Effect of elevated intra-abdominal pressure and hyperoxia on portal vein blood flow, hepatocyte proliferation and apoptosis in a rat model.

BACKGROUND/PURPOSE: Indications for a laparoscopic approach for the management of biliary atresia in children are not clearly defined. We have recently shown that persistent intra-abdominal pressure (IAP) significantly decreased portal vein (PV) flow. Ventilation with a high concentration of oxygen after abdomen deflation raises concerns of increased oxidative stress but has also been shown to exert beneficial effects on splanchnic ischemia/reperfusion. The purpose of the present study was to evaluate the effects of IAP and hyperoxia on liver histology, hepatocyte proliferation and apoptosis in a rat model of abdominal compartment syndrome (ACS). METHODS: Male Sprague-Dawley rats were anesthetized with intraperitoneal ketamine and xylasine. After a midline laparotomy, the PV was isolated. Ultrasonic blood flow probes were placed on the vessel for continuous measurement of regional blood flow. Mean arterial blood pressure (MABP) was continuously measured. Two large-caliber percutaneous peripheral intravenous catheters were introduced into the peritoneal cavity for inflation of air and measurement of IAP. Rats were divided into three experimental groups: 1) Sham rats were subjected to IAP of 0 mmHg; 2) ACS rats were subjected to IAP of 6 mmHg for 2 hours and were ventilated with air; and 3) ACS-O (2) rats were subjected to IAP of 6 mmHg for 2 hours and were ventilated with 100 % O (2) during the operation and ventilation was continued for 6 hours after operation. Liver structural changes, hepatocyte proliferation (using BrdU assay) and apoptosis (using Tunel assay) were determined 24 hours following operation. RESULTS: IAP at 6 mmHg caused a twofold decrease in PV flow compared to sham animals. Hyperoxia resulted in a less significant decrease in PV flow compared to air-ventilated animals. Despite a significant decrease in PV blood flow, 24 hours after abdominal deflation only a few animals demonstrated histological signs of liver damage. The small histological changes were accompanied by increased hepatocyte apoptosis and enhanced hepatocyte proliferation in 25 % of animals, suggesting a liver repair response. CONCLUSIONS: Despite a significant decrease in PV blood flow, persistent IAP for 2 hours results in few changes in liver histology, and stimulates hepatocyte proliferation and apoptosis in only a few animals, supporting the presence of a recovering mechanism. Treatment with hyperoxia did not significantly change hepatocyte proliferation and apoptosis.

The basic biology of apoptosis and its implications for pediatric surgery.

Apoptosis, or programmed cell death, is an evolutionarily conserved and highly regulated process of nonfunctional cell death. Through this process, the body disposes of unwanted cells by self-destruction: it is our final defense against damaged cells. In the last decades, many of the essential pathways that control this phenomenon have been elucidated. Apoptosis plays an important role in developmental processes, as well as in cellular homeostasis. This process is known to be accelerated or diminished in many pathologic states. Therefore the understanding of apoptotic regulation has significant clinical ramifications. This article reviews the basic understanding of programmed cell death with respect to areas of interest to pediatric surgeons, including: Hirschsprung disease, intestinal atresias, testicular disorders, short bowel syndrome, ischemia-reperfusion injury and pediatric oncology. Pro or antiapoptotic interventions may become a future target for cell and organ protection in patients suffering from these diseases.

Computer-assisted image analysis can aid the prognostication of advanced-stage neuroblastomas.

PURPOSE: The aim of this work was to detect nuclear parameters related to the prognosis of patients with stage III, IV or DS neuroblastomas. METHODS: Histological sections of 25 operation specimens obtained from children with advanced-stage neuroblastomas were subjected to computer-assisted image analysis. Statistical relationships between nuclear descriptors of the tumor cells and patients' clinical outcome were determined. RESULTS: The coefficient of variability of the mean nuclear area the mean nuclear elongation factor, and the mean nuclear averaged Feret diameter of the neuroblastoma cells were ascertained to be discriminators separating high-grade from low-grade tumors. CONCLUSIONS: The histomorphometrically gauged nuclear parameters may help oncologists to assess the prognosis of patients with advanced-stage neuroblastoma.

Delay of surgery in acute appendicitis.

BACKGROUND AND OBJECTIVES: It is generally assumed that delayed diagnosis of acute appendicitis results in higher morbidity but this assumption is not strongly supported in the literature. We attempt to define the effect of patient and physician delay on the outcome of patients with acute appendicitis. PATIENTS AND METHODS: We studied 486 patients admitted between 1980 and 1992. Patient delay in presenting to a physician and surgeon delay from hospital admission to operation were studied in relation to stage of disease at operation as well as to postoperative complications. RESULTS: Postoperative complications occurred in 10% of cases with simple acute appendicitis versus about 20% of cases with gangrenous or perforated appendicitis (P <0.001). The mean patient delay from onset of symptoms to presentation to a physician was 1.7 days in simple acute appendicitis versus 2.3 days in gangrenous or perforated appendicitis (P <0.001). Mean surgeon delay was 13.6 hours in simple acute appendicitis versus 14.5 hours in advanced appendicitis (P = NS). CONCLUSION: Delay in patient presentation adversely affects the stage of disease in acute appendicitis and leads to increased incidence of infectious complications and to prolonged hospital stay. Conversely, physician delay does not affect the stage of disease. A surgeon's decision to observe patients in hospital in order to clarify the diagnosis is justified, as it does not adversely affect outcome.

Adenoma of the gallbladder in childhood.

Adenoma of the gallbladder is a rare benign tumor presenting as a sessile or pedunculated lesion with a papillary or nonpapillary structure. Of late, attention has been drawn to its malignant potential; its occurrence has never been reported in children. An 8-year-old girl who was successfully treated by cholecystectomy for a symptomatic adenoma of the gallbladder is reported.

Life-threatening respiratory distress caused by a mediastinal teratoma in a newborn.

Mediastinal teratomas rarely cause symptoms in newborns. Case reports drawing attention to this presentation have appeared in the literature. A 2-day-old baby with respiratory distress treated by intubation and mechanical ventilation underwent an urgent thoracotomy to alleviate tracheal compression that was caused by a teratoma. The clinical, radiological, and surgical features related to this case are reported.

[Bloody nipple discharge in an infant].

A milky discharge from the nipple and breast hypertrophy are often seen in mature infants, but bloody nipple discharge is very rare in infancy and childhood. In adults, a bloody discharge may be associated with breast carcinoma, but in infants it is a benign, self-limited condition that should be managed conservatively. Surgical procedures should be avoided, because injury to the breast bud may cause permanent damage. We report a 3-month-old girl who presented with a bloody discharge from the left nipple. The discharge diminished gradually in the course of time and ceased completely at the age of 9 months.

[Diagnosis and treatment of Hirschsprung's disease in adolescence].

Hirschsprung's disease is the most frequent cause of large intestinal obstruction in the neonatal period, during which the majority of cases are diagnosed. In about 5 of cases diagnosis is not established until adolescence. We present a 12-year-old boy with Hirschsprung's disease, treated since childhood for constipation. Early diagnosis avoids complications.

[Idiopathic scrotal edema].

Idiopathic scrotal edema causes painful enlargement of the scrotum, as does torsion of the testis or of a testicular appendage, or epididymo-orchitis. Unilateral edema of the scrotum develops rapidly, the skin becomes pale pink or red, and there is discomfort rather than acute pain. Careful palpation reveals a nontender testis. The condition is usually self-limited, and resolves completely without treatment in 48 hours. It must be differentiated from testicular torsion, for which urgent surgical treatment is mandatory.

[Intestinal cystic duplication in infants and the etiology of intussusception].

2 infants, 3 months old and 8 months, respectively, with restlessness and vomiting were each found to have ileocolic intussusception with barium filling defects. Laparotomy disclosed in each a dome-shaped structure, 2 cm and 0.6 cm in greatest diameter, respectively, on the antimesenteric side of the ileal wall. Histological examination showed cystic duplication of the ileum. It is suggested that manual reduction generally fails when cystic duplication is an etiological factor, and surgery is then mandatory.

In utero sonographic appearance of intestinal duplication cysts.

The antenatal appearance of gastrointestinal duplication cysts is described. Two cases are presented: a duplication cyst of the pylorus and a cyst of the terminal ileum. The embryogenesis and the clinical utility of prenatal diagnosis of these malformations of the alimentary tract are discussed. Antenatal detection of these cystic masses allowed close neonatal surveillance and timely surgical intervention prior to neonatal complications.

Neonatal mastitis--diagnosis and treatment.

Neonatal mastitis is an uncommon infection. Twenty-one neonates with mastitis were treated at the Bnai Zion Medical Center and Hillel Yaffe Hospital during the years 1985-92. Half of them presented with mastitis, and the other half with breast abscess. The most common pathogen was Staphylococcus aureus, which was isolated in 85% of cases. Antibiotic therapy was the initial treatment in all cases except one, and included i.v. orbenin or augmentin. Puncture of six breast abscesses followed the initial antibiotic course, and another five abscesses were treated surgically by incision and drainage. About half the neonates (10 of 21) recovered after antibiotic treatment alone, indicating that aggressive antibiotic therapy is effective in about 50% of cases and, if started immediately upon diagnosis, no additional surgical treatment is necessary. When an abscess was formed, needle aspiration was as effective as incision and drainage.

Laparoscopic cholecystectomy for acute cholecystitis: how do fever and leucocytosis relate to conversion and complications?

OBJECTIVE: To find out whether fever and raised white cell count (WCC) are associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis, and whether their presence could help in deciding the place of laparoscopic procedures. DESIGN: Prospective study. SETTING: Teaching hospital, Israel. SUBJECTS: 256 patients who were treated for clinical acute cholecystitis between January 1994 and November 1997. INTERVENTIONS: Emergency laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Raised temperature and WCC; incidence of conversion and complications. RESULTS: Raised temperature (>38 degrees C) was independently associated with advanced cholecystitis (p = 0.002, odds ratio [OR] 2.7) and a palpable gallbladder preoperatively (p = 0.02, OR 2.1). Total complications correlated with a temperature of >38 degrees C. Raised WCC (>15 x 10(9)/L) was independently associated with age >45 years (p = 0.02, OR 2.4), a palpable gallbladder preoperatively (p = 0.001, OR 2.9), and a raised temperature (>38 degrees C) (p < 0.0001, OR 6.2). Conversion was associated with a WCC >18 x 10(9)/L (p = 0.0, OR 3.2). CONCLUSION: A WCC of >18 x 10(9)/L may assist in predicting conversion, and fever of >38 degrees C may assist in predicting the development of complications.

Laparoscopic cholecystectomy for acute cholecystitis and the consequences of gallbladder perforation, bile spillage, and "loss" of stones.

OBJECTIVE: To study the factors associated with accidental perforation of the gallbladder and spillage of bile and stones and to assess the consequences of these mishaps. DESIGN: Prospective study with retrospective bacteriological evaluation. SETTING: Teaching hospital, Israel. SUBJECTS: 189 Patients who were treated for clinical acute cholecystitis between January 1994 and August 1996. INTERVENTIONS: Emergency laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Incidence of accidental perforation of gallbladder and spillage of bile and stones and of conversion and complications in relation to preoperative and operative findings. RESULTS: Bile was spilt in 65 (34%) and gall-stones were "lost" in 27 (14%), 44 (23%) required conversion to an open approach and 36 (19%) developed complications. Preoperative duration of symptoms >96 hours and a palpable gallbladder were associated with accidental perforation of the gallbladder and spillage of bile. A palpable gallbladder, gangrenous cholecystitis, and WBC > 15 x 10(9)/L were associated with stones "lost" in the peritoneum. A history of biliary disease was inversely related to "lost" stones. Conversion of laparoscopic to open cholecystectomy was associated with male sex, age >60 years, a non-palpable gallbladder, WBC > 15 x 10(9)/L, and a gangrenous gallbladder. Complications of surgery were more common among men and associated with fever of >38 degrees C. Neither the conversion nor the complications were associated with perforation of the gallbladder or "lost" stones. CONCLUSION: Perforation of the gallbladder and intraperitoneal spillage of bile or stones during laparoscopic cholecystectomy for acute cholecystitis are not associated with undesirable events, are not indications for conversion, and are not associated with further complications. When patients are given appropriate antibiotics perioperatively and the spilt bile is properly aspirated and the peritoneum irrigated, the operative and postoperative courses are similar to those of patients with unperforated gallbladder.