Alpha-Gal specific IgG immune response after implantation of bioprostheses.

BACKGROUND: We have previously shown that the alpha-Gal (Galalpha1.3-Galbeta1-4GlcNAc-R) epitope is a relevant xenoantigen present on bioprostheses utilized in cardiac surgery and elicits an alpha-Gal specific IgM immune response. We sought to investigate whether that immune response continues after valve implantation. MATERIALS AND METHODS: We collected plasma samples from patients who underwent bioprosthesis implantation (n = 19) or mechanical valve replacement (n = 8), respectively, prior to, at 10 days and at 3 months after cardiac surgery. ELISA was utilized to quantify alpha-Gal specific IgG and IgG subclasses. 3 bioprosthetic tissue samples were obtained from patients who had to undergo re-operation within 1 week (n = 1) or at 12-15 months (n = 2) after the initial operation. We utilized confocal laser scanning microscopy (CLSM) to detect the presence of alpha-Gal epitopes (IB4) and cell nuclei (DAPI). RESULTS: alpha-Gal specific IgG was significantly increased 3 months after implantation of bioprostheses compared to preoperative values (p < 0.001) and was significantly higher than alpha-Gal specific IgG levels of the control group (p < 0.05). IgG3 was the major subclass directed against alpha-Gal (p < 0.05, pre- vs. postoperative values). In CLSM analysis we demonstrated that bioprostheses explanted 1 week after implantation contained IB4/DAPI positive cells within the collagen matrix. In contrast, in patients who underwent reoperation after 12 months, porcine tissue showed a complete lack of IB4/DAPI. CONCLUSION: Our results indicate that the implantation of bioprostheses elicits a specific humoral immune response against alpha-Gal bearing cells compared to controls within 3 months after cardiac surgery. The complete absence of IB4/DAPI positive structures 12 months after implantation indicates a specific degradation of alpha-Gal bearing cells through previous exposure to the human blood circuit.

Selective downregulation of VEGF-A(165), VEGF-R(1), and decreased capillary density in patients with dilative but not ischemic cardiomyopathy.

Cardiomyopathy (CM) comprises a heterogeneous group of diseases, including ischemic (ICM) and dilative (DCM) forms. The pathogenesis of primary DCM is not clearly understood. Recent studies in mice show that vascular endothelial growth factor (VEGF) is involved in ICM. Whether VEGF plays a role in human CM is unknown. We examined the mRNA and protein expression of VEGF and its receptors in hearts of patients with end-stage DCM and ICM and in healthy individuals using real-time polymerase chain reaction and Western blotting. Number of capillaries, area of myocytes, and collagen were calculated in cardiac biopsies using transmission electron microscopy. In DCM, except for VEGF-C, mRNA transcript levels of VEGF-A(165), VEGF-A(189), and VEGF-B and the protein level of VEGF-A and VEGF-R(1) were downregulated compared with controls (P:<0.05). However, in ICM, mRNA transcript levels of VEGF isoforms and protein levels of VEGF-C were upregulated. The vascular density was decreased in DCM but increased in ICM compared with controls (P:<0. 05). Muscular hypertrophy was not different for ICM and DCM, although DCM had more collagen (P:<0.05). Blunted VEGF-A and VEGF-R(1) protein expression and downregulated mRNA of the predominant isoform of VEGF-A, VEGF-A(165), to our knowledge shown here for the first time, provide evidence that the VEGF-A defect in DCM is located upstream. Whether downregulation of certain VEGF isoforms in DCM is a cause or consequence of this disorder remains unclear, although upregulated VEGF levels in ICM are most likely the result of ischemia.

Impact of cardiac transplantation on molecular pathology of ET-1, VEGF-C, and mitochondrial metabolism and morphology in dilated versus ischemic cardiomyopathic patients.

Little is known about the long-term impact of cardiac transplantation on activity and modifications of endothelin (ET)-1 system, vascular endothelial growth factor (VEGF), and mitochondrial metabolism and morphology in patients with ischemic cardiomyopathy (ICM) versus dilated cardiomyopathy (DCM). Messenger RNA (mRNA) expression levels of ET-1, endothelin converting enzyme (ECE)-1, VEGF-C, carnitine palmitoyltransferase (CPT)-1, and carnitine acetyltransferase (CARAT), as well as the number of normal, edematous, and degenerated mitochondria were assessed in left ventricular biopsies of 21 patients with DCM and 20 with ICM (New York Heart Association class III-IV) before and up to 3 months after cardiac transplantation. Cardiac samples of donated, nonfailing hearts served as controls (n=10). In cardiac biopsies of both ICM and DCM patients, ET-1, VEGF-C, CPT-1, and CARAT mRNA were up-regulated, whereas ECE-1 mRNA was down-regulated (P<0.05). Degenerated mitochondria had the highest number in both groups, followed by normal and edematous mitochondria. After cardiac transplantation, in ICM patients impaired gene expression levels decreased to, or below, normal levels, and the number of normal mitochondria increased (P<0.05). In implanted hearts of DCM patients, however, up-regulated ET-1 transcript levels persisted and the number of normal mitochondria decreased, whereas the number of degenerated mitochondria increased (P<0.05), and edematous mitochondria remained unchanged in number. These results show that cardiac transplantation corrects the impaired hemodynamic and echocardiographic parameters in both groups, whereas in DCM, the molecular pathology of ET-1 system and mitochondria persists. Therefore, it is more likely that these changes are the cause rather than a consequence of DCM.

Number and distribution of neuromuscular spindles in human extraocular muscles.

PURPOSE: To examine the number and distribution of muscle spindles in all extraocular muscles (EOMs) in humans. METHODS: Thirty-six EOMs were obtained after death from three persons 67, 72, and 83 years of age. Serial sections were made throughout the length of these muscles. Consecutive sections were stained with different methods. To discriminate true spindles from false spindles, light microscopic criteria were defined and were subject to ultrastructural investigation. A distal portion of a single EOM was gained from a multiorgan donor 17 years of age, processed for electron microscopy, and analyzed. RESULTS: Spindles were observed in all muscles studied, with the medial rectus exhibiting a mean of 18.8 spindles +/- 3.0 (+/- standard deviation), the lateral rectus 19.3 +/- 1.9, the superior rectus 15.8 +/- 2.5, the inferior rectus 34.0 +/- 4.4, , the superior oblique 27.3 +/- 8.2, and the inferior oblique 4.3 +/- 1.8 per muscle [corrected]. For each different human EOM, a typical distribution of spindles was observed in the persons examined. The ultrastructural investigation revealed sensory endings in structures primarily identified as spindles. CONCLUSIONS: By comparing 1 g of tissue, spindles are found to be at least as frequent in human EOM as in skeletal muscles known to have a high density of spindles. This fact and the peculiar distribution of spindles in human EOMs suggest that spindles are functionally important proprioceptors in EOM.

Innervated myotendinous cylinders in human extraocular muscles.

PURPOSE: To analyze palisade endings and their end organs, the so-called innervated myotendinous cylinders (IMCs), of human extraocular muscle (EOM) in more detail and to clarify with the help of double-fluorescent labeling and electron microscopy whether terminals in IMCs are sensory, serving proprioception. METHODS: EOMs obtained from a donated cadaver (66 years) and distal parts of EOMs from multiorgan donors (35, 53 years) were processed for double-fluorescent labeling. Antibodies against the protein gene product 9.5 and alpha-bungarotoxin labeling were used on cryostat sections of distal myotendons. EOMs from multiorgan donors (2, 17 years) were prepared for electron microscopy. RESULTS: Palisade endings investing muscle fiber tips established contacts with tendon fibrils and the muscle fiber attached. Alpha-bungarotoxin bound to myoneural contacts but not to axonal varicosities in the tendon compartment. Ultrastructural analysis revealed that palisade endings form IMCs, which were associated exclusively with multiply innervated global layer muscle fibers. IMCs consisted of a muscle fiber tendon junction, tightly enclosed by fibrocytes, and a supplying axon with preterminals and terminals. Terminals contained mitochondria, few neurotubuli, few neurofilaments, and accumulations of clear vesicles of uniform size. A basal lamina always intervened between axolemma and tendon fibrils as well as between axolemma and muscle fiber cell membrane. CONCLUSIONS: Palisade endings of human EOM form IMCs as in cat, monkey, and sheep. In contrast to animals, myoneural contacts in human IMCs are almost certainly motor, whereas terminals contacting tendon fibrils are arguably sensory. Thus, IMCs might be best described as "propriocept-effectors."

Muscle fiber types of human extraocular muscles: a histochemical and immunohistochemical study.

PURPOSE: To classify muscle fibers of human extraocular muscle (hEOM) and to compare them to previous studies on hEOM, as well as to nonhuman EOM classification schemes and skeletal muscle fiber types. METHODS: Muscle fibers cut in different muscle planes were followed on consecutive cross sections and typed with regard to their oxidative profile in combination with their myosin-immunohistochemical characteristics. RESULTS: Three zones were observed. In the global layer three muscle fiber types were observed: global layer singly innervated granular fibers, 79.4 +/- 8.1 microm (perimeter [values at midmuscle region] +/- SD); 59%; global layer singly innervated coarse fibers (80.3 +/- 10.8 microm; 21%); and global layer multiply innervated muscle fibers (4.1 +/- 9.7 microm; 21%). Two muscle fiber types were detected in the orbital layer: orbital layer singly innervated muscle fibers (54.1 +/- 8.5 microm; 83%) and orbital layer multiply innervated muscle fibers (53.5 +/- 7.6 microm; 17%). Three muscle fiber types were differed in the marginal zone: marginal zone singly innervated muscle fibers (83.1 +/- 15.8 microm; 56%), marginal zone multiply innervated low oxidative muscle fibers (84.4 +/- 23.3 microm; 7%), and marginal zone multiply innervated high oxidative muscle fibers (88.4 +/- 14.5 microm; 37%). Coexpressions of developmental myosin heavy chain isoforms and fast myosin heavy chain isoform were detected mainly in the marginal zone. CONCLUSIONS: hEOMs resemble mammalian EOM with regard to their organization. However, in addition to an inner global layer and an orbital layer an external marginal zone was described for the first time in hEOM in the present study.

Fine structural analysis of extraocular muscle spindles of a two-year-old human infant.

PURPOSE: To clarify whether structural peculiarities formerly described in extraocular muscle (EOM) spindles of aged persons are already present in EOM spindles of a 2-year-old infant. METHODS: Distal halves of two EOMs obtained from a 2-year-old multiorgan donor were immersion-fixed and prepared for electron microscopy. The fine structure of 10 muscle spindles and of 1 "false spindle" was investigated. RESULTS: Extraocular muscle spindles of an infant 2 years of age had 2- to 4-layered outer capsules, 376 microm (range, 217-606 microm) long and 97 microm (range, 55-140 microm) wide. In 10 EOM spindles, 4 to 16 intrafusal muscle fibers (mean, 7.9) were present. From a total of 79 intrafusal fibers, 43 (54%) were nuclear chain fibers, and 8 of the 43 exhibited posttraumatic degenerative changes. Thirty-six (46%) intrafusal fibers indistinguishable from extrafusal fibers were called anomalous fibers. No nuclear bag fibers were found. Each muscle spindle contained a variable number of chain fibers and at least one anomalous fiber. Sensory nerve terminals were restricted to the 35 normal chain fibers but were absent from damaged chain fibers and from anomalous fibers. One "false spindle" without a periaxial space was composed of three anomalous fibers and one chain fiber, all of them devoid of sensory terminals. CONCLUSIONS: Most structural particularities of human EOM spindles described in aged persons are already found in the infant. They cannot be interpreted as age-related changes, but rather they represent specific features of human EOM spindles.

Number, distribution, and morphologic particularities of encapsulated proprioceptors in pig extraocular muscles.

PURPOSE: To analyze qualitatively and quantitatively the total complement of encapsulated proprioceptors (Golgi tendon organs [GTOs] and neuromuscular spindles) in pig extraocular muscles (EOMs). METHODS: EOMs of four pigs of different ages were prepared for light microscopic histochemical and immunohistochemical analysis and for transmission electron microscopy. RESULTS: GTOs and muscle spindles were numerous in pig EOMs. GTOs were found to be distributed in aponeurotic expansions of the distal and proximal EOM tendons, being more numerous in the distal aponeurosis than in the proximal aponeurosis. The total number of GTOs was higher in the recti EOMs (100-128) than in the oblique EOMs (45-61). Spindles were distributed over the entire muscle length. In each EOM the number of muscle spindles (142-333) exceeded those of GTOs. The morphology of the GTOs was variable. In addition to collagen bundles, approximately one third of the GTOs contained intracapsular muscle fibers that resembled the multiply innervated fiber type. Intracapsular muscle fibers entered the poles of the GTOs and either terminated inside the receptors in collagen bundles or exited the GTOs at the opposite poles. Nerve terminals were numerous in each GTO and established intimate contacts with collagen fibrils. CONCLUSIONS: Most structural particularities formerly observed in GTOs of rhesus monkey and sheep EOMs are also present in GTOs of pig EOMs. The high number of GTOs with their typical nerve terminals indicates functional importance. During muscle activity, afferent signals from GTOs and muscle spindles may provide sufficient information about eye position.

Presence and structure of innervated myotendinous cylinders in sheep extraocular muscle.

Innervated myotendinous cylinders (IMCs) were for the first time described in a sheep extraocular muscle (EOMs). They were found at the distal myotendinous junction of a medial rectus and were investigated by light and transmission electron microscopy. The IMCs are enveloped by a multi-layered capsule of fibrocytes and each contains the terminal portion of one multiply-innervated muscle fibre and its corresponding tendon. The tendinous compartment of the IMC is entered by a single nerve fibre which, inside, spreads into several terminal branches. Numerous terminal branches were found among the collagen fibrils but few on the muscle fibre tips. Nerve terminals contain mitochondria and are full of clear vesicles. Within the nerve terminals, vesicles are often concentrated in an area where the axolemma exhibits dense patches. Innervated myotendinous cylinders of sheep EOMs exhibit the same ultrastructural features as those earlier described as palisade endings or myotendinous cylinders in cat, monkey and man.

Multivitamin administration before ischemia reduces ischemia-reperfusion injury in rabbit skeletal muscle.

This study investigated the effect of a multivitamin preparation administered before ischemia or before reperfusion, on ischemia-reperfusion (I/R) injury of skeletal muscle. An in vivo hindlimb skeletal muscle I/R model (2.5 h/2 h) was carried out on adult New Zealand white rabbits. Animals used as I/R models were treated with a multivitamin preparation (0.4 ml/kg bw i.v. bolus), containing alpha-tocopherol, ascorbic acid, retinol, vitamin B complex, 30 min before starting ischemia (group MV(isc)) or 5 min before reperfusion (group MV(rep)) and compared to animals with I/R without treatment (group IR) and sham operated animals (group SHAM). Interstitial edema (muscle interfiber area, %MIFA) and changes in microvessel size (microvessel cross sectional area, MVCSA, microm(2)) were measured. Plasma malondialdehyde concentrations (MDA-TBA, nmol/ml) served as a measure of lipid peroxidation. After 2h of reperfusion, ischemia-reperfusion developed a significant microvascular constriction and an interstitial edema (IR, vs SHAM;P<< 0.01), but administration of antioxidative vitamins before the onset of ischemia reduced microvascular constriction and edema formation (P<< 0.05 vs IR group). In a similar manner, administration of vitamins before ischemia lowered plasma MDA-TBA levels as compared to the untreated group during reperfusion (p<< 0. 05). In animals treated with vitamins before reperfusion, the biochemical and morphological results showed no differences as compared to the untreated group. Antioxidative treatment with a multivitamin preparation exerted a beneficial effect on I/R injury of skeletal muscle when the aforementioned vitamins were administered before ischemia but not before the onset of reperfusion.

Sensory control of extraocular muscles.

The role of sensory receptors in eye muscles is not well understood, but there is physiological and clinical evidence for the presence of proprioceptive signals in many areas of the central nervous system. It is unclear which structures generate these sensory signals, and which central neural pathways are involved. Three different types of receptors are associated with eye muscles: (1) muscle spindles, (2) palisade endings, and (3) Golgi tendon organs, but their occurrence varies wildly between species. A review of their organization shows that each receptor is mainly confined to a morphologically separate layer of the eye muscle. The palisade endings - which are unique to eye muscles, are associated with the global layer; and they have been found in all mammals studied so far. Their function is unknown. The muscle spindles, if they are present in a species, lie in the orbital layer, or at its junction to the global layer. Golgi tendon organs appear to be unique to artiodactyls (i.e., sheep and goats, etc.); they lie in an outer distal marginal layer of the eye muscle, called the "peripheral patch layer" in sheep. The specific association between palisade endings and the multiply innervated type of muscle fibers of the global layer has led to the hypothesis that together they may act as a sensory receptor, and provide a source of central proprioceptive signals. But other interpretations of the morphological evidence do not support this role.

Alpha-Gal on bioprostheses: xenograft immune response in cardiac surgery.

BACKGROUND: The alpha-Gal (Galalpha1,3-Galbeta1-4GlcNAc-R) epitope is the major xenoantigen causing hyperacute rejection of pig organs transplanted into primates. Porcine bioprostheses are utilized in cardiac surgery. However, premature degeneration of bioprostheses has limited utilization in younger patients and the immune response remains elusive. We sought to investigate whether a specific alpha-Gal immune response may play a role in this clinical scenario. MATERIALS AND METHODS: We investigated the presence of alpha-Gal-epitope on native and fixed porcine valves by means of confocal laser scanning microscope (CLSM). ELISA was utilized to evidence whether implantation of bioprostheses elicits augmentation of pre-existing cytotoxic anti alpha-Gal IgM antibodies within 10 days of surgery. Patients who underwent coronary artery bypass grafting (CABG) or mechanical valve replacement served as controls (each group, n = 12). To corroborate the clinical relevance of the alpha-Gal immune response in vivo, we studied serum obtained before and after implantation of bioprostheses and its potency to lyse porcine alpha-Gal-bearing PK15 cells. RESULTS: We found the immunogenic alpha-Gal-epitope on fibrocytes interspersed in the connective tissue of porcine valves as determined by vimentin/IB4 lectin binding. Moreover, patients who were provided with a bioprostheses had developed a significant increase of naturally occurring cytotoxic IgM antibodies directed towards alpha-Gal after surgical intervention as compared with control patients (P < 0.0001, respectively). Sera obtained from the patients after the implantation of bioprostheses demonstrated an increased cytotoxicity against alpha-Gal-bearing PK-15 cells as compared with preoperative sera (P < 0.001). The specificity of the cytotoxic effects was proven as soluble Galalpha1-3Galbeta1-4GlcNAc markedly inhibited cell death of alpha-Gal-bearing PK15 cells (P < 0.001). CONCLUSION: Our data suggest that implantation of bioprostheses in cardiac surgery induces a xenograft-specific immune response. Procedures diminishing the presence of alpha-Gal on bioprostheses, such as utilization of genetically manipulated alpha-Gal-deficient xenograft or pretreatment with alpha-Galactosidase, might diminuate the immune response against bioprostheses and extend durability.

Presence and morphological variability of Golgi tendon organs in the distal portion of sheep extraocular muscle.

This study was undertaken to demonstrate the presence of Golgi tendon organs (GTOs) in the distal portion of sheep extraocular muscle (EOM) and to describe the morphological variability of these receptors. Extraocular muscles of a young and an old sheep were perfusion fixed and/or immersion fixed. Tissue was prepared for light microscopy and transmission electron microscopy. Immunohistochemistry was done to demonstrate the myosin pattern of the intracapsular muscle fibers of the GTOs. All GTOs in the distal portions of the sheep EOMs were located in a distinct muscle layer which was designated in a former investigation as the so-called peripheral patch layer. Each EOM of the young sheep contained GTOs; between four and 15 GTOs were counted in the rectus EOMs. Eight GTOs were found in the superior rectus of the old sheep. Golgi tendon organs in EOMs of the young and the old sheep did not differ in their morphology. In the young sheep the mean length of the GTOs was 447 +/- 132 microm (n = 60) and their mean width 101 +/- 26 microm (n = 60). In the old sheep values were 576 +/- 188 microm (mean length, n = 8) and 103 +/- 18 microm (mean width, n = 8). The GTOs were encapsulated by perineurial cells. In 12 GTOs, only collagen bundles were inside. In the remaining GTOs (56), intracapsular muscle fibers were present. Muscle fibers entered the proximal poles of the GTOs and either terminated inside the receptors or muscle fibers left the GTOs at their distal poles. These intracapsular muscle fibers were of the multiply-innervated type. In the GTOs variably shaped nerve terminals were found which contained a high number of mitochondria. In two GTOs, additionally, nerve terminals with aggregates of densely packed vesicles were present.

Presence and structure of innervated myotendinous cylinders in rabbit extraocular muscle.

Innervated myotendinous cylinders (IMCs) in rabbit extraocular muscles (EOMs) were identified for the first time. The nature of IMC nerve terminals was demonstrated by means of electron microscopy and double fluorescent staining. The distal EOM portions of four rabbits of different age and sex were prepared for transmission electron microscopy and for double-fluorescent labelling. Antibody against neurofilament H and alpha-bungarotoxin were applied on longitudinal cryostat sections of distal myotendinous junction. IMCs were consistently and frequently observed at the distal myotendons of each EOM. More than 30 IMCs were counted in two medial recti of a 6 month and 3 year old rabbit. IMCs were enveloped by two to three layered capsules of fibrocytes. Each IMC contained the terminal portion of one multiply-innervated muscle fibre and its corresponding tendon. The tendon compartment of an IMC was entered by a single myelinated nerve fibre (2-3 microm in diameter). Inside the IMC, this nerve fibre ramified into up to four preterminal branches. Nerve terminals exclusively established contacts with the muscle fibre at its junction with the tendon fibrils. Nerve terminals contained mitochondria and a multitude of clear vesicles. Within the synaptic cleft a basal lamina was always present. alpha-Bungarotoxin labelled the muscle side of these myoneural contacts. Nerve terminals exhibited neither age nor sex differences. Among all species so far investigated, rabbit IMCs are unique by exhibiting exclusively myoneural terminal contacts. Based on fine structure and alpha-bungarotoxin binding, myoneural contacts in rabbit IMCs are almost certainly motor, as previously observed only in human IMCs. Thus, rabbit IMCs are supposed to have a predominant effector function.

[Proprioception of extra-ocular muscles in the human: on the morphology of muscle spindles]. / Propriozeption aus äusseren Augenmuskeln des Menschen: Zur Morphologie ihrer Muskelspindeln.

BACKGROUND: Increasing importance is attributed to the proprioceptive innervation of extraocular muscles for the development of binocular vision. In the literature, data on proprioceptors in human extraocular muscles are rare and inconsistent. Therefore a detailed morphological analysis of spindles in human extraocular muscles appeared indicated. MATERIAL AND METHODS: Complete serial sections of all extraocular muscles of 3 human individuals, 67, 72, and 83 years of age, were alternately impregnated with silver, stained following Mowry and immunohistochemically stained for S100 or PGP 9.5. Distal parts of extraocular muscles from multiorgan donors, 2, 17, and 34 years of age, were prepared for electron microscopy. RESULTS: Spindles contained 1 to 18 intrafusal muscle fibers, 55% of which were nuclear chain fibers, 2% nuclear bag fibers, and 43% fibers exhibiting the same morphological features as extrafusal fibers. The latter had been previously described as "anomalous fibers" (Ruskell). This intrafusal type exclusively occurs in human extraocular muscle spindles. Ultrastructural analysis revealed morphologically normal sensory terminals on all 3 types of intrafusal fibers. Findings in a two-year-old individual were similar to those in aged individuals. CONCLUSIONS: Spindles in human extraocular muscles are specifically structured. Their special morphological features are also present during the development of binocular vision. Spindles are supposed to play a role in the (fine) control of eye movements.

Development of 'no-reflow' phenomenon in ischemia/reperfusion injury: failure of active vasomotility and not simply passive vasoconstriction.

BACKGROUND/AIM: Local blood flow failure (no-reflow phenomenon) during ischemia/reperfusion (I/R) injury may be mediated by interstitial edema formation (passive vasoconstriction) and/or microvascular spasm (active vasoconstriction). The development of the no-reflow phenomenon in the rabbit hind limb I/R model and the influence of treatment with L-arginine and/or antioxidative vitamins were investigated. METHODS: Untreated rabbits were compared with those treated with L-arginine (4 mg/kg/min) or antioxidative vitamins (0.4 ml/kg) alone or in combination during hind limb I/R (2.5/2 h). Interstitial edema formation and microvessel diameter alterations were measured morphometrically. Capillary blood perfusion was measured continuously with laser Doppler flowmetry. RESULTS: I/R injury was expressed by interstitial edema formation (interstitial space increase by 80%), microvascular constriction (microvessel cross-sectional area decrease by 30%), and development of no-reflow phenomenon (blood flow reduction by 60%). Treatment with antioxidative vitamins alone or L-arginine alone reduced interstitial edema by 22 and 31%, consequently, while combined L-arginine/antioxidative vitamin treatment showed a more pronounced edema reduction by 40%. Treatment with only antioxidative vitamins failed to influence the development of no-reflow, although interstitial edema formation was reduced. L-Arginine treatment alone or in combination with antioxidative vitamins prevented microvascular constriction and preserved blood flow after reperfusion without development of no-reflow despite still apparent interstitial edema. CONCLUSIONS: Affections of active vasomotility and not merely passive changes of external pressure (i.e., interstitial edema formation) should be considered important in the development of microvascular constriction during 'no-reflow' phenomenon.

Comparison between umbilical and transverse right upper abdominal incision for pyloromyotomy.

BACKGROUND: Besides laparoscopic pyloromyotomy, the operation for pyloric stenosis has been performed using 2 standard open surgical exposures: the right upper quadrant (RUQ) incision and the semi-circumumbilical (UMB) incision. The aim of this study was to compare the morbidity and cosmetic results of both open exposures. METHODS: Between 1990 and 1995, we performed 104 pyloromyotomies through a RUQ incision. These operations were retrospectively compared with 133 UMB incisions performed between 1995 and 1999. RESULTS: There were no significant differences between the 2 groups regarding age at presentation, sex, and preoperative status. Only a significantly higher percentage of patients with a metabolic alkalosis before surgery was found in the UMB group, but this did not affect morbidity rate. The groups did not differ significantly with respect to mucosal perforations (P =.95), wound infections (P =.53), inadequate pyloromyotomies (P =.42), or other complications. The mean operating time was slightly longer in the UMB group (P <.025). The UMB approach produced a better cosmetic result, with an almost invisible scar. CONCLUSIONS: This study has shown that the UMB approach has equal intra- and postoperative complication rates as compared with the RUQ approach. The main advantage of the UMB approach is that it produces an excellent long-term cosmetic result.