Acute rejection of porcine small bowel allograft. An extended histological scoring system.

Using nonimmunosuppressed piglet small bowel grafts, we performed a detailed histological study on acute rejection and analyzed altogether 45 different histological parameters throughout the bowel wall, in 10 allografts and 6 autografts. Heterotopic grafts were followed by full-thickness biopsies every other day beginning on the 3rd day after transplantation. The parameters were scored from 0 to 3 according to the severity of the change and the values of every variable were compared statistically between the 2 groups. The earliest significant changes, beginning on days 3-5, were infiltration of inflammatory cells and pyroninophilia among these cells in lamina propria; edema, fibrosis, and inflammation in submucosa and muscularis; vacuolar degeneration of myocytes; and endothelial and intimal changes in vessels. Villous blunting and cuboidal epithelium were the other early markers. On day 7, the epithelial and vascular changes became most significant. We want to emphasize especially the vascular parameters: endothelial swelling and proliferation, intimal thickening, intramural inflammation, and obliteration of the lumen. The dilatation of lymph vessels and changes of Peyer's patches had no value in the estimation of rejection. All allografts became necrotic by day 11 after transplantation.

Stapled vs hand-sutured ileoanal anastomosis in restorative proctocolectomy. A prospective, randomized study.

A prospective, randomized study of hand-sutured (group 1, n = 19) and double-stapled (group 2, n = 21) ileoanal anastomosis was carried out in 40 consecutive patients during restorative proctocolectomy to compare complications and functional outcome. Eight patients (42%) in group 1 and 12 (57%) in group 2 had one or more complications. Four patients in group 1 and five in group 2 developed pelvic sepsis. One stapled anastomosis had to be converted to a hand-sutured one because of severe anastomotic stricture. Four patients in group 1 and eight in group 2 had no nighttime evacuations 3 months after surgery and seven patients in group 1 and 11 in group 2 had no nighttime evacuations six months after surgery. Mucous leakage occurred in two vs five patients after 6 months in groups 1 and 2, respectively. The mean resting anal pressure decreased 30% in group 1 and 28% in group 2. In conclusion, double-stapled ileoanal anastomosis does not offer any functional or technical advantage over hand-sutured anastomosis, but it does leave some of the disease behind.

Development and characterization of aqueous amylose-rich maize starch dispersion for film formation.

Development and characterization of amylose-rich starch dispersion for film forming was performed. The influence of dispersion preparation temperature on amylose-rich maize starch (Hylon VII) film formation, and the physical properties of the films were investigated. The film-forming ability of the dispersions was evaluated with free films plasticized with glycerol and sorbitol, and the films were prepared at an elevated temperature (70 degrees C) by a casting technique. The solid-state and particle properties of dispersions were investigated by means of X-ray diffraction (XRD), Fourier transform near infrared (FT-NIR) spectroscopy and laser diffraction particle size analysis. Free films were characterized with respect to their appearance, by FT-NIR spectroscopy, and by XRD. Mechanical stress-strain properties were also studied. Increasing the temperature of dispersion preparation results in higher crystallinity, thus affecting the film forming ability. Mechanically strong and elastic films can be formed from amylose-rich starch dispersion formed at 40 degrees C. The more crystalline precipitate complex (obtained at 80 degrees C) and the entirely amorphous gel (obtained at 10 degrees C) formed non-continuous and cloudy films. The better film-forming properties of the dispersion formed at 40 degrees C are probably due to the highly amorphous structure and smaller particle size. The study shows the possibility of using ambient tempered amylose-starch dispersion for film forming.

Characterization of microcrystalline cellulose and silicified microcrystalline cellulose wet masses using a powder rheometer.

A powder rheometer has been used to study the properties of wet powder masses and the results have been compared to the mixer torque rheometer (MTR). Two different microcrystalline cellulose (MCC) grades (Avicel and Emcocel) and silicified microcrystalline cellulose (SMCC, Prosolv) were used as model powders. The wet massing behaviour of one material (Prosolv) was studied by the powder rheometer using liquid addition experiments, while the rheological properties of wet granules were studied using both the powder rheometer and the MTR. In water addition measurements the torque behaved in a similar way to MTR measurements and the maximum value of ZTL (zero torque limit) was achieved at the capillary state of wet mass. The wet granules exhibited different behaviour in the powder rheometer and the MTR experiments, which indicates that these rheometers involve different shear forces or they measure different properties of the wet granules. Emcocel wet masses achieved the capillary state at lower liquid amount than Avicel and Prosolv masses, which indicates that Emcocel is not able to hold as much water in the internal structure as Avicel and Prosolv. The powder rheometer proved to be a sensitive piece of equipment, which can be used to study both dry and wet powder masses. It was able to distinguish wet granules from wet powder masses after liquid addition, whereas the MTR could not. However, before the powder rheometer can be properly utilised in wet powder mass studies, the problem of torque overload requires resolution.

Rheological characterization of microcrystalline cellulose and silicified microcrystalline cellulose wet masses using a mixer torque rheometer.

The rheological properties of silicified microcrystalline cellulose (Prosolv 50) were compared with those of standard grades of microcrystalline cellulose (Emcocel 50 and Avicel PH 101). Cellulose samples were analyzed using nitrogen adsorption together with particle size, flowability, density and swelling volume studies. The rheological behaviour of the wet powder masses was studied as a function of mixing time using a mixer torque rheometer (MTR). Silicified microcrystalline cellulose exhibited improved flow characteristics and increased specific surface area compared to standard microcrystalline cellulose grades. Although the silicification process affected the swelling properties and, furthermore, the mixing kinetics of microcrystalline cellulose, the source of the microcrystalline cellulose had a stronger influence than silicification on the liquid requirement at peak torque.

Use of a capillary rheometer to evaluate the rheological properties of microcrystalline cellulose and silicified microcrystalline cellulose wet masses.

The influence of microcrystalline cellulose (MCC) type and water content on the rheological properties of the wet powder masses were studied using two different MCC grades (Avicel and Emcocel) and silicified microcrystalline cellulose (SMCC, Prosolv). A ram extruder was used as a capillary rheometer and unique flow curves for each cellulose grade and moisture content were derived. In addition, the elastic parameters of recoverable shear and compliance were determined. From different flow curve models evaluated, it was not possible to obtain clear evidence, which model best described the rheological properties of each cellulose grade at each water level. Furthermore, the residuals were shear rate dependent, which indicates that the models do not perfectly agree with physical properties of the wet masses. The elastic properties of wet masses increased with increasing water content and decreased with increasing shear stresses. SMCC grade proved to be more elastic than the simple MCC grades at each moisture content. Thus, the rheological properties of MCC and SMCC wet masses were different and changed with water content. Consequently, it was not possible to achieve similar rheological properties between different grades of cellulose by altering the water content of the wet mass.

Long-term anal sphincter performance after surgery for Hirschsprung's disease.

BACKGROUND/PURPOSE: The aim of the study was to assess anal sphincter performance in relation to clinical fecal continence in adult patients who have Hirschsprung's disease. METHODS: Fifty-four adult patients (mean age, 29 +/- 7.2 years; 46 men; 8 women) who had undergone surgery for Hirschsprung's disease during their childhood underwent anorectal manometry and clinical examination. Fecal continence was evaluated with a quantitative scoring method (scoring, 0-14; 14, normal bowel function; 10-13, good continence, no social problems; 5-9, fair continence, marked social limitations; 0-4, total incontinence). Thirty healthy adults were used as controls. RESULTS: Fourteen patients had normal bowel habits according to the quantitative scoring. The median anal resting pressure of these patients was 25 cm H2O (range, 15-37.5). The median resting pressure of patients with good continence (n = 30; median, 20 cm/H2O; range, 5-27.5) and with fair continence (n = 6; median, 15 cm/H2O; range, 5-27.5) was significantly lower (P < .01) than in patients who had normal continence. There was no statistical difference in maximal squeeze pressure between the patient groups (median normal, 52.5; good, 45; fair, 52.5). In the controls, the median resting pressure (61.5 cm H2O; range, 34-105) and maximal squeeze pressure (86 cm H2O; range, 55-148) were significantly higher than in all patient groups (P < .0001). The voluntary sphincter force (maximal squeeze pressure minus resting pressure) was similar in patients and controls (patients median, 27 cm H2O; controls median, 16 cm H2O, NS). CONCLUSIONS: There is a positive correlation between functional outcome and anal resting pressure in adults who have repaired Hirschsprung's disease. The overall low resting pressure reflects internal sphincter dysfunction, which may be caused by operative trauma. Despite this, most patients have a satisfactory functional outcome, which is probably related to normal voluntary sphincter performance.

Decreased risk of gastric stump carcinoma after partial gastrectomy supplemented with bile diversion.

The exact incidence of gastric stump cancer is not known. The reported incidence varies greatly, even in studies using similar methods. The aim of this study was to re-evaluate the risk of gastric stump cancer after gastric surgery for peptic ulcer in the Finnish population. A total of 285 patients (252 men and 33 women) operated on for benign peptic ulcer between 1948 and 1954 were followed-up till the end of 1984 (mean follow-up for men = 19.4 years, for women = 22.9 years). At the end of 1984, 58 patients (20%) were still alive without verified gastric cancer. One patient developed gastric cancer within five years after the operation and was excluded from the series. Nine patients (3%) were lost to follow-up. Six patients (four men and two women) of the total 285 developed gastric cancer 6, 7, 8, 21, 25 and 27 years after the operation. The risk of contracting gastric cancer in a control population (no operation) of equal size and age during a similar follow-up period was 6.71 cases for men and 0.86 cases for women (total = 7.57). The observed number (6 patients) does not differ significantly (P less than 0.5) from the expected number (7.57). This study shows that the risk of gastric cancer does not significantly increase after partial gastrectomy for benign peptic ulcer.

Decreased risk of gastric stump carcinoma after partial gastrectomy supplemented with bile diversion.

The exact incidence of gastric stump cancer is not known. The reported incidence figures vary greatly, even in studies using similar methods. The aim of this study was to re-evaluate the risk of gastric stump cancer after gastric surgery for peptic ulcer in the Finnish population. A total of 285 patients (252 men and 33 women) operated on for benign peptic ulcer between 1948 and 1954 were followed-up till the end of 1984 (mean for men = 19.4 years, for women = 22.9 years). At the end of 1984 58 patients (20%) were still alive with no verified gastric cancer. One patient developed gastric cancer within five years after the operation and was excluded from the series. Nine patients (3%) were lost to follow-up. Six patients (four men and two women) of the total 285 had developed gastric cancer 6, 7, 8, 21, 25 and 27 years after operation. The risk of getting gastric cancer in a control population (no operation) of equal size and age during a similar follow-up period was 6.71 cases for men and 0.86 cases for women (total = 7.57). The observed number (6 patients) does not differ significantly (P greater than 0.5) from the expected number (7.57). According to this study the risk of gastric cancer is not significantly increased by partial gastrectomy for benign peptic ulcer.

A case report of biliary cystadenoma and cystadenocarcinoma.

Three cases of intrahepatic biliary cystadenoma with mesenchymal stroma and one case of biliary cystadenocarcinoma are presented. Their immunohistochemical features and the surgical treatment are discussed together with a brief review of the literature. The benign cystadenomas stained positive for cytokeratin and CA 19-9 in the epithelium of the cyst wall. Mesenchymal stromal cells were strongly positive for a-SMA and moderately positive for desmin. The epithelium of the cystadenocarcinoma, however, was positive only for cytokeratin and the stroma only for a-SMA. Our findings indicate that biliary cystadenomas seem to be of primitive hepatobiliary origin. Furthermore, the malignant variant cystadenocarcinoma may loose its immunoreactivity for CA 19-9 and desmin.

Process analysis of fluidized bed granulation.

This study assesses the fluidized bed granulation process for the optimization of a model formulation using in-line near-infrared (NIR) spectroscopy for moisture determination. The granulation process was analyzed using an automated granulator and optimization of the verapamil hydrochloride formulation was performed using a mixture design. The NIR setup with a fixed wavelength detector was applied for moisture measurement. Information from other process measurements, temperature difference between process inlet air and granules (T(diff)), and water content of process air (AH), was also analyzed. The application of in-line NIR provided information related to the amount of water throughout the whole granulation process. This information combined with trend charts of T(diff) and AH enabled the analysis of the different process phases. By this means, we can obtain in-line documentation from all the steps of the processing. The choice of the excipient affected the nature of the solid-water interactions; this resulted in varying process times. NIR moisture measurement combined with temperature and humidity measurements provides a tool for the control of water during fluid bed granulation.

[Single-stage proctocolectomy and ileo-anal anastomosis: benefits and risk factors]. / Coloproctectomie et anastomose iléo-anale en un temps: bénéfices et facteurs de risques.

A collective experience of restorative proctocolectomy with "J" pouch over seven and a half years is presented comparing 63 patients with covering ileostomy and 122 patients with no ileostomy. There was no postoperative mortality in either group, and permanent failure resulted in four (6.3%) and one (0.8%) of patients with and without covering ileostomy, respectively. Total number of postoperative complications was slightly more in the ileostomy group (38 vs. 30%), and significant ileostomy related complications or anastomosis leakage were more common in patients with covering ileostomy (24%) than anastomosis leakage needing later covering ileostomy in the no ileostomy group (14%). There was a median saving of 12 hospital days and 30 sick-leave days in favor of no ileostomy. Severe active ulcerative colitis and male sex (indicating technically difficult anastomosis) emerged as significant risk factors of anastomosis leakage in the no ileostomy group, while steroid use as such seemed not to be a special risk. It was concluded that one stage restorative proctocolectomy suits well for most patients in good general condition when a technically sound anastomosis without tension can be done.

Does preoperative radiotherapy with postoperative chemotherapy increase acute side-effects and postoperative complications of total mesorectal excision? Report of the randomized Finnish rectal cancer trial.

BACKGROUND AND AIMS: In a randomized trial the effect of short-term preoperative radiotherapy and postoperative chemotherapy was studied in patients undergoing total mesorectal excision (TME) for clinically resectable rectal cancer. The primary endpoint was overall survival. The secondary endpoints published herein were the incidence of postoperative complications and adverse events with perioperative adjuvant therapy. MATERIAL AND METHODS: In 1995-2002, 278 eligible patients with stage II and stage III rectal cancer were randomly assigned to TME alone (surgery group) or to preoperative 25 Gy radio-therapy in 5 fractions and postoperative 5-fluorouracil and leucovorin chemotherapy in addition (RT+CT group). RESULTS: Anastomotic leakage rate did not significantly differ between the surgery and the RT + CT group, 20.6% vs. 27.4%. Postoperative infections (15.5 vs. 26.2%, p = 0.037) and perineal wound dehiscence (15.9 vs. 38.5%, p = 0.045) were more common after radiotherapy. Grade 3-5 adverse events were uncommon with preoperative radiotherapy (one, 0.7% with reversible lumbar plexopathy) and postoperative chemotherapy (hematologic in 10.8%, with one septic death, and gastrointestinal in 4.8%). CONCLUSIONS: Perioperative adjuvant therapy was generally well tolerated and did not lead to an increase in serious surgical complications. Wound infections and perineal wound dehiscence were more common in irradiated patients.

Overlap technique improves results of primary surgery after obstetric anal sphincter tear.

PURPOSE: This study was designed to evaluate prospectively the results of the overlap technique in primary sphincter reconstruction after obstetric tear. METHODS: Obstetric tears in 44 women were operated on with primary overlap reconstruction. These women were investigated six to nine months after the operation. Results were compared with those of a historical control group of 52 women whose obstetric sphincter rupture had been treated with the end-to-end technique. RESULTS: The overlap group had significantly more incontinence symptoms after delivery and repair of the sphincter tear than before delivery (P < 0.0001); however, their incontinence symptoms were significantly fewer than those of the end-to-end group (P = 0.004). The prevalence of persistent rupture of the external anal sphincter was significantly lower in the overlap group (6/44, 13.6 percent) than in the end-to-end group (39/52, 75 percent; P < 0.0001). Internal anal sphincter rupture occurred in 5 patients (11.4 percent) in the overlap group and in 40 patients (76.9 percent) in the end-to-end group (P < 0.0001). CONCLUSIONS: The overlap technique should be adopted as the method of choice for primary sphincter repair after obstetric tear.

Manometric follow-up of anal sphincter function after an ileo-anal pouch procedure.

Between January 1985 and January 1987 restorative proctocolectomy with J-pouch was undertaken in 20 patients with ulcerative colitis. In all patients anal manometry was performed preoperatively, before closure of the temporary ileostomy (mean 3.9 months after operation) and 3,6 and 12 months after the closure of the ileostomy. Preoperatively the basal resting pressure was 60.2 +/- 12 cm water and the maximum squeeze pressure 88.5 +/- 18 cm water. After the operation the respective pressures were 33.2 +/- 8 and 68 +/- 21 cm water, a decrease of 45% (p less than 0.05) and 12% (p less than 0.05), respectively. One year after the closure of the loop ileostomy the basal pressure was 46.2 +/- 9 cm water, which is still 23% lower (p less than 0.05) than preoperatively. At the same time the maximum squeeze pressure was 96.5 +/- 13 cm water, 8% higher (p greater than 0.1) than preoperatively. The continence of the patients at the end of the follow-up was either good (n = 6) or excellent (n = 9). A correlation seemed to exist between sphincter pressures and the degree of continence. It is concluded that the internal anal sphincter suffers damage during the operation and slowly recovers up to 6 months after closure of the covering ileostomy. After that its function usually does not improve and remains at a lower level than preoperatively.

WAIS performances in antisocial personality (disorder).

In the present study, the WAIS performances of subjects with antisocial personality disorder were compared with the performances of controls, who had other personality disorders and had usually only occasional criminality. It appeared that in all subtests the age-scaled scores of the controls were higher than those of the subjects. Statistically significant differences emerged in subtests Information, Comprehension and Arithmetic of the Verbal Scale, and in the picture Completion subtest of the Performance Scale, as well as in the Verbal, Performance and Total IQ. In the light of these results, one fundamental feature in antisocial personality could be the lack of general interest and intellectual curiosity, which is probably associated with a poor ability to "feel" (inadequacy of feelings of pleasure) in those predisposed to antisocial personality.

Pelvic ileal reservoirs: experimental assessment of reservoir capacity in three reservoir designs.

In order to examine the possible effect of different pouch shape to the capacity of ileal reservoirs three different types of pelvic ileal reservoir (2-, 3- and 4-loop) were compared in piglets, with four animals in each group. The intraoperative volume of all of these reservoirs was 55 ml, measured with saline. A larger (110 ml) 2-loop reservoir was used in a control group of four animals. The animals were kept alive for 6 weeks after which time the capacity and emptying of the reservoirs were studied. The resulting volume increases (ml/kg) were 15.4, 9.2, 8.9 and 8.1 in J-, S-, large-J- and W-shaped reservoirs, respectively. The emptying of the reservoirs was incomplete in all designs. No statistical difference (P greater than 0.5) was found between groups for either of these parameters. If resistance to outflow from the pouch can be avoided, the capacity of the reservoir seems to depend more on its initial size at the time of construction than on the pouch design.

Restorative proctocolectomy for ulcerative colitis.

The results of 36 restorative proctocolectomies (with 2-loop reservoir) for ulcerative colitis (UC) performed in a three-year period were surveyed. These patients represented 69% of all those undergoing definitive surgery for UC at the same time at our department. There was no operative mortality. Both early (44.4%) and late complications (45.2%) were quite common, but they were mostly minor and only two were permanent failures (5.6%) requiring construction of conventional ileostomy. Anastomotic retraction and sinus formation (25%), as revealed by pouch x-ray, were the most frequent early complications, occurring in a lesser degree (19.4%) also after stoma closure. Pouchitis was also a common (20%) late complication, but usually resolved promptly with metronidazole treatment. The functional results in the 23 patients evaluated were satisfactory, with a mean defaecation frequency of 5.4 per 24 hour and a minor soiling frequency of 36%. None of the patients had to wear a pad. The over-all results are compatible to those from other centres and suggest that acceptable anal function follows restorative proctocolectomy in most suitable cases with UC. The role of adequate surgical experience and consideration of contraindications must, however, be emphasised, and the surgeon must be ready to handle many minor and even major complications.