Search

T-cells have been demonstrated to modulate ischemia–reperfusion injury (IRI) in the kidney, lung, liver, and intestine. Whereas most T-cell subpopulations contribute primarily to the antigen-specific effector and memory phases of immunity, γδ-T-cells combine adaptive features with rapid, innate-like responses that can place them in the initiation phase of immune reactions. Therefore, we aimed to clarify the role of γδ-T-cells in intestinal IRI. Adult wild-type (WT) and γδ-T-cell-deficient mice were subjected to acute intestinal IRI. Gene expression of pro-inflammatory cytokines and influx of leukocyte subpopulations in the gut were assessed by qPCR and flow cytometry. Serum transaminases were measured as an indicator of distant organ IRI. Intestinal IRI led to increased influx of neutrophils, pro-inflammatory cytokine expression and LDH/ALT/AST elevation. Selective deficiency of γδ-T-cells significantly decreased pro-inflammatory cytokine levels and neutrophil infiltration in the gut following IRI compared to controls. Furthermore, γδ-T-cell deficiency resulted in decreased LDH and transaminases levels in sera, indicating amelioration of distant organ injury. Increasing evidence demonstrates a key role of T-cell subpopulations in IRI. We demonstrate that γδ-T-cell deficiency ameliorated pro-inflammatory cytokine production, neutrophil recruitment and distant organ injury. Thus, γδ-T-cells may be considered as mediators contributing to the inflammatory response in the acute phase of intestinal IRI. [ABSTRACT FROM AUTHOR]

Background: Intermittent work breaks are common in fields with high workload but not yet for surgeons during operations. We evaluated the effects of intraoperative breaks during complex laparoscopic surgery (5 min every half hour) on the surgeon. Methods: Fifty-one operations were randomized to a scheme with intraoperative breaks and release of the pneumoperitoneum (intermittent pneumoperitoneum (IPP)) or conventional conduct (CPP). Stress hormones and α-amylase were determined in the surgeon's saliva pre-, intra-, and postoperatively. Mental performance and error scores, musculoskeletal strain, and continuous ECG were secondary endpoints. Results: Regular intraoperative breaks did not prolong the operation (IPP vs. CPP group: 176 vs. 180 min, p > 0.05). The surgeon's cortisol levels during the operation were reduced by 22 ± 10.3% in the IPP vs. the CPP group ( p < 0.05). There were significantly fewer ( p < 0.05) intraoperative events in the IPP vs. the CPP group, which yielded higher α-amylase peaks. The pre- to postoperative increase in the error rates of the bp-concentration test was fourfold reduced in the IPP group ( p = 0.052). The relevant locomotive strain-scores were grossly reduced by IPP ( p < 0.001). Conclusions: Our data support the idea that work breaks during complex laparoscopic surgery can reduce psychological stress and preserve performance without prolongation of the operation time compared with the traditional work scheme. [ABSTRACT FROM AUTHOR]

Effective analgesia is essential for the success of fast-track (FT) pediatric surgery. Aim of the study was to achieve an optimal analgesia protocol for a comfortable postoperative course and early mobilization in children undergoing urological procedures. A prospective study of two analgesia concepts in a series of children undergoing laparoscopic pyeloplasty (LP) and nephrectomy (LN) was performed. Thirty-six consecutive patients received analgesia according to the protocol “Fast Track I” (FT I), 23 patients according to the modified analgesia protocol “Fast Track II” (FT II). Differences between the protocols were frequency of pain measurement, more frequent use of local anesthesia and higher dosage of Acetaminophen. End points were pain intensity, use of opioids and side effects. Data derived from the German reimbursement system (G-DRG) regarding lengths of hospital stay were compared. On the day of operation (6:00 p.m.), pain scores of patients using FT II were significantly lower than those using the FT I protocol (1.51 ± 0.4 FT II versus 3.8 ± 0.4 FT I, p = 0.001). Pain scores still tended to be lower in the FT II group on the first postoperative day (8:00 a.m.), but from that point on, the difference was not significant (1.52 ± 0.5 FT II versus 2.3 ± 0.4 FT I, p = 0.186). Hospital stay was short, compared to the German average, in both groups. The modified analgesia protocol FT II leads to earlier and more effective pain reduction, lower use of opioids and fewer side effects than the previously used protocol FT I. Hence, modification of analgesia in pediatric urology is essential. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate fast-track concepts in routine pediatric surgery in a university clinic over 1 year. Fast-track concepts were established for procedures requiring hospital admission in patients up to 15 years of age. Patients were studied prospectively from June 2006 to June 2007. Out of a total of 436 potentially suitable patients, 155 (36%) were finally treated following the protocols. The mean intensity of pain in children younger than 4 years (CHIPPS, 0–10) was 1.3 ± 1.5 the evening of the operation day and decreased to <1 at all other time points. The initial postoperative mean pain intensity in older children (Smiley/VAS, 1–10) was 3.7 ± 2.2 and decreased constantly thereafter. The mean hospital stay of fast-track patients was significantly shorter compared with German diagnosis-related group data (4.6 ± 2.9 versus 9.7 ± 3.8, p < 0.01). There were four (3%) readmissions for minor complications. At follow-up after 2 weeks, 95% of patients and parents judged fast-track care as excellent. Fast-track concepts are feasible in one third of pediatric patients undergoing routine in-hospital surgery. Fast-track pediatric surgery achieves accelerated convalescence, minimal hospital stay, and high patient and parent satisfaction. [ABSTRACT FROM AUTHOR]

Purpose: Recent evidence suggests that transforming growth factor-alpha (TGF-alpha) enhances enterocyte proliferation and exerts a gut trophic effect. The purpose of the present study was to evaluate the effect of TGF-alpha on enterocyte proliferation and intestinal recovery following methotrexate (MTX)-induced intestinal mucositis in rats and in Caco-2 cells.Methods: Nonpretreated Caco-2 cells and those pretreated with MTX were incubated with increasing concentrations of TGF-alpha. Cell proliferation was determined by FACS cytometry. Adult rats were divided into three groups: control rats treated with vehicle, MTX rats treated with one dose (20 microg/kg) of MTX given intraperitoneally, and MTX-TGF-alpha rats treated with one dose of MTX followed by two doses of TGF-alpha (75 microg/kg a day). Three days after MTX injection, rats were sacrificed. Intestinal mucosal damage (Park's score), mucosal structural changes, and enterocyte proliferation were measured at sacrifice. Western blotting was used to determine the level of extracellular signal-related kinase (ERK) protein, a marker of cell proliferation. A nonparametric Kruskal-Wallis ANOVA test was used for statistical analysis with P value less than 0.05 considered statistically significant.Results: The in vitro experiment demonstrated that treatment with TGF-alpha of Caco-2 cells resulted in a significant stimulation of cell proliferation in a dose-dependent manner. The in vivo experiment showed that treatment with TGF-alpha resulted in a significant increase in bowel and mucosal weight, DNA and protein content in jejunum and ileum, villus height in jejunum and ileum, crypt depth in ileum, and increased cell proliferation in jejunum and ileum compared to the MTX group. MTX-TGF-alpha rats also had a significantly lower intestinal injury score in ileum when compared to MTX animals. The increase in levels of cell proliferation in MTX-TGF-alpha rats corresponded with the increase in ERK protein levels in intestinal mucosa.Conclusion: Treatment with TGF-alpha prevents mucosal injury, enhances ERK-induced enterocyte proliferation, and improves intestinal recovery following MTX-induced intestinal mucositis in rats. These findings correlated with the observation that TGF-alpha also caused a significant stimulation of cell proliferation in a Caco-2 cell culture model treated with MTX. These observations may have significant implications for the treatment of patients on chemotherapy who develop severe mucositis. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the current study was to investigate effects of CO(2) atmosphere, mimicking conditions of the pneumoperitoneum during laparoscopy, on epigenetic conditions of Rassf1A and DCR2 oncogenes in neuroblastoma cells.Methods: SH-SY5Y neuroblastoma cells were exposed to 100% CO(2) for 4 h. Cells were lysed 4, 8 and 168 h after exposure. After methylation analysis of Rassf1A and DCR2 with polymerase chain reaction, results were compared to those of physiologically incubated neuroblastoma cells.Results: No significant changes were found after exposure to carbon dioxide compared to the control. Values of methylated Rassf1A were 12.6 +/- 1.1 versus 13.2 +/- 1.4 ng/microl in the controls, respectively (4 h after incubation), 12.6 +/- 1.2 versus 15.1 +/- 0.9 ng/microl (8 h) and 14.2 +/- 1.5 versus 11.7 +/- 1.3 ng/microl (168 h). DCR2 showed values of 4.6 +/- 0.5 versus 3.7 +/- 0.5 ng/microl (4 h), 3.8 +/- 0.5 versus 4.1 +/- 0.4 ng/microl (8 h) and 3.6 +/- 0.4 versus 3.8 +/- 0.5 ng/microl (168 h).Conclusion: Exposure of neuroblastoma cells to 100% CO(2) does not alter methylation of two prognostic relevant index genes. It seems therefore unlikely that effects on methylation levels within CO(2) pneumoperitoneum lead to epigenetic changes in neuroblastoma. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Postoperative adjuvant steroid treatment is reported to improve jaundice-free survival in biliary atresia (BA) patients and to reduce the need for early liver transplantation. However, evidence of all retrospective studies is very limited, although high-dose corticosteroids were favored. The aim of this dosage finding study was to test the most promising corticosteroid protocol in a smaller but representative series, in order to optimize the settings of upcoming prospective and long-term multicenter studies. METHODS: Our prospective single-center and open-labeled pilot study on high-dose steroids included 49 consecutive BA patients. Basic data of the study group were not different from 29 controls. In the study group, 20 consecutive patients were treated after the Kasai with methylprednisolone (10 mg/kg day 1 to 5 and 1 mg/kg day 6 to 28). RESULTS: Overall survival with native liver was 63% after 6 months and 31% after 2 yr, with no statistical difference between the study and control groups. After 2 yr, 27% of all patients were still jaundice-free. With regard to predictive parameters, we found, 6 months after the Kasai, bilirubin <20 μmol/L as highly sensitive (97%) and specific (93%) for jaundice-free survival with native liver. CONCLUSIONS: In contrast to previous reports, this pilot study shows that high-dose steroid pulses after Kasai procedure are not effective in postoperative adjuvant therapy protocols and should be avoided in upcoming multicenter steroid studies. Therefore, we recommend extended and randomized multicenter studies to pre-evaluate the supposed effectiveness of alternative steroid protocols, by comparing, 6 months after the Kasai procedure, the number of patients with normal bilirubin. [ABSTRACT FROM AUTHOR]

Recent evidence suggests that transforming growth factor alpha (TGF-α) enhances enterocyte proliferation and stimulates intestinal adaptation after massive bowel resection. In the present study, we evaluated the effects of TGF-α on enterocyte turnover and correlated it with epidermal-growth factor (EGF) receptor expression along the villus–crypt axis in a rat model of short bowel syndrome (SBS). Male rats were divided into three groups, sham rats underwent bowel transection (group A); SBS rats underwent a 75% bowel resection (group B); and SBS/TGF-α rats underwent bowel resection and were treated with TGF-α (75 μg/kg) (group C) from the seventh postoperative day. Parameters of intestinal adaptation, enterocyte proliferation and apoptosis were determined on day 15. Villus tips, lateral villi and crypts were separated using laser capture microdissection. EGF receptor expression for each compartment was assessed by quantitative real-time PCR (Taqman). Statistical analysis was performed using one-way ANOVA test, with P < 0.05 considered statistically significant. Treatment with TGF-α resulted in a significant increase in all parameters of intestinal adaptation. EGF receptor expression in crypts significantly increased in SBS rats (vs sham rats) (0.035 ± 0.013 vs 0.010 ± 0.002 Log ng Total RNA/18 s) and was accompanied by a significant increase in enterocyte proliferation (169 ± 8 vs 138 ± 5 BrdU positive cells/per 10 crypts, P < 0.05) and decreased apoptosis following TGF-α administration (group C). A significant decrease in EGF receptor expression at the tip of the villus (0.005 ± 0.002 vs 0.029 ± 0.014 Log ng Total RNA/18 s) and in the lateral villus (0.003 ± 0.001 vs 0.028 ± 0.006 Log ng Total RNA/18 s) in SBS (group B) rats (vs sham, group A) was accompanied by increased cell apoptosis in these compartments following treatment with TGF-α (group C). In a rat model of SBS, TGF-α increased enterocyte proliferation and stimulated intestinal adaptation. The effect of TGF-α on enterocyte turnover is correlated with EGF receptor expression along the villus–crypt axis. [ABSTRACT FROM AUTHOR]

Numerous human macrophage (mphi) subpopulations with different behavior have been identified in adults. It is well known that peritoneal mphi are activated by abdominal surgery and subsequently contribute to a systemic inflammatory response that leads to immune suppression, increased morbidity and mortality. Information on the role of pleural mphi in adults is scarce and information on their role in children is lacking. We investigated the behavior of pleural versus peritoneal mphi in children and adolescents. As a first step, we compared the cellular composition of the pleural and peritoneal surface in children and adolescents. Pleural and peritoneal lavages were performed in 21 patients undergoing non-contaminated laparoscopic and thoracoscopic surgical procedures. We observed a significantly higher percentage of mphi in the pleural compared to the peritoneal cavity with less lymphocytes, a small amount of polymorphonuclear cells (PMNs) and other cells. To further study the mphi inflammatory response, we measured the spontaneous and LPS triggered cytokine release of isolated pleural versus peritoneal mphi (IL-1beta, IL-6, and IL-10). The pattern of cytokine release was similar in both, pleural and peritoneal mphi. Directly after lavage, they showed a strong activation, with no difference between stimulated and non-stimulated cells. After 24 h resting, mphi of both compartments reacted to LPS with a similar significant increase in the cytokine release. In conclusion, our results demonstrate that pleural mphi represent the dominant cell population in the pleural cavity of the young. They show a similar inflammatory response as peritoneal mphi and should be considered to play a major role in the local inflammatory response to thoracic surgery. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive techniques are increasingly applied to children with malignant tumors. We showed previously that CO2 used for pneumoperitoneum modulates the function of macrophages and polymorphonuclear cells via direct effects and via acidification. Numerous in vitro and small animal model studies also confirmed an alteration of the behavior of several types of adult tumor cells by CO2. The impact of CO2 and other gases used for pneumoperitoneum on the behavior of various pediatric tumors has not yet been determined. Methods: Cell lines of neuroblastoma (IMR 32, SK-N-SH, Sy5y), lymphoma (Daudi), hepatoblastoma (Huh 6), hepatocellular carcinoma (Hep G2), and rhabdomyosarcoma (Te 671) were incubated for 2 h. Incubation was performed with 100% CO2, 100% helium, and 5% CO2 as control. Cell proliferation was determined by the MTT-assay [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] by actively growing cells to produce a blue formazan product. The MTT-assay was performed before, directly after incubation, and daily for 4 days. Vitality of the cells was determined by trypan blue. The extracellular pH during incubation was measured during gas exposition every 10 min using Bayer Rapid Lab 855. Results: CO2 for 2 h significantly decreased the proliferation of neuroblastoma, lymphoma, hepatoblastoma, and hepatocellular carcinoma cells. This decrease persisted over 4 days in neuroblastoma, lymphoma, and hepatocellular carcinoma cells. The CO2 had no impact on hepatoblastoma and rhabdomyosarcoma cells. Helium had a similar effect on neuroblastoma cells. After 4 days, a significant decrease of cell activity was found in two neuroblastoma cell lines and in hepatoblastoma cells. Helium had no effect on lymphoma and hepatocellular carcinoma cells. The extracellular pH was 6.2 during incubation with CO2, and 7.6 during incubation with helium. Conclusion: CO2 and helium may affect the proliferation of some pediatric tumor cell lines in vitro. However, some of these effects and the impact on the extracellular pH are differential. The role of pH modulation, hypoxia and direct effects of gases remain to be investigated before a general recommendation on the use of minimally invasive techniques in pediatric oncology can be given. [ABSTRACT FROM AUTHOR]

One hypothesis of the pathogenesis of biliary atresia (BA) is a virus-induced and immune-mediated injury to bile duct cells as mimicked in the rotavirus-induced murine model. This theory is supported by studies showing a predominant T helper cell response type 1-like phenotype of inflammation with increased interferon gamma-induced chemokines in the liver of humans and mice suffering from BA. Recent gene expression profiling studies using microarray analysis showed the induction of a proinflammatory state in human liver specimens with high analogies in extrahepatic biliary tissue of BA mice. The aim of the present study was a microarray analysis of gene expression in the liver of Balb/c mice, comparing infected mice that show the phenotype of BA versus infected mice without symptoms, thus trying to elucidate genes that are not related to the viral origin of this model, but to the specific pathogenesis of the clinical picture of BA. Fifteen mug of RNA, each of three BA-positive and three BA-negative mice, were pooled and comparatively hybridized to spotted cDNA microarrays containing 250 key genes with high relevance to immunological settings. We identified the 40 genes most differentially expressed in mice with and without BA. The majority of genes with higher expression in BA-positive mice encoded proinflammatory cytokines involved in the Th1 pathway, such as CCL2, CCL5, CCR5, CXCL10, CCL2, IL1F5 and in apoptosis, such as DDR3 and granzyme A and B. In this initial study of the molecular characterization of our RRV-induced BA mouse model system, we also found potential novel candidates important to BA etiology, such as growth hormone receptor and insulin-like growth factor. Of particular interest, very low expression of TIMD2 was observed in BA-positive mice. TIMD2 plays a critical role in the regulation of a Th2-type response through the inhibition of IFN gamma. [ABSTRACT FROM AUTHOR]

Exclusive lower pole pelvi-ureteric junction obstruction (PUJO) in double collecting systems in children is a rare condition requiring reconstructive surgery. We report on the feasibility of laparoscopic transabdominal dismembered pyeloplasty in two cases. Two children with duplicated collecting systems presented with hydronephrosis of lower pole moiety due to exclusive PUJO. Isotope renography revealed impaired drainage of affected lower kidney pole. A four-trocar transabdominal technique was used. No stent was used in one patient with bilateral duplication (male, 6 years) while a 4 Fr. double-J stent was placed laparoscopically in another with unilateral duplication (male, 9 months). Both patients had uneventful laparoscopic transabdominal dismembered pyeloplasty. The operation time was 115 and 155 min, respectively, and was comparable to our previously reported patient series undergoing laparoscopic pyeloplasty for singular collecting systems. After a mean follow-up of 21 months (range 12-42), both patients were asymptomatic and showed improved pelvi-ureteric drainage on isotope renography and improved hydronephrosis on ultrasound scan. Laparoscopic transabdominal dismembered pyeloplasty is safe and effective in children with rare lower pole PUJO in double collecting systems. [ABSTRACT FROM AUTHOR]

Definitive medical treatment for benign recurrent intrahepatic cholestasis (BRIC) is not available and the significance of surgical treatment is a matter of debate. It has been postulated that BRIC may progress to progressive familial intrahepatic cholestasis (PFIC), which leads to liver insufficiency and cirrhosis. External biliary diversion represents an option for both conditions and we recently introduced a new laparoscopic technique for infants with PFIC. However, limited umbilical incision may interfere with creating a jejunal conduit by infraumbilical exteriorisation, in particular in obese adolescents. Therefore, we modified our technique by exteriorising a small bowel loop via the right midabdominal trocar incision at the position of the jejunostomy. The technique was used in a 17-year-old obese patient with BRIC. This is the first report on a patient with BRIC undergoing laparoscopic external biliary diversion. [ABSTRACT FROM AUTHOR]