Mallory-Weiss syndrome from giant gastric trichobezoar: A case report.

BACKGROUND: Mallory-Weiss syndrome (MWS), representing a linear mucosal laceration at the gastroesophageal junction, is a quite frequent cause of upper gastrointestinal bleeding, usually induced by habitual vomiting. The subsequent cardiac ulceration in this condition is likely due to the concomitance of increased intragastric pressure and inappropriate closure of the gastroesophageal sphincter, collectively inducing ischemic mucosal damage. Usually, MWS is associated with all vomiting conditions, but it has also been described as a complication of prolonged endoscopic procedures or ingested foreign bodies. CASE SUMMARY: We described herein a case of upper gastrointestinal bleeding in a 16-year-old girl with MWS and chronic psychiatric distress, the latter of which deteriorated following her parents' divorce. The patient, who was residing on a small island during the coronavirus disease 2019 pandemic lockdown period, presented with a 2-mo history of habitual vomiting, hematemesis, and a slight depressive mood. Ultimately, a huge intragastric obstructive trichobezoar was detected and discovered to be due to a hidden habit of continuously eating her own hair; this habit had persisted for the past 5 years until a drastic reduction in food intake and corresponding weight loss occurred. The relative isolation in her living status without school attendance had worsened her compulsory habit. The hair agglomeration had reached such enormous dimensions and its firmness was so hard that its potential for endoscopic treatment was judged to be impossible. The patient underwent surgical intervention instead, which culminated in complete removal of the mass. CONCLUSION: According to our knowledge, this is the first-ever described case of MWS due to an excessively large trichobezoar.

Low-Purine Diet Is More Effective Than Normal-Purine Diet in Reducing the Risk of Gouty Attacks After Sleeve Gastrectomy in Patients Suffering of Gout Before Surgery: a Retrospective Study.

BACKGROUND: Obese patients with preoperative gout often suffer of gouty attacks after bariatric surgery (BS), probably due to the lack of an adequate postoperative diet. OBJECTIVES: The objectives of the study are to assess whether sleeve gastrectomy (SG) is effective in reducing the frequency of gouty attacks and also whether a postoperative low-purine diet (LPD) may further reduce these attacks as compared to a normal-purine diet (NPD) in a series of patients suffering of gout before SG. METHODS: In this retrospective study, we measured and compared total body weight (TBW), body mass index (BMI), uric acid levels (UAL), anti-gout medication (allopurinol) requirements, and frequency in gouty attacks in 40 patients that underwent SG and who received either a LPD (n = 24) or NPD (n = 16). Compliance in following the prescribed diet was assessed in both groups study. RESULTS: Before surgery, LPD and NPD patients had hyperuricemia and were receiving allopurinol. One year after SG, LPD and NPD groups showed a significant decrease in serum UAL (p < 0.001 and p = 0.00175, respectively). However, serum UAL decreased more significantly with the LPD compared to the NPD (p < 0.001). Furthermore, while NPD group showed a significant decrease in allopurinol requirements (p = 0.00130) and on the frequency in gouty attacks (p < 0.001), LPD group were off allopurinol therapy and had no gouty attacks 12 months after SG. Both groups showed high compliance in following the prescribed diets. CONCLUSION: LPD is more effective in reducing the frequency of gouty attacks after SG compared with NPD in patients suffering of gout before surgery.

Novel nanohydrogel of hyaluronic acid loaded with quercetin alone and in combination with temozolomide as new therapeutic tool, CD44 targeted based, of glioblastoma multiforme.

Glioblastoma multiforme is the most common and aggressive primary brain cancer with only ∼3% of patients surviving more than 3 years from diagnosis. Several mechanisms are involved in drug and radiation resistance to anticancer treatments and among them one of the most important factors is the tumor microenvironment status, characterized by cancer cell hypersecretion of interleukins and cytokines. The aim of our research was the synthesis of a nanocarrier of quercetin combined with temozolomide, to enhance the specificity and efficacy of this anticancer drug commonly used in glioblastoma treatment. The nanohydrogel increased the internalization and cytotoxicity of quercetin in human glioblastoma cells and, when co-delivered with temozolomide, contribute to an improved anticancer effect. The nanohydrogel loaded with quercetin had the ability to recognize CD44 receptor, a brain cancer cell marker, through an energy and caveolae dependent mechanism of internalization. Moreover, nanohydrogel of quercetin was able to reduce significantly IL-8, IL-6, and VEGF production in pro-inflammatory conditions with interesting implications on the mechanism of glioblastoma cells drug resistance. In summary, novel CD44 targeted polymeric based nanocarriers appear to be proficient in mediating site-specific delivery of quercetin via CD44 receptor in glioblastoma cells. This targeted therapy lead to an improved therapeutic efficacy of temozolomide by modulating the brain tumor microenvironment.

Fat mass, fat-free mass, and resting metabolic rate in weight-stable sleeve gastrectomy patients compared with weight-stable nonoperated patients.

BACKGROUND: There is evidence that body composition and resting metabolic rate (RMR) in weight-stable patients after Roux-en-Y gastric bypass and duodenal switch is similar to that of nonoperated individuals within the same body mass index (BMI) interval. Currently, data concerning fat mass (FM), fat-free mass (FFM), and RMR on weight-stable patients after sleeve gastrectomy (SG) are lacking. OBJECTIVES: To assess FM, FFM, and RMR, in a selected and homogenous population of weight-stable SG patients (WSSG) and compare them with those obtained from healthy normal weight-stable nonoperated (WSNO) volunteers controls of similar sex, age, and BMI. SETTING: University hospital, Italy. METHODS: We assessed total weight, FM, and FFM by bioelectrical impedance assay, and RMR by indirect calorimetry, in 70 WSSG patients (47 females, 23 males) at a mean follow-up of 3.2 ± 2.1 years after SG and compared them with 70 healthy WSNO volunteers, as controls (47 females, 23 males). RESULTS: There was no significant difference between WSSG and WSNO groups concerning total weight (males, 72 ± 2.66 versus 72.8 ± 1.99 kg, P = .0254; females 65.1 ± 2.53 versus 63.7 ± 2.87 kg, P = .0139), FM (males, 17.7 ± 1.53 versus 16.7 ± 1.57 kg, P = .0341; females 19.6 ± 0.50 versus 18.5 ± 2.85 kg, P = .0104), FFM (males, 54.3 ± 3.07 versus 56.1 ± 3.30 kg; P = .049; females 45.5 ± 2.29 versus 45.1 ± 1.13 kg, P = .287), and RMR (males, 1541 ± 121.3 versus 1463 ± 74.4 kcal/d; P = .0118; females 1214 ± 54.9 versus 1250 ± 90.1 kcal/d, P = .0215). CONCLUSION: At a mean follow-up of 3.2 ± 2.1 years after SG, WSSG patients of both sexes have a FM, FFM, and RMR comparable to that of healthy WSNO individuals within the same age and BMI interval. These findings further support bariatric surgery-induced weight loss as a physiologic process and indicate that young patients, in the setting of an adequate preoperative and postoperative specific diet and moderate physical activity, do not suffer from excessive FFM depletion after SG in the mid-term.

A Comparative Study Examining the Impact of a Protein-Enriched Vs Normal Protein Postoperative Diet on Body Composition and Resting Metabolic Rate in Obese Patients after Sleeve Gastrectomy.

BACKGROUND: We recently showed that an 8-week preoperative protein-enriched diet (PED) is associated with significant reductions in body weight and fat mass (FM) without significant loss of fat-free mass (FFM) in morbidly obese patients scheduled for laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: The objective of this study is to evaluate the impact of PED vs a normal protein diet (NPD) on total weight loss (TWL), FM, FFM, and resting metabolic rate (RMR) in patients after LSG. METHODS: Before LSG and at 3, 6, and 12 months after, we prospectively measured and compared total body weight (TBW), FM, FFM, and RMR in 60 male patients who received either a NPD (n = 30) with protein intake 1.0 g/kg of ideal body weight, or a PED (n = 30) with protein intake 2.0 g/kg of ideal body weight. Compliance in following the prescribed diet was determined with food frequency questionnaires in all patients. The impact of NPD and PED on renal function was also evaluated. RESULTS: Despite non-significant variation in total body weight (TBW), FM decreased more significantly (p < 0.01) with the PED compared to the NPD. In addition, the PED group showed a significantly (p < 0.01) lower decrease in FFM and RMR when compared with the NPD group. Both groups showed high compliance in following the prescribed diets, without negative impact on renal function. CONCLUSION: PED is more effective than NPD in determining FM loss and is associated with a lower decrease in FFM and RMR, without interfering with renal function in male patients after LSG.

New Treatment of Medullary and Papillary Human Thyroid Cancer: Biological Effects of Hyaluronic Acid Hydrogel Loaded With Quercetin Alone or in Combination to an Inhibitor of Aurora Kinase.

The aim of this paper is based on the use of a hyaluronic acid hydrogel of Quercetin tested alone and in combination to an inhibitor of Aurora Kinase type A and B (SNS-314) on human medullary and papillary thyroid cancer cells. Biological investigations were focused on the cellular uptake of the hydrogel, cell viability, antioxidant, and cytokines secretion studies. Quercetin delivered from hydrogel show a time and CD44 dependent interaction with both cell lines with significant anti-inflammatory effects. Combination of Quercetin and SNS-314 leads to a synergistic cytotoxic effect on medullary TT and papillary BCPAP cell lines with a significant reduction of the IC50 value. These results, highlights the importance of synergistic effect of the hyaluronic acid hydrogel of Quercetin with SNS-314 in the regulation of human thyroid cancer cell proliferation and emphasize the anti-tumor activity of these molecules. J. Cell. Physiol. 231: 1784-1795, 2016. © 2015 Wiley Periodicals, Inc.

Nonsurgical management of multiple splenic abscesses in an obese patient that underwent laparoscopic sleeve gastrectomy: case report and review of literature.

Sleeve gastrectomy (SG) is a surgical weight-loss procedure. Splenic abscess is a rare complication of SG. Four cases of splenic abscess after SG have been reported, all managed by surgical intervention. We report the first documented case of multiple splenic abscesses following SG managed conservatively by an integrated medical treatment.

Clinical impact of Mediterranean-enriched-protein diet on liver size, visceral fat, fat mass, and fat-free mass in patients undergoing sleeve gastrectomy.

BACKGROUND: Weight loss before laparoscopic sleeve gastrectomy (LSG) is desirable because it can reduce visceral fat and liver size thereby facilitating the surgical procedure. Preoperative very-low-energy diets have been demonstrated to decrease weight, visceral fat, and liver size. However, no studies have been conducted using the Mediterranean-protein-enriched diet (MPED) or on the amount of preoperative weight loss attributed to the loss of fat-free mass (FFM). OBJECTIVES: To evaluate the effect of the MPED on weight, visceral fat, liver size, fat mass (FM), and FFM in obese patients undergoing LSG. SETTING: University Hospital, Italy. MATERIALS AND METHODS: Obese male patients (n = 37) with a mean body mass index (BMI) of 45.2 kg/m(2) scheduled for LSG underwent an 8-week preoperative MPED. Their weight, visceral fat, body composition, liver size, and biochemical and metabolic patterns were measured before and after the diet. Patient compliance was assessed by the presence of ketonuria and weight loss. Qualitative methods (5-point Likert questionnaire) were used to measure diet acceptability and side effects. RESULTS: We observed highly significant decreases in weight, liver size, visceral fat, and FM; however, there was no significant reduction in FFM. All tested patients showed a high frequency of acceptability and compliance in following the diet, and no secondary effects were observed. CONCLUSION: Based on our findings, we were able to support the hypothesis that MPED might be associated with significant reductions in weight loss, FM, and liver size without a significant loss of FFM.

Micronutrient Deficiencies in Patients Candidate for Bariatric Surgery: A Prospective, Preoperative Trial of Screening, Diagnosis, and Treatment.

Bariatric surgery candidates often show preoperative micronutrient deficiency. Although it is documented that a comprehensive micronutrient assessment should be conducted preoperatively to correct the deficiencies before surgery, no previous studies have been effective in correcting deficiencies in sufficient time prior to surgery. Our aim was to identify micronutrient deficiencies preoperatively and correct them before surgery.

Modified versus standard D2 lymphadenectomy in total gastrectomy for nonjunctional gastric carcinoma with lymph node metastasis.

BACKGROUND: Although D2 lymphadenectomy has been shown to improve outcomes in gastric cancer, it may increase postoperative morbidity, mainly owing to splenopancreatic complications. In addition, the effects of nodal dissection along the proper hepatic artery have not been extensively elucidated. We hypothesized that modified D2 (ie, D1+) lymphadenectomy may decrease surgical risks without impairing oncologic adequacy. METHODS: Patients with node-positive gastric cancer undergoing curative total gastrectomy were intraoperatively randomized to D1+ (group 1, 36 patients) or standard D2 lymphadenectomy (group 2, 37 patients), the latter including splenectomy and nodal group 12a. The index of estimated benefit was used to assess the efficacy of dissection of each nodal station. The primary endpoint for oncologic adequacy was the disease-free survival (DFS) rate. RESULTS: Surgical complications were significantly more common in group 2, which also included 2 postoperative deaths. Overall, 35 patients (49%) experienced tumor recurrence. The primary site of tumor relapse and the 5-year DFS rate were not different between the 2 groups. Involvement of the second nodal level was associated with a worse DFS rate; however, patients undergoing more extensive lymphadenectomy did not show a better DFS rate. The incidence of involvement of nodal stations 10, 11d, and 12a was 5%, and the 5-year DFS rate was zero. Consequently, the benefit to dissect such lymph nodes was null. CONCLUSION: These findings suggest that modified D2 lymphadenectomy confers the same oncologic adequacy as standard D2 lymphadenectomy, with a significant reduction of postoperative morbidity.

Therapy with autologous adipose-derived regenerative cells for the care of chronic ulcer of lower limbs in patients with peripheral arterial disease.

BACKGROUND: An ulcer is a trophic lesion with loss of tissue that often has a multifactorial genesis. It typically diverges from the physiologic processes of regeneration because it rarely tends to heal spontaneously. In this study, we used purified adipose-derived stem and regenerative cells (ADRCs) extracted from autologous fat, for the care of chronic ulcers of the lower limbs of arteriopathic patients. The primary objective of this study was complete re-epithelization of chronic ulcers; the secondary objective was a decrease in diameter and depth. METHODS: From January 2010 to January 2012, 20 patients with peripheral arterial disease, with an ankle-brachial index between 0.30-0.40, in the age range 60-70 y (14 men and six women), with chronic ulcers of the lower limb, were involved in the study. Only 10 arteriopathic patients (seven men and three women) with chronic ulcers of the lower limb were surgically treated. Using the Celution system, we isolated a solution of ADRCs in about 150 min. The isolated cells were injected through a 10-mL syringe into the edges of the ulcer, taking care to spread it in all directions. Using a small amount of Celution extract, we performed cell characterization by flow cytometry analysis and cell viability assay. RESULTS: We monitored patients treated with ADRC or untreated at 4, 10, 20, 60, and 90 d. In all cases treated with ADRC, we found a reduction in both diameter and depth of the ulcer, which led to a decrease in pain associated with the ulcer process. In six of 10 cases there was complete healing of the ulcer. Characterization of the cells by FACS clearly showed that the ADRC cells contained adipose-derived stem cells. Viability assays demonstrated that partial or total closure of the ulcer was attributable exclusively to ADRC cells present in the Celution extract, and not to growth factors extracted during the process of purification of the Celution and injected together with the cells. CONCLUSIONS: For the first time, the Celution method has been applied for the care of chronic ulcers in the lower extremity of patients with peripheral arterial disease. Our results demonstrate that the technique is feasible for autologous cell application and is not associated with adverse events. Moreover, the transplantation of autologous stem cells extracted with Celution may represent a valuable method for the treatment of chronic ulcers in lower limbs of arteriopathic patients.