Flow Grade-Based Success Rates, Complication Rates, and Balloon Pulmonary Angioplasty Patency for Total Occlusions

BACKGROUND

The number of successfully recanalized total occlusions affects hemodynamic improvement after balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to clarify the current efficacy, patency, and success rate of BPA for total occlusions.

METHODS

Between April 2016 and August 2021, 178 BPAs were performed in 100 patients with CTEPH and total occlusions. The primary success and subsequent patency rates immediately before the second BPA procedure (follow-up) were compared between the segmental and subsegmental groups, based on the flow grade, which was defined as follows: 0, no reperfusion; 1, minimal reperfusion; 2, partial reperfusion; and 3, complete reperfusion.

RESULTS

Total occlusions were mainly located in the right lung (70%) and lower lobes (48%). The primary success rate was 88%, with significant improvements in oxygenation, hemodynamic parameters, and 6-minute walk test. The primary flow grade did not differ between groups. However, the proportion of lesions with a flow grade of 2 or 3 at follow-up was significantly higher in the subsegmental group than in the segmental group (84% vs 45%, respectively; P < 0.01). In multivariate analysis, flow grade in the acute phase (odds ratio [OR], 46.9; 95% confidence interval [CI], 12.54-176.78; P < 0.01) and subsegmental lesions (OR, 13.8; 95% CI, 3.24-58.94; P < 0.01) were independently associated with better patency (flow grade of 2 or 3) at follow-up.

CONCLUSIONS

Total occlusions can be safely and effectively treated with BPA. BPA for total occlusions may be preferable for subsegmental over segmental lesions.

The results of genetic analysis and clinical outcomes after stent deployment in adult patients with isolated peripheral pulmonary artery stenosis

Peripheral pulmonary arterial stenosis (PPAS) is commonly observed in paediatric patients with associated congenital heart disease or systemic congenital syndromes, such as tetralogy of Fallot and Williams syndrome [1]. Meanwhile, isolated PPAS without other structural heart disease or systemic congenital syndromes is primarily reported in adulthood [2]. Recent genetic analyses have revealed that four cases of isolated PPAS in adulthood were homozygous for the ring finger protein 213 (RNF213) p.Arg4810Lys variant (also referred to as G to A alteration of rs112735431 and NM_001256071.3:c.14429G>A) [3]. RNF213 p.Arg4810Lys is a genetic determinant in moyamoya disease (MMD) in East Asians [4]. This genetic variant is unique to East Asians and is reported to have a frequency of approximately 0.8% in the general Japanese population [5, 6]. However, its prevalence in adult patients with isolated PPAS remains unknown.

The RNF213 p.Arg4810Lys mutation is closely linked to the development of PPAS. Stent deployment might be a promising treatment option, but further investigation would be warranted. https://bit.ly/40t8Gmz

High incidence of pulmonary artery thrombosis after balloon pulmonary angioplasty in CTEPH patients receiving direct oral anticoagulants

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) requires life-long anticoagulant therapy, whereas limited data exist on the safety and efficacy of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) along with balloon pulmonary angioplasty (BPA).

Objectives

To evaluate outcomes and complications in CTEPH following BPA for individuals receiving DOACs or VKAs.

Methods

Consecutive CTEPH patients underwent BPA from September 2014 to August 2021 were included in a retrospective analysis. Complications during BPA, post-BPA hemodynamics and bleeding events were obtained from patient's medical records. Our routine follow-up “selective” pulmonary angiography, to evaluate all segmental pulmonary arteries one by one at six months and every year after final BPA session, was performed to elucidate the incidence of in-situ fresh floating thrombus.

Results

Of total 250 individuals, 104 were treated with DOACs and 146 with VKAs following BPA. Mean observation period was 905 (SD ± 660) days. Total 1278 BPA sessions were performed among the period in which 409 sessions were treated with DOACs and 869 sessions with VKAs. Significant improvements in hemodynamics and functional status were observed in both groups following BPA. There was no significant difference of hemoptysis during BPA between DOACs and VKAs (7.1% vs 10.1%, P=0.131). Major bleeding events during observation period were equivalent in those treated with DOACs and VKAs. No significant re-elevation of pulmonary artery pressure was observed in both groups after BPA. Follow-up selective pulmonary angiography identified in-situ fresh floating thrombus in pulmonary artery in 22 cases of total 769 follow-up sessions. The occurrence of fresh thrombus was significantly higher in those receiving DOACs than VKAs in therapeutic range of PT-INR &gt;1.8 (3.9% vs 1.2%, P=0.023) whereas no significant difference between DOACs and overall VKAs (3.9% vs 2.4%, P=0.177)

Conclusions

Post-BPA hemodynamic outcomes and bleeding events appear unaffected by choice of anticoagulant. However, the incidence of in-situ pulmonary thrombosis detected by selective pulmonary angiography was significantly higher in those receiving DOACs than VKAs in therapeutic range, suggesting inadequate anticoagulation under current dose of DOACs. Our study provides a rationale for further examination to evaluate the efficacy of DOACs in CTEPH.

Funding Acknowledgement

Type of funding sources: None.

Triglyceride to HDL-cholesterol ratio is a predictor of future coronary events: a possible role of high-risk coronary plaques detected by coronary CT angiography

Background

For the prevention of future cardiovascular events, control of residual risks such as triglyceride rich lipoproteins and HDL-cholesterol is an emerging problem beyond LDL-cholesterol. Triglyceride to HDL-cholesterol ratio (TG/HDL ratio) has been reported to be useful for risk classification of cardiovascular diseases. Meanwhile, several studies showed that high-risk plaque characteristics evaluated with coronary CT angiography (cCTA) was associated with the incidence of acute coronary syndrome. However, the relationship of TG/HDL ratio with coronary plaque characteristics and its impact of this association on future coronary events have not been fully elucidated.

Purpose

The aim of this study was to evaluate the association between TG/HDL ratio and high-risk plaque detected by cCTA and its impact on future coronary events.

Methods

A total of 944 patients suspected stable coronary artery disease who underwent cCTA at our institution were analyzed (mean 64-year-old, 55% male). Patients were divided into two groups by the median value of TG/HDL ratio (higher TG/HDL: TG/HDL ratio ≥2.0, lower TG/HDL: TG/HDL ratio &lt;2.0). Coronary high-risk plaques were defined as a plaque with all three components; low attenuation plaque (&lt;50H.U.), positive remodeling (remodeling index &gt;1.1) and spotty calcification. Cardiovascular event was defined as cardiovascular death, acute coronary syndrome, and late coronary revascularization after 30 days of CT acquisition.

Results

The higher TG/HDL ratio was significantly associated with male gender (63% vs. 48%, P&lt;0.001), body mass index (24.8±3.8 vs. 22.9±4.0, p&lt;0.001), the prevalence of hypertension (65% vs. 54%, P&lt;0.001), dyslipidemia (60% vs. 42%, P&lt;0.001), diabetes mellitus (38% vs. 27%, P=0.001) and current smoking (26% vs. 10%, p&lt;0.001). Regarding cCTA findings, the prevalence of significant stenosis, calcified plaque, non-calcified plaque, coronary plaques with low attenuation plaque, positive remodeling and spotty calcification in the higher TG/HDL group were greater than those in the lower group (Figure 1A). Of note, the difference in high-risk plaque between two groups was significant. (18% vs. 11%, p=0.004). Multivariate logistic analysis revealed that the TG/HDL ratio was an independent risk factor for high-risk plaque even after adjustment (OR, 1.35; 95% CI, 1.01–1.81; p=0.049). Regarding coronary events (median follow-up duration; 48 months), Kaplan-Meier curve showed poor event-free rate in the higher TG/HDL group (Figure 1B). At Cox proportional hazard analysis, higher TG/HDL ratio (HR, 1.94; 95% CI, 1.01–3.70; p=0.046) and CT-verified high-risk plaque (HR, 2.36; 95% CI, 1.27–4.38; p=0.006) were independent predictive factors for coronary events even after adjustment.

Conclusion

TG/HDL ratio is involved in the vulnerability of CT-verified coronary plaque characteristics. This association may play an important role in the prognostic impact of TG/HDL ratio on future cardiovascular events.

Funding Acknowledgement

Type of funding source: None

Higher oxidized high-density lipoprotein to apolipoprotein A-I ratio is associated with high-risk coronary plaque characteristics determined by CT angiography

BACKGROUND

Oxidized high-density lipoprotein (oxHDL), unlike native HDL, is characterized by reduced cholesterol efflux capability and anti-inflammatory properties. The ratio of oxHDL to apolipoprotein A-I (oxHDL/apoAI) is a possible marker of dysfunctional HDL. The aim of this study was to evaluate the association between oxHDL/apoAI and coronary plaque characteristics that increase the likelihood of cardiovascular events as determined by coronary computed tomography (CT) angiography.

METHODS

A total of 297 patients (mean age; 67 years, men; 63%) who underwent coronary CT angiography for suspected stable coronary artery disease (CAD) were included. High-risk plaques (HRP) were defined by three characteristics: positive remodeling; low-density plaques; and spotty calcification. Significant stenosis was defined as a luminal narrowing of >70%. Serum concentrations of oxHDL were measured using an enzyme-linked immunosorbent assay.

RESULTS

Patients with higher oxHDL/ApoAI showed significantly greater prevalence of HRP (p = 0.03) and significant stenosis (p < 0.01) compared with patients with low oxHDL/ ApoAI. The multivariate logistic analysis demonstrated that oxHDL/ApoAI significantly associated with the presence of HRP and significant coronary stenosis (p = 0.01 and < 0.01). In the follow-up study including 243 patients for a median period of 1.8 years, univariate cox regression analysis showed that oxHDL/ApoAI, HRP and significant stenosis were significant predictors of cardiovascular events.

CONCLUSIONS

A high oxHDL/apoAI was associated with the presence of HRP and significant stenosis determined by coronary CT angiography, which can lead to cardiovascular events in patients with suspected stable CAD.

P4760New minimally invasive and tailor-made strategy for cryoballoon ablation in patients with paroxysmal atrial fibrillation

Background

Currently, cryoballoon ablation (CBA) has proven to be highly effective in achieving free from atrial fibrillation (AF), especially paroxysmal AF. However, the optimal freezing protocol for each patient to achieve successful pulmonary vein isolation by only CBA is still uncertain. The aim of this study was to evaluate the clinical implications of a reduction in the freezing duration (<180s) during CBA guided by the time to target temperature.

Methods

From November 2015 to August 2018, 286 consecutive paroxysmal AF patients undergoing CBA were enrolled. We compared 107 patients undergoing a tailor-made CBA procedure (Group A; August 2017-August 2018) to 179 patients with a standard CBA procedure (Group B; November 2015–July 2017). In Group A, the freezing duration was reduced to 150s when the temperature reached ≤−40°C within 40s. Furthermore, we reduced it to 120s when it reached ≤−50°C within 60s. In the other patients, the freezing time was 180s except for excessive freezing over −60°C and/or emergent situations while monitoring the esophageal temperature and for phrenic nerve injury as in Group B.

Results

The baseline clinical characteristics were similar between two groups. In Group A, 89 patients (83%) underwent CBA with a reduction in the freezing time. The rate of having reduction time in left inferior PV (LIPV) and right inferior PV (RIPV) was lower compared with left superior PV (LSPV) and right superior PV (RSPV) (respectively 17%, 29%, 56%, and 63.5%). However, for right inferior PV, in 31 patients having the reduced freezing time, none of them required touch-up ablation. Although the procedure time and frequency of touch-up ablation did not differ between the 2 groups, total freezing time for each PV was significantly shorter in Group A than Group B as shown in figure (LSPV: 164±28s vs. 216±67s; p<0.001, LIPV: 187±44s vs. 218±69s; p<0.001, RSPV: 147±31s vs. 192±51s; p<0.001, RIPV: 180±50 vs. 218±73s; p<0.001). The AF free survival rate during the follow-up period (356±167 days) was similar between the 2 groups (log-rank test, p=0.38). Furthermore, the complication rate was similar 2 groups.

The freezing time for each PV

Conclusion

The safety and efficacy of the new tailor-made CBA strategy were non-inferior to the standard procedure. This study showed that the unnecessary freezing time could be reduced in most of paroxysmal AF patients.

P2694Early and late restenosis after excimer laser coronary angioplasty and paclitaxel-coated balloon combination therapy for drug-eluting stent restenosis

Background

Drug-eluting stent restenosis (DES-ISR) is associated with poorer outcomes than those of bare-metal stent restenosis after treatment with paclitaxel-coated balloon (PCB), and late restenosis after PCB angioplasty for DES-ISR is a residual problem. Excimer laser coronary angioplasty (ELCA) is thought to be advantageous for ISR treatment by removing neointima. However, whether the combination of ELCA and PCB angioplasty is more effective than the use of PCB only angioplasty in DES-ISR has not been studied so far.

Purpose

We evaluated the efficacy of ELCA and PCB combination therapy for DES-ISR at mid-and late-term after revascularization.

Methods

From January 2014 to March 2016, 166 DES-ISR lesions were treated with ELCA and no-ELCA prior to PCB. Two serial angiographic follow-ups were planned for the patients (at 6–12 and 18–24 months after procedure). Acute procedural and follow-up angiographic results were assessed by quantitative coronary angiography. ELCA and no-ELCA group included 74 lesions and 92 lesions, respectively.

Results

There was no significant difference between the two groups in the clinical characteristics except the prevalence of hemodialysis, the rate of first-generation DES (37.9% vs 36.8%, p=0.897), previous stent size (2.90±0.39 mm vs 2.77±0.39 mm, p=0.063), and reference vessel diameter (2.65±0.46 mm vs 2.60±0.65 mm, p=0.593). Early follow-up angiography was performed in 66 lesions (89.1%) of ELCA group, and was done in 76 lesions (82.6%) of no-ELCA group. In the ELCA group, percentage diameter stenosis (%DS) just after procedure and at 6–12 months later were significantly smaller than those of no-ELCA group. Besides, target lesion revascularization (TLR) rate at 6–12 months after procedure was tended to be lower in the ELCA group. Late follow-up angiography was performed for 93 lesions (81.6%) of the remaining 114 lesions (excluding TLR lesion), late restenosis was found 9 lesions (18.6%) in the ELCA group and 11 lesions (24.4%) in the no-ELCA group (p=0.504). Late luminal loss was similar in both groups (0.37±0.71 mm vs 0.24±0.82 mm, p=0.438), and %DS at 12–18 months after revascularization was not different between the two groups.

Changes of %DS and TLR rate

Conclusions

%DS in the ELCA group was smaller at just after procedure and the advantage was kept even after 1-year. However, late restenosis and TLR at 2-year after revascularization for DES-ISR could not be reduced by ELCA and PCB combination therapy.

Enhancing effect of taurine on CYP7A1 mRNA expression in Hep G2 cells

Taurine has been reported to enhance cholesterol 7alpha-hydroxylase (CYP7A1) mRNA expression in animal models. However, no in vitro studies of this effect have been reported. The Hep G2 human hepatoma cell line has been recognized as a good model for studying the regulation of human CYP7A1. This work characterizes the effects of taurine on CYP7A1 mRNA levels of Hep G2 cells in a dose- and time-dependent manner. In the dose-dependent experiment, Hep G2 cells were treated with 0, 2, 10 or 20 mM taurine in the presence or absence of cholesterol 0.2 mM for 48 h. In the time-dependent experiment, Hep G2 cells were treated with 0 or 20 mM taurine for 4, 24 and 48 h with and without cholesterol 0.2 mM. Our data revealed that taurine showed time- and dose-response effects on CYP7A1 mRNA levels in Hep G2 cells. However, glycine - a structural analogue of taurine - did not have an effect on CYP7A1 gene expression. These results show that, in agreement to previous studies on animal models, taurine induces the mRNA levels of CYP7A1 in Hep G2 cells, which could enhance cholesterol conversion into bile acids. Also, Hep G2 cell line may be an appropriate model to study the effects of taurine on human cholesterol metabolism.

Modulation of the expression of peroxisome proliferator-activated receptor-dependent genes through disproportional expression of two subtypes in the small intestine

We have reported that dietary long-chain triacylglycerols (LCT) enhance the transcription of cellular retinol-binding protein, the type II (CRBPII) gene, and the liver-type fatty acid-binding protein (L-FABP) gene in the small intestine. Because the cis elements on the CRBPII gene consisting of two AGGTCA motifs separated by a single nucleotide are known to bind not only the 9-cis-retinoic acid receptor (RXR) homodimer, but also the peroxisome proliferator-activated receptor (PPAR)-RXR heterodimer, it has been implicated that the unsaturated long-chain fatty acids, as the ligands of the PPAR, might activate the transcription of the CRBPII gene, thereby making use of the RXR-response elements (RXRE and RE3) as the PPAR-response element (PPRE). In this study, we found that the PPARalpha mRNA level in the rat jejunum was elevated by dietary fat, whereas the PPARdelta mRNA level was reduced under this condition. Electrophoretic mobility-shift assay revealed that both PPARalpha-RXRalpha and PPARdelta-RXRalpha heterodimers, specifically and in a dose-dependent manner, bound to the two PPRE-like elements of the rat CRBPII gene as well as the known PPREs in the L-FABP and acyl-CoA oxidase genes. The binding of the PPARalpha-RXRalpha heterodimer to the CRBPII-RXRE, the CRBPII-RE3, and the PPREs of L-FABP, HMG-CoA synthase, and acyl-CoA oxidase was gradually diminished by the addition of increasing amounts of PPARdelta. The binding of the PPARdelta-RXRalpha heterodimer to CRBPII-RXRE, CRBPII-RE3, and other PPREs was also gradually reduced by the addition of increasing amounts of PPARalpha. Using Escherichia coli-expressed RXRalpha, we showed that the mutual competition for RXRalpha with PPARalpha and PPARdelta occurred at the protein level. These results suggest that the transcriptions of CRBPII, L-FABP, and the other PPAR-dependent genes in the small intestine may be coordinately regulated by the disproportional expression of PPARalpha and PPARdelta.

The expression of PPAR-associated genes is modulated through postnatal development of PPAR subtypes in the small intestine

In this study, we found that the mRNA level of peroxisome proliferator-activated receptor (PPAR) alpha, but not of PPARdelta, was elevated in the jejunum during the postnatal development of the rat. Moreover, we found that the expressions of PPAR-dependent genes, such as acyl-CoA oxidase, L-FABP, and I-FABP, were also increased during the postnatal development of the small intestine. Electrophoretic mobility shift assay revealed that both the PPARalpha-9-cis-retinoic acid receptor alpha (RXRalpha) heterodimer and the PPARdelta-RXRalpha heterodimer bound to the peroxisome proliferator response element (PPRE) of acyl-CoA oxidase and L-FABP genes. The binding of the PPARalpha-RXRalpha heterodimer to the PPREs of the various genes was enhanced by the addition of PPARalpha, with a concomitant reduction of the binding of PPARdelta-RXRalpha to the PPREs. Furthermore, the binding activity of PPARalpha-RXRalpha, but not PPARdelta-RXRalpha, to the PPREs was enhanced by the addition of a PPAR ligand, WY14,643. The GAL4-PPAR-chimera reporter assay showed that WY14,643 transactivated the reporter gene through action of PPARalpha, but not through PPARdelta, in Caco-2 cells. Furthermore, oral administration of a PPAR ligand, clofibrate, during 3 consecutive days of the weanling period caused a parallel increase in the mRNA levels of these PPAR-dependent genes. These results suggest that acyl-CoA oxidase, L-FABP and the other PPAR-dependent genes in the small intestine may be coordinately modulated during postnatal development by the disproportional expression of PPARalpha over PPARdelta.

Structure of cytochrome c6 from the red alga Porphyra yezoensis at 1. 57 A resolution

The crystal structure of cytochrome c(6) from the red alga Porphyra yezoensis has been determined at 1.57 A resolution. The crystal is tetragonal and belongs to space group P4(3)2(1)2, with unit-cell parameters a = b = 49.26 (3), c = 83.45 (4) A and one molecule per asymmetric unit. The structure was solved by the molecular-replacement method and refined with X-PLOR to an R factor of 19.9% and a free R factor of 25.4%. The overall structure of cytochrome c(6) follows the topology of class I c-type cytochromes in which the heme prosthetic group covalently binds to Cys14 and Cys17, and the iron has an octahedral coordination with His18 and Met58 as the axial ligands. The sequence and the structure of the eukaryotic red algal cytochrome c(6) are very similar to those of a prokaryotic cyanobacterial cytochrome c(6) rather than those of eukaryotic green algal c(6) cytochromes.

Regulation of vitamin A metabolism-related gene expression

Cellular retinol-binding protein, type II (CRBPII) is abundantly expressed in the small intestinal epithelial cells and plays a pivotal role in intestinal absorption and metabolism of retinol and beta-carotene. In the 5'-flanking region of rat CRBPII gene, two DR-1 type elements which consist of a direct repeat of the AGGTCA-like motif spaced by a single nucleotide have been identified as putative binding sites for a heterodimer of peroxisome proliferator-activated receptor (PPAR) and retinoid X-receptor (RXR). We found that CRBPII levels were elevated in the residual jejunal segment of rats subjected to jejunal bypass operation, where a concomitant increase in the apoprotein B levels occurred. This result suggested that CRBPII expression was enhanced by a condition where fat absorption was stimulated. Indeed, dietary fat (especially unsaturated fatty acids) has been shown to induce CRBPII gene expression in the jejunum. Nuclear run-on assays revealed that this increase of CRBPII mRNA levels by a high-fat diet was the result of the induction of the gene transcription through the rise in PPARalpha expression level as well as the increase in its ligand levels. Electrophoretic mobility shift assay using the DR-1 type cis-elements of CRBP II gene showed that PPARalpha-RXRalpha heterodimer was capable of binding to these elements, and that nuclear extracts from the jejunum of rats fed the high-fat diet gave greater density of retarded bands than those of rats fed a fat-free diet. We also found that the expression of PPARdelta was rather reduced by dietary fat. Thus, CRBPII gene expression is regulated predominantly by dietary fatty acids.

Developmental induction and villus-crypt distribution of retinol esterifying enzyme activities in chick duodenum

Retinol absorbed and generated from dietary beta-carotene can be esterified by retinol esterifying enzyme(s) in intestinal absorptive cells. In this study, we observed the developmental changes and villus-crypt distribution of the activities of two retinol esterifying enzymes (lecithin-retinol acyltransferase (LRAT); and acyl-CoA-retinol acyltransferase (ARAT) in chick duodenum) to seek the possibility that these enzymes play distinct roles in retinol absorption and metabolism. Intestinal LRAT activity was barely expressed in embryonic stages until 2-3 d before hatching, when its activity becomes detectable; thereafter it abruptly increased to the maximal level at the third day of the posthatch period. In contrast, ARAT activity was present in the duodenum at the earliest stage examined, the 15th day of embryogenesis, and was elevated to the maximal level 3-4 d after hatching. An assay of LRAT and ARAT activities along the villus-crypt axis of the duodenum by a cryostat sectioning technique revealed that between the day of hatching and 1 d posthatch, an abrupt induction of LRAT activity occurred only in the villus region of the duodenum, where a coordinated induction of cellular retinol-binding protein, type II (CRBPII), was observed. In contrast, the rise in ARAT activity observed around the hatching period occurred at the broader portions of the villi including the area of villus-crypt junction. These observations in the developmental changes and distribution of LRAT and ARAT activities suggest that LRAT activity but not ARAT activity is closely related to the induction of CRBPII in the duodenum of developing chicks.

Regulation of cellular retinol-binding protein type II gene expression by arachidonic acid analogue and 9-cis retinoic acid in caco-2 cells

We previously showed that unsaturated fatty acids induced gene expression of cellular retinol-binding protein type II (CRBPII) in rat jejunum [Suruga, K., Suzuki, R., Goda, T. and Takase, S. (1995) J. Nutr. 125, 2039-2044]. In the present study, we investigated this induction mechanism(s) using the human intestinal Caco-2 cell line. The postconfluent mature Caco-2 cells were maintained in serum-free medium containing arachidonic acid or its analogue, 5,8,11, 14-eicosatetraynoic acid (ETYA). Northern blot analysis showed that these compounds induced CRBPII mRNA levels to rise and that this induction was more effective when combined with 9-cis retinoic acid. This effect was independent of cycloheximide and inhibited by actinomycin D. Nuclear run-on assays confirmed that the ETYA and 9-cis retinoic acid-induced increase of CRBPII mRNA levels was due to an increased rate of transcription of its gene. In Caco-2 cells, the transcripts of peroxisome proliferator-activated receptor alpha (PPARalpha) and retinoid X receptor alpha (RXRalpha), which were activated by their ligands ETYA and 9-cis retinoic acid, respectively, were coexpressed. The gel shift study using rat CRBPII gene nuclear receptor response elements (RXRE, RE2, RE3) revealed that several forms of nuclear proteins from Caco-2 cells specifically bound to these elements. Some of these protein/DNA complexes reacted to both anti-RXRalpha and anti-PPAR antibodies. In addition, in-vitro synthesized RXRalpha and PPARalpha cooperatively bound to these elements as a heterodimer and these binding activities were enhanced by addition of ETYA or arachidonic acid but not by addition of 9-cis retinoic acid. These studies suggest that fatty acid or its analogue may regulate CRBPII gene expression through PPAR/RXR heterodimer bound to the nuclear receptor response element(s) of the CRBPII genes.

Transcriptional regulation of cellular retinol-binding protein, type II gene expression in small intestine by dietary fat

We have previously demonstrated that dietary fat, especially unsaturated fatty acids, induces cellular retinol-binding protein, type II (CRBPII) gene expression in rat jejunum. In the present study, we showed that feeding a high-fat diet caused parallel increases in jejunal CRBPII mRNA and CRBPII pre-mRNA levels. Nuclear run-on assay also revealed that this increase of CRBPII mRNA level by high-fat diet was, at least in part, triggered at a transcription level. Moreover, peroxisome proliferator-activated receptor alpha (PPARalpha) mRNA level was also increased in the jejunum by high-fat diet. Gel shift assay showed that the binding activity of rat jejunal nuclear protein to the nuclear receptor response elements located in the rat CRBPII gene (RXRE and RE3) was greater in rats fed high-fat diet than in those fed fat-free diet and were enhanced by addition of bacterially expressed PPARalpha protein. Also PPARalpha-retinoid X receptor alpha (RXRalpha) heterodimer was capable of binding to the CRBPII-RXRE and RE3 elements and these binding activities were enhanced by addition of some PPARalpha ligands in the gel shift assay. Taken together, these studies suggest that dietary fatty acids may lead to induction of CRBPII gene transcription through increases of PPARalpha as well as its ligand levels.

Dietary fatty acids are possible key determinants of cellular retinol-binding protein II gene expression

We previously found that dietary unsaturated fatty acids increase cellular retinol-binding protein type II (CRBP II) mRNA and its protein levels in rat jejunum. To obtain insight into mechanisms for its gene induction, we investigated the effect of depletion of dietary fat on CRBP II mRNA levels and we further examined whether dietary retinol is necessary for dietary fat-induced CRBP II gene expression. Feeding the fat-free diet, which contained a sufficient amount of vitamin A, repressed CRBP II mRNA accumulation by 50% within 1 day, and this low level was sustained over the next 9 days. Parallel to the decreased CRBP II mRNA level, the peroxisomal proliferator-activated receptor-alpha (PPAR-alpha) mRNA level in rat jejunum was decreased by long-term (7 days) feeding of an isocaloric low-fat diet compared with the control. Oral administration of corn oil in the animals fed vitamin A-free diet elicited approximately threefold accumulation of CRBP II mRNA within 6 h. However, the administration of 9-cis-retinoic acid brought about no accumulation of CRBP II mRNA. Even when rats were vitamin A-deficient, oral administration of corn oil, but not 9-cis-retinoic acid, caused an increase in jejunal CRBP II mRNA level. These results suggest that CRBP II gene expression in rat jejunum may be regulated predominantly by dietary fatty acids but little by dietary retinoids.

Peroxisome proliferator enhances gene expression of cellular retinol-binding protein, type II in Caco-2 cells

Both the mRNA and protein of cellular retinol-binding protein, type two (CRBP(II)) are induced in rat intestine by high fat (corn oil) diet (Biochim. Biophys. Acta 1200, 34-40, 1994) as well as by dietary unsaturated long-chain fatty acids (J. Nutr. 125, 2039-2044, 1995). To gain an insight into the mechanism for this induction, we investigated whether CRBP(II) gene was activated by exposure of the human intestinal cell line, Caco-2 to a peroxisome proliferator (clofibric acid) and/or 9-cis retinoic acid. Northern blot hybridization revealed that Caco-2 cells endogenously expressed the mRNAs of peroxisome proliferator-activated receptor alpha (PPARalpha) and retinoid X receptor alpha (RXRalpha). The expression of the genes encoding CRBP(II), PPARalpha, and RXRalpha increased progressively during differentiation of Caco-2 cells. The cells exposed to 100 microM clofibric acid exhibited 70% greater CRBP(II) mRNA and the exposure of the cells to 100 microM clofibric acid in combination with 100 microM 9-cis retinoic acid exhibited 130% greater CRBP(II) mRNA level, indicating that the effect of the combination of them was additive. Neither PPARalpha mRNA nor RXRalpha mRNA level was enhanced by clofibric acid. In conclusion, our data suggested that the CRBP(II) gene expression may be enhanced by an activation of PPARalpha-RXRalpha heterodimer through some putative metabolite(s) formed via fatty acid-related metabolic pathway in the clofibrc acid-treated cells.

Cloning of chick cellular retinol-binding protein, type II and comparison to that of some mammals: expression of the gene at different developmental stages, and possible involvement of RXRs and PPAR

We cloned chick cellular retinol-binding protein, type two (CRBP II) cDNA and compared it with those of some mammals. The deduced amino acid sequence showed that chick CRBP II was one amino acid greater in size than those of mammals, and the nucleotide sequence of chick CRBP II shared 72%-75% similarity with those of mammals. RNA blot hybridization analysis showed that CRBP II transcript of 0.7 kb was first detected in the duodenum of day-18 embryonic chick, and exhibited a rapid increase during 24 hr around the hatching. Northern blot hybridization also revealed that the transcripts of two types of retinoid X receptors (RXR alpha and RXR gamma) and peroxisome proliferator-activated receptor (PPAR) were expressed in the chick duodenum at hatching. The organ culture of day 16 embryonic chick duodenum showed that the addition of 9-cis retinoic acid in the medium caused a significant increase in CRBP II mRNA levels. In addition, arachidonic acid, from which putative ligands for PPAR were supposed to be generated, was accumulated around hatching in the duodenum. The results may suggest that the abrupt increase of the CRBP II gene expression in the chick duodenum around hatching may be related with RXRs and/or PPAR.

Perilla oil prevents the excessive growth of visceral adipose tissue in rats by down-regulating adipocyte differentiation

We examined the effect of dietary oils with different fatty acid compositions on the growth of visceral adipose tissue in rats. Rats were fed for 4 mo starting at weaning a basal diet containing (12 g/100 g diet) perilla oil rich in (n-3) polyunsaturated fatty acids (PUFA), safflower oil rich in (n-6) PUFA, olive oil rich in monounsaturated fatty acid, or beef tallow rich in saturated fatty acids. The amount of food consumed and body weight gain did not differ among the four dietary groups. The weight of the epididymal fat pad and the serum triglyceride concentration in perilla oil-fed rats were significantly lower (P < 0.05) than those of olive oil- and beef tallow-fed groups. The product of [(volume of individual adipocytes) x (number of adipocytes in epididymal fat pad)], which presumably represents total adipocyte volume in the fat pad, was significantly lower (P < 0.05) in perilla oil-fed rats than in beef tallow- and olive oil-fed groups. Expression of the late genes of adipocyte differentiation, peroxisome proliferator-activated receptor alpha, adipocyte P2 and adipsin, was significantly (P < 0. 05) down-regulated in epididymal fat tissue of rats that had been fed perilla oil rather than beef tallow or olive oil, whereas expression of the early gene, lipoprotein lipase, was not significantly affected. Greater levels (P < 0.05) of (n-3) PUFA in the membrane phospholipid fraction of the fat tissue were observed in perilla oil-fed rats than in the other dietary groups. These results suggest that perilla oil or (n-3) PUFA prevents excessive growth of adipose tissue in rats at least in part by suppressing the late phase of adipocyte differentiation.

Relationship between perinatal appearance of cellular retinol-binding protein, type II and retinal reductase activity in chick liver

To explore a role of the transiently appearing cellular retinol-binding protein, type II (CRBP(II)) in perinatal chick liver, we have examined whether the relationships exist among the perinatal changes in hepatic CRBP(II) protein and mRNA levels, retinal reductase activity and beta-carotene levels in liver and serum. Northern blot analysis for hepatic CRBP(II) revealed a transient expression of CRBP(II) mRNA around hatching. The protein of CRBP(II) was also expressed transiently and the highest levels of CRBP(II) were found in the livers 1-3 days after birth. The retinal reductase activity was very low at embryonic age, but its activity rapidly rose at hatching, peaking at 1 day after birth, followed by a gradual decrease to a lower level in 7-day-old chicks. This perinatal pattern of the retinal reductase activities was similar to the pattern of transient appearance of the hepatic CRBP(II), and was also paralleled to the developmental changes in serum and liver beta-carotene concentrations. These findings suggest that hepatic CRBP(II) transiently appearing during the perinatal period may involve in metabolizing hepatic beta-carotene, directing the retinal to the retinal reductase and leading further to the subsequent esterification of the converted retinol.

Dietary maltitol increases calcium content and breaking force of femoral bone in ovariectomized rats

Maltitol is a disaccharide alcohol generated by hydrogenation of maltose and exhibiting resistance to intestinal disaccharidases. We demonstrated previously that maltitol stimulates transepithelial transport of calcium in the ileum, accompanied by an elevation of intestinal calcium absorption as well as calcium retention in the body. In this study, we examined whether the maltitol-induced increase in intestinal calcium absorption leads to an alteration of the physical properties of bones in rats subjected to ovariectomy. We used this study as a simulation model for postmenopausal females who are at risk for osteoporosis. Following the intake of a low-calcium diet for 28 d ovariectomized rats were fed diets containing either 10% maltose (control) or 10% maltitol, together with increased amounts of calcium (0.3% in Experiment 1 and 1.2% in Experiment 2) for 21 d. Balance studies performed during the final 5-d (Experiment 1) or 2-d (Experiment 2) period of the experiments showed that maltitol increased intestinal calcium absorption and retention. The breaking force of femoral bones was significantly elevated (by 5-7%) in animals fed the maltitol diet compared with that in rats fed the maltose diet. The calcium content in the femoral bones as well as the mineral bone density of the tibial metaphysis was also elevated in rats fed the maltitol diet. These results indicate that maltitol stimulates the intestinal absorption of dietary calcium leading to an increase in calcium content in the bone, and coinciding with the elevation of the breaking strength of the bone in ovariectomized rats.

Unsaturated fatty acids regulate gene expression of cellular retinol-binding protein, type II in rat jejunum

We have shown that cellular retinol-binding protein, type II (CRBP II) mRNA and its protein levels are elevated in the jejunum of rats fed a diet rich in long-chain triacylglycerols. In the present study, we explored which types of fatty acids modulate CRBP II gene expression. Rats previously fed a low fat, high starch diet were force-fed a basal fat-free diet or the diet supplemented with 0.21 mol/L of various fatty acids (i.e., caprylic, palmitic, stearic, oleic, linoleic and alpha-linolenic acids). Force-feeding a diet containing linoleic acid produced an elevation of CRBP II mRNA levels in rats in both a dose-dependent (0.053-0.21 mol/L) and time-dependent (up to 6 h) manner. Among fatty acids tested, all unsaturated fatty acids (oleic, linoleic and alpha-linolenic acids) were able to enhance CRBP II mRNA levels by 54-63% within 6 h, whereas a medium-chain fatty acid (caprylic acid) and a saturated fatty acid (stearic acid) elicited little effect on the CRBP II mRNA levels; palmitic acid produced only a small elevation (16%) of the CRBP II mRNA level. Transcripts of both retinoid X receptor alpha and peroxisome proliferator-activated receptor (PPAR), which are thought to interact as a heterodimer with the cis-element located in the CRBP II promoter and to be activated by 9-cis retinoic acid and long-chain fatty acids, respectively, were constitutively expressed in the rat jejunum.(ABSTRACT TRUNCATED AT 250 WORDS)

New approach to assess quality of life in neonatal surgical cases: medical providers' subjective assessment of disease- and condition-related factors, using the linear analogue scale

A new questionnaire survey of pediatric surgeons and nurses, using the linear analogue scale, was used to determine subjective assessments of patients' quality of life (QOL) with regard to neonatal surgical diseases and conditions, including those involving anal and urinary functions. The results were analyzed according to the medical providers' years of professional experience. For six neonatal surgical diseases, QOL was assessed more favorably by less experienced surgeons and nurses. The result was similar for adulthood diseases. The development of medical technology can be attributed to this trend; however, QOL for patients with diaphragmatic hernia was assessed less favorably by less experienced surgeons (as 66.1%) than by more experienced surgeons (as 81.6%). Current technology has enabled the survival of neonatal surgical patients who are born prematurely and/or who have serious diseases or anomalies. Consequently this leads to poorer assessment of the surviving patients' QOL. QOL for patients with imperforate anus and spina bifida remained less favorably assessed. That of patients with conditions related to anal and urinary dysfunctions also scaled in the same manner. Anal dysfunction was less favorably assessed by less experienced surgeons (as 40.0%) than by more experienced surgeons (as 49.4%). In part, this discrepancy could be attributed to (1) better adjustment by the patients to their condition over time, and (2) greater focus on QOL issues in recent years. With regard to anal function, low QOL assessment correlated strongly with imperforate anus, Hirshsprung's disease, and spina bifida (P < .01).(ABSTRACT TRUNCATED AT 250 WORDS)

The future role of hepatic portoenterostomy as treatment of biliary atresia

According to our recent study, 38 of 93 patients (40.9%) who underwent portoenterostomy at Juntendo University Hospital between 1977 and 1986 survived for more than 5 years. In order to learn the future improvement of the prognosis of biliary atresia patients who undergo portoenterostomy, we investigated the relationship between the prognosis of biliary atresia patients and the age and the histological changes of liver at the time of surgery. Twenty-seven of 30 patients (90%) who survived for more than 5 years with no jaundice and no findings of liver cirrhosis had a mild degree of liver fibrosis (F1 or F2) and a mild degree of degeneration of intrahepatic bile ducts (B1 or B2) at the time of surgery, in spite of the difference of size of intrahepatic bile ducts at the porta hepatis. On the other hand, all 8 patients who showed severe liver fibrosis (F3) and severe degeneration of intrahepatic bile ducts (B3) did not survive for more than 5 years. Accordingly, we can expect promising prognoses in patients who undergo refined portoenterostomy procedures and receive proper postoperative treatment before they have severe histological changes of liver. The portoenterostomy will still play an important role as treatment of biliary atresia in the future.

A study on more than 20 years of postoperative follow-up in pediatric surgical cases

There have been very few postoperative follow-up studies from the aspect of philosophical anthropology in the field of pediatric surgery. Fifty patients who underwent surgery either during the neonatal period or infancy and have been receiving medical treatment or consultation for more than 20 years in Juntendo University Hospital and Katsunan Hospital, were investigated from the aspect of philosophical anthropology. During adolescence or young adulthood, 52% of the patients were suffering from their medical problems. Forty percent of patients were bullied by their peers during their elementary school age due to various medical problems. As patients became adolescents or young adults, 20% of them started to feel that others were prejudiced against them or they were discriminated against when going to school or looking for a job. About 30% of patients who were of elementary school age and of adolescent or adult age, were introverted and short-tempered. Eighteen percent of the patients who were of elementary school age and adolescent or young adult age, were not satisfied with their family, particularly their parents, because of their medical problems. When patients became adults, 40% were not satisfied with their own society, particularly with others in their working place. More than 80% of patients who were of preschool age were shielded from their medical problems by their parents. As they became older, their parents were not always able to cover up their medical problems, but understanding school teachers and their elders were able to shield some of patients from social ridicule. By learning the results of this study, it is important for pediatric surgeons to minimize postoperative medical problems, giving proper surgery and postoperative care. Pediatric surgeons should become very supportive medical doctors to patients who suffer from postoperative medical problems.

Hepaticportoenterostomy as surgical therapy for biliary atresia

The Kasai I and Suruga I procedures are the most commonly reported surgical procedures used for the correction of biliary atresia. Clinical results are similar for these two procedures, but the Suruga I procedure is associated with a lower incidence of death due to ascending cholangitis. Postoperative care is an important consideration in choosing between these two procedures. The hepaticportocholecystostomy is associated with a decreased incidence of ascending cholangitis, however, it is only an option for a select group of patients. For all procedures mentioned, the level of transection of the bile duct remnant is crucial and pathologic confirmation of patency of the bile duct is helpful.

[Transfer of antibiotics into the liver tissue of infants with hepatic dysfunction]

Transfer of antibiotic (cefmetazole, CMZ) into the liver tissues of the infant with hepatic dysfunction, 6 cases of congenital biliary atresia, 4 cases of congenital bile duct dilatation, 1 case of congenital biliary hypoplasia, hepatic hemangioma and umbilical hernia with congenital heart disease is reported here. CMZ level in the liver tissues with hepatic dysfunction shows extremely low. Our study revealed that poor transfer of CMZ into the liver tissues might be a main cause of the poor excretion of CMZ into the bile in case of jaundiced infant.

A study of patients with long-term bile flow after hepatic portoenterostomy for biliary atresia

Thirty-five cases of biliary atresia that demonstrated the creation of internal fistula between intrahepatic bile ducts at the portahepatis and intestine and showed long-term bile flow after our hepatic portoenterostomy were investigated from various aspects. These 35 cases were divided into Group A cases, in which jaundice disappeared within three months after surgery, and Group B cases, in which persistent jaundice was seen more than three months after surgery. (1) Severe liver fibrosis and degeneration of intrahepatic bile ducts were more often seen in Group B cases than in Group A cases. (2) The age at the time of surgery and the size of intrahepatic bile ducts at the portahepatis did not have much influence on the operative results in those 35 cases. (3) Measurement of the amount of bile flow and bile acid excretion obtained from Suruga II enterostomy is useful for evaluating the postoperative results of biliary atresia patients. (4) Reoperation that includes curettage and rehepatic portoenterostomy, and serious postoperative ascending cholangitis were each closely related to postoperative persistent jaundice.

New operative technique for Hirschsprung's disease

A new technique for definitive surgery in Hirschsprung's disease is described. After transection of the rectum at 2 cm above the peritoneal reflection, the distal rectum is incised laterally on both sides in a longitudinal direction half way to the anus. The mucosal lining of the anterior rectum is partially removed. The posterior portion of the rectum is divided into two flaps by sagittal incision up to the mucocutaneous junction of the anus, which are then reflected and everted through the anus. The proximal colon is then pulled through, exteriorizing 5 cm of ganglionic colon. The exteriorized colon is resected two weeks later. Nine cases were operated upon by this technique. The postoperative results were satisfactory in all cases.

Experimental study of the pathogenesis of choledochal cyst and pancreatitis, with special reference to the role of bile acids and pancreatic enzymes in the anomalous choledocho-pancreatico ductal junction

To investigate the mechanisms initiating pancreatic enzyme activation followed by the development of a choledochal cyst and/or pancreatitis under anomalous choledocho-pancreatic ductal junction (ACPDJ), choledocho-pancreatic end-to-side ductal anastomosis was successfully performed in 40 puppies as an experimental model of ACPDJ. As a result, reflux of pancreatic juice into the common bile duct readily and continuously occurred, and all pancreatic enzymes in bile obtained from the common bile duct were activated. Total bile acids increased about 2 months after surgery, and the ratio of taurodeoxycholic acid to total bile acids increased within the first months after surgery. Various degrees of common bile duct dilatation developed in all puppies within 7 to 10 days after the surgery, and no further dilatation occurred in the subsequent period. Histological change in the pancreatic duct was less prominent than that in the common bile duct, but histologically proved chronic pancreatitis was found in three of 23 sacrificed dogs, in which there was strong evidence of free and massive regurgitation of the bile-pancreatic juice mixture between the bile and the pancreatic duct systems. These findings in this experimental study constitute the first step to prove that ACPDJ, which is often found in patients with choledochal cyst, is an important etiologic factor not only for choledochal cyst but also for pancreatitis, and bile acids play an important role in the mechanism of pancreatic enzyme activation under the condition of ACPDJ.

A study on hepatic portoenterostomy for the treatment of atresia of the biliary tract

The results of our investigation have shown the crucial points of hepatic portoenterostomy used by us which is different from Kasai's portoenterostomy. First, the dissection of the rudimentary extrahepatic bile duct should be performed under magnification. Second, the transection of the rudimentary extrahepatic bile duct should be done using the microsurgical technique. Third, histologic verification of patency of the rudimentary extrahepatic bile ducts with frozen section during the operation should be carried out and the transection should be repeated under microsurgical control until the patency of the intrahepatic bile ducts at the porta hepatis area is confirmed. Fourth, the opening of the jejunal loop should be anastomosed quite close to the cut edge of the rudimentary extrahepatic bile duct at the porta hepatis by removing the mucosa of the posterior aspect of the jejunal opening. Fifth, the Suruga II procedure has been extremely successful in decreasing the incidence of postoperative ascending cholangitis and in preventing death in those infants who have postoperative ascending cholangitis develop. Sixth, if bile flow ceases postoperatively in spite of the forementioned technical refinements, then the curettage procedure should be carried out to the anastomotic site at the porta hepatis in order to resume bile flow.

Choledochopancreatic elongated common channel disorders

A choledochopancreatic end-to-side ductal anastomosis was successfully performed in 40 puppies as an experimental animal model of choledochopancreatic elongated common channel disorders. Follow-up periods were up to 1 year after surgery. Fusiform dilatation was developed in all puppies. The dilatation was completed within 1 week after surgery and did not increase its size after that. Also, all puppies developed pancreatic juice reflux into the bile duct. As for the etiology of the dilatation of the bile duct, temporary stricture of anastomosis was a more important factor than the pancreatic juice reflux in our models. In the biliopancreatic juice, we found no significant change of bile acid analysis between the control and our operated puppies, but almost all pancreatic enzyme activities were elevated. Bile acid was considered to play an important role in the activation of pancreatic enzymes. Epithelial hyperplasia was the only significant pathological change in the bile duct wall. Definite chronic pancreatitis developed in one puppy 16 months after surgery and was considered to be caused by the reflux of bile into the pancreatic duct. The action of biliopancreatic juice to both the bile duct and to the pancreas was mild and chronic.

[Postoperative evaluation of renal function from the aspect of urinary concentration of cefmetazole in infants and children with vesicoureteral reflux and hydronephrosis. I]

The urinary excretion of cefmetazole (CMZ) which was administered intravenously from both kidneys (affected side and normal side) was studied separately after surgery in 11 infants and children (10 cases of vesicoureteral reflux (VUR) and 1 case of hydronephrosis due to pelviureteric obstruction). In kidneys with VUR of grade IIb to III degree, urinary concentration of CMZ showed rather higher than that we expected from their creatinine clearance. On the contrary in kidneys with VUR of grade IV degree and hydronephrosis, urinary concentration of CMZ showed rather lower compared to their creatinine clearance.

[The correlation between the biliary excretion of cefmetazole and the bile acid metabolism in postoperative patients with biliary atresia]

The correlation between the biliary excretion of cefmetazole (CMZ) and the bile acid metabolism was studied in 17 postoperative children with congenital biliary atresia. B (total bile acid value in bile)/S (total bile acid value in serum) ratio is the best indicator in order to evaluate the postoperative condition of the liver in patients with biliary atresia at this time, that is, the B/S ratio is lower, the condition of the liver is deteriorated. The biliary excretion of CMZ was closely correlated to the B/S ratio, that is, the B/S ratio is lower, the biliary excretion of CMZ is discussed.

[Cefotiam excretion into the bile after radical operation of congenital biliary atresia]

Twelve infants having undergone extrahepatic cholangiojejunostomy (SURUGA'S procedure II) after portal hepaticojejunostomy as a radical operation for congenital biliary atresia received prophylactic cefotiam (CTM) against biliary tract infection, 50 mg/kg by intravenous drip in 1 hour, followed by serial determinations of bile and serum CTM levels. The patients were evaluated as to degree of CTM excretion into the bile, by classification into 4 groups according to success or failure in establishing the anastomosis, bile outflow and persistence of jaundice. Patients with an established anastomosis, satisfactory bile flow and no longer jaundice showed high biliary antibiotic concentrations whereas lower biliary antibiotic levels were seen in those with failure in anastomosis, poor bile flow and persistent jaundice. In both cases, nevertheless, the antibiotic concentration in bile sufficiently exceeded the MIC80 values of CTM against principal bacterial pathogens causative of biliary tract infections, thus demonstrating clinical significance of the use of CTM for this purpose. The antibiotic excretion into the bile improved with normalization of liver function in an infant displaying satisfactory bile outflow from an early postoperative stage. The bile and serum CTM assay data obtained by the agar well method showed a high degree of correlation with those by high performance liquid chromatography.

Experimental study of the pathogenesis of infantile obstructive cholangiopathy and its clinical evaluation

1,4-phenylenediisothiocyanate was given to five groups of rats of different developmental stages (97 in all), and the changes in the hepatobiliary system were compared histopathologically. Three groups of rats given the drug after birth showed dilatation of the extrahepatic bile ducts with inflammation. Two groups given the drug during the fetal period or added after birth showed stenotic or atretic extrahepatic bile ducts due to thickening and fibrosis of the wall. This experimental model suggests that differences in the pathologic features of infantile obstructive cholangiopathy (biliary atresia, neonatal hepatitis, and bile duct dilatation) may be the result of various developmental stages in the pathogenic process. After the experiment, 11 cases of correctable type biliary atresia were compared to 24 cases of noncorrectable type in various aspects. It is suggested that the correctable type may have suffered pathogenic process later in the developmental stages than noncorrectable type.

Antibiotic excretion into the bile after hepatic-portojejunostomy in biliary atresia

Antibiotic excretion into the bile was studied using LMOX and CMZ in 16 postoperative cases of biliary atresia patients who had had hepatic portoenterostomy with Suruga II type enterostomy with the following results: Group I: Excellent excretion which was almost the same as that seen with adult patients; Group IIa: Good or poor excretion, depending on the amount of bile flow and liver function; Group IIb: Very poor excretion; Group III: Good excretion but depending on the amount of bile flow and liver function. As the total bile acid level in bile showed a higher level, the biliary excretion of antibiotics was greater. Our study indicates that antibiotic excretion into the bile in infants is closely related to the condition of the liver function and the biliary passages.

[Cefmetazole excretion into the bile after hepatic portojejunostomy in congenital bile duct atresia]

Antibiotics excretion into the bile was studied using CMZ which was administered by drip infusion in 12 postoperative cases of congenital bile duct atresia patients who had hepatic portojejunostomy with SURUGA II type enterostomy with the following results. Group I (correctable type children, with good bile flow, no jaundice): Excellent excretion was almost the same as that seen in adult patients. Group IIa (uncorrectable type children, with good bile flow, no jaundice): Excretion was poor but good depending on the amount of bile flow and liver function. Group IIb (uncorrectable type children, with poor bile flow, jaundice): Excretion was very poor. Group III (uncorrectable type infants, with good flow, no jaundice): Excretion was good depending on the amount of bile flow and liver function. Our study indicates that antibiotics excretion into the bile in children is closely related to the condition of the hepatic function and biliary passage.

Reoperation in the treatment of biliary atresia

Rehepatic-portoenterostomy and curettage were performed as reoperative procedures for treatment of biliary atresia. In cases of rehepatic-portoenterostomy, microsurgical technique is an important factor in order to obtain satisfactory operative results. The indication for rehepatic-portoenterostomy, the age of the patient, the size of the intrahepatic bile ducts at the porta hepatis area, the degree of liver fibrosis and liver cell change are closely related to the prognosis of rehepatic-portoenterostomy cases. Since 1977, all seven cases who underwent rehepatic-portoenterostomy showed bile excretion and at present, 3 out of 7 have no jaundice. Curettage is an effective treatment for cessation of bile flow in cases which underwent hepatic portoenterostomy and showed bile excretion for a certain period postoperatively. The timing of curettage is closely related to the results of the curettage. In 9 out of 17 cases which received curettage, we were able to obtain fairly good bile flow and at present, 4 out of 9 show no jaundice.

"The choledocho-pancreatic long common channel disorders" in relation to the etiology of congenital biliary dilatation and other biliary tract disease

The amylase level of bile and various cholangiograms was studied in 36 cases of congenital biliary dilatation. (C.B.D.) The amylase level above 10000 U/L was considered to suggest the existence of choledocho-pancreatic long common channel formation. Radiologically, the dilatation of intrahepatic bile duct was seen in 9 out of 19 (47%) Type I cases and in all (100%) Type II cases. The cystic dilatation of intrahepatic bile duct was seen in all Type I cases which have cystic choledochal dilatation. On the other hand, fusiform dilatation was seen in all Type II cases with fusiform choledochal dilatation. End to side Choledocho-pancreatic anastomosis was performed to produce an experimental model of human choledocho-pancreatic long common channel disorders, thus leading to the dilatation of the common bile duct as well as the reflux of pancreatic juice into the bile duct. The reflux of Pancreatic juice and congenital stricture due to the choledocho-pancreatic long common channel formation were considered to be the important causative factors in the etiology of C.B.D.. Furthermore, pathology of the choledocho-pancreatic long common channel disorders was found to be important in relation to the etiology of both C.B.D. and other lesions of the biliary tract and pancreas.