Weihua Pan

Up-regulation of miR-200b in biliary atresia patients accelerates proliferation and migration of hepatic stallate cells by activating PI3K/Akt signaling.

An increasing body of evidence suggests that miRNAs are involved in fibrotic process of several organs including heart, lung and kidney. It has been observed recently that aberrant expression of miR-200s are associated with hepatic fibrosis. However, the role and underlying mechanism of miR-200s in hepatic fibrogenesis remains unknown. Here, we investigate the role of miR-200b in the activation of immortalized human hepatic stallate cells (HSCs), LX-2 cells. We firstly found that miR-200b significantly enhanced proliferation and migration of LX-2 cells. Secondly, our findings showed that miR-200b enhanced the phosphorylation of Akt, a downstream effector of phosphatidyl-inositol 3-Kinase (PI3K). FOG2, as the targets of fly miR-8 and human miR-200s, directly binds to p85α and inhibits the activation of the PI3K/Akt pathway. Here, we showed that FOG2 protein levels in LX-2 cells were suppressed significantly by miR-200b mimics. FOG2 knockdown by siRNAs activated the PI3K/Akt signaling, which increased cell growth and migration that mimicked the effect of miR-200b. Conversely, LY294002, a highly selective inhibitor of PI3K, could block phosphorylation of Akt and effect of miR-200b. In addition, we showed that miR-200b enhanced the expression of matrix metalloproteinase-2 (MMP-2), which may increase the migration of LX-2 cells. Finally, our results indicated that the expression of miR-200b was unregulated in the biliary atresia (BA) and associated with liver fibrotic progression. These data suggest a potential mechanism for Akt activation through FOG2 down-regulation by miR-200b that can lead to HSC growth and migration. In view of the putative pathogenic role of miR-200b in HSCs, miR-200b may constitute a potential marker for HSC activation and liver fibrosis progression.

Distinct Plasma Bile Acid Profiles of Biliary Atresia and Neonatal Hepatitis Syndrome.

Biliary atresia (BA) is a severe chronic cholestasis disorder of infants that leads to death if not treated on time. Neonatal hepatitis syndrome (NHS) is another leading cause of neonatal cholestasis confounding the diagnosis of BA. Recent studies indicate that altered bile acid metabolism is closely associated with liver injury and cholestasis. In this study, we systematically measured the bile acid metabolome in plasma of BA, NHS, and healthy controls. Liver bile acids were also measured using biopsy samples from 48 BA and 16 NHS infants undergoing operative cholangiography as well as 5 normal adjacent nontumor liver tissues taken from hepatoblastoma patients as controls. Both BA and NHS samples had significantly elevated bile acid levels in plasma compared to normal controls. BA patients showed a distinct bile acid profile characterized by the higher taurochenodeoxycholic acid (TCDCA) level and lower chenodeoxycholic acid (CDCA) level than those in NHS patients. The ratio of TCDCA to CDCA in plasma was significantly higher in BA compared to healthy infants (p < 0.001) or NHS (p < 0.001). The area under receiver operating characteristic curve for TCDCA/CDCA to differentiate BA from NHS was 0.923 (95% CI: 0.862-0.984). These findings were supported by significantly altered expression levels of bile acid transporters and nuclear receptors in liver including farnesoid X receptor (FXR), small heterodimer partner (SHP), bile salt export pump (BSEP), and multidrug resistant protein 3 (MDR3) in BA compared to NHS. Taken together, the plasma bile acid profiles are distinct in BA, NHS, and normal infants, as characterized by the ratio of TCDCA/CDCA differentially distributed among the three groups of infants.

Prolonged feeding difficulties after surgical correction of intestinal atresia: a 13-year experience

BACKGROUND Although surgical interventions for intestinal atresia are usually successful, oral feed intolerance could raise in certain cases. The aim of this study was to identify the factors that affect postoperative oral feed by retrospective analysis. METHODS Neonates meeting the inclusion criteria, who were admitted at our center from 1 January 2000 to June 2013, were enrolled into this retrospective study. Time to establishment of full oral intake (TOI), length of hospital stay (LOS) were outcome measures. Univariate and multiple regression were used. RESULTS Overall survival was 85.7%. Mean TOI was 20.4 ± 17.8 days, and mean LOS was 35.6 ± 44.8 days. Multivariate analysis confirmed a significant association with TOI for meconium peritonitis (P=0.024), luminal discrepancy between proximal and distal intestine (P=0.038), number of anastomoses (P=0.044), reportage of immature ganglion in proximal and/or distal intestine (P=0.029), and short bowel syndrome (P<0.001). Prematurity (P=0.022) increased the duration of hospitalization without affecting time to full oral intake. CONCLUSIONS Meconium peritonitis, luminal discrepancy, number of anastomoses, reportage of immature ganglion, and short bowel syndrome were factors related to prolonged feeding difficulties. We advocate alertness for patients with these factors to reduce postoperative morbidity and treatment costs.

Common Genetic Variations in Patched1 (PTCH1) Gene and Risk of Hirschsprung Disease in the Han Chinese Population

Hirschsprung disease (HSCR) is the most frequent genetic cause of congenital intestinal obstruction with an incidence of 1:5000 live births. In a pathway-based epistasis analysis of data generated by genome-wide association study on HSCR, specific genotype of Patched 1 (PTCH1) has been linked to an increased risk for HSCR. The aim of the present study is to examine the contribution of genetic variants in PTCH1 to the susceptibility to HSCR in Han Chinese. Accordingly, we assessed 8 single nucleotide polymorphisms (SNPs) within PTCH1 gene in 104 subjects with sporadic HSCR and 151 normal controls of Han Chinese origin by the Sequenom MassArray technology (iPLEX GOLD). Two of the eight genetic markers were found to be significantly associated with Hirschsprung disease (rs357565, allele P = 0.005; rs2236405, allele P = 0.002, genotype P = 0.003). Both the C allele of rs357565 and the A allele of rs2236405 served as risk factors for HSCR. During haplotype analysis, one seven-SNP-based haplotype was the most significant, giving a global P = 0.0036. Our results firstly suggest common variations of PTCH1 may be involved in the altered risk for HSCR in the Han Chinese population, providing potential molecular markers for early diagnosis of Hirschsprung disease.

Low doses of CMV induce autoimmune-mediated and inflammatory responses in bile duct epithelia of regulatory T cell-depleted neonatal mice

Recent studies have indicated that perinatal infection with cytomegalovirus (CMV) may promote bile duct damage in biliary atresia (BA) and that the decreased regulatory T cell (Treg) percentage associated with BA may further amplify the bile duct damage. Although a majority of BA patients have had previous CMV infections and lower percentages of Tregs, it is unknown whether an initial exposure to a low dose of CMV could induce exaggerated and progressive biliary injury. A Treg-depleted neonatal mouse was infected with low-dose CMV (LD-CMV) as a model to study BA patients. LD-CMV infection in Treg-depleted mice induced extensive inflammation in both the intrahepatic and extrahepatic bile ducts, accompanied with injury to and atresia of intrahepatic bile ducts and partial obstruction of the extrahepatic bile ducts. Serum total and direct bilirubin amounts were also elevated. Evidence for the involvement of cellular and humoral autoimmune responses in LD-CMV-infection of Treg-depleted mice was also obtained through detection of increased percentages of CD3 and CD8 mononuclear cells and serum autoantibodies reactive to bile duct epithelial proteins, one of which was identified as α-enolase. Depletion of Tregs that can lead to the decreased inhibition of aberrantly activated hepatic T-lymphocytes and generation of autoantibodies may lead to further injury. Increased hepatic expression of Th1-related genes (TNF-α), IFN-γ-activated genes (STAT-1) and Th1 cytokines (TNF-α, lymphotactin, IL-12p40 and MIP −1γ) were also identified. In conclusion, autoimmune-mediated and inflammatory responses induced by LD-CMV infection in Treg-depleted mice results in increased intrahepatic and extrahepatic bile duct injury and contributed to disease progression.

Delivery room surgery: an applicable therapeutic strategy for gastroschisis in developing countries

BackgroundThe survival rate of infants with gastroschisis has improved significantly. It is over 90% in developed countries, but 50% in developing countries. This study aimed to investigate the factors improving the survival rate of infants with gastroschisis in developing countries.MethodsNeonates meeting the inclusion criteria, who presented to our center since the establishment of delivery room surgery, were enrolled into this retrospective study. Data were evaluated specifically to determine the role of delivery room surgery in reducing the mortality and morbidity of infants with gastroschisis and to identify factors optimizing the conditions of outborn infants.ResultsA total of 64 infants were identified. The overall survival rate of the infants was 60.9%. The survival rate of infants in inborns was 76.5%, and the survival rate of infants in outborns was 43.3%. Infants of the outborn group took more time to reach full enteral feeding, and were more likely to require a prolonged stay in hospital when compared with those of the inborn group. Logistic analysis identified that the surgical technique, the presence of sepsis and intestinal necrosis could be expected to influence the outcome of gastroschisis.ConclusionsThe strategy of delivery of patients in a center prepared to perform delivery room closure of gastroschisis appears to improve the survival of patients with gastroschisis. Further reduction in mortality rates will depend on improved conditions of outborn infants.

Successful Sleeve Lobectomy of Inflammatory Myofibroblastic Tumor in a 4-year-old Child

Primary pulmonary tumors in small children have remained a challenge for pediatric surgeons. Pneumonectomy and radical lobectomy are limitedly indicated due to surgical difficulties and sequelae. Here, we present our experience with a 4-year-old patient who suffered from an inflammatory myofibroblastic tumor. A left lower sleeve lobectomy was performed, and the patient recovered significantly after surgery. At the last follow-up, the child was growing well without any sequel, which supports our hypothesis that in small children, sleeve resection is the preferred treatment for tumors on the main stem bronchus and presents an alternative to an otherwise unavoidable pneumonectomy.

Pathologically assessed grade of Hirschsprung-associated enterocolitis in resected colon in children with Hirschsprung's disease predicts postoperative bowel function

PURPOSE The aim of this study was to investigate the relationship between the grade of enterocolitis on pathological assessment of resected colon and postoperative bowel function in children with Hirschsprungs disease (HD). METHODS Children with HD who were seen at a large tertiary center from January 2012 to December 2013 were enrolled into this study. Resected colon was assessed using the histopathologic grade scoring system for Hirschsprung-associated enterocolitis (HAEC), and the relationship of these scores to postoperative bowel function was assessed. Time of recovery to normal defecation was the primary outcome measure. The t-test, analysis of variance, and Kaplan-Meier, univariate, and multiple regression analyses were performed. RESULTS Eighty children with HD (median age at repair 7.9months; range 1.3months to 9years) were included in the study. Nineteen children dropped out of the study and were considered as providing censored data, giving a follow-up rate of 76.3%. A total of 21 children (34.4%) were admitted to hospital with at least one episode of enterocolitis. Multivariate Cox proportional hazards models showed that compared with patients with a normal proximal colon, those with an inflamed proximal segment had a 1.5-fold higher risk of a poor recovery. Logistic regression analyses suggested that postoperative HAEC admissions increased by 57% with each HAEC pathological grade of the transitional segment and by 50% with each grade of the overall segment. Compared with normal bowel in the transitional segment, the detection of grade ≥3 HAEC in the transitional area increased the incidence of postoperative HAEC by 4.75-fold. CONCLUSIONS Children whose resected proximal colon showed inflammation on pathological assessment were at risk of poor recovery after surgery. A higher pathological HAEC score for the sum of the overall three segments suggested an increased risk for the subsequent development of enterocolitis. Among three segments, the severity of enterocolitis in the transitional segment was the most significant factor in predicting postoperative HAEC. TYPE OF STUDY Clinical study. LEVEL OF EVIDENCE Moderate.

Elongation of esophageal segments by bougienage stretching technique for long gap esophageal atresia to achieve delayed primary anastomosis by thoracotomy or thoracoscopic repair: A first experience from China

OBJECTIVES The treatment of long gap esophageal atresia (LGEA) is one of the most challenging congenital malformations in neonatal surgery. A preoperative bougienage stretching technique for elongation of the two segments of esophagus is applied to achieve utilizing the native esophagus to establish esophageal continuity by open or thoracoscopic approach. METHODS From January 2015 to May 2017, 12 neonates who suffered from LGEA were admitted to our department. They were divided into 2 groups (A and B) according to their admission time. They all accepted bougienage stretching technique before esophageal anastomosis. RESULTS Initially the lengths of esophageal gap in 12 infants ranged from 4 to 7.5 vertebral bodies (M=5.8±1.1). The gap lengths became -1 to 2.5 vertebral bodies after bougienage stretching technique and tension-free anastomosis were performed successfully for all 12 cases: Group A (n=5) by thoracotomy and group B (n=7) by thoracoscopic approach. 12 cases have been followed up for 1-25 months (M=12.4±8.5) after definitive surgery. CONCLUSIONS Bougienage stretching technique for LGEA is feasible with satisfactory clinical results. Thoracoscopic approach is a good choice for primary anastomosis in LGEA. LEVELS OF EVIDENCE Treatment Study Level IV.

Long-term outcome of laparoscopic Nissen-Rossetti fundoplication versus Thal fundoplication in children with esophageal hiatal hernia: a retrospective report from two children’s medical centers in Shanghai

BackgroundThis study was undertaken to investigate the intraoperative and postoperative complications, efficacy and outcome of two laparoscopic fundoplications for the treatment of esophageal hiatal hernia in children.MethodsTo find a rational procedure, we performed a retrospective analysis of 136 children with esophageal hiatal hernia who underwent laparoscopic Nissen-Rossetti or Thal fundoplication at two children’s hospitals in Shanghai over 13 years. The median follow-up time of the children was 42 months (range: 1-138 months). Their age varied from 1 month to 11 years (median: 18.6 months).ResultsAll the children underwent laparoscopic fundoplications (72 cases of Nissen-Rossetti and 60 cases of Thal fundoplication) and 4 children converted to open surgery. The mean age of the children at the time of operation was 1.6±1.9 years, and the mean weight was 9.1±5.6 kg. Gastroesophageal reflux was significantly more severe after a Thal fundoplication (P=0.003) and slight esophageal stenosis was significant after a Nissen-Rossetti fundoplication (P=0.02). The recurrent rate of hiatal hernia was 2.8% (2/72) after Nissen-Rossetti fundoplication in contrast to 5% (3/60) after Thal fundoplication. No death occurred after surgery.ConclusionThere was no statistical difference of recurrence between laparoscopic Nissen-Rossetti and Thal fundoplication in the long-term outcomes. The rate of slight dysphagia was higher in the Nissen-Rossetti group. The Thal group had a significantly higher recurrence rate of gastroesophageal reflux. There still exited learning curve for this procedure. The incidence rate of complications is significantly related to the proficiency of pediatric surgeon.