Juan Antonio Baena

Lower Zinc-α2-Glycoprotein Production by Adipose Tissue and Liver in Obese Patients Unrelated to Insulin Resistance

CONTEXT Zinc-alpha2 glycoprotein (ZAG) has been proposed as a new candidate in the pathogenesis of obesity, but most of the information stems from studies performed in rodents and in vitro assays. OBJECTIVE The main aim of the study was to compare serum levels of ZAG and its expression (mRNA levels and protein) in adipose tissue and the liver between obese and nonobese subjects. The relationship between ZAG and insulin resistance was also explored. DESIGN This was a case-control study. SETTING The study was conducted at a university referral center. PATIENTS AND METHODS Samples of serum, sc adipose tissue (SAT), visceral adipose tissue (VAT), and liver were obtained from 20 obese subjects during bariatric surgery. Samples from 10 nonobese patients matched by age and gender were used as a control group. Serum ZAG levels were determined by ELISA. ZAG mRNA levels were measured by real-time PCR and protein content by Western blot. The effect of insulin on liver production of ZAG was assessed using HepG2 cultures. RESULTS Serum concentration of ZAG (micrograms per milliliter) was significantly lower in obese subjects (40.87 +/- 10.45 vs. 63.26 +/- 16.40; P = 0.002). ZAG expression was significantly lower in the adipose tissue (SAT and VAT) and liver of obese patients than in control subjects. Significant negative correlations between body mass index and circulating ZAG (r = -0.65, P < 0.001) as well as between body mass index and mRNA ZAG levels in SAT (r = -0.68, P < 0.001) and VAT were detected (r = -0.64, P < 0.001). No relationship was found between ZAG and homeostasis model assessment for insulin resistance and insulin had no effect on ZAG production in vitro. CONCLUSION A down-regulation of ZAG in SAT, VAT, and liver exists in obese patients but seems unrelated to insulin resistance.

Preoperative Thyrotropin Serum Concentrations Gradually Increase from Benign Thyroid Nodules to Papillary Thyroid Microcarcinomas Then to Papillary Thyroid Cancers of Larger Size

We evaluated the preoperative serum thyrotropin (TSH) levels in 386 patients operated on for nodular thyroid disease (NTD). TSH levels for cases with final benign disease and differentiated thyroid carcinoma (DTC) were compared. No evidence of cancer was detected in 310 patients (80.3%), whereas malignancy was present in 76 cases (19.7%). Mean TSH concentration was 1.36 ± 1.62 mU/L in benign patients and 2.08 ± 2.1 in cases with malignant lesions (P = 0.0013). The group of malignancy was subdivided in papillary thyroid carcinoma (PTMC) versus thyroid cancer of larger size (TCLS). Mean TSH was 1.71 ± 1.52 in PTMC and 2.42 ± 2.5 in TCLS. Significant differences were found when all groups (benign, PTMC and TCLS) were compared (P < 0.001). However, pairwise comparisons between them showed that differences were only significant between benign and TCLS groups (P < 0.01). In conclusion, TSH levels were higher in patients with a final diagnosis of DTC. Moreover, it appears that there exists an increment in tumor size as a function of increment in the TSH level.

Clinical significance of RET/PTC and p53 protein expression in sporadic papillary thyroid carcinoma

Aims:  Rearranged during Transfection (RET)/papillary thyroid carcinoma (PTC) and p53 are two genes involved in the pathogenesis of PTC. It has been suggested that RET/PTC expression is associated with higher rates of local extension and lymph node involvement, whereas p53 mutations are more frequent in poorly differentiated and anaplastic carcinomas. In addition, experimental studies have shown that p53 activity can modify the behaviour of PTC carrying RET/PTC. The aim of this study was to investigate the expression of both RET/PTC and p53 in order to evaluate their usefulness as prognostic factors.

Differences in the Form of Presentation between Papillary Microcarcinomas and Papillary Carcinomas of Larger Size

Papillary thyroid carcinomas (PTCs) with a diameter ≤1 cm are referred to as papillary microcarcinomas (PTMCs). The prognostic factors for PTMCs have not been defined. Different clinical and histopathologic variables were studied in 152 PTCs, including 74 PTMCs and 78 PTCs of larger size. We found that PTMCs are associated with less multifocality (P = .046) and bilaterality (P = .003), fewer lymphadenectomies (P < .001), and a higher rate of incidental tumours (P < .001). Moreover, patients with a low aggressive profile were significantly older than the remaining patients (54 ± 13.7 years versus 45.8 ± 13.1 years; P = .001). In conclusion PTMCs show significant differences compared to PTCs of larger size in the form of presentation. Furthermore, it is possible that the classic risk factors, which are well validated in PTCs, such as age, must be cautiously interpreted in the current increasing subgroup of PTMCs.

Expression of p21cip1, p27kip1, and p16INk4a Cyclin-Dependent Kinase Inhibitors in Papillary Thyroid Carcinoma: Correlation with Clinicopathological Factors

In a variety of human malignancies, aberrant expression of proteins involved in the control of cell-cycle progression has been reported. In this study, p21cip1, p27kip1, and p16INk4a cyclin-dependent kinase inhibitors were analyzed to evaluate their usefulness in clinical management of papillary thyroid carcinoma (PTC). Archived material derived from 46 cases of PTC was analyzed immunohistochemically. Protein expression was ascertained on tissue microarrays, and results were correlated with clinicopathological features of the patients. Positive immunostaining was observed in 14 (30,4%) p21cip1, 26 (56,5%) p27kip1, and 14 (30,4%) p16INk4a cases. No significant correlation between p21cip1 or p27kip1 and clinical factors was found. In contrast, p16INk4a expression showed a significant correlation with initial extension of the disease. Therefore, 45.8% of patients with loco-regional extension were p16INk4a positive, whereas overexpression was only seen in 15.7% of cases with intrathyroid disease (p < 0.05). Moreover, all patients with simultaneous p16INk4a positivity and lack of p27kip1 staining (four patients) presented lymph node metastases. In contrast, only 12 (28.5%) of the remaining patients showed lymph node tumor involvement. In conclusion, p16INk4a expression suggests extrathyroid neck extension of PTC. This effect is enhanced when p27kip1 is negative. We think that their analysis by immunohistochemistry could be useful in the management of patients with PTC.

Isolated Langerhans Cell Histiocytosis of the Thyroid in an Adult Female: One-Year Followup

Thyroid gland involvement as the unique presentation of Langerhans cell histiocytosis is a rare phenomenon that can result in misdiagnosis. We report a case of Langerhans cell histiocytosis (LCH) presenting as a thyroid mass. It is a 52-year-old woman who presented an enlarged, diffusely firm, nontender, nonmobile, and not particularly nodular thyroid gland with mild compressive symptoms. Ultrasound and fine-needle aspiration showed a unique right node with benign signs. Patient was referred to our Ambulatory Surgery Department, where a hemithyroidectomy was performed. Histologic evaluation of the right thyroid gland revealed an involvement by LCH, confirmed by immunohistochemical analysis showing Langerhans cells that were positive for CD1a. LCH was a completely incidental occult finding apparent only after surgical resection and examination of the gland. Patient was evaluated, and no evidence of systemic affectation was found. LCH can rarely involve the thyroid gland in adults. Few cases have been reported in the literature. Most patients had evidence of LCH involving other anatomic sites.

Management of Patients with Hernia or Incisional Hernia Undergoing Surgery for Morbid Obesity

Morbidly obese patients (MOPs) are predisposed to developing abdominal wall hernias with the potential complication of small bowel obstruction and other morbidity. We report our experience in treating morbidly obese patients. Hernia prophylaxis has been attempted as a means of decreasing the incisional hernia risk associated with weight loss surgery. The controversy regarding the optimal time and method of repair of abdominal wall hernias in patients undergoing open or laparoscopic gastric bypass is discussed with emphasis placed on either a simultaneous repair or splits of the omentum, and of leaving a plug in the hernia defect, to allow time to perform a delayed repair.

Utilidad de la determinación intraoperatoria de parathormona en el tratamiento quirúrgico del hiperparatiroidismo primario por adenoma de paratiroides

Fundamento y objetivo La exploracion quirurgica de las 4 paratiroides es un procedimiento demasiadoagresivo para la mayoria de los casos de hiperparatiroidismo primario (HPTP) cuya causa es un adenoma preoperatoriamente localizado. Recientemente la determinacion intraoperatoria de paratormona (PTH) ha demostrado ser una herramienta util en el tratamiento de estos pacientes y permitiria el uso de tecnicas quirurgicas minimamente invasivas, con una menor morbilidad. El objetivo de nuestro trabajo es la valoracion de la utilidad de la determinacion intraoperatoria de la PTH en el abordaje quirurgico del HPTP. Pacientes y metodo Se incluyo a 27 pacientes consecutivos, diagnosticados de HPTP causado por un adenoma de paratiroides. El estudio de localizacion consto de ecografia cervical y gammagrafia con Tc-MIBI. Durante la intervencion, se determino la PTH en el momento de la induccion anestesica y 5 y 10 min despues de la exeresis del adenoma. Un descenso de la PTH mayor del 50% a los 10 min se considero criterio de curacion. La PTH se determino por un metodo quimioluminimetrico (Advantage, Nichols). El tiempo necesario para la obtencion del resultado fue de 20 min. Resultados En los 27 casos no existio hipercalcemia 24 h despues de la intervencion, por loque se consideraron curados. La PTH disminuyo mas de un 50% en todos ellos. En un caso, la PTH se mantuvo elevada despues de extirpar una lesion que se habia localizado preoperatoriamente. El dictamen patologico fue que se trataba de un tejido paratiroideo normal. La continuacion de la exploracion quirurgica permitio encontrar un adenoma en el lado contralateral. La PTH posterior fue menor del 50%. Por tanto, de las 28 determinaciones, la PTH fue predictiva del resultado quirurgico en la totalidad de los casos. Conclusiones La determinacion intraoperatoria de PTH es util en el abordaje quirurgico del HPTP y permite el uso de tecnicas quirurgicas minimamente invasivas.

Colouterine fistula complicating diverticulitis in elderly women

Dear Editor: Diverticulosis is a very common colonic pathology occurring in more than 65% of the population by the age of 80. The inflammatory process involving diverticulosis arises with an inflammatory response that may require surgery for hemorrhage, abscess, perforation, or fistula formation. The pathophysiology of colouterine fistulas includes destruction of two serosas of two epithelialized surfaces in close proximity. We describe the case of an elderly 76-year-old patient who presented within a period of 6 months with two episodes of acute diverticulitis that required endovenous treatment. The patient had already presented with fecal incontinence. At this time, the patient was taken to the emergency room because of the presence of a foul-smelling vaginal discharge with fecaloid flow. Abdominal examination revealed a low tenderness in the left lower quadrant, without palpable mass. The patient had no fever. Laboratory tests did not show any alteration in biological values. Antibiotic treatment was initiated and the patient was studied. A CT scan was performed that showed the presence of a uterus full of air and fecal content. Also, an inflammatory sigmoid colon with the presence of diverticles and a thick sigmoid wall could be seen. An image of malignancy could not be excluded. All these data confirmed the presence of a colouterine fistula. No colonoscopy had been yet performed because of the wish of the patient and their family. Surgery was performed and, at laparotomy, a chronic inflammatory mass was observed. This mass included the whole sigmoid colon and the posterior uterine wall. An en bloc resection was performed with a Hartman’s procedure. Colouterine fistulas were first reported by Lejemtel in 1909. At that time, three main etiologies were described: first, trauma or spontaneous rupture of a gravid uterus in which an intestinal loop impacted on the tear and a subsequent necrosis developed after constricting contractions of the myometrium; second, the presence of abscess rupture into the bowel and the uterus; third, a uterine or sigmoid carcinoma. In later years, radiotherapy has also been involved in colouterine fistula formation. Hawkes described obstetric trauma including curettage of the uterus with simultaneous perforation of the uterus and the colon. The first report of colouterine fistulas related to diverticulitis was by Noecker in 1929. This diagnosis is rare and even rarer is to observe colouterine fistulas related to diverticulitis. Among causes other than diverticulitis, endometriosis, gynecological cancer, and also apex abscesses have been described. Many reasons have been provided in order to explain colouterine fistula formation. Owing to the great thickness of the uterine wall, colouterine fistulas are very rare. The development of diverticulitis episodes may lead to a fistula formation, because of repeated inflammatory response in the tissues, such as in our patient. Repeated acute episodes of diverticulitis may lead to adhesions, local inflammation, with subsequent necrosis and fistula formation. It is usually the fundus of the uterus and the sigmoid colon that are linked. Also, a perforated sigmoid colon in the presence of an abscess may be the cause of the fistula formation, which was the case with our patient. Int J Colorectal Dis (2009) 24:599–600 DOI 10.1007/s00384-008-0630-x

Endoscopic Management of Drain Inclusion in the Gastric Pouch after Gastrojejunal Leakage after Laparoscopic Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity (LRYGBP)

Background. Drain inclusion inside the gastric pouch is rare and can represent an important source of morbidity and mortality associated with laparocopic Roux-en-Y gastric bypass (LRYGBP). These leaks can become chronic and challenging. Surgical options are often unsuccessful. We present the endoscopic management of four patients with drain inclusion. Patients. All four obese morbidly patients underwent LRYGBP and presented a gastro-jejunal fistula after acute anastomotic leakage. During follow-up endoscopy the drain was found inside the gastric pouch. It was moved into the abdominal cavity. Fistula debit reduced significantly and closed. Results. Gastric leak closure in less than 24 hours was achieved in all, with complete resolution of symptoms. These patients benefited exclusively from endoscopic treatment. Conclusions. Endoscopy is useful and technically feasible in chronic fistulas. This procedure is a less invasive alternative to traditional surgical revision. Other therapeutic strategies can be used such as clips and fibrin glue. Drains should not be placed in contact with the anastomosis or stapled lines. Drain inclusion must be suspected when fistula debit suddenly arises. If so, endoscopy is indicated for diagnostic accuracy. Under endoscopy vision, the drain is gently removed from the gastric reservoir leading to sudden and complete resolution of the fistula.