Gastroesophageal reflux after sleeve gastrectomy. Fact or fiction?

BACKGROUND: One of the most controversial issues surrounding laparoscopic sleeve gastrectomy is the development of gastroesophageal reflux disease following surgery. The aim of the study was to evaluate the occurrence of gastroesophageal reflux disease after laparoscopic sleeve gastrectomy and to analyze patients' weight loss, comorbidities, and quality of life after surgery. METHODS: The clinical records of 52 patients submitted to laparoscopic sleeve gastrectomy between January and November 2018, with 3 years of follow-up, were retrospectively reviewed. At the end of the follow-up period, the patients underwent screening endoscopy, and those with postoperative esophagitis were submitted to endoscopic biopsies and pH-impedance monitoring (MII-pH). The presence of gastroesophageal reflux disease symptoms was assessed using the modified clinical DeMesteer score questionnaire. The Bariatric Analysis and Reporting Outcome System score and 36-Item Short Form Health Survey were used to assess the postoperative quality of life. RESULTS: In the preoperative work-up, only 7.6% of patients had signs of esophagitis at esophagogastroduodenoscopy, whilst at 3-year follow-up, 50% of them had endoscopic signs of gastroesophageal reflux disease. Twenty-one out of 26 patients with signs of esophagitis agreed to undergo MII-pH. The median DeMesteer score questionnaire was 4.5, with only 4 patients (19%) exhibiting a value greater than the pH cut-off value (14.72), indicative of gastroesophageal reflux disease. MII-pH data analysis showed the presence of gastroesophageal reflux disease in 5 patients. An excellent outcome on the Bariatric Analysis and Reporting Outcome System score was reported in 50% of patients, and all 8 domains from the 36-Item Short Form Health Survey improved significantly. CONCLUSION: This study showed an improvement in these patients' quality of life and the limited refluxogenic nature of laparoscopic sleeve gastrectomy at 3-year follow-up when diagnosis of gastroesophageal reflux disease is based on the Lyon consensus.

Lessons from the COVID-19 pandemic: remote coaching in bariatric surgery.

BACKGROUND: The development of fast internet connection has stimulated different types of video-assisted teaching programs. However, a remote mentoring with the proctor not on site has never been reported in bariatric surgery. We described our experiences with remote telementoring for laparoscopic sleeve gastrectomy. METHODS: A qualified general surgeon at the beginning of his bariatric practice performed a series of 8 laparoscopic sleeve gastrectomies (LSG) while tutored by an experienced bariatric surgeon connected from a different city through a specific videoconferencing platform. Data on demographics at baseline, operative time, hospital stay, intraoperative early, and late complications were collected. RESULTS: Mean age and BMI of patients were 36.9 ± 9.6 years old and 41.8 ± 1.7 kg/m2. All procedures were carried out without conversion to open or complications. Mean operative time was 112.4 ± 21.9 min while the hospital stay was 3.5 ± 0.5 days. Operative time significantly decreased after the fourth operation. CONCLUSIONS: Remote coaching appears to be possible and safe for LSG.

Harnessing the Potential of Enzymes as Inhaled Therapeutics in Respiratory Tract Diseases: A Review of the Literature.

Respiratory tract diseases (RTDs) are a global cause of mortality and affect patient well-being and quality of life. Specifically, there is a high unmet need concerning respiratory tract infections (RTIs) due to limitations of vaccines and increased antibiotic resistance. Enzyme therapeutics, and in particular plant-based enzymes, represent an underutilised resource in drug development warranting further attention. This literature review aims to summarise the current state of enzyme therapeutics in medical applications, with a focus on their potential to improve outcomes in RTDs, including RTIs. We used a narrative review approach, searching PubMed and clinicaltrials.gov with search terms including: enzyme therapeutics, enzyme therapy, inhaled therapeutics, botanical enzyme therapeutics, plant enzymes, and herbal extracts. Here, we discuss the advantages and challenges of enzyme therapeutics in the setting of RTDs and identify and describe several enzyme therapeutics currently used in the respiratory field. In addition, the review includes recent developments concerning enzyme therapies and plant enzymes in (pre-)clinical stages. The global coronavirus disease 2019 (COVID-19) pandemic has sparked development of several promising new enzyme therapeutics for use in the respiratory setting, and therefore, it is timely to provide a summary of recent developments, particularly as these therapeutics may also prove beneficial in other RTDs.

Histopathologic findings on removed stomach after sleeve gastrectomy. Do they influence the outcome?

Little is known about the role of chronic gastritis on weight loss after laparoscopic sleeve gastrectomy (LSG). This study aims to investigate the relationship between histopathologic findings of gastric specimens, excess weight loss (% EWL), and excess BMI loss (% EBL) at 6 and 12 months follow up after LSG. We retrospectively reviewed the clinical records of 95 patients who had undergone LSG between January 2017 and December 2019. Based on the histopathological findings of gastric resection specimens, patients were divided into those with chronic gastritis (CG) and those without chronic gastritis (NoCG) and compared for their % EWL and % EBL at 6 and 12 months. The mean BMI was 44.74 kg/m2 in the CG group and 44.14 kg/m2 in the NoCG group. At 6 months follow up, the CG group had a mean % EWL of 45.7 and % EBL of 40.5, while NoCG had a mean % EWL of 51.1 and % EBL of 46.7. After 1-year follow-up, the CG group had a mean % EWL of 53.1 and a % EBL of 44.8, while the NoCG group had a % EWL of 54.1 and % EBL of 44. This observational study does not support the hypothesis that the occurrence of chronic gastritis can affect postoperative % EWL and % EBL.

Staple line reinforcement with nebulized cyanoacrylate glue in laparoscopic sleeve gastrectomy: A propensity score-matched study.

BACKGROUND: A dreaded complication of laparoscopic sleeve gastrectomy (LSG) is suture leak. The study aimed to assess the efficacy of the nebulized comonomer Glubran 2® (N-butyl-cyanoacrylate + metacrylosysolfolane) applied to the LSG staple line. METHODS: A propensity-matched comparison analysis was conducted in 125 patients undergoing LSG between 2017 and 2019. Groups included those treated with Glubran® (group 1, n = 70) and those without Glubran® treatment (group 2, n = 55). RESULTS: There were differences in the mean body mass index (44.4 vs 43 kg/m2; P < 0.05) between the groups. There was a non-significant increase in the operative time for group 1 compared with group 2 (97 ± 8 vs 93.8 ± 10.7 min; P = 0.07), with a greater amount of estimated blood loss (94.5 mL vs 87.8; P < 0.01). There were more severe complications in group 2 over group 1 cases (8 vs 0%; P < 0.05), although postoperative bleeding did not differ between the two groups (1.4 vs 5.4%). There were no postoperative leaks in group 1 patients, but there were two leaks in group 2 cases with an increased length of hospital stay in patients with a leak. CONCLUSION: Glubran® LSG support may reduce leak risk without increasing operating time.

Emerging Roles of Repetitive and Repeat-Containing RNA in Nuclear and Chromatin Organization and Gene Expression.

Genomic repeats have been intensely studied as regulatory elements controlling gene transcription, splicing and genome architecture. Our understanding of the role of the repetitive RNA such as the RNA coming from genomic repeats, or repetitive sequences embedded in mRNA/lncRNAs, in nuclear and cellular functions is instead still limited. In this review we discuss evidence supporting the multifaceted roles of repetitive RNA and RNA binding proteins in nuclear organization, gene regulation, and in the formation of dynamic membrane-less aggregates. We hope that our review will further stimulate research in the consolidating field of repetitive RNA biology.

Safety and Effectiveness of Tailored Hemorrhoidectomy in Outpatients Setting.

Introduction: Single or double prolapsed pile instead of full muco-hemorrhoidal prolapse is a common finding in patients with symptomatic III or IV degree hemorrhoids. For this selected group of patients, relief of symptoms could be achieved by managing the single/double prolapsed piles instead of performing traditional hemorrhoidectomy. The aim of this single-center study was to evaluate the safety and medium- and long-term effectiveness of an outpatient tailored Milligan-Morgan hemorrhoidectomy (MMH) performed under local anesthesia (LA). Material and methods: Clinical records of 202 patients submitted to outpatient tailored MMH, under LA and without anal dilation, treated between 2013 and 2020, were retrospectively reviewed using a prospectively maintained database and completed by a telephone interview or outpatient consultation. Postoperative pain score, the need for painkillers, postoperative complications and symptoms recurrence, return to working activities, and patient grading assessment scale were recorded. Results: Thirty-five (17%) out of 202 patients recruited were lost to the follow-up. One hundred and fifty-two and 15 patients underwent a single and double pile hemorrhoidectomy, respectively. With regard to postoperative outcomes, visual analogue scale (VAS) decreased from a median value of 4 [interquartile range (IQR) 2-6] on the day of surgery to 1 (IQR 0-4) on the 10th postoperative day (p < 0.001). Sixty-one patients (37%) needed oral painkillers during the 1st week after surgery. There was no mortality or major postoperative complication. Bleeding requiring hospital readmission was reported in seven (4%) patients, and one patient underwent emergency surgery with no need for blood transfusion. No postoperative urinary retention, anal incontinence, or stricture occurred in the series. During the median follow-up of 39 (IQR 12-60) months, 26 patients (16%) reported symptoms of recurrence but only six underwent traditional MMH. Recovery to normal activity occurred within a median period of 6 days (IQR 3-10) and the Clinical Patient Grading Assessment Scale (CPGAS) at 1 year after surgery was reported to be a "good deal better." Conclusions: Tailored MMH performed under LA in an ambulatory setting can be considered a safe and effective technique with high compliance and satisfaction of patients.

Chd8 regulates X chromosome inactivation in mouse through fine-tuning control of Xist expression.

Female mammals achieve dosage compensation by inactivating one of their two X chromosomes during development, a process entirely dependent on Xist, an X-linked long non-coding RNA (lncRNA). At the onset of X chromosome inactivation (XCI), Xist is up-regulated and spreads along the future inactive X chromosome. Contextually, it recruits repressive histone and DNA modifiers that transcriptionally silence the X chromosome. Xist regulation is tightly coupled to differentiation and its expression is under the control of both pluripotency and epigenetic factors. Recent evidence has suggested that chromatin remodelers accumulate at the X Inactivation Center (XIC) and here we demonstrate a new role for Chd8 in Xist regulation in differentiating ES cells, linked to its control and prevention of spurious transcription factor interactions occurring within Xist regulatory regions. Our findings have a broader relevance, in the context of complex, developmentally-regulated gene expression.

Fluorimetric ex vivo quantification of protease debriding efficacy on natural substrate.

Debridement is the process of removal of necrotic and infected tissue to clean a wound or burn and expedite healing. Proteases such as papain, bromelain, and collagenase that promote debridement by degrading proteins in the dead tissue are in use today. However, the only method to measure debriding efficacy in vitro is the fluorescent monitoring of the digestion of an Artificial Wound Eschar (AWE) substrate. This AWE substrate contains a pellet of only three eschar matrix proteins collagen, elastin, and fibrin which do not account for the complexity and the composition of necrotic tissue. Here, we describe an ex vivo method using dry necrotic full thickness human skin and ortho-phthalaldehyde (OPA), a molecule commonly used for sensitive fluorimetric protein detection to monitor debridement activity. We advocate this simple yet sensitive approach to detect debridement efficacy that can readily be used commercially to benchmark products prior to in vivo testing.

Pneumatosis Intestinalis and Hepatic Portal Venous Gas: Watch and Wait or Emergency Surgery? A Case Report and Literature Review.

BACKGROUND Hepatic portal venous gas (HPVG) associated with pneumatosis intestinalis (PI) can be indicative of several diseases, including inflammatory bowel disease (IBD), infective and obstructive gastrointestinal conditions, and also potentially life-threatening situations such as mesenteric ischemia. CASE REPORT A 60-year-old female patient came to our attention with evidence at computed tomography (CT) scan of gas in the portal vein and bowel walls with no sign of ischemia. General tenderness of the abdomen with absence of bowel sounds was detected at the physical examination. An exploratory laparotomy was performed with evidence of mesenteric ischemia. CONCLUSIONS Emergency surgery should be indicated when CT signs of PI and HPVG occur along with a clinical situation strongly suggestive of bowel ischemia, even with no radiological sign of this critical condition.

Efficacy of cyanoacrylate in the prevention of delayed bleeding after endoscopic mucosal resection of large colorectal polyps: a pilot study.

BACKGROUND: Postoperative bleeding is a common complication after endoscopic polypectomy, particularly after endoscopic mucosal resection (EMR) of large non-pedunculated polyps, despite prophylactic clipping can reduce its occurrence. Cyanoacrylate glue has recently been proposed as a useful tool in reducing bleeding in surgery because of its adhesive and haemostatic properties. The aim of this study is to evaluate the usefulness of endoscopic application of a modified cyanoacrylate glue in the prevention of early or delayed post EMR bleeding. METHODS: This is a pilot study. Inclusion criteria were patients between 18 and 75 years old affected by sessile or flat colonic polyps larger than 2 cm. Patients enrolled in the study were randomized in two groups: group A (EMR) and group B (EMR with the application of 0.3 ml of N-butyl-2-cyanoacrylate + methacryloxysulfolane-Glubran 2®). RESULTS: Fifteen patients in both group A and B were enrolled. There were no intraoperative complications but haemostatic clipping was necessary in 3 patients in each group because of active bleeding. Delayed (after 24 h) bleeding occurred in two patients (13.3%) in group A requiring hospital readmission and re-do endoscopy with apposition of haemostatic clips. No case of bleeding was recorded in group B (p = 0.48). CONCLUSION: The results of this pilot study suggest a potential role of local spray application of Glubran®2 in reducing post-procedural bleeding.

An alternative modular 'click-SNAr-click' approach to develop subcellular localised fluorescent probes to image mobile Zn2+ .

Zn2+ is involved in a number of biological processes and its wide-ranging roles at the subcellular level, especially in specific organelles, have not yet been fully established due to a lack of tools to image it effectively. We report a new and efficient modular double 'click' approach towards a range of sub-cellular localised probes for mobile zinc. Through this methodology, endoplasmic reticulum, mitochondria and lysosome localised probes were successfully prepared which show good fluorescence responses to mobile Zn2+in vitro and in cellulo whilst a non-targeting probe was synthesized as a control. The methodology appears to have wide-utility for the generation of sub-cellular localised probes by incorporating specific organelle targeting vectors for mobile Zn2+ imaging.

Endoplasmic reticulum targeting fluorescent probes to image mobile Zn2.

Zn2+ plays an important role in the normal function of the endoplasmic reticulum (ER) and its deficiency can cause ER stress, which is related to a wide range of diseases. In order to provide tools to better understand the role of mobile Zn2+ in ER processes, the first custom designed ER-localised fluorescent Zn2+ probes have been developed through the introduction of a cyclohexyl sulfonylurea as an ER-targeting unit with different Zn2+ receptors. Experiments in vitro and in cellulo show that both probes have a good fluorescence switch on response to Zn2+, high selectivity over other cations, low toxicity, ER-specific targeting ability and are efficacious imaging agents for mobile Zn2+ in four different cell lines. Probe 9 has been used to detect mobile Zn2+ changes under ER stress induced by both tunicamycin or thapsigargin, which indicates that the new probes should allow a better understanding of the mechanisms cells use to respond to dysfunction of zinc homeostasis in the ER and its role in the initiation and progression of diseases to be developed.

Biotin-tagged fluorescent sensor to visualize 'mobile' Zn2+ in cancer cells.

A cancer cell-targeting fluorescent sensor has been developed to image mobile Zn2+ by introducing a biotin group. It shows a highly selective response to Zn2+in vitro, no toxicity in cellulo and images 'mobile' Zn2+ specifically in cancer cells. We believe this probe has the potential to help improve our understanding of the role of Zn2+ in the processes of cancer initiation and development.

Tetra-2,3-pyrazinoporphyrazines with externally appended pyridine rings. 17. Photosensitizing properties and cellular effects of ZnII octacationic and ZnII/PtII hexacationic macrocycles in aqueous media: Perspectives of multimodal anticancer potentialities.

The photosensitizing activity of two multiply charged porphyrazine derivatives, i.e. the ZnII species [(CH3)8LZn]8+ and the ZnII/PtII heterobimetallic complex [(PtCl2)(CH3)6LZn]6+ (neutralized byI- ions; L=tetrakis-2,3-[5,6-di(2-pyridyl)pyrazino]porphyrazinato dianion) has been examined in the water medium in the presence of SDS under experimental conditions in which the two species are present exclusively in their monomeric form. The determined quantum yield values (ΦΔ) for both complexes, of interest in photodynamic therapy (PDT), are 2.3-2.5 higher than that of the aluminium compound PcAlSmix (Photosens®) used as the reference standard, an encouraging result for the application of the two cationic species as anticancer curative drugs in PDT. Investigation was also extended to explore the cellular effects on the melanoma C8161 and the oral squamous carcinoma CA-1 cell lines like viability, cellular uptake, cell death modality and cell cycle distribution experiments. The IC50 values for the ZnII and ZnII/PtII cations are consistently lower than those of the reference standard, thus the degree of efficiency as anticancer agents being in the order octacation≫hexacation>PcAlSmix. A large prevalence of apoptosis with respect to necrosis is observed for both charged complexes. Thus, all achieved information from photoactivity and in vitro tests in water solution further enhance perspectives for the application of the two ZnII cation [(CH3)8LZn]8+ and the related ZnII/PtII analog [(PtCl2)(CH3)6LZn]6+ as potential bi-multimodal anticancer drugs.

GLI2 Is a Regulator of ß-Catenin and Is Associated with Loss of E-Cadherin, Cell Invasiveness, and Long-Term Epidermal Regeneration.

Uncontrolled hedgehog (HH)/glioma-associated oncogene (GLI) and WNT/ß-catenin signaling are important events in the genesis of many cancers including skin cancer and are often implicated in tumor progression, invasion, and metastasis. However, because of the complexity and context dependency of both pathways, little is known about HH and WNT interactions in human carcinogenesis. In the current study, we provide evidence of HH/glioma-associated oncogene family zinc finger 2 (GLI2)-WNT/ß-catenin signaling crosstalk in human keratinocytes. Overexpression of GLI2ΔN in human keratinocytes resulted in cytoplasmic accumulation and nuclear relocalization of ß-catenin in vitro and in 3D organotypic cultures, accompanied by upregulation of WNT genes. Induction of GLI2ΔN enhanced the ß-catenin-dependent transcriptional activation and the subsequent activation of ß-catenin target genes including cyclin-D1. Additionally, GLI2 overexpression was associated with decreased E-cadherin protein levels; increased expression of SNAIL, matrix metalloproteinase 2, and integrin ß1; and increased cell invasion in 3D organotypic cultures. Invasion was reduced by WNT inhibition, thus unveiling the direct role of GLI2/WNT crosstalk in cell invasion. We show that GLI2 overexpression supported long-term epidermal regeneration in 3D organotypic cultures, and resulted in the manifestation of an undifferentiated basal/stem cell-associated phenotype in human keratinocytes. Both these observations are consistent with the role of ß-catenin and SNAIL in epidermal stem cell maintenance. This work suggests that GLI2 is a regulator of ß-catenin and provides insights into its role in tumorigenesis.

Retaining in-gel zymographic activity of cysteine proteases via a cysteine-supplemented running buffer.

Zymography is a powerful technique to separate and identify different enzymatic activities on a standard acrylamide gel. For oxidation prone enzymes such as cysteine proteases however, the oxidizing species generated by electrolysis of the gel running buffer may result in partial or complete inactivation, thus compromising the final readout. This can be only partially remedied by subsequent treatment of the gel with reducing agents. We demonstrate the generation of reactive oxidizing species during electrophoresis and discovered that supplementation of the gel running buffer with a minimum of 5 mM cysteine prevents enzyme inactivation and allows retention of proteolytic activity as measured by zymography on model substrate N α-benzoyl-l-arginine p-nitroanilide, without at the same time altering the mobilities of the gel proteins.

Topical 4-thiothymidine is a viable photosensitiser for the photodynamic therapy of skin malignancies.

The nucleoside analogue 4-thiothymidine has shown great potential in vitro as a photosensitiser for the photodynamic therapy of numerous cancer cell lines. However, the limited penetrating power of UV-A radiation, to which it responds, raises doubts as to its practical usefulness in clinical applications. We addressed this issue by studying the penetration extent of topical thiothymidine and the antiproliferative effect of its combination with UV-A radiation on ex vivo basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) skin cancer biopsies, and normal skin. Our results show that both the intralesional concentration of the drug and the intensity of UV-A radiation are sufficient to activate the molecule and cause extensive death by apoptosis of the malignant cells. Normal skin biopsies were not significantly affected by the treatment.

The insulin-like growth factor-I-mTOR signaling pathway induces the mitochondrial pyrimidine nucleotide carrier to promote cell growth.

The insulin/insulin-like growth factor (IGF) signaling pathway to mTOR is essential for the survival and growth of normal cells and also contributes to the genesis and progression of cancer. This signaling pathway is linked with regulation of mitochondrial function, but how is incompletely understood. Here we show that IGF-I and insulin induce rapid transcription of the mitochondrial pyrimidine nucleotide carrier PNC1, which shares significant identity with the essential yeast mitochondrial carrier Rim2p. PNC1 expression is dependent on PI-3 kinase and mTOR activity and is higher in transformed fibroblasts, cancer cell lines, and primary prostate cancers than in normal tissues. Overexpression of PNC1 enhances cell size, whereas suppression of PNC1 expression causes reduced cell size and retarded cell cycle progression and proliferation. Cells with reduced PNC1 expression have reduced mitochondrial UTP levels, but while mitochondrial membrane potential and cellular ATP are not altered, cellular ROS levels are increased. Overall the data indicate that PNC1 is a target of the IGF-I/mTOR pathway that is essential for mitochondrial activity in regulating cell growth and proliferation.

ASPP [corrected] and cancer.

One of the most frequently mutated genes in human cancers, tumour suppressor p53 (TP53), can induce cell-cycle arrest and apoptosis. The apoptotic function of p53 is tightly linked to its tumour-suppression function and the efficacy of many cancer therapies depends on this. The identification of a new family of proteins, known as ASPPs (ankyrin-repeat-, SH3-domain- and proline-rich-region-containing proteins), has led to the discovery of a novel mechanism that selectively regulates the apoptotic function, but not the cell-cycle-arrest function, of p53, and gives an insight into how p53 responds to different stress signals. ASPPs might be new molecular targets for cancer therapy.