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One of the most used cephalosporin in clinical practice is ceftriaxone. Anaphylaxis due to the administration of ceftriaxone is considered a rare event. Here, we report a case of fatal anaphylactic shock after the administration of ceftriaxone in a child who had tolerated the drug in past exposures. The allergic pathogenesis is sustained by the clinical data (short time between the inoculation of the drug and the onset of the symptoms; past exposure to the same molecule and probable sensitization) and the postmortem examination findings (polivisceral congestion and intense eosinophilia found in the histological examination).

Many women in the world are still undergoing female genital mutilations (FGMs) even if in almost all the countries, the practice of FGM is illegal. The increase of immigration, particularly from African Countries, to Europe, and Italy too, led to consider this phenomenon with particular attention and skill. All the operators in health services need to know the different types of FGMs and the related complications and the psychological and sexual sequels. Urological complications, in particular, are not rare and the changing anatomy of the external genital apparatus can also make the catheter insertion sometimes difficult. This review analyzes the epidemiology of FGMs, the reasons why the practice is still made, the complications, the ethical, and the principal legal aspects of this practise that must be hopefully early banned.

Purpose: Due to admitted limits of autopsy-based studies in the diagnosis of drowning, virtopsy is considered the new imaging horizon in these post-mortem studies. The aim of our study was to evaluate the role of virtopsy performed through computed tomography (CT) in the forensic diagnosis of drowning., Materials and Methods: We retrospectively examined the CT data of four cadavers recovered from sea water and suspected to have died by drowning. Each patient underwent a full-body post-mortem CT scan, and then a traditional autopsy., Results: All the cadavers showed fluid in the airways and patchy ground-glass opacities in the lung. Only one patient had no fluid in the digestive tract; this patient had a left parietal bone fracture with a large gap and other multiple bone fractures (nose, clavicle, first rib and patella). One of the three patients who had fluid in the digestive tract had no fluid in the paranasal sinuses. This latter patient showed cerebral oedema with subarachnoid and intraventricular haemorrhage, multiple bone fractures (orbital floor, ribs, sacrum and acetabular edge) and air in the heart, in the aorta and in bowel loops., Conclusion: To date, there are no autopsy findings pathognomonic of drowning. This study proves that virtopsy is a useful tool in the diagnosis of drowning in that it allows us to understand if the victim was alive or dead when he entered the water and if the cause of death was drowning.

Background/aim: Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy., Methods: A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case., Results: No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively., Conclusions: ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy., (© The Author(s) 2014.)

Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.

More than a decade has passed since robotic technology was adopted for abdominal surgery, and virtually every gastrointestinal operation has since been shown to be feasible, safe, and reproducible using the robotic approach. Robotic pancreatic surgery had been left behind at the beginning, because they were technically challenging, requiring not only being very familiar with the robotic technology but also having a perfect knowledge of the anatomical variations, very frequent in this area. Nonetheless in the last few years many authors have approached the robot for pancreatic surgery with very promising results in terms of surgical and oncological outcomes. The aim of this article is to review the literature on robotic pancreatic surgery and to define the state of the art use of the robotic approach for pancreatic disease.

Hepatobiliary surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive hepatobiliary surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant about the approach. On the other hand, gastric surgery is a very popular field of surgery with an extensive amount of literature especially regarding open and laparoscopic surgery but not much about the robotic approach especially for oncological disease. Recent development of the robotic platform has provided a tool able to overcome many of the limitations of conventional laparoscopic hepatobiliary surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera, allow for steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive hepatobiliary and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted hepatobiliary and gastric surgery.The English full-text version of this article is available at SpringerLink (under supplemental).

What Is Known and Objective: Safety of the anti-inflammatory drug flurbiprofen is comparable with that of other non-steroidal anti-inflammatory drugs of the propionic acid class, which are commonly associated with gastrointestinal and renal side effects. Here we report a case of a fatal hypersensitivity reaction to an oral spray of flurbiprofen taken for sore throat., Case Summary: A 29-year-old man came to the emergency care unit reporting sore throat with an intense burning sensation associated with fever. Pharyngotonsillitis was diagnosed, and local treatment with oral flurbiprofen spray was prescribed. Immediately after using the spray, the patient experienced a severe reaction characterized by serious dyspnoea, followed by death. The cause of death was heart failure with acute asphyxia from oedema of the glottis. The cause of death was concluded to be hypersensitivity to flurbiprofen spray., What Is New and Conclusion: Oral propionic acid derivatives have been associated with a relatively high frequency of allergic reactions. However, allergy to flurbiprofen has rarely been documented. Scientific literature reports two relevant cases of hypersensitivity reaction to flurbiprofen: in one case, a patient presented with a maculopapular rash 48 h after having taken oral flurbiprofen followed by angio-oedema and hypotension. In another case, a single oral dose of flurbiprofen caused itching and swelling around the eyes, redness and increased lacrimation. We describe, for the first time, a fatal case of hypersensitivity reaction to flurbiprofen oral spray. Hypersensitivity reactions to flurbiprofen are infrequent; however, health professionals should be aware of potential adverse reactions, even during topical administration as oral spray., (© 2013 John Wiley & Sons Ltd.)

Isolated arterial thrombi complicating inflammatory bowel disease occurs rarely. We encountered a case of a 28-year-old man with Crohn disease who presented with abdominal pain and severe claudication and was found to have an isolated aortoiliac thrombus. Bilateral aortoiliac thromboembolectomies were performed with successful restoration of femoral blood flow. Long-term anticoagulation therapy was instituted after an extensive hypercoagulable workup, which failed to reveal an etiology for the patient's coagulopathy. We present our case and perform an extensive literature review on this topic., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric surgery improves glucose homeostasis, but the mechanism of action is poorly understood. The aim of this study was to assess the effect of sleeve gastrectomy (SG) on glucose homeostasis in two obese populations of rats., Methods: Two strains of rats [Zucker fatty (ZF) and Zucker diabetic fatty (ZDF)] were each divided into two groups: sham and SG. Food intake was measured daily, and weight was measured bi-weekly. Oral glucose tolerance testing (OGTT) was performed before and 45 days after surgery., Results: In both strains of rats, there was no statistical difference in food intake and weight gain between the sham and SG rodents before and after surgery. In ZF rats, there was no change in fasting glucose or OGTT area under the curve (AUC) before or 45 days after surgery. In the ZDF rodents, the mean preoperative fasting glucose and OGTT AUC was 204 ± 25 and 25,441 ± 2,648, respectively. At 45 days after surgery, mean fasting glucose significantly increased in the sham (sham = 529 ± 26, p = 0.0003) but not in the SG rodents (SG = 289 ± 46, p = 0.1113). In ZDF sham animals, OGTT at 45 days showed a higher AUC compared to before surgery (44,983 ± 6,338, p = 0.006), whereas in ZDF SG rodents, the increase in AUC glucose approached but did not reach statistical significance (35,553 ± 3,925, p = 0.06)., Conclusions: In ZF and ZDF rodents, SG did not influence food intake and weight evolution. In ZDF rodents, diabetes progressed in the sham group but not in the SG group.

Background: The aim of this study was to examine the effect of small bowel resection with and without sleeve gastrectomy on glucose homeostasis in an obese rodent model of type 2 diabetes., Methods: Zucker diabetic fatty rats were randomized into three surgical groups: Sham, small bowel resection, and small bowel resection with sleeve gastrectomy (BRSG). Weight and fasting glucose levels were measured at randomization and monitored after surgery. Oral glucose tolerance testing was performed at baseline and 45 days after surgery to assess glucose homeostasis and peptide changes., Results: At baseline, all animals exhibited impaired glucose tolerance and showed no difference in weight or fasting (area under the curve) AUC(glucose). At sacrifice, Sham animals weighed more than BRSG animals (p = 0.047). At day 45, the Sham group experienced a significant increase in AUC(glucose) compared to baseline (p = 0.02), whereas there was no difference in AUC(glucose) in either surgical group at any time point: BR (p = 0.58) and BRSG (p = 0.56). Single-factor ANOVA showed a significant difference in AUC(glucose) of p = 0.004 between groups postoperatively: Sham (50,745 ± 11,170) versus BR (23,865 ± 432.6) (p = 0.01); Sham versus BRSG (28,710 ± 3188.8) (p = 0.02). There was no difference in plasma insulin, GLP-1, or adiponectin levels before surgery, although 45 days following surgery adiponectin levels where higher in the BRSG group (p = 0.004)., Conclusions: Partial small bowel resection improved glucose tolerance independent of weight. The combination of small bowel resection and sleeve gastrectomy leads to an increase in adiponectin levels, which may contribute to improved glucose homeostasis.

Introduction: Annular pancreas (AP) is a rare anomaly due to malrotation of the pancreatic ventral bud during embryologic development. AP has been extensively described in the pediatric population; however, in adults, the incidence has been reported to be only 1 in 22,000 patients with only a few cases presenting with simultaneous mucinous cystadenoma described in the recent literature., Case Report: We report the case of a 72-year-old female patient with a mucinous cystadenoma, who was found to have a concomitant AP during laparoscopic distal pancreatectomy., Discussion: The dual presentation of annual pancreas and mucinous cystoadenoma is an infrequent condition and can be managed with minimally invasive techniques; bypass in adults should only be performed in patients with symptomatic duodenal compression or recurrent bouts of pancreatitis.

Introduction: Epidural analgesia and/or systemic narcotics are used for pain control after video-assisted thoracic surgery (VATS) lobectomy despite side effects. We report a video of a technique to safely place subpleural catheters in order to provide multiple nerve blocks and the results from our series comparing this technique to a standard post-operative analgesia protocol after VATS., Methods: At the end of the VATS wedge resection, two small incisions were made below and parallel to the position of the trocars, at the level of the anterior and posterior axillary line and an introducer was used to place a catheter subcutaneously. At this point, the introducer was curved, in a way to follow the anatomic shape of the costal margin of the patient, inserted into posterior incision and advanced in between the thoracic pleura and the ribs. Under direct vision from the thoracoscope and paying careful attention not to perforate the pleura, the guide was pushed toward the first rib by using a combination of blunt and hydro dissection. Once the guide reached the first rib, the introducer was removed and the catheter was left in place., Results: We evaluated 64 patients (29 patient-controlled analgesia (PCA), 35 SC). Propensity weighting produced two matched groups for further analysis. Mean total morphine dose and mean total morphine dose/body mass index (BMI) were both significantly decreased in the SC group for the 0-24 h period only (mean total morphine 38.1 vs. 27.8; P = 0.024 and mean total morphine/BMI 1.15 vs 0.79; P = 0.024). Complication rates did not differ between groups., Conclusions: PCA narcotic analgesia with subpleural local anesthetic infusion provided similar pain control with less narcotic use in patients during the first 24 h after VATS lobectomy compared with PCA narcotic analgesia alone.

Introduction: Current effective bariatric procedures such as gastric bypass generate a duodenal-jejunal exclusion, which has been implicated in the resolution of type 2 diabetes. The aim of this study was to test the hypothesis that sleeve gastrectomy with ileal transposition (SGIT), a new procedure, is as effective as Roux-en-Y gastric bypass (RYGB) to induce glucose control on an obese rat model of type 2 diabetes mellitus., Methods: Twenty eight obese diabetic Zucker rats, weighing 571 ± 151 g were assigned into three procedures: SGIT (n = 11), RYGB (n = 7), and sham operation (n = 10). Animals were followed, evaluating weekly weight increase and food intake. We performed an insulin tolerance test after 8 weeks and measured serum peptide tyrosine-tyrosine (PYY 3-36) and ghrelin levels., Results: Nine weeks after surgery, sham-operated animals increased their body weight by 24%. In far contrast, SGIT and RYGB rats weighed 21% and 18% less than sham animals, respectively (sham, 884 ± 15 g; SGIT, 720 ± 19 g; RYGB, 754 ± 14 g; p < 0.001). No significant differences were found between SGIT and RYGB. Cumulative food intake in SGIT and RYGB procedures decreased by 29.6% and 32.9%, respectively (sham, 576.3 ± 33 g; SGIT, 405.8 ± 10 g; RYGB, 386.4 ± 21 g; p < 0.001). No differences were found between SGIT and RYGB rats. Sixty minutes after oral gavage, PYY levels were increased by 185% and 74% in SGIT and RYGB, respectively (sham, 63.4 ± 2.1 pg/ml; SGIT, 192.7 ± 17 pg/ml; RYGB, 117.7 ± 4.8 pg/ml; p < 0.001). Glucose tolerance was improved after SGIT and RYGB surgery demonstrated by area under the curve analysis (sham, 27,090 ± 1,424; SGIT, 17,704 ± 1,288 mg/dl; p < 0.018; RYGB, 16,212 ± 2,522; p < 0.01)., Conclusion: SGIT proved to be as effective as RYGB on obese diabetic rats as a weight loss procedure. Also, glucose homeostasis improved in SGIT, similar to RYGB, in spite of the absence of duodenal-jejunal exclusion. This observation does not support the theory that RYGB reversal of diabetes is due to duodenal-jejunal exclusion.

Background: Given the difficulty level of minimally invasive pancreatoduodenectomy (MIPD), limited data exist for a comparison to open pancreatoduodenectomies. As the technique becomes more diffuse, issues regarding the adequacy of oncologic margins and lymph node retrieval need to be addressed., Methods: All published cases of MIPD were examined. Variables analyzed included conversion rates, operating room time, estimated blood loss, length of stay, follow-up, complications, mortality, lymph node retrieval, and margins., Results: Twenty-seven articles describing outcomes after MIPD were found, and a total of 285 cases were described. Main malignancy treated was pancreatic adenocarcinoma, accounting for 32% of all cases. Eighty-seven percent were performed totally laparoscopically, and 13% were performed with a hand-assisted approach to facilitate the reconstruction step of the procedure. The rate of conversion to an open procedure was 9%. Estimated blood loss had a weighted average (WA) of 189 mL. Average length of stay had a WA of 12 days, and average follow-up had a WA of 14 months. The overall complication rate was 48%, and the overall mortality rate was 2%. Average lymph nodes retrieved ranged from 7 to 36 nodes, with a WA of 15 nodes, and positive margins of resection were reported to be positive in 0.4% of patients with malignant disease., Conclusions: This review found similar outcomes with respect to perioperative morbidity and mortality rates compared to open pancreatoduodenectomies. The oncologic goals of pancreatic resection may be able to be achieved by MIPD, but longer follow-up and larger series are still needed.

Exposure of human endothelial progenitor cells (EPCs) to tumor necrosis factor-α (TNF-α) reduced their number and biological activity. Yet, signal transduction events linked to TNF-α action are still poorly understood. To address this issue, we examined the possible effect of fasudil and Y27632, two inhibitors of Rho kinase pathway, which is involved in endothelial dysfunction, atherosclerosis, and in- flammation. Results demonstrated that incubation with fasudil starting from 50 μM but not Y27632 determined a dose-dependent improvement of EPC number during exposure to TNF-α (P < 0.05 vs. TNF-α alone). Analysis of the signal transduction pathway activated by TNF-α revealed that the increased expression of p-p38 was not significantly altered by fasudil. Instead, fasudil blocked the TNF-α induced phosphorylation of Erk1/2 (P < 0.05 vs. TNF-α) as well as the inhibitor of Erk1/2-specific phosphorylated form, i.e., PD98059 (P < 0.05 vs. TNF-α). These results were confirmed by analysis of these kinases by confocal microscopy. Finally, 2D-DIGE and MALDI-TOF/TOF analysis of EPCs treated with fasudil revealed increased expression levels of an actin-related protein and an adenylyl cyclase associated protein and decreased expression levels of proteins related to radical scavenger and nucleotide metabolism. These findings suggest that fasudil positively affects EPC number and that other major signals might take part to this complex pathway.

Introduction: Sclerosing peritonitis (SP) is a rare disease that can cause abdominal pain and intestinal obstruction. SP can be primary (also called abdominal cocoon) or secondary (when it is mainly due to systemic diseases or the intraperitoneal instillation of medications)., Methods: We report the video of a single incision diagnostic laparoscopy in a patient with SP with the educational intent of allowing easier recognition of this rare disease., Results: The patient is a 72-year-old female with a history of bladder cancer, salivary gland cancer, and squamous cell cancer of the skin. She was diagnosed with a suspicion of SP during a diagnostic laparoscopy made to rule out ovarian cancer at an outside institution. Due to worsening of her symptoms, she was presented to our hospital for a second opinion. Due to inadequate tissue from her first exploration, she was brought to the operating room for a diagnostic laparoscopy., Discussion: Although SP can mimic the gross appearance of peritoneal carcinomatosis, multiple biopsies should be obtained to allow for the diagnosis of SP. This video shows how this rare disease entity can present and how an abdomen with even thick fibrosis can be managed with a minimally invasive approach.

Endothelial progenitor cell (EPC) therapy is a promising approach to promote angiogenesis and endothelial repair in patients with cardiovascular diseases (CVD). However, their release of proinflammatory mediators may compromise the therapeutic efficacy. Little is known about the role of Platelet-Activating Factor (PAF) in EPC functional response. Here, we investigated the expression of PAF receptor (PAF-R) in early EPC and the release of PAF under stimulation with factors involved in endothelial dysfunction. Results indicated that early EPC express the PAF-R and respond to PAF signaling via a transient increase of cytoplasmic Ca(2+) concentration. EPC release PAF in a time dependent manner upon stimulation with tumor necrosis factor-alpha (TNF-alpha) or high-glucose concentration with a peak at 30 min and 10 min (p<0.01 vs. control), respectively. PAF, starting at concentration of 50 ng/ml, exerted a detrimental effect on EPC number with a concomitant increase of p38 activity. Furthermore, both the reduction of early EPC number and the enhanced p38 activity induced by PAF were abolished by CV3988, a PAF receptor antagonist. These novel findings, revealing that early EPC respond to PAF signaling, unveil an inflammatory pathway that may play a crucial role in the outcome of cardiovascular cell therapy with EPC., (Copyright @ 2010 Elsevier B.V. All rights reserved.)

Background: Pathological angiogenesis represents a critical issue in the progression of many diseases. Down syndrome is postulated to be a systemic anti-angiogenesis disease model, possibly due to increased expression of anti-angiogenic regulators on chromosome 21. The aim of our study was to elucidate some features of circulating endothelial progenitor cells in the context of this syndrome., Methods: Circulating endothelial progenitors of Down syndrome affected individuals were isolated, in vitro cultured and analyzed by confocal and transmission electron microscopy. ELISA was performed to measure SDF-1α plasma levels in Down syndrome and euploid individuals. Moreover, qRT-PCR was used to quantify expression levels of CXCL12 gene and of its receptor in progenitor cells. The functional impairment of Down progenitors was evaluated through their susceptibility to hydroperoxide-induced oxidative stress with BODIPY assay and the major vulnerability to the infection with human pathogens. The differential expression of crucial genes in Down progenitor cells was evaluated by microarray analysis., Results: We detected a marked decrease of progenitors' number in young Down individuals compared to euploid, cell size increase and some major detrimental morphological changes. Moreover, Down syndrome patients also exhibited decreased SDF-1α plasma levels and their progenitors had a reduced expression of SDF-1α encoding gene and of its membrane receptor. We further demonstrated that their progenitor cells are more susceptible to hydroperoxide-induced oxidative stress and infection with Bartonella henselae. Further, we observed that most of the differentially expressed genes belong to angiogenesis, immune response and inflammation pathways, and that infected progenitors with trisomy 21 have a more pronounced perturbation of immune response genes than infected euploid cells., Conclusions: Our data provide evidences for a reduced number and altered morphology of endothelial progenitor cells in Down syndrome, also showing the higher susceptibility to oxidative stress and to pathogen infection compared to euploid cells, thereby confirming the angiogenesis and immune response deficit observed in Down syndrome individuals.

Enthusiasm for natural orifice transluminal endoscopic surgery (NOTES) has been partly tempered by the reality that most NOTES procedures to date have been laparoscopically assisted. After safely performing transvaginal cholecystectomy in an IACUC-approved porcine model, the authors embarked on an institution review board (IRB)-approved protocol for ultimate performance of pure NOTES cholecystectomy in humans. They describe their experience performing a true NOTES transvaginal cholecystectomy after safely accomplishing three laparoscopically assisted or hybrid procedures in humans. One of the patients was a 35-year-old woman presenting with symptoms of biliary colic. Ultrasound confirmed gallstones, and her liver enzymes were normal. Pneumoperitoneum to 15 mmHg was obtained via a transvaginal trocar placed through a colpotomy made under direct vision. A double-channel endoscope then was advanced into the abdomen. To overcome the retracting limitations of currently available endoscopes, the authors used an extra-long 5-mm articulating retractor placed into the abdomen via a separate colpotomy made under direct vision using the flexible endoscope in a retroflexed position. Endoscopically placed clips were used for control of both the cystic duct and the artery. These techniques obviated the need for any transabdominally placed instruments or needles. This patient was the first to undergo a completely NOTES cholecystectomy at the authors' institution, and to their knowledge, in the United States. She was discharged on the day of surgery and at this writing has not experienced any complication after 1 month of follow-up evaluation. Performance of NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe for humans. Additional experience with this technique are required before studies comparing it with standard laparoscopy and hybrid techniques are appropriate.

Lumbar hernias, rarely seen in clinical practice, can be acquired after open or laparoscopic flank surgery. We describe a successful laparoscopic preperitoneal mesh repair of multiple trocar-site hernias after extraperitoneal nephrectomy. All the key steps including creating a peritoneal flap, reducing the hernia contents, and fixation of the mesh are described. A review of the literature on this infrequent operation is presented. Laparoscopic repair of lumbar hernias has all the advantages of laparoscopic ventral hernia repair.

Background: The current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m(2) or BMI >35 kg/m(2) with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it., Methods: An institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30-35 kg/m(2) and co-morbidities (n = 22) or a BMI of 35-40 kg/m(2) without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups., Results: The average BMI for the study group was 36.1 +/- 2.6 kg/m(2) compared with 46.0 +/- 7.3 kg/m(2) for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% +/- 9.0%, 28.5% +/- 14.0%, 44.7% +/- 19.3%, and 42.2% +/- 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities., Conclusion: Moderately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30-35 kg/m(2)., (Copyright 2010 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Studies have shown that type 2 diabetes (T2DM) improves or resolves shortly after Roux-en-Y gastric bypass (RYGB). Few data are available on T2DM recurrence or the effect of weight regain on T2DM status., Methods: A review of 42 RYGB patients with T2DM and >or=3 years of follow-up and laboratory data was performed. Postoperative weight loss and T2DM status was assessed. Recurrence or worsening was defined as hemoglobin A1c >6.0% and fasting glucose >124 mg/dL and/or medication required after remission or improvement. Patients whose T2DM recurred or worsened were compared with those whose did not, and patients whose T2DM improved were compared with those whose T2DM resolved., Results: T2DM had either resolved or improved in all patients (64% and 36%, respectively); 24% (10) recurred or worsened. The patients with recurrence or worsening had had a lower preoperative body mass index than those without recurrence or worsening (47.9 versus 52.9 kg/m2; P = .05), regained a greater percentage of their lost weight (37.7% versus 15.4%; P = .002), had a greater weight loss failure rate (63% versus 14%; P = .03), and had greater postoperative glucose levels (138 versus 102 mg/dL; P = .0002). Patients who required insulin or oral medication before RYGB were more likely to experience improvement rather than resolution (92% versus 8%, P

Background: Use of ultrasonic shears is currently the standard for advanced laparoscopic digestive surgery. The costs of medical care continue to increase, yet the amount of evidence-based information on cost differences in reusable and single-use equipment is scarce., Methods: All bariatric laparoscopic cases in our division that required the use of ultrasonic shears were observed during a 7-month period. The reusable and single-use scalpels were alternated weekly. Associated expenses (replacements, cleaning, sterilization), blood loss, complications, and ease-of-use were assessed. The total cost and cost per case for the two types of scalpels were calculated and compared., Results: Eighty-five cases with both the single-use and reusable scalpels were evaluated. Both groups of cases were comparable in type of surgeries and patient demographics. No significant difference in operation time (reusable, 156 +/- 15 min; single-use, 174 +/- 15 min; p = 0.34) or ease-of-use was noted. The equipment failure rate (one replacement each), complications, and estimated blood loss (reusable, 63 +/- 11 mL; single-use, 83 +/- 12 mL; p = 0.06) were similar. A total cost saving of $15,163 resulted from the use and processing of the reusable equipment. Using the reusable shears for 85 cases, the cost-per-case saving was $196.40., Conclusions: The reusable scalpel had a cost saving over single-use scalpel that increased with the number of cases. The reusable scalpel resulted in significant cost savings without impact on complication rate and ease-of-use.

Background: The aim of this study was to evaluate the effect of sleeve gastrectomy (SG) and duodenal-jejunal bypass (DJB) on glucose homeostasis and to evaluate the utility of positron emission tomography (PET) scanning for assessing beta-cell mass., Methods: Goto-Kakizaki rats were divided into 4 groups: control, sham, SG, or DJB. Oral glucose tolerance, insulin, and glucagon-like peptide-1 (GLP-1) were measured before and after surgery. Before and 90 days after treatment, [(11)C] DTBZ micro PET scanning was performed., Results: The control and sham animals gained more weight compared with SG and DJB animals (P < or = .05). Compared with control animals, the glucose area under the curve was lower in DJB animals 30 and 45 days after operations (P < or = .05). At killing, GLP-1 levels were greater in the DJB group compared with sham and SG (P < or = .05), whereas insulin levels were greater in both DJB and SG compared with sham (P < or = .05). With PET scanning, the 90-day posttreatment mean vesicular monoamine transporter type 2 binding index was greatest in the DJB animals (2.45) compared with SG (1.17), both of which were greater than baseline control animals (0.81)., Conclusion: In type 2 diabetic rodents, DJB leads to improved glucose homeostasis and an increase in VMAT2 density as measured by PET scanning., (Copyright 2010 Mosby, Inc. All rights reserved.)

Background: Laparoscopic adjustable gastric banding (LAGB) approved 6 years ago by the Federal Drug Administration is considered a safe and simple procedure for weight loss with a reported low mortality rate (0.05%) in the literature. The aim of the study was to probe the membership of the American Society for Bariatric Surgery (ASBS) to elucidate the incidence and possible causes of unreported operative and late mortality., Methods: A simple questionnaire on early (30 days) and late mortality after LAGB and reoperation for banding was sent to 1,437 of 2,500 members of ASBS. Incidences and causes were studied., Results: Of the 1,437 questionnaires sent, 453 (31%) were returned. Sixty-eight of the surgeons did not do any LAGBs, 350 had no operative mortalities, and 35 (9%) reported at least one operative mortality and had a total of 36 operative deaths and 19 late deaths, for a grand total of 55. Five additional deaths occurred after reoperations for LAGB, following removal, revisions, or conversions to another bariatric procedure. Of 62 deaths, the causes were: 20 (33%) cardiac origin, 11 (18%) thromboembolic, ten (16%) GI perforations, three (5%) bleedings, and 18 miscellaneous. Of all deaths, 40% occurred remotely from the band insertion date., Conclusions: Although LAGB is technically simple, it carries a non-negligible short- and long-term mortality, with the majority being cardiac or thromboembolic. Late mortalities from LAGB and reoperations appear to be under-reported.

CEST imaging is a recently introduced MRI contrast modality based on the use of endogenous or exogenous molecules whose exchangeable proton pools transfer saturated magnetization to bulk water, thus creating negative contrast. One of the critical issues for further development of these agents is represented by their limited sensitivity in vivo. The aim of this work is to improve the detection of CEST agents by exploring new approaches through which the saturation transfer (ST) effect can be enhanced. The performance of the proposed methods has been tested in vitro and in vivo using highly sensitive and highly shifted lipoCEST agents, and the results were compared with the standard ST evaluation mode. The acquired Z-spectra were interpolated locally and voxel-by-voxel by smoothing splines. Besides expressing the ST in the standard mode, we explore two methods, enhanced and integral ST, which better exploit all the information contained in the Z-spectrum. By combining different modes for ST assessment a significant improvement in the detection of the lipoCEST agents, both in vitro and in vivo, has been found. The results obtained from the application of the proposed methods outline the importance of post-processing analysis for highlighting the CEST-MRI contrast.

Introduction: We present a new technique for the surgical treatment of haemorrhoids, consisting of the repositioning of haemorrhoid cluster, using a rotating Proctoscope called Hemor Pex System((R)) (HPS). This procedure is performed as an outpatient procedure, with minimal postoperative pain and rapid integration into working life., Objectives: To present the experience with this technique during 3 years of follow up in two institutions in Genoa, Italy., Patients and Methods: from January 2003 to June 2006, 1112 patients with grade II, III and IV haemorrhoids were operated on using the HPS technique, in two different hospitals. Prospectively analyzed the following parameters: postoperative pain, incidence of complications and recurrence of symptoms., Results: A total of 1112 patients were operated, of whom 719 have completed the follow-up. The mean age was 47 years. In 92% of cases the intervention was performed under local anaesthesia. The average time of surgery time was 20+/-5min. A total of 97% of patients were discharged at 6h after surgery. The immediate postoperative pain, according to the Visual Analogue Scale (VAS): absent (0) in 38 cases, slight (1-3) in 431 cases, 218 medium and intense in 32 cases., Conclusions: We believe HPS is a safe procedure, with a short learning curve for surgeons, and in particular leads to a great reduction in post-operative pain for the patient.

Controversy exists as to the role of minimally invasive techniques in the management of early gallbladder cancer. The majority of early gallbladder cancers are diagnosed upon final pathology after laparoscopic cholecystectomy. For stage pT1a tumors, no further surgery is warranted; however, for pT1b or greater lesions, patients usually undergo port-site excisions and completion of open radical cholecystectomy involving a partial hepatectomy of segments IV and V and a lymphadenectomy of the hepatoduodenal ligament. Presented in this paper is a totally laparoscopic radical cholecystectomy performed for suspected early gallbladder cancer. Despite the fact that a preoperative serum IgG4 level was within normal limits, final pathology was consistent with autoimmune cholecystitis. As a result, the laparoscopic radical cholecystectomy may be useful in select patients with a preoperative suspicion of early-stage gallbladder cancer by sparing them the necessity of a second-stage open procedure.

Introduction: Initial excitement for Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been partly tempered by the reality that a NOTES procedure without laparoscopic or needleoscopic-assistance has not been performed by most groups. After safely performing laparoscopically-assisted transvaginal cholecystectomy in an IACUC-approved porcine model, we embarked on an IRB-approved protocol to ultimately perform a pure NOTES cholecystectomy., Materials and Methods: We describe our experience with performing a true NOTES tansvaginal cholecystectomy after safely accomplishing 3 laparoscopically-assisted hybrid NOTES procedures in humans. To overcome the retracting limitations of currently available endoscopes, we used a 5-mm curved or articulating retractor that was placed into the abdomen via a separate colpotomy in the second and third patient. In a fourth patient, pneumoperitoneum to 15 torr was obtained via a transvaginal trocar placed through a colpotomy made under direct vision and endoscopically placed clips were used for both the cystic duct and artery, thus, obviating the need for any transabdominally placed instruments or needles., Results: This patient was the first patient to undergo a completely NOTES cholecystectomy at our institution and to our knowledge in the United States. She was discharged on the day of surgery and has not suffered any complication after 1 month of follow-up., Conclusion: Pure NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe in humans. Additional experience with this technique will be required before comparative studies to standard laparoscopy and hybrid techniques are appropriate.

A recently convened Consortium at the Cleveland Clinic agreed on the term Laparo-Endoscopic Single-Site (LESS) surgery to describe minimally invasive techniques that use a single incision to accomplish laparoscopic procedures. These procedures are done by using either a single port through one fascial incision or multiple ports placed through separate fascial incisions. Because of cost containment issues and the lack of widespread availability of a single port, we currently use multiple reusable ports placed through three separate fascial incisions via a transumbilical incision. As opposed to standard laparoscopic cholecystectomy, a deflecting laparoscope and one articulating instrument are utilized to improve the safety and ease of this procedure. Presented in this video are the steps necessary to perform a LESS cholecystectomy via a transumbilical incision with commercially available instruments.

Background: Type 2 diabetes mellitus is a worldwide healthcare problem with major socioeconomic implications. Metabolic surgical procedures have been shown to improve diabetes, but the mechanism of action is poorly understood. The Goto-Kakizaki (GK) rodent is a type 2 diabetic animal model that is ideally situated for studying the effect of surgery on diabetes; however, the operative mortality is high. The aim of this study was to describe the operative technique, improvements in perioperative management, and the technique of micro-positron emission tomography (PET) scanning of the beta-cell mass in GK rodents., Methods: A total of 53 GK rats were divided into 1 of 3 operative groups: sham, sleeve gastrectomy, and duodenojejunal bypass. A subset of animals underwent micro-PET scanning with [11C]-dihydrotetrabenazine to determine the vesicular monoamine transporter 2 binding index, an indicator of beta-cell mass., Results: The 30-day mortality in the sham and sleeve gastrectomy rodents was 0; however, 2 sleeve gastrectomy rodents developed enterocutaneous fistula and 1 developed an abscess. In the duodenojejunal bypass group, the initial mortality rate was close to 90%; however, refinements in the surgical technique and perioperative management (fluids, antibiotics, pain control) lowered the mortality rate to 60%. The surgical technique is discussed in detail. [11C]-Dihydrotetrabenazine uptake in the pancreas was demonstrated on micro-PET scanning in the sham and duodenojejunal bypass rodents., Conclusion: Intensive medical management in the perioperative period and attention to the operative technique lowered the mortality. [11C]-Dihydrotetrabenazine micro-PET scanning is a feasible method for assessing the beta-cell mass in GK rodents and could prove to be an important modality for evaluating beta-cell performance in type 2 diabetes.

Natural orifice transluminal endoscopic surgery (NOTES) is considered the new frontier for minimally invasive surgery. NOTES procedures such as peritoneoscopy, splenectomy, and cholecystectomy in animal models have been described. The aim of our experiment was to determine the feasibility and technical aspects of a new endoluminal surgical procedure. After approval from Columbia's IACUC, a transvaginal laparoscopically assisted endoscopic cholecystectomy was performed on four 30 kg Yorkshire pigs. The first step was to insert a 1.5 cm endoscope into the vagina under direct laparoscopic vision. Then the gallbladder was reached and, with the help of a laparoscopic grasper to hold up the gallbladder, the operation was performed. At the end of the procedure the gallbladder was snared out through the vagina attached to the endoscope. There were no intraoperative complications such as bleeding, common bile duct or endo-abdominal organ damage. Total operative time ranged between 110 and 155 min. Based on our experience in the porcine model, we believe that a transvaginal endoscopic cholecystectomy is feasible in humans.

Background: Esophageal dilation can occur after laparoscopic adjustable gastric banding (LAGB). There are few studies in the literature that describe the outcomes of patients with esophageal dilation. The aim of this article is to evaluate weight loss and symptomatic outcome in patients with esophageal dilation after LAGB., Methods: We performed a retrospective chart review of all LAGBs performed at Columbia University Medical Center from March 2001 to December 2006. Patients with barium swallow (BaSw) at 1 year after surgery were evaluated for esophageal diameter. A diameter of 35 mm or greater was considered to be dilated. Data collected before surgery and at 6 months and 1, 2 and 3 years after surgery were weight, body mass index (BMI), status of co-morbidities, eating parameters, and esophageal dilation as evaluated by BaSw., Results: Of 440 patients, 121 had follow-up with a clinic visit and BaSw performed at 1 year. Seventeen patients (10 women and 7 men) (14%) were found to have esophageal dilation with an average diameter of 40.9 +/- 4.6 mm. There were no significant differences in percent of excess weight lost at any time point; however, GERD symptoms and emesis were more frequent in patients with dilated esophagus than in those without dilation. Intolerance of bread, rice, meat, and pasta was not different at any time during the study., Conclusions: In our experience the incidence of esophageal dilation at 1 year after LAGB was 14%. The presence of dilation did not affect percent excess weight loss (%EWL). GERD symptoms and emesis are more frequent in patients who develop esophageal dilation.

Increasing evidence indicates that mammalian SIRT1 mediates calorie restriction and influences lifespan regulating a number of biological molecules such as FoxO1. SIRT1 controls the angiogenic activity of endothelial cells via deacetylation of FoxO1. Endothelial dysfunction and reduced new blood vessel growth in diabetes involve a decreased bioactivity of endothelial progenitor cells (EPCs) via repression of FoxO1 transcriptional activity. The relative contribution of SIRT1 with respect to the direct effects of high glucose on EPC number is poorly understood. We report that treatment of EPCs with high glucose for 3 days determined a consistent downregulation of EPC positive to DiLDL/lectin staining and, interestingly, this was associated with reduced SIRT1 expression levels and enzyme activity, and increased acetyl-FoxO1 expression levels. Moreover, EPCs responded to high glucose with major changes in the expression levels of cell metabolism-, cell cycle-, and oxidative stress-related genes or proteins. Proteomic analysis shows increased expression of nicotinamide phosphoribosyl transferase and mitochondrial superoxide dismutase whereas a glucose-related heat shock protein is reduced. These findings show that SIRT1 is a critical modulator of EPCs dysfunction during alteration of glucose metabolism.

The water permeability of various liposome membranes has been determined at 298K by measuring the NMR longitudinal water proton relaxation rate of vesicles encapsulating the clinically approved Gd-HPDO3A complex (HPDO3A=10-(2-hydroxypropyl)-1,4,7,10-tetraazacyclododecane-1,4,7-triacetic acid). Two basic formulations based on DPPC (dipalmitoylphosphatidylcholine) and POPC (palmitoyl-oleylphosphatidylcholine) phospholipids were selected and investigated. Furthermore, the permeability changes caused by the membrane incorporation of amphiphiles like cholesterol and/or metal complexes of interest for designing improved liposome-based MRI contrast agents, were also investigated. The incorporation of cholesterol and metal complexes bearing C18 saturated chains in POPC-based liposomes reduces the water diffusivity across the membrane bilayer. On the contrary, the incorporation of a macrocyclic metal complex bearing four C12 alkylic chains, one for each coordination arm of the ligand, considerably enhances the water permeability in DPPC-based liposomes. Finally, it is reported that the permeability of POPC-based bilayer is increased when the liposomes are subjected to an osmotic stress.

Background: To describe the incidence, etiology, outcomes, and management of enteric leaks in patients who had undergone open or laparoscopic gastric bypass., Methods: From November 1996 to November 2006, 1133 patients underwent primary gastric bypass at Columbia University, New York-Presbyterian Hospital. A retrospective review of our prospective bariatric surgery registry identified 17 patients (1.5%) who developed a clinically apparent enteric leak after surgery. The demographic and outcome data were studied., Results: The mean body mass index was 52 kg/m(2) (range 35-65), and 15 (88%) of the 17 patients were women. The mean number of co-morbidities per patient was 1.3 and included hypertension in 11, diabetes in 9, and sleep apnea in 6. Ten patients had previously undergone abdominal surgery. The enteric leak was diagnosed by radiographic studies in 12 patients (9 of 12 by upper gastrointestinal series and 3 of 6 by computed tomography); the remaining 5 patients were diagnosed at re-exploration. Of the 17 patients, 12 (70%) were treated by laparoscopy and 5 (29%) by laparotomy. The mean time from completion of the index procedure to the diagnosis of the leak was 2 days (range 1-5) for patients treated by laparoscopy versus 4 days (range 1-6) for patients treated by laparotomy (P <.05). The patients treated by laparoscopy experienced a shorter hospital stay, but the difference was not statistically significant (mean 11.4 days, range 6-36, versus 18 days, range 7-33; P >.05). One of the laparoscopic patients (5.9%) died., Conclusion: Enteric leak is a significant complication after gastric bypass. Prompt treatment should be based on clinical suspicion, because contrast and cross-sectional imaging studies might not be reliable diagnostic tests. A laparoscopic index procedure might be associated with an earlier diagnosis.

Hypothesis: Laparoscopic liver surgery is significantly limited by the technical difficulty encountered during transection of substantial liver parenchyma, with intraoperative bleeding and bile leaks. This study tested whether the use of a bioabsorble staple line reinforcement material would improve outcome during stapled laparoscopic left lateral liver resection in a porcine model., Study Design: A total of 20 female pigs underwent stapled laparoscopic left lateral liver resection. In group A (n = 10), the stapling devices were buttressed with a bioabsorbable staple line reinforcement material. In group B (n = 10), standard laparoscopic staplers were used. Operative data and perioperative complications were recorded. Necropsy studies and histopathological analysis were performed at 6 weeks. Data were compared between groups with the Student's t-test or the chi-square test., Results: Operating time was similar in the two groups (64 +/- 11 min in group A versus 68 +/- 9 min in group B, p = ns). Intraoperative blood loss was significantly higher in group B (185 +/- 9 mL versus 25 +/- 5 mL, p < 0.05). There was no mortality. There was no morbidity in the 6-week follow-up period; however, two animals in group B had subphrenic bilomas (20%) at necropsy. At necropsy, methylene blue injection via the main bile duct revealed leakage from the biliary tree in four animals in group B and none in group A (p < 0.05). Histopathological examination of the resection site revealed minor abnormalities in group A while animals in group B demonstrated marked fibrotic changes and damaged vascular and biliary endothelium., Conclusion: Use of a bioabsorbable staple line reinforcement material reduces intraoperative bleeding and perioperative bile leaks during stapled laparoscopic left lateral liver resection in a porcine model.

Background: Laparoscopic adjustable gastric banding (LAGB) is 1 of the most used surgical procedures to treat obesity, with > 120,000 bands positioned around the world. LAGB is considered a safe and technically simple procedure, but it has many longterm complications, such as erosion, bleeding that requires reoperations, and sometimes even death of the patient., Study Design: This article reviews the deaths after LAGB reported in the literature. Eight hundred eighty articles were reviewed from 1994 to May 2006, using the PubMed Web site and French, English, and Australian health Web sites., Results: Data from 9,682 patients were collected from 24 articles and 48 (0.51%) deaths were reported. Twenty-eight patients died within 30 days of the operation, including 3 intraoperative deaths; 16 patients died 30 or more days after operation; and in 4 patients, the timing of death was not stated in the articles. Pulmonary embolism was the most frequent cause of death, in 11 (22.9%) patients, followed by myocardial infarction in 6 (12.5%) patients. Nine (18.7%) deaths were directly related to band positioning. Longterm mortality rates from LAGB, or reoperations from inadequate weight loss, could not be assessed., Conclusions: Although technically simple, LAGB has both short- and longterm complications that can be fatal for patients. We recommend surgeons consider perioperative pulmonary embolism prophylaxis and preoperative coronary evaluations on all patients.

Background: The safety and efficacy of laparoscopic sleeve gastrectomy followed by biliopancreatic diversion with duodenal switch for morbid obesity has been well established. We previously recommended 2-stage laparoscopic biliopancreatic diversion with duodenal switch for super-super obese patients. In the 2-stage version, these patients undergo laparoscopic sleeve gastrectomy as a first-stage procedure, followed by laparoscopic biliopancreatic diversion with duodenal switch as the second stage for more definitive treatment of their obesity. However, short-term weight regain may occur owing to gastric dilation after initial laparoscopic sleeve gastrectomy. The aim of this study was to prevent gastric dilation after sleeve gastrectomy. We designed a sleeve gastrectomy with wrapping using polytetrafluoroethylene dual mesh., Methods: Eleven Yorkshire pigs weighing 20-25 kg underwent sleeve gastrectomy with wrapping using polytetrafluoroethylene dual mesh (wrapping group) or sleeve gastrectomy only (control group) to compare the weight loss. The animals were weighed weekly postoperatively. Necropsy was performed 8 weeks postoperatively to confirm the wrapping by pathologic report., Results: Four pigs died because of staple line failure or strangulation; no perioperative complications occurred in the other pigs. The operative time for the control group was 198 +/- 60 minutes and for the wrapping group was 181 +/- 86 minutes (P = NS). The average weight of the removed stomach was 123.3 +/- 5.8 g in the control group and 140.3 +/- 69.9 g in the wrapping group (P = NS). The postoperative weight gain at 8 weeks was significantly slower in the wrapping group than in the control group (P <.0001). The pathologic necropsy report noted that the mesh was well attached to the stomach wall at 9 days postoperatively, with no unexpected deaths., Conclusion: Sleeve gastrectomy with wrapping using polytetrafluoroethylene dual mesh is feasible, and weight gain was reduced in the porcine model.

Circulating endothelial progenitor cells (EPCs) play a significant role in neovascularization of ischaemic tissues and in re-endothelization of injured blood vessels. Identification of compounds able to enhance EPC levels and improve their functional activity, noticeably compromised by risk factors for coronary heart disease, is of clinical interest. This study evaluates the effects of red wine on EPCs. After being isolated from total peripheral blood mononuclear cells, EPC phenotype was confirmed by the presence of double positive cells for DiLDL uptake and lectin binding and by expression of CD34, CD133 and VE-cadherin cell surface markers. Long-term culture in the presence of red wine (1 microl/ml), containing resveratrol (Resv) at physiological concentration (nM), determined a time-dependent amelioration of cell number (P < 0.05). The presence of red wine prevented the TNF-alpha-induced reduction of EPC number (P < 0.05) and this effect was accompanied by reduced p38-phosphorylation expression levels (P < 0.05) and increased NOx levels (P < 0.05) Indeed, pure Resv alone significantly improved the TNF-alpha reduced EPC number (P < 0.05). This evidence indicates novel beneficial effects of red wine and Resv in the positive modulation of EPCs levels.

The Gd(III) complexes of three new octadentate chelators, prepared by substitution of four, two, and one carboxylate groups of EGTA with phosphonate groups, have been investigated by 1H and 17O NMR relaxometric techniques in aqueous solutions. The analysis of the solvent proton relaxivity data as a function of pH, temperature, and magnetic field strength (nuclear magnetic relaxation dispersion (NMRD) profiles) in combination with the 17O transverse relaxation rate data at variable temperature allowed assessing the hydration state of the complexes, the occurrence of pH-dependent oligomerization processes for the tetraphosphonate derivative, the presence of a well-defined second sphere of hydration that markedly contributes to the relaxivity, and the values of the structural and dynamic relaxation parameters. In addition, in the case of the monophosphonate derivative the presence of a coordinated water molecule has allowed evaluation of the kinetic parameters of the exchange process, highly relevant for the possible use of this Gd(III) complex as an MRI probe. The rate of exchange of the water molecule, (298)k(ex) = 4.2 x 10(8)s(-1), is one of the highest measured so far for a nonacoordinate Gd(III) chelate and optimal for developing contrast-enhancing probes of high efficacy at high magnetic fields.

Purpose: We reviewed our experience of performing laparoscopic sleeve gastrectomy (LSG) in super-superobese (body mass index >60 kg/m(2)) patients and compared our results with those of laparoscopic adjustable gastric banding (LAGB) performed in similar patients., Methods: All LSGs performed by our group were reviewed retrospectively. We analyzed only patients whose preoperative body mass index (BMI) was greater than 60 kg/m(2) and compared the results with a report in the literature of super-super-obese patients treated with LAGB., Results: Between October 2000 and November 2005 we performed 63 LSGs for super-super-obese patients whose average preoperative BMI was 68 kg/m(2). By 6 months postoperatively, the average BMI had decreased to 58 kg/m(2). Forty-three patients subsequently underwent a second-stage duodenal switch procedure within 1 year. The BMI of the 20 patients who did not undergo further surgery decreased further to 50 kg/m(2), 1 year after the LSG., Conclusions: Laparoscopic sleeve gastrectomy is comparable with LAGB for promoting short-term weight-loss in the super-super-obese. The benefits of LSG over LAGB include a decreased need for reoperation; first, because foreign material is not implanted in the body; and second, because the residual ghrelin-producing gastric mass is much smaller.

One of the major advantages of the CEST methodology deals with the possibility of visualizing more probes in the same MR image voxels. This is a unique property within the contrast media that act on the (1)H-NMR signal of water protons, and it might considerably improve the potential of the technique. In addition to displaying sufficiently different resonance frequencies of their mobile protons, it is also important that the CEST agents designed for this application are highly sensitive. LIPOCEST agents represent the most sensitive class of CEST systems developed so far. On this basis, two LIPOCEST samples, a spherical one and an osmotically shrunken nonspherical one, endowed with markedly different resonance frequencies of their intraliposomal water protons, 3 ppm and 15 ppm, respectively, were prepared and tested both in vitro and in ex-vivo on a bovine muscle used as tissue-surrogate. The response of the two agents did not interfere each other, thus allowing the multiple visualization of the two agents present at nanomolar concentrations in the same image voxels., ((c) 2008 John Wiley & Sons, Ltd.)