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Feng Y, Zhou C, Zhao F, Ma T, Xiao Y, Peng K, Xia R. ZEB2 alleviates Hirschsprung's-associated enterocolitis by promoting the proliferation and differentiation of enteric neural precursor cells via the Notch-1/Jagged-2 pathway. Gene 2024; 912:148365. [PMID: 38485033 DOI: 10.1016/j.gene.2024.148365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/20/2024] [Accepted: 03/11/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Hirschsprung's-associated enterocolitis (HAEC) is a prevalent complication of Hirschsprung's disease (HSCR). Zinc finger E-box binding homeobox 2 (ZEB2) and Notch-1/Jagged-2 are dysregulated in HSCR, but their role in HAEC progression remains poorly understood. We aimed to explore the role and underlying mechanism of enteric neural precursor cells (ENPCs) and the ZEB2/Notch-1/Jagged-2 pathway in HAEC development. METHODS Colon tissues were collected from HSCR and HAEC patients. ENPCs were isolated from the HAEC group and stimulated by lipopolysaccharide (LPS). The expressions of ZEB2/Notch-1/Jagged-2 were measured using RT-qPCR and Western blot. Immunofluorescence and cell counting kit-8 assays were performed to assess the differentiation and proliferation of ENPCs. Inflammatory factors were measured by ELISA kits. Co-immunoprecipitation and bioinformatic analysis were used to explore the interaction between ZEB2 and Notch-1. Small interfering RNA and overexpression vectors were used to investigate the role and mechanism of ZEB2 and Notch-1 in regulating ENPCs' proliferation and differentiation during HAEC progression. RESULTS We observed increased LPS in the colon tissues of HAEC, with downregulated ZEB2 expression and upregulated Notch-1/Jagged-2 expression. ZEB2 interacts with Notch-1. LPS treatment downregulated ZEB2 expression, upregulated Notch-1/Jagged-2 expression, and induced proliferation and differentiation disorders in ENPCs, which were reversed by the knockdown of Notch-1. Furthermore, overexpression of ZEB2 inhibited Notch-1/Jagged-2 signaling and ameliorated inflammation and dysfunction in LPS-induced ENPCs. Notch-1 overexpression enhanced LPS-induced dysfunction, but this effect was antagonized by the overexpression of ZEB2. CONCLUSION Overexpression of ZEB2 ameliorates LPS-induced ENPCs' dysfunction via the Notch-1/Jagged-2 pathway, thus playing a role in HAEC.
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Affiliation(s)
- Yong Feng
- Department of Fetal and Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Chonggao Zhou
- Department of Fetal and Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Fan Zhao
- Department of Fetal and Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Tidong Ma
- Department of Fetal and Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Yong Xiao
- Department of Fetal and Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Kun Peng
- Department of Fetal and Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Renpeng Xia
- Department of Fetal and Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China.
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Feng W, Zhang B, Fan L, Song A, Hou J, Die X, Liu W, Wang Y, Guo Z. Clinical characteristics and influence of postoperative Hirschsprung-associated enterocolitis: retrospective study at a tertiary children's hospital. Pediatr Surg Int 2024; 40:106. [PMID: 38613719 DOI: 10.1007/s00383-024-05688-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 04/15/2024]
Abstract
PURPOSE To explore the influence of postoperative Hirschsprung-associated enterocolitis (post-HAEC) on long-term outcomes and to identify risk factors of post-HAEC. METHODS The medical records of 304 eligible patients diagnosed with Hirschsprung's disease (HSCR) were reviewed. We analyzed the clinical characteristics of post-HAEC and its influence on long-term outcomes. Furthermore, risk factors for early and recurrent HAEC were identified separately. RESULTS The overall incidence of post-HAEC was 29.9% (91/304). We categorized early HAEC as occurring within postoperative 3 months (n = 39) and recurrent HAEC as occurring ≥ 3 episodes within postoperative 6 months (n = 25). Patients with early HAEC were more likely to experience worse nutritional status, defecation function, and quality of life compared to those with late or no episodes (P < 0.05). Similarly, the adverse influences of recurrent HAEC on these outcomes were also significant (P < 0.05). The risk factors for early HAEC included preoperative undernutrition, long-segment HSCR, and postoperative Grade 3-4 complications within 30 days. For recurrent HAEC, risk factors were preoperative malnutrition, non-parental caregivers, long-segment HSCR, and postoperative Grade 3-4 complications within 30 days. CONCLUSION Classification of post-HAEC based on the first episode time and frequency was necessary. The earlier or more frequent episodes of post-HAEC have detrimental influences on long-term outcomes. Furthermore, risk factors for early and recurrent HAEC were different.
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Affiliation(s)
- Wei Feng
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Bobin Zhang
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Linxiao Fan
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Aohua Song
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Jinping Hou
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Xiaohong Die
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Wei Liu
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Yi Wang
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China
| | - Zhenhua Guo
- Department of General and Neonatal Surgery, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Structural Birth Defect and Reconstruction, Chongqing, China.
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Zhang X, Sun D, Xu Q, Liu H, Li Y, Wang D, Wang J, Zhang Q, Hou P, Mu W, Jia C, Li A. Risk factors for Hirschsprung disease-associated enterocolitis: a systematic review and meta-analysis. Int J Surg 2023; 109:2509-2524. [PMID: 37288551 PMCID: PMC10442125 DOI: 10.1097/js9.0000000000000473] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/08/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND The incidence of Hirschsprung disease (HSCR) is nearly 1/5000 and patients with HSCR are usually treated through surgical intervention. Hirschsprung disease-associated enterocolitis (HAEC) is a complication of HSCR with the highest morbidity and mortality in patients. The evidence on the risk factors for HAEC remains inconclusive to date. METHODS Four English databases and four Chinese databases were searched for relevant studies published until May 2022. The search retrieved 53 relevant studies. The retrieved studies were scored on the Newcastle-Ottawa Scale by three researchers. Revman 5.4 software was employed for data synthesis and analysis. Stata 16 software was employed for sensitivity analysis and bias analysis. RESULTS A total of 53 articles were retrieved from the database search, which included 10 012 cases of HSCR and 2310 cases of HAEC. The systematic analysis revealed anastomotic stenosis or fistula [ I2 =66%, risk ratio (RR)=1.90, 95% CI 1.34-2.68, P <0.001], preoperative enterocolitis ( I2 =55%, RR=2.07, 95% CI 1.71-2.51, P <0.001), preoperative malnutrition ( I2 =0%, RR=1.96, 95% CI 1.52-2.53, P <0.001), preoperative respiratory infection or pneumonia ( I2 =0%, RR=2.37, 95% CI 1.91-2.93, P <0.001), postoperative ileus ( I2 =17%, RR=2.41, 95% CI 2.02-2.87, P <0.001), length of ganglionless segment greater than 30 cm ( I2 =0%, RR=3.64, 95% CI 2.43-5.48, P <0.001), preoperative hypoproteinemia ( I2 =0%, RR=1.91, 95% CI 1.44-2.54, P <0.001), and Down syndrome ( I2 =29%, RR=1.65, 95% CI 1.32-2.07, P <0.001) as the risk factors for postoperative HAEC. Short-segment HSCR ( I2 =46%, RR=0.62, 95% CI 0.54-0.71, P <0.001) and transanal operation ( I2 =78%, RR=0.56, 95% CI 0.33-0.96, P =0.03) were revealed as the protective factors against postoperative HAEC. Preoperative malnutrition ( I2 =35 % , RR=5.33, 95% CI 2.68-10.60, P <0.001), preoperative hypoproteinemia ( I2 =20%, RR=4.17, 95% CI 1.91-9.12, P <0.001), preoperative enterocolitis ( I2 =45%, RR=3.51, 95% CI 2.54-4.84, P <0.001), and preoperative respiratory infection or pneumonia ( I2 =0%, RR=7.20, 95% CI 4.00-12.94, P <0.001) were revealed as the risk factors for recurrent HAEC, while short-segment HSCR ( I2 =0%, RR=0.40, 95% CI 0.21-0.76, P =0.005) was revealed as a protective factor against recurrent HAEC. CONCLUSION The present review delineated the multiple risk factors for HAEC, which could assist in preventing the development of HAEC.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Chunling Jia
- Stomatology, Qilu Hospital of Shandong University, Jinan, China
| | - Aiwu Li
- Departments ofPediatric surgery
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Ambartsumyan L, Patel D, Kapavarapu P, Medina-Centeno RA, El-Chammas K, Khlevner J, Levitt M, Darbari A. Evaluation and Management of Postsurgical Patient With Hirschsprung Disease Neurogastroenterology & Motility Committee: Position Paper of North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr 2023; 76:533-546. [PMID: 36720091 DOI: 10.1097/mpg.0000000000003717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Children with Hirschsprung disease have postoperative long-term sequelae in defecation that contribute to morbidity and mortality and significantly impact their quality of life. Pediatric patients experience ongoing long-term defecation concerns, which can include fecal incontinence (FI) and postoperative obstructive symptoms, such as constipation and Hirschsprung-associated enterocolitis. The American Pediatric Surgical Association has developed guidelines for management of these postoperative obstructive symptoms and FI. However, the evaluation and management of patients with postoperative defecation problems varies among different pediatric gastroenterology centers. This position paper from the Neurogastroenterology & Motility Committee of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition reviews the current evidence and provides suggestions for the evaluation and management of postoperative patients with Hirschsprung disease who present with persistent defecation problems.
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Affiliation(s)
- Lusine Ambartsumyan
- From the Division of Gastroenterology and Nutrition, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Dhiren Patel
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children's Medical Center, Saint Louis University School of Medicine, St Louis, MO
| | - Prasanna Kapavarapu
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ricardo A Medina-Centeno
- the Division of Gastroenterology, Hepatology and Nutrition, Phoenix Children's, College of Medicine, University of Arizona, Tucson, AZ
| | - Khalil El-Chammas
- the Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Julie Khlevner
- the Division of Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Marc Levitt
- the Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC
| | - Anil Darbari
- the Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC
- the Division of Gastroenterology and Nutrition, Children's National Hospital, Washington, DC
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Chantakhow S, Tepmalai K, Singhavejsakul J, Tantraworasin A, Khorana J. Prognostic factors of postoperative Hirschsprung-associated enterocolitis: a cohort study. Pediatr Surg Int 2023; 39:77. [PMID: 36622463 DOI: 10.1007/s00383-023-05364-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/10/2023]
Abstract
PURPOSE To identify prognostic factors of postoperative Hirschsprung-associated enterocolitis (HAEC). METHOD A retrospective cohort study of Hirschsprung patients between 2006 and 2021 was conducted. Patients with anorectal malformation and non-definitive surgery were excluded. Associated factors for postoperative HAEC were reported with hazard ratio (HR) and 95% confidence interval (CI). RESULTS Forty-nine patients were excluded due to concurrent anorectal malformation and incomplete data. Of 274 patients, 75 patients (27.4%) had at least one episode of postoperative HAEC. There were 28 patients (37.3%) who had multi-episodes of HAEC. The total episodes of post-operative HAEC in this study were 121 episodes (36.8%). In multivariable survival analysis, significant factors associated with postoperative HAEC were the aganglionic level above sigmoid colon (HR = 3.47, p = 0.023, 95% CI 1.19-10.09), and total colonic aganglionosis (HR = 14.83, p = 0.004, 95% CI 2.33-94.40). The patients who experienced clinical enterocolitis before 2 weeks after surgery significantly developed more postoperative HAEC (HR = 5.32, p = 0.038, % CI 1.09-25.92). The incidence of postoperative HAEC was increase in patients with postoperative obstructive symptoms (48.0%). One patient died due to severe sepsis from postoperative HAEC, while three others required intensive care. CONCLUSIONS The long involvement of aganglionic segment and early postoperative HAEC was significantly associated with postoperative HAEC. Frequent follow-up, parental education, and early treatment are recommended in these individuals, particularly in the first year after surgery.
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Affiliation(s)
- Sireekarn Chantakhow
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University Hospital Clinical Surgical Research Center, 110 Intavaroros Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand.,Faculty of Medicine, Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
| | - Kanokkan Tepmalai
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University Hospital Clinical Surgical Research Center, 110 Intavaroros Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand.,Faculty of Medicine, Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
| | - Jesda Singhavejsakul
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University Hospital Clinical Surgical Research Center, 110 Intavaroros Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand.,Faculty of Medicine, Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
| | - Apichat Tantraworasin
- Faculty of Medicine, Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand.,Faculty of Medicine, Clinical Epidemiology and Statistical Statistic Center, Chiang Mai University, Chiang Mai, Thailand.,Division of Thoracic Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Jiraporn Khorana
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University Hospital Clinical Surgical Research Center, 110 Intavaroros Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand. .,Faculty of Medicine, Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand. .,Faculty of Medicine, Clinical Epidemiology and Statistical Statistic Center, Chiang Mai University, Chiang Mai, Thailand.
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Harooni SAS, Prasad GR, Danda GR, Naureen M. Mortality Prediction Score for Hirschsprung's Disease-Associated Enterocolitis: A Novel Mortality Prediction Model. J Indian Assoc Pediatr Surg 2022; 27:594-599. [PMID: 36530801 PMCID: PMC9757779 DOI: 10.4103/jiaps.jiaps_243_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/18/2022] [Accepted: 02/12/2022] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Enterocolitis associated with Hirschsprung's disease is a fatal and serious complication. Number of scoring systems are in vogue to grade the severity of Hirschsprung's disease associated with enterocolitis (HDAEC), but none of these scoring systems help predict mortality. Hence, we attempt to develop a mortality prediction model (MPM) for HDAEC. MATERIALS AND METHODS A retrospective analysis of all cases of HDAEC encountered was analyzed. We also used the parameters of Elhalaby et al. for data collection. A total number of 71 cases were analyzed with regard to mortality in relation to each parameter. Sensitivity and specificity were calculated by statistician, and based on these values, a scoring model was proposed. All those with predicted mortality were given score 2 and those who did not were given score 1. RESULTS A total score of more than 16 predicted mortality, a score of <10 predicted survival, and a score between 11 and 15 predicted survival with morbidity. CONCLUSION A MPM for HDAEC is being proposed.
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Affiliation(s)
| | - G R Prasad
- Professor & HOD Surgery, DCMS, Hyderabad, Telangana, India
| | | | - Mahera Naureen
- Junior Resident in General Surgery, DCMS, Hyderabad, Telangana, India
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Zhan Z, Liu W, Pan L, Bao Y, Yan Z, Hong L. Overabundance of Veillonella parvula promotes intestinal inflammation by activating macrophages via LPS-TLR4 pathway. Cell Death Dis 2022; 8:251. [PMID: 35523778 PMCID: PMC9076897 DOI: 10.1038/s41420-022-01015-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/13/2021] [Accepted: 09/24/2021] [Indexed: 12/26/2022]
Abstract
Hirschsprung’s disease-associated enterocolitis (HAEC) is the most common complication of Hirschsprung’s disease (HSCR). The microbiome pattern of intestinal flora in HAEC patients was significantly abnormal compared to that in HSCR patients. The overabundance of V. parvula was detected in the gut of HAEC patients. To elucidate the pathological mechanisms of the overabundance of V. parvula, we established and analyzed inflammatory models induced by LPS or single-bacterial strain transplantation in vivo. The transplantation of V. parvula induced inflammatory response in the colon of mice. Besides, we found that LPS from V. parvula can significantly impair the barrier function of colonic epithelial cells and then activate macrophages which impaired pacemaker function of interstitial cells of Cajal (ICCs). It was thus a vicious cycle, where the macrophage-related inflammation caused by V. parvula via LPS-TLR4 pathway damaged the intestinal motility, which further aggravated the intestinal flora dysbiosis and promoted the development of HAEC. Itaconic acid could break the vicious cycle by inhibiting the activation of macrophages. It could be a potential therapeutic strategy for HAEC patients with intestinal flora dysbiosis.
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Affiliation(s)
- Zhiyan Zhan
- Department of Clinical Nutrition, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Wenxue Liu
- Department of Obstetrics and Gynecology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liya Pan
- Department of Clinical Nutrition, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Yiwen Bao
- Department of Clinical Nutrition, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Zhilong Yan
- Department of Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Li Hong
- Department of Clinical Nutrition, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China.
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Mei F, Wu M, Zhao L, Hu K, Gao Q, Chen F, Kwong JS, Wang Y, Shen XP, Ma B. Probiotics for the prevention of Hirschsprung-associated enterocolitis. Cochrane Database Syst Rev 2022; 4:CD013714. [PMID: 35470864 PMCID: PMC9039968 DOI: 10.1002/14651858.cd013714.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hirschsprung-associated enterocolitis (HAEC) is a leading cause of serious morbidity and potential mortality in children with Hirschsprung's disease (HD). People with HAEC suffer from intestinal inflammation, and present with diarrhoea, explosive stools, and abdominal distension. Probiotics are live microorganisms with beneficial health effects, which can optimise gastrointestinal function and gut flora. However, the efficacy and safety of probiotic supplementation in the prevention of HAEC remains unclear. OBJECTIVES To assess the effects of probiotic supplements used either alone or in combination with pharmacological interventions on the prevention of Hirschsprung-associated enterocolitis. SEARCH METHODS We searched CENTRAL, PubMed, Embase, the China BioMedical Literature database (CBM), the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, the Chinese Clinical Trials Registry, Australian New Zealand Clinical Trials Registry, and Clinical Trials Registry-India, from database inception to 27 February 2022. We also searched the reference lists of relevant articles and reviews for any additional trails. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing probiotics and placebo, or any other non-probiotic intervention, for the prevention of HAEC were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of the included studies; disagreements were resolved by discussion with a third review author. We assessed the certainty of evidence using the GRADE approach. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous outcomes. MAIN RESULTS We included two RCTs, with a total of 122 participants. We judged the overall risk of bias as high. We downgraded the evidence due to risk of bias (random sequence generation, allocation concealment, and blinding) and small sample size. The evidence is very uncertain about the effect of probiotics on the occurrence of HAEC (OR 0.58, 95% CI 0.10 to 3.43; I² = 74%; 2 studies, 120 participants; very low-certainty evidence). We found one included study that did not measure serious adverse events and one included study that reported no serious adverse events related to probiotics. Probiotics may result in little to no difference between probiotics and placebo in relation to the severity of children with HAEC at Grade I (OR 0.66, 95% CI 0.14 to 3.16; I² = 25%; 2 studies, 120 participants; low-certainty evidence). The effects of probiotics on the severity of HAEC at Grade II are very uncertain (OR 1.14, 95% CI 0.01 to 136.58; I² = 86%; 2 studies, 120 participants; very low-certainty evidence). Similarly, the evidence suggests that probiotics results in little to no difference in relation to the severity of HAEC at Grade III (OR 0.43, 95% CI 0.05 to 3.45; I² = 0%; 2 studies, 120 participants; low-certainty evidence). No overall mortality or withdrawals due to adverse events were reported. Probiotics may result in little to no difference in the recurrence of episodes of HAEC compared to placebo (OR 0.85, 95% CI 0.24 to 3.00; 1 study, 60 participants; low-certainty evidence). AUTHORS' CONCLUSIONS There is currently not enough evidence to assess the efficacy or safety of probiotics for the prevention of Hirschsprung-associated enterocolitis when compared with placebo. The presence of low- to very-low certainty evidence suggests that further well-designed and sufficiently powered RCTs are needed to clarify the true efficacy of probiotics.
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Affiliation(s)
- Fan Mei
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Mei Wu
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Li Zhao
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Kaiyan Hu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Qianqian Gao
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Fei Chen
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Yanan Wang
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xi Ping Shen
- Department of Statistics, School of Public Health, Lanzhou University, Lanzhou, China
| | - Bin Ma
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
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Pecoraro AR, Hunter CE, Bennett WE, Markel TA. Factors Affecting Higher Readmission Rates and Costs in Pediatric Patients With Hirschsprung Disease. J Surg Res 2021; 268:291-299. [PMID: 34392183 DOI: 10.1016/j.jss.2021.06.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hirschsprung disease is a relatively uncommon disorder of the developing gastrointestinal tract that requires surgical intervention to restore long-term function. While readmission for Hirschsprung-related complications is a known concern in these patients, we sought to identify patient-level factors associated with a prolonged hospital stay, increased costs at the time of a pull-through operation, as well as the risk for all-cause inpatient readmission after surgery. We hypothesized that higher level of care requirement during the operative stay, age at operation, and length of stay (LOS) would portend increased readmissions and disease-related complications such as Hirschsprung-associated enterocolitis. METHODS Data was obtained from the Pediatric Health Information System database on all Hirschprung patients who underwent a pull-through operation between 2004 and 2019. Regression analyses were performed on this cohort of 3345 patients. Multivariable regression models were utilized to analyze the key outcome variables of postoperative LOS and adjusted charges. RESULTS Post-operative LOS was significantly increased by the presence of a surgical complication, congenital/genetic defect, or neurologic/neuromuscular defect. Increased LOS was also seen in Black patients. The cost of pull-through operations was significantly higher in patients admitted to the NICU and ICU during index hospitalization, with a cost increase of approximately $75,000 and $57,000 respectively. Presence of a surgical complication, comorbid congenital/genetic defect, and need for mechanical ventilation were associated with higher odds of inpatient readmission. CONCLUSION The management of patients with Hirschsprung disease is longitudinal and complex. Identification of key patient metrics can aid clinicians in developing targeted care and education strategies to minimize readmission and excessive hospital charges.
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Affiliation(s)
- Anthony R Pecoraro
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - Chelsea E Hunter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - William E Bennett
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - Troy A Markel
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, Indianapolis.
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Chen Y, Yuan X, Li Y, Chen J, Wu S, Jiang A, Miao X, Shu Q. Circulating exosomal microRNA-18a-5p accentuates intestinal inflammation in Hirschsprung-associated enterocolitis by targeting RORA. Am J Transl Res 2021; 13:4182-4196. [PMID: 34150007 PMCID: PMC8205693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/15/2021] [Indexed: 06/12/2023]
Abstract
The relevance of stem cell-derived exosomes has been implicated in necrotizing enterocolitis, while the involvement of serum-derived exosomes from children with Hirschsprung-associated enterocolitis (HAEC) in pathogenesis of HAEC remains unclear. This study set to identify the roles of exosomal microRNA (miR)-18a-5p from sera of HAEC patients in human-derived colonic epithelial NCM460 cells and in mice with HAEC. Exosomes were isolated from the sera of healthy children (Healthy-exo), patients with Hirschsprung's disease (HSCR) (HSCR-exo) or HAEC (HAEC-exo). A microarray analysis of miRNAs was implemented to assess the enrichment of miRNAs in these exosomes. HAEC-exo was significantly enriched in miR-18a-5p. HAEC-exo led to the generation of a pro-inflammatory microenvironment, inhibition of cellular DNA synthesis, and promotion of apoptosis in NCM460 cells. Mechanistically, miR-18a-5p targeted and repressed retinoid-related orphan receptor α (RORA) expression, thereby regulating the Sirtuin 1 (SIRT1)/nuclear factor-kappa B (NFκB) pathway. Overexpression of RORA ameliorated inflammatory damage in NCM460 cells caused by exosomal miR-18a-5p. HAEC-exo exacerbated inflammatory damage in HAEC mice, and this facilitation was reversed after RORA overexpression. Collectively, exosomal miR-18a-5p was a promoter of HAEC, which induces the intestine cell apoptosis and inflammatory responses through the inhibition of SIRT1/NFκB pathway by targeting RORA.
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Affiliation(s)
- Yi Chen
- Department of Nosocomial Infection, Yiwu Maternity and Children HospitalJinhua 322000, Zhejiang, P. R. China
| | - Xiaojian Yuan
- Department of Pediatrics, Zhejiang University School of MedicineHangzhou 310011, Zhejiang, P. R. China
| | - Yonglin Li
- Department of Pediatric Surgery, Yiwu Maternity and Child Health HospitalJinhua 322000, Zhejiang, P. R. China
| | - Jie Chen
- Department of Pediatric Surgery, Jiaxing Maternal and Child Health HospitalJiaxing 314051, Zhejiang, P. R. China
| | - Shannan Wu
- Department of Pediatric Surgery, Yiwu Maternity and Child Health HospitalJinhua 322000, Zhejiang, P. R. China
| | - Amin Jiang
- Department of Pediatric Surgery, Yiwu Maternity and Child Health HospitalJinhua 322000, Zhejiang, P. R. China
| | - Xuefeng Miao
- Department of Pediatric Surgery, Yiwu Maternity and Child Health HospitalJinhua 322000, Zhejiang, P. R. China
| | - Qiang Shu
- Department of Cardio-Thoracic Surgery, Children’s Hospital Affiliated to Zhejiang UniversityHangzhou 310000, Zhejiang, P. R. China
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Lin Z, Lin Y, Bai J, Wu D, Fang Y. Outcomes of preoperative anal dilatation for Hirschsprung disease. J Pediatr Surg 2021; 56:483-486. [PMID: 32534905 DOI: 10.1016/j.jpedsurg.2020.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/18/2020] [Accepted: 05/01/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND/PURPOSE There are some studies about the effect of postoperative anal dilatation on anastomotic stenosis and Hirschsprung-associated enterocolitis (HAEC), but we have not seen any report about preoperative anal dilatation. We hypothesized that preoperative anal dilatation could reduce the incidence of HAEC and facilitate the operation. We aim to compare the HAEC rates and postoperative complications between groups who either had or did not have anal dilatations (AD or NAD) prescribed before laparoscopic-assisted Soave pull-through procedures for Hirschsprung disease (HD); by this means, we will evaluate the benefit of dilatations before the surgery for HD. METHODS A retrospective review of children with HD operated in our hospital between 2014 and 2018 was performed. Those with 21 trisomy, total colonic aganglionosis, multiple stage procedures, serious congenital malformations, and lost to follow-up were excluded. Patients were divided into preoperative anal dilatation group (AD group) and no preoperative anal dilatation group (NAD group). Routine anal dilatation was performed in both groups from 2 weeks after laparoscopic-assisted Soave pull-through. The anal dilatation was carried out daily with metal anal dilators with size appropriate to the age of the child. The size of the anal dilators was increased by 1 mm every 2 weeks for at least 3 months. Demographic data, operation time, pre- and postoperative HAEC rates and postoperative obstructive symptoms between groups were compared. Significance was considered at P < 0.05. RESULTS There were 95 children (17 female and 78 male) included, 36 AD and 59 NAD. There was no significant difference in demographic data between the two groups. The incidence of HAEC between the groups was not different both preoperatively (14% vs. 24%, P = 0.298) and postoperatively (11% vs. 19%, P = 0.171). The postoperative obstructive symptoms rates were 19% versus 22% for the AD and NAD groups, respectively (P = 0.802). The operation time of group AD was significantly shorter than that of group NAD (P = 0.008). Preoperative anal dilatation could shorten the operation time in short and typical-segment (2.08 ± 0.39 vs. 2.67 ± 0.37, P = 0.009 and 3.05 ± 0.38 vs. 3.29 ± 0.46, P = 0.042), but has no significant effect on long-segment disease (3.85 ± 0.41 vs. 3.89 ± 0.30, P = 0.839). CONCLUSION We have not shown a reduced risk of developing HAEC or postoperative obstructive symptoms if anal dilatations are prescribed before surgery. However, it may decrease the difficulties of surgeries, so the operative time is shortened. LEVEL OF EVIDENCE Prognosis study. LEVEL II.
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Affiliation(s)
- Zhixiong Lin
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Fujian, China
| | - Yu Lin
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Fujian, China
| | - Jianxi Bai
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Fujian, China
| | - Dianming Wu
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Fujian, China
| | - Yifan Fang
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, Fujian, China.
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Chen X, Meng X, Zhang H, Feng C, Wang B, Li N, Abdullahi KM, Wu X, Yang J, Li Z, Jiao C, Wei J, Xiong X, Fu K, Yu L, Besner GE, Feng J. Intestinal proinflammatory macrophages induce a phenotypic switch in interstitial cells of Cajal. J Clin Invest 2021; 130:6443-6456. [PMID: 32809970 DOI: 10.1172/jci126584] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 08/13/2020] [Indexed: 01/06/2023] Open
Abstract
Interstitial cells of Cajal (ICCs) are pacemaker cells in the intestine, and their function can be compromised by loss of C-KIT expression. Macrophage activation has been identified in intestine affected by Hirschsprung disease-associated enterocolitis (HAEC). In this study, we examined proinflammatory macrophage activation and explored the mechanisms by which it downregulates C-KIT expression in ICCs in colon affected by HAEC. We found that macrophage activation and TNF-α production were dramatically increased in the proximal dilated colon of HAEC patients and 3-week-old Ednrb-/- mice. Moreover, ICCs lost their C-KIT+ phenotype in the dilated colon, resulting in damaged pacemaker function and intestinal dysmotility. However, macrophage depletion or TNF-α neutralization led to recovery of ICC phenotype and restored their pacemaker function. In isolated ICCs, TNF-α-mediated phosphorylation of p65 induced overexpression of microRNA-221 (miR-221), resulting in suppression of C-KIT expression and pacemaker currents. We also identified a TNF-α/NF-κB/miR-221 pathway that downregulated C-KIT expression in ICCs in the colon affected by HAEC. These findings suggest the important roles of proinflammatory macrophage activation in a phenotypic switch of ICCs, representing a promising therapeutic target for HAEC.
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Affiliation(s)
- Xuyong Chen
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
| | - Xinyao Meng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
| | - Hongyi Zhang
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
| | - Chenzhao Feng
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Wang
- Department of Pediatric Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Ning Li
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
| | | | - Xiaojuan Wu
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
| | - Jixin Yang
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
| | - Zhi Li
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
| | - Chunlei Jiao
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
| | - Jia Wei
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
| | - Xiaofeng Xiong
- Department of Neonatal Surgery, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kang Fu
- Department of Neonatal Surgery, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Yu
- Department of Neonatal Surgery, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gail E Besner
- Department of Pediatric Surgery, Center for Perinatal Research, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College; and
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Talathi S, Wilkinson L, Meloni K, Shroyer M, Eipers P, Van Der Pol WJ, Martin C, Dimmitt R, Yi N, Morrow C, Galloway D. Scheduled Empiric Antibiotics May Alter the Gut Microbiome and Nutrition Outcomes in Pediatric Intestinal Failure. Nutr Clin Pract 2020; 36:1230-1239. [PMID: 33078427 DOI: 10.1002/ncp.10594] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 09/21/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In this study, we aim to determine the effect of scheduled antibiotics on gut microbiome in pediatric intestinal failure (IF) and to evaluate the effect of the gut microbiome on nutrition outcomes in IF. METHODS Fecal samples were collected at regular intervals from pediatric patients with IF for gut microbiome comparison between 2 cohorts: (group 1) those on scheduled prophylactic antibiotics and (group 2) those who were not on scheduled antibiotics. Gut microbiome composition and diversity were compared among the 2 cohorts. The association among gut microbiome composition, diversity, and nutrition outcomes (mainly ability to decrease parenteral nutrition [PN] energy requirement and ability to attain positive growth) was also determined. RESULTS The microbiome of patients with IF on scheduled antibiotics differed significantly from those not on scheduled antibiotics. Abundance of certain Gram-negative and pathogenic bacteria (Pseudomonas, Prevotella, and Sutterella) was higher in the scheduled cohort. Patients with decreased Enterobacteriaceae demonstrated a greater ability to demonstrate a reduction in PN requirement, as well as attain positive growth. CONCLUSION Scheduled antibiotics may alter the gut microbiome in children IF, which in turn may have an influence on important nutrition outcomes in pediatric IF. Further larger, multicenter studies are needed to determine the effect of scheduled antibiotics on the gut microbiome in this patient population and their overall effect on nutrition outcomes.
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Affiliation(s)
- Saurabh Talathi
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Linda Wilkinson
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katie Meloni
- Department of Clinical Nutrition, Children's of Alabama, Birmingham, Alabama, USA
| | - Michelle Shroyer
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter Eipers
- Department of Cell, Developmental, & Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - William J Van Der Pol
- Biomedical Informatics Center for Clinical and Translational Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Colin Martin
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Reed Dimmitt
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nengjun Yi
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Casey Morrow
- Department of Cell, Developmental, & Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David Galloway
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Kapur RP, Smith C, Ambartsumyan L. Postoperative Pullthrough Obstruction in Hirschsprung Disease: Etiologies and Diagnosis. Pediatr Dev Pathol 2020; 23:40-59. [PMID: 31752599 DOI: 10.1177/1093526619890735] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Some patients continue to have obstructive symptoms and/or incontinence after pullthrough surgery for Hirschsprung disease. Incontinence can be due to injury to the anal sphincter and/or dentate line, abnormal colonic motility (nonretentive), or a chronic large stool burden (retentive). A diagnostic algorithm based on clinical and pathological evaluations can be applied to distinguish potential etiologies for obstructive symptoms, which segregate into anatomic (mechanical or histopathological) or physiologic subgroups. Valuable clinical information may be obtained by anorectal examination under anesthesia, radiographic studies, and anorectal or colonic manometry. In addition, histopathological review of a patient's original resection specimen(s) as well as postoperative biopsies of the neorectum usually are an important component of the diagnostic workup. Goals for the surgical pathologist are to exclude incomplete resection of the aganglionic segment or transition zone and to identify other neuromuscular pathology that might explain the patient's dysmotility. Diagnoses established from a combination of clinical and pathological data dramatically alter management strategies. In rare instances, reoperative pullthrough surgery is required, in which case the pathologist must be aware of histopathological features specific to redo pullthrough resection specimens.
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Affiliation(s)
- Raj P Kapur
- Department of Pathology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Caitlin Smith
- Department of Pediatric Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Lusine Ambartsumyan
- Department of Gastroenterology, Seattle Children's Hospital, University of Washington, Seattle, Washington
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15
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Abstract
Diagnosis or exclusion of Hirschsprung disease (HSCR) is a frequent exercise in any pediatric hospital. Although HSCR may present at different ages and with varied clinical findings, the most common presentation is a neonate with severe constipation or signs of intestinal obstruction. A variety of diagnostic tests including contrast enema and anorectal manometry may be used as diagnostic screens, but diagnosis ultimately rests upon histopathological evaluation of a rectal biopsy. For the experienced pathologist, conventional hematoxylin-and-eosin-stained sections often suffice to exclude HSCR or establish the diagnosis. However, ancillary diagnostic tests such as acetylcholinesterase histochemistry or calretinin immunohistochemistry are complementary and extremely helpful in some cases. In this Perspectives article, we review the clinical and pathological features of HSCR, highlight those that are found in most patients, and discuss how to address particularly challenging aspects of the diagnostic workup.
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Affiliation(s)
- Lusine Ambartsumyan
- Department of Gastroenterology, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Caitlin Smith
- Department of Pediatric Surgery, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Raj P Kapur
- Department of Pathology, Seattle Children's Hospital and University of Washington, Seattle, Washington
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16
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Yulianda D, Sati AI, Makhmudi A, Gunadi. Risk factors of preoperative Hirschsprung-associated enterocolitis. BMC Proc 2019; 13:18. [PMID: 31890011 PMCID: PMC6912936 DOI: 10.1186/s12919-019-0172-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Hirschsprung-associated enterocolitis (HAEC) is a life-threatening complication of Hirschsprung disease (HSCR), that might occur preoperatively. We investigated the risk factors of preoperative HAEC. Method We retrospectively reviewed all medical records of HSCR patients admitted at Dr. Sardjito Hospital, Indonesia from March 2012 until March 2015. Diagnosis of HAEC was determined using the Delphi scoring system. Results Sixty-one HSCR patients were involved in this study, of whom 48 were males and 13 females. Eighteen percent (11/61) patients had a preoperative HAEC. The most common findings of the HAEC score found in our patients were distended abdomen (100%) and dilated loops of bowel (100%), followed by lethargy (72.7%), cut-off sign in rectosigmoid with absence of distal air (72.7%), leukocytosis (72.7%), and shift to left (63.6%). There was no association between gender, age of HSCR diagnosis, early/late diagnosis during neonatal period, aganglionosis type, albumin level nor body mass index with preoperative HAEC (p = 0.69, 0.76, 0.33, 1.0, 0.86, and 0.50, respectively). In addition, the maternal age, gestational age, and maternal education level also did not correlate with the development of preoperative HAEC (p = 0.71, 0.59, and 0.32, respectively). Conclusion The incidence of preoperative HAEC in our hospital is considered relatively moderate, with the most common findings of distended abdomen and dilated loops of bowel. None of the identified risk factors have an association with the development of HAEC in our patients.
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Affiliation(s)
- Dicky Yulianda
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281 Indonesia
| | - Andy Indra Sati
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281 Indonesia
| | - Akhmad Makhmudi
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281 Indonesia
| | - Gunadi
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281 Indonesia
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Lu C, Xie H, Li H, Geng Q, Chen H, Mo X, Tang W. Feasibility and efficacy of home rectal irrigation in neonates and early infancy with Hirschsprung disease. Pediatr Surg Int 2019; 35:1245-1253. [PMID: 31535199 DOI: 10.1007/s00383-019-04552-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE A single-stage pull-through (SSPT) is the most commonly performed procedure for Hirschsprung disease (HSCR) and has been shown to be better than multi-stage procedures. However, performing a SSPT in the neonatal period or early in infancy is a risk factor for an inaccurate diagnosis, post-operative enterocolitis, and a protracted post-operative recovery. The present study was primarily designed to evaluate the feasibility and efficacy of home rectal irrigation in the neonatal period and early in infancy, followed by a delayed and planned SSPT in a prospective cohort with HSCR. METHODS Between January 2014 and December 2016, a total of 147 neonates diagnosed with HSCR were enrolled in the study. Six patients were excluded as a result of ganglion cells found in second rectal biopsies after the neonatal period. One hundred twenty-two patients successfully underwent 2-4 months of home rectal irrigation during the neonatal period, followed by a SSPT procedure after the neonatal period (group A, n = 122). Nineteen patients were not candidates for home rectal irrigation, and thus, colostomies were performed during the neonatal period followed by multi-stage procedures after the neonatal period (group B, n = 19). One hundred twenty-two healthy children, age- and gender-matched to group A were enrolled as the healthy control group for assessment of nutrition status (group C, n = 122). The birth weight, gender ratio, aganglionic segment, age, and Hirschsprung-associated enterocolitis (HAEC) score at the time of HSCR diagnosis were measured to evaluate the feasibility of home rectal irrigation in neonates and early in infancy. The nutritional indices, including weight, body length, serum albumin, serum prealbumin, serum retinol-binding protein, and incidence of HAEC after 2-4 successful home rectal irrigation, were used to assess the efficacy of home rectal irrigation. Anastomotic strictures or leakage, perianal excoriation, frequency of defecation, and morbidity of post-operative HAEC were recorded to evaluate the beneficial effects to pull through (PT), which were facilitated by home rectal irrigation. RESULTS Higher HAEC scores and older age at the time of diagnosis of HSCR were associated with group B, compared to group A (4.34 ± 1.25 vs. 11.0 ± 2.56 [t = 18.20, p < 0.05] and 2.8 ± 1.46 days vs. 12.1 ± 5.3 days [t = 16.10, p < 0.05], respectively). The ratio of rectosigmoid HSCR to non-rectosigmoid HSCR was higher in group A than group B (104/18 vs. 4/15 [χ2 = 34.29, p < 0.05]). There were no differences in birth weight, weight at the time of diagnosis of HSCR, and gender ratio between groups A and B. There were no differences in birth weight, birth length, post-home rectal irrigation age, post-home rectal irrigation weight, post-home rectal irrigation length, and post-home rectal irrigation serum albumin between groups A and C (3.47 ± 0.42 kg vs. 3.48 ± 0.40 kg [t = 0.10, p > 0.05], 50.02 ± 0.49 cm vs. 50.05 ± 0.46 cm [t = 0.61, p > 0.05], 98.59 ± 13.34 days vs. 97.83 ± 13.58 days [t = 0.44, p > 0.05], 6.77 ± 0.66 kg vs. 6.97 ± 0.87 kg [t = 1.95, p > 0.05], 61.55 ± 2.14 cm vs. 61.70 ± 2.07 cm [t = 0.59, p > 0.05], and 41.78 ± 2.42 g/L vs. 41.85 ± 2.37 g/L [t = 0.22, p > 0.05], respectively). The rate of HAEC in the period of home rectal irrigation in group A was low; however, the post-home rectal irrigation serum prealbumin level and retinol-binding protein were significantly lower in group A than group C (0.15 ± 0.04 g/L vs. 0.17 ± 0.05 g/L [t = 3.50, p < 0.05] and 22.51 ± 7.53 g/L vs. 30.57 ± 9.26 g/L [t = 7.46, p < 0.05], respectively). There were no anastomotic strictures or leakage after definitive PT performed in group A. The frequency of defecation ranged from 2-6 times per day, 10 patients had perianal excoriation 3 months after PT, and 11 patients had post-operative HAEC during 6 months of follow-up after PT. CONCLUSION Home rectal irrigation in neonates and early in infancy, followed by a delayed and planned SSPT is feasible and effective in patients with HSCR, and could be beneficial to definitive PT. However, for patients with an extended aganglionic segment, older age, or high HAEC score at the time of diagnosis of HSCR, rectal irrigation maybe not suitable. TRIAL REGISTRATION This was a prospective comparative study designed to evaluate the effects of home rectal irrigation for facilitating and enhancing recovery after PT, and was registered at Clinical Trials.gov as NCT02776176.
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Affiliation(s)
- Changgui Lu
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Hua Xie
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Hongxing Li
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Qiming Geng
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Huan Chen
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Xuming Mo
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
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Zhang J, Liu F. Expression of BMP-4 and Smad1 in patients with Hirschsprung disease and its clinical significance. Exp Ther Med 2019; 18:225-229. [PMID: 31258657 PMCID: PMC6566125 DOI: 10.3892/etm.2019.7530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/04/2019] [Indexed: 11/06/2022] Open
Abstract
Expression and clinical significance of bone morphogenetic protein (BMP)-4 and Smad1 in patients with Hirschsprung disease (HD) were investigated. A retrospective analysis of 96 HD patients (experimental group) admitted to Xuzhou Children's Hospital, Xuzhou Medical University from June 2015 to June 2017 was performed. According to the samples, the experimental group was divided into the stenosis group, the transition group and the expansion group. Forty-seven children with colostomy due to intestinal obstruction were selected as the control group. The expression levels of BMP-4 and Smad1 proteins were detected by immunohistochemical staining. The expression levels of BMP-4 and Smad mRNA were detected by real-time quantitative PCR (RT-qPCR), and were quantified and compared. Via immunohistochemistry, BMP-4 and Smad1 proteins were detected in the samples of different parts of HD patients and children with intestinal obstruction. The positive expression levels of BMP-4 and Smad1 proteins in the transition group were decreased compared with those in the expansion and control groups (P<0.05), and the positive expression levels of BMP-4 and Smad1 proteins in the stenosis group were decreased compared with those in the transition, expansion, and control groups (P<0.05). Also, the gene expression levels of BMP-4 and Smad1 in the transition and stenosis groups were successively decreased, and the differences were statistically significant (P<0.05). In conclusion, the expression of BMP-4 and Smad1 in the intestinal plexus of HD lesions was significantly reduced, indicating that BMP-4 and Smad1 are closely related to the occurrence of HD, and it is suspected that they have a certain influence on the intestinal development of congenital digestive tract malformations.
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Affiliation(s)
- Jianjun Zhang
- Department of Gastroenterology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221000, P.R. China
| | - Fengli Liu
- Department of Neonatal Surgery, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221000, P.R. China
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Factors influencing the incidence of Hirschsprung associated enterocolitis (HAEC). J Pediatr Surg 2019; 54:959-963. [PMID: 30808539 DOI: 10.1016/j.jpedsurg.2019.01.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/27/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE This study aims to characterize risk factors for Hirschsprung-associated enterocolitis (HAEC). We hypothesize that earlier pull-through surgery is associated with lower risks of developing postoperative HAEC. METHODS A comparative study of 171 Hirschsprung patients treated from 1990 to 2017 was performed. Patients without HAEC were compared to patients with preoperative and/or postoperative HAEC. Results are presented as median [IQR] or frequency (%). Pearson's χ2 test and Wilcoxon rank sum test were performed with a significance level at p < 0.05. Multivariable logistic regression analysis was used to adjust for potential confounders. A subanalysis was done to evaluate laparoscopic, laparotomy, and transanal surgeries. RESULTS Risk of developing preoperative HAEC was significantly associated with congenital malformations (OR 2.63 [1.11, 6.24]; p = 0.02). Birth weight was lower in patients with preoperative HAEC (OR 0.48 [95% CI 0.25, 0.93]; p = 0.03). On regression analysis, intestinal obstruction after surgery was significantly associated with postoperative HAEC (OR 8.2 [3.18, 21.13]; p < 0.0001). Patients with earlier pull-through surgery did not have a lower risk of developing postoperative HAEC. CONCLUSIONS Timing of surgery does not seem to be associated with a higher risk of developing pre- and postoperative HAEC. Predisposing factors for preoperative HAEC included associated malformations and lower birth weight, whereas intestinal obstruction was found to be associated with postoperative HAEC. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
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Pini Prato A, Bartow-McKenney C, Hudspeth K, Mosconi M, Rossi V, Avanzini S, Faticato MG, Ceccherini I, Lantieri F, Mattioli G, Larson D, Pavan W, De Filippo C, Di Paola M, Mavilio D, Cavalieri D. A Metagenomics Study on Hirschsprung's Disease Associated Enterocolitis: Biodiversity and Gut Microbial Homeostasis Depend on Resection Length and Patient's Clinical History. Front Pediatr 2019; 7:326. [PMID: 31448249 PMCID: PMC6696876 DOI: 10.3389/fped.2019.00326] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 07/19/2019] [Indexed: 12/12/2022] Open
Abstract
Objectives: Since 2010, several researches demonstrated that microbiota dynamics correlate and can even predispose to Hirschsprung (HSCR) associated enterocolitis (HAEC). This study aims at assessing the structure of the microbiota of HSCR patients in relation to extent of aganglionosis and HAEC status. Methods: All consecutive HSCR patients admitted to Gaslini Institute (Genova, Italy) between May 2012 and November 2014 were enrolled. Institutional review board (IRB) approval was obtained. Stools were sampled and 16S rDNA V3-V4 regions were sequenced using the Illumina-MiSeq. Taxonomy assignments were performed using QIIME RDP. Alpha diversity indexes were analyzed by Shannon and Simpson Indexes, and Phylogenetic Diversity. Results: We enrolled 20 patients. Male to female ratio was 4:1. Six patients suffered from Total Colonic Aganglionosis (TCSA). Considering sample site (i.e., extent of aganglionosis), we confirmed the known relationship between sample site and both biodiversity and composition of intestinal microbiota. Patients with TCSA showed lower biodiversity and increased Proteobacteria/Bacteroidetes relative abundance ratio. When addressing biodiversity, composition and dynamics of TCSA patients we could not find any significant relationship with regard to HAEC occurrences. Conclusions: The composition of HAEC predisposing microbiota is specific to each patient. We could confirm that total colon resections can change the composition of intestinal microbiota and to dramatically reduce microbial diversity. The subsequent reduction of system robustness could expose TCSA patients to environmental microbes that might not be part of the normal microbiota. Future long-term studies should investigate both patients and their family environment, as well as their disease history.
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Affiliation(s)
- Alessio Pini Prato
- Division of Pediatric Surgery, AON SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.,Division of Pediatric Surgery, Giannina Gaslini Institute, Genoa, Italy
| | - Casey Bartow-McKenney
- Department of Dermatology and Microbiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Kelly Hudspeth
- Unit of Clinical and Experimental Immunology, Humanitas Clinical and Research Center, Milan, Italy.,Department of Medical Biotechnologies and Translational Medicine (BioMeTra), University of Milan, Milan, Italy
| | - Manuela Mosconi
- Division of Pediatric Surgery, Giannina Gaslini Institute, Genoa, Italy
| | - Valentina Rossi
- Division of Pediatric Surgery, Giannina Gaslini Institute, Genoa, Italy
| | - Stefano Avanzini
- Division of Pediatric Surgery, Giannina Gaslini Institute, Genoa, Italy
| | - Maria G Faticato
- Division of Pediatric Surgery, Giannina Gaslini Institute, Genoa, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science (DINOGMI), University of Genoa, Genoa, Italy
| | | | - Francesca Lantieri
- Biostatistics Section, Department of Health Science, University of Genoa, Genoa, Italy
| | - Girolamo Mattioli
- Division of Pediatric Surgery, Giannina Gaslini Institute, Genoa, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Science (DINOGMI), University of Genoa, Genoa, Italy
| | - Denise Larson
- Genomics, Development and Disease Section, National Human Genome Research Institute (NHGRI), National Institutes of Health (NIH), Bethesda, MD, United States
| | - William Pavan
- Genomics, Development and Disease Section, National Human Genome Research Institute (NHGRI), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Carlotta De Filippo
- Institute of Agriculture Biology and Biotechnology, National Research Council, Pisa, Italy
| | - Monica Di Paola
- Department, of Biology, University of Florence, Firenze, Italy
| | - Domenico Mavilio
- Unit of Clinical and Experimental Immunology, Humanitas Clinical and Research Center, Milan, Italy.,Department of Medical Biotechnologies and Translational Medicine (BioMeTra), University of Milan, Milan, Italy
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Abstract
OBJECTIVES The aim of the study was to characterize the microbiota profiles of patients with Hirschsprung disease (HD) and to evaluate this in relation to postoperative bowel function and the incidence of Hirschsprung-associated enterocolitis (HAEC). METHODS All patients operated on for HD at our center between 1987 and 2011 were invited to answer questionnaires on bowel function and to participate in a clinical follow-up for laboratory investigations, including fecal DNA extraction, fecal calprotectin (FC), and brush border lactase (LCT) genotyping. The microbiota compositions of patients with HD were compared with those of healthy controls aged between 2 and 7 years. RESULTS The microbiota composition of eligible patients with HD (n = 34; median age 12 [range, 3-25] years) differed from the healthy controls (n = 141), showing decreased overall microbial richness (P < 0.005). Seventy-seven percent had experienced HAEC. Normal maturation of the intestinal flora was not observed, but patients had a significantly increased abundance of Proteobacteria among other taxa (P < 0.005) resulting in a reduced carbohydrate degradation potential, as predicted by the taxonomic composition. Genetic lactase deficiency was present in 17% and did not correlate with bowel symptoms. No patients reported active HAEC at the time of sampling and FC was within the normal range in all samples. CONCLUSIONS Patients with HD and HAEC had a significantly altered intestinal microbiome compared to healthy individuals, characterized by a lack of richness and pathologic expansions of taxa, particularly Enterobacteria and Bacilli. Further evaluation is needed to identify whether these observations are intrinsic to HD or secondary to the recurrent use of antibiotics during early childhood.
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Wu S, Sun X, Yu Y, Shen Y. Hirschsprung's Disease-Related Giant Sigmoid Volvulus Complicated by Refractory Hypertension in an Elderly Man. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:467-471. [PMID: 29674606 PMCID: PMC5928755 DOI: 10.12659/ajcr.908389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patient: Male, 82 Final Diagnosis: Hirschsprung’s disease-related sigmoid volvulus complicated with refractory hypertension Symptoms: Constipation • moderate abdominal pain and progressive abdominal distension • hypertension Medication: Antihypertension medication Clinical Procedure: CT scan • Hartmann’s procedure Specialty: General Surgery
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Affiliation(s)
- Shaohan Wu
- Department of General Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China (mainland)
| | - Xiaofang Sun
- Department of Dermatology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China (mainland)
| | - Yawei Yu
- Department of Clinical Pathology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China (mainland)
| | - Yiyu Shen
- Department of General Surgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China (mainland)
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Li X, Li X, Cheng J, Zhang Y, Zou W, Xie F, Tao Z, Tang S, Du M, Liao X. Laparoscopic-assisted endorectal pull-through for Hirschsprung's disease. A retrospective study. Saudi Med J 2017; 38:1255-1258. [PMID: 29209677 PMCID: PMC5787639 DOI: 10.15537/smj.2017.12.20859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objectives: To summarize the efficacy of the laparoscopic-assisted transanal-endorectal pull-through procedure for Hirschsprung’s disease (HD). Methods: Between May 2006 and May 2013, 22 children with HD undergoing laparoscopic-assisted endorectal pull-through procedures were retrospectively analyzed. The operative time, pathology, intraoperative blood loss, recovery time for gastrointestinal function, postoperative hospital stay, complications, and defecation functions of the patients were analyzed. Results: The procedure was successfully completed in all 22 patients without conversion to open surgery. The operative time was 105-190 minutes (mean, 160.4 minutes), and the intraoperative blood loss was 20-50 ml. The mean time for the recovery of gastrointestinal function was 22 hours, and the mean postoperative hospital stay was 8 days. All patients had 1-3 defecations per day at 6 months postoperatively without constipation, soiling, or stoma stenosis. Conclusion: The laparoscopic-assisted transanal-endorectal pull-through procedure is a safe and feasible technique for patients with HD.
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Affiliation(s)
- Xiaogang Li
- Department of General Surgery, Xiangyang Central Hospital, Hubei College of Liberal Arts and Sciences, Xiangyang, China. E-mail.
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