Large Hiatal Hernia Repair with Urinary Bladder Matrix Graft Reinforcement and Concomitant Sleeve Gastrectomy.

BACKGROUND: There is no current consensus on the management of large hiatal hernias concomitant with performance of a sleeve gastrectomy procedure. Proposed solutions have included performing a modified Nissen fundoplication, performing cruroplasty alone, utilizing the Linx device, performing cruroplasty with reinforcement material, and avoiding the sleeve procedure altogether in favor of a bypass procedure in order to minimize gastroesophageal reflux. Urinary bladder matrix (UBM) represents a biologically derived material for use in hiatal hernia repair reinforcement with the potential to improve durability of repair without incurring the risks of other reinforcement materials. METHODS: This study reports the results of a retrospective chart review of 32 cases of large hiatal hernia repair utilizing both primary crural repair and UBM reinforcement concomitant with laparoscopic sleeve gastrectomy by a single surgeon. Hernia diameter averaged 6 cm (range 4-9 cm). After an average of 1 year followup, 30 patients were assessed for subjective symptoms of gastroesophageal reflux (GERD) using the Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score. Twenty patients were evaluated with either upper gastrointestinal (GI) series, endoscopy, or both. RESULTS: Each repair was successful and completed laparoscopically concomitant with sleeve gastrectomy. Anterior and posterior cruroplasty was performed using interrupted 0-Ethibond suture using the Endostitch device. The UBM graft exhibited favorable handling characteristics placed as a keyhole geometry sutured to the crura with absorbable suture. A careful chart review was undertaken to assess for complications. There have been no reoperations. After a median of 12 months (range, 4-27 months) of followup, an assessment of recurrences or long-term complications was completed. Median GERD-HRQL score was 6, with a range of 0 to 64 (of possible 75), indicating very low-level reflux symptomatology. Follow-up upper GI radiographs or endoscopy were obtained in 20 cases and show intact repairs. CONCLUSION: In this series of 32 cases, laparoscopic cruroplasty with UBM graft reinforcement has been effective and durable at 12 months of followup. This technique may offer one satisfactory solution for large hiatal hernia repair concomitant with laparoscopic sleeve gastrectomy that may achieve a durable repair with low GERD symptoms.

Multi-photon ionisation spectroscopy for rotational state preparation of [Formula: see text].

In this paper we investigate the 2 + 1' resonance enhanced multi-photon ionisation (REMPI) of molecular nitrogen via the a1Πg(v = 6) intermediate state and analyse its feasibility to generate molecular nitrogen ions in a well defined ro-vibrational state. This is an important tool for high precision experiments based on trapped molecular ions, and is crucial for studying the time variation of the fundamental constant mp/me using [Formula: see text]. The transition is not reported in the literature and detailed spectral analysis has been conducted to extract the molecular constants of the intermediate state. By carefully choosing the intermediate ro-vibrational state, the ionisation laser wavelength and controlling the excitation laser pulse energy, unwanted formation of rotationally excited molecular ions can be suppressed and ro-vibrational ground state ions can be generated with high purity.

Laparoscopic Rectopexy with Urinary Bladder Xenograft Reinforcement.

BACKGROUND AND OBJECTIVES: Rectal prolapse is often repaired laparoscopically, frequently with the use of reinforcement material. Both synthetic and biologically derived materials reduce recurrence rate compared to primary suture repair. Synthetic mesh introduces potential complications such as mesh erosion, fibrosis, and infection. Urinary bladder matrix (UBM) represents a biologically derived material for reinforcement of rectal prolapse repair with the potential to improve durability without risks of synthetic materials. The objective of the study is to evaluate the effectiveness, durability, and functional result of laparoscopic rectopexy using urinary bladder matrix xenograft reinforcement at three years follow up. METHODS: The 20 cases presented describe rectal prolapse repair by means of laparoscopic rectopexy with presacral UBM reinforcement. Patients were followed up for an average of 3 years and assessed with interviews, physical examination, manometry, and the fecal incontinence severity index (FISI). RESULTS: Each repair was completed laparoscopically. UBM exhibited favorable handling characteristics when sutured to the sacrum and the lateral rectal walls. One patient underwent laparoscopic drainage of a postoperative abscess; no other complications occurred. In 3 years of follow-up, there have been no full-thickness recurrences, erosions, reoperations, or long-term complications. Two patients exhibited a small degree of mucosal prolapse on follow-up physical examination that did not require surgery. Three-year FISI scores averaged 8 (range, 0-33 of a possible 61), indicating low fecal incontinence symptomatology. Follow-up anorectal manometry was performed in 9 patients, showing mixed results. CONCLUSION: Surgeons may safely use laparoscopic rectopexy with UBM reinforcement for repair of rectal prolapses. In this series, repairs with UBM grafts have been durable at 3-year follow-up and may be an alternative to synthetic mesh reinforcement of rectal prolapse repairs. Future studies may compare the advantages and cost-effectiveness of reinforcement materials for rectal prolapse repair.

RANKL-stimulated osteoclast-like cell formation in vitro is partially dependent on endogenous interleukin-1 production.

Receptor activator of NF-kappaB ligand (RANKL) and interleukin-1 (IL-1) individually plays a critical role in the differentiation and activation of osteoclasts in bone. In addition, both RANKL and IL-1 activate similar signal transduction pathways including p38 MAP kinase and c-Jun NH(2) terminal kinase (JNK). We examined if endogenously produced IL-1 influenced osteoclast-like cell (OCL) formation in murine bone marrow and bone marrow monocyte (BMM) cultures that were stimulated with M-CSF and RANKL. RANKL stimulated OCL formation in a dose-dependent manner in bone marrow cultures, and this response was significantly inhibited by IL-1 RA (100 ng/ml), a specific IL-1 antagonist. Interleukin-1 further increased OCL formation in BMM cultures that were treated with M-CSF (30 ng/ml) and RANKL (1, 3, 10 and 30 ng/ml). In addition, BMM cultures from IL-1 type I receptor-deficient mice, which do not respond to IL-1, demonstrated significantly less OCL formation compared to wild-type BMM cultures. We examined the time course and dose response of IL-1alpha protein expression by ELISA in BMM cultures that were treated with or without M-CSF and RANKL. RANKL dose dependently stimulated IL-1alpha protein significantly (up to 46%) in 6-day cultures. The interaction of RANKL and IL-1 on osteoclastogenesis did not appear significantly dependent on prostaglandin synthesis since PGE(2) expression in the conditioned medium of BMM cultures was nearly undetectable and the PGHS-2 specific inhibitor, NS-398, was without effect. We also investigated the effect of IL-1 on p38 MAP kinase and JNK in BMM cultures. The combination of RANKL and IL-1 had additive effects on JNK but not p38 MAP kinase compared to results in cultures treated with RANKL or IL-1 alone. In addition, SP600125, a specific JNK inhibitor, markedly reduced OCL formation in BMM cultures that were treated with RANKL or the combination of RANKL and IL-1. These findings demonstrate that endogenously produced IL-1 augments the response of bone marrow cells to RANKL, and this effect appears mediated by mechanisms that are associated with enhancement of JNK activity.