FOXM1 and CHD4 expression is associated with chemoresistance in hepatoblastoma.

Hepatoblastoma (HB) is the most common malignant liver tumor in childhood. Although pre-operative cisplatin (CDDP)-based chemotherapy is often used in cases of HB, about 20％ of HB patients exhibit resistance to CDDP. Forkhead box protein M1 (FOXM1) and chromo-domain-helicase-DNA-binding protein 4 (CHD4) have been associated with CDDP resistance in various tumors. We here analyzed the immunohistochemical expression of FOXM1 and CHD4 in HB specimens of 33 patients (mean age: 20 months) post-chemotherapy. The differentiation of specimens was assessed using the digital pathology software QuPath®, and then the relation between the FOXM1 or CHD4 expression and the differentiation and various other clinicopathological parameters was investigated. The histological type was epithelial in 19 cases (57.6%) and mixed epithelial and mesenchymal in 14 cases (42.4%). Nine cases had only a fetal component, 1 case had only an embryonal component, 22 cases had both fetal and embryonal components, and 1 case had no viable tumor. Both the FOXM1 and CHD4 immunoexpressions were found significantly more frequently in the embryonal than fetal components (p<0.0001 and p<0.0001, respectively). Regarding chemotherapy efficacy, the alpha-fetoprotein (AFP) level after chemotherapy was correlated with both the imaging shrinkage rate (R=-0.52) and histological residual rate (the percentage of the viable tumors of HB after chemotherapy)(R=0.62). High FOXM1 score was correlated with a high-postoperative AFP value (p<0.01) and a low AFP attenuation rate (p<0.05), but the FOXM1 score was not correlated with the imaging shrinkage rate (p=0.4418) or histological residual rate (p=0.4418). High CHD4 score showed a nonsignificant trend toward correlation with high postoperative AFP value (p=0.0849) and was not significantly correlated with the other parameters. Collectively, our results showed that FOXM1 expression may be useful in evaluating the response to CDDP-based chemotherapeutic regimens. Accurate measurement of FOXM1 expression by our scoring system using QuPath® is important in cases with mixed HB components of various differentiation levels.

Long-term cosmetic outcomes of the slit-slide procedure for umbilical hernia repair in children.

PURPOSE: To assess the long-term cosmetic outcomes of the "slit-slide procedure", designed to provide a more natural appearance for umbilical hernia repair, as perceived by the patients and their parents. METHODS: A total of 149 patients with umbilical hernia underwent the slit-slide procedure at our hospital. The slit-slide procedure allows for the creation of an umbilicus with a more natural and integrated appearance. The patient satisfaction survey questionnaire was mailed to the families (n = 139), and there were 74 (53.2%) respondents. A questionnaire survey on postoperative appearance was also distributed to pediatric surgeons. RESULTS: The median age at the time of operation was 2.5 years (range, 2 months to 14 years) and the average median age at the time of answering the questionnaire was 6.25 years old (range, 2.5-14.8 years). The average median period of observation was 3.2 years (range, 4 months to 8.97 years). Most patients (89.2%) and parents (93.2%) were satisfied with the appearance of the umbilicus. Twenty-seven patients reported improved satisfaction after surgery (36.2%). Surgeons tended to score the elongated-oval shape highly; however, there was no difference in satisfaction among the shapes. CONCLUSION: The slit-slide procedure is not only effective and safe, but it achieves a satisfactory aesthetic outcome.

Thoracoscopic repair for late-presenting congenital diaphragmatic hernia with thoracic kidney in a child.

Congenital diaphragmatic hernia (CDH) with a hernia sac and thoracic kidney is a very rare congenital anomaly. Recently, the usefulness of endoscopic surgery for CDH has been reported. We herein report a patient who underwent thoracoscopic repair of CDH with a hernia sac and thoracic kidney. A 7-year-old boy was referred to our hospital due to a diagnosis of CDH without clinical symptoms. Computed tomography showed herniation of the intestine into the left thorax and left-sided thoracic kidney. The key points of operation are resection of the hernia sac and identification of the suturable diaphragm under the presence of the thoracic kidney. In the present case, after repositioning the kidney to the subdiaphragmatic area completely, the border of the diaphragmatic rim was clearly visualized. Good visibility allowed resection of the hernia sac without damaging the phrenic nerve and closure of the diaphragmatic defect.

Feasibility of Laparoscopic Fundoplication Without Removing the Preceding Gastrostomy in Severely Neurologically Impaired Patients: A Multicenter Evaluation of the Traction Technique.

Purpose: Severely neurologically impaired patients sometimes require anti-reflux surgery with preceding gastrostomy. We apply a traction technique for laparoscopic fundoplication (LF) without gastrostomy takedown (GTD) in such cases. We conducted a multicenter review to assess the feasibility of our approach. Materials and Methods: In brief, the traction technique involves left-lateral-traction of the stomach body, right-lateral-traction of the round ligament of the liver, and elevation of the left liver lobe to create a sufficient field for manipulating the forceps. Patients who underwent LF with Nissen's procedures in 2010-2022 were retrospectively reviewed. Data were analyzed by a one-way analysis of variance. Results: The operative approaches included the traction technique (n = 16; Group 1), GTD and reconstruction (n = 5; Group 2), and LF followed by gastrostomy (n = 92; Group 3). In comparison with Group 1, significant differences were only found in pneumoperitoneum time (Group 1 versus Group 2 versus Group 3: 174.4 minutes versus 250.4 minutes versus 179.5 minutes; P = .0179). Operating time (222.7 minutes versus 303.0 minutes versus 239.7 minutes; P = .0743), duration to full-strength enteral nutrition (10.4 days versus 17.2 days versus 11.0 days; P = .0806), and length of hospital stay (17.2 days versus 31.0 days versus 18.5 days; P = .3247) were equivalent. No re-fundoplication was required in Group 1. Conclusion: The traction technique secures the operative quality and outcome of LF without GTD.

Spontaneous reduction age for ovarian hernia in early infancy.

BACKGROUND: Many articles recommend early surgery for ovarian hernia to avoid the risk of ovarian torsion. However, while ovarian hernia is known to undergo spontaneous reduction (SR) in early infancy, few reports have described the timing of SR. We therefore investigated the clinical features of SR for ovarian hernia in early infancy. METHODS: A total of 610 girls were diagnosed with inguinal hernia between 2008 and 2018. We focused on infants who had an ovarian hernia onset in the first 3 months of age. We reviewed the age retrospectively at the onset of hernia and age at SR. The data were compared statistically using the Kaplan-Meier method. RESULTS: Sixty-one infants with inguinal hernia were included in this study. Thirty-nine patients (64%) had ovarian hernia. The mean age at the onset of hernia was 44 ± 17 days of age. Thirty cases underwent SR (77%). A Kaplan-Meier analysis showed that 75% of ovarian hernias underwent SR by 6 months of age. There were no cases of ovarian torsion. CONCLUSIONS: Most cases of ovarian hernia underwent SR, so patients with ovarian hernia in early infancy might be treated by elective surgery after 6 months of age.

Support for Introduction of Pediatric Endosurgery in Nepal as Global Pediatric Surgery: Preliminary Needs Assessment Survey.

Background: Endosurgery provides several advantages over open surgery in the context of global surgery; however, there are several barriers to its introduction. The preliminary assessment of needs and barriers is essential for carrying out effective support as Global Surgery. However, no report has described the initiation of support for endosurgery based on a preliminary survey of the needs and barriers. The present survey study aimed at determining the needs and barriers of pediatric endosurgery in Nepal. Materials and Methods: A needs assessment survey was conducted among all pediatric surgeons in Nepal via an online platform. This was followed by workshop on pediatric endosurgical skills in Nepal. To assess the skills of participants and effectiveness of the workshop, the skill evaluation tests and the questionnaire survey were conducted. Results: Fourteen pediatric surgeons (response rate: 60.9%) responded to the needs assessment survey. More than 70% of the participants did not have any experience with advanced endosurgical procedures. However, advanced endosurgical procedures were strongly needed. A lack of training was indicated as a major barrier for the introduction of pediatric endosurgery. Fifteen participants completed the workshop. Participants' confidence in their endosurgical skills improved significantly after the workshop. The skill evaluation tests revealed that participants' endosurgical skills also improved significantly after the workshop, although even after the workshop, participants still took an average of 415.6 seconds to place and knot one suture. Conclusions: The needs assessment survey and workshop for Nepalese pediatric surgeons helped clarify their needs for endosurgery and the barriers to its introduction.

Stability of probiotics with antibiotics via gastric tube by simple suspension method: An in vitro study.

Data on the stability of probiotics with antibiotics delivered via gastric tube using the simple suspension method (SSM) are limited. Therefore, we investigated bacterial survivability in probiotics treated with antibiotics prepared by the SSM in vitro. Probiotics and antibiotics were suspended in 20 mL of sterilized hot water (55 °C) and then 1-mL of the suspensions were taken each at 10, 60, 120, 180 and 360 min. Thereafter, the samples were inoculated on 3 media and cultured at 37 °C for 24 h. Survival of probiotic strains was measured in colony-forming units. The growth of Clostridium butyricum did not change without antibiotics at all experimental times, but in the case of Enterococcus faecium tended to increase. On the other hand, the viable bacterial number of C. butyricum was decreased significantly by treatment with cefdinir, tosufloxacin, clarithromycin, or azithromycin, but was not altered by levofloxacin, minocycline, or vancomycin. The viable bacterial number of E. faecium was significantly decreased by treatment with tosufloxacin, levofloxacin, minocycline, vancomycin, or azithromycin, and was significantly increased by clarithromycin. In conclusion, our results suggest that the efficacy of probiotic therapies might be reduced by the SSM when specific antibiotics are used. Moreover, antibiotics might inhibit probiotic growth, although some probiotics are spore-forming and have high minimum inhibitory concentrations. Additionally, early administration of non-spore-forming bacteria might be desirable. Therefore, when patients are administered therapy combining probiotics and antibiotics by the SSM, we should consider the characteristics of the probiotics and the administration times.

Survival of two Orientia tsutsugamushi bacterial strains that infect mouse macrophages with varying degrees of virulence.

Orientia tsutsugamushi, an intracellular parasitic bacterium, comprises numerous strains of differing virulence. When BALB/c mice were infected intraperitoneally with this pathogen, a virulent strain known as Karp was found to multiply in the intraperitoneal macrophages and kill the mouse. In contrast, an avirulent strain, Kuroki, was shown to invade macrophages but be eliminated from the cells, allowing mouse survival. O. tsutsugamushi invades its host cell cytoplasm through phagocytosis and disruption of phagosomal membranes but some bacteria are then killed by phago-lysosomes within 1h of infection. Microscopic observations could not differentiate the Karp and Kuroki strains during entry and subsequent cell killing by phago-lysosomes. However, the Kuroki cells failed to divide and were markedly deformed following cytoplasmic invasion at several days post-infection. These findings suggest that macrophages have a mechanism to eliminate O. tsutsugamushi in the cytoplasm, if the invading bacteria escape phagosomal clearance, and that it is this mechanism that Kuroki does not survive. Additionally, significant levels of nitric oxide (NO) are produced in macrophages by Kuroki, but not by Karp. An NO synthase inhibitor, however, does not increase the growth of Kuroki, suggesting that NO is induced in a strain-dependent manner but does not effect proliferation.