1
|
Durmaz LO, Brunner SE, Meinzer A, Krebs TF, Bergholz R. Fetal Surgery for Gastroschisis—A Review with Emphasis on Minimally Invasive Procedures. CHILDREN 2022; 9:children9030416. [PMID: 35327788 PMCID: PMC8947425 DOI: 10.3390/children9030416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/07/2022] [Accepted: 03/12/2022] [Indexed: 11/19/2022]
Abstract
(1) Background: The morbidity of gastroschisis is defined by exposure of unprotected intestines to the amniotic fluid leading to inflammatory damage and consecutive intestinal dysmotility, the viscero-abdominal disproportion which results in an abdomen too small to incorporate the herniated and often swollen intestine, and by associated pathologies, such as in complex gastroschisis. To prevent intestinal damage and to provide for growth of the abdominal cavity, fetal interventions such as amnio exchange, gastroschisis repair or covering have been evaluated in several animal models and human trials. This review aims to evaluate the reported techniques for the fetal treatment of gastroschisis by focusing on minimally invasive procedures. (2) Methods: We conducted a systematic database search, quality assessment and analyzed relevant articles which evaluate or describe surgical techniques for the prenatal surgical management of gastroschisis in animal models or human application. (3) Results: Of 96 identified reports, 42 eligible studies were included. Fetal interventions for gastroschisis in humans are only reported for EXIT procedures and amnio exchange. In animal models, particularly in the fetal sheep model, several techniques of open or minimally invasive repair of gastroschisis or covering the intestine have been described, with fetoscopic covering being the most encouraging. (4) Discussion: Although some promising minimally invasive techniques have been demonstrated in human application and animal models, most of them are still associated with relevant fetal morbidity and mortality and barely appear to be currently applicable in humans. Further research on specific procedures, instruments and materials is needed before any human application.
Collapse
Affiliation(s)
- Lidya-Olgu Durmaz
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
| | - Susanne Eva Brunner
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
| | - Andreas Meinzer
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
| | - Thomas Franz Krebs
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
- Department of Pediatric Surgery, Children’s Hospital of Eastern Switzerland, Claudiusstrasse 6, 9006 St. Gallen, Switzerland
| | - Robert Bergholz
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Kiel Campus, Arnold-Heller-Strasse 3, 24105 Kiel, Germany; (L.-O.D.); (S.E.B.); (A.M.); (T.F.K.)
- Correspondence:
| |
Collapse
|
2
|
Bergholz R, Krebs T, Cremieux B, Georgi C, Fromm F, Boettcher M, Andreas T, Tiemann B, Wenke K, Reinshagen K, Hecher K. Fetoscopic techniques for prenatal covering of gastroschisis in an ovine model are technically demanding and do not lead to permanent anchoring on the fetus until the end of gestation. Surg Endosc 2020; 35:745-753. [PMID: 32072287 DOI: 10.1007/s00464-020-07441-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 02/10/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION This is the cumulative technical report on the operative procedures and limitations of fetoscopic bag insertion, intestinal bag placement, and bag fixation to the fetus in a series of pilot studies in an ovine model for prenatal treatment of gastroschisis. MATERIAL AND METHODS In 24 German blackhead sheep, a surgically created gastroschisis was managed by fetoscopic placement of the extruded intestines into a bag. The bag was then fastened onto the fetal abdominal wall. Different materials (sterile gloves, latex condoms, laparosopic retrieval bags) and different fixation techniques (laparoscopic staplers, interrupted and continuous sutures) have been examined. The fetuses were retrieved and evaluated at the end of gestation. RESULTS Uterine bag insertion was successful in 15 of 24 (62.5%) and intestinal bag placement in 10 of 15 available fetuses (66.6%). The main factor limiting fetoscopic procedures was chorioamniotic separation (CAS). Sterilized condoms provided the most appropriate type of bags and the V-Loc™ running suture, the most expedient type of fixation, which was achieved in 9 of the 10 fetuses (complete = 2, partially = 7) by using a three port access (5 mm and 2 × 3 mm). All bags were encountered completely or partially dislocated from the fetus at the end of gestation. CONCLUSIONS Fetoscopic intestinal bag placement and fixation in gastroschisis technically demanding. None of the evaluated techniques led to permanent anchorage of the bag to the fetus. The development of specially designed instruments, bags and fixation methods is required to optimize this approach.
Collapse
Affiliation(s)
- Robert Bergholz
- Department of General-, Visceral-, Thoracic-, Transplant- and Pediatric Surgery, University Hospital of Schleswig-Holstein, UKSH Kiel Campus, Arnold-Heller-Strasse 3, 20415, Kiel, Germany. .,Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Thomas Krebs
- Department of Pediatric Surgery, Ostschweizer Children's Hospital, Claudiusstrasse 6, 9006, St. Gallen, Switzerland
| | - Birte Cremieux
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Carla Georgi
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Felipe Fromm
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Thomas Andreas
- Department of Pediatric Surgery, Ostschweizer Children's Hospital, Claudiusstrasse 6, 9006, St. Gallen, Switzerland
| | - Bastian Tiemann
- Department of Experimental Animal Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Katharina Wenke
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| |
Collapse
|
3
|
Zani-Ruttenstock E, Zani A, Paul A, Diaz-Cano S, Ade-Ajayi N. Interstitial cells of Cajal are decreased in patients with gastroschisis associated intestinal dysmotility. J Pediatr Surg 2015; 50:750-4. [PMID: 25783375 DOI: 10.1016/j.jpedsurg.2015.02.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 02/13/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Gastroschisis associated intestinal dysmotility (GAID) is poorly understood. Animal experiments suggest that interstitial cells of Cajal (ICC), play an important role. METHODS Infants with gastroschisis (GS) and GAID (time to full feed >42days) were selected. Age matched GS and control (NEC, ileal atresia, malrotation, and volvulus) samples from primary (T1) and secondary (T2) time points underwent standard histopathology and immunohistochemistry for identification of ICC, followed by evaluation of ICC numbers, distribution, morphology, relation to ganglion cells, and myenteric plexus architecture. Groups were compared using parametric and nonparametric tests. MAIN RESULTS Twelve patients had samples available for histopathological evaluation. GAID patients had a significantly lower total number of ICCs than controls (3 vs. 8, P<0.0029). ICC number at T1 was 2.5 vs. 6 (P=0.0629) and significantly lower at T2. (3.5 vs. 11, P=0.0124). GAID patients did not show a significant increase of ICC from T1 to T2. Controls showed a significant increase of ICC over time (6 vs. 11, P=0.0408). CONCLUSION Intestinal samples from infants with GAID who underwent stoma formation demonstrated fewer ICC than controls. There was no improvement or cell recovery during the study period. The ability to modulate ICC may have significant implications for the management of GAID.
Collapse
Affiliation(s)
| | - Augusto Zani
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Anu Paul
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | | | - Niyi Ade-Ajayi
- Department of Paediatric Surgery, King's College Hospital, London, UK.
| |
Collapse
|
4
|
Caglar M, Karaguzel G, Gokhan-Ocak G, Yasar D, Berker-Karauzum S, Gelen T, Celik FN, Demir N, Melikoglu M. Multidirectional and simultaneous evaluation of gastroschisis-related intestinal damage in chick embryos. J Pediatr Surg 2014; 49:1577-84. [PMID: 25475797 DOI: 10.1016/j.jpedsurg.2014.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 06/05/2014] [Accepted: 06/09/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE In a chick model of gastroschisis, we aimed to investigate the morphological/cellular, molecular, and ultrastructural changes taking place in gastroschisis-related intestinal damage (GRID). METHODS 13-Day fertilized eggs were divided into two groups. CONTROL GROUP chorio-amnio-allontoic membranes opened and abdominal wall exposed. Gastroschisis group: an anterior abdominal wall defect created after opening membranes. Embryos from both groups were surgically removed on post-fertilization day 19. Intestinal samples were obtained for histopathology, immunohistochemistry, molecular biology, and electron microscopy. RESULTS The histopathological grade of intestinal damage which primarily involved mucosal structures was significantly higher in the gastroschisis group when compared to the control group (p<0.001). Immunohistochemically, E-cadherin and synaptophysin immunoreactivity in the gastroschisis group was significantly lower than control group (p<0.05 and p<0.01, respectively), whereas there was no significant difference in laminin and type-4 collagen immunoreactivity between the groups (p>0.05). Molecular analyses indicated a significant decrease in NFκB and IκB expression in the gastroschisis group (p<0.05 and p=0.001, respectively). Electron microscopy showed that the gastroschisis group had considerable ultrastructural damage, manifested by apoptosis in all layers. CONCLUSIONS GRID affected all layers but was more prominent in mucosa. The damage may depend on E-cadherin and synaptophysin downregulation. Increased apoptotic activity, associated with decreased NFκB and IκB expression, may be an important component of this multifactorial damaging process.
Collapse
Affiliation(s)
- Muge Caglar
- Akdeniz University School of Medicine, Department of Pediatric Surgery, Antalya, Turkey
| | - Gungor Karaguzel
- Akdeniz University School of Medicine, Department of Pediatric Surgery, Antalya, Turkey.
| | - Guzide Gokhan-Ocak
- Akdeniz University School of Medicine, Department of Pathology, Antalya, Turkey
| | - Duygu Yasar
- Akdeniz University School of Medicine, Department of Medical Biology and Genetics, Antalya, Turkey
| | - Sibel Berker-Karauzum
- Akdeniz University School of Medicine, Department of Medical Biology and Genetics, Antalya, Turkey
| | - Tekinalp Gelen
- Akdeniz University School of Medicine, Department of Pathology, Antalya, Turkey
| | - Fatma Nur Celik
- Akdeniz University School of Medicine, Department of Histology and Embryology, Antalya, Turkey
| | - Necdet Demir
- Akdeniz University School of Medicine, Department of Histology and Embryology, Antalya, Turkey
| | - Mustafa Melikoglu
- Akdeniz University School of Medicine, Department of Pediatric Surgery, Antalya, Turkey
| |
Collapse
|
5
|
Krebs T, Boettcher M, Schäfer H, Eschenburg G, Wenke K, Appl B, Roth B, Andreas T, Schmitz C, Fahje R, Jacobsen B, Tiemann B, Reinshagen K, Hecher K, Bergholz R. Gut inflammation and expression of ICC in a fetal lamb model of fetoscopic intervention for gastroschisis. Surg Endosc 2014; 28:2437-42. [DOI: 10.1007/s00464-014-3494-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 02/20/2014] [Indexed: 11/30/2022]
|
6
|
Régis AC, Rojas-Moscoso JA, Gonçalves FLL, Schmidt AF, Mónica FZ, Antunes E, Sbragia L. The cholinergic response is increased in isolated ileum from gastroschisis rat model. Pediatr Surg Int 2011; 27:1015-9. [PMID: 21590478 DOI: 10.1007/s00383-011-2923-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2011] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Babies with gastroschisis (G) have high morbidity rate and long hospital stay due to bowel hypomotility caused by chronic exposure of the bowel to the amniotic fluid. Our aim was to evaluate the reactivity of isolated ileum in fetal rats selected for experimental gastroschisis. METHOD G was surgically created at 18.5 days of gestation (term = 22 days). Concentration-dependent curve to the muscarinic agonist methacholine (1-30 μM) and contractions induced by electrical field stimulation (EFS, 1-16 Hz, 50 V, 1 ms) were carried out in isolated ileum of groups control (C), sham (S) and gastroschisis (G) (n = 30). Protein expression for M(3) was assessed by western blot analysis. RESULTS The frequency and amplitude of spontaneous contractions were decreased in G (p < 0.001). Methacholine produced concentration-dependent contractions being the maximal response values higher in G (p < 0.01). EFS-induced frequency-dependent contractions showed 1.8 times higher in G as well as an increase of M(3) expression. CONCLUSION The frequency and the amplitude of rhythmic contractions were reduced along with an increase in the contraction induced by mucarinic agonist and by EFS in G. These results suggest the occurrence of an adaptative supersensitivity to cholinergic response via increases in the protein expression for M(3) receptor.
Collapse
Affiliation(s)
- Aline Cristina Régis
- Department of Surgery, School of Medical Sciences, State University of Campinas-UNICAMP, Campinas, SP, Brazil
| | | | | | | | | | | | | |
Collapse
|
7
|
Christison-Lagay ER, Kelleher CM, Langer JC. Neonatal abdominal wall defects. Semin Fetal Neonatal Med 2011; 16:164-72. [PMID: 21474399 DOI: 10.1016/j.siny.2011.02.003] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Gastroschisis and omphalocele are the two most common congenital abdominal wall defects. Both are frequently detected prenatally due to routine maternal serum screening and fetal ultrasound. Prenatal diagnosis may influence timing, mode and location of delivery. Prognosis for gastroschisis is primarily determined by the degree of bowel injury, whereas prognosis for omphalocele is related to the number and severity of associated anomalies. The surgical management of both conditions consists of closure of the abdominal wall defect, while minimizing the risk of injury to the abdominal viscera either through direct trauma or due to increased intra-abdominal pressure. Options include primary closure or a variety of staged approaches. Long-term outcome is favorable in most cases; however, significant associated anomalies (in the case of omphalocele) or intestinal dysfunction (in the case of gastroschisis) may result in morbidity and mortality.
Collapse
|
8
|
|
9
|
Stephenson JT, Pichakron KO, Vu L, Jancelewicz T, Jamshidi R, Grayson JK, Nobuhara KK. In utero repair of gastroschisis in the sheep (Ovis aries) model. J Pediatr Surg 2010; 45:65-9. [PMID: 20105581 DOI: 10.1016/j.jpedsurg.2009.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Accepted: 10/06/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Gastroschisis is associated with inflammatory changes in the exposed bowel which leads to intestinal dysmotility after postnatal repair. The insult is a combined effect of amniotic fluid exposure and mechanical constriction. We hypothesized that in utero anatomic repair is possible in a sheep model, and that it may halt the inflammatory damage caused by both mechanisms. METHODS Gastroschisis was surgically created in mid-gestation (day 75) in 8 sheep fetuses. On gestational day 100, 2 fetuses underwent open fetal gastroschisis repair, where the eviscerated bowel was returned to the peritoneal cavity, and the abdominal wall was primarily closed. All fetuses were harvested at 135 days of gestation. RESULTS Six fetuses survived the initial operation, and both fetuses that underwent gastroschisis repair survived to term. At 100 and 135 days of gestation, the eviscerated bowel showed progressive signs of inflammation and peel development. The gross and microscopic inflammatory changes in the gastroschisis bowel at 100 days of gestation were completely resolved at term following in utero repair. CONCLUSION In utero anatomic repair of gastroschisis is possible in mid-gestation in the fetal lamb model, and it appears to ameliorate the inflammatory process.
Collapse
Affiliation(s)
- Jacob T Stephenson
- Fetal Treatment Center, Pediatric Surgery Department University of California, San Francisco, San Francisco, CA 94143-0570, USA
| | | | | | | | | | | | | |
Collapse
|
10
|
Hutchings G, Williams O, Cretoiu D, Ciontea SM. Myometrial interstitial cells and the coordination of myometrial contractility. J Cell Mol Med 2009; 13:4268-82. [PMID: 19732238 PMCID: PMC4496132 DOI: 10.1111/j.1582-4934.2009.00894.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A strict regulation of contractility in the uterus and fallopian tube is essential for various reproductive functions. The uterus contributes, through either increased contractility or periods of relative quiescence, to: (i) expulsion of menstrual debris, (ii) sperm transport, (iii) adequate embryo placement during implantation, (iv) enlarging its capacity during pregnancy and (v) parturition. The dominant cell population of the uterine wall consists of smooth muscle cells that contain the contractile apparatus responsible for the generation of contractile force. Recent interest has focused on a new population of cells located throughout the myometrium on the borders of smooth muscle bundles. These cells are similar to interstitial cells of Cajal (ICC) in the gut that are responsible for the generation of electrical slow waves that control peristalsis. A precise role for myometrial Cajal-like interstitial cells (m-ICLC) has not been identified. m-ICLC express the c-kit receptor, involved in creating and maintaining the ICC phenotype in the gastrointestinal tract. However, both acute and prolonged inhibition of this receptor with the c-kit antagonist imatinib mesylate does not appear to affect the spontaneous contractility of myometrium. Calcium imaging of live tissue slices suggests that contractile signalling starts on the borders of smooth muscle bundles where m-ICLC are located and recently the possible role of extracellular ATP signalling from m-ICLC has been studied. This manuscript reviews the evidence regarding tissue-level signalling in the myometrium with a particular emphasis on the anatomical and possible functional aspects of m-ICLC as new elements of the contractile mechanisms in the uterus.
Collapse
Affiliation(s)
- G Hutchings
- Perinatal Research Group, 10 floor, St Luc University Hospital, Brussels, Belgium.
| | | | | | | |
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW Abdominal wall defects comprising both gastroschisis and omphalocele remain a source of significant morbidity and mortality, despite the advances in neonatal and pediatric surgical care. Survival has improved over the past few decades, especially with parenteral nutrition and surgical repair. Yet, still, many questions remain regarding the outcome of these anomalies. RECENT FINDINGS Outcomes of abdominal wall defects have been discussed more often in the recent publications, with analysis of databases and evaluation of prenatal series. There have been a number of new prenatal interventions in gastroschisis, and a better understanding of gestational outcomes from omphalocele. Papers have discussed the optimal surgical management of these defects as well. SUMMARY This review helps to bring together the most recent findings regarding outcomes and interventions for abdominal wall defects. It also illustrates the pressing need for a large prospective database to better understand these anomalies and provide better care.
Collapse
|
12
|
Midrio P, Vannucchi MG, Pieri L, Alaggio R, Faussone-Pellegrini MS. Delayed development of interstitial cells of Cajal in the ileum of a human case of gastroschisis. J Cell Mol Med 2008; 12:471-8. [PMID: 18266958 PMCID: PMC3822536 DOI: 10.1111/j.1582-4934.2008.00277.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 02/05/2008] [Indexed: 12/12/2022] Open
Abstract
The Interstitial Cells of Cajal (ICC) are responsible for rhythmic electrical activity. A paralytic ileus is present in gastroschisis (GS), a malformation due to a defective closure of the abdominal wall through which part of the intestine herniates during pregnancy. In experimental GS, ICC morphological immaturity was shown in the rat foetus at-term but it could not be demonstrated whether differentiation is accomplished post-natally. For this purpose we morphologically investigated ICC, as well as enteric neurons and smooth muscle cells, in a case of human GS at birth and 1 month later when peristaltic activity had initiated. A 36 weeks gestation female was born by c/section with prenatal diagnosis of GS and possible volvulus of the herniated intestine. At birth, the necrotic intestine was resected and both ileostomy and colostomy were performed. The intestine continuity was restored after 4 weeks. Intestinal specimens, taken during both operations at the level of the proximal stoma, were immunostained with c-kit, neuron-specific-enolase and alpha-smooth-muscle-actin antibodies and some processed for electron microscopy. ICC were present at the myenteric plexus only. At birth, these cells were rare and ultrastructurally immature; 1 month later, when partial enteral feeding was tolerated, they formed rows or groups and many of them were ultrastructurally differentiated. Neurons and smooth muscle cells, immature at birth, had developed after 1 month. Therefore, ICC differentiation, as well as that of neurons and smooth muscle cells, is delayed at birth and this might explain the paralytic ileus in GS. One month later, differentiation quickly proceeded at all cellular levels paralleling the increasing tolerance of enteral nutrition.
Collapse
Affiliation(s)
- Paola Midrio
- Department of Pediatric Surgery, University of Padua, Padua, Italy
| | | | - Laura Pieri
- Department of Anatomy, Histology and Forensic Medicine, University of Florence, Florence, Italy
| | - Rita Alaggio
- Department of Pathology, University of Padua, Padua, Italy
| | | |
Collapse
|