Laparoscopic repair of Morgagni hernia in an adult: use of a porcine small intestine submucosa biocompatible prosthesis.

Morgagni hernia is a rare cause of diaphragmatic hernia. There are few reports of laparoscopic repair in the literature. Tension-free hernia closure with synthetic mesh reduces recurrence but occasionally results in complications, such as visceral stricture, erosion or perforation. We report a case of successful laparoscopic repair of a very large symptomatic Morgagni hernia in a 78-year-old patient, treated by positioning a gradually resorbable mesh made from porcine SIS (Surgisis Soft Tissue Graft device--Cook Inc, Bloomington, Ind). After surgery, the patient reported an immediate, marked improvement in clinical symptoms. During the postoperative course, pleural and pericardial leakage occurred. The pleural leakage was immediately drained with thoracentesis, and the pericardial leakage was treated conservatively. No other complications occurred after patient discharge. One year later, the patient was in very good general condition. No recurrence was documented with abdominal CT scan, which also demonstrated connective tissue proliferation that was progressively replacing the prosthesis. Laparoscopic repair is a safe, efficacious procedure for the treatment of diaphragmatic hernia, and presents all the advantages of minimally invasive surgery. The use of new types of material featuring marked biocompatibility and gradual reabsorbability characteristics offers considerable benefits.

Endoscopic gastrostomy for enteral nutrition in neurogenic dysphagia: Application of a nasogastric tube or percutaneous endoscopic gastrostomy.

Enteral nutrition can be administered via a nasogastric tube or, in selected patients, via a percutaneous endoscopic gastrostomy. In patients with neurogenic dysphagia, the choice of nutritional administration, and above all the timing, are crucial. Our aim was to retrospectively assess the impact of new guidelines for percutaneous endoscopic gastrostomy insertion adopted since January 2002 and compare them with our previous experience. From January 1992 to June 2007, 285 gastrostomies (168 M, 117 F) were positioned in our institute. We analysed 232 patients (139 M, 93 F) in whom a percutaneous endoscopic gastrostomy was applied for neurogenic dysphagia: Group A (from January 1992 to December 2001) consisting of 174 patients; Group B (from January 2002 to June 2007) consisting of 58 patients. The percutaneous endoscopic gastrostomy was positioned in all the cases with neurogenic dysphagia after a period of not less than 3 weeks of nutrition by nasogastric tube. A total of 6 major complications (2.3 %) occurred, almost all in group A. The mortality rate (3 patients, 2%) correlated with the complications in group A. In cases of neurogenic dysphagia we believe that greater methodological rigour in the multidisciplinary decision-making process, and a period of about 6-8 weeks' nutrition by nasogastric tube after the acute neurological damage may be useful to ensure a better prognostic evaluation of the patient and hence of the indications for percutaneous endoscopic gastrostomy.

Tachyarrhythmia due to atrial fibrillation in an intragastric balloon carrier: coincidence or consequence?

A morbidly obese patient is reported who underwent insertion of a BioEnterics Intragastric Balloon (BIB) as a pre-surgical procedure (ie. prior to restrictive gastric banding). While carrying the BIB, the patient suffered an episode of severe supraventricular tachyarrhythmia (atrial fibrillation). Although such an event is not definitely correlated to the BIB, the episode led us to modify the pre-treatment protocol, introducing dynamic Holter ECG into the work-up investigations and excluding subjects with a pathological cardiac rhythm.

Mutational patterns of paired blood and rectal biopsies in HIV-infected patients on HAART.

Blood and concurrent rectal biopsy samples of human immunodeficiency virus type 1 (HIV-1)-positive highly active antiretroviral therapy (HAART)-treated patients were tested for genotypic resistance by direct sequencing of reverse transcriptase (RT) and protease (PR) regions to compare the patterns of resistance in these compartments. Fourteen subjects (five with undetectable plasma viral load (pVL) and nine persistently viremic) were studied. Four of five patients with undetectable pVL also had undetectable mucosal HIV RNA; sequence analyses from proviral DNA (PBMCs and rectal biopsy) were obtained with none or few resistance-associated mutations and no alteration of susceptibility profile. All viremic patients, and one with negative pVL, had detectable levels of mucosal HIV RNA (1.93-4.21 log(10) copies/mg); sequences of HIV RNA (plasma and/or rectal biopsy) were also obtained, and multiple mutations generally compatible with current/past medications were detected. Overall, 40 HIV-1 PR and 42 RT sequences were analyzed, yielding a total of 42 PR and 47 RT sequence pairs (plasma/tissue-RNA; plasma-RNA/tissue-DNA; PBMC/tissue-DNA; tissue-DNA/RNA; tissue-RNA/PBMC-DNA; PBMC-DNA/plasma-RNA), which almost always differed at the total amino acid level (median percentage discordance 8.08% in the PR, 4.8% in RT). The median percentage of resistance position discordance equaled 88.8% (IQR = 20-100) in the PR and 74.55% (IQR = 31.75-100%) in the RT pairs, respectively. Different resistance levels were detected by means of a computer-assisted interpretation of mutational profiles. The results support the multiform evolution of HIV genotype in various body compartments and emphasize the participation of intestinal mucosa in HIV genotype selection. Samples from diverse tissues should be used for resistance evaluation to obtain a complete picture of drug resistance for antiretroviral-treated patients.