Laparoscopic repair of large hiatal hernia with polytetrafluoroethylene

Background: Several studies have shown that large hiatal hernias are associated with a high recurrence rate. Despite the problem of recurrence, the technique of hiatal herniorrhaphy has not changed appreciably since its inception. In this 3-year study we have evaluated laparoscopic hiatal hernia repair in individuals with a hernia defect greater than 8 cm in diameter. Methods: A series of 35 patients with sliding or paraesophageal hiatal hernias was prospectively randomized to hiatal hernia repair with (n= 17) or without (n= 18) polytetrafluoroethylene (PTFE). All patients had an endoscopic and radiographic diagnosis of large hiatal hernia. Both repairs were performed by using interrupted stitches to approximate the crurae. In the group randomized to repair with prosthesis, PTFE mesh with a 3-cm ``keyhole' was positioned around the gastroesophageal junction with the esophagus through the keyhole. The PTFE was stapled to the diaphragm and crura with a hernia stapler. Results: Patients were followed with EGD and esophagogram at 3 months postoperatively, and with esophagogram every 6 months thereafter. Individuals with PTFE had a longer operation time, but the 2-day hospital stay was the same in both groups. The cost of the repair was $1050 ± $135 more in the group with the prosthesis. There were two complications (1 pneumonia, 1 urinary retention) in the group repaired with PTFE and one complication (pneumothorax) in the group without prosthesis. The group without PTFE was notable for three (16.7%) recurrences within the first 6 months of surgery. Conclusion: On the basis of these preliminary results it appears that repair with PTFE may confer an advantage, with lower rates of recurrence in patients with large hiatal hernia defects. Received: 1 May 1998/Accepted: 22 December 1998     

Expanded polytetrafluoroethylene membrane for the prevention of peridural fibrosis after spinal surgery: a clinical study

Peridural fibrosis developing after laminectomy may cause pain that can necessitate reoperation. Many materials have been used as a barrier to invasion of fibrous tissue into the vertebral canal, but the ideal material has not been found. Various studies in animals have achieved favourable results with an expanded polytetrafluoroethylene (ePTFE) membrane. In a prospective, randomized study, we compared postoperative results in 33 patients who had an ePTFE membrane implanted to cover the defect caused by laminectomy during lumbar spine decompression with the results in 33 patients in whom no material was implanted. At operation, an ePTFE membrane was placed after the decompression procedure to cover the laminectomy defect completely. Systematic clinical and MRI follow-up evaluations of patients with and without the membrane were conducted 3, 6, 12, and 24 months postoperatively. The effect of ePTFE membrane implantation over laminectomy sites on postoperative peridural fibrosis, pain and neurological claudication was assessed. The ePTFE-membrane group had a significantly lower rate of epidural fibrosis on MRI (P < 0.0001) and of clinical manifestations of radiculalgia (P = 0.002) compared with the no-material group. Epidural fibrosis that occurred in the ePTFE group was generally less extensive than that in the no-material group. There was no significant difference in the rate of postoperative claudication in the two groups. Significantly more seromas occurred in the ePTFE group (P = 0.0002). There were no infections or other complications in either group. The results showed that placement of an ePTFE spinal membrane over the laminectomy defect produced by lumbar spine surgery provided a physical barrier to invasion of fibrous tissue into the vertebral canal, and patients with the membrane had less postoperative radicular pain. Received: 24 November 1997 Revised: 26 November 1998 Accepted: 2 December 1998     

聚四氟乙烯涂层微型节育器对输卵管复通的影响

目的：研究聚四氟乙烯涂层微型节育器取出后实验动物的输卵管通畅率及复孕情况,为可复性节育器的临床应用提供实验依据。方法：采用烧结法进行聚四氟乙烯表面喷涂成形技术,制备可复性输卵管节育器。选择SPF级新西兰雌兔18只,随机分为实验组12只,对照组6只。实验组双侧输卵管均放置可复性节育器,对照组不放节育器。在节育器放置术后4,12,24周,实验组分别取4只雌兔、对照组分别取2只雌兔进行输卵管通液术,对输卵管通畅的雌兔进行复孕实验。结果：聚四氟乙烯表面喷涂成形技术工艺简单、制备方便,节育器表面光滑,具有优良的不粘性。输卵管通液21条通畅,2条通而不畅,1条不通,输卵管通畅率为95.8%（23/24）。复孕实验显示11只怀孕,1只不孕,复孕率为91.66%（11/12）。结论：聚四氟乙烯涂层微型节育器安全、可行、无不良反应,取出后输卵管恢复通畅,无明显的粘连,具有复孕功能。     

Intraesophageal Polytef injection for the treatment of reflux esophagitis

Background: In view of the unsatisfactory results of medical and surgical treatment of reflux esophagitis, a treatment modality with polytetrafluoro-ethylene injection in the lower esophagus is presented. Methods: Twenty-one patients (13 men, 8 women; mean age 47.7 years) presented with a lower esophageal sphincter (LES) pressure which was significantly lower than normal (mean 5.3±1.1 SD cm H₂O) (P<0.001). Four to 6 ml Polytef was injected submucosally into the lower esophagus at 3 and 9 o'clock. Patients were followed up for 18–24 months. Results: No complications were encountered. In the first 3 postinjection months, symptoms disappeared and LES pressure was elevated (mean 24.2±6.6 SD cm H₂O) (P<0.001). At the 6th month, LES pressure dropped in nine patients (P<0.05), of whom three had become symptomatic again and were reinjected. Endoscopically, esophageal hyperemia and erosion disappeared in 16 patients. At the 12th month, LES pressure was normal in 10 patients; the remaining 11 showed a significant LES pressure drop (P<0.01) with reflux manifestations and were reinjected. At the 18th month, LES pressure was normal in all patients; endoscopically, there was mild lower esophageal hyperemia in five patients. The nine patients who were followed for 24 months had normal LES pressure and endoscopic findings and were symptom-free. Conclusions: Polytef injection achieved LES competence through elevation of LES pressure and restoration of lower esophageal rosette. Pressure drop could be due to implant egress. The technique is simple and easy, has no complications, and is performed on an outpatient basis.     

国产微孔聚四氟乙烯心脏补片的实验观察与临床应用

采用上海塑料研究所和我院协作研制的微孔聚四氟乙烯心脏补片经动物实验和６００余人次先心病纠治术中的应用，效果满意，使用安全，该补片裁剪方便，无正反面，修补前无需预凝，材料生物相容性好，修补时补片与受体组织平整服贴，强度高，耐老化，为目前较为理想的合成心脏修补材料。     

应用膨化聚四氟乙烯补片行开放式腹壁大切口疝修补术的临床分析

目的探讨腹壁大切口疝治疗经验。方法对我院采用补片行开放式腹壁大切口疝修补术的211例病人临床资料进行回顾性分析。结果手术平均时间为80 min(45~190 min),术中出血为15~90 ml,平均35.6 ml；术中无血管和内脏损伤等并发症。术后3~7 d(平均4.9 d)下床活动；平均住院时间为6.3 d(2~16 d)。1例病人由于网膜出血进行了急诊二次手术。2例病人由于皮下出血,于手术后2~6 h 进行了伤口修整术。211例 病 人 长 期 随 访 (60~178个月),有6例病人(2.8%)出现疝复发,所有病例无慢性疼痛。结论应用膨化聚四氟乙烯补片行开放式腹壁大切口疝修补术是一种安全、可靠的方法,复发率低。     

Chest stab wound-related coronary artery pseudoaneurysm sealed with a polytetrafluoroethylene-covered stent

We describe a case in which a polytetrafluoroethylene (PTFE)-covered stent was implanted to treat impending rupture of a coronary artery pseudoaneurysm related to a chest stab wound. In this case, transthoracic echocardiography was used to verify the characteristics of the pseudoaneurysm, and we concluded that a PTFE-covered stent may prevent rupture in post-traumatic pseudoaneurysm.     

Reinforcement Does Not Necessarily Reduce the Rate of Staple Line Leaks After Sleeve Gastrectomy. A Review of the Literature and Clinical Experiences

Background  Laparoscopic sleeve gastrectomy (SG) is an accepted bariatric procedure, with an advantaged by a low complication rate. A feared complication is stapler line leak. Buttressing materials have been suggested as a means of reducing staple line leak rates. We analyzed the leak rates from published series to help in demonstrating a potential cause. Methods  The study was institutional review board (IRB) approved retrospectively. A Medline search using the key words sleeve gastrectomy and bariatric surgery obtained 54 articles. Attention was restricted to 11 articles written in English that listed numbers of gastrectomy procedures and leaks. Poisson regression assessed the possibility that patients who received buttressing materials had a reduced rate of leaks. Results  Thirty-five patients were evaluated from Greece (15) and the United States (20); two patients developed staple line leaks that appeared to be related to problems associated with buttressing materials. Eleven prior studies and the present series yielded 1,589 procedures, 15 (0.94%) of which were complicated by leaks. The leak rate for patients who were known to have received reinforcement of some sort was 1.45 (95% confidence interval 0.41–3.43) times that for other patients. To detect a difference between 1% and 0.5% as statistically significant in 80% of cases, with a two tailed test and alpha set at 0.05, would require 9,346 procedures. Conclusions  There is no reason to believe, at this point, that reduction in leak rates occur because reinforcement is used. Because the leak rate is small, the routine reinforcement of the staple line after sleeve gastrectomy is questionable at best, although a decrease in hemorrhage has been reported.     

Aspects of nitrogen dioxide toxicity in environmental urban concentrations in human nasal epithelium

Cytotoxicity and genotoxicity of nitrogen dioxide (NO₂) as part of urban exhaust pollution are widely discussed as potential hazards to human health. This study focuses on toxic effects of NO₂ in realistic environmental concentrations with respect to the current limit values in a human target tissue of volatile xenobiotics, the epithelium of the upper aerodigestive tract.Nasal epithelial cells of 10 patients were cultured as an air-liquid interface and exposed to 0.01 ppm NO₂, 0.1 ppm NO₂, 1 ppm NO₂, 10 ppm NO₂ and synthetic air for half an hour. After exposure, genotoxicity was evaluated by the alkaline single-cell microgel electophoresis (Comet) assay and by induction of micronuclei in the micronucleus test. Depression of proliferation and cytotoxic effects were determined using the micronucleus assay and trypan blue exclusion assay, respectively.The experiments revealed genotoxic effects by DNA fragmentation starting at 0.01 ppm NO₂ in the Comet assay, but no micronucleus inductions, no changes in proliferation, no signs of necrosis or apoptosis in the micronucleus assay, nor did the trypan blue exclusion assay show any changes in viability. The present data reveal a possible genotoxicity of NO₂ in urban concentrations in a screening test. However, permanent DNA damage as indicated by the induction of micronuclei was not observed. Further research should elucidate the effects of prolonged exposure.     

Experience with aortic grafting during excision of large abdominal neuroblastomas in children

Background

Total or near total resection of high-risk, stage 4 abdominal neuroblastoma has been correlated with improved local control and overall survival but may be complicated by vascular injury. We describe our experience in the management of significant aortic injuries during this procedure.

Methods

With the institutional review board waiver, medical records of children who had major abdominal aortic reconstruction during neuroblastoma resection from 1996 to 2006 were retrospectively reviewed.

Results

There were 5 children with aortic grafting: 3 girls and 2 boys. Mean age at surgery was 7.2 years (range, 16 months to 17 years). Two children were operated on for recurrent retroperitoneal disease. Tumor encasement of the aorta was seen in all children. In 3 children, the injury occurred during dissection of paraaortic and interaortocaval lymph nodes below the level of the renal arteries. In the remaining 2 children, injury occurred early during mobilization of the tumor. Three polytetrafluoroethylene tube grafts and 1 on-lay patch graft were used to repair the 4 distal aortic injuries. One 4-year-old female with aortic and renal arterial injuries was managed with an aortic Dacron tube graft and a polytetrafluoroethylene tube graft for the renal artery. The mean period of follow-up is 28 months after aortic graft (range, 3 months to 10 years). Total colonic ischaemia, transient acute tubular necrosis, and duodenal perforation were seen in one child, who needed subtotal colectomy and ileostomy. Another child with an omental patch over the graft had a transient duodenal obstruction, which was managed conservatively. There were no other complications, and 4 of the 5 children are disease-free to date. One child at 10 years after his distal aortic tube graft remained asymptomatic with normal distal blood flow on magnetic resonance angiogram and with normal growth.

Conclusion

The neuroblastoma surgeon should be prepared to perform aortic and vascular reconstruction. Aortic encasement, preoperative radiation therapy, and reoperative surgery were observed in these patients and may be risk factors.