Congenital esophageal atresia with tracheoesophageal fistula occurring in both members of dizygotic twins

The authors present a pair of dizygotic twins with congenital esophageal atresia with tracheoesophageal fistula who underwent successful single-stage surgical repair. To our knowledge, this is the second set of dizygotic twins with this congenital anomaly in the literature.

Thirty-eight years experience of malignant hepatic tumors in infants and childhood

A description is given of therapeutic experiences with 39 cases of malignant liver tumors in infancy and childhood during the past 38 years. Of these patients, 9 not undergoing hepatic resection all died, while 18 (60%) of 30 patients treated by hepatic resection survived. When only patients with hepatoblastoma are considered, 14 of 24 patients are alive, although 3 of them had local recurrence and had lung metastasis. Among patients with other types of liver tumor, those with hepatocellular carcinomas (2 cases) and vascular neoplasms all died in a short period of time, whereas 2 with yolk sac tumor and one with metabolic pancreatic tumor are alive despite of tumor recurrence. In summary, the results of surgical treatment of malignant liver tumors in infancy and childhood, which formerly were poor, have been improved remarkably, which we owe mainly to: 1) advances in diagnostic imaging techniques (e.g., angiography, ultrasonography, CT and MRI) permitting early diagnosis, localization of tumor, visualization of the coursing of major vessels (particularly, hepatic artery & vein) and more accurate definition of resectability, 2) technical improvement of hepatic resection and 3) progress of chemotherapy mainly with cisplatin and adriamycin.

Amino acid metabolism in pediatric patients

As with energy requirements, protein requirements are relatively much greater in infants and decline progressively with age. Amino acid metabolism in pediatric patients is characterized by the following differences. The requirement for essential amino acids in neonates is larger than that in adults. Because of low activity of phenylalanine hydroxylase and cystathionase, hyperphenylalaninemia and hypermethioninemia tend to occur, whereas tyrosine and cysteine tend to be deficient. In addition to cysteine and tyrosine, histidine, lysine, arginine and taurine are considered as semiessential amino acids. Nowadays there are different kinds of amino acid formulas to satisfy these specific requirements, and most of these formulas are intended to normalize the plasma aminogram. However, the nutritional benefit of these formulas for growth and development is still not completely proven, and the pharmacological use for specific diseases is expected with some modification of these formulas.

Immunohistochemical assessment of the MIB-1 Labeling Index in human hepatoblastoma and its prognostic relevance

BACKGROUND/PURPOSE

The MIB-1 monoclonal antibody has been raised against recombinant parts of the Ki-67 antigen, which is a cell cycle-related nuclear protein that is elevated in late G1 and S phases. The aim of the study was to analyze the expression pattern of MIB-1 in hepatoblastoma and to assess whether it provides any prognostic information in clinical practice.

METHODS

Sections from formalin-fixed paraffin embedded tissues were collected from 18 patients who had hepatoblastoma and stained with MIB-1 antibody according to streptavidinbiotin method. A percentage score of positively stained nuclei, MIB-1 Labeling Index (LI), was determined and correlated with clinical variables. MIB-1 LI ranged from 0% to 39.5% with a mean value of 13.5%. Among them in 14 patients, who received preoperative chemotherapy, the authors analyzed the result of MIB-1 staining.

RESULTS

Although there were no significant correlations between MIB-1 LI and age, sex, or histological type, a statistically significant correlation was found between clinical stage and MIB-1 LI. Mean MIB-1 LI was lower in patients with stage I and II than in those with stages III and IV (P < .05). Metastatic lesions showed higher MIB-1 LI than primary lesions, indicating that metastatic tumor cells have an increased rate of cellular proliferation. Kaplan Meier survival curve showed that patients with MIB-1 higher than 10% (n = 3) had a worse survival rate than those with lower than 10% MIB-1 LI (n = 11), whereas there was no significant difference because of the limited number of cases. Because high MIB-1 LI was correlated with clinical stage and poor survival rate, MIB-1 LI may be considered an important prognostic factor in hepatoblastoma.

CONCLUSION

Although further studies, including larger series of patients, are required, the authors consider MIB-1 immunostaining an easy method to assess proliferative activity that provides useful prognostic information in hepatoblastoma.

Esophageal atresia in Osaka: a review of 39 years' experience

BACKGROUND

One hundred fifty-nine patients who had esophageal atresia with or without tracheoesophageal fistula have been treated at Osaka University Medical School and its affiliated hospitals since the initial (Japanese) experience of Dr T. Ueda in 1957.

METHODS

These cases were divided chronologically into three groups. With earlier recognition of surgical neonates and the development of perinatal care, the long-term survival of these patients has steadily improved over 39 years from 28% in the first period (1957 to 1967) to 80% in the third period (1980 to 1995). Of 141 patients treated in the second and third periods (1968 to 1995), 92 (65.2%) had associated anomalies. Cardiovascular and gastrointestinal malformations were the most frequently seen major anomalies. VATER or VACTER association was seen in 12.8% (18 of 141) of these patients. Survival of these cases according to Waterston risk factors was 100% for group A, 100% for group B, and 50% for group C, whereas the new classification proposed by Spitz showed survival of 92% for group 1, 50% for group 2, and 0% for group 3, showing better differentiation among the three groups.

RESULTS

There was a long gap between the proximal and distal esophageal ends in seven patients (type A), in all of whom primary anastomosis was possible after 28 to 128 days of elongation by bouginage. Although the survival of esophageal atresia patients dramatically improved in recent years, there is still a high incidence of early and long-term postoperative complications, ie, anastomotic leakage (26.5%), recurrent fistula (7.2%), anastomotic stricture (49.1%), postoperative pneumonia or atelectasis (57.0%), tracheomalacia (25.8%), and gastroesophageal reflux (52.0%).

CONCLUSIONS

Recently, there have been changing patterns in the occurrence of complications, which are mainly attributed to technical improvement, better perinatal care and early recognition of pathophysiologic conditions such as tracheomalacia and gastroesophageal reflux.

Prenatal diagnosis of congenital diaphragmatic hernia and pulmonary hypoplasia and therapeutic strategy

The outcome of fetuses with congenital diaphragmatic hernia (CDH) has been reported to be fatal when pulmonary hypoplasia (PH) is severe. As an indicator of PH, we attempted to measure the lung-thorax transverse area ratio (L/T) using ultrasonic echography. Immediate postnatal surgery was performed using high-frequency oscillatory ventilation (HFOV) and sometimes followed by extracorporeal membrane oxygenation (ECMO). Eighteen fetuses were treated and 14 survived. L/T correlated well with the best preductal arterial blood gas data before surgical reduction during manual ventilation and HFOV, while preductal PO2 and alveolar-arterial oxygen differences from patients managed with HFOV were better than those in patients with manual ventilation. Although L/T also correlated with the duration of O2 therapy and hospitalization in survivors without major anomalies, there was no significant difference between L/T in survivors and nonsurvivors. Because delayed institution of ECMO and complications related to ECMO management seemed to be a major cause of death in non-survivors, the unsalvageable L/T due to PH was estimated to be below 0.06 for HFOV and below 0.1 for conventional ventilation based on the correlation between L/T and preductal P02. These results suggest that L/T is a useful indicator of PH in patients with CDH and also that HFOV is advantageous in treating CDH with PH. The advantage of prenatal diagnosis in predicting unsalvageable L/Ts, should be considered in the therapeutic strategy.

Results of single and double autografts for high-risk neuroblastoma patients

Although intensive therapy with autologous bone marrow transplantation (ABMT) has improved the outcome of advanced neuroblastoma, nearly half the patients with this disease still relapse after a single ABMT. In our previous study, 10 of 22 patients relapsed within 16 months post-transplantation. Predictive risk-factors for relapse were the presence of bone lesions at diagnosis, and a minor response or progressive disease at transplantation. In order to improve the outcome of these high-risk patients, we tested the feasibility of double autografts. To date, eight patients have been treated, and no treatment-related deaths were observed. Six remain in CR or with stable disease for 6 to 29 months. Although more cases and longer observation are needed to draw conclusions, these results are encouraging.

[Changes of respiratory system compliance by closure of congenital abdominal wall defects and postoperative complications]

We treated four neonates with congenital abdominal wall defects and performed pulmonary function testing before and after closure of abdominal wall defects. Pulmonary mechanics were measured by passive occlusion technique. Static respiratory system compliance (Crs) was 0.61 +/- 0.16 ml.cmH2O-1 .kg-1 (mean +/- SD) preoperatively and decreased to 0.31 +/- 0.03 ml.cmH2O-1.kg-1 postoperatively. Two cases with a marked decrease in Crs after the abdominal wall closure seemed to have longer intubation time and N.P.O period and to have more complications than with the other two cases. Our experience provides an evidence that Crs measurement could be a useful index in decision-making of the treatment of neonates with congenital abdominal wall defects.

Hypercalcemia associated with infantile fibrosarcoma producing parathyroid hormone-related protein

We describe a 7-month-old boy who manifested severe hypercalcemia associated with mesenchymal neoplasm. A huge hypervascular tumor on the neck had been detected in prenatal ultrasonography. Surgical removal of the entire tumor at birth was not indicated, because the tumor was diagnosed as hemangioma. Chemotherapy and radiotherapy were attempted, but there was no effect on tumor growth. When the infant was 6 months old, the serum calcium level increased rapidly, associated with the expansion of the tumor. Hypophosphatemia due to phosphaturia was also observed. Serum PTH was undetectable, whereas the serum concentration of carboxyl-terminal (C-terminal) fragments of PTH-related protein (PTH-rP) was markedly elevated. Northern blot analysis and immunostaining demonstrated the expression of PTH-rP in the tumor. The tumor was transplantable to nude mice and caused elevation of circulating PTH-rP in the animals. Histological examination of the patient's bone revealed an increased number of osteoclasts. These findings were consistent with humoral hypercalcemia of malignancy caused by the excess production of PTH-rP. The tumor was identified histologically as infantile fibrosarcoma, which has not been reported as a cause of humoral hypercalcemia of malignancy to date. The expression of PTH/PTH-rP receptor messenger ribonucleic acid was detected in the tumor by the RT-PCR, suggesting that PTH-rP may have exerted its effect in the tumor in an autocrine/paracrine manner. In addition to the systemic effect of PTH-rP manifested as hypercalcemia, the PTH-rP secreted from the neoplasm could have been a local factor involved in the growth of the tumor.

In situ detection of DNA fragmentation and expression of bcl-2 in human neuroblastoma: relation to apoptosis and spontaneous regression

Spontaneous regression occurs in some cases of neuroblastoma, especially stage IVS. The incidence of neuroblastoma has been reported to be increasing since the mass screening program was introduced in Japan. This would indicate that the screening is detecting regressing tumors. However, the mechanism of regression is still unknown. To evaluate the hypothesis that the regression might be related to apoptosis, the authors examined apoptosis by in situ end-labeling of fragmented DNA and expression of the apoptosis-suppressing protein bcl-2.

MATERIALS AND METHODS

One hundred eighteen neuroblastoma cases were available for examination. Eighty (67.8%) were detected by the mass screening program. Serial sections were cut from paraffin-embedded tumors. A modified TdT-mediated dUTP nick end-labeling (TUNEL) method was performed to detect apoptosis. Immunohistochemical analysis was performed to detect bcl-2 expression.

RESULTS

In cases under 1 year of age or with a favorable clinical stage, the incidence of apoptosis was significantly high. Expression of bcl-2 was associated with N-myc amplification and unfavorable histology (Shimada classification). Tumors in patients under 1 year of age often had areas where cellularity was markedly decreased, and apoptosis was often observed while bcl-2 expression was reduced. In such cases, there was a negative correlation between occurrence of apoptosis and bcl-2 expression. This suggests that apoptosis may be related to spontaneous regression in neuroblastoma.

Prenatal diagnosis of abdominal wall defects and their prognosis

To determine whether associated anatomic features may be useful in predicting fetal prognosis, 43 fetuses who had ultrasonographic evaluation for abdominal wall defects during a 13-year period were reviewed. Thirty-one fetuses had omphalocele and were classified into three groups according to fetal ultrasonography results: ruptured omphalocele with exposed liver, giant omphalocele with exposed liver, and small omphalocele without liver herniation. Twelve fetuses had gastroschisis. Ten of the 12 fetuses with gastroschisis survived; one died in utero. Nine of the 12 with a small omphalocele survived. Ten of 12 fetuses with giant omphalocele survived, but six of the seven with ruptured omphalocele died of pulmonary hypoplasia and respiratory insufficiency. Ruptured omphalocele recognized in utero was accompanied by intrauterine growth retardation and liver herniation and frequently was associated with deformity of the spine, diaphragmatic defects, vesicointestinal fissure, and meningocele. These results indicated that, together with the deformity of the spine, rupture and absence of the covering membrane with an exposed liver (noted through fetal ultrasonography) may suggest a poor prognosis because of pulmonary hypoplasia.

Anomalies of the tracheobronchial tree in patients with esophageal atresia

To examine associated anatomic anomalies of the tracheobronchial tree and structural abnormalities of the trachea, and their clinical consequences, bronchoscopic examination and follow-up studies were performed in 32 patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) over a 5-year period. To evaluate structural abnormalities of trachea, the ratio of circumferential length of cartilaginous trachea to circumferential length of membranous trachea (C:M ratio) was determined before surgical repair. In patients examined before and after surgical repair, the motion of the posterior tracheal wall was observed under spontaneous respiration. Fifteen of the 32 patients (47%) had abnormalities of the tracheobronchial tree such as ectopic right upper bronchus (12), congenital bronchial stenosis (4), and absence of the right upper bronchus (2). The C:M ratio of the 27 patients with EA (2.0 +/- 0.6) was significantly lower than that of controls (3.0 +/- 0.3); the ratio for the 10 cases with ectopic right upper bronchus (1.7 +/- 0.4) was significantly lower than that of other cases (2.2 +/- 0.5). The C:M ratio for the 12 patients who had atelectasis (1.7 +/- 0.3) was significantly lower than that of the 15 who did not have atelectasis (2.2 +/- 0.6). Of 24 infants, nine had bulging of the posterior tracheal wall synchronized with expiration, and their C:M ratio (1.8 +/- 0.2) was significantly lower than that of the 15 patients without bulging (2.2 +/- 0.6). These data show an association between anatomic anomalies of the tracheobronchial tree and structural abnormalities of the trachea in patients with EA. Because these abnormalities may be related to the occurrence of respiratory disorders such as tracheomalacia and atelectasis, early bronchoscopic examination, including measurement of the C:M ratio and observation of the motion of the posterior tracheal wall under spontaneous respiration, may be useful in the care of patients with EA.

Unfavorable DNA ploidy and Ha-ras p21 findings in neuroblastomas detected through mass screening

BACKGROUND

Urinary mass screening has been available for 6-month-old infants throughout Japan since 1985. It is still controversial as to whether the program contributes to the detection of unfavorable neuroblastomas destined to present clinically when a patient reaches an older age. DNA diploidy and tetraploidy, low expression of Ha-ras p21, and an amplified N-myc gene status relate to an unfavorable prognosis. The authors examined these biologic indicators in neuroblastomas detected by urinary mass screening.

PATIENTS AND METHODS

Seventy-eight neuroblastomas detected by mass screening were studied for DNA ploidy using DNA flow cytometry, Ha-ras p21 expression using immunostaining, and N-myc gene copy number using slot-blot or Southern blot hybridization methods.

RESULTS

Of 73 tumors with analyzable DNA flow cytometric results, 18 (24.7%) had diploidy (n = 7) or tetraploidy (n = 11). Twenty-eight (40.0%) of 70 tumors examined showed low-to-absent expression of Ha-ras p21. DNA diploid and tetraploid status correlated significantly with the low-to-absent expression of Ha-ras p21 (P = 0.00021). Fourteen (20.0%) of the 70 patients had both of these two unfavorable prognostic markers. N-myc amplification was not detected in 41 of 41 tumors studied. All 78 patients were alive 8-92 months after completion of treatment.

CONCLUSIONS

At least 20.0% of neuroblastomas detected by mass screening have unfavorable biologic prognostic markers. These patients may benefit from early detection and immediate treatment. However, the biologic features associated with a poor prognosis are not predictive of poor outcome in individual patients, and, therefore, should not be used to justify more intensive therapies.

Posterior migration of cervical spinal cord between split laminae as a complication of laminoplasty

STUDY DESIGN

This is a case report.

OBJECTIVE

To focus attention on a possible neurologic complication of laminoplasty.

SUMMARY OF BACKGROUND DATA

An iatrogenic spinal cord lesion developed after laminoplasty as an operative complication of unknown cause.

METHODS

Two patients had iatrogenic damage to the spinal cord from an unknown cause after laminoplasty of the cervical spine, but recovered soon after an additional laminectomy. They were evaluated with regard to the mechanism of damage and prevention.

RESULTS

The spinal cord damage occurred when the spinal cord migrated posteriorly and deformed between the split laminae at the apex of the lordosis, where the maximum posterior displacement of the spinal cord was achieved.

CONCLUSION

This damage was caused by a relatively narrower canal resulting from the split laminae of the apex of the adjacent laminae.

Early postoperative change of plasma levels of amino acids in neonates with perforative peritonitis and its prognostic significance

As a possible prognostic index, plasma levels of amino acids were serially measured for 1 week in 22 neonates with perforative peritonitis including gastric rupture and necrotizing enterocolitis and 28 neonatal surgical patients without infection as a control, who were subjected to total parenteral nutrition with hypertonic glucose and amino acids formulated for neonates. Plasma levels of branched chain amino acids significantly increased on the first day after operation in peritonitis group, whereas plasma levels of phenylalanine and histidine increased on the third postoperative day and tyrosine increased seventh postoperative day. In the peritonitis group, 5 neonates died within 2 weeks after operation (early death group) because of cardiopulmonary failure and 5 neonates died with hyperbilirubinemia from 1 month to 6 months after operation (late death group). The early death group showed increased levels of total amino acids compared with those in the late death group and survivors. The late death group also showed higher levels of total amino acids than survivors. Plasma levels of tyrosine increased in the early and late death groups compared with survivors. These results indicated that serial measurements of plasma amino acids early after operation showed the existence of liver dysfunction in addition to the derangement of amino acid metabolism in the liver and muscle caused by septic insult, which predicted the prognosis of perforative peritonitis in neonates.

Two-dimensional demonstration of myenteric nerve plexus: application for pseudo-Hirschsprung's disease

The use of two-dimensional demonstration of myenteric nerve plexus for the morphological estimation of pseudo-Hirschsprung's disease is introduced. By fluorescent immunohistochemistry for S-100 protein on flat-mounted frozen sections, a decrease in the amount of ganglionic plexuses in the small intestinal segments in cases of pseudo-Hirschsprung's disease was able to be distinguished from normoganglionic plexuses in control cases. Moreover, a morphological difference between the two types of cases was clearly demonstrated. This method may be an indispensable tool in the reliable diagnosis of pseudo-Hirschsprung's disease.

The effect of donor-specific transfusion and cyclosporin A on small bowel transplantation in the rat

Pre-transplant blood transfusions are given as a means of desensitization to reduce the required dose of cyclosporin A (CsA). In this study, the effect of pretransplant blood transfusion on host survival and T-cell function against alloantigen were investigated. Male Lewis rats (RT1(1)) were used as the recipients in all experiments, and male DA rats (RT1a) were used as the blood and small bowel donors, and as a source of allogeneic stimulator cells. Male BUF rats (RT1b) were used as donors of third party blood, and of allo-stimulator cells in a delayed-type hypersensitivity (DTH) response. In our experimental design, Lewis rats were divided into the following groups according to the type of administration: (1) a donor-specific blood transfusion (DST) 8 days preoperatively and a concurrent 5-day course of CsA at 10 mg/kg per day; (2) a nonspecific third party blood transfusion (NST) and CsA at 10 mg/kg per day from day 8 to day 4 preoperatively; (3) CsA alone from day 8 to day 4 preoperatively; (4) DST alone 8 days preoperatively; or (5) no treatment, being the control group. Postoperative treatment consisted of CsA at 2.5 mg/kg per day for 30 days. Rats conditioned with NST plus CsA, CsA alone, DST alone, and the untreated control rats survived for 7.2 +/- 1.2, 9.0 +/- 2.2, 6.8 +/- 0.4, and 7.4 +/- 1.6 days, respectively. In contrast, the five rats conditioned with DST plus CsA survived for 100 days or more.(ABSTRACT TRUNCATED AT 250 WORDS)

Vitamin A status in biliary atresia: intestinal absorption and liver storage of retinol

The vitamin A status of 19 patients with corrected biliary atresia was examined. They had been receiving 5,000 IU of oral vitamin A daily postoperatively. Plasma vitamin A levels in the nonjaundiced group were almost within normal range, whereas those in the jaundiced group were significantly low compared with the controls. In the oral vitamin A tolerance test, plasma vitamin A levels increased from 33.1 +/- 11.8 to 215.4 +/- 100.7 micrograms/dL in the nonjaundiced group, and from 23.1 +/- 10.3 to 209.8 +/- 154.2 micrograms/dL in the slightly jaundiced group, at 4 hours after the administration of vitamin A, showing no difference between both group and control. In the severely jaundiced group, plasma vitamin A levels increased from 13.5 +/- 3.5 to 30.0 +/- 14.6 micrograms/dL, a significantly smaller increase compared with controls. However, liver vitamin A levels were greater than 20 micrograms/g liver in all patients, irrespective of the presence of jaundice. This study suggested that nutritional support to facilitate the synthesis of retinol-binding protein may be an important factor in addition to vitamin A supplementation.

Horizontal transmission of hepatitis B virus in children

Horizontal transmission of hepatitis B virus (HBV) is responsible for about half of the hepatitis B surface antigen (HBsAg) carriers in Taiwan. To investigate the routes and risk factors of horizontal HBV transmission, 131 HBsAg carrier children of HBsAg seronegative mothers were compared with 98 age-matched children seronegative for all hepatitis B markers. Possible factors influencing transmission of HBV, including family size, age at attending kindergarten, frequency of intramuscular injection during infancy and at the toddler stage, contact with HBsAg carriers, and HBV status of parents, siblings and caretakers were studied by questionnaire survey. Intramuscular injection frequency during infancy and at the toddler stage and prevalence of HBsAg positivity among siblings were significantly higher in carrier children than in the control group. Other factors studied were not different in these two groups. The results indicated that unsterilized, multiple intramuscular injections and intrafamilial spread among siblings might be the major routes of horizontal HBV transmission in children in Taiwan.

Intrapancreatic duodenal duplication associated with pancreatic pseudocysts

A rare case of intrapancreatic duodenal duplication causing pancreatitis is reported. At 2 years of age, the patient presented with a recurrent pancreatic pseudocyst. Intraoperative pancreatogram showed the presence of cystic duodenal duplication in the aberrant lobe of the pancreas communication with the pancreatic duct. Since the resection of the duplication, she has been free from recurrence of pancreatitis. In this case, intraoperative pancreatography was of great value.

Serum bile acid fractions in neonates on total parenteral nutrition is lithocholic acid responsible for the occurrence of cholestasis?

In order to determine whether lithocholic acid (LCA) contributes to the occurrence of total parenteral nutrition (TPN) associated intrahepatic cholestasis (IHC) in neonates, we investigated the serum bile acid fractions of neonates on TPN. Twenty-five surgical neonates, receiving TPN for more than 2 weeks were studied. TPN associated IHC was defined as serum defect bilirubin greater than 2.0 mg/dL. Serum bile acid fractions were examined by HPLC using 3α -hydroxy steroid dehydrogenase. Eight patients (32%; IHC group) developed TPN associated IHC. Serum direct bilirubin concentrations in the non IHC and IHC groups were 0.99 and 3.31 mg/dL respectively. Serum total bile acid levels in both groups were 14.4 and 71.6 nmol/ml respectively. Glycine and taurine conjugated cholic and chenodeoxycholic acids could be detected, and unconjugated and secondary (deoxycholic and lithocholic) bile acid were detected in trace levels in both the IHC and non-IHC groups. In conclusion, LCA is unlikely to be a causative factor in TPN associated IHC in neonates.

Prenatal diagnosis of congenital diaphragmatic hernia and perinatal care: assessment of lung hypoplasia

To assess the severity of lung hypoplasia, we have attempted to measure the lung thorax transverse area ratio (L/T) by using ultrasonic echography and to select immediate surgery after delivery by caesarean section. The evaluation of L/T for an index of lung hypoplasia was made by arterial blood gas data and clinical courses. Of 14 fetuses diagnosed, 13 had left sided CDH and one right sided case, from 11 to 38 weeks of pregnancy, 10 cases survived. The L/T in 14 fetuses with CDH was from 0.08 to 0.36 (mean 0.2 +/- 0.073) and was significantly lower than that of the controls. L/T was correlated best with data of arterial pH, PCO2, preductal A-aDO2 before operation and the duration of mechanical ventilation in survivors. Although L/T was also significantly low in the cases with severe grade, diaphragmatic patch closure and ECMO therapy, no significant differences were noted in L/T between survivors and non-survivors. These results indicated that L/T may predict the severity of lung hypoplasia in CDH and that the combination of perinatal management bases on prenatal diagnosis of CDH and ECMO support may improve the outcome of fatal CDH with severe lung hypoplasia.

The effects of branched-chain amino acid-enriched elemental diet in patients with biliary atresia

Supplemental administrations of ED-H, branched-chain amino acid (BCAA)-enriched elemental diet for hepatic disorder, were performed in 10 postoperative biliary atresia (BA) patients. These patients were exhibiting, more or less, cirrhotic changes. The duration of ED-H administration ranged from 7 months to 3 years. initially, these patients showed lowered molar ratios, Val+Leu+Ile/Phe+Tyr, in plasma aminograms with decreased levels of plasma rapid-turnover proteins. ED-H administration induced a significant increase in molar ratio as well as increases in plasma prealbumin and retinol-binding protein levels. With an improved general status, such as activity level and play performance, there were significant increases both in weight for age and weight for height. No particular deleterious effects were observed throughout the period of ED-H administration. In conclusion, supplemental ED-H administration can be performed safely with an efficacy in postoperative BA patients who need metabolic/nutritional supports due to abnormal liver functions.