Morphology of the enteric nervous system in the hindgut of an infant with cloacal exstrophy.

The authors describe the morphology of the enteric nervous system in the hindgut of an infant with cloacal exstrophy. Cloacal exstrophy was diagnosed at 32 weeks' gestation using prenatal ultrasonography. The baby was delivered at 34 weeks' gestation and underwent a separation of the cecum from bladder halves, reapproximation of hemibladders, closure of the omphalocele and pubic symphysis, and a distal colostomy. Intestinal wall specimens were obtained at colostomy from the distal end of the rudimentary hindgut. Serial frozen sections were prepared for histochemical acetylcholinesterase staining. Histological investigations demonstrated a strikingly crowded, immature enteric ganglia and prominent bundles of wandering cholinergic nerves. These findings suggest the unique pathology of the enteric nervous system development in cloacal exstrophy, in which the rudimentary hindgut behaves as a blind alley of the migratory pathway for neural crest-derived cells during embryogenesis. Histological examinations of the hindgut enteric nervous system in cloacal exstrophy may be beneficial for evaluating the postnatal development of the distal colon which might be utilized for a pull-through procedure.

A clinical analysis of prognostic parameters of survival in children with congenital diaphragmatic hernia.

BACKGROUND: Congenital diaphragmatic hernia (CDH) still has a high mortality because of accompanying lung hypoplasia and persistent pulmonary hypertension. Although prognostic parameters based on perinatal measurements have been proposed, our ability to accurately predict the surgical results remains insufficient. METHODS: We treated 55 infants with CDH from 1981 to 2004. Among them, 46 patients presented respiratory distress within the first 24 hours of life. Results of surgical treatment in the 46 infants were retrospectively correlated with gender, birth weight, gestational age at diagnosis, laterality, cardiac anomalies, diaphragmatic defect area, contents of herniated viscera, and the great vessel diameters measured by echocardiography. RESULTS: Out of 46 CDH neonates, 27 (58.7 %) survived and 19 (41.3 %) died aged 3 to 17 days. Non survivors had a significantly larger diaphragmatic defect and more frequent liver herniation. Out of possible predictive parameters studied, an index of the main pulmonary artery (cross-sectional area/diaphragmatic defect area ratio) most closely correlated with the surgical outcomes. CONCLUSIONS: The postoperative prognosis of CDH infants does not depend only on pulmonary hypoplasia, but also on other factors including the magnitude of abdominal visceral herniation. In this series of patients, the most reliable prognostic predictor was a clinical index reflecting the degree of both pulmonary hypoplasia and diaphragmatic maldevelopment.

Histological investigations into the difference between cystic and fusiform types of congenital biliary dilatation.

We investigated the histological differences in the common bile duct wall of bile ducts with congenital biliary dilatation, examining 10 cystic types and 11 fusiform types. A flattened mucosa was found in the cystic type, and a tufted mucosa was occasionally found in the fusiform type. Glands in the choledochus wall were less common in the cystic type than in the fusiform type. Smooth muscle fibre was more abundant in the cystic type than in the fusiform type, and it was markedly developed in the distal choledochus in the cystic type. Based on these results we suggest that the developmental difference of smooth muscle fibres in the distal choledochus in the embryonic period may be closely related to the morphological difference between the cystic and fusiform types of congenital biliary dilatation.

Relationship between the type of RET/GDNF/NTN or SOX10 gene mutations and long-term results after surgery for total colonic aganglionosis with small bowel involvement.

BACKGROUND/PURPOSE: Germline mutations of the RET-mediated or SOX10-mediated signaling pathway genes have been reported in total colonic aganglionosis (TCA). The authors investigated the possible relationship between the type of such genomic abnormalities and surgical outcomes. METHODS: Sixteen patients with TCA with extensive small bowel involvement were studied. DNA sequences of all the RET/GDNF/NTN and SOX10 coding regions were determined by the direct DyeDeoxy Terminator Cycle method. Data on the patients' clinical courses were obtained retrospectively from their medical charts and surgical records. RESULTS: RET or SOX10 germline mutations were identified in 11 of the 16 patients (68.8%). In children with aganglionosis up to the jejunum or ileum, most grew up within normal ranges, and the frequency of bowel movements decreased to 2 to 4 times per day within 5 years. However, in 5 infants with total intestinal aganglionosis, only 2 survived beyond 2 years of age, both of whom underwent Ziegler's myectomy-myotomy. A SOX10 mutation was identified in an infant with Shah-Waardenburg's syndrome, and he showed persistent bowel malfunction. CONCLUSION: The existence or type of RET mutation usually did not affect surgical results in this series of TCA patients, whereas the mutational analysis suggested 2 disease categories of TCA showing different postoperative courses, which may reflect the disparate pathogenesis in the enteric nervous system development induced by impaired RET or SOX10 signaling pathway.

Factors of biliary carcinogenesis in choledochal cysts.

The long-term complications of choledochal cysts include malignant degeneration of the epithelial lining of the biliary tract. Possible factors leading to malignant degeneration were examined by measuring amylase levels in the biliary tract, intraoperative biliary manometry and a histopathological study. 27 patients, 1 to 13 years of age, with choledochal cysts, were studied over a 13-year period. Amylase levels in the bile of choledochal cysts and the gallbladder were measured. The pressure profile of the biliary tract was recorded as the probe was withdrawn from the sphincter of Oddi (SO) to the distal end of the common bile duct. Hyperplasia of the gallbladder mucosa and malignancy of the biliary tract were investigated. Patients with high levels of biliary amylase had higher pressure differences between the SO and the duodenum than those with low levels of biliary amylase. The incidence of mucosal hyperplasia of the gallbladder mucosa was significantly higher in the fusiform type than in the cystic type. Adenocarcinoma in a cystic choledochal dilatation was found in a 12-year-old girl with high amylase levels. The cause of regurgitation of pancreatic juice into the biliary system might be due to a high pressure difference between the SO and the duodenum in addition to the lack of sphincter function at the abnormal junction of the pancreaticobiliary ductal system. Early diagnosis and surgical treatment to prevent the regurgitation leading to hyperplasia and malignancy of the biliary tract are important for children with choledochal cysts.

Mutational analysis of the RET and GDNF gene in children with hypoganglionosis.

Germline mutations of the RET (10q11.2) have been reported in Hirschsprung's disease (HSCR) at a rate of 15-45%. Recently, the glial cell line-derived neurotrophic factor (GDNF) was identified as one of the ligands of the RET, and GDNF (5p12-p13.1) mutations were also found in association with RET mutations in HSCR patients. We analysed the DNA sequence of RET and the GDNF of patients with hypoganglionosis. We investigated the germline mutation in 5 patients histologically diagnosed with hypoganglionosis. DNAs were extracted from peripheral blood lymphocytes of these patients. The PCR primers were designed for RET tyrosine kinase domain (exon 13-17) and GDNF (exon 1-2). The DNA sequence was determined using a direct DyeDeoxy Terminator Cycle method. The analysis of RET showed silent mutation at the codon 769 (CTT-->CTG) by DNA polymorphism in all patients. No other mutation of the RET or GDNF was evident. These results suggest that the RET or GDNF may not contribute to the pathogenesis of hypoganglionosis, which is suspected to be genetically different from HSCR.

A homozygous missense mutation in the tyrosine E kinase domain of the RET proto-oncogene in an infant with total intestinal aganglionosis.

Germline mutations of the RET proto-oncogene (RET), its ligand glial cell-derived neurotrophic factor (GDNF), and neurturin (NTN) gene have been reported in patients with Hirschsprung's disease. A targeted mutation in the tyrosine kinase domain of RET produced total intestinal aganglionosis and renal agenesis in homozygous transgenic mice. Here we describe a homozygous mutation of the human gene for the RET tyrosine kinase domain that was present in a male neonate with total intestinal aganglionosis. Gut wall biopsy specimens from the stomach to the anorectum showed no ganglion cells. No urinary tract abnormalities were detected. Genomic DNAs were isolated from peripheral blood lymphocytes of the infant and his parents. DNA sequences of all the RET/GDNF/NTN coding regions were determined using a direct DyeDeoxy Terminator Cycle method. A homozygous missense mutation (CGG-to-TGG) at RET codon 969 was identified in this patient, which resulted in an amino acid change from arginine to tryptophan. No germline RET/GDNF/NTN mutations were found in his parents. In this case, the homozygous RET mutation seemed to cause a critical alteration of the Ret tyrosine kinase activity, which resulted in total intestinal aganglionosis but not renal agenesis. Discrepancies in phenotypic expression between humans and mice suggest differing threshold values for RET signal transduction in species or organs.

Impaired distribution of retinoic acid receptors in the hindgut-tailgut region of murine embryos with anorectal malformations.

BACKGROUND/PURPOSE: Retinoid-mediated signal transduction plays a crucial role in the organogenesis of various organs. To investigate the pathogenesis of anorectal malformations (ARM), the authors studied the distribution pattern of retinoic acid receptors (RARs) in ARM murine embryos induced by overdose of all-trans retinoic acid (ATRA). METHODS: Pregnant mice were gavage-fed 100 mg/kg of ATRA on the ninth gestational day (E9.0). Embryos were obtained between E11.0 and E14.0 and were fixed immediately in a 4% paraformaldehyde solution. Frozen sections were prepared for immunohistochemistry using antibodies specifically raised against RAR-alpha, RAR-beta, and RAR-gamma. RESULTS: Over 98% of the embryos administered ATRA had ARM; rectoprostatic urethral and rectocloacal fistulas were the most frequent anomalies. The immunoreactivity of RAR-alpha was found equally in the epithelium of hindgut-tailgut in normal embryos on E11.5. However, it was absent in the hindgut in the treated embryos. The immunoreactivities of RAR-beta and RAR-gamma showed no difference in the distal hindgut. CONCLUSIONS: Impaired distribution of RAR-alpha in the hindgut-tailgut on E11.5 resulted in the incomplete partitioning of the cloaca and the rectourethral or rectocloacal fistula on E14.0. These results suggest that overdose of ATRA affects the distal hindgut development by directly disrupting the retinoid-mediated signalling pathway.

Congenital anomalies in mice induced by etretinate.

We report on the experimental induction of anorectal malformations (ARM) and other internal and external malformations in mouse fetuses induced by maternal administration of etretinate, a long-acting vitamin A analogue. The teratogen was administered to pregnant mice between the 7th and 10th gestational days (E7 and E10). The mice of the control group were given pure sesame oil on E9. We examined survival rates, crown-rump length, and the incidence of internal and external malformations, with particular attention to ARM, in each group. All mice in the E8 group exhibited rectovesical fistula, hydronephrosis, and spina bifida. All males and females in the E9 group given 60 mg/kg of etretinate developed rectoprostatic urethral fistula and rectocloacal fistula, respectively. The E10 group, given 60 mg/kg of etretinate displayed cleft palate (63.6%), forelimb malformation (68.2%), and a short club-shaped tail (100%). The fetuses had more severe types of ARM when etretinate had been administered on an earlier gestational day. The E9 group is a useful model for anorectal malformation, whereas the E8 group is a model for hydronephrosis and spina bifida.

Mutational analysis of RET/GDNF/NTN genes in children with total colonic aganglionosis with small bowel involvement.

Hirschsprung disease (HSCR) is characterized by the absence of intramural ganglion cells in the distal gut, resulting in bowel obstruction shortly after birth. Aganglionosis usually affects the distal colon, but may also extensively involve the entire colon and, rarely, the more proximal bowel. Recently, germline mutations of RET, GDNF, and NTN genes have been reported in HSCR. Here we describe the results of mutational analysis of these genes in 15 Japanese child patients with total colonic aganglionosis with small bowel involvement. DNA sequences of all the RET/GDNF/NTN coding regions were determined by the direct dyedeoxy terminator cycle method. Eight different RET mutations were identified in exons 1, 7, 10, 12, 15, and 17 in 10 of the 15 patients. Of these eight mutations, five were found in the tyrosine kinase domain. No GDNF or NTN mutation was found. Compared with typical HSCR, this patient group appeared to exhibit a higher percentage of RET mutations and accumulation of mutations in the tyrosine kinase domain. A homozygous (or hemizygous) RET mutation was found in a male baby with total intestinal aganglionosis, while the heterozygosity of the same mutation resulted in a less severe type of aganglionosis. In familial cases, all heterozygous for the same mutation, aganglionosis was more severe in male than in female siblings. These results also urge us to examine if the RET germline mutation may cause critical alteration of the GDNF/NTN-Ret signal transduction more severely in homo(hemi)zygosity and in male fetuses during organogenesis.

Ultrasonographic detection of intrauterine intussusception resulting in ileal atresia complicated by meconium peritonitis.

A neonate with ileal atresia (IA) complicated by meconium peritonitis (MP) whose prenatal ultrasonography (US) detected an intrauterine intussusception (IUI) is reported. Fetal ascites, dilated bowel loops, and abdominal calcifications were identified on serial US from 25 weeks of gestation. Intestinal loops with high echogenecity and a "target-like" appearance suggestive of IUI were detected in the right lower quadrant. The 2,680-g male was delivered vaginally at term and underwent a laparotomy. Fibrous adhesions and small calcifications were scattered throughout the peritoneal cavity. IA (interrupted type) was confirmed 17.0 cm cranial to the ileocecal valve (ICV). An ileo-ileal intussusception was also found between 16.5 cm and 9.0 cm cranial to the ICV. Partial resection of the ileum and an ileo-ileal anastomosis was performed. The postoperative course was uneventful. In this case, the pathological process of IUI resulting in IA and MP was demonstrated sonographically by identifying the "target-like" appearance in the fetus.

Mutational analysis of the RET proto-oncogene in a kindred with multiple endocrine neoplasia type 2A and Hirschsprung's disease.

BACKGROUND/PURPOSE: Germline mutations of the RET proto-oncogene (RET; 10q11.2) have been reported in multiple endocrine neoplasia type 2A (MEN 2A) and Hirschsprung's disease. The authors investigated a Japanese kindred in which MEN 2A and Hirschsprung's disease frequently have been found. METHODS: The pedigree consisted of 28 members (11 boys and 17 girls) spanning 4 generations, of whom, 8 were affected with MEN 2A or Hirschsprung's disease. RESULTS: Direct sequence DNA analysis of the RET proto-oncogene showed a heterozygosity for a G to C transition at the second nucleotide of codon 620 (exon 10) in the patients, resulting in the replacement of cysteine by a serine residue in the affected Ret protein. This family added a novel RET missense mutation (C620S) predisposing to the association of MEN 2A and Hirschsprung's disease. CONCLUSION: Detection of the mutated RET gene carriers may be used for genetic counseling of potential risk for Hirschsprung's disease as well as MEN 2A in the affected families.

Familial occurrence of intestinal obstruction in children with the syndrome of mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS).

The syndrome of mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is an uncommon neuromuscular disorder caused by mitochondrial dysfunctions that result in headaches, seizures, and progressive dementia. The authors describe a clinical case study of gastrointestinal manifestations in a pedigree with MELAS, in which all three children, ages 11, 8, and 6, demonstrated acute onset of intestinal obstruction. They unexpectedly showed severe abdominal distension and vomiting. Their parents had no clinical manifestation. The first female sibling underwent an emergent laparotomy because she was diagnosed to have intestinal strangulation. She had postoperative complications caused by progressive lactic acidosis and died the next day. The second and third sisters had similar onsets of the disease and were treated with gastrointestinal decompression and intravenous administration of lactate-free fluid and coenzyme Q10. Genetic testing using blood samples showed an A-to-G point mutation at nucleotide position 3243 in the tRNALeu(UUR) region in the mitochondrial DNA. In MELAS children who demonstrate acute onset of gastrointestinal manifestations, a careful review of family history and an elevation of serum lactate and pyruvate levels may enable a differential diagnosis to be made of acute abdomen to avoid unnecessary surgical intervention.

Terapia con OK-432 en linfangiomas de lengua / OK-432 therapy in tongue lymphangioma

Fue realizada una inyección intralesional de OK-432(una preparación con incubación liofilizada de streptococos pyogenes de origen humano)en 7 pacientes con linfangioma lingual bajo anestesia general, a intervalos de 6 semanas. Un paciente mostró una disminución marcada del volúmen del linfangioma con apariencia normal de la lengua y sin complicaciones relacionadas con el tratamiento. En los 6 pacientes restantes fue notada en 5 una disminución parcial del tamaño de la lesión, y en 1 no hubo respuesta.De los 5 pacientes con reducción parcial, en 4 se realizó una resección en cuña de la lesión para reducir el tamaño de la lengua obteniéndose excelente resultado en uno, bueno en 2 y regular en 1. Todos mostraban una mordida anormal antes de la reducción quirúrgica. Después de la reducción, uno mostró mordida completamente normal y 2 una mejoría en la misma. La terapia con OK-432 fue útil para el tratamiento del linfangioma cavernoso de la lengua y permitió la realización de una resección en cuña para reducir el tamaño de la lengua afectada, con baja incidencia de...

Absence of rectoanal inhibitory reflex in a child with multiple endocrine neoplasia type 2B.

BACKGROUND: Patients with multiple endocrine neoplasia (MEN) type 2B inherently present with gastrointestinal motility disorders as well as medullary thyroid carcinoma, adrenal pheochromocytoma, and Marfanoid habitus. METHODS: The authors examined gut motility function in a 7-year-old girl with MEN type 2B who had suffered from chronic constipation and recurrent acalculous cholecystitis since infancy. RESULTS: Results of total gastrointestinal barium meal and enema studies showed marked hypoperistalsis of the gut and entire colonic dilatation. Histopathologic study results of the gut wall from the stomach, duodenum, and rectum showed hyperplasia of the submucosal and intramuscular neural plexuses in all specimens. Anorectal manometry demonstrated disarrangement of the internal sphincter rhythmic wave and a complete absence of the rectoanal inhibitory reflex. CONCLUSION: These data suggest that gut motility disorders in MEN type 2B are caused by inadequately organized autonomic nervous system activity that originates from hyperplasia of the enteric nervous system.

Relationship between intraoperative cholangiographic patterns and outcomes in biliary atresia.

Intraoperative cholangiography revealed biliary tracts in 11 of 25 (44%) patients with biliary atresia. The outcome of these 11 patients was analyzed based on the cholangiographic patterns. In these 11 patients, 4 cases were the 1-cyst type, 3 showed a "cloudy shadow" pattern in the intrahepatic biliary tract, and 4 were subtype "a" pattern (distally patent common bile duct). Four patients showing the I-cyst type underwent hepaticojejunostomy with Rouxen-Y anastomosis, and all of the 4 became jaundice-free a few weeks after surgery. Three patients with the "cloudy shadow" pattern gained good bile drainage after hepatic portoenterostomy with Suruga II modification, all were complicated by ascending cholangitis. Three of the 4 subtype "a" pattern underwent hepatic portoenterostomy with Suruga II modification. Two became jaundice-free, while jaundice persisted in one. The subtype "a" patient who underwent hepatic porto-cholecystostomy showed poor bile drainage, and died of hepatic failure 17 months after surgery despite further surgery. From these results, we conclude that 1) hepatico-jejunostomy with Roux-en-Y anastomosis is indicated for I-cyst biliary atresia. 2) Prevention of ascending cholangitis is important in patients with the "cloudy shadow" pattern. 3) Hepatic porto-jejunostomy is indicated for the subtype "a" pattern rather than hepatic porto-cholecystostomy.

Development of anorectal malformations using etretinate.

PURPOSE: To investigate the pathogenesis of anorectal malformations (ARM), the authors studied cell proliferation and programmed cell death (apoptosis) patterns in murine embryos that develop ARM as a result of administering an overdose of etretinate, a long-acting vitamin A analogue (retinoid). METHODS: Pregnant mice were fed 60 mg/kg of etretinate on the ninth gestational day (E9). Embryos were obtained between E9.5 and E13, and prepared for histological study. Cell proliferation was examined using proliferative cell-specific nuclear antigen (PCNA) expression. Apoptosis was identified by detecting in situ DNA fragmentation using the TdT-mediated dUTP-digoxigenin nick end-labeling (TUNEL) method. RESULTS: Over 95% of etretinate-treated embryos had ARM including rectoprostatic urethral or rectocloacal fistula. In the histological study, ARM embryos showed defective cell proliferation in the cloacal membrane and excessive apoptosis in the dorsocaudal region on E11, which resulted in a lack of apoptosis in the anal orifice and a short tail on E12, respectively. Cells forming the urorectal septum showed the same pattern of cell proliferation and apoptosis both in ARM embryos and the controls. These results suggest that impairments of embryonal cellular dynamics in the cloacal membrane and dorsocaudal region induce some types of ARM.

Results of a modified Duhamel Operation for Hirschsprung's disease using the GIA stapler.

Thirty-six patients with Hirschsprung's disease underwent surgery using modified Duhamel operation with the GIA (gastrointestinal autosuture) stapler over a 12-year period at our institution. We now present our experience from the perspective of postoperative complications and anorectal function. Postoperative complications included minimal anal bleeding due to the GIA stapler in 2 patients, and mild enterocolitis in 6 patients. Severe complications such as anastomotic leakage or stricture were not observed in our series. Overall, postoperative anorectal function was good in patients without Down's syndrome or cerebral palsy. Follow-up of our patients showed that a good quality of life was achieved during childhood. We conclude, therefore, that the modified Duhamel operation, with the use of the GIA stapler, is a safe and easy procedure for correction of Hirschsprung's disease.