Genome-wide identification of core components of ABA signaling and transcriptome analysis reveals gene circuits involved in castor bean (Ricinus communis L.) response to drought.

Castor bean (Ricinus communis L.) can withstand long periods of water deficit and high temperatures, and therefore has been recognized as a drought-resistant plant species, allowing the study of gene networks involved in drought response and tolerance. The identification of genes networks related to drought response in this plant may yield important information in the characterization of molecular mechanisms correlating changes in the gene expression with the physiological adaptation processes. In this context, gene families related to abscisic acid (ABA) signaling play a crucial role in developmental and environmental adaptation processes of plants to drought stress. However, the families that function as the core components of ABA signaling, as well as genes networks related to drought response, are not well understood in castor bean. In this study 7 RcPYL, 63 RcPP2C, and 6 RcSnRK2 genes were identified in castor bean genome, which was further supported by chromosomal distribution, gene structure, evolutionary relationships, and conserved motif analyses. The castor bean general expression profile was investigated by RNAseq in root and leaf tissues in response to drought stress. These analyses allowed the identification of genes differentially expressed, including genes from the ABA signaling core, genes related to photosynthesis, cell wall, energy transduction, antioxidant response, and transcription factors. These analyses provide new insights into the core components of ABA signaling in castor bean, allow the identification of several molecular responses associated with the high physiological adaptation of castor bean to drought stress, and contribute to the identification of candidate genes for genetic improvement.

Alterations in the root phenylpropanoid pathway and root-shoot vessel system as main determinants of the drought tolerance of a soybean genotype.

Climate change increases precipitation variability, particularly in savanna environments. We have used integrative strategies to understand the molecular mechanisms of drought tolerance, which will be crucial for developing improved genotypes. The current study compares the molecular and physiological parameters between the drought-tolerant Embrapa 48 and the sensitive BR16 genotypes. We integrated the root-shoot system's transcriptome, proteome, and metabolome to understand drought tolerance. The results indicated that Embrapa 48 had a greater capacity for water absorption due to alterations in length and volume. Drought tolerance appears to be ABA-independent, and IAA levels in the leaves partially explain the higher root growth. Proteomic profiles revealed up-regulated proteins involved in glutamine biosynthesis and proteolysis, suggesting osmoprotection and explaining the larger root volume. Dysregulated proteins in the roots belong to the phenylpropanoid pathways. Additionally, PR-like proteins involved in the biosynthesis of phenolics may act to prevent oxidative stress and as a substrate for modifying cell walls. Thus, we concluded that alterations in the root-shoot conductive vessel system are critical in promoting drought tolerance. Moreover, photosynthetic parameters from reciprocal grafting experiments indicated that the root system is more essential than the shoots in the drought tolerance mechanism. Finally, we provided a comprehensive overview of the genetic, molecular, and physiological traits involved in drought tolerance mechanisms. Supplementary Information: The online version contains supplementary material available at 10.1007/s12298-023-01307-7.

Prospective study: Impact of breast magnetic resonance imaging on oncoplastic surgery and on indications of mastectomy in patients who were previously candidates to breast conserving surgery.

Background: Routine use of magnetic resonance imaging (MRI) in the staging of patients with early breast cancer is still controversial. Oncoplastic surgery (OP) allows for wider resections without compromising the aesthetic results. This study aimed to assess the impact of preoperative MRI on surgical planning and on indications of mastectomy. Methods: Prospective study including T1-T2 breast cancer patients treated between January 2019 and December 2020 in the Breast Unit of the Hospital Nossa Senhora das Graças in Curitiba, Brazil. All patients had indication for breast conserving surgery (BCS) with OP and did a breast MRI after conventional imaging. Results: 131 patients were selected. Indication for BCS was based on clinical examination and conventional imaging (mammography and ultrasound) findings. After undergoing breast MRI, 110 patients (84.0%) underwent BCS with OP and 21 (16.0%) had their surgical procedure changed to mastectomy. Breast MRI revealed additional findings in 52 of 131 patients (38%). Of these additional findings, 47 (90.4%) were confirmed as invasive carcinoma. Of the 21 patients who underwent mastectomies, the mean tumor size was 2.9 cm (± 1,7cm), with all having additional findings on breast MRI (100% of the mastectomies group vs 28.2% of the OP, p<0.01). Of the 110 patients submitted to OP, the mean tumor size was 1,6cm (± 0,8cm), with only 6 (5.4%) presenting positive margins at the final pathology assessment. Conclusion: Preoperative breast MRI has an impact on the OP scenario, bringing additional information that may help surgical planning. It allowed selecting the group with additional tumor foci or greater extension to convert to mastectomy, with a consequent low reoperation rate of 5.4% in the BCS group. This is the first study to assess the impact of breast MRI in the preoperative planning of patients undergoing OP for the treatment of breast cancer.

Endoscopic lumbar sympathectomy as a treatment option for primary erythromelalgia - case report and review.

Erythromelalgia is a rare disease, involving pain, edema, redness, and hyperthermia in the limbs. It is extremely refractory to drugs, has no defined treatment, and causes psychological comorbidities in the patient. We describe a case of erythromelalgia involving a 17-year-old boy who had been suffering from the disease for almost 4 years prior to finding an effective treatment. A bilateral endoscopic lumbar sympathectomy was performed, limited to L2 and L3 resections. Four weeks after the procedure, the patient's symptoms were significantly mitigated and at 8 months follow-up he remained almost asymptomatic. Endoscopic lumbar sympathectomy was an effective treatment for primary erythromelalgia in this teenager, with exceptional reduction of his symptoms.

Eritromelalgia é uma doença rara caracterizada por dor, edema, eritema e hipertermia nos membros. É extremamente refratária a medicamentos e não tem um tratamento definido, causando comorbidades psicológicas para o paciente. Descrevemos o caso de um menino de 17 anos que possuía eritromelalgia há quase 4 anos antes de ser submetido a um tratamento efetivo. Foi realizada simpatectomia lombar endoscópica bilateral limitada à ressecção dos gânglios L2 e L3. Após 4 semanas do procedimento, o paciente teve diminuição significativa dos seus sintomas e, com 8 meses de seguimento, permanece praticamente assintomático. A simpatectomia lombar endoscópica foi um tratamento eficaz para eritromelalgia primária em um adolescente, com redução excepcional dos seus sintomas.

Fiber-Optic Intracranial Pressure Monitoring System Using Wi-Fi-An In Vivo Study.

BACKGROUND: Continuous invasive monitoring of intracranial pressure (ICP) is essential in neurocritical care for surveillance and management of raised ICP. Fluid-based systems and strain gauge microsensors remain the current standard. In the past few decades, several studies with wireless monitoring were developed aiming to reduce invasiveness and complications. OBJECTIVE: To describe a novel Wi-Fi fiber-optic device for continuous ICP monitoring using smartphone in a swine model. METHODS: Two ICP sensors (wireless prototype and wire-based reference) were implanted in the cerebral parenchyma of a swine model for a total of 120 minutes of continuous monitoring. Every 5 minutes, jugular veins compression was performed to evaluate ICP changes. The experimentation was divided in 3 phases for comparison and analysis. RESULTS: Phase 1 showed agreement in ICP changes for both sensors during jugular compression and releasing, with a positive and strong Spearman correlation (r = 0.829, P < .001). Phase 2 started after inversion of the sensors in the burr holes; there was a positive and moderately weak Spearman correlation (r = 0.262, P < .001). For phase 3, the sensors were returned to the first burr holes; the prototype behaved similarly to the reference sensor, presenting a positive and moderately strong Spearman correlation (r = 0.669, P < .001). CONCLUSION: A Wi-Fi ICP monitoring system was demonstrated in a comprehensive and feasible way. It was possible to observe, using smartphone, an adequate correlation regarding ICP variations. Further adaptations are already being developed.

Endoscopic lumbar sympathectomy as a treatment option for primary erythromelalgia - case report and review / Simpatectomia lombar endoscópica como escolha de tratamento para eritromelalgia primária - relato de caso e revisão

Abstract Erythromelalgia is a rare disease, involving pain, edema, redness, and hyperthermia in the limbs. It is extremely refractory to drugs, has no defined treatment, and causes psychological comorbidities in the patient. We describe a case of erythromelalgia involving a 17-year-old boy who had been suffering from the disease for almost 4 years prior to finding an effective treatment. A bilateral endoscopic lumbar sympathectomy was performed, limited to L2 and L3 resections. Four weeks after the procedure, the patient's symptoms were significantly mitigated and at 8 months follow-up he remained almost asymptomatic. Endoscopic lumbar sympathectomy was an effective treatment for primary erythromelalgia in this teenager, with exceptional reduction of his symptoms.

Resumo Eritromelalgia é uma doença rara caracterizada por dor, edema, eritema e hipertermia nos membros. É extremamente refratária a medicamentos e não tem um tratamento definido, causando comorbidades psicológicas para o paciente. Descrevemos o caso de um menino de 17 anos que possuía eritromelalgia há quase 4 anos antes de ser submetido a um tratamento efetivo. Foi realizada simpatectomia lombar endoscópica bilateral limitada à ressecção dos gânglios L2 e L3. Após 4 semanas do procedimento, o paciente teve diminuição significativa dos seus sintomas e, com 8 meses de seguimento, permanece praticamente assintomático. A simpatectomia lombar endoscópica foi um tratamento eficaz para eritromelalgia primária em um adolescente, com redução excepcional dos seus sintomas.

Clinical trial and detection of SARS-CoV-2 by a commercial breath analysis test based on Terahertz technology.

Public health threats such as the current COVID-19 pandemics have required prompt action by the local, national, and international authorities. Rapid and noninvasive diagnostic methods may provide on-site detection and immediate social isolation, used as tools to rapidly control virus spreading. Accordingly, the aim of the present study was to evaluate a commercial breath analysis test (TERA.Bio®) and deterministic algorithm for detecting the SARS-CoV-2 spectral signature of Volatile Organic Compounds present in exhaled air samples of suspicious persons from southern Brazil. A casuistic total of 70 infected and 500 non-infected patients were sampled, tested, and results later compared to RT-qPCR as gold standard. Overall, the test showed 92.6% sensitivity and 96.0% specificity. No statistical correlation was observed between SARS-CoV-2 positivity and infection by other respiratory diseases. Further studies should focus on infection monitoring among asymptomatic persons. In conclusion, the breath analysis test herein may be used as a fast, on-site, and easy-to-apply screening method for diagnosing COVID-19.

Peri-operative Morbidity of Nissen Sleeve Gastrectomy: Prospective Evaluation of a Cohort of 365 Patients, Beyond the Learning Curve.

PURPOSE: Over the last decade, an important interest was taken to prevent the reflux following sleeve. A new variant, Nissen-sleeve, was described with the purpose to prevent GERD and to decrease the occurrence of leak. The current study reports the preliminary results of a prospective trial. MATERIALS AND METHODS: All consecutive patients who underwent a Nissen-Sleeve between January 2018 and September 2020 were included. Baseline characteristics including age, gender, weight, body mass index (BMI), GERD symptoms, and treatment were evaluated after 1 year. Operative time, length of stay, complication, and reoperation data were also collected. RESULTS: Three hundred sixty-five consecutive patients decided to undergo Nissen-sleeve: 75% females with median age of 41.2 years (+ / - 14.1) and an average BMI of 41.6 kg/m2 (+ / - 5.4). There were 16 cases (4.4%) of early postoperative complications (< 30 days): six cases of acute wrap perforation (1.6%), intraabdominal bleeding for 5 patients (1.4%), one case of wrap dilatation (0.3%), one case of acute complete aphagia, one case of incarcerated umbilical hernia, and 2 cases (0.5%) of pulmonary atelectasis/pneumonia and one venous pulmonary embolism. We recorded the following complications: 16 patients (4.4%) mild dysphagia; 3 patients (0.8%) chronic dysphagia; and 2 cases of wrap perforation that have been diagnosed 8 and 9 months respectively, after the procedure due to the use of steroids not associated with PPI intake. The mean operative time was 83 min (46-125 min). The conversion and mortality rates were nil. CONCLUSION: Following the initial learning curve and additional technical modifications, the Nissen-Sleeve appears to be a safe surgical technique with an acceptable early postoperative complication rate. CLINICAL TRIAL REGISTRATION: NCT02310178.

Using Cranial Sutures in a Single-Step Frame-Guided Resection and Reconstruction for Intraosseous Meningiomas: Technical Note.

BACKGROUND: Single-stage surgical treatment of cranial intraosseous meningiomas includes complete tumor resection followed by aesthetic reconstruction. Tailored tumor resection with a computer-aided design/computer-aided manufacturing custom-made implant for the defect has been advocated in recent years to achieve a satisfactory cosmetic result with reduced operative time and fewer complications. However, several technical nuances related to the area of osseous removal may compromise cranioplasty. METHODS: We present 2 cases of intraosseous meningiomas (sphenoid wing and retromastoid) to illustrate a step-by-step approach, from preoperative planning to single-step surgery. RESULTS: For each case, a customized frame template delimiting bone removal was designed using cranial sutures as anatomical landmarks for precise placement of the cranioplasty template over the area of interest. CONCLUSIONS: Custom templates based in cranial sutures may benefit single-step frame-guided resection and reconstruction of intraosseous tumors with compelling results.

Cranioplasty with three-dimensional customised mould for polymethylmethacrylate implant: a series of 16 consecutive patients with cost-effectiveness consideration.

BACKGROUND: Different methods of cranioplasty for the reconstruction of bony skull defects exist. In the absence of the autologous bone flap, a customised manufactured implant may be the optimal choice, but this implant has several limitations regarding its technical standardisation and better cost-effectiveness. METHODS: This study presents a series of 16 consecutive patients who had undergone cranioplasty with customised three-dimensional (3D) template moulds for polymethylmethacrylate (PMMA) implants manufactured after 3D modelling on a specific workstation. The virtual images were transformed into a two-piece physical model using a 3D printer for the biomaterials. PMMA implant was produced intraoperatively with the custom mould. Cosmetic results were analysed by comparing pre- and postoperative 3D computed tomography (CT) images and asking if the patient was satisfied with the result. RESULTS: The average total time for planning and production of customised mould was 10 days. The 16 patients were satisfied with the result, and CT images presented harmonious symmetry when comparing pre- and postoperative scans. Cases of postoperative infection, bleeding, or reoperation in this series were not observed. CONCLUSION: Cranioplasty with high-technology customised 3D moulds for PMMA implants can allow for an aesthetic reconstruction with a fast and cost-effective manufacturing process and possibly with low complication rates.

Revised Sleeve Gastrectomy: Our Experience.

Introduction: Laparoscopic sleeve gastrectomy (LSG) has rapidly become increasingly popular in bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe acid reflux after primary LSG can necessitate further interventions. The purpose of this study was to evaluate our initial case series regarding the complications and short-term weight loss results of the ReSleeve Gastrectomy (ReSG). Methods: From January 2010 to February 2016, all patients who underwent ReSG were included in this study. From a retrospective database, the demographic data, surgical history, comorbidities, American Society of Anaesthesiologists (ASA) score, time interval between the two procedures, and intra- and postoperative parameters and outcomes were analyzed. Results: ReSG was performed for 25 patients (7 men) with a mean age of 49 years (±11). Indications for ReSG were weight loss insufficiency for 1 patient (4%), weight regain for 23 patients (92%), and an acute dysphagia due to a residual fundic pouch for 1 patient (4%). Mean reoperation time before ReSG was 2.9 years (±1.5). The mean body mass index (BMI) for ReSG was 43.9 kg/m2 (±9.4). The first 4 patients (16%) had a barium swallow and the next 21 (84%) patients a computed tomography scan volumetry with a mean gastric volume of 526.7 cc (±168). All procedures were completed by laparoscopy with no intraoperative complication. An additional procedure was carried out for 3 patients (12%), including 1 cholecystectomy and 2 hiatal hernia repairs. Mean length of hospital stay was 5.2 days (±4.2), with no postoperative death. The complication rate was 60% (n = 15) including a Dindo-Clavien grade 2 complication for 7 patients (28%) and grade 3 for 8 patients (32%). One patient was lost to follow-up (4%). The mean BMI before RSG was 43.9 kg/m2 (±9.4). At a mean follow-up after ReSG of 37.3 months (range 6-80), the mean BMI and percentage of excess weight loss were, respectively, 35 kg/m2 (±6.7) and 38.2% (±19). Conclusions: ReSG should be proposed only for well-selected cases. This study has led us to change our habits by selecting only patients with a large gastric pouch ≥500 mL or with unresected fundus. Further prospective clinical trials are required to compare the outcomes of ReSG with those of laparoscopic Roux-en-Y gastric bypass or duodenal switch for weight loss failure after LSG.

The evolution of surgical treatment for chronic leak following sleeve.

BACKGROUND: Leak is estimated to be the most severe complication of laparoscopic sleeve gastrectomy (LSG), with sporadic failure of endoscopic techniques. In such cases, an aggressive management with surgical reconstructive procedures can be proposed to patients in whom all the conservative endoscopic techniques failed. OBJECTIVES: The purpose of the present study was to report our experience with surgical approach for the treatment of chronic leak after LSG. SETTING: University hospital, France. METHODS: Between January 2013-December 2019, 21 consecutive patients underwent reconstructive surgery for the treatment of chronic leak after LSG. The initial intervention, the endoscopic approach, and the definitive surgical repair were carefully reviewed. RESULTS: Twenty-one patients (17 women) with a mean (standard deviation [SD]) age of 42.7 years (9.81) and a mean (SD) body mass index (BMI) of 27.3 (5.2) kg/m2 underwent reconstructive surgery for persistent fistula. Seventeen patients (81%) had their early LSG performed in another hospital. Endoscopic treatment was represented by the pigtail drain or stent in 9 cases each, ovesco in 8 cases, and glue for 2 patients. The reconstructive surgery was performed within 6 months in 8 cases; between 6-12 months in 6 cases; between 1-3 years in 4 cases, and >3 years in 3 cases. There were 14 fistulo-jejunostomy (66.7%), 5 Roux-en-Y gastric bypass (23.8%), and 2 total gastrectomies (9.5%). The operative time was between 99 minutes and 5.5 hours (mean = 216.2, median = 225 min). The hospital stay ranged from 5-30 days (mean = 12.67, median = 11 d) and the surgical reintervention rate was 23.8% (5/21 patients), including 1 case of recurrent hemorrhage requiring 3 surgical operations over 1 month of postoperative follow-up. No postoperative mortality was recorded. CONCLUSIONS: Surgery should be considered in case of failure of the endoscopic treatment of chronic leak after LSG. Further research is needed to clearly identify the appropriate treatment, but in our experience the fistulo-jejunostomy approach shows a low morbidity rate. (Surg Obes Relat Dis 2020;17:278-283.) © 2020 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Distribution of freshwater fish from the Southern Neotropics reveals three new areas of endemism and show diffuse limits among freshwater ecoregions

Ecoregions and areas of endemism are central concepts in biogeography. Based on collection records and the Endemic Analyses implemented with NDM/VNDM method we analyzed fish areas of endemism in the junction of three freshwater ecoregions related to the Rio de la Plata estuary (Lower Parana, Lower Uruguay, Laguna dos Patos) in Southern Neotropical region. Using two grid cell sizes, results obtained showed the same general patterns. Areas of endemism recovered were mainly associated either to Lower Uruguay or to Laguna dos Patos. In both ecoregions nested areas of endemism were identified within larger patterns of endemism. Noteworthy, one area recovered occurred across Lower Uruguay and Laguna dos Patos limits. Our results also suggest a revision of the Lower Uruguay and Lower Parana ecoregion limits, and highlight the relevance of the Rio de la Plata estuary as a barrier and corridor for freshwater fishes in the area.(AU)

Las ecorregiones y áreas de endemismo son conceptos centrales en biogeografía. Basados en registros de colecciones y el análisis de endemismo implementado en NDM/VNDM, analizamos áreas de endemismo de peces en el sur de la región Neotropical, en la conjunción de tres ecorregiones de agua dulce relacionadas al estuario del Río de la Plata (Bajo Paraná, Bajo Uruguay, Laguna de los Patos). Usando dos tamaños de grilla, los resultados obtenidos mostraron los mismos patrones generales. Las áreas de endemismo obtenidas estuvieron principalmente asociadas tanto a la ecorregión Bajo Uruguay como a la Laguna de los Patos. En los dos casos, fueron identificadas áreas de endemismo anidadas dentro de los grandes patrones de endemismo. Además, se destacó un área que atravesó los límites de ambas ecorregiones. Nuestros resultados también sugieren que es necesaria una revisión de los límites entre Bajo Uruguay y Bajo Paraná y resaltan la relevancia del estuario del Río de la Plata como barrera y corredor para los peces de agua dulce de esta región.(AU)

Terahertz Spectroscopy Applied to Diagnostics in Public Health: A Review

Abstract Terahertz (THz) spectroscopy is an emerging technology that is that is bringing a number of technical breakthroughs in several scientific applications. This review aimed to describe potential applications of THz spectroscopy at the biochemistry and molecules detection for food industry, environment monitoring and diagnostics, and present the importance of such technological platform in disease control and Public Health.

Avalição da eficácia de dispositivo protetor de lipoaspiração modificado: estudo experimental em suínos / Evaluation of the effectiveness of a modified liposuction protective device: an experimental study in swine

A lipoaspiração é um dos procedimentos mais comuns na especialidade de cirurgia plástica. No levantamento da ISAPS de 2018 foi a segunda cirurgia mais realizada em todo o mundo. Devido aos movimentos repetitivos próprios da cirurgia, fricção importante é gerada no local e as consequências são queimaduras cutâneas que podem deixar cicatrizes inestéticas e discromias. O objetivo deste estudo é criar um protótipo de um dispositivo protetor da pele, a partir de um modelo antigo, que sirva a esse propósito, e observar sua funcionalidade e os efeitos da sua utilização na pele de suínos. Os testes foram realizados em animais mortos sem sofrimento disponibilizados pelo setor de Medicina Veterinária da Universidade Positivo. Foram feitas três incisões no abdome do animal para passagem da cânula de lipoaspiração e outras três para a inserção e utilização do protótipo, bem como para comparação com o dispositivo modelo. O tempo estabelecido de movimentos de lipoaspiração foi de vinte minutos, realizados com a cânula de 5mm diretamente em contato com a pele e dentro do protótipo. Foi avaliada a ergonomia do protótipo, facilidade de inserção e travamento adequado na pele com diferentes trações. Observação e avaliação da pele após os procedimentos e medição (cm) das incisões foram realizadas. O protótipo do dispositivo protetor cutâneo de lipoaspiração criado apresentou fácil manuseio e mecanismo de travamento na pele mais eficiente quando comparado ao modelo utilizado. A incisão cutânea para uso do protótipo foi ligeiramente maior e a pele não apresentou sinais de queimadura.

Liposuction is one of the most common procedures in the plastic surgery specialty. In the 2018 ISAPS survey, it was the second most performed surgery worldwide. Due to the repetitive movements typical of the surgery, significant friction is generated at the site, and the consequences are skin burns that can leave unsightly scars and dyschromias. This study aims to create a skin protective device prototype from an old model, which serves this purpose, and to observe its functionality and its effects on the pigskin. The tests were carried out on dead animals without suffering provided by the Veterinary Medicine sector at Universidade Positivo. Three incisions were made in the animal's abdomen to pass the liposuction cannula and another three for the insertion and use of the prototype to compare it with the model device. The established time for liposuction movements was twenty minutes, performed with the 5mm cannula directly in contact with the skin and inside the prototype. The prototype's ergonomics, ease of insertion, and good locking on the skin with different tractions were evaluated. Observation and evaluation of the skin were performed after procedures and incisions' measurements (cm). The cutaneous liposuction protective device prototype presented easy handling and a more efficient skin locking mechanism than the model used. The skin incision for using the prototype was slightly larger, and the skin showed no burning signs.

The Nissen Sleeve Gastrectomy: Technical Considerations.

Background: Laparoscopic sleeve gastrectomy (LSG) is currently the most performed bariatric procedure worldwide. We have developed a modification to the usual surgical technique of LSG by adding a Nissen fundoplication. Objectives: Provide the technical details of this new bariatric procedure. Materials and Methods: The first step of the N-sleeve technique involves dissection and reduction within the abdominal cavity of a possible hiatal hernia and closure of the hiatal orifice. A short 3 cm Nissen valve is created to maintain a gastric fundus as small and functional as possible. After that, the stapling process begins and continues in a standard pattern until the level of the previously created valve. Stapling the stomach around the valve must maintain its natural position and preserve vascularization. Results: The following are the five major technical tips: avoid thermic injuries of the gastric wall during short gastric vessel dissection; gently handle the gastric fundus during fundoplication; take the anterior and superior part of the fundus to create the wrap 4 cm from the His angle to avoid a wrong pathway for the food (the food should not go through the wrap); check the good pathway for the food at the end of the operation with the tube by moving it through the esophagogastric junction. Conclusion: N-sleeve is a new procedure, technically more challenging than standard LSG, but in our experience, it seems to show similar outcomes in terms of weight loss, effects on comorbidities, and lower rate of leak and gastroesophageal reflux disease.

Bariatric Surgery and the Mechanisms of Gastroesophageal Reflux Disease.

Introduction: The association between obesity and gastroesophageal reflux disease (GERD) is very well known and the pathophysiology of GERD is not completely understood but is likely to have a multifactorial nature especially after bariatric procedures. Methods: The current editorial summarizes the principal mechanisms involved in the reflux disease following different bariatric procedures. Results: Laparoscopic adjustable gastric banding could reduce the gastroesophageal reflux in the short term in some cases, but overeating will inevitably lead to enlargement of the pouch with loss of its antireflux properties. Although the laparoscopic Roux-en-Y gastric bypass was considered the gold standard procedure for obese patients with reflux disease, many patients had at least one complication within their follow-up period. One anastomosis gastric bypass remains a controversial procedure for GERD, especially when it is proposed as revisional surgery after laparoscopic sleeve gastrectomy. As revisional surgery, either single anastomosis duodeno-ileostomy (SADI) or duodenal switch (DS) have little or no impact on GERD and in our experience the indication for SADI/DS is a valid option in case of absence of any symptoms of reflux. The effect of sleeve for GERD is contradictory. Conclusion: For those with moderate reflux, since specific procedure guidelines are missing, surgical treatment for morbid obese patients must be selected according to the clinical characteristics of the patient, his eating habits and patient willingness. It should be based on a preoperative workup with shared decision making, with the double purpose of treating both GERD and obesity.