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Biliary atresia is a rare neonatal disease and the most common indication for pediatric liver transplantation. Kasai portoenterostomy is the initial treatment, aiming to prevent liver transplantation. Beyond age at Kasai, few prognostic factors are known. Multiple countries have established screening methods to reduce the age at Kasai and recent analysis shows significant better outcomes for screening cohorts. In 2016, we established a decentralized stool color card screening in Lower Saxony and we present our first 2 years of experiences. In cooperation with a major German health insurance company and the Medical Association of Lower Saxony, we established the screening project, printed 120,000 color cards, and distributed them to all maternity hospitals. Program advertises were printed in newspapers and medical journals. After the first year, the project was evaluated. Thirty maternity hospitals and local practitioners were contacted via telephone, Internet, intranet, and pediatric journals. One out of seventy-six maternity hospitals (1.3%) refused to participate in the screening. 30 hospitals (40%) were contacted and 93.5% of the interviewed staff reported that stool color cards were handed out regularly and discussed with the parents. Only 20% of local practitioners assessed neonatal cholestasis to be a relevant problem during daily practice, and 55% regarded a stool color card screening to be useful. In the second year, we extended the screening project to outpatient maternity clinics. Based on the responses of local practitioners, we regard the voluntary screening as insufficient and we have contacted the Federal Joint Committee for the initiation of a nationwide obligatory stool color card screening.

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.

Caudal anesthesia (CA) is widely recommended due to excellent analgesia in distal hypospadia repairs, but its potential side effect on urinary retention interferes with patient comfort. To objective is to determine the impact of CA versus penile block (PB) on postoperative micturition.Sixty distal hypospadia repairs performed over a 48-month period were analyzed concerning the impact of applicated analgesia on postoperative micturition. Inclusion criteria were Mathieu or Snodgrass procedures, use of a non-dribbling urethral stent, CA or PB. Endpoint was first postoperative micturation (6 h), or treatment of delayed postoperative micturation (6 h).CA was used in 27 and PB in 33 cases. Compared groups had similar age (mean: 31 months, range 12-68 vs. 28 months, range: 14-145), weight (mean: 13 kg, range 9-18 vs. 15 kg, range 8-59), operation duration (mean 61 min, range 30-105 vs. mean 67 min, range 35-120) and surgical technique (Mathieu/Snodgrass: 7/20 CA vs. 19/14 PB). Micturation was significantly less impaired in the PB than CA group (5/33 vs. 15/27; p0.05). Delayed or non-micturation was successfully treated in 4 and 14 patients, respectively, by cholinergic agonists. One patient of each group required a suprapubic drain on the first operative day after unsuccessful medical treatment.In our series, children undergoing distal hypospadia repair experienced significantly less impaired micturition when using penile block instead of caudal anesthesia. We recommend penile block as the first choice perioperative analgesia, when spontaneous postoperative micturition must be guaranteed.

Acute respiratory distress syndrome, with the need for invasive mechanical ventilation (MV) remains a major cause of neonatal mortality and morbidity. Although venovenous extracorporeal lung support (VV-ECLS) has become a standard of care procedure in neonatal patients with acute pulmonary failure there are no reports regarding the use of a double-lumen cannula for extracorporeal minimal invasive lung support via the umbilical vein. A neonatal lamb model was used (n = 3). Umbilical vein was cannulated with a double-lumen catheter allowing venovenous extracorporeal gas exchange. Cannula was positioned with its tip in the right atrium. VV-ECLS was started and ventilation was stopped. Providing oxygenation and CO2 removal solely through VV-ECLS hemodynamics, blood gases were measured. Total VV-ECLS without MV was applied to all three neonatal lambs. Time on venovenous ECLS was 60, 120 and 120 min. Initial pCO2 was 60, 56 and 65 mmHg compared to 31, 32 and 32 mmHg at the end of VV-ECLS. Initial pO2 was 30, 27 and 26 mmHg compared to 22, 19 and 23 mmHg. Initial lactate was 5, 10 and 3.7 mmol/l compared to 13.3, 12.6 and 11.3 mmol/l at the end of VV-ECLS. MAP at baseline was 51, 52 and 65 mmHg compared to 36, 38 and 41 mmHg at the end of VV-ECLS. In all three lambs inotropes were admitted to maintain MAD >35 mmHg. Even without mechanical ventilation we were able to sufficiently remove pCO2 with our new minimal invasive VV-ECLS using a double-lumen catheter via the umbilical vein, supporting the idea of a lung protective strategy in neonatal acute respiratory failure. pO2 was measured 22, 19 and 23 mmHg, respectively, at the end of VV-ECLS, at least partially caused by recirculation phenomenon, which could possibly be improved by different cannula design. Inotropic support was necessary during VV-ECLS to achieve targeted MAD > 35 mmHg. While technically feasible, this new approach might allow further research in the field of extracorporeal lung support and therefore will follow the concept of a lung protective strategy in acute neonatal respiratory failure.

Background: The murine model of biliary atresia (BA) is used for examining the pathogenesis of BA. The aim of the study was description of the morphological features and illustrating the detailed development of fibrosis using the Biliary Atresia Research Consortium (BARC) system.Methods: Neonatal mice were injected intraperitoneally with rhesus rotavirus (RRV) strain (N = 17). Healthy mice were the control group (N = 29). All mice were sacrificed at 7 or 14 days after birth. Two pathologists examined the morphological features using the BARC system; CK19, alpha SMA and collagen type I were assessed by immunohistochemistry.Results: In RRV mice, portal fibrous expansion with focal bile duct proliferation and strong portal cellular infiltrate was found in contrast to healthy mice. In RRV mice, CK19 bile duct staining was significantly less or absent (p Conclusions: The morphological features observed in the murine model of BA correspond with the BA characteristics according to the BARC criteria. Fibrosis is an important feature of the model. Therefore, this murine model is useful for investigating the pathogenesis of BA. (C) 2015 Elsevier Inc. All rights reserved.

This study aimed to determine the impact of prior surgery on the feasibility of laparoscopic surgery for children.A prospective study analyzed 471 consecutive children who underwent laparoscopic surgery over a 4-year period. Laparoscopic procedures were classified "easy," "difficult," or "demanding." The end points of the study were conversion rate, intraoperative events, and duration of operation.A total of 89 patients (19%) had undergone previous abdominal surgery. The conversion rate was 18% for the patients with prior surgery versus 9% for those without a prior operation (16/89 vs 35/382; p0.05). This difference reflects a significantly higher conversion rate for "easy" procedures among patients with than among those without prior surgery, but not for "difficult" and "demanding" procedures. The type of prior surgery had no significant impact on the mean duration of the operation. Of 71 procedures, 12 (17%) after prior conventional surgery were converted, as compared with 4 (22%) of 18 after prior laparoscopy (p0.05). Intraoperative events, mainly attributable to adhesions and lack of overview, occurred in 8% of patients with prior procedures, as compared with 2% without former surgery (7/89 vs 9/382; p0.05). Relevant complications were not significantly more frequent after prior surgery. The incidence of conversions decreased with increased time between current and previous surgery. It was 64% for surgeries less than 1 year later, 25% for surgeries 1 to 5 years later, and 5% for surgeries more than 5 years later (7/11 vs 6/24 vs 3/54; p0.001).Prior surgery has a limited impact on the feasibility of laparoscopic surgery for children. The conversion rate and the incidence of intraoperative events, mainly because of adhesions and lack of overviewing, is increased, but not the incidence of relevant complications. The feasibility improves considerably with increased time between surgery and prior surgery. The authors consider laparoscopy to be the first-choice technique after prior surgery.

Purpose Laparoscopy has been associated with lower inflammatory responses. However, it has been postulated that minilaparotomy, in contrast to full laparotomy, is equally minimally invasive. Objective The aim of this study was to investigate local, systemic, and distant organ immune responses after different surgical approaches to the abdominal cavity, such as minilaparotomy, full laparotomy, and laparoscopy, in a small animal model. Methods Male Lewis rats received a permanent central venous catheter and were randomized to 4 groups (n = 6 per group). The animals were subjected to anesthesia alone (control), minilaparotomy (1 cm), full laparotomy (7 cm), or laparoscopy for 60 minutes. Blood was collected via the central venous catheter before as well as 1 hour and 6 hours after the start of intervention. Peritoneal and bronchoalveolar lavages, as well as heart puncture, were performed after 24 hours. Results All surgical interventions led to a significant migration of polymorphonucleocytes into the abdominal cavity. Full laparotomy resulted in a significant increase in nitric oxide production by peritoneal macrophages as compared with control. Macrophage nitric oxide production after laparoscopy and minilaparotomy was not significantly different. A shift in the expression of OX-6 and CD54 was only detected after full laparotomy. Systemically, O 2 − release by circulating mononuclear cells was significantly increased after minilaparotomy and full laparotomy, but not after laparoscopy. The systemic levels of IL6 were significantly accelerated only after full laparotomy, with a maximum after 6 hours. In the lungs, function of alveolar macrophages was not altered in any group. Conclusions Any approach to the peritoneal cavity causes local inflammatory responses. Full laparotomy alters peritoneal macrophage functions more pronouncedly than does minilaparotomy or laparoscopy. Systemic inflammatory responses, such as free oxygen radical release, are significantly increased by both minilaparotomy and full laparotomy, whereas laparoscopy preserves systemic immune function. Our results may lead to further preference for the laparoscopic approach over minilaparotomy and full laparotomy.

The improved outcome after endoscopic surgery has been attributed to less surgical trauma. However, the underlying mechanisms are not fully understood, and direct effects of CO2 used for pneumoperitoneum, cellular acidification, and/or the lack of air contamination have been postulated to additionally modulate immune functions during endoscopic surgery. We investigated the effects of CO2 incubation, extracellular acidification, and air contamination on the inflammatory response of two distinct macrophage populations.R2 and NR 8383 rat macrophage cell lines were used. Interleukin-6 (IL-6) and nitric oxide after lipopolysaccharide (LPS) stimulation were determined in these sets of experiments: incubation in 100% CO2, 5% CO2, and room air for 2h; incubation at pH 7.4, 6.5, and 5.5 for 2 h in 5% CO2; and incubation in 100% CO2, 5% CO2 and room air in fixed pH 6.3. The extracellular pH was monitored during incubation. We determined the alteration of intracellular pH in cells subjected to extracellular acidification by fluorescence microscopy.Extracellular pH decreased to 6.3 during 100% CO2 incubation. IL-6 release was reduced after CO2 incubation in NR 8383 cells and increased in R2 cells (p0.05). It was not altered by air incubation. Decreasing the extracellular pH to 6.5 mimicked the effects of CO2 and a decrease to 5.5 suppressed IL-6 release in both cell lines. In fixed pH at 6.3, CO2 and air incubation had no effect. CO2 and pH had no impact on nitric oxide release and vitality. Intracellular pH decreased with extracellular acidification without significant difference between the two cell lines.A decrease in extracellular pH during incubation in CO2 differentially affects IL-6 release in macrophage subpopulations. This may explain contradictory results in the literature. Moreover, we demonstrated that air contamination does not affect macrophage cytokine release. The decrease in extracellular pH is the primary underlying mechanism of the alteration of macrophage cytokine release after CO2 incubation, and it appears that the ability to maintain intracellular pH is not determined by the effects of CO2 or extracellular acidification.

We analyzed the feasibility of laparoscopic nephroureterectomy in children younger than 1 year, with regard to size of impaired kidney.A total of 40 consecutive children underwent transperitoneal laparoscopic nephrectomy during a 4-year period. Of the patients 19 (48%) were younger than 1 year and were analyzed in detail. Nine of these patients (47.4%) had a multicystic dysplastic kidney, 9 (47.4%) had reflux nephropathy and 1 (5.3%) had obstructive nephropathy. The duration of operation, reasons for conversion, and intraoperative and postoperative complications were prospectively documented.Mean operative time was 133 minutes (range 60 to 240), and did not differ significantly between patients up to age 12 months compared to children 1 year and older (126 vs 148 minutes, NS). Nephroureterectomy was completed laparoscopically in 17 of 19 children (89%) up to age 12 months vs 20 of 21 (95%) 1 year and older (NS). In 1 child younger than 1 year suture dislocation at the renal artery required laparoscopic resuturing. No further complications were seen. In children younger than 1 year the mean operating time was not significantly different for resection of multicystic dysplastic kidney (8 patients, 113 minutes) compared to reflux nephropathy (9, 134 minutes, NS). Mean operating time did not differ significantly for kidney volumes less than 10 cc (8 patients, 119 minutes) compared to kidney volumes greater than 10 cc (9, 129 minutes, NS).The feasibility of transperitoneal laparoscopic nephroureterectomy in children younger than 1 year is excellent. The duration of operation is not affected by patient age, underlying disease or kidney size.

The neonatal surgical patient is threatened by exuberant inflammatory reactions. Neonatal macrophages are key players in this process. We investigated the ability of neonatal macrophages to initiate a local inflammatory reaction upon exposure to different bacterial or viral ligands to toll-like receptors (TLRs).Peritoneal wash outs from neonatal (24 h) and adult (42 days) C57BL/6J mice were gained by peritoneal lavages. In a first set of experiments, macrophages were purified and stimulated for 6 h by four different TLR ligands. mRNA was extracted for transcriptome analysis. In a second set of experiments, lipopolysaccharide was applied into peritoneal cavities. After 6 h of incubation, the cellular composition of the inflamed cavities was evaluated by cytological staining as well as chipcytometry.Neonatal murine peritoneal macrophages differed significantly in the expression of pro- and anti-chemotactic genes. Functional assignment of these genes revealed enhanced chemotactic potential of neonatal macrophages and was confirmed by a higher influx of pro-inflammatory cells into neonatal peritoneal cavities.Neonatal peritoneal macrophages demonstrated an enhanced chemotactic potential upon stimulation with four TLR ligands. This was associated with an increased influx of inflammatory cells to the peritoneal cavity. This might contribute to the strong inflammatory responses of neonates and preterms.