Viral myocarditis: Changing concepts in pathogenesis and implications in diagnosis and treatment

Viral myocarditis is an important potential precursor to idiopathic dilated cardiomyopathy. An understanding of its pathogenesis has evolved with the recent clarification of the role of immune mechanisms, which appears to have both protective and autodestructive effects. In animal models immune modulation has led to paradoxical worsening of the disease, and clinical trials of immunosuppression have not shown any beneficial effects. Through the use of molecular diagnostic techniques, a possible direct role for the virus itself is now increasingly recognized in human disease. This is supported by animal models demonstrating viral cytopathic effects and chronic persistence of virus within the myocardium. A novel contribution from microvascular ischemia has also recently been demonstrated; this may play a particularly important role in the evaluation and treatment of dilated cardiomyopathy. These changing concepts in pathogenesis will have an impact on diagnosis; myocardial biopsy will be used for molecular diagnosis of viral infection, in addition to providing important histological information. Therapy for viral myocarditis will also evolve in parallel to include trials of antiviral agents, targeted immune modulators, and anti-ischemic or vasodilator therapy. With new tools of molecular diagnosis in myocarditis complementing the traditional morphological and immunological assessments, we now have avenues of opportunity to explore in depth the pathogenesis, epidemiology, and prognosis of this challenging disease.     

Is there an abnormal fasting duodenogastric reflux in nonulcer dyspepsia?

A quantitatively and/or qualitatively abnormal duodenogastric reflux (DGR) could be involved in the pathogenesis of nonulcer dyspepsia (NUD). The aims of this prospective study were to look for (1) a pathological DGR profile during fasting and (2) an eventual correlation between DGR profile and clinical symptoms. Twenty-six NUD patients were investigated. Seven other operated patients with a surgical procedure facilitating DGR episodes and 27 healthy volunteers served as control groups. A clinical score was determined for each patient from a standardized questionnaire. Gastric aspiration was performed for 6 hr in fasting subjects. The aspirates were pooled into 17 samples. In each sample the concentration and the output of total bile acids was determined. If the concentration was larger than 30 mol/liter in pooled samples, the concentrations of free bile acids and the distribution of the conjugated bile acids was determined. The percentage of aliquots with a total bile acid concentration larger than 50 mol/liter (without upper limit), and the percentage with a concentration larger than 2500 mol/liter was also obtained. No significant difference was demonstrated between the healthy volunteers and NUD patients, whatever the parameter considered. However, there was a significant increase in each of the quantitative parameters for the group of operated patients in comparison with the NUD patient group. No significant correlation was found between the clinical score and the DGR profile in NUD patients. Apparently, DGR episodes do not play a primary role in the pathogenesis of NUD.Part of this work was presented at the 4th European Symposium on Gastrointestinal Motility, Krakow, Poland. September 22–24, 1988.Hepatogastroenterology, 35:178, 1988 (abstract).     

Resolution of Diabetes Following Vertical Gastroplasty in Morbidly Obese Patients

Case reports are presented on three patients treated for morbid obesity by vertical gastroplasty. Prior to surgery the patients had diabetes which required insulin, up to 200 units per day, or oral hypoglycaemics for its control. Six months after surgery the diabetes had been resolved in all three patients, and they were no longer dependent on medication. Subjective reports from the patients suggests that their quality of life improved significantly.     

The Superiority of the Left Subcostal Incision Compared to Mid-line Incisions in Surgery for Morbid Obesity

We describe a 13-year experience using a left subcostal incision in performing gastroplasties and Roux-en-Y gastric bypasses (RYGBP) in morbidly obese patients. We have also used it successfully in the general population in several other types of surgical procedures, including Nissen fundoplications in adults and infants, gastrectomies, truncal vagotomies, pyloroplasties, jejunoileal bypass reversals, and elective splenectomies. Over 200 cholecystectomies have been carried out through this incision as additional procedures with relative ease, not requiring any further extension of the incision. There were no hernias in a group of 1067 primary gastroplasty and RYGBP patients, and the wound infection rate has been quite low, apparently because of the incision's distance from the potentially contaminated umbillicus. We feel that the use of this incision further simplifies and therefore adds a safety factor not seen with the standard vertical incision in this group of surgical patients.     

Radical “Fleur-de-Lis” Abdominoplasty after Bariatric Surgery

The massive weight loss produced by bariatric surgical procedures on the morbidly obese can result in gross redundancy of abdominal and trunk skin. Standard abdominoplasty procedures may be insufficient to correct this debilitating deformity. A radical version of the “Fleur-de-Lis” abdominoplasty has been carried out on 45 such patients, with good cosmetic and functional results and low morbidity.     

Liposculpturing by Syringe Technique in Obesity

The author recommends liposuction by syringe technique instead of by the lipoaspirator machine. This technique has been applied to obese patients who were further stimulated to lose weight by dieting.