Laparoscopic tension-free repair of large paraesophageal hernias.

The paraesophageal hernia is an unusual disorder of the esophageal hiatus that may be associated with life-threatening mechanical problems. Elective repair is recommended at the time the condition is diagnosed, and open surgery can be accomplished with a low incidence of complications. The option of performing these repairs through a laparoscopic approach may further reduce morbidity and recovery time associated with surgical intervention. The purpose of this report was to review available options for laparoscopic repair and to present our experience with a tension-free technique for large paraesophageal hernias. Three patients with large diaphragmatic defects had laparoscopic repairs using an expanded polytetrafluorethylene (PTFE) patch secured with intracorporeal suturing techniques. One of these patients also underwent laparoscopic Toupet fundoplication in conjunction with repair of the hernia. In the other two patients, the fundus was secured to the right diaphragmatic crus to reduce the potential for recurrence and minimize postoperative reflux symptoms. All patients underwent successful repair without perioperative complications and had excellent long-term results. Laparoscopic repair of paraesophageal hernias can be accomplished by a number of different reported techniques. The use of a tension-free repair with PTFE may be particularly suitable for large diaphragmatic defects. An antireflux operation may be added selectively depending on clinical circumstances.

Fulminant colitis and toxic megacolon.

Twenty-seven cases of fulminant colitis are reported. All had at least five of the seven criteria of severity. Four developed toxic megacolon. Sixty-three per cent failed to respond to parenteral steroids, parenteral nutrition, and vigorous resuscitation and required surgery. Two of the patients with megacolon perforated and died. Prompt attention to these patients and a willingness to rely on surgery are important approaches. The experience reported here reiterates that previously published.

Crohn's disease. New concepts of pathogenesis and current approaches to treatment.

One theory of the pathogenesis of Crohn's disease is that rather than being caused by a unique environmental agent, it is the result of an abnormal immune response in the gastrointestinal tract. Recent studies indicate that Crohn's disease in its early stages is frequently associated with the presence of circulating antigen-non-specific suppressor T cells. Such T cells are also found in experimental inflammation caused by Chlamydia organisms in the gastrointestinal tract of nonhuman primates. Taken together, these data suggest that the suppressor T cells are markers of an underlying and persistent, antigen-specific immune response to an as yet unidentified antigen or set of antigens. We postulate that this underlying antigen-specific response is the result of a primary immunoregulatory abnormality involving an imbalance between the effects of antigen-specific helper and suppressor T cells which recognize a common antigen or antigens present in the mucosal environment.

Gastrointestinal function after forty.

Although hiatal hernia, diverticula and gallstones appear with increasing frequency during the middle years, these structural changes are most often asymptomatic. Many of the gastrointestinal complaints of patients in this age group are continuations of previous problems, such as an irritable bowel, or are related to dietary indiscretions. Esophageal function may also be altered.

Aortoenteric fistula. A complication of renal artery bypass graft.

The incidence of gastrointestinal bleeding secondary to aortoenteric fistula has increased in recent years consequent to more frequent aortic reconstructive procedures. It is necessary to approach any such patient with this diagnostic consideration in mind, since early specific therapy may decrease the mortality. In this setting, there is usually sufficient time available to perform definitive tests to establish the correct diagnosis. We report a 37-year-old patient in whom aortoenteric fistula developed following a renal artery bypass graft.

Pleuroperitoneal endometriosis.

A nearly unique case is presented of pleural and peritoneal endometriosis with bloody pleural effusion and 4700 cc of bloody ascites. Theories of pathogenesis, differential diagnosis, and treatment are discussed. This represents another of the protean manifestations of endometriosis to complement the many others described in the literature.