Collagen gene cluster expression and liver fibrogenesis in patients with biliary atresia: a preliminary study.

OBJECTIVE: Biliary atresia (BA) is a progressive fibro-obliterative disease of the biliary tract, which results in end-stage liver disease. However, liver fibrosis progression may continue even after Kasai surgery. Recent evidence showed that collagen plays a pivotal role in the progression of liver fibrosis in BA. However, most studies were conducted in developed countries. We investigated the expressions of the collagen gene cluster (COL6A1, COL6A2, COL6A3, and COL1A1) in BA patients in Indonesia. RESULTS: There was a significant down-regulated expression of COL6A1 (ΔCT 9.06 ± 2.64 vs. 5.42 ± 2.41; p = 0.0009), COL6A2 (ΔCT 8.25 ± 2.07 vs. 5.77 ± 3.51; p = 0.02), COL6A3 (ΔCT 11.2 ± 6.08 vs. 6.78 ± 3.51; p = 0.024), and COL1A1 (ΔCT 3.26 ± 1.71 vs. 0.19 ± 2.76; p = 0.0015) in BA patients compared to controls. Interestingly, the collagen gene cluster expressions were significantly associated with the presence of cirrhosis (p = 0.0085, 0.04, and 0.0283 for COL6A1, COL6A2, and COL6A3, respectively). In conclusion, our study shows the changes in the collagen gene cluster, particularly collagen type I and VI, expressions in patients with BA in a particular developing country. Our findings suggest the role of these collagen gene clusters in the liver fibrogenesis of BA.

Exome sequencing identifies novel genes and variants in patients with Hirschsprung disease.

BACKGROUND: Hirschsprung disease (HSCR) is a complex genetic disease characterized by the absence of ganglion cells in the intestines, leading to a functional obstruction in infants. At least 24 genes have been identified for the pathogenesis of HSCR. They contributed to approximately 72% of HSCR cases. We aimed to elucidate further the genetic basis of HSCR in Indonesia using the whole-exome sequencing (WES) approach. METHODS: WES was performed in 39 sporadic non-syndromic HSCR patients and 16 non-HSCR subjects as controls. Variants presented in controls were excluded, followed by in silico prediction tools and population allele frequency databases to select rare variants. We determined the minor allele frequency (MAF) using gnomAD (MAF <0.1%). RESULTS: We involved 24 (61.5%) males and 15 (38.5%) females. Most patients (62%) had short-segment aganglionosis and underwent the Duhamel procedure (41%). We identified several candidate novel variants in HSCR-related genes, including UBR4, GDNF, and ECE1. Moreover, we also identified some novel candidate genes, including a possible compound heterozygous variant in the MUTYH gene: the first variant, a known protein-truncating variant associated with colorectal cancer (CRC), p.Glu452Ter and the second variant is novel, p.Ala39Val. Moreover, the type of variants was not associated with the aganglionosis type. CONCLUSIONS: We identified several novel genes and variants, including the variant associated with CRC, that might contribute to the pathogenesis of HSCR. No genotype-phenotype associations were noted. Our study further confirms the complex network involved in enteric nervous system development and HSCR pathogenesis. LEVEL OF EVIDENCE: Level III.

Comparison and impact of associated anomalies on the anal position index in neonates with anorectal malformation.

OBJECTIVE: Some prognostic factors have affected the functional outcomes of patients with anorectal malformations (ARM) after definitive surgery, including the associated anomalies. Moreover, the anal position index (API) study in neonates from developing countries is minimal. We aimed to (1) compare the API between neonates with ARM and controls; and (2) determine the impact of associated anomalies on the API in neonates with ARM. RESULTS: We ascertained 68 subjects: 35 neonates with ARM and 33 controls. The API of neonates with ARM was similar to controls, either male or female neonates (p = 0.51 and 0.90, respectively). Interestingly, the API in ARM males with associated anomalies (0.42 ± 0.07) was significantly lower than in control males (0.48 ± 0.02) (p = 0.005). Moreover, the API of ARM neonates with vertebral anomalies (0.35 ± 0.04) was lower than ARM neonates without vertebral anomalies (0.47 ± 0.07) (p = 0.021). In conclusion, associated anomalies and sex might affect the API in neonates with ARM. These findings should be considered and informed during counseling to the parents regarding the prognosis of functional outcomes in ARM neonates, particularly with associated anomalies.

Comparison of Two Different Cut-Off Values of Scoring System for Diagnosis of Hirschsprung-Associated Enterocolitis After Transanal Endorectal Pull-Through.

Background: Hirschsprung-associated enterocolitis (HAEC) is a major contributor in the mortality of Hirschsprung disease (HSCR) patients that can occur both preoperatively and post-operatively. Several cut-off values of HAEC score have been used, i.e., ≥10 and ≥4. Here, we compared the HAEC frequency after transanal endorectal pull-through (TEPT) using two cut-offs of scoring system and associated them with the risk factors. Methods: Cross-sectional analysis was conducted using medical records of HSCR patients who were aged ≤18 years old and underwent TEPT at our institution, Indonesia between 2009 and 2016. HAEC was determined using the scoring system with cut-off values of ≥10 and ≥4. Results: Seventy subjects were used in the final analysis, consisting of 44 males and 26 females. There was a significant difference in one HAEC finding between the ≥10 and ≥4 cut-off groups; diarrhea with explosive stools (p = 0.002). The HAEC frequency was 5/70 (7.1%) and 49/70 (70%) patients using cut-off values of ≥10 and ≥4 (p < 0.0001), respectively. We found that patients with anemia (i.e., iron deficiency anemia) had a higher risk of HAEC after TEPT than patients with normal hemoglobin level with OR of 3.77 (95% CI = 1.28-11.1; p = 0.027), while no associations were found between other variables, including sex, age at diagnosis, age at definitive therapy, albumin level, and nutritional status and HAEC following TEPT (p = 0.87, 0.15, 0.33, 0.26, and 0.60, respectively). Also, no associations were observed between maternal education level, mother's age at pregnancy and gestational age and HAEC after definitive surgery (p = 0.10, 0.46, and 0.86, respectively). Conclusions: This report is the first study comparing two different cut-off values of scoring system to evaluate the HAEC frequency after TEPT and results suggest further using cut-off of ≥4 to expand the diagnosis of HAEC. Moreover, we also show for the first time that hemoglobin level is a strong risk factor for the HAEC development after TEPT.

TGF-ß expression on different suturing technique for abdominal skin wound closure in rats.

BACKGROUND: The method of closing the abdominal wall, as well as, the choice of material for stitching are important aspects of efficient incision closure. Generally, transforming growth factor-beta (TGF-ß) is involved in the wound healing process. Suturing procedures also play a part in the wound dehiscence occurrence. This study aimed to compare TGF-ß expressions in rats after using the large stitch vs. small stitch technique for abdominal skin wound closure. METHODS: A total of twenty Wistar rats (Rattus norvegicus) were used in this experiment. Small tissue bites of 5 mm were obtained by the small stitch group and the large stitch group received large bites of 10 mm. Abdominal skin incisions were closed by running sutures. On days 4 and 7, the animals were euthanized. For TGF-ß expressions, histological parts of the tissue-embedded sutures were analyzed. With significance set at p < 0.05, two-way ANOVA showed that on days 4 and 7, the TGF-ß expressions of the rats in the small stitch group were nearly identical to those in the large stitch groups. RESULTS: After including twenty rats in this study, results showed the TGF-ß expressions on days 4 and 7 in rats in the small stitch group were equivalent to those in the large stitch group. (p = 0.45). CONCLUSIONS: Between the small and the large stitch groups, the TGF-ß expressions are similar, suggesting that the suturing methods do not have any significantly different beneficial impact on the frequency of wound dehiscence.

Case Report: Complicated Meckel Diverticulum Spectrum in Children.

Background: Meckel diverticulum (MD) is the most common congenital anomaly of the intestines, with an incidence of 2% of the general population. It can present as various clinical features with complications and be life threatening if diagnosis is delayed and treatment late. Case Presentation: We report three pediatric cases with complicated MD: one female presented with small-bowel obstruction, one male with peritonitis, and one female with severe iron-deficiency anemia, without gross gastrointestinal bleeding nor any ectopic gastric mucosa. All patients underwent exploratory laparotomy, segmental small-bowel resection, and primary anastomosis. They successfully recovered and were uneventfully discharged on the fourth, seventh, and 10th postoperative days, respectively. Conclusions: MD can present with various complication spectrums, including small-bowel obstruction, peritonitis, and severe iron-deficiency anemia, which may cause difficulty in definitive diagnosis, particularly in children. Segmental small-bowel resection and primary anastomosis are effective surgical approaches and show good outcomes for MD patients.

The COVID-19 pandemic impact on pediatric surgery residency programs.

BACKGROUND: The residency program as a part of the clinical services itself has been influenced by the COVID-19 outbreak. Several reports have been published regarding the impact of COVID-19 on the residency programs; however, all studies were performed in developed countries or did not comprehensively analyze what residents think about the COVID-19 impact on their residency program. We investigated the impact of the COVID-19 pandemic on the pediatric surgery residency program in our institution as an important part of hospital medical services. METHODS: We developed and distributed a questionnaire to pediatric surgery residents in our institution who were registered from January 2015-July 2020. The questionnaire was consisting of 24 questions: a) the perspectives of residents about COVID-19 infection during their residency program; b) the learning process; c) academic evaluations; and d) residents' suggestions to improve the quality of their residency program during the outbreak. RESULTS: Most (82.6%) pediatric surgery residents agreed that elective surgeries should be postponed during the pandemic. Before the outbreak, almost all (82.6%) residents used textbooks and journals as their primary sources of learning, while during the outbreak, 69.5% of residents shifted to use online lectures either from the school or Association of Pediatric Surgeons. Interestingly, 91.3% of participants agreed that they had more time to complete their academic assignments during the pandemic. CONCLUSIONS: The pandemic has had a significant impact on the development of pediatric surgery residency programs. Moreover, the responses to the questionnaire are affected by the seniority and sex of the residents. A comprehensive approach is needed to maintain the high standard of competence of pediatric surgery without compromising our safety from the COVID-19 infection risk.

Outcomes and survival of infants with congenital duodenal obstruction following Kimura procedure with post-anastomosis jejunostomy feeding tube.

BACKGROUND: Several modifications of the Kimura procedure for congenital duodenal obstruction (CDO) have been reported, however, their effects on the outcomes show conflicting results. METHODS: We compared the CDO outcomes following the Kimura procedure with and without post-anastomosis jejunostomy feeding tube (JFT). RESULTS: A total of 52 CDO neonates were involved (JFT: 13 males and 2 females vs. non-JFT: 14 males and 23 females, p = 0.0019). Time to full oral feeding was significantly earlier in the JFT than non-JFT group (14 [interquartile range (IQR), 12-15] vs. 17 [IQR, 14-22.5] days; p = 0.04). Duration of parenteral nutrition given to infants with CDO after surgery was significantly shorter in the JFT than non-JFT group (12 [IQR, 10-15] vs. 17 [IQR, 13-23] days; p = 0.031). Moreover, enteral feeding was significantly earlier in the JFT than non-JFT group (2 [IQR, 1-3.5] vs. 5 [IQR, 4-6] days; p = < 0.0001). However, the length of stay following surgery was not significantly different between groups (16 [IQR, 14-22] vs. 20 [IQR, 17-28] days; p = 0.22). Also, overall patient survival did not significantly differ between JFT (66.7%) and non-JFT patients (59.5%) (p = 0.61). CONCLUSION: Jejunostomy feeding tube shows a beneficial effect on the time to full oral feeding, duration of parenteral nutrition and early enteral feeding in neonates with congenital duodenal obstruction after Kimura procedure.

Functional outcomes of patients with short-segment Hirschsprung disease after transanal endorectal pull-through.

BACKGROUND: Transanal endorectal pull-through (TEPT) is considered the most preferable treatment method for Hirschsprung disease (HSCR) since it is less invasive and has fewer morbidities than transabdominal pull-through. Here, functional outcomes in short-segment HSCR patients after TEPT were assessed and associated with the prognostic factors. METHODS: Krickenbeck classification was used to assess the functional outcomes in patients with HSCR after TEPT surgery at our institution from 2012 to 2020. RESULTS: Fifty patients were involved in this study. Voluntary bowel movement (VBM) was achieved in 82% of subjects. Nine (18%) subjects had soiling grade 1, while two (4%) and two (4%) patients suffered constipation that was manageable with diet and laxative agents, respectively. Patients who underwent TEPT at ≥ 4 years old tended to have soiling more than patients who underwent TEPT at < 4 years old (OR = 16.47 [95% CI 0.9-301.61]; p = 0.06), whereas patients with post-operative complications had 10.5-fold higher risk for constipation than patients without post-operative complications (p = 0.037; 95% CI 1.15-95.92). Multivariate analysis showed male sex was significantly associated with VBM (OR = 9.25 [95% CI 1.34-63.77]; p = 0.024), while post-operative complications were strongly correlated with constipation (OR = 10 [95% CI 1.09-91.44]; p = 0.04). CONCLUSIONS: The functional outcomes of HSCR patients after TEPT in our institution are considered relatively good. Moreover, the VBM, soiling, and constipation risk after TEPT might be affected by sex, age at TEPT performed, and post-operative complications, respectively, while the age at TEPT performed might not be associated with functional outcomes. Further multicenter studies with a larger sample size are necessary to clarify and confirm our findings.

Effect of semaphorin 3C gene variants in multifactorial Hirschsprung disease.

OBJECTIVE: Cluster genes, specifically the class 3 semaphorins (SEMA3) including SEMA3C, have been associated with the development of Hirschsprung disease (HSCR) in Caucasian populations. We aimed to screen for rare and common variants in SEMA3C in Indonesian patients with HSCR. METHODS: In this prospective clinical study, we analyzed SEMA3C gene variants in 55 patients with HSCR through DNA sequencing and bioinformatics analyses. RESULTS: Two variants in SEMA3C were found: p.Val337Met (rs1527482) and p.Val579 = (rs2272351). The rare variant rs1527482 (A) was significantly overrepresented in our HSCR patients (9.1%) compared with South Asian controls in the 1000 Genomes (4.7%) and Exome Aggregation Consortium (ExAC; 3.5%) databases. Our analysis using bioinformatics tools predicted this variant to be evolutionarily conserved and damaging to SEMA3C protein function. Although the frequency of the other variant, rs2272351 (G), also differed significantly in Indonesian patients with HSCR (27.3%) from that in South Asian controls in 1000 Genomes (6.2%) and ExAC (4.6%), it is a synonymous variant and not likely to affect protein function. CONCLUSIONS: This is the first comprehensive report of SEMA3C screening in patients of Asian ancestry with HSCR and identifies rs1527482 as a possible disease risk allele in this population.

Postoperative enterocolitis assessment using two different cut-off values in the HAEC score in Hirschsprung patients undergoing Duhamel and Soave pull-through.

BACKGROUND: Hirschsprung-associated enterocolitis (HAEC) is the most severe and potentially lethal complication of Hirschsprung disease (HSCR) which might occur following definitive surgery. Our objectives were: 1) to compare the incidence of HAEC after Duhamel and Soave procedures using different cut-off values of the HAEC scoring method; and 2) to associate them with the risk factors, including sex, aganglionosis type, mothers' age at childbirth, gestational age, and mothers' educational level. METHODS: Medical records of patients with HSCR who underwent Soave and Duhamel procedures in our institution, Indonesia (January 2012 - December 2016) were reviewed retrospectively. Two cut-off values of the HAEC scoring system (i.e., ≥10 and ≥ 4) were utilized. RESULTS: Eighty-three patients with HSCR were recruited in this study (Soave: 37 males and 7 females vs. Duhamel: 28 males and 11 females; p = 0.18). The incidence of HAEC after surgery was 14/83 (16.9%) and 38/83 (45.8%) for cut-off values of ≥10 and ≥ 4, respectively (p = 0.00012), and tended to have an association with sex (p = 0.09). Although it was not statistically significant (p = 0.07), the frequency of HAEC after Soave procedure tended to be higher in patients with their mother's age of ≤35 years at childbirth than those with their mother's age of > 35 years (OR = 7.9; 95% CI = 0.9-72.1). Multivariate analysis indicated none of the risk factors were associated with the frequency of HAEC after definitive surgery. CONCLUSIONS: The lower cut-off value of ≥4 might increase the possibility to diagnose HAEC, particularly the mild cases. The incidence of HAEC after definitive surgery was not associated with any risk factors in our cohort patients. Further multicenter studies with a larger sample size are necessary to confirm our findings.

Prognostic Factors for Survival of Patients with Biliary Atresia Following Kasai Surgery.

Biliary atresia (BA) is a progressive obstruction and fibro-obliteration of the extrahepatic and intrahepatic biliary tract that causes cholestatic jaundice in infants, resulting in biliary cirrhosis and even death in the first year of life if the Kasai procedure is not performed at an earlier age. There are many prognostic factors that could affect the survival of patients with BA after Kasai surgery, however results still show some conflicting findings. A retrospective study was conducted using medical records of patients with BA who underwent Kasai surgery at Dr. Sardjito Hospital, Yogyakarta, Indonesia from June 2012 to April 2018. Twenty-nine BA patients were involved in our study, with 16 males and 13 females. Log-rank analysis showed a significant association between survival rate of BA patients with albumin level 1 month and 3 months after Kasai surgery, with p-values of 0.043 and 0.016, respectively. Interestingly, multivariate analysis revealed that cholangitis tended to have an association with BA patients' survival (p=0.09). In conclusion, the BA patients' survival might be affected by the presence of cholangitis after Kasai surgery. Further multicenter studies with a larger sample size are important to verify our results.

The Impact of COVID-19 pandemic on pediatric surgery practice: A cross-sectional study.

BACKGROUND: Since the COVID-19 pandemic was declared by the World Health Organization on March 11, 2020, routine clinical practices were affected, including pediatric surgery services. We aimed to compare pediatric surgery practices, including the number and types of surgery, either elective or emergency surgeries and outpatient services, before the outbreak and during the COVID-19 pandemic in our institution. MATERIAL AND METHODS: We retrospectively compared pediatric surgery practices, including elective and emergency surgeries, and outpatient services between the previous one-year period (March 2019-February 2020), the last three months of that period (December 2019-February 2020) before the outbreak, and the three months (March-May 2020) during the COVID-19 pandemic in our hospital. RESULTS: The frequency of elective surgeries during the pandemic was lower than during the last three months before the outbreak: 61 vs. 18 (~3-fold), 19 vs. 13 (~1.5-fold), 19 vs. 5 (~4-fold), and 30 vs. 15 (~2-fold) for digestive, neonate, urology and oncology cases, respectively. No laparoscopic procedures were performed during the pandemic compared with the one-year period before the outbreak (0 vs. 16 cases). The frequency of all emergency pediatric procedures before and during the COVID-19 pandemic was similar (29 vs. 20 cases, respectively). Moreover, a declining trend was also clearly apparent in the outpatient services during the pandemic compared with before the outbreak, both in the new and the established patients. CONCLUSIONS: The pediatric surgery practices in our institution have been severely affected by the COVID-19 pandemic, including elective and outpatient services. This setback needs a comprehensive strategy to avoid morbidity from the neglected elective surgeries during the pandemic, including the proper comparison between the real risk of COVID-19 cross-infection and the benefits of elective procedures.

Histopathological findings for prediction of liver cirrhosis and survival in biliary atresia patients after Kasai procedure.

BACKGROUND: Without early recognition and Kasai procedure, biliary atresia (BA) results in liver cirrhosis and leads to either transplantation or death at a young age. We aimed to characterize the liver histopathological findings for prediction of cirrhosis and survival in BA patients after Kasai surgery. METHODS: We retrospectively reviewed all histopathological results for BA patients who underwent liver biopsy during Kasai surgery from August 2012 to December 2018 in Dr. Sardjito Hospital, Yogyakarta, Indonesia. RESULTS: Fifty infants with BA were ascertained in our study, of whom 27 were males and 23 were females. The median age of Kasai procedure was 102.5 days (interquartile range (IQR), 75.75-142.25 days). There were 33 (66%) and 17 (34%) BA patients with and without liver cirrhosis, respectively, while the overall survival was 52%. The patients with a severe bile duct proliferation, severe cholestasis, and severe portal inflammation have a higher risk by 27-, 22-, and 19.3-fold, respectively, to develop liver cirrhosis compared with patients with a moderate/mild bile duct proliferation, moderate/mild/without cholestasis, and moderate/mild portal inflammation, respectively (p = 3.6 × 10- 6, 5.6 × 10- 4, and 1.6 × 10- 3, respectively), while the giant cell transformation was not associate with the development of liver cirrhosis (p = 0.77). The bile duct proliferation was strongly correlated with cholestasis and portal inflammation (p = 7.3 × 10- 5 and 2 × 10- 4, respectively), and cholestasis was also significantly correlated with portal inflammation (p = 0.016). Interestingly, the age at Kasai procedure was strongly associated with the development of liver cirrhosis (p = 0.02), but not with the patients' survival (p = 0.33), while the degree of fibrosis and cholestasis were significantly correlated with the patients' survival, with HR of 3.9 (95% CI = 1.7-9.0; p = 0.017) and 3.1 (95% CI = 1.4-7.0; p = 0.016), respectively. CONCLUSIONS: Histopathological findings of bile duct proliferation, cholestasis, and portal inflammation can predict the liver cirrhosis development in patients with BA. Furthermore, degree of fibrosis and cholestasis affect the patients' survival following the Kasai operation.

Comparison of pre-operative Hirschsprung-associated enterocolitis using classical criteria and Delphi method: A diagnostic study.

BACKGROUND: Hirschsprung-associated enterocolitis (HAEC) is the most common complication of Hirschsprung disease (HSCR) that may happen pre-operatively. Several methods have been reported to determine HAEC. Because the diagnosis of pre-operative HAEC might change the surgical plan, we aimed to determine the accuracy of the classical criteria for diagnosis of pre-operative HAEC and using the Delphi method as a gold standard. METHODS: Medical records of HSCR children who were admitted to our hospital from January 2009 to December 2015 were retrospectively analyzed. RESULTS: Ninety-six subjects were involved in this study, consisting of 74 males and 22 females. The most common findings of the Delphi score were abdominal distension (100%) and dilated loops of bowel (100%), followed by leucocytosis (78.6%), lethargy (71.4%), cutoff sign in rectosigmoid with absence of distal air (71.4%), and shift to left (71.4%). The frequency of pre-operative HAEC was 4.2% and 14.6% using the classical criteria and Delphi method, respectively (p = 0.016). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy rates of the classical criteria for diagnosis of pre-operative HAEC were 14.3% (95% CI: 1.8-42.8%), 97.6% (95% CI: 91.5-99.7%), 50% (95% CI: 13.3-86.7%), 87% (95% CI: 84.3-89.2), and 85.4% (95% CI: 76.7-91.8%), respectively. CONCLUSIONS: The frequency of pre-operative HAEC is low in our hospital. The accuracy of the classical criteria is considered relatively moderate for diagnosis of pre-operative HAEC.

The effect of APTR, Fn14 and CD133 expressions on liver fibrosis in biliary atresia patients.

PURPOSE: Although some biomarkers of hepatic progenitor cells have been reported to be involved in the liver fibrosis in patients with biliary atresia (BA), however, research still shows conflicting results. Therefore, we investigated the effect of Alu-mediated p21 transcriptional regulator (APTR), fibroblast growth factor-inducible 14 (Fn14) and CD133 expressions on liver fibrosis in Indonesian BA patients. METHODS: Nineteen liver samples from BA patients and 9 liver specimens from non-BA controls were obtained. The expressions of APTR, Fn14 and CD133 were analyzed by quantitative real-time polymerase chain reaction (qPCR). RESULTS: APTR expression was strongly up-regulated (1.5-fold) in liver BA specimens compared to liver controls (ΔCT 3.2 ± 0.6 vs 3.8 ± 0.51; p = 0.028). Moreover, Fn14 and CD133 expressions were similar in the BA and control groups (ΔCT 2.7 ± 1.3 vs. 1.4 ± 1.6, p = 0.07; and 12.0 ± 3.7 vs. 11.78 ± 2.30, p = 0.88, respectively). Intriguingly, CD133 expression was strongly related with the survival of BA patients (p = 0.0061), but not with age at Kasai procedure (p = 0.36) and the presence of cirrhosis (p = 0.77). CONCLUSION: We present the first study of aberrant APTR expressions in the liver of BA infants which might contribute to liver fibrogenesis in BA infants.

Aberrant UBR4 expressions in Hirschsprung disease patients.

BACKGROUND: Recently, pathogenic alleles within ubiquitin N-recognin domain-containing E3 ligase 4 (UBR4) gene have been shown to be associated with Hirschsprung disease (HSCR). We determined the UBR4 expressions in Indonesian HSCR patients. METHODS: We analyzed the UBR4 expressions in the colons of HSCR patient and anorectal malformation (ARM) patient as control by real-time polymerase chain reaction (qPCR). RESULTS: Thirty-seven patients with non-syndromic HSCR and eighteen controls were involved in this study. qPCR revealed that the UBR4 expression was strongly decreased (0.77-fold) in the ganglionic group of patients with HSCR compared to the control group with ARM (ΔCT 2.43 ± 0.36 vs. 2.05 ± 0.69; p = 0.009), whereas the UBR4 expression was also significantly reduced (0.79-fold) in the aganglionic group of patients with HSCR compared to the control group with ARM (ΔCT 2.39 ± 0.46 vs. 2.05 ± 0.69; p = 0.044). However, the UBR4 expression change was not associated with gender (p = 0.35 and 0.80), nor with degree of aganglionosis both in ganglionic and aganglionic colons (p = 0.72 and 0.73), respectively. CONCLUSION: Our study demonstrates that expression of UBR4 is decreased in both aganglionic and ganglionic colon of HSCR patients.

microRNA-21 expressions impact on liver fibrosis in biliary atresia patients.

OBJECTIVE: Biliary atresia (BA) is the most common cause of neonatal jaundice, characterized by progressive and rapid liver fibrosis. Recent studies have shown that microRNAs (miRNAs) contribute to the liver fibrogenesis. We investigated the miRNA-21 impact in liver fibrogenesis in Indonesian BA patients. RESULTS: There were 5, 4, and 7 BA patients with type 2A, 2B, and 3, respectively. Quantitative real-time polymerase chain reaction (qPCR) showed that the miRNA-21 expression was significantly increased (18-fold) in BA patients compared to controls (- 4.4 ± 4.0 vs. - 0.2 ± 4.8; p = 0.041). Furthermore, the phosphatase and tensin homolog deleted on chromosome ten (PTEN) expression was significantly down-regulated (3.1-fold) in BA group compared to control group (0.2 ± 1.4 vs. - 1.4 ± 1.7; p = 0.036). The α-smooth muscle actin (α-SMA) expression was not statistically significantly different between groups (13.7 ± 3.8 vs. 15.0 ± 4.8; p = 0.87). Interestingly, the miRNA-21 expression was significantly lower (25-fold) in cirrhosis than non-cirrhosis BA patients (- 0.8 ± 2.2 vs. - 5.3 ± 3.9; p = 0.004). In conclusions, our study provides support for the association between miRNA-21 expression and liver cirrhosis in BA patients. Further study with a larger sample size of patients is important to confirm our results.

Aberrant expressions of miRNA-206 target, FN1, in multifactorial Hirschsprung disease.

BACKGROUND: MicroRNAs (miRNAs) have been associated with the Hirschsprung disease (HSCR) pathogenesis, however, the findings are still inconclusive. We aimed to investigate the effect of miRNA-206 and its targets, fibronectin 1 (FN1), serum deprivation response (SDPR), and paired box 3 (PAX3) expressions on multifactorial HSCR in Indonesia, a genetically distinct group within Asia. METHODS: We determined the miRNA-206, FN1, SDPR and PAX3 expressions in both the ganglionic and aganglionic colon of HSCR patients and control colon by quantitative real-time polymerase chain reaction (qRT-PCR). RESULTS: Twenty-one sporadic HSCR patients and thirteen controls were ascertained in this study. The miRNA-206 expression was up-regulated (2-fold) in the ganglionic colon and down-regulated (0.5-fold) in the aganglionic colon compared to the control group (ΔCT 12.4 ± 3.0 vs. 14.1 ± 3.9 vs. 13.1 ± 2.7), but these differences did not reach significant levels (p = 0.48 and p = 0.46, respectively). Interestingly, the FN1 expression was significantly increased in both the ganglionic (38-fold) and aganglionic colon (18-fold) groups compared to the control group ΔCT 5.7 ± 3.0 vs. 6.8 ± 2.3 vs. 11.0 ± 5.0; p = 0.001 and p = 0.038, respectively). Furthermore, the expressions of SDPR were similar in the ganglionic, aganglionic and control colon groups (ΔCT 2.4 ± 0.6 vs. 2.2 ± 0.4 vs. 2.1 ± 0.6; p = 0.16 and p = 0.39, respectively), while no change was observed in the PAX3 expression between the ganglionic, aganglionic, and control colon groups (ΔCT 3.8 ± 0.8 vs. 4.1 ± 0.8 vs. 3.7 ± 1.1; p = 0.83 and p = 0.44, respectively). CONCLUSION: Our study is the first report of aberrant FN1 expressions in the colon of patients with HSCR and supplies further insights into the contribution of aberrant FN1 expression in the HSCR pathogenesis.

Risk factors of preoperative Hirschsprung-associated enterocolitis.

BACKGROUND: Hirschsprung-associated enterocolitis (HAEC) is a life-threatening complication of Hirschsprung disease (HSCR), that might occur preoperatively. We investigated the risk factors of preoperative HAEC. METHOD: We retrospectively reviewed all medical records of HSCR patients admitted at Dr. Sardjito Hospital, Indonesia from March 2012 until March 2015. Diagnosis of HAEC was determined using the Delphi scoring system. RESULTS: Sixty-one HSCR patients were involved in this study, of whom 48 were males and 13 females. Eighteen percent (11/61) patients had a preoperative HAEC. The most common findings of the HAEC score found in our patients were distended abdomen (100%) and dilated loops of bowel (100%), followed by lethargy (72.7%), cut-off sign in rectosigmoid with absence of distal air (72.7%), leukocytosis (72.7%), and shift to left (63.6%). There was no association between gender, age of HSCR diagnosis, early/late diagnosis during neonatal period, aganglionosis type, albumin level nor body mass index with preoperative HAEC (p = 0.69, 0.76, 0.33, 1.0, 0.86, and 0.50, respectively). In addition, the maternal age, gestational age, and maternal education level also did not correlate with the development of preoperative HAEC (p = 0.71, 0.59, and 0.32, respectively). CONCLUSION: The incidence of preoperative HAEC in our hospital is considered relatively moderate, with the most common findings of distended abdomen and dilated loops of bowel. None of the identified risk factors have an association with the development of HAEC in our patients.