Abstract: Adrenocortical oncocytoma is a rare epithelial tumor only described in adults. We report the case of a 12-year-old female who presented a left adrenal mass with abdominal pain, fatigue, acne vulgaris, and elevation of the androstenedione and total testosterone. She had an adrenalectomy. A diagnosis of adrenocortical oncocytoma was made after detailed histological, immunohistochemical, and ultrastructural studies.

Abstract: This report correlates the clinical and biological findings, liver hemodynamics and histological features of focal INL in an infant with BA cirrhosis. An eight month old boy with BA, with previous successful porto-enterostomy, was admitted with signs of cholangitis and ascites. He was treated with antibiotics and diuretics with subsequent clinical improvement. Eight days later, while being fed with hyper-osmolar milk, he became febrile again: ASAT/ALAT climbed (9000/2300 IU/L), liver function deteriorated. Infectious work-up was negative. Liver-ultrasound showed reversed portal flow and a negative arterial diastolic flow. The patient recovered within five days under supportive treatment. A similar event recurred five days later. INL was suspected and semi-urgent living-related liver transplantation was performed, with uneventful post-operative course. Histology of the explanted liver showed extensive foci of INL of different ages. This report illustrates how the association of reversed portal and arterial diastolic flows, with subsequent liver hypoperfusion, may repeatedly cause foci of INL in BA cirrhosis, and lead to rapid progression to liver failure. Because of precarious hepatic blood supply in such patients, close monitoring of portal and diastolic arterial flows is recommended.

Abstract: OBJECTIVES: To determine the epidemiology of biliary atresia (BA) in Switzerland, the outcome of the children from diagnosis, and the prognostic factors. PATIENTS AND METHODS: The records of all patients with BA born in Switzerland between January 1994 and December 2004 were analyzed. Survival rates were calculated with the Kaplan-Meier method, and prognostic factors evaluated with the log rank test. Median follow up was 58 months (range, 5-124). RESULTS: BA was diagnosed in 48 children. Incidence was 1 in 17,800 live births (95% confidence interval 1/13,900-1/24,800), without significant regional, annual, or seasonal variation. Forty-three children underwent a Kasai portoenterostomy (PE) in 5 different Swiss pediatric surgery units. Median age at Kasai PE was 68 days (range, 30-126). Four-year survival with native liver after Kasai PE was 37.4%. Liver transplantation (LT) was needed in 31 in 48 children with BA, including 5 patients without previous Kasai PE. Four patients (8%, all born before 2001) died while waiting for LT, and 29 LT were performed in 27 patients (28 in Geneva and 1 in Paris). All of the transplanted patients are alive. Four-year overall BA patient survival was 91.7%. Four-year survival with native liver was 75% in patients who underwent Kasai PE before 46 days, 33% in patients operated on between 46 and 75 days, and 11% in patients operated on after 75 days (P = 0.02). CONCLUSIONS: Overall survival of patients with BA in Switzerland compares favorably with current international standards, whereas results of the Kasai operation could be improved to reduce the need for LTs in infancy and early childhood.

Abstract: Biliary atresia (BA) is a rare but potentially devastating disease. The European Biliary Atresia Registry (EBAR) was set up to improve data collection and to develop a pan-national and interdisciplinary strategy to improve clinical outcomes. From 2001 to 2005, 100 centers from 22 countries registered with EBAR via its website (www.biliary-atresia.com). In June 2006, the first meeting was held to evaluate results and launch further initiatives. During a 5-year period, 60 centers from 19 European countries and Israel sent completed registration forms for a total of 514 BA patients. Assuming the estimated incidence of BA in Europe is 1:18,000 live births, 35% of the expected 1488 patients from all EBAR participating countries were captured, suggesting that reporting arrangements need improvement. At the meeting, the cumulative evaluation of 928 BA patients including patients from other registries with variable follow-up revealed an overall survival of 78% (range from 41% to 92%), of whom 342 patients (37%) have had liver transplants. Survival with native liver ranged from 14% to 75%. There was a marked variance in reported management and outcome by country (e.g., referral patterns, timing of surgery, centralization of surgery). In conclusion, EBAR represents the first attempt at an overall evaluation of the outcome of BA from a pan-European perspective. The natural history and outcome of biliary atresia is of considerable relevance to a European population. It is essential that there is further support for a pan-European registry with coordination of clinical standards, further participation of parent support groups, and implementation of online data entry and multidisciplinary clinical and basic research projects.

Abstract: Complications related to the ingestion of magnetic foreign bodies by children represents an affirmed health hazard in the United States. In France, an alert has been announced. We report the 1st case in France. Our aim is to alert pediatricians and emergency physicians and to draw attention to the particularities of this type of foreign body. Responsible for complications is the ingestion of at least 2 magnets, or 1 magnet and a metallic foreign body, with a time interval between ingestions. In these cases, it is strongly recommended to extract the foreign bodies with endoscopy if they have not yet passed the pylorus. For those further advanced in the intestinal tract, continuous observation is warranted and surgical extraction is indicated on apparition of 1st clinical symptoms.

Abstract: Total parenteral nutrition (TPN) is correlated with progressive liver injury. Such injury may be associated with either an increase or decrease in hepatocyte growth. The goal of these experiments was to determine TPN-related alterations in intrahepatic genes, as they relate with the cell cycle, using microarray techniques. After 7 days of infusion of saline or TPN-solution, hepatocyte gene expression was examined with a 5000-cDNA microarray chip. TPN was associated with an up-regulation of the cyclin kinase Cdc25B mRNA, which controls the cell cycle at the G2/M phase. Based on this, our studies were directed at alterations in genes related to mitosis in this phase of the cell cycle. mRNA expression of mitotic phase inducers and inhibitors were examined. Cdc25B1 mRNA expression increased with TPN. TPN also led to additional significant alterations in the expression of other factors which mediate proliferation in this phase of mitosis. Histologically, TPN resulted in a significant decline in hepatocyte proliferation. Coincident with the alteration in cyclin expression was a significant decrease in hepatocytes in the G2/M phase with TPN administration. This study demonstrates significant alterations in cell cycle gene expression with TPN. The findings correlate with a loss of hepatocyte proliferation and may give insight into the potential mechanism of TPN-induced hepatocyte injury.

Abstract: Two cases of prenatally identified urinoma associated with an isolated hydronephrosis are presented, and the pathophysiology and prognosis of this rare condition are discussed. The presence in utero of a peri-renal collection associated with an isolated hydronephrosis seems to be a sign of significant renal dysplasia. These urinomas disappear spontaneously, thus drainage is not necessary, except in the case of compression of surrounding structures. The functional prognosis of these kidneys seems to be most unfavourable.

Abstract: Ulcerative colitis is characterized by elevated rates of epithelial cell apoptosis, and an up-regulation of pro-apoptotic cytokines including tumor necrosis factor alpha (TNF-alpha). Recently, angiotensin converting enzyme (ACE) has been shown to promote apoptosis. In addition, pharmacologic ACE inhibition (ACE-I) both prevents apoptosis and reduces TNF-alpha expression in vitro. We hypothesized that ACE-I, using enalaprilat, would decrease colonic epithelial cell apoptosis and reduce colitis severity in the dextran sulfate sodium (DSS)-induced colitis model in mice. We assessed the severity of colitis, and colonic epithelial cell apoptosis, after administration of DSS. Mice were given either daily ACE-I treatment or daily placebo. ACE-I treatment markedly improved clinical outcomes. In addition, ACE-I treatment significantly reduced the maximum histopathologic colitis grade. ACE-I also dramatically reduced the epithelial apoptotic rate. To investigate the mechanism by which ACE-I reduced apoptosis; we measured TNF-alpha, Bcl-2, and Bax expression. TNF-alpha mRNA was significantly lower with ACE-I treatment compared to placebo at every time point, as was the ratio of Bax to Bcl-2. We conclude that ACE-I reduces the severity of DSS-induced colitis and reduces epithelial cell apoptosis.

Abstract:

Abstract: Retroperitoneal cystic lymphangioma is a rare benign tumor of the retroperitoneal lymphatics that usually manifests in infancy. If surgical excision is used in treatment, it needs to be as complete as possible to reduce the risk of recurrence. Two pediatric patients, an 18-month-old girl and a 4-yearold boy, underwent laparoscopic excision of symptomatic retroperitoneal cystic lymphangiomas. Macroscopically, the resection was complete in both cases. The postoperative course in both cases was uneventful. Both children remained asymptomatic and no recurrence was observed at 18-month follow-up. Complete laparoscopic excision should be considered as a therapeutic option to treat retroperitoneal cystic lymphangioma.

Abstract: BACKGROUND: Ex vivo liver gene therapy provides an attractive alternative to orthotopic liver transplantation for the treatment of liver diseases. We previously reported a protocol in which human primary hepatocytes are highly transduced in Suspension with Lentiviral vectors and Immediately Transplanted (SLIT). Here, we evaluated the SLIT approach in Gunn rats, the animal model for Crigler-Najjar syndrome type 1, a defect in bilirubin UDP-glucuronosyltransferase (BUGT). METHODS: We constructed lentiviral vectors coding for BUGT under control of an ubiquitous promoter. Control vectors contained Green Fluorescent Protein (GFP) under control of the same promoter. Hepatocytes were isolated from jaundiced Gunn rats and transduced in suspension for four hr. After washing, 2x10 hepatocytes were immediately transplanted into syngeneic rats. Bilirubinemia and bile pigments were regularly assessed after cell transplantation. The percentage and presence of transduced hepatocytes was analyzed by immunohistochemistry in GFP-transplanted animals. RESULTS: In rats receiving BUGT-transduced hepatocytes, bilirubinemia decreased by about 30%. The level of correction remained stable for up to 240 days. Bilirubin glucuronides were present in the bile of treated animals, indicating the metabolic activity of engrafted hepatocytes. In contrast, bilirubinemia in GFP-transplanted rats did not decline but rather increased. GFP-positive hepatocytes amounted to 0.5-1% of the liver, which is in agreement with the number of transplanted and genetically-modified hepatocytes (6x10). CONCLUSIONS: This work reports the first demonstration of long-term metabolic benefit after rapid transplantation of ex vivo lentivirally tranduced hepatocytes. Therefore, this study demonstrates the therapeutic proof-of-principle and potential of the SLIT approach for treating inherited metabolic liver diseases.

Abstract: BACKGROUND: Total parenteral nutrition (TPN) results in a loss of mucosal immune function by alterations in both phenotype and function of intraepithelial lymphocytes (IEL). We hypothesized that the observed changes with TPN administration are caused by the lack of enteral feeding, and not to the TPN solution itself. METHODS: Mice received oral feeding (Control), TPN alone (TPN), or TPN plus oral feeding (TPN+Food). Mice were killed after 7 days, and bacteriological cultures from spleen, liver, and mesenteric lymph nodes obtained, with bacterial translocation (BT) being defined as a positive culture. IEL phenotype was analyzed by flow cytometry. IEL messenger RNA (mRNA) cytokine expression used reverse transcriptase polymerase chain reaction (RT-PCR). Apoptosis was detected by terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) staining. RESULTS: BT significantly (P < 0.05, with analysis of variance [ANOVA]) increased in the TPN group (53%) compared with Control (9%) and TPN+Food (14%) groups. TPN also resulted in a significant (P < 0.01) increase in epithelial cell apoptosis: TPN 7.6 +/- 1.1% versus Control 2.9 +/- 1.1% and TPN+Food 2.1 +/- 0.3% (mean +/- SD). Height of the villus-crypt complex was significantly decreased in TPN mice (315 +/- 16 microm) compared with Control (431 +/- 27 microm) and TPN+Food (421 +/- 26 microm) groups. IEL phenotypes significantly changed with TPN administration: CD4+ CD8- as well as CD4+ CD8+ subpopulations were reduced compared with Control or TPN+Food mice; as were the CD8alphabeta+ thymus-dependent, and CD8+ CD44+ mature IEL. IEL cytokine mRNA expression was also significantly altered with TPN: IL-2 and IL-10 expression declined, and IL-4 IL-6, interferon gamma (IFN-gamma), transforming growth factor beta-1 (TGF-beta1), and tumor necrosis factor-alpha (TNF-alpha) were increased, when compared with Control or TPN+Food mice. CONCLUSIONS: This study demonstrates that the major factor responsible for TPN-induced BT and IEL-changes is the lack of enteral feeding and not the administration of the TPN solution itself.

Abstract: BACKGROUND & AIMS: Intestinal adaptation in short bowel syndrome (SBS) consists of increased epithelial cell (EC) proliferation as well as apoptosis. Previous microarray analyses of intraepithelial lymphocytes (IEL) gene expression after SBS showed an increased expression of angiotensin converting enzyme (ACE). Because ACE has been shown to promote alveolar EC apoptosis, we examined if IEL-derived ACE plays a role in intestinal EC apoptosis. METHODS: Mice underwent either a 70% mid-intestinal resection (SBS group) or a transection (Sham group) and were studied at 7 days. ACE expression was measured, and ACE inhibition (ACE-I, enalaprilat) was used to assess ACE function. RESULTS: IEL-derived ACE was significantly elevated in SBS mice. The addition of an ACE-I to SBS mice resulted in a significant decline in EC apoptosis. To address a possible mechanism, tumor necrosis factor alpha (TNF-alpha) mRNA expression was measured. TNF-alpha was significantly increased in SBS mice, and decreased with ACE-I. Interestingly, ACE-I was not able to decrease EC apoptosis in TNF-alpha knockout mice. CONCLUSIONS: This study shows a previously undescribed expression of ACE by IEL. SBS was associated with an increase in IEL-derived ACE. ACE appears to be associated with an up-regulation of intestinal EC apoptosis. ACE-I significantly decreased EC apoptosis.

Abstract: PURPOSE: The aim of this study was to review outcomes after surgical treatment of total colonic Hirschsprung's disease (TCH). METHODS: Twenty-five records of patients with TCH treated between 1974 and 2002 were reviewed. Follow-up data were collected using a standardized questionnaire. Objective functional outcome was assessed using a scoring system. RESULTS: Twenty patients had aganglionosis of the colon and distal ileum, 5 of whom had a more extensive condition. One of these 5 patients underwent an endorectal pull-through (ERPT), 1 underwent intestinal transplantation, and 3 died. Four of the remaining 20 patients underwent a primary ERPT, 16 received a stoma as neonates followed by ERPT in 12, and a Martin-Duhamel procedure or Swenson's operation in 3 (median age, 10.5 months); 1 remains with an ostomy. Postoperative complications included enterocolitis (55%), anal stricture (25%), and perineal excoriation (20%). Mean follow-up were 17.5 years (+/-11.1 years). Eighty-nine percent were free of recurrent enterocolitis. Frequency of bowel movements is 1 to 5 per day in 82% of the patients, 18% have 6 or more bowel movements per day. Occasional soiling is noted in 40% (one third of those requiring nighttime diapers). Overall functional outcome was good in 83%. Those patients with the longest follow-up periods had the best stooling scores (P = .04). CONCLUSIONS: Surgical treatment of TCH is associated with a number of complications including recurrent enterocolitis and anal strictures. Long-term outcome is quite favorable.

Abstract: The giant umbilical cord is a rare malformation of the umbilical cord that can easily be diagnosed on prenatal scans and is unmistakable postnatally. We report a case to highlight issues of this rare finding. Visual diagnosis is easy and surgical repair is usually required.

Abstract: Foreign body ingestion is frequent in children and generally associated with little morbidity. However, some foreign bodies are innocent when ingested as a single object, but may have harmful effect if numerous. We report a 9-year-old girl who swallowed 5 magnets, causing acute intestinal obstruction. At laparotomy, 2 magnets were found in the cecum and 3 in the transverse colon, attracting each other and clasping a segment of ileum in between, causing a complete obstruction of the small intestine. If numerous magnets are ingested, particular concern is advised, and if signs of intestinal distress develop, prompt laparotomy to prevent serious gastrointestinal complications should be performed.

Abstract: Keratinocyte growth factor (KGF) promotes intestinal epithelial growth. To understand the relevance of intraepithelial lymphocyte (IEL)-derived KGF expression on epithelial growth, we used a mouse model of villus atrophy by the administration of total parenteral nutrition, and a model of villus hypertrophy by the creation of a short bowel syndrome. KGF expression was confined to gammadelta-TCR(+) IELs. IEL-derived KGF expression was highest in the crypts, somewhat less in the lower portion of villi, and markedly lower in the upper portion of villi. Total parenteral nutrition administration was associated with a down-regulation of IEL-derived KGF expression, and short bowel syndrome was associated with an up-regulation of IEL-derived KGF expression. In the absence of gammadelta-TCR(+) IEL, using gammadelta(-/-) mice, intestinal epithelial cell proliferation decreased in control, and in both mucosal atrophy (22% decline) and mucosal hypertrophy (14%) models. These results show that KGF from IELs is an important factor for maintenance of intestinal epithelial cell proliferation and villus growth.

Abstract: BACKGROUND: Hirschsprung's disease (HD) patients after pull-through (PT) may have recalcitrant constipation or recurrent enterocolitis (EC). Posterior myotomy/myectomy (POMM) are possible options for these problems. This study analyzed the outcome of POMM in HD patients post-PT. METHODS: Records of 348 HD patients were reviewed, and 32 were found to have undergone a POMM post-PT (1981 to 2002). Outcomes after this procedure were assessed. Statistics used linear and logistic regression. RESULTS: Of the 32 patients, 29 had complete records for analysis. Of those with pure constipation (12), 6 had aganglionosis post-PT. Of those with recurrent EC (17) only 1 had aganglionosis post-PT. POMM was performed at a mean of 3.1 years post-PT (11 myotomy, 18 myectomy). Average follow-up was 8.6 years (range, 0.7 to 21). Type of POMM had no correlation with overall functional outcome (P =.44). Of those with chronic constipation, 60% had good results after POMM; the remainder required a redo-PT or colostomy. Interestingly, most patients with retained aganglionosis and chronic constipation did not respond after POMM (83%). Of those with recurrent EC, 75% became free of symptoms; none of the patients not responding have required redo-PT. CONCLUSIONS: POMM to treat chronic constipation or recurrent EC in patients with HD post-PT is moderately successful. Because of the unsuccessful outcome with POMM in patients with a combination of constipation and aganglionosis, one should defer to a redo-PT in this group.

Abstract: BACKGROUND: The intestinal adaptive response [increased epithelial cell (EC) proliferation and apoptosis] after massive small bowel resection (SBR) is partially controlled by intraepithelial lymphocytes (IEL). To identify IEL factors contributing to EC adaptation post-SBR we utilized microarray assays. METHODS: Mice underwent a 70% SBR (SBR1w/SBR4w) or sham operation (Sham1w/Sham4w). After 1 or 4 weeks (1w, 4w) small bowel was harvested, and IEL isolated. Determination of the EC-proliferation rate used BrdU incorporation, and of the EC-apoptotic rate used Annexin V staining. Affymetrix system microarrays (12,491 genes) were performed to examine IEL-mRNA expression. Results were considered significant if fold-change (FC) between groups was >2 and P<0.05 (F-test), or FC>3 and 0.05> P >0.01, or FC>4 and P>0.05. Significant genes were confirmed by conventional RT-PCR. RESULTS: The SBR EC-proliferation rate increased significantly in both 1w and 4w groups compared to Sham: SBR1w 0.24+/-0.07 vs. Sham1w 0.12+/-0.02 (P=0.03); SBR4w 0.35+/-0.04 vs. Sham4w 0.19+/-0.02 ( P<0.01). The EC-apoptotic rate was unchanged in the 1w group, but significantly differed from controls after 4 weeks: SBR4w 39.92+/-6.78 vs. Sham4w 12.56+/-6.44 ( P<0.01). Microarray results were analyzed to identify potential growth-modifying IEL genes. The following were identified (function in parenthesis; A, apoptosis; P, proliferation): lipocalin 2 (promotes A), angiotensin converting enzyme (increases A), Rap2 interacting protein (reduces A, promotes P), amphiregulin (promotes P) and leucine-rich-alpha2-glycoprotein (promotes A, reduces P). Based on RT-PCR results these genes showed significant changes between groups. The increase in ACE at 1w preceded the observed apoptotic changes. The alterations in lipocalin 2, Rap2 and amphiregulin at 4w coincided with the marked changes in growth and apoptosis in the SBR mice. CONCLUSIONS: IEL undergo temporal changes after SBR. These findings provide profound insight into potential IEL-dependent regulation of EC homeostasis post-SBR.

Abstract: BACKGROUND/PURPOSE: Total parenteral nutrition (TPN) induces epithelial cell (EC) apoptosis. Keratinocyte Growth Factor (KGF) increases EC-growth; however, little is known of its effect on apoptosis. This study aims to determine if mRNA expression of Bcl-2 proteins (major mediators of epithelial cell apoptosis) is altered with TPN, and if KGF-administration influences Bcl-2 family expression. METHODS: C57BL/6J mice (n = 6 per group) received oral feeding (control), TPN (TPN), or TPN plus intravenous KGF daily (TPN + KGF). After 7 days, intestine was harvested and EC isolated. Apoptosis was identified using flow cytometry. EC mRNA expression of Bcl-2 family members was measured by reverse transcriptase polymerase chain reaction; Bcl-2 protein level was measured by immunoblot analysis. RESULTS: EC apoptotic rates were: control, 14.4% +/- 5.1%; TPN, 29.4% +/- 11.3%; KGF, 17.2% +/- 5.6%. Pro-apoptotic Bcl-2 proteins changed minimally with TPN or KGF; however, the antiapoptotic protein Bcl-2 changed significantly: control, 0.78 +/- 0.24; TPN, 0.10 +/- 0.13; KGF, 0.76 +/- 0.36. EC Bcl-2 protein levels were: control, 0.16 +/- 0.13; TPN 0.18 +/- 0.16; and TPN + KGF 0.47 +/- 0.19. CONCLUSIONS: TPN-induced apoptosis decreased Bcl-2 mRNA expression. KGF decreased EC apoptosis and increased Bcl-2 expression. Modalities to increase endogenous KGF, or KGF-administration may have benefit in patients on TPN.

Abstract: A paraneoplastic syndrome is occasionally the first clinical symptom seen with tumours. We report on two children who initially presented with paraneoplastic syndromes due to ganglioneuroblastomas: the first with severe watery diarrhoea caused by a ganglioneuroma producing vasoactive intestinal peptide, the second with non-treatable constipation, caused by ganglioneuroma-produced anti-neuronal nuclear antibodies. CONCLUSION: Either severe diarrhoea or chronic constipation may represent rare paraneoplastic syndromes in ganglioneuroblastomas.

Abstract: BACKGROUND: Massive small bowel resection with subsequent short bowel syndrome (SBS) leads to the acute loss of epithelial cell (EC) absorptive function. Keratinocyte growth factor (KGF) has been shown to improve EC growth, although little is known about KGF activity on EC function after SBS. We hypothesized that KGF would improve epithelial function in a mouse SBS model. METHODS: Adult C57BL/6J mice were randomized to a 55% mid-small bowel resection (SBS), SBS with KGF administration (SBSKGF), or sham-operated (Control) group, and were killed at 7 days. Ussing chambers were used to study epithelial function. Short circuit current (Isc) was monitored. EC absorption was studied by measuring (1) glucose [3-O-methyl-D-[1-3H]glucose (3-OMG)] absorption; (2) sodium coupled amino acid (alanine) absorption; and (3) changes in Isc by using the absorptive agent D-glucose (stimulated Na+ absorption). Epithelial barrier function was measured with transepithelial resistance (TER) and transmural passage of 3H-mannitol (Papp). ECs were separated along the crypt-villus axis with laser capture microdissection. Epithelial KGF receptor (KGFR) mRNA expression was studied using real time reverse transcriptase-polymerase chain reaction (RT-PCR). RESULTS: KGF administration increased the basic ion transport activity and net transepithelial absorption of 3-OMG and sodium-coupled alanine absorption. SBS significantly decreased epithelial ion transport, including the Na+ absorption stimulated by D-glucose and L-alanine. KGF administration partially improves Na+ absorption. KGF had no apparent effect on the TER and 3H-mannitol permeability in this study. KGF upregulated EC KGFR mRNA expression, predominately in the crypt and lower portion of the villus. CONCLUSIONS: KGF administration improves epithelial absorptive function and stimulates intestinal proliferation after SBS. This suggests that KGF improves intestinal adaptation after SBS and may have clinical applicability.

Abstract: BACKGROUND: Total parenteral nutrition (TPN) is associated with sepsis and loss of immune reactivity. The authors previously have shown that changes in the intestinal mucosal immune system--ie, intraepithelial lymphocytes (IEL)--lead to a loss of epithelial barrier function. This may be a mechanism by which bacteria and toxins endanger individuals receiving TPN. To identify altered IEL gene expression during TPN administration, microarray assays were used. METHODS: Mice received oral feeding (control) or TPN for 7 days. Small bowel IEL were separated and retained, RNA purified, and microarray assays performed (Affymetrix system, 12,491 genes). Results were expressed as quantile-normalized trimmed-means. Significance equals a greater than 2-fold change (TPN v control), P <.01 (t test) or greater than 3-fold, P <.05. RESULTS: In the TPN group 88, IEL genes were significantly up regulated and 114 downregulated (v control). Of these genes, 4 were identified to have highest degree of upregulation (FK506-binding protein 5; mannose-binding lectin, metallothionein 1 and 2), 2 were highly downregulated (microsomal epoxide hydrolase 1 and cytochrome P450 1a1). These genes were found to have high potential for immune-modulatory effects. CONCLUSIONS: The observed alterations in IEL gene expression may have an important role in the altered immune response with TPN and may relate to the increase in sepsis with TPN administration.

Abstract: BACKGROUND: Total parenteral nutrition (TPN) induces epithelial cell (EC) apoptosis. Keratinocyte growth factor (KGF) increases EC growth; however, little is known of its effect on apoptosis. This study aimed to determine the effect of recombinant human KGF (rHuKGF) on small bowel EC apoptosis. We further determined mRNA expression of Bcl-2 family members (major mediators of epithelial cell apoptosis) with TPN and whether KGF administration influences Bcl-2 family expression in EC. METHODS: C57BL/6J mice (n = 6/group) received oral feeding (Control); TPN; or TPN plus daily intravenous rHuKGF (TPN+KGF). After 7 days, intestines were harvested and EC isolated. Villus height was determined by microscopy and EC proliferation by immunohistochemistry using incorporation of 5-bromodeoxyuridine (BrdU). Apoptosis was identified by Annexin V as well as by TUNEL staining. EC mRNA expression of Bcl-2 family members was measured by reverse-transcriptase polymerase chain reaction and Bcl-2 protein level by immunoblot analysis. RESULTS: Villus height in Controls was 310 +/- 42 microm. This decreased with TPN to 210 +/- 45 microm; however, villus height was preserved in TPN + KGF mice (273 +/- 39 microm). EC proliferation rates decreased significantly in TPN mice, and this decline was prevented by administration of rHuKGF. EC apoptotic rate in Controls was 14.4 +/- 5.1%; TPN administration resulted in doubling of largely prevented TPN-induced EC apoptosis (29.4 +/- 11.3%) rHuKGF administration largely prevented TPN-induced EC apoptosis (17.2 +/- 5.6%). Proapoptotic Bcl-2 members changed minimally with TPN or rHuKGF; however, the anti-apoptotic Bcl-2 changed significantly: Control 0.78 +/- 0.24; TPN 0.10 +/- 0.13; rHuKGF administration prevented the decline in Bcl-2 expression observed with TPN (0.76 +/- 0.36). EC Bcl-2 protein levels were: Control 0.16 +/- 0.13; TPN 0.18 +/- 0.16; and TPN+KGF 0.47 +/- 0.19. CONCLUSIONS: TPN-induced apoptosis was associated with decreased Bcl-2 mRNA expression. rHuKGF decreased TPN-induced EC apoptosis and increased Bcl-2 expression. rHuKGF administration may have benefit in patients on TPN.

Abstract: PURPOSE: The aim of this study was to utilize clinical outcome methodology through multivariable analysis of perioperative factors to predict a successful Kasai-portoenterostomy (PE). METHODS: Records of 81 patients treated for biliary atresia (BA) were reviewed. Outcome was defined as successful if the patient was alive and had no liver transplant (LT). To predict future successful or failed PE, patients were categorized at 6 months post-PE into 2 groups: Success: direct bilirubin (DB) less than 2.0 mg/dL; Failure: DB greater than 2 mg/dL, or the patient was listed/had undergone LT, or had died. Groups were analyzed for positive or negative predictive values (PPV, NPV) at 2 and 5 years after PE. Cox regression was used to determine risk factors for PE. RESULTS: PE was successful in 38% and failed in 62%. PPV of future success was 96% at 2 years post-PE and 95% at 5 years post-PE, NPV of failure was 76% and 74%, respectively. Bridging liver fibrosis at the time of PE and postoperative cholangitic episodes were interdependent risk factors for a failed PE (P <.05). Other covariates showed no significant relationship for PE outcome. CONCLUSION: Classifying of patients 6 months postoperatively allowed us to determine a successful PE outcome. Bridging liver fibrosis at the time of the Kasai, and the increased number of postoperative cholangitic episodes were predictive of a poor PE outcome.

Abstract: BACKGROUND: The surgical management of Hirschsprung's disease (HD) has evolved from the original 3-stage approach to the recent introduction of minimal-access single-stage techniques. We reviewed the early results of the transanal Soave pullthrough from 6 of the original centers to use it. METHODS: The clinical course of all children with HD undergoing a 1-stage transanal Soave pullthrough between 1995 and 2002 were reviewed. Children with a preliminary stoma or total colonic disease were excluded. RESULTS: There were 141 patients. Mean time between diagnosis and surgery was 32 days, and mean age at surgery was 146 days. Sixty-six (47%) underwent surgery in the first month of life. Forty-seven (33%) had the pathologic transition zone documented laparoscopically or through a small umbilical incision before beginning the anal dissection. Mean blood loss was 16 mL, and no patients required transfusion. Mean time to full feeding was 36 hours, mean postoperative hospital stay was 3.4 days, and 87 patients (62%) required only acetaminophen for pain. Early postoperative complications included perianal excoriation (11%), enterocolitis (6%), and stricture (4%). One patient died of congenital cardiac disease. Mean follow-up was 20 months; 81% had normal bowel function for age, 18% had minor problems, and 1% had major problems. Two patients required a second operation (twisted pullthrough, and residual aganglionosis). One patient developed postoperative adhesive bowel obstruction. CONCLUSION: To date, this report represents the largest series of patients undergoing the 1-stage transanal Soave pullthrough. This approach is safe, permits early feeding, causes minimal pain, facilitates early discharge, and presents a low rate of complications.

Abstract: 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 3H-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.

Abstract: Intestinal pseudoobstruction may be part of a paraneoplastic syndrome. We report a teenage girl with ganglioneuroblastoma who presented with severe constipation. The intestinal pseudoobstruction was presumed to be due to inflammation of the myenteric plexus with destruction of the ganglion cells caused by antineuronal nuclear antibodies (ANNA or Anti-Hu).

Abstract: Apoptosis of intestinal epithelial cells (EC) plays a role in total parenteral nutrition (TPN)-induced villus atrophy. Among the mediators of apoptosis in EC are some members of the Bcl-2 family of proteins. Bcl-2 members can either be anti- (Bcl-2, Bcl-x(L), Bcl-w) or pro-apoptotic (Bax, Bak, Bid, Bad, Bcl-x(S)). To determine whether the observed increase in apoptosis induced by TPN is associated with an alteration in these Bcl-2 members' mRNA expression, mice were randomized to either TPN or oral feeding (controls). Animals were killed after 7 days and the intestine was harvested. EC were purified with magnetic beads. Apoptosis was detected by cell-surface expression of phosphatidylserine using flow cytometry. EC mRNA expression was determined by reverse-transcriptase polymerase chain reaction. Results were expressed relative to beta-actin. TPN resulted in a significant ( P < 0.05, unpaired t-test) increase in apoptosis: TPN 29.4 +/- 11.3% versus control 14.4 +/- 5.1%. The expression of the pro-apoptotic members Bax, Bak, Bid, and Bcl-x(S) was significantly ( P < 0.05) decreased after TPN. In contrast, a significant increase was observed in the anti-apoptotic member Bcl-2. mRNA expression of Bcl-w, Bad, and Bcl-x(L) was not significantly different between the control and TPN groups. Thus TPN-induced apoptosis was associated with an increased expression of anti-apoptotic factors and a decrease in pro-apoptotic factors. This contrasts with other reports where these factors showed converse effects under apoptotic conditions. Our results may demonstrate a unique regulatory pathway that may counter the observed increase in TPN-induced EC apoptosis.

Abstract: In a retrospective study (1987-1997) the complications of a totally implantable venous access device (Port-A-Cath, Fa. Pharmacia, Germany) were analysed in 91 children with 99 implants. All but 2 of these children had malignant diseases. Their age ranged from 0.1 to 18.1 (median 6) years. Overall implant time was 171.2 years (62,488 days), averaging 1.63 years (595 days) per device. 11 complications were registered, i.e. infections (6), occlusions (4) and disconnection (1), resulting in an overall infection rate of 0.06 and a total occlusion rate of 0.04. The overall complication rate was thus 0.11, which compares favourably with other studies. With careful handling, the Port-a-Cath device is very reliable and involves few complications.