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.

Factors associated with ileal mucosal morphology and inflammation in patients with ileal pouch-anal anastomosis for ulcerative colitis.

PURPOSE: Pouchitis has been associated with abnormal bacterial flora responding to antibiotics. Dietary factors may play a role in modifying the qualitative and quantitative components of the microflora. We evaluated interactions between nutritional factors, fecal and mucosal bacterial flora, and mucosal morphology in patients with a history of pouchitis compared with patients with optimal outcome at least five years after ileal pouch-anal anastomosis for ulcerative colitis. METHODS: Thirty-two patients were enrolled in the study: 11 (7 males; mean age, 49.8 years) with optimal outcome and 21 (11 males; mean age, 47.3 years) with pouchitis history. A seven-day food diary was recorded, endoscopy performed, and biopsies taken from the pouch for histology, mucin staining, and bacterial culture. Fresh fecal samples were quantitatively cultured, and fecal bile acids analyzed by gas-liquid chromatography. RESULTS: No differences existed in mean nutrient intake, composition of fecal bile acids, or microbial tissue biopsy cultures between the groups with and without pouchitis. Those with optimal outcome tended to have more benign disease course of ulcerative colitis than patients with pouchitis. In those patients, fecal concentrations (log10 colony-forming unit/g) of anaerobes and aerobes were significantly higher (P = 0.007). Degree of villous atrophy and colonic metaplasia were both associated with fecal anaerobic flora. Low intake of lactose was associated with sulfomucin predominance. A negative correlation existed between fecal aerobes and dietary lactose consumption. CONCLUSIONS: A higher total load of fecal anaerobic bacterial flora is strongly associated with degree of colonic metaplasia, villous atrophy, and inflammation activity after surgery for ulcerative colitis. An association existed between dietary lactose, fecal bacteria, and pouch morphology. Lactose may have prebiotic properties.

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.

Delayed sphincter repair for obstetric ruptures: analysis of failure.

OBJECTIVE: The aim of this study was to examine the clinical results after anterior anal sphincter repair in patients with obstetric trauma and to evaluate possible risk factors for poor outcome. PATIENTS AND METHODS: In years 1990-99 anterior anal sphincter repair for anal incontinence due to obstetric trauma was performed in 39 patients at Helsinki University Central Hospital. Clinical examination with Parks' classification and patients' questionnaire with endoanal ultrasound (EAUS) were done before and after surgery. Pudendal nerve terminal motor latency (PNTML) was measured postoperatively. The median follow-up time after the operation was 22 months (range 2-99). RESULTS: The follow-up results of the patients' questionnaire for 12 patients (31%) were good, for 15 patients (38%) acceptable and for 12 patients (31%) poor. Postoperative EAUS showed sphincter overlap in 28 (72%) patients but a defect was still found in 11 (28%) patients. A defect found on postoperative EAUS correlated with poor clinical result according to Parks' (R = 0.8, P < 0.01) and patients' questionnaire results (R = 0.7, P < 0.01). Patients with poor clinical results (Parks III/IV) were statistically significantly older (median 63 years, range 26-73) than those with favourable results (Parks I/II) (median 45 years, range 27-79) (P < 0.05). Further, the duration of incontinence symptoms correlated with poor functional results (R=0.4, P < 0.05). CONCLUSION: After obstetric trauma anterior anal repair gives acceptable short-term clinical results. EAUS investigation is easy and harmless to perform and should be used pre- and post-operatively. Advanced age, pre-operative signs of perineal descent, long-lasting severe incontinence symptoms and a persistent defect on postoperative EAUS seem to be related to poor clinical result.

Risk of osteopenia after proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis.

BACKGROUND: The aim of our study was to evaluate the influence of pouchitis and villous atrophy on bone mineral density and metabolism at least 5 years after ileal pouch-anal anastomosis for ulcerative colitis (UC). METHODS: Eighty-eight subjects with a J-pouch operated on between 1985 and 1994, and 20 ulcerative colitis subjects with a conventional ileostomy were enrolled. Endoscopy was performed and spine and femoral neck bone mineral densities measured. Bone metabolism was assessed by measurement of serum levels of parathyroid hormone, osteocalcin, 25-hydroxyvitamin D3, calcium, alkaline phosphatase and urinary N-telopeptide cross-linked of type I collagen (NTX). RESULTS: In the lumbar spine, 37% of the J-pouch subjects with subtotal to total villous atrophy had osteopenia (Z score <-1), whereas none of the subjects with normal villous structure had reduced bone densities in the spine or femoral neck. The highest prevalence of osteopenia (66.7%) and the lowest spine (mean -0.89+/-0.36; P = 0.006) and femoral neck (mean -0.63+/-0.29; P = 0.07) Z scores were found among the patients (n = 12) with inflammation in the proximal limb of the pouch. No biochemical parameters were found to predict osteopenia and in stepwise regression analysis, the only independent risk factors for osteopenia were low body mass index and villous atrophy. CONCLUSIONS: Patients with a J-pouch showing high inflammatory activity and villous atrophy in the pouch need long-term follow-up and should be ensured adequate intake of calcium and vitamin D.

Long term metabolic consequences of ileal pouch-anal anastomosis for ulcerative colitis.

OBJECTIVES: Chronic inflammation in the ileal pouch is the most significant late complication after ileal pouch-anal anastomosis (IPAA). It leads to changes in mucosal morphology, with consequent decreased vitamin B12, bile acid and cholesterol absorption documented. The aims of this study were to evaluate long term metabolic consequences at least 5 yr after IPAA and the influence of pouchitis on pouch histology and on bile acid, lipid, and vitamin B12, A, E, and D metabolism. METHODS: A total of 104 patients with a J-pouch who were operated on between 1985 and 1994, as well as 21 ulcerative colitis patients with a conventional ileostomy were enrolled for the study. Routine blood tests, vitamin status, vitamin B12 levels, and bile acid absorption were determined, as well as endoscopy with biopsies. The pouchitis disease activity index (PDAI) was calculated. On the basis of histology, IPAA patients were divided into three subgroups: 1) those with no villous atrophy, 2) those with partial villous atrophy, and 3) those with subtotal or total villous atrophy. RESULTS: Incidence of pouchitis was 42.3%, and was strongly associated with villous atrophy. In IPAA patients with subtotal or total villous atrophy (32.7%), serum levels of albumin, calcium, total cholesterol, triglycerides, and vitamin E were significantly reduced (p < 0.05). The lowest bile acid and vitamin B12 absorption rates were seen in patients with inflammation in the proximal limb. Vitamin D deficiency was seen in 10.6%, and vitamin A and B12 deficiency in approximately 5% of IPAA patients. CONCLUSIONS: Metabolic consequences after IPAA are associated with pouchitis, grade of villous atrophy, and extent of inflammation in the remaining ileum. Patients with active chronic inflammation need long term follow-up.

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.

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.

Characterization of wet massing behavior of silicified microcrystalline cellulose and alpha-lactose monohydrate using near-infrared spectroscopy.

The purpose of this study was to investigate the energetic state of water in silicified microcrystalline cellulose (SMCC) and alpha-lactose monohydrate wet masses using near-infrared (NIR) spectroscopy. The applicability of NIR spectroscopy to studying pharmaceutical wet masses at a wide moisture range was evaluated in comparison with mixer torque rheometry (MTR). With increasing moisture content changes in the physical properties of the samples resulted in an apparent increase in log (1/R) throughout the whole spectrum. The upward displacement of baseline and the relative height of water bands were greatest with materials that had a poor liquid-retention capacity. In the case of SMCC and 1:1 mixture of SMCC and alpha-lactose monohydrate, the height of the baseline-corrected water bands increased linearly at low moisture contents, thereafter achieving a plateau stage. According to the MTR results, the plateau stage of the band heights indicated a capillary state of liquid saturation. The second derivative spectrum was capable of distinguishing monohydrate, absorbed, and adsorbed water, which overlapped in the absorbance spectrum. When water was absorbed to the internal structure of the material (SMCC), the water bands were first seen at higher wavelengths, then followed by a shift to lower wavelengths. When water was only adsorbed onto the surface of the particles (glass ballotini), the water bands were seen directly in the region of bulk water.

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.

Microcrystalline cellulose-water interaction--a novel approach using thermoporosimetry.

PURPOSE: To study the physical state of water in microcrystalline cellulose (MCC) and in silicified microcrystalline cellulose wet masses and the effect of granulation on different water fractions. METHODS: Thermoporosimetry, together with the solute exclusion technique, was used to measure different water fractions and pore size distributions of wet granules. To understand the effect of granulation on the physical state of water, both ungranulated and granulated wet masses were studied. In addition, dynamic and isothermal step melting procedures were compared. RESULTS: Four distinct fractions of water (nonfreezing, freezing bound, free, and bulk water) could be detected in MCC wet masses. Granulation decreased the volume of bulk water and increased the volume of freezing bound and free water. Consequently, granulated wet masses were able to hold more water inside the particles compared to ungranulated wet masses. Thus, granulation had a similar effect on MCC as beating has on cellulose fibers in the papermaking proces CONCLUSIONS: Thermoporosimetry and solute exclusion increased the understanding of MCC-water interaction and showed how the physical state of water in MCC wet masses changes during granulation.

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.

Laparoscopic Nissen fundoplication: a prospective analysis of 200 consecutive patients.

Nissen fundoplication is now the most common antireflux operation for gastroesophageal reflux disease. This study is a report on the laparoscopically performed floppy Nissen procedure. Two hundred consecutive patients were analyzed (84 women, 116 men, mean age 49 years, mean duration of symptoms 5 years) after laparoscopic Nissen fundoplication between 1992 and 1996. The main indications for surgery were daily heartburn, retrosternal pain, and regurgitation demanding continuous medical therapy. Eight patients (4%) had esophageal stricture, and 21 (11%) had Barrett's esophagus with intestinal metaplasia. All patients underwent upper gastrointestinal endoscopy, 24-h esophageal pH monitoring, and esophageal manometry before and 3 months after the operation. In addition, a questionnaire was completed an average of 2.2 years (range 1.0-4.6) after the operation. The results of the study were as follows: mortality was zero, and the morbidity rate was 5%. The mean hospital stay was 3.8 +/- 2.8 days, and sick leave was 14.3 +/- 10.4 days. Postoperatively, esophagitis was healed or significantly improved in all but 4 patients (98%), and 24-h pH and lower esophageal sphincter pressure were normal. After 2 years, 87% of the patients had Visick scores of I-II. It is concluded that laparoscopic floppy Nissen fundoplication provides an efficient and safe alternative for surgical treatment of gastroesophageal reflux disease.

Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy, but controversy persists over use of this approach in the treatment of acute cholecystitis. We undertook a randomised comparison of the safety and outcome of LC and open cholecystectomy (OC) in patients with acute cholecystitis. METHODS: 63 of 68 consecutive patients who met criteria for acute cholecystitis were randomly assigned OC (31 patients) or LC (32 patients). The primary endpoints were hospital mortality and morbidity, length of hospital stay, and length of sick leave from work. Analysis was by intention to treat. Suspected bile-duct stones were investigated by preoperative endoscopic retrograde cholangiography (LC group) or intraoperative cholangiography (OC group). FINDINGS: The two randomised groups were similar in demographic, physical, and clinical characteristics. 48% of the patients in the OC group and 59% in the LC group were older than 60 years. 13 patients in each group had gangrene or empyema, and one in each group had perforation of the gallbladder causing diffuse peritonitis. Five (16%) patients in the LC group required conversion to OC, in most because severe inflammation distorted the anatomy of Calot's triangle. There were no deaths or bile-duct lesions in either group, but the postoperative complication rate was significantly (p=0.0048) higher in the OC than in the LC group: seven (23%) patients had major and six (19%) minor complications after OC, whereas only one (3%) minor complication occurred after LC. The postoperative hospital stay was significantly shorter in the LC than the OC group (median 4 [IQR 2-5] vs 6 [5-8] days; p=0.0063). Mean length of sick leave was shorter in the LC group (13.9 vs 30.1 days; 95% CI for difference 10.9-21.7). INTERPRETATION: Even though LC for acute and gangrenous cholecystitis is technically demanding, in experienced hands it is safe and effective. It does not increase the mortality rate, and the morbidity rate seems to be even lower than that in OC. However, a moderately high conversion rate must be accepted.

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.

Functional results after restorative proctocolectomy complicated by pouchitis.

UNLABELLED: This study aimed to examine the incidence and cumulative risk of pouchitis after restorative proctocolectomy for ulcerative colitis and to evaluate the clinical and functional results in patients with pouchitis. METHODS: A total of 291 patients had proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis between January 1985 and January 1996. During follow-up, 65 patients had one or more episodes of pouchitis based on clinical, histologic, and endoscopic criteria. Functional results and patient satisfaction in these patients were compared with those of 65 matched control patients who had experienced no episodes of pouchitis. RESULTS: Pouchitis developed in 65 patients (22 percent), giving rise to a cumulative frequency of 28 percent at 11 years after the operation. Only 13 patients (4.5 percent) had chronic pouchitis that required long-lasting treatment. A permanent ileostomy had to be constructed in one patient (0.3 percent) because of pouchitis. During the last year (1995), 60 percent of patients with pouchitis had medication, most often metronidazole and/or corticosteroids. Defecation frequency per 24 hours was 6.7 for all patients with pouchitis, 8.2 for those with chronic pouchitis (P < 0.05), and 6.3 for patients without pouchitis. Nighttime defecation occurred in 44 (80 percent) patients with pouchitis, compared with 37 (67 percent) of those without pouchitis (P > 0.05). Frequencies of soiling or flatus incontinence did not differ between the two groups. During the last year, 43 (80 percent) of the pouchitis patients, who answered the questionnaire, were working all the year or were on sick-leave less than one month. CONCLUSIONS: Episodic pouchitis is easily treated and causes minimum functional consequences, whereas chronic pouchitis increases defecation frequency and needs prolonged medication. Pouchitis seems not to be a major threat to preventing the use of restorative proctocolectomy in ulcerative colitis, but still the small group of chronic pouchitis patients remains a problem.

Cholesterol metabolism and non-cholesterol sterols in patients with ileal pouch anastomosis.

BACKGROUND: Previous studies suggest only minor changes in bile acid metabolism after panproctocolectomy with ileal pouch construction. AIMS/METHODS: To investigate these changes further, we studied cholesterol absorption and serum, biliary and fecal non-cholesterol sterols and lipids in 12 ileal pouch patients and 10 controls. RESULTS: In patients, cholesterol absorption was markedly reduced and was associated with low serum total and LDL cholesterol and LDL triglyceride levels, but surprisingly, cholesterol synthesis, as indicated by sterol-balance data or serum cholesterol precursor levels, was within low normal limits. The high proportions of serum plant sterol to cholesterol, particularly that of campesterol, were not related to cholesterol absorption, but were attributable to a markedly reduced biliary cholesterol secretion. Interestingly, in these patients the fractional absorption of campesterol was normal, whereas that of sitosterol, like cholesterol, was reduced and was positively related to the intestinal influx of cholesterol. The patients' serum cholestanol proportion was normal, but the proportion of the cholestanol formed during intestinal passage was significantly reduced (17.9% vs 65.2% in controls). CONCLUSIONS: Thus ileal pouch patients are characterized by sterol malabsorption, lowered serum total and LDL-cholesterol levels, but unexpectedly without any increase in cholesterol synthesis. The lack of high serum cholestanol, shown earlier frequently in unoperated patients with ulcerative colitis, may indicate reversible cholestasis, a finding deserving further exploration.

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.

Impaired absorption of cholesterol and bile acids in patients with an ileoanal anastomosis.

BACKGROUND: No data exist on cholesterol absorption in patients with an ileoanal anastomosis (IAA). AIMS: To study cholesterol absorption and its effects on cholesterol and bile acid metabolism in patients with an IAA. PATIENTS AND METHODS: Cholesterol absorption, and serum, biliary, and faecal lipids were studied in 24 patients with an IAA and 20 controls. RESULTS: Fractional cholesterol absorption was significantly lower in the patients (36% versus 47% in controls). Surprisingly, the calculated intestinal influx of endogenous cholesterol was reduced so that the absolute absorption of cholesterol was decreased; elimination of cholesterol as faecal neutral steroids remained normal. Thus, the slightly increased cholesterol synthesis was mainly due to increased faecal bile acid excretion, which, in turn, was associated with reduced absorption and biliary secretion of bile acids. Serum total and low density lipoprotein (LDL) cholesterol and LDL triglycerides were lower in the patients. Molar percentage and saturation index of biliary cholesterol were slightly higher in patients with an IAA. Proportions of secondary bile acids in bile and faeces were diminished, and faecal unidentified bile acids were higher in patients. CONCLUSIONS: Cholesterol absorption is significantly impaired in patients with an IAA, and is closely related to changes in serum and biliary lipids observed in these patients.