Endoscopic SIS injection into the lower oesophageal sphincter in dogs.

AIM: To determine the usefulness of endoscopically-delivered small intestinal submucosa (SIS) as a scaffold in enhancing the lower oesophageal sphincter (LOS) pressures. METHODS: Six dogs were endoscopically injected--four with the SIS and two with its glycerin carrier. Manometry was performed prior to injection and every four weeks post-op. RESULTS: Adequate and site correct injections were made in four dogs. In one dog, significant augmentation of pressures were obtained at four weeks. None had significant changes in pressure at eight weeks, differences in length at either four or eight weeks or significant differences in the thickness of the examined layers. Four of the six had capillary cushions on pathological examination. The dog injected with the carrier had a loose and disorganise collection, while the others were well organised. CONCLUSION: SIS is a biologically compatible material. Lack of an animal model for gastro-oesophageal reflux disease (GORD) makes determining the ability of injections of SIS to combat reflux problematic.

Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial.

BACKGROUND: A totally transoral outpatient procedure for the treatment of GERD would be appealing. METHODS: A multicenter trial was initiated that included 64 patients with GERD treated with an endoscopic suturing device. Inclusion criteria were 3 or more heartburn episodes per week while not taking medication, dependency on antisecretory medicine, and documented acid reflux by pH monitoring. Exclusion criteria were dysphagia, grade 3 or 4 esophagitis, obesity, and hiatus hernia greater than 2 cm in length. Patients underwent manometry, endoscopy, 24-hour pH monitoring, and symptom severity scoring before and after the procedure. Patients were randomized to a linear or circumferential plication configuration. Adverse procedural events were recorded. RESULTS: Mean 6-month symptom score changes demonstrated procedural efficacy. Heartburn severity and frequency as well as regurgitation all improved (p > 0.0001 for each). Twenty-four-hour pH monitoring showed improvement in number of episodes below pH of 4 at 3 and 6 months (p < 0.0007 and 0.0002) and percentage of total time the pH was less than 4 at 6 months (p < 0.011). Plication configuration did not affect symptoms or pH monitoring results. One patient had a self-contained suture perforation that was successfully treated with antibiotics. CONCLUSION: Endoscopic gastroplasty is safe. It is associated with reduced symptoms and medication use at 6 month follow-up in patients with uncomplicated GERD.

An assessment of pain and return to normal activity. Laparoscopic herniorrhaphy vs open tension-free Lichtenstein repair.

BACKGROUND: Laparoscopic herniorrhaphy is controversial and deserves critical evaluation. METHODS: In a randomized prospective study transabdominal preperitoneal laparoscopic herniorrhaphy (n = 24) was compared in patients to the tension-free Lichtenstein repair (n = 29) utilizing validated and reliable pain and activity assessment tools. The Sickness Impact Profile (SIP) was used to compare preoperative normal activity to postoperative activity. A Pain-O-Meter (visual analogue scale plus affective and sensory pain descriptors) assessed intensity of pain. The total pain assessment score and SIP were compared across time (postoperative day 1-42). Analgesic medication was used as a covariate. RESULTS: The total pain score was less for laparoscopic herniorrhaphy but this did not reach statistical significance. Similarly, the SIP showed modest improvement for laparoscopic herniorrhaphy. No differences between groups were noted for morphine equivalents of administered analgesics or length of hospitalization. CONCLUSION: Further investigation of laparoscopic herniorrhaphy is warranted.

Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial.

OBJECTIVE: The purpose of this study was to determine if laparoscopic inguinal herniorrhaphy represents a viable alternative to the conventional repair and to assess whether a prospective randomized controlled trial comparing both procedures is warranted. METHODS: Three types of laparoscopic inguinal herniorrhaphies (transabdominal preperitoneal [TAPP], intraperitoneal onlay mesh [IPOM], and totally extraperitoneal [EXTRA]) were studied in a phase II design. Twenty-one investigators from 19 institutions participated. Approval from the local human research committee was required at each institution before patients could be enrolled. RESULTS: There were 686 patients with 869 hernias; 366 (42.1%) were direct, 414 (47.6%) were indirect, 22 (2.5%) were femoral, and 67 (7.7%) were combination hernias. The TAPP procedure was used for 562 hernias, the IPOM was used for 217 hernias, and the EXTRA was used for 87 hernias. Sixty-one patients had additional abdominal procedures performed at the time of laparoscopy without any adverse affects on their herniorrhaphies. The overall recurrence rate was 4.5%, with a minimum follow-up of 15 months. Complications were divided into the following three groups: 1) those related to laparoscopy, 2) those related to the patient, and 3) those related to the herniorrhaphy. Complications related to the laparoscopy occurred in 5.4% of patients; bleeding or abdominal wall hematomas occurred 31 times, (two patients required transfusion); one patient had bowel perforation, which was sutured laparoscopically; a bladder injury required laparotomy for management. Patient complications occurred in 6.7%. The majority involved the urinary tract (5.8%). Two patients required secondary abdominal procedures for adhesions, one for pain in the right lower quadrant and the other for adhesive small bowel obstruction. Postoperative myocardial infarction on day 5 resulted in the only operative mortality, for a rate of 0.1%. Complications related to the herniorrhaphy itself occurred in 17.1%. Most of these were minor, consisting of transient groin pain (3.5%), seroma (3.5%), transient leg pain (3.3%), hematoma (1.5%), or transient cord or testicular problems (0.9%). The incidence of leg pain decreased dramatically as surgeons became more familiar with the anatomy of the nerve supply to the groin when viewed laparoscopically. Ninety-three percent of patients were discharged within 24 hours of their operations. CONCLUSIONS: Laparoscopic inguinal herniorrhaphy is an effective method to correct an inguinal hernia. It can be offered safely to patients undergoing other abdominal procedures. The TAPP, IPOM, and EXTRA procedures appear to be equally effective. A controlled randomized trial is needed to compare this procedure with conventional inguinal herniorrhaphy.

Numerical study of arterial flow during sustained external acceleration.

A computer model of the human arterial tree based upon the one-dimensional flow equations is used to study the effects of sustained acceleration (+Gz) on eye-level arterial pressure and flow. Steady-state physiological compensatory mechanisms are modelled using human centrifuge data found in the literature. Cases investigated include the supine and standing human (+1 Gz), the application of resistive and occlusive anti-G suits, and the occurrence of a stenosis proximal to the carotid bifurcation. Results indicate that the simulated eye-level pressures and flows satisfactorily correspond with those found in the literature.