The five-coordinate iron porphyrin carbene complexes [Fe(TPP) (CCl2)] (TPP = tetraphenylporphyrin), [Fe(TTP) (CCl2)] (TTP = tetratolylporphyrin) and [Fe(TFPP) (CPh2)] (TFPP = tetra(pentafluorophenyl)porphyrin), utilizing two types of carbene ligands (CCl2 and CPh2), have been investigated by single crystal X-ray, XANES (X-ray absorption near edge spectroscopy), Mössbauer, NMR and UV-vis spectroscopies. The XANES suggested the iron(II) oxidation state of the complexes. The multitemperature and high magnetic field Mössbauer experiments, which show very large quadrupole splittings (QS, ΔEQ), determined the S = 0 electronic configuration. More importantly, combined structural and Mössbauer studies, especially the comparison with the low spin iron(II) porphyrin complexes with strong diatomic ligands (CS, CO and CN-) revealed the covalent bond nature of the carbene ligands. A correlation between the iron isomer shifts (IS, δ) and the axial bond distances is established for the first time for these donor carbon ligands (:C-R).

There are many different methods of treating obesity, ranging from various medical options to several surgical therapies. This paper briefly summarizes current surgical options for weight loss with a focus on one of the newest US Food and Drug Administration-approved devices for surgical weight loss therapy, the Maestro Rechargeable System. Also known as the vagal blocking for obesity control implantable device, this tool blocks vagal nerve activity to induce weight loss.

Background: Devastating morbidity and mortality can result when patients with undiagnosed sleep apnea syndrome (SAS) undergo bariatric surgery. We evaluated the prevalence of SAS and its rate of nondiagnosis in bariatric patients at a university hospital.Methods: The demographic, anthropomorphic, and co-morbidity data were collected from 1368 patients evaluated for bariatric surgery. All patients were screened for symptoms of SAS, and symptomatic patients were evaluated with polysomnography.Results: At the time of this report, 834 patients (61%) had completed the preoperative evaluation. Of these patients, 210 (25%) presented with previously diagnosed SAS. An additional 174 patients (21%) exhibited symptoms of SAS and underwent polysomnography. Most patients tested (127, 73%) had SAS that required treatment, 11 patients (6%) had mild SAS not requiring treatment, and 36(21%) tested negative for SAS. Thus, symptom screening for SAS had a positive predictive value of 79% for predicting the presence of SAS and 73% for identifying patients who required SAS treatment. The patients with SAS tended to be older and male and have a greater body mass index (P < .05).Conclusion: Overall, SAS that required treatment with an oral appliance was prevalent (40%) in patients who presented for bariatric surgery. However, many of these patients with significant SAS (38%) were previously undiagnosed, despite exhibiting clear symptoms of the disease. Symptom screening appears to be effective in identifying patients who should be evaluated by polysomnography. To avoid the potential perils of undiagnosed SAS during the perioperative period, patients who undergo bariatric surgery should be screened, tested, and treated for this co-morbidity. (Surg Obes Relat Dis 2012;8:569-573.) (c) 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Devastating morbidity and mortality can result when patients with undiagnosed sleep apnea syndrome (SAS) undergo gastric bypass (GB). This study evaluates the prevalence of SAS and its rate of non-diagnosis in GB patients.

Retrocolic, retrogastric placement of the alimentary limb during laparoscopic Roux-en-Y gastric bypass (LRYGB) has been implicated in a higher rate of internal hernia (IH). This study examines the incidence of IH in our series of LRYGB with retrocolic, retrogastric routing of the alimentary limb accompanied by routine secure closure of all mesenteric defects.

Morbid obesity is a systemic disease which exerts significant harmful consequences on end organs, including the eyes. This prospective study was designed to investigate the prevalence of ophthalmologic abnormalities among bariatric surgical patients and to evaluate the association of these changes with comorbidities of obesity.

Background: Telestration is an important teaching tool in minimally invasive surgery (MIS). While robotic surgery offers the added benefit of three-dimensional (3-D) visualization, telestration technology does not currently exist for this modality. This project aimed to develop a video algorithm to accurately translate a mentor's two-dimensional (2-D) telestration into a 3-D telestration in the da Vinci visual field.Materials and Methods: A prototype 3-D telestration system was constructed to translate 2-D telestration from a mentor station into 3-D graphics for the trainee at the robotic console. This system uses fast image correlation algorithms to allow 2-D images to be placed over the same anatomic location in the two separate video channels of the stereoscopic robotic visualization system. Three subjects of varying surgical backgrounds, blinded to the mode of telestration (2-D vs. 3-D), were tested in the laboratory, using a simulated robotic task.Results: There were few technologic errors (2), only one of which resulted in a task error, in 99 total trials. Only the experienced MIS staff surgeon had a significantly faster task time in 2-D than in 3-D (P < 0.05). The MIS fellow recorded the fastest task times in 2-D and 3-D (P < 0.05). There were nine task errors, six of which were committed by the MIS fellow. The nonsurgeon trainee had the least number of errors but also had the slowest times.Conclusions: Robotic telestration in 3-D is feasible and does not negatively impact performance in laboratory tasks. We plan to refine the prototype and investigate its use in vivo.

Previous outcome research in bariatric surgery has been unable to document quantitative changes in co-morbidities associated with obesity due to a lack of a standardized instrument to grade severity. We report a detailed description of the early resolution of metabolic syndrome using our novel scheme for assessing co-morbidities.

Background: Previous outcome research in bariatric surgery has been unable to document quantitative changes in co-morbidities associated with obesity owing to a lack of a standardized instrument to grade the severity. We report a detailed description of the early resolution of the metabolic syndrome using our novel scheme for assessing co-morbidities. This study was performed at a tertiary care university hospital.Methods: Co-morbidity data were prospectively collected for 927 patients who underwent laparoscopic Roux-en-Y gastric bypass during a 4-year period using the Assessment of Obesity-Related Co-morbidities (AORC) scale. This scale assigns a score of 0-5 for the major medical conditions associated with obesity. The co-morbid conditions of obesity and biochemical markers of the metabolic syndrome were examined preoperatively and at the follow-up visits.Results: Of the 827 patients who underwent laparoscopic Roux-en-Y gastric bypass. 72 (8.7%) met the AORC criteria for the metabolic syndrome (AORC score >2 for diabetes mellitus [DIM I, hypertension [HTN]. and dyslipidemia [DYS]). Overall, 75% of patients with DM, 69.4% of patients with HTN, and 76.4% of patients with DYS showed improvement in these co-morbidities (decrease from the preoperative AORC score) within 2 months after surgery. Within this period, DM, HTN, and DYS resolved in 65.3%, 51.4%, and 73.6% of patients, respectively. Concurrent decreases in hemoglobin A1c, serum lipids, and blood pressure were observed (P<.05). Patients exhibited a modest excess body weight loss of 27.7% during this period. However. the mean AORC score for the whole group decreased significantly for DM, DYS, and HTN (P<.001) before significant weight loss occurred.Conclusion: We have demonstrated a new and novel approach to categorize and more accurately define the magnitude of improvement in co-morbidities after laparoscopic Roux-en-Y gastric bypass. This improvement preceded the weight loss effects on the metabolic syndrome. (Surg Obes Relat Dis 2009:346-351.) (C) 2009 American Society for Metabolic and Bariatric Surgery. All rights reserved.

BACKGROUND:Depression is prevalent among bariatric surgical patients, and previous studies have suggested a link between depression and quality of life. Our objective was to examine the relationship between depression and other co-morbidities of obesity at a university hospital in the United States. METHODS:Data were collected from 1368 consecutive patients evaluated for bariatric surgery. The demographic and co-morbidity profiles of these patients were compared between the depressed and nondepressed individuals. Depression was defined as an Assessment of Obesity-Related Co-morbidities score of > or = 3, signifying that the patient required medical treatment for (score of 3) or had complications of (score of 4-5) depression. RESULTS:The prevalence of depression among these patients was 36%. The mean age of the patients with depression was older (44.3 + or - 9.4 versus 42.2 + or - 9.6, P <.05), but the mean body mass index was similar. Depression was more prevalent among the female patients (37.4% versus 29.6%, P <.05). Diabetes mellitus, hypertension, polycystic ovarian syndrome, idiopathic intracranial hypertension, and obesity hypoventilation syndrome occurred with similar frequency and severity in persons with and without depression. The analysis revealed a significantly greater prevalence and severity of dyslipidemia (P <.05), gastroesophageal reflux disease (P <.05), back pain (P <.0001), joint pain (P <.05), sleep apnea (P <.01), stress incontinence (P <.01), and hernia (P <.05) among patients with depression. Overall, patients with depression had more co-morbidities per patient (5.46 versus 4.55) and a greater likelihood of severe or complicated co-morbidities (2.67 versus 1.89 per patient). CONCLUSION:This report has characterized a link between depression and other co-morbidities in bariatric surgical patients. This association was independent of the body mass index. Although a causal relationship could not yet be identified, our findings indicate that depression, in this patient population, is associated with a greater prevalence and increased severity of medical co-morbidities that express distinct physical symptoms.

Background: The purpose of this study was to evaluate the natural history of patients undergoing Roux-en-Y gastric bypass (RYGBP) with known asymptomatic cholelithiasis in whom prophylactic cholecystectomy was not performed at the time of surgery.Methods: The records of 144 consecutive patients from a single year experience in RYGBP surgery at the University of California, Davis Medical Center were reviewed. Patients undergoing RYGBP were routinely screened for cholelithiasis by ultrasound. Patients who did not have cholecystectomy were managed with ursodiol for 6 months postoperatively.Results: 13 males (9.0%) and 131 females (91%) underwent RYGBP. The mean age was 43 years (SD 8.55), and mean BMI was 46 kg/m(2) (SD 6.5). The co-morbidities of our patient population included diabetes (14%), hypertension (48%), gastroesophageal reflux disease (50%), dyslipidemia (35%), obstructive sleep apnea (31%), and musculoskeletal complaints (69%). 22 patients were diagnosed with cholelithiasis by ultrasonography preoperatively. 9 of these patients (41%) were symptomatic and underwent concurrent cholecystectomy and RYGBP. The remaining 13 patients (59%) had asymptomatic cholelithiasis preoperatively but did not undergo cholecystectomy at the time of surgery. Only one of these asymptomatic patients eventually developed symptoms necessitating cholecystectomy at up to 1 year follow-up.Conclusions: Our data suggest that it may not be absolutely indicated to perform prophylactic cholecystectomy at the time of RYGBP surgery for asymptomatic cholelithiasis. We believe that this phenomenon needs to be further studied in a randomized trial.

BACKGROUND:Routine upper gastrointestinal (UGI) studies following laparoscopic Roux-en-Y gastric bypass (LRYGBP) have the potential advantage of early identification of anastomotic complications. The aim of our study was to evaluate the efficacy of routine postoperative UGI and its relationship to clinical outcomes.METHODS:Over a three-year period, 516 patients underwent LRYGBP followed by routine postoperative UGI studies. Data were collected on the results of the UGI, clinical parameters, and patient outcomes. Study groups were composed of patients with a normal UGI (Group I, n = 455), abnormal UGI not requiring further intervention (Group II, n = 36), and abnormal UGI requiring further intervention (Group III, n =25). Statistical significance was set at alpha= 0.05 level for all analyses.RESULTS:The three study groups were not statistically different in mean age (42 years) or body mass index (BMI) (45) and were predominantly female (90%). Most patients had an uneventful postoperative course. Anastomotic complications (gastrojejunostomy and jejunojejunostomy) were uncommon (1.3%). The sensitivity of the UGI for anastomotic leak in this study was low (33%). However, all patients with alimentary limb obstruction (n = 3) had UGI evidence of this complication. Of the 516 UGI reports, there were only 25 (4.8%, Group III) that were abnormal and required some form of intervention ranging from serial imaging (84%) to reoperation (16%). Of the various clinical parameters examined, the patients in Group III demonstrated a significantly higher prevalence of fever (p < 0.001), tachycardia (p < 0.01), vomiting (p < 0.001), and postoperative day 1 leukocytosis (p < 0.005).CONCLUSIONS:Our data suggest that routine UGI after LRYGBP has limited utility as it may result in unnecessary intervention based on false-positive results or a delay in treatment based on false-negative results. We advocate selective UGI imaging following LRYGBP based on the patient's clinical factors, particularly fever and tachycardia.

BACKGROUND:This study was performed at a tertiary care university hospital. We hypothesized that weight loss before laparoscopic Roux-en-Y gastric bypass (LRYGB) is feasible, does not diminish the expected postoperative weight loss, and might enhance overall weight loss and maintenance. METHODS:A population of 351 consecutive patients, who had undergone LRYGB, was divided into 4 groups depending on the percentage of body weight loss achieved before surgery (group 1, none or gain; group 2, <5%; group 3, 5-10%; and group 4, >10%). Data were collected regarding the demographics, body mass index (BMI) change, and excess weight loss and analyzed by analysis of variance and Fisher's exact test at the alpha = 0.05 level. RESULTS:All groups were demographically similar in age and were predominantly women. The maximal follow-up was 36 months. Groups 3 and 4 had significantly greater initial excess weight and BMI (P <.05) but these became similar after the preoperative weight loss. Most patients (74%) were able to lose weight before surgery, with 36% losing >5% body weight. Preoperative weight loss did not decrease the magnitude of the expected postoperative weight loss. Patients who lost weight preoperatively demonstrated more excess weight loss and BMI change (from their initial weight) that was sustained far into the postoperative period and reached statistical significance at several points (P <.05). CONCLUSION:The results of this study have demonstrated that obese patients are capable of losing weight before LRYGB and that this weight loss does not negatively affect their expected postoperative weight loss. Furthermore, preoperative weight loss combined with LRYGB might result in better long-term excess weight loss and BMI change than surgery alone.

Purpose: Soluble leptin receptor (SLR) serves as a major leptin binding protein, but the SLR and the free leptin index (FLI) have not been studied yet in humans with nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH). Since the measured leptin in the previous studies represented total serum leptin, our goal was to test the hypothesis that SLR and/or FLI correlates better with steatosis, inflammation, and/or fibrosis in human NAFLD/NASH. Methods: Sixty-one patients who were listed for bariatric surgery were enrolled in this cohort study. Data including demographics and risk factors for the metabolic syndrome {BMI, diabetes mellitus type 2 (DM2), hypertension, and lipid profile} were obtained. Fasting blood was drawn at 1100h preoperatively, and the EDTA-plasma was analyzed for glucose, insulin, total leptin, and SLR. All patients had intraoperative liver biopsies read by a hepatopathologist. Results: Of 61 patients, 39 patients had sufficient liver specimens (size >1.5 cm and >10 portal tracts) and their serum was collected appropriately. Their demographics were: 10 male, 29 female and mean ages of 44.9 ± 1.5. Their mean BMI was 45.7 ± 0.9. Twenty patients had hypertension, 14 had DM2, and 20 had hyperlipidemia. Thirty-six of 39 had various degrees of steatosis: 5 had less than 10%, 15 had 10–29%, 13 had 30–60%, and 3 had greater than 60%. According to Brunt's scoring system, 14 patients had grade 0, 20 had grade 1, and 2 had grade 2 NASH. Twenty-five had stage 0, 8 had stage 1 and 3 had stage 3 fibrosis. Spearman correlation with two-tailed test showed that FLI was negatively correlated with advanced fibrosis (stage > = 3) (p= 0.007), Homeostasis Model Assessment (HOMA) score (p < 0.001) and DM2 (p= 0.003). In contrast, SLR was positively correlated with HOMA score (p < 0.001). NASH grading was not significantly correlated with SLR or FLI. Serum total leptin was positively correlated with the BMI (p= 0.006). Conclusions: Serum total leptin is increased in obesity, but the state of insulin resistance may promote high levels of SLR thus decreasing the amount of serum free leptin. The low free leptin index seen in advanced fibrosis in NASH in this population is a novel finding and needs validation with larger studies.

This article describes the procedures that are performed for weight loss and characterizes the associated short-term success (operative safety, in-hospital morbidity/mortality) and long-term efficacy(weight loss, weight loss maintenance, postoperative complications). It discusses each category of procedure and reviews the current outcomes literature. It also addresses the technical challenges that are involved with the performance of each procedure and how these challenges may affect short and long-term outcomes. It concludes by comparatively analyzing the outcomes of the various bariatric surgical procedures and their respective roles in effectively managing the morbidly obese patient.

We have identified propiololdehyde as a product of the action of an electric discharge on mixtures of methane and water or methane, nitrogen, and water. The aldehyde reacts with cyanoacetaldehyde and ammonia (other "prebiological molecules") to yield nicotinonitrile. This substance can be hydrolyzed to nicotinamide and nicotinic acid.

The synthesis of 4-aminoimidazole-5-carbonitrile and its derivatives from HCN has been discussed in a preceding paper. It is shown here that these imidazoles are readily cyclized to mono- and di-substituted purines. Since the photochemical synthesis of 4-aminoimidazole-5-carbonitrile from HCN is considered to be a particularly plausible prebiotic pathway, the conversion of 4-aminoimidazole-5-carbonitrile and of its hydrolysis product 4-aminoimidazole-5-carboxamide to adenine and guanine are examined in some detail

The isomers of 6-ribosylaminopurine (N6-ribosyladenine) are formed in up to 74% yield when a dry mixture of adenine and ribose is heated. Under these conditions ribose also reacts with the primary amine group of adenosine, guanosine and probably guanine to form the corresponding ribosylaminopurines, while hypoxanthine fails to react. In the presence of Mg2+ and inorganic polyphosphates the natural nucleosides are also formed. Maximum yields of β-inosine, β-adenosine and β-guanosine were 8%, 4% and 9%, respectively.