Sciatic nerve block downregulates the BDNF pathway to alleviate the neonatal incision-induced exaggeration of incisional pain via decreasing microglial activation.

Sciatic nerve block is under investigation as a possible therapeutic strategy for neonatal injury-induced exaggeration of pain responses to reinjury. Spinal microglial priming, brain-derived neurotrophic factor (BDNF) and Src homology-2 domain-containing protein tyrosine phosphatase-2 (SHP2) participate in exaggerated incisional pain induced by neonatal incision. However, effects of sciatic nerve block on exacerbated incisional pain and underlying mechanisms remain unclear. Here, we demonstrated that sciatic nerve block alleviates pain hypersensitivity and microglial activation in rats subjected to neonatal incision and adult incision (nIN-IN). Chemogenetic activation or inhibition of spinal microglia attenuates or mimics effects of sciatic nerve block on pain hypersensitivity, respectively. Moreover, α-amino-3-hydroxy- 5-methy- 4-isoxazole propionate (AMPA) receptor subunit GluA1 contributes to the exaggeration of incisional pain. The inhibition of BDNF or SHP2 blocks upregulations of downstream molecules in nIN-IN rats. Knockdown of SHP2 attenuates the increase of GluA1 induced by injection of BDNF in adult rats with only neonatal incision. The inhibition of microglia or ablation of microglial BDNF attenuates upregulations of SHP2 and GluA1. Additionally, sciatic nerve block downregulates the expression of these three molecules. Upregulation of BDNF, SHP2 or AMPA receptor attenuates sciatic nerve block-induced reductions of downstream molecules and pain hypersensitivity. Microglial activation abrogates reductions of these three molecules induced by sciatic nerve block. These results suggest that decreased activation of spinal microglia contributes to beneficial effects of sciatic nerve block on the neonatal incision-induced exaggeration of incisional pain via downregulating BDNF/SHP2/GluA1-containing AMPA receptor signaling. Thus, sciatic nerve block may be a promising therapy.

IGF-1 alleviates serum IgG-induced neuronal cytolysis through PI3K signaling in children with opsoclonus-myoclonus syndrome and neuroblastoma.

BACKGROUND: Opsoclonus-myoclonus syndrome (OMS) is a rare neurological disorder, usually accompanied by neuroblastoma (NB). There is no targeted treatment and animal model of OMS. We aimed to investigate whether insulin-like growth factor 1 (IGF-1)/phosphoinositide 3-kinase (PI3K) signaling alleviates neuronal cytolysis in pediatric OMS. METHODS: Cultured rat cerebral cortical neurons and cerebellar neurons were incubated with sera or IgG isolated from sera of children with OMS and NB. Cytolysis and PI3K expression were measured by the lactate dehydrogenase assay and enzyme-linked immunosorbent assay, respectively. Using inhibitors and activators, the effects of IGF-1 and PI3K on cytolysis were investigated. RESULTS: The incubation of sera or IgG from children with OMS and NB increased cytolysis in not only cerebellar neurons, but also cerebral cortical neurons. Furthermore, the IGF-1 receptor antagonist NVP-AEW541 exaggerated cytolysis in children with OMS and NB. IGF-1 alleviated cytolysis, which was blocked by the PI3K inhibitor LY294002. Additionally, sera or IgG from children with OMS and NB compensatively elevated PI3K expression. LY294002 exacerbated cytolysis; whereas, the PI3K activator 740 Y-P suppressed cytolysis. CONCLUSION: IGF-1/PI3K signaling alleviates the cytolysis of cultured neurons induced by serum IgG from children with OMS and NB, which may be innovation therapy targets.

Lymphangioma of the gallbladder in childhood: a case report and review of the literature.

Lymphangiomas are malformations of the lymphatic system, which is a common disease in children, usually superficial in body, but seldom seen in visceral organs. We present the case of a child with lymphangioma of the gallbladder. Also we reviewed the literatures. A 2-year-6-month-old boy complained of progressing difficulty in walking for 6 months. Cerebral MRI showed abnormal signals in the white matter suggesting leukodystrophy. Ultrasound of abdomen showed a mixed-echoic mass in the site of gallbladder. CT scan showed an enlarged gallbladder with increased density. Bloodcounting, liver function, and alpha fetal protein were within normal range. Exploratory laparotomy was done in order to rule out malignancy. The liver was found normal at surgery, and the gallbladder looked enlarged and deformed. The gallbladder wall was thick and edematous, and adherent with liver. The gallbladder was excised. Pathological examination gave the diagnosis as lymphangioma of the gallbladder wall. The postoperative recovery was uneventful. There was no evidence of recurrence. Searching in literatures, three cases of lymphangioma of gallbladder in adults were found. According to the pathology of lymphangioma and the anatomy of gallbladder, the outcome of this disease should be benign and may be symptomless throughout the life. No death was reported due to lymphangioma of gall bladder, nor severe complications endangering life at any age. The only indication for surgery in the reported cases was to rule out the risk of being malignancy. If MRI or other means can make a definite preoperative diagnosis of lymphangioma, being a stable lesion, surgery would be unnecessary unless there is a progressive organic obstruction causing repeated infection or persistent abdominal pain.

A shorter loop in Roux-Y hepatojejunostomy reconstruction for choledochal cysts is equally effective: preliminary results of a prospective randomized study.

BACKGROUND: Conventionally, an adult's standard of a 40-cm loop is adopted in Roux-Y hepatojejunostomy (RYHJ) in choledochal cyst (CDC) in children, irrespective of patient size. The redundant length of the jejunal limb may lead to complications. We compared the outcome of an individualized short Roux loop with the standard loop length in RYHJ in children with CDC. METHODS: Two hundred eighteen children with CDC undergoing laparoscopic RYHJ were prospectively randomized into 2 groups: (1) conventional group (CG; n = 108) where a standard 35-40 cm Roux-loop length was used regardless of the child's size and (2) short loop group (SLG; n = 110) in which the Roux-loop length was based on the distance between hepatic hilum and umbilicus. Ultrasonography, upper gastrointestinal contrast studies, and laboratory tests were conducted during the follow-up period. RESULTS: The mean Roux-loop length of SLG was significantly shorter than that of CG (Student t test, P < .05). There was no significant difference between the 2 groups in age, operative blood loss, operative time, postoperative hospital stay, and duration of drainage. In CG, 2 of (1.8%) 108 patients developed Roux-loop obstruction, whereas none was detected in SLG (0%). Mild reflux was detected in 2 CG patients and 1 SLG patient 1 month postoperatively, all of which subsided 6 months later. No episodes of cholangitis were observed in either group. CONCLUSIONS: An individualized short Roux-loop length in RYHJ is as effective as the conventional Roux-loop length.

Rectovestibular fistula with normal anus: a simple resection or an extensive perineal dissection?

PURPOSE: The purpose of the study was to review a 10-year experience of operative procedures for rectovestibular fistula with normal anus (RVFNA) at one institution. MATERIALS AND METHODS: From January 1999 to December 2008, 182 female patients of RVFNA were treated surgically in the Department of Surgery, Beijing Children's Hospital, Capital Medical University, China. The patients' age ranged from 4 months to 15 years, with a mean age of 3.4 years. Fourteen children had a failed previous operation in other institutions. One hundred fifty-six patients (85.71%) had a definite history of vulvar inflammation within 3 months after birth and fecal leakage thereafter. In 61 of the 156 patients, a perineal abscess appeared after an episode of diarrhea. Four cases (2.20%) had associated anomalies of the VACTERL type. One hundred seventy-three patients (95.05%) had 1 external opening, whereas 9 others (4.95%) had 2 external openings separated by a skin bridge. In all cases, the internal orifice opened above the dentate line. The fistula in 135 cases (74.18%) presented as an opening with a small diameter (<5 mm). In our series, vestibular-rectal pull-through procedure was performed in 98 cases, transanal procedure in 69 cases, and anterior perineal anorectoplasty in 15 cases. None had a diverting colostomy. RESULTS: Recurrence of fistula occurred in 5 to 10 days after operation in 21 cases (11.54%). Eight of them healed spontaneously after daily sitz bath with 3% boric acid, whereas other 13 patients (7.14%) required reoperation. Follow-up was obtained by telephone or by personal visit in the outpatient department, from 3 months to 10 years (median, 5.7 years). All the patients were continent and had regular bowel movement. CONCLUSIONS: Most RVFNA was acquired after infection. Procedure requiring extensive perineal dissection and diverting colostomy are unnecessary in most RVFNA cases. We performed simple resection in most patients with satisfactory results. In the cases with a large external opening and abnormal perineal appearance, a more extensive perineal dissection might be necessary.

Stability of a rat model of prehepatic portal hypertension caused by partial ligation of the portal vein.

AIM: To study the stability of portal hypertension (PHT) caused by partial ligation of the portal vein ligation (PVL) in a rat model. METHODS: Thirty male adult Wistar rats were divided into two groups: 10 in Group I received a sham operation; and 20 in Group II received partial PVL. Portal vein pressure (PVP) was measured at four time periods: before ligation, 2 wk, 6 wk and 10 wk post-surgery. Portal venography, blood sampling and liver and spleen pathological examinations were conducted at 10 wk after surgery. RESULTS: The PVP was 9.15 +/- 0.58 cmH(2)O before ligation, and increased to 17.32 +/- 0.63 cmH(2)O 2 wk after PVL. By repeat measurement of the PVP in each rat, it was shown to remain elevated for 10 wk. There were no significant differences in the pressure measurements at 2 wk, 6 wk and 10 wk. Varices were found mainly in the mesenteric vein 2 wk after PVL, which were more obvious later, while these manifestations were similar at week 6 and week 10. Portal venography demonstrated the varices and collaterals. There was no significant change in liver pathology. The volume of the spleen was enlarged 2-fold after ligation, and the sinus of the spleen was enlarged due to congestion. Significant sinus endothelial cell proliferation was observed, but no evidence of hypersplenia was found on hemogram and biochemical examination. CONCLUSION: These findings suggest that a satisfactory prehepatic PHT rat model can be obtained by partial ligation of the portal vein, and this PHT rat model was stable for at least 10 wk.

Space-occupying benign lesions in spleen: experiences in a single institute.

PURPOSE: To introduce a practical reference for the diagnosis and treatment of space-occupying benign lesions in children's spleens. METHOD: Ten cases were collected from 1988 to 2007, and analysis of some related literature were included with special attention to the criteria of the diagnosis and the indications of splenectomy, particularly to the age for operation. RESULTS: The age of patients on admission ranged from 5 to 15 years, with the mean age of 10 years. All chose the operation to mitigate the fear of either accidental rupturing or malignancy. The clinical diagnosis depended on ultrasonographic or other imaging findings, while the final diagnosis was based on pathological study of operative specimens. The final diagnosis of the five patients undergoing operation was benign tumors (angioma group), and the other five were cystic (mainly congenital). Eight children underwent primary splenectomy, and the other two underwent partial or secondary splenectomy, all with satisfactory results. Seven were followed up for more than 2 years and recovered uneventfully. CONCLUSION: Preoperative imaging examinations and postoperative pathology mutually confirmed space-occupying benign lesions in the spleen. The age of the children, size and character of the lesion, as well as the risk of rupturing and malignancy are reasonable indications of surgery. Splenectomy, unless with contra-indications, is a feasible choice of treatment.

Recto-vestibular disruption defect resulted from the malpractice in the treatment of the acquired recto-vestibular fistula in infants.

AIM: To explore the pathogenesis of the rectovestibular disruption (RVD) defect and to recommend a successful repair, and prevention of it. METHODS: Clinical records of 15 girls, age ranged from 3 to 15 (median, 7.5) years, with acquired rectovestibular fistula (RVF) mistreated before were retrospectively reviewed. All of them presented an abnormal appearance of perineum and were suffering from some degree of fecal incontinence, and those were graded III to IV by Li Zheng's Score. Repair of anal sphincters and reconstruction of perineum body and skin by anterior perineal rectoanoplasty were performed in all cases. RESULTS: Operation in all cases was successful. The perineum looked practically normal and fecal continence score rose up to VI by Li Zheng's Score. CONCLUSION: The conventional treatment for anal fistula, lay-open or string-treatment, should be considered as malpractice of RVF, and certainly leads to the RVD defect, and the anterior perineal rectoanoplasty could cure it satisfactorily.

Transanal approach in repairing acquired rectovestibular fistula in females.

AIM: To summarize the operative experience of the transanal approach in acquired rectovestibular fistula repair. METHODS: Ninety-six cases of acquired rectovestibular fistula in young females were analyzed retrospectively. The etiology and operative procedure were discussed. Operative essential points were, the patient was laid in prone frog position, with the knees and hips flexed at 90(o); the perineum was elevated; and the anal opening was exposed. Four stay sutures were applied to the margin of the fistular orifice in the anal opening at points 3, 6, 9 and 12 o'clock. A circular incision of mucosa surrounding the stay sutures was made. The fistula was dissected from its anal opening to its vestibular opening. The wound of vestibule was sutured, and the rectoanal wound was then sutured transversely. RESULTS: All the 96 patients recovered uneventfully from operation with a successful rate of 93.75%. CONCLUSION: The transanal approach in the treatment of the acquired rectovestibular fistula is a simple and feasible technique.

Evolution of surgical paediatrics in China.

Pediatric surgery of China was established in 1950. Being isolated from the world, China's first-generation pediatric surgeons were mainly self-taught. The technology of pediatric surgery of China practically followed Gross, and the aim of pediatric surgery was similar to that of BAPS, "not to seek a monopoly." Since 1980, after the scientific exchange with Western countries, the clinical results of common pediatric surgical diseases have reached the acceptable level of the world. China is a huge country with poor transportation, one-child family planning, and Chinese traditional medicine, which made certain peculiarities in the practice of paediatric surgery.

Anomalous pancreatic duct anatomy, ectopic distal location of the papilla of Vater and congenital biliary dilatation: a new developmental triad?

BACKGROUND: The opening of the papilla of Vater represents the orifice of the embryonic hepatic diverticulum from which the ventral pancreas, common bile duct, and liver are derived. Recently, we found a strong association between congenital biliary dilatation (CBD), certain types of pancreatic ductal anatomy (PDA), and ectopic distal location of the papilla of Vater which prompted us to study the relationship between the location of the papilla of Vater and abnormal PDA. METHODS: A total of 118 patients with CBD were studied. Cholangiograms documented the presence of pancreaticobiliary malunion (PBMU), the location of the papilla of Vater, and the PDA. Eleven age-matched patients with intermittent jaundice were used as controls. RESULTS: In the control group, the papilla of Vater was located normally in the descending portion of the duodenum in all cases. In the 118 CBD patients, the papilla of Vater was located normally in 38 (32.2%), but in 80 (67.8%), the papilla was located distal to the descending portion of the duodenum. When the papilla was located distally, the incidences of the specific types of PDA studied were significantly higher than when the papilla was located normally (p<0.01). Pancreatic duct dilatation was also more frequent if the papilla was located distally (28.7%) compared with CBD patients with a normal papilla (7.9%) or normal controls (0%) (both p<0.01). PBMU was present in all CBD patients and absent in all controls. CONCLUSION: Our study strongly suggests that abnormalities occurring during early embryological development of the hepatic diverticulum are responsible for the association between abnormal PDA and ectopic distal location of the papilla of Vater in CBD.

Abdominal pain among children re-evaluation of a diagnostic algorithm.

AIM: To re-evaluate the algorithm that has been used for over 40 years for diagnosis of acute abdominal pain among children. METHODS: Among the 937 cases admitted to the surgical emergency ward in 2000, 656 cases of acute appendicitis were studied to evaluate the usefulness of the present algorithm for its calculated accuracy, false positive and false negative rates, the sensitivity and specificity in the instant diagnosis of various types of acute appendicitis in different age groups. The algorithm used was established in 1958 and revised for this study in 1999. It includes a 3-step analysis of clinical presentations, i.e.: firstly, a diagnosis of surgical pain by definite organic abdominal signs; then a diagnosis of the subgroup of surgical condition by special signs; and finally the diagnosis of the present disease by specific signs. A footnote describes a "comparative technique" of abdominal examination in non-cooperative children. RESULTS: The general accuracy of diagnosis was 92.8 %, overall mortality 0.1 % among 973 cases of abdominal pain in 2000. 373 attending surgeons and 241 residents including trainees joined the diagnosis and treatment with no remarkable difference in the results. The incidence of acute appendicitis, 656 in 973 cases, was 67.4 % representing the majority of abdominal pain. In the series of 656 cases, the accuracy of diagnosis of acute appendicitis was 93.6 %, false positive 6.4 %, false negative 0.9 %, sensitivity at first visit 82.7 %, specificity for appendicitis 98.0 %, no death or documentary complication. CONCLUSION: The present algorithm used for diagnosis of acute abdominal pain is effective and preferable in reducing misdiagnosis and maltreatment at emergency. The use of some modern technology should be further explored.