Laparoscopic partial external biliary diversion procedure in progressive familial intrahepatic cholestasis

BACKGROUND

Progressive familial intrahepatic cholestasis results in fibrosis, cirrhosis, and liver insufficiency if untreated. Medical therapy often fails and partial external biliary diversion has been recommended to prevent early liver transplantation. We present a new technique of performing a laparoscopic partial external biliary diversion and report our experience in a first series of infants.

METHODS

From October to November 2004, four consecutive patients with progressive familial intrahepatic cholestasis underwent the laparoscopic partial biliary diversion procedure. A three-trocar technique was used. A proximal jejunal conduit was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. After repositioning of the bowel, an isoperistaltic cholecystojejunostomy was carried out laparoscopically. The distal jejunal conduit was placed as a stoma at the right abdominal trocar site.

RESULTS

There were no intraoperative events. The mean duration of the operation was 156.5 min. The postoperative course was uneventful in all patients with full enteral feedings on day 2. The laboratory and clinical signs of cholestasis were reduced up to a mean follow-up of 2 months (range, 1.5-2.5).

CONCLUSION

The laparoscopic partial biliary diversion procedure is feasible with all the benefits of minimally invasive surgery. Long-term results remain to be evaluated.

Laparoscopic Resection Of Congenital Choledochal Cyst, Choledochojejunostomy, and extraabdominal Roux-en-Y anastomosis

BACKGROUND

The feasibility of laparoscopic resection of choledochal cyst and hepaticojejunostomy in children is still unclear. This report presents the author's experience with a first series of patients.

METHODS

Data from 11 consecutive children (median age 17.5 months, SD 22, range 2 to 70) with choledochal cyst scheduled for laparoscopy were collected prospectively. There were nine type I and 2 type V cysts according to Todani's classification. All except one patient had intermittent jaundice or recurrent pancreatitis. The laparoscopic technique included excision of the cyst. A Roux-en-Y anastomosis was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. After repositioning of the bowel an end-to-side hepaticojejunostomy was carried out laparoscopically.

RESULTS

The procedures were carried out in nine children without intraoperative events and a median duration of 289 min (SD 62). In two patients, the operation was converted after 60 and 90 min due to a lack of overview at the dorsal margin with problems in separation of the portal vein. Oral food intake was started within 2 days and tolerated well in all except one patient, in whom biliar fluid from the drain led to laparoscopic reevaluation on day 1. A small leak was resutured and the patient was discharged on day 5. In one patient, recurrent cholangitis and a dilated Roux-en-Y loop led to correction of some kinking of the loop via laparotomy after 3 months. All other patients are well with bile-stained stools after a mean follow-up of 13 months.

CONCLUSIONS

Laparoscopic resection of congenital choledochal cyst and choledochojejunostomy in children is feasible. We feel that there is a considerable learning curve with the technique. Future studies will have to prove the feasibility of laparoscopic Roux-en-Y bowel anastomosis without the need for bowel exteriorization.

Different classes of EGFR inhibitors may have different potential to improve local tumour control after fractionated irradiation: a study on C225 in FaDu hSCC

BACKGROUND AND PURPOSE

Previous experiments reported from this laboratory have shown that simultaneous application of the selective epidermal growth factor receptor tyrosine kinase (EGFR-TK) inhibitor BIBX1382BS during fractionated irradiation significantly prolonged growth delay of FaDu human squamous cell carcinoma but did not improve local tumour control. The present study investigates the effect of the EGFR monoclonal antibody (mAb) C225 on local tumour control of FaDu tumours after combined treatment with single dose and fractionated irradiation to address whether different classes of EGFR inhibitors have different potential to improve the outcome of radiotherapy in the same tumour model.

MATERIAL AND METHODS

In unirradiated tumours, C225 was given either once or 4 times i.p. to the nude mice. Irradiation experiments were performed with graded single doses under clamp hypoxic conditions or with 30 fractions in 6 weeks with graded total doses under ambient blood flow. C225 was given 6h before or 6 h before and 2, 5 and 7 days after single dose irradiation. During fractionated irradiation C225 was given once per week. Experimental endpoints were tumour growth delay and local tumour control 120 after end of irradiation.

RESULTS

C225 treatment resulted in prolongation of tumour growth delay after drug treatment alone as well as after single dose and fractionated irradiation. TCD50 values were reduced from 56.3 Gy [95% CI 50; 62 Gy] after single dose irradiation alone to 46.0 Gy [41;51] (enhancement ratio [ER]=1.22, P<0.01) after 1 C225 injection and 47.7 Gy [44; 51] after 4 injections of the drug (ER=1.18, P=0.06). After fractionated irradiation, tumour control dose 50% (TCD50) was 73.0 Gy [64; 82] in control tumours and 63.1 Gy [57; 69] after simultaneous C225 treatment, corresponding to an ER of 1.2 (P=0.01).

CONCLUSION

Treatment of FaDu hSCC with the anti-EGFR mAb C225 resulted in a significant prolongation of tumour growth delay after single dose and fractionated irradiation. In contrast to previous results on the EGFR-TK inhibitor BIBX1382BS, this prolongation of growth delay translated into a slight but significant improvement of local tumour control. The data indicate that different classes of EGFR inhibitors may have different potential to improve the outcome of radiotherapy in the same tumour model.

Assessment of health-related quality of life in persons after traumatic brain injury — development of the Qolibri, a specific measure

BACKGROUND

Health-related quality of life (HRQOL) associated or not with the measurement of neuropsychological functioning is a relatively new outcome variable in the field of traumatic brain injury (TBI). In both cases, accuracy and precision are increased in outcome estimation. Validation of generic, cross-culturally (cc) administered HRQOL measures in persons after TBI is not yet well established. Disease-specific HRQOL instruments do not exist in an international context. The objective here is to present the TBI consensus group's (QOLIBRI-Group) approach in cc development of a specific HRQOL measure--the QOLIBRI (Quality of Life after Brain Injury).

METHODS

Special issues of TBI-specific instrument creation will be highlighted as well as cc questionnaire construction, development, translation and psychometric testing.

RESULTS

The validation process of the preliminary version of the disease-specific QOLIBRI in 15 countries and 13 languages will be described. The QOLIBRI assesses HRQOL within six domains (physical condition, thinking activities, feelings and emotions, functioning in daily life, relationships and social/leisure activities, current situation and future prospects). The QOLIBRI integrates disease-specific issues of TBI patients, i.e. cognition, existential aspects (as the sense of self) etc., which are missing in generic tools.

CONCLUSION

In TBI patients, generic and disease-specific aspects of HRQOL need to be assessed with measures of adequate psychometric quality, applicable across different populations and cultural conditions. The QOLIBRI is a promising instrument for sensitive patient-centered specific outcome evaluation after TBI.

Micromotor endoscope catheter for in vivo, ultrahigh-resolution optical coherence tomography

A distally actuated, rotational-scanning micromotor endoscope catheter probe is demonstrated for ultrahigh-resolution in vivo endoscopic optical coherence tomography (OCT) imaging. The probe permits focus adjustment for visualization of tissue morphology at varying depths with improved transverse resolution compared with standard OCT imaging probes. The distal actuation avoids nonuniform scanning motion artifacts that are present with other probe designs and can permit a wider range of imaging speeds. Ultrahigh-resolution endoscopic imaging is demonstrated in a rabbit with <4-microm axial resolution by use of a femtosecond Cr:forsterite laser light source. The micromotor endoscope catheter probe promises to improve OCT imaging performance in future endoscopic imaging applications.

Surgery in biliary atresia--futile or futuristic?

Kasai's portoenterostomy is, so far, the only option for patients with biliary atresia (BA) to survive with their own liver. The long-term results are closely related to the timing of the procedure and to the experience of the center. However, optimal conditions cannot guarantee stable liver function. Unfortunately, the majority of patients with BA eventually need liver transplantation, making them the largest group of pediatric organ recipients. Thus, surgery in patients with BA treats only the symptoms, but never the cause of the disease. In order to focus on this point, international and interdisciplinary cooperation is mandatory to improve early and effective diagnosis, to optimize surgical therapy, and to coordinate clinical and basic research in BA. Uncovering its unknown aetiology is crucial for developing and modifying new therapeutic attempts to treat the disease, including the opportunities for prophylaxis. Until then, surgical treatment is still the best approach for biliary atresia and, so far, no further prospects are apparent.

Identification of two Nereis virens (Annelida: Polychaeta) cytochromes P450 and induction by xenobiotics

Cytochrome P450 (CYP) enzyme catalysed metabolism of xenobiotics such as polycyclic aromatic hydrocarbons (PAHs) are known to occur in polychaetes. Yet specific polychaete CYP enzymes have so far not been identified. Here, we report two partial CYP cDNA sequences, both of 453 bp, characterised from Nereis virens. These are the first CYP sequences reported in annelids. The deduced amino acid sequences both share highest identities to mammalian CYP4F enzymes (61% and 58%), indicating membership of the CYP4 family (accordingly, referred to as CYP41 and CYP42, respectively). The CYP42 gene expression was significantly higher in vehicle controls (corn oil) compared to untreated controls. Clofibrate increased the expression of the CYP42 genes. The induction by clofibrate and corn oil indicates regulatory similarities to vertebrate CYP4 enzymes, which are primarily involved in the metabolism of endogenous compounds such as fatty acids. Crude oil and benz(a)anthracene significantly induced CYP42 gene expression 2.6-fold, and because CYP enzymes often are induced by their own substrates, this induction may indicate involvement of N. virens CYP4 enzymes in the detoxification of environmental contaminants such as PAHs. The present study demonstrates that these N. virens CYP genes are transcriptionally inducible, and suggests that N. virens CYP4 enzymes may be involved in the metabolism of both exogenous and endogenous compounds.

Repopulation of moderately well-differentiated and keratinizing GL human squamous cell carcinomas growing in nude mice

PURPOSE

It has been suggested that, reminiscent of the regulated proliferative response of normal squamous epithelium, squamous cell carcinomas that have preserved characteristics of differentiation have a greater repopulation capacity during fractionated irradiation than undifferentiated tumors. The aim of the present study was to investigate repopulation in moderately well-differentiated and keratinizing GL human squamous cell carcinomas in nude mice.

METHODS AND MATERIALS

GL human squamous cell carcinomas were transplanted s.c. into the right hind leg of NMRI nu/nu mice. Irradiation was performed with 5.4 Gy fractions under clamp hypoxia or with 2 Gy fractions under ambient conditions. Six, 12, or 18 fractions were given daily, every second day, or every third day. Graded top-up doses were applied under clamp hypoxia to determine the tumor control dose 50% (TCD(50)). A total of 20 TCD(50) assays were performed and analyzed using maximum-likelihood techniques.

RESULTS

With an increasing number of daily 5.4 Gy fractions under clamp hypoxia, the top-up TCD(50) values decreased significantly from 50.9 Gy (95% CI: 47, 54) after single doses to 0 Gy after 18 fractions. For the same number of fractions, the top-up TCD(50) increased with increasing overall treatment time. The results are consistent with a constant repopulation rate with a clonogenic doubling time (T(clon)) of 12.7 days (8.6, 16.8). Under ambient blood flow, the top-up TCD(50)s for daily 2 Gy fractions decreased significantly, but were less pronounced than for 5.4 Gy fractions under clamp hypoxia. For a given number of fractions under ambient conditions, the top-up TCD(50)s did not increase significantly with overall treatment time, except for irradiation with 12 fractions in 36 days compared to 12 and 24 days. The T(clon) value from these data was 24.0 days (11.6, 36.4).

CONCLUSION

Our data demonstrate a slow but significant rate of repopulation of clonogenic tumor cells during fractionated irradiation of GL human squamous cell carcinomas under clamp hypoxia without indication of a change of the repopulation rate during treatment. Less pronounced repopulation was observed for irradiation under ambient conditions, which might be explained by preferential survival of hypoxic and therefore nonproliferating cells. Taken together with our previous studies on poorly differentiated FaDu tumors (Petersen et al., IJROBP 2001;51:483-493), the results support important heterogeneity of kinetics and mechanisms of repopulation, in particular of the influence of the oxygenation status of surviving clonogenic cells on the repopulation rate during fractionated irradiation, in different experimental squamous cell carcinoma.

The Paracrine Role Played by Interleukin-1α in the Testis

Interleukin-1alpha (IL-1alpha) plays an important role(s) in the regulation of immune and inflammatory responses. The testis is an immunologically privileged organ and the variety of effects exerted by IL-1alpha on this organ have yet to be explored in detail. The aim of the present review is to describe our current view of the paracrine role played by IL-1alpha in testicular physiology. Testicular IL-1alpha is expressed during development, primarily in Sertoli cells, appearing in rats for the first time 20 days after birth. This cytokine is microheterogeneous, consisting of three molecular species with molecular weights of 45, 24 and 17 KDa. The 17 KDa form represents mature IL-1alpha, while the 24-KDa IL-1alpha has been shown by our research group to be an alternately spliced form of the 45-KDa pro-IL-1alpha. IL-1alpha was observed to stimulate the proliferation of immature Sertoli cells with higher efficacy than FSH. IL-1alpha was also found to exert mitogenic effects both on isolated peritubular cells and germ cells. Furthermore, isoforms of IL-1alpha were seen to stimulate basal testosterone production in immature Leydig cells, but not in the corresponding adult cells. This effect involved induction of the steroidogenic acute regulatory (StAR) protein and positively regulation by p38 MAPK. Recently, we have observed positive interactions between IL-1alpha and hormones of the GH/IGF-I system that lead to enhanced androgen production by the Leydig cell. In conclusion, our findings suggest that isoforms of IL-1alpha may serve as paracrine mediators, alone or in concert with other factors, that support proper testicular cell functioning and, thereby, reproduction and fertility.

Blunted increase in plasma adenosine levels following dipyridamole stress in dilated cardiomyopathy patients

BACKGROUND

Heart failure is characterized by chronically increased adenosine levels, which are thought to express a protective anti-heart failure activation of the adenosinergic system. The aim of the study was to assess whether the activation of adenosinergic system in idiopathic dilated cardiomyopathy (IDC) can be mirrored by a blunted increase in plasma adenosine concentration following dipyridamole stress, which accumulates endogenous adenosine.

METHODS

Two groups were studied: IDC patients (n = 19, seven women, mean age 60 +/- 12 years) with angiographically confirmed normal coronary arteries and left ventricular ejection fraction <35%; and normal controls (n = 15, six women, mean age 68 +/- 5 years). Plasma adenosine was assessed by high-performance liquid chromatography methods in blood samples from peripheral vein at baseline and 12 min after dipyridamole infusion (0.84 mg kg-1 in 10 min).

RESULTS

At baseline, IDC patients showed higher plasma adenosine levels than controls (276 +/- 27 nM L-1 vs. 208 +/- 48 nM L-1, P < 0.001). Following dipyridamole, IDC patients showed lower plasma adenosine levels than controls (322 +/- 56 nM L-1 vs. 732 +/- 250 nM L-1, P < 0.001). The dipyridamole-induced percentage increase in plasma adenosine over baseline was 17% in IDC and 251% in controls (P < 0.001). By individual patient analysis, 18 IDC patients exceeded (over the upper limit) the 95% confidence limits for normal plasma adenosine levels at baseline, and all 19 exceeded (below the lower limit) the 95% confidence limits for postdipyridamole plasma adenosine levels found in normal subjects.

CONCLUSION

Patients with IDC have abnormally high baseline adenosine levels and--even more strikingly--blunted plasma adenosine increase following dipyridamole infusion. This is consistent with a chronic activation of the adenosinergic system present in IDC, which can be measured noninvasively in the clinical theatre.

Proliferation and micromilieu during fractionated irradiation of human FaDu squamous cell carcinoma in nude mice

PURPOSE

Previous functional radiobiological experiments demonstrated a significant acceleration of repopulation after 3 weeks and reoxygenation after 12 days of radiotherapy of FaDu tumours. Owing to the temporal coincidence between repopulation and reoxygenation, it was hypothesized that the improved oxygenation status during fractionated irradiation might be the preceding stimulus for increased proliferation. The study investigated whether these changes in repopulation and re-oxygenation are reflected by histological parameters of proliferation and the tumour micromilieu.

MATERIALS AND METHODS

Human FaDu squamous cell carcinomas in nude mice were irradiated with three to 18 fractions of 3 Gy daily or every second day under normal blood flow and clamp hypoxia. At different time points, tumours were excised and stained for Ki67, BrdUrd, epidermal growth factor receptor (EGFR) and markers of the micromilieu (HOECHST 33342, pimonidazole, ER-MP12).

RESULTS

On average, Ki67 and BrdUrd labelling indices decreased initially and increased again at later times during the course of fractionated radiotherapy. A similar kinetic pattern was found for the staining intensity of the EGFR. The vascular density in the viable tumour area remained constant during the whole course of irradiation, while the perfused fraction of vessels decreased within the first week of irradiation and returned to baseline values after 2 weeks. There was a corresponding increase in perfusion and a decrease in cellular hypoxia.

CONCLUSIONS

The histological results were in surprisingly good agreement with the kinetics of clonogen repopulation and re-oxygenation determined previously using functional assays. The results support that the kinetics of repopulation of FaDu squamous cell carcinoma in response to fractionated irradiation are determined not only by intracellular processes, but also by a complex interaction of proliferation parameters with a changing microenvironment.

Die Trichterbrust

For many years, a variety of open surgery techniques represented the "golden standard" for remodeling the chest wall of patients with pectus excavatum. This situation changed when a minimally invasive approach was first introduced by D. Nuss (minimally invasive repair of pectus excavatum--MIRPE). This procedure was originally developed only for children and is based on the fact that the growing chest wall is still flexible. The indication for MIRPE is identical for both open surgery and the minimally invasive procedure. The new technique is gaining acceptance worldwide in the field of pediatric surgery, and older patients who resist open surgery for correction of their pectus excavatum now request the new and less invasive procedure. Most of them found their information via the Internet and it is noteworthy that patients, or their parents, are now looking differently at the indication for repairing pectus excavatum.

Ultrafractionation in A7 human malignant glioma in nude mice

PURPOSE

Low-dose hyperradiosensitivity (HRS) has been demonstrated in numerous cell lines in vitro, including a number of radioresistant human malignant glioma cell lines such as A7. The aim of our experiment was to show whether HRS can be exploited by using ultrafractionated irradiation (UF) to improve local control of A7 tumours growing in nude mice. Extrapolation of the in vitro results predict a 3.7-fold difference in the efficacy of UF compared with conventional fractionation (CF).

MATERIAL AND METHODS

Subcutaneuously growing A7 tumours were irradiated either with UF (126 fractions in 6 weeks, 0.4 Gy per fraction) or CF (30 fractions in 6 weeks, 1.68 Gy per fraction). The total dose was 50.4 Gy in both experimental arms. Fractionated irradiations were given under ambient conditions and followed by graded top-up doses under clamp hypoxia. Endpoints were tumour growth delay and local tumour control 180 days after the end of treatment.

RESULTS

UF resulted in a significant decrease of tumour growth delay and in a significant increase of the top-up TCD(50) compared with CF (40.0 Gy [95% CI 29; 61 Gy] versus 28.3 Gy [24; 35 Gy], p=0.047).

CONCLUSIONS

Despite a pronounced HRS phenomenon in vitro, UF was significantly less effective than CF in A7 human malignant glioma in nude mice. These results neither disprove the existence of HRS nor do they exclude a possible clinical value of UF. The findings rather indicate that simplistic extrapolation from results obtained after single-dose exposure or few fractions in vitro is not sufficient to predict outcome of UF in vivo and that comprehensive evaluation of novel treatment options in animal models continues to be an essential requirement for clinical translation.

What's new in biliary atresia?

The main problem with biliary atresia (BA) is three-fold. Early diagnosis and timely therapy is mandatory in this rare and life-threatening disease. In as much as the aetiology of BA is unknown, all therapeutic attempts are still symptomatically orientated and finally, at the end-stage of the disease, the majority of the patients need organ replacement. Due to promising interdisciplinary cooperation and improved outcomes after liver transplantation, the overall survival rate of patients with BA increased remarkably during the last decades. Additionally, every effort was made in clinical and basic research to obtain a better understanding of the disease and its clinical course. Nevertheless, the nature of biliary atresia still remains unclear and therapeutic options are unsatisfactory. Numerous papers about BA have appeared, reflecting clinical and scientific activity. Considering recent publications and prospective activities, in the following we will summarise what is new in biliary atresia.

Coping with chronic disease from the perspective of children and adolescents--a conceptual framework and its implications for participation

In medical and health psychology, efforts have increasingly been made to assess coping of children and adolescents with chronic conditions. In contrast to the study of coping in adults, approaches to define and assess adaptational processes in children pose a number of problems because coping and development are inherently connected with each other. Issues arising when applying theoretical concepts from developmental psychology to the area of coping in children and adolescents are highlighted. The most prominent approaches to conceptualize and assess coping with chronic disease in childhood and adolescence are illustrated. In future research, there is a need to focus the situational context and content of coping rather than to assess the effort employed and level of a particular coping strategy. Coping is not only a way of regulating emotions, but has an interpersonal meaning, depending on its interactional context. In the medical field, coping has a mediating function for participation and shared medical decision-making in health care processes.

Simultaneous correction of duodenal atresia due to annular pancreas and malrotation by laparoscopy

We report the case of a 3450 g newborn girl with prenatally diagnosed duodenal obstruction. At operation, duodenal atresia due to annular pancreas and intestinal, partially volvulated malrotation became apparent. Surgical correction was completely laparoscopic with 3-mm instruments. The operation consisted of reduction of the volvulated bowel loops, division of obstructing bands, and creation of a side-to-side duodenoduodenostomy. The technique, described in detail, proved to be feasible. No postoperative complication occurred and the girl is doing well 4 months postoperatively.

Impact of magnetic resonance urography on preoperative diagnostic workup in children affected by hydronephrosis: should IVU be replaced?

PURPOSE

The aim of this study was to determine the role of magnetic resonance urography (MRU) in preoperative diagnostic workup of children with hydronephrosis in a prospective clinical study with comparison of MRU, standard diagnostic investigations, and intraoperative findings.

METHODS

Thirty-one children with hydronephrosis secondary to different causes underwent ultrasound scan (US), intravenous urography (IVU), micturation cysto-urethrography (MCU), isotope nephrography (ING) and MRU. For MRU the authors performed sagittal and coronal halve-Fourier SSFSE scans in a 1.5 Tesla MR system. T1- and T2-weighted sequences were used in axial orientation to improve morphologic information. In 24 patients, preoperative data were compared with intraoperative findings.

RESULTS

Comparison of the different imaging modalities proved MRU to be able to provide more detailed information about the correct localization of stenoses along the urinary tract and the morphology of renal parenchyma. MRU showed the highest concordance of all imaging modalities with intraoperative findings.

CONCLUSION

As a reliable investigation, MRU has the potentials to replace IVU in preoperative diagnostic workup of hydronephrosis in childhood.

Minimally invasive repair of pectus excavatum--the Nuss procedure. A European multicentre experience

Since the first description in 1998, the minimally invasive repair of pectus excavatum has gained increasing acceptance. The aim of this survey is to report on the experiences of eight European centres with this technique. 172 patients with a mean age of 15.1 (+/- 4.6) years were treated and evaluated, 35.5 % were symptomatic. 45.3 % of the patients had an asymmetric configuration of the chest, 74.3 % had a CT index above 3.25. Mean duration of the operative procedure was 76 minutes. Major complications, including dislocation of the bar or stabiliser, pneumonia, atelectasis, local infection, pleural and pericardial effusion and liver injury occurred in 11.1 % of the patients. Minor complications, such as self-resolving pneumothorax, atelectasis and subcutaneous emphysema were reported in another 8.1 %. Early cosmetic results were excellent or good in 81.5 %. Although the surgical procedure is simple, blood-sparing and short, consideration of some important technical details, proper patient selection and knowledge of the limitations is of vital importance. Long-term results are still lacking.