Yuko Tazuke

Mechanisms underlying the antireflux effect of Nissen fundoplication in children

BACKGROUND/PURPOSE It is reported that the main mechanism responsible for gastroesophageal reflux (GER) is transient lower esophageal sphincter (LES) relaxation in children. However, the effect of Nissen fundoplication on transient LES relaxation has not been investigated in children. This study examined the effect of Nissen fundoplication on motor patterns of the LES in children with pathological GER. METHODS Esophageal manometry and pH were recorded concurrently for 2 hours after administration of apple juice (10 mL/kg). In seven children documented to have pathological GER by prolonged esophageal pH monitoring (%time pH less than 4.0>5.0), studies were performed preoperatively and 1 to 3 months after surgery. RESULTS Nissen fundoplication virtually eliminated reflux in all patients. Percentage of time pH was less than 4.0 reduced from 15+/-9 to 0+/-0. Basal LES pressure did not change significantly (pre, 21+/-10 mm Hg v post, 27+/-9 mm Hg). The number of transient LES relaxation reduced significantly from 13+/-4 to 7+/-7, and the mean nadir LES pressures during swallow-induced LES relaxation and transient LES relaxation increased significantly from 1+/-1 mm Hg to 13+/-5 mm Hg and from 0+/-0 mm Hg to 11+/-7 mm Hg, respectively. CONCLUSIONS Our findings suggest the antireflux effects of Nissen fundoplication may be based on changes of LES motor patterns that result in incomplete LES relaxation and reduction of the number of transient LES relaxation.

Keratinocyte growth factor stimulates the recovery of epithelial structure and function in a mouse model of total parenteral nutrition

Background: Keratinocyte growth factor (KGF) increases intestinal growth and is expressed by intestinal intraepithelial lymphocytes (IEL). Because total parenteral nutrition (TPN) leads to villus atrophy and a loss of epithelial function, we hypothesized that KGF administration could reverse these changes. Methods: Mice were randomized into three groups: oral feeding (Control); TPN; or TPN with recombinant human KGF. Mice were killed at 7 days, and the small bowel was harvested for histology, DNA, and protein content analysis. Epithelial cell proliferation was studied by 5-bromo-2-deoxyuridine (BrdU) incorporation, and apoptosis was detected by flow cytometry with Annexin V staining. Epithelial ion transport function was studied by Ussing chambers. Epithelial barrier function was assessed with transepithelial resistance and transmural passage of 3 H-mannitol. Epithelial KGF receptors expression was studied by using reverse transcriptase-polymerase chain reaction (RT-PCR) and Western blot. Results: TPN decreased intestinal DNA, protein content, villus height, and crypt cell proliferation. TPN also resulted in an increase in epithelial cell apoptosis. KGF administration significantly stimulated the recovery of mucosal structures including intestinal protein and DNA content, villus height, and crypt cell proliferation, and decreased epithelial apoptosis. KGF also up-regulate the epithelial KGF receptor expression. Moreover, KGF attenuated the TPN-induced increase in ion transport and increased the epithelial barrier function. Conclusions: KGF administration reversed many of the adverse epithelial changes associated with TPN administration. Additionally, KGF up-regulated epithelial KGF receptor expression. It is possible that KGF may have a therapeutic efficacy in patients who are receiving TPN.

Alanyl-glutamine-supplemented parenteral nutrition prevents intestinal ischemia-reperfusion injury in rats

BACKGROUND Intestinal ischemia-reperfusion (I/R) injury plays an important role in the pathogenesis of systemic inflammation and multiple-organ failure. We studied whether glutamine, the primary fuel of the small intestine, prevents intestinal mucosal damage after intestinal I/R in rats. METHODS Rats were randomly divided into 4 groups: a sham-standard amino acid (SAA) group (n = 8); a sham-glutamine (Gln) group (n = 8); an I/R-SAA group (n = 10); and an I/R-Gln group (n = 9). Alanyl-glutamine solution was produced by replacing 36% of the total amino acid nitrogen with Gln. The superior mesenteric artery was ligated. After 60 minutes of ischemia, reperfusion was initiated and infusion was started. After 24-hour reperfusion, the intestinal segment was removed for morphological and biochemical analysis, and blood samples were drawn from the portal vein. Fluorescein isothiocyanate-conjugated dextran 70,000 (FITC-dextran) was infused into the duodenum 2 hours before animal death. RESULTS In the I/R-SAA group, extensive epithelial sloughing and mucosal ulceration of villous tips were observed, whereas these findings did not occur in the I/R-Gln group. Mucosal wet weight, DNA, and protein content decreased significantly in the I/R-SAA group compared with the sham-SAA group and increased significantly in the I/R-Gln group compared with the I/R-SAA group. Plasma FITC-dextran significantly increased in the I/R-SAA group compared with the sham-SAA group, but the plasma level in the I/R-Gln group was comparable with that of each sham group. Mucosal glutaminase activity significantly increased in both the I/R-SAA and I/R-Gln groups compared with the sham-SAA and sham-Gln groups, respectively. CONCLUSIONS Alanyl-glutamine protects against morphologic and functional mucosal injury after intestinal I/R in rats.

Hepatic P-glycoprotein changes with total parenteral nutrition administration

BACKGROUND The mechanism(s) responsible for the development of parenteral nutrition-associated liver disease (PNALD) is unknown. Recently, a number of bile canalicular transport proteins have been identified that transport bile components out of hepatocytes. One group of these genes, multidrug resistance 1 (mdr1) and mdr2, encode P-glycoproteins. Mice lacking mdr2 expression develop liver disease that appears similar to PNALD. This study investigated the alteration in the expression of these transport proteins during the administration of total parenteral nutrition (TPN). METHODS Mice received either physiologic saline and standard chow or TPN. Mice were sacrificed on day 7, and hepatic DNA and RNA content, mRNA expression, and levels of mdr1 and mdr2 proteins were measured. RESULTS TPN administration led to a significant (p < .05) decline in mdr2 mRNA expression and an increase in mdr1 mRNA expression. Mdr2 protein expression declined by 66% in the TPN-treated group, and mdr1 protein expression significantly increased by 58%. Histology and biochemical parameters showed no evidence of liver injury. Serum bile acid levels were elevated in the TPN group, suggesting the development of early cholestasis. CONCLUSIONS The decline in mdr2 and rise in mdr1 mRNA and protein expression with TPN administration occurred before the development of liver injury but during an early state of cholestasis. This suggests that alterations in mdr gene expression may be a causative factor in the development of PNALD.

Risk Factors for the Recurrence of the Congenital Diaphragmatic Hernia—Report from the Long-Term Follow-Up Study of Japanese CDH Study Group

AIM OF THE STUDY Few follow-up studies focused on the recurrence regarding the postoperative course of congenital diaphragmatic hernia (CDH) survivors. The aim of this study was to report on risk factor for CDH patients who had the recurrence during the follow-up. MATERIALS AND METHODS A multicenter retrospective survey was conducted on neonates diagnosed to have CDH between January 2006 and December 2010. Follow-up survey was conducted between September 2013 and October 2013 (ethical approval: No. 25-222). Nine institutions agreed to participate in this survey. Out of 228, 182 (79.8%) patients were alive and 180 patients were included in this study. Two patients were excluded because the defect had not repaired at the primary operation. The patients were divided into the recurrence group (n=21) and the nonrecurrence group (n=159). Postnatal and postoperative variables were compared between these two groups. Baseline variables which showed significance in univariate analysis were entered into multiple logistic regression analysis for analyzing the recurrence. A value of p<0.05 was considered to be statistically significant by using the JMP software program (version 9; SAS Institute, Inc, Cary, North Carolina, United States). MAIN RESULTS Out of 180, 21 (11.7%) CDH neonates had the recurrence during the course of the follow-up. Five (2.8%) patients had the recurrence before primary discharge and 16 (8.9%) patients had the recurrence after discharge. Univariate analysis showed that liver herniation (crude odds ratio [OR], 7.4; 95% confidence interval [CI], 2.73-23.68), defect size C and D, proposed by the CDH Study Group (crude OR, 7.09; 95% CI, 2.73-19.99) and patch repair (crude OR, 5.00; 95% CI, 1.91-14.70) were risk factors. Multivariate logistic regression analysis showed liver herniation (adjusted OR, 3.96; 95% CI, 1.01-16.92) was the risk factor for the recurrence. CONCLUSION A wide spectrum of the disease severity and the rarity of the disease mask the risk of the recurrence for CDH patients. This study showed the only factor to predict the recurrence was the liver herniation. These data will be helpful for providing information for the long-term follow-up of the CDH patients.

Alteration of canalicular transporters in a mouse model of total parenteral nutrition.

Objectives: Parenteral nutrition–associated liver disease (PNALD) is a major problem with prolonged total parenteral nutrition (TPN) administration. Our laboratory previously demonstrated significant changes in the expression of multidrug resistance genes (MDRs) 1 and 2, hepatocyte transporters, in a TPN mouse model. The present study hypothesized that these changes would lead to functional changes in the liver, and would contribute to the development of liver dysfunction. Materials and Methods: Mice received either intravenous saline and standard chow or TPN with or without intravenous lipids. Functional assays were performed after 7 days of infusion. Results: TPN with lipids led to a significant increase in serum bile acid levels, consistent with an early state of PNALD. Use of TPN without lipids prevented an elevation in bile acid levels. In both TPN groups, MDR2 expression was significantly (68%) lower than controls and bile phosphatidylcholine content, a functional measure of MDR2, was 40% less than controls. MDR1 expression in the TPN with lipid group was 31% higher than controls, whereas in the TPN without lipids mice there was no significant change. Hepatocyte extrusion of rhodamine dye, a measure of MDR1 function, declined only in the TPN with lipid group. Peroxisome proliferator–activated receptor-α expression decreased in both TPN groups. Fenofibrate given with TPN resulted in an increased expression of MDR1 and MDR2, and functionally increased hepatocyte rhodamine extrusion and presence of bile phosphatidylcholine in the TPN with lipid group. Conclusions: The study shows that TPN led to alterations in the function of MDR1- and MDR2-expressed proteins. The changes help in the understanding of the mechanisms leading to PNALD, and suggest that fibrate administration may palliate these changes.

Use of a palmaz stent for tracheomalacia: Case report of an infant with esophageal atresia

A male infant with congenital cardiac anomalies and esophageal atresia with tracheoesophageal fistula (EA-TEF) showed intractable respiratory symptoms after delayed primary repair of EA-TEF. Computed tomography demonstrated that the trachea was compressed by the enlarged aorta. Artificial ventilation was necessary even after aortopexy performed at 2 months of age. At 140 days of age, an expandable metallic stent (Palmaz stent) was inserted through a rigid bronchoscope into the trachea underfluoroscopic control. His respiratory status improved dramatically, and he was extubated in 18 hours. Although the follow-up period has been 9 months, the short-term result is satisfactory. The expandable metallic stent placement should be considered in patients with EA-TEF who show intractable respiratory symptoms caused by tracheomalacia.

Transumbilical resection and umbilical plasty for patent omphalomesenteric duct

Abstract This paper describes a transumbilical resection and umbilical plasty for treatment of a patent omphalomesenteric duct (POMD). In a newborn infant with a POMD, a skin incision was made circumscribing the mucocutaneous junction of the protruded duct. The duct was completely extirpated with a wedge resection of the connection to the intestine and an umbilical plasty was performed. The postoperative appearance was excellent. It appears that transumbilical resection and umbilical plasty may be a satisfactory operation for POMD.

Cisplatin upregulates glutamine transport in human intestinal epithelial cells: the protective mechanism of glutamine on intestinal mucosa after chemotherapy.

BACKGROUND Glutamine (GLN) prevents the intestinal mucosal injury induced by chemotherapy, although the mechanism of this protective action has not yet been elucidated. Amino acid transport across the plasma membrane is essential for supplying enterocytes with amino acids for cellular metabolism. It was hypothesized that chemotherapy stimulates GLN transport, which enables GLN to be used more efficiently as a metabolic fuel. METHODS A rat model was used to examine the effect of enteral GLN on intestinal mucosal injury induced by intraperitoneal injection of cisplatin (7.0 mg/kg of body weight). The effects of cisplatin on amino acid transport and the expression of messenger RNA and protein were evaluated by real-time polymerase chain reaction and Western blot analysis, respectively, in the human intestinal epithelial cell line Caco-2. The effects of cisplatin on glutaminase activity and intracellular glutathione were also studied. RESULTS GLN prevented mucosal atrophy induced by cisplatin in rats. In Caco-2 cells, cisplatin significantly increased GLN transport and the expression of GLN transporter ASCT2 messenger RNA and protein. Leucine, but not glutamate, transport significantly increased in the cisplatin-treated group due to the increase in LAT1 (leucine transporter) protein expression. Glutaminase activity and intracellular glutathione increased significantly in the cisplatin-treated group. CONCLUSIONS Bolus enteral GLN prevents intestinal mucosal injury induced by cisplatin in rats, as demonstrated by increased GLN transport and increased GLN transporter expression after cisplatin administration.

The most reliable early predictors of outcome in patients with biliary atresia after Kasai’s operation

BACKGROUND/PURPOSE The purpose of this study was to determine reliable predictors of outcome of biliary atresia (BA) after Kasais operation. PATIENTS AND METHODS Fifty-four BA cases that underwent Kasais operation at our institution over two decades were reviewed. The cases were divided into two groups: Group I: cases that required liver transplantation or died (n=30) and Group II: cases alive with the native liver. Serum levels of total bilirubin (TB), direct bilirubin (DB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (GGT) were measured sequentially after surgery. For cut-off determination, receiver operating characteristic (ROC) analysis was employed. RESULTS Serum TB, DB, AST, and ALT in Group I were significantly higher than those in Group II at 1, 2, and 3 months after surgery (p<.05). The most reliable cut-offs determined by ROC analysis were DB of 0.7 mg/dl at 2 months (sensitivity; 93%, specificity; 75%) and AST of 94 IU/L at 2 months (sensitivity; 87%, specificity; 71%). The 54 cases were re-divided into three groups according to the cut-off values: group G (good) with DB and ASTcut-offs (n=9; Group I:II=4:5), and group P (poor) with DB and AST ≥ cut-offs (n=29; Group I:II=25:4). The 15-year survival rate in groups G, M, and P was 94%, 44%, and 22%, respectively (p<.001). CONCLUSION The combination of serum DB and AST at 2 months after Kasais operation is a reliable predictor of long-term BA outcome.