A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity

PURPOSE

Bariatric surgery is the method of choice for the management or treatment of obesity. Bariatric surgery brings about several physiological changes in the body and is associated with set of complications. The aim of this study is to provide guidelines on post bariatric surgery management based on consensus by the Spanish society for Obesity Surgery (Sociedad Española de Cirugía de la Obesidad) (SECO) and the Spanish Society for the Study of Obesity (Sociedad Española para el Estudio de la Obesidad) (SEEDO).

METHOD

The boards proposed seven experts from each society. The experts provided the evidence and a grade of recommendation on the selected topics based on systematic reviews/meta-analysis. A list of clinical practical recommendations levels of evidence and grades of these recommendations was derived from the consensus statements from the members of these societies.

RESULTS

Seventeen topics related to post-operative management were reviewed after bariatric surgery. The experts came with 47 recommendations and statements. The mean number of persons voting at each statement was 54 (range 36-76).

CONCLUSION

In this consensus, we have designed a set of guidelines to be followed while managing patients after bariatric surgery. Expertise and knowledge of the clinicians are required to convey suitable considerations to the post-bariatric patients. There should also be extensive follow-up plans for the bariatric surgery patients.

The uptake inhibitors cocaine and benztropine differentially alter the conformation of the human dopamine transporter

The binding affinity of the cocaine analog [(3)H]2 beta-carbomethoxy-3beta-(4-fluorophenyl) tropane (WIN) for the dopamine transporter (DAT) is increased by the reaction of Cys-90, at the extracellular end of the first transmembrane segment, with methanethiosulfonate (MTS) reagents. Cocaine enhances the reaction of Cys-90 with the sulfhydryl reagents, thereby augmenting the increase in binding. In contrast, cocaine decreases the reaction of Cys-135 and Cys-342, endogenous cysteines in cytoplasmic loops, with MTS reagents. Because this reaction inhibits [(3)H]WIN binding, cocaine protects against the loss of binding caused by reaction of these cysteines. In the present work, we compare the abilities of DAT inhibitors and substrates to affect the reaction of Cys-90, Cys-135, and Cys-342 with MTS ethyltrimethylammonium (MTSET). The results indicate that the different abilities of compounds to protect against the MTSET-induced inhibition of binding are attributable to differences in their abilities to attenuate the inhibitory effects of modification of Cys-135 and Cys-342 as well as to enhance the reaction with Cys-90 and the resulting potentiation of binding. The inhibitor benztropine was unique in its inability to protect Cys-135. Moreover, whereas cocaine, WIN, mazindol, and dopamine enhanced the reaction of Cys-90 with MTSET, benztropine had no effect on this reaction. These two features combine to give benztropine its weak potency in protecting ligand binding to wild-type DAT from MTSET. These results indicate that different inhibitors of DAT, such as cocaine and benztropine, produce different conformational changes in the transporter. There are differences in the psychomotor stimulant-like effects of these compounds, and it is possible that the different behavioral effects of these DAT inhibitors stem from their different molecular actions on DAT.

[3H]MFZ 2-12: a novel radioligand for the dopamine transporter

In an effort to develop a tritiated dopamine transporter radioligand with higher affinity than the widely used [(3)H]WIN 35,428, we have synthesized [(3)H]2beta-carbomethoxy-3beta-(3',4'-dichlorophenyl)tropane ([(3)H]MFZ 2-12). Unlabeled MFZ 2-12 and the N-demethylated intermediate (MFZ 2-13) inhibited dopamine uptake by the human dopamine transporter with IC(50)'s of 1.1 and 1.4nM, respectively. The N-nor-intermediate (MFZ 2-13) was treated with CT(3)I resulting in [(3)H]MFZ 2-12; S.A.=80 Ci/mmol). [(3)H]MFZ 2-12 reversibly bound with a K(D) of 2.8nM to human dopamine transporter expressed heterologously in EM4 cells.

Reaction of oxidized dopamine with endogenous cysteine residues in the human dopamine transporter

There is evidence to suggest that dopamine (DA) oxidizes to form dopamine ortho-quinone (DAQ), which binds covalently to nucleophilic sulfhydryl groups on protein cysteinyl residues. This reaction has been shown to inhibit dopamine uptake, as well as other biological processes. We have identified specific cysteine residues in the human dopamine transporter (hDAT) that are modified by this electron-deficient substrate analog. DAQ reactivity was inferred from its effects on the binding of [(3)H]2-beta-carbomethoxy-3-beta-(4-fluorophenyl)tropane (beta-CFT) to hDAT cysteine mutant constructs. One construct, X5C, had four cysteines mutated to alanine and one to phenylalanine (Cys(90)A, Cys(135)A, C306A, C319F and Cys(342)A). In membrane preparations 1 mM DAQ did not affect [(3)H]beta-CFT binding to X5C hDAT, in contrast to its effect in wild-type hDAT in which it reduced the B:(max) value by more than half. Wild-type cysteines were substituted back into X5C, one at a time, and the ability of DAQ to inhibit [(3)H]beta-CFT binding was assessed. Reactivity of DAQ with Cys(90) increased the affinity of [(3)H]beta-CFT for the transporter, whereas reactivity with Cys(135) decreased the affinity of [(3)H]beta-CFT. DAQ did not change the K:(D) for [(3)H]beta-CFT binding to wild-type. The reactivity of DAQ at Cys(342) decreased B:(max) to the same degree as wild-type. The latter result suggests that Cys(342) is the wild-type residue most responsible for DAQ-induced inhibition of [(3)H]beta-CFT binding.

Amphetamine-induced loss of human dopamine transporter activity: an internalization-dependent and cocaine-sensitive mechanism

The dopamine transporter (DAT) is a target of amphetamine (AMPH) and cocaine. These psychostimulants attenuate DAT clearance efficiency, thereby increasing synaptic dopamine (DA) levels. Re-uptake rate is determined by the number of functional transporters at the cell surface as well as by their turnover rate. Here, we present evidence that DAT substrates, including AMPH and DA, cause internalization of human DAT, thereby reducing transport capacity. Acute treatment with AMPH reduced the maximal rate of [(3)H]DA uptake, decreased AMPH-induced currents, and significantly redistributed the immunofluorescence of an epitope-tagged DAT from the plasma membrane to the cytosol in human embryonic kidney 293 cells. Conversely, DAT inhibitors, such as cocaine, mazindol, and nomifensine, when administered with AMPH, blocked the reduction in [(3)H]DA uptake and the redistribution of DAT immunofluorescence to the cytosol. The reductions of [(3)H]DA uptake and AMPH-induced DAT internalization also were inhibited by coexpression of a dominant negative mutant of dynamin I (K44A), indicating that endocytosis modulates transport capacity, likely through a clathrin-mediated pathway. With this mechanism of regulation, acute application of AMPH would reduce DA uptake not only by direct competition for uptake, but also by reducing the available cell-surface DAT. Moreover, AMPH-induced internalization might diminish the amount of DAT available for DA efflux, thereby modulating the cytotoxic effects of elevated extracellular DA.

Transport-dependent accessibility of a cytoplasmic loop cysteine in the human dopamine transporter

The effect of covalent sulfhydryl modification on dopamine uptake by the human dopamine transporter was determined by rotating disc electrode voltammetry. A transporter construct, X5C, with five mutated cysteines (C90A, C135A, C306A, C319F, and C342A) and the constructs into which the wild-type cysteines were substituted back into X5C, one at a time, all showed nearly normal binding affinity for [(3)H]CFT and for cocaine, but they displayed significant reductions in K(m) and V(max) for DA uptake. Reaction of Cys-90 or Cys-306 with impermeant methanethiosulfonate derivatives enhanced dopamine uptake to a similar extent as the previously observed enhancement of [(3)H]CFT binding caused by the same reaction, suggesting that cocaine may bind preferentially to a conformation in the transport cycle. m-Tyramine increased the rate of reaction of (2-aminoethyl)methanethiosulfonate (MTSEA) with X-A342C, the construct with a cytoplasmic loop residue Cys-342 restored. This m-tyramine-induced increase in reactivity appeared to require the inward transport rather than the outward transport or external binding of m-tyramine, and it was prevented by cocaine. Thus, inward translocation of substrates may involve structural rearrangement of hDAT, which likely exposes Cys-342 to reaction with MTSEA, and Cys-342 may be located on a part of the transporter associated with cytoplasmic gating.

Cocaine alters the accessibility of endogenous cysteines in putative extracellular and intracellular loops of the human dopamine transporter

Cocaine and other psychostimulants act by blocking the dopamine transporter. Binding of the cocaine analog, [3H]2-beta-carbomethoxy-3-beta-(4-fluorophenyl) tropane (CFT) to the dopamine transporter is sensitive to polar sulfhydryl-specific derivatives of methanethiosulfonate (MTS). These reagents preferentially react with water-accessible, reduced cysteines. The human dopamine transporter has 13 cysteines. Their topology is not completely determined. We sought to identify those cysteine residues the modification of which affects CFT binding and to determine the topology of these reactive cysteines. We mutated each of the cysteines, one at a time and in various combinations, to residues that preserved binding and transport, and we tested the sensitivity of each of the mutant transporters to the reagents. One construct, X5C, had five mutated cysteines (C90A, C135A, C306A, C319F, and C342A). Using a membrane preparation in which both extracellular and intracellular cysteines could be accessible, we found that CFT binding in X5C, as compared with wild-type transporter, was two orders of magnitude less sensitive to MTS ethylammonium (MTSEA). The wild-type cysteines were substituted back into X5C, one at a time, and these constructs were tested in cells and in membranes. Cys-90 and Cys-306 appear to be extracellular, and Cys-135 and Cys-342 appear to be intracellular. Each of these residues is predicted to be in extramembranous loops. The binding of cocaine increases the rate of reaction of MTSEA and MTS ethyltrimethylammonium with the extracellular Cys-90 and therefore acts by inducing a conformational change. Cocaine decreases the rate of reaction of MTSEA with Cys-135 and Cys-342, acting either directly or indirectly on these intracellular residues.

[Acute cholecystitis: analysis of the different therapeutic approaches in a General Surgery Service during the years 1994-1996]

INTRODUCTION

The commonly accepted approach in the treatment of acute cholecystitis is urgent cholecystectomy. Laparoscopy has renewed interest in the option of "cooling" the inflammatory process, in order to subsequently carry out a programmed cholecystectomy through the technique mentioned. We present an analysis of the data collected on hospital stay and medico-surgical complications in both therapeutic options. The aim of this work is to reflect on the results obtained in the treatment of acute cholecystitis and to evaluate the results of the application of laparoscopic cholecystectomy in the emergency area.

MATERIAL AND METHODS

152 patients diagnosed with acute cholecystitis are studied. They are distributed in 3 groups, analysing the simple and accumulated hospital stay, the index of medical and surgical complications and mortality.

RESULTS

Of the 152 patients with a diagnosis of acute cholecystitis, 91 (59.8%) were operated on in their first admission, 47 (30.9%) were treated using "cooling" of the process to be operated on in a second admission and 14 (9.3%) by means of percutaneous cholecystostomy. A total of 29 patients were readmitted, 4 for relapse of acute cholecystitis and 25 for programmed operations. Urgent conventional cholecystectomy shows a greater rate of infections. The cholecystectomy on second admission supposes a moderate increase of the accumulated average stay. 17% of these patients were operated on using open surgery.

CONCLUSIONS

Urgent surgery seems the most suitable approach in acute cholecystitis. The employment of laparoscopic surgery in these cases probably reduces the rate of the medical and surgical complications due to laparotomy in infectious acute pathology, and increases the comfort of the patient

The fission yeast UVDR DNA repair pathway is inducible

In addition to nucleotide excision repair (NER), the fission yeast Schizosaccharomyces pombe possesses a UV damage endonuclease (UVDE) for the excision of cyclobutane pyrimidine dimers and 6-4 pyrimidine pyrimidones. We have previously described UVDE as part of an alternative excision repair pathway, UVDR, for UV damage repair. The existence of two excision repair processes has long been postulated to exist in S.pombe, as NER-deficient mutants are still proficient in the excision of UV photoproducts. UVDE recognizes the phosphodiester bond immediately 5'of the UV photoproducts as the initiating event in this process. We show here that UVDE activity is inducible at both the level of uve1+ mRNA and UVDE enzyme activity. Further, we show that UVDE activity is regulated by the product of the rad12 gene.

[Utilisation of organs proceeding from donors with heart failure: review of the pathogenesis of organic damage and the possible mechanisms of prevention]

There is an evident imbalance between the number of patients awaiting a kidney transplant and the availability of organs proceeding from donors with brain death. A high number of patients die each day from heart failure, whose organs could be used for transplants if specific care is employed. Although centres do exist where these methods of extraction are established, the problems of organic damage have yet to be resolved, since one third of the organs are still lost, besides the increase in the need for early dialysis, and the number of dysfunctioning grafts two years after the transplant, when this type or organ is employed. There is increasingly detailed knowledge of the pathogenesis of organic damage following heart failure and reanimation, as well as of the damage following the conservation and reimplantation of the kidney. Knowledge of the maximum time of hot ischemic that an organ can withstand is of crucial importance if organs are not to be unduly discarded. Besides, the increasing understanding of the physiopathology of oxidative stress could make it possible for us, through the use of antioxidants, to attempt to improve the utilisation of the organs and diminish the incidence of dysfunctions and rejections.

Pseudoaneurysm of the inferior epigastric artery. Pathogenesis, diagnosis, and treatment

We present a new case of pseudoaneurysm of the abdominal wall, subsidiary to the inferior epigastric artery, associated with the use of discharge sutures. Pseudoaneurysms are a well-known complication of surgery, puncture, or trauma. Pseudoaneurysms of the inferior epigastric artery are very infrequent. We know of only two cases in the literature. In both cases, the pseudoaneurysm was associated with the use of discharge sutures. We discuss its pathogenesis, diagnosis, and treatment.

An alternative eukaryotic DNA excision repair pathway

DNA lesions induced by UV light, cyclobutane pyrimidine dimers, and (6-4)pyrimidine pyrimidones are known to be repaired by the process of nucleotide excision repair (NER). However, in the fission yeast Schizosaccharomyces pombe, studies have demonstrated that at least two mechanisms for excising UV photo-products exist; NER and a second, previously unidentified process. Recently we reported that S. pombe contains a DNA endonuclease, SPDE, which recognizes and cleaves at a position immediately adjacent to cyclobutane pyrimidine dimers and (6-4)pyrimidine pyrimidones. Here we report that the UV-sensitive S. pombe rad12-502 mutant lacks SPDE activity. In addition, extracts prepared from the rad12-502 mutant are deficient in DNA excision repair, as demonstrated in an in vitro excision repair assay. DNA repair activity was restored to wild-type levels in extracts prepared from rad12-502 cells by the addition of partially purified SPDE to in vitro repair reaction mixtures. When the rad12-502 mutant was crossed with the NER rad13-A mutant, the resulting double mutant was much more sensitive to UV radiation than either single mutant, demonstrating that the rad12 gene product functions in a DNA repair pathway distinct from NER. These data directly link SPDE to this alternative excision repair process. We propose that the SPDE-dependent DNA repair pathway is the second DNA excision repair process present in S. pombe.

Effect of aging on metabolic zonation in rat liver: acinar distribution of GSH metabolism

The effect of age on the glutathione antioxidant system and its acinar distribution in rat liver was studied. GSH/GSSG ratio in blood and liver was lower in old than in young rats. Hepatic glutathione peroxidase and glutathione S-transferase activities were higher in old than in young rats, whereas hepatic gamma-glutamyl transpeptidase activity was lower in old than in young rats. Glutathione reductase and glucose-6-phosphate dehydrogenase activities did not change with age in rat liver. Total glutathione levels and glutathione peroxidase activity were higher in periportal than in perivenous areas of young rats, but this heterogeneous distribution did not occur in old rats. No change with age was found in hepatic zonation of glutathione reductase and glucose-6-phosphate dehydrogenase.

Age-related changes in glutathione synthesis in the eye lens

Eye lenses from young rats or mice synthesize GSH from methionine or N-acetylcysteine. However, lenses from old animals do not synthesize GSH from methionine. This is due to the absence of cystathionase activity in old lenses. GSH monoethyl ester, but not free GSH, increases GSH content and protects the lens against experimental oxidative stress. The importance of these results in the prevention of cataractogenesis is discussed.