Surgical treatment of pectus excavatum: 30 years 398 patients of experiences.

PURPOSE: The aim of the study is to review the surgical experiences with pectus excavatum (PE) chest deformities at the Department of Pediatric Surgery, West China Hospital of Sichuan University (Sichuan, PR China), during a 30-year period. METHOD: Records of 398 PE patients (396 congenital, 2 acquired) who underwent surgical repair between 1975 and 2005 were reviewed. Modified sternal elevation was applied in all patients. Repair was performed with subperiosteal resection of the abnormal cartilages, transverse wedge osteotomy of the anterior sternum, and internal support with a metal strut for 1 year. Five technical details were strictly followed for each case. Three hundred twelve patients (78.39%) were followed up from 1 to 16 years. RESULT: There were no deaths. Normal contour of the costal cage was constructed postoperatively in 98.74% (393/398) of the patients. Exercise tolerance was improved, and cardiac function recovered to the healthy level of same age. But pulmonary function recovered slowly after surgery. CONCLUSIONS: The 5 technical details are key principles for sternal elevation. Normal appearance of chest wall can be recovered; normal cardiopulmonary function can be restored by the modified sternal elevation with excellent long-term physiologic, cosmetic results and low rate of complications.

[Clinical characteristics of Bochdalek hernia in neonates and infants].

OBJECTIVE: To summarize the clinical characteristics, diagnosis and treatment of Bochdalek hernia in neonates and infants. METHODS: The data of 15 neonates and 10 infants with Bochdalek hernia,undergoing the normal diagnosis and surgical repair from August 1983 to June 2004, were retrospectively reviewed. Location was left in 22 cases and right in 3 cases. Twenty-four cases were treated by operation and 1 case died of respiratory failure before operation. RESULTS: Before April 1998, 7 of 8 (5 neonates, 3 infants) cases of Bochdalek hernia stayed healthy and respiratory symptom-free 1 year after operation; they were followed up 1 year and 3 months to 11 years. One premature neonate with Bochdalek hernia died of respiratory failure before operation, and his lung volume was found to be dysplasia. From April 1998 to June 2004, 15 (8 neonates,7 infants) of 17 (10 neonates, 7 infants)cases of Bochdalek hernia survived postoperatively, while 2 neonates died of respiratory failure. CONCLUSION: The earlier dyspnoea of neonates of Bochdalek hernia occur, the worse their healthy status appear. The standard and timely surgical repairs could improve the curative ratio. Whether the operation was suspended depended on the healthy states of babies.

[Analysis of shape and retractability of the prepuce in 1,015 Chinese boys aged from 0 to 18 years old].

OBJECTIVE: To evaluate the characteristics of the preputial development in Chinese boys and indications as well as occasion of circumcision. METHODS: The shape and retractability of prepuce were evaluated in 1,015 Chinese boys from 0 to 18 years old without heteroplasia of prepuce and penis. RESULTS: Ratio of children with phimosis decreases progressively with increasing age, from 64.09% in the first group (0 approximately 3 years old) to 7.66% in the fourth group (11 approximately 18 years old). CONCLUSION: Phimosis and incomplete separation of the prepuce is normal in the neonate and infant. Prepuce will separate from the glans progressively till adolescence, so it's unnecessary to perform circumcision for them when without any complications.

Microcirculatory detection of Toll-like receptor 4 in rat pancreas and intestine.

This paper was aimed to detect Toll-like receptor 4 (TLR4) microcirculatory expression and localization in rat pancreas and intestine. Acute pancreatitis (AP) was induced by twice injections of cerulein (20 mug in total) and acute necrotizing pancreatitis (ANP) was induced by intraductal injection of 5% taurocholate (1 ml/kg.bw). Reverse transcription polymerase chain reaction (RT-PCR) and immunohistochemistry (IHC) were used to detect and localize TLR4 in the pancreas and intestine. Results showed that RT-PCR of RNA isolated from pancreatic and intestinal tissue yielded the predicted amplicon for TLR4; IHC analysis localized TLR4 expression to the endothelium of pancreatic arteriole, venule, acinar capillary network and sinusoidal capillary of endocrine islet; TLR4 expression in intestine was principally in the microvascular endothelium and leucocytes within the mucosa lamina propria. TLR4 staining in intestine was more intense in taurocholate-induced pancreatitis (TIP) than that in cerulein-induced pancreatitis (CIP). In conclusion, TLR4 could be detected in the pancreatic and intestinal microcirculation, suggesting TLR4 involved in the microcirculatory impairment in AP; the more intense intestinal TLR4 expression in TIP suggests a potential risk for secondary infection.

[The outcome of modified procedure for pectus carinatum correction].

OBJECTIVE: To improve the surgical procedure to correct pectus carinatum. METHODS: From 1990 to 2003, 9 patients with pectus carinatum were treated, whose ages ranged from 3 years and 6 months to 16 years. The conventional operation was performed on 4 patients, the modified procedure on 5 patients. The modified procedure included: (1) the shortening rib periosteum was not sutured transversally; (2) the corrected position of the sternum was stabilized with the metal strut. RESULTS: In 4 patients corrected by the conventional procedure, the sternum depression as pectus excavatum occurred in 1 case five years postoperatively. The results were satisfactory in 5 patients corrected by the modified procedure. The reconstructed thorax was symmetrical, without bulging or dimpling of sternum and costal cartilage. CONCLUSION: The improvement of operative method is reasonable and effective in correcting pectus carinatum.

Congenital jugular vein phlebectasia.

BACKGROUND/PURPOSE: The purpose of the present study was to elucidate the clinical presentation, diagnosis, treatment, and postoperative complications of jugular vein phlebectasia (JVP), and to recommend diagnostic methods and treatment choices. MATERIALS AND METHODS: Thirty-six cases of JVP were reviewed (right vein in 27, left in 6, and bilateral in 3). The internal jugular veins were the most commonly involved. The main complaint was the soft and compressible mass in the neck. Ultrasound or color Doppler flow imaging (CDFI) was performed on all the children. Surgical intervention was performed in 32 cases, and the other 4 cases were conservatively followed up for 4 to 6 years. RESULTS: Ultrasound or CDFI demonstrated local dilatation of the unilateral or bilateral veins in all the patients. Surgical intervention included ligation of the involved jugular vein in 31 cases and draping with medical Dacron cloth in 1 case. All of the operated children recovered uneventfully, except 3 for cases who underwent ligation of the right internal jugular vein. CONCLUSIONS: Valsalva maneuver was most important for establishing the diagnosis. Ultrasound or CDFI was the diagnostic procedure of choice to confirm the diagnosis of JVP. Surgical ligation or excision of unilateral jugular vein was recommended for cosmetic and psychological purposes. However, special attention must be paid to prevent postoperative complications in case of ligation of right internal jugular vein. Or else, treatment should be conservative (follow-up).

Toll-like receptor 4 detected in exocrine pancreas and the change of expression in cerulein-induced pancreatitis.

OBJECTIVES: To detect Toll-like receptor 4 (TLR4) expression and distribution in rat pancreas and the change of TLR4 expression in cerulein-induced pancreatitis (CIP). METHODS: Acute pancreatitis was induced by subcutaneous injections of cerulein at a total dose of 20 microg/kg. Immunohistochemistry (IHC) was used to detect and localize TLR4 in rat pancreas, and real-time reverse transcription-polymerase chain reaction (RT-PCR) was used to quantitatively determine the expression of TLR4 mRNA in CIP. RESULTS: IHC showed the presence of TLR4 in rat pancreas, and its distribution was specifically localized to pancreatic ductal epithelium, vascular endothelium, and islet. No TLR4 staining was detected in exocrine acinar cells. Real-time RT-PCR results revealed low-level TLR4 mRNA expression in the rat pancreas, and the change of TLR4 in CIP only developed within the first 4 hours, which is a rapid up-regulation process that peaks at the first hour. TLR4 mRNA was sustained at baseline level from 4 to 24 hours. CONCLUSIONS: TLR4 protein was expressed in pancreas and localized to epithelial (pancreatic duct) or endothelial (vessels) tissues; TLR4 responded favorably to the inflammatory process, and the change of expression was characterized as a rapid up-regulation in the early stage of CIP.

[Surgical correction of Poland's syndrome in children].

OBJECTIVE: To introduce a method of the surgical correction of Poland's syndrome in children. METHODS: From May 1990 to May 2002, 3 female children with Poland's syndrome were treated. One child of 12 years old with defects of the right second and third costal cartilages, pectoralis major and pectoralis minor underwent repair of chest wall with graft of autologous costal cartilage from left sixth costal cartilage and transfer of the latissimus dorsi flap. The other 2 children, 3 and 16 years old, with defects of the left second, third and fourth costal cartilages, pectoralis major and pectoralis minor underwent graft of autogenous costal cartilage from the right sixth costal cartilage and implant of Dexon mesh. RESULTS: Three patients were followed up 1, 7 and 10 years postoperatively, respectively. The contour of chest wall in 3 patients were improved. The functions of the chest, back and upper limbs in the deformitis side were good and the growth and development of the children were normal during follow-up postoperatively. CONCLUSION: The congenital deformities of multiple systems and parts in the body are involved in Poland's syndrome so that it is necessary to make a proper surgical plan according to the extent of lesions for a satisfactory result.

[Purification, induced differentiation and identification of rat embryonic neural stem cells].

The methods of purification, expanding, marking, conservation, induced differentiation and identification of neural stem cells (NSCs) in vitro were explored for further research and treatment of tethered cord syndrome in children and other neural system diseases. The cells derived from the cerebral cortex of frontal lobe in 14.5 d rat embryos were maintained in serum-free DMEM/F12 medium containing 20 ng/ml bFGF, 20 ng/ml EGF and B27 supplement. The NSCs of suspending single-cell-colon were isolated and passaged, were purified by limited dilution, and were expanded numerously with sub-colon in consecutive generations. Then, Nestin antigen expression was detected by immunohistochemistry techniques. The cells of the purified and expanded NSCs were frozen, recovered and incubated in BrdU, and the NSCs were induced to differentiate in serum or feeder layer. These revived NSCs from frozen cells could express Nestin antigen and could be induced in serum or feeder layer to differentiate into neurons and glias expressing tubulin-III and GFAP respectively. It is good and simple for purification and proliferation of NSCs numerously by the limited dilution and consecutive generations suspending single-cell-colon of NSCs from the cerebral cortex of frontal lobe in rat embryos. The NSCs could be induced on feeder layer to differentiate into neural cells numerously. BrdU can mark and trace NSCs for the research and treatment of the animal model of neural system diseases. By good command of the technlogies for the purification proliferation, and induced differentiation of NSCs in vitro, it is possible to find a new way for further research of the biologic specificity and the treatment of the disease in nervous system.

[Triplex operations for children with extrahepatic portal hypertension].

OBJECTIVE: To evaluate the effect of triplex operations (splenopneumopexy, portal azygous devascularization and ligation of splenic artery) for children with extrahepatic portal hypertension. METHODS: From March 1993 to November 1998, 7 children with extrahepatic portal hypertension underwent triplex operations. The diagnosis for these patients were confirmed by gastroscopy, barium meal and Doppler ultrasonography. The number of WBC and platelet and the hepatic function were checked before and after operations. And the free portal pressures were checked before and after ligations of the splenic artery. All patients were followed up for 2 to 8 years (5.6 years on average). The episodes of upper gastrointestinal bleeding were recorded. The degrees of varices of distal esophagus and proximal stomach were assessed by barium meal and gastroscopy. The diameters of the splenic and portal veins were obtained by B ultrasound. The portopulmonary shunt and portal blood flow were evaluated by color Doppler flow image. The indices of hemorheology such as hematocrit, viscosity of whole blood and plasma, and the index of deformability and aggregability of RBC were obtained through viscometer (R-20 Seerle, Beijing). RESULTS: There was no operative fatal case in this group. Postoperatively, hemorrhage from the esophagus and gastric varices was completely controlled. Although the diameter of spleen reduced progressively, no patient's spleen recovered to normal size during the follow up period. The degree of varices was mitigated and the free portal pressure was significantly decreased to (34.48+/-5.71) cm H2O from the preoperative one (42.62+/-6.72) cm H2O (P<0.05). The rate of portal flow was also decreased. The direction of portal vein was bidirection (one part was away from the liver and the other was toward the liver). The number of WBC and platelet and the viscosity of whole blood and hematocrit were increased to normal value after operation. CONCLUSION: The triplex operation is an effective procedure for the control of hemorrhage from varices in children with extrahepatic portal hypertension.

[A new procedure in making reliable experimental models of gastroesophageal reflux].

OBJECTIVE: To provide a reliable experimental model for gastroesophageal reflux (GER) study. METHODS: Twenty Japan 5-month-old male rabbits were randomly divided into two groups: group cardiomyotomy (n=10), group partial cardiomyectomy (n=10). The operations of cardiomyotomy and parital cardiomyectomy were performed in 2 groups respectively. All the animals underwent intraesophageal pH detection 1 week before operation and 4 weeks after operation. The mean changes of reflux ratios were compared between before operation and after operation. RESULTS: In gastroesophageal reflux ratio between before operation and after operation, there was no significant difference in group cardiomyotomy (1.98%+/-1.52% and 4.32%+/-2.39%, P>0.05) and there was significant difference in group partial cardiomyectomy (1.56%+/-1.57% and 13.56%+/-3.27%, P<0.05). CONCLUSION: The reliable experimental model of GER can be made with procedure of partial cardiomyectomy. It can be used in estimating the operative procedure of anti-reflux and is conducive to dynamic observation and study of esophagitis.

[Comparative study on a short-term curative result between Nissen, Thal and Toupet fundoplications].

OBJECTIVE: To compare the short-term curative results between Nissen, Thal and Toupet fundoplications in treatment of gastroesophageal reflux (GER) and to provide the basis for operative procedure. METHODS: Thirty-three male Japan rabbits were randomly divided into six groups: group reflux (n = 7), transabdominal Heller's esophagomyotomy (TAHE); group Nissen (n = 7), TAHE and Nissen fundoplication; group Thal (n = 7), TAHE and Thal fundoplication; group Toupet (n = 7), TAHE and Toupet fundoplication; control group (n = 5), ventrotomy. The anti-reflux efficacy of fundoplication was evaluated by intraesophageal pH monitoring and MGV (maximal gastric volume sustained by lower esophageal sphincter) 4 weeks postoperatively. RESULTS: 1. The total number of reflux episodes and the reflux ratio (0.83 +/- 0.41, 2.20% +/- 1.12%) of group Nissen were significantly lower than those of group Thal (2.20 +/- 0.45, 4.32% +/- 0.82%) and group Toupet (1.80 +/- 0.45, 4.20% +/- 0.57%), respectively (P < 0.05). 2. MGV of group Nissen (233.00 +/- 9.44)ml was significantly larger than those of group Thal (203.40 +/- 11.13)ml and group Toupet (197.60 +/- 10.99)ml, respectively (P < 0.05). 3. There were no significant difference in total number of reflux episodes, reflux ratio and MGV between group Thal and group Toupet (P > 0.05). CONCLUSION: Nissen fundoplication was better than Thal and Toupet fundoplications, Thal and Toupet fundoplications are similar in short-term curative result.

Effect of epidermal growth factor on pulmonary hypoplasia in experimental diaphragmatic hernia.

BACKGROUND/PURPOSE: Currently, tracheal occlusion (TO) is a potent stimulus for fetal lung growth but also a rather invasive and high-risk procedure. The aim of this study was to investigate a new and much less invasive therapeutic strategy, namely the maternal intraperitoneal administration of epidermal growth factor (EGF) and its effect on pulmonary hypoplasia in the nitrofen-induced congenital diaphragmatic hernia (CDH) rat model, especially its effect on type II pneumocytes. METHODS: CDH was induced by maternal administration of a single oral dose (100 mg) of nitrofen on day 8.5 of pregnancy. Four groups of pregnant rats were designed on day 18.5: normal control (n = 4), CDH (n = 4), CDH plus Dex (n = 4), CDH plus EGF (n = 8). All fetuses were delivered by cesarean section on day 21. Accordingly, there were 4 groups of fetuses: normal controls (n = 33), nitrofen-induced CDH (n = 19), CDH plus Dex treatment (n = 15), and CDH plus EGF treatment (n = 24). Lung tissue weight (LW) and body weight (BW) of each fetus were recorded, lung histologic and morphometric evaluations were performed, and image analysis was combined after lung processing. Transmission electron microscopy was used for ultrastructural observation, especially type II pneumocytes. RESULTS: CDH was observed in 58 of the 94 rat fetuses (61.7%). Lw/Bw of CDH group was significantly lower than those of Dex and EGF (P <.05). The lungs of CDH fetuses showed marked hypoplasia, in contrast to improved mesenchymal differentiation in that of Dex and EGF fetuses. Statistical differences of these morphologic parameters (RAC, MTBD, interstitial%, and alveoli%) were found (P <.05). As to ultrastructural features, type II cells of CDH lungs had few if any lamellar bodies and cytoplasmic organelles, and showed evidence of abundant glycogen granules. The sparse type II cells also showed cytoplasmic degenerative changes. By contrast, type II cells of EGF lungs showed numerous mitochondria, abundant lamellar bodies (surfactant) and deficiency of glycogen granules, and displayed prominent microvillous projections and pitlike depressions. The density of type II pneumocyte were 65 +/- 4.5, 31 +/- 3.1, and 8 +/- 1.5 for EGF, Dex, and CDH, respectively (EGF v Dex, P <.05; EGF v CDH, P < 0.01). CONCLUSIONS: Compared with TO, prenatal EGF administration as a much less-invasive therapeutic strategy had shown marked improvement in pulmonary hypoplasia and promotion of type II pneumocyte differentiation in the nitrofen-induced CDH rat model. Thus, EGF could improve the prognosis of CDH by means of promoting pulmonary hypoplasia and improving the surfactant deficiency, which suggested a potential role in the clinical treatment of CDH.

Ureteral triplication: the first report in China.

Ureteral triplication is a rare congenital anomaly of the urinary tract. Since the first description of ureteral triplication by Wrany in 1870, only about 100 cases have been reported in the literature. Pediatric cases are very few. Here, 2 cases of ureteral triplication were reported. Diagnosis was established preoperatively in 1 case and intraoperatively in 1. To the authors knowledge, this is the first report of ureteral triplication in China.

Single ureteral ectopia with congenital renal dysplasia.

PURPOSE: We reviewed the clinicopathological features and surgical management of 16 cases of single ureteral ectopia with congenital renal dysplasia. MATERIALS AND METHODS: Excretory urography, retrograde ureterography, computerized tomography, diuretic B-mode ultrasound (B-US) and color Doppler imaging (CDI) were performed in 16 females. Explorative operations were performed in all 16 patients and renal dysplasia was further confirmed by pathological examination. RESULTS: The 16 female patients were 1.5 to 12 years old. The main clinical signs were urinary incontinence accompanied by regular voiding since birth. Vaginal ectopic ureters were observed in 6 patients and vestibular ureters in 10. Excretory urography did not show dysplastic kidney except some indirect signs of renal dysplasia. Computerized tomography clearly revealed renal dysplasia in 4 of 9 cases performed without contrast medium. Dysplastic kidneys were precisely located and diagnosed by diuretic B-US in 6 of 8 cases, and by CDI in 7 of 7 cases. Nephrectomy was performed in all 16 patients with satisfactory results. CONCLUSIONS: Single ureteral ectopia with congenital renal dysplasia is exceedingly rare. B-US, especially CDI, is the recommended procedure for preoperative localization and diagnosis. Nephrectomy of dysplastic kidney is the treatment of choice.