Laparoscopic repair of a spontaneous diaphragmatic hernia.

BACKGROUND: Spontaneous diaphragmatic hernia without a previously documented history of trauma is uncommon and clinical presentation can often be atypical ranging from an incidental radiological finding to patients presenting with complications. CASE PRESENTATION: In this video we present the case of a patient presenting with gastric perforation within a large spontaneous diaphragmatic hernia in the central part of the left hemidiaphragm. CONCLUSIONS: Management of a complicated diaphragmatic hernia could be achieved using laparoscopic approach. The rarity of these hernias means that the operative strategy necessary for safe dissection and repair has to be individualized for each patient.

Vascular smooth muscle cells from small human omental arteries express P2X1 and P2X4 receptor subunits.

Stimulation of P2X receptors by ATP in vascular smooth muscle cells (VSMCs) is proposed to mediate vascular tone. However, understanding of P2X receptor-mediated actions in human blood vessels is limited, and therefore, the current work investigates the role of P2X receptors in freshly isolated small human gastro-omental arteries (HGOAs). Expression of P2X1 and P2X4 receptor subunit messenger RNA (mRNA) and protein was identified in individual HGOA VSMCs using RT-PCR and immunofluorescent analysis and using Western blot in multi-cellular preparations. ATP of 10 µmol/l and αß-meATP of 10 µmol/l, a selective P2X receptor agonist, evoked robust increases in [Ca(2+)]i in fluo-3-loaded HGOA VSMCs. Pre-incubation with 1 µmol/l NF279, a selective P2X receptor antagonist, reduced the amplitude of αß-meATP-induced increase in [Ca(2+)]i by about 70 %. ATP of 10 µmol/l and αß-meATP of 10 µmol/l produced similar contractile responses in segments of HGOA, and these contractions were greatly reduced by 2 µmol/l NF449, a selective P2X receptor inhibitor. These data suggest that VSMCs from HGOA express P2X1 and P2X4 receptor subunits with homomeric P2X1 receptors likely serving as the predominant target for extracellular ATP.

'Stent in a stent'--an alternative technique for removing partially covered stents following sleeve gastrectomy complications.

Endoscopic stenting is a relatively new technique for the treatment of post sleeve gastrectomy complications. Partially covered stents are used in this method to minimise the risk of migration but they are associated with difficulties with removal. Patients requiring emergency stenting following sleeve gastrectomy underwent insertion of a partially covered metallic stent. One month later, if the stent was not easily removable, a fully covered overlapping stent was inserted and the patient was readmitted 2 weeks later for removal of both stents. Four patients required stenting following sleeve gastrectomy leaks, and one patient required stenting for a stricture. In these cases, a 'stent in a stent' technique was used for removal. This technique allows the safe removal of partially covered stents inserted following sleeve gastrectomy complications.

Staple line reinforcement during laparoscopic sleeve gastrectomy: does it affect clinical outcomes?

Although laparoscopic sleeve gastrectomy (LSG) is safe and efficacious treatment for morbid obesity, this procedure is associated with major staple line complications including leakage and bleeding. Staple-line reinforcement (SLR) either through suturing or buttressing with biological or synthetic material has been suggested as a method to prevent these complications. A Best Evidence Topic was constructed to address the question of whether SLR reduced these and other complications. MEDLINE, EMBASE and CINAHL searches up to October 2012 returned 97 unique results, of which nine (one meta-analysis, two randomised controlled trials (RCTs), six prospective cohort studies) provided the best evidence to answer this clinical question. We conclude that current evidence suggests that staple-line reinforcement reduces the incidence of leakage and postoperative complications than non-reinforcement but does not significantly reduce bleeding complications. However, we cannot as yet recommend staple-line reinforcement as the strength of the presented evidence is limited by the variable quality of the published studies. The full-length publication of several abstracts of randomised, controlled trials presented at various recent conferences is awaited. This may provide more data on the effect of staple-line reinforcement on other outcomes largely neglected by currently available studies.

Simultaneous intra-gastric balloon removal and laparoscopic sleeve gastrectomy for the super-super obese patients--a prospective feasibility study.

BACKGROUND: The aim of the study was to prospectively evaluate the feasibility and clinical efficacy of a strategy of performing simultaneous balloon removal and sleeve gastrectomy in the super-super obese patients. METHODS: Forty consecutive super-super obese patients underwent intra-gastric balloon insertion followed by simultaneous balloon removal and sleeve gastrectomy 6 months later. RESULTS: Balloon insertion resulted in a reduction in mean body mass index from 69.3 ± 1.4 to 62.3 ± 1.3 kg/m2. Simultaneous balloon removal and sleeve gastrectomy was achieved in 39 cases. There were no operative mortality and no leaks. Six months following sleeve gastrectomy, the mean BMI of the cohort had fallen to 54.1 ± 1.2 kg/m2. CONCLUSIONS: Simultaneous balloon removal and sleeve gastrectomy in the super-super obese patients is feasible as a single-stage procedure with good perioperative outcomes.

Potent vasorelaxant activity of the TMEM16A inhibitor T16A(inh) -A01.

BACKGROUND AND PURPOSE: T16A(inh) -A01 is a recently identified inhibitor of the calcium-activated chloride channel TMEM16A. The aim of this study was to test the efficacy of T16A(inh) -A01 for inhibition of calcium-activated chloride channels in vascular smooth muscle and consequent effects on vascular tone. EXPERIMENTAL APPROACH: Single channel and whole cell patch clamp was performed on single smooth muscle cells from rabbit pulmonary artery and mouse thoracic aorta. Isometric tension studies were performed on mouse thoracic aorta and mesenteric artery as well as human abdominal visceral adipose artery. KEY RESULTS: In rabbit pulmonary artery myocytes T16A(inh) -A01 (1-30 µM) inhibited single calcium (Ca(2+) )-activated chloride (Cl(-) ) channels and whole cell currents activated by 500 nM free Ca(2+) . Similar effects were observed for single Ca(2+) -activated Cl(-) channels in mouse thoracic aorta, and in both cell types, channel activity was abolished by two antisera raised against TMEM16A but not by a bestrophin antibody. The TMEM16A potentiator, F(act) (10 µM), increased single channel and whole cell Ca(2+) -activated Cl(-) currents in rabbit pulmonary arteries. In isometric tension studies, T16A(inh) -A01 relaxed mouse thoracic aorta pre-contracted with methoxamine with an IC(50) of 1.6 µM and suppressed the methoxamine concentration-effect curve. T16A(inh) -A01 did not affect the maximal contraction produced by 60 mM KCl and the relaxant effect of 10 µM T16A(inh) -A01 was not altered by incubation of mouse thoracic aorta in a cocktail of potassium (K(+) ) channel blockers. T16A(inh) -A01 (10 µM) also relaxed human visceral adipose arteries by 88 ± 3%. CONCLUSIONS AND IMPLICATIONS: T16A(inh) -A01 blocks calcium-activated chloride channels in vascular smooth muscle cells and relaxes murine and human blood vessels.

Resident phenotypically modulated vascular smooth muscle cells in healthy human arteries.

Vascular interstitial cells (VICs) are non-contractile cells with filopodia previously described in healthy blood vessels of rodents and their function remains unknown. The objective of this study was to identify VICs in human arteries and to ascertain their role. VICs were identified in the wall of human gastro-omental arteries using transmission electron microscopy. Isolated VICs showed ability to form new and elongate existing filopodia and actively change body shape. Most importantly sprouting VICs were also observed in cell dispersal. RT-PCR performed on separately collected contractile vascular smooth muscle cells (VSMCs) and VICs showed that both cell types expressed the gene for smooth muscle myosin heavy chain (SM-MHC). Immunofluorescent labelling showed that both VSMCs and VICs had similar fluorescence for SM-MHC and αSM-actin, VICs, however, had significantly lower fluorescence for smoothelin, myosin light chain kinase, h-calponin and SM22α. It was also found that VICs do not have cytoskeleton as rigid as in contractile VSMCs. VICs express number of VSMC-specific proteins and display features of phenotypically modulated VSMCs with increased migratory abilities. VICs, therefore represent resident phenotypically modulated VSMCs that are present in human arteries under normal physiological conditions.

Management of a ruptured bile duct cyst.

A case of a ruptured bile duct cyst in a 25-year-old male patient is presented. The initial management of the clinical presentation of acute abdomen consisted of an exploratory laparotomy and a T-tube cystostomy of a choledochal cyst. Two months later, he was admitted to our surgical department. Preoperative evaluation showed a type IV-A choledochal cyst. The patient underwent excision of the choledochal cyst, cholecystectomy, and the construction of a Roux-en-Y end-to-side hepaticojejunostomy.