Laparoscopic paraesophageal hernia repair

The term paraesophageal hernia is described as a herniation of the gastric fundus through the open hiatus into the thoracic cavity while the lower esophageal sphincter (LES) remains in its normal anatomic position. This is considered a rolling esophageal hernia (Type II), and it is the least commonly encountered hiatal hernia. A more commonly encountered herniation of the fundus of the stomach is the Type III hernia, in which both the LES and the fundus herniate into the chest. This has also been classified as a paraesophageal hernia. The most common hiatal hernia is a sliding hiatal hernia (Type I), which consists of herniation of the stomach through the esophageal hiatus, causing the LES and gastric cardia to lie in the thoracic cavity. There are several controversial issues involved in paraesophageal hernia repair, including indications for surgery, the most appropriate surgical approach, and the need for a concomitant antireflux procedure. The increasing popularity of laparoscopic paraesophageal hernia repair has dramatically altered the approach to these patients and has allowed patients at higher risk to better tolerate this procedure with a decrease in morbidity and mortality. However, they remain difficult surgical procedures.     

Laparoscopic reoperation after failed antireflux surgery

INTRODUCTION: Laparoscopic surgery for the treatment of gastroesophageal reflux disease has been established as being safe, effective, and the best alternative to continuous life-long medical therapy. Antireflux surgery is not, however, devoid of complications and failures. Treatment of these patients represents a major challenge, especially when reoperation is indicated. PATIENTS: One-hundred consecutive patients had a reoperation in our clinic. Previous antireflux procedures were laparoscopic (52 patients), laparotomy (39 patients), and thoracotomy (9 patients). RESULTS: Peri- or postoperative complications occurred in 30 patients (30%). Operative complications were stomach perforation (14), significant bleeding (6), esophageal mucosal perforation (4), gastrocutaneous fistula (2), small bowel enterotomy followed by fistula (1), and tension pneumothorax (1). Reoperation was required in only 2 patients because of a missed stomach perforation or persistent chest leak. The conversion rate (from laparoscopic to open procedure) was 17% overall. CONCLUSION: Laparoscopic reoperation after a failed antireflux procedure is a major surgical challenge, and it is not devoid of morbidity. The surgeon must have extensive experience in laparoscopic surgery and should be able to perform reoperative open surgery through the abdomen and chest. Laparoscopic redo surgery is feasible with good results. Many patients in whom previous open surgery has failed enjoy the advantages of a laparoscopic redo procedure.     

高压培养对血管内皮细胞t-PA和PAI-1的影响及卡托普利干预的效果

目的：高血压常伴有纤溶功能的异常,但其机制尚不清楚。本研究拟观察高静水压培养对人脐静脉内皮细胞（HUVECs）t-PA和PAI-1的影响以及卡托普利的干预效果,并探讨其可能的作用机制。方法：选用第4～6代HU-VECs,接种于24孔培养板中。依培养压力分为3组：大气压组（0mmHg）,中压组（90mmHg）,高压组（180mmHg）。在同一压力组,根据不同药物干预又分为两个亚组。即对照组（Ctrl）和卡托普利组（Cap,10^-5mol/L）。每组6份标本。采用ELISA法测定上清液t-PA和PAI-1的抗原浓度,并用细胞内总蛋白进行标化（单位：ng/μg proteins）。同时测定细胞内Ca^2＋浓度（nmol/L）。结果：与大气压组相比,中压和高压组t-PA浓度均显著降低,PAI-1浓度显著增高,t-PA/PAI-1比值显著降低,[Ca^2＋]i也显著增高。卡托普利对大气压组的t-PA、PAI-1和[Ca^2＋]i无显著影响,但在两个高压组,卡托普利显著升高t-PA浓度,显著降低PAI-1浓度,t-PA/PAI-1比值显著升高,[Ca^2＋]i显著地降低。结论：高静水压可损害内皮细胞的纤溶功能,而卡托普利的干预可降低高压所升高的[Ca^2＋]i,并改善高静水压对内皮细胞纤溶功能的影响。     

Antireflux surgery. Indications, preoperative evaluation, and outcome

Gastroesophageal reflux disease (GERD) is an extremely common disorder. Many patients require lifelong medical therapy for symptom control. In patients being considered for antireflux surgery, thorough evaluation is required. Laparoscopic antireflux surgery is a safe and effective method of treating patients who have severe, refractory, or complicated GERD. Excellent long-term results are obtained with minimal morbidity, freeing the patient from the burden of chronic medical therapy.     

Comparison of the initial hemodynamic effects of immediate-release versus sustained-release isosorbide-5-mononitrate following single oral doses

In this double-blind, randomized, placebo-controlled cross-over study, the authors investigated the initial time course of effects of isosorbide-5-mononitrate (IS-5-MN) on hemodynamic parameters in 15 healthy male volunteers after administering a single oral dose of either an immediate-release formulation (IS-5-MN 20 mg) or of a sustained-release formulation (IS-5-MN 50 mg). The latter formulation released 15 mg IS-5-MN immediately, while 35 mg of the dose was sustained release. The onset of effect on the a/b-ratio of the finger pulse curve (20 minutes after administration) and on heart rate following orthostatic challenge (30 minutes) was not different following ingestion of either the immediate-release or the sustained-release formulation. Only the systolic blood pressure following orthostatic challenge was affected earlier after ingestion of the immediate-release form of IS-5-MN (10 vs. 30 minutes). There was no statistically significant difference in the maximum effect on the measured hemodynamic parameters between the two formulations. There was no significant difference with respect to the effect per dose between both of the active treatments (i.e., IS-5-MN 20 mg immediate release and IS-5-MN 50 mg sustained release) within 6 hours after administration. The hemodynamic findings were consistent with the observed rates of the increase of plasma concentrations of IS-5-MN following both formulations. Thus, the administration of the sustained-release formulation of IS-5-MN 50 mg caused similar maximum effects when compared with an immediate-release formulation (20 mg). While the onset of effect of IS-5-MN on the a/b-ratio of the finger pulse curve and on heart rate following orthostasis was similar after administration of either the immediate- or the sustained-release formulation, the onset of effect of the sustained-release formulation on systolic blood pressure orthostasis was determined slightly later. However, the latter difference seems to be of minor clinical relevance.     

Dermatomyositis in childhood. Review of eight cases

Eight cases of dermatomyositis in children admitted to Scottish hospitals between 1962 and 1972 have been reviewed. 6 of the 8 were currently in complete remission. In the other 2 cases the disease remained active in 1 and 1 had died of cardiac failure 6 years after the onset of disease. 5 had developed extensive soft tissue calcification for which 2 were treated with ethanehydroxydiphosphonate, one showing definite improvement and the other no change. All had been treated with corticosteroids and two in addition had had cytotoxic agents (methotrexate or cyclophosphamide). The overal prognosis had probably been improved by the use of corticosteroids but not by the cytotoxic drugs. Only one of the patients was incapacitated by residual contractures or calcinosis.     

The immunohistology of follicle lysis in lymph node biopsies from homosexual men

Follicle lysis is a characteristic alteration of B cell follicles described recently in lymph node biopsies from homosexual men. It consists of disruption of germinal centers by aggregates of small mature lymphocytes variably associated with erythrocyte extravasation. We studied the immunohistology of follicle lysis identified in lymph node biopsies from 11 homosexual men. The results indicate that follicle lysis has two principal immunohistologic features: (1) intrafollicular aggregates of small lymphocytes predominantly of polytypic mantle B cell phenotype (T015+/Leu-8+/mu+/delta+/k+ or lambda+), and (2) disruption of the normal, unified follicular meshwork of R4/23+ dendritic reticulum cells by these B cell aggregates. These structural alterations may affect the functional integrity of the germinal center as it pertains to the abnormal B cell effector function and the increased prevalence of B cell lymphoma recently documented in the acquired immunodeficiency syndrome and related disorders. Because dendritic reticulum cells weakly express the Leu-3 (T4) antigen, which is known to be an essential component of the receptor for human T- lymphotropic virus type III/lymphadenopathy-associated virus (HTLV- III/LAV) retrovirus infection, it is possible that retroviral infection of dendritic reticulum cells may play a role in the pathogenesis of follicle lysis.     

A model of corrective gene transfer in X-linked ichthyosis

Single gene recessive genetic skin disorders offer attractive prototypes for the development of therapeutic cutaneous gene delivery. We have utilized X-linked ichthyosis (XLI), characterized by loss of function of the steroid sulfatase arylsulfatase C (STS), to develop a model of corrective gene delivery to human skin in vivo. A new retroviral expression vector was produced and utilized to effect STS gene transfer to primary keratinocytes from XLI patients. Transduction was associated with restoration of full-length STS protein expression as well as steroid sulfatase enzymatic activity in proportion to the number of proviral integrations in XLI cells. Transduced and uncorrected XLI keratinocytes, along with normal controls, were then grafted onto immunodeficient mice to regenerate full thickness human epidermis. Unmodified XLI keratinocytes regenerated a hyperkeratotic epidermis lacking STS expression with defective skin barrier function, effectively recapitulating the human disease in vivo. Transduced XLI keratinocytes from the same patients, however, regenerated epidermis histologically indistinguishable from that formed by keratinocytes from patients with normal skin. Transduced XLI epidermis demonstrated STS expression in vivo by immunostaining as well as a normalization of histologic appearance at 5 weeks post-grafting. In addition, transduced XLI epidermis demonstrated a return of barrier function parameters to normal. These findings demonstrate corrective gene delivery in human XLI patient skin tissue at both molecular and functional levels and provide a model of human cutaneous gene therapy.