Guillermo Gomez

Laparoscopic hysterectomy using a computer-enhanced surgical robot

ObjectiveThe objective of this study was to describe the technique of laparoscopic hysterectomy using a computer-enhanced robotic surgical system.MethodsEleven patients underwent laparoscopic hysterectomy and bilateral salpingo-oophorectomy using a computer-enhanced surgical robot. Four trocars were used: one for the camera, two for the robotic arms controlled by the operating surgeon from the surgeon’s console, and an additional port for use by the surgical assistant.ResultsAges ranged from 27 to 77 years, and weight ranged from 54 to 100 kg. Operative time ranged from 4.5 to 10 hours. Estimated blood loss ranged from 50 to 1500 ml. The patients tolerated the procedure and recovered satisfactorily.ConclusionThis is the first case series reporting the use of a computer-enhanced surgical robot for performing hysterectomy in humans. It is feasible and well tolerated in this series of patients. As this technology develops, the applications for its use in gynecology and gynecologic oncology will increase.

Regulation of the release of cholecystokinin by bile salts in dogs and humans

The objective of these studies was to investigate the role of bile salts in the regulation of release of cholecystokinin in response to nutrients in dogs and humans. In dogs, the intraduodenal administration of a bile salt sequestrant, cholestyramine (2, 4, or 8 g/h), resulted in a dose-related enhancement of the release of cholecystokinin-33/39 and pancreatic protein secretion in response to intraduodenal administration of amino acids. Intraduodenal administration of cholestyramine alone did not affect basal levels of cholecystokinin-33/39 or pancreatic protein secretion. Total diversion of bile also significantly increased the release of cholecystokinin and pancreatic protein secretion in response to intraduodenal administration of amino acids. Replacement of the bile salt pool by intraduodenal administration of taurocholate completely reversed the enhancement effect of both cholestyramine and bile diversion. In humans, oral ingestion of cholestyramine (12 g) significantly increased the release of cholecystokinin-33/39 and gallbladder contraction in response to the oral ingestion of either a triglyceride or amino acids. These results support a physiologic role of bile salts in the negative feedback regulation of release of cholecystokinin in response to luminal nutrients.

Mechanisms of Disease: the pathological basis of gastroparesis—a review of experimental and clinical studies

The pathogenesis of gastroparesis is complicated and poorly understood. This lack of understanding remains a major impediment to the development of effective therapies for this condition. Most of the scientific information available on the pathogenesis of gastroparesis has been derived from experimental studies of diabetes in animals. These studies suggest that the disease process can affect nerves (particularly those producing nitric oxide, but also the vagus nerve), interstitial cells of Cajal and smooth muscle. By contrast, human data are sparse, outdated and generally inadequate for the validation of data obtained from experimental models. The available data do, however, suggest that multiple cellular targets are involved. In practice, though, symptoms seldom correlate with objective measures of gastric function and there is still a lot to learn about the pathophysiology of gastroparesis. Future studies should focus on understanding the molecular pathways that lead to gastric dysfunction, in animal models and in humans, and pave the way for the development of rational therapies.

Changes in the gastric enteric nervous system and muscle: A case report on two patients with diabetic gastroparesis

BackgroundThe pathophysiological basis of diabetic gastroparesis is poorly understood, in large part due to the almost complete lack of data on neuropathological and molecular changes in the stomachs of patients. Experimental models indicate various lesions affecting the vagus, muscle, enteric neurons, interstitial cells of Cajal (ICC) or other cellular components. The aim of this study was to use modern analytical methods to determine morphological and molecular changes in the gastric wall in patients with diabetic gastroparesis.MethodsFull thickness gastric biopsies were obtained laparoscopically from two gastroparetic patients undergoing surgical intervention and from disease-free areas of control subjects undergoing other forms of gastric surgery. Samples were processed for histological and immunohistochemical examination.ResultsAlthough both patients had severe refractory symptoms with malnutrition, requiring the placement of a gastric stimulator, one of them had no significant abnormalities as compared with controls. This patient had an abrupt onset of symptoms with a relatively short duration of diabetes that was well controlled. By contrast, the other patient had long standing brittle and poorly controlled diabetes with numerous episodes of diabetic ketoacidosis and frequent hypoglycemic episodes. Histological examination in this patient revealed increased fibrosis in the muscle layers as well as significantly fewer nerve fibers and myenteric neurons as assessed by PGP9.5 staining. Further, significant reduction was seen in staining for neuronal nitric oxide synthase, heme oxygenase-2, tyrosine hydroxylase as well as for c-KIT.ConclusionWe conclude that poor metabolic control is associated with significant pathological changes in the gastric wall that affect all major components including muscle, neurons and ICC. Severe symptoms can occur in the absence of these changes, however and may reflect vagal, central or hormonal influences. Gastroparesis is therefore likely to be a heterogeneous disorder. Careful molecular and pathological analysis may allow more precise phenotypic differentiation and shed insight into the underlying mechanisms as well as identify novel therapeutic targets.

Nutrient inhibition of ghrelin secretion in the fasted rat

Ghrelin is a recently discovered stomach hormone whose secretion increases with fasting; the fasting-induced elevation is inhibited by refeeding. The aim of this study was to determine whether all nutrient types (i.e., carbohydrates, proteins, fats) and soybean trypsin inhibitor (SBTI), a secretagogue for intestinal cholecystokinin (CCK), given individually into the stomach or intravenously can inhibit ghrelin secretion in the fasted rat. Intragastric (i.g.) administration of intact protein, a protein digest, SBTI, dextrose, or fat decreased plasma ghrelin levels significantly (p<0.05). All nutrients inhibited ghrelin secretion equally. Fat and dextrose given intravenously (i.v.) also reduced ghrelin secretion. These data demonstrate that nutrients can inhibit ghrelin secretion by both the luminal and systemic routes. Additionally, the findings show that all nutrient types given orally are capable of inhibiting ghrelin secretion, and suggest that intestinal CCK may participate in the inhibition of ghrelin secretion following oral intake of nutrients.

Neural regulation of peptide YY secretion

The purpose of these experiments was to investigate the neural control of peptide YY (PYY) secretion. The effects of various pharmacological manipulations and vagotomy on peptide YY (PYY) secretion was examined in dogs. Atropine, hexamethonium and atropine plus hexamethonium treatment blocked food-induced release of PYY significantly. Integrated release of PYY in response to food alone and in combination with atropine, hexamethonium and atropine plus hexamethonium were 8.8 +/- 2.2, -1.1 +/- 2.3, -2.7 +/- 2.2 and -3.2 +/- 3.1 (ng (0-150) min/ml), respectively. beta-Adrenergic blockade with propranolol or depletion of nerve terminal stores of catecholamines with reserpine did not affect food-stimulated release of PYY. Truncal vagotomy resulted in significant elevations of basal and food-induced release of PYY. IV administration of bethanechol, a cholinergic agonist, and electrical stimulation of the vagus nerve resulted in release of PYY. Together, these data suggest that food-stimulated PYY secretion is dependent on ganglionic transmission and an atropine-blockable postganglionic parasympathetic pathway; and that PYY release is inhibited tonically, probably through a vagal cholinergic mechanism. Adrenergic pathways do not participate in food-stimulated PYY release; however, electrical stimulation of the splanchnic nerves increased basal levels of PYY, suggesting that the sympathetic nervous system affects release of PYY.

Acute Pancreatitis Signals Activation of Apoptosis-Associated and Survival Genes in Mice

In experimental models of acute pancreatitis (AP), acinar cell death occurs by both necrosis and programmed cell death or apoptosis. Apoptosis is an active form of cell death associated with a tightly regulated expression of gene products that are either pro- or antiapoptotic. The aim of this study was to characterize pancreatic mRNA levels by Northern blotting analysis of apoptosis-associated genes used during the course of cerulein-induced AP in mice. Histone H3 mRNA levels were also examined as an indicator of cell proliferation. Acinar cell apoptosis was confirmed histologically. The findings show that AP modifies pancreatic mRNA levels of both pro- and antiapoptotic genes simultaneously. Pancreatic bclXL, bax, and p53 mRNA levels increased significantly in a temporal fashion during induction of AP. Pancreatic bcl-2 mRNA levels were unchanged during AP. Pancreatic mRNA levels of insulin-like growth factor-1 (IGF-1), a mitogen and cell survival factor, and its receptor (IGF-1R) also increased in a temporal fashion during induction of AP. In summary, this study indicates that acinar cell death during cerulein-induced AP in mice can occur by the apoptotic pathway. Since factors promoting and antagonistic for cell survival are activated simultaneously, regulation of acinar cell survival appears complex and dynamic during AP.

Peptide YY inhibits nutrient-, hormonal-, and vagally-stimulated pancreatic exocrine secretion.

Peptide YY (PYY) is a recently isolated gut peptide that is found primarily in the mucosal endocrine cells of the terminal ileum, colon, and rectum of several mammalian species, including humans. The purpose of this study was to characterize the effect of PYY on pancreatic exocrine secretion in six conscious dogs prepared with pancreatic and gastric fistulas. In control experiments, pancreatic exocrine secretion was stimulated by either intrave-nous (i.v.) administration of secretin (100 ng/kg/h), cholecystokinin-8 (50 ng/kg/h), neurotensin (5 μg/kg/h), or 2-deoxy-D-glucose (75 mg/kg); or by the intraduodenal infusion of hydrochloric acid (4 mEq/h), a mixture of amino acids (phenylalanine + tryptophan at 5 mmol/h), sodium oleate (9 mmol/h), or a liquid meal. On separate days, PYY (12.5, 25,50, 100, 200, or 400 pmol/kg/h) was given intravenously in combination with one of the above pancreatic se-cretagogues. Intravenous PYY at 200 and 400 pmol/kg/h inhibited secretin-stimulated pancreatic bicarbonate output significantly (p <0.05). Pancreatic bicarbonate and protein responses to all pancreatic secretagogues were re-duced significantly (p <0.05) by PYY at 400 pmol/kg/h. Intravenous adminis-tration of atropine (0.6 mg bolus, followed by 0.02 mg/kg/h) did not abolish the ability of PYY to inhibit secretin-stimulated pancreatic bicarbonate secretion. This study demonstrates that PYY can inhibit nutrient-, hormonal-, and va-gally-stimulated pancreatic exocrine secretion in the dog; its mechanism of action appears to be independent of cholinergic innervation.

Increased colonic apelin production in rodents with experimental colitis and in humans with IBD

Apelin and its receptor, the APJ receptor, are expressed in the gastrointestinal tract. The aims of this study were to examine the effects of sodium dextran sulfate (DSS)-induced experimental colitis in rats and mice and inflammatory bowel disease (IBD) in humans on intestinal apelin production, and the influence of exogenous apelin on colonic epithelial cell proliferation in mice. In rodents with experimental colitis, colonic apelin mRNA levels were elevated during the inflammatory reaction as well as during the tissue repair phase that ensues after DSS withdrawal. Fluctuations in colonic apelin expression were paralleled by similar changes in apelin immunostaining. Apelin immunostaining was increased in the surface epithelium, in epithelial cells along the length of the tubular gland and in the stem cell region at the gland base. In ulcerative colitis (UC) and Crohns disease patients, apelin immunostaining revealed a pattern of increased intestinal apelin content similar to that observed in rodents with experimental colitis. Administration of synthetic apelin to mice during the recovery phase of DSS-induced colitis stimulated colonic epithelial cell proliferation significantly. Our observations that colonic apelin production is increased during and after DSS exposure indicate that apelin plays multiple roles during the different stages of colitis. Additionally, the stimulatory action of exogenous apelin on colonic epithelial proliferation suggests that the increased apelin production during intestinal recovery stage may contribute to the repair of the intestinal epithelium in experimental rodent models of colitis and in IBD patients.

Effect of Peptide YY on Cephalic, Gastric, and Intestinal Phases of Gastric Acid Secretion and on the Release of Gastrointestinal Hormones

The objective of this study was to investigate the effects of a novel gut peptide, peptide YY (PYY), on the cephalic, gastric, and intestinal phases of gastric acid secretion and to explore the mechanisms involved. The cephalic phase of gastric acid secretion, stimulated by the intravenous injection of 2-deoxyglucose (75 mg/kg), was found to be inhibited by intravenous PYY (100, 200, 400 pmol/kg X h) in a dose-related fashion. Peptide YY (200 and 400 pmol/kg X h) also resulted in a significant dose-dependent inhibition of the gastric phase of acid secretion. On the other hand, PYY (400 pmol/kg X h) failed to affect the intestinal phase of gastric acid output. Serum gastrin levels were increased on infusion of 10% liver extract into stomach, but were unaffected on instillation of liver extract into duodenum. Peptide YY did not inhibit the release of gastrin in either the gastric or intestinal phase studies. Furthermore, PYY had no significant effect on either the basal release of secretin, gastric inhibitory polypeptide, pancreatic polypeptide, or neurotensin, or on the stimulated release of pancreatic polypeptide by 2-deoxyglucose. The specific binding of gastrin to its receptors on the fundic mucosa was also unaffected by PYY. These results indicate that PYY inhibits the cephalic and gastric phases of acid secretion independently, and that its actions are not mediated by either a negative effect on gastrin release or a positive effect on the release of some of the known acid inhibitors, or by an inhibition of gastrin binding to its receptors on the fundic cells. Our present findings (in combination with our previous findings of inhibition of pentagastrin- and bethanechol-stimulated gastric acid secretion by PYY, independent of the vagal cholinergic mechanism) indicate that the action of PYY is either direct on the parietal cells or is mediated by yet another, unidentified, inhibitor.