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Chen SY, Gao L, Imagawa KK, Roseman ER, Shin CE, Kim ES, Spurrier RG. Screening for Child Abuse in Children With Isolated Skull Fractures. Pediatr Emerg Care 2023; 39:374-377. [PMID: 36018728 DOI: 10.1097/pec.0000000000002823] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Head trauma is the most common cause of death from child abuse, and each encounter for recurrent abuse is associated with greater morbidity. Isolated skull fractures (ISF) are often treated conservatively in the emergency department (ED). We determined patterns of physical abuse screening in a children's hospital ED for children with ISF. METHODS A retrospective review was performed for children aged 3 years and younger who presented to the ED with ISF from January 1, 2015 to December 31, 2019. Children were stratified by age (<12 mo, ≥12 mo) and witnessed versus unwitnessed injury. Primary outcome was social work (SW) assessment to prescreen for abuse. Secondary outcomes were suspicion for abuse based on Child Protective Services (CPS) referral and subsequent ED encounters within 1 year. RESULTS Sixty-six ISF patients were identified. Of unwitnessed injury patients aged younger than 12 months (n = 17/22), 88.2% (n = 15/17) underwent SW assessment and 47.1% (n = 8/17) required CPS referral. Of witnessed injury patients aged younger than 12 months (n = 23/44), 60.9% (n = 14/23) underwent SW assessment, with no CPS referrals. Overall, 18.2% (n = 4/22) unwitnessed and 20.5% (n = 9/44) witnessed injury patients returned to our ED: 2 were aged younger than 12 months and had recurrent trauma. CONCLUSIONS To decrease risk of missed physical abuse, SW consultation should be considered for all ISF patients.
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Affiliation(s)
| | | | | | - Eric R Roseman
- Department of Social Work, Children's Hospital Los Angeles
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Chang GY, Salazar T, Karnwal A, Kun SS, Ellashek J, Shin CE, McComb JG, Keens TG, Perez IA. Perioperative outcomes and the effects of anesthesia in congenital central hypoventilation patients. Sleep Breath 2022; 27:505-510. [DOI: 10.1007/s11325-022-02632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 03/31/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
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Kwon A, Lodge M, McComb JG, Durham S, Shin CE, Keens TG, Perez IA. An unusual cause of diaphragm pacer failure in congenital central hypoventilation syndrome. J Clin Sleep Med 2022; 18:949-952. [PMID: 34846295 PMCID: PMC8883077 DOI: 10.5664/jcsm.9778] [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: 11/13/2022]
Abstract
Congenital central hypoventilation syndrome is a rare genetic disorder affecting ventilatory response to hypercapnia and/or hypoxemia. We describe a case of diaphragm pacing (DP) failure in a 38-year-old woman with congenital central hypoventilation syndrome who used DP as ventilatory support only during sleep for 24 years. Diagnostic evaluation began with examination of external DP equipment, but adjustment did not elicit adequate diaphragm contractions. Clinical evaluation and transtelephonic monitoring showed absent function of the right pacer and diminished function of the left pacer. The patient had surgical exploration of her internal DP components. The operation revealed that the right pacer receiver had significant circumferential calcium accumulation. After replacement of the receivers in subcutaneous pockets closer to the skin surface, robust diaphragm contractions bilaterally occurred with stimulation. This case suggests DP failure can result from development of calcification and increased distance from the skin surface to the receivers due to weight gain. CITATION Kwon A, Lodge M, McComb JG, et al. An unusual cause of diaphragm pacer failure in congenital central hypoventilation syndrome. J Clin Sleep Med. 2022;18(3):949-952.
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Affiliation(s)
- Ashley Kwon
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Madison Lodge
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - J. Gordon McComb
- Keck School of Medicine of the University of Southern California, Los Angeles, California,Division of Pediatric Neurosurgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Susan Durham
- Keck School of Medicine of the University of Southern California, Los Angeles, California,Division of Pediatric Neurosurgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Cathy E. Shin
- Keck School of Medicine of the University of Southern California, Los Angeles, California,Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Thomas G. Keens
- Keck School of Medicine of the University of Southern California, Los Angeles, California,Division of Pediatric Pulmonology and Sleep Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Iris A. Perez
- Keck School of Medicine of the University of Southern California, Los Angeles, California,Division of Pediatric Pulmonology and Sleep Medicine, Children’s Hospital Los Angeles, Los Angeles, California,Address correspondence to: Iris A. Perez, MD, Department of Pediatrics, Division of Pulmonology and Sleep Medicine, Keck School of Medicine of the University of Southern California, Children’s Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027; Tel: (323) 361-2101;
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Diep B, Wang A, Kun S, McComb JG, Shaul DB, Shin CE, Keens TG, Perez IA. Diaphragm Pacing without Tracheostomy in Congenital Central Hypoventilation Syndrome Patients. Respiration 2015; 89:534-8. [DOI: 10.1159/000381401] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 03/03/2015] [Indexed: 11/19/2022] Open
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Nicholson KJ, Nosanov LB, Bowen KA, Kun SS, Perez IA, Keens TG, Shin CE. Thoracoscopic placement of phrenic nerve pacers for diaphragm pacing in congenital central hypoventilation syndrome. J Pediatr Surg 2015; 50:78-81. [PMID: 25598098 DOI: 10.1016/j.jpedsurg.2014.10.002] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/06/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE Congenital central hypoventilation syndrome (CCHS), or Ondine's curse, is a rare disorder affecting central respiratory drive. Patients with this disorder fail to ventilate adequately and require lifelong ventilatory support. Diaphragm pacing is a form of ventilatory support which can improve mobility and/or remove the tracheostomy from CCHS patients. Little is known about complications and long-term outcomes of this procedure. METHODS A single-center retrospective review was performed of CCHS patients undergoing placement of phrenic nerve electrodes for diaphragm pacing between 2000 and 2012. Data abstracted from the medical record included operation duration, ventilation method, number of trocars required, and postoperative and pacing outcomes. RESULTS Charts of eighteen patients were reviewed. Mean surgical time was 3.3±0.7 hours. In all cases except one, three trocars were utilized for each hemithorax, with no conversions to open procedures. Five patients (27.8%) experienced postoperative complications. The mean ICU stay was 4.3±0.5 days, and the mean hospital stay is 5.7±0.3days. Eleven patients (61.1%) achieved their daily goal pacing times within the follow-up period. CONCLUSIONS Thoracoscopic placement of phrenic nerve electrodes for diaphragmatic pacing is a safe and effective treatment modality for CCHS. Observed complications were temporary, and the majority of patients were able to achieve pacing goals.
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Affiliation(s)
| | - Lauren B Nosanov
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Kanika A Bowen
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Sheila S Kun
- Department of Pulmonology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Iris A Perez
- Department of Pulmonology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Thomas G Keens
- Department of Pulmonology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Cathy E Shin
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA.
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Jensen AR, Short SS, Anselmo DM, Torres MB, Frykman PK, Shin CE, Wang K, Nguyen NX. Laparoscopic versus open treatment of congenital duodenal obstruction: multicenter short-term outcomes analysis. J Laparoendosc Adv Surg Tech A 2014; 23:876-80. [PMID: 24079961 DOI: 10.1089/lap.2013.0140] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Laparoscopic repair of congenital duodenal obstruction has become popularized over the past decade. Comparative data on outcomes, however, are sparse. We hypothesized that laparoscopic repair of congenital duodenal obstruction could be performed with similar outcomes to traditional open repair. PATIENTS AND METHODS Medical records for all cases of congenital duodenal obstruction from 2005 to 2011 at three academic teaching hospitals were retrospectively reviewed. Patients were excluded from the analysis if they had confounding surgical diseases, did not have duodenoduodenostomy during the first hospital admission, had the repair performed before transfer from a referring hospital, or weighed less than 1.7 kg at the time of surgery. Analysis was performed as intention to treat, with laparoscopic converted to open cases included in the laparoscopic group. RESULTS Sixty-four cases were included in the analysis (44 open, 20 laparoscopic). Baseline characteristics were similar between the two groups with the exception that the open group, on average, underwent repair later than the laparoscopic group (6 days versus 4 days, respectively). Seven laparoscopic cases were converted to an open procedure (35%), most commonly for difficulty in exposing the decompressed distal duodenum. Laparoscopic repair did take significantly longer than open repair (145 minutes versus 96 minutes, respectively), but clinical outcomes were similar. Complications were rare and were similar between methods of repair. Two patients in the laparoscopic group required subsequent open revision. CONCLUSIONS Laparoscopic duodenoduodenostomy for congenital duodenal obstruction is a technically challenging procedure with a steep learning curve. Despite a relatively high conversion rate, clinical outcomes remained similar to the traditional open repair in selected patients.
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Affiliation(s)
- Aaron R Jensen
- 1 Division of Pediatric Surgery, Children's Hospital Los Angeles , Los Angeles, California
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7
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Lee FL, Said N, Grikscheit TC, Shin CE, Llanes A, Chmait RH. Treatment of congenital pulmonary airway malformation induced hydrops fetalis via percutaneous sclerotherapy. Fetal Diagn Ther 2012; 31:264-8. [PMID: 22354268 DOI: 10.1159/000336226] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 12/29/2011] [Indexed: 11/19/2022]
Abstract
Large type II and III congenital pulmonary airway malformations (CPAMs) can cause pulmonary hypoplasia, non-immune hydrops fetalis and fetal demise. Fetal intervention is indicated if hydrops fetalis develops. In this report, we describe three cases of type II and III CPAMs complicated by hydrops and treated with percutaneous sclerotherapy by ethanolamine injection into the tumor. All 3 cases demonstrated reduction in size of the CPAM and resolution of the hydrops with subsequent delivery at term. We believe that fetal percutaneous sclerotherapy can be used as a minimally invasive palliative strategy to treat CPAM-induced hydrops fetalis. Further studies are needed to delineate the risks of this novel technique.
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Affiliation(s)
- Frances L Lee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, Calif. 90027, USA
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Guner YS, Emami CN, Chokshi NK, Wang K, Shin CE. Inversion Herniotomy: A Laparoscopic Technique for Female Inguinal Hernia Repair. J Laparoendosc Adv Surg Tech A 2010; 20:481-4. [DOI: 10.1089/lap.2009.0169] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yigit S. Guner
- Department of Pediatric Surgery, Childrens Hospital Los Angeles, Los Angeles, California
- Department of Pediatric Surgery, University of California Davis Medical Center, Sacramento, California
| | - Claudia N. Emami
- Department of Pediatric Surgery, Childrens Hospital Los Angeles, Los Angeles, California
- Department of Pediatric Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nikunj K. Chokshi
- Department of Pediatric Surgery, Childrens Hospital Los Angeles, Los Angeles, California
| | - Kasper Wang
- Department of Pediatric Surgery, Childrens Hospital Los Angeles, Los Angeles, California
- Department of Pediatric Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Cathy E. Shin
- Department of Pediatric Surgery, Childrens Hospital Los Angeles, Los Angeles, California
- Department of Pediatric Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Chokshi NK, Guner YS, Ndiforchu F, Mathis R, Shin CE, Nguyen NX. Combined laparoscopic and thoracoscopic esophagectomy and gastric pull-up in a child. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S197-200. [PMID: 19196095 DOI: 10.1089/lap.2008.0222.supp] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Severe caustic burns to the esophagus may necessitate esophagectomy with replacement, if stictures form which are not amenable to dilation. Traditionally, the operation is performed via open transabdominal and/or thoracic approaches. Here we describe our minimally invasive approach, combining laparoscopy and thoracoscopy for esophagectomy, stomach tubularization and a cervical esophagogastrotomy. We successfully performed the procedure in a 4-year-old boy. There were no intraoperative complications, and his initial esophagram showed good patency with no leaks. However, one week postoperatively he was noted to have a retained foreign body and a minor anastomotic leak, which was most likely caused by the foreign body. He underwent a neck re-exploration,removal of the foreign body, and repair of the anastomotic leak. His subsequent hospital course was uneventful. He tolerated feedings and was discharged home on an unrestricted diet. The minimally invasive approach to esophagectomy and esophageal replacement is feasible and is an excellent option in select patients.
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Affiliation(s)
- Nikunj K Chokshi
- Department of Pediatric Surgery, Children's Hospital Los Angeles, University of Southern California, LosAngeles, CA, USA
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10
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Abstract
X-linked hydrocephalus (XLH) is characterized by increased intracranial ventricle size and head circumference secondary to aqueduct of Sylvius congenital stenosis. Exceedingly rare is the concurrence of XLH and Hirschsprung's disease (HSCR) with a theoretical incidence of 1 in 125-250 million cases. Herein, we are describing a case of a patient with concurrent XLH and HSCR. The patient was delivered via cesarean section at 37 weeks gestation and underwent uneventful ventriculoperitoneal shunt placement. As a part of a workup for constipation, we performed a rectal biopsy, which was consistent with HSCR. Genetics testing showed hemizygous for R558X hemizygous mutation in the L1CAM gene. A C --> T nucleotide substitution in exon 13 resulted in replacement of an arginine codon with a stop codon, a nonsense mutation. Although it is widely accepted that HSCR represents the failure of early embryonic neural crest cells to migrate properly, the exact mechanism is not known. The association of HSCR with XLH in the presence of L1CAM mutations remains quite interesting because cell adhesion molecules are involved in the proper migration of neural components throughout the body. Additional studies are necessary to fully elucidate the relationship between XLH and HSCR in the presence of L1CAM mutations.
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Affiliation(s)
- Sha-Ron Jackson
- Department of Pediatric Surgery, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Mailstop #72, Los Angeles, CA 90027 USA
| | - Yigit S. Guner
- Department of Pediatric Surgery, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Mailstop #72, Los Angeles, CA 90027 USA
| | - Russell Woo
- Department of Pediatric Surgery, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Mailstop #72, Los Angeles, CA 90027 USA
| | - Linda M. Randolph
- Department of Pediatrics, Division of Medical Genetics, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Mailstop #72, Los Angeles, CA 90027 USA
| | - Henri Ford
- Department of Pediatric Surgery, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Mailstop #72, Los Angeles, CA 90027 USA
| | - Cathy E. Shin
- Department of Pediatric Surgery, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Mailstop #72, Los Angeles, CA 90027 USA
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Guner YS, Chokshi N, Aranda A, Ochoa C, Qureshi FG, Nguyen NX, Grikscheit T, Ford HR, Stein JE, Shin CE. Thoracoscopic repair of neonatal diaphragmatic hernia. J Laparoendosc Adv Surg Tech A 2009; 18:875-80. [PMID: 19105674 DOI: 10.1089/lap.2007.0239] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The use of minimally invasive surgery (MIS) in the neonatal population is increasing. Thoracoscopic intervention for congenital diaphragmatic hernia (CDH) is no exception. In this report, we describe our initial experience with thoracoscopic repair of left-sided diaphragmatic defects in neonates. MATERIALS AND METHODS We performed retrospective chart reviews on all neonates who underwent thoracoscopic repair of CDH between November 2004 and January 2008. Neonates that underwent thoracoscopic repair were physiologically stable with resolved pulmonary hypertension and minimal to moderate ventilatory support. They had no associated cardiac anomalies. RESULTS We identified 15 neonates with CDH who underwent thoracoscopic repair during the study period. Ten neonates underwent primary repair of the diaphragmatic defect. Five neonates with large defects required closure with a synthetic patch, which was placed thoracoscopically. The average operating room time was 134 minutes. There were no instances of intraoperative respiratory or cardiac instability. Three patients had a recurrence. One recurrence was seen after thoracoscopic patch repair. Two recurrences occurred following primary repair of left diaphragmatic hernias. There were no deaths. Follow-up has been 4-40 months. CONCLUSIONS Neonatal MIS for CDH should be limited to stable patients. The ideal candidate is the newborn without associated anomalies, not requiring extracorporeal membrane oxygenation, on minimal ventilatory support, and without evidence of pulmonary hypertension. It is technically possible to perform thoracoscopic repair with a patch.
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Affiliation(s)
- Yigit S Guner
- Department of Pediatric Surgery, Childrens Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California 90027, USA
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Chokshi NK, Guner YS, Aranda A, Petrosyan M, Shin CE, Ford HR, Nguyen NX. Laparoscopic Choledochal Cyst Excision: Lessons Learned in Our Experience. J Laparoendosc Adv Surg Tech A 2009; 19:87-91. [DOI: 10.1089/lap.2008.0045] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Nikunj K. Chokshi
- Department of Pediatric Surgery, Childrens Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Yigit S. Guner
- Department of Pediatric Surgery, Childrens Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Arturo Aranda
- Department of Pediatric Surgery, Childrens Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mikael Petrosyan
- Department of Pediatric Surgery, Childrens Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Cathy E. Shin
- Department of Pediatric Surgery, Childrens Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Henri R. Ford
- Department of Pediatric Surgery, Childrens Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nam X. Nguyen
- Department of Pediatric Surgery, Childrens Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
- Long Beach Memorial Medical Center, Children's Hospital, Long Beach, California
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Chokshi NK, Guner YS, Ndiforchu F, Mathis R, Shin CE, Nguyen NX. Combined Laparoscopic and Thoracoscopic Esophagectomy and Gastric Pull-Up in a Child. J Laparoendosc Adv Surg Tech A 2009. [DOI: 10.1089/lap.2008.0222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Gastrointestinal (GI) symptoms in Henoch-Schönlein purpura (HSP) are common and occur in about two-thirds of patients. Surgical complications, while uncommon, are potentially severe. The preoperative diagnosis is based mainly on a high index of suspicion leading to imaging studies that may include abdominal sonography. We describe here the first case of a patient who developed recurrent intussusception attributed to HSP that led to repeated surgical interventions.
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Affiliation(s)
- O Zmora
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA.
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15
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Speer AL, Schofield DE, Wang KS, Shin CE, Stein JE, Shaul DB, Mahour GH, Ford HR. Contemporary management of lipoblastoma. J Pediatr Surg 2008; 43:1295-300. [PMID: 18639685 DOI: 10.1016/j.jpedsurg.2007.10.068] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [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] [Received: 06/29/2007] [Revised: 10/28/2007] [Accepted: 10/30/2007] [Indexed: 11/27/2022]
Abstract
PURPOSE Lipoblastoma is a rare, benign, adipose tissue tumor. We report the largest single institution experience managing these uncommon neoplasms. METHODS We retrospectively reviewed 32 cases of lipoblastoma entered in the pathology database at our institution between January 1991 and August 2005. We conducted a comprehensive literature review of lipoblastoma and summarized the results of the largest series published. RESULTS Most patients presented with an enlarging, palpable, firm, nontender, mobile mass. The male-to-female ratio was 1.9:1. The anatomical distribution was trunk (n = 12), extremity (n = 12), groin (n = 5), and neck (n = 3). Average age at resection was 2.8 years (range, 2.6 months to 12 years). Thirty-one cases were completely excised, although 1 patient underwent staged partial excision to preserve nerve function. Chromosomal analysis performed in selected patients revealed characteristic aberrations in chromosome 8. Complications included keloid formation (n = 3), wound infection/dehiscence (n = 2), wound seroma (n = 1), and transient brachial plexus neurapraxia (n = 1). Average follow-up was 7.4 months (range, 1 day to 6.5 years); 2 patients were lost to follow-up. There were no recurrences. CONCLUSIONS A staged approach with meticulous sparing of the neurovascular bundle provides excellent functional outcome for patients with large tumors. Nonmutilating surgical excision is the treatment of choice.
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Affiliation(s)
- Allison L Speer
- Department of Surgery at the University of Southern California, Los Angeles, CA 90033, USA
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Onland W, Shin CE, Fustar S, Rushing T, Wong WY. Ethanol-lock technique for persistent bacteremia of long-term intravascular devices in pediatric patients. ACTA ACUST UNITED AC 2006; 160:1049-53. [PMID: 17018464 DOI: 10.1001/archpedi.160.10.1049] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To use the ethanol-lock technique (in conjunction with systemic antibiotics) to salvage central lines from removal and to prevent persistence of catheter-related infections among pediatric patients with long-term intravascular devices. DESIGN Medical records of patients treated with ethanol locks were retrospectively reviewed from June 1, 2004, through June 22, 2005. SETTING Childrens Hospital Los Angeles, Los Angeles, Calif, a tertiary care pediatric hospital. Patients Forty children with diverse underlying disorders were treated for 51 catheter-related infections using the Childrens Hospital Los Angeles ethanol-lock technique. INTERVENTIONS Eligible infected central lines were instilled with a dose volume of 0.8 to 1.4 mL of 70% ethanol into the catheter lumen during 12 to 24 hours and then withdrawn. The volume of ethanol used was based on the type of intravascular device. MAIN OUTCOME MEASURES Clearance of infection and incidence of recurrence. RESULTS Of the 51 ethanol-lock treatments in 40 children, no catheters were removed because of persistent infection. Eighty-eight percent (45/51) of the treated episodes cleared without recurrence (defined as a relapse within 30 days with the same pathogen). Twelve (75%) of 16 polymicrobial isolates and 33 (94%) of 35 monomicrobial isolates were successfully treated. There were no adverse reactions or adverse effects reported. CONCLUSION This retrospective study supports the use of the ethanol-lock technique in conjunction with systemic antibiotics as an effective and safe method to retain the use of a previously infected central venous catheter, decrease the need for line removal, and eradicate persistent pathogens in catheter-related infections.
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Affiliation(s)
- Wes Onland
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
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Abstract
Salivary gland choristoma (heterotopic salivary gland tissue) is a rare condition that occurs at various locations within the head and neck. Diagnostic criteria and embryogenesis of this entity remain unclear. Presented herein is the first reported case of salivary gland choristoma on the anterior chest wall. Surgical treatment is recommended.
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Affiliation(s)
- C E Shin
- Division of Pediatric Surgery, University of Chicago Medical Center, Illinois 60637, USA
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18
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Abstract
BACKGROUND/PURPOSE Because epidermal growth factor (EGF) is trophic to the intestinal mucosa, and neonatal necrotizing enterocolitis (NEC) is associated with a disrupted intestinal mucosal barrier, the authors sought to determine whether diminished levels of EGF were present in infants with NEC. METHODS Saliva, serum, and urine specimens were obtained from infants with NEC during a 3-year period (February 1995 to May 1998). Control patients without NEC were chosen based on similar postnatal age and birthweight. EGF levels were determined by enzyme-linked immunosorbent assay (ELISA). Differences between groups were compared using Mann-Whitney Rank sum test with P less than .05 considered significant. Results are presented as mean values +/-SEM. RESULTS Twenty-five infants with NEC were compared with 19 control patients. Birth weight (1,616+/-238 g control v. 1,271+/-124 g NEC) and postnatal age (23+/-6 days control v. 22+/-3 days NEC) were similar. Infants with NEC had significantly lower levels of EGF in both saliva (590+/-80 pg/mL control v. 239+/-41 pg/mL NEC; P<.001) and serum (35+/-8 pg/mL control v. 5.6+/-1.9 pg/mL NEC; P<.001). Urinary EGF was also lower in the NEC group, but was not statistically significant. CONCLUSIONS Premature infants with NEC have significantly diminished levels of salivary and serum EGF. Reduced levels of this growth factor may distinguish infants at risk for NEC and play a pivotal role in the pathogenesis of the perturbed intestinal mucosal barrier that is central to this condition.
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Affiliation(s)
- C E Shin
- Department of Surgery, Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH 45229-3039, USA
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Falcone RA, Shin CE, Stern LE, Wang Z, Erwin CR, Soleimani M, Warner BW. Differential expression of ileal Na(+)/H(+) exchanger isoforms after enterectomy. J Surg Res 1999; 86:192-7. [PMID: 10534423 DOI: 10.1006/jsre.1999.5720] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Na(+)/H(+) exchangers (NHE) are transporters involved in the absorption of NaCl along the gastrointestinal tract. The aim of this study was to determine the expression pattern of the intestinal brush border NHE isoforms 2 and 3 following massive small bowel resection (SBR). Additionally, the effect of epidermal growth factor (EGF) and salivarectomy (removal of the primary source of EGF) on the expression pattern was studied. MATERIALS AND METHODS ICR mice underwent a proximal SBR or sham surgery and then received either orogastric saline or EGF (50 microg/kg/day). In separate experiments mice underwent salivarectomy followed by SBR or sham. Postoperatively the remaining ileum was isolated and levels of NHE-2 and NHE-3 mRNA and protein were resolved. RESULTS Following SBR, the expression of both mRNA and protein for NHE-3 increased by approximately 2.5-fold. Treatment with EGF enhanced NHE-3 mRNA in sham animals with further elevation following SBR. The expression of NHE-2 mRNA demonstrated minimal change while protein marginally increased (40%) following SBR. EGF did not affect the expression of NHE-2 mRNA. Salivarectomy did not influence NHE-2 protein expression and inhibited the increased NHE-3 protein expression following SBR. CONCLUSIONS Following SBR, the expression pattern for brush border NHE isoforms is distinctive. Increased expression of NHE-3 secondary to SBR and/or EGF treatment with loss of this increase following salivarectomy implies a common mechanism to enhance enterocyte proliferation and luminal absorption of NaCl and water. These results suggest that NHE-3 is an important ileal exchanger following SBR.
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Affiliation(s)
- R A Falcone
- Department of Surgery, Children's Hospital Medical Center, Cincinnati, Ohio, 45229, USA
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Erwin CR, Helmrath MA, Shin CE, Falcone RA, Stern LE, Warner BW. Intestinal overexpression of EGF in transgenic mice enhances adaptation after small bowel resection. Am J Physiol 1999; 277:G533-40. [PMID: 10484377 DOI: 10.1152/ajpgi.1999.277.3.g533] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The effect of direct intestinal overexpression of epidermal growth factor (EGF) on postresection adaptation has been investigated by the production of transgenic mouse lines. A murine pro-EGF cDNA construct was produced, and expression of the EGF construct was targeted to the small intestine with the use of the rat intestinal fatty acid-binding protein promoter. An approximately twofold increase in intestinal EGF mRNA and protein was detected in heterozygous mice. No changes in serum EGF levels were noted. Except for a slightly shortened small intestine, no other abnormal phenotype was observed. Intestinal adaptation (increases in body weight, DNA, protein content, villus height, and crypt depth) was markedly enhanced after a 50% proximal small bowel resection in transgenic mice compared with nontransgenic littermates. This transgenic mouse model permits the study of intestinal adaptation and other effects of EGF in the small intestine in a more physiological and directed manner than has been previously possible. These results endorse a direct autocrine/paracrine mechanism for EGF on enterocytes as a means to enhance adaptation.
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Affiliation(s)
- C R Erwin
- Department of Surgery, Division of Pediatric Surgery, Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio 45229-3039, USA.
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Shin CE, Falcone RA, Kemp CJ, Erwin CR, Litvak DA, Evers BM, Warner BW. Intestinal adaptation and enterocyte apoptosis following small bowel resection is p53 independent. Am J Physiol 1999; 277:G717-24. [PMID: 10484399 DOI: 10.1152/ajpgi.1999.277.3.g717] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Adaptation following small bowel resection (SBR) signals enterocyte proliferation and apoptosis. Because p53-induced p21(waf1/cip1) may be important for apoptosis in many cells, we hypothesized that these genes are required for increased enterocyte apoptosis during adaptation. Male C57BL/6 (wild-type) or p53-null mice underwent 50% proximal SBR or sham operation (bowel transection-reanastomosis). Adaptation (DNA-protein content, villus height-crypt depth, enterocyte proliferation), appearance of apoptotic bodies, and p53 and p21(waf1/cip1) protein expression were measured in the ileum after 5 days. Adaptation was equivalent after SBR in both wild-type and p53-null mice as monitored by significantly increased ileal DNA-protein content, villus height, and enterocyte proliferation. The number of crypt apoptotic bodies increased significantly after SBR evenly in both wild-type and p53-null mice. In the p53-null mice, SBR substantially induced the expression of p21(waf1/cip1) protein in villus enterocytes. The p53-independent induction of p21(waf1/cip1) may account for the similar intestinal response to SBR between wild-type and p53-null mice. Intestinal adaptation and increased enterocyte apoptosis following intestinal resection occur via a p53-independent mechanism.
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Affiliation(s)
- C E Shin
- Division of Pediatric Surgery, Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio 45229-3039, USA
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Abstract
INTRODUCTION Following massive small bowel resection (SBR), histologic evidence of increased enterocyte apoptosis has been demonstrated in several animal models. Deoxyribonuclease I (DNase I) is requisite for intranuclear cleavage of DNA during apoptosis; we therefore hypothesized that the expression of this gene would be increased following SBR. METHODS Male ICR mice underwent either 50% proximal SBR or sham surgery (bowel transection/reanastomosis). After 12 h and 1, 3, and 7 days, rates of enterocyte proliferation and apoptosis were recorded as well as DNase I mRNA expression and activity. RESULTS Adaptation after SBR was confirmed at each time point by increased proliferation. Enterocyte proliferation was increased by 12 h and apoptosis was increased by 24 h and remained elevated through Day 7. When compared with sham-operated mice, SBR resulted in a twofold increase in both DNase I expression and activity at 24 h postoperatively, which returned to baseline by Postoperative Day 3. CONCLUSIONS DNase I expression and activity are increased early following massive SBR but return to baseline despite persistent increased rates of enterocyte apoptosis and proliferation. This enzyme may be important in the early induction of apoptosis following massive SBR, but not once a new set point has been established in the balance between the rate of enterocyte production and enterocyte loss.
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Affiliation(s)
- R A Falcone
- Department of Surgery, Children's Hospital Medical Center, Cincinnati, Ohio, 45229-3039, USA
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Abstract
BACKGROUND/PURPOSE The Src family of protein tyrosine kinases has been implicated in the downstream mitogenic signaling of several ligands including epidermal growth factor (EGF). Because EGF likely plays a role in adaptation after massive small bowel resection (SBR), we tested the hypothesis that c-src is required for this important response. METHODS A 50% proximal SBR or sham operation (bowel transection or reanastomosis alone) was performed on c-src-deficient (n = 14) or wild-type (C57bl/6) mice (n = 20). The ileum was harvested on postoperative day 3 and adaptive parameters determined as changes in ileal wet weight, protein and DNA content, proliferation index, villus height, and crypt depth. Comparisons were done using analysis of variance (ANOVA), and a Pvalue less than .05 was considered significant. Values are presented as mean +/- SEM. RESULTS The activity of c-src was increased in the ileum of wild-type mice after SBR but remained unchanged in c-src-deficient mice. Despite this lack of increase, adaptation occurred after SBR in the c-src-deficient mice as demonstrated by increased ileal wet weight, protein and DNA content, proliferation index, villus height, and crypt depth similar to wild-type mice. CONCLUSIONS The adaptive response of the intestine to massive SBR is preserved despite reduced activity of the c-src protein. The mitogenic signaling that characterizes intestinal adaptation and is associated with receptor activation by EGF or other growth factors probably occurs by mechanisms independent of c-src protein tyrosine kinase.
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Affiliation(s)
- R A Falcone
- Children's Hospital Medical Center, and the Department of Surgery, University of Cincinnati College of Medicine, OH 45229-3039, USA
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Abstract
BACKGROUND/PURPOSE After massive small bowel resection (SBR), epidermal growth factor (EGF) and its intestinal receptor (EGF-R) play major roles during adaptation. The expression of a homologous enterocyte receptor termed c-neu (c-neu-R) is capable of forming heterodimers with EGF-R to facilitate cellular signaling. The purpose of this study was to determine the expression and activation of EGF-R and c-neu-R during the adaptive intestinal response to SBR. METHODS Male ICR mice underwent either SBR or sham surgery. After 1, 3, and 7 days, enterocytes were isolated and protein immunoprecipitated with antibody to either EGF-R or c-neu-R. Receptor protein expression and activation status were determined. RESULTS When compared with sham operation, the expression and activation status of both EGF-R (six- and twofold, respectively) and c-neu-R (nine- and twofold, respectively) were increased substantially in enterocytes from the adapting ileum after SBR by postoperative day 3. Minimal changes were appreciated for either EGF-R or c-neu-R expression or activation in the remnant bowel after enterocyte removal, liver, or kidney. CONCLUSIONS Both the expression and activation status of EGF-R and c-neu-R are increased substantially in enterocytes from the adapting ileum by postoperative day 3 after massive SBR. These changes provide a unique mechanism for the enterocyte to enhance cellular signaling in response to EGF during intestinal adaptation.
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Affiliation(s)
- R A Falcone
- Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, OH 45229-3039, USA
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Abstract
BACKGROUND/PURPOSE In previous studies using mucosal scrapings or whole-bowel homogenates, epidermal growth factor (EGF) augments adaptation after massive small bowel resection (SBR). The purpose of this study was to determine directly the effect of adaptation and EGF on enterocyte differentiation using an explicit enterocyte cell population. METHODS Male ICR mice underwent 50% proximal SBR or sham (bowel transection-reanastomosis) and were selected randomly to either orogastric saline or EGF (50 microg/kg/d). After 3 days, enterocytes were isolated from the remnant ileum by mechanical vibration and assayed for DNA and protein content as well as sucrase and alkaline phosphatase (AlkP) activity. RESULTS Ileal wet weight, enterocyte protein, and DNA content were increased significantly after SBR and boosted even further with EGF. When normalized for protein, SBR caused an increase in AlkP and sucrase activity, and EGF treatment caused AlkP and sucrase activity to return to baseline. CONCLUSIONS EGF enhances adaptation; however, when normalized for protein, the activity of two enterocyte-specific enzymes was not significantly altered by EGF. This analysis of an explicit enterocyte population supports the notion that the beneficial effects of EGF are more likely caused by increased numbers of enterocytes rather than an increase in the functional activity of each individual cell.
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Affiliation(s)
- R A Falcone
- Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, OH 45229-3039, USA
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Shin CE, Falcone RA, Duane KR, Erwin CR, Warner BW. The distribution of endogenous epidermal growth factor after small bowel resection suggests increased intestinal utilization during adaptation. J Pediatr Surg 1999; 34:22-6. [PMID: 10022137 DOI: 10.1016/s0022-3468(99)90222-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND/PURPOSE Although exogenous epidermal growth factor (EGF) amplifies adaptation after massive small bowel resection (SBR), the role for endogenous EGF is unclear. The authors sought to determine whether SBR was associated with changes in the levels of EGF in the serum, saliva, or urine and EGF receptor (EGF-R) signaling in the ileum. METHODS Male ICR mice underwent 50% proximal SBR or sham surgery bowel transection/reanastomosis). After 3 days, levels of EGF were measured by enzyme-linked immunosorbent assay (ELISA) in the serum, saliva, and urine. EGF-R activation was measured in isolated ileal enterocytes by probing an EGF-R immunoprecipitate with an antibody to phosphotyrosine. RESULTS When compared with sham, SBR resulted in no change in serum, increased salivary (2209+/-266 nmol SBR v 1183+/-119 nmol sham, P<.05) and decreased urinary (417+/-58 nmol SBR v 940+/-143 nmol sham; P<.05) EGF levels. EGF-R activation increased 2.5-fold after SBR. CONCLUSIONS Increased salivary and reduced urinary EGF linked with enhanced EGF-R activation suggests increased ileal utilization of EGF during adaptation. This observation, along with the known beneficial effects of exogenous EGF, infers a crucial role for endogenous EGF in the pathogenesis of intestinal adaptation after SBR.
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Affiliation(s)
- C E Shin
- Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, OH 45229-3039, USA
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Helmrath MA, Shin CE, Fox JW, Erwin CR, Warner BW. Adaptation after small bowel resection is attenuated by sialoadenectomy: the role for endogenous epidermal growth factor. Surgery 1998. [PMID: 9823398 DOI: 10.1016/s0039-6060(98)70008-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Epidermal growth factor (EGF) is likely involved during adaptation after small bowel resection (SBR) because some studies have shown enhanced adaptation by EGF administration. Because the major source of endogenous EGF in mice is the submandibular glands, we sought to determine the effect of submandibular gland excision (SAL) and luminal or systemic EGF replacement on adaptation after SBR. METHODS A 50% proximal SBR or Sham-SBR (bowel transection and reanastomosis) was performed on male C57BL/6 mice after either SAL or gland mobilization only. Additional mice underwent both SBR and SAL and then received daily EGF or saline solution by intraperitoneal or orogastric administration. At 1 week, adaptation was characterized in the ileum as changes in villus height, DNA, and protein content. RESULTS SAL significantly attenuated the increase in ileal villus height, total protein, and DNA content after SBR. Both systemic and oral EGF reversed these findings equally and significantly augmented all parameters of intestinal adaptation after SAL. CONCLUSIONS Submandibular EGF is important for the adaptive response to massive SBR. As both luminal and systemic EGF equally reversed the findings following SAL and SBR, the specific site of action for endogenous EGF during adaptation is either the luminal or basolateral surface of the enterocyte.
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Affiliation(s)
- M A Helmrath
- Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, Ohio 45229-3039, USA
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Helmrath MA, Shin CE, Erwin CR, Warner BW. Intestinal adaptation is enhanced by epidermal growth factor independent of increased ileal epidermal growth factor receptor expression. J Pediatr Surg 1998; 33:980-4; discussion 984-5. [PMID: 9694081 DOI: 10.1016/s0022-3468(98)90518-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND/PURPOSE Intestinal adaptation after massive small bowel resection (SBR) is augmented by epidermal growth factor (EGF) via an unknown mechanism. We recently have observed that EGF increases the expression of EGF receptor mRNA and protein content in the remnant ileum after SBR. The purpose of this study was to determine whether the magnitude of EGF-induced receptor expression correlates with intestinal adaptation. METHODS A 50% proximal SBR or sham operation (bowel transection with reanastomosis) was performed on male ICR mice. Animals from each group were then selected randomly to receive either human recombinant EGF (150 microg/kg/d) or saline by twice daily intraperitoneal injections. The remnant ileum was harvested at 1 week, and parameters of adaptation measured as changes in protein content. Ileal EGF receptor mRNA was quantitated using a ribonuclease protection assay. Changes in the expression ileal EGF receptor protein were determined by Western blot after immunoprecipitation. Comparisons of mean values between groups was performed using analysis of variance (ANOVA) and a P value of less than .05 was considered significant. Values are presented as mean +/- SEM. RESULTS EGF was mitogenic to the ileum after sham operation as monitored by increases in ileal protein content (2.21 +/- 0.002 mg/cm Sham v 2.97 +/- 0.25 mg/cm Sham +/- EGF; P < .05). After SBR, adaptation resulted in increased ileal protein content (4.45 +/- 0.27 mg/cm), which was substantially boosted by EGF (5.98 +/- 0.39 mg/cm; P < .05). No differences were detected in ileal EGF receptor mRNA or protein expression between Sham or SBR groups that did not receive EGF. However, EGF significantly enhanced the expression of ileal EGF receptor mRNA to an equal extent after both sham and SBR (approximately threefold). The magnitude of this increase in EGF receptor protein (four- to sixfold) was similar in both EGF groups as shown by Western blotting. CONCLUSIONS Changes in ileal EGF receptor expression are not mandatory for adaptation to occur. EGF upregulates the expression of mRNA and protein for its own intestinal receptor in vivo. Because EGF-induced receptor expression was comparable after both SBR and Sham operation, the beneficial effect of EGF during adaptation is likely caused by other factors in addition to increased receptor expression.
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Affiliation(s)
- M A Helmrath
- Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, Ohio 45229-3039, USA
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Abstract
BACKGROUND Adaptation after small bowel resection (SBR) is characterized by a new set point in the balance of enterocyte proliferation and apoptosis. Since epidermal growth factor (EGF) augments both proliferation and adaptation, we sought to determine the effect of EGF receptor manipulation on apoptosis following SBR. MATERIALS AND METHODS Male ICR mice underwent 50% SBR or sham operation (bowel transection with reanastomosis) and then were given EGF (50 microg/kg/day) or saline by orogastric gavage. At 1 week, a proliferation index (PI) was measured in the ileum by BrdU uptake and an apoptosis index in crypts (cAI) and villi (vAI) scored by counting apoptotic bodies in enterocytes. In other experiments, AI was scored after SBR in mice with defective receptors (waved-2). Results are expressed as means +/- SE and evaluated statistically using ANOVA. # denotes P < 0.001. RESULTS Following SBR, EGF increased PI (40 +/- 2% vs 50 +/- 1% BrdU + cells; #), villus height (252 +/- 4 micro(m) vs 401 +/- 15 micro(m); #), and crypt depth (77.3 +/- 1.5 micro(m) vs 120.8 +/- 5 micro(m); #). When compared with sham, SBR resulted in increased cAI (0.3 +/- 0.02 vs 2.0 +/- 0.1; #) and vAI (0.4 +/- 0.05 vs 1.1 +/- 0.1; #). EGF attenuated both cAI (0.5 +/- 0. 04) and vAI (0.5 +/- 0.03) following SBR. In the waved-2 mice, the highest levels of cAI (3.1 +/- 0.2) and vAI (3.6 +/- 0.3) were noted after SBR. CONCLUSIONS Enterocyte apoptosis during adaptation is attenuated by EGF and exaggerated when the EGF receptor is defective. In addition to enhancing proliferation, suppression of apoptosis may provide a previously unrecognized mechanism for the beneficial effect of EGF during intestinal adaptation.
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Affiliation(s)
- M A Helmrath
- Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, 45229-3039, USA
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Shin CE, Helmrath MA, Falcone RA, Fox JW, Duane KR, Erwin CR, Warner BW. Epidermal growth factor augments adaptation following small bowel resection: optimal dosage, route, and timing of administration. J Surg Res 1998; 77:11-6. [PMID: 9698525 DOI: 10.1006/jsre.1998.5336] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In assorted animal models of small bowel resection (SBR), exogenous epidermal growth factor (EGF) has been shown to augment intestinal adaptation. This study was designed to elucidate the optimal dose, route, and timing of exogenous EGF to boost adaptation in our murine model of SBR. METHODS Male ICR mice underwent either 50% proximal SBR or sham surgery (bowel transection with reanastomosis) and then randomized to receive either saline or human recombinant EGF (5, 50, 150, or 300 microg/kg/day) by twice daily intraperitoneal (i.p.) injection or orogastric gavage (o.g.). At 7 days, protein and DNA content, crypt depth, and villus height were determined in the ileum. The premium dose and route was then given for 1 week either during (1 week after SBR) or after the adaptive phase (1 month after SBR). Differences between group means were analyzed using ANOVA. A P < 0.05 was considered significant. RESULTS EGF enhanced DNA and protein content, crypt depth, and villus height to the greatest extent at a dosage of 50 microg/kg/day by the o.g. route. EGF had no significant effect on enhancing adaptation when given after the adaptive response had already occurred. CONCLUSIONS Intestinal adaptation is optimally enhanced by a specific dose and route of EGF. Exogenous EGF enhances adaptation only during the adaptive response to SBR and not after it has already taken place. Determination of the best circumstances for EGF administration will permit a systematic approach toward understanding a mechanism for the beneficial effect of EGF during intestinal adaptation.
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Affiliation(s)
- C E Shin
- Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, 45229-3039, USA
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Abstract
BACKGROUND/PURPOSE Epidermal growth factor (EGF) binds to its enterocyte receptor and enhances intestinal adaptation after massive small bowel resection (SBR). To ascertain the mechanism for enhanced adaptation by EGF, we sought to determine the effect of EGF administration on in vivo expression of the intestinal EGF receptor after SBR. METHODS Male ICR mice underwent a 50% proximal SBR and then were assigned randomly to EGF (150 microg/kg/d) or saline by twice daily intraperitoneal injection. After 3 days, the ileum was harvested and total protein and DNA content were measured. Northern hybridization and a ribonuclease protection assay were used to detect qualitative and quantitative expression of EGF receptor mRNA. The remaining ileum was pooled for each group and Western blotting used to determine expression of EGF receptor protein. RESULTS EGF augmented adaptation after SBR as monitored by significant increases in ileal protein (2.7+/-0.08 saline versus 3.9+/-0.17 mg/cm EGF; P<.001) and DNA (55.8+/-1.6 saline versus 104+/-8.4 microg/cm EGF; P<.001) content. Northern blotting results showed a marked (>fivefold) increase in ileal EGF receptor mRNA, which was confirmed with the ribonuclease protection assay. Administration of EGF after SBR induced a similar expression of EGF receptor protein. CONCLUSIONS EGF enhanced intestinal adaptation after SBR. This augmented response is associated with increased ileal expression of EGF receptor mRNA and protein. Increased EGF receptor expression and subsequent enhanced ligand/ receptor activity may be one important mechanism for the beneficial effect of EGF administration during intestinal adaptation.
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Affiliation(s)
- M A Helmrath
- Children's Hospital Medical Center, Department of Surgery, University of Cinncinnati College of Medicine, OH 45229-3039, USA
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Abstract
With the widespread availability and use of pelvic sonography, the rate at which ovarian cysts are detected in the pediatric population has increased, and such cysts are an important problem encountered in pediatric surgical practice. Rational management should take into account key factors such as symptoms, patient age, menarchal status, cysts size, and character, as well as associated medical conditions. The purpose of this review is to discuss the incidence and pathophysiology of ovarian cysts in children. A management strategy is presented based on the above-mentioned key factors.
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Affiliation(s)
- M A Helmrath
- Division of Pediatric Surgery, Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA
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Abstract
The intestinal mucosa is in a steady state of turnover as the rate of cellular proliferation is balanced by the rate of cell death. Although it is accepted that adaptation after small bowel resection (SBR) results in increased proliferation, its effect on apoptosis is not known. The purpose of this study was to determine the effect of adaptation following SBR on rates of enterocyte apoptosis. Male ICR mice underwent either 50% proximal SBR or sham operation (bowel transection/reanastomosis). After 12 and 24 hours, and 3 and 7 days, rates of proliferation were measured in the ileum as the percentage of crypt cells incorporating bromodeoxyuridine. Apoptosis was quantiated by end labeling of DNA strand breaks and propidium iodide staining of the number of apoptotic bodies per crypt and villus. Significant increases in enterocyte proliferation (30% to 40%) as well as apoptosis (57% to 87%) occurred at all time points following SBR when compared with sham-operated mice. Adaptation following SBR increases both the rate of enterocytc proliferation and the rate of apoptosis. Understanding the pathophysiology of intestinal adaptation and therapeutic interventions designed to augment this important response will require complete characterization of their effects on both proliferation and apoptosis.
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Affiliation(s)
- M A Helmrath
- Division of Pediatric Surgery, Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cininnati, Ohio, USA
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Abstract
BACKGROUND Adaptation following massive small bowel resection (SBR) is an important compensatory response. While epidermal growth factor (EGF) has been shown to augment this response, the mechanism and role of EGF and its intestinal receptor (EGF-R) during adaptation are not known. The purpose of this study was to determine the effect of massive SBR and adaptation on intestinal expression of EGF-R. MATERIALS AND METHODS Male Sprague-Dawley rats underwent either a 75% mid-SBR with primary reanastomosis or sham operation (bowel transection with reanastomosis). Ileal mucosa was harvested from animals of each group at 6 and 12 hr, 1, 3, and 5 days, and 1, 2, and 4 weeks after operation. Expression of EGF-R protein was studied by Western blotting. Expression of EGF-R mRNA was determined by quantitative reverse-transcriptase polymerase chain reactions normalized to beta-actin. RESULTS When compared with sham, SBR resulted in a modest (32%) increase in the expression of EGF-R mRNA at 1 week (P < 0.003). A twofold greater expression of EGF-R protein corresponded to this time point. While not statistically significant, expression of EGF-R mRNA was slightly greater after SBR at every other time point measured. CONCLUSION Following massive SBR, expression of both EGF-R mRNA and protein is slightly increased in the ileum with a more pronounced increase in protein. These findings, which have not previously been reported, suggest that changes in EGF-R signaling may not play a major role during the initiation and or progression of intestinal adaptation following massive SBR.
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Affiliation(s)
- B W Warner
- Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, Ohio 45229, USA
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