Resection for primary liver tumors in children: an experience of 52 cases at one institution.

OBJECTIVE: To review the authors' experiences of liver resection for primary tumors in children. MATERIAL AND METHOD: The children who had undergone liver resection for any masses between January 1996 and December 2005 were studied. Their clinical data and pathological reports were reviewed for descriptive study. Surgical data including the extent of lesions, type of resection, and post-operative complications within 60 days after surgery were analyzed. Data are expressed as mean and standard deviation (SD). RESULTS: Fifty-two children, with a male to female sex ratio of 28:24, underwent resection for primary liver tumors. Their average age was 36.64 +/- 4.05 months and average weight was 12.02 +/- 6.76 Kg. Asymptomatic mass was the main complaint. Ultrasonography was the initial investigation and CT scan was performed later in all patients with suspected liver mass to confirm the diagnosis and to assess the resectability. CT scan was also useful for the diagnosis of liver tumor in six cases which ultrasonography could not differentiate from other abdominal tumors. The tumors were assessed to be unresectable in 28 of 52 (53.8%) patients who had preoperative chemotherapy and became resectable later. Surgical procedures were as follows: 39 hepatic lobectomies, six extended hepatic lobectomies, and seven segmentectomies. Mean operative time was 251.04 +/- 89.22 min. Mean ICU stay was 2.8 +/- 3.2 days. Pathology revealed 38 hepatoblastomas, five hemangioendotheliomas, four hepatomas, two harmatomas, and three other lesions. Post-operative complications occurred in 15 children (29%) including intra-abdominal bleeding (3), subphrenic collection (1), acute liver failure (3), wound infection (2), and atelectasis (6). No mortality within 60 days after surgery occurred. Most of the patients were discharged within 10 days after surgery. CONCLUSION: With the advancement of preoperative evaluation, more accurate diagnosis of liver tumors, and the extent of lesions has led to the proper more effective surgical resection and further treatment, then led to zero mortality rate related to liver resection for primary tumors in the present series. Although there were significant complications, mostly minor problems and all both minor and major complications were manageable; their fatal potentials should not be underestimated.

Demonstration of nasogastric intubation using video compact disc as an adjunct to the teaching processes.

BACKGROUND: An in-house produced video compact disc (VCD) demonstrating nasogastric intubation was introduced to the medical curriculum at Buddhachinaraj Hospital, Clinical Teaching Centre, Phitsanulok in 2005. OBJECTIVE: The present study aimed to qualitatively evaluate the effect of the VCD on our medical students' procedural skills. MATERIAL AND METHOD: The 6th year medical students were randomly allocated into two groups; one group viewed the VCD (test, n = 30), and the other group did not (control, n = 31). After 2 months, the authors examined all students by asking them to perform the procedure using a manikin and a checklist. The examiners were blind to the allocations at the time of examination. Unpaired t-tests and Chi-square tests were used Data are expressed as mean and SD. RESULTS: Total checklist's score was 20. There was no diference in terms of age or gender between the two groups. Thirty of 61 medical students who had watched the VCD got an average score of 15.9 +/-1.86, while the control group's average score was 13.2+/-1.94. Statistical analyses showed that the difference was significant (p < 0.0001). CONCLUSION: The medical students were able to self-improve their procedural skills of nasogastric intubation after viewing the VCD. Application of this method to other basic procedures may be useful.

Analysis of connective tissue growth factor promoter polymorphism in Thai children with biliary atresia.

OBJECTIVE: Connective tissue growth factor (CTGF) has been proposed to play a key role in the pathogenesis of hepatic fibrosis in biliary atresia (BA). The aim of the present study was to determine the single nucleotide polymorphism (SNP) in the promoter region of CTGF gene in a Thai population, and to investigate the possible role of CTGF promoter polymorphism in the susceptibility of BA. MATERIAL AND METHOD: Genomic DNA was obtained from 84 patients with BA and 142 healthy controls. The -447 G/C and -132 C/G in CTGF promoter were amplified and examined by amplification-refractory mutation system (ARMs) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis, respectively. The test of Hardy-Weinberg equilibrium (HWE) was performed using HWE program of SNPAnalyzer. Statistical analysis was carried out with SPSS and Epi Info. RESULT: According to the previous experiment, there were two SNPs, which were at position -447 and -132 on the promoter. However, there was only one SNP at the position -447 in the Thai population. No significant differences in genotype and allele frequency were observed between BA and controls or with BA subgroups. CONCLUSION: The present study demonstrated that CTGF polymorphism at -447 G/C was not associated with BA and the jaundice status of the postoperative BA patients.

Association of serum levels of tissue inhibitors of metalloproteinase-1 with clinical outcome in children with biliary atresia.

The purpose of this study was to determine the possible role of serum levels of tissue inhibitors of metalloproteinase-1 (TIMP-1) in the pathogenesis of the progressive inflammation and fibrosis in biliary atresia (BA). Serum concentrations of TIMP-1 were measured in 57 BA patients and 15 healthy controls using commercially available enzyme-linked immunosorbent assays. The mean ages of the BA patients and the controls were 6.1 +/- 0.6 and 6.7 +/- 1.1 years, respectively. The patients were categorized into two groups according to their clinical outcomes: patients with jaundice (total bilirubin > or = 2 mg/dl) and patients without jaundice (total bilirubin < 2 mg/dl). In our study, serum levels of TIMP-1 were significantly higher in the BA patients than in healthy subjects (4.8 +/- 0.4 vs. 3.5 +/- 0.3 ng/ml, respectively; p < 0.05). Additionally, serum levels of TIMP-1 significantly increased in the BA patients with jaundice in comparison to those without jaundice (6.3 +/- 0.7 vs. 3.1 +/- 0.3 ng/ml, respectively; p = 0.001). Patients with persistent jaundice had lower levels of albumin but had greater levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transpeptidase compared with patients without jaundice. Furthermore, patients with portal hypertension (PH) had higher TIMP-1 levels than those without PH (5.3 +/- 0.4 vs. 1.9 +/- 0.3 ng/ml, respectively; p < 0.001). It is concluded that serum levels of TIMP-1 increased in patients with BA. The significant increase in TIMP-1 levels is related to the presence of PH and the severity of jaundice. The elevated TIMP-1 levels may reflect the degree of hepatic fibrosis and development of PH. The data suggest that TIMP-1 may play a role in the pathophysiology of post-Kasai BA.

Pregnancy in biliary atresia after kasai operation complicated by portal hypertension.

Hepatic portoenterostomy or Kasai operation has been widely accepted as the standard therapy for biliary atresia. Recently, more female patients have grown up and reached adulthood; therefore, pregnancy in women with biliary atresia is sometimes inevitable. The authors report a 17-year-old woman with biliary atresia post Kasai operation at 3 months of age. After the operation, she became jaundice-free but developed portal hypertension with abnormal liver function. She had several episodes of esophageal variceal bleeding and was treated by beta-blocker and endoscopic sclerotherapy. Since then, she was lost to follow up for nearly 2 years. She came back again with 12 weeks of gestation with no symptoms of gastrointestinal bleeding for antenatal care. At 32 weeks of gestation, she presented with severe hematemesis from variceal bleeding and had thrombocytopenia from hypersplenism. She was treated with somatostatin analogue, fluid and blood component replacement and other supportive treatments. Cesarean section was performed when she was stable at 33 weeks of gestation. After the operation, her clinical status was improved and had no other complications. Her baby experienced complications of prematurity but improved after treatment. Pregnancy may affect the natural course of portal hypertension and worsen the clinical outcome. Pregnancy should be avoided in patients with portal hypertension, however it is not contraindicated. Pregnancy in biliary atresia patients needs intensive prenatal care.

An evidence of intestinal mucosal injury in dengue infection.

The aim of this study was to determine whether there is an association between dengue infection and intestinal mucosal injury. Serum levels of intestinal fatty acid binding protein (I-FABP) were used as a specific marker for mucosal injury. The diagnosis of all patients was serologically confirmed by anti-dengue IgG or IgM. Serum I-FABP levels of 120 patients were determined and compared to those of 25 controls using ELISA. In order to investigate serum I-FABP among dengue patients, they were categorized into 5 groups according to disease severity: dengue fever (DF), dengue hemorrhagic fever (DHF) grade I through DHF grade IV. The dengue patients had higher levels of serum I-FABP compared to 25 controls (408.0 +/- 499.3 vs 124.72 +/- 147.81 pg/ml, p=0.006). The patients with DHF grade IV had the highest levels of serum I-FABP, ALT, and AST compared to the other groups. However, there were no differences in serum I-FABP, ALT, and AST levels among patients with DF, DHF grade I, grade II, and grade III. Evidence of intestinal mucosal injury in patients with dengue infection was demonstrated. Patients with DHF grade IV had high serum I-FABP levels and had associated liver injury.