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Aphthous lesions in the neoterminal ileum from patients operated for Crohn's disease are an early sign of recurrence that can be identified during ileocolonoscopy. The origin of these lesions was studied in nine patients treated by terminal ileal resection and right hemicolectomy for complicated Crohn's disease. During surgery the neoterminal ileum was turned inside out, the mucosa was carefully inspected and two large mucosal biopsies were obtained. The same procedure was carried out in seven patients operated for other diseases. Four to six months after surgery endoscopy of the neoterminal ileum was carried out and multiple biopsies were obtained from the neoterminal ileum. Another follow-up colonoscopy with biopsies was carried out one year after the operation. The operative specimens and the per- and postoperative biopsies were submitted to routine microscopy and immuno- and enzyme-histochemistry. None of the Crohn's patients had macroscopic lesions in the neoterminal ileum at operation and only one had microscopic signs of inflammation and a positive section margin. Four-six months after operation all Crohn's patients had active aphthous lesions in a 5-20 cm segment of the neoterminal ileum at endoscopy. Biopsies taken at this time showed microscopic features which were not observed in biopsies from control subjects: an increase of HLA-DR+, ATPase+ dendritic cells in the ileal mucosa and a defective expression of MHC class II antigens by the small intestinal epithelial cells. MHC class II expression by the small intestinal epithelial cells returned towards normal after one year.(ABSTRACT TRUNCATED AT 250 WORDS)

106 patients had a partial gastrectomy for a benign gastric ulcer. 63 of them got a long-term follow-up. The mean follow-up is 127 months. The mortality rate of the emergency operation is 20%. For the elective operation the mortality rate is 0%. More than 90% of the patients have no complaints after a long time. Following a Billroth I operation most patients feel better initially but later there is no difference at all. The frequency of the ulcer recurrence following a B I is higher than following a B II, but it is lower than after another operation (resp. 5.8% and 2.2%). For these reasons we propose a partial gastrectomy for a benign gastric ulcer in elective circumstances. To prevent alkaline biliary reflux gastritis a 2/3 distal gastrectomy with selective vagotomy and Roux-in-Y anastomosis has to become a routine operation. In emergency circumstances a partial gastrectomy is not indicated because of the high mortality rate.

Some damaging effects that occur during cryopreservation by freezing to -196 degrees C have been evaluated in rabbit taenia coli by analyzing the proportional recovery of acetylcholine- and histamine-induced maximal contractions. Dimethyl sulfoxide (Me2SO) 10 v/v% was used as the cryoprotectant; it reversibly abolishes spontaneous contractility even after incubation at 37 degrees C during 2 hr. Programmed freezing at 0.6 degrees C/min with compensation for the latent heat of fusion and warming at 35 degrees C/min proved to be slightly superior to programmed cooling without compensation and slower warming. The degree of functional recovery was comparable after either abrupt or stepwise removal of Me2SO. Freeze-thawing resulted in a significant reduction of contractile force in each buffer solution tested, and acetylcholine-induced contractility was always better preserved than histamine-induced contractility. The best preservation (approximately 65%) was obtained in a potassium-rich buffer solution. The absence of calcium and magnesium from the incubating medium had no influence, whereas the presence of EDTA significantly affected functional recovery. It is difficult to compare our results with those reported by others because of multiple methodological differences. However, it seems that previous results can be improved by changing the freezing rate and the composition of the incubating and cryoprotecting medium.

The parameters of defecation, i.e., maximum rectal pressure increase during straining, duration of effective evacuation, and the work performed to evacuate a simulated stool, can be quantified by defecometry, a new method to evaluate the defecation act. Simultaneous anal pressure records demonstrate the nature of the sphincter activity during simulated defecation. The test was performed on 19 patients with constipation and on 14 controls. Five patients could not evacuate the simulated stool, while five others could, but more laboriously than the remaining nine patients whose defecation was comparable with the controls. Laborious defecation is characterized by longer duration and more performed work during evacuation. Every patient with difficult or ineffective evacuation had sphincter contraction during defecation, whereas this phenomenon was not observed in patients with normal defecation. Defecometry permits more adequate identification and characterization of the outlet-obstruction-type constipated patients than the simple balloon expulsion test and the analysis of sphincter activity during straining with empty rectum in lateral decubitus. Early diagnosis and treatment of patients with outlet obstruction is important to avoid late neuromuscular damage to the pelvic floor.

The immunohistochemical findings in granulomatous lymphadenitis in patients with Crohn's disease are presented and compared with conventional light microscopic findings. The cellular composition of the granulomas in mesenteric lymph nodes was examined with a broad panel of monoclonal and polyclonal antibodies directed to B-cells, T-cells, monocytes/macrophages, dendritic reticulum cells, HLA-DR antigens and the transferrin receptor. The centre of the granulomas contains OKIa+, OKM1+, OKT9+, DRC-, To5- epithelioid cells and giant cells and OKT3+ lymphocytes. In general, the majority of the small lymphocytes within the granulomas expresses the OKT3+, OKT4+ Leu 3a+ phenotype which points toward T-helper cells. Fewer OKT3+ OKT8+ T suppressor/cytotoxic cells are observed. At the periphery of the granulomas a lymphocytic corona composed of BA1+, B1+ B lymphocytes may be present. From these findings it can be concluded that the granulomas in mesenteric lymph nodes from patients with Crohn's disease are composed of centrally located T-lymphocytes and of epithelioid cells which are of monocyte/macrophage origin and have the characteristics of antigen-presenting cells.

The early occurrence of peritoneal signs and hyperamylasemia in a 14-year-old boy, who had fallen off his horse, urged us to perform a sonographic and computed tomographic study of the upper abdomen. Both examinations showed a complete pancreatic rupture. Distal pancreatectomy led to a rapid and uneventful recovery.

The maximal anal basal pressure (MABP) was measured with probes of 0.3, 1, 2 and 3 cm diameter in 21 subjects, 60 years old, without anal pathology. The components of MABP were analyzed by inducing a maximal internal sphincter (IS) relaxation, taking pressure measurements in the conscious state and during narcosis with curarization. In seven cases pressure measurements were done on isolated anorectum after abdominoperineal rectum amputation. MABP increases with probe diameter before as well as during anaesthesia with curarization. The contribution of the striated sphincter tonic activity is constant within the range of probe diameters used. At rest, i.e. when the 0.3 cm diameter pressure recording probe is used, 30% of MABP is made up by striated sphincter tonic activity, 45% of it is due to nerve induced IS activity, 10% to purely myogenic IS activity and 15% can be attributed to the expansion of the haemorrhoidal plexuses. Although MABP is mainly based on active forces generated by the smooth and striated sphincter apparatus, the presence of the anal cushions is essential for perfect anal continence, as they have to fill the gap within the IS ring to hermetically close the anal canal. The global IS activity, contributing 50-60% of MABP at rest, can completely be inhibited by a maximal rectoanal inhibitory reflex. Stretching of passive elements starts at 1 cm anal distension, but steeply increases thereafter, accounting for 65% of the MABP at 3 cm anal distension. It is deduced that optimal stool diameter is about 2 cm.

Thirteen cases of intestinal atresia are described: 9 jejunal and 4 ileal. The duration of pregnancy was significantly shorter and the birthweight significantly lower in jejunal than in ileal atresia. The proximal intestine was strongly dilated in 8/9 cases with jejunal atresia. This group also contains several complex and extended varieties of atresia. The postoperative mortality was 8%. Gastrointestinal functional disturbances occurred only in the group treated for jejunal atresia. These disturbances were temporary and occurred postoperatively in 2 cases but reoperation was mandatory in another 2 cases, once without functional success. There were no problems in the other cases. Ileal atresia is easy to treat and the result is always good. In contrast, the situation is much more challenging in cases of jejunal atresia: prematurity, higher incidence of complex and extended gastrointestinal malformations, impossibility to resect the dilated proximal segment, presence of a long under-developed distal segment. No problems have been observed after construction of a double stoma and restoration of the intestinal continuity. However a proximal stoma leads to important fluid and electrolyte losses, necessitating total parenteral nutrition. Functional gastrointestinal disturbances are frequently observed after end-to-side anastomosis in Y with mucous fistula. An end-to-end anastomosis can be combined with enteroplasty of the proximal distended bowel segment, eventually including the duodenum. Although the enteroplasty technique is an important progress in the treatment of neonates with extended types of jejunal atresia, transit problems cannot always be prevented by this procedure.

The occurrence of complete wound dehiscence is analyzed in a group of 4538 patients treated with abdominal surgery. All possible measures for the prevention of wound dehiscence should be taken at the time of operation, especially when two or more of the following predisposing factors are present: male, more than 64-years-old, complicated neoplastic and inflammatory diseases, as well as bleeding and noncomplicated inflammatory diseases (except appendicitis), as well as emergency interventions. The use of Ventrofil plates for the prevention of wound dehiscence is recommended in these cases. It is demonstrated that the incidence of complete wound dehiscence in cases with predisposing factors in significantly decreased when extrapreventive measures are taken at the time of wound closure, what results in a decrease of the frequency by which wound dehiscence after gastrointestinal operations occurs.

The healing of anastomoses performed by single- or double-row circular stapling instruments is analyzed in the dog colon. Mucosal healing is better in single-row stapled anastomoses. Apposition of the outer intestinal layers is superior in double-row stapled anastomoses. Bursting pressure and circular wall tension values are identical in both anastomotic types except at 24 hours after surgery when the strength of a double-row stapled anastomosis is superior. A cost-benefit analysis is still in favor of single-row circular instruments. In our opinion, adequate preoperative bowel preparation and a thorough surgical technique, when preparing the cut edges to be anastomosed and placing purse-string sutures, are infinitely more important than making a choice between single- or double-row stapling machines.

Benign neoplasms of the stomach lead to atypical symptoms. Radiological and endoscopic investigations are always recommended. Our surgical experience with 11 epithelial and 26 mesenchymal benign neoplasms is discussed. A local excision could be carried out in 24 patients, of whom 4 developed postoperative complications and one deceased. Ten cases required a partial and 3 cases a total gastrectomy. This was mainly due to the localisation or the extent of the lesions. One surgical complication occurred and one patient died. Relapse was never observed in the long-term (i.e. 6 years) follow-up of 29 patients. Nonetheless, a yearly radiological or endoscopical control is advocated since hyperplastic polyps can relapse as exaggerated healing of an ulcer, and because especially leiomyomas, neurilemmomas en lipomas carry a substantial risk of malignant degeneration.

Lactate dehydrogenase has been measured in the small-intestinal mucosa in order to assess its value as a marker for the effects of ischemia and of reperfusion. The decrease in specific activity of the enzyme illustrates the deleterious effect of reperfusion on the quality of the remaining epithelial cells. However, this parameter fails to detect the loss of epithelial cells, which is the major event during ischemia as well as during reperfusion. In contrast, the expression of enzyme activity per g protein of the underlying intestinal muscle allowed us, in addition, to assess quantitatively the loss of epithelial cells, in good agreement with the histological data.

Fourteen patients with primary malignant duodenal tumors are studied. Twelve patients had adenocarcinomas and two patients had malignant lymphomas. Preoperative diagnostic procedures, such as radiographic study of duodenum with hypotonic duodenography, complete duodenoscopy with biopsy and artertiographic studies are discussed. Early diagnosis is the key for curative surgical treatment since these tumors seem to disseminate rather late. In patients with primary duodenal carcinoma the resectability rate was 66.7%-seven Whipple resections and one segmental resection. Only one patient in our series died after a Whipple resection. There was no mortality after other procedures. The five year survival rate was 14.2%. There is a definite correlation between regional lymph node involvement and survival time. The mean survival period after Whipple resection without lymph node invasion is 56.5 months in our series. The survival period after Whipple resection for adenocarcinoma with regional lymph node invasion (6 months) is identical to the survival after palliative internal derivations for duodenal adenocarcinoma (5.8 months). It is concluded that a positive peroperative frozen section of a regional lymph node should exclude resective procedures (except in patients who hemorrhage) because they have a higher mortality rate as derivative procedures. Fifty per cent of the patients treated for malignant duodenal lymphoma is tumor free two years after a radical surgical therapy combined with chemotherapeutical treatment from the early postoperative period.

Evaluation of anorectal function in faecal incontinence. In cases presenting faecal incontinence, an etiological diagnosis should be based on history, clinical examination, anuscopy and rectoscopy. This diagnosis should be confirmed or contradicted by the results of objective investigations, especially manometry, myography and radiology. In the absence of anorectal anatomical defects, a functional cause of incontinence has to be found: megarectum with pseudo-incontinence, psychogenic encopresis, lesions of the nervous system, pudendal neuropathy. In the presence of obvious anatomical defects, the function of all components of the anorectal continence apparatus has to be evaluated; in this way, it will be possible to objectivate the results of conservative or surgical treatment by repetition of the technical investigations. In practice, a complete functional evaluation of the anorectum has to be performed in patients in whom the results of previous therapy remain unsatisfactory.

Manometric assessment was performed in 54 infants with congenital ano-rectal anomalies including those with a blindly ending rectum (6 cases) or with an ectopic bowel outlet either in the perineum (25 cases), vulva (8 cases), vagina (8 cases), urethra (5 cases) or bladder (2 cases). Infants with an externally accessible orifice were investigated preoperatively whereas those with an internal orifice or no orifice could only be evaluated after surgical correction. In all operated cases presented, the ectopic rectal opening was preserved together with its surrounding smooth musculature. It was transplanted ventral to the puborectalis sling into the anal dimple if present. A normal functioning internal sphincter was observed in all infants even after transplantation. Anal resting tone was normal in all cases with mean values in the various subgroups ranging from 32 +/- 10 mmHg to 51 +/- 6 mm Hg. Frequency of anal slow pressure wave activity ranged from 11.6 +/- 1.5/min to 15.7 +/- 1.3/min. The recto-anal inhibitory reflex was present in all cases. The term fistula should be reserved for morphologically and physiologically abnormal microscopic communications. Failure to appreciate the presence of a normal internal sphincter may account for poor functional results after surgery. The results demonstrate the importance of preserving the internal sphincter in surgical correction of anorectal anomalies.