Efficacy and safety of live varicella zoster vaccine in diabetes: a randomized, double-blind, placebo-controlled trial.

AIMS: To elucidate varicella zoster virus (VZV)-specific cell-mediated immunity and humoral immunogenicity against live attenuated Oka varicella zoster vaccine concurrently vaccinated with 23-valent pneumococcal polysaccharide vaccine (PPSV23) in elderly people with diabetes mellitus. METHODS: This double-blind randomized controlled single-centre study of 60-70-year-old people with diabetes compared immunity and safety profiles 3 months after one dose of varicella zoster vaccine or placebo. PPSV23 was immunized simultaneously. Primary analysis evaluated cell-mediated immunity using the VZV skin test. Secondary analyses were a VZV interferon-γ enzyme-linked immunospot (ELISPOT) assay and immunoadherence haemagglutination test. Adverse experiences were recorded using diary questionnaires. RESULTS: By intent-to-treat analysis, 27 participants with diabetes who had been administered the vaccine were compared with 27 participants who were given a placebo. Changes in skin test scores were 0.41 ± 0.80 and 0.11 ± 0.93 (P = 0.2155), and geometric mean fold rises of the ELISPOT counts were 1.2 [95% confidence interval (CI) 0.2, 7.9] and 1.2 (95% CI 0.2, 7.3) (P = 0.989) in the vaccine and placebo groups, respectively. The geometric mean titre did not increase 3 months after vaccination in either group. No vaccination-related severe adverse experience was reported and no participant developed herpes zoster. DISCUSSION: Our previous results demonstrated that varicella zoster vaccine safely enhanced VZV-specific immunity in elderly people with or without diabetes. The results of this study showed that varicella zoster vaccine can be used safely, but it cannot boost virus-specific immunity in elderly people with diabetes when administered with concurrent PPSV23. Alternative strategies are needed to prevent VZV-associated diseases in this population.

A combination of ultrasound-guided rectus sheath and transversus abdominis plane blocks is superior to either block alone for pain control after gynecological transumbilical single incision laparoscopic surgery.

PURPOSE: To investigate the efficacy of the combination of ultrasound-guided rectus sheath (RS) and transversus abdominis plane (TAP) blocks compared with TAP or RS block alone in gynecological single-incision laparoscopic surgery (SILS). MATERIALS AND METHODS: Bilateral TAP blocks (Group A, n = 12), TAP and RS blocks (Group B, n = 12), and RS blocks (Group C, n = 12) with 40 ml ropivacaine/patient were performed for ovarian tumor SILS. The analgesic effects were evaluated using a numerical rating scale (NRS) at zero, six, 12, 24, and 48 hours post-surgery. RESULTS: Umbilical pain on completion of general anesthesia was significantly less frequent in Group B (1/12) than Group A (7/12) (p = 0.03). The postoperative NRS scores were significantly lower in Group B than Group A at zero (p = 0.02) and six (p = 0.03) hours and Group C at zero (p = 0.001), six (p = 0.02), and 12 (p = 0.004) hours. CONCLUSION: The combination of RS and TAP blocks reduced early postoperative pain compared with RS or TAP block alone for gynecological SILS.

Histopathologic findings in patients with idiopathic megacolon: a comparison between dilated and non-dilated loops.

BACKGROUND: Idiopathic megacolon (IMC) is an intractable motility disorder in which chronic symptoms of colonic dysmotility appear with no mechanical cause. Although a pathological analysis is essential to understand the mechanism of IMC, no study has compared the histopathologic findings between dilated and non-dilated loops in IMC cases, and little is known about the proportion of each disease subtype. METHODS: Fifty-three full-thickness samples (dilated loops, n = 31; non-dilated loops, n = 22) from 31 IMC cases and 16 samples (dilated loops; n = 8, non-dilated loops; n = 8) from eight controls were collected. All the samples were stained with hematoxylin-eosin (HE), Hu C/D antibody, and CD117 antibody to assess degenerative myopathy, degenerative neuropathy, inflammatory neuropathy, hypoganglionosis, and mesenchymopathy according to the London Classification. Findings of the dilated and non-dilated loop samples were compared, and the proportions of each subtype were analyzed. KEY RESULTS: Based on a control study, <60 ganglion cells/cm was defined as hypoganglionosis in our series. Myopathy was observed in 11 patients (35.5%), neuropathy was in 19 patients (61.3%), and mesenchymopathy was in 10 patients (32.2%). An overlap between subtypes was observed in some cases. Surprisingly, the non-dilated loop samples exhibited very similar histopathologic abnormalities to those observed in the dilated loop samples in most cases. CONCLUSIONS & INFERENCES: Our study is the first to compare the histopathologic findings between dilated and non-dilated loops in IMC patients. Histopathologic abnormalities precede the clinical manifestation of IMC, and may consequently lead to gradual colonic dilatation; however, detailed mechanism including dilation triggering factor needs further elucidation.

Inhibition of fatty acid amide hydrolase unmasks CB1 receptor and TRPV1 channel-mediated modulation of glutamatergic synaptic transmission in midbrain periaqueductal grey.

BACKGROUND AND PURPOSE: While arachidonyl ethanolamine (anandamide) produces pharmacological effects mediated by cannabinoid CB1 receptors, it is also an agonist at the transient receptor potential vanilloid type 1 (TRPV1) ion channel. This study examined the cellular actions of anandamide in the midbrain periaqueductal grey (PAG), a region implicated in the analgesic actions of cannabinoids, and which expresses both CB1 receptors and TRPV1. EXPERIMENTAL APPROACH: In vitro whole cell patch clamp recordings of glutamatergic excitatory postsynaptic currents (EPSCs) were made from rat and mouse PAG slices. KEY RESULTS: Capsaicin (1 µM) increased the rate, but not the amplitude of miniature EPSCs in subpopulations of neurons throughout the rat and mouse PAG. Capsaicin had no effect on miniature EPSCs in PAG neurons from TRPV1 knock-out mice. In mouse PAG neurons, anandamide (30 µM) had no effect on the rate of miniature EPSCs alone, or in the presence of either the CB1 antagonist AM251 (3 µM) or the TRPV1 antagonist iodoresiniferatoxin (300 nM). Anandamide produced a decrease in miniature EPSC rate in the presence of the fatty acid amide hydrolase (FAAH) inhibitor URB597 (1 µM). By contrast, anandamide produced an increase in miniature EPSC rate in the presence of both URB597 and AM251, which was absent in TRPV1 knock-out mice. CONCLUSIONS AND IMPLICATIONS: These results suggest that the actions of anandamide within PAG are limited by enzymatic degradation by FAAH. FAAH blockade unmasks both presynaptic inhibition and excitation of glutamatergic synaptic transmission which are mediated via CB1 receptors and TRPV1 respectively.

Disturbed blood flow induces erosive injury to smooth muscle cell-rich neointima and promotes thrombus formation in rabbit femoral arteries.

BACKGROUND: Plaque erosion is a cause of atherothrombosis that preferentially occurs on smooth muscle cell (SMC)- and proteoglycan-rich rather than lipid-rich plaques. However, its underlying mechanisms remain unknown. OBJECTIVE: To determine whether disturbed blood flow induces erosive injury and thrombus formation on SMC-rich neointima. METHODS: Three weeks after balloon injury, SMC-rich neointima with increased tissue factor (TF) activity developed in rabbit femoral arteries that were narrowed with a vascular occluder to disturb blood flow after stenosis. Neointimal injury and thrombus formation were assessed at 15, 30, and 180 min after the vascular narrowing. RESULTS: Endothelial detachment, platelet adhesion and neointimal cell apoptosis became evident at the post-stenotic regions of all femoral arteries (n = 5) within 15 min of narrowing. Mural thrombi composed of platelet and fibrin developed after 30 min, and then occlusive thrombi were generated in three out of five vessels after 180 min. The identical vascular narrowing of normal femoral arteries also induced endothelial detachment with small platelet thrombi at post-stenotic regions, but fibrin and occlusive thrombi did not develop. Computational simulation analysis indicated that oscillatory shear stress contributes to the development of erosive damage to the neointima. CONCLUSIONS: These results suggest that disturbed post-stenotic blood flow can induce erosive injury in SMC-rich plaques and promote thrombus formation that results in vascular events.

Major orthopaedic surgeries for haemophilia with inhibitors using rFVIIa.

SUMMARY: Between 2000 and 2008, 11 major orthopaedic surgeries for 7 congenital haemophilia patients with inhibitors were performed by the first author as the primary doctor using recombinant activated factor VII (rFVIIa). Orthopaedic surgical treatments were performed for six surgeries for four high-responder haemophilia A patients, three surgeries for two high-responder haemophilia B patients and two surgeries for one low-responder haemophilia B patient. This low-responder patient is allergic to factor IX products, so he usually uses rFVIIa as a haemostatic agent. All of the surgeries were major, such as joint arthroplasty, arthroscopic synovectomy, and a combination of both, and excellent surgical results were achieved. Seven cases were controlled by bolus infusion of rFVIIa, and the other four cases were controlled by combined bolus and continuous infusion of rFVIIa. An anti-fibrolytic agent was used for all cases. There were no thrombogenic adverse effects, only two bleeding episodes. As for haemostatic control, nine surgeries were excellent, one was good and one was fair. This report is the largest clinical report on major orthopaedic surgeries at a single institute. We have concluded that the combination of bolus and continuous infusion of rFVIIa is safe and effective, and more convenient to administer than simple bolus infusion therapy to achieve haemostasis at peri-operative periods. In addition, our data also concurs with the data of several previous reports which showed that orthopaedic surgery for haemophilia patients with inhibitors by means of rFVIIa is safe and effective.

Frey procedure for chronic pancreatitis in a child with duodenal atresia and complex pancreaticobiliary disorders.

A boy aged 2 years and 7 months who had undergone duodeno-duodenostomy for duodenal atresia and annular pancreas in the neonatal period presented with recurrent pancreatitis. ERCP showed an incomplete pancreas divisum associated with pancreaticobiliary maljunction. At 3 years and 8 months of age, we performed a Frey procedure in combination with total excision of the extrahepatic bile duct. The main pancreatic duct was opened in the body and the head was cored out anteriorly. The pancreaticobiliary system was reconstructed with a Roux-en-Y anastomosis. The patient has been free from symptoms with excellent weight gain in the follow-up period of 20 months. The Frey procedure can be a safe and effective operation in children with chronic pancreatitis caused by complex pancreatobiliary disorders associated with duodenal atresia.

Cross sections for electron impact excitation of the C (1)Pi and D (1)Sigma(+) electronic states in N(2)O.

Differential and integral cross sections for electron-impact excitation of the dipole-allowed C (1)Pi and D (1)Sigma(+) electronic states of nitrous oxide have been measured. The differential cross sections were determined by analysis of normalized energy-loss spectra obtained using a crossed-beam apparatus at six electron energies in the range 15-200 eV. Integral cross sections were subsequently derived from these data. The present work was undertaken in order to check both the validity of the only other comprehensive experimental study into these excitation processes [Marinkovic et al., J. Phys. B 32, 1949 (1998)] and to extend the energy range of those data. Agreement with the earlier data, particularly at the lower common energies, was typically found to be fair. In addition, the BEf-scaling approach [Kim, J. Chem. Phys. 126, 064305 (2007)] is used to calculate integral cross sections for the C (1)Pi and D (1)Sigma(+) states, from their respective thresholds to 5000 eV. In general, good agreement is found between the experimental integral cross sections and those calculated within the BEf-scaling paradigm, the only exception being at the lowest energies of this study. Finally, optical oscillator strengths, also determined as a part of the present investigations, were found to be in fair accordance with previous corresponding determinations.

Peripherally administered ghrelin induces bimodal effects on the mesolimbic dopamine system depending on food-consumptive states.

Ghrelin induces orexigenic behavior by activation of growth hormone secretagogue 1 receptors (GHSRs) in the ventral tegmental area (VTA) as well as hypothalamus, suggesting the involvement of mesolimbic dopamine system in the action of ghrelin. The present study aimed to identify neuronal mechanisms by which peripherally administered ghrelin regulates the mesolimbic dopamine system under different food-consumptive states. Ghrelin was administered to rats peripherally (3 nmol, i.v.) as well as locally into the VTA (0.3 nmol). Dopamine in the nucleus accumbens shell (NAc) was measured by microdialysis. Peripheral administration of ghrelin decreased dopamine levels in the NAc when food was removed following ghrelin administration. This inhibitory effect was mediated through GABA(A) and N-methyl-D-aspartate (NMDA) receptors in the VTA. In contrast, when animals consumed food following ghrelin administration, dopamine levels increased robustly. This stimulatory effect was mediated through NMDA receptors, but not through GABA(A) receptors, in the VTA. Importantly, both the inhibitory and stimulatory effects of ghrelin primarily required activation of GHSRs in the VTA. Furthermore, local injection of ghrelin into the VTA induced dopamine release in the NAc and food consumption, supporting the local action of ghrelin in the VTA. In conclusion, peripherally administered ghrelin activates GHSRs in the VTA, and induces bimodal effects on mesolimbic dopamine neurotransmission depending on food-consumptive states.

Neurotensin inhibition of GABAergic transmission via mGluR-induced endocannabinoid signalling in rat periaqueductal grey.

Neurotensin modulates pain via its actions within descending analgesic pathways which include brain regions such as the midbrain periaqueductal grey (PAG). The aim of this study was to examine the cellular actions of neurotensin on PAG neurons. Whole cell patch clamp recordings were made from rat midbrain PAG slices in vitro to examine the postsynaptic effects of neurotensin and its effects on GABA(A) mediated inhibitory postsynaptic currents (IPSCs). Neurotensin (100-300 nM) produced an inward current in subpopulations of opioid sensitive and insensitive PAG neurons which did not reverse over membrane potentials between -50 and -130 mV. The neurotensin induced current was abolished by the NTS1 and NTS1/2 antagonists SR48692 (300 nM) and SR142948A (300 nM). Neurotensin also produced a reduction in the amplitude of evoked IPSCs, but had no effect on the rate and amplitude of TTX-resistant miniature IPSCs. The neurotensin induced inhibition of evoked IPSCs was reduced by the mGluR5 antagonist MPEP (5microM) and abolished by the cannabinoid CB(1) receptor antagonist AM251 (3 microM). These results suggest that neurotensin produces direct neuronal depolarisation via NTS1 receptors and inhibits GABAergic synaptic transmission within the PAG. The inhibition of synaptic transmission is mediated by neuronal excitation and action potential dependent release of glutamate, leading to mGluR5 mediated production of endocannabinoids which activate presynaptic CB(1) receptors. Thus, neurotensin has cellular actions within the PAG which are consistent with both algesic and analgesic activity, some of which are mediated via the endocannabinoid system.

Protein crystallization in a 100 nl solution with new stirring equipment.

To investigate quantitatively the effects of stirring on protein crystallization, a new stirring system which can agitate a protein solution, approximately 100 nl, by providing Hagen-Poiseuille flow has been successfully developed. In addition, this new stirring system provides flow with a well defined pattern and velocity. Using this system, hen egg-white lysozyme was crystallized in 100-200 nl solutions while being stirred. The optimum stirring conditions for lysozyme crystals have been explored by evaluating the Reynolds (Re) number and the crystals obtained. Intermittent flow, as well as a low Re number, was found to contribute significantly to the growth of a smaller number of larger crystals.

Cross sections for electron impact excitation of the vibrationally resolved A 1Pi electronic state of carbon monoxide.

The authors report new differential cross section measurements for electron impact excitation of the A (1)Pi(v(')) states of carbon monoxide. The energy range is 20-200 eV. They also reanalyze the A (1)Pi(v(')) manifold cross sections of Middleton et al. [J. Phys. B 26, 1743 (1993)] in order to provide a basis for comparison with our new vibrationally resolved differential cross sections. Excellent agreement is found between the two sets of measurements at all common energies. From 20 to 200 eV the present differential cross sections are extrapolated and integrated, and the corresponding integral excitation cross sections determined. New scaled Born integral cross sections, calculated as a part of the present study, are compared against these experimental integral cross sections, with excellent agreement being found for all the A (1)Pi(v(')=0-7)<--X (1)Sigma(g) (+)(v(")=0) transitions. In addition our scaled Born integral cross sections are found to be in excellent agreement between 300 and 1500 eV with those derived from the previous experiments of Lassettre and Skerbele [J. Chem. Phys. 54, 1597 (1971)] and of Zhong et al. [Phys. Rev. A 55, 1799 (1997)] and from near threshold to 15 eV with those derived from Zobel et al. [J. Phys. B 29, 813 (1996)] and Zetner et al. (J. Phys. B 31, 2395 (1998)].

Electron microscopic investigation on the osteogenesis at titanium implant/bone marrow interface under masticatory loading.

Electron microscopic investigation on osteogenetic process at the implant surface of threadless rod-type titanium implants with different surface roughness of Ra 0.4 +/- 0.01 microm, Sm 2.6 +/- 0.3 microm and Ra 2.0 +/- 0.12 microm, Sm 36 +/- 9.1 microm was performed at the early stage of 21 and 42 days post implantation into the jawbones of four beagles under the load bearing condition of functional mastication. The implant surfaces were covered with a blood clot and haematopoietic stem cells (HSC) including phagocytic monocytes immediately after the implantation. Successively, osteogenic stem cells (OSC) migrated from cortical and/or trabecular endosteum to the HSC-layer on the implant surface. The new bone formation at the implant/bone marrow interface was developed by collaboration of osteomediator cells (OMC) differentiated from monocytes of HSC and osteoblast phenotype cells of OSC derived from endosteum of cortical bone and/or trabecular. The new bone layer at the implant surface consisted of two layers, solution-mediated calcification layer of pseudo bone and cell (osteoblast) -mediated calcification layer of true bone. The pseudo bone was produced by solution-mediated calcification of OMC- and HSC-remnants near by the implant surface. The bone healing process at the implant/bone marrow interface depended upon two factors; the migration of OSC from cortical and/or trabecular endosteum to the implant surface and the healing potentiality. Topographic dependency upon the bone healing potential at implant/bone marrow interface was not confirmed in this experiment under the load bearing condition of functional mastication.

No evidence to indicate topographic dependency on bone formation around cp titanium implants under masticatory loading.

In vitro studies have proved the topographic dependency upon osteogenesis on titanium plate by investigating the cell-adhesion, -shape, -proliferation, -differentiation, ALP activity and osteocalcin production of osteogenic stem cells, MG36, MC3T3-E1 and wild strains of bone formative cells from animal and human. However, this in vivo study on bone growth around cp titanium dental implants under masticatory loading did not demonstrate significant difference among the different surface roughness in the range of Ra 0.4-1.9 microm, Rz 2.8-11.2 microm, Rmax 3.6-28.1 microm and Sm 2.9-41.0 microm, which was estimated by measuring the bone contacts, bone occupancies and bone bonding strengths at the implant/bone marrow interface. It is revealed that the topographic dependency on the osteogenetic activity is apt to be covered with wide variation in bone healing potential under the clinical condition with functional biting load.

Knocking out ubiquitin proteasome system function in vivo and in vitro with genetically encodable tandem ubiquitin.

At present, the 26S proteasome-specific inhibitor is not available. We constructed polyubiquitin derivatives that contained a tandem repeat of ubiquitins and were insensitive to ubiquitin hydrolases. When these artificial polyubiquitins (tUbs, tandem ubiquitins) were overproduced in the wild-type yeast strain, growth was strongly inhibited, probably because of inhibition of the 26S proteasome. We also found that several substrates of the ubiquitin-proteasome pathway were stabilized by expressing tUbs in vivo. tUbs containing four units or more of the ubiquitin monomer were found to form a complex with the 26S proteasome. We showed that tUb bound to the 26S proteasome inhibited the in vitro degradation of polyubiquitinylated Sic1 by the 26S proteasome. When tUB6 (six-mer) messenger RNA was injected into Xenopus embryos, cell division was inhibited, suggesting that tUb can be used as a versatile inhibitor of the 26S proteasome.

Laparoscopic percutaneous extraperitoneal closure (LPEC) method for the exploration and treatment of inguinal hernia in girls.

We recently introduced the laparoscopic percutaneous extraperitoneal closure (LPEC) method for the treatment of girls with inguinal hernia. Using the LPEC method, 129 girls underwent laparoscopic herniorrhaphy. A 5 mm laparoscope was inserted via the umbilicus. A 3 mm "snake retractor" was advanced through the lateral abdominal wall to measure the length of the hernia sac and contralateral patent processus vaginalis (PPV), respectively. The hernia sac and PPV were closed at the level of the internal inguinal ring with a 2-0 non-absorbable purse-string suture using Lapaherclosure, a special 19G needle that can hold a suture at the tip. The length of the hernial sac was significantly longer than that of contralateral PPV (mean 41 mm; range 18-70 mm; P < 0.05). There were no serious complications associated with the procedure. No recurrence of hernia or metachronous contralateral hernia has been identified so far. This approach enables us to perform contralateral exploration without any additional techniques, followed by immediate and accurate closure of the hernia sac and PPV. We conclude that the LPEC method is a safe and efficacious procedure with a low recurrence rate that should be viewed as an acceptable alternative to the traditional open approach.

Clinical outcome of laparoscopically assisted endorectal pull-through in Hirschsprung's disease: comparison of abdominal and perineal approaches.

BACKGROUND/PURPOSE: Laparoscopically assisted endorectal pull-through (EPT) via a perineal approach using a prolapsing technique (PA) for Hirschsprung's disease (HD) has been reported. However, the clinical outcome after this approach has not been reported. The purpose of this study was to compare the clinical outcome of PA and the conventional transabdominal approach (TA). METHODS: In the period between 1990 and 2001, 20 cases of HD underwent EPT with TA (group O), and 21 underwent EPT with PA (group L). There was no difference in age and weight distribution between the 2 groups. Clinical outcome was assessed 3 years after surgery. RESULTS: The operation time was comparable in the 2 groups (4.9 +/- 0.8 v 5.2 +/- 0.8 hr), whereas blood loss (98 +/- 52 v 36 +/- 30 mL) and postoperative complications requiring surgical intervention (26% v 0%) were significantly lower in group L. The incidence of postoperative enteritis (27% v 28%) and voluntary defecation (more than once every/2 days) were compatible in the 2 groups (70% v 87%). Soiling (small amount of involuntary stooling; >1 per month) was significantly less frequent in group L (45% v 14%). CONCLUSIONS: Laparoscopically assisted ETP with PA is less invasive and can provide a better clinical outcome compared with TA in terms of postoperative soiling.

In vitro study on bone formation and surface topography from the standpoint of biomechanics.

Effect of surface topography upon cell-adhesion, -orientation and -differentiation was investigated by in vitro study on cellular responses to titanium substratum with different surface roughness. Cell-shape, -function and -differentiation depending upon the surface topography were clarified by use of bone formative group cells (BFGCs) derived from bone marrow of beagle's femur. BFGCs consisted of hematopoietic stem cells (HSC) and osteogenetic stem cells (OSC). Cell differentiation of BFGCs was expressed and promoted by structural changes of cytoskeleton, and cell-organella, which was caused by mechanical stress with cytoplasmic stretching of cell adhesions to the substratum. Phagocytic monocytes of HSC differentiated to osteomediator cells (OMC) by cytoplasmic stretching with cell adhesion to the substratum. The OMC mediated and promoted cell differentiation from OSC to osteoblast through osteoblastic phenotype cell (OBC) by cell-aggregation of nodules with "pile up" phenomenon of OBC onto OMC. The osteogenesis might be performed by coupling work of both cells, OMC originated from monocyte of HSC and OBC originated from OSC, which were explained by SEM, TEM and fluorescent probe investigation on BFGCs on the test plate of cp titanium plates with different topographies. This osteogenetic process was proved by investigating cell proliferation, DNA contents, cell-adhesion, alkaline phosphatase activity and osteocalcine productivity for cells on the titanium plates with different topographies. The study showed increased osteogenic effects for cells cultured on Ti with increased surface roughness. Possible mechanisms were discussed from a biomechanical perspective.

Endorectal pull-through with posterior sagittal approach to the repair of postoperative rectourethral and rectovaginal fistula.

BACKGROUND/PURPOSE: Rectourethral (RUF) or rectovaginal fistula (RVF) is a troublesome complication after anorectal surgery because of dense adhesions around the fistula. The authors applied a new technique for the redo surgery. METHODS: Case 1 is Hirschsprung's disease in a 1-year-old boy who underwent modified Duhamel's procedure and had RUF. Case 2 is rectovestibular fistula in an 11-year-old girl who had anterior sagittal anorectoplasty complicated by RVF. Case 3 is multiple urogenital anomalies including rectovesical fistula in a 4-year-old boy in whom transvesical repair was unsuccessful. The colon was mobilized as far as possible at laparotomy. The rectum was opened via a posterior sagittal approach leaving 1 cm of the anal canal. Extended endorectal mucosectomy was performed to the dentate line, and the fistula was closed from inside of the rectum. The remaining mucosal cuff was everted out of the anus and the intact colon was pulled through the rectum and anastomosed to the cuff extraanally. RESULTS: The postoperative contrast enema showed no recurrent fistula, and defecation was not impaired. CONCLUSIONS: Endorectal pull-through of the intact colon can spare troublesome mobilization of the fistula and can prevent the recurrence of fistula. Rectal incision via a posterior sagittal approach provides a direct view of the fistula.

Laparoscopic intervention for intrathoracic stomach in infants.

BACKGROUND: Intrathoracic stomach is an uncommon condition in infants. We report our experience managing such a condition successfully by laparoscopy in four patients. METHODS: Patients' ages at the time of operation ranged from 30 days to 14 months. In all cases, the intrathoracic stomach was easily pulled down into the abdominal cavity. The phrenoesophageal ligament was completely resected, and the enlarged hiatus was narrowed by intraabdominal suturing technique. The esophagus was wrapped with the mobilized fundus in a floppy fundoplication. Anchoring sutures were placed between the wrapping cuff and crura. RESULT: One patient had paraesophageal hernia (type 2), whereas the other had combined hiatal hernia (type 3). No adverse complications were observed in any of the cases. Symptomatic gastroesophageal reflux and radiographic recurrence of hernia were not seen in any case. The cosmesis was excellent in all cases. CONCLUSIONS: We conclude that laparoscopic repair for intrathoracic stomach is a safe and feasible method when preoperative evaluation is conducted adequately.