Shao-tao Tang

Elevated Th17 cells accompanied by decreased regulatory T cells and cytokine environment in infants with biliary atresia

AbstractPurposenThe aim of this study was to investigate the role of Th17 and Treg cells in biliary atresia (BA) and to assess the liver cytokine environment in BA patients.MethodsnThe percentages of Th17 and Treg cells in peripheral blood mononuclear cells (PBMCs) of BA patients and healthy controls (HC) were evaluated. The serum concentrations of IL-17a and IL-23 as well as Foxp3, IL-17a, ROR-γt, IL-6, IL-1β and TGF-β1 m-RNA and protein expressions in liver tissues and the number of Foxp3, IL-17a, ROR-γt, CD4 expressing cells which infiltrated the hepatic tissues were determined.ResultsThe Th17/Treg cell ratio (Pxa0<xa00.001) and blood concentrations of IL-17a and IL-23 (Pxa0<xa00.05) were increased in the BA as compared to the HC group. Expressions of Foxp3, ROR-γt, IL-17a, IL-1β, IL-6 as well as TGF-β1 mRNA and proteins were significantly increased in BA as compared to HC livers (Pxa0<xa00.01, Pxa0<xa00.05). High levels of IL-17a/ROR-γt-positive and moderate levels of Foxp3-positive cells infiltrated damaged BA bile ducts and the ratio of FoxP3+ T to CD4+ T cells was significantly lower in BA than in HC samples (Pxa0<xa00.01).ConclusionCytokine-induced imbalance between Th17 and Treg cells in BA livers may be involved in bile duct damage.

10 years of experience with laparoscopic-assisted endorectal Soave pull-through procedure for Hirschsprung's disease in China.

OBJECTIVEnTo report early and late results of laparoscopic-assisted endorectal Soave pull-through (LAEPT) with a short and V-shaped partial resection muscular cuff for Hirschsprungs disease (HD) over a 10-year period.nnnMETHODSnThe clinical courses of 218 patients who underwent modified LAEPT for HD were reviewed. LAEPT was described by the Georgeson technique. The main modifications included less dissection of the bottom of the pelvis, rectal mucosa dissection with a long cuff, coloanal anastomosis with a short cuff, and a V-shaped partial resection in the posterior wall of the muscular cuff.nnnRESULTSnFrom September 1999 to July 2009, 218 patients were operated on by the same surgeon. Ages ranged from 15 days to 12 years old. The aganglionic segment was located in the rectum or sigmoid colon in 176 patients, in the left colon in 38 children, and in the transverse colon in 4 patients. The median operating time was 176 minutes. Conversion to open surgery was required in 2 patients. Bleeding of the left iliac vein occurred in 1 patient, and a 180° twist of the neorectum occurred in 2 cases. Median first bowel movement time was 23 hours, and median postoperative hospital stay was 10.4 days. Median daily defecation frequency was 4.6 within 2 weeks and 2.3 at 3 months postoperatively. The immediate postoperative complications included intestine herniation from the trocar site in 2 patients, perianal excoriation in 32 patients, and anastomotic leakage in 3 patients. Follow-up ranging from 6 to 120 months was obtained for 182 patients. Late postoperative complications included postoperative adhesive bowel obstruction (1.1%), enterocolitis (7.7%), anasomostic stenosis (2.2%), constipation (1.6%), and soiling (3.6%). Eighty-seven percent had excellent and good bowel function.nnnCONCLUSIONnLAEPT with a short muscular cuff with a V-shaped partial resection in the posterior wall is a safe and effective procedure for HD.

Transanal endorectal pull-through for Hirschsprung’s disease using long cuff dissection and short V-shaped partially resected cuff anastomosis: early and late outcomes

BackgroundTransanal endorectal pull-through was described by De la Torre-Mondragon’s technique. In the original transanal pull-through procedure, a long rectal muscular cuff was dissected and left for anocolic anastomosis, which would sometimes lead to postoperative obstructive symptoms and enterocolitis. While a modified short mucosal dissection may increase the risk of injury to pelvic and perirectal nerves and other structures when dissected on the outside of the rectum deep in the pelvis. We report early and late results of the modified transanal procedure for Hirschsprung’s disease (HD) over 8xa0years.MethodsThe clinical course of all children with aganglionic rectum or sigmoid colon receiving the modified transanal pull-through between May 2003 and April 2011 were reviewed. The main modifications were rectal mucosa dissection with a long cuff, coloanal anastomosis with a short cuff and a V-shaped partial resection in the posterior wall of the muscular cuff. Children with preliminary stoma or total colonic disease were excluded.ResultsShort- and long-term follow-up was obtained in 137 patients with HD operated upon by the same surgeon. The aganglionic segment was located in the rectum or sigmoid colon in all patients. The mean age at surgery was 165xa0±xa074xa0days. The mean operating time was 108xa0±xa038xa0min. Mean intra-operative blood loss was estimated to be 15xa0±xa010xa0ml. No patient required a blood transfusion. Mean postoperative hospital stay was 7xa0±xa02xa0days. Early postoperative complications included perianal excoriation in 38 patients (27.7xa0%), enterocolitis in two patients (1.4xa0%), and anastomotic leak in two patients (1.4xa0%). Late postoperative complications included perianal excoriation in 16 patients (11.7xa0%), anal stricture in two patients (1.4xa0%), constipation in four patients (2.8xa0%), enterocolitis in 10 patients (7.3xa0%), and soiling problems in six patients (4.4xa0%). Mean follow-up was 56xa0months (6xa0months–9xa0years). In patients older than 4xa0years, 85.4xa0% of them had excellent/good bowel function, 9.4xa0% had fair bowel function, and 5.2xa0% of patients had bad bowel function.ConclusionTransanal endorectal pull-through with a long cuff dissection and a short V-shaped resected cuff anastomosis is a safe and effective procedure for HD. It reduced incidence of anastomotic stricture and constipation without an increased soiling incidence.

The Evaluation of Laparoscopy-Assisted Cholangiography in the Diagnosis of Prolonged Jaundice in Infants

BACKGROUNDnBiliary atresia (BA) is the progressive inflammatory obstruction and fibro-obliteration of all or part of the extrahepatic biliary tree and the intrahepatic bile ducts and has its onset exclusively within the first several months of life. This study was undertaken to present the value of diagnostic laparoscopy in infants with prolonged jaundice and technique for laparoscopic cholangiography.nnnMETHODSnA 5-mm umbilical trocar was introduced to create a port for a 30-degree laparoscope. If the gallbladder was of good size, the fundus was exteriorized through the right subcostal trocar site and a catheter was inserted into the gallbladder for cholangiography, following partial dissection from the liver bed, if required. If the gallbladder was atretic, the fundus was not exteriorized and a laparotomy was performed and cholangiography was abandoned, because the lumen of an atretic gallbladder was usually not fully patent.nnnRESULTSnAt laparoscopy, 12 patients had good-sized gallbladders and minimal-to-mild liver fibrosis. They underwent cholangiography via the exteriorized fundus, and infantile hepatitis syndrome (HIS) or cholestatic syndrome (CS) in 8 cases, BA in 2 cases, and biliary hypoplasia (CBDH) in 2 cases were identified. Five patients gallbladders dissected from the liver bed underwent cholangiography, and BA in 3 cases and CBDH in 2 cases were identified. The remaining 21 had atretic gallbladders and varying degrees of liver fibrosis, so cholangiography via the exteriorized fundus was abandoned and converted to open Kasai portoenterostomy.nnnCONCLUSIONSnLaparoscopy-assisted cholangiography is a simple, accurate, and safe method in the diagnosis of prolonged jaundice in infants and allows the anatomic structure of the biliary tree to be obtained accurately with minimal surgical intervention.

Dendritic Cells Regulate Treg-Th17 Axis in Obstructive Phase of Bile Duct Injury in Murine Biliary Atresia

Several cell types are considered to be effector cells in bile duct injury in rhesus rotavirus (RRV)-induced experimental biliary atresia (BA). Here, we identified an increased T helper 17 (Th17) cell population in a BA mode. By depleting the Th17 cells, the BA symptoms (onset of jaundice, acholic stools and retarded growth) were attenuated and the survival rate was improved. Furthermore, we found that in mice with BA, the percentage of CD4+CD25highFoxp3+ T regulatory (Treg) cells decreased along with the increased percentage of Th17 cells. However, the absolute numbers of Treg and Th17 cells were both increased in liver of RRV-injected mice compared to saline-injected mice. The proportion of Th17 cells at 7 days post-infection was decreased if Treg cells isolated from normal adult mice, but not Treg cells from the livers of mice with BA, were intraperitoneally transferred on day 5 of life. In vitro experiments also showed that Treg cells from mice with BA had a diminished suppressive effect on Th17 cell generation. To determine the mechanisms, we investigated the production of cytokines in the liver. The level of IL-6, which has been shown to be abundantly secreted by activated dendritic cells (DCs), was remarkably elevated. Importantly, in a Treg/Th17 cell suppression assay, IL-6 was demonstrated to paralyze the Treg cells’ suppressive effect on Th17 cells and eventually the unrestrained increase of Th17 cells contributed to bile duct injury. In conclusion, the DC-regulated Treg-Th17 axis, probably in conjunction with other effector T cells, aggravates progressive inflammatory injury at the time of ductal obstruction.

Nuss repair of pectus excavatum after surgery for congenital heart disease: Experience from a single institution

OBJECTIVEnPectus excavatum developing after surgery for congenital heart disease has its own clinical characteristics. The present study aimed to present our technique and outcomes for the Nuss procedure in the repair of these cases.nnnMETHODSnWe conducted a retrospective study of all patients who had not been diagnosed as pectus excavatum preoperatively but subsequently had developed pectus excavatum after surgery for congenital heart disease from February 2005 to November 2012. The Nuss procedure was applied using a series of perioperative management techniques. The data relating to the surgical technique, complications, and outcomes were analyzed. The clinical evaluation was performed using the Nuss criteria.nnnRESULTSnA total of 30 cases (14 boys and 16 girls) were included. The mean operative time was 73.5 minutes (range, 58-82). The mean length of hospital stay was 6.0 days. Complications occurred in 5 patients (16.7%), including asymptomatic pneumothorax, hematoma in the wound, pericardial penetration, and bar displacement. The mean follow-up period was 32 months (range, 9-60). Initially, 29 patients (96.7%) had excellent results, and 1 patient had a good result. The mean point of bar removal was 35.8 months (range, 30-39) after implantation. The postoperative results after bar removal in 17 patients were also recorded, including excellent results in 14 (82.4%), good results in 2 (11.7%), and a fair result in 1 patient.nnnCONCLUSIONSnThe Nuss procedure has been shown to be a safe and effective approach for the repair of pectus excavatum after surgery for congenital heart disease, although dissection of substernal adhesions can increase the risk of heart injury.

Single-incision laparoscopic versus conventional laparoscopic endorectal pull-through for Hirschsprung's Disease: A comparison of short-term surgical results ☆

BACKGROUNDnSingle-incision laparoscopy has recently become a popular procedure in pediatric surgery. The current series is the largest study to evaluate the operative complications and results of single-incision laparoscopic endorectal pull-through (SILEP) for the treatment of HD through a retrospective comparison with conventional laparoscopic endorectal pull-through (CLEP).nnnMETHODSnTwenty eight patients who underwent single-incision laparoscopic endorectal pull-through for HD between July 2010 and August 2011 were compared to thirty patients who underwent CLEP. Patient age, gender, transitional zone, operative time, blood loss, intraoperative and postoperative complications, as well as short-term results, were assessed.nnnRESULTSnA total of 28 patients were included for SILEP, and historical reported 30 patients were completed by CLEP. The SILEP and CLEP groups were similar in regard to age, gender, transition zone, operative time, blood loss, hospital stay, and intraoperative complications. Postoperative results were not different, including equal daily defecation frequency and early postoperative complications. No patients with recurrent constipation were seen. Two patients with the transitional zone in the descending colon in the SILEP group had a 3mm trocar added in the left abdomen, and there were no conversions in the conventional laparoscopic group.nnnCONCLUSIONnWe have shown that in selected HD patients, the SILEP technique was safe and technically feasible in experienced hands. It results in similar operative results compared with conventional laparoscopic endorectal pull-through. However, the operation is more difficult if the transition zone was higher than the rectosigmoid.

Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis

BACKGROUND/PURPOSEnTo evaluate surgical outcomes of Nuss versus Ravitch repair of pectus excavatum via a systematic review and meta-analysis.nnnMETHODSnMedline, PubMed, Cochrane, EMBASE, and Google Scholar databases were searched up to September 5, 2016 using the following search terms: pectus excavatum, funnel chest, Nuss; Ravitch, minimally invasive, and open surgery. Randomized controlled trials, two-arm prospective, and two-arm retrospective studies were eligible for inclusion.nnnRESULTSnNineteen studies were included with a total of 1731 patients: 989 treated with Nuss and 742 treated with Ravitch. The overall analysis revealed that patients in the Nuss group had significantly shorter operation time (pooled SMD=-2.83, 95% CI=-3.76 to -1.90, p<0.001) and less blood loss (pooled SMD=-1.68, 95% CI=-2.28 to -1.09, P<0.001) than the Ravitch group. However, the length of hospital stay was similar between groups (pooled SMD=-0.55, 95% CI=-1.44 to 0.35, p=0.230). These findings were similar in the subgroup analysis for randomized and non-randomized controlled studies. Complications were not assessed due to inconsistent reporting across the included studies.nnnCONCLUSIONSnOur meta-analysis demonstrate that the Nuss procedure has a shorter operative time and less operative blood loss than the Ravitch procedure while the postoperative length of stay was similar.nnnLEVELS OF EVIDENCEnLevel III.

Clinical outcomes and ergonomics analysis of three laparoscopic techniques for Hirschsprung's disease

AIMnTo report the clinical outcomes and ergonomics analysis of three laparoscopic approaches in the management of Hirschsprungs disease (HD).nnnMETHODSnThere were 90 pediatric patients (63 boys, 27 girls; mean age: 3.6 ± 2.7 mo; range: 1.0-90.2 mo) who underwent laparoscopic endorectal pull-through Soave procedures for short- and long-segment HD in our hospital. Three laparoscopic approaches were used: conventional laparoscopic pull-through (CLP) in 30 patients between 2009 and 2013, single-incision laparoscopic pull-through (SILP) in 28 patients between 2010 and 2013, and hybrid single-incision laparoscopic pull-through (H-SILP) in 32 patients between 2011 and 2013. We applied the hybrid version of the single-incision approach in 2011 to preserve the cosmetic advantage of SILP and the ergonomic advantage of CLP. We retrospectively analyzed the clinical data, cosmetic results, and ergonomics of these three approaches to have a better understanding of the selection of one approach over another.nnnRESULTSnThe CLP, SILP, and H-SILP groups were similar in regard to age, sex, transition zone, blood loss, hospital stay, and intraoperative complications. Early and late postoperative results were not different, with equal daily defecation frequency and postoperative complications. No conversion to open technique was needed and none of the patients had recurrent constipation. With proper training, the ergonomics challenges were overcome and similar operative times were registered for the general operative time in the patients < 1 year of age and the short-segment HD patients. However, significantly shorter operative times were registered compared to SILP for patients > 1 year of age (CLP and H-SILP: 120 ± 15 min and 119 ± 12 min, respectively, vs 140 ± 7 min; P < 0.05) and for long-segment HD patients (152 ± 3.5 min and 154 ± 3.6 min, respectively, vs 176 ± 2.3 min; P < 0.05). The best cosmetic result was registered with the SILP (scarless), followed by the H-SILP (near scarless appearance) and the CLP (visible scars) procedures.nnnCONCLUSIONnBased on the results, we believed that the laparoscopic approach should be selected according to the age, transition zone, and desired cosmetic result.

Two-stage laparoscopic approaches for high anorectal malformation: Transumbilical colostomy and anorectoplasty

BACKGROUNDnTrans-umbilical colostomy (TUC) has been previously created in patients with Hirschsprungs disease and intermediate anorectal malformation (ARM), but not in patients with high-ARM. The purposes of this study were to assess the feasibility, safety, complications and cosmetic results of TUC in a divided fashion, and subsequently stoma closure and laparoscopic assisted anorectoplasty (LAARP) were simultaneously completed by using the colostomy site for a laparoscopic port in high-ARM patients.nnnMETHODSnTwenty male patients with high-ARMs were chosen for this two-stage procedure. The first-stage consisted of creating the TUC in double-barreled fashion colostomy with a high chimney at the umbilicus, and the loop was divided at the same time, in such a way that the two diverting ends were located at the umbilical incision with the distal end half closed and slightly higher than proximal end. In the second-stage, 3 to 7 months later, the stoma was closed through a peristomal skin incision followed by end-to-end anastomosis and simultaneously LAARP was performed by placing a laparoscopic port at the umbilicus, which was previously the colonostomy site. Umbilical wound closure was performed in a semi-opened fashion to create a deep umbilicus.nnnRESULTSnTUC and LAARP were successfully performed in 20 patients. Four cases with bladder neck fistulas and 16 cases with prostatic urethra fistulas were found. Postoperative complications were rectal mucosal prolapsed in three cases, anal stricture in two cases and wound dehiscence in one case. Neither umbilical ring narrowing, parastomal hernia nor obstructive symptoms was observed. Neither umbilical nor perineal wound infection was observed. Stoma care was easily carried-out by attaching stoma bag. Healing of umbilical wounds after the second-stage was excellent. Early functional stooling outcome were satisfactory.nnnCONCLUSIONSnThe umbilicus may be an alternative stoma site for double-barreled colostomy in high-ARM patients. The two-stage laparoscopic approaches for high-ARM, TUC and stoma closure with simultaneously LAARP are both technically feasible and safe with excellent cosmetic result.