Maternal age affects pronuclear and chromatin dynamics, morula compaction and cell polarity, and blastulation of human embryos.

STUDY QUESTION: Does maternal ageing impact early and late morphokinetic and cellular processes of human blastocyst formation? SUMMARY ANSWER: Maternal ageing significantly affects pronuclear size and intra- and extra-nuclear dynamics during fertilization, dysregulates cell polarity during compaction, and reduces blastocoel expansion. WHAT IS KNOWN ALREADY: In ART, advanced maternal age (AMA) affects oocyte yield, fertilization, and overall developmental competence. However, with the exception of chromosome segregation errors occurring during oocyte meiosis, the molecular and biochemical mechanisms responsible for AMA-related subfertility and reduced embryo developmental competence remain unclear. In particular, studies reporting morphokinetics and cellular alterations during the fertilization and pre-implantation period in women of AMA remain limited. STUDY DESIGN, SIZE, DURATION: A total of 2058 fertilized oocytes were stratified by maternal age according to the Society for Assisted Reproductive Technology classification (<35, 35-37, 38-40, 41-42, and >42 years) and retrospectively analysed. AMA effects were assessed in relation to: embryo morphokinetics and morphological alterations; and the presence and distribution of cell polarity markers-Yes-associated protein (YAP) and protein kinase C-ζ (PKC-ζ)-involved in blastocyst morphogenesis. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 1050 cycles from 1050 patients met the inclusion criteria and were analysed. Microinjected oocytes were assessed using a time-lapse culture system. Immature oocytes at oocyte retrieval and mature oocytes not suitable for time-lapse monitoring, owing to an excess of residual corona cells or inadequate orientation for correct observation, were not analysed. Phenomena relevant to meiotic resumption, pronuclear dynamics, cytoplasmic/cortical modifications, cleavage patterns and embryo quality were annotated and compared among groups. Furthermore, 20 human embryos donated for research by consenting couples were used for immunofluorescence. MAIN RESULTS AND THE ROLE OF CHANCE: Static microscopic observation revealed that blastocyst formation and expansion were impaired in the 41-42 and >42-year groups (P < 0.0001). The morphological grades of the inner cell mass and trophectoderm were poorer in the >42-year group than those in the <35-year group (P = 0.0022 and P < 0.0001, respectively). Time-lapse microscopic observation revealed a reduction in nucleolus precursor body alignment in female pronuclei in the 41-42 and >42-year groups (P = 0.0010). Female pronuclear area decreased and asynchronous pronuclear breakdown increased in the >42-year group (P = 0.0027 and P < 0.0122, respectively). Developmental speed at cleavage stage, incidence of irregularity of first cleavage, type and duration of blastomere movement, and number of multinucleated cells were comparable among age groups. Delayed embryonic compaction and an increased number of extruded blastomeres were observed in the >42-year group (P = 0.0002 and P = 0.0047, respectively). Blastulation and blastocyst expansion were also delayed in the 41-42 and >42-year groups (P < 0.0001 for both). YAP positivity rate in the outer cells of morulae and embryo PKC-ζ immunoflourescence decreased in the >42-year group (P < 0.0001 for both). LIMITATIONS, REASONS FOR CAUTION: At the cellular level, the investigation was limited to cell polarity markers. Cell components of other developmental pathways should be studied in relation to AMA. WIDER IMPLICATIONS OF THE FINDINGS: The study indicates that maternal ageing affects the key functions of embryo morphogenesis, irrespective of the well-established influence on the fidelity of oocyte meiosis. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the participating institutions. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Quality of life after type-A esophageal atresia surgery: changes over time and effect of pre-anastomotic elongation.

AIM: To assess mid-/long-term postoperative quality of life (QOL) of esophageal atresia (EA) patients. METHODS: Modified gastrointestinal quality-of-life index surveys were administered to postoperative EA patients who were at least 7 years old at evaluation to assess three topics about general lifestyle (GL), five topics about EA, and four topics about mental health (MH). For MH, caregivers were also interviewed, but separately. Subjects were divided according to age: children (7-12 years old), teenagers (13-19), and adults (20 and over) and compared according to Foker or Kimura elongation (FK) or bougienage stretching (BS). RESULTS: There were 22 patients evaluated. Responses for GL, EA, and MH did not differ significantly between age groups, but MH responses by caregivers for subjects who were children or teenagers scored significantly lower than responses they made themselves. For primary esophageal elongation technique (PET), age at esophagoesophagostomy was significantly higher in FK. Despite FK scoring 15.1 versus 12.4 for BS during EA evaluation, this difference was not statistically significant. CONCLUSION: Changes in QOL responses according to age were unremarkable. However, discrepancies in MH indicate that subjects felt better than their caregivers thought. PET did not appear to influence QOL.

Changes in postoperative quality of life of pediatric total colonic aganglionosis patients: effect of pull-through technique.

AIM: To assess mid-/long-term quality of life (QOL) of total colonic aganglionosis (TCA) patients. METHODS: Modified pre-existing QOL assessment tools for general lifestyle (GL), bowel function (BF), and mental health (MH) were administered to postoperative TCA patients from five institutions, who were at least 7 years old to compare Duhamel (with pouch) and Swenson/Soave (without pouch) techniques between children (Ch 7-12 years old), teenagers (Tn 13-19), and adults (Ad 20 and over). For MH, caregivers were also interviewed, but separately. Maximum scores were 12 for GL/MH and 18 for BF. RESULTS: There were 32 subjects. GL and BF scores increased significantly from Ch (GL 4.8 ± 2.5, BF: 11.3 ± 4.6) to Tn (GL 7.8 ± 2.6, BF 16.2 ± 3.0); scores for MH did not change significantly. Mean caregiver MH scores were significantly lower than mean subject MH scores for all age groups (subject scores: 10.1, 10.7, 10.7 versus caregiver scores: 6.8, 7.8, 8.1 for Ch, Tn, Ad, respectively). PT technique/presence of a pouch did not influence the incidence of enterocolitis or QOL scores. CONCLUSION: MH responses showed subjects felt better than caregivers believed. This discrepancy could cause conflict despite steadily improving GL/BF. QOL was unaffected by PT technique/presence of a pouch.

Association between a deep learning-based scoring system with morphokinetics and morphological alterations in human embryos.

RESEARCH QUESTION: What is the association between the deep learning-based scoring system, iDAScore, and biological events during the pre-implantation period? DESIGN: Retrospective observational study of patients (n = 925) who underwent oocyte retrieval in a clomiphene citrate-based minimal stimulation cycle and obtained expanded blastocysts between October 2019 and December 2020. The association between iDAScore with morphokinetics and morphological alteration during fertilization, cleavage stage, compaction and blastocyst stage was analysed. RESULTS: The duration of the cytoplasmic halo was significantly prolonged in low-scoring blastocysts (P < 0.0001). The timing of female and male pronuclei breakdown was significantly delayed in low-scoring blastocysts compared with high-scoring blastocysts (P < 0.0001 in both). Embryos with either trichotomous, multi-chotomous, rapid or reverse cleavage or asymmetric division had a lower score than embryos with normal cleavage (P < 0.0001-0.0098). The cell number and amount of blastomere fragmentation on days 2 and 3 were significantly associated with iDAScore (P < 0.0001-0.0008). Delayed compaction, blastulation and blastocyst expansion were observed in low-scoring embryos (P < 0.0001 in all). The incidence of blastomere exclusion and extrusion during embryonic compaction was significantly higher in low-scoring embryos than in high-scoring embryos (P ≤ 0.0001 in both). Blastocyst morphology was significantly associated with iDAScore (P < 0.0001). Multiple linear regression analysis revealed that, during the transformation to blastocyst stage, morphokinetic and morphological events were strongly associated with iDAScore (P < 0.0001-0.0116). CONCLUSIONS: iDAScore was significantly correlated with morphokinetics and morphological alterations of pre-implantation embryos, especially during the late pre-implantation period. Our findings contribute to research on deep learning model-based embryo selection, which may provide patients with a compelling explanation of blastocyst selection.

Human 1PN and 3PN zygotes recapitulate all morphokinetic events of normal fertilization but reveal novel developmental errors.

STUDY QUESTION: Does mono- (1PN) and tri-pronuclear (3PN) fertilization recapitulate the morphokinetic changes of normal bi-pronuclear (2PN) fertilization? SUMMARY ANSWER: Abnormal fertilization retraces the overall choreography of normal fertilization but reveals novel morphokinetic phenomena and raises scientifically and clinically relevant questions. WHAT IS KNOWN ALREADY: ART has allowed the extracorporeal observation of early human development. Time-lapse technology (TLT) has revealed the complexity of the morphokinetic changes underpinning fertilization and the importance of this process for the genetic and cellular integrity of the embryo. Abnormal fertilization has remained neglected, despite its relevance to the physiology and pathology of early human development. STUDY DESIGN, SIZE, DURATION: This retrospective study involved TLT observation of normally (2PN, N = 2517) and abnormally (1PN, N = 41; 3PN, N = 27) fertilized oocytes generated in ICSI cycles performed between October 2019 and December 2020. Oocyte retrieval was carried out after clomiphene citrate-based minimal ovarian stimulation. Oocytes of patients with different diagnoses of infertility were included in the analysis, while cases involving cryopreserved gametes or surgically retrieved sperm were excluded. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study included 1231 couples treated for diverse infertility causes. The fraction of male factor cases was substantial (36.1%). Microinjected oocytes were assessed by a combined TLT-culture system. Oocytes not suitable for TLT assessment, owing to an excess of residual corona cells or inadequate orientation for correct observation, were not analysed. Phenomena relevant to meiotic resumption, pronuclear dynamics, cytoplasmic/cortical modifications, cleavage patterns and embryo quality were annotated and compared between groups. MAIN RESULTS AND THE ROLE OF CHANCE: Extrusion of the second polar body (PBII) was observed in almost all 2PN/1PN (99.9% and 100.0%, respectively) and in a vast majority of 3PN zygotes (92.1%). Rates of PBII fusion with the ooplasm were much higher in 1PN and 3PN zygotes (P < 0.0001 versus 2PN). The cytoplasmic wave was observed not only in 2PN and 3PN but also in 1PN zygotes (positivity rates of 99.8% and 100% and 82.9%, respectively; P < 0.0001). More rarely, 2PN and 1PN zygotes emitted a third polar body (PBIII). The average times of this event were comparable. The presence and position of the cytoplasmic halo were comparable among the three classes of zygotes. In the 1PN group, the single PN was maternally or paternally derived in 17 and 24 zygotes, respectively, while in the vast majority of 3PN zygotes (121/127) the supernumerary PN was of maternal origin. Average times of maternal PN appearance were comparable, while average times of paternal PN appearance were delayed in 3PN zygotes (P = 0.0127). Compared with the control group, the area of the maternal PN was larger in 1PN zygotes, but smaller in 3PN zygotes (P < 0.0001). The paternal PNs displayed the same trend (P < 0.0001), although such values were consistently smaller than maternal PNs. The area of the third PN in the 3PN group was on average more than 50% smaller than those of maternal and paternal PNs. In maternal PNs of 3PN zygotes, nucleolus precursor bodies (NPBs) aligned along the area of PN juxtaposition at a lower rate compared with the 2PN group. The rate of NPB alignment was ∼50% smaller in 1PN zygotes (P = 0.0001). In paternal PNs, the rates of NPB alignment were not statistically different among the three groups. Asynchronous PN breakdown was increased in 3PN compared with 2PN zygotes (P = 0.0026). In 1PN zygotes, a developmental delay was observed starting from the disappearance of the cytoplasmic halo, reaching 9 h at the time of the first cleavage (P < 0.0001). Higher rates of abnormal cleavage patterns and blastomere fragmentation (P < 0.0001) were observed in 1PN compared to 2N and 3PN zygotes. Cleavage progression was increasingly affected after abnormal fertilization, especially 1PN, finally resulting in blastocyst formation rates of 70.2%, 12.2% and 53.5% in 2PN, 1PN and 3PN embryos, respectively (P < 0.0001). Both maternal and paternal ages were higher in cases involving 3PN fertilization. LIMITATIONS, REASONS FOR CAUTION: The study data were obtained from ICSI, but not standard IVF, treatments carried out in a single centre. The study findings therefore require independent verification. WIDER IMPLICATIONS OF THE FINDINGS: This study reports the first detailed morphokinetic map of human abnormal fertilization. Collectively, this evidence prompts new scientific hypotheses and raises clinical questions relevant to the aetiology and the treatment of abnormal fertilization. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the participating institutions. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Successful Transcatheter Arterial Embolization to Control Intratumoral Hemorrhage in Clear-Cell Sarcoma of the Kidney.

Clear-cell sarcoma of the kidney (CCSK) is a rare, aggressive pediatric renal tumor. Intratumoral hemorrhage and tumor rupture are oncologic emergencies requiring a rapid and appropriate response. An 11-year-old boy visited our hospital with abdominal distension of 1 month's duration. Computed tomography (CT) revealed a tumor in the left kidney (size: 200 mm), and analysis of a biopsy specimen confirmed a diagnosis of CCSK. Chemotherapy was initiated to shrink the large, densely vascularized tumor before surgical removal. Two days after starting chemotherapy, the patient developed abdominal and back pain, anemia, and hypotension. CT scanning showed intratumoral bleeding. Emergency transcatheter arterial embolization (TAE) was performed to control the bleeding. Three tumor feeding vessels were identified: an ascending branch from the celiac artery, an intermediate branch from the left renal artery, and a descending branch from the inferior mesenteric artery, of which the intermediate and descending branches were large and bleeding profusely. Therefore, the intermediate branch was injected with ethanol, and the descending branch was treated by gel-foam embolization. Chemotherapy was resumed, and the patient's condition gradually stabilized. The tumor began to shrink, and subsequent chemotherapy progressed well. In week 12 of chemotherapy, the patient underwent tumor resection and left nephrectomy. Postoperative chemotherapy was completed without complications, and there was no recurrence during a 6-year follow-up period. Therefore, TAE can effectively control intratumoral bleeding in pediatric solid tumors, thus preventing high-risk open surgery.

Role of a Fetal Ultrasound Clinic in Promoting Multidisciplinary and Inter-Facility Perinatal Care.

BACKGROUND: With the increasing rate of high-risk pregnancies, there is an increased need for early evaluation of at-risk fetuses. Fetal ultrasound imaging has become a pivotal part of this evaluation. METHODS: To evaluate the role played by a fetal ultrasound clinic in promoting comprehensive perinatal care of patients with high-risk pregnancies, we retrospectively analyzed the indications and findings of fetal scans and the outcomes of the examined fetuses collected over the past 7 years (2014-2020) by our institute, which is reorganized as a perinatal medical center. RESULTS: During the study period, we conducted 345 fetal scans in high-risk pregnancy cases. Of these, 158 cases (46%) were referrals from other institutes. Eighty-nine neonates were admitted to our neonatal intensive care unit (NICU) after being evaluated, of which 10 neonates underwent surgery during their NICU stays. Thirty-nine pregnant women were referred to other tertiary care hospitals mainly due to fetal diagnoses with complex cardiac anomalies. Fourteen cases resulted in intrauterine fetal death or artificial abortion. CONCLUSIONS: Fetal ultrasound clinics have established their role in facilitating sophisticated regional perinatal care via multidisciplinary and inter-facility cooperation for high-risk pregnancy cases. In addition, providing psychological support and counseling for pregnant women whose fetuses are diagnosed with severe congenital anomalies should not be neglected.

Forty-Year Experience Alleviating Postoperative Hirschsprung-Associated Enterocolitis by Complete Full-Thickness Posterior Rectal Cuff Excision. The Anorectal Line Eliminates Problematic Anastomoses.

Introduction: A modified pull-through (PT) distinguished by complete full-thickness removal of the posterior rectal cuff, initially developed as an open procedure in 1980, has been performed with laparoscopic assistance since 1997. Postoperative bowel dysfunction improved when the anatomic landmark for PT surgery was revised from the dentate line (DL) to the anorectal (or Herrmann's) line (ARL) in 2007. A 40-year (1980-2019) review of 153 consecutive rectal/rectosigmoid type Hirschsprung's disease (HD) patients is presented. Methods: Data for postoperative bowel dysfunction and Hirschsprung-associated enterocolitis (HAEC) classified according to the American Pediatric Surgical Association (APSA) scale were obtained retrospectively. Results: PT was open (n = 43) and laparoscopic (n = 110). Dissection was DL (n = 57) and ARL (n = 96). Over 40 years, 5/153 patients (3.3%) had postoperative obstructive symptoms (POS), and 10/153 patients (6.5%) had 13 episodes of postoperative HAEC; APSA grades were: I (n = 4); II (n = 8); and III: (n = 1) presenting with explosive diarrhea (10/13; 76.9%), fever (10/13; 76.9%), abdominal distension (9/13; 69.2%), or bloody stools/shock (1/13 with grade III; 7.7%). The grade III case had histologically-proven transitional zone PT. Postoperative HAEC developed in 3/5 (60.0%) POS+ patients and 7/148 (4.7%) POS- patients (P = .002). Symptom duration and treatment were not correlated with APSA grades. Conclusions: Complete full-thickness posterior rectal cuff excision and using the ARL reduced postoperative HAEC significantly in this series. Despite being anatomically distinct, the DL is inadequate as a precise landmark for PT surgery because it lacks functional relevance. The APSA scale could benefit from timely review to improve its clinical and prognostic value.

Health Observation App for COVID-19 Symptom Tracking Integrated With Personal Health Records: Proof of Concept and Practical Use Study.

BACKGROUND: As a counter-cluster measure to prevent the spread of the infectious novel coronavirus disease (COVID-19), an efficient system for health observation outside the hospital is urgently required. Personal health records (PHRs) are suitable for the daily management of physical conditions. Importantly, there are no major differences between the items collected by daily health observation via PHR and the observation of items related to COVID-19. Until now, observations related to COVID-19 have been performed exclusively based on disease-specific items. Therefore, we hypothesize that PHRs would be suitable as a symptom-tracking tool for COVID-19. To this end, we integrated health observation items specific to COVID-19 with an existing PHR-based app. OBJECTIVE: This study is conducted as a proof-of-concept study in a real-world setting to develop a PHR-based COVID-19 symptom-tracking app and to demonstrate the practical use of health observations for COVID-19 using a smartphone or tablet app integrated with PHRs. METHODS: We applied the PHR-based health observation app within an active epidemiological investigation conducted by Wakayama City Public Health Center. At the public health center, a list is made of individuals who have been in close contact with known infected cases (health observers). Email addresses are used by the app when a health observer sends data to the public health center. Each health observer downloads the app and installs it on their smartphone. Self-observed health data are entered daily into the app. These data are then sent via the app by email at a designated time. Localized epidemiological officers can visualize the collected data using a spreadsheet macro and, thus, monitor the health condition of all health observers. RESULTS: We used the app as part of an active epidemiological investigation executed at a public health center. During the investigation, 72 close contacts were discovered. Among them, 57 had adopted the use of the health observation app. Before the introduction of the app, all health observers would have been interviewed by telephone, a slow process that took four epidemiological officers more than 2 hours. After the introduction of the app, a single epidemiological officer can carry out health observations. The app was distributed for free beginning in early March, and by mid-May, it had been used by more than 20,280 users and 400 facilities and organizations across Japan. Currently, health observation of COVID-19 is socially recognized and has become one of the requirements for resuming social activities. CONCLUSIONS: Health observation by PHRs for the purpose of improving health management can also be effectively applied as a measure against large-scale infectious diseases. Individual habits of improving awareness of personal health and the use of PHRs for daily health management are powerful armaments against the rapid spread of infectious diseases. Ultimately, similar actions may help to prevent the spread of COVID-19.

Recurrent Bowel Obstruction Caused by Cecal Volvulus: A Case Report.

The preoperative diagnosis of cecal volvulus (CV) is rare and difficult and emergent laparotomy is frequently performed. Here, we report a case of CV that was diagnosed by preoperative computed tomography in a patient with an intellectual disability. In addition, we demonstrate that elective laparoscopic cecopexy can be performed following conservative treatment, such as the use of an ileus tube per anus.

A Case of Anomalous Congenital Band that Was Difficult to Differentiate from Omphalomesenteric Duct Anomaly.

Anomalous congenital band (ACB) is rare and difficult to identify preoperatively. Here we report a pediatric ACB case that was preoperatively suspected using computed tomography and was difficult to differentiate from omphalomesenteric duct anomaly. ACB should be considered in the differential diagnosis of acute abdomen.

Usefulness of Kent retractor and lifting hook for Nuss procedure.

Although the Nuss procedure for pectus excavatum has been widely employed, a variety of complications have been reported. The most dangerous complication is cardiac injury from the insertion of the introducer. To eliminate these complications, we present a sternum elevating technique using a Kent retractor and a lifting hook.

Effect on clinical work practice of establishing a neonatal intensive care unit at a medical school-affiliated teaching hospital.

OBJECTIVE: The aim of this study was to examine the effects of a newly established neonatal intensive care unit (NICU) on clinical work practice and educational activity at Nippon Medical School Musashikosugi Hospital. METHODS: This retrospective study analyzed the clinical records of all neonates admitted to the NICU from December 2010 through November 2013. Anthropometric data, clinical status, problems, and outcomes of patients and the related obstetrical history were extracted and analyzed. RESULTS: Of the 568 neonatal admissions, about half were related to preterm birth (49%) and low birth weight (55%). Forty-eight percent of patients were born via caesarean delivery. Maternal hypertension, diabetes, and thyroid disease were found in 8%, 5%, and 2% of cases, respectively. Mechanical ventilatory support was provided for 20% of patients. Neonates from multiple pregnancy and with significant congenital anomalies accounted for 17% and 10% of all patients, respectively. Five patients died during hospitalization. In addition training was provided in the NICU for an average of 10 residents and 20 medical students per year. CONCLUSION: Since the NICU was established, closer cooperation beyond the framework of a single department has come to be needed. In addition, NICUs in teaching hospitals are expected to provide opportunities for medical students and residents to observe and participate in multidisciplinary medical care.

Apple latent spherical virus vector as vaccine for the prevention and treatment of mosaic diseases in pea, broad bean, and eustoma plants by bean yellow mosaic virus.

We investigated the protective effects of a viral vector based on an Apple latent spherical virus (ALSV) harboring a segment of the Bean yellow mosaic virus (BYMV) genome against mosaic diseases in pea, broad bean, and eustoma plants caused by BYMV infection. In pea plants pre-inoculated with the ALSV vaccine and challenge inoculated with BYMV expressing green fluorescence protein, BYMV multiplication occurred in inoculated leaves, but was markedly inhibited in the upper leaves. No mosaic symptoms due to BYMV infection were observed in the challenged plants pre-inoculated with the ALSV vaccine. Simultaneous inoculation with the ALSV vaccine and BYMV also prevented mosaic symptoms in broad bean and eustoma plants, and BYMV accumulation was strongly inhibited in the upper leaves of plants treated with the ALSV vaccine. Pea and eustoma plants were pre-inoculated with BYMV followed by inoculation with the ALSV vaccine to investigate the curative effects of the ALSV vaccine. In both plant species, recovery from mosaic symptoms was observed in upper leaves and BYMV accumulation was inhibited in leaves developing post-ALSV vaccination. These results show that ALSV vaccination not only prevents mosaic diseases in pea, broad bean, and eustoma, but that it is also effective in curing these diseases.

Preventive and curative effects of Apple latent spherical virus vectors harboring part of the target virus genome against potyvirus and cucumovirus infections.

Apple latent spherical virus (ALSV)-based vectors experimentally infect a broad range of plant species without causing symptoms and can effectively induce stable virus-induced gene silencing in plants. Here, we show that pre-infection of ALSV vectors harboring part of a target viral genome (we called ALSV vector vaccines here) inhibits the multiplication and spread of the corresponding challenge viruses [Bean yellow mosaic virus, Zucchini yellow mosaic virus (ZYMV), and Cucumber mosaic virus (CMV)] by a homology-dependent resistance. Further, the plants pre-infected with an ALSV vector having genome sequences of both ZYMV and CMV were protected against double inoculation of ZYMV and CMV. More interestingly, a curative effect of an ALSV vector vaccine could also be expected in ZYMV-infected cucumber plants, because the symptoms subsided on subsequent inoculation with an ALSV vector vaccine. This may be due to the invasion of ALSV, but not ZYMV, in the shoot apical meristem of cucumber.

Patchy innervation confirmed in pull-through bowel with normal conventional biopsy results in Hirschsprung's disease - the benefit of circumferential biopsying.

The effectiveness of pull-through for Hirschsprung's disease is dependent on accurate identification of normoganglionic bowel in intraoperative biopsy specimens. We report 2 cases of patchy innervation of pull-through bowel in children with Hirschsprung's disease only identified by circumferential biopsying. Case 1 was an 8-month-old boy. During laparoscopy-assisted transanal endorectal pull-through, extra biopsies of bowel were taken circumferentially, 2 cm proximal to the level of normoganglionosis confirmed by laparoscopic colon biopsies. Aganglionosis was found at 3 o'clock, suggesting that bowel innervation at this level was patchy. Circumferential biopsies were performed a further 2cm proximally, and all sites were normoganglionic. This level was used for pull-through with excellent outcome. Case 2 was a 27-day-old boy. Similarly, extra biopsies were taken circumferentially, 2cm proximal to the level of "normoganglionosis" as indicated by conventional biopsying. Normoganglionosis was found only at 3 o'clock, while all other sites were hypoganglionic. A further series of circumferential biopsies was performed 2 cm proximally and hypoganglionosis was still identified, but only at 6 o'clock. Circumferential biopsies were repeated another 2cm proximally, and all sites were normoganglionic. We recommend circumferential biopsies be performed routinely to prevent bowel with patchy innervation from being used for pull-through and possibly causing postoperative bowel dysmotility in a subgroup of Hirschsprung's disease patients.

Thoracoscopic plication for diaphragmatic eventration in a neonate.

BACKGROUND: Currently, thoracoscopic surgery is replacing thoracotomy for an ever increasing number of indications, even in pediatric surgery. However, there are few reports describing thoracoscopic plication (TP) for diaphragmatic eventration in children, particularly in neonates. We report a case of TP under single-lung ventilation in a neonate with diaphragmatic eventration. CASE REPORT: A 10-day-old boy was referred for surgical management of right diaphragmatic eventration. Birth was at term, following an uncomplicated pregnancy and delivery. Shortness of breath, labored respiration and chest retraction presented soon after birth, necessitating mechanical ventilation. Chest radiography and computed tomography revealed an elevated right hemidiaphragm. Attempted weaning off mechanical ventilation failed with persistence of respiratory symptoms, requiring nasal directional positive airway pressure. However, because there was no resolution of symptoms, TP was performed using a 3 port technique under single-lung ventilation on day 17 of life. The postoperative course was excellent with complete resolution of respiratory symptoms with no recurrence for 9 months. CONCLUSION: To the best of our knowledge, this is the youngest case of TP for diaphragmatic eventration performed under single-lung ventilation. TP is safe, effective and minimally invasive and should be considered actively for the treatment of symptomatic diaphragmatic eventration even in neonates.

An unusual foreign body in an inguinal hernia sac: case report and literature review.

A 13-month-old boy accidentally ingested a 5 cm dressmaker's pin. On presentation, the pin was in the duodenum and there was a right inguinal hernia. After 17 days, the pin failed to progress. At surgery, the sac contained appendix perforated by the pin. This is the first case in the literature.

Management of inguinal hernia in children can be enhanced by closer follow-up by consultant pediatric surgeons.

AIM: To determine if follow-up by consultant pediatric surgeons (CPS) affects morbidity due to incarceration (INC) in children with indirect inguinal hernia (IH). METHODS: We educate parents so they can identify possible INC and advise them to attend our emergency department anytime for immediate review by on-call CPS. RESULTS: We reviewed 3,493 cases of IH by grouping them according to age at diagnosis: neonatal (G1; n = 96), 2-3 months (G2; n = 331), 4-6 months (G3; n = 118), 7-12 months (G4; n = 193), and over 12 months (G5; n = 2,755). Data per group were: mean gestational age (weeks): 32.1, 38.0, 36.4, 37.4, 38.7; mean birth weight (g): 1,645, 2,736, 2,471, 2,769, 2,930; mean age at elective hernia repair (HR) (months): 11.3, 4.9, 10.1, 12.9, 56.5; mean weight at elective HR (kg): 6.8, 6.4, 7.3, 9.1, 17.4; mean duration from diagnosis to elective HR (months): 10.9, 3.1, 6.3, 3.6, 3.0; mean follow-up: 6.7 years. Overall, INC occurred in 203/3,493 during follow-up. Incidence per group was: G1: 4/96, G2: 62/331, G3: 6/118, G4: 47/193, G5: 84/2,755. All INC were reduced manually without complications. HR complications occurred in 7/3,493 (0.2%). CONCLUSIONS: With CPS follow-up, INC can be managed without morbidity, allowing elective HR to be performed later with fewer complications.

Tubularized incised plate urethroplasty with dorsal inlay graft prevents meatal/neourethral stenosis: a single surgeon's experience.

BACKGROUND/PURPOSE: Snodgrass tubularized incised plate urethroplasty (SUP) is versatile and has good cosmesis. However, postoperative meatal/neourethral stenosis (M/N-S) is common enough for some surgeons to add a dorsal inlay graft (DIG) harvested from the inner prepuce and sutured to cover the longitudinal midline incision of the urethral plate. This is the first formal assessment of the effectiveness of DIG for preventing M/N-S. METHODS: We reviewed the medical records of 100 consecutive SUP cases performed by a single surgeon between 2003 and 2010 comparing SUP + DIG (S + D group, n = 50) with SUP - DIG (S - D group, n = 50). Mean follow-up was 3.6 years. Data were analyzed statistically using the χ(2), 2-way ANOVA, and Mann-Whitney tests, with P < .05 considered significant. RESULTS: Severity of hypospadias and type of SUP were similar. Mean age at SUP was 3.3 years in S + D and 3.6 years in S-D (P = NS). There were 4 complications in the S + D group: urethrocutaneous fistula (n = 3) and neourethral stenosis without diverticulum (n = 1). There were 15 complications in the S-D group : meatal stenosis (n = 2), neourethral stenosis with or without diverticulum (n = 6), urethrocutaneous fistula (n = 7) (P < .01). M/N-S was significantly less in the S + D group (1 vs 8; P < .05). CONCLUSIONS: We strongly recommend that DIG be performed routinely during SUP.