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Background Excessive adiposity provides an inflammatory environment. However, in people with severe obesity, how systemic and local adipose tissue (AT)-derived cytokines contribute to worsening glucose tolerance is not clear. Methods Ninty-two severely obese (SO) individuals undergoing bariatric surgery were enrolled and subjected to detailed clinical phenotyping. Following an oral glucose tolerance test, participants were included in three groups, based on the presence of normal glucose tolerance (NGT), impaired glucose tolerance (IGT), or type 2 diabetes (T2D). Serum and subcutaneous AT (SAT) biopsies were obtained and mesenchymal stem cells (MSCs) were isolated, characterized, and differentiated in adipocytes in vitro. TNFA and PPARG mRNA levels were determined by qRT-PCR. Circulating, adipocyte- and MSC-released cytokines, chemokines, and growth factors were assessed by multiplex ELISA. Results Serum levels of IL-9, IL-13, and MIP-1β were increased in SO individuals with T2D, as compared with those with either IGT or NGT. At variance, SAT samples obtained from SO individuals with IGT displayed levels of TNFA which were threefold higher compared to those with NGT, but not different from those with T2D. Elevated levels of TNFα were also found in differentiated adipocytes, isolated from the SAT specimens of individuals with IGT and T2D, compared to those with NGT. Consistent with the pro-inflammatory milieu, IL-1β and IP-10 secretion was significantly higher in adipocytes from individuals with IGT and T2D. Moreover, increased levels of TNFα, both mRNA and secreted protein were detected in MSCs obtained from IGT and T2D, compared to NGT SO individuals. Exposure of T2D and IGT-derived MSCs to the anti-inflammatory flavonoid quercetin reduced TNFα levels and was paralleled by a significant decrease of the secretion of inflammatory cytokines. Conclusion In severe obesity, enhanced SAT-derived inflammatory phenotype is an early step in the progression toward T2D and maybe, at least in part, attenuated by quercetin.

Background: Bilio-intestinal bypass (BIBP) is an uncommon bariatric procedure. In 1999, a prospective trial was started at our institution to evaluate the effectiveness of BIBP. Trial was interrupted in 2006 due to high rate of complications. The aim of the present paper was to retrospectively review 10-year outcomes of BIBP. Methods: Retrospective review of bariatric database was performed to find patients that had undergone BIBP from 1999 to 2006. Data collected were as follows: age, gender, body weight, body mass index (BMI), percentage of excess weight loss (%EWL), remission from weight-related diseases, complications, and deaths at 1,3, 5, 7, and 10 years. Quality of life was evaluated using “BAROS” questionnaire. Results: From May 1999 to September 2006, 86 patients underwent BIBP. The mean age was 34.9 ± 22.4 years, and the initial weight and BMI were 141.2 ± 40.4 kg and 49.8 ± 15.5 kg/m 2 , respectively. After 10 years, the mean %EWL and BMI were 72.6 ± 18.7 and 31.2 ± 5.6 kg/m 2 . Almost all patients had diarrhea after surgery. Bloating syndrome occurred in 24% of patients, 48% had nephrolithiasis, and 20.9% had cholelithiasis. Remission from diabetes and hypertension was obtained in 75% and 80% of patients. Mortality was 3.2% and reoperation rate was 14.5%. Conclusions: Malabsorption plays a determinant role to obtain a long-lasting treatment for obese patients. However, BIBP is not recommendable due to high rate of complications and metabolic disorders.

Background Excessive adiposity provides an inflammatory environment. However, in people with severe obesity, how systemic and local adipose tissue (AT)-derived cytokines contribute to worsening glucose tolerance is not clear. Methods 92 severely obese (SO) individuals undergoing bariatric surgery were enrolled and subjected to detailed clinical phenotyping. Following an Oral Glucose Tolerance Test, participants were included in three groups, based on the presence of normal glucose tolerance (NGT), impaired glucose tolerance (IGT) or Type 2 Diabetes (T2D). Serum and subcutaneous AT (SAT) biopsies were obtained and Mesenchymal Stem Cells (MSCs) were isolated, characterized and differentiated in adipocytes in vitro. TNFA and PPARG mRNA levels were determined by qRT-PCR. Circulating, adipocyte- and MSC-released cytokines, chemokines and growth factors were assessed by multiplex ELISA. Results Serum levels of IL-9, IL-13 and MIP-1β were increased in SO individuals with T2D, as compared with those with either IGT or NGT. At variance, SAT samples obtained from SO individuals with IGT displayed levels of TNFA which were 3-fold higher compared to those with NGT, but not different from those with T2D. Elevated levels of TNFα were also found in differentiated adipocytes, isolated from the SAT specimens of individuals with IGT and T2D, compared to those with NGT. Consistent with the pro-inflammatory milieu, IL-1β and IP-10 secretion was significantly higher in adipocytes from individuals with IGT and T2D. Moreover, increased levels of TNFα, both mRNA and secreted protein, were detected in MSCs obtained from IGT and T2D, compared to NGT SO individuals. Exposure of T2D and IGT–derived MSCs to quercetin reduced TNFα levels and was paralleled by a significant decrease of the secretion of inflammatory cytokines. Conclusion In severe obesity, enhanced SAT-derived inflammatory phenotype is an early step in the progression toward T2D and may be, at least in part, attenuated by quercetin.

Excessive adiposity provides an inflammatory environment. However, in people with severe obesity, how systemic and local adipose tissue (AT)-derived cytokines contribute to worsening glucose tolerance is not clear.Ninty-two severely obese (SO) individuals undergoing bariatric surgery were enrolled and subjected to detailed clinical phenotyping. Following an oral glucose tolerance test, participants were included in three groups, based on the presence of normal glucose tolerance (NGT), impaired glucose tolerance (IGT), or type 2 diabetes (T2D). Serum and subcutaneous AT (SAT) biopsies were obtained and mesenchymal stem cells (MSCs) were isolated, characterized, and differentiated in adipocytes in vitro. TNFA and PPARG mRNA levels were determined by qRT-PCR. Circulating, adipocyte- and MSC-released cytokines, chemokines, and growth factors were assessed by multiplex ELISA.Serum levels of IL-9, IL-13, and MIP-1β were increased in SO individuals with T2D, as compared with those with either IGT or NGT. At variance, SAT samples obtained from SO individuals with IGT displayed levels of TNFA which were threefold higher compared to those with NGT, but not different from those with T2D. Elevated levels of TNFα were also found in differentiated adipocytes, isolated from the SAT specimens of individuals with IGT and T2D, compared to those with NGT. Consistent with the pro-inflammatory milieu, IL-1β and IP-10 secretion was significantly higher in adipocytes from individuals with IGT and T2D. Moreover, increased levels of TNFα, both mRNA and secreted protein were detected in MSCs obtained from IGT and T2D, compared to NGT SO individuals. Exposure of T2D and IGT-derived MSCs to the anti-inflammatory flavonoid quercetin reduced TNFα levels and was paralleled by a significant decrease of the secretion of inflammatory cytokines.In severe obesity, enhanced SAT-derived inflammatory phenotype is an early step in the progression toward T2D and maybe, at least in part, attenuated by quercetin.

Purpose: In the last decade contrast-enhanced magnetic resonance imaging (MRI) has gained a growing role as a complementary tool for breast cancer diagnosis. Currently the relationship between the kinetic features of a breast lesion and pathologic prognostic factors has become a popular field of research. Our aim is to verify whether breast MRI could be considered a useful tool to predict Ki-67 score, thus resulting as a breast cancer prognosis indicator. Methods: From June to December 2014, we enrolled patients with breast cancer who underwent preoperative dynamic contrast-enhanced MRI at the local health agency. We analyzed the time-signal intensity curves calculating the mean values of the following parameters: the basal enhancement (Ebase), the enhancement ratio (ENHratio), the maximum enhancement (Emax), and the steepest slope of the contrast enhancement curve (Smax). Scatterplots and Pearson correlation test were used to investigate the eventual associations among these parameters. Results: A total of 27 patients underwent breast MRI during the study period. The mean ± SD Ki-67 percentage was 27.03 ± 16.8; the mean Emax, Smax, Ebase, and ENHratio were 433.9 ± 120.2, 267.3 ± 96.8, 165.5 ± 77.1, and 187.1 ± 94.8, respectively. Scatterplots suggest a positive correlation between Ki-67 and both Emax and Smax. The correlation tests between Ki-67 and Emax, Ki-67 and Smax showed statistical significance. Conclusions: Our preliminary data suggest that enhancement pattern is closely linked to breast cancer proliferation, thus proving the relationship between more proliferating tumors and more rapidly enhanced lesions. This is hypothesis-generating for further studies aimed at promoting breast MRI in the early estimation of cancer prognosis and tumor in vivo response to chemotherapy.

Introduction: Bariatric surgery is considered the most effective treatment for obesity. A recent worldwide survey demonstrated that Laparoscopic Sleeve Gastrectomy (LSG) is the most commonly performed bariatric procedure, while Laparoscopic Adjustable Gastric Banding (LAGB) has been almost abandoned. Objectives: The aim of this retrospective study was to compare 5-year results of LSG and LAGB at our Institution. Materials and Methods: Prospective maintained database of our Institution was reviewed to find all patients who had undergone LSG between January 2009 and December 2011. Inclusion criteria were BMI of 40–50 kg/m2 and age of 18–60 years old. Patients with Class I and II obesity, superobese subjects, and patients with previous history of bariatric surgery were excluded. Data on sex, age, pre-operative BMI, obesity-related diseases (diabetes, hypertension, dyslipidemia), and early and late complications were collected. Each subject who underwent LSG was matched one-to-one with a patient that had undergone LAGB. Outcomes were analyzed at 1, 3, and 5 years of follow-up. Results: A total number of 122 patients were included in this study, 61 in each group. Better %EWL was observed in the LSG group at 1, 3, and 5 years. Both procedures induced improvements of obesity-related diseases without significant difference. In the LAGB group, ten patients underwent uneventful band removal. In the LSG group, two patients had serious postoperative complications. Conclusion: LSG achieves better %EWL than LAGB within 5 years, but comorbidities improvement is not significantly different. Severity of complication is higher after LSG. LAGB is still a good option for selected patients.

Conflict of interest statement: Authors state no conflict of interest. Luigi Sivero: Participated substantially in the conception, design and execution of the study and in the analysis and interpretation of data; also participated substantially in the drafting and editing of the manuscript. Giuseppe Galloro: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data. Simona Ruggiero: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data. Donato Alessandro Telesca: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data. Teresa Russo: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data. Maurizio Amato: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data. Immacolata Di Palma: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data. Speranza Iovino: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data. Bruno Amato: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data. Stefania Sivero: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data. Pietro Forestieri: Participated substantially in the conception, design, and execution of the study and in the analysis and interpretation of data.

Introduction: The American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation of Surgery for Obesity (IFSO) have both stated that bariatric surgery (BS) should not be denied in Class I patients. However, lifestyle intervention (LI), such as diet plus gym programs, is still considered the preferred approach for subjects with a BMI ranging from 30 to 35 kg/m2. The aim of this study was to retrospectively compare results of LI and BS in patients in Class I obesity. Methods: Retrospective analysis of prospective maintained databases of two centers for the “Interdisciplinary Treatment of Obesity” was performed. All patients in Class I obesity and follow-up >7 years were included in the study. Subjects were divided into two groups: BS group that included patients who had undergone surgery and LI group that included patients who underwent lifestyle intervention (LI). Percentage of excess body mass index loss (ëMIL) and comorbidities remission were recorded. Results: Seventy-six patients were included in the study. Fifty-six subjects were submitted to surgery (BS group); 20 subjects were treated with nonsurgical approach (LI group). In BS group, 34 underwent laparoscopic adjustable gastric band, 13 laparoscopic sleeve gastrectomy (LSG), and 9 laparoscopic Roux-en-Y gastric bypass. EWL% resulted significantly higher in BS group at 1, 3, 5, 7 and 10 years (p < 0.01). Conclusion: Bariatric surgery is more effective than LI for patients in Class I obesity. Due to its versatility, low-risk profile and high-effectiveness LSG could be the standard intervention for these patients.

Introduction The spreading of laparoscopic surgery has increased the occurrence of trocar site hernias, along with their related complications. Bariatric surgery combines two important risk factors in hernia formation: obesity and complexity of port-site closure. Several techniques and devices have been proposed to close the trocar wounds to minimize the risk of hernia occurrence. Materials and methods The records of 624 obese patients who underwent laparoscopic bariatric procedures between January 2006 and December 2012 were retrospectively reviewed. In no patient was performed the closure of the fascial layers of trocar incisions. Weight, BMI, E%WL and onset of complications were monthly collected for the first year after the procedure, then every six month. Results 10 patients showed trocar site hernia, for an overall prevalence of 1.6%. The mean time of occurrence was 15 months. None developed intestinal obstruction or other complications as a consequence of the hernia. The mean time of follow-up was 54 months. The mean weight and BMI before interventions were 136.3 ± 17.7 kg and 46.0 ± 4.6 kg/m² respectively. The mean percentage of excess weight loss (E%WL) at one year was 45.9%. Conclusion We avoided complicating the wound closure with fascia closure, accepting the risks related to the BMI. So far our procedure for port-site closure is relatively simple, safe, less invasive, less time-consuming and costless. These advantages could arise from the fact that our patients benefit from a remarkable weight loss after the intervention thus reducing one of the most important risk factors in the onset of trocar site hernia.

Sentinel lymph node biopsy (SLNB) is a minimally invasive technique to stage the axillary lymph node status. The burden of nodal metastasis is of great concern, as the clinical relevance and therapeutic implications of pN1mi and pN0(i+) in the sentinel lymph node (SLN) remain a matter of debate.We examined the pathological features of 901 patients above the age of 65 presenting with clinical T1-T2 N0M0 breast tumours (3 cm), detecting tumours related to llary non-sentinel node (NSN) metastases when the SLN was minimally involved.A total of 270 patients underwent complete axillary lymph node dissection (cALND) after their SLNB specimen tested positive for macrometastasis, micrometastasis and isolated tumour cells (ITCs). Seventy-six patients were diagnosed with micrometastatic disease pN1mi (27.5%), whilst ITCs (pN0i+) were detected in seven patients (2.5%). NSNs were found to be involved in two patients (2.6%) with micrometastases at the SLN. No further metastatic disease was detected in NSNs when the SLN contained ITCs. At a median follow-up period of 5.8 years, no axillary recurrence was observed among pN1mi and pN0(i+) patients. Lobular histotype, multicentricity and lymphovascular invasion were found to be associated with NSN involvement.The results from our case series are supported by IBCSG 23-01 level 1 evidence, which demonstrated a local recurrence rate of 1% in 'minimally involved not-surgical treated axilla'.Based on current evidence, we spare well-informed and consenting patients from further axillary surgery when the SLN is minimally involved in early breast cancer within an agreed protocol, whilst scheduling adjuvant treatment based on the patients' primary tumour characteristics.

Epigenetic modifications alter transcriptional activity and contribute to the effects of environment on the individual risk of obesity and Type 2 Diabetes (T2D). Here, we have estimated the in vivo effect of a fat-enriched diet (HFD) on the expression and the epigenetic regulation of the Ankyrin repeat domain 26 (Ankrd26) gene, which is associated with the onset of these disorders. In visceral adipose tissue (VAT), HFD exposure determined a specific hyper-methylation of Ankrd26 promoter at the −436 and −431 bp CpG sites (CpGs) and impaired its expression. Methylation of these 2 CpGs impaired binding of the histone acetyltransferase/transcriptional coactivator p300 to this same region, causing hypo-acetylation of histone H4 at the Ankrd26 promoter and loss of binding of RNA Pol II at the Ankrd26 Transcription Start Site (TSS). In addition, HFD increased binding of DNA methyl-transferases (DNMTs) 3a and 3b and methyl-CpG-binding domain protein 2 (MBD2) to the Ankrd26 promoter. More importantly, Ankrd26 down-regulation enhanced secretion of pro-inflammatory mediators by 3T3-L1 adipocytes as well as in human sera. Thus, in mice, the exposure to HFD induces epigenetic silencing of the Ankrd26 gene, which contributes to the adipose tissue inflammatory secretion profile induced by high-fat regimens.

Background. Laparoscopic adjustable gastric banding (LAGB) results in significant lasting weight loss and improved metabolism in obese patients. To evaluate whether epigenetic factors could concur to these benefits, we investigated the subcutaneous adipose tissue (SAT) microRNA (miRNA) profile before (T0) and three years (T1) after LAGB in three morbidly obese women. Case Reports. SAT miRNA profiling, evaluated by TaqMan Array, showed four downexpressed (miR-519d, miR-299-5p, miR-212, and miR-671-3p) and two upexpressed (miR-370 and miR-487a) miRNAs at T1 versus T0. Bioinformatics predicted that these miRNAs regulate genes belonging to pathways associated with the cytoskeleton, inflammation, and metabolism. Western blot analysis showed that PPAR-alpha, which is the target gene of miR-519d, increased after LAGB, thereby suggesting an improvement in SAT lipid metabolism. Accordingly, the number and diameter of adipocytes were significantly higher and lower, respectively, at T1 versus T0. Bioinformatics predicted that the decreased levels of miR-212, miR-299-5p, and miR-671-3p at T1 concur in reducing SAT inflammation. Conclusion. We show that the miRNA profile changes after LAGB. This finding, although obtained in only three cases, suggests that this epigenetic mechanism, by regulating the expression of genes involved in inflammation and lipid metabolism, could concur to improve SAT functionality in postoperative obese patients.

Introduction The breast and salivary gland tissue share embryologic and thus pathological similarities. Acinic cell carcinoma (ACC) is a typical tumor in salivary glands, but rarely arises in breast too. We reviewed 38 cases of mammary ACC reported in literature and our case, the first ACC born within a fibroadenoma. Materials and methods Data were collected by a research for the key words acinic cell carcinoma breast on Pubmed in March 2014, including a case treated in our department. All reviewed cases were compared for clinical approach and histological pattern. Results To date 23 articles presenting cases of ACC of the breast are reported in literature. We included in our review 38 cases previously described and one new case. The histological pattern was predominantly solid with a microglandular structure. All the tumor cells were cytologically characterized by monotonous round cells with a finely granular, weakly eosinophilic, or clearly vacuolated cytoplasm. The most of the cells were intensely stained with anti-lysozime, anti-amylase, anti-α1-chimotripsin, anti-EMA and anti-S100 protein antisera. Immunohistochemistry was also performed to point out: estrogen receptor (ER), progesterone receptor (PR), androgen receptors (AR), human epidermal growth factor receptor 2 overexpression (HER2/neu), E-cadherin (E-cad), cytokeratin-7 (CK7), gross cystic disease fluid protein 15 (GCDFP15), smooth muscle actin (SMA). Conclusion ACC of the breast is a rare tumor, showing similarities with the salivary gland counterpart, above all in terms of good prognosis, and differences from the ordinary invasive breast carcinoma. Further investigations are needed to elucidate the true histogenesis and the correct treatment.

Background: Significant and sustained excess weight loss (EWL) appears to reduce the risk of obesity-related comorbidities (insulin resistance, hyperlipidemia, and inflammation), but this has been primarily shown in adult diabetic obese patients. We evaluated whether the EWL obtained 3 years after laparoscopic adjustable gastric banding (LAGB) improves the metabolic phenotype in nondiabetic morbidly obese (NDMO) individuals from south Italy. Methods: Serum and subcutaneous adipose tissue (SAT) samples from 20 obese individuals (median BMI = 41.5 kg/m2) before (T0) and after LAGB (T1) and from 10 controls (median BMI = 22.8 kg/m2) were taken. Serum leptin, adiponectin, C reactive protein (CRP), and main analyte levels were evaluated by routine methods or immunoassay. In SAT, adipocyte size was measured by hematoxylin/eosin staining, cluster of differentiation 68 (CD68) macrophage infiltration marker by immunohistochemistry, and adiponectin, adiponectin receptors 1 and 2, and interleukin 6 (IL6) messenger RNAs by qRT-PCR. Results: The average EWL was 66.7 %, and CRP, triglycerides, hepatic markers, leptin levels, homeostasis model assessment, and the leptin/adiponectin ratio were lower (p < 0.05) at T1 than at T0. The expression of small adipocytes and adiponectin was increased (p < 0.05), and inflammation markers (CD68 and IL6) decreased (p < 0.05) at T1 vs. T0. At linear regression multivariate analysis, over 90 % (R2 = 0.905) of EWL (dependent variable) was explained by CD68, adiponectinemia, triglyceridemia, CRP, and total protein levels. Conclusions: The EWL obtained 3 years after LAGB resulted in an improvement of lipid metabolism and a reduction of inflammation in NDMO patients, thereby decreasing the risk of obesity-associated diseases.

La diffusione epidemica dell’obesitapediatrica, con la precoce insorgenza di co-morbilita, ha favorito l’estensione delle procedure bariatriche in eta adolescenziale. La chirurgia bariatrica deve pero fare parte di un programma multidisciplinare che valuti pre- e post-operativamente l’adolescente obeso e la sua famiglia. Aspetti nutrizionali, psicologici ed endocrino-metabolici, oltre che chirurgici, rendono particolarmente complesso il management chirurgico dell’obesita adolescenziale.

The 2 L polyethylene glycol (PEG) lavage solution has been proved to be similarly safe and effective as 4 L PEG formulations, in spite of the reduced volume.To compare low-volume PEG-based solution combined with ascorbic acid with high-volume PEG-based solution combined with simethicon in terms of efficacy and patient tolerability.This was a single-blind prospective randomized trial. Patients were randomized to receive either 2 L PEG plus ascorbic acid (PEG+Asc) or 4 L PEG plus simethicon (PEG+Sim). The primary endpoint was overall colon cleansing evaluation, assessed by blinded investigators using Aronchick score. Secondary end points included patient compliance and tolerability and adverse events.Sixty patients received PEG+Asc and 60 received PEG+Sim. Overall bowel cleansing score was considered adequate in 81.67% of the PEG+Asc and 80% of the PEG+Sim groups, respectively. Excellent and good ratings were recorded in 11.6% and 38.3% receiving PEG+Asc as compared with 26.6% and 23.3% of patients receiving PEG+Sim. Patient tolerability and safety were similar with both the preparations.According to our data, low-volume PEG+Asc has comparable efficacy, safety, and tolerability as high-volume PEG+Sim; therefore, it can be considered as a good alternative solution for bowel preparation. More improvements are necessary to achieve the target of a perfect preparation.

Laparoscopic adjustable gastric banding (LAGB) is a well-established and effective bariatric procedure, whose outcomes can be compromised by the slippage and the following removal of the band; the association between LAGB and gastric plication has recently been proved as a successful treatment for morbid obesity. The aim of this prospective randomized study was to compare weight loss and slippage rate between LAGB and LAGB plus anterior fundoplication.From January 2012 to May 2012, a total of 40 patients were allocated to undergo either LAGB (group A, n=20) or LAGB plus anterior fundoplication (group B, n=20). Data on the operative time, complications, hospital stay, total weight loss percentage (%TWL), percentage of excess weight loss (%EWL), and improvement of comorbidities were collected at 6, 12, and 36 months of follow-up.All procedures were completed laparoscopically, and no significant difference of mean operative time was found between the 2 groups. The mean hospital stay was longer in group B than in group A (2.3±0.8 vs. 1.4±0.7 d, P0.005). Greater weight loss was found in group B rather than in group A at 6, 12, and 36 months. Obesity related comorbidities improved in both groups. Number of band regulations and slippage rate were lower in group B.Our experience shows that 36 months after surgery LAGB plus anterior fundoplication increases weight loss and reduces the slippage rate.

The discovery of the anti-proliferative activity of nelfinavir in HIV-free models has encouraged its investigation as anticancer drug. Although the molecular mechanism by which nelfinavir exerts antitumor activity is still unknown, its effects have been related to Akt inhibition. Here we tested the effects of nelfinavir on cell proliferation, viability and death in two human breast cancer cell lines and in human normal primary breast cells. To identify the mechanism of action of nelfinavir in breast cancer, we evaluated the involvement of the Akt pathway as well as the effects of nelfinavir on reactive oxygen species (ROS) production and ROS-related enzymes activities. Nelfinavir reduced breast cancer cell viability by inducing apoptosis and necrosis, without affecting primary normal breast cells. The antitumor activity of nelfinavir was related to alterations of the cell redox state, coupled with an increase of intracellular ROS production limited to cancer cells. Nelfinavir treated tumor cells also displayed a downregulation of the Akt pathway due to disruption of the Akt-HSP90 complex, and subsequent degradation of Akt. These effects resulted to be ROS dependent, suggesting that ROS production is the primary step of nelfinavir anticancer activity. The analysis of ROS-producers and ROS-detoxifying enzymes revealed that nelfinavir-mediated ROS production was strictly linked to flavoenzymes activation. We demonstrated that ROS enhancement represents the main molecular mechanism required to induce cell death by nelfinavir in breast cancer cells, thus supporting the development of new and more potent oxidizing molecules for breast cancer therapy.

BACKGROUND: At present, prospectively collected data on rhabdomyolysis (RML) after bariatric surgery are limited. OBJECTIVES: To evaluate the incidence, risk factors, and therapeutic strategy of RML in different bariatric procedures. SETTING: University hospitals, Italy. METHODS: Obese patients were prospectively enrolled. Preoperative demographic characteristics and clinical data, as well as type of anesthesia and type and total duration of surgery, were recorded as potential risk factors for RML. RML was defined as postoperative creatine kinase (CK)>1000 U/L. Incidence, possible risk factors, and therapeutic outcome of RML were assessed and compared with comparative groups. RESULTS: Four hundred eighty obese patients were included in the study. After surgery, RML was diagnosed in 62 (12.9%) patients. Muscular pain was present in 12 patients (19.3%). In RML patients, mean CK value was 1346±2132.5 U/L (range 1191-37,400). Only duration of surgery was identified as an independent risk factor for RML (P230 minutes. CK testing should be performed in all patients after bariatric surgery to make an early diagnosis and properly start fluids and diuretics.

Obesity is a consequence of imbalance of food intake and energy expenditure that results in storage of energy as fat, primarily in adipose tissue. MicroRNAs are non-coding RNAs that regulate gene expression in metabolic pathways and they are also involved in fat-cell development. The aim of this study was to evaluate whether microRNA dysfunction contributes to obesity. We analyzed, by microarray, the expression profile of 1,458 microRNAs in subcutaneous adipose tissue (SAT) from nondiabetic severely obese (n = 20) and nonobese adults (n = 8). Among 42 differently expressed microRNAs, we confirmed by reverse-transcription PCR (RT-PCR) that miR-519d was overexpressed whereas the protein levels of peroxisome proliferator-activated receptor-alpha (PPARA) (a predicted miR 519d target) were lower, at western analysis, in severely obese vs. nonobese subjects. We also show that miR-519d specifically and dose-dependently suppressed translation of the PPARA protein, and increased lipid accumulation during preadipocyte differentiation. Because PPARA plays a central role in fatty acid homeostasis, and in the transcriptional regulation of genes that are necessary for maintenance of the redox balance during the oxidative catabolism of fatty acids, we suggest that PPARA loss and miR-519d overexpression could be associated with metabolic imbalance and subsequent adipocyte hypertrophy in SAT during obesity.

Introduction Recent reports have demonstrated improvement in the 5-years serviva with resecate ductal adenocarcinoma. The aim of study is to determinate the factor influencing long-term survival after DCP. Materials and methods We have critically reviewed a group of 85 patients how were admitted to our department with diagnosis of ductal adenocarcinoma of the head of pancreas between January 1974 and January 1998. Results Patients were stratified according to stage using TNM classification; in stage I 31 patients with 5 T1aN0M0 disease, 11 patients with T1bN0M0 and 15 patients T2N0M0 disease. By contrast, in stage III 54 patients with 48 patients T2N1M0 and 6 patients with T3N1M0. Tumour size was recorded for 72 patients with a median of 3.8 cm. The R1 dissection was performed in 67 patients. The R2 resection was performed in 18 patients. In our series we verified and analysed the histopathologic features of 5 patients with 15-years survival (5.8%). The features regard age, male or female, tumours size, stage and positive lymph node resection. Discussion We found a specifically subset of patients where the combination of prognostic factors, in particular, negative surgical margins R0, tumour size ≤30 mm and the absence of lymph node metastasis independently reduced the mortality indicating that earlier tumour detection and histologically curative resection are important factors contributing to long term survival and healing of ductal adenocarcinoma of the head of the pancreas.

Background : Indications for endoscopic snare papillectomy (ESP) remain controversial. Main concerns with ESP are related to the incomplete removal of the lesion, high recurrence rates and inadequate oncological resection. Aim of the study is to report short and long term outcomes after endoscopic papillectomy in a single institutional series with strict inclusion criteria and a standardized technique. Methods : Patients with ampullary tumors who underwent endoscopic papillectomy over a 5 year period were reviewed. Inclusion criteria for endoscopic resection were: tumor diameter less than 3 cm, no endoscopic evidence of malignancy, absence of infiltration of biliary and pancreatic duct at pre-operative ERCP and tumor confined to the submucosa at EUS. An en-block resection was attempted in all cases, followed by a pancreatic stent insertion whenever possible. Results : Twenty-seven patients (10 female, mean age 68 y) have been identified. Ampullectomy was successfully performed in all the cases. En bloc resection was completed in 24 patients (88.8%), while 3 patients had a piecemeal resection. A pancreatic stent was successfully placed in all the patients. Five patients experienced complications, including bleeding (2 cases, 7.4%) and acute pancreatitis (3 cases, 11.1%). There was no procedure-related mortality. Histology revealed a poor prognosis in two patients, which were subsequently treated by duodenopancreatectomy. Over a long-term follow-up (median 18 months), one patient developed local recurrence, which was successfully treated with further endoscopic resection. Overall curative resection rate was 92.6%. Conclusions : Endoscopic ampullectomy allows resection of benign tumors and in situ carcinoma. Strict indications and a proper standardized technique seem to be key factors in order to achieve excellent short and long-term results.

Background: The Lap-Band System® is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI ≤ 35. We report the Italian multicentre experience with BMI ≤ 35 kg/m2 over the last 5 years. Patients and Methods: Data were obtained from 27 centres involved in the Italian Collaborative Study Group for Lap-Band System®. Detailed information was collected on a specially created electronic data sheet (MS Access 2000) on patients operated in Italy since January 1996. Items regarding patients with BMI ≤ 35 were selected. Data were expressed as mean ± SD except as otherwise indicated. Results: 225 (6.8%) out of 3,319 Lap-Band® patients were recruited from the data-base. 15 patients, previously submitted to another bariatric procedure (BIB =14; VBG= 1) were excluded. 210 patients were eligible for study (34M/176F, mean age 38.19±11.8, range 17-66 years, mean BMI 33.9±1.1, range 25.1-35 kg/m2, mean excess weight 29.5±7.1, range 8-41). 199 comorbidities were diagnosed preoperatively in 55/210 patients (26.2%). 1 patient (0.4%) (35 F) died 20 months postoperatively from sepsis following perforation of dilated gastric pouch. There were no conversions to laparotomy. Postoperative complications presented in 17/210 patients (8.1%). Follow-up was obtained at 6, 12, 24, 36, 48 and 60 months. At these time periods, mean BMI was 31.1±2.15, 29.7±2.19, 28.7±3.8, 26.7±4.3, 27.9±3.2, and 28.2±0.9 kg/m2 respectively. Co-morbidities completely resolved 1 year postoperatively in 49/55 patients (89.1%). At 60 months follow-up, only 1 patient (0.4%) has a BMI >30. Conclusions: Although surgical indications for BMI ≤ 35 remain questionable, the Lap-Band® in this study demonstrated that all but 1 patient achieved normal weight, and most lost their co-morbidities with a very low mortality rate.

Background: The Lap Band system procedure is currently the most common bariatric surgical procedure worldwide. This is an interim report of the experience of the 27 Italian centers participating in the national collaborative study group for Lap Band® (GILB). Methods: An electronic database was specifically created. It was mailed and e-mailed to all of the surgeons now performing the laparoscopic gastric banding operation in Italy. Results: Beginning in January 1996, 1893 patients were recruited for the study. There were 1534 women and 359 men with a mean body mass index (BMI) of (range 30.4–83.6) and a mean age of 37.8 ± 10.9 years (range; 17–74). The mortality rate has been 0.53% (n = 10), mainly due to cardiovascular complications (myocardial infarction, pulmonary embolism). The laparotomic conversion rate has been 3.1% (59/1893) and was higher in superobese patients (BMI>50) than in to morbidly obese patients (BMI

Background Breast neoplasms include different histopathological entities, varying from benign tumors to highly aggressive cancers. Despite the key role of imaging, traditional histology is still required for a definitive diagnosis. Confocal Laser Endomicroscopy (CLE) is a new technique, which enables to obtain histopathological images in vivo, currently used in the diagnosis of gastrointestinal diseases. This is a single-center pilot feasibility study; the main aim is to describe the basic morphological patterns of Confocal Laser Endomicroscopy in normal breast tissue besides benign and malignant lesions. Methods Thirteen female patients (mean age 52.7, range from 22 to 86) who underwent surgical resection for a palpable breast nodule were enrolled. CLE was performed soon after resection with the Cellvizio® Endomicroscopy System (Mauna Kea Technologies, Paris, France), by using a Coloflex UHD-type probe; intravenous fluorescein was used as contrast-enhancing agent. The surgical specimen was cut along the main axis; dynamic images were obtained and recorded using a hand-held probe directly applied both to the internal part of the lesion and to several areas of surrounding normal tissue. Each specimen was then sent for definitive histologic examination. Results Histopathology revealed a benign lesion in six patients (46%), while a breast cancer was diagnosed in seven women (54%). Confocal laser endomicroscopy showed some peculiar morphological patterns. Normal breast tissue was characterized by a honeycomb appearance with regular, dark, round or hexagonal glandular lobules on a bright stroma background; tubular structures, representing ducts or blood vessels, were also visible in some frames. Benign lesions were characterized by a well-demarcated “slit-like” structure or by lobular structures in abundant bright stroma. Finally, breast cancer was characterized by a complete architectural subversion: ductal carcinoma was characterized by ill-defined structures, with dark borders and irregular ductal shape, formingribbons, tubules or nests; mucinous carcinoma showed smaller cells organized in clusters, floating in an amorphous extracellular matrix. Conclusions This is the first pilot study to investigate the potential role of confocal laser imaging as a diagnostic tool in breast diseases. Further studies are required to validate these results and establish the clinical impact of this technique.

After publication of our article [1], it has come to our attention that Professor Cesare Formisano was incorrectly excluded from the list of authors in the initial version of this manuscript. We publish this correction to update the author list to include Professor Formisano as an author. The correct author list is as follows

Background Staple-line leak is the most serious complication of laparoscopic sleeve gastrectomy (LSG) occurring in .5−7% of cases. Patients with this complication are often managed with an esophageal covered, self-expandable metal stent positioned at endoscopy. Unfortunately, migration of these stents has been reported in 30–50% of cases. A novel fully-covered, self-expanding metal stent (Megastent), specifically designed for post-LSG leaks is now available. The objective of this study was to describe the first case series of patients with a staple-line leak after LSG who were endoscopically managed with such a novel stent. Methods Four patients who developed a staple-line leak after LSG were treated by positioning a Megastent at endoscopy. The stents were removed after 8 weeks. Results A complete leak repair was achieved in all patients. No stent migration occurred. Prokinetic therapy was needed to treat vomiting episodes during stent presence. At endoscopic evaluation after stent removal, a decubitus lesion at the distal part of the duodenal bulb was observed. Conclusion These preliminary results would suggest the use of the Megastent as an option for stenting of a staple-line leak after LSG. Further studies are still necessary.

Introduction Laparoscopic Adjustable Gastric Banding (LAGB) is a safe and effective treatment for obesity. A strong evidence links weight loss with improved fertility outcomes and reduced gestational complications in subsequent pregnancies. Our aim is to describe the impact of LAGB on maternal and neonatal outcomes. Methods Data were collected retrospectively from the database of our University Center for the Multicentric Treatment of Severe Obesity. From January 2006 to December 2011, 438 patients underwent LAGB. Of these, 140 women of reproductive age (18–46 years old) were included in our study. The following parameters were registered during follow-up: number of pregnancies, delivery and miscarriage, time from LAGB to pregnancy, band adjustments, weight gain during pregnancy, gestational and obstetrical complications (gestational diabetes mellitus, hypertensive disorders, prolonged labor), mode of delivery, neonatal birth weight and complications (low birth weight, IUGR, prematurity, macrosomy). Results We registered 26 pregnancies with a total of 22 babies born and 4 miscarriages. The mean time from LAGB to pregnancy was 15.8 months. Band adjustments were performed in 100% of patients during the first trimester; the average weight gain at the end of pregnancy was 14.66 kg. None presented gestational or obstetrical complications. One patient presented band slippage, which required surgery, and one patient presented iron-deficiency anemia. 100% of deliveries were by cesarean section. No perinatal complications or malformations were recorded, and the average baby weight was 3027 g. Conclusion LAGB is a safe procedure, well tolerated during pregnancy and without negative implications on both the mother and the baby. According to our experience and recent studies, band loosening should be reserved to symptomatic patients to avoid unhealthy weight gain.

The serum collection under the abdominal flap is the most common complication after a lipo-abdominoplasty. The frequency of seroma increases further among obese patients, who have achieved massive weight loss after bariatric surgery. The purpose of this study is to demonstrate the effectiveness of fibrin glues with a low concentration of thrombin in reducing seroma formation after a lipo-abdominoplasty. Thirty patients, that had achieved a significant weight loss after an intervention of laparoscopic adjustable gastric banding (LAGB), underwent a circular lipo-abdominoplasty at our bariatric surgery department. Patients were divided into two groups of 15 subjects each: group A underwent traditional surgery; in group B, we applied a slow-clotting variant of fibrin glue (ARTISS, Baxter) under the abdominal flap. All subjects were evaluated clinically using an ultrasound device on postoperative day 15. We considered positive for seroma, those cases with a liquid collection greater than 20 cc. The groups were homogeneous for age, BMI, male/female ratio, and diabetic or smoker patients. The mean hospital stay was significantly longer in group A than in group B. We found eight cases of serum collection >20 cc in group A and only one case in group B. Hematoma, umbilicus necrosis, and surgical site infection occurred in both groups, but overall complication rate was lower in group B. The use of a fibrin glue with a low concentration of thrombin could be useful during wound closure and may decrease seroma formation in postbariatric patients undergoing lipo-abdominoplasty.

A case of acinic cell carcinoma of the breast is reported in a 26-year-old woman. She presented a lump in her right breast, that seemed to be a fibroadenoma. The open biopsy revealed a well-bordered fibroadenoma, together with a proliferation of cells characterized by serous acinar differentiation and eosinophilic cytoplasmic granules. Tumor cells stained for amylase, lysozyme, α-1-antichymotripsin, epithelial membrane antigen, S-100 protein, pan-cytokeratin, cytokeratin 7 and E-cadherin. Estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2 overexpression, CD10, P63, smooth muscle actin, cytokeratin 5/6 were negative. The sentinel node was negative. 8 months after surgery she is in good clinical conditions without recurrence or metastases.

Background: An increasing number of surgeons with different levels of experience with laparoscopic surgery and open obesity surgery have started to perform laparoscopic implantation of the Lap-Band®. Methods: An electronic patient data sheet was created and was mailed and e-mailed to all surgeons performing laparoscopic adjustable silicone gastric banding (LASGB) in Italy. Patients were recruited since January 1996. Data on 1,265 Lap-Band System® operated patients (258 M / 1,007 F; mean BMI 44.1, range 27.0-78.1; mean age 38, range 17-74 years) were collected from 23 surgeons performing this operation. Results: Intra-operative mortality was absent. Post-operative mortality was 0.55% (7 patients) for causes not specifically related to LASGB implantation. The laparotomic conversion rate was 1.7% (22 patients). LASGB related complications occured in 143 patients (11.3%). Pouch dilatation was diagnosed in 65 (5.2%), and 28 (2.2%) of these underwent re-operation. Band erosion was observed in 24 patients (1.9%). Port or connecting tube-port complications occurred in 54 patients (4.2%), 12 of whom required revision under general anesthesia. Follow-up was obtained at 6, 12, 18, 24, 36 and 48 months, and mean BMI was respectively 38.4, 35.1, 33.1, 30.2, 32.1 and 31.5. The percentage of patients observed at each follow-up was >60%. There was no intra-operative mortality and no complication-related mortality, with acceptable weight loss. Conclusion: The LASGB operation is safe and effective, and deserves wider use for treatment of morbid obesity.

Background: In the treatment of morbid obesity, surgery had been the only method of obtaining a good and enduring weight loss. Although the procedure of choice is still a matter of debate, among gastric restriction procedures LAP-BAND™ has become our first choice. Methods: We report the results from 62 morbidly obese patients operated in the period October 1994-December 1996. Their characteristics were: mean age 35.6 years, mean body weight 130.6 kg, mean height 162.3 cm, mean body mass index (BMI) 49.9 kg/m2, mean percentage ideal body weight (%IBW) 215.7 and mean excess weight (EW) 69.57 kg. Results: Twenty-four months after surgery we found a mean BMI of 39.3, a mean %IBW of 168.6 and a mean % EW loss of 88.5. We removed the band in two patients: one after 9 months because of stoma stenosis and pouch enlargement in a woman who had been lost at follow-up, and the other for gastric slippage occurring after 18 months due to incorrect fixation of the band. Conclusion: Our results led us to consider LAP-BAND™ as the surgical approach for severe obesity among those patients selected for gastric restriction; indeed, it was very safe as well as effective and was rarely followed by complications.

Background: Various intragastric balloons have been used in obese patients for temporary weight loss. Recently, a new balloon, the Heliosphere® Bag, was proposed. In a preliminary study, we evaluated the safety and efficacy of this device. Methods: The Heliosphere® Bag was used in 10 patients, selected according to the guidelines for obesity surgery. The manufacturer's instructions were followed in positioning the device. Heliosphere® Bag positioning was performed, after diagnostic endoscopy, under unconscious sedation. After placement, the balloon was slowly inflated with 840-960 cc of air, which gives the inflated final volume of 650-700 cc of air, as the air is compressed. On the first and second post-treatment day, intravenous saline (30-35 ml/kg/d) with omeprazole (20 mg/d), ondansetron (8 mg/d) and butylscopolamine bromide (20 mg t.i.d.) were given to all patients. All patients from day 3 after placement began liquid diet and were discharged home on day 4 on a 1000 kcal diet (carbohydrate 146 g, lipid 68 g, protein 1 g/kg ideal weight). After 6 months, the Heliosphere® Bag was removed. The patients were followed monthly, and complications and their treatment, post-placement symptoms, BMI and %EWL were recorded. Data were expressed as mean ± SD. Results: From Sept-Dec 2004, 10 patients (5M/5F) underwent Heliosphere® Bag placement, with age 35.2 ± 15.7 years (17-49), BMI 43.3 ± 8.1 kg/m2 (35-51.2), and weight 126.8 ± 23.7 kg (98.4-148). Heliosphere® Bag positioning was quite difficult in all patients due to low pliancy and large size of the bag, causing patient discomfort. System failure at time of Heliosphere® Bag positioning was observed in 5/10 patients (50%). At time of removal, the Heliosphere® Bag was not found in the stomach in one patient. In 3 other patients, the balloon was found partially deflated. At the time of balloon removal after 6 months, BMI was 37.4 ± 13.4 (28.9-42.1) and %EWL was 29.1 ± 20.1 (9.0-57.4). BMI loss was 5.2 ± 13.1 (1.9-11.2) and mean weight loss was 17.5 ± 16.2 kg (5-33). Conclusions: Although weight loss was satisfactory, this device cannot be considered an advance for the temporary treatment of morbid obesity. This balloon still has some instrumental and technical problems that need to be solved: high rate of system failure at positioning, high rate of spontaneous deflation, absence of a marker such as methylene blue, and large size with low pliability that cause significant patient discomfort.

BACKGROUND: Confocal laser enables in vivo real-time histopathology of the mucosa layer of gastrointestinal tract. The aim of this study was to assess the feasibility and the role of probe-based confocal laser endomicroscopy in extemporary examination of staple rings of patients with colorectal cancer. METHODS: This was a prospective, single-center pilot study. Patients who underwent end-to-end stapled surgical resection for colorectal cancer were included. Confocal imaging was analyzed with great attention to image quality evaluation of cellular morphology and cellular structures of the serosal, muscular, and mucosal layers of the doughnuts than comparing results with definitive histopathology. RESULTS: Twenty-six doughnuts were analyzed. Real-time video sequences were obtained in all patients, with a total of 204 mosaic images. For each doughnut, most of the images were adequate for evaluation of cellular morphology and cellular structure of the serosal, muscular, and mucosal layers. CONCLUSIONS: Perioperative assessment of doughnut tissues in patients with colorectal cancer by confocal laser endomicroscopy is feasible and safe. Prospective studies are warranted for further evaluation of the clinical impact of this technology during surgery.

Background Fibroadenomas are the second most common breast pathology occurring in young women under the age of 35 years old. Fibroadenomas can be classified as simple or complex according to histological features. Complex fibroadenomas differ from simple fibroadenomas because of the presence of cysts (3 mm), sclerosing adenosis, epithelial calcifications, or papillary apocrine changes. Most fibroadenomas are clinically identifiable. In 25% of cases, fibroadenomas are non-palpable and are diagnosed with mammography and ultrasound. Differential diagnosis with well differentiated breast cancer is often necessary, particularly with medullary or mucinous tumors. Calcification findings within fibroadenomas by mammogram have to be investigated. The age of a lump is usually reflected by calcifications. Microcalcification can hide foci of carcinoma in situ when they are small, branching type, and heterogeneous. However, many morphological possibilities may not be reliable for deciding whether a certain calcification is the product of a malignant or a benign process. From a radiological point of view, fibroadenomas containing foci of carcinoma in situ can be indistinguishable from benign lesions, even if the incidence of carcinoma within fibroadenomas is estimated as 0.1–0.3%, and it could be a long-term risk factor for invasive breast cancer. Case presentation A 44-year-old woman presented with a 1.5-cm palpable, smooth, mobile lump in the lower-inner quadrant of her right breast. Standard mediolateral oblique and craniocaudal mammograms showed a cluster of eccentric popcorn-like calcifications within the fibroadenoma. After lumpectomy, a definitive histological examination confirmed the intra-operative diagnosis of a benign mass. However, lobular intraepithelial neoplasia foci were found, surrounded by atypical lobular hyperplasia. Conclusions The possibility of an old benign breast lump might be supported by fine needle aspiration biopsy or core biopsy before initiating follow-up. According to our experience, when patients are older than 40 years and have a familial history of breast cancer, we prefer to carry out lumpectomy with follow up to avoid the risk of underestimation in situ foci within the lump.

Despite progress made in the control of post-operative infections, the incidence of surgical site infections (SSIs) is still high. An improper perioperative antibiotic use can expose patients to the risk of resistant microorganisms, and, in surgical obese patients, the drug dosage and infusion time are critical points. The aim of our study was to evaluate the effectiveness of ertapenem in the prophylaxis of SSIs in obese patients undergoing general or bariatric surgery. METHODS: A total of 63 obese patients, candidates for several surgical interventions, were enrolled and divided into two groups. Patients received antibiotic prophylaxis before surgery: the case group received venous infusion of ertapenem; the control group received standard prophylaxis. Serum samples were tested for antimicrobial activity against Gram-positive and Gram-negative bacteria. RESULTS: After single-dose ertapenem in obese patients, we registered in vitro activity of sera against the growth of non-extended beta lactamase (ESBL)-producing Escherichia coli, Proteus mirabilis, Citrobacter freundii, Enterobacter cloacae, and non-ESBL-producing Klebsiella pneumoniae. Moreover, methicillin-sensitive Staphylococcus aureus and Streptococcus viridans were also inhibited. We found in vivo efficacy according to clinical monitoring: at the weekly and monthly follow-ups, one patient in the case group and six patients in the control group presented superficial incisional SSIs. CONCLUSIONS: These preliminary results are suggestive of the efficacy of ertapenem in perioperative prophylaxis of SSIs in obese patients; however, they need to be confirmed by further investigations and more defined trials.

ObjectiveAdiponectin is an adipocytokine that exerts beneficial effects on obesity and related disorders by two receptors (ADIPORs). Adiponectin is produced as a monomer that circulates in serum as different oligomers. The oligomerization state and the tissue expression of adiponectin and ADIPORs are linked to its biological activities. In this study, the levels of total adiponectin and its oligomers were evaluated in relation to obesity and surgical weight loss. The expression of adiponectin and ADIPORs was analyzed in visceral and subcutaneous adipose tissues of obese patients.Design and methodsIn 25 obese patients and 44 age- and sex-matched controls, the serum levels of adiponectin and its oligomers were measured and compared by ELISA, western blotting, and gel filtration. The expression of adiponectin and ADIPORs in both adipose tissues was evaluated by real-time quantitative PCR and western blotting.ResultsThe amount of each adiponectin oligomer, including the monomer, increases after weight loss. The reduced circulating levels of adiponectin and its oligomers are not associated with the adipose tissue depot-specific expression of adiponectin and ADIPORs.ConclusionsOur results suggest that in patients, adiposity is associated with the serum concentrations of adiponectin and its oligomers but not with adipose tissue depot-specific expression of adiponectin and ADIPORs. In particular, the increase in adiponectin monomer levels could probably be related to the improvement of the whole-body energy metabolism then being involved in the improvement of adipose tissue function after weight loss. This work indicates the importance of assessing the whole adiponectin oligomeric profile as further potential indicators of adipose tissue functions in obesity.

Bariatric surgery procedures are more and more performed in women of reproductive age, whose fertility often increases after weight loss, so they frequently become pregnant. In this condition they require appropriate management, according to the type of procedure, malabsorptive or restrictive. If health risks related to obesity (gestational diabetes, pregnancy induced hypertension, pre-eclampsia) decrease after weight loss, other risks related to bariatric procedures could appear. LAGB is a safe and well-tolerated procedure, but some complications could appear more frequently during pregnancy; some symptoms could be suggestive for important complications, that if not treated in the best way could threaten mother and child's health. Emesis of the first trimester could favor slippage, thus influencing feeding and fetal growth. The slippage of the band is a common complication of LAGB, that usually does not lead to serious conditions, but in our case the pregnant risked a lot because of malnutrition. The purpose of this article is to present an obstetric case study of a woman who experienced this complication postbariatric surgery and the implications for mother and child. A correct diagnosis and management of the clinical case led to a positive conclusion, thus underlining bariatric surgery and its complications should be known and taken into account by every physician.

Adipose tissues show selective gene expression patterns, to whom microRNAs (miRNAs) may contribute. We evaluated in visceral adipose tissue (VAT) from obese and nonobese females, both miRNA and protein expression profiles, to identify miRNA/protein target pairs associated with obesity (metabolic pathways miRNA-deregulated during obesity). Obese and nonobese females [BMI 42.2 ± 1.6 and 23.7 ± 1.2 kg/m(2) (mean ± SEM), respectively] were enrolled in this study. Notably, most miRNAs were down-expressed in obese tissues, whereas most of the proteins from the investigated spots were up-expressed. Bioinformatics integration of miRNA expression and proteomic data highlighted two potential miRNA/protein target pairs: miR-141/YWHAG (tyrosine 3-monooxygenase/tryptophan 5-monooxygenase activation protein, gamma polypeptide) and miR-520e/RAB11A (Ras-related protein RAB-11A); the functional interaction between these miRNAs and their target sequences on the corresponding mRNAs was confirmed by luciferase assays. Both RAB11A and YWHAG proteins are involved in glucose homeostasis; YWHAG is also involved in lipid metabolism. Hence, the identified miRNA/protein target pairs are potential players in the obese phenotype.

Introduction. Milligan-Morgan haemorrhoidectomy performed with LigaSure system (LS) seems to be mainly effective where a large tissue demolition is required. This randomized study is designed to compare LigaSure haemorrohidectomy with conventional diathermy (CD) for treatment of IV-degree haemorrhoids. Methods. 52 patients with IV-degree haemorrhoids were randomized to two groups (conventional diathermy versus LigaSure haemorrhoidectomy). They were evaluated on the basis of the following main outcomes: mean operative time, postoperative pain, day of discharge, early and late complications. The time of recovery of work was also assessed. All patients had a minimum follow-up of twelve months (range 12–24). All data were statistically evaluated. Results. 27 patients were treated by conventional diathermy, 25 by LigaSure. The mean operative time was significantly shorter in LS, such as postoperative pain, mainly lower on the third and fourth postoperative day: moreover pain disappeared earlier in LS than CD. The time off-work was shorter in LS, while there was no difference in hospital stay and overall complications rate. Conclusions. LigaSure is an effective instrument when a large tissue demolition is required. This study supports its use as treatment of choice for IV degree haemorrhoids, even if the procedure is more expansive than conventional operation.

Retrospective multicenter analysis of the results of two different approaches for band positioning: perigastric and pars flaccida.Data were collected from the database of the Italian Group for LapBand (GILB). Patients operated from January 2001 to December 2004 were selected according to criteria of case-control studies to compare two different band positioning techniques: perigastric (PG group) and pars flaccida (PF group). Demographics, laparotomic conversion, postoperative complications, and weight loss parameters were considered. Data are expressed as mean +/- standard deviation.2,549 patients underwent the LapBand System procedure [age: 40 +/- 11.7 years; sex: 2,130 female, 419 male; body mass index (BMI): 46.4 +/- 6.9 kg/m(2); excess weight (EW): 60.1 +/- 23.6 kg; %EW: 90.1 +/- 32.4]. During this period 1,343/2,549 (52.7%) were operated via the pars flaccida (PF group) and 1,206/2,549 (47.3%) via the perigastric approach (PG group). Demographics for both groups were similar. Thirty-day mortality was absent in both groups. Operative time was significantly longer in the PG group (80 +/- 20 min versus 60 +/- 40 min; p0.05). Hospital stay was similar in the two groups (2 +/- 2 days). Laparotomic conversion was significantly higher in the PG group (6 versus 2 patients; p0.001). Overall postoperative complication rate was 172/2,549 (6.7%) and was linked to gastric pouch dilation/slippage (67/172), intragastric migration/erosion (17/172), and tube/port failure (88/172). Gastric pouch dilation and intragastric migration were significantly more frequent in the PG group: 47 versus 20 (p0.001) and 12 versus 5 (p0.001), respectively. Patients eligible for minimum 3-year follow-up were 1,118/1,206 (PG group) and 1,079/1,343 (PF group). Mean BMI was 33.8 +/- 12.1 kg/m(2) (PG group) and 32.4 +/- 11.7 kg/m(2) (PF group) (p = ns), and mean percentage excess weight loss (%EWL) was 47.2 +/- 25.4 and 48.9 +/- 13.2 in PG and PF groups, respectively (p = ns).Significant improvement in LapBand System results with regard to laparotomic conversion and postoperative complication rate, with similar weight loss results, was observed in the pars flaccida group.

Obesity is considered a strong risk factor for renal cell carcinoma, the most common primary renal malignant neoplasm. An association between renal cell carcinoma and obesity has been reported in numerous trials. Several potential mechanisms may be responsible for the risk of renal cell carcinoma in obese subjects. We report the cases of two patients, submitted to bariatric malabsorbtive surgery, who presented a renal clear cell carcinoma several months after the operation. The diagnosis was made by routine postoperative ultrasound examination and confirmed by computed tomography in both cases. Both were treated surgically. Our approach after diagnosis of cancer consisted in evaluation of the patient's immunological, metabolic and nutritional status to establish whether it was a case of real malnutrition or an oncological risk condition. We judged that restoration of original gastrointestinal continuity was not necessary. In the literature, we found no evidence of an association between a cancer histotype and bariatric surgery. Confirming the association between renal cell carcinoma and morbid obesity, these case reports indicate the importance of imaging control, especially with non-invasive diagnostic studies, in high-risk cancer patients, such as obese patients, to detect lesions incidentally at an early stage. After a thorough review of the literature data, we consider bariatric patients a suitable group to be assessed for an early diagnosis of various types of cancer, detectable at preoperative or postoperative screening. Weight loss and continuous instrumental exams are conditions favourable to an early diagnosis. Guidelines regarding the management of oncological patients with a history of bariatric surgery are indispensable.

BACKGROUND: There are limited data on appropriate dosing of low-molecular-weight heparins (LMWHs) for venous thromboembolism (VTE) prophylaxis in bariatric surgery. The primary objective of this preliminary study was to evaluate the preoperative effects of increasing doses of the LMWH parnaparin on coagulation in severely obese patients undergoing bariatric surgery. METHODS: Severely obese patients (BMI > 50 kg/m(2)) were administered three increasing single doses of parnaparin (3200, 4250, and 6400 IU) on the three consecutive days leading up to biliointestinal bypass surgery. Activated partial thromboplastin time (APTT), anti-factor IIa and anti-factor Xa levels were measured 1 h before and 4 h after dosing. The highest dose (6400 IU/day) was continued from the day of surgery until day 30 (recovery period). Intermittent pneumatic compression and stockings were applied during surgery and the recovery period, respectively. Lower limb echoDoppler and phleboscintigraphy, and pulmonary scintigraphy were used for VTE detection. RESULTS: Ten patients (mean BMI 52.4 kg/m(2)) were recruited into this study. During the preoperative dosing phase, parnaparin dose-dependently prolonged APTT, with the 6400 IU dose significantly prolonging APTT versus the lower doses. Meanwhile, anti-factor Xa and anti-factor IIa activity was increased by the 4250 and 6400 IU doses. After surgery, one patient with heparin resistance experienced pulmonary embolization. No bleeding complications were observed. CONCLUSION: The dose-response data reported in this preliminary study suggest that parnaparin doses of 4250 and 6400 IU may provide effective prophylaxis for VTE in patients undergoing bariatric surgery. However, given the small number of patients, larger, well-controlled trials are required to confirm these findings.

This report describes a case of successful endoscopic management of intragastric penetrated adjustable gastric band in a patient with morbid obesity. The favorable course of the case described here demonstrates that adjustable gastric bands in the process of migration need not be removed surgically in patients who are asymptomatic.