Effect of acellular human dermis buttress on laparoscopic hiatal hernia repair.

PURPOSE: The objective of this study was to evaluate the performance of acellular human dermis reinforcement during laparoscopic hiatal hernia repair. METHODS: A prospective non-randomized, single institution study enrolled patients undergoing laparoscopic hiatal hernia repair. Acellular human dermis, FlexHD (Musculoskeletal Transplant Foundation, Edison, NJ) or AlloDerm (LifeCell Inc., Branchburg, NJ) were used to buttress the repair after primary closure. A protocol barium swallow (BAS) was performed at 6 months and then as needed due to clinical indications. Primary outcome measure was recurrence. Patients completed preoperative and postoperative GERD symptom questionnaires and quality of life surveys (SF-36). Kruskal-Wallis ANOVA, Student's t test, Fisher's exact test, or Wilcoxon signed-rank test were utilized as appropriate (p < 0.05 considered statistically significant). RESULTS: Fifty-four patients (10 men and 44 women) with a mean age of 62 ± 10 years underwent laparoscopic hiatal hernia repair using Flex HD (n = 37) or AlloDerm (n = 17). Both groups were similar with respect to gender, age, hiatus size, hernia type [sliding/Type I (n = 14) or paraesophageal/Type III/IV (n = 40)], esophageal motor function (manometry), preoperative SF-36 quality of life surveys, and GERD symptom questionnaires. Forty-seven patients (87 %) completed the BAS at 6 months; each group had two recurrences (p = 0.597). At median follow-up of 33 months, there were 3 recurrences (18 %) in the AlloDerm group and 5 recurrences (14 %) in the Flex HD group (p = 0.365). Minimal differences in GERD symptoms or SF-36 scores were detected between groups. However, anti-reflux medication usage, GERD symptoms, and quality of life significantly improved for both groups after laparoscopic hiatal hernia repair. CONCLUSIONS: Laparoscopic hiatal hernia repair with acellular human dermis reinforcement results in improvement of GERD-related symptoms and quality of life without mesh-associated complications. The type of acellular human dermis did not influence recurrence rate.

Topography of Purkinje cells and other calbindin-immunoreactive cells within adult and hatchling turtle cerebellum.

The turtle's cerebellum (Cb) is an unfoliated sheet, so the topography of its entire cortex can be easily studied physiologically by optical recordings. However, unlike the mammalian Cb, little is known about the topography of turtle Purkinje cells (PCs). Here, topography was examined using calbindin-D(28K) immunohistochemistry of adult and hatchling turtles (Trachemys scripta elegans, 2.5-15 cm carapace length). Each Cb was flattened between two Sylgard sheets and fixed in paraformaldehyde. Sections (52 microm thick) were cut parallel to the flattened cortex (tangential), resulting in calbindin-immunolabeled PCs being localized to three to six sections for each turtle. PC position and size were quantified using Neurolucida Image Analysis system. Although hatchling Cb were medial-laterally narrower (3.0 vs. 6.5 mm) and rostral-caudally shorter (2.5 vs. 5.5 mm) than adult Cb, both averaged near 15,000 PCs distributed uniformly. Hatchling PCs were smaller than adult PCs (178 vs. 551 microm(2)) and more densely packed (2,180 vs. 625 cells/mm(2)). Calbindin immunoreactivity also labeled non-PCs along the Cb's marginal rim and its caudal pole. Many of these were very small (22.9 microm(2)) ovoid-shaped cells clustered together, possibly proliferating external granule layer cells. Other labeled cells were larger and fusiform-shaped (12.6 x 33.4 microm) adjacent to inner granule cells along the marginal rim, suggestive of migrating cells. It is not known whether these are new neurons being generated within the adult and hatchling Cb and if they connect to efferent and afferent paths. Based on these anatomical findings, we suggest that unique physiological features may exist along the rim of the turtle Cb.