P3495Long-term engraftment of human CD271-positive adipose-derived stem cells with pericytic and less-aged gene profile in a mouse model of hindlimb ischemia

Background

Therapeutic angiogenesis using adipose-derived stem cells (ADSCs) is an attractive strategy for ischemic cardiovascular diseases. We previously reported that human CD271+ population of adipose-derived stem cells (ADSCs) promoted neovascularization with enhanced engraftment in a mouse model of hindlimb ischemia. However, whether and how CD271+ ADSCs promote the long-term engraftment is still uncertain.

Purpose

We aimed to examine whether the angiogenic effect and cell engraftment capacity of CD271+ ADSCs would be sustained in long-term period. Then, comparative gene profiling between CD271+ and CD271- ADSCs were analyzed. Finally, cell proliferation and endothelial differentiation assays were conducted.

Methods

ADSCs were isolated from subcutaneous adipose tissue of 5 patients received cardiovascular surgery. CD271+ and CD271- ADSCs were sorted from CD45-CD31-CD34+ ADSCs fraction by FACS sorting (Fig. A). Cultured CD271+ and CD271- ADSCs at passage 6 were labeled by PKH26 cell linker dye and used for xenograft experiments. Briefly, athymic nude mice were subjected to hindlimb ischemia and one million of human ADSCs were injected into the ischemic muscles. In control group, PBS was solely injected. At 2 and 5 weeks, neovascularization was evaluated by immunohistochemistry (capillary density using lectin perfusion). Cell engraftment was assessed by counting PKH26-positive cells. Furthermore, we compared gene profiling between CD271+ and CD271- ADSCs by microarray. Proliferative capacity was evaluated by colony-forming unit (CFU) assay with Giemsa staining. In endothelial differentiation assay, CD271+ and CD271- ADSCs were cultured in differentiation induction medium containing vascular endothelial growth factor for 2 weeks and stained with anti-human CD31 antibody.

Results

Cell therapy using CD271+ ADSCs demonstrated approximately 3-fold more enhanced neovascularization than those using CD271- ADSCs or PBS in histological analysis of capillary density at 2 weeks from cell therapy (Fig. B and C). At 5 weeks, mice treated with CD271+ ADSCs were significantly rescued from limb ischemia and this was accompanied by sustained engraftment of ADSCs (Fig. D). In microarray analysis, the differentially expressed 2167 genes were extracted to classify CD271+ and CD271- ADSCs. Pathway analysis demonstrated CD271 expression on ADSCs was associated with the pathways related to stemness and cell differentiation. Indeed, we found that genes related to cell proliferation (PI3K, Cyclin D, and Cyclin D2) were up-regulated in CD271+ ADSCs. Additionally, we found the pericytic marker nestin which was significantly up-regulated in CD271+ ADSCs. Consistent with these findings, CD271+ ADSCs were more proliferative and capable for endothelial differentiation while CD271- ADSCs were not.

FACS and cell therapy experiments

Conclusion

These results suggest that CD271+ ADSCs possess long-term engraftment and angiogenic capacity due to their less-aged and more pericytic gene profile.

Acknowledgement/Funding

Japan Society for the Promotion of Science (JSPS) KAKENHI (Tokyo, Japan) Grant Number JP16H06828

P649Validation of clinical diagnostic criteria of familial hypercholesterolemia in Japan: evidence from a comprehensive genetic analysis

Background

Although awareness of familial hypercholesterolemia (FH) is increasing, this common, potentially fatal, treatable condition remains underdiagnosed. Japanese clinical diagnostic criteria of FH include LDL cholesterol level ≥180 mg/dl, Achilles tendon thickness (ATT) ≥9.0 mm, and family history of FH or premature coronary disease. Despite FH being a genetic disorder, genetic testing is rarely used, few data exist regarding the validation of those criteria, especially, by studies using comprehensive genetic analyses.

Methods

This study included 680 subjects (344 men, mean LDL cholesterol = 175 mg/dl) who underwent the full assessments for FH, including LDL cholesterol measurement, Achilles tendon X-ray, investigations for family history, and comprehensive genetic analyses on FH-associated genes (LDL receptor, PCSK9, APOB, and LDLRAP1) in our University Hospital since 2006 to 2018. The area under curve (AUCs) of receiver-operating characteristic (ROC) curve analyses predicting FH-mutation positive were compared among those determined by each component.

Results

ROC analyses revealed the optimal cutoff LDL cholesterol value for predicting the presence of FH-mutation was 181 mg/dl, and that of ATT was ≥7.0 mm. AUCs of each component (ATT, LDL cholesterol, and family history) were 0.827, 0.889, and 0.906, respectively, and the combination of all components increased it to 0.975. When adopting ATT ≥7.0 mm as one of the clinical diagnostic criteria, 13 individuals (2%) were newly classified as true-FH, whereas, 27 (4%) individuals were newly misclassified as FH.

Conclusion

The current Japanese clinical diagnostic criteria of FH were pretty well validated in our independent cohort. However, the threshold of ATT could be lowered to 7.0 mm to raise the sensitivity of its criteria.

Unexpected gap between intraoperative caliber change of the intestine and normoganglia in patients with intestinal aganglionosis

PURPOSE

Intestinal aganglionosis (IA) is so rare that the entity remains unclear. The aim of the present study was to compare the outcomes of patients with IA and those with total colonic aganglionosis (TCA).

METHODS

The hospital records were retrospectively reviewed from 1977 to 2018. Outcomes were analyzed for the IA group and the TCA group, including clinical presentation, initial management, and operative details.

RESULTS

There were six patients were managed in IA (all male) and seven patients in TCA (4 male). The median age at the first operation was significantly younger in IA than TCA (2 days vs 24 days, p = 0.01). The gap between the intraoperative caliber change (CC) of the intestine and the initial stoma location was not significantly different (7.5 cm vs 12 cm, p = 0.61), but the rate of stoma dysfunction was significantly higher in IA (83% vs 0%, p = 0.005). The gap between the CC and the ganglionated bowel was significantly longer in IA (85 cm vs 10 cm, p = 0.003).

CONCLUSION

Patients with IA appear to have a high risk for stoma dysfunction after the first operation because of the unexpected gap between the CC and normoganglia. The initial location of the stoma requires careful consideration.

Single-incision laparoscopic gastropexy for mesentero-axial gastric volvulus

BACKGROUND

Mesentero-axial gastric volvulus (MAGV) is a rare but critical condition as delay in treatment can lead to lethal situations. Although the report of the surgical treatment with laparoscopic approach for MAGV has recently come to be seen, no standard procedures have been established. We aim to describe our operative technique of single-incision laparoscopic gastropexy (SILG) for MAGV and review the relevant literature to ascertain the most appropriate treatment option in these patients.

CASE PRESENTATION

Three patients were referred to our hospital because abdominal pain and vomiting suddenly occurred. Acute MAGV was diagnosed by upper gastrointestinal study. After overnight gastric decompression with a nasal tube, the GV was resolved spontaneously. Elective SILG was planned. Single incision at the umbilicus was made and three 5-mm trocars were inserted. The anterior wall of the body of the stomach was sutured to the peritoneum using 6 × 4-0 non-absorbable sutures for prevention of recurrence of GV and occurrence of internal hernia through the space created between the sutures. Two boys and a girl with mean age 4 ± 2 years underwent SILG. The mean time of the operation was 48 ± 23 min. All of the procedures were completed safely, and there were no postoperative complications. The mean time of postoperative hospitalization was 4 ± 1 days. All patients had good cosmetic and clinical results.

CONCLUSION

We found SILG is a safe, technically feasible, and minimally invasive approach with low incidence of postoperative complication and the best cosmetic result for the patients with MAGV.

Characteristics, management, and outcomes of congenital biliary dilatation in neonates and early infants: a 20-year, single-institution study

BACKGROUND

The aim of the present study was to investigate the characteristics, management, and outcomes of congenital biliary dilatation (CBD) in neonates and infants (<1 year old) in a single institution over the past 20 years.

METHODS

From 1997 to 2016, 21 patients <1 year old underwent definitive surgery for CBD. Open surgery (OS) was performed between 1997 and 2008, and laparoscopic surgery (LS) has been performed since 2009.

RESULTS

The bile duct showed cystic dilatation in all patients. Sixteen (76.2%) of the 21 patients were diagnosed prenatally, and the incidence increased with time (OS 63.6%, LS 90%). Fourteen patients (66.7%) were symptomatic before surgery, with jaundice in 11 (52.4%), acholic stool in seven (33.3%), and vomiting in three (14.3%). There were no significant differences in operation time and blood loss, but the postoperative fasting period and hospital stay were significantly shorter in the LS group (P < 0.05). There were no intraoperative complications, but there was one postoperative early complication in one LS group patient, who had bile leakage and was treated with redo hepaticojejunostomy.

CONCLUSION

The incidences of prenatally diagnosed and asymptomatic patients increased with time. Although longer follow-up is needed, LS for CBD could be safely performed even in neonates and early infants.

Serial intralesional triamcinolone acetonide injections for acquired subglottic stenosis in premature infants

PURPOSE

Long-term intubation of premature infants sometimes induces acquired subglottic stenosis (SGS), causing glottic or supraglottic problems. These kinds of SGS often require tracheostomy and subsequently make decannulation difficult. The aim of our study was to clarify the efficacy of repeated intralesional steroid injections to the stenosis.

METHODS

Six children with acquired SGS, who were treated with triamcinolone acetonide injections to the subglottic space just below the vocal folds between September 2015 and December 2017 were retrospectively reviewed.

RESULTS

The patients' mean age was 4.3 (range 1.3-4.4) years, the mean gestational age at birth was 25 (23-28) weeks, and the mean birth weight was 591 (456-734) g. The degree of SGS was grade II in one patient and III in five patients, with both tracheostoma and glottic or supraglottic abnormalities. They generally underwent ten procedures, every 3-4 weeks. In most cases, the patency of the injected space improved by 25-220%, and the symptoms were relieved. One patient achieved decannulation, and another one underwent laryngotracheal reconstruction and decannulation. Two patients started using a speech cannula. There were no severe complications.

CONCLUSION

Serial intralesional steroid injections are likely to be effective in improving the patency of acquired SGS.

New prognostic classification and managements in infants with esophageal atresia

PURPOSE

The aim of this study was to investigate the risk factors for in hospital mortality in infants with esophageal atresia (EA) without critical chromosome abnormality disorders and develop a new prognostic classification to assess the influence of external risk factors on the prognosis of EA, which could provide more effective treatment strategies in clinical practice.

METHODS

A retrospective chart review of all consecutive patients between January 1994 and December 2017, which included 65 EA infants who were admitted to Shizuoka Children's Hospital, was conducted. Based on multivariate analysis data and ROC analysis, the discrimination of the new prognostic classification was quantified and compared with that of the Spitz classification using the area under the ROC curve (AUC).

RESULTS

Multiple logistic regression analysis showed that birth weight of < 1606 g (adjusted OR, 13.16; 95% CI, 1.16-352.75), and complex cardiac anomalies (adjusted OR 22.39; 95% CI 2.45-569.14) were significant risk factors for death. We have created a new classification close to Spitz classification using the presence of complex cardiac anomalies and birth weight. The mortality rates were 0% for class I (n = 0/40), 7.1% for class II (n = 1/14), 33.3% for class III (n = 3/9), and 100% for class IV (n = 2/2). The AUC of the new classification was better than that of the Spitz classification (0.939 vs 0.812, respectively; p = 0.04).

CONCLUSION

New prognostic classification can improve the stratification of EA patients and be a useful predictor of survival.

Microlaryngoscopic surgery for pyriform sinus fistulas in children: a report of two cases

Background

A pyriform sinus fistula (PSF) is a rare branchial anomaly that causes recurrent cervical infections. Open neck surgery has widely been accepted as a definitive treatment for PSFs, and endoscopic surgery has been reported in recent years. However, both approaches are not satisfactory because of high recurrence rates and postoperative complications. Microlaryngoscopic surgery (MLS) is a transoral surgical technique involving the use of an operating microscope. In this report, we present a new procedure involving MLS for resection and closure of a PSF without a skin incision.

Case presentation

Technique: MLS was performed under general anesthesia with endotracheal intubation. The patient was placed in the supine position, and a direct laryngoscope was inserted to expose the pyriform sinus, which was then magnified using an operating microscope. The mucosal layer was carefully resected using scissors and cupped forceps with sharp edges. The fistula was securely sutured using absorbable suture material. Case 1: A 9-year-old boy with recurrent neck abscesses since 8 years of age presented to our hospital after receiving antibiotics and undergoing drainage in other hospitals. After admission to our hospital, barium esophagography and oral contrast coronal computed tomography showed a PSF on the left side, and open neck surgery was performed to resect the fistula. He was eventually discharged from the hospital without any problem. However, a PSF recurred 2 weeks later. As reoperation with the cervical approach was considered difficult owing to severe adhesions, we adopted MLS as a definitive operation. The postoperative course was uneventful. No recurrence was observed during an 18-month follow-up. Case 2: A 10-year-old girl presented to our hospital with recurrent left-sided neck swelling since 6 years of age. After inflammation control, a PSF was identified on the left side on barium esophagography and computed tomography. MLS was performed safely, and the postoperative course was uneventful. No recurrence was observed during a 10-month follow-up.

Conclusions

MLS allows excellent visualization and effective closure for PSFs, and this approach is suitable for recurrence after open neck surgery. Therefore, MLS might become a first-line treatment for PSFs in children.

Outcomes of Transumbilical Laparoscopic-Assisted Appendectomy and Conventional Laparoscopic Appendectomy for Acute Pediatric Appendicitis in a Single Institution

Background: Single-incision laparoscopic appendectomy (SILA) is a potentially safe and feasible alternative to conventional laparoscopic appendectomy using three ports (CLA). However, the safety and efficacy of SILA for complicated appendicitis (gangrenous and perforated) remain unclear. The aim of this study was to evaluate the outcomes of transumbilical laparoscopic-assisted appendectomy (TULAA) not only for simple appendicitis but also for complicated appendicitis, and to compare them with the outcomes of CLA. Methods: All cases of acute pediatric appendicitis who underwent laparoscopic appendectomies in our hospital from 2007 to 2016 were retrospectively reviewed. CLA was performed between January 2007 and October 2011, and TULAA was performed between November 2011 and December 2016. In this study, patients' demographics and operative outcomes for simple appendicitis (catarrhal and phlegmonous) and complicated appendicitis were analyzed, comparing the results of TULAA and CLA. Results: In total, 262 patients underwent laparoscopic appendectomy: CLA in 103 patients and TULAA in 159 patients. All appendectomies were performed in the acute phase. Complicated appendicitis accounted for 60 CLA cases and 81 TULAA cases. There were no significant differences in patients' demographics. Mean operative time in simple appendicitis was significantly shorter in TULAA than in CLA. In addition, complication rates in complicated appendicitis were significantly lower in TULAA than in CLA. Moreover, in each comparison, the postoperative hospital stay was significantly shorter in TULAA than in CLA. Conclusion: In our institution, TULAA has shown to be a safe and effective alternative for both simple and complicated appendicitis in children compared with CLA.

Diagnostic features of acquired dermal melanocytosis of the face and extremities

Acquired dermal melanocytosis of the face and extremities (ADMFE) is an unusual form of acquired dermal melanocytosis (ADM). In this paper, we report a case of ADMFE and review the published literature. Our review highlights several clinical differences between ADMFE and ADM: (i) more frequent involvement of the nasal alae in ADMFE than in ADM, (ii) less frequent involvement of the cheeks in ADMFE than in ADM, (iii) limbs affected in all cases of ADMFE but in few cases of ADM, and (iv) frequent involvement of conjunctiva and/or gingiva in ADMFE but very rare involvement in ADM. These findings strongly support the hypothesis that ADMFE is clinically distinct from the classic form of ADM, and gaining an understanding of its phenotype will enable accurate diagnosis and early intervention by Q-switched laser therapy, which should benefit those patients with disease-related cosmetic issues.

The fetal lung-to-liver signal intensity ratio on magnetic resonance imaging as a predictor of outcomes from isolated congenital diaphragmatic hernia

PURPOSE

We investigated the developmental changes in the unaffected contralateral lungs of patients with isolated left-sided congenital diaphragmatic hernia (CDH) using signal intensity ratios on prenatal magnetic resonance imaging (MRI) and determined whether these changes correlated with clinical outcomes.

METHODS

We performed 47 fetal MRI screens on 30 patients with isolated left-sided CDH. A cohort of 88 fetuses was selected as the control. We calculated the lung-to-liver signal intensity ratio (LLSIR) using region of interest analysis and compared LLSIR between the groups and between those in the CDH group with good and poor prognoses.

RESULTS

In the control group, LLSIR increased as pregnancy progressed [regression line = 2.232 + 0.135 × (GW-23), r = 0.669]. In the CDH group, especially in the poor prognosis group, LLSIR did not significantly increase as pregnancy progressed [regression line for good prognosis = 1.827 + 0.092 × (gestational week-23), r = 0.733; regression line for poor prognosis = 1.731 + 0.025 × (gestational week-23), r = 0.634].

CONCLUSION

Fetal LLSIR on T2-weighted MRI is an accurate marker of fetal lung maturity that correlates with postnatal survival and can potentially be used as a prognostic parameter in CDH management.

Risk factors for recurrence and contralateral inguinal hernia after laparoscopic percutaneous extraperitoneal closure for pediatric inguinal hernia

BACKGROUND

The use of laparoscopic percutaneous extraperitoneal closure (LPEC) for pediatric inguinal hernia has recently been increasing. Recurrence and contralateral metachronous inguinal hernia (CMIH) are important problems for LPEC. This study analyzed the risk factors for recurrence and CMIH.

METHODS

This study included 1530 patients. The mean follow-up period was 48months. Of 1530 patients, 847 were boys and 683 were girls. The mean age at operation was 3.9years. The asymptomatic contralateral internal ring was routinely observed during the operation, and when a patent processus vaginalis (PPV) was confirmed, prophylactic surgery was performed.

RESULTS

Recurrence was seen in 0.48% of patients (8/1653 sides), all of whom were male (P=0.01: male versus female). On multivariate analysis, age less than 1year was the only risk factor for recurrence in male patients (hazard ratio: 4.54, 95% CI: 1.07-19.25, P=0.04). CMIH was seen in 0.22% of the patients (3/1382), again only in male patients (P=0.12: male versus female). As a result of intraoperative observation, 44.6% of patients were confirmed to have an asymptomatic contralateral PPV and underwent prophylactic LPEC. Female, age 1year or older, right side, and surgeon's experience were identified as factors associated with asymptomatic contralateral PPV.

CONCLUSIONS

To prevent recurrence, surgeons need to be careful when operating on young male patients. Whereas no specific factor could be identified as a risk factor for CMIH, some factors associated with asymptomatic PPV were identified. Further study and discussion will be needed to identify correlations between CMIH and these factors for PPV.

LEVEL OF EVIDENCE

Level III.

Risk factors and prevention for surgical intestinal disorders in extremely low birth weight infants

PURPOSE

Surgical intestinal disorders (SID), such as necrotizing enterocolitis (NEC), focal intestinal perforation (FIP), and meconium-related ileus (MRI), are serious morbidities in extremely low birth weight (ELBW, birth weight <1000 g) infants. From 2010, we performed enteral antifungal prophylaxis (EAP) in ELBWI to prevent for SID. The aim of this study was to identify disease-specific risk factors and to evaluate the efficacy of prevention for SID in ELBW infants.

METHODS

A retrospective chart review of all consecutive patients between January 2006 and March 2015, which included 323 ELBW infants who were admitted to Shizuoka Children's Hospital, was conducted.

RESULTS

The number of infants with NEC, FIP, and MRI was 9, 12, and 13, respectively; 28 in 323 ELBW infants died. The control group defined the cases were not SID. In-hospital mortality was higher in infants with NEC relative to those in the control group. On logistic regression analysis, low gestational age and cardiac malformations were associated with increased risk of NEC. IUGR were associated with increased risk of MRI. EAP decreased risk of NEC and FIP. Low gestational weight and NEC were associated with increased risk of death.

CONCLUSION

Survival to hospital discharge after operation for NEC in ELBW infants remains poor. EAP decreased risk of NEC and FIP in ELBW infants.