Conversion from Roux-En-Y Gastric Bypass to Sadi-S, with a Gastro-Gastric Jejunal Bridge as a Treatment of Obesity Recidivism: Case Report

There is a considerable weight regain after the Roux-en-Y gastric bypass (RYGB) surgery. Surgical conversion to more powerful metabolic techniques, like one anastomosis duodenal switch with sleeve gastrectomy (SADI-S), can be effective in this scenario, but surgically challenging. This case report aims to demonstrate technical modifications that simplifies the conversion of Roux-en-Y gastric bypass to SADI-S, in one stage. Female patient submitted to laparoscopic RYGB 10 years before with nadir of 29,47Kg/m². In the last 4 years, she had regained weight, reaching a body mass index of 46,48Kg/m². Surgical conversion was done laparoscopically, preserving the gastrojejunal anastomosis from the previous RYGB and the proximal 8cm of jejunal alimentary limb, which was transected at this level and used as a bridge between gastric pouch and antrum. Previously, the fundus, gastric body and part of the antrum were removed. The remaining alimentary limb, the gallbladder and the candy cane was removed. This was a single stage procedure, without complications. The interposition of the proximal alimentary limb of gastric bypass, between gastric pouch and antrum, has shown to be safe and feasible in RYGB conversion to SADI-S. The removal of the remnant alimentary limb makes the procedure shorter.info:eu-repo/semantics/publishedVersio

Sleeve Gastrectomy Associated with Antral Lesion Resection and Roux-en-Y Antrojejunal Reconstruction

Obesity has been growing worldwide, reaching epidemic proportions. Bariatric surgery is the most effective and durable treatment for severe obesity and related diseases. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are the most frequently performed bariatric operations, with long-term good results, in terms of weight loss and comorbidities control. Gastroesophageal Reflux Disease (GERD) is commonly associated with obesity. In general, it precludes the indication of sleeve gastrectomy, since this technique has a refluxogenic potential, as shown in many studies. In such cases, RYGB is considered the best surgery, reaching good weight loss and gastroesophageal reflux disease control. The drawback of this technique is that it leaves the remnant stomach, the duodenum, and the proximal part of the jejunum inaccessible. Besides, RYGB makes transoral endoscopic access to the biliary tree impossible. For all these reasons, this bariatric technique is not indicated in cases of gastric polyposis, gastric dysplasia, or strong family history of cancer, among others. We report a case of a morbidly obese patient with intense GERD, for whom a RYGB was precluded due to her strong family history of cancer, even knowing that it would be the best choice for reflux disease control. Instead, SG was chosen, even knowing it could worsen the gastroesophageal reflux disease. The patient signed an informed consent, after being fully enlightened about the risks. During the surgery, a small subserosal whitish lesion was detected, near the pylorus, on the anterior wall of the antrum. Thinking in a Gastrointestinal Stromal Tumor (GIST), it was resected, with a 2 cm safety margin, leaving a 4 to 5 cm hole on the gastric wall. The decision to maintain the proposed sleeve gastrectomy was made, to avoid leaving a remnant stomach, in a patient with such a strong family history of cancer. In the area of the resected lesion, an intraoperative decision was made not to just close the big gastric hole, being afraid of causing some anatomic or functional disturbance in gastric emptying. Instead, we decided to use the gastric opening to construct a Roux-en-Y antrotrojejunal anastomosis, with a 50 cm alimentary limb and a 200 cm biliopancreatic limb. Accordingly, it was performed a sleeve gastrectomy, associated with an antrojejunostomy in a Roux-en-Y fashion. The patient had an uneventful postoperative course. In the second year, she achieved normal weight and good nutritional status, without gastroesophageal reflux symptoms complaints. Seriography study shows that most of the contrast material passes through the antrojejunal anastomosis, instead of the pylorus, while the duodenum is endoscopically patent. This case report shows an unexpected surgical finding that led to a tactic of adding a Roux-en-Y gastric bypass in the antrum, associated with a sleeve gastrectomy, a strategy that may be adopted in cases of morbidly obese patients with important GERD, for whom gastrointestinal exclusions are contraindicated. To confirm this hypothesis, controlled studies are needed.info:eu-repo/semantics/publishedVersio

SADI-S with Extended Duodeno-Bulb Preservation: Case Report

Obesity has been growing in Brazil and in the world. It is reaching epidemic proportions, and bariatric surgery is the most effective treatment for patients with this disease. Among the procedures described in the literature, ileal surgeries such as biliopancreatic diversion with duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) present better long-term results in terms of weight loss and comorbidities control. However, there are concerns regarding long term nutritional problems with these procedures. In this case report the aim is to demonstrate the technical feasibility of preserving an extended duodenal bulb segment, in the SADIS-S procedure, when there are difficulties in dissecting the retrobulbar region, as occurred here, due to fibrosis in this area. This assures the maintenance of the proposed surgical technique, in such a situation. The dissection and transection of the duodenum was done 7 cm distally to the pylorus, under endoscopic view, proximally to the papillae, where the tissue was normal. Additionally, due the importance of the duodenal mucosa on minerals and trace elements absorption and the release of important hormones in this region, this case report elicits the evaluation of the impact of this technical modification, which occurred casually, in the nutritional, hormonal and metabolic results, long term. In this case report, the extended duodenal length has demonstrated reasonable weight loss, adequate comorbidities control and good nutritional status, so far. These aspects must be evaluated in the long term, by clinical trials.info:eu-repo/semantics/publishedVersio

Cenários e oportunidades para a produção familiar de suínos: o que há de novo e o que já é possível.

bitstream/item/135079/1/final7930.pd

Hypoxia Regulates BMP4 Expression in the Murine Spleen during the Recovery from Acute Anemia

Bone marrow erythropoiesis is primarily homeostatic, producing new erythrocytes at a constant rate. However at times of acute anemia, new erythrocytes must be rapidly produced much faster than bone marrow steady state erythropoiesis. At these times stress erythropoiesis predominates. Stress erythropoiesis occurs in the fetal liver during embryogenesis and in the adult spleen and liver. In adult mice, stress erythropoiesis utilizes a specialized population of stress erythroid progenitors that are resident in the spleen. In response to acute anemia, these progenitors rapidly expand and differentiate in response to three signals, BMP4, SCF and hypoxia. In absence of acute anemic stress, two of these signals, BMP4 and hypoxia, are not present and the pathway is not active. The initiating event in the activation of this pathway is the up-regulation of BMP4 expression in the spleen.In this paper we analyze the regulation of BMP4 expression in the spleen by hypoxia. Using stromal cell lines, we establish a role for hypoxia transcription factor HIFs (Hypoxia Inducible Factors) in the transcription of BMP4. We identified putative Hypoxia Responsive Elements (HREs) in the BMP4 gene using bioinformatics. Analysis of these elements showed that in vivo, Hif2alpha binds two cis regulatory sites in the BMP4 gene, which regulate BMP4 expression during the recovery from acute anemia.These data show that hypoxia plays a key role in initiating the BMP4 dependent stress erythropoiesis pathway by regulating BMP4 expression

An updated checklist of the vascular flora native to Italy

An updated inventory of the native vascular flora of Italy, providing details on the occurrence at regional level, is presented. The checklist includes 8195 taxa (6417 species and 1778 subspecies), distributed in 1092 genera and 152 families; 23 taxa are lycophytes, 108 ferns and fern allies, 30 gymnosperms and 8034 angiosperms. The taxa currently occurring in Italy are 7483, while 568 taxa have not been confirmed in recent times, 99 are doubtfully occurring in the country and 19 are data deficient. Out of the 568 not confirmed taxa, 26 are considered extinct or possibly extinct

An updated checklist of the vascular flora native to Italy

An updated inventory of the native vascular flora of Italy, providing details on the occurrence at regional level, is presented. The checklist includes 8195 taxa (6417 species and 1778 subspecies), distributed in 1092 genera and 152 families; 23 taxa are lycophytes, 108 ferns and fern allies, 30 gymnosperms and 8034 angiosperms. The taxa currently occurring in Italy are 7483, while 568 taxa have not been confirmed in recent times, 99 are doubtfully occurring in the country and 19 are data deficient. Out of the 568 not confirmed taxa, 26 are considered extinct or possibly extinct

Domain Analysis Reveals That a Deubiquitinating Enzyme USP13 Performs Non-Activating Catalysis for Lys63-Linked Polyubiquitin

Deubiquitination is a reverse process of cellular ubiquitination important for many biological events. Ubiquitin (Ub)-specific protease 13 (USP13) is an ortholog of USP5 implicated in catalyzing hydrolysis of various Ub chains, but its enzymatic properties and catalytic regulation remain to be explored. Here we report studies of the roles of the Ub-binding domains of USP13 in regulatory catalysis by biochemical and NMR structural approaches. Our data demonstrate that USP13, distinct from USP5, exhibits a weak deubiquitinating activity preferring to Lys63-linked polyubiquitin (K63-polyUb) in a non-activation manner. The zinc finger (ZnF) domain of USP13 shares a similar fold with that of USP5, but it cannot bind with Ub, so that USP13 has lost its ability to be activated by free Ub. Substitution of the ZnF domain with that of USP5 confers USP13 the property of catalytic activation. The tandem Ub-associated (UBA) domains of USP13 can bind with different types of diUb but preferentially with K63-linked, providing a possible explanation for the weak activity preferring to K63-polyUb. USP13 can also regulate the protein level of CD3δ in cells, probably depending on its weak deubiquitinating activity and the Ub-binding properties of the UBA domains. Thus, the non-activating catalysis of USP13 for K63-polyUb chains implies that it may function differently from USP5 in cellular deubiquitination processes

Immunological Balance Is Associated with Clinical Outcome after Autologous Hematopoietic Stem Cell Transplantation in Type 1 Diabetes

Transplantation and autoimmunit

Age and Diet Affect Gene Expression Profile in Canine Skeletal Muscle

We evaluated gene transcription in canine skeletal muscle (biceps femoris) using microarray analysis to identify effects of age and diet on gene expression. Twelve female beagles were used (six 1-year olds and six 12-year olds) and they were fed one of two experimental diets for 12 months. One diet contained primarily plant-based protein sources (PPB), whereas the second diet contained primarily animal-based protein sources (APB). Affymetrix GeneChip Canine Genome Arrays were used to hybridize extracted RNA. Age had the greatest effect on gene transcription (262 differentially expressed genes), whereas the effect of diet was relatively small (22 differentially expressed genes). Effects of age (regardless of diet) were most notable on genes related to metabolism, cell cycle and cell development, and transcription function. All these genes were predominantly down-regulated in geriatric dogs. Age-affected genes that were differentially expressed on only one of two diets were primarily noted in the PPB diet group (144/165 genes). Again, genes related to cell cycle (22/35) and metabolism (15/19) had predominantly decreased transcription in geriatric dogs, but 6/8 genes related to muscle development had increased expression. Effects of diet on muscle gene expression were mostly noted in geriatric dogs, but no consistent patterns in transcription were observed. The insight these data provide into gene expression profiles of canine skeletal muscle as affected by age, could serve as a foundation for future research pertaining to age-related muscle diseases