Publications by authors named "Mitsuru Muto"

55 Publications

How should we treat representative neonatal surgical diseases with congenital heart disease?

Pediatr Surg Int 2022 Sep 15;38(9):1235-1240. Epub 2022 Jul 15.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890 -8520, Japan.

Purpose: Representative neonatal surgical diseases are often complicated by congenital heart disease (CHD). We reviewed our decade of experience from the perspective of the prognosis and report on the management of infants with CHD.

Methods: Cases with and without CHD between 2011 and 2020 were retrospectively compared. Qualitative data were analyzed using a chi-square test with Yates' correction, and quantitative data were compared using Student's t-test.

Results: Of the 275 neonatal surgical cases, 36 had CHD (13.1%). Ventricular septal defect was the most common cardiac anomaly, followed by atrial septal defect. Esophageal atresia showed the highest complication rate of CHD (43.8%, 14/32) followed by duodenal atresia (38.5%, 10/26). The mortality rates of patients with and without CHD (22.2% [8/36] vs. 1.3% [3/239]) were significantly different (χ = 30.6, p < 0.0001). Of the eight deaths with CHD, six patients had cyanotic complex CHD. Notably, four of these patients died from progression of inappropriate hemodynamics in the remote period after definitive non-cardiac surgery.

Conclusion: Considering its high-mortality, the presence of CHD, especially cyanotic heart disease, is an important issue to consider in the treatment of neonatal surgical diseases. Pediatric surgeons should be alert for changes in hemodynamics after surgery, as these may affect mortality.
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http://dx.doi.org/10.1007/s00383-022-05178-zDOI Listing
September 2022

Is anemia frequently recognized in gastroschisis compared to omphalocele? A multicenter retrospective study in southern Japan.

Pediatr Surg Int 2022 Sep 28;38(9):1249-1256. Epub 2022 Jun 28.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, 890-8520, Japan.

Purpose: We compared cases of anemia in gastroschisis versus omphalocele and investigated this clinical question.

Methods: A multicenter study of five pediatric surgery departments in southern Japan was planned. Sixty patients were collected between 2011 and 2020, with 33 (gastroschisis: n = 19, omphalocele: n = 14) who met the selection criteria ultimately being enrolled. Anemia was evaluated before discharge and at the first outpatient visit.

Results: Despite gastroschisis cases showed more frequent iron administration during hospitalization than omphalocele (p = 0.015), gastroschisis cases tended to show lower hemoglobin values at the first outpatient visit than omphalocele cases (gastroschisis: 9.9 g/dL, omphalocele: 11.2 g/dL). Gastroschisis and the gestational age at birth were significant independent predictors of anemia at the first outpatient visit, (gastroschisis: adjusted odds ratio [OR] 19.00, p = 0.036; gestational age at birth: adjusted OR 0.341, p = 0.028). A subgroup analysis for gastroschisis showed that the ratio of anemia in the 35-36 weeks group (8/10, 80.0%) and the > 37 weeks group (6/6, 100%) was more than in the < 34 weeks group (0/3, 0.0%).

Conclusions: Gastroschisis may carry an increased risk of developing anemia compared with omphalocele due to the difference of direct intestinal exposure of amnion fluid in utero.
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http://dx.doi.org/10.1007/s00383-022-05150-xDOI Listing
September 2022

Feasibility of delayed anastomosis for long gap esophageal atresia in the neonatal period using internal traction and indocyanine green-guided near-infrared fluorescence.

Asian J Endosc Surg 2022 Jun 17. Epub 2022 Jun 17.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Introduction: Management of neonates with long gap esophageal atresia (LGEA) is one of the most challenging situations facing pediatric surgeons. Delayed anastomosis after internal traction for esophageal lengthening was reported as a useful technique for long gap cases. Additionally, the use of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in pediatric surgery, especially for blood perfusion validation. We report a novel technique for safe and secure anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence.

Patient And Surgical Technique: A pregnant woman with polyhydramnios was admitted to the department of obstetrics in our hospital. At 29 weeks of gestation, ultrasound showed mild polyhydramnios and absence of the fetal stomach. A male neonate was born at 38 weeks of gestation with 21 trisomy. EA (Gross type A) was diagnosed based on an X-ray study that showed the absence of gastric bubble with a nasogastric tube showing the "coil-up" sign. Thoracoscopic internal traction and laparoscopic gastrostomy were performed on day 4 after birth. We confirmed the distance between the upper pouch and lower pouch on X-ray. On day 16 after birth, thoracoscopic anastomosis was performed. We successfully performed esophageal anastomosis without tearing the esophageal wall. Blood perfusion of the upper and lower pouch was validated after anastomosis using ICG-guided NIR fluorescence.

Conclusion: Delayed anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence is safe and feasible.
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http://dx.doi.org/10.1111/ases.13098DOI Listing
June 2022

How we acquire suturing skills for laparoscopic hepaticojejunostomy.

Asian J Endosc Surg 2022 May 24. Epub 2022 May 24.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Laparoscopic choledochal cyst excision and hepaticojejunostomy is a representative surgical procedure requiring laparoscopic suturing including needle driving and knot tying. Laparoscopic needle driving and knot tying is a highly technically demanding skill, especially in small infants and children. We developed a laparoscopic hepaticojejunostomy simulator for training. This simulator was developed for a 1-year-old infant body size based on computed tomography data and reproduced a pneumoperitoneum condition based on 3D scanner data of the clinical situation. Surgeon in training (SITs) of our institution have to acquire practice of laparoscopic hepaticojejunostomy using a simulator before performing clinical cases. Thirteen cases of choledochal cyst have been managed at our institution since the introduction of practice using this simulator in 2016. Six SITs performed 13 cases of laparoscopic choledochal cyst excision and hepaticojejunostomy. There were no cases of anastomotic bile leakage. Laparoscopic disease-specific simulator practice is effective for the acquisition of secure hepaticojejunostomy skills for the treatment of choledochal cysts in children as off-the-job training.
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http://dx.doi.org/10.1111/ases.13083DOI Listing
May 2022

Successful laparoscopy-assisted en bloc resection of bulky omental malignant lymphoma involving the ascending colon and multiple lymph node metastases: Report of a technically demanding case in a pediatric patient.

Asian J Endosc Surg 2022 May 17. Epub 2022 May 17.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

We herein report a 13-year-old boy with a chief complaint of abdominal pain and a palpable mass. Contrast-enhanced computed tomography (CT) scan showed an abdominal bulky tumor involving the ascending colon causing severe stenosis, with multiple abdominal lymph node metastases detected by positron emission tomography (PET)-CT. Laparoscopic radical resection with right hemicolectomy and lymph node dissection was planned. The bulky tumor was dissected from the retroperitoneum and resected en bloc with the right-side colon and omentum. The preoperatively detected metastatic lymph nodes were resected along with the tumor. A 6-cm longitudinal umbilical incision was made, and the huge tumor was removed, with functional end-to-end anastomosis performed for intestinal reconstruction. The pathological diagnosis was Burkitt-like lymphoma with 11q aberration. The postoperative course was uneventful. Laparoscopy-assisted extirpation is feasible for pediatric solid tumors involving other organs, but indications and procedures should be carefully determined based on preoperative imaging, intraoperative findings and surgeon's skills.
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http://dx.doi.org/10.1111/ases.13081DOI Listing
May 2022

The analgesic effect of the intravenous administration of acetaminophen for pediatric laparoscopic appendectomy: A comparison of scheduled and on-demand procedures.

Asian J Endosc Surg 2022 Apr 22. Epub 2022 Apr 22.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Purpose: The intravenous administration of acetaminophen (IAA) has become standard postoperative analgesic management for pediatric surgery. However, the most effective methods of IAA for postoperative acute appendicitis are unclear. We evaluated the analgesic efficacy of scheduled IAA vs on-demand IAA for postoperative acute appendicitis.

Methods: Ninety-four patients who underwent laparoscopic appendectomy in our institution between January 2017 and December 2020 were enrolled. The patients were divided into two groups based on the postoperative pain control protocols. The scheduled IAA group (SA group, n = 42) was managed by scheduled IAA and additional on-demand use of pentazocine as rescue therapy. The on-demand IAA group (ODA group, n = 52) was managed by on-demand IAA as the first choice, with pentazocine as the second choice for pain control. The patients' background characteristics, operative results and postoperative outcomes were reviewed.

Results: The number of times pain complaints were made per patient per day (NPPD) on postoperative days (POD) 1 and 2 was significantly lower in the SA group than in the ODA group (POD 1; 1.12 ± 1.21 vs 2.62 ± 1.89, p < 0.01; POD 2; 0.45 ± 0.86 vs. 1.31 ± 1.69, p < 0.01). According to pathological findings, NPPD was lower in the SA group than in the ODA group for both phlegmonous appendicitis (0.71 ± 1.01 vs. 2.10 ± 2.13, P < .05) and gangrenous appendicitis (1.33 ± 1.50 vs 2.94 ± 1.68, P < .01). On POD 2, the incidence of gangrenous appendicitis was significantly lower in the SA group than in the ODA group (0.57 ± 0.93 vs 1.78 ± 1.86, P < .01).

Conclusions: Scheduled IAA may have favorable efficacy for postoperative pain control after emergency surgery for acute appendicitis in pediatric patients.
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http://dx.doi.org/10.1111/ases.13068DOI Listing
April 2022

The preventive effect of recombinant human hepatocyte growth factor for hepatic steatosis in a rat model of short bowel syndrome.

J Pediatr Surg 2022 Jul 13;57(7):1286-1292. Epub 2022 Mar 13.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan. Electronic address:

Purpose: Short bowel syndrome (SBS) patients require total parenteral nutrition (TPN) following massive small bowel resection (SBR), which may cause intestinal failure-associated liver disease (IFALD), a life-threatening complication. Hepatocyte growth factor (HGF) acts as a potent hepatocyte mitogen with anti inflammatory and antioxidant actions. The present study evaluated the effect of recombinant human HGF (rh-HGF) on SBR and subsequent IFALD using a parentally fed rat model of SBS.

Methods: Rats underwent jugular vein catheterization for continuous TPN and 90% SBR. They were divided into 2 groups: TPN alone (SBS/TPN group: n = 7) or TPN plus the intravenous administration of rh-HGF (0.3 mg/kg/day) (SBS/TPN+HGF group: n = 7). On day 7, their tissues and stool were harvested to evaluate the effects of HGF.

Results: Regarding the histological findings, based on the nonalcoholic fatty liver disease (NAFLD) activity score, the SBS/TPN+HGF group showed significantly less hepatic steatosis and inflammatory cell infiltration than the SBS/TPN group (NAFLD activity score, 4.00 ± 1.83 vs. 1.00 ± 0.82; p < 0.01). The SBS/TPN+HGF group showed a higher expression of Farnesoid X receptor in the liver and lower expression of Toll-like receptor 4 in the ileum than the SBS/TPN group. Regarding the composition of the bacterial gut microbiota, Actinobacteria, Bacteroidetes and Proteobacteria were decreased in the SBS/TPN+HGF group compared with the SBS/TPN group.

Conclusion: In our SBS with TPN rat model, rh-HGF administration had a preventive effect against hepatic steatosis and dysbiosis. rh-HGF may therefore be a potentially effective therapeutic agent for SBS and subsequent IFALD.

Type Of Study: Experimental research.
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http://dx.doi.org/10.1016/j.jpedsurg.2022.02.030DOI Listing
July 2022

An unusual presentation of intestinal duplication mimicking torsion of Meckel's diverticulum: a rare report of a pediatric case.

Surg Case Rep 2022 Mar 28;8(1):53. Epub 2022 Mar 28.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, 8908520, Japan.

Background: Enteric duplication is a congenital disease that occurs throughout the entire gastrointestinal tract. Although it may sometimes cause intestinal volvulus, a few reports have described cases of enteric duplication twisted on itself. We experienced a rare pediatric case of long-segment tubular ileal duplication showing torsion. Torsion of enteric duplication is extremely rare. We herein report a pediatric case showing unusual torsion of ileal duplication requiring emergency surgery.

Case Presentation: A 3-year-old boy presented with abdominal pain and vomiting. Contrast-enhanced computed tomography (CT) revealed a cystic luminal structure with a blind end and fluid collection in the pelvic cavity. CT also showed no findings of ileus or intestinal dilatation except for a cystic luminal structure. The preoperative diagnosis was torsion of Meckel's diverticulum. The patient underwent emergent explorative diagnostic laparoscopy. As a result, a necrotic luminal structure and bloody ascites were recognized, and small-scale laparotomy was performed. Long-segment ileal duplication was recognized. The long-segment tubular ileal duplication shared the anti-mesenteric side of the intestinal wall along one-third of its length. The residual two-thirds of its length was free from the ileum and its blind end was twisted in a manner that looked similar to Meckel's diverticulum. Normal ileum and the duplication, including the twisted necrotic portion, were resected, and ileal anastomosis was performed. The postoperative course was uneventful. A pathological examination confirmed the definitive diagnosis of enteric duplication.

Conclusions: We reported the unusual presentation of intestinal duplication mimicking torsion of Meckel's diverticulum. Enteric duplication shows various clinical symptoms and presentations. We must understand that the classification of digestive enteric duplication is diverse with a variety of associated clinical symptoms.
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http://dx.doi.org/10.1186/s40792-022-01409-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8960505PMC
March 2022

Intraoperative visualization of urethra using illuminating catheter in laparoscopy-assisted anorectoplasty for imperforated anus-A novel and safe technique for preventing urethral injury.

Asian J Endosc Surg 2022 Mar 27. Epub 2022 Mar 27.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Purpose: In this study, we used a near-infrared ray catheter (NIRC) to visualize the urethral line. We herein report our intraoperative visualization technique of the urethra using an illuminating catheter in laparoscopy-assisted anorectoplasty (LAARP) for imperforated anus.

Patient And Surgical Technique: A 3.0-kg term male neonate with anorectal malformation was delivered. An invertogram revealed the type as intermediate. Transverse colostomy was performed at the left upper abdomen. A recto-bulbar urethral fistula (RBUF) was diagnosed via distal colostogram and voiding cystourethrogram. LAARP was planned at 6 months of age. We performed the operation with four trocars. A 45° 5-mm scope was used to clearly view the deep pelvic space. Before starting rectal dissection, a 6-Fr pig-tail-type NIRC was inserted through the external opening of the urethra to visualize the urethra during the laparoscopic procedure. The catheter tip was placed in the bladder, and excretion of urine was maintained through the NIRC during the procedures. While dissecting the deep pelvic space between the posterior wall of the urethra and anterior wall of the rectum, the exact line of the urethra was clearly confirmed by overlay images of the NIRC. The RBUF was dissected safely using this innovative image-guided technique. Anoplasty was performed between the rectal stump and perineal skin. The postoperative course was uneventful. Oral intake was started on postoperative day 1. Postoperative dynamic urography showed no complications.

Conclusion: An NIRC is useful for detecting the urethra during LAARP.
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http://dx.doi.org/10.1111/ases.13061DOI Listing
March 2022

Biliary atresia: graft-versus-host disease with maternal microchimerism as an etiopathogenesis.

Transfus Apher Sci 2022 Apr 11;61(2):103410. Epub 2022 Mar 11.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Japan. Electronic address:

Biliary atresia (BA) is an inflammatory disease of the biliary system in newborns and infants. The etiology is largely unknown. Approximately half of BA patients require liver transplantation by 20 years of age, even after surgical correction due to progressive fibrosis of the liver. Regarding the disease mechanism, there is circumstantial evidence to support the hypothesis of graft-versus-host disease because of the existence of maternal cells in the liver (maternal microchimerism, MMC), histopathological similarity of the liver and an intense maternal response to the BA patient with mixed lymphocyte culture. Immune dysregulation with decreased Treg and increased Th1 and Th17 cells are the pathogenic features of BA, which are homologous to the pathogenic features of GvHD. Further elucidation of the etiopathogenetic mechanism of BA is warranted for development of new therapeutic strategies for native liver survival.
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http://dx.doi.org/10.1016/j.transci.2022.103410DOI Listing
April 2022

Impact of the Number of Board-Certified Pediatric Surgeons per Pediatric Population on the Outcomes of Laparoscopic Fundoplication for Neurologically Impaired Patients.

J Laparoendosc Adv Surg Tech A 2022 May 25;32(5):571-575. Epub 2022 Feb 25.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

The distribution of board-certified pediatric surgeons (BCPSs) in Japan is highly biased. While Prefecture has one of the smallest numbers of BCPSs per pediatric population, neighboring Prefecture has one of the largest numbers of BCPSs per pediatric population. We examined the effect of BCPSs population on laparoscopic surgery and postoperative management and outcomes. We compared postoperative duration to full-dose enteral nutrition, postoperative hospital stay, and complications of neurologically impaired patients who underwent laparoscopic fundoplication in two prefectures from 2006 to 2019. Laparoscopic fundoplication was performed in 17 patients in Prefecture and 63 in . The mean operative time was 248.8 ± 79.9 minutes in Prefecture and 260.8 ± 94.8 in ( = .64). The median number of days to full-dose enteral nutrition was 11.5 in Prefecture and 10 in ( = .29). The median postoperative hospital stay was 14 days in Prefecture and 15 days in ( = .38). Postoperative complications occurred in 7 cases in Prefecture and in 10 in . The incidence was significantly higher in Prefecture than in ( = .041). Areas with insufficient numbers of BCPSs have a higher risk of complications in laparoscopic surgery than areas with sufficient numbers.
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http://dx.doi.org/10.1089/lap.2021.0713DOI Listing
May 2022

Left paraduodenal hernia with intestinal volvulus mimicking midgut volvulus.

Pediatr Int 2022 Jan;64(1):e14964

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

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http://dx.doi.org/10.1111/ped.14964DOI Listing
January 2022

Useful traction technique for laparoscopic fundoplication without removing proceeding gastrostomy in a neurologically impaired patient with a body deformity.

Asian J Endosc Surg 2022 Jul 23;15(3):697-699. Epub 2022 Jan 23.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Severely neurologically impaired patients often require the creation of a gastrostomy when they develop difficulty with oral intake followed by antireflux surgery. We use a traction technique for laparoscopic fundoplication without removing the gastrostomy in such cases. Right lateral traction of the round ligament of the liver and left lateral traction of the stomach body are performed using a needle device. The left liver lobe is elevated with a liver retractor inserted via the epigastrium. This traction technique allows a sufficient surgical field for manipulating forceps to be created in cases with a gastrostomy, enabling fundoplication to be performed safely without removing the gastrostomy.
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http://dx.doi.org/10.1111/ases.13028DOI Listing
July 2022

A safe and effective laparoscopic Ladd's procedure technique involving the confirmation of mesenteric vascular perfusion by fluorescence imaging using indocyanine green: A case report of an infant.

Asian J Endosc Surg 2022 Apr 5;15(2):410-414. Epub 2022 Jan 5.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

We herein report a 20-month-old boy who underwent laparoscopic Ladd's surgery. He showed intermittent bilious vomiting after birth and received a definitive diagnosis of intestinal malrotation. Laparoscopic Ladd's procedure was performed with four trocars. Midgut volvulus (180° counterclockwise) was resolved by retrogradely tracing the small intestine from the ileocecal region. After dividing Ladd's ligament, fluorescent navigation with indocyanine green was used. We decided where to dissect the mesenteries by confirming the vascular perfusion through clamping the tissue. Fibrous adhesions were gradually dissected, and it was confirmed that the mesenteric root was sufficiently broadening. Surgeons hesitate to dissect the mesenteric root in laparoscopic procedures compared with open procedures because of the narrow operative view and the risk of vascular injury. Laparoscopic Ladd's procedure using indocyanine green to confirm intestinal blood flow is safe and useful for the small working space in pediatric patients with intestinal malrotation and midgut volvulus.
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http://dx.doi.org/10.1111/ases.13026DOI Listing
April 2022

Ambidextrous needle driving and knot tying helps perform secure laparoscopic hepaticojejunostomy of choledochal cyst (with video).

J Hepatobiliary Pancreat Sci 2022 Apr 21;29(4):e22-e24. Epub 2021 Dec 21.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Ieiri and colleagues report an ingenious technique for performing ambidextrous suturing in laparoscopic hepaticojejunostomy for cases with small hepatic ducts. Surgeons who devote professional attention to minimally invasive surgery should take care to practice extensively with their non-dominant as well as dominant hand to improve the quality of laparoscopic surgery.
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http://dx.doi.org/10.1002/jhbp.1100DOI Listing
April 2022

The protective effects of hepatocyte growth factor on the intestinal mucosal atrophy induced by total parenteral nutrition in a rat model.

Pediatr Surg Int 2021 Dec 26;37(12):1743-1753. Epub 2021 Aug 26.

Department of Pediatric Surgery, Medical and Dental Area, Research and Education Assembly, Research Field in Medical and Health Sciences, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, 890-8520, Japan.

Purpose: Total parental nutrition (TPN) causes gastrointestinal mucosal atrophy. The present study investigated the effects of hepatocyte growth factor (HGF) on the intestinal mucosal atrophy induced by TPN.

Methods: Rats underwent jugular vein catheterization and were divided into four groups: oral feeding (OF), TPN alone (TPN), TPN plus low-dose HGF (0.3 mg/kg/day; TPNLH), and TPN plus high-dose HGF (1.0 mg/kg/day; TPNHH). On day 7, rats were euthanized, and the small intestine was harvested and evaluated histologically. The expression of c-MET, a receptor of HGF, and nutrition transporter protein were evaluated using quantitative polymerase chain reaction.

Results: The jejunal villus height (VH) and absorptive mucosal surface area in the TPNHH group were significantly higher than in the TPN group (p < 0.05). The VH in the ileum showed the same trend only in the TPNHH group, albeit without statistical significance. The crypt cell proliferation rate (CCPR) of the jejunum in both HGF-treated groups was significantly higher than in the TPN group (p < 0.01). The expression of c-MET and transporter protein in all TPN-treated groups was decreased compared with that in the OF group.

Conclusion: HGF attenuated TPN-associated intestinal mucosal atrophy by increasing the villus height, which was associated with an increase in CCPR.
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http://dx.doi.org/10.1007/s00383-021-05002-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8563669PMC
December 2021

Optimal timing of definitive surgery for Hirschsprung's disease to achieve better long-term bowel function.

Surg Today 2022 Jan 12;52(1):92-97. Epub 2021 Aug 12.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, 890-8520, Japan.

Purpose: Few studies have focused on the operative age for Hirschsprung's disease (HD). We evaluated the optimal timing of surgery in HD patients based on their long-term bowel function.

Methods: HD was diagnosed in 65 pediatric patients in our institute between 1992 and 2018. Twenty-five patients underwent the Soave-Denda procedure (SD) and 40 underwent transanal endorectal pull-through (TA). We divided these patients into two groups: those who underwent surgery at < 6 months of age (younger group) and those who underwent surgery at 6-12 months of age (older group). We assessed bowel function at 5, 7, and 9 years of age.

Results: The bowel function of the patients who underwent the SD did not differ significantly between the groups. Similarly, the total bowel-function scores of the patients who underwent TA did not differ between the groups at any age. However, the soiling score at 7 years of age in the older group of patients who underwent TA was significantly lower than that in the younger group (p = 0.02).

Conclusions: Our data suggest that to achieve optimal bowel function, TA should be performed at < 6 months of age.
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http://dx.doi.org/10.1007/s00595-021-02356-9DOI Listing
January 2022

Retroperitoneal teratomas in children: a single institution experience.

Surg Today 2022 Jan 19;52(1):144-150. Epub 2021 Jun 19.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan.

Purpose: Retroperitoneal teratomas (RPTs) are rare in infants. We report our experience of treating pediatric patients with RPTs over many years at a single institution, with the aim of developing a safe and secure operative strategy for RPTs in infants.

Methods: We reviewed the medical records of patients who underwent treatment for RPTs in our institution between April, 1984 and December, 2017, to analyze their background and clinical data. The diagnosis of RPT was confirmed histologically in all patients.

Results: The subjects of this retrospective analysis were 14 pediatric patients (female, n = 11; male, n = 4), ranging in age from 6 days to 12 years, 11 (73.3%) of whom were under 1 year of age. Complete surgical resection was performed in all patients. The tumor ruptured during surgery in four (26.7%) patients and perioperative vessel injuries occurred in six (40.0%) patients, resulting in nephrectomy in one (6.7%). Three (20.0%) patients suffered unilateral renal dysfunction as a surgical complication. Only one patient received postoperative chemotherapy. All patients were free of disease at the time of writing.

Conclusion: Perioperative complications are not uncommon during surgery for RPTs, despite their benign nature. Preoperative imaging evaluation is important and operative management may be challenging. Because of the favorable prognosis and the frequency of adverse events in surgery, partial resection or split excision is sometimes unavoidable. Meticulous follow-up for recurrence is required for such patients.
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http://dx.doi.org/10.1007/s00595-021-02327-0DOI Listing
January 2022

A rare case of accessory liver lobe torsion in a pediatric patient who showed recurrent epigastralgia and who was treated by elective laparoscopic resection.

Surg Case Rep 2021 Jun 15;7(1):143. Epub 2021 Jun 15.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, 890-8520, Japan.

Background: Accessory liver lobe (ALL) is a rare liver malformation. An ALL develops due to malformation of the endodermal caudal foregut and segmentation of the hepatic bud in the third week of gestation. Most ALLs are asymptomatic and are detected incidentally during abdominal surgery. The incidence of ALL is < 1% in patients who undergo abdominal surgery. However, some ALLs twist and cause acute abdomen. We experienced a pediatric case of ALL torsion in a patient who underwent elective laparoscopic surgery.

Case Presentation: The 5-year-old girl had a 3-month history of epigastralgia and vomiting, which occurred every 2 weeks. Abdominal ultrasonography with color Doppler imaging revealed an 11.8 × 13.6 mm nonvascular lesion with mixed echogenicity near the round ligament of the liver. Enhanced computed tomography confirmed a 14 × 16 × 20 mm low-attenuation mass surrounded by a hyperdense line and disproportionate fat stranding on the right side of the round ligament of the liver. There was no ascites or hemorrhage. These findings suggested an abscess of the round ligament of the liver. Her symptoms improved with the administration of oral antibiotics; thus, we planned to perform elective exploratory laparoscopy and subsequent resection. Two trocars (5 mm) were inserted through a multichannel port device at the umbilicus and one trocar (3 mm) was inserted at the right lateral abdomen. Upon observation of the abdominal cavity, the omentum was observed adhering to the round ligament of the liver. Macroscopic observation revealed no apparent mass lesions. We performed adhesiolysis of the omentum from the round ligament of the liver using a vessel sealing system. We performed resection at the site at which adhesion had formed between the round ligament of the liver with the surrounding tissue using a vessel sealing system and the resected specimen was extracted through the umbilical wound. The postoperative course was uneventful. A pathological examination revealed necrotic liver tissue. The resected tissue was founded to be an ALL with ischemic change.

Conclusions: The recurrent abdominal pain was induced by torsion of the ALL. Pediatric surgeons should consider ALL torsion as a differential diagnosis for epigastralgia of unknown etiology.
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http://dx.doi.org/10.1186/s40792-021-01231-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8206295PMC
June 2021

Potential predictors of the onset of focal intestinal perforation in extremely low birth weight infants based on an analysis of coagulation and fibrinolysis markers at birth: A case-control study based on ten years of experience at a single institution.

J Pediatr Surg 2021 Jul 28;56(7):1121-1126. Epub 2021 Mar 28.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan. Electronic address:

Purpose: We aimed to investigate potential predictors of focal intestinal perforation (FIP) in extremely low birth weight infants (ELBWIs) among coagulation and fibrinolysis markers at birth.

Methods: We reviewed the medical records of FIP patients and their coagulation and fibrinolysis markers at birth between 2010 and 2019, and matched patients according to gestational age. FIP was diagnosed based on macroscopic intestinal perforation with a punched-out lesion without necrosis. Patient characteristics and blood test results, including coagulation and fibrinolysis marker levels, were compared between the groups.

Results: Two hundred forty ELBWIs were enrolled in this study (FIP, n = 18; controls, n = 222). In the FIP group, the gestational age at birth was significantly younger (p = 0.023) and the birth weight was significantly lower (p = 0.007) in comparison to the control group. Furthermore, the FIP group showed significantly lower levels of fibrinogen (p = 0.027) and factor XIII (F-XIII) (p = 0.007). The receiver operating characteristics curves for fibrinogen and F-XIII revealed that the 95% confidence intervals of fibrinogen and F-XIII were 0.530-0.783 (p = 0.027), and 0.574-0.822 (p = 0.007), respectively.

Conclusions: This is the first report focusing on coagulation and fibrinolysis markers in FIP patients at birth. The fibrinogen and F-XIII values at birth are potential predictors of FIP in ELBWIs.

Type Of Study: Study of Diagnostic Test (Case Control Study) LEVEL OF EVIDENCE: : Level IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.03.043DOI Listing
July 2021

A retrospective analysis of the real-time ultrasound-guided supraclavicular approach for the insertion of a tunneled central venous catheter in pediatric patients.

J Vasc Access 2021 Apr 7:11297298211008084. Epub 2021 Apr 7.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Purpose: Tunneled central venous catheter (tCVC) placement plays an important role in the management of pediatric patients. We adopted a real-time ultrasound (US)-guided supraclavicular approach to brachiocephalic vein cannulation. We evaluated the outcomes of tCVC placement via a US-guided supraclavicular approach.

Methods: A retrospective study was performed for patients who underwent US-guided central venous catheterization of the internal jugular vein (IJV group) and brachiocephalic vein (BCV group) in our institution. The background information and outcomes were reviewed using medical records.

Results: We evaluated 85 tCVC placements (IJV group:  = 59, BCV group:  = 26). Postoperative complications were recognized in 19 patients in the IJV group (catheter-related bloodstream infection (CRBSI),  = 14 (1.53 per 1000 catheter days); occlusion,  = 1 (1.7%, 1.09 per 1000 catheter days); accidental removal,  = 3 (5.2%, 0.33 per 1000 catheter days); and other,  = 1 (1.7%, 1.09 per 1000 catheter days)) and five patients in the BCV group (CRBSI,  = 2 (0.33 per 1000 catheter days); catheter damage,  = 1 (3.8%, 1.67 per 1000 catheter days); and accidental removal,  = 2 (7.7%, 0.33 per 1000 catheter days)). In the BCV group, despite that, the incidence of postoperative complications was lower ( = 0.205) and the period of placement was significantly longer in comparison to the IJV group ( = 0.024).

Conclusion: US-guided placement of tunneled CVC though the BCV results in a low rate of postoperative complications despite longer CVC indwelling times compared to IJV insertion. Our results suggest that BCV insertion of tunneled CVC in children may offer advantages in terms of device performance and patient safety.
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http://dx.doi.org/10.1177/11297298211008084DOI Listing
April 2021

Differential gastric emptiness according to preoperative stomach position in neurological impaired patients who underwent laparoscopic fundoplication and gastrostomy.

Surg Today 2021 Dec 30;51(12):1918-1923. Epub 2021 Mar 30.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, 890-8520, Japan.

Purpose: We sometimes experienced prolonged delayed gastric emptying (DGE) in neurologically impaired patients undergoing laparoscopic fundoplication and gastrostomy. We explored the difference in the DGE rate according to the preoperative stomach position.

Methods: Thirty-two neurological impaired patients who underwent laparoscopic fundoplication and gastrostomy between 2015 and 2019 were classified into two groups based on stomach position: non-elevated stomach position (NESP) and elevated stomach position (ESP). Patients' characteristics, operative result and postoperative gastric emptying were reviewed.

Results: The 11 ESP patients were significantly older than the 21 NESP patients (p < 0.05). The ESP patients had a significantly heavier body weight (BW) than the NESP patients (p < 0.05). The time taken (days) to reduce gastric drainage (days, below BW × 10 ml) in the NESP (4.3 ± 3.6) was significantly longer than that of ESP (1.3 ± 1.6) (p < 0.05). The time taken (days) to achieve full enteral nutrition in the NESP (14.1 ± 8.9) was significantly longer than that of the ESP patients (8.8 ± 3.1) (p < 0.05).

Conclusion: Elevated stomach position (ESP) patients archived full enteral nutrition earlier than NESP patients after laparoscopic fundoplication and gastrostomy. Stomach position correction might, therefore, be involved in the incidence of DGE.
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http://dx.doi.org/10.1007/s00595-021-02274-wDOI Listing
December 2021

Association between physical activity and changes in renal function in patients after acute myocardial infarction: A dual-center prospective study.

J Cardiol 2021 08 23;78(2):120-128. Epub 2021 Mar 23.

Department of Rehabilitation, Shin Yurigaoka General Hospital, Kawasaki, Japan.

Background: Acute myocardial infarction (AMI) causes a decline in renal function. This study aimed to elucidate the longitudinal association between physical activity levels and changes in renal function up to 6 months after the onset of AMI.

Methods: In this dual-center prospective observational study, 73 AMI patients (67 men; average age, 65.0±11.7 years) were enrolled from 2017 to 2019. Blood biochemistry, urinalysis, and physical function tests were conducted at discharge and 3 and 6 months post-discharge. The renal function was evaluated based on cystatin C-based estimated glomerular filtration rate (eGFRcys). The number of steps was recorded for 6 months post-discharge. Generalized estimating equation (GEE) models were used to test the longitudinal association between physical activity levels and within-patient changes in eGFRcys. Both GEE models with a follow-up period of 3 and 6 months were constructed to assess the effects of the passage of time.

Results: Patients were stratified into the low (n=36; 2903±1187 steps/day) and high groups (n=37; 7988±3192 steps/day) based on the median number of steps. Both GEE models at the 3- (p=0.027) and 6-month follow-up (p=0.034) showed a significant positive association between the physical activity levels and within-patient changes in eGFRcys. The changes in eGFRcys at 6 months were -0.3 mL/min/1.73 m and +4.4 mL/min/1.73 m among the low and high group participants, respectively.

Conclusions: There was a significant positive association between physical activity and renal function changes after the onset of AMI, which persisted when the follow-up period was extended from 3 to 6 months. Our findings support the importance of interventions that enable maintaining high physical activity levels as a strategy for preserving renal function in AMI patients.
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http://dx.doi.org/10.1016/j.jjcc.2021.03.007DOI Listing
August 2021

Trans-perineal transection through "Neo-Anus" for recto-bulbar urethral fistula using a 5-mm stapler in laparoscopically assisted anorectoplasty - A novel and secure technique.

Asian J Endosc Surg 2021 Oct 21;14(4):828-830. Epub 2021 Mar 21.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Laparoscopically assisted anorectoplasty (LAARP) for recto-bulbar urethral fistula (RBUF) is not now a standard operation due to urethra injury risk and incomplete removal of fistula. Our approach is a novel and secure technique of trans-perineal transection using a 5-mm stapler for RBUF. Before performing LAARP, the orifice of RBUF was confirmed under flexible cystoscope inspection. Before transection of RBUF, the center of the muscle complex was detected at perineal skin. The muscle complex and the pubo-rectal sling were then also confirmed with electrical nerve stimulator under laparoscopic approach. A 5-mm trocar was inserted to pass through the center of the muscle complex from perineal incision of the neo-anus. RBUF was stapled and transected using a 5-mm stapler inserted from the neo-anus. The operator successfully confirmed complete adequate closure of RBUF under flexible cystoscope inspection. A 5-mm stapler was effective and useful for the transection of RBUF.
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http://dx.doi.org/10.1111/ases.12934DOI Listing
October 2021

The evaluation of eye gaze using an eye tracking system in simulation training of real-time ultrasound-guided venipuncture.

J Vasc Access 2022 May 12;23(3):360-364. Epub 2021 Feb 12.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Purpose: Real-time ultrasound (RTUS)-guided central venipuncture using the short-axis approach is complicated and likely to result in losing sight of the needle tip. Therefore, we focused on the eye gaze in our evaluation of the differences in eye gaze between medical students and experienced participants using an eye tracking system.

Methods: Ten medical students (MS group), five residents (R group) and six pediatric surgeon fellows (F group) performed short-axis RTUS-guided venipuncture simulation using a modified vessel training system. The eye gaze was captured by the tracking system (Tobii Eye Tacker 4C) and recorded. The evaluation endpoints were the task completion time, total time and number of occurrences of the eye tracking marker outside US monitor and success rate of venipuncture.

Result: There were no significant differences in the task completion time and total time of the tracking marker outside the US monitor. The number of occurrences of the eye tracking marker outside US monitor in the MS group was significantly higher than in the F group (MS group: 9.5 ± 3.4, R group: 6.0 ± 2.9, F group: 5.2 ± 1.6;   0.04). The success rate of venipuncture in the R group tended to be better than in the F group.

Conclusion: More experienced operators let their eye fall outside the US monitor fewer times than less experienced ones. The eye gaze was associated with the success rate of RTUS-guided venipuncture. Repeated training while considering the eye gaze seems to be pivotal for mastering RTUS-guided venipuncture.
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http://dx.doi.org/10.1177/1129729820987362DOI Listing
May 2022

Early definitive operation for patients with anorectal malformation was associated with a better long-term postoperative bowel function.

Pediatr Surg Int 2021 Apr 25;37(4):445-450. Epub 2021 Jan 25.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan.

Purpose: In general, patients with anorectal malformation (ARM) undergo surgical treatment at around 6 months of age in Japan. We aimed to clarify whether the timing of a definitive operation affects the long-term bowel function.

Methods: Patient data were collected from 1984 to 2007. Fifty-two male patients with high- and intermediate-type ARM were enrolled. Patients were classified into two groups based on their operative period: the early group (EG) underwent anorectoplasty at < 5 months of age (n = 22); the late group (LG) underwent anorectoplasty at ≥ 5 months (n = 30). The bowel function was evaluated at 3, 5, 7, 9, and 11 years of age using the evacuation score (ES) of the Japan Society of Anorectal Malformation Study Group.

Results: The total score and four functional outcomes improved chronologically with age. The constipation score in the EG showed significantly better improvement in comparison to the LG. The total score and the incontinence score in the EG were significantly higher than those in the LG at 11 years of age.

Conclusion: The long-term bowel function in the EG was better than that in the LG. Anorectoplasty at an early age was important for achieving a better postoperative bowel function in ARM patients.
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http://dx.doi.org/10.1007/s00383-020-04842-6DOI Listing
April 2021

An overview of the current management of short-bowel syndrome in pediatric patients.

Surg Today 2022 Jan 19;52(1):12-21. Epub 2021 Jan 19.

Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

Short-bowel syndrome (SBS) is defined as a state of malabsorption after resection or loss of a major portion of the bowel due to congenital or acquired factors. This article presents an overview on the recent management of pediatric SBS. The pediatric SBS population is very heterogeneous. The incidence of SBS is estimated to be 24.5 per 100,000 live births. The nutritional, medical, and surgical therapies available require a comprehensive evaluation. Thus, multidisciplinary intestinal rehabilitation programs (IRPs) are necessary for the management of these complex patients. The key points of focus in IRP management are hepato-protective strategies to minimize intestinal failure-associated liver disease; the aggressive prevention of catheter-related bloodstream infections; strategic nutritional supply to optimize the absorption of enteral calories; and the management and prevention of small bowel bacterial overgrowth, nephrocalcinosis, and metabolic bone disease. As the survival rate of children with SBS currently exceeds 90%, the application of small bowel transplantation has been evolving. The introduction of innovative treatments, such as combined therapy of intestinotrophic hormones, including glucagon-like peptide-2, may lead to further improvements in patients' quality of life.
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http://dx.doi.org/10.1007/s00595-020-02207-zDOI Listing
January 2022

Discrepancy between the survival rate and neuropsychological development in postsurgical extremely low-birth-weight infants: a retrospective study over two decades at a single institution.

Pediatr Surg Int 2021 Mar 11;37(3):411-417. Epub 2021 Jan 11.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan.

Purpose: Necrotizing enterocolitis (NEC), focal intestinal perforation (FIP), and meconium-related ileus (MRI) are major diseases that cause gastrointestinal disorders in extremely low-birth-weight infants (ELBWIs). We conducted a review to compare the postoperative outcomes of ELBWIs with these diseases in our neonatal intensive-care unit.

Methods: A retrospective chart review of ELBWIs surgically treated for NEC (n = 31), FIP (n = 35), and MRI (n = 16) in 2001-2018 was undertaken. This period was divided into early (2001-2005), middle (2006-2010), and late (2011-2018) periods. Data were analyzed with the Cochran-Armitage test. Statistical significance was defined as p < 0.05.

Results: The survival rates in ELBWIs with NEC (early/middle/late: 36.4%/42.9%/61.5%; p = 0.212) and FIP (20%/50%/70.6%; p = 0.012) improved over time; all patients with MRI survived. The neuropsychological development of 24 cases was assessed with the Kyoto Scale of Psychological Development in the Postural-Motor, Cognitive-Adaptative, and Language-Social domains. The mean developmental quotient of all domains was 68.4 (range 18-95) at corrected 1.5 years of age and 69.1 (range 25-108) at chronological 3 years of age, both were considered as poor development. There was no improvement over time (p = 0.899).

Conclusion: Ideal neuropsychological development was not observed with the improvement of survival rate. Less-invasive surgical intervention and adequate postoperative care are required to encourage further development.
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http://dx.doi.org/10.1007/s00383-020-04825-7DOI Listing
March 2021

Successful laparoscopic extirpation of a vasoactive intestinal polypeptide-secreting neuroblastoma originating from the right adrenal gland: A report of an infantile case.

Asian J Endosc Surg 2021 Jul 3;14(3):611-614. Epub 2021 Jan 3.

Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.

We herein report a 10-month-old female infant with a 4-month history of diarrhea with electrolyte abnormalities and growth impairment. A 4-cm right adrenal tumor was detected by computed tomography. No metastasis or accumulation on I -metaiodobenzylguanidine scintigraphy was recognized in the tumor. A vasoactive intestinal peptide-secreting neuroblastic tumor was suspected, and octreotide was started, but the diarrhea persisted. Tumor extirpation was laparoscopically performed. After tumor removal, the symptoms improved immediately, and her growth caught up by 9 months after surgery. A minimally invasive approach for pediatric solid tumor is difficult, especially for neuroblastoma, but may be beneficial for the patient's recovery.
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http://dx.doi.org/10.1111/ases.12916DOI Listing
July 2021

What is the optimal lipid emulsion for preventing intestinal failure-associated liver disease following parenteral feeding in a rat model of short-bowel syndrome?

Pediatr Surg Int 2021 Feb 3;37(2):247-256. Epub 2021 Jan 3.

Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, 890-8520, Japan.

Purpose: Composite lipid emulsion (CLE) has been used for intestinal failure-associated liver disease (IFALD) to compensate for the disadvantages of soybean oil lipid emulsion (SOLE) or fish oil lipid emulsion (FOLE). However, the influence of its administration is unclear. We evaluated the effects of these emulsions on IFALD using a rat model of the short-bowel syndrome.

Methods: We performed jugular vein catheterization and 90% small bowel resection in Sprague-Dawley rats and divided them into four groups: control (C group), regular chow with intravenous administration of saline; and total parenteral nutrition co-infused with SOLE (SOLE group), CLE (CLE group) or FOLE (FOLE group).

Results: Histologically, obvious hepatic steatosis was observed in the SOLE and CLE groups but not the FOLE group. The liver injury grade of the steatosis and ballooning in the FOLE group was significantly better than in the SOLE group (p < 0.05). The TNF-α levels in the liver in the FOLE group were significantly lower than in the SOLE group (p < 0.05). Essential fatty acid deficiency (EFAD) was not observed in any group.

Conclusion: Fish oil lipid emulsion attenuated hepatic steatosis without EFAD, while CLE induced moderate hepatic steatosis. The administration of CLE requires careful observation to prevent PN-induced hepatic steatosis.
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http://dx.doi.org/10.1007/s00383-020-04802-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847428PMC
February 2021
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