minutes for the LC group (P<.001). Complications occurred in 14% of the patients in the LC group and in 23% of the patients in the OC group, with no significant differences between the 2 groups (P=.06). The number of moderate or severe complications was similar in both groups, whereas mild complications were more common in the OC group (P<.02). The length of the hospital stay averaged 8.1 days for the OC group and 3.3 days for the LC group (P<.001). CONCLUSIONS: Laparoscopic cholecystectomy is a safe, valid alternative to OC in patients with acute cholecystitis. The technique has a low rate of complications, implies a shorter hospital stay, and offers the patient a more comfortable postoperative period than OC.

Laparoscopic cholecystectomy in the treatment of acute cholecystitis.

BACKGROUND: Laparoscopic cholecystectomy has several advantages over traditional cholecystectomy, which make it the treatment of choice for patients with uncomplicated biliary lithiasis. However, in patients with acute cholecystitis, the role of this technique remains controversial and some clinicians regard this condition as a contraindication to laparoscopic cholecystectomy. STUDY DESIGN: Between June, 1991 and July, 1993, a total of 259 patients with cholelithiasis underwent laparoscopic cholecystectomy at the "Virgen de la Arrixaca" University Hospital. Of these patients, 60 underwent laparoscopic cholecystectomy for acute cholecystitis. RESULTS: Conversion to laparotomy was necessary in eight patients (13 percent). Mean operating time was 83 minutes (range, 45 to 180 minutes). Overall mean hospital stay (laparoscopy and conversions) was 3.1 days (range, one to nine days). There was no mortality or injury to the common bile duct in our series. CONCLUSIONS: We believe that laparoscopic cholecystectomy in patients with acute cholecystitis is a safe and effective procedure, in which the patient can benefit from the advantages of laparoscopic surgery without an increase in mortality and morbidity rates.

Laparoscopic gastric bypass in the treatment of morbid obesity. Preliminary results of a new technique.

INTRODUCTION: Gastric bypass is one of the most commonly used surgical techniques for the management of morbid obesity. It is usually done as an open surgery procedure, and in recent years surgeons have begun to perform it via the laparoscopic approach. The aim of this paper is to describe our surgical technique for laparoscopic gastric bypass (LGBP) and present the short-term results. MATERIALS AND METHODS: Between January 2000 and January 2002 we operated on 50 patients with morbid obesity who met criteria for bariatric surgery. The patients had a mean age of 34 years and a body mass index (BMI) of 47. RESULTS: Conversion was necessary in 4 of the 50 patients (8%). Mean operating time was 181 min, with a difference of 60 min between the first 10 and last 10 cases. There was a 26% rate of complications, 14% of which were early (%<% 30 days) and 12% late (%>%30 days). Mean hospital stay was 4.5 days. CONCLUSION: LGBP is a technique with good short-term results as far as weight loss is concerned, although it has one of the most complex learning curves in laparoscopic surgery. Surgeons who regard gastric bypass as the technique of choice for the surgical management of morbid obesity should consider performing it via the laparoscopic approach.

Role of liver transplantation in the management of metastatic neuroendocrine tumors.

INTRODUCTION: In the majority of patients transplanted for unresectable liver metastases, long-term results are disappointing because of early tumor recurrence. Due to its biologically less aggressive nature, neuroendocrine metastases (NM) may represent a good indication for liver transplantation (LT). PATIENTS AND METHODS: Between January 1996 and May 2000, five patients with NM were transplanted. The primary tumors were located in the pancreas (n=4) and the small bowel (n=1). In three cases there were symptoms related to hormone production: two carcinoids, and one gastrinoma. The management of primary tumors was sequential in three patients with the tumor being resected before LT (one Whipple procedure and two left pancreatectomies). In two patients the resections of the primary tumors and the LT were simultaneous namely one bowel resection and one left pancreatectomy. All patients were treated with chemotherapy. RESULTS: Two patients developed recurrent disease succumbing at 15 months (nonfunctioning NE pancreatic head tumor) and 17 months (carcinoid of the pancreatic tail) post-LT. Another patient died at 3 months post-LT due to technical complications. The other two patients are alive and free of recurrence. CONCLUSION: Despite the promising results obtained with LT for NM, our experience indicates that patients must be carefully selected. Perhaps the use of more aggressive chemotherapeutic protocols combined with an individualized approach will improve the results.

Fulminant hepatic failure and liver transplantation: experience of Virgen de la Arrixaca Hospital.

INTRODUCTION: For patients with fulminant hepatic failure who show a poor evolution despite medical treatment, liver transplantation is an option, with survival rates of greater than 50%. The ideal time to perform the transplant is controversial, as it must not be done too soon (when the liver disease is still reversible) or too late (when the patient is in an irreversible clinical situation). PATIENTS AND METHODS: Retrospective review of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure included 26 who underwent transplantation. The most frequent cause was viral (n=10, 38%); with no etiology established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of AB0/DR compatibility, 13 cases were identical (40%), 17 compatible (51%), and the other three incompatible (9%). RESULTS: Thirty-three transplants were performed in 26 patients: four were retransplants due to chronic rejection, two for primary graft failure, and one for hyperacute rejection. The overall mortality rate was 46% (12 patients). The most frequent cause of death was infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years, and 59% at 5 years. The factors associated with a poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the last being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the last being the only prognostic factor identified in the multivariate analysis. CONCLUSION: Good results of transplantation for the management of fulminant hepatic failure depends on optimal selection of transplant candidates, which means identifying them early, reducing the waiting time, and excluding factors associated with a poor prognosis.

Eversion thromboendovenectomy for organized portal vein thrombosis encountered during liver transplantation.

INTRODUCTION: Due to the technical experience acquired in the field of liver transplantation portal vein thrombosis is no longer considered a contraindication for transplantation. Nevertheless, the results obtained in patients with portal vein thrombosis are at times suboptimal, and there is no consensus on the appropriate surgical technique. PATIENTS AND METHODS: Among the 455 liver transplants performed between May 1988 and December 2001, 32 (7%) presented with portal vein thrombosis. Twenty (62%) were type Ib, seven (22%) type II/III, and five (16%) type IV. Twenty-two were men (69%), with a mean age of 50 years (range: 30-70 years); the thrombosis in all cases developed in a cirrhotic liver. The surgical method in all cases consisted of an eversion thromboendovenectomy under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. RESULTS: Among the 32 cases undergoing thrombectomy, 31 (96%) were successful with a failure in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis rethrombosed. The 5-year survival rate of the patients in the series was 69%. Only two patients died from causes related to the thrombosis, both showing type IV thrombosis. CONCLUSION: The ideal treatment for portal thrombosis during liver transplantation depends on its extension and on the experience of the surgeon. In our experience, eversion thromboendovenectomy resolves most thromboses (types I, II, and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal hemitransposition.

Sexual dimorphism in clock genes expression in human adipose tissue.

BACKGROUND: This study was carried out to investigate whether sex-related differences exist in the adipocyte expression of clock genes from subcutaneous abdominal and visceral fat depots in severely obese patients. METHODS: We investigated 16 morbidly obese patients, eight men and eight women (mean age 45 ± 20 years; mean BMI 46 ± 6 kg/m(2)), undergoing laparoscopic gastric bypass surgery. Biopsies were taken as paired samples [subcutaneous and visceral adipose tissue (AT)] at the beginning of the surgical process at 11:00 h in the morning. Metabolic syndrome features such as waist circumference, plasma glucose, triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were also studied. The expression of clock genes (PER2, BMAL1, and CRY1) was measured by quantitative real-time PCR, Western blot, and immunohistochemical analysis. RESULTS: Gene expression was significantly higher in women than in men for the three genes studied in both ATs (P < 0.05). In visceral fat, these differences were more marked. (P < 0.001). Western blot analysis partially confirmed these results since statistical differences were observed for PER2 in both ATs and for CRY1 in subcutaneous adipose tissue. There were no differences in BMAL1 protein expression. Interestingly, clock gene expression level was correlated with LDL-C and HDL-C (P < 0.05). Moreover, we found significant associations with body fat mass in women and with age in men. CONCLUSIONS: Clock genes expression is sex dependent in human adipose tissue from morbidly obese subjects and correlates to a decreased in metabolic syndrome-related traits. These preliminary results make necessary to go deep into the knowledge of the molecular basis of the sexual dimorphism in chronobiology.

Site-specific circadian expression of leptin and its receptor in human adipose tissue.

INTRODUCTION: Circadian variability of circulating leptin levels has been well established over the last decade. However, the circadian behavior of leptin in human adipose tissue remains unknown. This also applies to the soluble leptin receptor. OBJECTIVE: We investigated the ex vivo circadian behavior of leptin and its receptor expression in human adipose tissue (AT). SUBJECTS AND METHODS: Visceral and subcutaneous abdominal AT biopsies (n = 6) were obtained from morbid obese women (BMI ≥ 40 kg/m²). Anthropometric variables and fasting plasma glucose, leptin, lipids and lipoprotein concentrations were determined. In order to investigate rhythmic expression pattern of leptin and its receptor, AT explants were cultured during 24-h and gene expression was analyzed at the following times: 08:00, 14:00, 20:00, 02:00 h, using quantitative real-time PCR. RESULTS: Leptin expression showed an oscillatory pattern that was consistent with circadian rhythm in cultured AT. Similar patterns were noted for the leptin receptor. Leptin showed its achrophase (maximum expression) during the night, which might be associated to a lower degree of fat accumulation and higher mobilization. When comparing both fat depots, visceral AT anticipated its expression towards afternoon and evening hours. Interestingly, leptin plasma values were associated with decreased amplitude of LEP rhythm. This association was lost when adjusting for waist circumference. CONCLUSION: Circadian rhythmicity has been demonstrated in leptin and its receptor in human AT cultures in a site-specific manner. This new knowledge paves the way for a better understanding of the autocrine/paracrine role of leptin in human AT.

Factors causing early relapse after lung metastasis surgery.

Haematogenous lung metastases are usually considered a sign of widespread metastatic disease. However, in most primary cancers, the first filter for distant tumours are the lungs. In some patients, the metastatic process may stop at the lungs. In these selected patients, there are studies that have shown the benefits of metastasectomy. The objective of this paper is to analyse the morbidity and mortality of lung metastasectomy and determine the factors that predispose to early relapse. Forty-two patients operated on for lung metastases, and four were excluded as they were assessed intraoperatively to be unresectable, leaving 38 patients to be analysed. The variables analysed were: age, sex, primary tumour, disease-free interval, number of metastases, bilaterality, morbidity and mortality, relapse, reinterventions, relapse-free interval after metastasectomy and survival. The surgical technique was a posterolateral thoracotomy, and there were no perioperative deaths. Morbidity was 11% (n = 4), and surgical reintervention of the haemothorax was necessary. Survival after 1, 2 or 3 years was 87%, 61% and 25% respectively, and the percentage of relapse-free patients was 71%, 56% and 17% respectively. The main factors associated with early relapse were histological type of tumour (more relapse in sarcoma, and less in adenocarcinoma), the disease-free interval between the primary tumour and lung metastases, and the number of metastases. Surgery was required a second time in five patients who had relapsed lung metastases, but extirpation could be performed in only four patients, of whom three were relapse free after 6, 12 and 24 months respectively, and the fourth had relapsed lung metastases after 18 months. Resection of lung metastases can be performed with low morbidity and mortality. The main prognostic factors for survival are complete surgery, histological type, disease-free interval between the primary tumour and metastases, and the number of lung metastases.