PPARδ dysregulation of CCL20/CCR6 axis promotes gastric adenocarcinoma carcinogenesis by remodeling gastric tumor microenvironment

BACKGROUND

Peroxisome proliferator-activated receptor delta (PPARδ) promotes inflammation and carcinogenesis in many organs, but the underlying mechanisms remains elusive. In stomachs, PPARδ significantly increases chemokine Ccl20 expression in gastric epithelial cells while inducing gastric adenocarcinoma (GAC). CCR6 is the sole receptor of CCL20. Here, we examine the role of PPARδ-mediated Ccl20/Ccr6 signaling in GAC carcinogenesis and investigate the underlying mechanisms.

METHODS

The effects of PPARδ inhibition by its specific antagonist GSK3787 on GAC were examined in the mice with villin-promoter-driven PPARδ overexpression (PpardTG). RNAscope Duplex Assays were used to measure Ccl20 and Ccr6 levels in stomachs and spleens. Subsets of stomach-infiltrating immune cells were measured via flow cytometry or immunostaining in PpardTG mice fed GSK3787 or control diet. A panel of 13 optimized proinflammatory chemokines in mouse sera were quantified by an enzyme-linked immunosorbent assay.

RESULTS

GSK3787 significantly suppressed GAC carcinogenesis in PpardTG mice. PPARδ increased Ccl20 level to chemoattract Ccr6+ immunosuppressive cells, including tumor-associated macrophages, myeloid-derived suppressor cells and T regulatory cells, but decreased CD8+ T cells in gastric tissues. GSK3787 suppressed PPARδ-induced gastric immunosuppression by inhibiting Ccl20/Ccr6 axis. Furthermore, Ccl20 protein levels increased in sera of PpardTG mice starting at the age preceding gastric tumor development and further increased with GAC progression as the mice aged. GSK3787 decreased the PPARδ-upregulated Ccl20 levels in sera of the mice.

CONCLUSIONS

PPARδ dysregulation of Ccl20/Ccr6 axis promotes GAC carcinogenesis by remodeling gastric tumor microenvironment. CCL20 might be a potential biomarker for the early detection and progression of GAC.

Abstract 3821: Rapid acceleration of KRAS-mutant pancreatic carcinogenesis via remodeling of tumor immune microenvironment by PPARD

Pancreatic intraepithelial neoplasia (PanIN) is a precursor of pancreatic ductal adenocarcinoma (PDAC), which commonly occurs in the general populations with aging. Although most PanIN lesions (PanINs) harbor oncogenic KRAS mutations that initiate pancreatic tumorigenesis, PanINs rarely progress to PDAC. Critical factors that promote this progression, especially targetable ones, remain poorly defined. We show that peroxisome proliferator-activated receptor-delta (PPARD), a lipid nuclear receptor, is upregulated in PanINs in humans and mice. Furthermore, PPARD ligand activation by a high-fat diet or GW501516 (a highly selective, synthetic PPARD ligand) in mutant KRASG12D (KRASmu) pancreatic epithelial cells strongly accelerates PanIN progression to PDAC. This PPARD activation induces KRASmu pancreatic epithelial cells to secrete CCL2, which recruits immunosuppressive macrophages and myeloid-derived suppressor cells into pancreas via the CCL2/CCR2 axis to orchestrate an immunosuppressive tumor microenvironment and subsequently drive PanIN progression to PDAC. Our data identify PPARD signaling as a potential molecular target to prevent PDAC development in subjects harboring PanINs.

Citation Format: Yi Liu, Yasunori Deguchi, Daoyan Wei, Micheline J. Moussalli, Fuyao Liu, Eriko Deguchi, Donghui Li, Huamin Wang, Lovie Ann Valentin, Jennifer K. Colby, Jing Wang, Xiaofeng Zheng, Haoqiang Ying, Mihai Gagea, Baoan Ji, Jiaqi Shi, James C. Yao, Xiangsheng Zuo, Imad Shureiqi. Rapid acceleration of KRAS-mutant pancreatic carcinogenesis via remodeling of tumor immune microenvironment by PPARD [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3821.

Rapid acceleration of KRAS-mutant pancreatic carcinogenesis via remodeling of tumor immune microenvironment by PPARδ

Pancreatic intraepithelial neoplasia (PanIN) is a precursor of pancreatic ductal adenocarcinoma (PDAC), which commonly occurs in the general populations with aging. Although most PanIN lesions (PanINs) harbor oncogenic KRAS mutations that initiate pancreatic tumorigenesis; PanINs rarely progress to PDAC. Critical factors that promote this progression, especially targetable ones, remain poorly defined. We show that peroxisome proliferator-activated receptor-delta (PPARδ), a lipid nuclear receptor, is upregulated in PanINs in humans and mice. Furthermore, PPARδ ligand activation by a high-fat diet or GW501516 (a highly selective, synthetic PPARδ ligand) in mutant KRASG12D (KRASmu) pancreatic epithelial cells strongly accelerates PanIN progression to PDAC. This PPARδ activation induces KRASmu pancreatic epithelial cells to secrete CCL2, which recruits immunosuppressive macrophages and myeloid-derived suppressor cells into pancreas via the CCL2/CCR2 axis to orchestrate an immunosuppressive tumor microenvironment and subsequently drive PanIN progression to PDAC. Our data identify PPARδ signaling as a potential molecular target to prevent PDAC development in subjects harboring PanINs.

Redundant roles of EGFR ligands in the ERK activation waves during collective cell migration

By knocking out all four EGFR ligands expressed in MDCK cells, this study shows the redundant and specific roles of each EGFR ligand in the ERK activation waves during collective cell migration.

Epidermal growth factor receptor (EGFR) plays a pivotal role in collective cell migration by mediating cell-to-cell propagation of extracellular signal-regulated kinase (ERK) activation. Here, we aimed to determine which EGFR ligands mediate the ERK activation waves. We found that epidermal growth factor (EGF)–deficient cells exhibited lower basal ERK activity than the cells deficient in heparin-binding EGF (HBEGF), transforming growth factor alpha (TGFα) or epiregulin (EREG), but all cell lines deficient in a single EGFR ligand retained the ERK activation waves. Surprisingly, ERK activation waves were markedly suppressed, albeit incompletely, only when all four EGFR ligands were knocked out. Re-expression of the EGFR ligands revealed that all but HBEGF could restore the ERK activation waves. Aiming at complete elimination of the ERK activation waves, we further attempted to knockout NRG1, a ligand for ErbB3 and ErbB4, and found that NRG1-deficiency induced growth arrest in the absence of all four EGFR ligand genes. Collectively, these results showed that EGFR ligands exhibit remarkable redundancy in the propagation of ERK activation waves during collective cell migration.

Distribution of gene segments of the pandemic A(H1N1) 2009 virus lineage in pig populations

Swine influenza viruses (SIVs) are important not only for pig farming, but also for public health. In fact, pandemic A(H1N1) 2009 viruses [A(H1N1)pdm09] were derived from SIVs. Therefore, timely characterization of locally circulating SIVs is necessary for understanding the global status of SIVs. To genetically characterize SIVs circulating in Japanese pig populations, we isolated 24 SIVs of three subtypes (17 H1N1, four H1N2 and three H3N2 strains) from 14 pig farms in Japan from 2013 to 2016. Genetic analyses revealed that the haemagglutinin (HA) and neuraminidase (NA) genes of the 17 H1N1 and the HA gene of one H1N2, A/swine/Aichi/02/2016 (H1N2), SIVs belonged to the A(H1N1)pdm09 lineage. More importantly, all of the remaining six gene segments (i.e., PB1, PB1, PA, NP, M and NS) of the 24 SIVs, regardless of the HA and NA subtype, were also classified as belonging to the A(H1N1)pdm09 lineage. These results indicate that gene segments of A(H1N1)pdm09 lineage are widely distributed in SIVs circulating in Japanese pig populations In addition, the NA gene of A/swine/Aichi/02/2016 (H1N2) shared less than 88.5% nucleotide identity with that of the closest relative A/swine/Miyagi/5/2003 (H1N2), which was isolated in Japan in 2003. These results indicate the sustained circulation of classical H1N2-derived SIVs with remarkable diversity in the NA genes in Japanese pig populations. These findings highlight the necessity of both intensive biosecurity systems and active SIV surveillance in pig populations worldwide for both animal and public health.

Application of mycotoxin adsorbent to cattle feed contaminated with zearalenone: urinary zearalenone excretion and association with anti-Müllerian hormone

This study investigated (1) protective effects of a commercially available mycotoxin adsorbent (MA) and (2) endocrine effects of in vivo exposure to zearalenone (ZEA) in cattle. The sample included a Japanese Black female cattle herd (MYT herd) that displayed persistently high urinary ZEA concentrations. A second herd (NM herd) was used as a control. Three groups from each herd were assessed: MX (n=6; MA mixed with concentrate), TD (n=6; MA applied as topdressing with the concentrate), and a positive control (n=6; no MA application). Urine and blood samples were collected at the start of MA supplementation (day 0), on the final day of supplementation (day 16), and on the final day of the sampling period (day 58 for MYT herd and day 50 for NM herd). Urinary ZEA concentrations (pg/mg of creatinine) were measured by ELISA and liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS). Haematological and serum biochemical analyses were performed to monitor hepatic, renal, nutritional, and mineral intake statuses. Ovulation status was assessed by progesterone (P4) and antral follicle population by anti-Müllerian hormone (AMH) levels. The urinary concentrations of ZEA and its metabolites in the MX and TD groups were significantly lower (P<0.05) at day 16 compared with the control group, as measured by LC-MS/MS. The valid ratio of AMH-positive (≯0.08 ng/ml) cattle was significantly higher in the NM herd than in the MYT herd without affecting the P4-positive (≯3 ng/ml) ratio, suggesting different populations of antral follicles. Significant differences were also observed between the MX and the control in aspartate aminotransferase and γ-glutamyltransferase at day 58, suggesting preventive effects of MA supplementation. Our field trial indicated that MA supplementation of a ZEA-contaminated diet has beneficial effects in reducing ZEA absorption from the intestine of cattle, maintaining endocrine homeostasis and reversing hepatic effects.

Natural contamination of dietary rice straw with zearalenone and urinary zearalenone concentrations in a cattle herd

The present study was conducted to 1) identify the natural source of feed contamination by zearalenone (ZEN), which was suspected to have caused persistently increased urinary ZEN concentrations in one of our experimental cattle herds, and 2) evaluate the effects of intervention against this source of contamination. As an experimental model, a fattening Japanese Black cattle herd showing persistently increased urinary ZEN concentrations was identified. Urinary ZEN concentrations of cows fed with new rice straw (experimental group, n = 6) vs. cows that continued to feed on the old rice straw (control group, n = 4) were measured at the start (d 1) and at 2 wk (d 14) after the onset of feeding with straw. In addition, the ZEN concentration in feed and water samples was measured by using both the ELISA and HPLC methods. Furthermore, isolation and identification of fungi from rice straw and concentrate feed samples were performed. The urinary ZEN concentration [ZEN (pg/mL)/creatinine (mg/mL) = pg/mg of creatinine] of cows fed with new rice straw was significantly (P < 0.05) less (843 pg/mg of creatinine) than that of cows fed with old rice straw (15,951 pg/mg of creatinine). On both d 1 and 14, the ZEN concentrations of old rice straw were greater than those of new rice straw. In addition, fungal colonies were observed in the culture media that was obtained from the old rice straw suspected of ZEN contamination, but not in the culture media from new rice straw or other feed samples. In conclusion, our field trials clearly indicate that the rice straw fed to the cows was naturally contaminated with ZEN, and that the monitoring of urinary ZEN concentrations could prove to be a useful tool for detecting the exposure of cattle to ZEN contamination at the farm level.

PCSK5 and GDF11 expression in the hindgut region of mouse embryos with anorectal malformations

BACKGROUND/PURPOSE

Retinoid-mediated signal transduction plays a crucial role in the embryonic development of various organs. We previously reported that retinoic acid induced anorectal malformations (ARM) in mice. GDF11 is a TGFβ superfamily molecule and is cleaved and activated by proprotein convertase subtilisin/kexin 5 (PCSK5). PCSK5 (PC5/6) mutations result in an abnormal expression of Hlxb9 and Hox genes, which include known GDF11 targets that are necessary for caudal development in vertebrate embryos. To determine a possible role of the retinoid-mediated signaling pathway in the pathogenesis of ARM, we investigated whether all-trans retinoic acid (ATRA) affected the expression patterns of PCSK5 and GDF11 in ARM-treated mouse embryos.

METHODS

Pregnant ICR-Slc mice were administered 100 mg/kg ATRA by gavage on embryonic day (E) 9.0. Embryos were harvested between days E12 and E18, and mid-sagittal sections of the hindgut region were prepared for immunohistochemistry using antibodies against PCSK5 (PC5/6) and GDF11 (GDF8/11).

RESULTS

Over 95% of the embryos treated with ATRA showed ARM, with rectourethral fistula or rectocloacal fistula, and a short tail. Furthermore, most of these embryos exhibited sacral malformations, tethered spinal cords, and presacral masses resembling those malformations found in caudal regression syndrome. By E14, normal mouse embryos formed a rectum and anus, and the somites behind the hindgut were positive for PC5/6 and GDF8/11. In contrast, in ARM embryos, the somites behind the hindgut were negative for PC5/6 and GDF8/11.

CONCLUSION

ATRA treatment affected the caudal development in mouse embryos, resulting in anorectal, sacral, and spinal malformations, and inhibited PCSK5 and GDF11 expression in the hindgut region. These findings indicate that the expression of PCSK5 and GDF11, which plays a crucial role in the organogenesis of the hindgut, was disturbed in the hindgut region when retinoid-mediated signaling was disrupted. This study offers a new insight into the pathogenesis of ARM in mice as affected by the interaction between ATRA and PCSK5/GDF11.

The significance of steroid therapy after hepatoportoenterostomy in infants with biliary atresia

PURPOSE

Despite improvements in the surgical management of biliary atresia (BA), it is still difficult to maintain good bile flow. In the present study, we examined steroid therapy and determined the appropriate dose to achieve freedom from jaundice after hepatoportoenterostomy (HPE) in the uncorrectable type of BA.

METHODS

A retrospective clinical analysis was done in 23 of 29 (79 %) cases who had become jaundice-free after undergoing HPE with steroid therapy between 1988 and 2004. A correlation between the total or mean steroid dose and the postoperative jaundice period (serum total bilirubin > 1.0 mg/dl) was evaluated using linear regression analysis. The regimen was as follows: prednisolone was given intravenously, starting with 3 to 5 mg/kg/day, and then gradually tapered with repetition until freedom from jaundice was achieved.

RESULTS

Age at HPE was 72 +/- 20 days (mean +/- SD), and the postoperative jaundice period was 108 +/- 68 days. Total and mean steroid doses were 118 +/- 73 mg/kg and 1.31 +/- 0.8 mg/kg/day, respectively. There was no correlation between the total steroid dose and the period of jaundice. However, there was a significant correlation between the mean steroid dose and the period of jaundice (p = 0.021).

CONCLUSION

A high mean dose of steroids could shorten the jaundice period after HPE in the uncorrectable type of BA.

Significance of the anomalous arrangement of the pancreaticobiliary duct in the etiology of biliary atresia

BACKGROUND/PURPOSE

The anomalous arrangement of the pancreaticobiliary duct (AAPBD) is one theory used to explain the etiology of biliary atresia. We investigated whether AAPBD could be involved and evaluated its significance for the etiology of biliary atresia.

MATERIALS AND METHODS

Of 43 patients with biliary atresia, the area between the common bile duct and the duodenum could be visualized by operative cholangiogram in 5 patients with an uncorrectable type of biliary atresia. Three of the 5 showed an anomalous arrangement of the pancreaticobiliary duct. In these 3 patients, the type of anomalous arrangement of the pancreaticobiliary duct and the length of the common channel were studied by operative cholangiogram. Histological findings of the gallbladder and the common bile duct were examined in addition to the measurement of the serum amylase levels.

RESULTS

All 3 patients showed AAPBD with the P-C type of pancreaticobiliary junction. The length of the common channel ranged from 7 mm to 12 mm. Two of the 3 cases did not show an elevated serum amylase level. Epithelial hyperplasia of the gallbladder was observed in one patient, while the other two showed no hyperplasia. Inflammatory changes in the mucosa of the gallbladder and the common bile duct were not remarkable in these 3 patients.

CONCLUSIONS

From these results it seems that AAPBD in biliary atresia might not be an etiological factor for atresia of the extrahepatic bile duct, but might be an associated anomaly in biliary atresia. Other factors should be examined to clarify the etiological factor leading to lumenal obstruction of the extrahepatic bile duct.

Bleeding tendency as a first symptom in children with congenital biliary dilatation

AIM OF THE STUDY

Although a bleeding tendency as a first symptom is a critical condition in congenital biliary dilatation (CBD), the clinical details of this symptom remain unclear. We assessed this condition in children with CBD in this paper.

MATERIALS AND METHODS

Sixty-five children with CBD were treated at our institute between 1983 and 2004. The children, initially presenting with bleeding manifestations such as intracranial hemorrhage and bloody stools, were defined as the bleeding group, and the remaining children with digestive symptoms such as abdominal pain and vomiting were defined as the digestive group. The clinical features were compared between these two groups.

RESULTS

In 6 of the 65 cases, bleeding manifestations were noted (9.2 %). All six had cystic-type choledochal dilatation. The mean age of the bleeding group was significantly younger than that of the digestive group, and bleeding was more frequent, especially in infants less than 12 months of age. In a laboratory study, the bleeding group showed a more prolonged blood coagulation time than the digestive group did. Serum amylase and lipase levels in the bleeding group were almost normal, while those in the digestive group were significantly higher. The direct bilirubin level in the bleeding group was significantly higher than that in the digestive group.

CONCLUSIONS

Disturbed blood coagulation due to vitamin K deficiency related to cholestasis results in a bleeding tendency in children with CBD. Therefore, pediatric surgeons should be aware of this rare but critical condition which can be prevented by rapid and precise treatment with vitamin K supplementation.

Primary erythrocytosis in a Japanese black calf: a case report

An 8-month-old Japanese Black heifer with severe erythropoietic symptoms was subjected to clinical, histological and cytological examinations. During the 1 month clinical observation period, severe increases in RBC count, packed cell volume and haemoglobin concentration were observed. The plasma erythropoietin (Epo) concentration of the heifer (20.7 mIU/ml) was similar to that observed in normal control heifers. Blood gas examinations of the arterial and venous blood revealed low levels of partial pressure O(2) (PaO(2)), partial pressure CO(2) (PaCO(2)) and O(2) saturation (SaO(2)), while the blood pH was within the normal range. Gross lesions could not be detected. However, microscopic observation revealed severe proliferation of erythroblasts in the bone marrow and in the spleen without evidence of neoplastic changes. Based on these clinical and pathological examinations, we diagnosed the heifer as being the first case of primary erythrocytosis in Japanese Black cattle.

A clinical analysis of prognostic parameters of survival in children with congenital diaphragmatic hernia

BACKGROUND

Congenital diaphragmatic hernia (CDH) still has a high mortality because of accompanying lung hypoplasia and persistent pulmonary hypertension. Although prognostic parameters based on perinatal measurements have been proposed, our ability to accurately predict the surgical results remains insufficient.

METHODS

We treated 55 infants with CDH from 1981 to 2004. Among them, 46 patients presented respiratory distress within the first 24 hours of life. Results of surgical treatment in the 46 infants were retrospectively correlated with gender, birth weight, gestational age at diagnosis, laterality, cardiac anomalies, diaphragmatic defect area, contents of herniated viscera, and the great vessel diameters measured by echocardiography.

RESULTS

Out of 46 CDH neonates, 27 (58.7 %) survived and 19 (41.3 %) died aged 3 to 17 days. Non survivors had a significantly larger diaphragmatic defect and more frequent liver herniation. Out of possible predictive parameters studied, an index of the main pulmonary artery (cross-sectional area/diaphragmatic defect area ratio) most closely correlated with the surgical outcomes.

CONCLUSIONS

The postoperative prognosis of CDH infants does not depend only on pulmonary hypoplasia, but also on other factors including the magnitude of abdominal visceral herniation. In this series of patients, the most reliable prognostic predictor was a clinical index reflecting the degree of both pulmonary hypoplasia and diaphragmatic maldevelopment.

Esophagogastrostomy reconstruction after limited proximal gastrectomy

BACKGROUND/AIMS

Recent advances in diagnostic techniques have led to the detection of an increasing number of early gastric cancers in the upper third of the stomach. The objective of this study was to determine the most appropriate surgical treatment for these cancers.

METHODOLOGY

The clinicopathologic characteristics of 35 patients with early gastric cancer in the upper third of the stomach who underwent three different types of gastrectomies were reviewed retrospectively from hospital records between January 1992 and August 1999.

RESULTS

Patients undergoing limited proximal gastrectomy with esophagogastrostomy reconstruction had shorter operation times and less blood loss than those for patients undergoing total gastrectomy or proximal gastrectomy with jejunal interposition. No lymph node metastasis was identified in any of these patients. Heartburn due to reflux esophagitis was seen in a few patients of each group, but they were successfully treated by antacids. The extreme reduction in food intake volume was more frequently experienced in patients with total gastrectomy than those with both proximal gastrectomies. When mortality due to other disease was excluded, all patients survived without recurrence.

CONCLUSIONS

A limited proximal gastrectomy with esophagogastrostomy reconstruction decreased surgical risk and realized preservation of maximal function.

Antenatal diagnosis of biliary atresia (noncorrectable cyst type): a case report

At 32 weeks of gestation a cystic mass was identified in the hepatic hilum of a fetus by maternal sonography. Laparotomy was performed at 39 days of life after a diagnosis of correctable type of biliary atresia (Type I). A cystically dilated extrahepatic duct, in which the proximal and distal sides of the common bile duct were occluded (Type III with cyst, noncorrectable type), was identified by operative cholangiography. A standard Kasai operation was performed, and 1 year after operation the patient was doing well and was jaundice-free. From this experience in routine maternal sonography, a cystic mass in the hepatic hilum may also suggest Type III biliary atresia with a cyst.

Morphological changes of platelets following platelet aggregation induced by collagen in Japanese Black cattle with delta-storage pool deficiency

Electron microscopic observation was performed on platelets activated by collagen stimulation in Japanese Black cattle with delta-storage pool deficiency (delta-SPD) to identify their morphological and functional abnormalities compared from normal bovine platelets. Platelets of normal Japanese Black cattle changed their shapes to spherical and were in the phase of release reactions 5 min after the collagen (90.9 microg/ml) stimulation, and most of platelets were aggregated. On the other hand, in GSPD cattle, most of a granules were still dispersed in activated platelets, although the spherical shape change of the platelets was observed. These results suggested that there are abnormalities in the release reactions in platelets of delta-SPD cattle.

Changes of platelet cytoskeletal proteins following platelet aggregation induced by collagen and platelet membrane glycoprotein in Japanese black cattle with delta-storage pool deficiency

Five Japanese Black cattle showing the tendency of persistent hemorrhage were diagnosed as delta-storage pool deficiency because of lack of dense bodies in platelets. There was no significant difference in the platelet count, fibrinogen concentration, prothrombin time and activated partial thromboplastin time between the cases and normal control cattle. However, the maximum platelet aggregation rate and the values of myosin in the cytoskeletons during platelet aggregation induced by collagen were significantly lower in the cases compared with those in normal control cattle. The quantities of platelet membrane glycoprotein were in the range of 94-160 kDa and were not different between the cases and control cattle. However, a decrease of thrombospondin in alpha-granules in platelet cytoplasm were suspected in two of the 5 cases.

Relationship between intraoperative cholangiographic patterns and outcomes in biliary atresia

Intraoperative cholangiography revealed biliary tracts in 11 of 25 (44%) patients with biliary atresia. The outcome of these 11 patients was analyzed based on the cholangiographic patterns. In these 11 patients, 4 cases were the 1-cyst type, 3 showed a "cloudy shadow" pattern in the intrahepatic biliary tract, and 4 were subtype "a" pattern (distally patent common bile duct). Four patients showing the I-cyst type underwent hepaticojejunostomy with Rouxen-Y anastomosis, and all of the 4 became jaundice-free a few weeks after surgery. Three patients with the "cloudy shadow" pattern gained good bile drainage after hepatic portoenterostomy with Suruga II modification, all were complicated by ascending cholangitis. Three of the 4 subtype "a" pattern underwent hepatic portoenterostomy with Suruga II modification. Two became jaundice-free, while jaundice persisted in one. The subtype "a" patient who underwent hepatic porto-cholecystostomy showed poor bile drainage, and died of hepatic failure 17 months after surgery despite further surgery. From these results, we conclude that 1) hepatico-jejunostomy with Roux-en-Y anastomosis is indicated for I-cyst biliary atresia. 2) Prevention of ascending cholangitis is important in patients with the "cloudy shadow" pattern. 3) Hepatic porto-jejunostomy is indicated for the subtype "a" pattern rather than hepatic porto-cholecystostomy.

Effects of fighting after grouping on plasma cortisol concentration and lymphocyte blastogenesis of peripheral blood mononuclear cells induced by mitogens in piglets

One litter (Group A) of three unacquainted groups of littermates (4 piglets/litter), 64.0 +/- 0.8 days old, was moved to the pen of another litter (Group B) and they were housed together for 19 days after grouping (phase 1). The pigs in Group B violently attacked all the pigs in Group A for 9 hr after grouping. The remaining group was not grouped and used as controls. The plasma cortisol concentrations 1 hr after grouping were significantly higher than those 1 hr before and 24 hr after grouping, and the suppression of lymphocyte blastogenesis of peripheral blood mononuclear cells (PBMC) induced by mitogens was observed on 3, 8 and 19 days after grouping. After phase 1 ended, the pigs in Group A were returned to their own pen for 7 days, and then they were regrouped with the pigs in Group B and reared together for a further 14 days. Neither agonistic behavior nor change of plasma cortisol after regrouping was seen. Though the lymphocyte blastogenesis of PBMC induced by the mitogens on day 0 after regrouping was significantly lower in the pigs of Groups A and B compared to those in control pigs, a significant difference in lymphocyte blastogenesis among three groups was not seen on 7 and 14 days after regrouping. These findings indicate that fighting after grouping unacquainted litters increases plasma cortisol, and suppresses lymphocyte blastogenesis for 26 days after grouping.

Ongoing osteolysis in patients with lymphangioma

Severe osteolysis is a rare complication of lymphangioma. It can progress despite treatment and may be fatal. Four patients presented with massive osteolysis and serious related complications. Of these, two responded well to OK-432 therapy with arrest of the osteolysis. Complete recovery from life-threatening pleural effusion has been noted in one. Of the two nonresponders, one died of progressive osteolysis of the cervical and occipital bones, the other, despite therapy, still shows progressive osteolysis of the left leg from the femur to the phalanges. A boneless leg may be the outcome.

Renal clearance of endogenous creatinine, urea, sodium, and potassium in normal cats and cats with chronic renal failure

The renal clearance test was carried out in 6 normal male cats and 12 male cats with chronic renal failure. The average concentrations of creatinine (Cr), urea, sodium (Na), and potassium (K) in the serum of the cats with chronic renal failure were 5.09, 136.7 (mg/100 ml), 143.9 and 3.71 (mEq/l) respectively, and the specific gravity of urine was 1.009. The renal clearances of Cr, urea, Na, and K (ml/min/kg of body weight) were 2.639 +/- 0.217, 1.034 +/- 0.110, 0.024 +/- 0.007 and 0.266 +/- 0.028, respectively in normal cats, and were 0.789 +/- 0.407, 0.358 +/- 0.211, 0.095 +/- 0.084 and 0.872 +/- 0.204 in cats with chronic renal failure. Clearance of Cr and urea was significantly lower in cats with chronic renal failure than in normal cats, while the values of Na and K were significantly higher in cats with chronic renal failure. The glomerular filtration of Cr and urea and the urinary excretion of these 4 substances were significantly higher in cats with chronic renal failure. The tubular reabsorption rates of Na and K were significantly lower in cats with chronic renal failure compared to those in normal cats, but there was no significant difference in urea and creatinine.

Relation between daily urinary creatinine and body weight in castrated male Landrace pigs

For clarifying the relation between the amount of daily urinary creatinine (Cr) and the body weight (BW), fifty-eight healthy castrated male Landrace pigs ranging from 28.6 kg to 93.5 kg in body weight (BW) were examined. There was a significant positive correlation between the BW (X = kg) and Cr (Y = mg/day), and a linear regression formula of Y = 40.7X-224.9 (R2 = 0.985, P < 0.001) was obtained. The coefficient of variation of the daily urinary Cr was small (5.1 +/- 2.4%). On the other hand, in the relation between the BW and quantity of urine in 24 hr, and in the relation between the daily urinary creatinine and daily urinary volume, no significant correlation was recognized (P > 0.2), respectively.

Results of a modified Duhamel Operation for Hirschsprung's disease using the GIA stapler

Thirty-six patients with Hirschsprung's disease underwent surgery using modified Duhamel operation with the GIA (gastrointestinal autosuture) stapler over a 12-year period at our institution. We now present our experience from the perspective of postoperative complications and anorectal function. Postoperative complications included minimal anal bleeding due to the GIA stapler in 2 patients, and mild enterocolitis in 6 patients. Severe complications such as anastomotic leakage or stricture were not observed in our series. Overall, postoperative anorectal function was good in patients without Down's syndrome or cerebral palsy. Follow-up of our patients showed that a good quality of life was achieved during childhood. We conclude, therefore, that the modified Duhamel operation, with the use of the GIA stapler, is a safe and easy procedure for correction of Hirschsprung's disease.

Management and design of the maintenance of SAM mouse strains: an animal model for accelerated senescence and age-associated disorders

The Senescence-Accelerated Mouse (SAM) was established by inbreeding and pedigree selection based on the life span, degree of senescence, as well as the incidence and degree of several age-associated disorders. At first, SAM strains were developed under conventional conditions, but now some strains are also maintained under specific pathogen-free conditions. There are many methods used to maintain such strains of mice; our methods will be introduced as one example of how to develop and maintain strains of mice used in aging research.

OK-432 therapy for lymphangioma in children: why and how does it work?

Intralesional injection of OK-432 (lyophilized incubation mixture of group A Streptococcus pyogenes of human origin) is safe and effective therapy for lymphangioma. The authors evaluated the mechanism of this therapy in 6 patients who had cystic lymphangioma. The intracystic fluid of the cystic lymphangioma was aspirated before and after (on days 1 and 4) the OK-432 therapy. Changes in cell populations and cytokine productions in each aspirated fluid were analyzed. White blood cells in the intracystic fluid increased markedly in number. Before OK-432 therapy, 96% of the intracystic white blood cells were lymphocytes, and the remaining were neutrophils and macrophages. On day 1, the percentages of neutrophils and macrophages increased to 72% and 21%, respectively. On day 4, the percentage of lymphocytes increased to 72%. Flow cytometry analysis using monoclonal antibodies showed that the number of natural killer cells (CD56+) and T cells (CD3+) had increased. The activity of cytotoxic tumor necrosis factor (TNF) and interleukin-6 increased immediately after OK-432 injection and remained high in titer until day 4. These findings suggest that the white blood cells induced and activated by OK-432, and the cytokines (including TNF) produced by these cells increased the endothelial permeability, and thus the accelerated lymph drainage and increased lymph flow let to shrinkage of the cystic spaces.

An association of multiple intestinal atresia and biliary atresia: a case report

This is the first report of a 2-day-old girl having an association of biliary atresia and multiple intestinal atresia. She developed intractable vomiting in the first hours of life. An upper gastrointestinal series and barium enema showed jejunal atresia and rectal atresia. A laparotomy was performed on the fourth day of life. The operative findings were multiple sites of atresia of the intestine, 10 atretic sites in the small bowel, and 3 in the colon. The gall bladder was normal in size and position. After the operation, the patient's stool remained acholic and her jaundice did not resolve. On the 58th day of life, another laparotomy was performed with the presumptive diagnosis of biliary atresia. The operative finding was biliary atresia, type 3; the Kasai operation with external jejunostomy was performed. The patient suffered from postoperative cholangitis and enterocolitis because of her short bowel and subsequently died at 9 months of age. This is the first case of biliary atresia associated with multiple intestinal atresia reported in the literature.

Impaired proliferative activity of mesenchymal cells affects the migratory pathway for neural crest cells in the developing gut of mutant murine embryos

The developmental expression of neural and cell proliferation-related antigens in guts from mutant murine embryos (Is, lethal spotted) as a model for Hirschsprung's disease was studied. The expression was examined immunohistochemically using antibodies specific for neural cell adhesion molecule (NCAM), the L1 molecule, and proliferative cell-related nuclear antigen (PCNA). Cells immunoreactive for neural components proceeded from the esophagus to the anorectum showing a one-way migratory wave between embryonal day 10 (E10) and E14 in control specimens (Is/+, +/+). The patterns of NCAM and L1 immunoreactivity in Is/Is mutant specimens was the same as in controls on E10. However, from E10.5 to E13.5, the immunoreactivity in the mutants decreased and remained in the more oral side as compared with controls. No migration of immunoreactivity was found after E14.0. Therefore, the terminal portion of the colon remained aganglionic in Is/Is mutant embryos. PCNA immunoreactivity of mesenchymal cells preceded the migratory wave of the neural specific immunoreactivity, but the PCNA-positive cells were meager and poorly organized in the mutant embryos. Deficient PCNA staining patterns were found in mesenchymal tissue rather than in the migrating cells themselves. This impaired PCNA expression may reflect a deficient microenvironment for migration such that neural crest cells cannot colonize properly.

Increased numbers of argyrophilic nucleolar organizer regions between primary and metastatic sites predict tumor progression in stage IV and IV-S neuroblastoma

BACKGROUND

A silver colloid technique to determine nucleolar organizer region (AgNOR) number was used to study the proliferative activity of Stage IV-S neuroblastoma in which a spontaneous tumor regression is often observed.

METHODS

Primary regional lymph nodes and hepatic lesions from five children with Stage IV-S and five with Stage IV neuroblastoma were examined.

RESULTS

Average AgNOR counts per tumor cell nucleus from all five children with Stage IV neuroblastoma were lowest in the primary lesions, intermediate in the metastatic regional lymph nodes, and highest in the distant metastases. However, in four Stage IV-S patients whose metastases later disappeared and showed no sign of recurrence, the average AgNOR number was similar in primary tumors and metastatic lesions. In the other patient with progressive metastases initially diagnosed as Stage IV-S, the data showed the same pattern as in Stage IV neuroblastoma.

CONCLUSIONS

The unique AgNOR staining pattern may reflect the proliferative activity of Stage IV-S neuroblastoma. This method may provide further information to differentiate a subtype of metastatic neuroblastoma showing spontaneous tumor regression and/or favorable prognosis.

OK-432 therapy in 64 patients with lymphangioma

Intralesional injection of OK-432 was employed to treat 64 lymphangiomas between 1986 and 1992. This was used as primary therapy for 46 lesions (group A), as treatment following incomplete surgical removal in 14 (group B), and as therapy after failure of bleomycin in 4 (group C). In group A (n = 46), total shrinkage of the lesion, without serious complications, was noted in 23; there was marked shrinkage in 8, slight shrinkage in 12, and no response in 3. Of the cystic lesions (n = 24), significant shrinkage occurred in 22; of the cavernous lesions (n = 22), only 9 improved after treatment. In groups B (n = 14) and C (n = 4) there was significant clinical improvement occurred in 5 and 2, respectively. No recurrence was noted during follow-up (6 to 87 months). The only side effects were fever lasting 2 to 4 days and a local inflammatory reaction of 3 to 7 days' duration. The local inflammation did not cause any damage to the overlying skin and did not lead to scar formation. These data suggest that intralesional injection of OK-432 is effective treatment for lymphangiomas and should be considered as the primary method of treatment.

Changes of serum amylase, its isozyme fractions and amylase-creatinine clearance ratio in dogs with experimentally induced acute pancreatitis

To investigate the diagnostic application of amylase to canine pancreatic diseases, serum amylase activities, its isozyme fractions and amylase-creatinine clearance ratio (ACCR) were analyzed in normal intact dogs and dogs experimentally induced acute pancreatitis. There was no statistic difference between normal male and female dogs. Amylase specific activities in pancreatic tissue extracts were more than 2,300 times higher than that in serum, and were also higher than those in other tissues; parotid and mandibular salivary glands, lung, heart, liver, spleen, duodenum, jejunum, ileum and kidney. Following the chloroform injection into the pancreatic tissue, WBC increased from 6 to 240 hr and serum glucose significantly increased at 72 and 96 hr, and no urine glucose was detected. BUN as well as serum and urine creatinine showed normal levels. ACCR increased until 96 hr without statistic significance. Serum amylase activities increased significantly after 3 hr and its isozyme was separated into 4 fractions (Amy1-Amy4) in contrast to 3 fractions (Amy2-Amy4) in intact dogs. Since this extra Amy1 seen from 1 hr increasing after 6 hr similarly to other 3 fractions, the evaluation of serum amylase and its isozyme fractions was indicated to be useful for the diagnosis of acute pancreatitis in dogs.

An immunohistochemical study of neurofilament and microtubule-associated Tau protein in the enteric innervation in Hirschsprung's disease

The distribution and localization of neurofilament (NF) and microtubule-associated tau protein (Tau) in the colon from Hirschsprung's disease were examined by immunohistochemistry. Specimens of the normoganglionic, oligoganglionic, and aganglionic segments of colons from nine patients with Hirschsprung's disease were used in this study. Normal colon specimens obtained at the time of colostomy closure from two patients with anorectal malformations were also examined as controls. In normoganglionic segments, anti-NF-H and anti-NF-M immunoreactivity appeared within the nerve fibers of both the myenteric and submucosal plexuses. These findings were also observed in the oligoganglionic segments. In the aganglionic segment, hypertrophic nerve fascicules and the nerve fibers in circular muscle were positively stained with anti-NF-H and anti-NF-M antibodies. Anti-Tau staining appeared in the ganglion cell bodies of both myenteric and submucosal plexuses and in nerve fibers distributed among the circular muscles of the normal control colons, and the normoganglionic and oligoganglionic Hirschsprung's specimens. Nerve fibers in the circular muscle layer of aganglionic segments were also stained with anti-Tau serum, although the hypertrophic nerve fascicules in the intermuscular and submucosal layers did not stain. The so-called nerve fascicules distributed in the subserosal layer also did not stain with anti-Tau. These results suggest that Tau may be used as a specific marker to identify ganglion cells and intrinsic nerve fibers in colons affected by Hirschsprung's disease.

Serum total amylase activity and its isoenzyme fractions in newborn pigs with relation to growth and iron dextran-treatment

Serum amylase activity was analyzed chromogenically (blue starch method) and its isoenzyme was separated by cellulose acetate membrane electrophoresis in newborn pigs comparing with those in adult pigs. Serum amylase activity in newborn pigs was about one half of adults' and increased with age. Serum amylase isoenzymes were separated into 4 fractions from the cathode. The isoenzymes were also classified in 5 types on the basis of the combination of these 4 fractions. Incidences of the fractions and the types were not significantly different between adults and newborns. After the iron dextran treatment, serum amylase activity as well as levels of erythrocytes, hemoglobin and packed cell volume increased. The rates of increase in hemoglobin and packed cell volume were more significant in the double treatment group than in the single treatment group, while serum amylase activity increased similarly in these 2 groups. The increase in serum amylase activity seemed to indicate that the development of amylase-producing organs was reinforced by the iron compound treatment. It is thought that serum amylase activity may be an indicator of healthy growth in newborn pigs.

Thermography in a child with varicocele

A 12-year-old boy with a left-sided varicocele (Grade 3) was assessed preoperatively and followed postoperatively by computer-assisted infrared thermography. The temperature of the left scrotum was 35.4 degrees C before surgery which was 4 degrees C higher than that of the right scrotum. After ligation of the left internal spermatic vein and removal of the varicocele, scrotal thermograms 39 days and 12 months after operation were normal. Therefore, it seems that thermography is very valuable in the evaluation of testicular function in children with varicocele, in whom semen analysis is impossible.

The future role of hepatic portoenterostomy as treatment of biliary atresia

According to our recent study, 38 of 93 patients (40.9%) who underwent portoenterostomy at Juntendo University Hospital between 1977 and 1986 survived for more than 5 years. In order to learn the future improvement of the prognosis of biliary atresia patients who undergo portoenterostomy, we investigated the relationship between the prognosis of biliary atresia patients and the age and the histological changes of liver at the time of surgery. Twenty-seven of 30 patients (90%) who survived for more than 5 years with no jaundice and no findings of liver cirrhosis had a mild degree of liver fibrosis (F1 or F2) and a mild degree of degeneration of intrahepatic bile ducts (B1 or B2) at the time of surgery, in spite of the difference of size of intrahepatic bile ducts at the porta hepatis. On the other hand, all 8 patients who showed severe liver fibrosis (F3) and severe degeneration of intrahepatic bile ducts (B3) did not survive for more than 5 years. Accordingly, we can expect promising prognoses in patients who undergo refined portoenterostomy procedures and receive proper postoperative treatment before they have severe histological changes of liver. The portoenterostomy will still play an important role as treatment of biliary atresia in the future.

Postoperative management of children with biliary atresia and heart failure

The postoperative course in two children with extrahepatic biliary atresia and cardiovascular disease was reviewed and the correlation between biliary drainage and cardiac function was analyzed. Both patients obtained satisfactory biliary drainage after Kasai's hepatic portoenterostomy. One patient developed heart failure postoperatively due to severe viral myocarditis. This child's total serum bilirubin concentration remained elevated for eight months, despite adequate bilirubin excretion, until her cardiac function returned to normal. Another patient died of cardiac failure due to congenital heart disease 83 days after Kasai's operation, but his postoperative biliary drainage was satisfactory as long as cardiac function remained compensated. In both cases, fluid intake was restricted severely (30 to 70 ml/kg body weight/day), as titrated by echocardiographic assessment of cardiac function, but biliary excretion was satisfactory as long as the cardiac fractional shortening ratio was greater than 30% and the ejection fraction was greater than 55%. This suggests that cardiac decompensation affects postoperative biliary excretion in patients with biliary atresia; however, with careful medical management satisfactory biliary drainage can be achieved even in patients with severe heart diseases.

Histological investigation of the myenteric plexus of the entire gut in an infant with hypogenesis of the intestine

A male infant with pseudo-Hirschsprung's disease was treated for 2 years and 10 months, then died of severe enterocolitis. At autopsy examination of the entire gut was possible, and a definite histological examination could be performed which threw light on the pathogenesis. The ganglion cells of the esophagus, stomach, small intestine, colon and rectum were examined, diameters of their nuclei were measured, and their nuclear volumes were calculated. S-100 and anti-neurofilament stainings were also performed in an immunohistological investigation of the glial cells and nerve fibers. Both the diameter of the volume of the nuclei of the ganglion cells in the small intestine and colon were significantly smaller than normal. Even in the esophagus the nuclear volume was smaller than normal. The glial cells and nerve fibers gradually decreased in the caudal direction. Thus, histomorphometry and immunohistochemistry both showed that the neuroblasts in the intestine were immature and the migration of ganglion cells was disturbed in this case. The final diagnosis was hypogenesis of the intestine.

OK-432 therapy for unresectable lymphangiomas in children

To avoid surgery-related complications, intralesional OK-432 therapy was used in 23 patients with unresectable lymphangiomas (1986 through 1989). Total or near total shrinkage of the lesions, without serious complication, was noted in 10, marked shrinkage in 8, slight shrinkage in 3, and no response was noted in the remaining 2. Recurrence of the lesions has not been observed during follow-up (4 to 35 months). The side effects of OK-432 therapy were a fever for 2 to 3 days and a local inflammatory reaction lasting 3 to 5 days. The local inflammation did not cause any damage to the overlying skin and did not lead to scar formation. The results suggest that intralesional OK-432 therapy is effective for most unresectable lymphangiomas.

Cancer arising in a choledochal cyst in a 12-year-old girl

An adenocarcinoma was found in a choledochal cyst in a 12-year-old girl. This is the youngest patient so far reported with an adenocarcinoma in a choledochal cyst. The cyst consisted of dilatations of the intrahepatic bile ducts and the extrahepatic bile duct. Most of the cyst wall was resected. However, resection of the distal part of the cyst wall in the infrapancreatic region was impossible because of invasion of the portal vein and the inferior vena cava. This patient is now being treated with chemotherapy. We believe that early diagnosis is mandatory, and that total excision of a choledochal cyst is advisably to prevent the development of carcinoma.

Bile duct patterns in the hilar region of the liver in two cases of biliary atresia

Bile duct patterns in the hilar region of the liver were demonstrated in two autopsy cases of biliary atresia by three-dimensional graphic reconstructions. In one case, jaundice had completely disappeared after successful hepatic portojejunostomy. However, at the age of 4 months, this patient died of cardiac failure caused by endocardial cushion defect. The histological reconstruction of this case showed that there were large patent bile ducts, 150 microns to 400 microns in diameter, and plenty of bile ductules surrounding the large ducts to form networks. The other patient died of hepatic failure at the age of 9 months. In this case, only a few large ducts ended in bile lakes that did not connect with the portojejunostomy, and only a few ductules were found around the large ducts. These results indicate that the existence of networks of bile ductules and the patency of large bile ducts at the porta hepatis contribute to good postoperative bile excretion.

Biological effects of lipopolysaccharide from Achromobacter stenohalis on lymphocytes and macrophages

The immunopotentiating activities of lipopolysaccharide from Achromobacter stenohalis (A-LPS) were examined. A-LPS was structurally atypical and gave no endotoxin shock in A-LPS-inoculated mice. Analysis in vitro showed that A-LPS was a potent activator of both macrophages and B-lymphocytes. After macrophage stimulation with A-LPS, interleukin-1 (IL-1) secretion, interferon (IFN) production and chemiluminescence (CL) response were induced. A-LPS was a potent mitogen for spleen lymphocytes. However, induction of interleukin-2 (IL-2) secretion in T lymphocytes was not observed. These activities of A-LPS were similar to or higher than that of enterobacterial LPS.

[Treatment of lymphangiomas arising around cervico-facial region: surgery, bleomycin therapy and OK-432 therapy]

To determine a favorable treatment for lymphangiomas arising around cervico-facial region, a 10-year (1979, 1-1988, 9) experience with 58 these lesions were reviewed. Therapeutic records were divided into 3 groups according to the treatment: surgical Excision (n = 16), intralesional Bleomycin (BLM) therapy (n = 11), and intralesional OK-432 Picibanil therapy (n = 31). Complete disappearance of the lesions without serious complications was noted in 3 of 16 patients treated by surgery, in 3 of 11 patients treated by BLM therapy, and in 21 of 31 patients treated by OK-432 therapy. Serious complications such as facial nerve palsy (3), ugly scars due to repeated excision (5) and short of tongue (1) were noted in surgically treated group. In BLM and OK-432 therapy groups, only a fever of 2 to 3 days' duration and local inflammatory reaction of 3 to 5 days were noted. The results suggest that OK-432 therapy is effective for these lesions.

Reliability of anorectal manometry in the diagnosis of Hirschsprung's disease

Anorectal manometry was performed in 79 patients, aged 2 days to 19 years, who were referred to us because of constipation or symptoms of intestinal obstruction. A definitive diagnosis was obtained in 75 of the 79 patients (95%). Thus, anorectal manometry is a reliable tool in the diagnosis of Hirschsprung's disease. In the neonatal period, however, a definite diagnosis was possible in only 17 of the 21 neonates (81%). The age at the time of the first examination was 14 +/- 2 days in those with a definite diagnosis and 5 +/- 1 days in those with an indefinite diagnosis (p less than 0.001). If intestinal obstruction can be managed by conservative therapy, examination should be repeated after two weeks of age if the diagnosis before one week of age is not definite. These results indicate that anorectal manometry is non-invasive and reliable in the diagnosis of Hirschprung's disease. However, further examinations such as barium enema or rectal biopsy should be done, even in the neonatal period.

Giant cavernous haemangioma: treatment with intralesional injection of OK-432

Giant cavernous haemangioma was treated successfully with a new therapy consisting of intralesional injection of OK-432 (group A Streptococcus pyogenes of human origin). Complete regression was observed within 3 months without serious side effects except for fever of 2-3 days' duration and local inflammatory reaction lasting for 3-4 days. Local inflammatory reaction did not cause any damage to the overlaying skin and did not lead to scar formation.

Voluntary anal continence after surgery for anorectal malformations

Electromyography (EMG) and measurement of voluntary contraction pressure of the external sphincter muscle were performed in 28 patients, aged 5 to 14 years, to assess the function of the external sphincter after surgical correction of anorectal malformations. Ten normal children, aged 5 to 15 years, served as controls. External sphincter function in patients with high-type anomalies was disturbed in the areas of tonic activity, inflation reflex, and activity during further rectal filling. In patients with low-type or intermediate-type anomalies, function was preserved and was equal to that in normal controls. Phasic activity was observed in patients with all types of anomalies and in normal subjects. Among those with high-type anomalies, the three patients with Kelly's score of less than 2 had voluntary contractions of 20 cmH2O or less. However, the mean voluntary contraction pressures were not significantly different among the three types of anomalies. Therefore, patients with high-type anomalies may acquire compensatory voluntary continence through bowel training.

Results of surgical correction of anorectal malformations. A 10-30 year follow-up

Of 119 patients with surgical correction of anorectal malformations, 47 who were 10-30 years of age were interviewed personally and had manometric studies to evaluate postoperative continence. This clinical study included not only long-term anorectal function but also sexual function. Patients with low type anomalies or with intermediate type anomalies were more likely to be continent, whereas patients with high type lesions had some problems with continence. However, only two of the 16 patients (12%) with high type anomalies were classified as having poor results. This rate is perhaps lower than might be expected. Thus, incontinent patients may become continent even if they were classified as having fecal incontinence before 6 years of age. Most patients who were 15-30 years of age had normal sexual function except for two females with irregular menstruation. These results indicate that achievement of fecal continence and sexual function in patients with high type anomalies treated by abdominoperineal rectoplasty depends on careful dissection as close as possible to the rectal wall and bringing the terminal bowel down exactly within the sling of the puborectal muscle.