Pulmonary Function Abnormalities in Regard to Age at the Time of Diagnosis of Hypersensitivity Pneumonitis.

Hypersensitivity pneumonitis (HP) is a complex syndrome caused by exaggerated immune response to inhalation of a variety of organic particles in susceptible individuals. In this study we assessed the relationship between age at the time of diagnosis and the degree of functional and radiological changes in HP. The diagnosis of HP was made on the basis of a combination of clinical symptoms, medical history, serological tests, radiologic evidence of diffuse lung disease, and absence of other identifiable causes of lung disease. We reviewed the records of 111 patients (68 women) diagnosed with HP over a period of 18 years (1995-2013). The patients were stratified into 3 age-groups: <30, 30-49, and ≥50 years old. The commonest cause of HP was avian antigens (56.8 %). Dyspnea was present in 97.3 % of patients, weight loss in 54.7 % of patients, and respiratory insufficiency in 24.3 % of patients. Lung fibrosis in chest computed tomography was found in 35.1 % of patients. Lung function was impaired more seriously in the youngest age-group, with lung diffusing capacity for carbon monoxide (DLCO) <40 % in 69.2 % of these patients. Restrictive pattern was present in 92.3 % of patients in this group, as compared with the 41.0 % in the whole cohort. In this group, desaturation in the six minute walk test also was most notable, amounting to a median of 11 %. In conclusion, diagnosis of HP at young age is predictive of a more severe clinical course of disease, with lung fibrosis and higher disturbances in pulmonary function.

Inflammatory activation after experimental cardiac tamponade.

BACKGROUND/PURPOSE: Cardiac tamponade is a medical emergency situation associated with a high rate of life-threatening complications, even after immediate interventions. Our aim was to characterize the acute inflammatory consequences of this event in a clinically relevant large animal model. METHODS: Cardiac tamponade was induced for 60 min in anesthetized, ventilated and thoracotomized minipigs by intrapericardial fluid administration, the mean arterial pressure (MAP) being maintained in the interval of 40-45 mm Hg (n = 8). A further group (n = 7) served as sham-operated control. The global macrohemodynamics, including the right- and left-heart end-diastolic volumes (RHEDV and LHEDV), the pulmonary vascular resistance index (PVRI) and the superior mesenteric artery (SMA) flow, were monitored for 240 min, and the intestinal microcirculatory changes (pCO2 gap) were evaluated by indirect tonometry. Blood samples were taken for the determination of cardiac troponin T and vasoactive inflammatory mediators, including histamine, nitrite/nitrate, big-endothelin, superoxide and high-mobility group box protein-1 levels in association with intestinal leukocyte and complement activation. RESULTS: The cardiac tamponade induced significant decreases in MAP, cardiac output, LHEDV and SMA flow, while the PVRI and the pCO2 gap increased significantly. After the removal of fluid from the pericardial sac, the MAP and the LHEDV were decreased, while the PVRI and the pCO2 gap remained elevated when compared with those in the sham-operated group. In the posttamponade period, the abrupt release of inflammatory mediators was accompanied by a significant splanchnic leukocyte accumulation and complement activation. CONCLUSIONS: The macrocirculatory and splanchnic microcirculatory disturbances were accompanied by a significant proinflammatory reaction; endothelin and the complement system may be significant components of the inflammatory cascade that is activated in this porcine model of pericardial tamponade.

Bronchial hyperreactivity in sarcoidosis patients: correlation with airflow limitation indices.

UNLABELLED: Bronchial hyperreactivity (BHR) in sarcoidosis has been reported in 5 to 83% of patients, but the relationship between BHR and airway functional status being unclear. The aim of the study was to assess the prevalence and degree of BHR in a group of pulmonary sarcoidosis patients and how BHR does relate to the functional status of airways. MATERIAL AND METHODS: 56 consecutive sarcoidosis outpatients (26 f, 30 m) were included. There were 14 (25%) patients in stage I, 32 (57.1%) patients in stage II and 10 (17.9%) patients in stage III. In all patients the standard evaluation included a history, physical examination, chest radiogram, serum ACE activity and lung function assessment were done. The provocation challenge test with doubling concentrations of histamine was performed in all patients using the standardized protocol recommended by the ERS. RESULTS: 4 patients (7%) were restrictive, airway obstruction was detected in 7 (12.5%) cases. Up to 32% of patients had maximal expiratory flows at low lung volumes below the lower limit of normal (LLN). The histamine challenge test results: in 9 cases (16%) the fall in FEV1 was < 20% of the baseline; mean PC20H (n = 47) was 5.7 +/- 5.9 mg/mL, range: 0.56-26.7 mg/mL. The challenge test was regarded as positive (PC20H < or = 8 mg/mL) in 71.4% of the group. BHR expressed as ln(PC20H) correlated weakly but significantly with FEV1, FEV1%VC, MMEF and PEF. CONCLUSION: BHR occurs frequently in sarcoidosis patients and should be considered especially in patients with airflow limitation.

Muscle-derived cells for treatment of iatrogenic sphincter damage and urinary incontinence in men.

INTRODUCTION: Aim of this study was to assess the safety and efficacy of injection of autologous muscle-derived cells into the urinary sphincter for treatment of postprostatectomy urinary incontinence in men and to characterize the injected cells prior to transplantation. METHODS: 222 male patients with stress urinary incontinence and sphincter damage after uroloical procedures were treated with transurethral injection of autologous muscle-derived cells. The transplanted cells were investigated after cultivation and prior to application by immunocytochemistry using different markers of myogenic differentiation. Feasibility and functionality assessment was achieved with a follow-up of at least 12 months. RESULTS: Follow-up was at least 12 months. Of the 222 treated patients, 120 responded to therapy of whom 26 patients (12%) were continent, and 94 patients (42%) showed improvement. In 102 (46%) patients, the therapy was ineffective. Clinical improvement was observed on average 4.7 months after transplantation and continued in all improved patients. The cells injected into the sphincter were at least ~50% of myogenic origin and representative for early stages of muscle cell differentiation. CONCLUSIONS: Transurethral injection of muscle-derived cells into the damaged urethral sphincter of male patients is a safe procedure. Transplanted cells represent different phases of myogenic differentiation.

The antisense homology box: a new motif within proteins that encodes biologically active peptides.

Amphiphilic peptides approximately fifteen amino acids in length and their corresponding antisense peptides exist within protein molecules. These regions (termed antisense homology boxes) are separated by approximately fifty amino acids. Because many sense-antisense peptide pairs have been reported to recognize and bind to each other, antisense homology boxes may be involved in folding, chaperoning and oligomer formation of proteins. The antisense homology box-derived peptide CALSVDRYRAVASW, a fragment of human endothelin A receptor, proved to be a specific inhibitor of endothelin peptide (ET-1) in a smooth muscle relaxation assay. The peptide was able to block endotoxin-induced shock in rats as well. Our finding of endothelin receptor inhibitor among antisense homology box-derived peptides indicates that searching proteins for this new motif may be useful in finding biologically active peptides.

[Liver transplantation--indications, surgical technique, results--the analysis of a clinical series of 200 cases]. / Transplantul hepatic--indicati, tehnica, rezultate-analiza unei serii clinice de 200 de cazuri.

INTRODUCTION: Initially considered experimental, liver transplantation (LT) has become the treatment of choice for the patients with end-stage liver diseases. MATERIAL AND METHODS: Between April 2000 and October 2009, 200 LTs (10 reLTs) were performed in 190 patients, this study being retrospective. There were transplanted 110 men and 80 women, 159 adults and 31 children with the age between 1 and 64 years old (mean age--39.9). The main indication in the adult group was represented by viral cirrhosis, while the pediatric series the etiology was mainly glycogenosis and biliary atresia. There were performed 143 whole graft LTs, 46 living donor LTs, 6 split LTs, 4 reduced LTs and one domino LT RESULTS: The postoperative survival was 90% (170 patients). The patient and graft one-year and five-year survivals were 76.9%, 73.6% and 71%, 68.2%, respectively. The early complications occurred in 127 patients (67%). The late complications were recorded in 71 patients (37.3%). The intraoperative and early postoperative mortality rate was 9.5% (18 patients). CONCLUSIONS: The Romanian liver transplantation program from Fundeni includes all types of current surgical techniques and the results are comparable with those from other international centers.

Anti-inflammatory action of a phosphatidylcholine, phosphatidylethanolamine and N-acylphosphatidylethanolamine-enriched diet in carrageenan-induced pleurisy.

BACKGROUND/AIMS: Phosphatidylcholine (PC)-derived choline exhibits anti-inflammatory properties in stress conditions. Phosphatidylethanolamine (PE) and N-acylphosphatidylethanolamines (NAPEs) are endogenous bioactive phospholipids linked to the PC and endocannabinoid metabolisms. We hypothesized that an increased dietary input of PC, PE and NAPE may interfere with leukocyte reactions and thus decreases the inflammatory activation. METHODS: CFLP mice were fed with a control diet or with a diet supplemented with 1% PC, 0.4% PE and 0.1% NAPE for 7 days before the induction of pleurisy with carrageenan. Pleural leukocyte migration, pulmonary mast cell degranulation (Alcian blue-safranin O staining), and the activities of inducible nitric oxide synthase, xanthine oxidoreductase and myeloperoxidase were determined in lung tissue biopsies. RESULTS: The carrageenan-induced inflammatory response was characterized by pulmonary leukocyte infiltration, mast cell degranulation and significantly increased inducible nitric oxide synthase and xanthine oxidoreductase activities (by 82 and 60%, respectively). Treatment of mice with acetylsalicylic acid or with dietary PC + PE + NAPE supplementation significantly decreased the leukocyte reaction, and suppressed the activity of the pulmonary proinflammatory enzymes. CONCLUSION: This study confirms a potential for dietary PC + PE + NAPE supplementation to influence events crucial for the remission of acute inflammation. PC + PE + NAPE administration could possibly be a novel preventive or pharmacotherapeutic option in inflammatory pathologies.

Kynurenic acid inhibits intestinal hypermotility and xanthine oxidase activity during experimental colon obstruction in dogs.

Kynurenic acid (KynA), an endogenous antagonist of N-methyl-d-aspartate (NMDA) glutamate receptors, protects the central nervous system in excitotoxic neurological diseases. We hypothesized that the inhibition of enteric glutamate receptors by KynA may influence dysmotility in the gastrointestinal tract. Group 1 of healthy dogs served as the sham-operated control, in group 2, the animals were treated with KynA, while in groups 3 and 4 mechanical colon obstruction was maintained for 7 h. Group 4 was treated with KynA at the onset of ileus. Hemodynamics and motility changes were monitored, and the activities of xanthine oxidoreductase (XOR) and myeloperoxidase (MPO) were determined from tissue samples. Colon obstruction induced a hyperdynamic circulatory reaction, significantly elevated the motility index and increased the mucosal leucocyte accumulation and the XOR activity. The KynA treatment augmented the tone of the colon, permanently decreased the motility index of the giant colonic contractions and reduced the increases in XOR and MPO activities. These effects were concomitant with the in vitro inhibition of XOR activity. In conclusion, KynA antagonizes the obstruction-induced motility responses and XOR activation in the colon. Inhibition of enteric NMDA receptors may provide an option to influence intestinal hypermotility and inflammatory changes.

Hepatocellular carcinoma in Riedel's lobe.

We present a rare case of 65-year female with right abdominal mass and abdominal discomfort; a combination of Doppler ultrasonography, computed tomography and laparotomy was utilized to make a diagnosis of tumoral Riedel's lobe. In our case, laparotomy with resection of Riedel's lobe was the proper therapeutical solution.

Methods for syntheses of N-methyl-DL-aspartic acid derivatives.

A novel practical method for the synthesis of N-methyl-DL-aspartic acid 1 (NMA) and new syntheses for N-methyl-aspartic acid derivatives are described. NMA 1, the natural amino acid was synthesized by Michael addition of methylamine to dimethyl fumarate 5. Fumaric or maleic acid mono-ester and -amide were regioselectively transformed into beta-substituted aspartic acid derivatives. In the cases of maleamic 11a or fumaramic esters 11b, the alpha-amide derivative 13 was formed, but hydrolysis of the product provided N-methyl-DL-asparagine 9 via base catalyzed ring closure to DL-alpha-methylamino-succinimide 4, followed by selective ring opening. Efficient methods were developed for the preparation of NMA-alpha-amide 13 from unprotected NMA via sulphinamide anhydride 15 and aspartic anhydride 3 intermediate products. NMA diamide 16 was prepared from NMA dimethyl ester 6 and methylamino-succinimide 4 by ammonolysis. Temperature-dependent side reactions of methylamino-succinimide 4 led to diazocinone 18, resulted from self-condensation of methylamino-succinimide via nucleophyl ring opening and the subsequent ring-transformation.

Early microcirculatory changes after ischemic preconditioning and small bowel autotransplantation.

BACKGROUND/AIMS: Ischemia-reperfusion injury contributes to the high complication rate of small bowel transplantation (SBTX). Ischemic preconditioning (IPC) protects against reperfusion injury in several organs, but the IPC-induced microcirculatory reaction in the intestine is unknown. METHODS: We examined the effects of IPC on the macrohemodynamics and graft microcirculation in a canine model of SBTX during a 4-hour reperfusion period. In group 1 SBTX was performed, in group 2 IPC was induced before graft harvesting (ischemia 3 times for 5 min, followed by 10 min of reperfusion). Cardiac index and mesenteric blood flow were measured, and the mucosal microcirculation, villus epithelial thickness and functional capillary density were monitored by orthogonal polarization spectral imaging. Leukocyte-endothelial cell interactions were monitored in the postcapillary venules, with intravital fluorescence microscopy. RESULTS: Reperfusion decreased cardiac index and mesenteric blood flow during reperfusion; IPC significantly improved these changes. Reperfusion was accompanied by decreased functional capillary density and epithelial thickness of the villi and increased leukocyte-endothelial cell interactions. IPC increased functional capillary density, prevented epithelial narrowing and reduced leukocyte rolling and adherence. CONCLUSION: IPC improves the macrohemodynamics and the intestinal microcirculation and reduces leukocyte-mediated tissue injury during reperfusion. IPC can be an effective tool to limit reperfusion injury during SBTX.

Excessive alcohol consumption induces methane production in humans and rats.

Various studies have established the possibility of non-bacterial methane (CH4) generation in oxido-reductive stress conditions in plants and animals. Increased ethanol input is leading to oxido-reductive imbalance in eukaryotes, thus our aim was to provide evidence for the possibility of ethanol-induced methanogenesis in non-CH4 producer humans, and to corroborate the in vivo relevance of this pathway in rodents. Healthy volunteers consumed 1.15 g/kg/day alcohol for 4 days and the amount of exhaled CH4 was recorded by high sensitivity photoacoustic spectroscopy. Additionally, Sprague-Dawley rats were allocated into control, 1.15 g/kg/day and 2.7 g/kg/day ethanol-consuming groups to detect the whole-body CH4 emissions and mitochondrial functions in liver and hippocampus samples with high-resolution respirometry. Mitochondria-targeted L-alpha-glycerylphosphorylcholine (GPC) can increase tolerance to liver injury, thus the effects of GPC supplementations were tested in further ethanol-fed groups. Alcohol consumption was accompanied by significant CH4 emissions in both human and rat series of experiments. 2.7 g/kg/day ethanol feeding reduced the oxidative phosphorylation capacity of rat liver mitochondria, while GPC significantly decreased the alcohol-induced CH4 formation and hepatic mitochondrial dysfunction as well. These data demonstrate a potential for ethanol to influence human methanogenesis, and suggest a biomarker role for exhaled CH4 in association with mitochondrial dysfunction.

Surgical treatment of intercostal hernia with implantation of polypropylene mesh.

The intercostal hernia of the lung is a very rare extraordinary disease that requires operation because of the complaints and potential complications. The authors review cases of their operations and analyze the subsequence and treatment. Three patients have been treated for intercostal lung hernia in our treatment. The causes of this disease were a previous thoracotomy in one case and fits of coughing in the other two cases. The diagnosis was set up on the grounds of the specific clinical symptoms, thoracic X-ray and CT scan. The hernia was dissolved with percostal stitches and with the suture of the thoracic musculature in two cases. Plastic operation of the thoracic wall by implanting a polypropylene surgical mesh (Prolen, Ethicon, Johnson & Johnson) was performed in the case of the third patient and later in the first two patients due to recrudescence. In one case the authors were constrained to resect the dystelectasial lung in the hernial sac. The three patients had been operated five times. Relapse of hernia was detected in two patients, in whom the intercostal space had been reconstructed with percostal stitches. We did not detect any relapsing in those two patients at 33 and 66 months after the second operation with mesh implantation. The third patient who got mesh implant immediately did not relapse 12 months after the operation. Intercostal lung hernia is an indication of operation. A plastic operation of the thoracic wall combined with the implantation of a surgical mesh is recommended to close the hernial orifice, which is suitable for treating both primary and relapsed hernias. Recurrence is rare in those patients treated with this method.

Pathophysiology of ischemia-reperfusion injury.

Our studies characterized the intestinal microcirculatory changes in canine models of intestinal hypoperfusion (hemorrhagic shock) or ischemia-reperfusion (small bowel autotransplantation). The villus microcirculatory parameters (functional capillary density, mean red blood cell velocity) were observed by intravital microscopy using orthogonal polarization spectral imaging. The leukocyte reaction (rolling and firm adherence) in the mesentery was quantified by using conventional fluorescence videomicroscopy. The investigations were aimed at determining whether the compromised intestinal villus perfusion could be influenced by endothelin-A receptor inhibition, volume resuscitation, or ischemic preconditioning. The results demonstrated the pathophysiological significance of endothelin-A receptor activation in ischemia-reperfusion-induced microcirculatory changes. Second, it was shown that colloid fluid therapy with hydroxyethyl-starch effectively ameliorated the microcirculatory consequences of hypovolemia, which correlated with a lower endothelin release. Third, ischemic preconditioning when applied 60 minutes before ischemia, inhibited the reperfusion-induced superoxide production, improved capillary perfusion, and attenuated leukocyte activation within the intestinal graft. Among the examined therapeutic strategies aimed at improving the outcome of intestinal microcirculatory dysfunction, endothelin-A receptor antagonist pretreatment and ischemic preconditioning are promising tools to decrease the harmful consequences of ischemia/reperfusion.

Two-stage hepatectomy: an analysis of a single center's experience.

Hepatic resection remains the only potential curative treatment for either primary or secondary liver tumors. In order to increase the resectability of initially unresectable tumors and to decrease the posthepatectomy morbidity and mortality, ligation and section of a portal branch with consecutive hepatic resection is recommended. Between September 1st 1999 and January 1st 2006, in the Department of General Surgery and Liver Transplantation of Clinical Institute Fundeni (Bucharest), the ligation of a portal branch was performed in 15 patients with gross hepatic tumors: hepatocellular carcinoma (2 cases), peripheral cholangiocarcinoma (6 cases) and hepatic metastases for colorectal cancer (7 cases). Two-stage hepatectomy was performed in 8 cases. The interval between the two operations ranged between 4 weeks and 2 months (except one case that returned to us only after 6 months, when was reevaluated and resected). Hepatic resection could not be performed in 7 cases due to the local and regional progression of the disease (4 cases) or to the absence of the hypertrophy-atrophy process (3 cases). In the 8 resected cases, hepatic failure occurred posthepatectomy in 2 patients, resulting in the death of one patient; that means a mortality of 12.5%. Other two patients died at 4 and 10 months respectively, as a result of distant metastases. The rest of 5 patients are alive, free of recurrence; two of them have more than 5 years from the operation. CONCLUDING: portal vein ligation can be performed in selected cases of unresectable gross hepatic tumors. Two-staged hepatectomy is not always feasible. Moreover, the hypertrophy of the contralateral lobe does not always prevent the postoperative hepatic failure. For the cases that can be resected, both survival and quality of life are significantly improved.

A rare indication for liver resection.

We present the rare case of a young female with a right upper abdomen tumoral mass and suffering abdominal discomfort. A combination of ultrasonography, computed tomography, magnetic resonance imaging and laparotomy was utilized to conclude a diagnosis of Riedel's lobe. Laparotomy and a resection of Riedel's lobe were selected as the correct therapeutic solutions.

[Therapy of malignant liver tumors using microwave and radiofrequency ablation]. / Terapia tumorilor hepatice maligne cu microunde si unde de radiofrecventa.

The aim of our study was to evaluate the efficiency for thermo-ablation with microwave and radiofrequency on patients with malignant liver tumors. From January 2002 to January 2005, in our Center of General Surgery and Liver Transplantation in 53 patients 70 sessions of thermoablation were carried out. The mean age was 58 years (25-79 years). Sex ratio men: women was 1.8 (34:19). The diagnosis was hepatocarcinoma in 38 patients (72%), liver metastases from colorectal cancer in 9 (17%) and from non-colorectal cancer (6-11%). The most tumors were single (36-68%). The mean diameter was 39.5 mm (9-94 mm). Percutaneous approach was used in 14 interventions (20%), laparoscopic in 2 (3%) and open approach in 54 cases (77%). We performed 54 sessions of microwave ablation in 42 patients and 8 sessions of radiofrequency ablation in 5 patients. Both methods were applied in 6 patients during 8 sessions. Tumor ablation was done together with liver resection in 10 patients (19%) and resections of other organs in other 8 patients (15%). Morbidity was 12%. The encountered complications were ascites, right pleural effusion and liver abscesses. There was no death. Total and partial necrosis was observed in 27, respectively 20 patients. Local recurrence occurred in one patient but distal liver recurrences were diagnosed in 13 patients. After thermoablation for partial necrosis, local or distal recurrences patients received arterial chemoembolization (5), systemic chemotherapy (23), liver resection (1) and transplantation (1). The mean survival at 1 year and 3 years was 77% and respectively 38%. Microwave or radiofrequency ablation is a simple treatment method, with proved efficiency and minimal risks whose main indication is unresectable tumor.

[Orthotopic liver transplantation in adult patients with cadaveric grafts. Experience of the Fundeni Center of General Surgery and Liver Transplantation]. / Transplantul hepatic ortotopic de la donator cadavru la adult. Experienta Centrului de Chirurgie Generalai si Transplant Hepatic Fundeni.

We analyze the experience of the Center of General Surgery and Liver Transplantation from the Fundeni Clinical Institute (Bucharest, Romania) regarding orthotopic liver transplantation (OLT) in adult recipients, with whole liver grafts from cadaveric donors, between April 2000 (when the first successful LT was performed in Romania) and December 2004. This series includes 37 OLTs in adult recipients (16 women and 21 men, aged between 29-57 years--average 46 years). Other two LT with whole liver cadaveric grafts and two reduced-size LT were performed in children; also, in the same period, due to the acute organ shortage, other methods of LT were performed in 28 patients (21 living donor LT, 6 split LT and one "do mino" LT), that were not included in the present series. The indications for OLT were HBV cirrhosis--10, HBV+HDV cirrhosis--4, HCV cirrhosis--11, HBV+HCV cirrhosis--2, biliary cirrhosis--5, Wilson disease--2, alcoholic cirrhosis--1, non-alcoholic liver disease--1, autoimmune cirrhosis--1. With three exceptions, in which the classical transplantation technique was used, the liver was grafted following the technique described by Belghiti. Local postoperative complications occurred in 15 patients (41%) and general complications in 17 (46%); late complications were registered in 18 patients (49%) and recurrence of the initial disease in 6 patients (16%). Intrao- and postoperative mortality was 8% (3/37). There were two patients (5%) who died because of immunosuppressive drug neurotoxicity at more than 30 days following LT. Four patients (11%) died lately because of PTLD, liver venoocclusive disease, recurrent autoimmune hepatitis and liver venoocclusive disease, myocardial infarction, respectively. Thirty-four patients survived the postoperative period (92%); according to Kaplan-Meier analysis, actuarial patient-survival rate at month 31 was 75%.

Exhaled methane concentration profiles during exercise on an ergometer.

Exhaled methane concentration measurements are extensively used in medical investigation of certain gastrointestinal conditions. However, the dynamics of endogenous methane release is largely unknown. Breath methane profiles during ergometer tests were measured by means of a photoacoustic spectroscopy based sensor. Five methane-producing volunteers (with exhaled methane level being at least 1 ppm higher than room air) were measured. The experimental protocol consisted of 5 min rest--15 min pedalling (at a workload of 75 W)--5 min rest. In addition, hemodynamic and respiratory parameters were determined and compared to the estimated alveolar methane concentration. The alveolar breath methane level decreased considerably, by a factor of 3-4 within 1.5 min, while the estimated ventilation-perfusion ratio increased by a factor of 2-3. Mean pre-exercise and exercise methane concentrations were 11.4 ppm (SD:7.3) and 2.8 ppm (SD:1.9), respectively. The changes can be described by the high sensitivity of exhaled methane to ventilation-perfusion ratio and are in line with the Farhi equation.

Alternative ileal flap for bladder augmentation if mesentery is short.

PURPOSE: To date the clam ileocystoplasty is the preferred method of bladder augmentation in children when the urodynamic problem is non-compliance and/or detrusor overactivity. The key to this technique is the incision of the bladder wall deep into the pelvis down to the trigone in order to avoid a diverticulum like neobladder and to provide adequate margin for augmentation. The detubularised ileum flap therefore has to reach to the bottom of the divided bladder on a reliable vascular pedicle without significant tension. A short ileal mesentery caused by previous surgery, peritonitis, peritoneal dialysis or ventriculo-peritoneal shunt may complicate surgery and compromise outcome. We hypothesized we can rely on the communication of the intramural vessels within the intestine and can detubularise the ileum adjacent to the mesentery rather than along the antimesenteric line and this could be combined with ligation of some vasa recta (VR) in order to create alternative ileum flaps, which reach further into the pelvis. Our aim was to assess the viability of the alternative flaps detubularised along the paramesenteric line and measure how many VR could be sacrificed beyond the tertiary arcades. MATERIALS AND METHODS: After ethical approval adjacent ileal segments were detubulirased along the antimesenteric line (Group 1) and along the paramesenteric line (Group 2) in 5 minipigs in general anaesthesia. Ligation of 0,1,2,3 and 4 VR has been performed starting from the free end of the segments. The length of the ileal flaps was recorded. The microcirculation of flap edges was detected by in vivo microscopy using orthogonal polarising spectral imaging (Cytoscan A/R Cytometrics, PA, USA). Clam ileocystoplasty was performed with the ileum detubularised along the paramesenteric line without ligation of VR. Specimens of the augmented bladder were obtained after 4 weeks and stained with Hematoxilin + Eosin. RESULTS: No alteration in capillary red blood cell velocity (RBCV) and perfusion rate (PR) was observed after paramesenteric detubularisation. The flaps in Group 2 reached 20.25 ± 0.5 mm longer vs. CONTROL: This is 98% of the mean bowel width (20.5 ± 0.57 mm) measured in the animals. Ligation of each VR further increased the length of both flaps (mean: 10.59 ± 3.18 mm) however ligation of more than 2 VR gradually decreased the microcirculation in both groups. All animals augmented with alternative flap survived, there was no urine leak or suture break down. Histology confirmed viable bowel flaps. CONCLUSION: Paramesenteric detubularisation of the ileum is fully tolerated and results in longer reaching ileal flap vs. CONTROL: Only limited ligation of VR is tolerated. DISCUSSION: This study showed the first time that clam ileocystoplasty is feasible with ileal flap detubularised along the paramesenteric line. The use of the animal model and the relative short postoperative observation are the main limitations of this study.