Prophylactic treatment with proton pump inhibitors in children operated on for oesophageal atresia.

INTRODUCTION: Oesophageal stricture is a frequent complication following repair of oesophageal atresia (EA). The aim of this study was to conduct a pre- and postintervention study and analyze the incidence of stricture formation and need for balloon dilatation after introducing prophylactic proton pump inhibitor (PPI) treatment. CHILDREN AND DESIGN: All children operated for EA during 2001 to 2009 (n = 39) were treated with prophylactic PPIs (PPI group) for at least 3 months postoperatively. The frequency of stricture formation in the anastomosis and need for balloon dilatation was registered. A previously published group of children (n = 63) operated for EA during 1983 to 1995 not treated with prophylactic PPI was used as control group. Duration of follow-up time in the PPI group was equal to the one in the control group, and set to 1 year after the last oesophageal dilatation procedure. RESULTS: The PPI and control group were comparable regarding patient characteristics, gestational age and birth weight, prevalence of chromosomal aberration, and VACTERL (vertebral, and, cardiac, tracheal, esophageal, renal, limb) malformations. Also, survival rate and prevalence of surgery were similar in both groups. Mortality was mainly determined by associated malformations. The dilatation frequency needed in each child did not differ between the two groups. The prevalence of stricture formation was 42% in the control group compared with 56% in the PPI group, p = 0.25. Number of dilatations needed varied between 1 and 21, with a median value of 3 and 4, respectively, for the PPI and the control group. The children in the PPI group were significantly younger at the time of dilatation. This difference reflects a change in policy and increased experience. CONCLUSION: The incidence of anastomotic stricture following repair for esophageal atresia remains high also after introduction of PPI. The results cannot support that prophylactic treatment with PPI prevent anastomotic stricture formation.

Glial cells in the mouse enteric nervous system can undergo neurogenesis in response to injury.

The enteric nervous system (ENS) in mammals forms from neural crest cells during embryogenesis and early postnatal life. Nevertheless, multipotent progenitors of the ENS can be identified in the adult intestine using clonal cultures and in vivo transplantation assays. The identity of these neurogenic precursors in the adult gut and their relationship to the embryonic progenitors of the ENS are currently unknown. Using genetic fate mapping, we here demonstrate that mouse neural crest cells marked by SRY box-containing gene 10 (Sox10) generate the neuronal and glial lineages of enteric ganglia. Most neurons originated from progenitors residing in the gut during mid-gestation. Afterward, enteric neurogenesis was reduced, and it ceased between 1 and 3 months of postnatal life. Sox10-expressing cells present in the myenteric plexus of adult mice expressed glial markers, and we found no evidence that these cells participated in neurogenesis under steady-state conditions. However, they retained neurogenic potential, as they were capable of generating neurons with characteristics of enteric neurons in culture. Furthermore, enteric glia gave rise to neurons in vivo in response to chemical injury to the enteric ganglia. Our results indicate that despite the absence of constitutive neurogenesis in the adult gut, enteric glia maintain limited neurogenic potential, which can be activated by tissue dissociation or injury.

Increased expression of nitric oxide synthase in cultured neurons from adult rat colonic submucous ganglia.

Neuronal plasticity in the enteric nervous system (ENS) is probably a key step in intestinal adaptation during growth, maturation and ageing as well as in several pathophysiological situations. Studies on cultured myenteric neurons have revealed an increased vasoactive intestinal peptide (VIP) expression in neuronal nitric oxide synthase (NOS)-expressing neurons. In addition, both VIP and nitric oxide (NO) promote survival of cultured myenteric neurons. The aim of the present study was to investigate possible changes in the expression of VIP and NOS in cultured submucous neurons from adult rat large intestine. Submucous neurons were cultured as explants or as dissociated neurons for 3 and 8 days. Immunocytochemistry was used to determine the proportions of neurons containing VIP or NOS in preparations of uncultured controls (reflects the conditions in vivo) and in cultured explants of submucosa and dissociated submucous neurons. In situ hybridization was used to determine changes in the expressions of NOS and VIP mRNA. The relative number of NOS-expressing neurons increased significantly during culturing. The percentage of all neurons expressing NOS was 22% in controls, while approximately 50% of the cultured submucous neurons expressed NOS. VIP-expressing neurons constituted approximately 80% of all submucous neurons in controls as well as in cultured explants or dissociated neurons. Studies on coexistence revealed that the VIP-containing neurons were the ones that started to express NOS during culture. The induced expression of NOS in cultured adult submucous neurons indicates that nitric oxide, possibly in cooperation with VIP, is important for neuronal adaptation, maintenance and survival.

Congenital diaphragmatic hernia: a survey of practice in Scandinavia.

There is no consensus on the treatment of congenital diaphragmatic hernia (CDH), and practice seems to vary between centres. The main purpose of the present study was to survey current practice in Scandinavia. Thirteen paediatric surgical centres serving a population of about 22 million were invited, and all participated. One questionnaire was completed at each centre. The questionnaire evaluated management following prenatal diagnosis, intensive care strategies, operative treatment, and long-term follow-up. Survival data (1995-1998) were available from 12 of 13 centres. Following prenatal diagnosis of CDH, vaginal delivery and maternal steroids were used at eight and six centres, respectively. All centres used high-frequency oscillation ventilation (HFOV), nitric oxide (NO), and surfactant comparatively often. Five centres had extracorporeal membrane oxygenation (ECMO) facilities, and four centres transferred ECMO candidates. The majority of centres (7/9) always tried HFOV before ECMO was instituted. Surgery was performed when the neonate was clinically stable (11/13) and when no signs of pulmonary hypertension were detected by echo-Doppler (6/13). The repair was performed by laparotomy at all centres and most commonly with nonabsorbable sutures (8/13). Thoracic drain was used routinely at seven centres. Long-term follow-up at a paediatric surgical centre was uncommon (3/13). Only three centres treated more than five CDH patients per year. Comparing survival in centres treating more than five with those treating five or fewer CDH patients per year, there was a tendency towards better survival in the higher-volume centres (72.4%) than in the centres with lower volume (58.7%), p =0.065.

Increased expression of vasoactive intestinal polypeptide in cultured myenteric neurons from adult rat small intestine.

Adult neurons possess the ability to adapt to a changing environment. Loss of target-derived neurotrophic factors due to axotomy or isolation by culturing is known to induce changes in neuropeptide expression in several types of peripheral neurons. The aim of the present study was to investigate changes in the expression of vasoactive intestinal polypeptide (VIP) and nitric oxide synthase (NOS) in cultured myenteric ganglia and dissociated neurons. Myenteric ganglia and neurons from rat small intestine were dissociated and cultured for up to 21 days. Immunocytochemistry was used to determine the total number of neurons and the proportions of subpopulations containing VIP or NOS or both in preparations of whole mounts (controls used to determine the conditions in vivo), myenteric ganglion culture and dissociated myenteric neuronal culture. In situ hybridization was used to determine changes in the expressions of NOS and VIP mRNA. The relative number of VIP-expressing neurons increased significantly during culturing. The percentage of all neurons expressing VIP was 3.6+/-0.3% in whole mounts, 22-24% in cultured myenteric ganglia, and up to 35% in cultured dissociated neurons. NOS-expressing neurons constituted approximately 30-40% of all neurons in whole mounts as well as in cultured ganglia or dissociated neurons. A dramatic increase in NOS/VIP-containing neurons were detected in cultured neurons irrespective of whether they were arranged in ganglia or dissociated, as compared to whole mount preparations. This suggests that the NOS-containing neurons are the ones that increase their VIP expression. The induced expression of VIP in cultured adult myenteric neurons indicates that VIP is important for neuronal adaptation, maintenance and survival.

Vasoactive intestinal peptide and nitric oxide promote survival of adult rat myenteric neurons in culture.

Several motility disorders originate in the enteric nervous system (ENS). Our knowledge of factors governing survival of the ENS is poor. Changes in the expression of vasoactive intestinal peptide (VIP) and nitric oxide synthase (NOS) in enteric neurons occur after neuronal injury and in intestinal adaptation. The aim of this study was to evaluate whether VIP and nitric oxide (NO) influence survival of cultured, dissociated myenteric neurons. Neuronal survival was evaluated after 0, 4, and 8 days in culture. Influence of VIP and NO on neuronal survival was examined after culturing in the presence of VIP, NO donor, VIP antiserum, or NOS inhibitor. A marked loss of neurons was noted during culturing. VIP and NO significantly promoted neuronal survival. Corroborating this was the finding of an enhanced neuronal cell loss when cultures were grown in the presence of VIP antiserum or NOS inhibitor.

Differential effects of VIP and PACAP on survival of cultured adult rat myenteric neurons.

Our knowledge of neuroprotective factors important for the adult enteric nervous system is poor. Changes in expression of vasoactive intestinal peptide (VIP) and pituitary adenylate cyclase-activating peptide (PACAP) in enteric neurons in response to neuronal injury or colchicine treatment, as well as in intestinal adaptation, have been described. Cultured myenteric neurons increase their expression of VIP; furthermore, culturing myenteric neurons in the presence of VIP enhances neuronal survival. The aims of this study were to evaluate possible changes in PACAP expression in dissociated and cultured myenteric neurons from adult rat small intestine, and to determine the ability of PACAP-38 and PACAP-27 to promote survival of cultured myenteric neurons, as compared with that of VIP. A marked decrease in the number of surviving neurons was noted during culturing. No difference in neuronal survival was found after culturing in the presence of PACAP-38 or PACAP-27, whereas VIP significantly increased neuronal survival. In contrast to the marked increase noted in the number of VIP-expressing neurons, culturing caused no change in the number of PACAP-expressing myenteric neurons. We were thus able to demonstrate that VIP, but not PACAP, promoted survival of myenteric neurons in culture. This suggests the presence of a VIP-specific receptor mediating neuroprotection in adult myenteric neurons.

Congenital diaphragmatic hernia in Scandinavia from 1995 to 1998: Predictors of mortality.

BACKGROUND/PURPOSE: There is a lack of large contemporary studies on the management of congenital diaphragmatic hernia (CDH), and the prediction of mortality remains difficult. The aim of this study was to investigate the influence of perinatal factors on mortality rate in a contemporary multicenter study. METHODS: The authors conducted a retrospective multicenter cohort study. Twelve of 13 Scandinavian pediatric surgical centers participated in the study. During a 4-year period (1995 through 1998) 195 children with CDH were included. The main endpoints were hospital mortality rate and total mortality rate (before 2001). Bivariate and multivariate survival analyses were performed using Kaplan-Meier plots, Log-rank test, and Cox regression. RESULTS: Overall hospital mortality rate was 30%. Among 168 neonates with symptoms within 24 hours (early presenters) 35% died before discharge. All 61 deaths occurred in 157 neonates with symptoms within the first 2 hours of life. Among early presenters, 27% had prenatal ultrasound diagnosis, 26% were delivered by cesarean section, and 21% had associated major malformations. Bivariate analysis of early presenters showed increased risk of death in neonates with prenatal diagnosis, associated anomalies, right-sided diaphragmatic hernia (RCDH), low 1-minute and 5-minute Apgar scores, low birth weight, short gestational age, and cesarean delivery. Neonates with prenatal diagnosis were characterized by significantly lower Apgar scores, lower birth weight, and increased frequency of associated anomalies than those diagnosed after birth. Multivariate analysis found that prenatal diagnosis (P =.004), 1-minute Apgar (P =.001), and RCDH (P =.042) were independent predictors of total mortality rate. CONCLUSIONS: In a series of 195 CDH patients, all 61 deaths occurred in the 157 neonates presenting with symptoms within the first 2 hours of life. Prenatal diagnosis, 1-minute Apgar score, and RCDH were significant independent predictors of total mortality.

Widespread changes in neurotransmitter expression and number of enteric neurons and interstitial cells of Cajal in lethal spotted mice: an explanation for persisting dysmotility after operation for Hirschsprung's disease?

Gastrointestinal motor dysfunction persists in a large number of children subjected to surgical treatment for Hirschsprung's disease, indicating abnormalities in the remaining intestine. The aim of the study was to detect possible alterations in frequency and topographic distribution of enteric neurons and interstitial cells of Cajal in an experimental model (the lethal spotted mouse displaying a short rectal aganglionosis) for Hirschsprung's disease. Specimens from the intestinal tract from homozygous (aganglionic) and heterozygous (healthy littermates) were examined using histochemistry, in situ hybridization, and immunohistochemistry. In ileum and colon, ie, regions proximal to the aganglionosis, changes in the expression of neuropeptides and neuronal nitric oxide synthase and in the number of enteric neurons and interstitial cells of Cajal could be detected in homozygous versus heterozygous mice. The described changes are suggested to contribute to the dysmotility remaining after surgical resection of the aganglionic segment in Hirschsprung's disease.