The Clinical Course and Treatment of a Case of Refractory Systemic Juvenile Myasthenia Gravis Successfully Treated with Thymectomy

Juvenile myasthenia gravis (JMG) exhibits a more favorable response to glucocorticoids and has a better prognosis than adult myasthenia gravis. However, no established treatment exists for refractory JMG. Although thymectomy has been performed in several patients with refractory systemic JMG, there are few detailed clinical descriptions of patients who underwent thymectomy. Here, we present the case of a 10-year-old boy with refractory systemic JMG who was successfully treated with thymectomy. The patient developed symptoms, including dysphagia, malaise, diurnal ptosis, and weakness in the trunk muscles, and he was diagnosed with generalized JMG. Despite undergoing various treatments, including steroids, tacrolimus, steroid pulse therapy, intravenous immunoglobulin, azathioprine (AZT), and rituximab, his symptoms did not improve. Therefore, he underwent a thoracoscopic thymectomy 24 months after disease onset. Thymectomy led to remission, as demonstrated by a significant reduction in the quantitative myasthenia gravis score and anti-acetylcholine receptor antibody levels, which persisted for 43 months after surgery. Our case demonstrates the effectiveness of thymectomy in systemic JMG patients with positive anti-acetylcholine receptor antibodies, despite therapeutic failure with AZT and rituximab, within 2 years of disease onset.

Successful administration of eltrombopag in preparation for peritoneal dialysis catheter placement in a girl with MYH9-related disease

MYH9-related disease is an autosomal dominant disorder characterized by macrothrombocytopenia, nephropathy, inclusion bodies in leukocytes, sensorineural hearing loss, and cataract. Severe cases require kidney replacement therapy in the patient's second decade of life; thrombocytopenia constitutes a major risk factor for hemorrhagic complications during dialysis initiation or kidney transplantation. Prophylactic platelet transfusion prior to surgery is commonly administered to affected patients in these cases. However, transfusion in such patients has limitations other than the general risk of allergic reactions and blood-borne infections; it may also trigger alloimmunization, leading to platelet transfusion resistance or the development of anti-donor antibodies in potential kidney transplant recipients. Here, we describe prophylactic administration of eltrombopag, an oral thrombopoietin receptor agonist, prior to laparoscopic peritoneal dialysis catheter placement in a 15-year-old girl with MYH9-related disease. Her platelet count was approximately 30 × 103/μL at baseline; it increased to 61 × 103/μL on the day before surgery, thereby avoiding the need for platelet transfusions. There were no major bleeding or adverse events associated with eltrombopag administration. Thus, eltrombopag may be a safe and effective alternative to prophylactic platelet transfusions in patients with MYH9-related disease.

Auto-Lectin Dotcoding by Two Octopuses: Rapid Analysis of Fluorescence-Labeled Glycoproteins by an 8-channel Fully-Automatic Bead Array Scanner with a Rolling-Circle Detector

Protein glycosylation is a crucial factor that must be evaluated in biological pharmaceuticals. The glycoform profile of a protein can vary depending on the conditions of the cultivation, purification process, and the selection of a host cell. Lectin microarrays are reliable bioanalytical methods used in the early phases of bioprocesses for the detection of glycosylation. The concept of a fully automated glycan detection with a bead array has been previously reported; however, no simple system has been constructed on fluorescence-based detection using a microarray. Here, we present a fully automated detection system equipped with a novel fluorescence detector for a 13-lectin bead array with a single tip. The lattice-like arrangement of a set of fibers proximate to the tip of the light emitting diode and photomultiplier tube detector minimized the noise caused by the reflection of incident light on the plastic capillary tip and bead. A unique rolling-circle fiber unit with quadruple lattices stacked in two layers realizes the 8-parallel automeasurement with a drastic reduction in scanning time and machine size. The 8-glycan profiles obtained automatically within 25 min were identical with those obtained with the conventional lectin microarray after overnight incubation. The signals obtained were represented as lectin dotcodes. Therefore, autolectin dotcoding assisted by the twin 8 legs named as "detection and irradiation octopuses" may be a rapid glyco-evaluation system during the production and development of biopharmaceuticals.

Decreased liver damage in rat models of short bowel syndrome through DPP4 inhibition

PURPOSE

Total parenteral nutrition causes liver damage in patients with short bowel syndrome (SBS), in whom intestinal failure-associated liver disease (IFALD) is the strongest risk factor for mortality. We previously demonstrated the efficacy of dipeptidyl peptidase-4 inhibitors (DPP4-Is) for nutritional absorption and intestinal barrier function enhancement. Herein, we investigated the efficacy of DPP4-Is in preventing liver damage in SBS rat models.

METHODS

Rats were allocated to one of five groups: normal saline (NS) + sham, DPP4-I + sham, NS + SBS, DPP4-I + SBS, and GLP-2 + SBS. DPP4-I or NS was administered orally once daily. Serum aspartate aminotransferase, alanine aminotransferase (ALT), alkaline phosphatase, and total bile acid levels were measured to assess liver function. Moreover, we evaluated liver damage using the SAF (steatosis activity fibrosis) score, which is also used to assess nonalcoholic steatohepatitis.

RESULTS

ALT levels and SAF scores were significantly lower in the DPP4-I + SBS group than in the NS + SBS group. Jejunal and ileal villus heights were significantly higher in the DPP4-I + SBS group than in the GLP-2 + SBS group.

CONCLUSIONS

The downregulation of ALT levels and SAF scores triggered by DPP4-I use may be correlated with DPP4-I-induced adiposis inhibition in SBS and NASH models. Therefore, DPP4-I may be used to reduce IFALD in patients with SBS.

Development of a Fully Automated Desktop Analyzer and Ultrahigh Sensitivity Digital Immunoassay for SARS-CoV-2 Nucleocapsid Antigen Detection

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has had a significant impact on public health and the global economy. Several diagnostic tools are available for the detection of infectious diseases, with reverse transcription-polymerase chain reaction (RT-PCR) testing specifically recommended for viral RNA detection. However, this diagnostic method is costly, complex, and time-consuming. Although it does not have sufficient sensitivity, antigen detection by an immunoassay is an inexpensive and simpler alternative to RT-PCR. Here, we developed an ultrahigh sensitivity digital immunoassay (d-IA) for detecting SARS-CoV-2 nucleocapsid (N) protein as antigens using a fully automated desktop analyzer based on a digital enzyme-linked immunosorbent assay. Methods: We developed a fully automated d-IA desktop analyzer and measured the viral N protein as an antigen in nasopharyngeal (NP) swabs from patients with coronavirus disease. We studied nasopharyngeal swabs of 159 and 88 patients who were RT-PCR-negative and RT-PCR-positive, respectively. Results: The limit of detection of SARS-CoV-2 d-IA was 0.0043 pg/mL of N protein. The cutoff value was 0.029 pg/mL, with a negative RT-PCR distribution. The sensitivity of RT-PCR-positive specimens was estimated to be 94.3% (83/88). The assay time was 28 min. Conclusions: Our d-IA system, which includes a novel fully automated desktop analyzer, enabled detection of the SARS-CoV-2 N-protein with a comparable sensitivity to RT-PCR within 30 min. Thus, d-IA shows potential for SARS-CoV-2 detection across multiple diagnostic centers including small clinics, hospitals, airport quarantines, and clinical laboratories.

Nationwide survey of pediatric gastrointestinal endoscopy in Japan

BACKGROUND AND AIM

The implementation rates of pediatric gastrointestinal endoscopy are increasing with advancements in the devices used and pediatricians' skills. As part of the Japan Pediatric Endoscopy Study Group, we aimed to investigate the rates of pediatric gastrointestinal endoscopy use and the associated adverse events through a nationwide survey.

METHODS

A questionnaire was sent to 630 institutions in Japan. The numbers of pediatric gastrointestinal endoscopy cases and adverse events occurring during endoscopy, from April 2011 to March 2016, were investigated.

RESULTS

Responses were obtained from 445 facilities. The total number of pediatric gastrointestinal endoscopies was 37 447 and that of endoscopic examinations was 32 219 (86.0%), with esophagogastroduodenoscopy accounting for 18 484 cases; ileal colonoscopy, 11 936; endoscopic retrograde cholangiopancreatography, 389; wireless capsule endoscopy, 897; and balloon-assisted enteroscopy, 513. The number of endoscopic treatments was 5228, followed by balloon dilatation (1703), foreign body removal (989), and polypectomy (822); 201 adverse events (0.54%) occurred, 79 of which presented during endoscopic examination (0.25%). Eight serious perforations were noted in 0.0054% and 0.025% of those undergoing esophagogastroduodenoscopy and colonoscopy, respectively. Overall, 122 adverse events (2.33%) occurred in association with endoscopic treatment. One case of cardiopulmonary arrest occurred because of accidental extubation. However, no deaths occurred.

CONCLUSION

Endoscopic examinations had a slightly higher adverse event rate, because of an increase in endoscopic retrograde cholangiopancreatography and small intestine enteroscopy, than that reported in previous studies, but the adverse event rate of endoscopic treatment did not increase.

GlycoBIST: A System for Automatic Glycan Profiling of a Target Protein Using Milli-Bead Array in a Tip

Lectin is a biomolecule that recognizes a specific part of glycans and, thus, has been used widely as a probe for glycoprotein analysis. Owing to the wide repertoire in nature combined with the recent two decades of advances in microarray technology, the multiplexed use of lectins has been widely used for glycan profiling of endogenous proteins. Because protein glycosylation is recognized as being biologically important and is expected to be a reliable disease marker, lectin microarray analysis with highly sensitive detection has been used to discover disease-relevant glycosylation alterations. However, the conventional system is limited to research purposes; thus, its implementation in clinical settings is warranted. Here, we provide an automatic glycan profiling method using GlycoBIST. A unique array format is used for 10-plexed lectin-glycoprotein interaction analysis on 1-mm-sized beads, which are arranged vertically in a capillary-shaped plastic tip. Using a one-boxed autopipetting machine, the whole process (including interaction, washing, and detection) is performed automatically and serially, resulting in reproducible measurements. In this article, a typical method for glycan profiling of a purified glycoprotein and the fabrication of GlycoBIST tips is explained. © 2020 by John Wiley & Sons, Inc. Basic Protocol 1: Fabrication of a GlycoBIST tip Basic Protocol 2: Automatic profiling of a target glycoprotein using GlycoBIST.

A case of cervical esophageal duplication cyst in a newborn infant

Esophageal duplication cyst is a rare congenital anomaly resulting from a foregut budding error during the fourth to sixth week of embryonic development. Cervical esophageal duplication cysts are very rare and may cause respiratory distress in infancy. A full-term newborn girl who was born by normal delivery was transferred to our hospital because of swelling of the right anterior neck since birth. Cervical ultrasonography showed a 40 × 24 × 33 mm simple cyst on the right neck. Tracheal intubation was required at 2 weeks of age because of worsening external compression of the trachea. Fine-needle aspiration cytology revealed the existence of ciliated epithelium. At 1 month of age, exploration was performed through a transverse neck incision. The cyst had a layer of muscle connected to the lateral wall of the esophagus. Histopathological diagnosis was a cervical esophageal duplication cyst. We describe the clinical features of infantile cervical esophageal duplication cysts based on our experience of this rare disease in a neonate, along with a review of 19 cases previously reported in literature.

Current Practice and Outcomes of Thoracoscopic Esophageal Atresia and Tracheoesophageal Fistula Repair: A Multi-institutional Analysis in Japan

BACKGROUND

In order to better understand the current practice and outcomes of thoracoscopic repair of esophageal atresia (EA)/tracheoesophageal fistula (TEF), a multi-institutional analysis was conducted among seven Japanese institutes.

MATERIALS AND METHODS

A survey was sent to the seven institutes regarding the surgical technique, postoperative management, and outcomes of thoracoscopic repair of EA/TEF.

RESULTS

The operation was uniformly performed via an intrapleural approach in the 0-45° prone position. The TEF was occluded with suture ligature in four (57.1%) institutes and clips in the remaining three (42.9%) institutes. Anastomosis was performed using the extracorporeal knot-tying technique in four institutes and the intracorporeal technique in three institutes. Patients were routinely left intubated and paralyzed for 3-7 days postoperatively in four institutes. In total, 58 patients underwent thoracoscopic repair of EA/TEF. Fifty-two (89.7%) of the patients underwent successful thoracoscopic repair. Six (10.3%) operations were converted to open thoracotomy because of a long gap (n=4), right aortic arch (n=1), and intraoperative instability (n=1). The body weight at operation ranged from 1.2 to 4.6 kg, and the operative time ranged from 115 to 428 minutes. There were no major intraoperative complications. Eleven patients (19.0%) suffered from anastomotic leakage. Twenty-eight patients (48.3%) developed anastomotic stricture. One patient died during the postoperative period because of an unrelated disease. Recurrent TEF developed in three patients (5.2%). Thirteen patients (22.4%) later required fundoplication.

CONCLUSIONS

The outcome of thoracoscopic repair of EA/TEF was comparable to that of the open procedure. As considerable variability was observed among the seven institutes with respect to the surgical technique and management, standardizing the surgical management may improve the outcome.

Skill qualifications in pediatric minimally invasive surgery

PURPOSE

In 2006, The Japanese Society of Pediatric Endoscopic Surgeons devised a plan to develop a pediatric endoscopic surgical skill qualification (ESSQ) system. This system is controlled by The Japan Society for Endoscopic Surgery. The standard requirement for skills qualification is the ability of each applicant to complete common types of laparoscopic surgery. The main goal of the system is to decrease complications of laparoscopic surgery by evaluating the surgical skills of each applicant and subsequently certify surgeons with adequate skills to perform laparoscopic operations safely.

METHODS

A committee of pediatric ESSQ created a checklist to assess the applicant's laparoscopic surgical skills. Skills are assessed in a double-blinded fashion by evaluating an unedited video recording of a fundoplication for pediatric gastroesophageal reflux disease.

RESULTS

The initial pediatric ESSQ system was started in 2008. In 2008 and 2009, respectively, 9 out of 17 (53%) and 6 out of 12 (50%) applicants were certified as expert pediatric laparoscopic surgeons.

CONCLUSIONS

Our ultimate goal is to provide safe and appropriate pediatric minimally invasive procedures and to avoid severe complications. To prove the predictive validity of this system, a survey of the outcomes of operations performed by certified pediatric surgeons is required.

Interleukin-18 promoter polymorphisms and the disease progression of Hepatitis B virus-related liver disease

In this study, we aimed to explore whether interleukin-18 (IL-18) gene-promoter polymorphisms are associated with the outcome of hepatitis B virus (HBV) infection. In all, 204 chronically HBV-infected patients were recruited in this study. Of the 204 HBV-infected patients, 43 were considered to be inactive HBV carriers based on the sustained normalization of serum alanine aminotransferase (ALT) together with seropositivity for the antibody to hepatitis B e-antigen (anti-HBe). A total of 161 patients were found to have chronic progressive liver disease, which included cirrhosis. In these HBV-infected patients, the frequencies of AA genotype of IL-18 gene-promoter polymorphisms at position -607 and C allele at position -137 were significantly higher in inactive HBV carriers compared with those in patients with chronic progressive liver disease. These polymorphisms of the IL-18 promoter regions (-607 and -137) could be associated with different outcomes of HBV infection.

Development of the Handy Bio-Strand and its application to genotyping of OPRM1 (A118G)

We previously developed a three-dimensional microarray system, the Bio-Strand, which exhibits advantages in automated DNA analysis in combination with our Magtration Technology. In the current study, we have developed a compact system for the Bio-Strand, the Handy Bio-Strand, which consists of several tools for the preparation of Bio-Strand Tip, hybridization, and detection. Using the Handy Bio-Strand, we performed single nucleotide polymorphism (SNP) genotyping of OPRM1 (A118G) by allele-specific oligonucleotide competitive hybridization (ASOCH). DNA fragments containing SNP sites were amplified from genomic DNA by PCR and then were fixed on a microporous nylon thread. Thus, prepared Bio-Strand Tip was hybridized with allele-specific Cy5 probes (<15mer), on which the SNP site was designed to be located in the center. By optimizing the amount of competitors, the selectivity of Cy5 probes increased without a drastic signal decrease. OPRM1 (A118G) genotypes of 23 human genomes prepared from whole blood samples were determined by ASOCH using the Handy Bio-Strand. The results were perfectly consistent with those determined by PCR direct sequencing. ASOCH using the Handy Bio-Strand would be a very simple and reliable method for SNP genotyping for small laboratories and hospitals.

Development of an automated SNP analysis method using a paramagnetic beads handling robot

Biological and medical importance of the single nucleotide polymorphism (SNP) has led to development of a wide variety of methods for SNP typing. Aiming for establishing highly reliable and fully automated SNP typing, we have developed the adapter ligation method in combination with the paramagnetic beads handling technology, Magtration(R). The method utilizes sequence specific ligation between the fluorescently labeled adapter and the sample DNAs at the cohesive end produced by a type IIS restriction enzyme. Evaluation of the method using human genomic DNA showed clear discrimination of the three genotypes without ambiguity using the same reaction condition for any SNPs examined. The operations following PCR amplification were automatically performed by the Magtration(R)-based robot that we have previously developed. Multiplex typing of two SNPs in a single reaction by using four fluorescent dyes was successfully preformed at the almost same sensitivity and reliability as the single typing. These results demonstrate that the automated paramagnetic beads handling technology, Magtration(R), is highly adaptable to the automated SNP analysis and that our method best fits to an automated in-house SNP typing for laboratory and medical uses.

Development of a novel method for operating magnetic particles, Magtration Technology, and its use for automating nucleic acid purification

Magnetic particles are useful for simple and efficient nucleic acid extraction. To achieve fully automated nucleic acid extraction and purification using magnetic particles, a new method for operating magnetic particles, Magtration Technology, was developed. In this method, magnetic separation is performed in a specially designed disposable tip. This enables high recovery of magnetic particles with high reproducibility. The features of this technology are (i) a simple mechanism for process control and (ii) flexible software to enable adaptation to commercially available reagents. Automated instruments based on Magtration Technology were developed and used for nucleic acid extraction. Total DNA, total RNA and plasmids were purified by Magtration Technology at an efficiency comparable to that of manual methods.

Development of an integrated automation system with a magnetic bead-mediated nucleic acid purification device for genetic analysis and gene manipulation

We have developed an integrated automation system for genetic analysis and gene manipulation. The system, SX-8G Plus, is equipped with an 8-nozzle dispensing unit, a thermal cycler, a cooled reagent reservoir, four tip storage racks, four microplate platforms, buffer reservoirs, an agarose gel electrophoresis unit, a power supply, a pump for exchanging electrophoresis buffer, and a CCD camera. Automation of nucleic acid extraction and purification, the most difficult step in automating genetic analysis and gene manipulation, was realized using magnetic beads with Magtration Technology, which we have previously developed for automating the handling of paramagnetic beads. Using this system, we could perform the automated separation and purification of DNA fragments by agarose gel electrophoresis starting from sample loading. The system would enable the automation of almost all procedures in genetic analysis and gene manipulation.

Laparoscopically assisted anorectovaginoplasty for selected types of female anorectal malformations

PURPOSE

The aim of this study was to describe laparoscopically assisted anorectovaginoplasty (LAARVP) for the repair of selected types of female anorectal malformation.

METHODS

Five cases (case 1, rectovaginal fistula with a high rectum; case 2, rectovestibular fistula with double vagina; case 3, rectovestibular fistula with absent vagina; case 4, anovestibular fistula with absent vagina; case 5, cloaca) were reviewed.

RESULTS

Patient 4 had undergone a posterior sagittal anorectoplasty without vaginoplasty at another hospital after misdiagnosis of simple anovestibular fistula. Mean age at LAARVP was 15.4 months. At LAARVP, the fistula was divided in cases 1 through 4 and dissected as low as possible in case 5. In cases 3 and 4, the distal fistula was used to create the neovagina. In cases 1 through 3, the proximal rectum was mobilized and brought through the pelvic floor sphincter muscles using Georgeson's laparoscopically assisted colon pull-through technique through a minimal perineal incision. A posterior sagittal incision was required in cases 4 and 5. However, the initial laparoscopic approach was very helpful in both cases. Currently, all patients are well after a mean follow-up period of 32.2 months. Mean current age is 4.0 years. Patients 1 through 3 are continent, patient 4 is incontinent with soiling, and patient 5 is too young to be evaluated.

CONCLUSIONS

LAARVP helps to achieve low dissection of the fistula, gives optimal view of the pelvic organs, provides accurate placement of the anorectal pull-through, and minimizes abdominal perineal scars.

Multipurpose robot for automated cycle sequencing

Paramagnetic beads have the superior advantages of easy separation and resuspension by controlling the magnetic filed. Previously, we have developed Magtration technology to automate paramagnetic bead handling and have built several automated instruments that handle 1-12 samples simultaneously. To achieve more high-throughput sample processing, two types of a 96-arrayed Integrated Magtration Unit (IMU) were developed, one installed with electromagnets and the other with thin rod-shaped magnets made of neodymium. A multipurpose robot (SX-96GC) equipped with the IMU was also developed for fully automatic processing of 96 samples in parallel. The cleanup of dye-terminator sequencing products was performed using the robot installed with the permanent magnet version of IMU. The results had quality comparable to those by the same protocol in manual handling or to those by the conventional protocols. The robot processed 96 samples in a microplate within 30 min. The protocol that can purify 384 samples within 1 h by processing two microplates concurrently was successfully designed.

Intraoperative endosonography enhances laparoscopy-assisted colon pull-through for high imperforate anus

PURPOSE

The authors used ultrasonographic endoprobes during laparoscopy-assisted colon pull-through (LACPT) for the repair of high imperforate anus to confirm the pull-through canal was surrounded symmetrically by pelvic floor muscles.

METHODS

Six patients with high imperforate anus were treated by LACPT (mean age at LACPT, 8.2 months). An endoscopic (12-MHz, 2.5-mm in diameter) and proctoscopic (7.5-MHz, 12-mm in diameter) probe were inserted into the proposed route of dissection intraoperatively to measure the thickness of the surrounding muscle tissue at at least 3 levels: the external anal sphincter, the levator ani muscle sling, and the intervening muscle complex.

RESULTS

The average thickness of the external anal sphincter was 2.3 +/- 0.4 mm anteriorly, 2.4 +/- 0.4 mm on the left, 2.4 +/- 0.5 mm posteriorly, and 2.6 +/- 0.6 mm on the right. The average thickness of the muscle complex was 2.3 +/- 0.6 mm anteriorly, 2.2 +/- 0.5 mm on the left, 2.1 +/- 0.4 mm posteriorly, and 2.2 +/- 0.5 mm on the right. The average thickness of the left crus of the levator ani muscle was 1.8 +/- 0.3 mm, the right crus was 1.9 +/- 0.4 mm, and the rim located posterior to the rectum was 2.0 +/- 0.3 mm. No statistically significant difference was found between the measurements taken at each level.

CONCLUSION

Intraoperative endosonography during LACPT can greatly enhance the precision of positioning the pull-through canal.

Laparoscopy-assisted suction colonic biopsy and intraoperative rapid acetylcholinesterase staining during transanal pull-through for Hirschsprung's disease

BACKGROUND

It is crucial to identify the exact level of transition to normal ganglion cells in instances of Hirschprung's disease. This report describes a technique for laparoscopy-assisted suction colonic biopsy during transanal pull-through.

METHODS

Laparoscopy-assisted suction colonic biopsy (SCBx) was used in 12 patients with Hirschsprung's disease affecting the rectosigmoid. Average age was 4.4 +/- 2.1 months with a mean operative weight 6.2 +/- 1.0 kg. The pull-through was performed as the primary operative procedure in 11 patients. Using a 2-team approach (laparoscopic team and transanal team), the site was chosen for transanal suction biopsy and marked externally by the laparoscopic team with a silver clip. Biopsies were processed for ganglion cells and rapid AChE technique.

RESULTS

There were no biopsy-induced perforations. Abnormal biopsies were repeated more proximally until ganglion cells were observed. Transanal pull-through was performed and an open full-thickness biopsy performed to confirm the presence of ganglion cells. All procedures were performed successfully.

CONCLUSIONS

Laparoscopy-assisted SCBx can be used successfully in patients with Hirschsprung's disease affecting the rectosigmoid (80% of cases). The technique, when used with rapid AChE staining, provides accurate identification of the level of normoganglionosis.

Precise localization of a recurrent tracheo-oesophageal fistula using retrograde guide wire placement

A 4-month-old-infant was presented with a presumptive diagnosis of a recurrent tracheo-oesophageal fistula. Preoperative bronchoscopy failed to reveal any defects on the tracheal lumen; however, combined oesophagoscopy and bronchoscopy successfully identified the tracheal orifice of the fistula, which facilitated surgical identification of the recurrent fistula and proper placement of the tracheal tube.

Laparoscopic muscle electrostimulation during laparoscopy-assisted anorectal pull-through for high imperforate anus

PURPOSE

Our technique for laparoscopic muscle electrostimulation during laparoscopy-assisted anorectal pull-through (LAARPT) for high imperforate anus (HIA) in 3 patients is described.

METHODS

The distal rectum and rectourethral fistula is dissected laparoscopically. A muscle stimulator is passed through one of the trocars and used to identify the center of contraction of the levator ani. The same muscle stimulator is used to identify the center of the external sphincter muscle transcutaneously. An intravenous cannulation device (SURFLO Flash IV catheter, TERUMO, CO, Yamanashi, Japan) is inserted through this proposed anus and observed piercing the center of the levator ani. A guide wire is passed through the SURFLO, and a series of dilators are passed along it to create a canal for the colonic pull-through. An anoplasty then was performed.

RESULTS

Our technique was successful in all patients. Laparoscopic electrostimulation produced good levator ani contraction in patients I and II and weak contraction in patient III. Patients I and II have symmetrical anal contraction during rectal examination, but patient III has poor contraction. Stool frequency is decreasing in all.

CONCLUSION

Direct laparoscopic observation of levator ani contraction allows intraoperative assessment of functional contractility and assists in the accurate placement of the colonic pull-through.

Ectopic distal location of the papilla of vater in congenital biliary dilatation: Implications for pathogenesis

BACKGROUND/PURPOSE

This study investigates the relationship between the location of the papilla of Vater and the length of the common channel in patients with congenital biliary dilatation (CBD).

METHODS

Cholangiograms from 121 CBD patients and 13 normal controls were the subjects for this study. A length index defined as the length of the common channel divided by the height of the second lumbar vertebra was used for standardization.

RESULTS

In the controls, the papilla of Vater was located in the middle of the descending or second part of the duodenum in all cases. In 39 (32.2%) of the 121 CBD patients papilla of Vater was located in the descending duodenum (group I), and in 82 (67.8%) it was distal to the descending duodenum (group II). The average length index of the common channel in group II was significantly longer than in group I (1.123 +/- 0.374 v 0.660 +/- 0.246; P <.001). Findings for the common bile duct were similar.

CONCLUSIONS

There is a significantly higher incidence of ectopic distal location of the papilla of Vater in CBD patients than in controls. The more distal the location of the papilla of Vater, the longer the common bile duct and the common channel.

Magnetic resonance cholangiopancreatography in assessing the cause of acute pancreatitis in children

Magnetic resonance cholangiopancreatography (MRCP) is a new noninvasive method of obtaining images of the pancreaticobiliary tract. Recent advances in MR technology and image quality have made it easy to diagnose structural abnormalities of the pancreaticobiliary tract (SAPBT) in children. To examine the usefulness of MRCP in assessing the cause of acute pancreatitis in children, we performed MRCP in 16 patients with acute pancreatitis. The study population was divided into two groups according to the cause of acute pancreatitis as follows: group 1 consisted of seven patients sonographically diagnosed with choledochal cysts; and group 2 consisted of nine patients with no obvious cause of acute pancreatitis. Non-breath-hold MRCP using the half-Fourier, single-shot, fast spin-echo imaging method was performed within 7 days after the onset of pancreatitis. Abnormal union of the pancreaticobiliary junction was detected in six of seven group 1 patients and in one of nine group 2 patients. Pancreatic divisum was detected in one patient of group 1, but could not be confirmed in one patient of group 2. Dilatation of the main pancreatic duct was detected in one patient of group 1 and in three patients of group 2. Our results suggest that MRCP is a useful, noninvasive method of identifying and ruling out SAPBT as a cause of acute pancreatitis in children with early-stage pancreatitis.

A case of biliary atresia with duplication of the common bile duct

The authors report a case of biliary atresia (BA) with duplication of the common bile duct. A 1-month-old girl was referred for investigation of persistent jaundice. BA was suspected and confirmed with intraoperative cholangiography. A portoenterostomy was performed at 50 days of age. During dissection of the fibrous remnant of the common bile duct, a separate fibrous bile duct remnant running in parallel on the left, was identified. Histologically, there was bile duct proliferation at the porta hepatis of the left bile duct remnant. A diagnosis of BA with duplicated common bile duct was made. Postoperative course was uneventful, and at a follow-up assessment at 7 months, she was jaundice free, and her progress has been unremarkable.

Tubed latissimus dorsi musculocutaneous flaps for esophageal replacement in puppies: long-term follow-up

PURPOSE

The aim of this study was to show that a tubed latissimus dorsi musculocutaneous flap (tubed LDMCF) may be useful for treating circumferential esophageal defects.

METHODS

A segment of esophagus 3 vertebrae long was excised through a right thoracotomy in each of 6 puppies, and a tubed LDMCF was interposed between the cut ends of esophagus. The puppies were sacrificed after a mean follow-up period of 6.6 years. The tubed LDMCF was examined histologically. Functional integrity was assessed using barium meal and endoscopy before sacrifice.

RESULTS

All puppies survived and grew normally on a normal diet, although 4 vomited occasionally. There was smooth passage of barium through the tubed LDMCF without stenosis, although endoscopy showed regrowth of hair. Histologically, no metaplasia, dysplasia, or malignancy was observed in any tubed LDMCF.

CONCLUSIONS

The tubed LDMCF is technically safe, obviates the necessity for laparotomy, and long-term follow-up would suggest that it is histologically stable. Thus, it could become an alternative procedure for bridging esophageal defects.

Intraoperative pancreatoscopy for pancreatic duct stone debris distal to the common channel in choledochal cyst

BACKGROUND/PURPOSE

Pancreatic duct stone debris is a recognised problem in patients with choledochal cyst (CC). The authors present the use of intraoperative pancreatoscopy (IP) in diagnosis and treatment of pancreatic duct stone debris distal to the common channel (distal PDSD).

METHODS

Sixty-seven patients with CC treated over the past 12 years were reviewed retrospectively. Distal PDSD was detected in 8 of these 67 cases (11.9%) using cholangiography. IP of the common channel or pancreatic duct at the time of surgery for CC was performed using a pediatric cystoscope in 7 of these 8 cases.

RESULTS

All 8 patients had a long common channel. All presented with acute pancreatitis. In 7 of these 8 patients, IP was efficient in detecting and for removing distal PDSD by irrigation. In the remaining case associated with annular pancreas, distal PDSD was identified in the proximal pancreatic duct and was removed directly after incision of the pancreatic duct. Postoperative pancreatitis occurred in only 1 case. All patients are well after a mean follow-up period of 7.3 years.

CONCLUSION

Distal PDSD should not be ignored. IP allows direct examination of the pancreatic duct system and facilitates complete removal of distal PDSD, which may be the cause of relapsing pancreatitis or pancreatolithiasis after radical surgery for CC.

Laparoscopic surgery in newborn infants

BACKGROUND

Thanks to various technical innovations and advances in instrumentation, laparoscopic surgical intervention is now possible for certain congenital anomalies in children. To test the applicability of laparoscopic surgery in neonates, we reviewed our personal experience of neonatal laparoscopic surgery, focusing on cardiopulmonary function, surgical procedures, problems with devices, and degree of associated surgical stress.

METHODS

We performed 65 laparoscopic procedures in neonates. Their ages ranged from 2 to 30 days old, and their body weights ranged from 1,980 to 4,780 g. All 65 laparoscopic procedures were carried out without mortality or serious morbidity.

RESULTS

As complications, we encountered four cases of hypothermia due to rapid insufflation of carbon dioxide (CO(2)). We also found that relative hypercapnea (increase in end-tidal CO(2) as high as 61 mmHg) developed unless hyperventilation and a relatively high peak insufflation pressure were maintained during pneumoperitoneum. No cardiac depression developed at this insufflation pressure. Fluid and electrolyte balance during our cases of newborn laparoscopic surgery, as well as the doses and volumes of fluid and electrolytes administered, were identical to those required for open surgery. Interleukin-6 (IL-6) was measured serially to estimate the degree of associated surgical stress and was found to be significantly lower in neonates who had received laparoscopic procedures than in those who had received open procedures.

CONCLUSION

Laparoscopic surgery can be carried out safely even in neonates.

Different types of congenital biliary dilatation in dizygotic twins

A pair of dizygotic twins who were both found to have congenital biliary dilatation, but of different types, is reported. This case is of academic interest from an etiologic point of view.

Laparoscopic extramucosal pyloromyotomy versus open pyloromyotomy for infantile hypertrophic pyloric stenosis: which is better?

BACKGROUND/PURPOSE

The aim of this study was to evaluate the advantages or disadvantages of laparoscopic pyloromyotomy compared with open transumbilical fold pyloromyotomy.

METHODS

Thirty consecutive laparoscopic extramucosal pyloromyotomies (LP) performed from 1994 to 1997 were compared with 30 consecutive open pyloromyotomies (OP) performed during the same period with regard to age at operation, body weight, thickness of hypertrophied pyloric muscle, operating time, time of return to full feeding, frequency of postoperative emesis, surgical complications, and degree of surgical stress reflected by interleukin-6 (IL-6). LP was performed according to conventional techniques, and OP was performed using a transumbilical fold approach.

RESULTS

The groups were matched for age at operation, preoperative clinical and physical status, laboratory data, and size of the hypertrophied pylorus assessed by ultrasonography. There was a learning curve with LP; the average operating time required for the first 10 cases was significantly longer than the time required for OP, but later cases took just as long as OP cases. Time taken to full feeding was significantly shorter in the LP group than the OP group (LP, 38 hours v OP, 64 hours). One case was converted from LP to OP because of mucosal perforation. The incidence of postoperative emesis was significantly higher in the OP group than in the LP group (OP, 25% v LP, 3%). The mean length of hospitalization was significantly shorter in LP (P < .01). The intraoperative peak values of IL-6 in LP were significantly lower than those in the OP group (P < .01).

CONCLUSIONS

The advantages of LP are improved cosmesis, decreased surgical stress with earlier postoperative recovery, and shorter hospitalization. Because LP uses reusable devices, and the mean period of hospitalization is shorter, average operating costs could be reduced, representing a net saving in total hospital charges.

Initial experience with non-breath-hold magnetic resonance cholangiopancreatography: a new noninvasive technique for the diagnosis of choledochal cyst in children

BACKGROUND/PURPOSE

Magnetic resonance cholangiopancreatography (MRCP) is an emerging tool for the noninvasive evaluation of the pancreaticobiliary tree.

METHODS

Non-breath-hold MRCP was used in three children to evaluate choledochal cyst; a first for this new modality of diagnostic imaging. In all cases, the intrahepatic and extrahepatic bile ducts, and the pancreatic duct were clearly visualized.

RESULTS

Two cases were found to have a fusiform choledochal cyst, and non-breath-hold MRCP demonstrated pancreaticobiliary malunion and a long common channel. In the remaining case, the size and location of the huge cyst prevented visualization of any pancreaticobiliary malunion. Endoscopic retrograde cholangiopancreatography (ERCP) in this patient failed to provide any additional information. All patients underwent cyst excision with hepaticoenterostomy, and made an uneventful recovery.

CONCLUSIONS

Our initial experience suggests that non-breath-hold MRCP is a reliable method for the diagnosis of choledochal cyst in children and could replace ERCP.

Pancreaticobiliary maljunction associated with nondilatation or minimal dilatation of the common bile duct in children: diagnosis and treatment

It is known that the etiology of congenital biliary dilatation (CBD) is closely associated with pancreaticobiliary maljunction (PBMJ). Treatment of CBD today is primary excision of the cyst followed by hepaticoenterostomy. However, PBMJ without dilatation of the biliary tract has recently been reported and its treatment is still controversial. In adults, simple cholecystectomy without biliary reconstruction is often performed, because it usually presents as an anomaly of the gallbladder. Over 30 years, we have encountered 8 patients with PBMJ without dilatation of the common bile duct in 180 pediatric cases of CBD. The presenting symptoms of these patients were those of pancreatitis i.e. abdominal pain associated with elevation of serum amylase levels. Five cases presented with jaundice or a history of pale colored stools. Endoscopic retrograde cholangiopancreatography was performed to confirm the diagnosis. Five (62.5%) of these 8 patients were found to have dilatation of the common channel, which was seen in 50 (29%) of the 172 other cases with biliary tract dilatation. Three cases (37.5%) had proven protein plugs or debris at the level of the common channel, and this was observed in 28 (16%) of the 172 other cases. It is strongly suggested that the manifestation of clinical symptoms in these patients results from stasis or obstruction at the level of the common channel. In children who present with recurrent pancreatitis, PBMJ must be suspected even if the common bile duct appears to be normal. It is difficult to resolve these anomalies without operative repair. The authors consider that radical treatment of PBMJ is required in these children to prevent serious long-term complications.

Hepaticoenterostomy after excision of choledochal cyst in children: a 30-year experience with 180 cases

In the long-term follow-up of patients with choledochal cyst, postoperative ascending cholangitis and/or stone formation in the intrahepatic bile ducts (IHBD) owing to anastomotic stricture present serious problems. To prevent the formation of anastomotic strictures, some surgeons recently have performed hepaticoenterostomy at the hepatic hilum, with a wide stoma, in all patients with choledochal cyst. The authors of the present study review the surgical procedures performed on a total of 180 children with choledochal cyst and discuss the treatment of choice, with special reference to the types of hepaticoenterostomy. The medical records and radiographs of all patients treated for choledochal cyst between January 1964 and December 1993 at the authors' institutions were reviewed. A total of 180 patients (mean age at time of surgery, 4.3 years) had follow-up for a mean of 11.1 years; 174 of them had cyst excision and hepaticoenterostomy, and six had cystoenterostomy. Of the 174 patients who underwent cyst excision, 171 had a conventional hepaticoenterostomy; two had an intrahepatic cystoenterostomy, and one had a hepaticoenterostomy at the hepatic hilum. IHBD stones with or without cholangitis developed postoperatively in four (2.3%) of the 171 patients who had conventional hepaticoenterostomy. The age at time hepaticoenterostomy of these four patients was 12, 7, 16, and 6 years. Postoperative IHBD stone formation and cholangitis were not found in 121 patients under 5 years of age. The authors recommend conventional hepaticoenterostomy as the treatment of choice for children with choledochal cyst. Hepaticoenterostomy at the hepatic hilum is indicated in only selected cases.

[Surgical strategy for the treatment of congenital biliary dilatation based on the location of intrahepatic bile duct dilatation]

Congenital biliary dilatation used to be regarded as having a good prognosis. However, some recent long-term follow-up studies have shown there to be quite a high incidence of postoperative intrahepatic bile duct (IHBD) stone formation. In most of the cases in whom IHBD stones form, the IHBD were found to be dilated as the time of initial surgery. Therefore, preoperative evaluation of IHBD dilatation using various imaging studies is extremely important. Surgically, in cases involving structure of the common hepatic duct (CHD) with dilatation above the structure, resection of the stricture and a wide hepaticointestinal anastomosis are strongly recommended. In cases where there is a stricture of the CHD or of the first branch of the IHBD, a reconstructive technique should be applied to dilate the stricture. Patients who have a structure and cystic dilatation of the IHBD above the second branch should be carefully followed-up postoperatively. Partial liver resection to remove the cyst may be required at the time of initial operation or at a later stage.

Laparoscopic bipolar strip-tease appendicectomy. A new endosurgical technique

Since its conception, several techniques have been described for laparoscopic appendicectomy. We describe a technique which utilizes a 5-mm bipolar forceps designed to coagulate and cut tissues at the same time; 50 pediatric patients underwent laparoscopic appendicectomy for acute appendicitis using this "stripping and teasing" technique. No bleeding complications occurred. There were only two postoperative abscesses in the series. We believe that the bipolar laparoscopic striptease appendicectomy technique as developed by the senior author is safe, quick, and effective, even for severe appendicitis.

Tubed latissimus dorsi musculocutaneous flaps for thoracic esophageal replacement: an experimental study

Tubed musculocutaneous flap has never been used to replace a circumferential defect of the thoracic esophagus in adults or children. The aim of this study was to examine whether a tubed latissimus dorsi musculocutaneous flap (TLDMF) can be used to repair a long gap defect of the thoracic esophagus. In 14 puppies with an average weight of 4.9 kg, part of the esophagus (two vertebrae in length) was excised through a right thoracotomy. A latissimus dorsi musculocutaneous flap was introduced into the thoracic cavity. The cutaneous layer was rolled into a tube and interposed in the space of the excised esophagus. The muscle layer was wrapped around the anastomosis. Three puppies died of operative complications, such as a minor anastomotic leakage and postoperative bleeding. One died of an unknown cause. Ten puppies were studied postoperatively with a barium meal, endoscopic examination, and autopsy. The management of these puppies over 4 months is described. It proved possible to replace a long gap thoracic esophageal defect with a TLDMF, which was safe, easy to be transferred, and obviated a laparotomy. Thus, this technique might offer an alternative method to bridge a long gap in patients with esophageal atresia or severe stenosis.

Actin and myosin deposition around bile canaliculi: a predictor of clinical outcome in biliary atresia

The role of pathological changes of the intrahepatic bile canaliculi in determining postportoenterostomy bile drainage in biliary atresia (BA) patients remains unestablished. It is known that canalicular contraction contributes an active force for bile flow in normal ductal systems. This motility is controlled by the bile canalicular membrane-associated filaments (BCMF), particularly actin and myosin. Wedge resected specimens of liver from 13 patients with BA were studied using histopathological markers of BCMF in order to clarify the morphological and functional changes of bile canaliculi. Histopathological data were also compared with clinical outcomes after portoenterostomy. Patients who showed sufficient bile flow after the operation showed an almost normal shape and level of BCMF accumulation around bile canaliculi, whereas there was markedly increased BCMF volume in patients who did not exhibit bile flow after surgery. The clinical staining patterns of BCMF in BA patients appears closely related to clinical outcome. These findings suggest that BCMF plays an important role in determining the rate of postoperative bile flow in BA patients.