Evaluation of DualMesh for repair of large hiatus hernia in a porcine model.

BACKGROUND: Prosthetic fascial grafts are frequently used for augmentation of cruroplasty in large hiatus hernia repair to decrease the chances of recurrence. Potential complications such as intraluminal erosion may be related to the constant movement of mesh and diaphragm over the outer surface of the esophagus. This study aimed to evaluate DualMesh for repair of large hiatal defects in a porcine model. METHODS: In this study, 18 Landrace x large white x Duroc crossbred pigs underwent either primary hiatal repair or tension-free prosthetic repair using DualMesh (80 x 50 mm or 80 x 100 mm). The animals were killed at 3 or 28 weeks for macroscopic and histologic evaluation of the hiatal region and gastroesophageal junction. RESULTS: All grafts had become encapsulated at 28 weeks, and the majority had filmy adhesions only to the visceral aspect. In all models, the esophagus moved freely over the cut edge of the prosthesis. No signs of intraluminal erosion were documented. At histologic examination, significant ingrowth was noted on the porous side of the mesh, whereas no defined mesothelial layer was identified on the capsule of the nonporous side. CONCLUSION: In this animal model of large hiatus hernia repair, DualMesh showed optimal characteristics in terms of host tissue incorporation on the porous side and absence of adhesions on the visceral side of the prosthesis. The absence of adhesions and intraluminal erosion in this study may provide reassurance to surgeons using mesh at the hiatus.

Symptomatic and radiological follow-up after para-esophageal hernia repair.

The treatment of para-esophageal hernia by the laparoscopic approach has been described by a number of authors. The lower morbidity of the laparoscopic approach compared with the open approach holds some attraction, however, reservations regarding the durability of laparoscopic repair exist. There is a paucity of objective follow-up data in the literature with regard to repair durability and symptomatic outcome. A review was undertaken of 94 patients over a 7 year period undergoing attempted laparoscopic repairs of para-esophageal hernia. Preoperative and operative data was collected and patients underwent postoperative interview and barium meal. Laparoscopic repair was successfully completed in 86 patients. Symptomatic reherniation occurred in 12% (10/86) of patients undergoing laparoscopic repair. These patients underwent open reoperative surgery. There were no symptomatic recurrences in patients undergoing initial open repair. Symptomatic outcome was assessed by interview in 78% (73/94) of patients at a median of 27 months (3-93 months) postoperatively. Ninety-seven percent (71/73) of patients were satisfied with their ultimate symptomatic outcome however, this group included seven patients who had required reoperative surgery for symptomatic recurrence and were therefore laparoscopic failures. In order to determine the asymptomatic recurrence rate patients were requested to undergo a barium meal. A further nine small asymptomatic recurrences were diagnosed in 42 patients having had laparoscopic repair. This represents an asymptomatic radiographic recurrence rate of 21%. Laparoscopic repair in this series was associated with a 12% symptomatic recurrence rate. The majority of patients with symptomatic recurrence underwent open reoperation with good results. Strategies for reducing recurrences should be examined in prospective series.

Laparoscopic excision of esophageal leiomyoma through an anterior esophagotomy.

Esophageal leiomyoma are usually intramural and the most common minimally invasive approach is thoracoscopic excision leaving the mucosa intact. We report the case of a 58-year-old woman who underwent laparoscopic excision of a pedunculated esophageal leiomyoma.

A trial of prophylactic mexiletine in home coronary care.

A double blind randomised study was undertaken comparing the effects of oral mexiletine and placebo given by general practitioners at home in the early stages of suspected acute myocardial infarction, and continued for six weeks. The study comprised 216 patients. In 59 the diagnosis of acute myocardial infarction was not confirmed. Of the 72 patients with confirmed myocardial infarction treated with mexiletine, 11 (15.3%) died, compared with 19 (22.4%) of the 85 patients given the placebo, and significantly fewer of the former compared with the latter had frequent ventricular ectopics or ventricular tachycardia recorded on 24 hour electrocardiograms. Numbers of patients transferred to hospital or withdrawn from the trial because of arrhythmia or heart failure were similar in the two treated groups. Ten (13.9%) of the patients taking mexiletine had the drug withdrawn because of side effects attributed to it, compared with three (3.5%) of the group taking the placebo. A further five patients (all on mexiletine) also had treatment withdrawn because of side effects but infarction was not later confirmed. The results indicate that oral mexiletine can be given safely to patients with suspected myocardial infarction at home by their general practitioners in the absence of a positive electrocardiographic diagnosis. The frequency of ventricular tachycardia is significantly reduced; but there is no evidence of reduced mortality.