Alaa El Ghoneimi

Calretinin immunohistochemistry: a simple and efficient tool to diagnose Hirschsprung disease

Diagnosis of Hirschsprung disease (HD) is quite entirely based on the histopathological analysis of suction rectal biopsies. This hematoxylin and eosin approach has some limitations, despite the help of acetylcholinesterase staining. The aim of this study was to assess the diagnostic value of calretinin immunochemistry as a simple and reliable method in the diagnosis of HD. A total of 131 initial rectal biopsies carried out for suspicion of HD in children were retrieved, and calretinin immunohistochemistry was carried out on paraffin-embedded biopsies. Diagnosis of HD was made when no staining was observed. The results were statistically analyzed in comparison with our standard method (histology and acetylcholinesterase staining). 130 biopsies were accurately diagnosed on the basis of the positivity or negativity of calretinin staining. The senior pathologists diagnosed all cases of HD with no false positives. Furthermore, 12 additional cases initially considered as doubtful for HD using the standard method, were accurately diagnosed using calretinin immunohistochemistry. The false negative was a case of HD with a calretinin-positive biopsy. We also demonstrate the ease of calretinin interpretation compared with acetylcholinesterase for the junior pathologist. Calretinin immunohistochemistry overcomes most of the difficulties encountered using the combination of histology and acetylcholinesterase staining, and detects almost all cases of HD with confidence, with no false positives. Thus, we demonstrate that calretinin is superior to acetylcholinesterase to complete histology and could advantageously substitute for acetylcholinesterase.

High Cyclin E Staining Index in Blastemal, Stromal or Epithelial Cells Is Correlated with Tumor Aggressiveness in Patients with Nephroblastoma

Purpose Identifying among nephroblastoma those with a high propensity for distant metastases using cell cycle markers: cyclin E as a regulator of progression through the cell cycle and Ki-67 as a tumor proliferation marker, since both are often deregulated in many human malignancies. Methodology/Principal Findings A staining index (SI) was obtained by immunohistochemistry using anti-cyclin E and anti-Ki-67 antibodies in paraffin sections of 54 postchemotherapy nephroblastoma including 42 nephroblastoma without metastasis and 12 with metastases. Median cyclin E and Ki-67 SI were 46% and 33% in blastemal cells, 30% and 10% in stromal cells, 37% and 29.5% in epithelial cells. The highest values were found for anaplastic nephroblastoma. A correlation between cyclin E and Ki-67 SI was found for the blastemal component and for the epithelial component. Univariate analysis showed prognostic significance for metastases with cyclin E SI in stromal cells, epithelial cells and blastemal cells (p = 0.03, p = 0.01 and p = 0.002, respectively) as well as with Ki-67 SI in blastema (p<10−4). The most striking data were that both cyclin E SI and blastemal Ki-67 SI discriminated between patients with metastases and patients without metastasis among intermediate-risk nephroblastoma. Conclusions Our findings show that a high cyclin E SI in all components of nephroblastoma is correlated with tumor aggressiveness and metastases, and that assessment of its expression may have prognostic value in the categorization of nephroblastoma.

Laparoscopic management of congenital duodenal atresia or stenosis: A single-center early experience.

BACKGROUND The background is to review our experience with laparoscopic repair of congenital duodenal atresia or stenosis (CDAS) and compare postoperative outcome with a group control of laparotomy repair. METHODS Retrospective chart review of all cases of CDAS undergoing laparoscopic surgery at our institution between July 2013 and May 2014 and comparison with a group control of open operation performed between 2007 and 2010. Data were compared using Fishers exact test for qualitative values and Mann-Whitney test for quantitative values. P values less than 0,05 were considered statistically significant. RESULTS Ten consecutive cases were identified in laparoscopic group (7 duodenoduodenostomy and 3 duodenojejunostomy) and 19 cases in laparotomy group (16 duodenoduodenostomy and 3 web excision). Median birth weight was lower in laparoscopic group (2125 grams Vs 2777 grams p=0,04). In laparoscopic group, there was no conversion and no intraoperative complication. Median duration of surgery was 90minutes (80-150). In both groups, the surgical morbidity rate was 10%. Median time to initiation of oral feeding was significatively shorter in laparotomy group (8days Vs 4 p=0,009). Median time to full oral feeding and length of stay were shorter in laparotomy but not statistically different. (36days Vs 16,5 p=0,14 and 45,5days Vs 25,5 p=0,09 respectively) After a median follow up of 149,5days (24-355) in laparoscopic group, 8 children had a full oral intake. Five children had a weight below the 10th percentile. CONCLUSION The laparoscopic approach for CDAS is safe and reproducible with outcomes similar to open repair even in the beginning of a learning curve for pediatric surgeons with appropriate laparoscopic skills. In this small series, laparoscopy did not appear to decrease time to full oral intake or length of stay. Larger studies are suggested to provide more conclusive results.

Outcomes of Hirschsprung's disease associated with Mowat-Wilson syndrome

PURPOSE Mowat-Wilson syndrome (MWS) is a developmental disorder presenting with mental retardation, delayed motor development, and a wide spectrum of clinical features. Hirschsprungs disease (HD) is associated in almost 50% of cases. This report aims to analyze the course of HD and to evaluate the clinical outcomes of these patients. PATIENTS AND METHODS Between 1997 and 2007, 110 patients presenting with HD were diagnosed and managed in our institution. Five of them presented the association of HD and MWS. Their records were reviewed retrospectively. RESULTS All of the 5 patients have a genetic disorder specific of MWS (nonsense mutation or deletion on SIP1 gene, locus 2q22). Two patients underwent transanal endorectal pull-through procedure for classic rectosigmoid HD. Three patients were operated on for total colonic aganglionosis using Duhamel procedure. The median follow-up was 4 (range, 0.3-7) years. Only one patient is doing well (rectosigmoid HD). Two patients have a stoma diversion for severe motility disorders. Of the 3 total colonic aganglionosis, one still has repeated episodes of obstruction requiring total parenteral nutrition (TPN). The 2 others still have repeated episodes of enterocolitis. All patients required a prolonged TPN (32.5 months in average). CONCLUSION Hirschsprungs disease associated with MWS is a severe condition. Even in case of short segment HD, patients can present motility disorder requiring a prolonged TPN. Physician and surgeon should be aware about the evolution of this rare condition.

Renal parenchymal fibrosis and atrophy are not correlated with upper tract dilatation: Long-term study of partial unilateral ureteral obstruction in neonatal mice

PURPOSE The mechanism underlying the evolution of congenital obstructive hydronephrosis is still unclear. In a previous study, we have shown that it is possible to create renal lesions in newborn mice specific to partial ureteral obstruction. We aimed to study the long-term results of such partial obstruction. METHODS Mice were operated on the third day of life. We created 2 groups: partial unilateral obstruction and control. We studied antero-posterior pelvis diameter, kidney length and volume on magnetic resonance imaging at day 10 and 3 months. We assessed ureteric patency by injecting Patent Blue dye. Kidney weight and fibrosis were histologically assessed. Fibrosis was assessed using Sirius Red staining and morphometry. RESULTS Imaging showed parenchymal atrophy in the partially obstructed kidney and compensatory hypertrophy of the contralateral kidney. Pelvis dilatation was detected at day 10 but remained stable without significant increase at 3 months. The patency test confirmed the absence of total obstruction in the long term. There was no correlation between the degree of dilatation and parenchymal atrophy or the contralateral hypertrophy. Pathological studies at 3 months revealed fibrosis in the parenchyma without significant correlation with pelvis dilatation. CONCLUSIONS Long-term results confirmed that partial ureteral obstruction in newborn mice produces fibrotic lesions of the renal parenchyma, which are not correlated with dilatation of the upper tract. These results could contribute to the clinical management of obstructive uropathy in children, emphasizing that follow up with simple evaluation of upper tract dilatation is insufficient to predict renal deterioration.

Stomal prolapse in children with chronic intestinal pseudoobstruction: a frequent complication?

AIM The aim of the study was to evaluate the morbidity rate of stoma in children diagnosed with chronic intestinal pseudoobstruction (CIPO) and try to determine risk factors. MATERIAL AND METHODS Twenty-two children (65%) of 34 referred to our center between 1988 and 2008 had a stoma. They were compared with 22 other children referred for another pathology necessitating a stoma. RESULTS The incidence of stomal prolapse in CIPO children was 45% vs 9% in non-CIPO children (P = .01). Prolapse occurred between the first postoperative day and the 10th postoperative month, with a median of 2 months. Surgical management was required in 60%, with an intestinal necrosis rate of 20% leading to intestinal resection. No mortality was noted. No risk factors favoring prolapse in CIPO children were identified. CONCLUSION Children with CIPO have a high rate of stomal prolapse with an increased risk of intestinal necrosis. Careful management of the stoma is necessary to avoid the risk of intestinal resection, which may aggravate the underlying intestinal disorder.

Mast Cells and MCPT4 Chymase Promote Renal Impairment after Partial Ureteral Obstruction

Obstructive nephropathy constitutes a major cause of pediatric renal progressive disease. The mechanisms leading to disease progression are still poorly understood. Kidney fibrotic lesions are reproduced using a model of partial unilateral ureteral obstruction (pUUO) in newborn mice. Based on data showing significant mast cell (MC) infiltration in patients, we investigated the role of MC and murine MCPT4, a MC-released chymase, in pUUO using MC- (Wsh/sh), MCPT4-deficient (Mcpt4−/−), and wild-type (WT) mice. Measurement of kidney length and volume by magnetic resonance imaging (MRI) as well as postmortem kidney weight revealed hypotrophy of operated right kidneys (RKs) and compensatory hypertrophy of left kidneys. Differences between kidneys were major for WT, minimal for Wsh/sh, and intermediate for Mcpt4−/− mice. Fibrosis development was focal and increased only in WT-obstructed kidneys. No differences were noticed for local inflammatory responses, but serum CCL2 was significantly higher in WT versus Mcpt4−/− and Wsh/sh mice. Alpha-smooth muscle actin (αSMA) expression, a marker of epithelial–mesenchymal transition (EMT), was high in WT, minimal for Wsh/sh, and intermediate for Mcpt4−/− RK. Supernatants of activated MC induced αSMA in co-culture experiments with proximal tubular epithelial cells. Our results support a role of MC in EMT and parenchyma lesions after pUUO involving, at least partly, MCPT4 chymase. They confirm the importance of morphologic impairment evaluation by MRI in pUUO.

Is intraabdominal pressure a good predictor of mortality in necrotizing enterocolitis

Sir: Intraabdominal pressure (IAP) is elevated in many pediatric patients with critical illnesses, injuries, or surgery. Several methods for measuring intravesical pressure (IVP) have been described [1, 2]. At the acute phase of necrotizing enterocolitis, both fluid resuscitation and medications lead to the development of a third abdominal compartment and, therefore, to IAP elevation, which worsens the bowel ischemia. We are prospectively evaluating IVP as a predictor of death in neonates with necrotizing enterocolitis, and we report our preliminary results. All neonates admitted to our pediatric ICU for severe necrotizing enterocolitis were enrolled prospectively from December 2004 to December 2005. Necrotizing enterocolitis was diagnosed when pneumatosis intestinalis was visible on the abdominal radiographs. A Foley catheter was placed to monitor the urine output. Surgery was performed when radiographs showed free intraperitoneal gas or the medical treatment induced no response. IVP was measured via a transurethral bladder catheter as first suggested by Kron et al. [3] and described recently by Davis et al. [4]. Intra-vesical pressure was used instead of gastric pressure because we felt that manipulating the nasogastric tube of patients who required continuous suction for an occlusive condition was problematic. Furthermore, nasogastric tube placement varies widely, especially in very premature babies. The tube is often obstructed by the gastric mucosa because of the low levels of Gomco suction used. IVP was measured every 3 h for 48 h (ten values per patient). Quantitative data were described as median (range) and qualitative data as number (percentage). Spearman’s correlation coefficient was computed to assess correlations between the ten IVP values and the ten mean pressure values, both summarized as the mean in each patient. The relationship between IVP and mortality was evaluated using the generalized estimating equation method. Statistical tests were performed using SAS 9.1 (Cary, NC). P values \ 0.10 were considered statistically significant. There were seven patients (Table 1) with a median gestational age of 32.9 weeks (range, 27–41) and a median birth weight of 1,689 g (range, 840–3,340). Surgery was needed in five patients. Another patient (no. 4) responded well to medical treatment. Patient 5 was too unstable for surgery. Three patients died (3/7, 43%). IVP was associated with mortality (odds ratio for a 1-mmHg increase, 1.22; 95% confidence interval, 0.96–1.55; P = 0.098). Individual mean IVP correlated with individual mean value of mean ventilatory pressure (rho = 0.68, P = 0.094). Mean IVP value did not correlate with FiO2 or mean fluid resuscitation volume. IVP measurement to assess IAP may help to predict mortality in premature babies with necrotizing enterocolitis. Furthermore, a study in

Laparoscopic Mitrofanoff procedure in children: Critical analysis of difficulties and benefits

OBJECTIVES The Mitrofanoff principle is an accepted continent urinary diversion. We studied the feasibility and the possible benefits of using a laparoscopic approach in children with significant bladder dysfunction associated with difficulty doing efficient urethral catheterization. PATIENTS AND METHODS A fully laparoscopic Mitrofanoff continent cystostomy was attempted in 15 children with a median age of 9 years (IQR 6), between 2003 and 2013. Before the Mitrofanoff procedure was considered, urodynamic evaluation was done for each patient, to study bladder compliance, detrusor activity, and bladder capacity. The procedure was performed using a transperitoneal four-port approach. A 30-degree down camera angle was optimal for viewing the appendix and the posterior wall of the bladder. The operative steps of the open procedure were replicated laparoscopically. The proximal end of the appendix was spatulated and anastomosed to the posterior wall of the bladder, providing an antireflux mechanism by an extramucosal tunnel. The distal end of the appendix was brought out as the cutaneous umbilical stoma. Some modifications were done because of the high rate of conversion due to early opening of the mucosa (harmonic hook) or difficult anastomosis: (a) use of 5-mm trocars to change the laparoscope position from the left to right subcostal area to better visualize the anastomosis, (b) the anastomosis was suspended at its two ends during suturing; a trans-abdominal traction suture of the bladder was inserted for better exposure of the anastomosis (hitch stitch) and to stabilize the anastomotic line during suturing, (c) use of a monopolar hook to cut the detrusor muscle fibers, to avoid incidental opening of the mucosa, and (d) the window between the appendix and the peritoneum was closed to avoid internal hernia. RESULTS The procedure was totally completed by laparoscopy in 12 cases. Three were converted to an open procedure due to tearing of bladder mucosa (n = 2) or appendix ischemia (n = 1). Median operative time for fully laparoscopic Mitrofanoff was 255 min (IQR 52). Median follow-up was 18 months (IQR 35). No patient required stomal revision. Seven patients were continent, five experienced urinary leakage from urethra n = 1 and/or stoma n = 5. Three patients with stomal urinary leakage were successfully managed by Deflux (dextranomer-based implants) injection in the catheterizable channel. Two patients required an open revision of the appendicovesical anastomosis. The patient with both stomal and urethral urinary leakage also required the implantation of an artificial urinary sphincter 1.5 years after Mitrofanoff. One patient had bladder augmentation. CONCLUSION Although our results of laparoscopic Mitrofanoff procedure in children are unsatisfying in cases of high-pressure bladders in terms of incontinent stoma, we still believe that it is justified to develop this challenging technique with more refinement and improvement, to provide a minimal invasive procedure that may postpone or even avoid bladder augmentation in pediatric age.

Cloaca in discordant monoamniotic twins: prenatal diagnosis and consequence for fetal lung development.

Objective Describe a case of cloaca prenatally diagnosed in one of a set of monoamniotic twins. Study Design Retrospective review of a case. Results Cloaca is one of the most complex and severe degrees of anorectal malformations in girls. We present a discordant cloaca in monoamniotic twins. Fetal ultrasound showed a female fetus with a pelvic midline cystic mass, a phallus-like structure, a probable anorectal atresia with absence of anal dimple and a flat perineum, and renal anomalies. The diagnosis was confirmed by fetal magnetic resonance imaging postnatally. Conclusions The rarity of the malformation in a monoamniotic pregnancy, the difficulties of prenatal diagnosis, the pathogenic assumptions, and the consequences of adequate amniotic fluid for fetal lung development are discussed.