Identification, Classification, and Transcriptional Analysis of Rab GTPase Genes from Tomato (Solanum lycopersicum) Reveals Salt Stress Response Genes.

Salinity in plants generates an osmotic and ionic imbalance inside cells that compromises the viability of the plant. Rab GTPases, the largest family within the small GTPase superfamily, play pivotal roles as regulators of vesicular trafficking in plants, including the economically important and globally cultivated tomato (Solanum lycopersicum). Despite their significance, the specific involvement of these small GTPases in tomato vesicular trafficking and their role under saline stress remains poorly understood. In this work, we identified and classified 54 genes encoding Rab GTPases in cultivated tomato, elucidating their genomic distribution and structural characteristics. We conducted an analysis of duplication events within the S. lycopersicum genome, as well as an examination of gene structure and conserved motifs. In addition, we investigated the transcriptional profiles for these Rab GTPases in various tissues of cultivated and wild tomato species using microarray-based analysis. The results showed predominantly low expression in most of the genes in both leaves and vegetative meristem, contrasting with notably high expression levels observed in seedling roots. Also, a greater increase in gene expression in shoots from salt-tolerant wild tomato species was observed under normal conditions when comparing Solanum habrochaites, Solanum pennellii, and Solanum pimpinellifolium with S. lycopersicum. Furthermore, an expression analysis of Rab GTPases from Solanum chilense in leaves and roots under salt stress treatment were also carried out for their characterization. These findings revealed that specific Rab GTPases from the endocytic pathway and the trans-Golgi network (TGN) showed higher induction in plants exposed to saline stress conditions. Likewise, disparities in gene expression were observed both among members of the same Rab GTPase subfamily and between different subfamilies. Overall, this work emphasizes the high degree of conservation of Rab GTPases, their high functional diversification in higher plants, and the essential role in mediating salt stress tolerance and suggests their potential for further exploration of vesicular trafficking mechanisms in response to abiotic stress conditions.

The accumulation of ERAS (enhanced recovery after surgery) components reduces post-colectomy length of stay at small and low volume hospitals.

In small hospitals, where the majority of colectomy surgery is performed in the United States, adopting more individual ERAS components improves outcomes. The accumulation of individual ERAS components influences outcome more than an "ERAS designation" and this can be used by small hospitals to improve outcomes.

A 5-Year History of Laparoscopic Gastric Band Removals: an Analysis of Complications and Associated Comorbidities.

OBJECTIVE: This study was undertaken to examine the factors contributing to laparoscopic adjustable gastric band (LAGB) removals among adults > 18 years of age. We hypothesized that female patients with multiple comorbidities would have increased removals. DESIGN: This retrospective exploratory study uses internal records and standard statistical methods of analysis. RESULTS: Eighty-five bands were removed (11.8% males, 88.2% females). The average BMI was 40.7 (n = 83). 2.4% of patients had removals between 0 and 12 months, 18.8% between 39 and 51 months, and 35.3% between 39 and 64 months. 8.2% of treatment times were unknown. The average treatment time was 67.9 months. 48.2% of patients had ≥ 2 comorbidities, GERD (44.2%) being the most frequent. 49.4% of patients reported dysphagia as the reason for band removal. 22.4% of removals were associated with band failures, none with port complications. The reason for band removal was unknown in 21.2% of patients. 67.1%, 32.9%, and 23.5% attended 30-, 60-, and 90-day follow-up appointments, respectively. Weight post-band removal surgery at 30, 60, and 90 days was noted to be - 0.4%., 0.9%, and 0.4%, respectively. CONCLUSION: This study supports current literature suggesting LAGB may not be an effective long-term surgical intervention for obesity. Patients with > 2 comorbidities had increased rates of removal. Dysphagia was noted to be the primary reason cited for LAGB removal. Postoperative follow-up was found to be a significant challenge for LAGB removal patients. Further study is warranted to explore if these poor follow-up rates should be considered when risk stratifying LAGB patients for revisional surgery.

Involvement of SchRabGDI1 from Solanum chilense in endocytic trafficking and tolerance to salt stress.

Physiological responses of plants to salinity stress requires the coordinated activation of many genes. A salt-induced gene was isolated from roots of the wild tomato species Solanum chilense and named SchRabGDI1 because it encodes a protein with high identity to GDP dissociation inhibitors of plants. These proteins are regulators of the RabGTPase cycle that play key roles in intracellular vesicular trafficking. The expression pattern of SchRabGDI1 showed an early up-regulation in roots and leaves under salt stress. Functional activity of SchRabGDI1 was shown by restoring the defective phenotype of the yeast sec19-1 mutant and the capacity of SchRabGDI1 to interact with RabGTPase was demonstrated through BiFC assays. Expression of SchRabGDI1 in Arabidopsis thaliana plants resulted in increased salt tolerance. Also, the root cells of transgenic plants showed higher rate of endocytosis under normal growth conditions and higher accumulation of sodium in vacuoles and small vesicular structures under salt stress than wild type. Our results suggest that in salt tolerant species such as S. chilense, bulk endocytosis is one of the early mechanisms to avoid salt stress, which requires the concerted expression of regulatory genes involved in vesicular trafficking of the endocytic pathway.

The REDUCE pivotal trial: a prospective, randomized controlled pivotal trial of a dual intragastric balloon for the treatment of obesity.

BACKGROUND: Saline-filled intragastric balloon devices are reversible endoscopic devices designed to occupy stomach volume and reduce food intake. OBJECTIVE: To evaluate the safety and effectiveness of a dual balloon system plus diet and exercise in the treatment of obesity compared to diet and exercise alone. SETTING: Academic and community practice, United States. METHODS: Participants (n = 326) with body mass index (BMI) 30-40 kg/m(2) were randomized to endoscopic DBS treatment plus diet and exercise (DUO, n = 187) or sham endoscopy plus diet and exercise alone (DIET, n = 139). Co-primary endpoints were a between-group comparison of percent excess weight loss (%EWL) and DUO subject responder rate, both at 24 weeks. Thereafter DUO patients had the DBS retrieved followed by 24 additional weeks of counseling; DIET patients were offered DBS treatment. RESULTS: Mean BMI was 35.4. Both primary endpoints were met. DUO weight loss was over twice that of DIET. DUO patients had significantly greater %EWL at 24 weeks (25.1% intent-to-treat (ITT), 27.9% completed cases (CC, n = 167) compared with DIET patients (11.3% ITT, P = .004, 12.3% CC, n = 126). DUO patients significantly exceeded a 35% response rate (49.1% ITT, P<.001, 54.5% CC) for weight loss dichotomized at 25%EWL. Accommodative symptoms abated rapidly with support and medication. Balloon deflation occurred in 6% without migrations. Early retrieval for nonulcer intolerance occurred in 9%. Gastric ulcers were observed; a minor device change led to significantly reduced ulcer size and frequency (10%). CONCLUSION: The DBS was significantly more effective than diet and exercise in causing weight loss with a low adverse event profile.

Sleeve gastrectomy in the elderly: a safe and effective procedure with minimal morbidity and mortality.

BACKGROUND: Previously, we demonstrated the safety and efficacy of laparoscopic gastric bypass surgery in patients over 65 years of age. The aim of this study is to demonstrate the safety and efficacy of this procedure as a final step for treatment of morbid obesity in the same population. METHODS: A retrospective review of a prospectively collected database was performed. Between 2004 and 2010, a total of 35 patients age 60 and greater were analyzed from a total of 512 sleeve gastrectomy patients. Demographics, preoperative body mass index, complications, and excess weight loss were recorded and compared to bougie size and follow-up in months. Mean age was 66.3 years (range, 60-79 years), mean body mass index was 46.3 kg/m(2) (range, 33.7-77.6 kg/m(2)), and mean excess weight loss was 148.49 lb (range, 72-252 lb). RESULTS: One patient (2.8 %) had an incidental colotomy as a result of trocar insertion, one patient (2.0 %) bled, and one patient (2.8 %) had small-bowel enterotomy. Overall, morbidity was 8.4 % with no mortality. Mean percent excess weight loss results for bougie size 52 were 28, 34, 26, 18, and 27 % at 3, 6, 12, 24 and 48 months, respectively; for bougie size 46 were 31, 57, 64, 62, and 82 % at 3, 6, 12, 24 and 48 months, respectively; and bougie size 38 were 37, 50, 55, and 56 % at 3, 6, 12 and 24 months, respectively. CONCLUSIONS: Laparoscopic sleeve gastrectomy is an effective procedure for morbidly obese patients age 60 and greater that can be performed safely.

Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases.

BACKGROUND: It is common practice to close mesenteric defects in abdominal surgery to prevent postoperative herniation and subsequent closed-loop obstruction. The aim of this study was to review our experience with antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGBP) without division of the small bowel mesentery or closure of potential mesenteric defects. METHODS: Data for 1400 patients who underwent AA-LRYGBP between January 2001 and December 2004 was prospectively collected and retrospectively analyzed for the incidence of internal hernias. In all cases, an antecolic antegastric approach was performed without division of the small bowel mesentery or closure of potential hernia defects. RESULTS: Three patients (0.2%) developed a symptomatic internal hernia. Two of these patients had a 200-cm-long Roux limb, and the other had a 100-cm-long Roux limb. All three patients exhibited mild symptoms of partial small bowel obstruction. In all three cases the internal hernia was clinically manifested more than 10 months after the original AA- LRYGBP. Exploration revealed that the hernia site was between the transverse colon and the mesentery of the alimentary limb at the level of the jejunojejunostomy (Petersen's defect) in all three cases. All three patients underwent successful laparoscopic revision, hernia reduction, and mesenteric defect closure. CONCLUSIONS: AA-LRYGBP without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.

Management of ulcerative colitis in the morbidly obese patient: is bariatric surgery indicated?

Ulcerative colitis and obesity share a systemic chronic inflammatory response manifested by increased inflammatory markers. There are data suggesting a benefit in both diseases after inflammatory markers are decreased. We present a 39-year-old morbidly obese male with a history of ulcerative colitis who manifested significant symptomatic improvement after an 86.8% excess weight loss following gastric bypass surgery. We believe that this result may have been due to a reduction of inflammatory markers secondary to considerable weight loss. Although to our knowledge there are no publications showing a direct relationship between symptomatic improvement of ulcerative colitis and weight loss in the obese patient, we believe that weight loss surgery could become a promising tool in the treatment of ulcerative colitis when associated with morbid obesity.

Gastric bezoar after laparoscopic Roux-en-Y gastric bypass.

Gastric bezoar is an uncommon complication following Roux-en-Y gastric bypass (RYGBP). We report two cases of bezoar formation that occurred following laparoscopic RYGBPs. In both cases, the patients presented with abdominal pain, nausea, and "frothy" vomiting. The patients were successfully treated by endoscopic fragmentation and removal of the bezoar.

Laparoscopic surgery for morbid obesity: 1,001 consecutive bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida.

BACKGROUND: Morbid obesity is an epidemic in America. This series evaluates the safety and efficacy in the first 1,001 laparoscopic bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. METHODS: A retrospective review was conducted examining all patients undergoing a primary bariatric procedure (either laparoscopic gastric bypass or laparoscopic gastric banding) from July 2000 to December 2003. RESULTS: 2 surgeons performed 1,001 laparoscopic bariatric operations. Average age was 47 (19-75) years, average BMI was 55.6 (35-97) kg/m2, and average ASA class was III. Excess weight loss was 51% at 6 months, 73.4% at 1 year for the gastric bypass group and 54% at 1 year for the laparoscopic banding group. The overall complication rate was 31.8% (12.4% major and 19.4% minor) in the gastric bypass group and 13% in the laparoscopic banding group. There was no postoperative mortality. CONCLUSION: Laparoscopic bariatric surgery is feasible and safe for weight loss. Results obtained have been comparable to those reported for the open approach for weight loss, with a similar major morbidity rate and an improved mortality rate.

Diagnosis and management of partial small bowel obstruction after laparoscopic antecolic antegastric Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: The resultant derangement of the normal gastrointestinal anatomy after a gastric bypass procedure increases the incidence of, and level of difficulty diagnosing, partial small bowel obstruction (SBO) in morbidly obese patients. We evaluated the diagnostic methods for partial SBO and the clinical characteristics according to the time after initial operation. STUDY DESIGN: Data of 1,400 consecutive patients who underwent antecolic antegastric laparoscopic Roux-en-Y gastric bypass between 2001 and 2004 were retrospectively analyzed. RESULTS: Partial SBO developed in 21 (1.5%) patients after laparoscopic Roux-en-Y gastric bypass. Five of 15 patients were preoperatively diagnosed with SBO by a gastrograffin study and CT scan diagnosed 17 of 19 patients (p = 0.002). Causes of SBO included jejunojejunostomy stenosis (n = 6), adhesions (n = 5), incarcerated ventral hernia (n = 5), internal hernia (n = 3), and other (n = 2). The majority of patients (n = 19) underwent surgical treatment. CONCLUSIONS: The most frequent cause of early SBO is jejunojejunal anastomotic stenosis. CT scan is a more accurate diagnostic tool for detecting partial SBO, compared with use of a gastrograffin study. Operation remains the most appropriate and definitive treatment for this complication and the laparoscopic approach is a feasible and safe surgical treatment option.

Myasthenia gravis improvement after laparoscopic Roux-en-Y gastric bypass.

Many diseases in the obese population have been found to improve after weight loss. A 56-year-old female with a long history of myasthenia gravis (MG) and morbid obesity is reported. Preoperatively, she presented with a BMI of 46.5 kg/m2, and was on three medications and IV immunoglobulin every 5 weeks. After the surgical procedure, she improved and required less medication. Because MG and morbid obesity require careful perioperative management in order to avoid complications, a multidisciplinary approach is recommended.

Topical anesthesia-induced methemoglobinemia in bariatric surgery patients.

Methemoglobinemia leads to rapid oxygen desaturation, requiring prompt recognition and treatment. We present two severely obese patients who developed methemoglobinemia following the use of topical or local anesthetic. This complication was detected by analysis of arterial blood gases, and was successfully treated with methylene blue i.v. and 100% O2 supplementation.

Development of acute gouty attack in the morbidly obese population after bariatric surgery.

BACKGROUND: Gout is associated with increased body weight. We evaluated the prevalence of gout and acute gouty attacks in the morbidly obese population who underwent bariatric surgery. METHODS: The medical records and operative reports of 1,240 patients who underwent bariatric surgery were reviewed retrospectively for weight parameters, BMI, weight loss, medical history of gout, and onset of acute gouty attacks. RESULTS: Of the 1,240 patients, 5 (0.4%) had been previously diagnosed with gout. 2 of these 5 had acute attacks during the postoperative period, and responded successfully to intravenous colchicine. CONCLUSION: Although rare, gout must be considered a co-morbid illness in obese and morbidly obese patients. Surgeons should be familiar with the signs and symptoms of attacks in the postoperative period, and be knowledgeable in the management.

Renal failure, glomerulonephritis and morbid obesity: improvement after rapid weight loss following laparoscopic gastric bypass.

There is experimental evidence but very few human studies that suggest a role for obesity in the formation and progression of some glomerular lesions. We report the case of a morbidly obese male with hematuria and proteinuria that was subsequently diagnosed with renal failure which required dialysis. Histological findings of the renal biopsy performed during a laparoscopic gastric bypass are presented. His renal failure resolved with the weight loss.

Laparoscopic removal of gastric band after early gastric erosion: case report and review of the literature.

Laparoscopic gastric banding is a popular method for treating morbid obesity. One of the most serious complications is band erosion into the gastric lumen. We present the case of a patient who underwent gastric banding and presented with symptoms of gastrointestinal reflux and mild-to-moderate hypertension, fever, and pain. UGI revealed stomach wall erosion and partial migration of the band into the gastric lumen. The band was laparoscopically removed without any further complications. Migration after laparoscopic gastric banding must be immediately addressed to prevent infection. Close monitoring of the band location during adjustments as well as a high index of suspicion is necessary.

Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure. METHODS: We report a series of 1,292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1,292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery. RESULTS: The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m(2), respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically. CONCLUSION: Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer follow-up is needed to better define the management of this patient population and provide a more accurate incidence of its occurrence.

Routine abdominal drains after laparoscopic Roux-en-Y gastric bypass: a retrospective review of 593 patients.

BACKGROUND: The authors reviewed the benefits of routine placement of closed drains in the peritoneal cavity following laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of the study was to determine whether routine closed abdominal drainage provides diagnostic and therapeutic advantages in the presence of complications such as bleeding and leaks. MATERIALS AND METHODS: The medical records of 593 consecutive patients who had undergone LRYGBP from July 2001 through May 2003 were retrospectively reviewed. In all cases, antecolic antegastric LRYGBP was performed. Two 19-Fr Blake closed suction drains were left in place, one at the gastrojejunostomy and the other at the jejunojejunostomy. The incidence of bleeding and leaks was reviewed, and the utility of the drains relative to diagnosis and management was evaluated. RESULTS: Bleeding presented in 24 patients (4.4%); in 8, the diagnosis was based on increased sanguinous output from the drain and decreased hematocrit. None of the patients with intraabdominal bleeding required reoperation. Of the 10 patients (1.68%) who presented with leaks, the diagnosis was made within 48 hours postoperatively in 5 patients (50%), based on the characteristics of the drain output. Nonoperative management with drainage and total parenteral nutrition was accomplished in 5 (50%) of the 10 patients with leaks. There was no mortality in the series. CONCLUSION: The routine use of abdominal drains after LRYGBP appears to be beneficial. Drains allowed early diagnosis of complications and in most cases, the successful treatment of leaks. When bleeding is suspected or documented, appropriate volume replacement therapy is mandatory to maintain adequate hemodynamic parameters. Drain output may orient the surgeon to take preventive measures such as discontinuing anticoagulation and early fluid resuscitation. In this series, in most cases the bleeding spontaneously stopped and no further surgical management was required.

Psoriasis remission after laparoscopic Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: Psoriasis is a chronic skin disease characterized by epithelial hyperplasia and an accelerated rate of epithelial turnover affecting approximately 1-3% of the population. Exogenous and endogenous factors including morbid obesity can increase the morbidity of psoriasis. CASE REPORT: A 55-year-old male, who weighed 131 kg with BMI 41 kg/m2, underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). He had a 15-year duration of severe psoriasis and was being medically treated. At 12 months after LRYGBP, he had lost 39 kg (68% EWL), and had complete resolution of the psoriasis and had discontinued all preoperative medications related to the disease. At 2 years after LRYGBP, psoriasis has not recurred. CONCLUSION: Weight loss after LRYGBP should be considered as a strategy in the treatment of severe psoriasis in morbidly obese patients.