Laparoscopic repair of type III/IV giant para-oesophageal herniae with biological prosthesis: a single centre experience.

PURPOSE: Repair of giant paraoesophageal herniae (GPEH) is technically challenging and requires significant experience in advanced foregut surgery. Controversy continues on suture versus mesh cruroplasty with the most recent systematic review and meta-analysis putting the onus on the operating surgeon. Study aim was to review whether the biological prosthesis (non-cross-linked bovine pericardium and porcine dermis) and the technique adopted for patients with GPEH had an influence on clinical and radiological recurrences. METHOD: A retrospective analysis of a prospectively collected data of 60 consecutive patients with confirmed 5 cm hiatus hernia and ≥ 30% stomach displacement in the thorax that were operated in the upper gastrointestinal unit of a large district general hospital between September 2010 and August 2017. Pre and post-surgery Gastro-Oesophageal Reflux Disease Questionnaire [(GORD-HRQOL)] and a follow up contrast study were completed. RESULTS: 60 included 2 (3%) and 58 (97%) emergency and elective procedures respectively with a male: female ratio of 1:3, age 71* (Median) (42-89) years, BMI 29* (19-42) and 26 (43%) with ASA III/IV. Investigations confirmed 46* (37-88) mm and 42* (34-77) mm transverse and antero-posterior hiatal defect respectively with 60* (30-100)% displacement of stomach into chest. Operative time and length of stay was 180* (120-510) minutes and 2* (1-30) days respectively. One (2%) converted for bleeding and 2 (3%) peri-operative deaths. Five (8%), 5 (8%) and 4 (7%) have dysphagia, symptomatic and radiological recurrences respectively. GORD-HRQOL recorded preoperatively was 27* (10-39) dropping significantly postoperatively to 0* (0-21) (P < 0.005) with 95% patient satisfaction at a follow up of 60* (36-84) months. CONCLUSIONS: Our technique of laparoscopic GPEH repair with biological prosthesis is safe with a reduced symptomatic and radiological recurrence and an acceptable morbidity and mortality.

Transitional behavior in hydrodynamically coupled oscillators.

In this article we consider the complete set of synchronized and phase-locked states available to pairs of hydrodynamically coupled colloidal rotors, consisting of spherical beads driven about circular paths in the same, and in opposing senses. Oscillators such as these have previously been used as coarse grained, minimal models of beating cilia. Two mechanisms are known to be important in establishing synchrony. The first involves perturbation of the driving force, and the second involves deformation of the rotor trajectory. We demonstrate that these mechanisms are of similar strength, in the regime of interest, and interact to determine observed behavior. Combining analysis and simulation with experiments performed using holographic optical tweezers, we show how varying the amplitude of the driving force perturbation leads to a transition from synchronized to phase-locked states. Analogies with biological systems are discussed, as are implications for the design of biomimetic devices.

[Medicine of the Zemstvos]. / La médecine des Zemstvos.

In 1864 the government of Alexander II revolutionised the management of the countryside in Russia. The establishment of the Zemstvos marked the beginning of a decentralised system of organisation at a time when the health situation of the Empire was catastrophic. The decentralisation also affected the health system. The new organisation led to a focus on prevention. Doctors and their assistants (feldshers) began to travel out to where the patients were. Their action marked the beginning of free and equal care. At the same time, the development of public health was aiming to fight epidemics, monitor factories, schools and water quality.... However effective it was, the system didn't survive Alexander II's death. But it was on these foundations that public health in the USSR were built.