Wound Healing Process in Post-bariatric Patients: an Experimental Evaluation

Bariatric surgery is the most effective treatment for morbid obesity. Despite this, side effects are recorded. One of them is redundant skin hanging from the patients’ body causing both aesthetical and functional deformities. They can only be corrected with body contouring surgery, whose wound complication rate is very high in previously obese population. Despite several hypotheses, an adequate explanation is still awaited. The aim of our study was to evaluate the wound healing process in post-bariatric patients. Seven patients, six women and one man, were enrolled. They all were nonsmokers and nondiabetic. They all underwent biliopancreatic diversion (BPD). After 36 months, abdominoplasty was performed. Biochemical parameters before and after bariatric surgery were evaluated. The content of total protein and hydroxyproline was assessed in multiple scar biopsies before and after BPD. Abdominoplasty horizontal scar skin samples were subjected to histological evaluation with Weigert–Van Gieson stain for elastic fibers and connectivum. All biochemical parameters analyzed were reduced post-BPD compared to the preoperative period. Tissue proteins were significantly reduced after BPD both in their totality and as hydroxyproline and hydroxyproline/total tissue protein. Histological evaluation revealed abnormal dermal elastic and collagen fibers. The cause of aberrant healing in massive weight loss body contouring is likely multifactorial. A relationship between nutritional state, wound collagen accumulation, and elastic fiber content seems to be only partially involved. The high mechanical stress of tissues before BPD probably influences the wound healing process after BPD.     

Reduced survival of type 2B von Willebrand factor, irrespective of large multimer representation or thrombocytopenia

Background

Type 2B von Willebrand factor (VWF) is characterized by gain of function mutations in the A1 domain inducing a greater affinity for platelet GPIb, possibly associated with the disappearance of large VWF multimers and thrombocytopenia.

Design and Methods

VWF survival was explored using 1-desamino-8-D-arginine vasopressin (DDAVP) in 18 patients with type 2B von Willebrand disease (VWD) and compared with their platelet count and large VWF multimer representation.

Results

A similarly significant shorter VWF survival, expressed as T_1/2elimination (T_1/2el), was observed in patients lacking large VWF multimers (type 2B) and in those with a normal multimer pattern (atypical type 2B) (4.47±0.41 h and 4.87±0.9 h, respectively, vs. normal 15.53±2.17 h) due mainly to a greater VWF clearance. The half-life of large VWF multimers, explored by VWF collagen binding (VWF:CB) activity, was likewise reduced. The similarly reduced VWF half-life was also confirmed by the increase in the VWF propeptide ratio (a useful tool for exploring VWF survival) which was found to be the same in type 2B and atypical type 2B patients. The post-DDAVP drop in platelet count occurred in all patients lacking large multimers but not in those with a normal multimer pattern. A correlation was always found between pre- and/or post-DDAVP thrombocytopenia and the lack of large VWF multimers in type 2B VWD while these were unrelated to the reduced VWF half-life.

Conclusions

In addition to demonstrating that a shorter VWF survival contributes to the type 2B and atypical type 2B VWD phenotype, our findings suggest that VWF clearance and proteolysis are independent phenomena.     

Endotoxin filtration and immune stimulation improve survival from gram-negative sepsis

Polymyxin B, when bound to a polystyrene fiber (PMX-F), has been used experimentally as an extracorporeal blood filter to reduce serum lipopolysaccharide levels, which are believed to be responsible for physiologic alterations in the septic state. To validate our theory that a combination of PMX-F, systemic antibiotics, and immune stimulation would improve survival, 78 rats were given intravenous doses of Escherichia coli (range, 4.6 to 6.2 X 10(8) colony-forming units/ml). They were then randomized into groups receiving either systemic gentamicin (n = 10); pretreatment with muramyl dipeptide (n = 11); or extracorporeal hemoperfusion through either a sham column (n = 8), PMX-F-packed column with systemic gentamicin (n = 8); or PMX-F-packed column with systemic gentamicin and muramyl dipeptide pretreatment (n = 8). Thirty-three control rats received no treatment. Sham hemoperfusion (13%) and control (21%) rats had the lowest survival rate, although increased improvement was noted in rats treated with gentamicin (30%) or the combination of PMX-F filtration and gentamicin (50%). The most significant improvements occurred in rats pretreated with muramyl dipeptide (53%) and in rats treated with a combination of PMX-F, gentamicin, and muramyl dipeptide (88%). These data show that lipopolysaccharide filtration and nonspecific immune stimulation are additive to antibiotic therapy and are useful as adjunctive measures in the multimodal treatment of experimental gram-negative bacterial infection.     

Primary colonic lymphoma: report of two cases

Primary colonic lymphoma is a rare condition. It may be associated with immunosuppressed states and inflammatory bowel disease. The pattern of presentation is not specific, this leads to lengthy in diagnosis. Authors report two personal cases and discuss the problem of diagnosis. Surgery followed by adjuvant chemotherapy is the standard treatment. Using this approach 5-years survival ranges from 27-55%.     

The judet quadricepsplasty: Long-term outcome of 21 cases

BACKGROUND: The lack of knee flexion represents a possible complication in severe femur fractures. In 1956, Judet proposed a quadricepsplasty technique that allowed for a graded release without the disruption of the vastus medialis obliqus, vastus lateralis, or rectus femoris. METHODS: This article reports the clinical outcome of 21 cases of Judet quadricepsplasty after an average follow-up of 101.0 months (range, 21-204 months). The definitive flexion gain was classified as excellent, good, fair, or poor. Excellent when >100 degrees, good when >80 <99 degrees, fair when >50 degrees <79 degrees, poor when <50 degrees. The flexion and extension strength were graded from 0 to 5, according to the Daniel's scale. RESULTS: The average strength score was 4.71 in flexion, 4.81 in extension. The average definitive flexion was 95.67 degrees (range, 54-128 degrees) and the average definitive flexion gain was 72.43 degrees (range, 40-122 degrees). When the patients were grouped on the basis of the definitive flexion, excellent results were observed in eight cases (38.10%), were good in nine (42.86%), and fair in four (19.05) with zero poor results. CONCLUSIONS: Our experience has shown that, even if first proposed in 1956, the Judet procedure still gives a reproducible amount of good results.     

The lost gallstone

Laparoscopic cholecystectomy has become the treatment of choice for most patients with gallstones. During this procedure it is not uncommon for the gallbladder to be entered inadvertently, spilling gallstones freely into the peritoneal cavity. Finding and removing all of the spilled gallstones can be difficult and time consuming. The natural history of stones left in the peritoneal cavity, outside the gallbladder, bile ducts, or intestine, is not known.This is a case report of a complication related to several gallstones left in the peritoneal cavity after laparoscopic cholecystectomy. An abscess developed around them, which necessitated the drainage of purulent exudate from the right flank 8 months postoperatively. The abscess and sinus tract did not heal until the stones were removed. If possible, all stones should be removed during laparoscopic cholecystectomy to forestall the development of this type of complication.     

Effects of binge eating behavior on fuel oxidation and body composition

OBJECTIVE: To investigate energy expenditure and glucose metabolism after a standard oral glucose load (75 g) in 8 normal weight bulimic women and 8 normal weight control women and to evaluate the relative endocrine implication. DESIGN: Serum glucose and insulin were measured both in basal conditions and after the glucose load; a basal endocrine assessment and body composition was evaluated and glucose induced thermogenesis (GIT) was calculated during 300 min following the glucose load. RESULTS: Serum glucose levels were significantly lower in bulimics both in fasting and in post-prandial state. Insulin levels were similar in bulimic and control women before and after the glucose load. FSH, leptin and free urinary cortisol (FUC) were all within the normal ranges, but significantly lower in bulimic patients compared with controls (p < 0.001). Fat mass (FM) and Fat-free mass (FFM) were reduced in bulimic patients, even if they normalized after correction per body weight. Resting energy expenditure (REE) was similar in the two groups even after FFM normalization, while GIT was lower in bulimic patients and it was strongly related to free urinary chortisol. Glucose oxidation was higher in fasting state and post glucose load, while lipid oxidation was strongly reduced. CONCLUSION: An energy preservation mechanism seems to be the key element for normal-weight bulimic patients' metabolism, consisting in leptin levels and GIT reduction, and lipid oxidation inhibition.     

Effects of weight loss and calorie restriction on carbohydrate metabolism

PURPOSE OF REVIEW: This article provides an overview of the most recent molecular and clinical outcomes of studies that investigate the effect of weight loss and calorie restriction on carbohydrate metabolism, obtained either by dieting or bariatric surgery. It will focus on aspects of carbohydrate metabolism related to insulin action. The discussion begins by describing attempts to restrain calories by shifting the macronutrient balance from carbohydrates to a higher protein and fat content. The topics covered include insulin secretion and resistance, glucose homeostasis and allostasis, changes in the secretive patterns of adipose tissue and the entero-insular axis. RECENT FINDINGS: Any improvement in glucose homeostasis, insulin sensitivity and secretion after a low-carbohydrate high-fat diet is still unproved. However, the restriction of dietary carbohydrate seems to reduce glycogenolysis and endogenous glucose production in type 2 diabetes mellitus, thus inducing the amelioration of plasma glucose levels, ultimately resulting in a reduction in the glycated haemoglobin concentration. The increased endogenous glucose production caused by enhanced gluconeogenesis and glycogenolysis, reduced insulin sensitivity, mainly caused by acquired defects of glucose transport and phosphorylation, and the impairment of insulin secretion all together contribute to maintain a chronic status of hyperglycaemia. Weight loss and calorie restriction restore glucose homeostasis and produce changes in the secretive activities of adipose tissue and the entero-insular axis. SUMMARY: Weight loss and calorie restriction partly explain the positive changes of glucose disposal. The multistep interaction of several factors at sites of insulin action, insulin secretion, adipose tissue and the entero-insular axis needs further investigation.