Search

Byline: Ryozo Hashimoto (1), M. Nagaya (2), Y. Ishiguro (3), M. Inouye (4), H. Aoyama (5), S. Futaki (1), Y. Murata (1) Keywords: Fistula Anorectal malformations Experimental model All-trans retinoic acid Cloaca Abstract: Since high anorectal malformations with fistulae in human embryos and fetuses of successive developmental stages have not been reported, the embryologic relationship between the rectal fistula (RF) and the genitourinary tract (GUT) in high anorectal agenesis (ARA) remains to be elucidated. This study investigates the developmental relationship between the RF and the GUT in male and female fetuses with high ARA using our established model for high ARA with fistula in mice. Pregnant mice received all-trans retinoic acid suspended in corn oil (5 mg/ml) 100 mg/kg i.p. on day 9 of pregnancy. All fetuses were removed from the uterus on a single day from days 12 to 18 of pregnancy. The caudal regions were analyzed histologically with hematoxylin and eosin staining. All fetuses examined had high ARA with fistula. On day 12 of pregnancy, an anomalous communication was seen between the urogenital sinus (UGS) and the rectum. In the affected female fetuses, on day 14 of pregnancy the paramesonephric (mullerian) ducts and mullerian tubercle were located above the rectocloacal fistula (RCF), and on day 18 of pregnancy the uterovaginal canal was located between the cloaca and the RCF. In the male fetuses, on day 14 of pregnancy the junction between the mesonephric (wolffian) duct and the UGS was located away from the junction between the rectum and the UGS. On day 18 of pregnancy the ejaculatory duct was located between the urinary bladder and the rectourethral fistula. The results of our experiment clearly show the embryologic relationship between the RF and the GUT with high ARA. The anomalous communication between the UGS and the rectum may interfere with normal caudal migration along the dorsal wall of the UGS at the junction between the UGS and the mesonephric or paramesonephric duct. Author Affiliation: (1) Department of Teratology and Genetics, Research Institute of environmental Medicine, Nagoya University, Nagoya 464-8601, Japan (2) Department of pediatric Surgery, Central Hospital, Aichi prefectural Colony, Kasugai, Japan (3) Japanese Red Cross Aichi Junior College, Nagoya, Japan (4) Shin Nippon Biomedical Laboratories, Yoshida Kagoshhima, Japan (5) Department of Surgery, Fujita Health University, Toyoake, Japan Article History: Accepted Date: 19/12/2001 Article note: Electronic Publication

Byline: M. Nagaya (1), J. Kato (1), N. Niimi (1), S. Tanaka (1) Keywords: KeywordsaExtracorporeal membrane oxygenation; Sepsis; Gastric rupture Abstract: aExtracorporeal membrane oxygenation (ECMO) has been recognized to be beneficial to overcome not only persistent pulmonary hypertension of the newborn, but also cardiopulmonary distress due to neonatal sepsis. However, few papers have reported on the efficacy of ECMO for surgical sepsis in neonates with underlying diseases. This paper reports our experience with ECMO in three newborns with gastric rupture, one of the most serious causes of surgical sepsis in the neonatal period. Over the past 12 years, 14 newborns had gastric rupture 3 developed lethal cardiopulmonary distress that conservative strategies, including aggressive intensive care, failed to manage, and were selected for ECMO. The clinical data of these patients were retrospectively analyzed. The onset time and duration of ECMO varied from 23 to 143h of age and 72 to 294h, respectively. In case 3, complicated by massive intra-abdominal hemorrhage during ECMO, anticoagulants were changed from heparin alone to combined use with nafamostat mesilate, a thrombin inhibitor with a very short half-life. Ultrafiltration or hemodialysis was added in two cases to regulate massive volume overload associated with renal failure. Despite major hemorrhagic complications in two cases, all patients survived. Thus, ECMO may be beneficial in managing neonates with therapy-resistant gastric rupture. Author Affiliation: (1) Department of Pediatric Surgery, The Central Hospital, Aichi Prefectural Colony, 713-8 Kamiya, Kasugai, Aichi, 480-0392 Japan, JP Article note: Accepted: 1 February 2000

Byline: S. Fukuda (1), M. Aoyama (1), Y. Yamada (1), N. Saitoh (1), T. Honjoh (1), T. Hasegawa (1), M. Futamura (1), J. Katoh (2), N. Niimi (2), S. Tanaka (2), M. Nagaya (2) Keywords: Key words Extracorporeal membrane oxygenation; Cerebral blood flow velocity; Cerebral hemorrhage Abstract: This study was designed to compare venoarterial (VA) with venovenous (VV) access in the cerebral circulation of newborn infants during extracorporeal membrane oxygenation (ECMO). Among 14 infants with VA ECMO, 7 had no intracranial complications (group 1), while the others (group 2) developed intracranial hemorrhage (ICH). In contrast, among 19 infants with VV ECMO, only 1 developed ICH. Serial echocardiograms were performed before and after 1, 6, 12, and 24h and 2 and 3 days of ECMO. The mean cerebral blood flow (CBF) velocities were measured in the anterior cerebral artery (ACA), right and left internal carotid arteries (Rt, Lt-ICA), basilar artery (BA), and right and left middle cerebral arteries (Rt, Lt-MCA). Ejection fraction (EF), cardiac output (CO), and stroke volume (SV) were also measured using standard echography. The velocity levels in the ACA, Rt-MCA, and Lt-MCA in VA ECMO were lower than those in VV ECMO, while those in the Lt-ICA and BA in VA ECMO were higher than those in VV ECMO. The EF, CO, and SV were lower in cases of VA ECMO than in VV ECMO. In cases of VA ECMO, there were no differences between groups 1 and 2 in velocities in the ACA, Rt-ICA, or Lt-ICA. However the velocities in group 2 in the BA, Rt-MCA, and Lt-MCA were lower than those in group 1 before and during ECMO. Similarly, the EF, CO, and SV were lower in group 2 (12.0%--31.0%, 0.10--0.32l/min, and 0.66--1.55ml, respectively) than in group 1 (29.5%--49.3%, 0.25--0.63l/min, and 2.15--3.85ml) during ECMO. However, in the infants on VV ECMO the CBF was either maintained or gradually increased before and during ECMO. Their cardiac parameters were: EF 46.1%--53.0%, CO 0.43--0.52l/min, and SV 2.72--3.84ml during ECMO. It is concluded that in VA ECMO CBF velocities, particularly in infants who developed ICH, decreased after the onset of ECMO in association with poor cardiac function, while in VV ECMO they were stable, probably due to normal systemic hemodynamics and cardiac function. Author Affiliation: (1) Department of Neonatology, Central Hospital, Aichi Prefectural Colony, 713-8 Kagiya, Kasugai, Aichi 480-0392, Japan, JP (2) Department of Pediatric Surgery, Central Hospital, Aichi Prefectural Colony, 713-8 Kagiya, Kasugai, Aichi 480-0392, Japan, JP

Byline: M. Nagaya (1), J. Kato (1), N. Niimi (1), S. Tanaka (1), T. Tanaka (1) Keywords: Key words Congenital diaphragmatic hernia; ; Extracorporeal membrane oxygenation; Pulmonary; hypoplasia Abstract: The purpose of this report was to analyze the patients requiring preoperative extracorporeal membrane oxygenation (ECMO) as the most critical group of patients with congenital diaphragmatic hernia (CDH) and to identify any special features. Over the past 11years, out of 72 neonates with CDH admitted before 24h of age, 40 (56%) could be managed with conventional therapies while the other 32 (44%) required ECMO. Seventeen infants requiring preoperative ECMO were classified as group 1, and the 15 with postoperative ECMO as group 2 (controls). The records of patients in both groups were analyzed. Patients in group 1 were not only severely hypoxic, but also significantly hypercapneic on admission, and in 14 (82%) the diaphragmatic defect was so large or totally agenetic that a prosthetic patch was necessary. The average age at onset of ECMO in group 1 was 13.1h, and the average duration was 159h. Major hemorrhagic complications including intracranial hemorrhage occurred with a significantly higher frequency in group 1. The survival rate in group 1 was 41%, compared with 73% in group 2 and 85% in non-ECMO patients. Four infants in group 1 with extremely hypoplastic lungs could not be weaned from ECMO, and died without undergoing an operation. Moreover, 4 of the 7 survivors in group 1 required prolonged (105--658days) ventilator care with a tracheostomy after weaning from ECMO, and were frequently hospitalized thereafter. The pulmonary function of these patients remained severely underdeveloped for a long time indeed, the average pulmonary perfusion ratio of the affected side remained at only 40% of the contralateral side in group 1, although the volume ratio reached 85%. These findings may suggest that the main pathology of the patients requiring preoperative ECMO was a high degree of pulmonary hypoplasia, and that there will be limitations to management using ECMO. Author Affiliation: (1) Department of Pediatric Surgery, The Central Hospital, Aichi Prefectural Colony, 713-8 Kamiya, Kasugai, Aichi, 480-0392 Japan, JP Article note: Accepted: 8 April 1998

Purpose: The current study was designed to investigate the association between the average preoperative physical activity and postoperative outcomes in patients undergoing surgeries for hepato-pancreato-biliary (HPB) malignancy., Methods: Patients who were scheduled to undergo open abdominal surgeries for HPB malignancies (major hepatectomy, pancreatoduodenectomy, or hepato-pancreatoduodenectomy) between 2016 and 2017 were included. The average steps per day were recorded by a pedometer and calculated for each patient during the preoperative waiting period. Physical activity levels were classified according to the average number of daily steps as poor (< 5000 steps/day) and good (≥ 5000 steps/day)., Results: Of the 105 eligible patients, 78 met the inclusion criteria. The median number of steps per day was 6174. There were 48 patients (62%) with good physical activity and 30 patients (38%) with poor physical activity. Patients with poor physical activity revealed a significantly higher rate of major complications with Clavien grade ≥ 3 (63% vs. 35%, p = 0.016), a higher rate of infectious complications (53% vs. 23%, p = 0.006), and a longer postoperative hospital stay (median, 30 vs. 21 days, p < 0.001) compared with those with good physical activity. After a multivariate analysis, poor physical activity was identified as an independent risk factor for the development of major complications (odds ratio, 2.842, p = 0.042) and infectious complications (odds ratio, 3.844, p = 0.007)., Conclusions: The current study demonstrated that preoperative physical activity levels are associated with the incidence of major postoperative complications following HPB surgery for malignancy.

Background: The impact of prehabilitation on physical fitness and postoperative course after hepato-pancreato-biliary (HPB) surgeries for malignancy is unknown. The current study aimed to investigate the effect of preoperative exercise and nutritional therapies on nutritional status, physical fitness, and postoperative outcomes of patients undergoing an invasive HPB surgery for malignancy., Methods: Patients who underwent open abdominal surgeries for HPB malignancies (major hepatectomy, pancreatoduodenectomy, or hepato-pancreatoduodenectomy) between 2016 and 2017 were subjected to prehabilitation. Patients before the introduction of prehabilitation were included as historical control subjects for 1:1 propensity score-matching (no-prehabilitation group). The preoperative nutritional status and postoperative course were compared between the two groups., Results: The prehabilitation group consisted of 76 patients scheduled to undergo HPB surgeries for malignancy. An identical number of patients were selected as the no-prehabilitation group after propensity score-matching. During the waiting period, serum albumin levels were significantly deteriorated in the no-prehabilitation group, whereas this index did not deteriorate or even improved in the prehabilitation group. By performing prehabilitation, a 6-min walk distance and total muscle/fat ratio were significantly increased during the waiting period. Although the overall incidence of postoperative complications did not differ between the two groups, the postoperative hospital stay was shorter in the prehabilitation group than in the no-prehabilitation group (median, 23 vs 30 days; p = 0.045)., Conclusion: The introduction of prehabilitation prevented nutritional deterioration, improved physical fitness before surgery, and shortened the postoperative hospital stay for the patients undergoing HPB surgeries for malignancy.

Background: The aim of this retrospective study was to clarify the safety and efficacy of dendritic cell (DC)-based immunotherapy targeting synthesized peptides, Wilms tumor 1 (WT1) and Mucin 1, cell surface associated (MUC1) for biliary tract cancers (BTCs)., Methods: Sixty-five patients who had nonresectable, recurrent, or metastatic BTCs and received the DC-based immunotherapy were selected for the study. DCs were pulsed with WT1 and/or MUC1. The adverse events (AEs) and clinical responses were examined., Results: No serious treatment-related AEs were observed. Median survival time (MST) from diagnosis and from the first vaccination was 18.5 and 7.2 months, respectively. By multivariate Cox proportional hazard analysis, the significant independent factors were found to be (1) combined chemotherapy, (2) albumin level ≥4.0 g/dL before vaccination, (3) C-reactive protein level <0.5 mg/dL before vaccination, and (4) fever after vaccination. The MST from the first vaccination with or without chemotherapy was 8.2 and 5.3 months, respectively (P = 0.016), and MST for the patients with prognostic nutritional index ≥40 and <40 was 8.1 and 5.0 months, respectively (P = 0.023)., Conclusions: Although a small uncontrolled nonrandomized study, DC-based immunotherapy for BTCs was safe and produced a clinical response for the patients who underwent chemotherapy and maintained a good nutrition status.