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Luglio M, Marques TDCS, Pereira MFB, Delgado AF, de Carvalho WB, Tannuri ACA, Sandy NS, Litvinov N, de Paula CSY, Dos Santos AG, Lazari CDS, Gouvea MSG, de Paula AV, Mendoza TRT, Tanigawa RY, Lima FR, Hirayama AB, Dos Santos IGG, Pinho JRR, Sabino EC, Mendes-Correah MC, Alves VAF, Marques HHDS. Clinical Aspects and Etiologic Investigation of Pediatric Patients With Acute Liver Failure. Transplant Proc 2023; 55:2121-2125. [PMID: 37758563 DOI: 10.1016/j.transproceed.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 07/12/2023] [Accepted: 08/01/2023] [Indexed: 09/29/2023]
Abstract
A new outbreak of hepatitis of unknown origin raised awareness in the international community. A few reports have attempted to associate new cases with adenovirus infection and the immunologic effects of previous SARS-CoV-2 infections through a superantigen mechanism. Moreover, according to a case series, viral isolates were identified in 7 of 10 cases of pediatric patients with hepatitis of unknown origin and acute liver failure. Adenovirus was detected by respiratory secretion polymerase chain reaction in 2 patients, with neither presenting with SARS-CoV-2 acute infection. Clinical and laboratory descriptions and cross-referencing epidemiologic and pathophysiological data can help identify possible disease etiologies.
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Affiliation(s)
- Michele Luglio
- Instituto da Criança e do Adolescente do Hospital das Clínicas da FMUSP, São Paulo, Brazil; Pediatric Intensive Care Center, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo.
| | | | - Maria Fernanda Badue Pereira
- Pediatric Infectology Department, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
| | - Artur Figueiredo Delgado
- Pediatric Intensive Care Center, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
| | - Werther Brunow de Carvalho
- Pediatric Intensive Care Center, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery and Liver Transplantion Department, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
| | - Natascha Silva Sandy
- Pediatric Hepatology Departament, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
| | - Nadia Litvinov
- Pediatric Infectology Department, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
| | - Camila Sanson Yoshino de Paula
- Pediatric Infectology Department, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
| | - Ariane Guissi Dos Santos
- Pediatric Infectology Department, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
| | - Carolina Dos Santos Lazari
- Central Laboratory, Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
| | | | | | | | - Ryan Yukimatsu Tanigawa
- Department of Pathology, Surgical Pathology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Fabiana Roberto Lima
- Department of Pathology, Surgical Pathology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - André Bubna Hirayama
- Department of Pathology, Surgical Pathology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Isabela Gusson Galdino Dos Santos
- Pediatric Surgery and Liver Transplantion Department, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
| | | | - Ester Cerdeira Sabino
- Instituto de Medicina Tropical da Faculdade de Medicina da Universidade de São Paulo
| | | | | | - Heloisa Helena de Sousa Marques
- Pediatric Infectology Department, Instituto da Criança e do Adolescente da Faculdade de Medicina da Universidade de São Paulo
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Bigio JZD, Tannuri ACA, Falcão MC, Matsushita FY, de Carvalho WB. Factors associated with cholestasis in newborns with gastroschisis. Rev Paul Pediatr 2023; 42:e2022152. [PMID: 37436246 DOI: 10.1590/1984-0462/2024/42/2022152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 02/14/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To describe the incidence and to analyze risk factors associated with cholestasis in neonates with gastroschisis. METHODS This is a retrospective cohort study in a tertiary single center analyzing 181 newborns with gastroschisis between 2009 and 2020. The following risk factors associated with cholestasis were analyzed: gestational age, birth weight, type of gastroschisis, silo closure or immediate closure, days of parenteral nutrition, type of lipid emulsion, days of fasting, days to reach a full diet, days with central venous catheter, presence of infections, and outcomes. RESULTS Among the 176 patients evaluated, 41 (23.3%) evolved with cholestasis. In the univariate analysis, low birth weight (p=0.023), prematurity (p<0.001), lipid emulsion with medium-chain triglycerides and long-chain triglycerides (p=0.001) and death (p<0.001) were associated with cholestasis. In the multivariate analysis, patients who received lipid emulsion with fish oil instead of medium chain triglycerides/long chain triglycerides (MCT/LCT) emulsion had a lower risk of cholestasis. CONCLUSIONS Our study shows that lipid emulsion with fish oil is associated with a lower risk of cholestasis in neonates with gastroschisis. However, this is a retrospective study and a prospective study should be performed to confirm the results.
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Nishie EN, Osmundo Junior GDS, Mohamed SHM, Tannuri ACA, Gibelli MABC, Carvalho WBD, Peres SV, Francisco RPV, Brizot MDL. Three-Dimensional Ultrasound Evaluation of Lung Volume in Fetuses with Abdominal Wall Defect. Fetal Diagn Ther 2023; 50:259-268. [PMID: 37379809 DOI: 10.1159/000531594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/01/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Abdominal wall defects (AWDs) interfere with postnatal respiratory parameters. We aimed to evaluate lung volume (LV) in fetuses with AWD using three-dimensional (3D) ultrasound (US) and to correlate AWD with the type (omphalocele and gastroschisis) and size of the defect and neonatal morbidity and mortality. METHODS This prospective observational study included 72 pregnant women with fetuses with AWD and a gestational age <25 weeks. The data on abdominal volume, 3D US LV, and herniated volume were acquired every 4 weeks up to 33 weeks. LV was compared with normal reference curves and correlated with abdominal and herniated volumes. RESULTS Omphalocele (p < 0.001) and gastroschisis (p < 0.001) fetuses had smaller LV than normal fetuses. LV was positively correlated with abdominal volume (omphalocele, r = 0.86; gastroschisis, r = 0.88), whereas LV was negatively correlated with omphalocele-herniated volume/abdominal volume (p < 0.001, r = -0.51). LV was smaller in omphalocele fetuses that died (p = 0.002), were intubated (p = 0.02), or had secondary closure (p < 0.001). In gastroschisis, a smaller LV was observed in fetuses discharged using oxygen (p = 0.002). CONCLUSION Fetuses with AWD had smaller 3D LV than normal fetuses. Fetal abdominal volume was inversely correlated with LV. In omphalocele fetuses, a smaller LV was associated with neonatal mortality and morbidity.
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Affiliation(s)
- Estela Naomi Nishie
- Obstetrics, Department of Obstetrics and Gynecology, Hospital das Clinicas, Faculdade de Medicina (FMUSP), Universidade de São Paulo, São Paulo, Brazil,
| | - Gilmar de Souza Osmundo Junior
- Obstetrics, Department of Obstetrics and Gynecology, Hospital das Clinicas, Faculdade de Medicina (FMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Samirah Hosney Mahmoud Mohamed
- Obstetrics, Department of Obstetrics and Gynecology, Hospital das Clinicas, Faculdade de Medicina (FMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Division of Neonatology, Department of Pediatrics, Hospital das Clínicas, Faculdade de Medicina (FMUSP), Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Stela Verzinhasse Peres
- Obstetrics, Department of Obstetrics and Gynecology, Hospital das Clinicas, Faculdade de Medicina (FMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Rossana Pulcineli Vieira Francisco
- Obstetrics, Department of Obstetrics and Gynecology, Hospital das Clinicas, Faculdade de Medicina (FMUSP), Universidade de São Paulo, São Paulo, Brazil
| | - Maria de Lourdes Brizot
- Obstetrics, Department of Obstetrics and Gynecology, Hospital das Clinicas, Faculdade de Medicina (FMUSP), Universidade de São Paulo, São Paulo, Brazil
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Abreu MS, Tannuri ACA, Rodrigues RFG, Silva RJD, Gonçalves JDO, Serafini S, Tannuri U. Effects of local and remote ischemic postconditioning methods on ischemiareperfusion injury in a young animal model of acute mesenteric ischemia. Acta Cir Bras 2023; 38:e381323. [PMID: 37283357 DOI: 10.1590/acb381323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 06/08/2023] Open
Abstract
PURPOSE Acute mesenteric ischemia (AMI) is a condition in pediatric surgery that ranges from intestine necrosis to death. Ischemic postconditioning (IPoC) methods were developed to reduce the damage caused by revascularization. This study aimed to evaluate the efficacy of these methods in an experimental weaning rat model. METHODS Thirty-two 21-day-old Wistar rats were allocated into four groups according to the surgical procedure performed: control, ischemia-reperfusion injury (IRI), local (LIPoC) and remote IPoC (RIPoC). At euthanasia, fragments of the intestine, liver, lungs, and kidneys were submitted to histological, histomorphometric, and molecular analyses. RESULTS In the duodenum, intestines, and kidneys histological alterations promoted by IRI were reversed by remote postconditioning method. In the distal ileum, the histomorphometric alterations could be reversed by the postconditioning methods with more evident effects promoted by the remote method. The molecular analysis found that the levels of expression of Bax (proapoptotic) and Bcl-XL (antiapoptotic) genes in the intestine were increased by IRI. These alterations were equally reversed by the postconditioning methods, with more evident effects of the remote method. CONCLUSIONS IPoC methods positively reduced the damage caused by IRI in weaning rats.
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Affiliation(s)
- Mateus Souza Abreu
- Universidade de São Paulo - Faculdade de Medicina - Divisão de Cirurgia Pediátrica - São Paulo (SP), Brazil
| | - Ana Cristina Aoun Tannuri
- Universidade de São Paulo - Faculdade de Medicina - Divisão de Cirurgia Pediátrica - São Paulo (SP), Brazil
| | | | - Rafael José da Silva
- Universidade de São Paulo - Faculdade de Medicina - Divisão de Cirurgia Pediátrica - São Paulo (SP), Brazil
| | | | - Suellen Serafini
- Universidade de São Paulo - Faculdade de Medicina - Divisão de Cirurgia Pediátrica - São Paulo (SP), Brazil
| | - Uenis Tannuri
- Universidade de São Paulo - Faculdade de Medicina - Divisão de Cirurgia Pediátrica - São Paulo (SP), Brazil
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Serafini S, Santos MM, Tannuri ACA, Di Loreto C, Gonçalves JDO, Tannuri U. A new systematization of histological analysis for the diagnosis of Hirschsprung's disease. Clinics (Sao Paulo) 2023; 78:100198. [PMID: 37075514 PMCID: PMC10126911 DOI: 10.1016/j.clinsp.2023.100198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 01/31/2023] [Accepted: 03/28/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Hirschsprung's Disease (HD) is characterized by intestinal sub-occlusion and the absence of enteric ganglion cells. A rectal biopsy examination is performed to confirm the diagnosis. In a recent study, we demonstrated that the analysis of 60 sections of rectal mucosa and submucosa stained by H&E may ensure a 90% diagnostic accuracy. Although the need to analyze so many sections makes the process of reading the slides more time-consuming, this encouraged us to study their distribution in the healthy rectal submucosa, to simplify the diagnosis. OBJECTIVES To develop a method that facilitates HD diagnosis by studying the distribution of ganglion cells in the submucosal plexus. METHODS Using the calretinin technique, we studied the distribution of plexuses in 60 fragments of rectal submucosa from 19 cadavers. After the study, the reading method created was used for diagnosis in 47 cases of suspected HD, using H&E staining. The accuracy was verified by comparing the results obtained with H&E to those obtained with the acetylcholinesterase technique, the golden standard in our laboratory. RESULTS The study of submucosal plexus distribution showed that just by examining the submucosal region every 20 µm, approximately, it is possible to locate a ganglionic plexus, and we have already been able to diagnose HD with 93% accuracy. CONCLUSION The study of ganglion cell distribution enabled the creation of a simplified method for reading the slides. The method applied achieved good accuracy and it can be used as an alternative method in HD diagnosis.
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Affiliation(s)
- Suellen Serafini
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Maria Mercês Santos
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Celso Di Loreto
- Department of Pathology, Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - Josiane de Oliveira Gonçalves
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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Brener PZ, Tannuri ACA, Teixeira RAP, Cristofani LM, Evangelista ABR, Sugiyama RM, Tannuri U. Wilms tumor in children: A multivariate analysis of prognostic factors, with emphasis on inferior vena cava/right atrium extension. Results from a single-center study. Surg Oncol 2023; 46:101896. [PMID: 36571933 DOI: 10.1016/j.suronc.2022.101896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/13/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND To identify prognostic factors for overall survival through the analysis of 132 patients with Wilms tumor followed at a single center, with emphasis on the inferior vena cava/right atrium extension. METHODS Retrospective analysis of overall survival using logistic regression models and including age, sex, clinical features, associated syndromes, comorbidities, tumor size before chemotherapy, stage, presence of metastatic disease and its site, invasion of adjacent structures, inferior vena cava/right atrium extension, laterality, tumor histology, chemotherapy protocol, and radiotherapy as potential risk factors. RESULTS From January 2000 through November 2021, 132 patients met the inclusion criteria, 64 females and 68 males; 15 (11.4%) patients presented with tumoral extension to inferior vena cava/right atrium and 44 had metastatic disease (33.3%). Based on logistic regression, the factors correlating to a fatal outcome were male sex (p = 0.046), high risk histology (p = 0.036), and the presence of metastatic disease (p = 0.003). None of the patients presenting inferior vena cava/right atrium extension died (p = 0.992). In a specific analysis of metastatic sites, hepatic metastasis alone showed correlation with a fatal outcome (p = 0.001). CONCLUSION These results underline the importance of identifying and treating metastatic disease and high-risk tumors. The female gender as a potential driver for a less aggressive disease is a new finding that deserves further investigation. The accurate identification of inferior vena cava/right atrium extension, subsequent preoperative chemotherapy, and resection with a skilled team promoted survival rates of all patients. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Pedro Zanetta Brener
- Pediatric Surgery Division, Pediatric Onco-Hematology Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Onco-Hematology Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Roberto Augusto Plaza Teixeira
- Pediatric Surgery Division, Pediatric Onco-Hematology Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Lilian Maria Cristofani
- Pediatric Surgery Division, Pediatric Onco-Hematology Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Beatriz Rabelo Evangelista
- Pediatric Surgery Division, Pediatric Onco-Hematology Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Renata Morita Sugiyama
- Pediatric Surgery Division, Pediatric Onco-Hematology Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Onco-Hematology Division, University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Colleti Junior J, Tannuri ACA, Tannuri U, Delgado AF, de Carvalho WB. Development of a prognostic model for pediatric acute liver failure in a Brazilian center. J Pediatr (Rio J) 2022; 98:607-613. [PMID: 35405144 PMCID: PMC9617273 DOI: 10.1016/j.jped.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/25/2022] [Accepted: 03/07/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Pediatric acute liver failure (PALF) is a heterogeneous, rare, and severe condition, which outcome is survival due to liver spontaneous recovery or death. The patients who do not recover may be allocated to liver transplantation, which is the standard treatment. This study aimed to build a prognostic model to support the clinical decision to indicate liver transplantation for patients with PALF in a Brazilian center. METHODS The authors retrospectively analyzed the clinical variables of 120 patients in the liver transplantation program of the 'Children's Institute of the University of São Paulo, Brazil. The authors conducted a univariate analysis of variables associated with survival in PALF. Logistic multivariate analysis was performed to find a prognostic model for the outcome of patients with pediatric acute liver failure. RESULTS Risk factors were analyzed using univariate analysis. Two prognostic models were built using multiple logistic regression, which resulted in 2 models: model 1(INR/ALT) and model 2 (INR/Total bilirubin). Both models showed a high sensitivity (97.9%/96.9%), good positive predictive value (89.5%/90.4%), and accuracy (88.4%/88.5%), respectively. The receiver operating characteristic was calculated for both models, and the area under the curve was 0.87 for model 1 and 0.88 for model 2. The Hosmer-Lemeshow test showed that model 1 was good. CONCLUSION The authors built a prognostic model for PALF using INR and ALT that can contribute to the clinical decision to allocate patients to liver transplantation.
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Affiliation(s)
- José Colleti Junior
- Universidade de São Paulo, Departamento de Pediatria, Instituto da Criança, São Paulo, SP, Brazil.
| | | | - Uenis Tannuri
- Universidade de São Paulo, Departamento de Pediatria, Instituto da Criança, São Paulo, SP, Brazil
| | - Artur Figueiredo Delgado
- Universidade de São Paulo, Departamento de Pediatria, Instituto da Criança, São Paulo, SP, Brazil
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Santos MM, Tannuri ACA, Lacerda AV, Gonçalves JDO, Ricardi LRS, Tannuri U. Microsurgical arterial anastomosis in young and adult rats: an evolutive and comparative study. Acta Cir Bras 2022; 37:e370604. [PMID: 36074397 PMCID: PMC9448246 DOI: 10.1590/acb370604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose: To evaluate the caliber of an arterial micro-anastomosis in the young growing animal using a continuous suture technique. Additionally, late morphological changes and blood flows distal to the anastomosis were evaluated. Methods: Seventy-four Wistar rats were submitted to laparotomy to access the aorta for blood flow measurement. The aorta was sectioned using microsurgery technique and an end-to-end anastomosis with continuous suture. After a period of six months to one year, the anastomosis was checked. Results: Regarding the size of the aortas, comparing the pre- and postoperative values, there was an increase of 13.33% in adult animals and 25% in young animals, without any difference in the blood flows. Conclusions: The arteries of young rats show signs of growth at the site of the anastomosis performed with continuous suture.
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Affiliation(s)
- Maria Mercês Santos
- PhD. Universidade de São Paulo - Medical School - Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery - Pediatric Surgery Division - São Paulo (SP), Brazil
| | - Ana Cristina Aoun Tannuri
- Associate professor. Universidade de São Paulo - Medical School - Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery - Pediatric Surgery Division - São Paulo (SP), Brazil
| | - Adriana Vasconcelos Lacerda
- Laboratory tecnician. Universidade de São Paulo - Hospital das Clínicas - Instituto da Criança - Pediatric Liver Transplantation Unit - Pediatric Surgery Division - São Paulo (SP), Brazil
| | | | - Luiz Roberto Schlaich Ricardi
- PhD. Universidade de São Paulo - Medical School - Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery - Pediatric Surgery Division - São Paulo (SP), Brazil
| | - Uenis Tannuri
- Head professor. Universidade de São Paulo - Medical School - Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery - Pediatric Surgery Division - São Paulo (SP), Brazil
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Éboli LPDCB, Tannuri ACA, Tannuri U. Seropositivity for cytomegalovirus and PCR-EBV monitoring: Protective factors for posttransplant lymphoproliferative disorder in pediatric liver transplant. Pediatr Transplant 2022; 26:e14226. [PMID: 35037358 DOI: 10.1111/petr.14226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 12/26/2021] [Accepted: 12/27/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND PTLD is a clinical condition with high mortality. Monitoring EBV replication can be a useful tool to avoid the development of PTLD. MATERIALS AND METHODS This was a retrospective analysis of 428 pediatric patients who underwent liver transplantation between 1989 and 2016. The patients were divided into 2 groups (transplanted before 2006, when PCR-EBV was not monitored, and after 2006, when PCR-EBV monitoring was started). Patients with continuous PCR measurements for EBV were evaluated for the impact of a reduction in immunosuppression or a change in immunosuppressants on the number of viral copies. A logistic regression model was applied to evaluate factors related to PTLD. RESULTS The prevalence of PTLD was 4.2%. After monitoring patients with PCR for EBV levels, a predominance of the most severe, monomorphic form of lymphoproliferative disorder was observed (p = .009). The PTLD mortality was 5%. There was a change in the PCR level after tacrolimus reduction (p = .002) and after tacrolimus exchange for mTOR (p = .008). The number of EBV copies was significantly higher (p = .029) in patients who developed PTLD. In the multiple regression model, seropositivity for CMV was an independent protective factor for lymphoproliferative disorder (OR=0.09; 95% CI 0.02-0.42), reducing the chance of having PTLD adjusted by serology for EBV by 91%. CONCLUSIONS Monitoring the EBV viral load by PCR seems to prevent the emergence of milder forms of lymphoproliferative disorder. Pretransplant seropositivity for CMV is a protective factor for PTLD.
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Affiliation(s)
| | - Ana Cristina Aoun Tannuri
- Pediatric Liver Transplant Department, Instituto da Criança da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Liver Transplant Department, Instituto da Criança da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Del Bigio JZ, Tannuri ACA, Falcão MC, de Carvalho WB, Matsushita FY. Gastroschisis and late-onset neonatal sepsis in a tertiary referral center in Southeastern Brazil. J Pediatr (Rio J) 2022; 98:168-174. [PMID: 34153237 PMCID: PMC9432041 DOI: 10.1016/j.jped.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To analyze late-onset sepsis and to describe the etiological agents in newborns with gastroschisis. METHODS A retrospective cohort, including newborns with gastroschisis whose admissions occurred in the period between January 2012 to December 2018 in a tertiary referral center. Maternal and newborn characteristics, surgical procedures and evolution in hospitalization were verified. A bivariate analysis was performed with patients with proven late-onset neonatal sepsis and according to the simple or complex gastroschisis category, the prevalent microorganisms in positive cultures were identified, statistical tests were carried out and the significance level adopted was p < 0,05. Results are presented in proportions, averages and standard deviation or medians. The level of significance adopted was p < 0.05. RESULTS 101 newborns were analyzed, 45 (44.5%) were confirmed late-onset sepsis. The median birth weight was 2285+498 grams, and the gestational age was 35.9 +1.74weeks. The incidence of complex gastroschisis was 17.8%, the hospitalization time was 48.2+29.67 days and mortality was 9.9%. The newborns were divided into 2 groups: Group 1: late-onset sepsis (44.6%), and Group 2: no late-onset sepsis. The presence of complex gastroschisis was a factor associated with infection (p < 0.009). Fasting time (p < 0.001), parenteral nutrition time (p < 0.001), time to achieve full diet (p < 0.001), and hospitalization stay (p < 0.001) were higher in group 2. Gram-positive were the most frequent (51.1%), followed by Gram-negative (20%), and fungi (4.4%). CONCLUSIONS Newborns with gastroschisis have a higher risk of evolving with late-onset sepsis, despite this study did not calculate the risk of sepsis statistically, and the main germs detected by cultures were gram-positive bacteria, specifically Staphylococcus epidermidis.
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Affiliation(s)
- Juliana Zoboli Del Bigio
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança e do Adolescente, Unidade de Terapia Intensiva Neonatal, São Paulo, SP, Brazil.
| | - Ana Cristina Aoun Tannuri
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Divisão de Cirurgia Pediátrica, São Paulo, SP, Brazil
| | - Mário Cícero Falcão
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança e do Adolescente, Unidade de Terapia Intensiva Neonatal, São Paulo, SP, Brazil
| | - Werther Brunow de Carvalho
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança e do Adolescente, Unidade de Terapia Intensiva Neonatal, São Paulo, SP, Brazil
| | - Felipe Yu Matsushita
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança e do Adolescente, Unidade de Terapia Intensiva Neonatal, São Paulo, SP, Brazil
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Falcão MC, Castro GIMD, Framil JVDS, Bigio JZD, Tannuri ACA. Profilaxia com lock de etanol em cateter venoso central de longa permanência em crianças com disfunção intestinal grave: relato de seis casos. J Vasc Bras 2022; 21:e20210221. [PMID: 35911477 PMCID: PMC9296061 DOI: 10.1590/1677-5449.202102211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/09/2022] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to report on use of ethanol lock in long-term catheters in newborns with severe intestinal dysfunction, dependent on total and prolonged parenteral nutrition, in a Neonatal Intensive Care Center (tertiary level), between 2015 and 2020. Six infants (0.65%) out of the 914 admitted during the period met the inclusion criteria. The median age at catheter placement was 121.5 days. Two Powerpicc (PICC Power Sinergy™, São Paulo), one Groshong (Groshong™ Central Venous Catheter BD, São Paulo), and three silicone catheters were used, all tunneled, and the median dwell duration was 182.5 days. Four patients had at least one episode of infection related to the central venous catheter, and Gram-positive, Gram-negative, and fungal agents were isolated. The median length of hospital stay was 555 days and mortality was 33.3%. The ethanol lock did not cause any side effects and was relatively effective in preventing infections related to the central venous catheter.
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12
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Falcão MC, Castro GIMD, Framil JVDS, Bigio JZD, Tannuri ACA. Ethanol lock prophylaxis in long-stay central venous catheters in children with severe intestinal dysfunction: a report of six cases. J Vasc Bras 2022. [DOI: 10.1590/1677-5449.202102212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract The aim of this study was to report on use of ethanol lock in long-term catheters in newborns with severe intestinal dysfunction, dependent on total and prolonged parenteral nutrition, in a Neonatal Intensive Care Center (tertiary level), between 2015 and 2020. Six infants (0.65%) out of the 914 admitted during the period met the inclusion criteria. The median age at catheter placement was 121.5 days. Two Powerpicc (PICC Power Sinergy™, São Paulo), one Groshong (Groshong™ Central Venous Catheter BD, São Paulo), and three silicone catheters were used, all tunneled, and the median dwell duration was 182.5 days. Four patients had at least one episode of infection related to the central venous catheter, and Gram-positive, Gram-negative, and fungal agents were isolated. The median length of hospital stay was 555 days and mortality was 33.3%. The ethanol lock did not cause any side effects and was relatively effective in preventing infections related to the central venous catheter.
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13
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Amaral RND, Tannuri ACA, Neri JMTR, Reis HDS, Gonçalves JO, Serafini S, Tannuri U. Wound healing in weaning, adult, and old rats with provoked incisional hernias. A comparative study. Clinics (Sao Paulo) 2022; 77:100106. [PMID: 36137344 PMCID: PMC9493376 DOI: 10.1016/j.clinsp.2022.100106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/14/2022] [Accepted: 08/29/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Incisional hernias are more frequent in adults than in children. It is hypothesized that a more efficient healing process in pediatric patients could explain this difference in incidence. Certain elements of healing such as neovascularization, degree of inflammation, percentage of mature and immature collagen, the proliferation of fibroblasts, and expression of certain genes could explain why healing in children is more efficient when compared to the adult and elderly populations. MATERIALS AND METHODS Seventy-one rats of 3 different age groups (weaning, adult, and old) underwent surgery with 3 different incisions (vertical, oblique, and horizontal). During the procedure, the skin and abdominal wall of the animal were sectioned and only the skin was sutured to mimic incisional hernia in the animals. Four weeks after surgery, the rats were euthanized, their skin was removed, and the extent of scar tissue formed in the muscle opening was measured. In addition, samples of the scar tissue were collected for histological, immunohistochemical, and molecular analyzes. Nine rats served as controls. RESULTS Shorter-length hernias were formed in weaning rats when compared to old ones when the surgical incision was horizontal (p = 0.03). There was a greater proliferation of fibroblasts in rats in the younger age groups, regardless of the type of incision. The Lox gene was more expressed in weaning rats with vertical and oblique incisions. CONCLUSIONS These differences could explain the better healing and lower incidence of hernias in the pediatric population, although this aspect requires further studies.
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Affiliation(s)
- Raphael Nogueira do Amaral
- Medical Researcher, Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ana Cristina Aoun Tannuri
- Professor, Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Junia Marielle Teixeira Rodrigues Neri
- Medical Researcher, Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Hugo de Souza Reis
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Josiane Oliveira Gonçalves
- Biologist, Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Suellen Serafini
- Biologist, Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Uenis Tannuri
- Head Professor, Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
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Torres RR, Tannuri ACA, Serafini S, Belon A, Gonçalves JO, Loreto CD, Tannuri U. Does Arterialization of Portal Vein Have Any Effects in Large-for-Size Liver Transplantation? Hemodynamic, Histological, and Biomolecular Experimental Studies. J INVEST SURG 2021; 35:1197-1207. [PMID: 34965813 DOI: 10.1080/08941939.2021.2021333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND In pediatric liver transplantation, the optimal size of the transplanted liver ranges between 0.8% and 4.0% of the recipient's weight. Sometimes, the graft weight exceeds this upper limit, characterizing the large-for-size condition potentially associated with reduced blood flow and worsening of ischemia-reperfusion injury. Therefore, it would be beneficial to increase the portal flow through arterialization of the portal vein. Materials and methods: Fifteen pigs underwent large-for-size liver transplants. They were divided into two groups: control (CTRL 6 animals - conventional technique) and arterialization - a shunt was established between the portal vein and the splenic artery (ART 9 animals). Hemodynamic, biochemical, histological, and molecular variables were compared. Results: Arterialization resulted in a significant increase in portal vein pressure but no changes in other hemodynamic variables, as shown in the analysis of variance. It was observed lower ALT values (p = 0.007), with no differences regarding the values of blood pH and lactate (p = 0.54 and p = 0.699 respectively) or histological variables (edema, steatosis, inflammation, necrosis, and IRI - p = 1.0, p = 0.943, p = 0.174, p = 0.832, p = 0.662, respectively). The molecular studies showed significantly increased expression of IL6 after 3 hours of reperfusion (p = 0.048) and decreased expression of ICAM immediately after reperfusion (p = 0.03). The regression analysis suggested a positive influence of portal flow and pressure on biochemical parameters. Conclusion: Arterialization of the portal vein showed no histological, biochemical, or molecular benefits in large-for-size transplantation.
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Affiliation(s)
- Rafael Rodrigues Torres
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Suellen Serafini
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alessandro Belon
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Josiane Oliveira Gonçalves
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Celso di Loreto
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
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Bigio JZD, Falcão MC, Tannuri ACA. GROWTH ANALYSIS OF PRETERM NEWBORNS WITH GASTROSCHISIS DURING HOSPITALIZATION IN A NEONATAL INTENSIVE CARE UNIT. Arq Gastroenterol 2021; 58:504-508. [PMID: 34909857 DOI: 10.1590/s0004-2803.202100000-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/18/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Gastroschisis, especially complex type, prematurity and low birth weight are associated with a worse clinical outcome with higher mortality, higher incidence of sepsis and catheter-related infection, cholestasis, short bowel syndrome, greater number of days to achieve full diet, longer time of parenteral nutrition and longer hospitalization time. OBJECTIVE To evaluate the growth of preterm newborns with gastroschisis during their hospitalization in the neonatal intensive care unit. METHODS Descriptive study, based on a retrospective cohort (January 2012 to December 2018), including preterm newborns (gestational age less than 37 weeks) with simple and complex gastroschisis admitted in a tertiary neonatal intensive care unit. The following parameters were analyzed: maternal age, parity, type of delivery, birth weight, gender, gestational age, nutritional adequacy, type of gastroschisis, fasting time, parenteral nutrition time, time until achieving full enteral nutrition, hospitalization time, weight gain and outcome. The results were expressed in percentage, average, and median. RESULTS A total of 101 newborns with gastroschisis were admitted, of which 59.4% were premature (80.7% of late preterm infants). From the maternal data, the mean age was 21.2 years and 68.3% were primiparous. Regarding childbirth: 80% were cesarean sections. From newborns: the average birth weight was 2137 g, 56.6% were female, the average gestational age was 34.8 weeks, the average weight gain was 20.8 g/day during hospitalization and 83.3% were discharged from the hospital. CONCLUSION The growth analysis by weight gain (grams/day) during hospitalization in the intensive care unit showed that more than 90% of the sample presented acceptable or adequate weight gain.
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Affiliation(s)
- Juliana Zoboli Del Bigio
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Instituto da Criança, São Paulo, SP, Brasil
| | - Mário Cícero Falcão
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Instituto da Criança, São Paulo, SP, Brasil
| | - Ana Cristina Aoun Tannuri
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Instituto da Criança, São Paulo, SP, Brasil
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Tannuri ACA, Chavez LS, Guimarães JX, Gonçalves JDO, Serafini S, Souza GCD, Malheiros DMAC, Paes VR, Tannuri U. Cardiac and renal effects of liver cirrhosis in a growing animal model. Acta Cir Bras 2021; 36:e360806. [PMID: 34644774 PMCID: PMC8516424 DOI: 10.1590/acb360806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/02/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To assess the biochemical, histological, histomorphometric and molecular effects of biliary duct ligation (BDL) induced liver cirrhosis in the heart and kidneys. METHODS Thirty-two weaning rats (21 days old, 50-70 g) underwent BDL and were divided in four groups (euthanasia after two, four, six, and eight weeks, respectively) and compared to control groups. RESULTS The animals' hearts of group 3 were bigger than those of the control group (p=0.042), including thinner right ventricle wall, decreased internal diameter of ventricles, and increased perivascular collagen deposition in left ventricle, as well as increased interstitial collagen in right ventricle after six weeks. In the kidneys of groups 3 and 4, bilirubin impregnation in the tubules, hydropic degeneration, loss of nuclei and lack of plasmatic membrane limits were noted. Nitric oxide synthase (NOS) gene expressions were higher in group 1 (p=0.008), and endothelial nitric oxide synthase (eNOS) gene expressions were elevated in all experimental groups (p=0.008, p=0.001, p=0.022, and p=0.013, respectively). In the heart, a decreased expression of eNOS in group 1 (p=0.04) was observed. CONCLUSIONS Liver cirrhosis leads to histological and histomorphometric alterations in the heart and kidneys, with changes in the NOS and eNOS gene expressions, that may suggest a role in the associated myocardial and renal manifestations.
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Mussolino AFJ, Tannuri ACA, Gonçalves JDO, Serafini S, Tannuri U. Adaptation Processes of the Remaining Jejunum or Ileum after Extensive Intestinal Resection. J INVEST SURG 2021; 35:793-800. [PMID: 34583613 DOI: 10.1080/08941939.2021.1963355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To compare the adaptation processes of the remaining jejunum or ileum after extensive intestinal resection in a growing animal model. MATERIALS AND METHODS Forty 21-day old rats were divided into four groups: JG: remaining jejunum group - ileal enterectomy; IG: ileum remaining group - jejunum enterectomy; SHAM: sham-operated group - open-and-close laparotomy; and NO: non-operated animals. RESULTS After 3 weeks, JG and IG animals had decreased weights comparing to SHAM and NO animals (p = 0.017 and p = 0.005, respectively). The histomorphometric analysis showed that in JG animals the villi were higher than in SHAM, NO, and IG animals (p = 0.007, p = 0.008, and p = 0.01), the depth of crypts in JG and IG animals was greater than in NO and SHAM animals (p = 0.03, p = 0.002, and p = 0.003 respectively), and muscle layer thickness of the jejunum of JG animals had values greater than SHAM and NO animals (p = 0.01 and p = 0.02, respectively). The Ki-67 expression in the ileum was higher in comparison with the jejunum (p = 0.014). The pro-apoptotic gene (Bax) expression was decreased in JG animals compared to IG, SHAM, and NO animals (p = 0.013, p = 0.024, and p = 0.021). The anti-apoptotic gene (Bcl-XL) expression was decreased in JG animals in comparison to IG and NO animals (p = 0.002 and p = 0.046) although it was increased in the colon of IG animals in comparison to JG, SHAM, and NO animals (p = 0.002, p = 0.001, and p = 0.001, respectively). The Bax/Bcl-XL ratio was higher in JG than in IG animals (p = 0.011). CONCLUSION Adaptive responses seemed to be more effective in the ileum than in the jejunum.
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Affiliation(s)
- Affonso Flávio Jorge Mussolino
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Josiane de Oliveira Gonçalves
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Suellen Serafini
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
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18
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Belon AR, Tannuri ACA, de Albuquerque Rangel Moreira D, Figueiredo JL, da Silva AM, Serafini S, Guimarães RR, Faria CS, de Alexandre AS, Gonçalves JO, Paes VR, Tannuri U. Impact of Three Methods of Ischemic Preconditioning on Ischemia-Reperfusion Injury in a Pig Model of Liver Transplantation. J INVEST SURG 2021; 35:900-909. [PMID: 34180750 DOI: 10.1080/08941939.2021.1933274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ischemic preconditioning (IPC), either direct (DIPC) or remote (RIPC), is a procedure aimed at reducing the harmful effects of ischemia-reperfusion (I/R) injury. OBJECTIVES To assess the local and systemic effects of DIPC, RIPC, and both combined, in the pig liver transplant model. MATERIALS AND METHODS Twenty-four pigs underwent orthotopic liver transplantation and were divided into 4 groups: control, direct donor preconditioning, indirect preconditioning at the recipient, and direct donor with indirect recipient preconditioning. The recorded parameters were: donor and recipient weight, graft-to-recipient weight ratio (GRWR), surgery time, warm and cold ischemia time, and intraoperative hemodynamic values. Blood samples were collected before native liver removal (BL) and at 0 h, 1 h, 3 h, 6 h, 12 h, 18 h, and 24 h post-reperfusion for the biochemical tests: aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), creatinine, BUN (blood urea nitrogen), lactate, total and direct bilirubin. Histopathological examination of liver, gut, kidney, and lung fragments were performed, as well as molecular analyses for expression of the apoptosis-related BAX (pro-apoptotic) and Bcl-XL (anti-apoptotic) genes, eNOS (endothelial nitric oxide synthase) gene, and IL-6 gene related to inflammatory ischemia-reperfusion injury, using real-time polymerase chain reaction (RT-PCR). RESULTS There were no differences between the groups regarding biochemical and histopathological parameters. We found a reduced ratio between the expression of the BAX gene and Bcl-XL in the livers of animals with IPC versus the control group. CONCLUSIONS DIPC, RIPC or a combination of both, produce beneficial effects at the molecular level without biochemical or histological changes.
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Affiliation(s)
- Alessandro Rodrigo Belon
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Daniel de Albuquerque Rangel Moreira
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Jose Luiz Figueiredo
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alessandra Matheus da Silva
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Suellen Serafini
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Raimundo Renato Guimarães
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Caroline Silverio Faria
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alcione Sanches de Alexandre
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Josiane Oliveira Gonçalves
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Vitor Ribeiro Paes
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Laboratory of Experimental Surgery (LIM26), Department of Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
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Tannuri ACA, Angelo SS, Takyi P, da Silva AR, Tannuri U. Esophageal substitution or esophageal elongation procedures in patients with complicated esophageal atresia? Results of a comparative study. J Pediatr Surg 2021; 56:933-937. [PMID: 32838973 DOI: 10.1016/j.jpedsurg.2020.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/15/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND In newborns with complex esophageal atresia, there are situations in which a primary anastomosis cannot be safely performed. The alternative is performing a late anastomosis after the esophageal ends have gone through a period of spontaneous growth or after elongations of the distant ends of the esophagus and create an anastomosis under tension which causes risks of morbidity. An alternative to the elongation procedures is to perform a cervical esophagostomy with a gastrostomy for nutritional support and later on an esophageal replacement. The purposes of this retrospective chart review study are to report on our experience with esophageal substitution procedures in such cases, address the quality of life of a group of patients, and compare our results with those of patients who underwent esophageal elongation procedures as reported in the literature. METHODS Patients with esophageal atresia underwent esophageal replacement procedures and quality of life was assessed in a group of esophagocoloplasty patients. RESULTS From February 1978 to July 2019, 276 children (232 colonic interpositions and 44 total gastric transpositions) were studied; the most frequent complication was cervical anastomosis leakage [70 (30.2%) esophagocoloplasty patients and 7 (15.9%) gastric transposition patients], which sealed spontaneously in all but 4 patients. The quality of life was considered excellent or good in approximately 90% of the studied 70 out of the 276 patients; the comparison with the esophageal elongation procedures showed that esophageal substitution procedures promoted excellent long-term results with normal deglutition function (98.2% of patients, versus 33.3%, 36.5%, and 62.5%, respectively from the elongation series, P <0.0001 for all comparisons). CONCLUSION Esophagocoloplasty or total gastric transposition is a good alternative to treat patients with complex esophageal atresia. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Simone Santoro Angelo
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Priscilla Takyi
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Armando Ribeiro da Silva
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Tannuri ACA, Escobar AMDU, Gomes FMDS, Tannuri U, Grisi SJFE. Lessons learned about teaching and medical care at the Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da USP during the COVID-19 pandemic. Clinics (Sao Paulo) 2021; 76:e3579. [PMID: 34878036 PMCID: PMC8610215 DOI: 10.6061/clinics/2021/e3579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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21
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Van Vaisberg V, Tannuri ACA, Lima FR, Tannuri U. Ileal exclusion for pruritus treatment in children with progressive familial intrahepatic cholestasis and other cholestatic diseases. J Pediatr Surg 2020; 55:1385-1391. [PMID: 31708211 DOI: 10.1016/j.jpedsurg.2019.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/02/2019] [Accepted: 09/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pruritus is a major health-related quality-of-life burden in progressive familial intrahepatic cholestasis (PFIC) and other childhood cholestatic liver diseases. Several nontransplant surgical techniques were developed in an attempt to ameliorate symptoms and slow disease progression. Very few case-series have been published on a particular intervention, ileal exclusion (IE), which has been considered to be inferior to the other approaches. METHODS We conducted a single-center retrospective chart-review case-series of patients submitted to IE as the first-line surgical treatment at our institution from 1995 to 2018. The primary goal was pruritus relief, followed by survival with the native liver and improvement in biochemical parameters. RESULTS Eleven patients were submitted to IE, with a mean follow-up of 60 months. Complete resolution or significant reduction of pruritus was obtained in 72.7% (n = 8) of patients. One patient (9.1%) had a major postoperative complication that required surgery. No other morbidities were reported. Two cases progressed to end-stage liver disease (ESLD) within the short-term and one year after surgery. CONCLUSIONS This case series study shows that IE provided excellent results in pruritus control and permitted survival with the native liver. We believe IE is a safe procedure, with few associated morbidities, and should be considered more often as primary surgical treatment for PFIC and other cholestasis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Victor Van Vaisberg
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Fabiana Roberto Lima
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Tannuri U, Tannuri ACA, Cordon MNDA, Miyatani HT. Low incidence of COVID-19 in children and adolescent post-liver transplant at a Latin American reference center. Clinics (Sao Paulo) 2020; 75:e1986. [PMID: 32520226 PMCID: PMC7247737 DOI: 10.6061/clinics/2020/e1986] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Uenis Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Ana Cristina Aoun Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Mariana Nutti de Almeida Cordon
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Helena Thie Miyatani
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
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de Moraes PAD, Tannuri ACA, Rios LM, Paes VR, Gonçalves JDO, Serafini S, Tannuri U. Sepsis and cirrhosis in growing animals: description of a new experimental model and its pathological and immunological reliability. Clinics (Sao Paulo) 2020; 75:e1858. [PMID: 32997081 PMCID: PMC7510946 DOI: 10.6061/clinics/2020/e1858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/29/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES In cirrhotic children, infection events and sepsis are more frequent and more severe due to immune dysfunction. The objectives of the current study were therefore to develop an experimental model of infection and sepsis in cirrhotic weaning growing rats, by the use of bile duct ligation (BDL) and cecal ligation and puncture (CLP). Additionally, the correlation of the clinico-histopathological data and serial cytokine levels in septic cirrhotic and non-cirrhotic animals was studied. METHODS Young Wistar rats of age 21 days and of weight between 70-90 g were divided into 12 groups according to the surgical procedure performed: sham (sacrificed after 2 or 4 weeks), BDL (sacrificed after 2 or 4 weeks), CLP (2- or 4-week old animals sacrificed after 12 or 24 hours), BDL+CLP (2- or 4-week old animals sacrificed after 12 hours). Histopathological studies and determination of serum levels of cytokines IL-1 beta, IL-10, and TNF-alpha, for studies of systemic infection, were performed. Murine sepsis scores (MSS) based on the clinical aspects just before euthanasia were also included. RESULTS A transitory increase in IL-1, IL-10, and TNF-alpha levels was observed, with different patterns according to the groups. Two-hit groups tended to present with higher values of serum cytokines and histopathological scores than their septic non-cirrhotic counterparts. There was a correlation between mortality rate and MSS (p<0.0001). CONCLUSION The model is feasible and may be utilized in studies on liver cirrhosis and infection in growing animals.
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Tannuri ACA, Hara LADA, Paganoti GDF, Andrade WDC, Tannuri U. Choledochal cysts in children: How to Diagnose and Operate on. Clinics (Sao Paulo) 2020; 75:e1539. [PMID: 32215454 PMCID: PMC7074585 DOI: 10.6061/clinics/2020/e1539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/18/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To identify the best mode for diagnosing and treating the patients with choledochal cysts. METHODS A retrospective study was performed with medical records of patients diagnosed with choledochal cysts from January 1994 to December 2017. In all cases, the diagnosis was based on ultrasound examination. All the patients underwent cyst resection and were divided in two groups: bile enteric anastomosis in the high portion of the common hepatic duct or in the dilated lower portion. RESULTS Eighty-one cases were studied. The age of presentation was 4 y 2 mo ± 4 y 1 mo, and the age for the surgical treatment was 5 y 5 mo ± 4 y 6 mo. In 61 cases, US was the only image examination performed. There were 67 cases of Todani type I (82.7%), 13 cases of type IV (16.0%) and one case of type III (1.2%). Nine patients (29.0%) in the first period and 2 patients (4.0%) in the second period presented with postoperative complications (p=0.016). CONCLUSION In patients with choledochal cysts, US is the only necessary diagnostic imaging. Performing the bile enteric anastomosis in the lower portion of the common hepatic duct is safer and has a lower risk of complications.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Lucas Arjona de Andrade Hara
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Guilherme de Freitas Paganoti
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Wagner de Castro Andrade
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Uenis Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
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de Freitas Paganoti G, Tannuri ACA, Dantas Marques AC, Torres RR, Mendes Gibelli NE, Tannuri U. Extensive Hepatectomy as an Alternative to Liver Transplant in Advanced Hepatoblastoma: A New Protocol Used in a Pediatric Liver Transplantation Center. Transplant Proc 2019; 51:1605-1610. [PMID: 31155201 DOI: 10.1016/j.transproceed.2019.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Surgery is a key factor in the treatment of hepatoblastoma, but choosing between an aggressive resection and liver transplant may be an extremely difficult task. The aim of this study was to describe the outcomes of patients with advanced hepatoblastoma: pretreatment extent of disease (PRETEXT)/post-treatment extent of disease (POST-TEXT) III and IV undergoing aggressive resections or living donor liver transplant in cases involving the entire liver. Based on this experience, a new protocol for the treatment of these patients was proposed. METHODS A retrospective study included patients with advanced hepatoblastoma (POST-TEXT III and IV) who were referred for a liver transplant from 2010 to 2017. RESULTS A total of 24 children were included: 13 (54.2%) were male, with a median age at diagnosis of 42 months (range, 15-120 months), and a history of prematurity was identified in 20.8% of the patients. Ten cases (41.7%) were staged as PRETEXT/POST-TEXT III, and 12 cases (50.0%) were staged as PRETEXT/POST-TEXT IV. Two patients were referred after posthepatectomy recurrence. Five patients underwent a liver transplant, with recurrence and death in 2 patients (40.0%) within a mean period of 6 months. In the extensive hepatectomy group, there was recurrence in 6 patients (31.6%), with disease-free outcomes and overall survival in 63.2% and 94.7% of patients, respectively. CONCLUSION In cases of advanced hepatoblastoma, an extensive surgical approach is a valuable option. The fact that the team was fully prepared to proceed with living donor liver transplant allowed the surgeon to be more aggressive and to switch to transplantation when resection was not possible.
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Affiliation(s)
- G de Freitas Paganoti
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - A C A Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - A C Dantas Marques
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - R R Torres
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - N E Mendes Gibelli
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - U Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Passos ACV, Barros FD, Damiani D, Semer B, Cespedes WCJ, Sannicola B, Tannuri ACA, Tannuri U. Hypothyroidism associated with short bowel syndrome in children: a report of six cases. Arch Endocrinol Metab 2019; 62:655-660. [PMID: 30624508 PMCID: PMC10118669 DOI: 10.20945/2359-3997000000093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/31/2018] [Indexed: 11/23/2022]
Abstract
Short bowel syndrome (SBS) is the leading cause of intestinal failure in children, a condition of absence of sufficient bowel to meet the nutritional and metabolic needs of a growing individual. The treatment of patients in this situation is based on the association of parenteral and enteral nutrition for prolonged periods of time until intestinal rehabilitation occurs with complete enteral nutrition autonomy. Six consecutive cases of children with SBS (residual intestinal length of 5 cm to 75 cm) were managed with this program and were diagnosed with associated hypothyroidism during the treatment (ages at the diagnosis 5 months to 12 years). All patients were successfully treated with oral hormone reposition therapy and in one patient, the replacement was performed via rectal enemas due to a complete absence of small bowel. Although iodine deficiency associated to long-term parenteral nutrition is a well-known condition, this is the first report in the literature about an expressive number of patients with hypothyroidism detected in patients with SBS during the prolonged treatment for intestinal rehabilitation.
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Affiliation(s)
- Ananda Castro Vieira Passos
- Serviço de Cirurgia Pediátrica e Transplante Hepático, Laboratório de Investigação em Cirurgia Pediátrica (LIM-30), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Fábio de Barros
- Serviço de Cirurgia Pediátrica e Transplante Hepático, Laboratório de Investigação em Cirurgia Pediátrica (LIM-30), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Durval Damiani
- Unidade de Endocrinología Pediátrica, Divisão de Pediatria, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP Brasil
| | - Beatriz Semer
- Unidade de Endocrinología Pediátrica, Divisão de Pediatria, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP Brasil
| | - Wendy Cira Justiniano Cespedes
- Unidade de Endocrinología Pediátrica, Divisão de Pediatria, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP Brasil
| | - Bruna Sannicola
- Unidade de Endocrinología Pediátrica, Divisão de Pediatria, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP Brasil
| | - Ana Cristina Aoun Tannuri
- Serviço de Cirurgia Pediátrica e Transplante Hepático, Laboratório de Investigação em Cirurgia Pediátrica (LIM-30), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Uenis Tannuri
- Serviço de Cirurgia Pediátrica e Transplante Hepático, Laboratório de Investigação em Cirurgia Pediátrica (LIM-30), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
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Osmundo Junior GDS, Mohamed SHM, Nishie EN, Tannuri ACA, Gibelli MABC, Francisco RPV, Brizot MDL. Association of spontaneous labor onset with neonatal outcomes in pregnancies with fetal gastroschisis: A retrospective cohort analysis. Acta Obstet Gynecol Scand 2018; 98:154-161. [PMID: 30264855 DOI: 10.1111/aogs.13473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/21/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The present study aims to investigate the association of spontaneous labor onset with neonatal outcomes in pregnancies with fetal gastroschisis. The secondary goal was to evaluate the association between ultrasound markers and labor onset in pregnancies with fetal gastroschisis. MATERIAL AND METHODS A retrospective analysis was performed for 207 pregnancies with fetal gastroschisis between 2005 and 2017. Patients were followed according to a strict protocol involving ultrasound scans and routine evaluations of fetal biophysical profile parameters and intra- and extra-abdominal bowel diameters. Labor, delivery and neonatal records were reviewed. The neonatal outcomes were complex gastroschisis, staged surgical closure of the abdominal defect, short bowel syndrome, time on mechanical ventilation, time to full enteral feeding and necrotizing enterocolitis. RESULTS Spontaneous labor onset was associated with complex gastroschisis (30.7% vs 6.8%, P = 0.002) and short bowel syndrome (13.2% vs none, P = 0.013) in cases with spontaneous preterm delivery compared with the indicated preterm deliveries. Spontaneous labor onset was associated with a longer time on mechanical ventilation for term and preterm newborns. Associations were not observed between ultrasound markers and spontaneous labor onset. CONCLUSIONS Spontaneous labor onset in pregnancies with fetal gastroschisis was associated with adverse neonatal outcomes, particularly in those born preterm.
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Affiliation(s)
| | | | - Estela Naomi Nishie
- Department of Obstetrics and Gynecology, Hospital das Clínicas, São Paulo University Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Division of Pediatric Surgery, Department of Pediatrics, São Paulo University Medical School, Sao Paulo, Brazil
| | - Maria Augusta Bento Cicaroni Gibelli
- Division of Neonatology, Department of Pediatrics, Hospital das Clínicas, São Paulo University Medical School, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Maria de Lourdes Brizot
- Department of Obstetrics and Gynecology, Hospital das Clínicas, São Paulo University Medical School, Sao Paulo, Brazil
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Tannuri ACA, Rotondo ÍG, Barros GG, Van Vaisberg V, Mendes-Neto C, Paes VR, Coelho MCM, Gonçalves J, Serafini S, Tannuri U. Are there differences in the growth adaptation processes of growing and mature organism models of short bowel syndrome? Clinics (Sao Paulo) 2018; 73:e499. [PMID: 30365828 PMCID: PMC6178875 DOI: 10.6061/clinics/2018/e499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/17/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The purpose of this study was to present an experimental model of short bowel syndrome (SBS) in weaning rats and to compare the adaptative mechanisms of the remaining bowel in weaning rats and adult animals by means of morphometric, histologic and molecular methods. METHODS Twenty-four weaning rats were divided into 3 groups of 8 animals, one control group and two short bowel groups (euthanasia after 4 and 21 days), and were compared with similar adult groups. Morphometric evaluations of the animals and histopathological and molecular studies of the remaining bowel were performed. RESULTS The weight of young rats increased after enterectomy, whereas that of adult rats decreased after enterectomy (p<0.0001). The ratio of intestinal length/body weight was significantly higher in weaning rats than in adults (p<0.002), showing that intestinal growth was more intense in weaning rats. Intestinal resection promoted increased thickness of the small bowel lamina propria (p=0.001) and reduced thickness of the colon lamina propria (p=0.04) in weaning rats relative to those in adults. In addition, intestinal resection promoted increased expression of the Bcl-xl gene (antiapoptotic) in adult animals compared with that in weaning rats (p=0.001). CONCLUSION Morphometric, histological and molecular differences were shown in the adaptation processes of growing and mature organisms.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ítalo Geraldo Rotondo
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Guilherme Garcia Barros
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Victor Van Vaisberg
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Cícero Mendes-Neto
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vitor Ribeiro Paes
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Cecilia Mendonça Coelho
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Josiane Gonçalves
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Suellen Serafini
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Uenis Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Andrade WDC, Silva MM, Tannuri ACA, Santos MM, Gibelli NEM, Tannuri U. Current management of biliary atresia based on 35 years of experience at a single center. Clinics (Sao Paulo) 2018; 73:e289. [PMID: 29995099 PMCID: PMC6024511 DOI: 10.6061/clinics/2018/e289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 01/08/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The prognosis of patients with biliary atresia undergoing Kasai portoenterostomy is related to the timing of the diagnosis and the indication for the procedure. The purpose of the present study is to present a practical flowchart based on 257 children who underwent Kasai portoenterostomy. METHODS We conducted a retrospective cohort study of patients who underwent Kasai portoenterostomy between 1981 and 2016. RESULTS During the first period (1981 to 2009), 230 infants were treated, and the median age at the time of surgery was 84 days; jaundice was resolved in 77 patients (33.5%). During the second period, from 2010 to 2016, a new diagnostic approach was adopted to shorten the wait time for portoenterostomy; an ultrasonography examination suggestive of the disease was followed by primary surgical exploration of the biliary tract without complementary examination or liver biopsy. Once the diagnosis of biliary atresia was confirmed, a portoenterostomy was performed during the same surgery. During this period, 27 infants underwent operations; the median age at the time of surgery was 66 days (p<0.001), and jaundice was resolved in 15 patients (55.6% - p=0.021), with a survival rate of the native liver of 66.7%. CONCLUSION Primary surgical exploration of the biliary tract without previous biopsy was effective at improving the prognostic indicators of patients with biliary atresia undergoing Kasai portoenterostomy.
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Affiliation(s)
- Wagner de Castro Andrade
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marcos Marques Silva
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ana Cristina Aoun Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Merces Santos
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Nelson Elias Mendes Gibelli
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Uenis Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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de Aro Braz MJ, Corbi LE, Tannuri ACA, Coelho MCM, Gonçalves JO, Serafini S, Tannuri U. Analysis of the reversibility of biliary cirrhosis in young rats submitted to biliary obstruction. J Pediatr Surg 2018; 53:1408-1413. [PMID: 28889961 DOI: 10.1016/j.jpedsurg.2017.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/09/2017] [Accepted: 08/16/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Biliary atresia and other liver biliary obstructions are relevant conditions in pediatric surgery due to their progression to biliary cirrhosis and indication for liver transplantation. It is known that the period during which biliary obstruction persists determines the development of cirrhosis and its reversibility after a biliary drainage procedure. However, no time or histological markers of biliary cirrhosis reversibility have been established. MATERIALS AND METHODS One hundred and twenty-nine young Wistar rats underwent surgery for ligation of the common bile duct and were maintained until 8weeks. A part of these animals was submitted to biliary drainage surgery at 2, 3, 4, 5, or 6weeks after the initial procedure. After cyst formation at the site of obstruction, cyst-jejunal anastomosis was performed to restore bile flow. After biliary obstruction and drainage, liver samples were collected for histological and molecular analysis of the genes responsible for collagen deposition and fibrosis. RESULTS The mortality rates were 39.8% and 56.7% after the first and second procedures, respectively. Ductular proliferation (p=0.001) and collagen deposition increased according to the period under obstruction (p=0.0001), and both alterations were partially reduced after biliary drainage. There were no significant differences in the values of desmin and α-actin according to the period during which the animal remained with biliary obstruction (p=0.09 and p=0.3, respectively), although increased values of transforming growth factor beta 1 (TGFβ1) occurred after 8weeks (p=0.000). Desmin levels decreased, and α-actin and TGFβ1 levels increased according to the period under obstruction. The molecular alterations were partially reversed after biliary drainage. CONCLUSIONS The histologic and molecular changes in the liver parenchyma promoted by biliary obstruction in the young animal can be partially reversed by a biliary drainage procedure.
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Affiliation(s)
- Maria Julia de Aro Braz
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Leonardo Ervolino Corbi
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Maria Cecília Mendonça Coelho
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Josiane Oliveira Gonçalves
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Suellen Serafini
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Serafini S, Santos MM, Aoun Tannuri AC, Zerbini MCN, de Mendonça Coelho MC, de Oliveira Gonçalves J, Tannuri U. Is hematoxylin-eosin staining in rectal mucosal and submucosal biopsies still useful for the diagnosis of Hirschsprung disease? Diagn Pathol 2017; 12:84. [PMID: 29212517 PMCID: PMC5719668 DOI: 10.1186/s13000-017-0673-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 11/23/2017] [Indexed: 11/21/2022] Open
Abstract
Background Hematoxylin-eosin (HE) staining of a full-thickness rectal wall fragment is classically used for the diagnosis of Hirschsprung disease (HD). However, this technique requires large fragments for a better diagnosis. Additionally, the histochemical and immunohistochemical methods of staining small fragments of rectal mucosal and submucosal biopsies are not available in all centers. Therefore, the possibility of diagnosing HD through HE staining in these biopsies could be a valuable alternative for centers that do not have more specific techniques. The objectives of the current investigation were to evaluate the concordance of the results obtained by HE staining and the calretinin method with acetylcholinesterase (AChE) activity in fragments of mucosa and submucosa in the diagnosis of HD. Methods For this study, 50 cases from our laboratory were selected. The tissue material was embedded in paraffin. Sixty levels of each fragment were utilized for HE, and the other 3 levels were used for calretinin. These slides were analyzed under the microscope, photographed and classified as either positive for HD when no ganglion cells were found with nerve trunks present or as negative when ganglion cells were found. The results from reading the slides were compared with those of AChE. Results Of the 50 cases evaluated by the HE technique, only 5 contradicted the diagnosis based on AChE, with a Kappa value of 0.800 and an accuracy of 90%. In the comparison between calretinin and AChE, 8 cases were discordant, with a Kappa value of 0.676 and an accuracy of 84%. Conclusions The concordance of results from AChE and HE methods was satisfactory, allowing for the potential use of the HE method for fragments of mucosa and submucosa as a valid alternative in the diagnosis of HD. The immunohistochemical technique of calretinin did not show good agreement with the AChE activity in our study.
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Affiliation(s)
- Suellen Serafini
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil. .,Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Avenida Dr. Arnaldo 455, 4º andar sala 4108, CEP: 01246-903, São Paulo, SP, Brazil.
| | - Maria Mercês Santos
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Maria Cecília de Mendonça Coelho
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Josiane de Oliveira Gonçalves
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
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Tannuri ACA, de Albuquerque Rangel Moreira D, Belon A, Coelho MCM, Gonçalves JO, Serafini S, Tannuri U. Does a meso-caval shunt have positive effects in a pig large-for-size liver transplantation model? Pediatr Transplant 2017; 21. [PMID: 28436075 DOI: 10.1111/petr.12928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 02/06/2023]
Abstract
In pediatric liver transplantations with LFS grafts, higher incidences of graft dysfunction probably occur due to IRI. It was postulated that increasing the blood supply to the graft by means of a meso-caval shunt could ameliorate the IRI. Eleven pigs underwent liver transplantation and were divided into two groups: LFS and LFS+SHUNT group. A series of flowmetric, metabolic, histologic, and molecular studies were performed. No significant metabolic differences were observed between the groups. One hour after reperfusion, portal flow was significantly lower in the recipients than in the donors, proving that the graft was maintained in low portal blood flow, although the shunt could promote a transient increase in the portal blood flow and a decrease in the arterial flow. Finally, it was verified that the shunt promoted a decrease in inflammation and steatosis scores and a decrease in the expression of the eNOS gene (responsible for the generation of nitric oxide in the vascular endothelium) and an increase in the expression of the proapoptotic gene BAX. The meso-caval shunt was responsible for some positive effects, although other deleterious flowmetric and molecular alterations also occurred.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Daniel de Albuquerque Rangel Moreira
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alessandro Belon
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Maria Cecília Mendonça Coelho
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Josiane Oliveira Gonçalves
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Suellen Serafini
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
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de-Paula EM, Porta G, Tannuri ACA, Tannuri U, Befi-Lopes DM. Language assessment of children with severe liver disease in a public service in Brazil. Clinics (Sao Paulo) 2017; 72:351-357. [PMID: 28658434 PMCID: PMC5463267 DOI: 10.6061/clinics/2017(06)04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/10/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE: The aim of this research was to compare language development (expressive and receptive skills) in children awaiting liver transplantation with that of children who have already undergone the surgical procedure. METHODS: An observational, descriptive, cross-sectional study was conducted with 76 children divided into groups, as follows: 31 children who were candidates for liver transplantation (Group 1; G1), 45 children who had already undergone liver transplantation (Group 2; G2), and a control group (CG) of 60 healthy, normally developing children. Health status information was gathered, and the Test of Early Language Development (TELD)-3 was used to assess language skills. Family household monthly income data were also gathered using a specific questionnaire. RESULTS: G1 had poorer language performance compared with G2 and the CG. G2 had lower language performance when compared with the CG. However, when considering the TELD-3 standard scores, G2 had scores within normal limits. The regression analysis indicated age as a risk factor for language deficits in Group 1 and family income as a risk factor for language deficits in G2. CONCLUSIONS: The results suggested that children with chronic liver disease have delays in language development. Transplanted children have linguistic performance within normal limits, but their scores tended to be lower than the CG.
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Affiliation(s)
- Erica Macêdo de-Paula
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Gilda Porta
- Unidade de Hepatologia, Instituto da Crianca, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ana Cristina Aoun Tannuri
- Divisão de Cirurgia Pediatrica e Unidade de Transplante de Figado, Instituto da Crianca, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade Sao Paulo, Sao Paulo, SP, BR
| | - Uenis Tannuri
- Divisão de Cirurgia Pediatrica e Unidade de Transplante de Figado, Instituto da Crianca, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade Sao Paulo, Sao Paulo, SP, BR
| | - Debora Maria Befi-Lopes
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Tannuri ACA, Ferreira MAE, Mathias AL, Tannuri U. Long-term results of the Duhamel technique are superior to those of the transanal pullthrough: A study of fecal continence and quality of life. J Pediatr Surg 2017; 52:449-453. [PMID: 27836370 DOI: 10.1016/j.jpedsurg.2016.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/26/2016] [Accepted: 10/11/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND/PURPOSE The Duhamel and transanal pull-through (TAPT) techniques have been commonly used for the treatment of children with Hirschsprung disease (HD). However, despite adequate treatment, some patients present with fecal incontinence that severely affects the quality of life (QoL) and lead to psychiatric disorders. The objectives of the present study were to evaluate, through previously adapted questionnaires, the incidence of fecal incontinence and the quality of life (QoL) of children with HD who underwent Duhamel or TAPT techniques. In addition, we compared the incidence of fecal incontinence and QoL indices in these patients with those in healthy children. MATERIALS/METHODS The Fecal Continence Index (FCI) questionnaire and the questionnaire for the Assessment of Quality of Life in Children and Adolescents with Fecal Incontinence (AQLCAFI) were used in this study. A series of 41 patients with HD were divided into 2 groups according to the utilized surgical technique: the Duhamel group (20 patients) and the TAPT group (21 patients). The patients were compared with a control group of 59 healthy children. RESULTS In the control group, 25 (42.4%) children had good continence and 34 (57.6%) had normal continence. In contrast, among patients with HD, 4 (9.8%) had poor fecal continence, 11 (26.8%) had fair continence, 18 (43.9%) had good continence, and 8 (19.5%) had normal continence. The QoL of children with HD was globally impaired in all domains of the AQLCAFI as well as in the FCI, when compared with the QoL of healthy children (P=0.001). The comparison between children who underwent surgery with the Duhamel technique and those who underwent surgery with TAPT technique showed similar outcomes according to the FCI. However, the results were inferior in patients who underwent TAPT technique according to the AQLCAFI questionnaire (P=0.003), lifestyle (P=0.006), behavior (P=0.01), depression (P=0.01), and embarrassment (P=0.003). CONCLUSION The QoL and the FCI were impaired in patients who underwent surgery for correction of HD compared with healthy children; however, the impairment in QoL was greater in patients who underwent TAPT technique. LEVEL OF EVIDENCE 2B.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Arthur Loguetti Mathias
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Tannuri U, Barros FD, Tannuri ACA. Treatment of short bowel syndrome in children. Value of the Intestinal Rehabilitation Program. Rev Assoc Med Bras (1992) 2017; 62:575-583. [PMID: 27849236 DOI: 10.1590/1806-9282.62.06.575] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/26/2016] [Indexed: 12/13/2022] Open
Abstract
The main cause of acute intestinal failure is short bowel syndrome, generally as a result of resection of extensive segments of small intestine. As a result, the main symptoms are watery diarrhea, malabsorption syndrome, chronic malnutrition, and death, if the patient is not properly treated. If the length of the remaining intestine is greater than 30 cm, complete adaptation is possible and the patient may not require parenteral nutrition. The currently recommended treatment includes the use of prolonged parenteral nutrition and enteral nutrition, always aimed at constant weight gain, in conjunction with surgeries aimed at elongating the dilated bowel. This set of procedures constitutes what is called an Intestinal Rehabilitation Program. This therapy was used in 16 children in periods ranging from 8 months to 7.5 years, with survival in 75% of the cases. Finally, the last resort to be used in children with complete resection of the small bowel is an intestinal transplant. However, to date there is no record of a Brazilian child that has survived this procedure, despite it being attempted in seven patients. We conclude that the results of the intestinal rehabilitation program are encouraging for the continuation of this type of treatment and stimulate the creation of the program in other pediatric care institutions.
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Affiliation(s)
- Uenis Tannuri
- Full Professor, Department of Pediatric Surgery and Liver Transplant, Faculdade de Medicina, Universidade de São Paulo (FMUSP). Head of the Service of Pediatric Surgery and Liver Transplant at Instituto da Criança, Hospital das Clínicas, and of the Pediatric Surgery Research Laboratory, FMUSP. Head of the Laboratory of Pediatric Surgery at Hospital das Clínicas, FMUSP, São Paulo, SP, Brazil
| | - Fabio de Barros
- Physician, Service of Pediatric Surgery, Instituto da Criança, Hospital das Clínicas, FMUSP, São Paulo, SP, Brazil
| | - Ana Cristina Aoun Tannuri
- Associate Professor, Department of Surgical Technique and Experimental Surgery, FMUSP. Physician, Service of Pediatric Surgery, Instituto da Criança, Hospital das Clínicas, and the Pediatric Surgery Research Laboratory (LIM-30), FMUSP, São Paulo, SP, Brazil
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Tannuri ACA, Ferreira MAE, Mathias AL, Tannuri U. Long-term evaluation of fecal continence and quality of life in patients operated for anorectal malformations. Rev Assoc Med Bras (1992) 2016; 62:544-552. [DOI: 10.1590/1806-9282.62.06.544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/26/2016] [Indexed: 11/21/2022] Open
Abstract
Summary Introduction: Patients operated for correction of anorectal malformations (ARM) can develop fecal incontinence, constipation, and soiling, with loss in quality of life. Objective: To evaluate, through the use of questionnaires, fecal continence, and quality of life of children in the late postoperative follow-up of ARM correction, both high and low. In addition, the levels of fecal continence and quality of life were compared with those of a control group. Method: A Fecal Continence Index Questionnaire (ICF) and a Questionnaire for Assessment of Quality of Life Related to Fecal Continence in Children and Adolescents (QQVCFCA) were administered to 63 patients with ARM, aged from 7 to 19 years, whose surgical treatment had been completed for at least 6 months. The patients were compared to a control group of 59 children. Results: In the control group, 25 (42.4%) patients had good continence and 34 (57.6%), normal continence. We found that the quality of life in children with ARM is compromised globally, in all areas and in the ICF questionnaire, compared to controls (p<0.001). There was no difference between patients with high and low defects. Thirty-two (50.8%) patients had other associated anomalies. Conclusion: In patients operated for ARM correction, quality of life and ICF were compromised, and there was no difference between patients with high-type and low-type of the disease. In about half the cases there are other associated malformations.
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Tannuri ACA, Porta G, Kazue Miura I, Santos MM, Moreira DDAR, de Rezende NMA, Miyatani HT, Tannuri U. Pediatric acute liver failure in Brazil: Is living donor liver transplantation the best choice for treatment? Liver Transpl 2016; 22:1006-13. [PMID: 26946330 DOI: 10.1002/lt.24435] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 02/04/2016] [Accepted: 02/07/2016] [Indexed: 02/07/2023]
Abstract
Acute liver failure (ALF) in children is a life-threatening condition that often leads to urgent liver transplantation (LT). The aim of the present investigation was to describe the experience in Brazil in treating pediatric ALF, with an emphasis on the role of living donor liver transplantation (LDLT) in treating this condition. All children with ALF who fulfilled the criteria for an urgent LT were admitted to the intensive care unit. Patients were divided into 2 groups based on the moment of admission: before and after June 2007, when the LDLT program for ALF was started. Statistical analyses were performed to identify prognostic factors of patients with ALF. For the study, 115 children with ALF were admitted. All patients had some degree of encephalopathy. Among the patients, 26% of them required intracranial pressure monitoring (IPM), 12.8% of the patients required hemodialysis, and 79 patients underwent transplantation (50 deceased donors and 29 living donors) corresponding to 12.4% of all pediatric LTs. Only 9 children recovered without LT. The need for IPM and nonperformance of LT were related to a higher mortality. The mortality rate of patients who underwent LT was significantly lower than that of children with ALF who did not undergo a LT (48.1% versus 75%; P = 0.02). The incidences of primary nonfunction and mortality were statistically higher among deceased donor liver transplantations than LDLTs. Finally, it was verified that the overall survival rate of transplanted patients was increased after the introduction of LDLT (P = 0.02). In conclusion, ALF in children continues to be a severe and devastating condition, and a LT should be performed promptly. The introduction of LDLT could increase the survival rate of patients in Brazil. Liver Transplantation 22 1006-1013 2016 AASLD.
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Affiliation(s)
| | - Gilda Porta
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
| | - Irene Kazue Miura
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
| | - Maria Merces Santos
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
| | | | | | - Helena Thie Miyatani
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
| | - Uenis Tannuri
- Liver Transplantation Unit, Children's Institute, University of São Paulo, São Paulo, Brazil
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Tannuri ACA, Lima F, de Mello ES, Tanigawa RY, Tannuri U. Prognostic factors for the evolution and reversibility of chronic rejection in pediatric liver transplantation. Clinics (Sao Paulo) 2016; 71:216-20. [PMID: 27166772 PMCID: PMC4825201 DOI: 10.6061/clinics/2016(04)07] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/01/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Chronic rejection remains a major cause of graft failure with indication for re-transplantation. The incidence of chronic rejection remains high in the pediatric population. Although several risk factors have been implicated in adults, the prognostic factors for the evolution and reversibility of chronic rejection in pediatric liver transplantation are not known. Hence, the current study aimed to determine the factors involved in the progression or reversibility of pediatric chronic rejection by evaluating a series of chronic rejection cases following liver transplantation. METHODS Chronic rejection cases were identified by performing liver biopsies on patients based on clinical suspicion. Treatment included maintaining high levels of tacrolimus and the introduction of mofetil mycophenolate. The children were divided into 2 groups: those with favorable outcomes and those with adverse outcomes. Multivariate analysis was performed to identify potential risk factors in these groups. RESULTS Among 537 children subjected to liver transplantation, chronic rejection occurred in 29 patients (5.4%). In 10 patients (10/29, 34.5%), remission of chronic rejection was achieved with immunosuppression (favorable outcomes group). In the remaining 19 patients (19/29, 65.5%), rejection could not be controlled (adverse outcomes group) and resulted in re-transplantation (7 patients, 24.1%) or death (12 patients, 41.4%). Statistical analysis showed that the presence of ductopenia was associated with worse outcomes (risk ratio=2.08, p=0.01). CONCLUSION The presence of ductopenia is associated with poor prognosis in pediatric patients with chronic graft rejection.
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Tannuri ACA, Tannuri U. Pediatric Liver Transplantation Program at the Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Clinics (Sao Paulo) 2016; 71:185-6. [PMID: 27166766 PMCID: PMC4825203 DOI: 10.6061/clinics/2016(04)01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Mathias AL, Tannuri ACA, Ferreira MAE, Santos MM, Tannuri U. Validação de questionários para avaliação da qualidade de vida relacionada à continência fecal em crianças com malformações anorretais e doença de Hirschsprung. Revista Paulista de Pediatria 2016. [DOI: 10.1016/j.rpped.2015.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mathias AL, Tannuri ACA, Ferreira MAE, Santos MM, Tannuri U. [Validation of questionnaires to assess quality of life related to fecal incontinence in children with anorectal malformations and Hirschsprung's disease]. ACTA ACUST UNITED AC 2015; 34:99-105. [PMID: 26522822 PMCID: PMC4795728 DOI: 10.1016/j.rppede.2015.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 06/11/2015] [Accepted: 06/16/2015] [Indexed: 11/19/2022]
Abstract
Objective: Surgical treatment of anorectal malformations (ARMs) and Hirschsprung's disease
(HD) leads to alterations in bowel habits and fecal incontinence, with consequent
quality of life impairment. The objectives were to create and validate a
Questionnaire for the Fecal Incontinence Index (FII) based on the Holschneider
score, as well as a Questionnaire for the Assessment of Quality of Life Related to
Fecal Incontinence in Children and Adolescents (QQVCFCA), based on the Fecal
Incontinence Quality of Life. Methods: The questionnaires were applied to 71 children submitted to surgical procedure, in
two stages. Validity was tested by comparing the QQVCFCA and a generic quality of
life questionnaire (SF-36), and between QQVCFCA and the FII. A group of 59 normal
children was used as control. Results: At two stages, 45.0% (32/71) and 42.8% (21/49) of the patients had fecal
incontinence. It was observed that the QQVCFCA showed a significant correlation
with the SF-36 and FII (Pearson's correlation 0.57), showing that the quality of
life is directly proportional to improvement in fecal incontinence. Quality of
life in patients with fecal incontinence is still globally impaired, when compared
with control subjects (p<0.05, Student's
t-test). There were also significant differences between the
results of children with ARMs and children with HD. Conclusions: QQVCFCA and FII are useful tools to assess the quality of life and fecal
incontinence in these groups of children. Children with ARMs submitted to surgical
procedure and HD have similar quality of life impairment.
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Affiliation(s)
- Arthur Loguetti Mathias
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP, Brasil
| | - Ana Cristina Aoun Tannuri
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP, Brasil
| | | | - Maria Mercês Santos
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP, Brasil
| | - Uenis Tannuri
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP, Brasil.
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Tannuri ACA, Cristofani LM, Teixeira RAP, Filho VO, Tannuri U. New concepts and outcomes for children with hepatoblastoma based on the experience of a tertiary center over the last 21 years. Clinics (Sao Paulo) 2015; 70:387-92. [PMID: 26106955 PMCID: PMC4462574 DOI: 10.6061/clinics/2015(06)01] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/05/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of this study was to summarize the experience of a tertiary center in treating hepatoblastoma for the last 21 years. PATIENTS AND METHODS Fifty-eight cases were included. The tumor extent and prognosis were assessed using the PRETEXT system. The following data were analyzed: age at diagnosis, comorbidities, prematurity, treatment modalities, histopathological findings, surgical details and complications, treatment outcomes, chemotherapy schedules, side effects and complications. Treatment outcomes included the occurrence of local or distant recurrence, the duration of survival and the cause of death. The investigation methods were ultrasonography, CT scan, serum alpha-fetoprotein level measurement and needle biopsy. Chemotherapy was then planned, and the resectability of the tumor was reevaluated via another CT scan. RESULTS The mean numbers of neoadjuvant cycles and postoperative cycles of chemotherapy were 6±2 and 1.5±1.7, respectively. All children except one were submitted for surgical resection, including 50 partial liver resections and 7 liver transplantations. Statistical comparisons demonstrated that long-term survival was associated with the absence of metastasis (p=0.04) and the type of surgery (resection resulted in a better outcome than transplantation) (p=0.009). No associations were found between vascular invasion, incomplete resection, histological subtype, multicentricity and survival. The overall 5-year survival rate of the operated cases was 87.7%. CONCLUSION In conclusion, the experience of a Brazilian tertiary center in the management of hepatoblastoma in children demonstrates that long survival is associated with the absence of metastasis and the type of surgery. A multidisciplinary treatment involving chemotherapy, surgical resection and liver transplantation (including transplantations using tissue from living donors) led to good outcomes and survival indexes.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Faculdade de Medicina da Universidade de Sao Paulo, Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Sao Paulo/SP, Brazil
| | - Lilian Maria Cristofani
- Faculdade de Medicina da Universidade de Sao Paulo, Pediatric Oncology Division, Sao Paulo/SP, Brazil
| | | | - Vicente Odone Filho
- Faculdade de Medicina da Universidade de Sao Paulo, Pediatric Oncology Division, Sao Paulo/SP, Brazil
| | - Uenis Tannuri
- Faculdade de Medicina da Universidade de Sao Paulo, Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Sao Paulo/SP, Brazil
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Santos MM, Tannuri ACA, Coelho MCM, de Oliveira Gonçalves J, Serafini S, da Silva LFF, Tannuri U. Immediate expression of c-fos and c-jun mRNA in a model of intestinal autotransplantation and ischemia-reperfusion in situ. Clinics (Sao Paulo) 2015; 70:373-9. [PMID: 26039956 PMCID: PMC4449475 DOI: 10.6061/clinics/2015(05)12] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 02/06/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Intestinal ischemia-reperfusion injury occurs in several clinical conditions and after intestinal transplantation. The aim of the present study was to investigate the phenomena of apoptosis and cell proliferation in a previously described intestinal ischemia-reperfusion injury autograft model using immunohistochemical markers. The molecular mechanisms involved in ischemia-reperfusion injury repair were also investigated by measuring the expression of the early activation genes c-fos and c-jun, which induce apoptosis and cell proliferation. MATERIALS AND METHODS Thirty adult male Wistar rats were subjected to surgery for a previously described ischemia-reperfusion model that preserved the small intestine, the cecum and the ascending colon. Following reperfusion, the cecum was harvested at different time points as a representative segment of the intestine. The rats were allocated to the following four subgroups according to the reperfusion time: subgroup 1: 5 min; subgroup 2: 15 min; subgroup 3: 30 min; and subgroup 4: 60 min. A control group of cecum samples was also collected. The expression of c-fos, c-jun and immunohistochemical markers of cell proliferation and apoptosis (Ki67 and TUNEL, respectively) was studied. RESULTS The expression of both c-fos and c-jun in the cecum was increased beginning at 5 min after ischemia-reperfusion compared with the control. The expression of c-fos began to increase at 5 min, peaked at 30 min, and exhibited a declining tendency at 60 min after reperfusion. A progressive increase in c-jun expression was observed. Immunohistochemical analyses confirmed these observations. CONCLUSION The early activation of the c-fos and c-jun genes occurred after intestinal ischemia-reperfusion injury, and these genes can act together to trigger cell proliferation and apoptosis.
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Leal AJG, Tannuri ACA, Belon AR, Guimarães RRN, Coelho MCM, Gonçalves JDO, Serafini S, Melo ESD, Tannuri U. Effects of ischemic preconditioning in a pig model of large-for-size liver transplantation. Clinics (Sao Paulo) 2015; 70:126-35. [PMID: 25789522 PMCID: PMC4351307 DOI: 10.6061/clinics/2015(02)10] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/05/2014] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE In most cases of pediatric liver transplantation, the clinical scenario of large-for-size transplants can lead to hepatic dysfunction and a decreased blood supply to the liver graft. The objective of the present experimental investigation was to evaluate the effects of ischemic preconditioning on this clinical entity. METHODS Eighteen pigs were divided into three groups and underwent liver transplantation: a control group, in which the weights of the donors were similar to those of the recipients, a large-for-size group, and a large-for-size + ischemic preconditioning group. Blood samples were collected from the recipients to evaluate the pH and the sodium, potassium, aspartate aminotransferase and alanine aminotransferase levels. In addition, hepatic tissue was sampled from the recipients for histological evaluation, immunohistochemical analyses to detect hepatocyte apoptosis and proliferation and molecular analyses to evaluate the gene expression of Bax (pro-apoptotic), Bcl-XL (anti-apoptotic), c-Fos and c-Jun (immediate-early genes), ischemia-reperfusion-related inflammatory cytokines (IL-1, TNF-alpha and IL-6, which is also a stimulator of hepatocyte regeneration), intracellular adhesion molecule, endothelial nitric oxide synthase (a mediator of the protective effect of ischemic preconditioning) and TGF-beta (a pro-fibrogenic cytokine). RESULTS All animals developed acidosis. At 1 hour and 3 hours after reperfusion, the animals in the large-for-size and large-for-size + ischemic preconditioning groups had decreased serum levels of Na and increased serum levels of K and aspartate aminotransferase compared with the control group. The molecular analysis revealed higher expression of the Bax, TNF-alpha, I-CAM and TGF-beta genes in the large-for-size group compared with the control and large-for-size + ischemic preconditioning groups. Ischemic preconditioning was responsible for an increase in c-Fos, IL-1, IL-6 and e-NOS gene expression. CONCLUSION Ischemia-reperfusion injury in this model of large-for-size liver transplantation could be partially attenuated by ischemic preconditioning.
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Affiliation(s)
- Antonio José Gonçalves Leal
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alessandro Rodrigo Belon
- Department of Surgical Technique and Experimental Surgery, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Raimundo Renato Nunes Guimarães
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Maria Cecília Mendonça Coelho
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Josiane de Oliveira Gonçalves
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Suellen Serafini
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Evandro Sobroza de Melo
- Liver Function Research Laboratory (LIM-14), Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Uenis Tannuri
- Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), Pediatric Surgery Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Tannuri ACA, Monteiro RF, Santos MM, Miyatani HT, Tannuri U. A new simplified technique of arterial reconstruction in pediatric living-donor liver transplantation: a comparison with the classical technique. J Pediatr Surg 2014; 49:1518-21. [PMID: 25280659 DOI: 10.1016/j.jpedsurg.2014.02.084] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 02/16/2014] [Accepted: 02/17/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND/AIM Hepatic artery anastomosis (HAA) is the most important aspect of living donor liver transplantation (LDLT), and it is currently performed by a specialized microsurgeon using micro surgical techniques, with interrupted sutures and the aid of an operative microscope. To simplify the procedure, we studied a new, simpler technique performed by pediatric transplant surgeons with continuous sutures and the same 3.5× magnification loupe used during other transplant procedures. The aim of this study was to compare these two hepatic artery reconstruction techniques in two pediatric LDLT series. METHODS This study was initiated in January 2010 and finished in June 2013. In the first period, the arterial reconstruction was performed with an operating microscope and the classical technique of 9-0 separate sutures. In the second period, the arterial reconstruction was performed using a simpler technique, with surgical loupe and continuous 8-0 Prolene sutures. The incidences and outcomes of complications within the two periods were analyzed and compared. RESULTS A total of 82 LDLTs were performed, 38 in the first period and 44 in the second period. There were no differences between the periods, except for the arterial ischemia time, which was lower in the second period. CONCLUSION Hepatic artery anastomosis can be safely performed with low complication rates by a pediatric transplant surgeon using continuous sutures with a 3.5× magnifying loupe. This technique is simpler, less time consuming and simplifies the complex pediatric LDLT procedure.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil
| | - Roberta Figueiredo Monteiro
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil
| | - Maria Mercês Santos
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil
| | - Helena Thie Miyatani
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil.
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Gonçalves JO, Tannuri ACA, Coelho MCM, Bendit I, Tannuri U. Dynamic expression of desmin, α-SMA and TGF-β1 during hepatic fibrogenesis induced by selective bile duct ligation in young rats. ACTA ACUST UNITED AC 2014; 47:850-7. [PMID: 25140817 PMCID: PMC4181220 DOI: 10.1590/1414-431x20143679] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 04/29/2014] [Indexed: 01/11/2023]
Abstract
We previously described a selective bile duct ligation model to elucidate the process
of hepatic fibrogenesis in children with biliary atresia or intrahepatic biliary
stenosis. Using this model, we identified changes in the expression of alpha
smooth muscle actin (α-SMA) both in the obstructed
parenchyma and in the hepatic parenchyma adjacent to the obstruction. However, the
expression profiles of desmin and TGF-β1, molecules
known to be involved in hepatic fibrogenesis, were unchanged when analyzed by
semiquantitative polymerase chain reaction (RT-PCR). Thus, the molecular mechanisms
involved in the modulation of liver fibrosis in this experimental model are not fully
understood. This study aimed to evaluate the molecular changes in an experimental
model of selective bile duct ligation and to compare the gene expression changes
observed in RT-PCR and in real-time quantitative PCR (qRT‐PCR). Twenty-eight Wistar
rats of both sexes and weaning age (21-23 days old) were used. The rats were
separated into groups that were assessed 7 or 60 days after selective biliary duct
ligation. The expression of desmin, α-SMA and
TGF-β1 was examined in tissue from hepatic parenchyma with
biliary obstruction (BO) and in hepatic parenchyma without biliary obstruction (WBO),
using RT-PCR and qRT‐PCR. The results obtained in this study using these two methods
were significantly different. The BO parenchyma had a more severe fibrogenic
reaction, with increased α-SMA and TGF-β1
expression after 7 days. The WBO parenchyma presented a later, fibrotic response,
with increased desmin expression 7 days after surgery and increased
α-SMA 60 days after surgery. The qRT‐PCR technique was more
sensitive to expression changes than the semiquantitative method.
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Affiliation(s)
- J O Gonçalves
- Laboratório de Pesquisa em Cirurgia Pediátrica (LIM-30), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - A C A Tannuri
- Laboratório de Pesquisa em Cirurgia Pediátrica (LIM-30), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - M C M Coelho
- Laboratório de Pesquisa em Cirurgia Pediátrica (LIM-30), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - I Bendit
- Laboratório de Pesquisa em Cirurgia Pediátrica (LIM-30), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - U Tannuri
- Laboratório de Pesquisa em Cirurgia Pediátrica (LIM-30), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Backes AN, Tannuri ACA, Backes FN, Queiroz AJR, Coelho MCM, da Silva EL, de Mello ES, Tannuri U. Effects of tacrolimus and insulin in a liver regeneration model in growing animals with portal vein stenosis: immunohistochemical and molecular studies. Pediatr Surg Int 2014; 30:423-9. [PMID: 24468714 DOI: 10.1007/s00383-014-3464-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The aim of the present investigation was to describe a new model of liver regeneration in growing rats with reduced portal flow. In addition, it was studied whether tacrolimus and insulin could have any pro-regenerative effect under such conditions. Ninety-five rats were divided into five groups: Group 1 (sham), abdominal incision without intervention; Group 2, 70% hepatectomy; Group 3, 70% hepatectomy + PV stenosis; Group 4, 70% hepatectomy + portal vein stenosis + insulin; and Group 5, 70% hepatectomy + portal vein stenosis + tacrolimus. The remnant liver lobes were harvested for analyses. The liver weight decreased in the PV stenosis group and it increased with the use of insulin and tacrolimus. The mitotic activity was higher in the hepatectomy, insulin and tacrolimus groups and this parameter was reduced by portal stenosis. Levels of interleukin 6 (IL-6) were higher in the hepatectomy group compared to the sham and PV stenosis groups. The expression of IL-6 and Ki67 was significantly increased in the insulin and tacrolimus groups compared to the portal stenosis group. A highly reproducible model was standardized to study liver regeneration with portal blood inflow reduction in weaning rats. It was demonstrated that insulin or tacrolimus administration may partially reverse the harmful effects of PV stenosis.
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Affiliation(s)
- Ariane Nadia Backes
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
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Rangel Moreira DDA, Aoun Tannuri AC, Belon AR, Mendonça Coelho MC, Oliveira Gonçalves J, Serafini S, Roberto Lima F, Agostini LO, Guimarães RR, Tannuri U. Large-for-size liver transplantation: a flowmetry study in pigs. J Surg Res 2014; 189:313-20. [PMID: 24721605 DOI: 10.1016/j.jss.2014.03.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 03/01/2014] [Accepted: 03/05/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ischemia-reperfusion injury is partly responsible for morbidity in pediatric liver transplantation. Large-for-size (LFS) liver transplantation has not been fully studied in the pediatric population, and the effects of reperfusion injury may be underestimated. MATERIALS AND METHODS Thirteen Landrace-Large white pigs weighing 23 kg (range, 17-38 kg) underwent orthotopic liver transplantation. They were divided into two groups according to the size of the donor body: LFS and control (CTRL). After transplantation, the abdominal cavity of the recipient was kept open and portal venous flow (PVF) was measured after 1 h. The ratio of recipient PVF (PVFr) to donor PVF was used to establish correlations with ischemia and reperfusion parameters. Liver biopsies were taken 1 h after transplantation to assess ischemia and reperfusion and to quantify the gene expression of endothelial nitric oxide synthase, interleukin 6, BAX, and BCL. RESULTS Recipient weight, total ischemia time, and warm ischemia time were similar between groups. Among hemodynamic and metabolic analyses, pH, central arteriovenous PCO2 difference, and AST were statistically worse in the LFS group than in the CTRL group. The same was found with endothelial nitric oxide synthase (0.41 ± 0.18 versus 1.56 ± 0.78; P = 0.02) and interleukin 6 (4.66 ± 4.61 versus 16.21 ± 8.25; P = 0.02). In the LFS group, a significant decay in the PVFr was observed in comparison with the CTRL group (0.93 ± 0.08 and 0.52 ± 0.11, respectively; P < 0.001). CONCLUSIONS The implantation of a graft was responsible for poor hemodynamic status of the recipient 1 h after transplantation. Furthermore, the LFS group demonstrated markers of ischemia and reperfusion that were worse when compared with the CTRL group and exhibited a more significant decrease in PVF from donor to recipient.
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Affiliation(s)
- Daniel de Albuquerque Rangel Moreira
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alessandro Rodrigo Belon
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Maria Cecília Mendonça Coelho
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Josiane Oliveira Gonçalves
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Suellen Serafini
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Fabiana Roberto Lima
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Luciana Orsi Agostini
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Raimundo Renato Guimarães
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Monteiro RF, Santos MM, Tannuri ACA, Leal AJG, Tannuri U. A new technique for redo operation after failed endoanal pull-through procedure for correction of Hirschsprung's disease. Journal of Pediatric Surgery Case Reports 2014. [DOI: 10.1016/j.epsc.2013.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Abstract
In the last 25 years, liver transplantation in children has become an effective, definitive, and universally accepted treatment for terminal liver diseases. Long-term survival exceeds 80% and improves each year as the result of constant technical advancements and improvements in immediate postoperative intensive care and clinical control.
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Affiliation(s)
- Uenis Tannuri
- Laboratory of Pediatric Surgery Research (LIM-30), Pediatric Surgery and Liver Transplantation Division, Medical School, University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Ana Cristina Aoun Tannuri
- Laboratory of Pediatric Surgery Research (LIM-30), Pediatric Surgery and Liver Transplantation Division, Medical School, University of Sao Paulo, Sao Paulo, SP, Brazil
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